What holds back the referral health system in Bangladesh?

In the UK, one cannot visit a specialist doctor straight on one's own. A general practitioner will decide if seeing a specialist is clinically necessary for a patient. A specialist will only see a patient with a referral letter from his or her general practitioner.

Not just in government hospitals, a private specialist will also ask you for a referral from your general practitioner.

But, in Bangladesh, specialists are generous enough in seeing as many patients as they can, and patients are free to self-refer to any specialist they like.

People with symptoms of simple ailments, which can easily be treated at the primary level, tend to see specialists, creating a huge rush at medical college hospitals and private chambers of senior physicians in the cities.

This overflow of patients, mostly unreferred, leads to inferior quality of services, causing patients' dissatisfaction and depriving critically ill patients of due attention and care.

A study this year shows that a referral system can filter 65% of patients at primary and secondary healthcare facilities at upazila and district levels, thus lessening pressures on tertiary facilities like medical college hospitals.

A referral system can create an effective linkage among three tiers of healthcare services, helping them to spread right from community clinics at union levels to medical universities in Dhaka.

In the absence of a referral system, the cost burden on patients is increasing on the one hand and the creation of skilled physicians is being disrupted on the other, observes Dr Syed Abdul Hamid, professor at the Institute of Health Economics at Dhaka University.

"In most cases, it takes two to three months to get a specialist doctor's appointment in our country. Again, even if an appointment is obtained, the doctor cannot give enough time because they see 50-60 patients in his chamber on any given day. As a result, most people are found dissatisfied after they leave the doctor's room," he tells The Business Standard.

Had there been a referral system, a patient could not have reached a senior doctor without seeing a junior doctor first, Dr Syed Abdul Hamid notes.

"Then the pressure on senior doctors would be reduced and they could devote more time to critical patients.

"Besides, as patients do not want to go to junior doctors, they cannot treat an adequate number of patients. This is why their capacity is not increasing. Even when these doctors become professors, their skills will remain the same," he says.

He emphasises the need for government efforts to improve patient satisfaction and enhance the skills of junior doctors.

Healthcare professionals, officials and experts are well aware of the benefits of the referral system in healthcare, and it has been talked about for decades, with healthcare practitioners citing the UK's referral system back in the 1990s in the way they are stressing the same today.

But it could not be put into practice effectively yet. Some initiatives fell apart halfway through.

Why?

Professor Liaquat Ali, a biomedical scientist and educationist, says in the developed world there are three levels of care – primary, secondary and tertiary care.

"A patient goes to secondary or tertiary care only when referred from the primary care. But, in our country, it is the opposite. This is because there is no policy in the rural areas and no infrastructure in the cities."

Professor Liaquat says the rural areas of the country have sufficient infrastructure needed for a functional referral system.

"In rural areas, there are community clinics, upazila health complexes and district hospitals. Initiatives and regulations are needed to make them operational.

"But the necessary infrastructure has not been built in the cities where about 40% of the country's total population live. Here tertiary level hospitals have been established directly without primary and secondary health complexes being set up, and people flock to medical college hospitals even in cases of minor ailments," he tells TBS.

He adds that there is an infrastructure named "Urban Primary Healthcare Centre", but it is not under the purview of the Ministry of Health but under the Local Government Ministry, which is usually dependent on donors.

"These facilities do not have health infrastructure in the real sense of the matter. Also, there is no infrastructure for linkages with secondary and tertiary level hospitals that lay the groundwork for the referral system," says Professor Liaquat Ali.

A study, "Bangladesh health sector: present challenges and future guidelines", was conducted through policy dialogue with 60 individuals, among whom were eminent doctors, politicians, and journalists, from 11 March to 2 July 2021 in order to identify and solve existing problems in the country's health sector. Former health minister Dr AFM Ruhul Haque, in collaboration with the non-government organisation Eminence Associates for Social Development, conducted the study.

According to the study report published on 20 March this year, 33.3% of eminent citizens feel that it is possible to ensure quality and accountability in health services if a referral system is introduced comprehensively through a digital system.

How to, then, make it happen in Bangladesh?

In 2016, the health directorate took an initiative to introduce a structured referral system in Rangpur and Nilphamari for medical services, but it is yet to see the light of day.

Professor Liaquat Ali thinks to introduce the referral system, "we need to build infrastructure or recruit general physicians where such facilities, such as community clinics, already exist."

The health ministry needs to create a new chain for urban health, which is now the weakest point of the health sector, he says. 

In the absence of the referral system, complaints run rife that doctors do not give enough time to patients, he notes.

Professor Liaquat points out that there are various tertiary and specialised hospitals, including ward-based community clinics, union sub-centres, upazila health complexes, district hospitals, and medical college hospitals across the country, but when people feel ill in remote areas, they come directly to Dhaka for treatment instead of going to these health centres.

Professor Dr Samiul Islam Sadi, director (administration) of the DGHS, who took the initiative to launch the referral system in 2016, tells TBS that the latest experience of Covid-time health emergency has made the referral system more relevant.

He recalls the feasibility study he did in Rangpur back in 2016 through assessing the needs of grassroots people as also the availability of specialised resources and facilities.

People in nearby districts depend on district hospitals and public medical college hospitals for major ailments that require specialists' supervision, he says.

"But those health facilities are already overloaded. If we start referring patients before improving facilities and making more specialists available, then people will have to queue again for serials outdoors and lose interest in the system," Professor Sadi says.

He stresses the urgency of creating a referral desk and preparing a list of specialists.

Why did the initiative not make further headway?

Prof Sadi avoids a direct answer to the question but says it is the right time now to take the process forward. Health infrastructures have seen further improvements in recent years and now all upazilas have pathological testing facilities and 10-bed hospitals, with a few even privy to 250-bed facilities, with necessary equipment and staff.

"Our health services have seen much expansion. Now service quality needs to improve. We need to be directed to healthcare as practised worldwide. The system will tell which patient needs what kind of specialist treatment," he says.

No new law is required for the introduction of a referral system in the health services, he notes, adding that the system exists in official documents and can be put into practice right away.