Assessment of Governmental-Funded International Referral Program to Treat Patients

ABSTRACT


INTRODUCTION
Globally, increasing numbers of patients travel to various destinations worldwide for medical/surgical care. Driven by a number of motives, these "medical tourists" seek solutions for their medical problems at affordable prices in other countries (1) . In Iraq, international referral programs have been adopted, governed by specific inclusion measures.
Although common barriers to successful referral are generally known, the relative significance of these barriers should be assessed in each country or region to guide the design of targeted appropriate interventions to improve referral outcome (2) .
On the other hand, the country of referral destination needs also to be evaluated according to specific criteria, such as economic conditions, and regulatory policies. Also, costs, hospital accreditation, quality of care, and physician training impact the choice of healthcare facility. These factors must be considered to evaluate the effectiveness and efficiency of the referral programs (3) .
The absence of evaluation of the international medical referral programs leads to unmet needs. Especially, when this is added to the common health systems problems, when highly fragmented underfunded healthcare systems already face many challenges. Also, international referral and health inequities shape each other in low-and middle-income countries (4) . Therefore, such evaluative efforts need to be Corresponding Author: Alaa H. Abed carried out in order to plan for and support an integrated health system.
A governmental international medical referral program has been adopted in Basra Governorate since 2013. Till the time of this assessment more than 4000 patients had been referred to foreign countries, Turkey, Iran, and India. The reasons for choosing these countries over others have been reasonable health services costs, the presence of direct flights between Basra and the cities in which the hospitals are located and ease of obtaining a visa for Iraqi citizens.
A comparative or descriptive evaluation of the referral process of this large number of referred patients had not been conducted before. This has motivated the researchers to conduct an evaluative study of the program's inputs and outputs in order to present recommendations to improve the results of referral.
The main aim of this study was to use the output/ outcome of an international referral program to address the shortages in a national medical care system.

METHOD
The research data were collected from the database of the Committee for the Treatment of Patients Outside Iraq at Basra Governorate office. It contains all the data of patients whom were referred outside Iraq for the purpose of treatment. The researchers received electronic version of the database and after studying it, they were fed into an electronic statistical package and analyzed in percentages. Basically, they were classified, coded and divided according to age group, gender, specialization and other divisions needed for the purpose of research.
Ethically, the researchers followed anonymity, privacy, confidentiality, and honest recording of data principles. An ethical approval was obtained from the Research Ethics Committee at the Iraqi Association for Medical Research and Studies, decision number 47 in December 5 2021. Moreover, the study was carried out in accordance with the Helsinki Declaration Principles. (1) shows that the gender of beneficieary patients was nearly equally distributed.

Figure (1): Distribution of the patients according to gender
According to age distribution, it is clear in Figure (2) that about 59.42% of the beneficiaries were children.

Pediatric Patients Adult Patients
It is clear from Figure (3) that the most frequent reason behind the referral program were the open-heart surgery including cardiovascular diseases followed by ophthalmological diseases that needed therapeutic surgeries.

Figure (3): Distribution of the referred patients according to the type/ system of the disease
Most of the referred patients within the government adopted program, were referred to Turkey, when, in 94.80% of the referred patients, the targeted intervention was successful ( Figure (4)).   Inoperable referred case rates ranged from 0.1% to 0.3%. These included patients with cardiovascular diseases, patients with neurosurgical diseases, patients with orthopedic diseases, and patients with urosurgical diseases. Patients who were found not fit for surgery due to pathologies other than the disease of concern were mostly those who were referred for organ transplantation surgeries (Figure (6)).

Figure (6):
Patients who were found not fit for surgery due to pathologies other than the disease of concern distributed according to the type/ system of the disease Patients who refused, by themselves or by their chaperon parents, to be managed after arrival to the hospital were those who needed neurosurgery, pediatrics needed hematological intervention or cardiovascular surgeries, patients needed orthopedic surgeries, or those needed general surgical intervention. Those who were assigned as their conditions did not need surgical intervention, after their arrival to the referral hospital, were patients referred to undergo orthopedic, neuro, cardiovascular, organ transplantation, and micro surgeries and hematological and radiological interventions.

DISCUSSION
The international medical referral is a widely used approach to help patients with complicated cases receive effective The nearly equal distribution of beneficiearies gender may refer to that there was no gender bias in selecting patients and the main determinant of selection was the diagnosis, severity of disease, and inability to manage it inside the country. This can be one of the positive points of the program, when it may point out equity and justice.
The high percentage of children, mostly with cardiovascular diseases; patients who needed open heart surgery; and ophthalmological diseases among those referred may be due to shortage in qualified medical doctors and/or supportive staff to manage such conditions; or shortage in well-equipped medical facilities. It may also refer to a high incidence of the diseases to a rate more than what the health system capacity to deal with.
Turkey was the referral destination of most referred patients when compared to India, because of the short-time direct flights and availability on daily basis, in addition to good weather, availability of Halal food, and high patient preference. Regarding IRI, the contract was only for ophthalmological surgeries.
The presence of patients who refused to be managed after arrival to the hospital may indicate that there was a noncompetent level of patient satisfaction after arrival and/or condition assessment before the referral decision was made. The 94.80% success rate among the referred patients may generally refer to acceptable standards to nominate the needy disease conditions and acceptable standards to refer patients. These success rates for most of the surgical interventions, according to the category, were comparable to figures found in other parts of the world. For example ophthalmological surgeries in this study had a rate of 84.05% compared to 76.5% in Japan (5) . Orthopedic surgeries had a rate 98.7%, compared to 93.84 -98% in USA (6) . The neurosurgeries had a rate of 74.94% compared to 97% in the UK with 100% early survival compared to 3% death in same study (7) . Bone marrow transplantation success rate was 73.33%, early procedural death was zero compared to the figures of the European society of hematology of 1-year survival is 65.6% (8) . Liver transplantation showed 50% success and 2.5% mortality, compared to the U.S figure of only 8.9% failure and 3% death; this can mostly be linked to the advanced clinical state of the referred patients of this transplantation category (9) . Open heart surgery showed a greatly lesser figure of procedural death than what was found in European multicenter study 0.08% (10) with a success rate of 90.03%.
The rate of deaths occurred in some referred patients; the inoperable referred case rates; those who were found not fit for surgical interventions; and those who were assigned as being in no need for surgical intervention after their arrival to the referral hospital may arrow to a non-strict procedure, although it is very small. The reasons for not performing a number of surgeries were for purely scientific and technical reasons, such as not undergoing open heart surgeries due to increased blood pressure in the pulmonary artery and Eisenmenger syndrome due to the delay in receiving treatment; the presence of non-feasible corneal replacement surgeries because of damage to the optic nerve or damage to the retina; the operations were not feasible due to severe injuries to the spinal cord and paralysis that cannot be repaired surgically; the surgeons were not able to conduct operations for some widespread cancerous tumors because of their danger to the patient's life; the co-existence of multiple health problems that prevented them from performing complex orthopedic operations; and not having marrow or liver transplants due to problems matching donor tissues.

CONCLUSIONS
Generally, the program well-followed the principles of medical care, patient's beneficence, non-maleficence, respecting patient's autonomy, justice and equity. The high treatment success rate among the referred patients means that there were some gaps in the Iraqi health system in the fields of pediatric CVS diseases, bone marrow and liver transplant and ophthalmology should be fixed. These gaps include shortage in qualified resources in Iraq. The program faced 2 obstacles, the loss of continuity due to intermittent funding and absence of special system for follow up of referred cases after return to Iraq.

RECOMMENDATIONS
Although international medical referral is a widely used approach, even by developed countries, there is an urgent need for funding to train the medical staff and upgrade the facilities in Iraq to be able to restrict referral.