Physiotherapy services in patient care in Bhutan

Physiotherapy services are integral component of holistic care of patients and are provided in different settings ranging from intensive care units to community settings [1]. Physiotherapists are part of a multidisciplinary team that provide preventive, curative, and rehabilitative care to promote healthy lifestyles, and provide therapy addressing musculoskeletal, neurological, cardiovascular and integumentary conditions [2, 3]. Rehabilitation aims to enhance physical, psychological, emotional, and social well-being for persons with disabilities by giving them opportunities for optimum participation and inclusion in society [2]. Physiotherapists also have increasing roles in acute and critical care units where appropriate therapies have shown to reduce the length of hospitalisation, prevent ventilator-associated pneumonia and physical impairments [4, 5]. Physiotherapy in appropriate settings also reduces the need for pharmacological agents for pain management such as opioids [6].

However, the role of physiotherapy in health systems is poorly understood in developing countries and patients do not have access to services [2]. Rehabilitation is often viewed as a fallback strategy when pharmacological interventions fail and receives minimal priority and resource allocation. For example in Sri Lanka, a country with good basic health indicators and a well-developed critical care system, physiotherapy services are available in only 91 of 100 state critical care units [7]. Though undergraduate training in physiotherapy is provided in Sri Lanka, there is a lack of regulated and systematic postgraduate training for physiotherapists [7]. Physiotherapy is often “linked” to persons with disabilities, which is only a small proportion of its clients [8]. The referral of patients to physiotherapists for assessment and management of musculoskeletal conditions is disproportionate to the number of affected individuals and is often delayed [9]. In South Africa, 90% of individuals with low back pain seen in primary care received pain medicine as their only form of treatment [10]. Likewise, in Ghana, the access to physiotherapy is limited due to out-of-pocket cost to the patients [11]. In Nigeria, clients had poor knowledge about physiotherapy as a form of treatment and patients did not seek physiotherapy services [12].

Generally, human resources constraints in the health sector have been a chronic challenge in many developing countries with gross disparities across income levels. Among the member countries of the World Confederation for Physical Therapy (now World Physiotherapy) in 2018, developed countries had more physiotherapists per 10,000 population: > 20 in Finland, Iceland, Norway and Belgium; 10–15 in Australia, New Zealand, France, and Spain; 5–10 in the United States and Canada; and < 1 in developing countries such as Nepal, Bangladesh, Mexico, Burma, Thailand, and countries in Africia [13] (Fig. 1).

The situation of physiotherapy services in Bhutan is similar to that of many other developing countries. Bhutan is a small lower-middle income country with a population of 0.7 million people located in the Eastern Himalayas. It has a fully government-sponsored free health care system including physiotherapy services. However, amongst many other challenges faced by the health system in Bhutan, physiotherapy services have not yet been recognised as a priority sector and are yet to be integrated into all levels of patient care. This article aims to explore the challenges and opportunities faced by the physiotherapy professionals in Bhutan.

Physiotherapy services in Bhutan were established by an expatriate from Burma in 1984. As of 2021, the Royal Government of Bhutan trains physiotherapists in colleges in the neighbouring countries and offers diploma-level physiotherapy training at the Faculty of Nursing and Public Health, Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu [14]. The physiotherapy sector also receives support in the form of visiting experts from the Health Volunteer Overseas from the US and the Interplast team from Australia.

The physiotherapy department at the Jigme Dorji Wangchuck National Referral Hospital provides in-patient, out-patient, paediatric, hand, and maternal physiotherapy as well as assistive technology services [14]. The in-patient physiotherapy team provides services to the orthopaedic surgery, general surgery, medicine, and intensive care units facilitating early mobilisation and rehabilitation of patients.

In out-patient units, Women’s Health team provides antenatal and postnatal exercise programs. The Hand Therapy team works with patients following hand surgeries in addition to treating other musculoskeletal and neurological hand conditions, and providing splinting services. The musculoskeletal unit works with patients with non-traumatic musculoskeletal conditions such as low back pain, neck pain, osteoarthritis, etc. The neuro-rehabilitation team works with patients requiring long-term rehabilitation; and the paediatrics physiotherapy team works with children requiring physical rehabilitation. Similar in-patient and out-patient services are provided in two other Regional Referral Hospitals while only basic physiotherapy services are available in the district hospitals.

Bhutan is witnessing a rapidly changing demographic and socio-economic profile of the population. With increasing demand and expectation for better health and well-being, the country needs an overall strategic framework and policy to deliver to the present and future health needs. We suggest that one component of the framework should be dedicated to proper planning on the human resources for physiotherapy services with the scope of expansion of services, making it accessible to more people and specialisation of physiotherapists to provide better quality care. Attrition of physiotherapy professionals is aggravating the already inadequate human resources in the country. Therefore, innovative retention strategies need to be implemented [17].

The country needs a dedicated rehabilitation centre to cater to the specialised needs of patients requiring both short- and long-term rehabilitation services. There is a need to integrate physiotherapy services in patient care across all disciplines so that proper planning of care and follow-up can be made. Integration of physiotherapy services at the primary care level has a good scope in bringing about improvement of quality of life of older adults residing in villages and those who are unable to access hospitals.

There is a need to create awareness about the utility of physiotherapy and rehabilitation services through national television and print media, social media, inter-professional workshops, and maintenance of dedicated webpage to debunk common myths and provide evidence-based information.

The demand for physiotherapy and rehabilitation services is on the rise in developing countries. However, many countries including Bhutan lack proper planning of human resources, infrastructure and policy framework to incorporate physiotherapy services into patient care at hospital and primary health care levels.