Amid rising medical referrals, can prevention offer relief?

Jigmi Wangdi

Not finding a cure for the heart conditions Nima suffered for months, the referral committee at the national referral hospital decided to send the 48-year-old driver of a company to Kolkata, India, for treatment.

He was among the  first group of patients referred to Kolkata after the Covid-19 pandemic. Nima returned after nearly two weeks cured. Today, he is literally a changed man. His health restored, he embraced a new lifestyle, forsaking his beloved pork and alcohol while adopting a healthier diet.

 “I am very grateful to the government for sending me to a “big” hospital in India,” said Nima who remembers the medical bill he was handed over to submit to officials. “The government spent well over Nu 300,000 to treat me. They even paid me and my escort some money to cover daily needs.” The medical bill alone amounted to nearly twice Nima’s annual salary.

Nima’s story is not unique. Many echo his sentiments, appreciating the free healthcare system that extends to costly referrals to prominent hospitals in India. From July of the previous year until April 2024, over 1,000 patients were referred abroad, predominantly to India, for various treatments—a number on the rise. Consequently, the financial burden on the government has escalated over time.

Between 2021 and 2022, the health ministry spent about Nu 206.7 million on referral cases. It increased to Nu 501 million between 2022 and 2023 and to  and Nu 529.95 million from 2023 to April 2024.

Cost of referrals increased by 154.3 percent, between 2021 and 2023. The total spending touched Nu  1.2 billion between 2021 and 2024. An additional Nu 80 to Nu 100 million is required till the end of June 2024.

What medical cases are referred?

Many of the patients referred are for cancer treatment, neurosurgery requirements, heart conditions, kidney diseases, hip and knee replacements, immune deficiency disorders, dental conditions,and other complicated diseases that require surgical procedures.

According to officials from the National Medical Services, referrals typically occur when local facilities, like JDWNRH, lack the requisite infrastructure for treatment. Physicians refer patients following consultations with colleagues and departments. The final decision rests with the National Referral Committee, chaired by the Medical Superintendent.

Health officials note a predominant trend: the surge in referral cases predominantly comprises diseases linked to lifestyle or non-communicable diseases (NCDs), alongside victims of severe accidents—many of which are preventable.

On why referral cases are increasing every year, the former health minister and a public health specialist, Dasho Dechen Wangmo said that hospitals in the country are not equipped with necessary equipment and expertise. Dasho Dechen Wangmo said it would be relatively easy for the government to invest in equipment, which could ease the burden of cost. 

“Buying equipment isn’t the only challenge. We do not have trained experts who can use the equipment,” Dasho added, “It takes years to build the capacity of a technician.” 

She also added that the country’s health system focuses on the primary health care (PHC) model and recognises the importance of emphasising prevention methods, as a high number of referral cases are patients suffering from non-communicable diseases (NCDs) or lifestyle diseases such as diabetes and hypertension, along with kidney or liver diseases, which are preventable.

If NCDs are preventable, how much is spent on prevention to avoid referrals costing hundreds of thousands of Ngultums?

The Department of Public Health (DoPH), officials said, carry out multiple initiatives to create awareness among the public on how NCDs or communicable diseases can be prevented.

The Director of DoPH, Karma Jamtsho, said that the ministry is using every avenue possible to disseminate information to the public. “We share infographics on certain diseases from time to time through social media.”

Karma Jamtsho added that advocacy and awareness, including simple information like the benefits of salt intake, the importance of  early detections, screenings and how NCDs could be prevented is an ongoing programme. 

“We are always exploring new ideas and avenues with experts and international partners on how to deliver timely information to citizens and to ensure the remotest parts of the country are also reached,” Karma Jamtsho said.

Karma Jamtsho shared that it is also a big responsibility on the part of the citizens to use the information effectively. “Our people should know how diseases can be prevented. It is something to be done together, as the government can only do so much.”

Observers said that improved attention and budget on prevention could save the government millions, especially if NCD are the common cases referred. Some inside the health system, including doctors, said that the budget on prevention is too small to make an impact.

Officials from the health ministry disagree.  They said that the health promotion and disease prevention effort in the past three decades has seen healthy adoption of behaviours and practices among the general population. 

As prevention has been highlighted as the most effective way to combat NCDs, the health ministry has allocated a budget to be pooled into carrying out prevention methods. 

The ministry had a capital budget of Nu 1 billion allocated for prevention in the 12th Plan. In the 13th FYP, a total budget of around Nu 5 billion has been proposed to focus on prevention. 

There has been an increase from the initial baseline of 15 percent to 30 percent for the 13th FYP, said officials.

Officials also claim that latest medical technologies in hospitals like JDWNRH have effectively reduced referral cases. The first Cath Lab, which opened in September 2023, has significantly lowered referrals by providing timely interventions and treatments for heart patients, they said. 

Before its installation, over 100 patients were referred annually for heart problems, with more than 80 percent needing Cath Lab services. JDWNRH used to send 15 to 20 patients to India each month, but this has decreased to just three or four complex cases requiring open-heart surgery. 

The Cath Lab now performs procedures like angioplasty and angiograms and plans to have an open-heart surgery team by mid-2025, further reducing heart patient referrals.