Minister wants to break the chain to ensure equality and eliminate inequity in health services 

Younten Tshedup

A sharp pain in the abdomen had been bothering Tashi for long. Her son, a cashier in one of the banks, takes her to see the doctor at the national referral hospital. They see the general duty medical officer after hours of waiting in line. She is given some painkillers and sent home.

The same day, Sangay who had a strain on his neck managed to meet a medical specialist at the same hospital. His daughter, who works at the hospital, had arranged the appointment.

This is an example of inequity in getting access to health services, health minister Dechen Wangmo gave while talking about access to health services. But this is quite apparent today and those with ‘connections’ and at the higher social and economic status get the priority.

Acknowledging this, Health Minister Dechen Wangmo said that many people, even before visiting hospitals are preoccupied with  ‘who do I know at the hospital’. “This is only natural as our system is so. But this is not right. Regardless of who you are, every Bhutanese must get the best quality health service.”

The country today enjoys almost 97 percent access to health services. However, the question is on access to quality services, she added.

She said that Bhutan must be the only country in the world today that provides free health care services without a gatekeeping mechanism in place. She explained that with a proper gatekeeping system, a person suffering from a stomach ache would first visit a general doctor. The doctor, after considering the severity of the condition, would refer the patient to a surgeon and if required the surgeon would then refer him or her to an oncologist.

However, in Bhutan, Lyonpo said that if a person has a stomach ache, he or she could directly see a surgeon or even an oncologist using their connections. Likewise, if an individual has a pain in his or her shoulder, they can straight away get an MRI scan today.

“But does the disease require an MRI? It may not but because of your social connection, you can go and get the services. This is where we need to streamline the system,” the minister said. “Referrals should be based on your disease condition and not your social connections.”

The consumption of tertiary health care services in the country, Lyonpo said was mostly used by those who were economically affluent. She said that this was only natural because those individuals were empowered by the virtue of their status (social and economic) and other facilities like education and better knowledge.

“But someone from Sakteng will depend on whatever the doctor would say. He or she cannot google their symptoms and ask for a CT scan or MRI directly,” she said.

Small steps of change

Beginning last year, the health ministry decided to send all referral cases abroad by air. The decision was reached after the health minister had a personal experience with a referral case.

Lyonpo shared that a cervical cancer patient with a swollen leg was travelling to Kolkata in a bus from Phuentsholing. “Although not serious then, having to deal with cancer already, she was struggling in a cramped bus with a swollen leg.”

She said, “There are some people who come to my office requesting kidu so that they can travel by air. If they can reach here, to my office, they don’t need kidu. They already have a network, which is why you are able to reach here.”

Realising that the system needed a change, Lyonpo approached the prime minister and requested that all referral cases abroad had to be sent by air. “Lyonchhen was very supportive and asked me to do the math. Surprisingly, there was very little difference financially in sending patients by air. The two airlines also gave us some discount.”

Equitable and quality health service was the right of every Bhutanese, Lyonpo said. “A pregnant mother in Mongar should get the same treatment she would receive in Thimphu,” she said. “This is the kind of health system I would like to leave behind – a resilient and people centric health system.”

A healthy nation with equitable and quality access to health services was the ultimate goal of the government, the minister said.

To further improve the health service delivery, the ministry is also working to introduce the electronic patient information system (ePIS) as a part of the Digital Drukyul flagship programme.

The system would digitally record information of patients which can be assessed by a doctor in any part of the country. Besides reducing the use of paper-based prescription, ePIS is expected to enhance the use of information and communications technology in the health sector.

Lyonpo said that once this system is in place, the issue of unequal access and inequity in availing health services would be significantly reduced.

Despite the Covid-19 pandemic, the health ministry has raised substantial amounts of money in grants from donors. Through the grant, Lyonpo said that the ministry has managed to put in X-ray and ultrasound machines in the remotest of the health centres. “The X-ray and ultrasound service coverage is almost 90 percent today.”

The ministry has also managed to procure eight high-end ambulances through Japanese grants. “We hope to continue with the same momentum. In the end this is it. If the nation wants to progress, we must invest in health,” she said.

With the current set of teams at the ministry, Lyonpo said that what the government aspires to achieve in the health sector was ‘doable’. “I’m optimistic. I’ll aim for the moon and end up somewhere in the sky and that’s okay. I’m very committed to this vision and this is what makes me excited to come to the office every morning. Covid has given us more confidence that we can achieve what we aspire.”