Despite the health care services being free across all three levels of the health care systems, the out-of-pocket expenditure for health care is on the rise in Bhutan. According to the Annual Health Bulletin 2020, the out of pocket payments increased from 11 per cent in 2010 to 20 per cent in 2016. Out-of-pocket payments are expenditures borne directly by a patient. According to international research, out-of-pocket expenditure forms a major barrier to health-seeking behaviour. The poor sections are forced to resort to borrowings or selling assets to meet this expenditure.
Based on the Global Health Expenditure database, out of pocket expenditure declined from 1995 till 2010 but noted an increase from then on in the country. And as per the global health expenditure report 2018, one consequence of out-of-pocket expenditure is a hundred million people pushed into extreme poverty each year.
“The out of pocket expenditure that people incur is having to come here and wait for the appointment and the money that is spent, although we have free health care. And in reality, it is not free because there are many other costs associated with it,” said Dechen Wangmo, the Health Minister.
“For a health system that is supposedly free not only within the country but even referral outside of the country and this to me is very puzzling as to why first of all, of course, there will be some amount of out of pocket payment, but a steady rise and for a system that is supposed to be totally free. A 10% ratio or 20% ratio, I think is a relatively significant amount of money that individual patients are paying,” said Dr Pem Namgyal, the Director, Programme Management with the WHO/South-East Asia Region.
According to the Bhutan Living Standards Survey report 2017, the majority of the health care expenditure was made on rimdro or puja followed by transportation for emergency and non-emergency. However, expenses incurred on rimdro or puja is not included in the out-of-pocket expenditure, as per the national health accounts. The recently held health policy dialogue expressed a need to conduct a broad study to understand the out-of-pocket expenses in the country.
“I think it is important to understand what is contributing to this. So the suggestion is that to conduct a comprehensive study on out of pocket payment to understand who is paying, how much is the out of pocket really because we need clear cut on what is it that we are paying and for what kind of expenditure is it being incurred so that we can look into the system deficiencies where we may be able to rectify that to either sort of hold it steady and ideally to reduce it,” he added.
As reported in the health system review 2017, high transportation costs incurred in availing health services could be attributed to the country’s terrain and in accessing specialised care. For instance, a patient from the eastern or central part of the country prescribed a CT scan has to travel to the national referral hospital. And other reasons could be due to bypassing the nearest health centre to seek consultation at a higher-level health facility.
Sonam Pem
