For efficiency and improved services

Jigmi Wangdi

The burden on both hospitals and patients could be eased if the new initiatives tried out to change the current referral system, without hampering medical services, are implemented.

This could be made possible by strategies like Package of Essential Non-communicable Diseases (NCD) (PEN) protocol and its Service with Care and Compassion Initiative (SCCI) the health ministry piloted in Punakha, Tsirang, Wangdue and Zhemgang in 2018.

The health minisrty with support from WHO piloted the strategies and found out that SCCI helped patients with NCDs get timely checkups and medicine refills without having to travel.

Associate Lecturer at KGUMSB, Bhawani Shankar Dungana, said that SCCI ensured that patients need not have to be referred frequently as the drugs were all available at the primary healthcare centres.

This could also resolve the issue of  delays in referrals because of the inaccessibility of roads during monsoon and the remoteness of certain communities. “A patient in a far-flung village could lose the critical period (golden period) by the time the health workers reach, check the patient’s condition and call an ambulance,” Bhawani said.

Dr Namsa Dorji, Chief Medical Officer of Trashiyangtse shared multiple challenges that exist in the current referral system.  “When a district hospital is located near cluster or referral hospitals, there are situations where there is a lack of communication between the medical specialists,” Dr Namsa said.  “Often it is because of personal matters between the specialists, where their issues hamper the services to the patients.”

Dr Namsa added that during such situations, they are sent on a wild goose chase because the specialists instruct them to go to different centres. “The patients then feel that it is us that aren’t working properly.”

The Medical Superintendent (MS) of the Eastern Regional Referral Hospital in Mongar, Dr Pelden Wangchuk shared concerns of personal problems among doctors or specialists leading to patients suffering. “When it comes to equipment or facilities, Mongar has more to offer than Tashigang. When two specialists don’t get along, they tend not to refer the patient to a higher centre, compromising the services.”

Another challenge Dr Pelden shared was the absence of a back-referral programme. He said that once the patient is referred to a higher centre when discharged, the back-referral mechanism is not clear.

“A patient who is supposed to get follow-up checkups and treatment is not aware of what they have to do next. There is a gap here,” Dr Pelden Wangchuk said.

According to Dr Pelden, medical jurisdiction is also a big issue. Some health centres are closer to another jurisdiction, and doctors do not accept patients from other jurisdictions.

“For instance, Samdrup Jongkhar is closer to the Central Regional Referral Hospital in Gelephu in terms of distance and time. However, health professionals would say that the patient’s jurisdiction is Mongar. Who will bear the brunt? The patient,” Dr Pelden said.

Improving the

referral system?

The referral issue is recognized at the tertiary level. The national referral hospital MS, Dr Sonam Tshering, said that a proper referral guideline is required to gain the confidence of the people. This, he said,  can only be achieved by developing an adequate human resource, equipment and functioning infrastructure.

Dr Sonam said that the electronic patient information system (ePIS) is expected to be rolled out in June. This would allow access to patients’ data to get a profile of the disease, category of diseases and base them regionally to understand which patients suffer from what type of diseases.

Since access to specialists and modern equipment is mainly restricted to the Thimphu national referral hospital, Dr Sonam said that a referral guideline can address this.

Others feel that a standard operating procedure (SOP) or protocol is prerequisite for referrals. “We can treat a lot of patients at the district level, we only need reassurance and technical assistance from relevant specialists.”

Dr Namsa said that this would be beneficial for the patients as their out-of-pocket expenses can be spared and specialists will also have time to treat other immediate cases. “The standard treatment protocol which exists today is outdated. It has to be updated to meet the evolution in the health sector.”

“There were also many clerical errors in the guidelines in the past. Unfortunately, only those who attended training or workshops were aware of the mistakes. The books which are sent to the centres are still full of mistakes and health workers refer to the books to treat patients. This is risky and even unethical,” Dr Namsa said.

Medical experts recommended a SOP and clear referral guidelines to make referrals effective and improve efficiency in the referral system.