The Bhutanese Leading the way.
Minister responds to various issues raised by medical professionals
The higher allowance hikes for doctors, nurses and clinical staff has led to cheer and higher morale among medical professionals.
A senior doctor said, “This pay hike is the first time an elected government is recognizing the contribution of the health professionals. Prior to that His Majesty The Fourth King had granted a clinical allowance of around 40 percent in 2005-06 period.”
However, even within medical professionals there is an acknowledgement that more has to be done beyond salary to improve the quality of medical care.
The Bhutanese talked to an array of doctors and nurses to gauge their reactions, but on the condition of anonymity. The paper then also talked to the health minister about these issues.
Patient Load
Some doctors and nurses said a major stumbling block in the way of quality care was a higher than normal Patient load.
A doctor said that the patient load should be around 30 to 40 patients in six hours but it goes from 40 upto 60 patients.
A nurse said that ideally the nurse to patient ratio in the general ward should be one nurse to six patients but in the JDWNRH it is one nurse to eight patients. Similarly, in the intensive care unit it should be one nurse for one patient but the reality is around one nurse for three patients.
Doctors also pointed out that patient loads are highest in places like JDWNRH, Paro and Phuentsholing.
A specialist said that normally specialists are supposed to look at more complex cases but if the patient load is too high then that time is not enough.
Continuous Medical Education
Another issue brought up by doctors and nurses was the need to give continuous and equal training opportunities to stay updated with their skills, and to also be able to interact with their colleagues in international circles.
A specialist said that the Bhutan Medical Health Council now mandates a minimum training score every five years to be able to practice, and this would not be possible without training.
A doctor said that currently the training and conference opportunities are not fairly given and a few medical professionals with links or access go for most of the trainings and conferences.
Another doctor said that there should be at least one opportunity per year for a doctor to go out for conferences to update their skills and meet other doctors.
A nurse pointed out that while nurses are happy with the hike relevant training and courses would also go a long way.
Monitoring, accountability and support
A senior doctor said that a major problem is a lack of supportive monitoring around the clock.
He said, “I have been working for more than 20 years and nobody has asked me what I have done, whether I need to improve or if I need some help.”
The doctor said that there is no accountability for doctors and even other medical staff as no one is tracking what they are all doing and also if they are doing a good job or not.
“The system should actually be able to track which doctors or medical staff are not doing well and find out why and then offer support as some may require additional training and help and if they still don’t improve then they they can be sent to different placements,” said the senior doctor.
He said similarly the system is also not able to track well performing doctors and reward them and this impacts morale.
The senior doctor lambasting some of his fellow colleagues said that patient load may not actually be an issue if some of them come on time or do not attend to private works during working hours.
This senior doctor also criticized a growing practice among even senior doctors of ‘defensive medicine’ whereby the doctors order a large number of tests and then only take a call which he said will cause a heavy burden on the medical system.
The senior doctor also criticized both the ministry of health and doctors for taking away doctors from hospitals for various advocacy programs or projects for which the MoH should be having their own experts.
“The doctors will go as it will entail workshops and travel and hence more money but that eats into time he or she should be spending in the hospital,” said the senior doctor.
The senior doctor said that in the absence of such tracking even an audit on the performance of medical staff cannot be done.
“If the health system needs to improve there needs to be supervision and accountability,” he added.
He said that if the hospitals can get autonomy then there should even be a hire and fire policy.
Management support and understanding
Doctors and nurses also pointed to a gap between the medical professionals and the non-medical management.
A doctor said that everything is not about money but it is also about respect and being given due importance.
The doctor said, “The officials are from non-medical backgrounds and there is a total lack of support by the management to doctors and nurses and this is a popular feeling among medical professionals.”
The doctor said that in fact even when professionals from the medical background go to the ministry they turn their backs on the professionals and are more interested in their own seat.
He said that a lot of the medical programs from the MoH are run by even young graduates who just got through RCSC and many who don’t even have basic understanding of the field.
He said that senior doctors who worked decades are put at par with these young officials and by the time the young officer starts to have an understanding then the officer moves out and the same cycle is repeated.
The doctor pointed out that these programs come with significant budget and quite a large portion is used by these administrative officials in their own travels and workshops.
Doctors also pointed out that in other countries hospitals are run by people from medical backgrounds but in Bhutan it is run by people from administrative backgrounds.
“The RCSC should allow seasoned medical professionals on the verge of retirement to fill these top posts,” said a doctor.
Doctors said they do make recommendations but nobody really listens to them.
Entry and Bonds
Doctors pointed out that compared to other civil servants, doctors lose out on seniority as they have a six-year MBBS course.
They also pointed out that RCSC’s bond systems may be intended to retain doctors but it is starting to have the opposite impact of discouraging young doctors from getting in and demoralizing the ones in the system.
A MBBS doctor who does the six years course has a 12 years bond but unlike other civil servants even if he wants to leave after 10 years then he has to pay the entire bond amount of 12 years.
Similarly, a doctor doing a masters and further sub-specialization courses will have three times the bond period which means a two years’ course will give a six-year bond period.
“A doctor can be a bonded employee for up to 30 years and this why some young doctors who just finished their MBBS are paying back the government the 12-year bond value of Nu 8 mn to Nu 10 mn and they are going abroad,” said a doctor.
One doctor said that in some cases RCSC did not even track certain graduate doctors who have not even come back after their courses.
Medical Procurement
One issue doctors raise is on how unsuitable the government procurement system is for the medical field as equipment that are needed urgently only arrive months later due to a long process.
They also pointed out that the lowest bid concept often leads to higher end quality equipment being left out and as a result the same vendors every year supply cheaper equipment which has be replaced constantly.
A doctor said that something even as basic as good gloves are not available as the cheap surgical gloves even come with holes and at times hair in them. As a result, some medical staff wear multiple gloves just to be sure.
“This cheap gloves can be dangerous for both the doctors and the patients,” said a doctor.
Facilities and accommodation
Doctors said that the only space they have is their room where they can see patients but it would be good to have a common room for doctors where they can interact, subscribe international journals, have secretarial staff for the common room and even a basic place to keep their things.
A doctor pointed out that often nurses on night duty have to travel late at night to their homes.
He said that if accommodation can be provided in the hospital complex or or near it then the nurses and clinical staff can come even faster in case of emergencies.
Referrals
Doctors and nurse pointed out out that one problem right now is that all cases come to JDWNRH without a proper referral system from the districts and as a result the JDWNRH is overburdened with even very minor cases that can actually be handled by a BHU.
Emergency
Doctors said that when a service satisfaction survey is done then overwhelmingly most of the complaints are in the emergency.
They said this is due to two reasons. The first is the patient and family who is under great stress and don’t get the concept of triage or waiting.
The other they said is the small limited space and limited number of beds, equipment and doctors there. They say this is one interface that needs work on both sides.
Resources
Doctors pointed out that Bhutan with free medical care and no private medical system spends only around 3.5 percent of GDP on healthcare while other countries like Nepal, Sri Lanka and others with private hospitals spend 8 to 12 percent of GDP and in the west that goes upto 20 percent of GDP.
They pointed out that Bhutan needs to spend more on health and the current allocation of GDP is not adequate.
Health Minister responds
The Health Minister Lyonpo Dechen Wangmo in an interview to The Bhutanese addressed all the issues raised above.
Lyonpo said that in the case of the patient load the main cause is everything coming to JDWNRH and so the government is bringing in a systematic way of referring patients from the BHU to District Hospital to Regional Referral Hospital to JDWNRH.
She said this would prevent today’s situation of an oncologist seeing a diarrhea patient that can actually be handled by a BHU.
The system has also identified eight strategic hospitals that will get more equipment and specialists to prevent patient load and ensure treatment at the regional level. The government is also looking to hire more specialists from abroad.
She said this referral system would bring in accountability from medical professionals as there has to be a written record and diagnosis and so there would be a case history.
On the issue of medical accountability, the minister said that the MoH will soon be rolling out an online patient record system so that the medical history and records of patients can be be kept online with due privacy and this would also track the name of the doctors and their treatments.
Lyonpo said that the doctors just can’t order tests but has to given a relevant diseases code with recommendations which will also guard against defensive medicine.
The minister said that in terms of accountability the voices of patient is not there and so the MoH will set up a unit in its quality assurance division that will allow patients or family members to call up or walk in and file complaints on issues ranging form rude staff, doctor not being there to medical malpractice.
The BMHC Act is also being amended to make it more patient centric than the current act which is more profession centric.
On CME, Lyonpo said the merger of the JDWNRH, Mongar Referral hospital and Gelephu Referral hospital into one as teaching hospitals will allow for more training and research budget and thus give opportunities for more trainings and conferences.
Lyonpo said that she personally did not notice any tension between the management and medical professionals and they are in fact consulted.
She admitted that MoH programs do take away doctors but the solution to this would be for MoH to build its own in house capacity in the longer run.
On bonds the minister said that it was the decision of the RCSC which had its own justification. She said that the issue of doctors leaving needs to be seen from a holistic angle and bonds may or may not be a factor there.
In terms of GDP spend the minister admitted that 3.5 is not enough and that the government is working on a Health Bill that would specify a higher percentage of the GDP.
The minister said that while in the 12th plan the official budget is 3.5 percent of GDP the government was carrying out upto Nu 13 bn of health related activities outside the plan like the Tertiary hospital, mother and child allowance, flu vaccine and medical outreach.
On procurement the minister said that the MoH has made certain recommendations to the Ministry of Finance which is reviewing the procurement regulations.
For nurses Lyonpo said that the MoH will open a division for them and launch a separate program that will look at their professional capacity development and other issues. She said that many nurses only had a diploma and so an opportunity would be given to upgrade that.
In terms of the emergency the minister said a new inner section for serious patients had already been opened recently and another development is triage to see what kind of help the patient needs.
She said that while the emergency is improving it would require a mindset change from patients too as they would have to cooperate with triage and the emergency staff there who are trained to assess them.
Lyonpo said as part of its outreach program strategic BHUs, Dzongkhag hospitals and others would be upgraded based on its patient load and there would be mobile medical teams to reach remote areas.
She said this is the new approach rather then the old system of promising the same numbers of doctors and equipment in all Dzongkhags when the patient loads are different to the point of some being overburdened and some not even being utilized.
