WHO Country Cooperation Strategy Bhutan 2009–2013
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. 3. Health Planning. 5. Strategic Planning. ISBN 978-92-9022-391-7 2. Delivery of Health Care. 4. International Cooperation. 6. Bhutan. (NLM classification: WA 540)
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Contents 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
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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
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Foreword 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
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List of acronyms AC AEFI AFP AI AIDS ARI BHTF BHUs CAP CCA CCM CCS DD DOTS DRA DVED EmOC GATS GAVI GDP GEF GFATM GNH GNM GPW GSM HA HIV HMN IDD IHR IMCI IMR IT JE MDGs MDR MMR MoH MOSS NCD NGO assessed contribution adverse effects/events following immunization acute flaccid paralysis avian influenza acquired immune deficiency syndrome acute respiratory infection Bhutan Health Trust Fund basic health units consolidated appeal process Common Country Assessment Country Coordinating Mechanism Country Cooperation Strategy diarrhoeal diseases directly observed treatment, short-course Drug Regulatory Authority Drugs, Vaccines and Equipment Division emergency obstetric care General Agreement on Trade in Services Global Alliance for Vaccines and Immunization gross domestic product Global Environment Facility Global Fund to Fight AIDS, Tuberculosis and Malaria Gross National Happiness general nurse midwife General Programme of Work Global Management System health assistant human immunodeficiency virus Global Health Matrix Network iodine deficiency disorder International Health Regulations Integrated Management of Childhood Illnesses infant mortality rate information technology Japanese encephalitis Millennium Development Goals multidrug resistance maternal mortality ratio Ministry of Health minimum operating security standard noncommunicable diseases nongovernmental organization
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NHA NIPPP NITM NPO ORCs PHC PRSP RB RGoB RIHS RSTA RWSS SARS SEAR SEARO STI SWAp TB TRIPS UCI UN UNDAF UNFPA UNICEF VC VHW WB WFP WHO WR WTO
National Health Account national influenza pandemic preparedness plan National Institute of Traditional Medicine National Professional Officer out-reach clinics primary health care Poverty Reduction Strategy Paper regular budget Royal Government of Bhutan Royal Institute of Health Sciences Road Safety and Transport Authority rural water supply and sanitation severe acute respiratory syndrome South-East Asia Region Regional Office for South-East Asia (of WHO) sexually transmitted infections sector-wide approach tuberculosis Trade-Related Aspects of Intellectual Property Rights universal child immunization United Nations United Nations Development Assistance Framework United Nations Population Fund United Nations Children’s Fund voluntary contribution village health workers World Bank World Food Programme World Health Organization WHO Representative World Trade Organization
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Message from the Honourable Minister, Ministry of Health, Royal Government of Bhutan
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Executive summary 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:
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Public health policy development: Though most of the elements of the National Health Policy are in place they are scattered and compartmentalized in different units. Acute shortage of qualified human resources for health: There is a shortage of especially doctors and nurses at all levels of the health system to ensure quality services in health facilities and to undertake outreach activities. It is a cross-cutting issue for the health sector that affects management, delivery of services and quality assurance. Further strengthening of the health system: Challenges in this regard include: (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: Tuberculosis case detection 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 lowprevalence 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: Bhutan faces a 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 tobacco control culminating in a ban on the sale of tobacco products in Bhutan. However, alcohol abuse remains a major risk factor for noncommunicable
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diseases and substance abuse is a potential problem in the country. Communitybased 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: Bhutan is committed to sustain and 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.
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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 Master Plan.
Strategic Priority 03: Contribute to the strengthening of the health system Fostering the efficient use of health information at all levels of the health system. Development of options for sustainable health system financing. Improved management of decentralized health services and facilities. Norms and standards and quality assurance for basic health care scaled up 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. Further improvement of maternal health with emphasis on reduction of maternal mortality.
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Strategic Priority 05: Help reduce the burden of disease through key interventions focusing on Health Promotion and risk factors with a multisectoral approach Prevention and control of communicable and emerging diseases. Noncommunicable diseases prevention, care and support, emphasizing health 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 for health Provide support to the coordination of partners in health. 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.
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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
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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.
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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
Per cent of population
Source: Population and Housing Census of Bhutan, 2005. Bhutan
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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.
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Table 2.1: Quantitative indicators of poverty Poverty rate (% of people) Whole country Urban Rural Region Western Central Eastern Source: PAR, 2004
Poverty rate (% of households) 25 3 32 13 22 40
Poverty gap index 0.086 0.007 0.105 0.046 0.066 0.147
Severity index 0.031 0.002 0.038 0.016 0.021 0.056
32 4 38 19 30 49
Map of Bhutan
2.3
Health situation
The health situation in Bhutan has improved significantly as revealed by the four national surveys conducted in 1984, 1994, 2000 and 2005, as seen in Table 2.2 below:
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Table 2.2: Overview of major trends revealed by the four national surveys Health status indicator Total fertility rate Crude birth rate (per 1000 population) Crude death rate (per 1000 population) Population growth rate in % Infant mortality ratio (per 1000 live births) Under-5 mortality rate (per 1000 live births) Year 1984 NA 39.0 13.0 3.0 103.0 162.0 1994 5.6 39.9 9.0 3.1 70.7 96.9 380.0 10.9 2000 4.7 34.1 8.9 2.5 60.5 84.0 255.0 23.6 2005* 2.5 20.0 7.0 1.3 40.1 61.5 NA 49.1
Maternal mortality ratio (per 100 000 live 770.0 births) Births attended by trained health staff * Population & Housing Census 2005
NA
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.
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Figure 2.2: Causes of death in 2005 (excluding 33% other causes)
Diarrhoea
10% 3% 5%
1%
6%
1% 9% 2% 5%
TB malaria Cancer diabetes Meningitis/encephalitis heart disease Cerebro-vascular diseases other circulatory diseases common cold pneumonia alcohol liver diseases Other kidney, UT/Genital Disorders pregnancy related Injuries & trauma
19%
9% 4% 9% 16%
1%
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
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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 areas) has been virtually eliminated through strict control of the distribution of noniodized salt. Vitamin A deficiency does not appear to be a major problem because of the routine distribution of large doses of vitamin A during immunization visits. A
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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.
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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. Conservation of the environment. Preservation and promotion of culture. Promotion of good governance. While putting people at the centre of development, sustainable socioeconomic development is not possible without giving due priority to health. The Government sets aside an average of 10% – 11% of the national allocation annually for health. During the Ninth Five Year Plan, the health sector received a 16.6% increase over the original budget. To ensure equity, a pro-poor strategy of providing free basic health-care services for all citizens has been adopted by Bhutan. The Government-donor funding ratio of allocation so far is approximately 60:40.
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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. Bhutan
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Table 2.3: Human resource projections/requirements Type of health worker Medical doctors Specialists* BHU assistant clinical officers BHU health assistants BHU assistant nurse midwives BHU basic health workers BSc nurses General nurse midwives Assistant nurses Technologists’ group Technicians’ group TOTAL *26 specialists were expatriates contracted in 2008 2008 90 64 45 239 122 172 15 270 177 25 476 1695 2013 165 64 45 364 122 172 90 520 177 54 736 2509
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 five and three years respectively. Besides, the Institute also offers two-year certificate
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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 stressand 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 tertiarylevel 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
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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 Constitution, the democratically elected government took charge in January 2008. The Tenth Five Year Plan is being implemented by the new government. With such change in the government certain changes in the organization of
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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.
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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 continued availability of vaccines and essential drugs.
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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.
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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 biennium, this level of support increased to US$ 2 519 000 from assessed contributions (ACs) and about US$ 1000 000 in additional funds from voluntary contributions.
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Table: 4.1: WHO Budget (assessed contributions only) support for Bhutan Year/Biennium 1983 1984–1985 1986–1987 1988–1989 1990–1991 1992–1993 1994–1995 Budget (US$) 258 470 642 000 843 300 1 097 300 1 207 000 1 336 100 1 748 600 Year/Biennium 1996–1997 1998–1999 2000–2001 2002–2003 2004–2005 2006–2007 2008–2009 Budget (US$) 1 897 300 2 184 000 2 184 100 2 075 100 2 051 000 2 731 000 2 519 000
Mobilizing voluntary contributions to WHO has not yet met the full potential to support the work of the Organization in realizing the Strategic Agenda of WHO in the country. Although VC funds were planned in the recent biennium workplans, only a small percentage of planned funds were mobilized. In order to help realize this planned funding, WHO has provided support to the Ministry of Health in conducting a workshop on resource mobilization, including support for improved proposal development. The WHO Country Office consists of the WHO Representative (WR) and six General Service staff members, including two drivers and a messenger. In 1990 a National Professional Officer (NPO) was added to the office staff and in 2008 a second NPO joined the office. The efforts of the Country Office are further augmented through frequent visits of technical staff from the Regional Office and other consultants.
4.2.2 Analysis of WHO contribution to health development through the implementation of the CCS Strategic Agenda WHO’s support to Bhutan in the past emphasized the development and expansion of the basic health services and programmes. In line with the shift in its policies, WHO placed greater emphasis on the quality of health care starting with Bhutan’s Ninth Five Year Plan. The first CCS for Bhutan, although not formally published, covered the period of 2002 to 2007. The Strategic Agenda identified by this CCS included the following Strategic Priorities: (1) Human resource development at all levels. (2) Health systems strengthening. (3) Reducing risks to health. (4) Reducing the burden of disease. (5) Promoting health environments for sustainable development.
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The detailed contribution of WHO in each of the above areas is described in the sections below: Human resource development at all levels: Lack of capacity is a cross-cutting issue involving the management and delivery of health services at all levels. WHO provided technical support to update the Master Plan for Human Resources for the period of 2002 to 2006, including both clinicians and managers (see Table 4 in Annex 2). WHO also supported the implementation of this plan by funding a bachelor’s degree in science-level nursing courses at the Royal Institute of Health Science (RIHS) with academic support from La Trobe University in Australia. Three batches of nurses of 15 nurses each have been trained using this mechanism. Teaching institutes such as the RIHS and the National Institute of Traditional Medicine (NITM) have received technical and financial support for their effective functioning. Overall, more than 40% of WHO’s budget supported human resource development. Health systems strengthening: WHO provided technical support and facilitated the formulation of policies and strategies for health work in Bhutan. Not only did the Organization provide technical support in the formulation of the FYPs, it also facilitated reviews of each technical area of health through the annual health conferences. As the cost of health care increases every year and the Royal Government began to consider privatization of certain aspects of the health-care services, WHO assisted Bhutan in exploring the possibility of privatization of health-care services. Technical and logistic support was also provided for resource mobilization, especially for the Bhutan Health Trust Fund through which Bhutan aimed to achieve self-reliance for drugs and vaccines. As increasing institutional deliveries are seen as the most suitable method to control maternal and infant mortalities, WHO provided technical support to develop strategies for this approach. Community health workers have been trained to notice the danger signs in pregnant mothers and report and refer them if detected. To improve data recording and reporting and encourage use of data for planning, support has been continued over the years to build the health information system. Recently funds have been raised from the Global Health Matrix Network (HMN) programme. A study was conducted to identify the extent of errors accruing with manual data entry at the health facilities. WHO also facilitated the formation of the Health Information System Development Coordination Group consisting of all stakeholders and the Health Information System Task Force consisting of a technical core group in the country. The vital registration system and general health information system was also reviewed to provide exposure of key national staff to such systems in other countries. After the establishment of the Quality Assurance Standardization Division under the Ministry of Health, WHO provided technical support in related programme areas.
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Quality standardization guidelines were developed for laboratory services and a quality assurance group has been formed in the Ministry. For improving access to specialized health-care services in the districts, a telemedicine programme was initiated with technical and financial support from WHO. A National Medical Officer was recruited to support the programme from the WHO Country Office. Reducing risks to health: While the country still continues to control communicable diseases, lifestyle-related chronic diseases are already increasing. Notable problems include hypertension, diabetes, cancers and stress-related mental issues. Abuse of harmful substances is also on the rise among the general population, but the country has focused on controlling tobacco. WHO has continued to provide support to tobacco control through the provisioning of legal framework and advocacy. In order to facilitate the reporting of vital data on noncommunicable diseases (NCDs), work on the NCD infobase has been initiated through workshops on evidencebased NCD planning. To improve reporting and care of mental illnesses in communities, village health workers have been trained on community-based mental health. In the education sector, WHO has provided technical support to introduce life-skills training on adolescent mental health. One of the major causes of disability in Bhutan has been the rising number of traffic injuries because of the difficult terrain. WHO provided support to train traffic police, schoolchildren and staff of the Road Safety and Transport Authority (RSTA) in first aid and basic traffic injury management. Support has also been provided to strengthen nutrition and food safety programmes. Reducing the burden of disease: While direct programme support for communicable disease programmes was limited, WHO provided technical support in specific areas in the government’s project with the World Bank for HIV/AIDS prevention and control. HIV/AIDS, tuberculosis and malaria programmes were reviewed with WHO technical support. WHO also supported Bhutan in developing proposals for the three programmes for submission to the Global Fund. HIV/AIDS, tuberculosis and malaria programmes are already supported by the Global Fund. Key technical guidance has been provided for malaria and other vector-borne diseases. Support continues for the leprosy programme in terms of capacity development and drug supplies. Work on a post-elimination leprosy strategy has already started through exposing the programme staff to similar situations in the Region.
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In the area of immunization, WHO support has continued over the years and notable contributions have been the routine revision of the EPI manual and the introduction of new vaccines for HIB and rubella through careful feasibility studies. Technical and financial support was also provided for planning and carrying out the nationwide measles-rubella vaccination campaign in 2005. WHO also supported the country to prepare proposals for GAVI funds that included assistance with a comprehensive multiyear plan for the programme. The Integrated Management of Childhood Illnesses (IMCI) approach has been introduced in the country and expanded to every district, assisted by WHO technical and financial support and by donor partners such as UNICEF. The country also prepared for avian influenza (AI), which resulted in strengthening collaboration between the health, agriculture, trade and home affairs sectors. WHO has provided technical support to prepare the National Pandemic Preparedness Plan for Bhutan. Support was also provided to implement certain aspects of this Plan during 2006–2007 in terms of stockpiling drugs and personal protection equipment and training health workers so as to establish a core group to deal with the AI pandemic. Since such preparation cannot be done in isolation, key sectors have been sensitized on the International Health Regulations (IHR) 2005 and an IHR Focal Person has been designated in the Ministry of Health to continue related work. Promoting healthy environments for sustainable development: The water supply and sanitation programme received continued support from WHO in terms of both technical guidance and financial assistance and new technologies were explored. Since most of the water supply schemes in the eastern part of the country were damaged by the flash floods of 2003, WHO extended additional support to rehabilitate these inpaired schemes and also helped the country mobilize additional funds for the programme. To improve the water supply management information system and quality testing, BHU staff, laboratory technicians and engineers were trained in their respective areas. Healthy towns and model village concepts were also established throughout the country. To control medical infections, training was conducted for hospital staff on hospital waste management and on prevention and control of hospital infections together with the formation of committees for hospital infection control. Surveillance systems, including pharmacovigilance, have been put in place for monitoring health careassociated infections. With the importance of climate change issues increasing and with Bhutan’s fragile ecosystem, WHO has supported the country in preparing a project proposal on the health response to climate change for funding by the Global Environment Facility (GEF). Support for advocacies in all areas of health continued through the Information Education Bureau of the Health Ministry.
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5 — Strategic Agenda for WHO cooperation The WHO Strategic Agenda for cooperation with Bhutan is the core element of the Country Cooperation Strategy process.
5.1
Guiding principles for WHO at the country level
WHO’s cooperation in Bhutan is firmly anchored in the country’s unique social, cultural and spiritual development system based on the philosophy of Gross National Happiness. It gives the highest priority to the physical, mental and spiritual well-being of the people within a safe and secure environment. This concept goes beyond WHO’s broad and inclusive definition of health and coincides with the values of equity and social justice that the organization promotes. The CCS is a tool that will guide the entire WHO Secretariat’s work in Bhutan. It aims at creating a flexible dialogue platform to work with all partners at the country level.
5.2
Strategic Priorities and main focus for WHO cooperation
The Strategic Agenda consists of six Strategic Priorities within the realm of both the Secretariat’s support to Bhutan’s health development and the country’s contribution to the Global Health Agenda. It is based on WHO’s values and corporate and regional policy frameworks. It results from strategic choices as to which national health and development priorities will be supported by WHO for the next five years, and where it will focus its technical and other resources. It clearly fits into and contributes to shaping the health dimension of the United Nations Development Assistance Framework (UNDAF). The Strategic Priorities selected here continue WHO’s cooperation in Bhutan during the past CCS cycle (2002–2007). WHO is adjusting its cooperation levels to the important changes that have recently occurred in the country, with Bhutan institutionalizing democracy, establishing in its Constitution the mandate for the State to provide free basic health care to each Bhutanese citizen, and adopting its Tenth Five Year Plan for the period 2008–2013. There has been dramatic progress in life expectancy at birth and the overall health status of the population of Bhutan over the past decades. The country is on track towards achieving most of the health-related Millennium Development Goals during the
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Tenth Five Year Plan. The last mile to the goals is often the most difficult and resourceconsuming. As expressed by the Minister of Health, the first elected Government of Bhutan is working towards these goals with complete transparency. It feels “even more accountable to the people” and is exploring new strategies for “tangible and visible results” in the best interests of the people. The 2010–2013 period covered by this Country Cooperation Strategy coincides with the cycle of the Tenth Five Year Plan. During this period the gamut of WHO cooperation will concentrate on six Strategic Priorities. The main focus areas are identified under each priority. As part of the support provided to the Royal Government of Bhutan and in accordance with the following commonly agreed Strategic Priorities, during the 2010–2013 CCS cycle that has been adjusted to align with the Tenth Five Year Plan, WHO will engage in the following Strategic Prioriries:
Strategic Priority #1 Support for the review, consolidation and strengthening of health policies into a National Health Policy Most of the elements of the National Health Policy exist but they are scattered and compartmentalized in different units. WHO will provide technical support to consolidate this policy into one document. WHO will bring the necessary public health expertise to contribute to this effort in accordance with one of its main core functions.
Support for the development of the National Health Policy document
Strategic Priority #2 Support to further strengthen the development of human resources for health Contribute towards revising the Human Resources Development Master Plan for Health based on the national health priorities Bhutan faces an acute shortage of qualified manpower, especially of doctors and nurses, at all levels of the health system. The Ministry of Health is concerned about ensuring that there are adequate human resources to ensure quality services in health facilities and to undertake outreach activities. It is a crosscutting issue for the sector, and affects management, delivery of services and quality assurance. There is currently an extraordinary ongoing effort to address these issues that should be supported by the design and implementation of a comprehensive human resource development plan for health. It should, therefore, entail:
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◊ Building capacity for planning and management of programmes within the context of the decentralization policy. ◊ Ensuring an optimum number of adequately trained clinicians, nurses, technicians and paramedics for all health facilities. ◊ Improving the teaching capacity of the existing health institutes such as the Royal Institute of Health Sciences (RIHS) and National Institute of Traditional Medicine (NITM).
The Tenth Five Year Plan has established targets to cover the last pockets of the unreached population, improve access to health services and intensify activities to increase institutional deliveries. It also envisages a dramatic increase in the number of doctors, nurses and other health workers, as well as an upgrade of their competencies and skills through institutional and in-service training. It will require strengthened links with training institutes in the Region and elsewhere as well as the scaling up of the in-country generation of health workers involving both infrastructure and faculty. New teaching facilities, such as the Medical College, will be developed and existing ones strengthened to supplement their current capacity. WHO will provide specialized expertise on human resources for health to support the revision of the Human Resources Development Master Plan.
Key support to the implementation of the Human Resources Development Master Plan for Health WHO will support the implementation of human resources development focusing on public health, in-service upgrading of skills for health assistants as well as support for the development of various training programmes for nurses, medical staff and other health professionals. UN Volunteers will also be recruited to fill key medical services positions as needed, depending on the availability of resources.
Strategic Priority #3 Contribute to the strengthening of the health system Support will be provided to strengthen the decentralized health system that is based on primary health care, integrating traditional and allopathic medicine. It will also build upon the current system of community health involvement, especially through village health workers.
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Promotion of the efficient use of health information at all levels of the health system The Health Management Information System, including the registration of vital statistics, is improving. It is commonly agreed that data are available at all levels of the health systems including at the basic health unit (BHU) level. However, analysis and use of these data for decision-making at appropriate levels of the health system are often insufficient. WHO will support the MoH in strengthening the analytical capacity of health workers at the BHU, district and central levels. It will support the adaptation of tools for the efficient use of information and its consolidation into a comprehensive Health Information System. WHO will provide the necessary expertise and training as part of its core function. Financial resources for the health sector have substantially increased over the past decade. The proportion of the recurrent budget allocated to health is around 10% for 2008–2009. This is far above the average in the Region as well as the global average, and demonstrates the priority given to health by the Royal Government of Bhutan. The Constitution of the Royal Government of Bhutan reinforces the State’s mandate to provide free basic health care to the population as a means of contributing to the overarching goal of Gross National Happiness. The mandate is being fulfilled but health costs are rapidly rising along with the demand from a section of the population for more sophisticated services, raising concerns about the sustainability of financing the health system. Sustaining the extra effort needed to reach the 5% to 10% of the unreached segment of the population, as well as financing the referral of patients for tertiary care unavailable in the country represents a financial challenge for the sector. The Bhutan Health Trust Fund is an innovative mechanism to finance the priority needs for essential inputs for primary health care and traditional medicine. The government is also currently considering the possibility and modalities of public-private partnerships in the health sector. WHO will support the introduction of the National Health Accounts (NHA) methodology to provide a comprehensive baseline to monitor health expenditures, especially the impact of new health financing strategies on the poor. Along with relevant partners, WHO will also support a health financing study to present the pros and cons of an array of sustainable financing options that are compatible with the principles of equity and solidarity adopted by the Royal Government of Bhutan. WHO will bring the necessary expertise to provide NHA training as well as enable senior-level health economics experts to share experiences from other countries and regions on developing health financing options.
Development of options for sustainable health systems financing
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Improved management of decentralized health services and facilities Bhutan has evolved from being a country with the poorest health indicators in the world to one well on the road to attaining most of the health-related Millennium Development Goals. These important achievements have been possible due to the continuous leadership and vision of the last five monarchs (Druk Gyalpo) and their sustained focus on primary health care and the successful integration of traditional and allopathic medicine. The Tenth Five Year Plan aims to achieve the government’s overall goal of poverty reduction, emphasizing an assured quality of services, the development of human and institutional capacities, and decentralization, sustainability and uniformity of services. WHO will contribute by strengthening the capacity of personnel in district health management, including district hospitals and BHUs, with a focus on reaching the unreached. It will also actively contribute to improving the referral system for primary health care, including facilitating the transportation of patients.
Norms, standards and quality assurance for basic health-care scale-up towards achieving universal coverage WHO will support quality assurance systems by providing support for the development of guidelines, standards and a regulatory framework to enhance the delivery of quality health services. It will continue to provide technical support, as required, for: ◊ the improvement of procurement procedures, storage and monitoring of health inputs to achieve the availability of appropriate, quality medicines and medical devices; ◊ ensuring the rational use of essential medicines for safe and cost-effective treatment of patients; ◊ a pharmacovigilance system to prevent the increased resistance to antibiotics; ◊ strengthening the Drug Regulatory Authority to ensure the safety, quality and efficacy of medicines; ◊ the appropriate use of medicines in the treatment of emerging diseases; and ◊ providing advice on GATS and TRIPS. Roles of the community in supporting the health system At the present time, Bhutan has relied on the community to support the delivery of basic health services, especially by using village health workers. WHO will continue to support the involvement of the community and expand the use of village volunteers.
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Research to support the health system The capacity to conduct and use research and its data is required to adjust to and evaluate the delivery of health services in the country. WHO will support the development of health research emphasizing the cross-cutting and intersectoral nature of health issues, identification of research priorities and the use of research findings for improving the operations of the health system.
Strategic Priority #4 Foster the improvement of maternal health, child health and nutrition (MDGs 3, 4 and 5) Improvement of the nutritional status of the population (MDG#3) WHO will continue to strengthen the capacity of health workers to improve the nutrition of mothers, children and HIV/AIDS patients, as well as support the post-elimination strategy for iodine deficiency disorders (IDDs). With changing epidemiological trends, health promotion will also address the prevention of obesity and noncommunicable diseases.
Further reduction of child mortality and improvement of child health (MDG 4) Acute respiratory infection (ARI) and diarrhoeal diseases (DD) continue to be the major causes of morbidity despite the improvements in community water supplies and sanitation facilities. Bhutan has introduced the Integrated Management of Child Illnesses (IMCI) strategy so that common childhood problems can be attended to simultaneously and in a comprehensive manner. This strategy will be continued and intensified. WHO will continue to support this strategy, as well as other evidence-based child survival strategies, providing and adapting international norms and guidelines as well as monitoring, supervision and evaluation tools. As the immunization coverage is increasing, the country will introduce the pentavalent vaccines supported by GAVI and the Bhutan Health Trust Fund. WHO will continue to support the country’s Universal Child Immunization Policy, focusing its technical support on: (i) the improvement of the cold chain and vaccine management; (ii) strengthening the surveillance of all vaccine preventable disease and of the adverse effects following immunization (AEFI); (iii) ensuring effective AFP surveillance for polio; and (iv) the evidence-based and cost-effective introduction of new vaccines.
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Further improvement of maternal health with emphasis on reduction of maternal mortality (MDG 5) Bhutan has made tremendous progress in reducing maternal mortality by half in 10 years, but the maternal mortality rate (estimated in 2007 at 255 per 100 000 live births) is nevertheless still high. The access to critical antenatal care and the establishment of numerous emergency obstetric care (EmOC) centres has intensified Bhutan’s efforts to achieve the MDG 5 target by 2015. The country has set out a more ambitious “MDG plus” target of reducing maternal mortality to 100 per 100 000 live births by 2013. Maternal mortality surveys revealed that most maternal and perinatal deaths occurred at home and that the direct causes are haemorrhage, sepsis and obstructive labour. Hence, the Government has adopted the policy of 100% births in the health centres attended by trained health personnel. With that objective, the Tenth Five Year Plan targets the establishment of 18 new grade-I BHUs, in addition to the existing 10 in strategic locations to provide basic emergency obstetric care service to the population in remote areas. This will be further supported by a comprehensive EmOC services provided by the 27 district hospitals. Both the antenatal and postnatal services will be improved together with providing a mother- and child-friendly atmosphere in health facilities to increase compliance levels for safe institutional delivery. Essential perinatal care will form an important component of this strategy. WHO will: ◊ guide the planning of facilities and services for safe deliveries for both mother and child, and ◊ develop capacity of health personnel for EmOC services and perinatal care.
Strategic Priority #5 Help reduce the burden of diseases through key interventions focusing on health promotion and risk factors with a multisectoral approach Communicable and emerging diseases (MDG 6) Tuberculosis case detection and completion of treatment using the DOTS strategy has significantly improved in Bhutan. Community participation has been enhanced through the Gewog DOTS committees. However, extra effort is required to prevent and control multidrug resistance (MDR) to TB. With an increasing number of HIV/AIDS cases in the country, TB incidences may flare up again. Therefore, appropriate strategies and resources need to be put in place.
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Although Bhutan is considered a low-prevalence country for HIV/AIDS with mainly heterosexual transmission in the 15–24-year age group, it is likely that there are undetected infections in the population. These are potential factors for the progression of the epidemic that could be aggravated by increasing use of injecting drugs and through commercial sex workers. The substantial achievements made by the leprosy programme have to be sustained through multidrug therapy (MDT) for new cases. WHO will support the design and implementation of the post-elimination strategy for leprosy. Cases of malaria have decreased significantly over the recent years but there are still focal outbreaks causing morbidity and mortality. WHO will support: ◊ further strengthening of the surveillance and monitoring systems both for case detection and epidemic prediction, focusing on enhancing the technical skills and competence of field and programme personnel; ◊ further enhancing the country’s capacity for longer-term entomological studies to provide comprehensive data for vector control; and ◊ review of the strategy for the vector control programme with special attention on climate change.
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. WHO will support: ◊ institutionalization of effective epidemic prediction and surveillance systems that use modern technology; ◊ cross-border activities to ensure appropriate coordination with neighbouring countries regarding the control of communicable diseases; and ◊ increased attention on zoonotic diseases, especially for their importance as emerging diseases.
Noncommunicable diseases prevention, care and support, emphasizing health promotion and behaviour changes, and support for mental health Bhutan faces a double burden of disease with a rising trend of noncommunicable diseases. Commendable efforts have focused on tobacco control leading to a ban on tobacco products in Bhutan. However, alcohol abuse remains a major risk factor for noncommunicable diseases, and substance abuse is a potential problem in the country. Community-based mental health programmes require more resources to intensify activities and solve the problem of lack of 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
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WHO Country Cooperation Strategy 2009-2013
rehabilitation, especially at the community level. Oral health programmes require strengthening, especially through primary oral health care and school health programmes.
The Tenth Five Year Plan signals a high level of commitment of national authorities to scale up prevention and control of noncommunicable diseases. The response in the primary health care model needs to consider these trends and the associated risk factors. Current services should be upgraded with a special focus on BHUs and district health services, and prioritizing evidencebased interventions. This will entail a modest increase in the capacity of health services in terms of equipment, consumables, medicines, and skills and competence of the workforce. WHO will: ◊ Provide technical, evidence-based recommendations for providing additional medicines and equipment in BHUs. ◊ Support the development of complementary protocols for health education and counselling through community outreach activities. ◊ Provide protocols for early recognition of alcohol and substance abuse. ◊ Provide technical support for implementing the WHO package of Essential Noncommunicable Diseases Interventions, including monitoring tools. ◊ Strengthen the community mental health programme. ◊ Promote community-based rehabilitation and programmes to deal with hearing and vision impairments.
Healthy environment (water, sanitation, food safety, occupational health and climate change) The Royal Government of Bhutan is committed to sustain and expand its promotional efforts for the control of pollution in urban areas and homes. 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 overflowing. Climate change also may change the ecosystem, leading to internal migration and affecting the availability of plants used for traditional medicine. Bhutan has achieved impressive results in terms of water supply and basic sanitation coverage. The current challenge is to ensure the functionality of the existing water system, and the quality of water, as well as to expand coverage to reach the unreached and achieve universal coverage. This usually is expensive and requires new approaches. Assessments may also be required regarding the use of sanitary facilities so that appropriate strategies and new technologies
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can be put in place to increase their use. Sanitary facilities in public places, especially those for seasonal festivals, have to be given special attention. WHO will: ◊ provide technical support for water quality control in both rural and urban areas; ◊ collaborate with relevant partners to support the improvement of hygiene and basic sanitation; ◊ support programmes to improve food safety and occupational health; and ◊ support the monitoring and prevention of adverse health effects of climate change on the population of Bhutan. Emergency preparedness and response including the reduction of the vulnerability of health facilities Bhutan is a country prone to natural disasters since it is located in a highly active seismic area. In addition, climate change increases the risk of glacial lakes melting. WHO, along with relevant partners, will continue to enhance the national capacity for emergency preparedness and response to natural disasters. It will also promote and support the implementation of the safe hospitals initiative to reduce the vulnerability of health facilities during a disaster.
National influenza pandemic preparedness plan (NIPPP) and implementation of the International Health Regulations (IHR) 2005 WHO will continue to provide technical support to the NIPPP to enhance national capacity for quick response to a pandemic. Regarding IHR 2005, tangible progress has already been made, especially with the appointment of a full-time IHR Focal Point at the Ministry of Health to coordinate activities. Many activities conducted under the avian influenza workplan are common to IHR implementation and should be considered part of the same programme. 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. WHO will support the: ◊ review of progress of NIPPP implementation; ◊ development of core capacities for IHR 2005 implementation; ◊ development and strengthening of the laboratory network; ◊ development of curricula for training Airport Health Officers; and ◊ initiatives at resource mobilization.
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Strategic Priority #6 Enhance partnerships and resource mobilization for health Provide support to the coordination of partners in health WHO will support further complementarity and synergy with other UN agencies, using its Country Cooperation Strategy to contribute to the outcomes of the UNDAF in support of the Tenth Five Year Plan. It will also promote a dialogue with the other partners in health and development at the country level and support the Ministry of Health in coordinating partners, especially through the MoH’s unit for the coordination of International Health. WHO, at all levels of the Organization’s Secretariat, will use the CCS to intensify the mobilization of voluntary contributions for the health sector in Bhutan. WHO will continue to help mobilize resources for health by supporting the MoH in preparing proposals for the Global Fund, GAVI, World Bank and other funding mechanisms and agencies. WHO supported the launch of the BHTF at WHO headquarters in Geneva in May 1998 and will continue to assist in mobilizing resources for the Fund through the dissemination of information about its achievements in the health sector.
Resource mobilization
5.3
Strategic approaches based on WHO Core Functions
WHO, according to the principles of the Paris Declaration on Aid Effectiveness, is aligning its cooperation in Bhutan with the Tenth Five Year Plan and harmonizing the same within the UN country team through the implementation of the UNDAF, and with other partners in health. WHO will use the CCS as a basis for its operational planning. According to its core functions, during the 2009–2013 CCS cycle WHO will help monitor the health situation and trends in the country, provide scientific evidence for the articulation of public health policy options, share international norms and standards and promote their adaptation to the country context, provide technical support to strengthen a sustainable institutional capacity in the health sector, and promote operational research.
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6 — Implementing the Strategic Agenda As seen in the previous chapters, most of the current key global health issues are also important concerns of the Royal Government during the Tenth Five Year Plan period. It is also convenient that the timing of the current CCS matches with that of the Tenth Five Year Plan. To realize the goals of the CCS, the WHO Country Office commits itself to the priority areas that have been listed in the previous sections. The Country Office also seeks the commitment of the higher levels of the Organization, especially the Regional Office, to support it through the provision of the required technical backup and mobilization of resources. The Country Office also commits to reorganize and adapt itself to the requirements of the CCS.
6.1
The Country Office
WHO’s financial resource and programme areas for Bhutan have increased steadily over the years while the number of staff has remained small. Hence, there is need to review the existing staff strength and capacity. Further, if WHO succeeds in mobilizing more funds, especially the voluntary contribution (VC) part, staff cost has to be embedded within the additional funds mobilized for effective management, particularly if the amount is substaintial. Further, support from WHO SEARO has to continue as a backup for the country team. The staff time of the limited number of WHO Country office staff is valuable in providing support to the Ministry of Health to implement its programmes. Efforts should not be wasted on the work of other collaborating partners and, as per the general directive, resources should not be pooled for common agency functions. However, efforts should be made to maintain a cordial working relationship with them. Further, WHO has to continue its intense partnership with the Ministry of Health and support national programmes. For that matter, it will be profitable for both WHO and the Ministry of Health to strengthen the joint WHO coordination mechanism that will facilitate regular consultation and reviews of collaborative programmes in Bhutan. WHO will continue to provide technical assistance in the form of advice, guidance and advocacy. In order to support the Ministry of Health in terms of information and facilitate programme reviews, the WHO Country Office should improve its information
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management system by putting the necessary system in place with appropriate human resources. This requirement becomes even more important in the light of the Global Management System (GSM) that headquarters and the Regional Office have now rolled out.
6.2
The Regional Office and headquarters
As stated above, the Country Office needs firm commitment from the Regional Office and WHO Headquarters to provide the necessary technical back-up as and when required in view of the small set-up of the Country Office in Bhutan. There has been a shortcoming in planning the activities to be supported by VC funds from other sources in the past. A very small amount of VC funds have materialized for Bhutan, making the planning exercise a waste of time. Hence, in the current CCS cycle, the country-level planners should plan VC activities as realistically as possible. WHO at the higher levels, especially the Regional Office, should support the country in mobilizing enough funds to implement all activities planned under VCs. In terms of resource mobilization, the situation in Bhutan differs widely from the other Member States in the Region. Since there is very little donor presence in the country, resource mobilization is only possible at the regional level and, therefore, requires the full support of the Regional Office. WHO should also make provisions for expanding the collaboration area of the CCS to include unforeseen emergencies during this CCS period.
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References (1) (2) (3) (4) (5) (6) (7) (8) (9) World Health Organization. Engaging for health: Eleventh General Programme of Work, 2006-2015: A global health agenda. Geneva, 2006. World Health Organization. Medium-term Strategic Plan. Geneva, 2006. World Health Organization, Dept. of Cooperation and Country Focus. WHO country cooperation strategies: A guiding framework. Geneva, 2005. World Health Organization, Country Office for Bhutan. WHO Country Cooperation Strategy, Bhutan (unpublished). Thimphu, January 2003. Royal Government of Bhutan, Ministry of Health, Policy and Planning Division. Draft Tenth Five Year Plan Document for Consultation. Thimphu, 2007. Royal Government of Bhutan, Ministry of Health. Health sector review Bhutan, 1027 January 2007. Thimphu, 2007. United Nations Development Programme. Common Country Assessment for Bhutan 2006. Thimphu, 2006. United Nations Development Programme. United Nations Development Assistance Framework for the Kingdom of Bhutan, 2008–2012. Thimphu, June 2007. United Nations Development Programme. Common Country Programme Action Plan (cCPAP) 2008-2012. Thimphu, December 2007.
(10) United Nations Development Programme. Bhutan’s Progress: Midway to the Millennium Development Goals. November 2008. (11) Royal Government of Bhutan, Planning Commission. Bhutan Millennium Development Goals, Needs Assessment and Costing Report (2006–2015). Thimphu, November 2007. (12) Royal Government of Bhutan, Gross National Happiness Commission. Tenth Five Year Plan 2008–2013, Volume 1: Main Document. Thimphu, 2009. (13) Royal Government of Bhutan, Gross National Happiness Commission. Tenth Five Year Plan 2008–2013, Volume 2: Programme Profiles. Thimphu, 2009. (14) Royal Government of Bhutan, Ministry of Health. Tenth Five Year Plan: A different approach. Annual Health Bulletin. 2009: p. 5-14.
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MINISTRY OF HEALTH Minister Internal Audit
Bhutan Medical & Health Council
Secretary ICT Unit Drug Regulatory Authority Bhutan Health Trust Fund
Ministry of Health Organigram
PPD
QASD
AFD
Annex-1
Department of Public Health Public Health Engineering Division Information & Communication Bureau Non-Communicable Disease Division Health Care & Diagnostic Services HIDP * Programmes/Projects
Department of Medical Services Biomedical Engineering Services/HERM
Public Health Laboratory
Communicable Disease Division
DVED
JDWNR Hospital Reg. Ref Hospitals National Traditional Medicine
* Programme: PEC, Oral Health Diabetes, Infection Control & others, eg. Wlcare, HVO, Magee Project, Danchu, Institutional mechanisms
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Annex-2 Reference tables Table 1: Key indicators of infant and child health by district, 2005 Sl. No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 District Bumthang Chukha Dagana Gasa Haa Lhuentse Mongar Paro Pemagatshel Punakha Samdrupjongkhar Samtse Sarpang Thimphu Trashigang Trashiyangtse Trongsa Tsirang Wangdi Zhemgang TOTAL Live births 285 1 248 435 72 205 321 832 613 270 349 818 1 182 830 1 866 1 082 426 292 384 650 378 12 538 Pop. inder 4 years 1 366 6 960 2 031 325 995 1 582 3 817 3 045 1 362 1 714 4 221 6 025 4 401 9 463 5 082 1 939 1 326 1 944 3 142 1 813 62 553 Infant deaths 8 38 17 0 3 16 42 13 13 11 51 40 45 56 68 13 12 9 35 13 503 Deaths 1 to 4 years 3 73 9 1 8 4 17 4 4 1 14 27 21 26 25 5 1 5 12 9 269 IMR 28.1 30.4 39.1 0.0 14.6 49.8 50.5 21.2 48.1 31.5 62.3 33.8 54.2 30.0 62.8 30.5 41.1 23.4 53.8 34.4 40.1 Under-5 mortality rate 38.6 88.9 59.8 13.9 53.7 62.3 70.9 27.7 63.0 34.4 79.5 56.7 79.5 43.9 86.0 42.3 44.5 36.5 72.3 58.2 61.6 % low weight visits* 6% 10% 13% 8% 11% 11% 12% 5% 12% 7% 9% 10% 12% 6% 13% 16% 8% 8% 7% 13% 10%
Sources: Except for low-weight visits, all data are from Census of Bhutan 2005 * Number of underweight children divided by number of attending clinics (source: Annual Health Bulletin, 2008, page 78)
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Table 2: Utilization and coverage of basic health services by district % households visiting health facilities (2005) 90% 88% 93% 89% 91% 92% 93% 85% 79% 96% 89% 86% 95% 90% 91% 91% 90% 96% 91% 91% 90% Coverage of measles immunizations (2007) 129% 131% 107% 111% 105% 107% 110% 114% 188% 146% 149% 60% 76% 141% 84% 116% 115% 152% 122% 99% 115% % of deliveries with ANC visit 3 (2007) 64% 108% 45% 94% 62% 58% 70% 79% 77% 65% 76% 83% 76% 65% 64% 49% 67% 55% 70% 71% 71% % births attended by a health professional (2007) 38% 50% 20% 59% 24% 55% 64% 74% 57% 86% 56% 45% 61% 68% 47% 25% 13% 43% 33% 55% 54% % of deliveries at health facilities (2007) 32% 45% 16% 6% 19% 47% 56% 70% 30% 73% 40% 38% 56% 68% 35% 13% 3% 38% 25% 18% 46%
District
Bumthang Chukha Dagana Gasa Haa Lhuentse Mongar Paro Pemagatshel Punakha Samdrupjongkhar Samtse Sarpang Thimphu Trashigang Trashiyangtse Trongsa Tsirang Wangdi Zhemgang Total
Sources: 2005 Census and Annual Health Bulletin, 2008
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Table 3: Health Facilities in Bhutan by district (2009) Sl no 1 2 Basic Health Units 2009 4 8 ORC 2009 14 47 Inpatient days 2007 3 441 15 277 Bed occupancy rate 2007 47% 47%
District
Hospital
Beds
Bumthang Chukha
Bumthang Tsimalakha Phuentsholing Gedu
20 20 50 20 20 12 20 150 40 20 40 30 20 20 10 10 60 350 10 50 60 40 10 10 20 20 20 40 40 1232
3 4 5 6 7 8 9 10 11 12
Dagana Gasa Haa Lhuentse Mongar Paro Pemagatshel Punakha Samdrupjongkhar Samtse
8 4 4 11 24 3 12 6 8 9
16 13 15 33 57 27 33 9 36 18
Dagapela IMTRAT Lhuentse Mongar RRH Paro Pemagatshel Punakha Samdrupjongkhar Samtse Gomtu Sipsu
244 1 606 4 152 19 005 7 059 4 312 7 401 13 501 15 532
3% 37% 57% 35% 48% 59% 51% 123% 85%
13 14
Sarpang Thimphu
10 7
11 19
Sarpang Gelephu RRH JDWNRH IBF Hospital Lungtenphu RBA Gidakom
12 091 80 699
47% 47%
15
Trashigang
19
57
Trashigang Riserboo Yongphula RBA
13 541
62%
16 17 18 19 20
Trashiyangtse Trongsa Tsirang Wangdi Zhemgang TOTAL
7 6 4 10 14 178
23 19 13 23 38 521
Yangtse Trongsa Damphu Tencholing RBA Yebilaptsa
3 037 1 092 3 794 2 662 4 803 213 249
42% 15% 52% 18% 33% 47%
Source: MoH report as of March 2009 2007 Inpatient days from Annual Health Bulletin, 2008
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Table 4: Implementation of the HRH Master Plan 2002–2006 Programme Super-Specialization Specialization Masters PG Diploma Diploma Certificate Grand total Planned 8 22 9 4 23 90 156 Revised 11 38 42 15 55 550 711 Completed 1 4 28 6 29 580 648 Undertaking 8 18 18 7 33 56 140 Recalled 0 3 0 1 0 0 4 Total 9 25 46 14 62 636 792
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42 WHO Strategic Priority Support the development of the National Health Policy document WHO main focus UNDAF outcome 1. Support for the review, consolidation and strengthening of health policies in a National Health Policy Capacity of RGoB to formulate and implement results-oriented policies and strategies that create an enabling environment for reproductive health, maternal and child health, STIs and HIV/AIDS, TB and malaria programmes strengthened.
Alignment of WHO Strategic Agenda/directions with the Tenth Five Year Plan for the health sector and UNDAF outcome
Health Sector Tenth Five Year Plan strategic objectives/output
MoH/01: Health Management and Development Programme
Evidence-based decision enhanced
MoH/04: Sustainability, Regulatory and Monitoring Programme
BMHC and DRA delinked from the Ministry and functions as an independent agency.
WHO Country Cooperation Strategy 2009-2013
Role and composition of the BHMC revised and all medical and Health professions registered.
Annex-3
Provisions of the Bhutan Medicine Act 2002 enforced.
MoH/01: Health Management and Development Programme
HR capacity enhanced.
MoH/01: Health Management and Development Programme
2. Support to further strengthen the development of human resources for health
HR capacity enhanced.
Contribution to the 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 Master Plan for Health
Health Sector Tenth Five Year Plan strategic objectives/output WHO Strategic Priority 3. Contribute to the strengthening of the health system WHO main focus UNDAF outcome
MoH/01: Health Management and Development Programme
Evidence-based decision enhanced.
Use of ICT strengthened.
Promotion of the efficient use of health information at all levels of the health system
MoH/03: Diagnostic and Curative Services Programme
Referral hospital management and services strengthened.
Capacity of RGoB to formulate and implement results-oriented policies and strategies that create an enabling environment for reproductive health, maternal and child health, STIs, and HIV/AIDS. TB and malaria programmes strengthened.
MoH/01: Health Management and Development Programme
Evidence-based decision enhanced
Development of options for sustainable health system financing
MoH/04: Sustainability, Regulatory and Monitoring Programme Improved management of decentralized health services and facilities
Health Trust Fund fully operationalized
MoH/03: Diagnostic and Curative Services Programme
Referral hospital management and services strengthened.
Telemedicine services strengthened and expanded.
Indigenous hospital services strengthened.
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44 WHO Strategic Priority 3. Contribute to the strengthening of the health system WHO main focus UNDAF outcome Norms and standards and quality assurance for basic health care scaled up towards universal coverage Capacity of RGoB to formulate and implement results-oriented policies and strategies that create an enabling environment for reproductive health, maternal and child health, STIs, and HIV/AIDS. TB and malaria programmes strengthened. Roles of the community in supporting the health system Research to support the health system
Health Sector Tenth Five Year Plan strategic objectives/output
MoH/01: Health Management and Development Programme
QA instituted and capacity enhanced
MoH/02: Health Promotion and Disease Prevention and Control Programme
Quality of laboratory services strengthened.
WHO Country Cooperation Strategy 2009-2013
MoH/03: Diagnostic and Curative Services Programme
Quality and reach of health infrastructure improved
MoH/02: Health Promotion and Disease Prevention and Control Programme
VHW services strengthened.
Awareness on NCDs enhanced.
MoH/01: Health Management and Development Programme
Evidence-based decision enhanced
Health Sector Tenth Five Year Plan strategic objectives/output WHO strategic priority Improvement of the nutritional status of the population WHO Main focus UNDAF Outcome
MoH/02: Health Promotion and Disease Prevention and Control Program
Nutritional status improved.
MoH/02: Health Promotion and Disease Prevention and Control Programme
4. Foster the improvement of maternal, child health and nutrition (MDGs 3, 4 and 5) Further reduction of child mortality and improvement of child health
ARI and diarrhoea incidence reduced.
Enhanced immunization coverage & awareness on communicable diseases.
MoH/02: Health Promotion and Disease Prevention and Control Programme
Capacity of RGoB to formulate and implement results-oriented policies and strategies that create an enabling environment for reproductive health, maternal and child health, STIs, and HIV/AIDS. TB and malaria programmes strengthened.
Reproductive Health services enhanced.
Further improvement of maternal health with emphasis on reduction of maternal mortality
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46 WHO strategic priority Communicable and emerging disease WHO Main focus UNDAF Outcome 5. Help reducing the burden of diseases through key interventions focusing on health promotion and risk factors using a multisectoral approach Capacity of the government to respond to prevention, care and treatment of HIV/ AIDS and STIs through multisectoral approach strengthened Noncommunicable disease prevention, care and support; emphasizing health promotion and behavior changes; and support for mental health
Health Sector Tenth Five Year Plan strategic objectives/output
MoH/02: Health Promotion and Disease Prevention and Control Program
TB & leprosy case detection and management strengthened.
Halt & reverse the spread of HIV & STIs.
Increased coverage of vector-borne diseases prevention and treatment.
Incidence of zoonotic diseases reduced.
WHO Country Cooperation Strategy 2009-2013
MoH/02: Health Promotion and Disease Prevention and Control Programme
Reduced incidence of disability.
Mental health services strengthened.
VHW services strengthened.
School health advocacy strengthened.
Awareness on NCD enhanced.
MoH/03: Diagnostic and Curative Services Programme
Health facilities with timely and adequate medical supplies.
Reduced hospital-acquired infections.
Hospital-based services improved and clinical care strengthened.
Health Sector Tenth Five Year Plan strategic objectives/output WHO strategic priority Healthy environment (water, sanitation, food safety, occupational health and climate change) WHO Main focus UNDAF Outcome
MoH/02: Health Promotion and Disease Prevention and Control Program
Water and sanitation programme sustained at over 90%.
Alternative technologies for difficult & unreached areas introduced successfully.
5. Help reduce the burden of diseases through key interventions focusing on health promotion and risk factors using a multisectoral approach
Capacity of government to respond to prevention, care and treatment of HIV/ AIDS and STIs through multisectoral approach strengthened
Workers’ Health services strengthened.
Nutritional status improved.
MoH/02: Health Promotion and Disease Prevention and Control Programme
Effective control and response mechanism to health pandemic/disaster put in place.
MoH/03: Diagnostic and Curative Services Programme
Emergency preparedness and response including the reduction of the vulnerability of health facilities.
Health facilities with timely and adequate medical supplies.
Quality and reach of health infrastructure improved.
At least two functional ambulances provided to all hospitals and paramedics introduced.
Telemedicine services strengthened and expanded.
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48 WHO strategic priority WHO Main focus UNDAF Outcome 5. Help reduce the burden of diseases through key interventions focusing on health promotion and risk factors using a multisectoral approach National influenza pandemic preparedness plan (NIPPP) and the implementation of the International Health Regulations (2005) Capacity of government to respond to prevention, care and treatment of HIV/ AIDS and STIs through multisectoral approach strengthened
Health Sector Tenth Five Year Plan strategic objectives/output
MoH/02: Health Promotion and Disease Prevention and Control Programme
Quality of laboratory services strengthened.
MoH/03: Diagnostic and Curative Services Programme
Health facilities with timely and adequate medical supplies.
WHO Country Cooperation Strategy 2009-2013
Quality and reach of health infrastructure improved.
At least two functional ambulances provided to all hospitals and paramedics introduced.
Telemedicine services strengthened and expanded.
Health Sector Tenth Five Year Plan strategic objectives/output WHO Strategic Priority 6. Enhance partnerships and resource mobilization for health Support to the coordination of partners in health RGoB and community partnerships enhanced to promote utilization of health services WHO main focus UNDAF Outcome
MoH/01: Health Management and Development Program
MoH/02: Health Promotion and Disease Prevention and Control Programme
MoH/03: Diagnostic and Curative Services Programme
MoH/04: Sustainability, Regulatory and Monitoring Programme Resource mobilization
MoH/04: Sustainability, Regulatory and Monitoring Programme
Health Trust Fund fully operationalized
MoH/01: Health Management and Development Programme
MoH/02: Health Promotion and Disease Prevention & Control Program
MoH/03: Diagnostic and Curative Services Programme
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