WHO Country Cooperation Strategy Bhutan 2009–2013 docx

This WHO Country Cooperation Strategy CCS 2009–2013 reflects the medium-term vision for the World Health Organization’s collaboration with the Royal Government of Bhutan RGoB in support

WHO Country Cooperation Strategy

Bhutan 2009–2013

© World Health Organization 2010

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WHO Library Cataloguing-in-Publication data

World Health Organization, Regional Office for South-East Asia

WHO country cooperation strategy Bhutan: 2009-2013.

1 Health Status - statistics and numerical data 2 Delivery of Health Care

3 Health Planning 4 International Cooperation

5 Strategic Planning 6 Bhutan.

ISBN 978-92-9022-391-7 (NLM classification: WA 540)

Foreword v

List of acronyms vi

Message from the Honourable Minister, Ministry of Health, Royal Government of Bhutan viii

Executive summary ix

1 Introduction .1

2 Health and development challenges .3

2.1 The country and the people 3

2.2 Stage of development 4

2.3 Health situation 5

2.4 Health systems 10

2.5 Major issues and challenges in the health sector 13

3 Development cooperation and partnerships: Technical assistance, aid effectiveness and coordination .16

4 Past and current WHO cooperation 18

4.1 WHO country cooperation overview .18

4.2 Operational aspects of the implementation of the Strategic Agenda 18

5 Strategic Agenda for WHO cooperation 23

5.1 Guiding principles for WHO at the country level .23

5.2 Strategic Priorities and main focus for WHO cooperation 23

Strategic Priority #1 24

Strategic Priority #2 24

Strategic Priority #3 25

Strategic Priority #4 28

Strategic Priority #5 29

Strategic Priority #6 33

5.3 Strategic approaches based on WHO Core Functions 33

6 Implementing the Strategic Agenda 34

6.1 The Country Office 34

6.2 The Regional Office and headquarters 35

References 36

Annexes 1 Ministry of Health Organigram 37

2 Reference tables .38

3 Alignment of WHO Strategic Agenda/directions with the Tenth Five Year Plan for the health sector and UNDAF outcome 42

This WHO Country Cooperation Strategy (CCS) 2009–2013 reflects the medium-term vision for the World Health Organization’s collaboration with the Royal Government

of Bhutan (RGoB) in support of its national health strategies

Bhutan has a robust and functional primary health-care delivery system Over the years, the Royal Government of Bhutan has taken several measures to improve the health infrastructure, human resource development and preventive health programmes These initiatives have resulted in significant improvement in the health outcomes and indicators However, in the context of the present demographic and epidemiological transition, Bhutan will face and need to address new health issues and challenges in the coming years

The government’s Tenth Five Year Plan reflects these concerns and priorities which are expected to be taken up during 2009–2013 Strategic objectives and agendas identified in the CCS have been formulated in line with these priorities identified in the Tenth Five Year Plan while harmonizing with the work of other UN organizations and agencies and development partners

The development of the CCS has also taken into consideration these aspects of the plan and a thorough analysis of health care trends and situations have been carried out Further, a wide range of consultations and dialogues has been conducted with the RGoB, UN agencies and other development partners in Bhutan which resulted in the formulation of Six Strategic Approaches in the CCS

The Ministry of Health, RGoB and the WHO Country Office for Bhutan played a central role in the development of this CCS Extensive support and assistance was provided

by the WHO Regional Office for South-East Asia (SEARO) and WHO headquarters in order for us to come out with this comprehensive strategic document

I have the pleasure of presenting this Country Corporation Strategy document to the RGoB as well as to all our development partners This Strategy Document reflects our collaborative efforts in developing and nurturing the Health Service of Bhutan WHO will continue to work in collaboration with the Royal Government of Bhutan to further the attainment of Gross National Happiness for the people of Bhutan

Dr HSB Tennakoon WHO Representative to Bhutan

Foreword

AC assessed contribution

AEFI adverse effects/events following immunization AFP acute flaccid paralysis

AI avian influenza

AIDS acquired immune deficiency syndrome

ARI acute respiratory infection

BHTF Bhutan Health Trust Fund

BHUs basic health units

CAP consolidated appeal process

CCA Common Country Assessment

CCM Country Coordinating Mechanism

CCS Country Cooperation Strategy

DD diarrhoeal diseases

DOTS directly observed treatment, short-course

DRA Drug Regulatory Authority

DVED Drugs, Vaccines and Equipment Division

EmOC emergency obstetric care

GATS General Agreement on Trade in Services

GAVI Global Alliance for Vaccines and Immunization GDP gross domestic product

GEF Global Environment Facility

GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GNH Gross National Happiness

GNM general nurse midwife

GPW General Programme of Work

GSM Global Management System

HA health assistant

HIV human immunodeficiency virus

HMN Global Health Matrix Network

IDD iodine deficiency disorder

IHR International Health Regulations

IMCI Integrated Management of Childhood Illnesses IMR infant mortality rate

IT information technology

JE Japanese encephalitis

MDGs Millennium Development Goals

MDR multidrug resistance

MMR maternal mortality ratio

MoH Ministry of Health

List of acronyms

NHA National Health Account

NIPPP national influenza pandemic preparedness plan

NITM National Institute of Traditional Medicine

NPO National Professional Officer

ORCs out-reach clinics

PHC primary health care

PRSP Poverty Reduction Strategy Paper

RB regular budget

RGoB Royal Government of Bhutan

RIHS Royal Institute of Health Sciences

RSTA Road Safety and Transport Authority

RWSS rural water supply and sanitation

SARS severe acute respiratory syndrome

SEAR South-East Asia Region

SEARO Regional Office for South-East Asia (of WHO)

STI sexually transmitted infections

SWAp sector-wide approach

TB tuberculosis

TRIPS Trade-Related Aspects of Intellectual Property Rights

UCI universal child immunization

UN United Nations

UNDAF United Nations Development Assistance Framework

UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

VC voluntary contribution

VHW village health workers

WFP World Food Programme

WHO World Health Organization

WR WHO Representative

WTO World Trade Organization

Message from the Honourable Minister, Ministry of Health, Royal Government of Bhutan

The Kingdom of Bhutan is a fascinating, landlocked and mountainous country nestled in

the eastern Himalayas, bordering China to the north and India to the south Partly due

to its difficult geographical boundaries, Bhutan has always preserved its independence

and its rich and unique cultural heritage has mostly remained intact over the ages The

Bhutanese have developed a strong sense of common identity despite a mosaic of

cultures with extraordinary ethnic and linguistic diversity The kingdom has recorded

impressive achievements on many fronts over the last four decades and is one of the

few countries where macroeconomic progress in terms of per capita GDP growth as

well as the physical infrastructure in terms of improved communications and electrical

connectivity has been matched by the social sector with provisions of free education and

free health care, safe drinking water and basic sanitation Under the visionary leadership

of its monarchs, Bhutan has challenged many traditional concepts of development

with its unique development philosophy based on the principles of Gross National

Happiness The monarchs’ long-term vision of democratization and decentralization

has been implemented through a peaceful step-by-step devolution of power to the

people that culminated in 2008 with the adoption of the Constitution of the Kingdom

of Bhutan, making Bhutan the world’s youngest democracy

Since the early 1960s the health status of the Bhutanese population has dramatically

and consistently improved In 1978 Bhutan signed the Alma Ata Declaration and

introduced the primary health care approach to build a modern health system in

harmony with its traditional health services, including the manufacturing of traditional

herbal medicines, along with a strong emphasis on community participation Village

health workers are the link between the communities and the institutions of health

system With over 90% health coverage with basic services, 90% access to clean drinking

water and 88% basic sanitation coverage there has been a spectacular decrease in

mortality and morbidity in recent years Life expectancy at birth has risen from 33

years in 1960 to 66 today

WHO has a long-standing collaboration on health with the Royal Government of

Bhutan In 2000 Bhutan started developing its first Country Cooperation Strategy A

remarkable improvement was witnessed in the health sector during the 2000–2008

Bhutan is now close to achieving many of the health-related MDGs and has opted for

“MDG-plus” during the Tenth Five Year Plan aiming to reach the MDGs and beyond

by 2015 and also achieve other priority health targets

While there has been considerable progress in health development, the country

is still facing major challenges in terms of:

Executive summary

Public health policy development:

 Though most of the elements of the National Health Policy are in place they are scattered and compartmentalized

Further strengthening of the health system:

(i) the improvement of the health information system; (ii) the identification and implementation of a sustainable health financing system to cope with the rapidly rising health costs along with the rise in demands of the better educated population for more sophisticated services; (iii) the promotion of operational research in health; and (iv) steadily reaching out to the unreached, who constitute 5% to 10% of the population

Further reducing child health mortality, especially its perinatal component



and maternal mortality: Acute respiratory infection (ARI) and diarrhoeal

diseases (DD) continue to be the major causes of morbidity despite tangible improvements in community water supplies and sanitation facilities Bhutan has made tremendous progress in reducing maternal mortality by half in the last 10 years, but current maternal mortality rates (estimated in 2007 at 255 per 100 000 live births) are still high

Communicable diseases prevention and control:

and completion of treatment using the DOTS strategy have significantly improved in Bhutan However, greater efforts are required to prevent and control multidrug resistance (MDR) Although Bhutan is considered a low-prevalence country for HIV/AIDS with the epidemic mainly prevalent through heterosexual transmission in the 15–24-year age group, it is likely that there are undetected infections in the population Cases of malaria have decreased significantly over the recent years but there are still focal outbreaks causing morbidity and mortality With the first outbreak of dengue in Bhutan in 2004, prevention and control activities for this and other vector-borne diseases such

as malaria, Japanese encephalitis (JE), kala azar and leishmaniasis need to be intensified

Noncommunicable diseases prevention, care and support:

double burden of disease with a rising trend of noncommunicable diseases The response of the primary health care model needs to consider this rising trend and the associated risk factors Commendable efforts have focused on

diseases and substance abuse is a potential problem in the country

Community-based mental health programmes require more resources to intensify activities,

and lack adequately trained mental health professionals Injuries are also an

increasing cause of morbidity in Bhutan Disabilities, especially related to vision

and hearing, are a growing concern in the country and programmes are needed

to strengthen rehabilitation, especially at the community level Oral health

programmes require strengthening, especially through primary oral health care

and the school health programme

Promotion of healthy environment:

expand its promotional efforts to control pollution in urban areas and homes

A proper assessment of occupational hazards, especially in industries, needs to

be carried out to initiate preventive and management measures A multisectoral

approach is needed to strengthen and ensure food safety New concerns are

emerging with regard to climate change and its influence on health, especially

the risk of glacial lakes melting Climate change may also alter the ecosystem

leading to a spurt in internal migration and affecting the availability of plants

used for traditional medicines

Bhutan has achieved impressive results in terms of water supply and basic



sanitation coverage The current challenge is to ensure the functionality of

existing water systems, the quality of water, as well as to expand facilities to

reach the unreached and achieve universal water coverage, which usually is

expensive and requires new approaches Assessments may also be required

regarding the use of sanitary facilities

Emergency preparedness and response – National Influenza Pandemic



Preparedness Plan (NIPPP) and implementation of the International Health

Regulations (IHR) 2005: Bhutan is a country prone to natural disasters since it

is located in a highly active and fault-prone seismic area In addition, climate

change increases the risk of glacial lakes melting and overflowing Many

activities conducted under the avian influenza workplan are common to IHR

implementation This should offer opportunities for resource mobilization for

IHR implementation and will strengthen the capacity of the country to deal

with epidemic diseases, including avian influenza

The present Country Cooperation Strategy (CCS) is based on the WHO guiding

principles for work at the country level, in line with the principles of ownership,

alignment and harmonization in accordance with the 2005 Paris Declaration on Aid

Effectiveness which was reaffirmed in the Accra Agenda for Action It is firmly anchored

in the country’s unique social, cultural and spiritual development system based on the

Gross National Happiness philosophy that gives the highest priority to the people’s

physical, mental and spiritual well-being within a safe and secure environment This CCS

is a tool that will guide the entire WHO Secretariat’s work in Bhutan It aims to create

a flexible dialogue platform to work with all partners in health at the country level

As Bhutan incorporated in its Constitution the mandate for the State to provide free basic health care to each Bhutanese citizen, WHO is aligning its cooperation in the 2010–2013 cycle with the priorities of the Tenth Five Year Plan (FYP) through the following six Strategic Priorities, aligned with its core functions, that form the Strategic Agenda of the CCS

The main focus of cooperation is identified under each of the Strategic Priorities, which are as follows

Strategic Priority 01: Support the review, strengthening and

consolidation of health policies into a National Health Policy

Support the development of the National Health Policy document



Strategic Priority 02: Support strengthening the process of

development of human resources for health

Revision of the Human Resources Development Master Plan for Health based



on national health priorities

Key support to the implementation of the Human Resources Development

towards universal coverage

Expanding the roles of the community in supporting the health system



Research to support the health system



Strategic Priority 04: Foster the improvement of maternal health, child

health and nutrition according to the MDGs 3, 4, and 5

Improvement of the nutritional status of the population



Further reduction of child mortality and improvement of child health

Strategic Priority 05: Help reduce the burden of disease through key

interventions focusing on Health Promotion and risk factors with a

promotion and behaviour changes, and support for mental health

Ensuring a healthy environment (water, sanitation, food safety, occupational



health and climate change)

Emergency preparedness and response, including the reduction of the



vulnerability of health facilities

National Influenza Pandemic Preparedness Plan (NIPPP) and implementation



of the International Health Regulations (IHR) 2005

Strategic Priority 06: Enhance partnerships and resource mobilization

The Country Cooperation Strategy will guide the entire gamut of WHO cooperation

with the Kingdom of Bhutan during the period 2009–2013 The WHO Country Office

will use this flexible instrument to guide its operational planning and mobilize the

necessary technical expertise from its Regional Office as well as from Headquarters

and other sections of the Organization WHO will also contribute to disseminate the

unique health achievements made by the country

Bhutan’s unique environment, culture, and its preserved way of living that carefully

contribute to “Gross National Happiness” are attracting the world’s attention The

country can play a special role in contributing to shaping the regional and global agenda,

and in exporting best practices and knowledge in specific domains such as the integration

of traditional and allopathic medicine, the development of herbal medicines, and the

successful development of health systems, based on primary health care with specific

emphasis on community participation

1 — Introduction

Bhutan has officially planned and implemented two rounds of the Country Cooperation Strategy already although none of these documents were published The first round was prepared in early 2000 and was used as a guideline for the formulation of the 2000–2001 and 2002–2003 workplans for the country The second round was prepared

in early 2003 and that formed the framework for the World Health Organization’s work in Bhutan during the 2004–2005 and 2006–2007 biennium Those rounds of CCS were prepared by teams consisting of representatives from WHO headquarters, the Regional Office for South-East Asia and the Bhutan Country Office in consultation with the Ministry of Health

Both WHO and the Royal Government of Bhutan felt the need for another revision the CCS because there had been several changes both at the global level and in the country since the previous round

As WHO entered into its 11th General Programme of Work (GPW) from 2006 incorporating the new global health agenda based on the changing health situation, its priorities changed Such priority shifts, too, had to be incorporated in the CCS that forms the framework for WHO’s work at the country level

For the country, the latest population figures and other key development indices were firmly established by the 2005 National Population and Housing Census Prior

to 2005, the population figures were not authenticated and disaggregated data for population was not available for the different age groups and districts The 2005 census gives reliable figures that help in better assessment of the situation and planning

Secondly, there have been major changes in the political arena over the last few years The National Constitution of Bhutan was drafted and the country adopted the democratic system beginning with the formation of political parties during 2007, followed by elections in 2008 The Fourth Druk Gyalpo abdicated and handed the throne to his son, the Fifth Druk Gyalpo An office has opened for public accounts at the national level and corruption watchdogs have been put in place and the auditing system bolstered All these developments will have a bearing on WHO’s work in this country

Thirdly, there have also been marked improvements in the health status of the country Although the major priorities still remain the same, there have been a shift in

other priorities for health For example, the Millennium Development Goals (MDGs) have now become important considerations for planning, and other priorities have also emerged after review of the health sector’s performance during the Ninth Five

Year Plan (2002–2007), but due to transition of the Government, the Ninth Plan now ends on 30 June 2008 instead of 30 June 2007.

Fourthly, up until the Eighth Five Year Plan (1997–2002), the country was more concerned with expansion and coverage of health services Quality issues have become more important starting with the Ninth Five Year Plan (2002–2008) The Tenth Five Year Plan is now concerned with reaching out to the yet unreached and ensuring the quality of services Reaching the last pockets of the unreached population would cost considerably more and balancing cost efficiency against coverage and quality while

at the same time ensuring sustainability is going to be more difficult than before All these national concerns also need WHO consideration since it will be one of the major contributors to national health in the Tenth Plan

Further, the macroeconomic initiative has highlighted the need to plan health interventions focusing on the poor During the Tenth Plan, the Ministry of Health plans

to allocate more resources to the districts than in the past This entails capacity-building

in the districts to cope with additional work and funds

Finally, the Tenth Five Year Plan (1 July 2008 to 30 June 2013) will be the first development plan to be implemented by the new democratic government Hence, the need to develop a viable cooperation framework during this particular Plan period

is viewed as crucial for WHO

In view of all this, the CCS for Bhutan had to be formulated afresh to take into account the changing priorities and provide a strong framework for WHO and the Government of Bhutan to cooperate and work for the people during the early years

of representative government

The CCS discussion process was initiated with the visit of a technical staff from WHO SEARO in December 2006 This was followed by the preparation of a draft CCS document by the WHO Country Office through extensive consultations with WHO SEARO, headquarters and resident offices of UNDP, UNICEF, UNFPA, WFP on the one hand and the Ministry of Health and the Netherlands Development Organization (SNV), in the light of the Tenth Five Year Plan, on the other hand

2 — Health and development challenges

2.1 The country and the people

Bhutan consists of 20 districts lying on the south-facing slopes of the eastern Himalayas Hence the topography is rugged with altitudes ranging from that of the Indian plains

to heights of over 24 000 feet Health problems ranging from tropical diseases to

respiratory illnesses from the cold climate have been recorded in the country, which has a total population of 672 425 (2005 census)

Till the Population and Housing Census conducted in 2005, the population of the country was only based on estimates The 2005 census revealed the calculated total population of 672 425, which includes 37 443 persons with a non-permanent residence

Figure 2.1: Population pyramid, Bhutan 2005

Source: Population and Housing Census of Bhutan, 2005.

Per cent of population

The census calculated the population growth rate at 1.3% as indicated in the age pyramid (Figure 2.1) showing a decrease in the number of births over the last 15 years However, 46 per cent of the population is aged between 5 and 24 years indicating that health and development efforts need to intensify support for children, adolescents and the young The census calculated life expectancy at 66.1 years, which was a dramatic increase since 1960 when life expectancy was only 37 years

2.2 Stage of development

The overall education level of the people has improved over the years The 2005 National Population Census revealed a literacy rate of 69.1% for males and 48.7% for females, with a higher literacy in urban areas GDP growth has averaged 7.0% per annum since 1980 However, the Bhutanese economy is fragile and highly dependent

on the hydropower industry Between 1980 and 2004, this industry was the major contributor to GDP growth although agriculture remains the source of income for the majority of the population

Rural electrification has led to an increase in power-intensive industries Besides industry, tourism also plays an increasingly important role in the country’s economy This sector not only generates foreign exchange but also has employment opportunities for the educated youth The number of tourists visiting the country has been increasing rapidly from 6300 in 2003 to about 13 600 in 2005 The government intends to promote this sector in the years to come

In 2007, net primary school enrolment was 83.7% with gender parity with 85.4%

of those enrolled in grade 1 completing grade 7 (MDG book, p 40) This has led to a rapid increase in the number of educated graduates not yet matched by employment opportunities both in the public and private sectors The national unemployment rate increased from 1.8% in 2003 to 2.5% in 2004 The 2005 census calculated the unemployment rate at 3.1% for ages 15 years and above This is a grave concern as unemployed youth may engage in activities that jeopardize their own health and welfare

as well as that of other people

In 2007 it was also estimated that 23.2% of the population lived below the poverty line (MGD book, p.30) and Bhutan’s Tenth Five Year Plan targets a reduction of the same to 15% by 2013 However, there is a considerable gap between urban and rural areas as well as different regions of the country as seen in Table 2.1 It is estimated that 98% of the poor live in rural areas (MDG book, p 35) The poverty rate in 2004 increased markedly across the country from west to east While the poverty rate in the western region was 19%, it increased to 30% in the central region and to half of the population (49%) in the eastern region

Table 2.1: Quantitative indicators of poverty

Poverty rate (% of people)

Poverty rate (% of households)

Poverty gap index

Severity index

Table 2.2: Overview of major trends revealed by the four national surveys

Crude birth rate (per 1000 population) 39.0 39.9 34.1 20.0Crude death rate (per 1000 population) 13.0 9.0 8.9 7.0Population growth rate in % 3.0 3.1 2.5 1.3Infant mortality ratio (per 1000 live births) 103.0 70.7 60.5 40.1Under-5 mortality rate (per 1000 live births) 162.0 96.9 84.0 61.5Maternal mortality ratio (per 100 000 live

births)

770.0 380.0 255.0 NA

Births attended by trained health staff NA 10.9 23.6 49.1

* Population & Housing Census 2005

Bhutan’s Tenth Five Year Plan places considerable importance on the achievement

of the Millennium Development Goals (MDGs) Considerable progress has already been made towards achieving the MDG targets for the health sector, and Bhutan has targeted to go beyond the MDG targets during the Tenth Five Year Plan The MDG plus targets include other priority indicators for health

The causes of death for 2005 (Figure 2.2) show that Bhutan is clearly experiencing

an epidemiological transition with a reduction in deaths due to communicable diseases Only about a quarter of deaths are caused by communicable diseases while cancer and heart diseases account for 31% of deaths Accidents and other related causes are responsible for about 18% of deaths As with other countries in this stage of epidemiological transition, mortality due to noncommunicable diseases and injuries is likely to increase in the coming years while efforts to control communicable diseases must be sustained

Health of infants and children

The reduction of infant and under-5 mortality rates over the last 15 years has been impressive with the country’s infant mortality rate and under-5 mortality rate at 40.1 and 61.5 respectively in 2005 However, these rates are not uniform throughout the country Table 1 in Annex 2 shows that the districts of Samdrupjongkhar and Trashigang have an IMR above 60 Under-5 mortality rates are also about 80 in these two districts along with Chukha This indicates that further reduction in mortality rates will depend

on improving services to select specific districts and areas

Figure 2.2: Causes of death in 2005 (excluding 33% other causes)

Cerebro-vascular diseases other circulatory diseases common cold pneumonia alcohol liver diseases Other kidney, UT/Genital Disorders pregnancy related Injuries & trauma

Source: Annual Health Bulletin 2009

Reducing infant mortality entails making further concerted efforts at closing the knowledge, attitude and behaviour gaps in safe hygienic practices at birth, better nutritional and improved sanitation and hygiene In addition, it appears that a majority of

infant deaths occur during the first month after birth, which emphasizes the importance

of interventions to reduce neonatal mortality

Reproductive health and safe motherhood

Despite the tremendous achievements made in improving maternal health, the maternal mortality ratio (MMR) still remains high The primary health-care system has resulted in

high coverage of antenatal care (ANC) Table 2 in Annex 2 shows that 71% of pregnant women have at least three ANC visits, although coverage is not even The districts of Dagana and Trashiyangtse less than 50% figures for the ANC visit

However, the most important factor going against the reduction of MMR is the considerable distance to health-care facilities and the varying coverage of deliveries assisted by health professionals In 2007, only 51% of deliveries were assisted by health professionals and this rate was below even 30% in Lhuentse and Trashiyangste districts The Ministry of Health has attempted to increase the number of women who go to

health facilities for delivery While the overall rate of deliveries in health facilites was 46% in 2007, six districts had rates of less than 20% of the same Increasing deliveries

in health facilities for these districts will be a challenge for the health system

The population pyramid emphasizes the fact that Bhutan has a young population with the majority in the reproductively fertile age groups Total fertility rate is on the decline but measures need to be continued to prevent unplanned pregnancies In addition, important reproductive health diseases, such as cervical cancer and sexually transmitted diseases including HIV/AIDS, are an increasing risk to reproductive health These require appropriate health promotion efforts and programmes focused on them

Communicable diseases

While communicable diseases still remain a cause of morbidity and mortality, there has been steady improvement over the last 20 years Tuberculosis cases have dropped from 4232 cases in 1990 to 874 in 2007 Malaria remains a problem especially in the districts bordering India, although the number of cases has dropped from 22 126 in

1990 to 793 in 2007

Sexually transmitted infections (STIs) have yet to be controlled and the number

of HIV/AIDS cases is increasing over the last ten years, with 144 cumulative cases in

2008 Since most of the HIV cases detected in recent years were contracted several years ago, there is the danger of it unknowingly spreading to many sex partners in the interim between contracting and detection

Acute respiratory infection and diarroheal diseases remain the two major causes of morbidity despite improvements in water supply and sanitation facilities in communities Finally, high coverage of immunization has been maintained by the country since the achievement of UCI in the Eighties No case of polio has been detected since 1982

Nutrition

Despite the improved nutritional status achieved over the last two decades, malnutrition and micronutrient deficiencies are still major health problems, especially among children and pregnant women The percentage of under-5 children who are underweight has decreased from 38% in 1989 to 19% in 2000 (MDG book, p 34) In 2007, the overall percentage of underweight children visiting health clinics was 10% The rate

of underweight children was highest in Trashiyangtse district (16%) while three other districts had 13% (see Table 1 in Annex 2)

Micronutrient deficiencies in Bhutan are related to iron, iodine and vitamin A The programme to reduce iodine deficiency (normally a major problem in high-altitude

study in 2003 estimated that 28% of men, 55% of women and 81% of children were

anaemic due to iron deficiency (UNICEF, A Situation Analysis of Children and Women

in Bhutan, 2006) Severe anaemia during pregnancy is a special concern because of

its relation to maternal mortality Routine supplementation with iron and folate tablets

is normally indicated

A sedentary lifestyle is gradually overtaking the hardworking agricultural workers and the average diet has improved However, the traditional Bhutanese fondness for fatty food has led to an increase in cases of obesity Recent assessments have revealed that obesity is now a public health concern in Bhutan

Noncommunicable diseases

Noncommunicable diseases now account for more deaths than communicable

diseases (Figure 1) Although there has been no in-depth assessment, the trend in admissions at the National Referral Hospital (Figure 2.3) shows that the proportion of noncommunicable diseases is steadily increasing

Figure 2.3: Distribution of hospital admissions by types of NCD

Source: Health Sector Review 2007

The major risk factors include alcohol consumption along with the use of tobacco and betel nuts The use of narcotic drugs and other substances among adolescents are also on the rise Although the general pace of life in Bhutan is not stressful and people are more spiritual, psychiatric and anxiety-related problems have not spared them Mental health problems are becoming more serious as the country modernizes The community-based mental health programme is now being developed to provide basic services for mental health problems

Emergency medical services

Bhutan is no exception when it comes to natural and man-made disasters The last few decades have witnessed the loss of precious life and property due to flash floods, landslides, earthquakes and traffic accidents As cases of severe acute respiratory syndrome (SARS), avian influenza and influenza A occur in the Region, Bhutan too has to prepare itself to deal with such problems Although the country has a good network of health-care facilities, most of them are ill equipped to deal with such emergencies in an organized and rapid manner As disasters can occur unexpectedly, being prepared is the only way to deal with them

Rural water supply and sanitation (RWSS)

The high number of diarrhoea and skin infection incidences makes the water supply and sanitation programme assume crucial importance

Bhutan’s water supply and sanitation coverage extends to more than 85% and 90% of the population respectively From ethical and equity angles, it is critical that the unreached 10% to 15% of the population has to be covered The cost of reaching out

to the last far-flung population pockets comes to much higher The demand-responsive approach, as opposed to the earlier supply-driven approach, has contributed to the enhancement of ownership and increased prospect of sustainability The supply of water and sanitation facilities needs to be seen as an integrated package along with other public health activities

2.4 Health systems

Policy and financing

The philosophy of economic development in Bhutan is based on the principle of Gross National Happiness (GNH) delivered through the following four areas:

Sustainable and equitable socioeconomic development

History, organization and facilities

A modern health system in Bhutan came into existence with the launch of the five-year

development plans in the 1960s The primary health-care approach has been formally

adopted by the country as its main strategy for ensuring the health of its people

The health system in Bhutan has evolved and improved over the years At the

central level, the Ministry of Health with its two Departments and other sections is

responsible for formulating policies, designs, technical guidelines and directives for all

preventive, promotive and curative health programmes Policies are formulated based

on available evidence and the requirements from the communities, blocks and districts

(an organigram of the Ministry of Health is provided in the Annexure)

The National Referral Hospital in Thimphu is the apex patient referral and provides

the technical back-up to two other regional and 26 district hospitals (see Table 3 in

Annex 2) The district hospitals serve as the referral centres for the 178 Basic Health

Units (BHUs) The BHUs reach out to the people through 521 outreach clinics (ORCs)

and about 1250 village health workers (VHWs) who act as volunteers

BHUs are normally staffed by three persons: a male basic health worker, a female

nurse midwife and an auxiliary nurse midwife These facilities are normally provided

with adequate medicine to provide basic curative services Staff members from the

BHUs normally travel to ORCs where they provide basic curative care and preventive

services such as immunizations At each ORC, BHU personnel are assisted by the VHW

The distance to some of these ORCs may entail a walk over two or three days across

remote areas These basic health services are the backbone of the health-care system

and have made the high rate of coverage of basic services to the community possible

In the 2005 census it was found that 90% of households had visited health facilities

during the previous year (see Table 3 in Annex 2) Furthermore, high visit rates were

also found in all districts and even in remote areas of the country

In April 2009 the new 350-bed National Referral Hospital was completed in

Thimphu The two regional referral hospitals are in Mongar (with 150 beds) and Gelephu

(with 60 beds) Most of the district hospitals are small with 20 to 40 beds each There

are a total of 1232 hospital beds in the whole country However, there is much variation

in the utilization of these hospitals Three of the district hospitals have bed occupancy

rates of less than 20% while the average for the country is 47%

Health workforce

Bhutan has made considerable progress in providing the human and infrastructure

resources for the provision of health services Capacity has certainly increased and

improved at the central level to design and manage health programmes The Royal

Institute of Health Sciences (RIHS) and the National Institute of Traditional Medicine

(NITM) have made significant contributions in developing human resources by training

nurses, technicians and paramedics for the hospitals and BHUs

Table 2.3: Human resource projections/requirements

*26 specialists were expatriates contracted in 2008

In preparing the Tenth Five Year Plan, the Ministry of Health, working together with the Civil Service Agency, developed a Human Resource Plan for the five-year period of the plan Table 2.3 shows the targets for this Plan compared to the health personnel in

2008 It should be noted that this plan does not yet include the health staff required with the establishment of the Medical College, although the completion of this new institute

is likely to happen near the end of the Plan period Nonetheless, since the time taken

to train staff is long, the Medical College needs to be considered when implementing the human resource plan In addition, this Plan does not yet include recent initiatives

to develop a school of public health which is also to be located at the RIHS

The current Plan indicates an 83% increase in the number of general doctors, a six-fold increase in the number of nurses with bachelor’s degrees, a doubling of nurse midwives and a 52% increase in the number of BHU health assistants Educational institutions will have to be bolstered in order to meet these new targets for health personnel

Traditional medical system

Traditional medicine is as important as modern allopathic medicine and, except at the centre where there is a separate hospital for traditional medicine, traditional medical services are provided by the same district hospitals Currently, the Institute offers a Bachelor’s Degree and Diploma in Traditional Medicine with course durations of

courses for pharmacy technicians and research technicians as and when required The

required traditional drugs are manufactured within the country and distributed through

the DVED distribution system like allopathic drugs and vaccines

2.5 Major issues and challenges in the health sector

(1) Expanding coverage: As seen from the major health indicators in the previous

section, much has been achieved in Bhutan despite the difficult terrain and

harsh climate The government assessed the situation and realized that for

further improvement a major shift in strategies and technology was required

Towards this end, planning and management will be further decentralized to

the districts and communities as part of the pro-poor approach Efforts will be

made to cover the last 10%–15% of the unreached population with the basic

health services including water supply and sanitation

These new approaches planned during the Tenth Five Year Plan include

capacity-building at the district level in terms of planning and management

of health programmes, including management of financial resources and for

the Centre to provide the required technical back-up and support to the

districts The new approach also includes expansion of infrastructure in new

geographical locations with staff and equipment and connecting them with

optimum transport and communication facilities Although such solutions are

not cost-effective, ethical considerations make them necessary so as to provide

equal opportunity to every citizen of the country

(2) Double burden of diseases: Like any developing country, lifestyle and food

habits have been changing and this has led to an epidemiological transition

While Bhutan is still battling infectious diseases, noncommunicable diseases

such as diabetes, rheumatic heart diseases, arthritis, cancers and other stress-

and diet-related ailments are on the rise This creates a double burden of

disease for the country Given the rising trend of such problems, the

tertiary-level care facilities require expansion At the same time, primary health-care

services would have to be sustained, improved and their coverage further

expanded

(3) Health workforce: The MoH has made great efforts to attain the targets of

the Human Resources for Health Master Plan of 2002 As planning and

implementation of health programmes are mostly decentralized along with

providing the resources, capacity has to be increased in the districts to be able

to shoulder such responsibility Capacity at the centre needs improvement

equally to be able to not only provide technical support to the districts but

also to plan and manage sound evidence-based health programmes

In the service area, at the central level the major challenge will be to provide

staff for specialized services as more functions, which are currently being

referred outside provided within the country The health sector continues to suffer from a shortage of all categories of staff This situation is further aggravated

by the decision to increase the number of institutional deliveries, which means that there must be a female HA in every BHU At the start of the Ninth Five Year Plan only 30% of BHUs had a female health worker This figure has doubled during the Plan period and needs to reach 100% during the Tenth Five Year Plan On the whole, the shortage is estimated to be around 300 staff at the start of the Tenth Five Year Plan and is expected to grow to about 900 staff The production capacity at the RIHS is currently 30 GNMs and 20 HAs per year, which is far from sufficient The main constraint is shortage of physical facilities, especially classrooms and hostel beds

(4) Sustainability: Average levels of education in Bhutan have improved and access

to knowledge increased, raising people’s expectations The health sector has to cover not only new ground in terms of geography but also in terms of service areas, and at the same time keep abreast of changing technologies

in health Huge costs are incurred on drugs and health equipment every year Besides, the country depends totally on the import of these items from outside Achievements have also been made in the areas of immunization (UCI), nutrition (IDD elimination), leprosy (elimination) and polio (nearing eradication) control All these achievements have to be sustained

The country has created the Bhutan Health Trust Fund to deal with some of the sustainability issues Further, though the Trust Fund was created mainly to deal with essential drugs and vaccines, the upper limit has been kept flexible

so as to take care of shortages in other areas of health as well Hence, the Trust Fund has a long way to go to be able to support the country in sustaining the achievements made so far

(5) Diagnostic facilities: Diagnostic services form the main component of the

curative services Diagnostic capacity has become even more important with the threat of recent epidemics such as SARS, avian influenza and influenza

A The diagnostic area – either for clinical purpose or for public health – is resource intensive as it requires infrastructure, equipment, human resource and consumables on a daily basis Improved diagnostic services for diagnosing cancer and chronic diseases have to be started in the light of the changing disease epidemiology Since laboratory services are highly technical, quality has to be assured In order to strengthen district health services, laboratory services need further expansion in the districts

(6) Decentralization, management and regulation of the health system: With

the democratic process put in place in the country with the drafting of the

the health system are also inevitable, and more community participation likely

Strategies are required to prevent fundamental changes in the organization and

in the processes that may disrupt the progress made so far Even the quality of

services and facilities could vary from place to place with decentralization, since

each individual district now has to decide for itself Hence, quality standards

and systems need to be put in place so that while individual districts can make

decisions, the framework remains the same for all districts

When the management is decentralized, there is all the more reason to rely

on a good information system and IT network to keep the centre and districts

well connected for informed decision-making and coordination The health

workers in the districts need to be backed up in technical terms by the Centre

using the telehealth system Research has to be stepped up and systematized for

evidence-based planning and decision-making However, health information

and research are not yet strong areas of the health sector and the telehealth

system requires innovation and capacity-building for greater effectiveness

As cost of health care mounts over the years, privatization of selected aspects

of the health services is being considered Regulation and legislation need

further strengthening to keep abreast of the changes with the expansion of

services, amendments in policy and advancement of technology

3 — Development cooperation and partnerships: Technical assistance, aid effectiveness and

coordination

Bhutan has adopted a balanced approach to development, seeking to achieve its developmental goals without creating social alienation or excessive economic inequality

“Gross National Happiness” is the defining principle of Bhutan’s development efforts

to achieve not only economic progress but also spiritual well-being

Bhutan differs from most other aid-dependent countries in that the government has a very strong sense of vision and development priorities that help determine where technical and financial assistance is most needed, and which donors can best provide it The government is very proactive in managing donor assistance, and fitting aid into a well-defined framework instead of allowing donors to drive its development programmes Assistance efforts are well managed to avoid duplication, with each donor active in preferred areas of assistance

To be able to manage the donors as per the country’s own requirements, Bhutan prefers to limit the number of individual donors present in the country However, their contribution through the agencies – especially the UN specialized agencies – already present in the country is welcomed Bhutan encourages close liaison between donors both overall and within the health sector This framework has resulted in partnerships with relatively small donors with the exception of India, which has remained Bhutan’s largest development partner over the past 40 years

Other important partners in the health sector include Denmark, the Global Fund, GAVI, Japan, the European Union, World Bank and other UN agencies (UNICEF and UNFPA) All other agencies provide programme-tied funds and Denmark provides budget support GAVI has committed US$ 3.3 million to support tuberculosis and HIV/AIDS programmes The HIV-AIDS programme is also supported by the World Bank that provided US$ 5.3 million for five years starting from 2004

As part of an effort to move towards self-reliance and financial sustainability in the health sector, the Bhutan Health Trust Fund was created in 1997 with the primary objective of enhancing accessibility and quality of primary health care by ensuring the

Specific to the flow of funds from WHO to the government, the Country Office

releases funds to the Gross National Happiness Commission that registers the funds

and releases them to the Ministry of Health through the Ministry of Finance With

the democratization process, the Public Accounts Office has been opened at the

national level and corruption watchdogs have been put in place together with further

strengthening of the auditing system to ensure greater accountability

4 — Past and current WHO cooperation

4.1 WHO country cooperation overview

To assist the Kingdom of Bhutan to attain the highest level of health for its people, WHO has provided continuous support to the Ministry of Health over the last 25 years This support has included the gamut of a wide variety of areas in support of public health in Bhutan The main focus of work has been on capacity-building, especially to support the provision of basic health services to the people of all parts of the country

In the past, this support concentrated on programmes such as immunizations and the control of communicable diseases such as tuberculosis and malaria With the successful reduction of infant, child and maternal mortality in the recent past, the focus of WHO’s work has shifted to providing technical support in health policy development, especially

in the area of human resources for health, prevention of noncommunicable diseases, and preparedness for health emergencies arising from natural disasters and disease outbreaks

The WHO Country Office is a small operation with only one permanent international staff and local administrative support Much of the technical support for WHO activities

in the country has been provided by the Regional Office in New Delhi, along with short-term consultants In the past decade, two National Professional Officers have been added to the office staff to provide additional capacity to support country work.WHO’s budget for Bhutan has been limited and has not increased substantially in the last 10 years As additional financial resources are needed to support the increased work

of WHO, more needs to be done to mobilize voluntary contributions (VCs) This will allow greater capacity in the Country Office to provide continued support in the future

4.2 Operational aspects of the implementation of the Strategic Agenda 4.2.1 Resources: Budget, planning, staffing and infrastructure

WHO’s support to Bhutan began operationally in 1983 with two programmes on primary health care with a provision of US$ 258 470 The number of programmes and resource allocation steadily increased over the years to cover many areas In the 2008–2009