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B hutan’s development goal of Gross National Happiness, although not synonymous, is in harmony with the Global Sus- tainable Development Goals (SDGs). This provides a unique platform for synchronization, coherence and col- laboration with the UN partners, both on thematic areas and monitoring frame- works. Bhutan is preparing to graduate from Least Developing Countries (LDCs) status by 2023. At this critical juncture, the Country Cooperation Strategy (CCS) 2020-24 reaffirms the strength of the relationship and WHO’s contribution to Bhutan’s path to development thus far and beyond. This also reaffirms WHO’s commitment as a wider UN system to Bhutan’s endeavours. The Royal Government of Bhutan provides free health care services includ- ing inpatient services, essential drugs and diagnostics and referral outside the country for those cases that cannot be treated within Bhutan. Guided by the principles of Primary Health Care, Bhutan has progressed steadily towards maturing health systems. Hence, WHO support for Bhutan within this current CCS will mainly focus on providing high level qual- ity technical support, supporting high quality training activities such as training of trainers and institutional development. This will enable Bhutan’s commitment towards achieving the SDG target ahead of the 2030 set timeline. I am happy that the WHO Bhutan-CCS 2020-24 aligns with the 12FYP of Bhutan and the current government pledge of narrowing the gap. The CCS also focuses on generating reliable and robust data, which is crucial not only for planning processes but also for measuring results. I commend and congratulate WHO for coming up with the CCS through an in-depth consultative process that reflects the needs of the Royal Government of Bhutan. The Royal Government of Bhutan is committed to working closely with WHO in fulfilling the common outcomes and aspirations of elevating health and happiness of the people of Bhutan and of the globe. Lyonpo Dechen Wangmo Minister for Health Royal Government of BhutanF O R E W O R D
B hutan is committed to advanc- ing health and well-being for all. In recent years Bhutan has controlled hepatitis B, elimi- nated measles and controlled rubella and congenital rubella syndrome. It was a leader in the Region in eliminat- ing maternal and neonatal tetanus and in the fight against polio. Bhutan continues to be a pioneer in health systems and health workforce strengthening, with the government constitutionally mandated to ensure a “safe and healthy environment” and to provide “free access to basic public health services”. Bhutan is one of two countries in the Region to have achieved health service coverage and financial protection that is above the global median. As this WHO-Bhutan Country Cooper- ation Strategy (CCS) outlines, WHO will continue to support Bhutan to advance health and well-being overall, and in pri- ority areas, via high-quality technical and capacity development. As documented in WHO’s Thirteenth General Programme of Work (GPW), WHO is committed to driving impact at the country level, as per country priorities, and ensuring all coun- tries achieve the GPW and Sustainable Development Goal targets. This CCS will be implemented be- tween 2020 and 2024 and is focused on strengthening data, research, innovation and knowledge brokerage. This CCS will enable Bhutan to address present and emerging challenges, in line with the Region’s ‘Sustain. Accelerate. Innovate’ vision. WHO is committed to supporting Bhutan as it continues to develop sus- tainably and for the health and well-being of all. Together we have achieved much. Together we will achieve more. Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia M E S S A G E
9W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : W HO-Bhutan CCS-2020-24 has been developed to provide strategic direction and sup- port the Ministry of Health in priority health sectors over the next five years. This CCS is a result of a consultative process with technical inputs from various key programmes and agencies of the health sector and relevant organiza- tions. The strategic priorities, overall goal and outcomes of this CCS builds upon the work that the WHO has been carrying out and aligns with the Royal Government of Bhutan’s 12th FYP (2018- 2023), government’s flagship programmes on health and United Nations Sustainable Development Partnership Frame- work for Bhutan 2019-2023. Further, it also considers and aligns with the WHO regional and Global initiatives and priorities and will contribute towards the WHO triple Billion commitment of GPW 13. The CCS identifies the current epide- miological and diseases burden challenges as well as pertinent public health concerns nationally, regionally and globally, and pave the way forward through the following stra- tegic priorities: 1. Achieve UHC through integrated people-centered quality health care services 2. Improve reproductive, maternal, newborn, child, adolescent health (RMNCAH) and healthy aging 3. Build health system resilience to address communicable diseases and effects of health emergencies and climate change 4. Address NCDs and its determinants with strategic priority 5. Strengthen data, research, inno- vation and knowledge brokerage, providing enabling support to the other four strategies Within the current CCS, it is worth noting that WHO will focus on providing high level technical support, policy guidance, high level training such as training of trainers and insti- tutional capacity development. This CCS will be jointly monitored by MoH and WHO during midterm and end term and any adjustment shall be made during the midterm review. WHO country office is fully committed to supporting Bhutan and fulfilling the aspira- tion of the Royal Government of Bhutan in providing the best health care services to the people. We look forward towards a strong partner for this CCS period and beyond. Dr Rui Paulo de Jesus WHO Representative to Bhutan M E S S A G E 10 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : ACRONYMS AND ABBREVIATIONS AIDS Acquired Immunodeficiency Syndrome AMR Antimicrobial Resistance ADB Asian Development Bank CCS Country Cooperation Strategy CCM Country Coordinating Mechanism EU European Union FYP Five Year Plan GDP Gross Domestic Product GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GLOF Glacial Lake Outburst Floods GNH Gross National Happiness GNHC The Gross National Happiness Commission GPW General Programme of Work HA Health Assistant HIV Human Immunodeficiency Virus HEOC Health Emergency Operation Center HHC Health Help Centre HMIS Health Management Information System IHR International Health Regulations IMNCI Integrated Management of Neonatal and Childhood Illness IPCC International Panel on Climate Change JICA Japan International Cooperation Agency KGUMSB Khesar Gyalpo University of Medical Sciences of Bhutan 11 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : LDC Least Developing Countries LMIC Lower Middle Income Countries MDR-TB Multi-Drug Resistant Tuberculosis NCDs Noncommunicable Diseases NTDs Neglected Tropical Diseases MOH Ministry of Health NGO Non-Governmental Organization NHA National Health Accounts RMNCAH Reproductive, Maternal, New born, Child and Adolescent Health SDGs Sustainable Development Goals SAARC South Asian Association for Regional Cooperation SDF SAARC Development Fund SEARHEF South-East Asia Regional Health Emergency Fund UNSDPF United Nations Sustainable Development partnership Framework VHW Village Health Worker WCO WHO Country Office WHO World Health Organization WASH Water, Sanitation and Hygiene WHO-SEARO WHO South-East Asia Regional Office TB Tuberculosis UHC Universal Health Coverage UN United Nations UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund CONTENTS Acronyms and abbreviations 10 Executive summary 15 1. Introduction 16 2. Health and development situation 17 2.1 Political, social and economic context 18 2.2 Overall health status 21 2.3 Universal health coverage 21 2.4 Emergency preparedness and response 31 2.5 Health and gross national happiness 33 3. The development partners 34 3.1 Main health and development partners in Bhutan 34 3.2 Collaboration with the united nations system at country level 34 3.3. Engagement of WHO with development partners in Bhutan 35 4. History of collaboration: WHO & Bhutan 36 5. Setting the strategic priorities 38 5.1 Strategic priorities 38 5.2. Prioritisation process and alignment to gpw, national plan and UNSDPF 40 6. Measuring & accounting for results 44 7. Monitoring and evaluation of CCS 47 8. Implementation: contribution from WHO & partners 48 9. CCS implementation approaches: 54 10. References 55 11. Annexes 56
15 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : T he Country Cooperation Strategy (CCS) will provide broad strategic directives for WHO to work in and with the country in the priority health sector, where WHO has an advantage. This CCS will cover the period 2020-24. The main focus for this CCS are: 1. Achieve UHC through integrated people-centred quality health care services 2. Improve reproductive, maternal, new born, child, adolescent health (RM- NCAH) and healthy aging 3. Build health system resilience to address communicable diseases and effects of health emergencies and climate change 4. Address NCDs and its determinants and 5. Strengthen data, research, innovation and knowledge brokerage providing enabling support to the other four strategies. The strategic document was developed in close consultation with stakeholders, particu- larly with the departments and programmes of the Ministry of Health (MoH). The CCS devel- opment process also reviewed key country and WHO documents, including the new guidelines. This CCS is at the critical juncture of Bhutan’s development process as it prepares to graduate from LDC status by 2023. The implementation of the CCS strategic priority areas is therefore envisaged to prepare Bhutan in making tactical shifts in health policies and directions. This would be required as donors and strategic developmental partners may reduce their support and presence in Bhutan. Within this CCS, WHO will mainly focus on providing high quality technical assistance and capacity building. Through the implementation of the CCS, it is expected that Bhutan will con- tribute to the WHO global ‘triple billion goals’ and achievement of regional targets/flagship priority areas, the General Programme of Work 13 and SDGs. EXECUTIVE SUMMARY 16 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : T he Country Cooperation Strategy Bhutan 2020-24 was developed to provide strategic directions for WHO to work in and with Bhu- tan. This document will be the basis for the preparation of WHO biennial work plans during 2020-24. It responds to Bhutan’s health and development agenda where WHO has compar- ative advantage to deliver and support public health impacts. The process involved review, analysis and mapping of all national priorities, particularly outlined in the SDGs 2030, 12th Five Year Plan of Bhutan (2018-2023), 13th General Programme of Work (2019-2023), United Nation Sustainable Development Partnership Framework for Bhutan (UNSDPF) 2019-2023, and regional and national flag- ship programmes. The process also involved extensive dialogue with government and partner agencies in getting priority inputs and agreeing to strategic priorities. Following are the five broad strategic priorities identified, which are aligned with the three strategic priorities set in the GPW13: 1. Achieve UHC through integrated people- centred quality health care services 2. Improve reproductive, maternal, newborn, child, adolescent health (RMNCAH) and healthy aging 3. Build health system resilience to address communicable diseases and effects of health emergencies and climate change 4. Address NCDs and its determinants 5. Strengthen data, research, innovation and knowledge brokerage The CCS priorities provide a high-level overview of WHO activities. The CCS also takes into account equity, gender, human rights (EGHR) as the underlying principle, and is embedded within the strategic priorities and impact framework. The CCS is designed for a coherent one WHO and One UN approach interacting hor- izontally and vertically at the development, implementation and monitoring levels in a transparent and accountable manner. The CCS is also envisaged to be evaluated at midterm and at end of its term, jointly by the govern- ment and the WHO. The implementation of the CCS 2020-24 is expected to result in improved health and wellbeing of the Bhutanese people through a people centred Primary Health Care approach. It is also expected that WHO will respond to the changing needs of Bhutan and provide policy, advocacy and technical ap- proaches that would shape the health systems of Bhutan beyond LDC graduation in a sustain- able, affordable and efficient manner, without compromising the quality of care. INTRODUCTION1 17 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : INTRODUCTION HEALTH AND DEVELOPMENT SITUATION B hutan progressed in all aspects of develop- ment within a short span of time. Political- ly, the country peacefully transitioned to a “Democratic Constitutional Monarchy” with Parliament elected every five years. It has successfully im- plemented this democratic form of gov- ernment since 2008. Economically, with GDP per capita of USD 3438 [1], Bhutan aims to move from LDC to LMIC by 2023. Similarly, as of 2017 youth literacy had reached to 93.1 % although general literacy rate remained at 71.4 [1]. Life expectancy, infant mortality, maternal mortality and other indicators have also improved significantly. 2.1 Political, social and economic context 2 transition to LMIC 2023 18 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : 2010 2011 2012 2013 2014 2015 2016 2017 2018 6.7 11.7 7.9 5.1 2.1 5.8 6.6 8 4.6 40,000 30,000 20,000 10,000 0 10,000 20,000 30,000 40,000 Male Female 75 to 79 70 to 74 65 to 69 60 to 64 55 to 59 50 to 54 45 to 49 40 to 44 35 to 39 30 to 34 25 to 29 20 to 24 15 to 19 10 to 14 5 to 9 0 to 4 GDP Growth Rate 2.1 Political, social and economic context POLITICAL: Bhutan celebrates ten years of successful democracy since 2008. The Constitution was enacted on July 18, 2008. Under the leadership of the Kings, Bhutan has al- ways enjoyed peace, prosperity, and progress. The democratic process has acceler- ated the growth and progress of the country. The principles of equity, sustainability and empowerment, are enshrined in the constitution and also deeply embedded in the Bhutanese developmental policies, which is guided by the principles of Gross National Happiness. Further, democratisation is developing the core institutions to sustain development with values and empowers citizens to make decisions as part of a collective responsibility. Civil societies are growing and taking more responsi- bilities in augmenting and complementing the government in reaching the develop- mental activities including health agenda to the unreached population. ECONOMIC: Fueled by hydroelectrici- ty power generation and sound economic policies the GDP per capita in- creased from USD 2,464 in 2013 to 3,542 in 2018. Bhutan ranks 81 of 180 countries in ease of doing business. Bhutan is ranked the 26th least corrupt country and is the only carbon negative country in the world. 19 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : 2010 2011 2012 2013 2014 2015 2016 2017 2018 6.7 11.7 7.9 5.1 2.1 5.8 6.6 8 4.6 40,000 30,000 20,000 10,000 0 10,000 20,000 30,000 40,000 Male Female 75 to 79 70 to 74 65 to 69 60 to 64 55 to 59 50 to 54 45 to 49 40 to 44 35 to 39 30 to 34 25 to 29 20 to 24 15 to 19 10 to 14 5 to 9 0 to 4 DEMOGRAPHIC: The population pyramid indicates declining fertility rates (TFR 1.7) in Bhutan. The 2017 PHCB counted 681,720 Bhutanese (F: 47.8% M: 52.3%); Rural population 62.2 %; Population density 19 person/KM2; median age 26.9 years. 26.1% of the total population falls within the child population group (189,417), 68.0% within the productive aged population group (494,664), and 5.9% (43,064) within the elderly population group, 65 years and above. The male and female proportions are 50.1% and 49.9% respective- ly. With declining fertility rate, an increasing proportion of the elderly population is expected over the years. SOCIAL: Bhutan pursues Gross National Happiness (GNH) as its developmental philoso- phy. It has four pillars and nine domains and GNH indicators are measured peri- odically as a yardstick of social development. The 11th FYP evaluation revealed that literacy rate increased from 59.5% in 2005 (M - 69.1%, F - 48.7%) to 71.4% in 2017 (M - 78.1%, F - 63.9%). The ratio of female to male at the tertiary level education increased from 71% in 2013 to 83% in 2017. 20 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : GRADUATION FROM LDC AND ITS IMPACT ON BHUTAN HEALTH SYSTEM2 B hutan is currently in the preparatory phase to graduate to a lower middle-income country by 2023. Bhutan’s GDP and per capita income is fueled by sale of hydroelectric power to India. Most people still live in rural areas with livelihood dependent on subsistence farming. Bhutan’s economic structure is largely based on agriculture, hydropower and tourism, which are vulnerable to economic shocks and to natural disasters. Fragile Himalayan eco-systems, prone to natural calamities including glacial lake outburst floods, persistent landslides, rising frequency of earthquakes, floods, forest fires and windstorms, makes Bhutan highly vulnerable not only to economic shocks but also to health impacts. Although, health facility coverage is significant, the quality of care needs strengthening. The shortage of skilled heath workforce in Bhutan has been perva- sive and the problem will exist for years to come. There is still no institute to pro- duce undergraduate medical doctors. Without robust health systems and capable institutions to produce a competent health workforce, the country’s capacity to manage and contain epidemics and natural calamities would be highly compro- mised. Nutrition of children, adolescents and youths is still a problem. Meanwhile, newly arising issues are being identified and addressed, but Bhutan still faces a challenge to sustain the achievements made so far. The immediate challenge is to improve the quality of care to satisfy the ever-increasing expectations of the peo- ple and also to sustain the current free health care system. As the country grad- uates from LDC, most development partners may withdraw support. Therefore, at this critical time period, WHO’s role to provide leadership and strategic direction to Bhutan’s vision and investment in health would be increasingly required. 21 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : 2.2 Overall Health Status Since the start of modern health care system in 1960s, Bhutan has achieved remarkable progress across all health care delivery systems. Life expectancy at birth for Bhutan’s female population is 71.7 years and male population is 68.8 years, with average life expectancy of 70.2 years at birth. Healthy life expectancy of Bhutan is estimated by WHO at 60.7 in 2016. The average global healthy life expectancy is 63.3 years. Currently, there are 29 Hospitals, 25 BHUs Gr. I, 186 BHUs Gr. II, 52 Sub-Posts and 551 Out- Reach clinics (ORCs) spread across the country (Figure 1). There are about 4.3 doctors per 10,000 people and 16.2 nurses and midwifery personnel per 10,000 population [3]. While significant improvements in the health indicators had been made over the years, Bhutan faces an increasing burden of non-communicable diseases even when com- municable diseases are still prevalent. Bhutan is also prone to natural disasters and hazards such as earthquakes, landslides, floods and glacial lake outbursts. Sustaining free health services is becoming increasingly challenging with ever increasing health care cost within Bhutan and referrals outside the country. Human resource has always been a challenge throughout the developmental era of Bhu- tan, particularly in the categories of clinical specialists, specialised nurses and technicians (ICU, OT and Dialysis, Nurse Anesthetist, oncology, etc.). Further, the government’s policy so far has been to expand services and increase reach. It is now high time to take stock of achievements and accurately measure the reach of quality services to people in need and also to measure the degree to which services have resulted in quality health improvements in an equitable and all-inclusive manner. 2.3 Universal Health Coverage Bhutan has provided comprehensive health care since the 1970s, through its Primary Health Care approach, and has committed in achieving Universal Health Coverage (UHC) by 2030. Working towards UHC is the linchpin in ensuring health and wellness and reaching the most disadvantaged, vulnerable and unreached population. To address this, there is a need for reliable data which is coordinated and avail- able for developing evidenced based policy decisions. The annual health bulletin, which is the annual publication of the MoH, does not provide adequate and reliable information for deciding policy decisions. National Health Sur- vey and other programme related surveys are also conducted periodically. There is a need for more timely, reliable and readily available data that can be used by academicians, researchers and leaders to infuse policy shifts and deci- sions based on evidence. With wide reach of health services and government paying all health cost, including referral outside the country, it is presumed that health services are accessible to all and is com- prehensively covered (Figure 2). UHC index was 75 % in Bhutan in 2018. While significant improvements in key 22 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : health outcomes have been made over the last couple of years, as shown in figures (Figure 3-7), Bhutan is still struggling to combat the triple burden of diseases. PEMAGATSHEL SAMDRUPJONGKHAR TRASHIGANG TRASHIYANGTSELHUENTSE MONGAR ZHEMGANG BUMTHANG TRONGSA SARPANG TSIRANG WANGDUEPHODRANG GASA PUNAKHA THIMPHU CHUKHA DAGANA PARO HAA SAMTSE N Health facilities by Dzongkhag, 2018 NR Hospital RR Hospital Hospital BHU I BHU SP Figure 1: Map showing health facilities in Bhutan 23 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : • Bhutan spent 4% of total expenditure on health as a percentage of gross domestic product in 2017 • As per Health financing profile of Bhutan 2018, the Out-of-pocket (OOP) spending consti- tuted about 20% of total health expenditure. However, as per the BLSS 2017, from the total OOP health expenditure, more than 58% was spent on ”Rimdo”, the highest share among the expenditures. “Rimdo” is Buddhist rituals performed by Buddhist practitioners to prevent and cure diseases and forms a crucial component of health activities carried out by Bhuta- nese people. • Transportation charges constituted a fourth (25.1%) of the total health expenditure, while purchase of medicine and health accessories accounted for only about 7%. 21% 75% 79% 4% people without coverage of essential services people with UHC people with coverage of essential services people experienced financial hardship in accessing health services Figure 2: UHC Coverage 24 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : Figure 3: Maternal Mortality 0 50 100 150 200 250 300 2000 255 86 89 83 70 2012 2017 2023 12th FYP 2030 SDG 0 50 100 150 200 250 300 30 216 164 126 174 82 68 20 148 215 178 176 258 Global South-East Asia Thailand Sri Lanka Maldives Democratic Indonesia Bhutan India Bangladesh Myanmar Timor-Leste Nepal Underlying Factors • Improved access to health and development and decline in fertility rates has led to a reduction in maternal mortality • High rate of institutional delivery (93.4%) and deliveries conducted by skilled birth attendants (97.2%) • 85% of pregnant women attended 4 or more ante-natal care check ups • Free access to a strong health system • Provision of basic EmONC in 41 health facilities and 6 cEmONC • Greater access for women of reproductive age to family planning services • Improved prenatal and postpartum care Bhutan Maternal Mortality Maternal Mortality Ratio in SEAR countries vs global and regional average4 Implications for WHO and partners to address the issue • Reaching all females of child-bearing age for nutrition and care advocacy • Improving quality of services at health facility • Capacity building of local health pro- fessionals • Strengthening women’s socioeconomic status • Strengthening health system and support research studies to identify priorities and needs of women and girls • Ensuring universal health coverage for comprehensive reproductive, maternal, and newborn health care • Addressing inequalities in access to and quality of reproductive, maternal, and- newborn health care services especially for unreached urban poor and hard to reach areas • Instituting/strengthening surveillance systems to address quality gaps 25 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : Figure 4: Under-fives mortality 0 20 40 60 80 100 2000 84 37.3 34.1 20.3 25 2012 2017 2023 2030 12th FYP Target 0 10 20 30 40 50 60 49.7 40.8 38.9 34.2 26.4 34.5 43 50.8 32.4 9.4 12.2 20 8.5 Global South-East Asia Myanmar Timor-Leste India Nepal Bangladesh Bhutan Indonesia Democratic... Thailand Sri Lanka Maldives Underlying Factors • Decline in under-five mortality is attributed to better access and increased births attended by skilled health professionals • Education level and socio - economic development of population • Nationwide IMNCI implementation • Skilled birth assistance for all deliveries (97.2%) • Nationwide IMNCI implementation • Sustained high (>95%) immunisation coverage • Improved literacy rate and socio- economic status Bhutan under-fives mortality Under-fives mortality in SEAR countries vs global and regional average4 Implications for WHO and partners to address the issue • Greater engagement of community clin- ics and rural health centres in promot- ing better nutrition • Supporting NICU and strengthening nursing skill and capacity • Strengthening infection control mecha- nisms and AMR stewardship • Strengthening surveillance, social mo- bilisation and community engagement • Improved neonatal care and promotion of exclusive breastfeeding • Uninterrupted supply of vaccines • Reduction of household air pollution • Safe drinking water and food Note: SDG targets are global targets, however, Bhutan plans to achieve even higher targets within 12FYP. 26 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : Figure 5: TB Incidence 0 50 100 150 200 250 300 350 2010 313 164 113 98 0 2015 2017 2023 2030 12th FYP Target 0 100 200 300 400 500 600 498 140 240 221 178 361 391 513 211 65 154 172 49 Global South-East Asia Democratic... Timor-Leste Indonesia Myanmar Bangladesh India Bhutan Thailand Nepal Sri Lanka Maldives Underlying Factors • Better living conditions and socio- economic improvement • Better screening, detection, treatment facilities • Good funding support • Case detection and treatment success rate highly sustained • Access to free healthcare • Reporting and recording system in place Bhutan TB Incidence TB Incidence in SEAR countries vs global and regional average4 Implications for WHO and partners to address the issue • High level commitment and financing • Engaging partners from non-health sectors • Operationalise End TB Strategy and monitor implementation • Tackling rising trend MDR-TB • Reinventing a functional DOTs system • Improving diagnostic technology • Strengthening cross border TB screening • TB & HIV programme collaboration • Involve NGO in the care and support of TB patients 27 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : Figure 6: Stunting 0 5 10 15 20 25 30 35 40 2010 33.5 21.1 15.14 0 2015 2023 2030 12th FYP Target 0 10 20 30 40 50 60 17.3 22.2 33 29.2 35.8 27.9 20.3 10.5 33.6 38.4 36.4 36.1 50.2 Global South-East Asia Thailand Sri Lanka Maldives Democratic... Myanmar Bhutan Nepal Bangladesh Indonesia India Timor-Leste Underlying Factors • Economic growth and less poverty • Education and understanding of nutritional values • Fortification of food and exclusive breast feeding • Good access to ANC and PNC Bhutan Stunting Stunting in SEAR countries vs global and regional average4 Implications for WHO and partners to address the issue • Improving nutritional status of girls of child-bearing age, pregnant mothers, exclusive breast feeding and child nutri- tion • Changing pattern of dietary habits of adolescents and youths towards more junk food and lack of food diversifica- tion is a challenge • Controlling inflation to enable common people to buy nutritious food • More effort required to minding gaps in all aspects, including nutrition intake 28 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : Figure 7: Sanitation coverage in Bhutan 0 20 40 60 80 100 2012 66.3 70.6 74.8 100 2015 2017 2030 12th FYP Target Underlying Factors • Education and socioeconomic development and rigorous awareness programmes may be attributed as one of the factors for increase in improved sanitation facilities in Bhutan Implications for WHO and partners to address the issue • Increasing funding for sanitation facilities • Local capacity building for greater investment in improving sanitation facilities, especially in unreached areas • Behavioural change through hygiene promotion to achieve the health benefit of sanitation coverage • Addressing climate change and climate sensitive diseases. 29 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : Non-Communicable Disease in Bhutan Despite model initiatives for a healthy society through the principles of GNH, Bhutan faces a triple burden of disease: communicable diseas- es, emerging/re-emerging issues/diseases and escalated prevalence of non-communicable diseases (NCD). To fight against the growing trend of NCDS, The Multi-sectoral National Ac- tion Plan for the control of Non-Communicable Diseases (2015-2020) [5] was approved by the cabinet of Bhutan on 6th July 2017. However, a review conducted in 2018 [6], identified var- ious implementation obstacles including poor coordination, low understanding by agencies regarding the rules of engagement, capacity of the secretariat and lack of human resource at the MoH to drive the policy forward. As per the National Health Accounts[7] (NHA), the gov- ernment is the principal contributor with more than 70% of health expenditure spent from government budget and only 5% contributed by donors. Bhutan plans to reduce premature mortality due to NCDs, including cancer, by 25% by 2025 and by one third by 2030. Within this context, the Parliamentarians’ Forum of Bhutan in 2018 adopted a policy vision of ‘Happy and Healthy Bhutan by 2030’ [8] which outlines NCD agenda as a national priority. Bhutan has also launched and is leading the cervical cancer initiative and plans to eliminate cervical cancer as a public health problem in Bhutan by 2023. The elderly population in Bhutan is also increasing year by year. In 2017, the number of people aged 60 years and above was 63,775 constituting 8.77 percent of the total population. By 2027, the percentage is expected to increase to 10.71. Old age depen- dency ratio has slowly increased from 7.5 in 2005 to 8.7 in 2017. Given demographic trends, and changes in traditional family structure, the need for appropriate care and support systems for the elderly is crucial. With support of WHO, MoH has already drafted the strategy on healthy ageing to support healthy life for the elderly. NCDs burden and risk factors in Bhutan6 25% 50% 33% 9gm Bhutanese adult population use tobacco in any form (smoke and/or smokeless) Of all MEN surveyed drank alcohol in the preceding 30 days Of all WOMEN surveyed drank alcohol in the preceding 30 days TOBACCO USE ALCOHOL USE SALT INTAKE The mean salt intake of Bhutanese adult population per day This is almost double the recommended amount by WHO BLOOD PRESSURE: The prevalence of raised blood pressure or hypertension (SBP ≥140 and/or DBP ≥90), excluding those on medication, was 32.9% (men 33.6%, women 32.0 %). This figure rose to 35.7% (men 35.5%, women 35.9%) when those currently using medication were included. 30 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : BROAD SPECTRUM OF HEALTH CHALLENGES FOR BHUTAN: Key Issues Sustaining and improving the accessibility to es- sential health care services including access to medi- cines, technology and vaccines Increasing trend of overweight, obesity and other NCD risk factors in ado- lescent, youth and adults Inadequacy of high-quality reliable and timely data for evidenced based planning and strategic development Addressing the emergence of high-threat infectious haz- ards, commu- nicable disease and health emergencies Increasing challenges of urban health, pollution and healthy ageing 01 05 04 02 03 31 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : 2.4 Emergency preparedness and response Bhutan is vulnerable to a multitude of climate induced events and disasters owing to its mountainous terrain and fragile ecosystem. There have been reports of increasing incidenc- es of wild forest fires, glacial lake outburst floods and landslides, flash floods, drying up of water sources, crop diseases, windstorm and erratic rainfall. In addition, Bhutan falls within the most active seismic zone IV and V of the Indian tectonic plate where experts believe that a major earthquake is in the offing. These disasters can induce disease outbreaks, loss of life and properties[9]. WHO estimates that there will be 5% increase in diarrhoeal disease incidence for every 1% rise in average temperature and according to International Panel on Climate Change (IPCC), temperature will increase by 3-4 degree centigrade by 2100. Bhutan is home to more than 2,674 glacial lakes; 25 of them pose a potential Glacial Lake Outburst Floods (GLOF) threat. If mitigation and preparedness are not adequately ad- dressed, Bhutan is at risk of being severely impacted not only by natural calamities but also by climate sensitive water, air and vector borne diseases such as diarrhoeal diseases, acute respiratory infections, malaria, dengue, leishmaniases and chikungunya. Since Bhutan shares a porous unfettered border with Indian states of Assam and West Ben- gal in the south, which are endemic to malaria and other tropical diseases, it poses a challenge to control diseases, particularly vector-borne diseases, where not only people with infections cross borders but also vectors carrying parasites. In order to aid in times of disaster, the government has supplied basic search and rescue equipment to all 20 Dzongkhags and 4 (municipalities) Thromdes. Further, through the De-sung programme, about 3,495 volunteers are trained, who are capable of participating in disaster response and relief efforts. Likewise, Bhutan Red Cross Society, established in 2016, provides voluntary services in the areas of di- saster management, health, and social services. In addition, disaster contingency plans have been prepared for 15 Dzongkhags[10]. MoH has undertaken emergency response mechanisms such as procurement of medical kit camps, conducting vulnerability assessment and estab- lishment of Health Emergency Operation Center (HEOC), besides simulation exercises. Number of deaths and individuals affected by natural disasters (1994-2016)11 Natural Disasters No. of deaths No. of individuals affected Flood EarthquakeStorm 222 1,600 29 65,000 12 20,028 Total 304 87,369 32 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : As per the Comprehensive National De- velopment Plan (CNDP) 2030 for Bhutan, pre- pared jointly by Bhutan and Japan, the team has identified Nation-wide Disaster Risks in major towns of Bhutan which is shown in Table 2. Table 2: Nationwide Disaster Risk by Major Town in Bhutan Earthquake (including landslide due to earthquake) Landslide (due to rain) Flood GLOF Thimphu, Paro, Haa Medium Low Medium Low Punakha, Wangduephodrang Low Low High High Trongsa Medium High Low Low Bumthang Low Low High High Mongar, Trashigang High High Medium Low Samdrup Jongkhar High Medium Medium Low Gelephu, Sarpang Medium High High Low Phuentsholing High High High Low Figure 8: Pictures showing emergency response training. The 2017 joint external evaluation of IHR core capacities found that Bhutan had developed 45% of its 19 core capacities for emergency preparedness which is at level 3[12]. WHO has also supported and propagated the emergency simulation exercises in many health facilities and currently simulation exer- cises are routinely conducted in most health facilities. Further, the National Health Security Action Plan was also developed. 33 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : The score revealed that Bhutan needs to strength- en the IHR core capacity standing at the legislative, implementation and coordination level. Bhutan scored very low, 1 out of 5, in bio safety and bio security, linking public health to security authorities, medical countermeasure and personnel deployment, point of entry, chemical event and radiation emergencies. Bhu- tan did very well, scoring 4 and above, in immunisation coverage. Rest of areas, Bhutan scored either 3 or 2. Figure 9: IHR core capacity and potential hazards in Bhutan, 2011-2016 2.5 Health and Gross National Happiness In Bhutan, all developmental policies are guided by the principles of Gross National Happiness (GNH). The Gross National Hap- piness Commission (GNHC) is the Planning Commission which is chaired by the Prime Minister. All policies and plans for Bhutan are screened through a GNH lens prior to approval by the government. Since GNHC is mandated to develop, recommend and approve national plans and strategies, and carry out monitoring of implementation, it plays a central role in collaboration and harmon- isation of all national plans and resource allocation. The central role played by the GNHC for planning, budgeting and monitoring has uniquely positioned Bhutan to implement “Health in All Policies”, SDGs and other develop- mental activities through the overar- ching principles of GNH. As shown in Figure 10, Gross National Happiness has four Pillars and nine domains with Physical Health and Psycho- logical wellbeing as the centre for health and wellbeing. All other domains, including time use, also has impact on health of population. All planning processes are prioritised based on its contribution to the nine domains. For example, the 12th FYP was developed based on its contributions to the nine domains and any proposal/developmental activity that negative- ly impacts the domain are given lesser priority during the planning and budget allocation process. 45% Gross National Happiness En vi ro nm en ta l C on se rv at io n Pr es er va ti on o f cu lt ur e & tr ad it io n G oo d G ov er na nc e So ci o ec on om ic de ve lo pm en t Living standard Community vitality Time-use Psychological well-being Good Governance Cultural resilience & promotion Education Health Environment Figure 10: GNH with four Pillars & nine domains 34 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : THE DEVELOPMENT PARTNERS 3.1 Main health and development partners in Bhutan Apart from WHO, there are other bilateral and multilateral develop-ment partners that contribute to the development of health in Bhutan. Among the bilateral partners, the Government of India, Switzerland and Bangladesh are the current partners. European Union (EU), SAARC Development Fund (SDF), Asian Development Bank (ADB), UNDP, UNICEF, UNFPA, GFATM, and GAVI are the multilateral collaborating partners. Among the international NGOs, Rotary Club of Thimphu, Bhutan Foundation, Himalayan Cataract Project, JICA are some of the main partners (Annexure 1). In the past DANIDA and World Bank made substantial inputs to health development. 3.2 Collaboration with the United Nations System at country level The UNSDPF (2019-2023) aims to mobilise and invest an estimated USD 120 million to achieve results in the following four outcome areas, by 2023: 1. Enhanced access to and use of reliable and timely data for inclusive and evidence-based policy and decision making; 2. Vulnerable and unreached people access and receive quality health, nutrition, protection, education, water, sanitation and hygiene services; 3. National stakeholders strengthened to provide equal opportunities for all, particularly women, and vulnerable groups; and 3 35 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : 4. Bhutan’s communities and its economy are more resilient to cli- mate-induced and other disasters and biodiversity loss as well as economic vulnerability. These four outcomes directly support the RGoB’s 12th Five Year Plan 2019 – 2023 and 10 of its 17 National Key Results Areas of the 12thFYP[13]. 3.3. Engagement of WHO with development partners in Bhutan • WHO collaborates with UNICEF and UNFPA on maternal, neonatal, repro- ductive, child and adolescent health. • Development partners such as the World Bank, Asian Development Bank (ADB) and Japan International Cooper- ation Agency (JICA) engage and coor- dinate with WHO for technical support on health policy and planning. • As a member of the Country Coor- dinating Mechanism (CCM), WHO continues to provide technical assis- tance for effective implementation of activities funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria in Bhutan. • The country office received support for implementing activities in response to flash floods and landslides in 2016 from the South-East Asia Regional Health Emergency Fund (SEARHEF) [14]. • There are 24 UN agencies, includ- ing WHO, that work closely with the Royal Government of Bhutan. One UN working modality is guided by the United Nations Sustainable Develop- ment Partnership Framework and this framework was agreed mutually by the United Nations and the Royal Govern- ment of Bhutan [13]. • Other developmental partners can leverage on WHO’s close working rela- tionship with MoH and also utilise the technical capacity of WHO, for health related policies, activities and other initiatives. • WHO can also coordinate and provide technical support for other develop- mental partners in health sector. 36 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : HISTORY OF COLLABORATION: WHO & BHUTAN MILESTONES • Established in 1983 to provide technical advisory cooperation CORE FUNCTIONS • Provide health leadership & gover- nance • Generation, translation and dis- semination of knowledge through research • Setting norms and standards • Articulating ethical & evi- dence-based policy options • Providing technical support • Monitoring health situation and assessing health trends AREAS OF FOCUS • Universal Health Coverage & PHC • Communicable diseases • Noncommunicable diseases & lifestyle-re- lated disorders • Promoting health through life course with focus on RMNCAH • Health systems strengthening • Preparedness, surveillance & response • Environmental health including water, sanitation & waste management and climate change • Capacity building of health workforce. KEY ACHIEVEMENTS OVER PAST 5 YEARS • Bhutan received the Polio Free Certification in 2014 • Measles eliminated in 2017 and elimination sustained • Achievement towards malaria elimination is on track • Maternal and neonatal tetanus eliminated in 2016 • Conferred with the 2017 World No Tobacco Award 4 WHO’s work in Bhutan 37 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : HISTORY OF COLLABORATION: WHO & BHUTAN LESSONS LEARNT & OPPORTUNITIES 9 Bhutan has managed to have a func-tional and effective primary health care with Health Assistants (HA), Auxiliary Nurse Midwives (ANMs) and Basic Health Workers (BHW) as the foot soldiers. This focus on primary and public health approach- es has yielded dividends in improving the overall health and wellbeing of the population. Notwithstanding the constraints of human resources shortage, in-house institutional capacity, geographical terrain, health informa- tion system and data management, Bhutan still has the added advantages as outlined below: • Bhutan is a peaceful and stable coun- try with progressive socio-economic development • The health systems in Bhutan is grounded on the principles of PHC and is guided by the developmental philos- ophy of GNH, that has both physical and mental health as the core domain • All healthcare services are provid- ed free by the Royal Government of Bhutan and no private practices are allowed in the country • Health Help Centre (HHC) was es- tablished for tele-consultations and maintains a fleet of ambulances in all hospitals across the country for quick referrals • The helicopter services for emergen- cy patient evacuation has become a popular means of patient referral since 2014 • With the establishment of Khesar Gyalpo University of Medical Sciences (KGUMSB) in the country, the skills development of health workforce has become more convenient • Supplied seven MCKs to JDWNRH, CRRH, MRRH, Trashiyangtse, Trongsa, Chhukha and Trashigang Hospitals • Supported establishment and growth of Bhutan Health Trust Fund • Supported in Piloting PEN-HEARTS people centered NCD approaches in four Districts of Wanduephodrang, Zhemgang, Punakha and Tsirang and plans for nationwide roll out after evaluation • Supported expansion of health and well-being promotion through installations of about 700 units of Open Air Gym equipment in 20 districts and 4 thromdes • Electronic Patient Information systems (Epis) launched • National Action Plan on AMR 2018-2022, launched on Nov 2017 • Controlled rubella and congenital rubella syndrome 38 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : SETTING THE STRATEGIC PRIORITIES 5.1 Strategic Priorities The main documents reviewed for setting the priorities of this CCS are 12th FYP, WHO 13th GPW and UNSDPF 2019-2023. In addition, programme specific strategic documents, situational analysis reports, published and grey literature, Bhutan “health in transition” doc- ument, health situational analysis and review documents were also reviewed. Consultation with key MoH leaders and programme manag- ers, Gross National Happiness Commission and with UN partners were also carried out. The findings consolidated towards five key stra- tegic priorities after identifying the gaps and aligning the outcomes. The following five keys strategic priority and focus areas were agreed to by the core working group and presented to stakeholders after which comments were incorporated. Achieve UHC through Integrated people- centered quality health care services15 • Strengthening health governance and leadership with focus on PHC • Enhancing accessibility to integrated people-centered quality health care services across continuum of care and life cycle • Promotion of multi-sectoral collab- oration and actions for Health in All Policies • Development of health workforce com- petency and institutional capacity to create PHC specialists and coaches • Developing and implementing innova- tive model of care • Instituting sustainable health financing model and making an investment case for health beyond LDC graduation Improve reproductive, maternal, newborn, child, adolescent health (RMNCAH) and healthy aging • Strengthening quality SRH services • Strengthening prevention of maternal death, newborn deaths and stillbirths • Strengthening cancer prevention and care with special focus on cervical cancer elimination • Enhancing demand creation of adolescent friendly health services • Establishing Health Promoting institutions including schools and monastic institutions • Sustaining high routine immunisation coverage 1 2 5 39 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : Build health system resilience to address communicable diseases and effects of health emergencies and climate change • Strengthening IHR and emergency risk management including bio-safety and bio-security • Elimination of malaria, MTCT of HIV,- syphilis and hepatitis B, leishmaniasis and other NTD, sustain elimination of leprosy, measles, and accelerate end TB strategy • Establish urban health to meet growing needs of urban population and rural-ur- ban migration • Conducting Health Impact Analy- sis(HIA) • Strengthen diagnosis, surveillance, outbreak management and advocacy of AMR, zoonotic, dengue and other vec- tor-borne diseases, food safety including bio-safety and bio-security systems • Strengthen health adaptation plans for climate change • Strengthen advocacy and risk commu- nication on communicable diseases Address NCDs and its determi- nants with strategic priority • Reducing burden of NCDs through multi-sectoral actions and WHO recommended best buys approaches • Initiatives to reduce alcohol consumption • Initiatives to reduce overweight, under nutrition and physical inactivity • Implementation of people-centred team based NCD programme in all health facilities • Strengthen mental health services with emphasis on suicide prevention • Strengthen health promotion on NCD’s prevention Strengthen data, research, innovation and knowledge brokerage • Strengthening health surveillance and research capacity • Strengthening laboratory diagnostic capacity to address emerging and re- emerging diseases • Adoption of digital technology to deliver quality primary health care • Strengthen WCO capacity to provide independent technical and policy direction to MoH • Enhance Institution capacity for research, training, innovation, primarily focusing on PHC • Establish health data repository and health metrics • Establishing “Centre of excellence” in traditional medicine and priority public health areas 3 4 5 CCS - 2020-24 S tr at eg y 1 S tr at eg y 2 S tr at eg y 3 S tr at eg y 4 5 - Strengthen data, research Innovation + knowledge brokerage 40 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : 5.2. Prioritisation process and alignment to GPW, National Plan and UNSDPF 12th FYP Joint WHO-Country Priorities Identified 2020-2024 Sustainable Development Goal 2030: Ensure Healthy lives and Promote Wellbeing for all at all ages Comparative analysis across elements undertaken 1. Definition of WHO’s comparative advantage in country, capacity and resources 2. Review of good practices and lessons learned 3. Extensive cross-sectoral dialogue, consultation and negotiation Health Situation Analysis WHO’s13th GPW 3 strategic priorities UNSDPF 2019-2024 Outcome CCS 2020-2024 PRIORITIES IDENTIFIED – AND KEY ALIGNMENT Achieve UHC through integrated people-centered quality health care services Improve reproductive, maternal, newborn, child, adolescent health (RMNCAH) and healthy aging Build health system resilience to address communicable diseases and effects of health emergencies & climate change Address NCDs and its determinants Strengthen data, research, innovation and knowledge brokerage SDG 2030 Goal 1, 2, 3, 4, 5, 6, 10, 11, 17 Goal 1, 2, 3, 4, 5, 6, 10 Goal 1, 2, 3, 5, 6, 9, 10, 11, 13, 15 Goal 1, 2, 3, 6, 10, 11 Goal 1, 2, 3, 5, 6, 10, 13 GPW13 Strategic Priorities focus & Outcome Outcome 1.1, 1.2, 1.3, 4.1, 4.2, 4.3 Outcome 1.1, 1.2, 1.3, 4.2, 4.3 Outcome 2.1, 2.2, 2.3, 2.4 Outcome 3.1, 3.2, 3.3 Outcome 4.1 UNSDFP 2019-23 Outcome 2, 3 Outcome 2, 3 Outcome 2, 4 Outcome 2 Outcome 1 41 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : 12th Five Year Plan 2019-23 NKRA *14: Healthy & Caring Society AKRA* 1: Improved access to quality health care services that is inclusive, responsive and equitable NKRA3: Reducing poverty and inequality NKRA 10: Gender Equality AKRA2: Efficiency, effectiveness in delivery of health service strengthened NKRA17: Sustainable water supply AKRA 13: Drinking water supply and sanitation improved NKRA 14: Healthy & Caring Society AKRA 1: Improved access to quality health care services that is inclusive, responsive and equitable NKRA3: Reducing poverty and inequality NKRA 10: Gender Equality AKRA2: Efficiency, effectiveness in delivery of health service strengthened NKRA 14: Healthy & Caring Society NKRA 6: Carbon neutrality, climate change and disaster resilient NKRA 14: Healthy & Caring Society NKRA 8: Food and Nutrition Security NKRA 14: Healthy & Caring Society NKRA3: Reducing poverty and inequality NKRA 10: Gender Equality NKRA 7: Quality education and skills *National Key Result Areas (NKRA), Agency Key Result Areas (AKRA) Bhutan CCS seeks to build on the previous CCS and achieve what was not achieved [16]. The Bhutan WHO-CCS was developed in line with global and national priorities particularly with the following strategies: a. Sustainable Development Goals 2030 Developed in 2015, SDG covers 17 Sustainable Development Goals and 169 targets [17]. These targets are balanced under the socio-economic and environmental dimensions and are integrated and non-divisible. Although, Goal 3 with 13 indicators is the primary target relevant for health, 10 other goals and more than 50 indicators are pertinent and contributory to the health goals. 42 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : b. 13TH General Programme of Work 2019-2023 [18] The 13th GPW 2019-2023, with triple billion goal of achieving: a) 1 billion more people benefiting from universal health coverage b) 1 billion more people better protected from health emergencies c) 1 billion more people enjoying better health and wellbeing The GPW outlines 10 outcomes, out of which outcome 9 and 10 are WHO leadership and enabling Outcome. c. United Nations Sustainable Development Partnership Framework for Bhutan 2019- 2023[13] To assist the developmental goals of Bhutan and to enable Bhutan to successfully graduate from LDC in a sustainable manner, the UNSDPF articulates collective vision of the UN systems in Bhutan for 2019-2023. The CCS draws from UN guidance for priority and outcome setting. While Outcome 1 and 2 are the most relevant, Outcome 3 and 4 also contribute to the overall improve- ment of health and that is unique to Bhutan. d. WHO Regional priorities and Flagship programmes Under the leadership of the Regional Director, WHO SEARO is dynamically moving forward within next five years for a “A more responsive WHO in the South-East Asia Region [19] with fol- lowing four strategic visions: a) Addressing the persistent and emerging epidemiological and demographic challenges b) Strengthening emergency risk management for sustainable development c) Advancing universal health coverage and robust health systems d) Articulating a strong regional voice in global health Outcome Enhanced access to and use of reliable and timely data for inclusive and evi- dence-based policy and decision making; Outcome Vulnerable and unreached people ac- cess and receive qual- ity health, nutrition, protection, education, water, sanitation and hygiene services; Outcome National stakehold- ers strengthened to provide equal opportunities for all, particularly wom- en, and vulnerable groups; Outcome Bhutan’s communi- ties and its economy are more resilient to climate- induced and other disasters and biodiversity loss as well as economic vulnerability. 1 2 3 4 43 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : The Regional Director’s Flagship Programme 1. Eliminate measles and rubella by 2023 2. Prevent and control non-communicable diseases through multi-sectoral policies and plans, with a focus on “best buys” 3. Accelerate reduction of maternal, neonatal and under five mortality 4. Continue progressing towards universal health coverage with a focus on human resources for health and essential medicines 5. Further strengthen national capacity for preventing and combating anti-microbial resistance 6. Scale-up capacity development in emergency risk management in countries 7. Finish the task of eliminating neglected tropical diseases (NTDs) and other diseases on the verge of elimination 8. Accelerate efforts to end TB by 2030 e. 12th Five Year Plan and Flagship programmes The 12th FYP covers the period from 2018-2023. For the first time, it diverges from the earlier plans by using the nine domains of GNH and moves towards consolidation, coordination and collaboration. Of the nine domains, psychological wellbeing, health and community vitality are directly related to the MoH’s National Key Result Area (NKRA) 14 “Healthy and Caring Society”. Other domains also impact on the Health NKRA. For example, KGUMSB’s responsibility for health HR production is responsible for NKRA 7 that is “Quality Education and skill” of the Ministry of Education. Main focus for MoH Flagship:2019-2023 1. Early screening and prevention of cancers 2. Provision of specialised outreach camps 3. Expanding people centered team-based PEN-HEARTS initiatives to all districts 4. Accelerating mother and child health 5. Improving capacity of health facilities to reduce referrals - Expanding services at the regional referral hospitals - Upgrading strategic BHU-IIs to BHU-Is to more diagnostic services and human resources 44 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : MEASURING & ACCOUNT- ING FOR RESULTS At the end of successful implementation of Bhutan CCS 2020-2024, it is expected that: Indicators Baseline (year) Target (2024) Sources of baseline Indicator alignment Priority 1 – Achieve UHC through Integrated people-centered quality health care services Universal health coverage Index 75 >90 Base line as per SGD report GPW, SDG No of doctors per 10,000 population 4.3 4.9 As per AHB 2018 12FYP, SDG, GPW • Bhutan has successfully graduated from LDC with robust health systems based on the principles of PHC • Bhutan is self-sufficient of core health workforce. • Reduced maternal and newborn deaths • Strengthened adoles- cent health services • Healthy aging strat- egy developed and implemented • Bhutan on track towards cervical cancer elimination • People-centered team based NCD approach imple- mented in all health facilities and premature death due to NCDs reduced • MTCT of HIV, syphilis and hepatitis B, leishmaniasis and other NTDs are eliminated, elimination of leprosy and measles is sustained and end TB strategy accelerated • Increased response to AMR, emergen- cy response capacity and access to medicines • Malaria is successfully elim- inated and institutions to sustain elimination is put in place • IHR core capaci- ties are strengthened • Capacity for research, training, innova- tion, primarily focusing on PHC, are strengthened • WCO capacity is enhanced to guide and provide strategic and technical directions to the gov- ernment of Bhutan 6 45 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : Indicators Baseline (year) Target (2024) Sources of baseline Indicator alignment Percentage of private expenditure (OOP) on health as percent of total health expenditure 20 % <25 % 12FYP base and target 12 FYP, SDG, UNSDPF, GPW Current health expenditure as percentage of GDP 3.71% 5% 12FYP base and target 12 FYP, SDG, UNSDPF, GPW Priority 2: Improve reproductive, maternal, newborn, child, adolescent health (RMNCAH) and healthy aging Maternal mortality ratio (per 100,000 live births) 89 83 12FYP base and target 12 FYP, SDG, GPW Infant mortality rate 15.1 <15 12FYP base and target 12 FYP, SDG, GPW Newborn mortality rate 21 13 12FYP base and target 12 FYP, SDG Prevalence of stunting in children under 5 (%) 21.5 15.1 World Health Statistics 2018, Monitoring Health for SDGs SDG, 12FYP, GPW Anemia prevalence in children 43.8% 31.2% UNSDPF UNSDPF, SDG 12FYP Proportion of women screened by Pap smear (25-65 years) 56 70 12FYP base and target 12FYP, SDG Adolescent fertility rate 14.2 14.2 12FYP base and target 12FYP, SDG Proportion of elderly population reached through community based elderly care services 50 >90 12FYP base and target 12FYP, SDG 46 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : Indicators Baseline (year) Target (2024) Sources of baseline Indicator alignment Priority 3 – Build health system resilience to address communicable diseases and effects of health emergencies & climate change % of people using basic sanitation services 63% 95% UNSDPF SDG IHR core capacity index 45.4% 60 Joint external evaluation 2017 SDG, UNSDPF, 12FYP, GPW Eliminate malaria (No of indigenous malaria cases) 15 0 12FYP 12 FYP, SDG, GPW Number of health facilities implementing health and climate change programmes 25 45 12FYP 12 FYP Priority 4: Address NCDs and its determinants Mortality between 30 and 70 years of age from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases (male/female) 34 <25 12FYP base and target SDG, UNSDPF, 12FYP, GPW Suicide rate per 100,000 population 12 <12 12FYP base and target SDG, 12FYP, GPW % of population aged 18-69 years who currently use alcohol 42.4 39.4 12FYP base and target GPW, SDG 12FYP Priority 5: Accelerate research, innovation and knowledge brokerage % of health facilities using electronic patient information system 0 75 12FYP 12FYP, UNSDPF No of peer reviewed research paper published 25 100 12FYP (KGUMSB) Health information management systems incorporate relevant SDG and WHO indicators 0 100 UNSDPF SDG, UNSDPF 47 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : MONITORING AND EVALUATION OF CCS 7.1. KEY MILESTONES, APPROACH & ACTIVITIES 2020 2021 2022 20232024 CCS Launched Monitoring of implementation CCS mid-term evaluation Monitoring of implementation CCS final evaluation • Main health outcomes, baseline and targets established for each strategic priority. • Ensure country- level data available or capacity strengthened where required. • Monitoring the programme implementation, efficient and effective utilisation of budget. Country Office- led evaluation of: • Progress toward health outcomes • Implementation of Country Work Plan 2020-21 • Report with recommendations shared with the government, within WHO and partners • Monitoring the programme implementation, efficient and effective utilization of budget Beginning 2024 joint evaluation for: • Health outcomes • Implementation of work plans • Qualitative success stories • Lessons learned CCS Final Evaluation published and extension/new CCS development initiated 7 48 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : IMPLEMENTATION: CONTRIBUTION FROM WHO & PARTNERS 8.1. Key contributions to the four Strategic Priorities Priority 1 –Achieve UHC through integrated people-centered quality health care services WHO’s Key Contribution Country office Regional Office Headquarters • Strengthen national capacity to make systematic shifts for team based PHC at the District aimed at ensuring UHC and reducing gender and health equity gaps. • Provide governance and technical guidance for ensuring quality PHC that is all inclusive, comprehensive, community focused, people centered and sustainable, including alternative health financing models. • Strengthen country office capacity in supporting the adaptation and strengthening of health information systems. • Adapt global tools to the regional context to improve health system governance, including institutional, legal, regulatory and societal frameworks, and coordinate with regional partners to accelerate UHC. Advocate for regional voice and fund mobilisation. • Develop guidance and support for improving equitable access to medicines and health technology. Provide global standards for delivering people- centred team based PHC. • Generate international best practices and develop guidance in leading multi-sectoral policy dialogue and capacity-building for effective development and implementation of “Health in All Policies” towards UHC. Success will look like: • Strengthened leadership for equity and financial protection of health care delivery • Re-aligned health service delivery to cater effective, people-centred integrated quality health care across continuum of care and life cycle 8 49 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : • Strengthened multi-sectoral collaboration and actions with health in all policies • Strengthened health workforce competency • Developed institutional capacity to create PHC specialist and coaches • Enhanced elderly and palliative care services to provide quality service in proximity to their houses • Established a sustainable health financing model Key partners • MoH, GNHC provide leadership in delivering UHC. UNICEF, UNFPA, ADB, WB to support RGOB initiatives. NGOs, CSO, CBO to support RGOB in reaching vulnerable and unreached population. • Local government and districts to support implementation of UHC at community level. • KGUMSB and other health institutes to develop training modules to equip health workers during pre and in-service periods, particularly in critical areas of health needs. • BMHC to ensure that the quality of training is maintained. Priority 2: Improve reproductive, maternal, newborn, child, adolescent health (RMNCAH) and healthy aging WHO’s Key Contribution Country office Regional Office Headquarters • Support establishment and coordination of cross-sectoral partnership mechanisms on strengthening RMNCAH initiatives. • Engage partners to create synergies between different programmes for ending preventable maternal and newborn deaths. • Support capacity to develop and implement programmes to address violence against children, women and young people, and monitor their implementation. • Strengthen capacity and support generation of evidence in Bhutan for reaching the unreached and meeting the unmet needs of RMNCA Health issues. • Provide a platform for advocacy and sharing of policy options, experiences and best practices, and support policies and strategies to end preventable maternal and peri-natal death • Conduct regional and inter- country capacity-building efforts for policy and programme development and monitoring to prevent and respond to violence. • Develop evidence- based policies and technical and clinical guidelines covering unmet needs in sexual and reproductive health and healthy aging. • Design and disseminate tools to help strengthen, develop, and monitor national nutritional plans and policies. 50 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : Success will look like: • Quality SRH services are available, accessible and accountable to clients and communities served • Newborn deaths and stillbirths due to preventable causes reduced • Cervical cancer eliminated • Adolescent friendly health services strengthened • Health Promoting schools instituted • Healthy ageing strategy implemented • People-centred health services, based on PHC strategies and comprehensive essential service packages, provided Key partners • Key UN partners that share core mandates of RMNCAH are UNICEF, UNFPA and WFP. In addition, GNHC will provide key coordination stewardship. • NGOs such as Bhutan Cancer Society, Lhaksam, Royal Society of Senior Citizens, Bhutan Kidney Foundation, YDF and others will complement government initiatives. Youth group’s engagement for activities will focus on adolescents. Priority 3: Build health system resilience to address communicable diseases and effects of health emergencies & climate change WHO’s Key Contribution Country office Regional Office Headquarters • Support establishment and maintenance of surveillance and prevention programmes for high-threat infectious hazards, AMR. • Support the evaluation and strengthening of IHR core capacities. • Lead health cluster response in emergencies. • Provide technical support for HTA and HIA. • Support country office to run simulation exercises and after-action reviews as part of country IHR evaluation. • Support establishment of national health emergency operations centres, early warning and response, laboratories. • Provide technical assistance and training for country office in the performance management systems • Develop methodologies and tools and generate evidence to support development of policies, strategies and regulations for prevention and management of environmental and occupational risks and climate change, including in sectors of the economy other than health. 51 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : Success will look like: • Strengthened IHR and emergency risk management including bio-safety and bio- security • Elimination of diseases earmarked for elimination including malaria, PMTCT, cervical cancer, leprosy, measles, leishmaniasis • Strengthened urban health to cater to needs of urban population and address influx of rural-urban migration • Country capacity enhanced to assess health risks and to develop and implement policies, strategies or regulations for prevention, mitigation and management of health impacts related to environmental and occupational hazards • Strengthened diagnosis, surveillance, outbreak management and advocacy of AMR, zoonotic diseases, food safety including bio-safety and bio security systems • A health adaptation plan for climate change is developed and implemented Key partners • Ministry of Health– preparedness • WFP, MSF and UNICEF – delivering essential food, health services and vaccinations in emergencies • World Bank – Providing funding to strengthen IHR core capacities, Ministry of Environment / Ministry of Health – programme implementation and monitoring • UNEP - advocacy and monitoring of climate index • UNICEF is key partner in water and sanitation, contributing financial and technical assistance • CSO and community action on climate change and the climate coalition 52 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : Priority 4: Address NCDs and its determinants WHO’s Key Contribution Country office Regional Office Headquarters • Strengthen MoH capacity on implementation of multi-sectoral approach to NCD prevention and control. • Provide TA on STEP survey and establishing NCD burden. • Provide Technical Guidance and Assistance on Cancer Control, management, establishing cancer registry. • Provide support in strengthening WHO country office capacity. • Provide regional voice for resource mobilisation and making visible the growing burden of NCD in SEARO. • Provide technical support and resource to the country office. • Provide WHO technical documents and good practices on NCD prevention and control. Success will look like: • Reduced burden of NCDs through multi-sectoral actions • Reduced harmful use of alcohol • Reduce overweight and physical inactivity • People-centered team based on NCD approach implemented in all health facilities • Gaps in Mental Health initiatives supported • Reducing trend of suicide rate • Multi-sectoral risk factors addressed through engagement with public and private sector as well as civil society Key partners • MoH to provide stewardship and policy directives; Local leaders to implement community action to reduce alcohol and other NCDs • NGOS and other CSO and CBOs to augment MoH initiatives 53 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : Priority 5: Accelerate research, innovation and knowledge brokerage WHO’s Key Contribution Country office Regional Office Headquarters • Provide technical support to strengthen national level capacity and institute WHO collaborating centres where Bhutan is to showcase e.g. PHC. • Provide policy and strategic guidance to MoH. • Invest in data repository and data management and information generation for policy shifts. • SEA-ACHR to provide strategic direction in strengthening research capacity of country and the WHO office. • Provide global platform for data repository and data management and information generation for policy through WHO-iris. Success will look like: • Accurate measurement of the population in need of services • Monitoring equality in access to quality health services • Enhanced research and laboratory capacity to address emerging and re-emerging diseases • Digital technology adopted as a means to delivering quality PHC • Strengthened WHO staff capacity to provide independent technical and policy direction to MoH • Enhanced academic institution capacity for research, training, innovation, primarily focusing on PHC • More effective and efficient WHO country office supporting countries in a better way Key partners • MoH and NSB to provide policy directives and technical expertise • KGUMSB to facilitate research and develop data repository and information sharing • Private companies /individuals/NGOS/CSOs to complement the MoH in research initiatives 54 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : B hutan has a maturing health system and as Bhutan prepares to graduate from LDC in 2023, there is need for greater involvement of WHO as an independent technical organisation. The current CCS, therefore, mandates the WHO country office to provide technical direc- tions, policy guidance and strategic approaches for further development of Bhutan’s health systems. It will also provide intense advocacy for making investment case in the Bhutanese health system. WHO should now focus towards providing high quality technical support, institutional devel- opment and human resource development for more specialised patient care. In order to achieve the goals of the CCS, the WHO country office for Bhutan should have ade- quate staff with technical expertise in specialised health domains, as such there is a need to review the current staffing pattern and strengthen it if necessary. In addition, WHO may maintain repository of national technical individuals and institutes in order to augment the WCO as and when required. WHO may complement the efforts of the RGoB and other development partners in improving health outcomes. It will also liaise with other international players to explore viable health financing op- tions to sustain the provision of free health care services at the point of contact. The WHO may follow the WHO-SAI matrix as envisioned by the Regional Director, SEARO, to provide impetus to the implementation of the CCS, as highlighted in annex 2. The CCS will also require coordination and provision of technical expertise and resource back- up, both from the WHO Regional Office for South–East Asia and WHO headquarters. In implementing the CCS, the country office will work in close collaboration with MoH as the direct government implementation partner. However, other ministries, autonomous agencies, United Nations team, other bilateral and international organizations and stakeholders in the country would become ever more important to promote WHO agenda for advocating health and wellbeing of the Bhutanese population. Collaboration with NGOs in reaching out to the unreached or hard to reach population by the government agencies will be an added value in achieving the UN agenda of leaving no one behind. Implementing the CCS will be as per existing mechanisms, with MoH taking the lead role in setting national health agenda and priorities. WHO will work as a Health Sector support and will engage with health sector related agencies within the ambit of the health sector priorities and policies. To monitor the outcome, CCS will require constant monitoring both internally and jointly. More so, a CCS monitoring team may be instituted with representatives of WHO, GNHC, MoH and UN to frequently check the progress of the CCS and also enhance collaborative approaches of the CCS. 9 CCS IMPLEMENTA-TION APPROACHES: 55 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : 1. National Statistical Bureau, Key Indicators 2019. 2. Richard Marshall, Graduation from the group of least developed countries: prospects and challenges for Bhutan 2013. 3. Ministry of Health, Annual Health Bulletin. 2019. 4. World Health Organization, Global Health Observatory (GHO) data. 2018. 5. Ministry of Health, The Multi-sectoral National Action Plan for the and Control of Non-Communicable Diseases (2015-2020). 2015. 6. World Health Organization, WHO, Review of capacity needs for implementation of the national multisectoral response for prevention and control of NCDs and the UNIATEF recommendations in Bhutan. 2018. 7. Ministry of Health, National Health Accounts, Bhutan Fiscal Years 2014-15 & 2015-16 8. World Health Organization, Parliamentarians’ resolve to accelerate NCD prevention and control for a ‘Happy and Healthy Bhutan by 2030’. 2019. 9. Gross National Happiness Commission, 12 Five Year Plan: Vol 1. 2019. 10. Gross National Happiness Commission, Final Report of Eleventh Five Year Plan 2013- 2018. 2018. 11. Ministry of Health, Health Emergency and Disaster Contingency Plan. 2016. 12. World Health Organization, Joint External Evaluation of IHR Core Capacities of the King- dom of Bhutan. 2017. 13. United Nation, United Nations Sustainable Development Partnership Framework for Bhutan: 2019-2023. 2019. 14. World Health Organization, South-East Asia Regional Health Emergency Fund (SEARHEF). 2019. 15. World Health Organization, WHO Framework on integrated people-centred health ser- vices Integrated primary health care-based service delivery in the Global Conference on Primary Health Care. 2017. 16. World Health Organization, WHO, Country Office of Bhutan, Mid-Term WHO Country Cooperation Strategy Bhutan 2014-2018. 17. United Nations, Sustainable Development Goals. 18. World Health Organization, Thirteenth general programme of work 20192023. 2018. 19. World Health Organization, 1by4 Strategic Vision of Regional Director: SEA Region. 10 REFERENCES 56 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : ANNEXES Annexure 1: Development Partners Country/organization/Agency Health Focus area India Health infrastructure development & HR developments Switzerland Construction of Wangdicholing hospital, promotion of primary health care through General Practioner. The project is in collaboration with MoH, Bumthang Hospital and KGUMSB. Denmark ( DANIDA) Supported Infrastructure strengthening; Rural Water Supply Scheme before they phased out in 2010: Human resource development; Bangladesh Supply of essential medicines European Union (EU) Emergency Health in collaboration with WHO SAARC Development Fund (SDF) Supported was mainly in MCH (infrastructure, equipment and capacity building in the 10th FYP Asian Development Bank (ADB) Currently supporting in three areas of Primary Health Services i.e Support to health sector financing enhanced for HTF and Disease surveillance and Health Information Systems enhanced UNICEF Child health (IMNCI, nutrition, IYCF, PMTCT, AFHS) 11 57 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : ANNEXES UNFPA Reproductive health GFATM HIV/AIDS, TB and malaria GAVI Improving Immunisation Coverage, Health system strengthening Bhutan Red Cross Society Disaster management health promotion and social services Rotary Club of Thimphu Safe drinking water especially in schools Bhutan Foundation Research and Publication at KGUMSB and Emergency Health Service Himalayan Cataract Project Capacity building; Cataract services; Primary eye care (minimal) JICA Medical equipment and ambulances 58 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : WHO SIA matrix for Key Priority areas Key Priority area Sustain, Innovate and Accelerate Sustain Innovate Accelerate Achieving UHC through Integrated people- centered quality health care services • Current momentum of political leadership • Free health care for all • Current focus on PHC • Realign and Re- orient the current health care deliver to make it people centred approach • Sustainable financing mechanism • To reduce OOP expenditure • Development and implementation of health ACT • Human Resource Development and institutional capacity • Mechanisms to reach the unreached and reduce equity gaps • Fulfilling CCS, GPW & SDG targets Improving reproductive, maternal, new-born, child, adolescent health (RMNCAH) and healthy aging • Current coverage of immunisation, institutional delivery, ANC & PNC coverage • Reaching the unreached and getting 100% coverage • Reaching the adolescent in reducing health risk behaviours • Support healthy aging innovations • Reorient health care delivery to align life course approach at hospitals • Reaching the unreached and reaching 100% services for RMNACH • Reaching adolescents for reducing health risk behaviour • Implementation of healthy aging strategies Building health system resilience to address communicable diseases and effects of health emergencies & climate change • Current efforts for disease elimination, AMR activities, climate change mitigation and adaptations including other communicable diseases • Mechanisms to sustain elimination activities • Climate change and disaster resilient health infrastructure and systems • Reducing AMR • Improving IHR index • Elimination of diseases on the verge of elimination • Curbing AMR and MDR TB 59 W H O C O U N T R Y C O O P E R A T I O N S T R A T E G Y 2 0 2 0 - 2 0 2 4 : Key Priority area Sustain, Innovate and Accelerate Sustain Innovate Accelerate Addressing NCDs and its determinants • Multisectoral actions for curbing NCDS • Current legal, political and community pressure to reducing smoking and alcohol consumption • Ways to reduce alcohol, salt and trans fat consumption • Promotion of physical activity • Palliative care and premature death • Reduce NCD risk factors through multi-sectoral people centred team based approaches • Institute palliative and elderly care services. Strengthening data, research, innovation and knowledge • Key surveys conducted periodically by programmes and MoH • B-SMART courses conducted by MoH/KGUMSB • Bhutan Health Journal publication • Institute data repository system for all surveys and develop policy briefs and information packages • Establish centre of excellence to boost institutional capacity • Research activities in funding modality and health systems • Research activities and publications to improve knowledge bank • Developing data to information and brokerage evidence based policy shifts and decisions