WAS the tumour malignant? Nguyen Thi Hoat’s doctors could not tell because their public hospital lacks brain-scanners. Ms Hoat’s only option was to travel 130km (80 miles), on the back of her sister’s motorbike, from her village to a crowded public hospital in the capital. Yet her state insurance policy covers just 30% of any medical expenses incurred outside her home province. The $150 that Ms Hoat, a rice farmer, put towards blood tests and a brain scan is equal, for her, to a month’s earnings.

It is the job of the authorities to look after health care. The Communist Party of Vietnam first pledged health-sector reform as early as the 1920s, well before it declared the country independent in 1945. It developed a publicly financed health-care system even as it was fighting wars against France and then America. The provision of health care is supposed to be one of the pillars on which the party’s legitimacy is based.

Yet the health-care system, like the state-dominated economy, is limping. The 3% of GDP the state spends on the system (nearly half of total health spending) is not enough to improve health infrastructure. Hospitals have outdated facilities and maddeningly opaque bureaucracies. A law on health insurance passed in 2008, created to assist the poor and ethnic minorities, is far from comprehensive. But the government knows that providing proper health care is key to preventing the kind of social unrest that undermines its authority.

Some reform is under way. The government has given some hospitals more autonomy. And in June the national assembly passed a new version of the insurance law designed to make participation compulsory. The idea is to lure into the fold poorer and black-market workers who have long avoided paying insurance.

Yet distrust of the system runs deep. Some public hospitals have built flashy new wings which cater to well-heeled patients but do little to meet general demand. Bed-sharing is common, especially in urban wards flooded by patients from the countryside.

Though this is an authoritarian state, ordinary Vietnamese are remarkably outspoken about social issues. In health, they complain of the prevalence of “out of pocket” payments, which happen in around half of health-care transactions. Many of the payments are really bribes paid on top of formal hospital fees. They mean that affordability is often a larger factor than need, for all but the richest patients. In a typical case, a university lecturer in Hanoi says she slipped doctors and nurses about $250 to ensure attentive treatment when she gave birth at a public maternity hospital. The rate, she says, was $1 per injection, $2 for a bath and $5 to sidestep a queue.

The health minister, Nguyen Thi Kim Tien, has faced blistering criticism this year after a parade of health scandals, including a measles outbreak that killed more than 100 children. Online, thousands have called for her resignation. A popular television satire advises sick patients to avoid corrupt doctors by curing themselves. The fault is not all the minister’s—or the doctors’; they have long earned as little as $100 a month, for instance.

In order to get by, doctors moonlight at private hospitals and clinics that are popping up in cities, led by Hanoi and Ho Chi Minh City, to serve foreigners and affluent Vietnamese, people who would otherwise opt for treatment in Singapore or Hong Kong. One such institution is Vinmec International Hospital, a 600-bed facility financed by Vingroup, a property developer. Its director, Nguyen Thanh Liem, says private hospitals help to minimise overcrowding elsewhere. And they showcase an international standard of care that may one day spread to the public sector.

That is cold comfort for Nguyen Thi Hoat, the rice farmer with a brain tumour. She says if her tumour proves cancerous, she will need to borrow from her brother and sister for surgery in Hanoi. Her family is worried. Yet poorer neighbours, she says, have fewer options. She considers herself lucky.