Subarna Akhter, a 31-year-old mother of two from Chuadanga, was diagnosed with gallbladder stones recently.

Doctors were willing to do the surgery, but the family, doubtful of the skills of small town physicians, decided to travel over 200-km to Dhaka for the treatment.

Since the family cannot afford the costs at reputed private hospitals, Subarna and her husband tried tertiary-level public hospitals in the city. But they found out after a few days that they would have to wait for weeks to get the procedure done at such facilities because of the long queue of patients.

"Eventually, we left Dhaka and I got treated in Rajshahi without having to wait for days," Subarna said.

Like the couple, thousands of people go through unnecessary hassles due to what experts say is the absence of a patient referral system.

This also disproportionately increases the number of patients at tertiary-level facilities, they added.

In a proper referral system, a patient first goes to a nearby primary healthcare centre, which, if needed, will send them to more advanced facilities.

This way, advanced hospitals do not have to deal with patients with minor problems. They will treat only patients referred by the smaller facilities.

The system creates a link between the primary, secondary and tertiary hospitals.

A recent study published in the peer-reviewed journal BMC Health Services Research said three out of five patients in the country go to tertiary-level hospitals without being referred there.

It also found that 58 percent of the 822 respondents were unaware of the referral system.

The study was conducted at two tertiary hospitals' outpatient and inpatient sections.

It found that only 41 percent of the patients were referred by other facilities.

In 2014, then health minister Mohammad Nasim introduced a patient referral system in Rangpur.

But it did not work because of a lack of facilities, expert physicians, and staff at primary healthcare centres, officials said.

In 2016, National Institute of Preventive and Social Medicine (NIPSOM), conducted a feasibility study in Rangpur, Kurigram, Panchagarh and Nilphamari for a referral system.

Prof Samiul Islam, director of the institute, said, "An effective referral system guideline should be formulated.

"Doctors have to be motivated and trained. People's trust has to be earned for the system to work."

He added that decentralising specialised health services will also reduce the pressure of patients in secondary- and tertiary-level hospitals.

Unless primary healthcare facilities are improved and there are more specialists, a referral system will frustrate people, he said.

The health directorate took an initiative to introduce a system in Manikganj and Chapainawabganj in 2019. But that too failed.

Syed Abdul Hamid, professor at the Institute of Health Economics (IHE) at Dhaka University, said that the lack of a proper referral system leads patients to often bypass primary care and head straight to specialists, creating a long queue.

Dr Supriya Sarkar, deputy programme manager (hospital) at the Directorate General of Health Services (DGHS), said a directive for the community clinics was made in 2019, but it was not fully implemented.

The health directorate will soon introduce a guideline, he said.

Prof Ahmedul Kabir, additional director general (administration) at DGHS, said, "We are working on creating an effective referral system. The work on digitising patient data is underway."

Ahmedul said poor services in primary facilities were major barriers to the referral system.