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Bhutan: Bhutan Health Profile 2012

2012/02/22

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Bhutan Health Profile 2012

After ascending the throne in 1974 at the young age of 17, The Fourth Monarch, His Majesty King Jigme Singye Wangchuck has skillfully steered the country through unprecedented development. The development partners of Bhutan have often called Bhutan's development documents as "Happiness Documents" as the king has guided the country to strive for "gross national happiness" rather than for mere gross national product. By being a late starter in the modernization process, Bhutan has learned a lot from the experiences of the other countries that are ahead of it.
 
It became evident for Bhutan quite early that for a holistic development of the society, it was essential that development must be both social and economic and that it was necessary to give equal importance to the spiritual, emotional and cultural needs on the one hand and the material well-being of society on the other. It was also recognized that at the heart of society is the individual whose welfare and well-being must be provided by the society and that the economic growth is essential to support and nurture the spiritual and social needs of the community. This has led the country to clearly stipulate that economic growth, while essential, is not an end itself but is one among many means of achieving holistic development. This has led to the declared objective of viewing development as a continuous process towards a balance between material and non-material needs of individuals and society.
 
The concept of health in Bhutan must be seen in the context of the overall development strategy that, as stated just above, defines development as the preservation of spiritual and emotional, as well as economic well being. Therefore, the health sector policy objectives reflect the national ones: equity, social justice, sustainability and efficiency, in the context of preservation of national culture. The long term objective of the health services is to "facilitate, through a dynamic professional health care, the attainment of a standard of healthy living by the people of Bhutan to lead a socially, mentally and economically productive life, and within the broader framework of overall national development, enhance the quality of life of the people in the spirit of social justice and equity".
Till the end of Eighth Plan (June 2002), the focus of health sector has been to increase the accessibility to health care. Basic health care service and essential drugs are provided free of charge to all the patients.
 
food and Nutrition
Nutrition is an integral component of Bhutanese primary health care. The nutritional status of Bhutanese has improved over the years, more significantly for women and children because of an effective network of health care services, increased awareness in health care and growing economic prosperity. However, the overall nutritional status of the population still requires concerted effort from different sectors and agencies to target the probable causes of malnutrition like food shortages, infections, poor dietary habits and child care practices etc.
 
The Royal Government if paying special attention to problems related to nutrition. Several nutrition and micronutrient deficiency studies has been conducted over past decade. In 1999 the national anthropometric study was conducted. The results of the study indicate marked improvement in the nutritional status of the under five children as compared to the 1989 national nutrition survey.
Micronutrient deficiencies like of iodine deficiency disorder is on the verge of elimination. The 1996 IDD study "tracking progress towards sustainable elimination of IDD" revealed Total Goiter Rate (TGR) of 14%, Median Urinary Iodine level of 298 m /L and iodated salt coverage of 82%.
 
Following the 1988 survey, the National Assembly adopted a resolution expressing concern for the nutritional well being of all citizens. Special emphasis was given to the importance of nutrition in development.
 
A more recent survey indicated the continuing problem of food insecurity in Bhutan. This survey, which did not cover the south, much of the east, or remote districts of the north, revealed that 17% of respondents experienced some periods of food shortage. Nearly one-third of these were road workers.
 
Lifestyle
Basically an agrarian society, people still depend largely on back-breaking agricultural activities in the districts. In the main towns, people work in Government and private offices and there is a general lack of physical exercise in most of them.
 
Archery is still the most popular sport although the traditional bamboo bow and arrows are getting replaced by expensive modern spring bows and aluminum arrows manufactured abroad. Football is played in schools and towns from time to time in particular seasons.
 
Rice is the main staple diet followed by maize. Wheat, barley, buckwheat are other food items along with vegetables and meat. Traditionally Bhutanese diet contains more fat from items like pork and butter and most curry items are seasoned with heavy doses of chili. The fat intake is also getting reduced - especially in towns as the people find it difficult to digest fats with the sedentary lifestyle they lead.
 
Tobacco consumption, both chewing and smoking, once very rampant is now on the decline in the face of the strong advocacy and intervention activities that the health sector is carrying out. Chewing doma, beetle nut with a leaf and some lime, is a habit built into the tradition. Most of the formal get-togethers are punctuated with this item. But today this habit is more common with the elderly people although the younger generation too does resort to this habit.
Another hazardous habit of the Bhutanese is drinking liquor. With strong advocacy from the Government, the situation is much improved.
 
Water supply and sanitation
Both rural and urban water supply and sanitation has been treated as one of the country's central development themes by all the Five-Year Plan documents since the 7th Plan. Today the coverage has reached up to 80% as shown in the following figure.
 
Physical infrastructure
Health service is provided through a four-tiered network consisting of a National Referral Hospital, Regional Referral Hospitals, District Hospitals and Basic Health Units. There are 30 hospitals including one hospital for traditional medicine and 160 basic health units. These facilities are supported by 447 out-reach clinics at the community level. Traditional medicines services are available in all the districts.
Health infrastructure expansion took place in the 1970s reaching the peak of expansion activities in the 1980s. In line with the Alma Ata Declaration, the country committed itself to establishing a relevant and cost-effective health care delivery system based on the primary health care approach. Despite the high cost of health care service delivery in a country with a population scattered thinly over the mountainous terrain, Bhutan has managed to establish a fairly uniform spread of Basic Health Units, District Hospitals, and Regional Referral Hospitals.
 
Financial resources for Health
Although only 2.9% of total outlay for the First Plan (1962-1967) was given for health, the Government recognized the importance of the social sectors. The current Government allocation for Health is around 10% of the total outlay, which comes to 4% of the GDP. This is perhaps the highest allocation for health in the Region.
In the past Plans, donors played a significant role in supporting the health sector. However, to reduce the over dependence on donors the Government is now taking steps to bear the major portion of the cost. On an average the Government now bears about 49% of the total outlay.
The main development partners in the health sector are Governments of India, DANIDA, UNICEF, UNFPA, WHO.
 
Human resources for Health
Along with the expansion of health infrastructure, human resources for the Health Sector have also been built steadily over the years. The country still faces shortage of medical personnel with only 109 doctors. Developing medical doctors is still very difficult as Bhutan has to depend on the neighboring countries as Bhutan does not have any institute. Candidates are sent to Bangladesh, India, Myanmar, and Sri Lanka for their MBBS course.
Other categories of middle and lower level human resource is developed by the country itself at the Royal Institute of Health Sciences. This institute that got the WHO's 50th Anniversary Award for Primary Health Care, is the main contributor to the primary health care development in Bhutan in terms of human resource. The institute trains health assistants (HA), basic health workers (BHW), auxiliary nurse-midwife (ANM), general nurse midwife (GNM), assistant nurse (AN), and technicians of various disciplines (laboratory, pharmacy, dental, x-ray, ophthalmology, physiotherapy, operation theatre). With the support of WHO, this institute is now affiliated to La Trobe University in Australia to train nurses at post-basic level.
On the other side, the National Institute of Traditional Medicines trains both full-fledged traditional physicians, Drungtshos and the Menpas to support them.
 
Essential Drugs and other supplies
Bhutan has no pharmaceutical industries and relies on imports for its entire requirement. Traditional medicine is manufactured at the National Institute of Traditional Medicine Services (NIMS) in Thimphu. Although the country succeeds in making the programme self-sufficient in terms of budget after the operationalization of the Health Trust Fund, the country will still be dependent on the outside world for the actual drugs, vaccines and other supplies like laboratory reagents and medical equipment.
Presently the country has one of the best programmes in the South-East Asia Region. With an effective medical supplies management and the systematic drug indentation system, an average of 80% of all essential drugs allocated to hospital and Basic Health Units were found to be available on one particular day in 1998.
As Bhutan is dependent on the outside world for the medicines, vaccines and reagents, quality control in a way is out of hands of the Bhutanese. In this regard, Bhutan relies on WHO collaborating laboratories in the Region for testing the quality of imported drugs and vaccines.

Health policies and strategies

The Royal Government gives great importance to the social sectors- especially education and health. The Government pursues a policy of providing essential health care services free of charge.

In order to sustain achievements in Primary Health Care and reduce the dependency on donors, the Royal Government has initiated the creation of a Health Trust Fund. The total capital for the Health Trust Fund has been initially set at US $ 24 million. As per the Royal Charter of the Health Trust Fund, the Royal Government will match, on a one-to-one basis, any donor contribution to the Fund. The fund will be maintained in US dollars and invested in reliable financial institutions abroad. It will be governed by the Management Board consisting of high-level members representatives from the relevant Ministries and organizations.

This initiative is expected to support the Royal Government's policy of providing free essential health care.

For the purpose of maintaining quality of health care service and protecting the qualified human resource for health, private practice has never been introduced.

As the traditional medicine practiced in Bhutan, Sowa Rigpa, is a systematic field of knowledge, traditional medical care is provided side by side with modern allopathic health care. These two systems are now more or less integrated.

Within the overall long-term objective of the Health Ministry, "attaining a healthy living standard by the people living within the broader framework of the overall development of the country", there has been a shift from expansion of services which was emphasized in the earlier plans to the quality of services which entails setting up of standards at various levels of health care delivery system. Strategies have been developed to reach the un-reached through decentralization of planning and management systems; to strengthen management information system, to develop research and their use which leads logically to one of the Ministry's most important objectives: intensifying human resource development for health and establishing a system of continuing education. To this end, the Ministry has developed the Master Plan for Human Resource as a guide for developing human resource for health.

Intensification of prevention and control of prevailing health problems and dealing with the emerging and re-emerging ones require extra resources and effort and the Ministry has prepared itself in dealing with this problem. Other objectives that have flowed from the past plans are intensification of reproductive health services and sustaining population planning activities; promoting community-based rehabilitation, mental health, and finding innovative means to enhance the mental well-being of the people; and maintaining balance between primary, secondary, and tertiary health care so that the higher levels of service can back up the needs created or problems identified by the lower ones.

With the intentions on health coverage, the Royal Government has not been able to give a legal framework for medical services both to protect the medical practitioners and the patients. Now the Bhutan Medical and Health Council Act has been passed by the National Assembly in 2002. Further, the Medicines Act is being drawn up to regulate the sell of the medicines, drugs and other substances in the country.

Managerial process

The Ministry of Health and Education is headed by a Minister. A Secretary looks after both the Health and Education affairs at policy level. The Health Department is headed by a Director. Please see the organogram in Annexure.

The health services in the districts are directly under the administration of the Dzongdag, district magistrate. The Health Department provides technical support to the districts. District Medical Officers look after the hospitals and District Supervisory Officers look after the primary health care concerns in the districts. The Basic Health Units at the community level are directly under the administration of the District Health Supervisory Officers.

However, in line with good governance policy, the Royal Government has now decided to restructure the Ministry of Health and Education into two separate Ministries.

Organization of the health system

The basis for Bhutan's health care delivery system is the primary health care system starting with the 445 outreach clinics and 163 basic health units at the community levels. The districts have the district hospitals organized under the three Regional Referral Hospitals and one of these Regional Referral Hospitals also serve as the National Referral Hospital.

Patients at the basic health unit level are referred to their respective district hospitals for secondary or tertiary health care. The district hospitals likewise refer to their respective Regional Referral Hospitals and that in turn rely on the National Referral Hospital. As it is not yet possible to have very specialized health care in the country, a good number of cases requiring such health care are referred outside the country.

The healh service system at the district and lower levels depend on the district authorities for their administrative support and on the Health Department at the centre for technical support. The basic health units submit their case reports directly to the District Supervisory Officers who compiles them and submit to the Health Department at the national level. However, the diseases under strict surveillance like HIV, Poliomyelitis, etc. that come under the notifiable category are reported directly to the national level immediately.

Community participation

In order to bridge the gap between the organized health service and the community, the Government trains village health workers who are chosen by the communities themselves. As of 2000, there are 1,327 village health workers who advocate health to the people and who help in bringing the health problem of the people in the communities to the health workers. They are also taught and allowed to dispense a few basic allopathic medicines.

The communities also look after the development schemes like those for drinking water supplies in their own areas. The programme assists the communities by providing them the required training.

Then there are the traditional faith healers, astrologers and religious leaders in the communities. The Ministry also takes the support of these respected people in imparting specific health messages -ranging from the need to take iodized salt to family planning - to the people in the communities along with their routine work.

Health information system

Realizing the importance of information in management, Health Information Unit was established in 1983. Since then the Annual Health Bulletin was compiled on a yearly basis and published. WHO has put in substantial support to develop the Health Information System in the 1990s. During 1999-2000, the information system was reviewed and the Health Information Management System was instituted with support from DANIDA. Presently HMIS is being computerized and experimented.

The basic health facilities have been given standardized reporting forms to report the morbidity, mortality and other health data collected at that level. This is compiled and consolidated every month and submitted to the District Health Supervisory Officers who, in turn, compiles and submits to the national level every quarter. At the national level the Health Information Unit compiles and makes it available to all concerned.

However, the human resource for the Health Information Unit has to be further improved both in terms of expertise and number to make the Health Information System dynamic and helpful for evidence-based planning for the future.

Inter-sectoral coordination

Intersectoral coordination at different levels of the Government is achieved through different ways. At the national level, the Planning Commission coordinates the plans of various development sectors and the Department of Aid and Debt Management of the Ministry of Finance coordinates resource allocation. At the district level, when the plans are implemented, the Dzongdag is the overall head. All the sector representatives at the district level function under the Dzongdag. Thus duplication of efforts is avoided and the actions are coordinated.

Even at the Department and programme level, there are a lot of coordination mechanisms through Policy and Planning Division of the Ministries. Additionally, individual programmes have their own coordination mechanism with other concerned sectors. Malaria programme, for instance, has direct coordination mechanism with the agriculture and municipal departments. Similarly environmental health programme liaises with the National Environment Commission, Municipal Corporations of each district and even the police force. The nutrition coordinates its efforts with the Agriculture, Trade, and other relevant sectors. Further, there are the multi-sectoral task forces that also address the issues that cut across many sectors.

Emergency preparedness

Of the numerous emergency situations, the one that concerns the country most is the traffic accidents. Flash floods and landslides also contribute to the problem. The country being in an earthquake zone, severe earthquake is also read about in its history but it is less frequent. Glacial flood also cause damage to the life and property. A rough study in the recent years revealed numerous glacial lakes that are potentially dangerous to the country. Further, of late the presence of the militants from across the southern border poses an enormous threat to the national peace and security.

In order to deal with all these eventualities, the Ministry of Health and Education has established a rapid response team consisting of several relevant sectors. An emergency medical team further backs this establishment.

Health research

Health research is comparatively new for Bhutan although Bhutan has been a participant to WHO's research consultations in Region. To be able to carry out research for the health sector so that there will be evidence-based health interventions; the country has been building its research unit. The Research Unit was formally established in 1995. The key staffs are still being trained abroad. The unit has played crucial roles in conducting vital studies for health in the recent years. It has contributed in the conducting of the National Health Survey in 2000 and in carrying out the survey on mental health in 2002.

Coming to the area of other kinds of research, the Pharmaceutical and Research Unit at the National Institute of Traditional Medicines conduct research related to indigenous medicines. Further it is also documenting the medicinal plants and herbs that are found in Bhutan.

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