Tshokey¹, Kelzang²,Tshering Gyeltshen³, Monu Tamang⁴

¹Traditional Medicine Unit, Eusa Hospital, Ministry of Health, Wangdue Phodrang, Bhutan

²Traditional Medicine Unit, Wangdue Phodrang Hospital, Ministry of Health, Wangdue Phodrang, Bhutan

³Traditional Medicine Unit, Kanglung Hospital, Ministry of Health, TrashiGang, Bhutan

⁴Department of Physiotherapy, Central Regional Referral Hospital, Gelephu, Bhutan

Corresponding author: Tshokey, Traditional Medicine Unit, Eusa Hospital, Ministry of Health, Wangdue Phodrang, Bhutan.

Email: tshokey16@gmail.com

DOI: https://doi.org/10.47811/bsj.0011050814

ABSTRACT

Bhutanese Traditional Medicine (Sowa Rigpa) and allopathic medicine are integrated and state-funded in the three-tier healthcare system of Bhutan. Bhutanese Traditional Medicine services are available in all three levels of the healthcare system offering a range of services, from consultations to therapies and drug dispensations. Except for the National Traditional Medicine Hospital in Thimphu, all the centres across the country offer only outpatient services. Out of 81 traditional medicine centres, 55 centres are located at the primary level, serving people in different geographical areas of the country. Despite an increasing number of patients availing the traditional medicine services, the facilities at the primary level continue to face several challenges. The challenges include delayed and disruptive medicine supply chain, lack of an effective and systematic patient referral system, misconceptions and lack of awareness of traditional medicine services and inadequate infrastructure. All of these impede the provision of traditional medicine services in the communities. We recommend a technology-based drug delivery system in addition to resilient production centres, an effective patient referral system in traditional medicine practice by leveraging on the guideline and electronic patient information system, advocacies in the communities to dispel the myths and misconceptions regarding the Bhutanese Traditional Medicine, and adequate and architecturally smart infrastructure. Implementing these solutions could enhance access and utilization of traditional medicine services, leveraging the best use of this important component of the healthcare system.

Key words: Healthcare System; Health Research; Patient Satisfaction; Primary Healthcare; Traditional Medicine services

INTRODUCTION

The World Health Organization identified traditional medicine as an integral part of the healthcare system. The first Global Summit on traditional medicine held in Gujarat, India in 2023 reiterated global commitments, emphasizing the promotion of evidence-based traditional medicine practice to achieve both universal health coverage and sustainable development goals [1].

In Bhutan, both traditional and allopathic medicines are state-sponsored as a constitutional mandate [2]. Bhutanese Traditional Medicine, commonly called Sowa-Rigpa, is part of the country’s intangible heritage. It encompasses spiritual, physical and mental well-being as synergistic elements for patient care. Prior to 2023, the Department of Traditional Medicine Services oversaw these services in the country. After the Health Transformation initiative, Bhutanese Traditional Medicine services, provided through the National Medical Services, offer both pharmacological and non-pharmacological interventions [3]. While inpatient admission is available only at the National Traditional Medicine Hospital in Thimphu, all other centres across the country provide only outpatient services.

Drungtshos and Menpas are the core service providers of Bhutanese Traditional Medicine. The Faculty of Traditional Medicine of the Khesar Gyalpo University of Medical Sciences of Bhutan, is the sole institution responsible for producing traditional medicine human resources [4]. The Royal Civil Service Commission recruits Drungtshos based on their merit ranking in a two-stage Bhutan Civil Service Examination. Meanwhile, Menpas are recruited either through a common written exam or viva voce conducted by the Ministry of Health. As of 2024, there were 58 Drungtshos and 141 Menpas working in the country, constituting 1.19 Drungtshos and 2.64 Menpas per 10,000 Bhutanese [3, 5].

Out of 101,956 patients who availed the Bhutanese Traditional Medicine services in 2022, 1.7% were children below 8 years, 65.6% were aged between 9 – 59 years, and 32.7% were above 60 years old [3]. The disease conditions of patients ranged from mild headaches to chronic neurological conditions. Despite the growing trend in the use of traditional medicine, the traditional medicine centres at the primary level continue to face many challenges, including delays in medicine supply, inadequate advocacy, lack of systemic referrals, and insufficient infrastructure. In this commentary, we highlight the current status of Bhutanese Traditional Medicine at primary healthcare centres and the way forward to address the challenges of delivering holistic healthcare services.

As of 2024, Bhutan’s healthcare system comprises 55 hospitals, 187 PHCs, and 51 sub-posts. Of the 81 Traditional Medicine Units (TMUs) co-located with allopathic facilities in the country, 55 units are situated at the primary level [4]. Those centres across the country offer basic consultations, therapies and medicine dispensations. Therapies include gold and silver needle therapy, bloodletting, nasal lavage, medicated oil compression, herbal steam applications, moxibustion, and cupping. Currently, 8 (13.7%) of Drungtshos and 56 (39.7%) of Menpas in the country work at primary health centres.

CHALLENGES IN SERVICE DELIVERY

Delay in Medicine Supply and Disruptions

The Medical Product Division of National Medical Services procures and supplies the requisitions. The traditional medicines are indented through the Electronic Bhutan Medical Supply Inventory System. As per the Essential Traditional Medicines List 2023, 123 types of medicines are available at the National Traditional Medicine Hospital, 121 at the Regional Referral Hospitals, 100 at the District Hospitals, 64 at the 10-Bedded Hospitals and 61 at the Primary Healthcare Centres [6]. The medicines are collected from the Quantification and Procurement Division located in Thimphu by the respective store in charge of TMUs. For a few units, the delivery of medicines is done by the district hospitals.

TMUs across the country, however, have experienced delays in medicine supply, sometimes extending up to a year, which affects the service delivery. For instance, a defective formulation of a few batches of Agar 35 and Duetse-ngalum medicines in 2023 hampered the services throughout the country. While Duetse-ngalum is an important component in steam therapy, herbal compression and herbal bath, Agar 35 is the analgesic used for suppressing the wind disorders before treating bile and phlegm disorders. It is also used as a post-medication after venesection. The delays in supply of such essential medicines disrupted the service delivery across the country.

Lack of Systematic Data Recording and Referral System

The World Health Organization defines patient referral as a process in which the health workers at one level of healthcare system with inadequate facilities and expertise seek the help of better or differently resourced facilities to provide optimum care to the patients [7]. In Bhutan, the co-location of TMUs with allopathic hospitals has facilitated cross-referrals between practitioners of both fields [2]. Allopathic practitioners refer patients when they judge that patients would benefit more from the Bhutanese Traditional Medicine or when non-life-threatening trasymptoms persist despite prolonged allopathic treatments. On the other hand, Drungtshos and Menpas refer patients requiring an immediate and advanced medical attention to the allopathic doctors.

However, patient referral among traditional medicine centres lacks clarity. From a primary health centre, Drungtshos and Menpas refer patients to higher-level hospitals through phone calls or by informing the patient. The lack of an effective patient referral system in the traditional medicine results in inefficient care and inconsistent patient flow.

Inadequate Advocacy and Misconceptions

Many people are unaware of the availability of traditional medicine services at primary healthcare centres, leading to a lower number of patient visits. For instance, some people painstakingly travel to Thimphu to avail traditional medicine services. Additionally, people perceive that Bhutanese Traditional Medicine impose diet restrictions, especially on meat, alcohol, and eggs. Such misconceptions may divert patients to allopathic medicine.

Invasive therapies are not performed on the 15th and 30th day of the lunar calendar, because subtle energy called La-ney wanders the entirety of the body from big toes to head and vice-versa [8]. The energy movement differs on different days of the lunar month, days of the week and times of the day. On such days or times, any invasive therapies or surgeries carried out are comparatively less effective and sometimes susceptible to failure and death [8]. A study on Buddhist astrological recommendations for surgery reported that only one per cent among 420 participants were aware of the astrological concepts of timing for surgeries [8]. The practice of prohibiting invasive procedures on astrologically inauspicious days is often perceived as an interruption in services.

Lack of Adequate Infrastructure

According to the National Traditional Medicine Professional Service Standard, TMUs at the primary level require at least a consultation room, a dispensing room, a therapy room with wash basins, and an additional room for any other activities related to traditional medical services [9]. However, many TMUs are confined to a single room, limiting the delivery of a range of services and compromising infection control measures. The lack of a proper store room with suitable temperature and ventilation increases the risk of damage to medicines. Additionally, the recent introduction of Sorig Zhiney (Sowa Rigpa-based mindfulness practice) and Luejong (Yoga) in collaboration with the National Traditional Medicine Hospital and the Faculty of Traditional Medicine further underscores the necessity for spacious accommodations.

IMPROVING EFFICIENCY OF SERVICES

An accessible database, resilient production centres, and stringent monitoring mechanisms are necessary for the supply of essential traditional medicines across the country without disruption. While the Electronic Bhutan Medical Supply Inventory System has been incorporated in the traditional medicine settings, collaboration with the allopathic medicine supply system would enhance the timely supply of essential medicines. For example, transporting annual consignments by utility vehicles, as done for allopathic medicine, is recommended. Likewise, timely revision of essential traditional medicine lists is a cornerstone for making essential medicine available at all centres at all time.

An effective patient referral system will enable continuous patient monitoring and provision of safe and effective interventions. The recently developed Standard Treatment Guidelines [10] and implementation of Electronic Patient Information System (ePIS) show a promising avenue for record-keeping and effective referral systems. However, proper and consistent implementation of the guidelines and ePIS in all TMUs is necessary. It also requires proper consultation, collaboration and effective planning among all levels of traditional medicine centres to foster a robust referral system.

The World Health Organization identified advocacy as one of the key strategies for achieving health promotion goals [11]. The traditional medicine practitioners in Primary Healthcare Centres should advocate the services available in the centres through various mediums, including social media, national television and radio, as well as in-person advocacies in the communities. The counter-arguments on general perception of Bhutanese Traditional Medicine being explicitly religion-oriented is required. Although the principles of Bhutanese Traditional Medicine are based on the Buddhist philosophy, it is the blend of science and spiritual healing that includes pathology, physiology and anatomy of human body entailing physical, mental, and spiritual wellbeing. Further, the World Health Organization defines traditional medicine as the sum total of the knowledge, skill and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness [12]

Studies have emphasized the physical environment of the health facilities as the potential factors influencing the patients’ satisfaction [13]. Therefore, an architecturally smart and adequate infrastructure is required to provide all varieties of therapies and ensure easy access for persons with disabilities.

CONCLUSION

Though Bhutanese Traditional Medicine services are available at the grassroots level, challenges in providing services include unreliable and disruptive medicine supply chain, lack of effective referral system, inadequate advocacies and misconceptions about traditional medicine services, and inadequate infrastructure. We have made some pragmatic recommendations to overcome these challenges.

Declarations

Not applicable

Consent to participate

Not applicable

Competing interests

T and MT are members of the editorial board of this journal. T and MT were blinded during the peer review process of this article.

There was no funding for this article.

All public sources of data have been cited in this article.

Conceptualization: T, MT, TG

Data curation, writing – original draft, review & editing:T, K, TG, MT

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