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Bypassing Primary Health Care in Bhutan: Complex Interplays between Demand and Supply-side Influences

Background: Comprehensive health services delivered through a Primary Health Care (PHC) approach with proper referral to hospital services contribute to equitable access while ensuring health systems efficiency. Yet, designing and enforcing proper referral systems are challenging in developing country context. Bhutan has adequate availability of and accessibility to PHC; a tax-financed free comprehensive package of health services is provided to the entire population through an extensive PHC network. Yet, bypassing of primary care facilities by patients results in underutilization of rural and urban primary health care facilities and overcrowding of hospitals, particularly the National Referral Hospital, affecting the hospital service quality. Several policy options explored by government of Bhutan in response to this issue could not be implemented due to lack of adequate evidence. Hence, it is necessary to understand the factors influencing the bypassing of primary health care facilities in Bhutan to inform appropriate policy reform. This study may also contribute to other developing countries in strengthening their referral systems.

Given these contexts, this paper describes Bhutan’s health systems; PHC in particular, reviews demand- and supply-side factors, both push by PHC facilities and pull by referral hospitals that influence bypassing of PHC facilities, and discuss the complex interplays between these factors. Further, it aspires to identify evidence gaps that require additional research to support improved policy reform. Identify evidence gaps that require additional research to support improved policy reform.

Methods: The synthesis of data from routine health information systems, national health surveys, annual health bulletins, health system review reports, relevant policy documents including unpublished grey literature kept by Ministry of Health, Bhutan, formed the basis for assessment of factors influencing the bypassing of PHC facilities Bhutan. Findings from Bhutan were compared with global experiences through review of published studies on PHC system, referral and bypassing PHC.

Results: A complex interplay of demand and supply side push- and pull- forces appear to influence the by passing of PHC facilities in Bhutan. The rapid rural-urban migration and depleting size of rural communities also indicate a critical influence on under use of PHC facilities However, in absence of adequate data, an in-depth primary research is needed to further assess the complexities to inform effective mitigating policy reform that ensures proper use of PHC facilities, and effective referral to secondary and tertiary hospitals.

Conclusion: In Bhutan, further generation of evidence together with series of intensive evidence-informed policy formulation engaging all relevant stakeholders including the general public at the community level would ensure evidence based policy reform towards efficient PHC system and service delivery


Sangay Wangmo, Walaiporn Patcharanarumol, Tandin Dorji, Kinzang Wangmo and Viroj Tangcharoensathien

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