Aboubacar Traoré took his two-year-old daughter Hadya Bintou for emergency medical treatment at the Donka paediatrics hospital in Boké, Conakry after she had spent two days crying in pain.

A sign on the wall clearly marked the consultation fee of US$5. But when Traoré tried to hand over the money the doctor asked for more.

“I refused to pay; the fee was clearly marked on all the official forms,” Traoré said, “so the doctor made me take back our forms and ordered us to leave.”

Traoré ended up paying the bribe he was asked for and his daughter was treated. “What choice did I have?” He asked IRIN.

These additional fees are crippling for many Guineans. Almost half the estimated population of 9.5 million lives on under US$1 a day.

Aissatou Diallou, a doctor at the Donka hospital, told IRIN she was not surprised. “I have seen colleagues here persuade patients that only they can treat them, and once the patient has gained trust in that doctor, he or she bribes the patient. “

The problem is difficult to tackle because it is often hidden.

Moussa Kourouma, director-general at Conakry’s Ignace Deen hospital, one of the city’s finest, told IRIN: “Lots of doctors ask for extra money but it is often quite hidden in the system, so it is hard to track down.” But, he added, “I understand why they are driven to do it – because their salaries are so low.”

Despite endemic corruption he insists all patients who come for treatment in Ignace Deen will be treated, whether they have the money or not. “That is the oath we have pledged as doctors,” Kourouma said.

Salaries ‘not enough to live on’

Doctors earn on average $102 a month in a public hospital, which, after paying bills, leaves them little to live on, according to Cherif Moussa, a doctor in his first year of work at Ignace Deen.

“After I pay for my housing, $32 per month; daily expenses, $2 a day; and food, $56 for a 50kg bag of rice; I don’t have enough to live on month to month,” Moussa said.

Often a public sector doctor’s only choice is to moonlight with a private clinic, go private full-time or leave the country all together, according to Moussa.

Doctors who go private are paid $6.80 per consultation and can earn up to $136 per month by working three hours a day, according to medical professor Sekou Donkoure who works at the national school of health in Boké, Conakry.

Corruption in Guinea’s health sector is not limited to doctors’ pay, but occurs all the way up the chain to the pharmacists who run private clinics on the sly in state hospitals, to senior managers who sell off medical equipment.

“The guys at the top make sure equipment and medicines arrive in their name so they can sell some of it on. There is gangrene everywhere in the system. And ultimately it is the sick who pay,” said Moussa. “There are lots of honest doctors, of course, but in most hospitals the dishonest outweigh the honest.”

Hidden costs

For patients in public hospitals, the hidden costs are unpredictable.

Hadya Diawara, 65, was admitted to the Ignace Deen emergency ward and stayed a week after developing a heart condition. When her family members tried to visit her they were charged $1.13 every time they entered the hospital grounds.

“It is impossible! Not only did we pay $135 in treatment, but each of my relatives has had to pay each day to visit my mother,” her daughter said to IRIN. “They said it was for upkeep.”

But inside her ward the conditions were insalubrious. A filthy sign on the wall pronounced the importance of cleanliness while cockroaches scuttled across the floor, and there was no electricity in the stifling room. “This room hasn’t been cleaned in a week, except by us,” Diawara told IRIN from her hospital bed, “and we don’t even have running water!”

When IRIN spoke to Kourouma, the hospital director, in his office on the floor beneath, he insisted conditions at Ignace Deen were better than elsewhere.

“This hospital is at the top of the pyramid, so you can only imagine what it looks like further down the chain,” he said. “It is hard to know what to do. We cannot afford to pay doctors higher wages because we are scraping by. This hospital runs purely on the money it brings in day-to-day except for a few government subsidies here and there.”

Kourouma blames backhanders partly on the persistently low fees that are set by central government. “Fees have hardly risen over the past 25 years,” he said.

He has fought to increase fees for certain procedures and has been partially successful. Using a life-support system now costs $68, up from $11 in 2007, and a straightforward initial consultation is now $1.13, up from $0.33, but other treatments are “still too low” for him to improve standards.

Incentives

Kourouma is trying to create stronger incentives for doctors to move away from accepting kickbacks. “We need to make doctors’ jobs fulfilling, stop irregularities and stem the brain drain,” Kourouma said.

He has started by setting aside some money for medical training, and is trying to set up a system to increase salaries the longer doctors stay; at the moment their pay is stagnant. In future, high performers will be given ‘certificates of satisfaction’ while under-performers will remain on the same pay rate.

But Kourouma admits his options are limited. “There will always be irregularities in the system but I will keep on pressing for change, at least in this hospital,” he said.