Patient Referral System: Still elusive after all these years
There are well-defined and established practices of referral systems in many countries. But the policymakers fail to understand it when they speak about the referral system.
In 2014, then health minister Mohammad Nasim at an event in Rangpur Medical College Hospital officially announced the inception of a patient referral system for Rangpur division.
It, however, fell flat due to inadequate logistic support and unavailability of qualified physicians and auxiliary workforce at primary healthcare centres.
Two more attempts to get the referral system going in 2016 and 2019 too failed. Both fizzled out after discussions among high-ups.
Under a referral system, a patient first goes to a nearby primary healthcare centre, public or private. If need be, that healthcare centre will send the patient to hospitals that are better equipped to treat them.
Major hospitals, on the other hand, will not see any walk-in patient, unless the patient is in critical condition. They will treat only patients referred by the smaller hospitals and healthcare centres.
The larger hospitals can send patients back to smaller hospitals for follow-ups.
The system creates a link between the hospitals of three tiers -- primary, secondary and tertiary -- to ensure quality of services, reduce cost, and avoid unnecessary rush at tertiary hospitals.
For years, the government could not prepare a protocol for the referral system, let alone introduce it, resulting in anarchy in the country's health sector, health experts said.
Currently, patients bear on average 68.5 percent of all healthcare costs. If the referral system was in place, this cost could be slashed as they would not be paying for the inefficiency of the healthcare system, they said.
Health officials said if the system were in place, pressure on large tertiary hospitals could be halved. Presently, many go straight to those hospitals with minor illnesses, deterring the hospital's ability to properly treat critical and emergency patients.
They said a solid patient referral system could connect around 18,000 public and 16,000 private healthcare facilities with all other high-level hospitals countrywide.
NO TRUST IN PRIMARY CARE
About 5,000 union healthcare centres countrywide are supposed to be the first place for patients to go to. But none of them work 24/7 due to a lack of doctors and other support staff, health officials said.
Most of the upazila health complexes also fail to properly serve patients due to shortages of doctors, support staff, logistics, and inefficiency in hospital operations.
Without options, people rush to large hospitals in cities.
Joynal Abedin, 62, of Cumilla, had been suffering from chest pain for six months. He had no confidence in the upazila health complex or the medical college hospital in Cumilla. "There's no proper treatment there," he said.
He travelled 70km to Dhaka and stood in a queue of 500 patients at the National Institute of Cardiovascular Diseases (NICVD).
The NICVD doctor, Nurun Un Nobi Khandaker, said Abedin could have had treatment in his locality. "This is a specialised hospital that handles complex heart-related illnesses. But we have to handle a large number of patients with minor illnesses every day," he said, adding, "The rush could have been halved if these patients had visited primary healthcare hospitals first."
If there had been a patient referral system, Abedin would have been seen by a primary healthcare doctor first, who would have sent him for an ECG. After going through the results, the doctor, if needed, would have sent the patient to a better equipped hospital like NICVD. This would have saved travel costs and ensured timely treatment of the patient and reduced overcrowding of NICVD.
Prof Ahmedul Kabir, additional director general (administration) at the Directorate General of Health Services (DGHS), said poor services in primary healthcare facilities make for a great barrier to the referral system.
"Until we are able to provide quality services at the primary level and gain public trust, no matter what we say, the referral system will not be a reality."
WHY IT FAILS
Health experts believe that budget constraints, inefficiency, and a lack of commitment from policymakers to ensure quality healthcare have been the biggest impediments to the introduction of the referral system.
Regarding the 2019 initiative to introduce the system in Manikganj and Chapainawabganj, Mohammad Zaved, deputy programme manager at hospital service management of the DGHS, said, "We only had two consultation meetings with healthcare staff in Manikganj, and could not progress further due to the pandemic."
But the 2016 initiative in Nilphamari and Rangpur, long before the pandemic, suffered a similar fate.
POLITICAL WILL
Experts say that developing a system to manage this massive network requires a political will and a proper budget that can ensure skilled workforce and necessary logistic support at the grassroots.
But keeping medical professionals in rural areas has been a big challenge.
The health and family welfare ministry issued a circular on August 27, 2021, proposing to extend the year-long internship programme for MBBS graduates to two years.
If the proposal had been adopted, the interns would have had to spend the second year at union-level healthcare centres.
The government, however, backtracked amid protests from interns and medical students.
"This was a very good move. But I don't know why the government retracted. It exposes a lack of political commitment," Gonoshasthaya Kendra Founder Zafrullah Chowdhury told The Daily Star.
He, however, said the rural healthcare centres were not suitable for interns and doctors to stay.
Currently, doctors under the government healthcare service are required to spend the first three years of their job in rural areas. In many cases, they do not stay the full three years, citing poor lodging facilities and a lack of other amenities.
"Healthcare professionals serving in rural areas are incentivised in developed countries. Unless the government incentivises medical students and professionals, they will not like to stay in rural areas. There are security issues too," Zafrullah said.
Syed Abdul Hamid, professor at the Institute of Health Economics (IHE) at Dhaka University, said secondary and tertiary hospitals need to be simultaneously readied before introducing the referral system.
"There are well-defined and established practices of referral systems in many countries. But the policymakers fail to understand it when they speak about the referral system," said Muhammad Abdus Sabur, adjunct faculty at the IHE of DU.
Prof Md Eshreshamul Huq Chowdhury, secretary general of Bangladesh Medical Association, said the country's doctors would happily comply with any initiative to introduce a referral system.
"A referral system will pave the way for utilising the full capacity of our healthcare system and create more jobs," he said.
In India, there is no nationwide referral system, but many provinces have their own system that connects healthcare facilities at different levels, according to Shariful Haque, deputy programme manager (hospital service management) at the DGHS.
In England, the NHS e-Referral Service (e-RS) is a national digital platform through which patients are referred from primary care to elective care services. The e-RS allows patients to choose their first hospital or general practitioner.
WHAT NEXT
Currently, the hospital service management at the DGHS is working on a referral system, involving public and private facilities, in Manikganj and Gopalganj.
There will be a round-the-clock referral desk at each hospital where the staffers will connect patients to upper-level hospitals, said Borsha Jchinta Soren, deputy programme manager for the structural referral system at the DGHS.
"We have been designing this in a way that hospitals will stay ready with proper treatment arrangements so that patients don't struggle to get treatment in time," added Borsha.