The increasing cost of referral system of patients, service gaps in health system and human resource constraint are some challenges the health system is facing today, health officials said.

Director General of medical services, Dr Pandup Tshering, said, one of the challenges is the rising number of referral cases abroad.  “Before most referral cases were cervical cancers and stomach cancers, but now the trend is changing,” he said.

He said the change in the type of cancers was because intervention programs have been put in place for primary prevention and clinical care in the country. For instance, HPV vaccination to young girls and endoscopic services are provided for cervical cancers. Today, he said that the cases referred are poly-trauma and ultra head injuries. Patients are also referred abroad for head and neck cancers, chemotherapy, radiotherapy, cardio-vascular, neuro and nephrology cases. Most patients are also referred for renal transplant, which occur due to hypertension and diabetes mellingtus.

“Around 2010 and 2011, referral cost was 5.37 percent of our total health expenditure which amounts to Nu 122 million,” he said. “In 2014, the expenditure increased to Nu184.5M.”

He said that Thimphu referral hospital now has head and neck surgeons.  The hospital will also soon introduce radiotherapy and oncology services, which would help reduce referral costs.

Dr Pandup Tshering also said that eight hospitals across the country have been identified for development into emergency, surgical and trauma centres, which would also reduce referral.

Health secretary Dr Ugen Dophu said the country has enough general doctors but is short of specialists. According to the annual health bulletin, 2017, there are 5,028 health professionals in the country. During the mid-term review last year, the ministry has to fill a gap of about 379 general doctors and 111 specialists.

Chief of Healthcare and Diagnostic Division at national referral hospital, Tandin Dorji said that because of the small population and cost effectiveness, they are unable to provide more specialised service. “At the same time the health human resource services are still in the stage of development,” he said. “We have done a very good job with health education. But in terms of health promotion and behavioural change, we are not doing a good job.”

Concerns were also raised on the equitable distribution of health services across the country and whether or not disparity existed in the services provided to the people.

Health secretary Dr Ugen Dophu said issues of disparity are addressed by conducting various surgical camps, ambulance and helicopter services provided during emergencies.

The secretary said there were also service gaps in mental health patients and neuro developmental disorder patients. “Services of elderly care need to be strengthened also,” he added.

The ministry would be using community health workers to address the issues and educate rural population to avail services.

To control overcrowding at JDWNRH, the ministry is planning to introduce two CT scans in the two regional referral hospitals in Mongar and Gelephu.

Dr Pandup Tshering said the ministry is also looking at strengthening intensive care units in some of the referral hospitals. “These are all done to improve the efficiency of service delivery.”

Dr Ugen Dophu also pointed out that Bhutan’s expense is devoted to curative measures than on preventive. “Only three percent of health expenditure is used in health promotion and diseases prevention, which is bad,” he said. “The ministry will be addressing this and will ask the government to deliberate on allocating five percent of the GDP for health expenses.”

Regarding the quality of health services provided by the ministry, he said that patient safety is the biggest issue. “It has to be addressed in the coming years,” he said. “We also have set up a standard list of services for all hospitals where they must have x-ray and ultra sound facilities, and dental services.”

Researches in public health and disease are picking up but research on human resource (HR) is non-existent in Bhutan, the Director of Khesar Gyalpo University of Medical Sciences, Dr Tashi Tobgay said.

He suggested development of human resource through a comprehensive HR policy in terms of production, deployment and retention. “We need to have HR data which is inclusive of competency skills for better planning,” he said. “Right now we might have the numbers but we don’t have the competency data of all health workers.”

He stressed the need for a dedicated fund for human capital development to advocate and invest more research on health workers, nurses, and paramedics.

Asia Pacific Observatory on Health systems and policies in collaboration with ministry of health had organised the panel discussion on future challenges of the health system in Bhutan during the launch of the Bhutan Health System Review on June 26 in Thimphu.

Rinchen Zangmo