Road to SDGs: encapsulating works of WHO in Bhutan 2018

Road to SDGS Encapsulating works of WHO in Bhutan 2018 World Health Organization P.O. Box: 175 Thimphu: Bhutan Telephone: +975 2 322864 Fax: +975 2 323319 E-mail: sebhuinfo@who.int www.searo.who.int/bhutan/en/ https://www.facebook.com/WHOBhutan/ ©WHO, 2019 ISBN: 978-92-9022-697-0 Cover: Pilgrims hike up to Taktshang monastery in Paro Disclaimer Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO license (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/ licenses/by-nc-sa/3.0/igo). Under the terms of this license, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organisation, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons license. 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The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Encapsulating works of WHO in Bhutan 2018 Road to SDGS Foreword As a close partner, it was a matter of priv-ilege to witness yet another successful election, another milestone covered in the country’s democratic process. Health, as we learn, is a priority of this government. This agrees with the pursuit of Sustain- able Development Goals (SDGs), a checklist of mindful pointers toward ethical development approach, in which health is one of the key determinants. We are pleased to inform that Bhutan is already on its way to achieving the targets laid out in the SDGs. WHO will continue to support its endeavours. Among others, the signing of Astana Declaration on Primary Health Care in 2018 reaffirms our commitment to aligning with the SDGs and venture forth with renewed commitment. As much as WHO brings in some of the best practic- es and experiences to Bhutan the world has to offer, in terms of modern science, medicines and technological improvements, there is much more Bhutan gives the world. The country is a reference point contributing to development of numerous regional and global decisions and policies. As Bhutan participates in global events and shares its stories, nations within the region and around the world find themselves fascinated by this Kingdom, though little and still developing, is big in public health standards, foresight and mindfulness. There are nations that wish to learn of the country’s exceptional primary health care, its health policies, how it tackles noncommunicable diseases and witness the unquestioning responsibility with which it takes health to its people over most hostile of terrains and distant of land. This is one reason Bhutan’s active participation in Regional Committees, at World Health Assembly and Executive Boards is much valued. That way in health, Bhutan is not only receiving support, but contributing to global decisions. WHO facilitates and supports how Bhutan can give. As a technical agency, WHO Bhutan will continue supporting the government in realising its health agenda and priorities. Our support will manifest in better capaci- ties of health professionals and workers, in inclusive policies and numerous health programs. It is my pleasure to present this publication that cap- tures WHO Bhutan’s journey of 2018 and we want you to be a part of it. Dr Rui Paulo de Jesus WHO Representative Dr Rui Paulo de Jesus, WHO Representative In 2018, people of Bhutan went with the political party that prioritised health care improvements on its agenda. This corroborates the fact that Bhuta-nese were eager about advancements in health care services and facilities. Today, as we begin working towards realising the promises made, which is also the aspiration of the people, we see WHO as a valuable partner whose support becomes ever more critical. The nation takes pride in being known as a champion with- in the region in its primary health care coverage and provision, having witnessed dramatic transformations in the last five decades. We have come a long way. But even today, Bhutanese living in far-flung corners of the country walk for hours to seek some of the most basic health ser- vices, sometimes even for a pill to dull out pain. If not the Basic Health Units, they wait overnight to travel another day to get to a Aspiration of the people Dr Lotay Tshering Prime Minister nearest hospital, often to only face delayed diagnosis and treat- ment. There too, facilities and services are bare and minimum. Should we continue to boast about our health system as it is today, which is more or less a continuation of a past system? Times have changed. We need to respond to the needs of to- day. As much as we reinforce primary health care, to enhance secondary and tertiary cares is long overdue. Assessments on Bhutan’s graduation from least developed country (LDC) category indicate our country has done well in the social sphere, and health has, no doubt, contributed immensely. It goes to show WHO’s steadfast efforts in helping Bhutan realise its health care priorities. In the expertise they rendered, timely interventions at times of epidemics, laboratories they helped equip, every syringe and test kit provided, or every staff trained, WHO has saved that many Bhutanese lives and helped us live healthier. We offer our sincere gratitude. Now, while we start to embrace the “lower middle income country” status, we solicit WHO’s partnership in dealing with our changing needs and challenges associated with it. We are looking at boosting secondary and tertiary health services. We are looking at quality care, as much as we seek nationwide coverage. Priorities would increasingly shift to battling noncommunicable diseases. Diabetes, hypertension and cancer are already a health burden. We require support in terms of intellectual input, enhanc- ing knowledge and skills of our healthcare providers that match the needs of the age, digitalising and enhancing effi- ciency of our services, of creating awareness, and changing mindset and habits. As much as we work towards preventive aspects, our emphasis should be on curative. Given our geographical terrain and considering the vulner- ability of our economy, it is difficult to avoid the steep per-cap- ita expenditure on health. But we need to do it. A standard health care is a fundamental human right. That is why, among other significant transformations we aspire to bring about in the health sector this 12th Five-Year Plan, reaching the unreached is a key motivation. Rather than expecting people to go through the hassles of availing health care services, we need to take more secondary and tertiary facilities to the people. It is evident that we have come this far in health through generous support of WHO and allied agencies. Hereon, if pri- orities are not in sync, the risk of falling back to LDC category is irrefutable. Therefore, we request WHO to consider aligning focus and support required of a middle income country. I wish WHO Bhutan team all the success in its endeavours. Tashi Delek Dr LotAy Tshering Prime Minister Royal Government of Bhutan It was a momentous year for WHO Bhutan as the team operated with renewed vigour and purpose in 2018.In the scores of activities we launched during the year, every correspondence with partners, the workshop formats or quick exercise routines woven into meetings, we have been mindful about advancing towards achieving the Sustainable Development Goals (SDGs). The journey to that, we have come to understand, is not so much the end, which is the goals, but the means entailed in the process. The publication, there- fore, is an endearing project we pursued with inten- tions to share our stories with the people of Bhutan and beyond. The publication is the second of the series we bring you. In encapsulating our annual activities, by way of documentation, we realised it served the purpose of communicating and creating awareness on not just the activities but the health subjects we pursued. Therefore, for ease of comprehension for readers beyond the health system, we adopted the presenta- tion and format of a coffee table book. Titled Road to SDGs: Encapsulating works of WHO in Bhutan 2018, the publication is guided by overarching theme of Bhutan and its journey towards achieving SDGs. The opening section delves into understanding Bhutan’s journey towards achieving good health and wellbeing, while also looking at how health contributes to achieving other SDGs. Beyond that, the activities have been segregated based on WHO’s six core mandates of Providing leadership, Shaping research agenda, Setting norms and standards, Ethical and evidence-based policy, Providing technical support, and Monitoring situa- tions and assessing trends. Every initiative we take up are within the framework of these mandates. Wherever possible, human interest stories have been braided to give a picture of reality and tradi- tions that prevail. Closing the publication, we have senior health representatives, including the health minister, sharing thoughts on WHO’s works and their expectations hereafter. Introduction 9Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Toward SDGs 2030 12 Pulse of SDGs 14 Health in numbers 16 The third SDG 17 On the flip side 18 From Alma Ata to Astana 20 Adding up to SDGs 23 Providing leadership 24 At the hub 26 Exchange and learn 29 UNGA experience 31 Political will to deliver 32 Setting goals 34 Leading in health 35 Shaping research agenda 36 E-health to go nationwide 38 Understanding Bhutan’s mental health 40 What lacks to beat NCDs? 43 For the record 44 Setting norms & standards 46 Relook at essential medicines 49 Standardising viral hepatitis treatment 50 Commitment to cancer 52 Ensuring better care 54 Vital vaccine van 57 Tracking rotavirus 58 Making every drop count 61 Slowing down on salt 62 Recognition in public health 63 Ethical & evidence-based policy 64 Act the time 67 Respecting ability 68 Updating the Act 71 Mapping birth defects 72 Providing technical support 74 Planning a healthy family 76 Good start for POCQI 79 Centre for emergency 81 Emergency medical supplies 82 Back to contribute 84 Checking fish for formalin 87 Monitoring situations & assessing trends 88 A tab on polio 90 To hold the title 92 Feeding foodborne diseases database 94 What about WASH? 97 Going around Dra Karpo 99 For body and mind 100 Looking forward 102 A relevant health care 105 Technical benefactor 106 Facilitating the authority 107 Greater awareness 108 Through the years 110 Team Bhutan 112 Contents HEALTH IN THE SDG ERA Captured within one of eight auspicious Buddhist signs, the wheel (khorlo) represents the interconnection of SDGs, with health and well being as its mainstay 1 NO POVERTY 2 ZERO HUNGER 4 QUALITY EDUCATION 5 GENDER EQUALITY 6 CLEAN WATER AND SANITATION 7 AFFORDABLE AND CLEAN ENERGY 8 DECENT WORK AND ECONOMIC GROWTH9 INDUSTRY, INNOVATION AND INFRASTRUCTURE 10 REDUCED INEQUALITIES 11 SUSTAINABLE CITIES AND COMMUNITIES RESPONSIBLE CONSUMPTION AND PRODUCTION 12 CLIMATE ACTION 13 LIFE BELOW WATER 14 LIFE ON LAND 15 PEACE AND JUSTICE 16 PARTNERSHIPS FOR THE GOALS 17 GOOD HEALTH AND WELL BEING 3 Toward SDGs 2030 The third SDG ensures healthy lives and promotes well being for all at all ages. The SDGs are interconnected and the third is a critical component for the success of all 14 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 TOWARD SDGs 2030 Of many domains of Sustainable Development Goals (SDGs), health is the mainstay of the blueprint that calls for a global shift to a more sustainable future. Although all 17 goals complement one another, in that, the outcome of one goal determines those of the others, better health can effectuate achievements of most other SDGs. For instance, for a resilient economy, the seventh SDG, a healthy population that contributes towards its growth in terms of human resources is essential. In building the kind of human capital bestowed with ingenuity required to launch the nation to greater heights in modern times is largely determined by its quality of education and the levels its people attain. But that alone cannot pull off the trick in absence, again, of a healthy population a society nurtures. The tenth SDG, nurturing those with disabilities and the society’s marginalised so that they can participate in the main- stream socio-economic activities, bodes well for a society of 700,000 people. Include gender equality to that and a nation might be looking at the kind of progression unprecedented the world over. All of that makes for psychological and physical health and well being. Likewise, the health of a nation and its people is highly de- pendent of its natural environment, how a society cares for its forests through sustainable use, curbing biodiversity loss and acting against land degradation. Responsibility towards natural environment contributes to realising food security, essential for elimination of poverty, the first SDG, subsequently ensuring zero hunger, the second SDG and the sixth SDG of securing clean water for drinking and sanitation. Seen together, they further the cause of health and its com- mitment to the rest of the SDGs. Pulse of SDGs 15Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Women’s participation: SDG 5 is about achieving gender equality and empowering all women and girls Photo: Gengop Karchung 16 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Health in numbers 15.1 87.9% 89 95% 74.8% 345 99% 70.6 843 Infant mortality per 1,000 live births Population within two-hour reach from nearest health facility Maternal mortality ratio per 100,000 live births Coverage of essential medicines in all health facilities at all times Households with improved sanitation Doctors, 1,264 nurses, 600 health assistants Child immunisation coverage (DTP3) Years life expectancy Health facilities at primary, secondary and tertiary levels Source: PHCB, 2017 Annual Heath Bulletin, 2018 Health in SDGs, WHO, 2018 National Health Survey, 2012 17Road to SDGs: Encapsulating works of WHO in Bhutan 2018 TOWARD SDGs 2030 For a country guided by the development philosophy of Gross National Happiness (GNH), health has been a fundamental component. Of the nine domains of GNH considered important to create favourable conditions for pursuit of happiness, health is one. Therefore, the quest for the third SDG - good health and well being - is intrinsic to Bhutan. The 13 health targets tied to the goal are reiterations of what Bhutan had committed to since the evolution of health care system. Health facts and figures testify that Bhutan is well on track to achieving the goals by 2030. Acknowledging that free health care is a basic human right and attaining universal health coverage, an irrefutable journey, Bhutan has always kept human well being at the heart of all its national goals and policies. Essential health system coverage is over 72 percent. Life expectancy has reached 70.6 years in 2016. More than 840 health facilities at primary, secondary and tertiary levels across the country deliver free health services. Almost 87.9 percent of the population are within two-hour distance from the nearest health facility. In recent years, Bhutan has made headlines in global health, having eliminated measles before its 2020 target or in inching closer toward malaria elimination, among others. The mortality rate has drastically reduced, while the population covered by most vaccines is almost 100 percent. Major leap in health delivery system has ensured people experience minimal financial hardship in availing its services. Meanwhile, narrowing gaps pertaining to health care services and quality was also an election agenda in the coun- try’s 2018 parliamentary elections. With people voting for the political party that emphasised the message, it is understood that health would receive utmost priority during the term of this democratically elected government. Reaching those in the deep pockets of the country, a sub- stantial per capita expenditure owing to geographical terrain and increasing NCD burdens with changing lifestyle are some evident challenges. However, with major backstopping from WHO and other partners, bolstered, this time, by political will, efficient health system and a holistic approach, Bhutan has the advantage of smooth-sailing towards the third SDG, in other words, achiev- ing good health and well being. The third SDG 18 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 TOWARD SDGs 2030 On the foothills of the eastern district of Mongar, on the tropical laps of Yangbari, nestles a school that hosts slightly less than a hundred students. In the backyard of the school is a home, an ensemble of used timber, ply-board and corrugated galvanised iron (CGI) sheets. Next to it, a few more sheets are stacked on wooden poles to accommodate a bed. On it lies a weary, almost debili- tated figure. In her early ‘30s, Sonam, a mother of two, has been sleep- ing outside her house, in that shed, for almost a year. She can barely move the lower part of her body. Every touch around that region causes pain. It was about eight years ago, soon after the birth to her sec- ond child that she sensed pain in her legs. Other days her lower limbs felt benumbed. Gradually it refused to move at her will. With no sign of improvement, she resorted to medical help from nearby Basic Health Unit. Back home, hopes were hinged on numerous traditional rituals to relieve Sonam of her illness. With two growing children to look after, Sonam asked her mother in the village to live with her. What her husband earned as a school cleaner could barely make ends meet. Two years ago, they decided to visit a “bigger” hospital. Since Sonam’s condition did not favour travelling in public transport, the family hired a utility truck. Two days on the road and they reached the hospital in Gelephu. Over the weeks, they put up with a relative while undergo- ing treatment involving several tests. To rent a room in town was expensive. They returned, but with barely any signs of improvement. According to Sonam’s mother, they borrowed twice from the bank to perform rituals and hire vehicles to visit the hos- pital. Until recently, Sonam could go to bathroom on her own, but now needs assistance. Why outside? Sonam said she felt better in the open, rather than feeling stifled in an enclosed room. Hot weather also spurred bugs and infection inside. The family has given up exploring more options for treat- ment. Coming to the capital, Thimphu, is a distant consid- eration. Reeling under borrowed money is far grimmer an option. “I don’t think I would want to go to Thimphu,” Sonam, who continues her medication, said. “It’s too painful to move. More- over, I have caused my family enough trouble.” Note: The patient’s name has been changed for privacy. On the flip side 19Road to SDGs: Encapsulating works of WHO in Bhutan 2018 The burden: Though free, accessibility and out-of-pocket expenditure to avail of health services, continue to pose challenge for many in rural areas 20 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 TOWARD SDGs 2030 Renewed commitment: Health Secretary Dr Ugen Dophu at the Global Conference on Primary Health Care in Astana, Kazakhstan From Alma Ata to Astana When Bhutan joined the world leaders and committed to the Alma Ata declaration on primary health care in 1978, the country’s modern health system was in its infancy. Bhutan’s modernisation and development process started with the initiation of the first Five-Year Plan in 1961. Two hospitals were established then. According to Annual Health Bulletin 2018, 87.9 percent of the population live within two-hour walking distance from a health facility. This has had an overall impact on mortality and morbidity. Life expectancy at birth has increased from 33 years in 1960 to 47 in 1985 to 70.6 today. Immunisation coverage has increased in facili- ty-based delivery (99 percent, DPT3), leprosy and endemic goiter have been eliminated, including measles, rubella and polio in recent years. All health related indicators have improved and 21Road to SDGs: Encapsulating works of WHO in Bhutan 2018 SEPTEMBER 2011 Jaipur Declaration on Antimicrobial Resistance adopted by the WHO/SEAR member countries most Millennium Development Goals (MDGs) were achieved by 2015. Maternal health was improved and the fight against HIV/AIDS, malaria and other diseases strengthened. Bhutan opted for MDG-plus during its 10th Five-Year Plan to reach the MDGs and achieve other priority health targets. However, despite progress, Bhutan continues to face challenges in fighting the burden of noncommunicable diseases, faces acute shortage of qualified human resources and lacks a strong emergency preparedness and response system. The health system also needs living up to the 21st century and the growing expectations of its people. The Bhutan Living Standard survey 2017 shows that despite free health care, there exists wide disparities in access to health care in the country. For those in rural Bhutan, out-of-pocket expenditure is still an impedi- ment. In continuation to its commitment to provide primary health care to its people, Bhutan joined the global leaders and adopted the Astana dec- laration during the 2018 global conference on primary health care (From Alma Ata toward universal health coverage and Sustainable Development Goals). Bhutan is also committed towards eliminating TB by 2030. With renewed commitment, Bhutan continues to strengthen and in- vest in primary health care for a strong and comprehensive health system to achieve universal health coverage and drive equity through improved access. SEPTEMBER 2018 Delhi Declaration on Improving Access to Essential Medical Products in SEAR and beyond NOVEMBER 2017 Moscow Declaration: First WHO Global Ministerial Conference - Ending TB in the Sustainable Development Era: A Multisectoral Response NOVEMBER 2017 Colombo Declaration - International Symposium on Traditional and Complementary Medicine, Sri Lanka NOVEMBER 2017 Ministerial Declaration accelerating Malaria Elimination in WHO/ South-East Asia, New Delhi NOVEMBER 2017 Phuket Commitment on Accelerating Actions for Implementation of Decade of Action for Road Safety APRIL 2017 Jakarta Call for Action on Accelerating Progress Towards Eliminating Neglected Tropical Diseases Endemic in WHO/South- East Asia APRIL 2017 Thimphu Declaration on Autism and Neurodevelopmental Disorders SEPTEMBER 2017 Male Declaration on Building Health Systems Resilience on Climate Change OCTOBER 2018 Astana Declaration on Primary Health Care: From Alma Ata towards Universal Health Coverage and the SDGs MARCH 2017 Delhi Call for Action on Ending TB in South East Asia APRIL 2010 Thimphu Statement on Climate Change signed by SAARC member countries SEPTEMBER 1978 Alma Ata Declaration on Primary Health Care 22 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 In a nutshell: Recollection of 2018 events and activities 23Road to SDGs: Encapsulating works of WHO in Bhutan 2018 From improving neonatal care to participating in global assessment of sanitation and drinking water, from reviewing essential medicines list to developing guideline for viral hepatitis treatment, all of WHO Bhutan’s 2018 activities contribute to meeting SDGs. One of the final programs of 2018, the Parliamentarians’ Fo- rum, concluded with parliament representatives committing to work towards “healthy and happy Bhutan” through accelerating prevention and control of NCDs. Today, NCDs account for 69 percent of deaths, the leading cause of preventable deaths. Programs like upgradation of laboratories at Royal Centre for Disease Control and establishment of health emergency operation centre prepare the country for risk reduction and management of national and global health risks, one of the health targets. Introduction of new vaccines, revision of essential medi- cines list and decisions to make them available in additional health facilities go with the SDG target of enabling access to safe, effective, quality and affordable essential medicines and vaccines for all. Activities have also been held to ensure universal access to sexual and reproductive health care like strengthening capacity of family planning services and other maternal and new born health programs. This also adds to reducing preventable deaths of newborns and children under five years. Meanwhile, besides health related SDG targets, the activities carried out last year also add up to achieving other goals. Participating in global assessment of sanitation and drink- ing water is instrumental in meeting the sixth goal of clean wa- ter and sanitation. Development of strategy to include people with disability to participate in mainstream activities align with SDG 10 of reducing inequalities. Adding up to SDGs TOWARD SDGs 2030 Providing leadership 25Road to SDGs: Encapsulating works of WHO in Bhutan 2018 The directing and coordinating authority in international health within the UN system, WHO provides leadership on matters critical to health and engages partnership under its ‘One Health’ agenda 26 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 PROVIDING LEADERSHIP In times of disease outbreak, in the face of medical emergencies, or in matters of health policy directions, the one agency that can be called on to arrive at an informed decision is the WHO. With offices in more than 190 countries across the globe, supported by a well-knit team of health experts, scientists and researchers, WHO has always been regarded for the technical support it has come to be known for today. During disease outbreaks, not just within the country that are a few, but threats of entry from across porous borders, WHO rolls out precautions much in advance before preparing for situations. WHO has also been catalytic in establishing mechanisms, communications facilities and fulfilling other logistical require- ments in preparation for emergencies and disasters in future. Apart from that, the organisation’s assistance and support is also sought in relation to strengthening human resource capac- ity in the health ministry, where experts are either flown in, or ministry officials sent to where the experts are. For supply of medicines, medical equipment and, of late, test kits, the organisation is always seen as a critical partner. Riding on WHO’s identity, the quality and standards of medical supplies are also ensured. At the hub 27Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Bio-safety: In preparation for disease outbreak and medical emergencies, laboratories at RCDC in Serbithang, Thimphu were upgraded with WHO support 28 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Meeting of minds: Light physical activities are a part of WHO agenda in almost all of its meetings 29Road to SDGs: Encapsulating works of WHO in Bhutan 2018 PROVIDING LEADERSHIP As the lead technical agency in health, WHO active-ly supports development and implementation of strategies and plans, and also monitors and assesses national health policies to achieve universal health coverage. WHO provided significant technical assistance, on request from Ministry of Health, in strengthening health services by bringing in international experts and creating platforms to share and exchange ideas. Some of the key areas were noncommunicable diseases, mental health and substance abuse. Disabilities and rehabili- tation, reproductive maternal, neonatal, child and adolescent health, health and environment were others. Various surveillances involving birth defects, foodborne diseases and rotavirus received technical assistance, for which trainings and workshops were organised and guidelines devel- oped. Besides bringing in experts, WHO also supported exchange of ideas by creating platforms such as the 11th Meeting of the South-East Asia Regional Certification Commission for Polio Eradication in November 2018 in Paro, which brought partici- pants and experts from 11 countries. The training of health workers on case/outbreak investiga- tion of Vaccine Preventable Diseases was also conducted with support from WHO for all 20 District Health Rapid Response Team. The main objectives of the training were to develop skills of health care providers to investigate measles and ru- bella case and outbreak investigation and to sensitise them on surveillance guidelines of the diseases. A Regional Advisor also came in to guide and help review the Bhutan Medicines Rules and Regulations. Advice was also sought with regard to improving access to safe, effective and quality medicines and diagnostics among health staff in Depart- ment of Medical Supplies and Health Infrastructure and Essen- tial Medicines and Technology Division. WHO also supported the review of existing information on health workforce. Exchange and learn 30 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 High-profile gathering: For the first time, two health professionals represented the country at the 73rd UN General Assembly in New York 31Road to SDGs: Encapsulating works of WHO in Bhutan 2018 It was such a privilege to have been given an opportunity of this sort, to be part of such an assembly, witnessing how decisions at the global level is arrived at. On the sidelines of the UNGA, we met nu- merous experts from various nations on health and related policies that enriched our knowl- edge of the two epidemics of TB and NCDs. As we joined the different nations in our bold commitments to ending TB epidemic by 2030 and reducing by one-third, by that same year, premature mortality from NCDs, we also learnt of how different nations were working towards fulfilling these commitments. Stringent legislations against tobacco, policies to reduce alcohol consumption and promotion of healthy lifestyles through WHO-supported outdoor gyms were some of the highlights of our stories. Besides health, the forum also discusses a wide array of international issues covered by the UN Charter, from development to security, including social and cultural aspects. UNGA experience PROVIDING LEADERSHIP Among the high-profile get-together from 193 member states at the United Nations General Assembly (UNGA) in 2018 were, for the first time, two health professionals representing the country at the 73rd session held in New York. With support from WHO, Dr Pandup Tshering was among numerous other health professionals from around the globe to join their leaders in committing to act against the two epidemics of tuberculosis (TB) and noncommunicable diseases (NCDs). He shares his experience. Dr Pandup Tshering Director General Department of Medical Services 32 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Deaths from noncommunicable diseases (NCDs) in the country increased to 69 percent in 2018, from 53 about seven years ago. Amid rising trend, numerous initiatives have been launched in recent years to prevent and detect NCDs at earlier stag- es. Introducing package of essential NCDs (PEN), framing multi-sectoral action plan and forming national steering com- mittee were some of the notable developments. Yet, riddled by poor coordination among sectors, inade- quate budget in the face of NCDs consuming significant pro- portion of it, indifference to the disease and ineffective involve- ment of local governments were challenges making NCDs the leading cause of all preventable deaths. Given the critical challenge NCDs posed to the country and its people, a rational approach was highly desired and that had to come from political leaders and parliamentarians. Timely as it was, considering a new government had stepped in during the year, WHO and health ministry con- ducted a high-level advocacy for accelerating prevention and control of NCDs in December 2018. The first of a kind in the country and the region, the event themed “time to deliver”, saw policy makers being brought up to speed on threats of NCDs. They acknowledged the urgency to deal with this fast-catching social malady. National Assembly speaker, finance and health ministers were among the participants at the forum, which ended on an enthusiastic note with parliamentarians committing to a list of priority actions for the coming decade. This is expected to take the country closer to realising 2030 SDG targets. Political will to deliver PROVIDING LEADERSHIP 33Road to SDGs: Encapsulating works of WHO in Bhutan 2018 On high note: A high level advocacy on the burden will go a long way in efforts to preventing and controlling NCDs 34 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 It is through a set of regionally and globally agreed health targets that WHO helps individual member states realise their own. In turn, the collective suc- cess of these countries contribute to the global good health that WHO aspires for. In a decentralised process, scientists and health pro- fessionals representing various member states deliberate on various endemic diseases and identify means to tackle them. They then consider how WHO fits into the overall scheme. The decision they arrive at is then put up to the regional committee, which is a representation of health ministers of the region. That is where resolutions are reached and declarations made, like elimination of malaria, measles and rubella, to which Bhutan is party and, so far, it has spelt well for the country. That, however, would not have been possible without WHO guiding the country in the process through various strategies, guidelines and interventions that emphasise prevention and control of these diseases. Apart from such key roles, its function extends to intro- duction of new vaccines and prequalification of medicines, so they meet the organisation-prescribed quality. Of late, especially in the Bhutanese health system, it has spurred a shift to electronic convenience, so much so, the country feels confident to go e-health nationwide. Setting goals PROVIDING LEADERSHIP 35Road to SDGs: Encapsulating works of WHO in Bhutan 2018 In 2018, WHO Bhutan welcomed appointment of Acting Representative Dr Rui Paulo de Jesus as the Representative. Its counterpart, Ministry of Health, saw appointment of a new minister, Lyonpo Dechen Wangmo. In the region, Dr Poonam Khetrapal Singh (right) was re-elected as the WHO South-East Asia Regional Director. Leading in health Shaping research agenda 37Road to SDGs: Encapsulating works of WHO in Bhutan 2018 As a leading organisation in health, WHO plays a critical role in shaping the health research agenda by stimulating generation, translation and dissemination of valuable knowledge 38 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Triggered by global shift, piloted to a success at the hospitals of Paro and Thimphu and, above all, with the political will this time around, e-health is slated for nationwide implementation in the 12th Plan. Integrated into the National Health Policy since 2011, digitilisation of health system took off only in 2017. Numerous departments under the health ministry initiated their own dig- itilasation processes in tele-medicine, blood donation, lab-in- formation system, picture (x-ray) archive system and National Early Warning, Alert and Response Surveillance (NEWARS) among 17 such schemes. Although that bode well for the process, without synchrony under one system, it failed in purpose. “A doctor needs to see a patient’s report in its entirety to make informed decisions,” health ministry’s Research Officer Mongal Singh Gurung said. Lack of synchrony in digitally-generated reports had patients running from one facility to another to compile the reports for a doctor, a waste of resources in time and papers. “All systems have to communicate to enable an inter-oper- able system for which we needed a standard data and compati- ble system,” Mongal Singh said. But to consolidate these activities, a strategy was required and that was where WHO came in. Today, the ministry has an e-health steering committee, a government body and ICT division providing technical in- puts and responsible for synchrony of existing digital systems. Seen as a possible key to the growing public concern over deteriorating health services, e-health is poised to shorten waiting time, generate accurate medical records, ease paper- work for health workers and enrich medical research. “We’re talking about knowing a patient’s medical history, health condition, allergies to certain medicines and medicines prescribed in the past with a click of a button,” Mongal Singh said. “We’ll be taking e-health until BHU-I to cater to more than 80 percent of the Bhutanese people.” E-health to go nationwide SHAPING RESEARCH AGENDA 39Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Enabling technology: The e-health system was piloted in Thimphu and Paro hospitals in 2017 40 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 To strengthen national mental health disorders and substance use information system, a situation analy-sis was carried out towards the end of 2018. The analysis was carried out to get an insight into what ‘oth- er mental disorder’ were. This is a categorisation, listed in health ministry’s Annual Health Bulletin along with six categories of dementia, mental and behavioral disorders due to alcohol, mental and behavioral disorders due to multiple drug use and other use of psychoac- tive substances, psychosis, depression and anxiety. Other mental disorders account for a large chunk of mental health data in the bulletin and, therefore, require scrutiny. Information on mental health related morbidity and mortal- ity in health facilities are collected through Health Information and Management System from hospitals in Gelephu, Mongar, Thimphu, Tsirang, Haa and Paro and published in the bulletin. Data from selected health facilities were collected and will be reviewed for “other mental health disorders” to strength- en mental health information system and frame appropriate interventions. The analysis is expected to help health ministry’s Mental Health Program identify common mental disorders, list ones that have been overlooked, and conduct further research and plan appropriate interventions to address the increasing burden of mental illness. To improve mental health services and information, apart from district mental health focal nurse, focal persons at the Basic Health Unit I level are also being identified and trained in basic mental health services, record keeping, counseling and patient follow up. Understanding Bhutan’s mental health SHAPING RESEARCH AGENDA 41Road to SDGs: Encapsulating works of WHO in Bhutan 2018 2013 2014 2015 2016 2017 Dementia - - - 21 18 Mental and behavioral disorders 774 129 1,442 1,023 923 due to alcohol Mental and behavioral disorders due 137 447 269 282 193 to multiple drug use & other use of psychoactive substances Psychosis 132 564 526 318 160 Depression 653 1,044 667 743 501 Anxiety 654 2,146 1,524 2,141 1,143 Other Mental Disorders 1,170 129 2,576 1,723 1,354 cases seen in Bhutan Source: Annual Health Bulletin, 2018 42 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Alcohol ahead: Lack of coordination and feeble implementation of laws and global recommendations continue to hobble efforts to preventing and controlling NCDs in the country 43Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Ministry of Economic Affairs should review alco-hol licensing policies and set up a mandatory education program for license holders. Alcohol tax should be increased and fund generated should support implementation of public health initiatives. Similarly, Ministry of Education, together with health min- istry, should initiate 30 pilot health promoting schools, while Thromdes (municipalities) should identify private partners to maintain open air gyms. On the other hand, Bhutan Agricul- ture and Food Regulatory Authority should don a formal role to enforce salt reduction strategy. These are a few recommendations from a set of 16 that emerged out of a review to assess capacity needs of health sector and its partners to accelerate implementation of non- communicable diseases (NCDs) prevention and control in the country. Latest report revealed NCDs caused 70.6 percent of death in the country. The figure came to light despite comprehen- sive NCD related strategies and action plans in place. Among others, UN High Level Declaration on NCDs endorsed in 2011 and Bhutan Multisectoral Action Plan (MSAP) in 2015 brought about significant progress in prevention and control of NCDs. But much remains to be done. The UN Interagency Task Force (UNIATF) recommendations of 2017 saw a rather slow implementation. That is when WHO’s support was sought to review the capacity needs for implementation of the national multisectoral response for prevention and control of NCDs and the UNIATF recommendations. Two teams comprising members of national officers and WHO experts carried out the review in April 2018 that identi- fied gaps and arrived at realistic solutions to build capacity and scale up NCD interventions, taking them closer to achieving national targets of MSAP. What lacks to beat NCDs? SHAPING RESEARCH AGENDA 44 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 For the record As part of its mandate to shape research agenda, WHO produces numerous publications and materials on varying themes every year for information dissemination. Communicated through print, broadcast and social media, the initiative is an effective public education tool. 45Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Setting norms & standards 47Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Setting norms & standards For a robust and progressive health system, norms and standards are critical. WHO not only contributes to the process of setting norms and standards but also promotes and monitors their implementation 48 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 On the shelves: With revision of essential medicines list, some 22 new ones will hit the pharmaceutical racks 49Road to SDGs: Encapsulating works of WHO in Bhutan 2018 SETTING NORMS & STANDARDS In 2018, 22 new medicines were added to the list of essential medicines in the country, while 12 others were struck off the record. About 24 medicines would also be made available to health facilities beyond the national and referral hospitals. The National Medicine Committee comprising pharma- cists and clinicians revised the essential medicines list, in keeping with international practices and guided by WHO standards. According to WHO, essential medicines are those that “satisfy the priority health care needs of the population; they should therefore be available at all times in adequate amounts and in appropriate dosage forms, at a price the community can afford.” The revision was based on the 2016 edition, which required reviewing and updating as per the “priority conditions” that were based on current and estimated future public health rele- vance and potential for safe and cost-effective treatment. The final list, featuring about 430 medicines with the latest revision, is fed into the annual procurement cycle, for use and distribution in the coming year. Relook at essential medicines 50 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 To boost on-track works toward elimination of viral hepatitis, a treatment guideline and a national strate-gic plan for prevention and control of viral hepatitis were developed. The guideline and strategic plan will also help support sus- tainability of the achievements made so far. The 2017 sero survey recorded the prevalence of hepatitis B surface antigen (HBsAg) in adult population at two percent, a big drop from 1997 survey’s 5.9 percent. Similarly hepatitis C virus (HCV) prevalence had reduced from 1.3 percent in 1997 to 0.3 in 2017. The 2017 survey recorded no prevalence of hepatitis B virus (HBV) in children aged 0-4 years. For children between five and 17 years, the prevalence was 0.7 percent and two percent in adults above 20 years. High coverage of infant vaccine programs for birth dose and three doses were attributed to this achievement. Bhutan achieved hepatitis B control in 2017, which is way ahead of the regional and global target. To sustain this status and to work towards elimination of other viral hepatitis, standardisation of treatment and a strate- gic plan are critical. In the absence of treatment guideline, no treatments were carried out in Basic Health Units (BHUs) and district hospitals. Patients are referred to the national referral hospital in Thim- phu for treatments. Viral hepatitis treatment will be initiated in district health centres and rolled out to BHUs, becoming a norm like HIV treatment in country. Intervention at BHU levels can address the issue of timely diagnosis and treatment. The guideline and strategic plan also requires training of health workers, capacity building and a standard recording and reporting instrument. Together they are geared towards access to strategic information, which will help devise appropriate interventions for prevention of viral hepatitis. SETTING NORMS & STANDARDS Standardising viral hepatitis treatment 51Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Strategic plan: A national treatment guideline was developed to prevent and control viral hepatitis prevalence 52 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Cancer cases in the country continue to rise steadily every year, as does the number of Bhu-tanese that succumb to it. Bhutan cancer report, 2015 recorded an increase of cancer cases in the country from 211 in 2008 to more than 600 in 2014. In light of growing expenses from cancer referrals outside the country and considering cancer is avoidable, in the backdrop of significant savings of resources, it makes all the more sense for the country to have measures in place. A National Cancer Control Strategy that WHO helped draft for the country aims at reducing number of cancer cases and deaths, besides improving quality of life for patients. The strategy will be guided by four basic components of the control programme, mainly strengthening prevention, early screening and detection, stepping up diagnosis and treatment and improving palliative care. Together these measures are intended to reduce can- cer cases and related deaths besides improving quality of life of patients. Commitment to cancer SETTING NORMS & STANDARDS In view of most cancer cases being preventable, it is deemed to be one of the most cost-effective long-term strategies for cancer con- trol. Of many, regulating exposure to environmental and occupational carcinogen and instituting targeted preventive measures for common cancers are suggested few. Focusing on detection of symptomatic patients at the earliest, it is believed, ensures greater chances for successful treatment. Improving awareness and strengthening existing screening programs for common cancers are some of the ways defined in the strategy. Treatments ensuring timely and effective therapy for advanced stages of cancers but with potential for cure have been prescribed under the diagnostic and treatment services. Strengthening avail- ability and access to basic chemotherapy drugs, among others, are considered effective treatments to ensure quality life of patients and possibly survival. A key component of the strategy delves into strengthening pallia- tive care service for cancer patients, especially in view of the condi- tion being diagnosed at advanced stages. The strategy recommends integrating such a service into the health care system and expanding it to health facilities across the country. 53Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Commitment for life: In the face of growing cancer cases and deaths from it, a strategy to deal with the condition was necessary Photo: Bhutan Cancer Society 54 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 SETTING NORMS & STANDARDS A nationwide emergency obstetric and newborn care assessment was conducted as part of activities towards Bhutan Every Newborn Action Plan (2016- 2023) implementation. The objective was to identify current needs and gaps related to infrastructure, equipment, supplies, essential medicines and human resource. Addressing shortcomings there would im- prove basic emergency obstetric and newborn care (BemONC) and comprehensive emergency obstetric and newborn care service provision (CEmONC). There are six basic and 44 comprehensive emergency obstet- ric and newborn care facilities across the country. The assessment also observed competency of health care staff providing basic and comprehensive services through use of standard averting maternal death and disability. Strengthening emergency obstetric and newborn care is part of newborn action plan. In Bhutan the concept for emergency obstetric care services was adopted towards end of 1999 to address maternal health care. A needs assessment for establishing emergency obstetric care (EmOC) facilities was done in March 2000. The assess- ment covered 31 health facilities but found only four function as basic emergency obstetric care. Safe motherhood project to strengthen quality EmOC in district and referral hospitals was implemented from 2000- 2002, with eight EmOC and 14 basic EmOC centres in place by the end of project period. Ensuring better care 55Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Better care: Strengthening emergency obstetric and newborn care is part of newborn action plan 56 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 A prized possession: The van carries vaccines for distribution to health facilities across the country 57Road to SDGs: Encapsulating works of WHO in Bhutan 2018 SETTING NORMS & STANDARDS One of the prized possessions of the Department of Medical Supplies and Health Infrastructure at Changzamtok, neighbouring the school, is its vac- cine van, brandishing at the front parking lot of the office. Not so much for the price, which of course cranks out into a prohibitive figure, the refrigerator mounted, single-cabin, six-cylinder, angelic white 70-series Land Cruiser is held dear for its function. Its worth escalates by almost the same price as the van when it is laden with some of the most essential vaccines it carries from the airport to the storage facility, a structure almost the size of a football field. When fully loaded, the WHO donated wheel carries vaccines worth about Nu 3M. It carries an array of vaccines, including Expanded Pro- gramme on Immunisation (EPI) for children and rabies vac- cines that require storage under specific temperatures, mostly between two and eight degree Celsius. Flown in from overseas to reach the medical storage at the quickest and shortest time possible, they arrive at the storage facility packed in iceboxes of various shapes, sizes and colours neatly stacked on its bunk-like shelves on either side of the freezer. Thereon, it distributes vaccines to health facilities across the country’s western and central regions and to the regional referral hospitals. Vital vaccine van 58 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 A vaccine for rotavirus could be introduced in the coming year if studies prove it feasibile.In the face of introducing more compelling vaccines like Pneumococcal Conjugate Vaccine (PCV) and sustainability of routine immunisation programs, introduction of rotavirus vaccination has become a challenge. On the other hand, diarrhoea, with rotavirus as the leading cause, continues to remain one of the top 10 diseases in the country. A study conducted by Royal Centre for Disease Con- trol reveals the infection is prevalent mostly among children under five years. The centre, however, has been carrying out surveillance in the past but financial constraints impeded the process. With considerations to introduce the vaccine in the country today, the need to closely monitor rotavirus and its genotype is felt crucial to draw evidence for vaccine introduction, to understand its effectiveness and the shift of genotypes after introduction of vaccine. Even otherwise, the rotavirus surveillance would monitor trends of diarrhoea, help determine its magnitude, provide early detection of outbreaks and generate reliable data for evidence-based clinical management strategy and public health policy and plans, among others. As such, with WHO’s support, initiative to establish intus- susception and rotavirus sentinel surveillance in the country kicked off in November 2018. Towards that, activities included development of surveil- lance guidelines and training of health professionals on them. SETTING NORMS & STANDARDS Tracking rotavirus 59Road to SDGs: Encapsulating works of WHO in Bhutan 2018 On top ten: Rotavirus is the leading cause of diarrhoeal disease mostly infecting children under five years 60 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Six major centres: In efforts to address human resource constraints and ensure quality and safety, the existing 28 blood centres in the country will combine to form six major ones 61Road to SDGs: Encapsulating works of WHO in Bhutan 2018 The existing 28 blood centres across the country today will be combined to form six major ones in the com-ing years. This is in keeping with the strategic plan being prepared in line with the National Blood Policy, which delves into consol- idation of limited resources, while ensuring better quality and blood safety. The consolidation plan would help avoid spacing human and other resources too thin, while ensuring standard and professionalism in the processes are spelt out in the operating guidelines. Work towards this began in October 2018, as part of the ongoing efforts toward strengthening blood related systems and services in the country with WHO support. Besides the national referral hospital in Thimphu, the two regional hospitals of Gelephu and Mongar and the general hos- pitals in Phuentsholing, Trongsa and Samdrupjongkhar would operate as major blood centres. These locations, where blood collection, transfusion and transmission transfusion infection (TTI) testing are carried out, would supply blood to other health facilities in the country. Bhutan currently gets 80 percent of the blood from “volun- tary donors” with the idea to do away with “replacement do- nors” entirely by 2020. WHO also helped develop the strategic framework and national strategic plan of action for the next five years (2019-2023). Meanwhile, the strategic plan also seeks to upgrade blood safety information system and App with inclusion of more fea- tures aimed at effective blood collection, transfusion processes and sufficiency. While the standard operating procedures on clinical trans- fusion, developed with WHO support in 2017, are being implemented in blood centres, more staff are being sensitised to ensure uniform practice in all health facilities, including laboratories. Works are also underway to broaden and improve data com- pilation for the hemo-vigilance system, being piloted in four blood centres for now. Making every drop count SETTING NORMS & STANDARDS 62 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 At nine grams: Bhutanese are known to consume twice the WHO recommended amount of salt a day SETTING NORMS & STANDARDS The National Salt Strategy (2018-2023), developed with technical assistance from WHO aims at reducing salt intake of Bhutanese by 15 percent by 2023. The STEPS survey on noncommuni- cable diseases (NCDs) risk factor 2014 indicated that Bhutanese were consum- ing more than 9gms of salt a day, which is double the WHO recommended amount of 5gms. NCDs cause 69 percent of all deaths in the country, making it one of the biggest challenges for Bhutan and its health care system. Reducing salt intake has been iden- tified as one cost effective measure to improve population health outcomes. The strategy lists four priority directions - strengthening governance, partnership and regulatory measures, increasing information, education and communication, promoting healthy settings and strengthening evidence generation, monitoring and evaluation - to reduce salt intake. These are aimed at creating a social, economic and legal environment to support reduction of salt intake. The National Steering Committee for Multisectoral National Action Plan for prevention and control of NCDs has been identified as the main body to manage and implement the strategy nationwide. The Lifestyle Related Disease Pro- gramme is the secretariat, responsible for compiling the progress of activities biannually. Slowing down on salt 63Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Bhutan received an award under public health achievement for control of rubella and congenital rubella syndrome in September, 2018 Recognition in public health Ethical & evidence-based policy 65Road to SDGs: Encapsulating works of WHO in Bhutan 2018 To encourage wholesome growth of the health system, ethical and evidence-based policy options are mandatory. WHO partners with lead agencies to realise this requirement 66 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Review: The health council revisited the Act to ensure its relevance 67Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Much has transpired under the Bhutan Medical and Health Council Act of 2002. Much has also advanced in the Bhutanese health system in the last more than a decade and a half. The Act needed coping with the age of digital doctors, technological advances in medical care, the country’s changing disease patterns and growing demands for service upgrades. So, evoking chapter 10 of the Act that has to do with amendments, empowering the council to review the law from time to time so it stays relevant, some 20 health planners and legal officers got down to review and finalise the Act during a 10-day workshop. Of many, the draft medical and health amendment bill looked at drawing a clear delineation of structure and function within the council, defining terms of reference for its office bearers, including board members and committees. It also deliberated on penalties for breach of ethics and neglect of professional conduct and duty. ETHICAL & EVIDENCE-BASED POLICY Act the time 68 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 In Bhutan, for people with disabilities, societal acceptance or tolerance is not so much an issue inhibiting their par-ticipation in the social mainstream. It is more the lack of public awareness and policy limitations on the rights and needs of people with disabilities, in terms especially, of accessibility to health facilities and public infra- structure. In filling the awareness gap, WHO continues to educate and train parents, family members and communities of different- ly-abled children and adults. Besides that it has helped develop and finalise the National Disability Strategic Plan with inputs from persons with disabilities, their parents or caregivers, health professionals, relevant Civil Society Organisations and represen- tatives from concerned government agencies. According to the recent Population and Housing Census, 2017, more than 15,000 people were recorded as living with disabilities of some form. ETHICAL & EVIDENCE-BASED POLICY Respecting ability Some of the main components of the strategy delves into early detec-tion for prevention, stepping up the health system to fit in the needs of people with disabilities and improving access to health services for them. For early detection, the strategy spells out the need to strengthen birth defect surveillance programme and enhance collaboration with Public Health Programmes for interventions in preventing birth defects. It also looks at strengthening and expanding early identification, referrals and interventions of children with developmental delay, hearing, vision and other cognitive impairments. The strategy calls for review of current designs and drawings of health infrastructures to develop a standard universal access design for the physically challenged. The beef of the strategy is in the improvement of health facilities and services, sensitive to the needs of people with disabilities, like provision of priority sitting areas, waiting queues, token system and attendees to assist them. Other aspects of the strategy include development of curriculum for people with disabilities in monastic education, providing approaches to breaking stigma associated with disabilities and integrating Disability Action Plan activities into yearly work plans of the local government. 69Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Inclusive policy: The rights and needs of people with disabilities have to be considered so they can contribute in their own ways to society 70 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Sharpening tool: The revised Medicines Act will enable authority to regulate more products 71Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Fifteen years after its enactment, the Medicines Act of Bhutan, 2003, is up for an overhaul for effective control and regulation of medicinal products in the country. Over the years, some of the provisions in the Act and sub- sequent rules and regulation have been rendered redundant and irrelevant. Among others, the Act barely covers the role of its imple- menting agency, Drug Regulatory Authority, whose mandates have grown since inception in 2004. The revision will ensure incorporation of core functions of a drug regulatory agency as outlined by WHO. New provisions in relation to regulation of medical devices, blood and blood products, cosmetics and health supplements also need to be drawn. For now, with approval of the Board, DRA regulates these components under the definition of me- dicinal products. Moreover, the Act has to be reworked on to align with the Constitution and the Penal Code of Bhutan, particularly in the context of offences and penalties. The discords were also point- ed out by the National Law Review Task Force. WHO’s support enabled the technical working group to review the Act and regulations over series of meetings in the last three months of 2018. The draft will be processed through stakeholder consultation and further reviewed before seeking Parliament endorsement. ETHICAL & EVIDENCE-BASED POLICY Updating the Act 72 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 ETHICAL & EVIDENCE-BASED POLICY The national neonatal death review in the last three years indicate birth defects among the top three causes of neonatal mortality in Bhutan. Until recently, the leading causes were low birth weight, prematurity, and sepsis and infections. To reduce neonatal mortality and to map birth defects, Na- tional Birth Defects Action Plan was drafted and hospital based birth defects surveillance was initiated in the three referral hospitals of Thimphu, Mongar and Gelephu in 2015. Since 2017, the data has been entered into WHO’s South- East Asia Region Newborn and Birth Defect Surveillance System. Still birth and birth defect data have also been entered into the system. This year, the birth defect surveillance system was revised and a newborn and stillborn surveillance standard operating procedures (SOPs) developed during a three-day workshop, organised with support from WHO. Birth defects focal persons from three surveillance sites and supporting staff members attended the workshop. Gaps in the surveillance system, challenges and good prac- tices were identified and discussed to help improve the system. Some of the challenges identified were in data entry, track- ing processes and system problem, including poor Internet connectivity. Awareness level of the surveillance among staff members and inclusion of birth defect description in the clini- cal chart were among good practices. For better coordination and improvement in data complete- ness and timeliness, trainings and sensitisations workshops were recommended. One of the outcomes of the workshop was expansion of the surveillance to Samtse, Phuentsholing and Trashigang hospitals. While raw data indicated high number of congenital heart diseases and birth defects originating from alcohol consump- tion by mothers, the findings are yet to be established through a detailed analysis, which will be carried out by the Disability Pre- vention and Rehabilitation Programme under health ministry. Mapping birth defects 73Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Birth defects among top 3 causes of neonatal mortality in Bhutan Birth defects, prematurity, low birth weight, and sepsis and infections are leading causes of neonatal mortality Neonatal mortality rate - 18.1 deaths per 1,000 live births during the first 28 days Birth defect surveillance started in 2015 in 3 referral hospitals High occurrence of congenital heart diseases and birth defects originating from alcohol consumption by mothers – initial findings of birth defect surveillance Source: Annual Health Bulletin 2018, UNICEF, Birth Defect Surveillance Newborn and birth defects Bhutan ranked60th among 184 countries in neonatal mortality rate Providing technical support 75Road to SDGs: Encapsulating works of WHO in Bhutan 2018 WHO’s technical cooperation brings about catalytic change aimed at building sustainable institutional capacity 76 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 One of WHO updates incorporated in the revised Family Plan-ning Standards of Bhutan is how family planning providers should respect, protect and fulfill the human rights of clients. This element is one of Bhutan’s initiatives to provide universal access to health service, in a fair and equitable manner. WHO also provides information on new contraceptive methods like the use of implants, which will be introduced in Bhutan in 2019. The revised standards also recognises the importance of family plan- ning services addressing adolescents, a section representing 60 percent of the population. The adolescent birth rate is 28.4 per 1,000 women. The 2030 agenda for Sustainable Development Goals sets a global target to ensure universal access to sexual and reproductive health services, which include family planning under global strategy for women’s, chil- dren’s and adolescent’s health. To update health workers on new theoretical and practical skills and knowledge on family planning, and contraceptives and methods, trainings on revised family planning standards were organised with support from WHO. PROVIDING TECHNICAL SUPPORT Planning a healthy family Bhutan’s contraceptive prevalence Source: Family Planning Standards of Bhutan Family Planning Services introduced in 1974 18.8% 1994 65.5% 2010 70% 12th Plan target 77Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Healthy family: Besides a small family, the revised standards encourage use of contraceptives for proper spacing between children 78 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Point of care: A project that resulted in timely treatment of patients, reduced waiting time for new admission and out-of-pocket spending 79Road to SDGs: Encapsulating works of WHO in Bhutan 2018 As part of improving quality at the point of care, the national referral hospital in Thimphu has success-fully implemented a programme, that of increasing proportion of neonates discharge from hospital by 11am. This initiative, a problem identified and addressed by the neonate staff themselves, is one of the four components under Point of Care Quality Improvement (POCQI) implemented with support from WHO. It is also one of the 50 key performance indicators in the Annual Performance Agreement of the hospital with the gov- ernment. The hospital staff has identified the problem of late patient discharge, mostly in the afternoon, which led to delay in treat- ment of newly admitted patients. The successful implementation of POCQI project had result- ed in timely treatment of patients and reduced waiting time for new admission and out-of-pocket expenses. It also improved staff efficiency and teamwork. POCQI started in 2017 in three referral hospitals of Thim- phu, Gelephu and Mongar and district hospitals of Samdrup- jongkhar, Lhuentse and Punakha. It is a quality improvement method involving four steps of identifying the problem and forming a team to write an aim statement; analysing the problem and measuring quality of care; developing and testing changes; and sustaining improvement. Besides trainings organised with support from WHO, health workers also have access to e-learning POCQI manuals and materials. In 2018, a group attended a training of trainers on POCQI in All India Institute of Medical Science (AIIMS) in New Delhi and in December another training of trainers was conducted in Mongar. Improving quality of care is expected to help realise Bhutan’s aspiration to reduce maternal and newborn mortality ratios, which stands at 89 per 100,000 and 21 per 1,000 live births re- spectively. The target is to reduce maternal mortality to 83 and newborn mortality to 13.2. The high institutional delivery rate, as high as 90 percent, is an added advantage for the implementation of POCQI. The other three POCQI components implemented are prop- er and complete charting of partograph readings, hand hygiene, and Early Essential Newborn Care and Kangaroo Mother Care. Good start for POCQI PROVIDING TECHNICAL SUPPORT 80 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 In emergencies: A cargo container equipped with state of the art communications technology will be the centre for communications, decisions, coordination and mobilisation of medical services during disasters 81Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Outside the gigantic structure housing the health ministry and WHO Bhutan office, is a modest, one-story white building dotted with traditional Bhutanese paintings. This structure, a modified cargo shipping container, also known as convertainer, is equipped with state of the art commu- nications technology. It will function as the centre for communi- cation and decision-mak- ing for health emergencies during disasters. The shipping contain- er building is a concept adopted from the Health Emergency Operations Centre (HEOC) built in Nepal during the 2015 earthquake. The health emergen- cy operation centre will be the nodal point of all health related communica- tions. Health Emergency National Committee, headed by health secretary, will meet at the centre for communication, deci- sion-making, coordination among health centres and mobilising medical services during disasters. The centre is electricity powered, backed by solar and diesel generators. It has a conference room with video conferencing mon- dopad screen and two workstations. The centre has a radio repeater installed for analog walkie-talkies, which have been distributed to health committee members. The centre also has satellite phones and an international broad- band connection, which can be used when all communication systems in the country are down. It also has capacity to backup the health ministry’s data, if required, during disasters. Inaugurated earlier this year, the centre, under health ministry’s Emergency Medical Services Division was built with financial and technical assistance from DIPECHO and WHO. Centre for emergency PROVIDING TECHNICAL SUPPORT With support from WHO, a medical camp kit installation train-ing was conducted in central regional referral hospital in December. A workshop on developing health centre contingency plan was conducted in Samdrupjongkhar for Basic Health Unit I staff and mock drills were carried out in Pemagatshel, Bumthang and Lhuentse hospitals. 82 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 PROVIDING TECHNICAL SUPPORT At the entrance of WHO Country Office in Thimphu is a convertainer housing emergen-cy medical supplies and a small office setup. The medical supplies consists of Interagency Emer- gency Health Kit (IEHK), and a personal deployment kit ready for use to meet priority health needs during emer- gencies. The kit is for use in the early phase of emergency and for health care facilities and hospitals that have been affected by disaster. The IEHK, a standard WHO health kit, contains essential medicines and medical devises for common diseases to be used by professional health workers. The kit can cater to 10,000 people for three months or 30,000 people for one month. The emergency health kit is managed by the WHO Country Office. Emergency medical supplies 83Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Medical exigency: The health kit has medical and other supplies to last a month for 30,000 people 84 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 PROVIDING TECHNICAL SUPPORT Just a few months after Sonam Gyeltshen retired from his 35 years career in civil service, he returned to do what he always enjoyed doing - combating malaria. The senior malaria technician completed his career with the health ministry as he hit 55 years in 2018. Given the dearth of manpower and more so in experience and knowl- edge in the particular field, Sonam Gyeltshen was made an offer to continue, this time with WHO fund support. “Thanks to WHO, with whatever knowledge I have, I can continue contributing to the cause of malaria elimina- tion in the country,” Sonam Gyeltshen, who is among the three WHO supported professionals in the ministry, said. Based in Jomotsangkha, Samdrupjongkhar, while he is not at Basic Health Unit handling diagnosis, data enter- ing and case reporting, Sonam goes door to door creating awareness on malaria. He started his career with malaria programme in 1984. Since then, he said malaria prevalence has drastically dropped, so much so that Bhutan is almost on the verge of eliminating indigenous malaria. “Challenges remain in southern districts where our pre- ventive efforts are rendered ineffective,” he said. While there was no evidence to back up, he said use of mosquito nets and insecticide sprays carried out twice annually proved most effective in countering the disease. “However, despite all the awareness, people are not receptive to some of the measures we introduce, like the spray of insecticide in their homes and that makes it diffi- cult,” Sonam Gyeltshen said. On a two-year contract with WHO, Sonam Gyeltshen said he would make the best of the opportunity he received until the last day. The highest case of malaria nationwide, over 39,000 was reported in 1994. In 2017, 62 cases were detected and 40 in 2018. Back to contribute 85Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Combating malaria: With over 35 years of experience as malaria technician, Sonam Gyeltshen (left) was recruited by WHO after his superannuation from the civil service in 2018 86 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Off the menu: Import of fish was regulated after detection of formalin during tests around July 2018 87Road to SDGs: Encapsulating works of WHO in Bhutan 2018 PROVIDING TECHNICAL SUPPORT Within days following media reports from parts of India of formalin-smeared fish, Bhutan Agriculture and Food Regulatory Authority (BAFRA) stepped up vigilance over imported fish. Formalin, a cancer-inducing chemical applied on fresh catch to extend its shelf life is forbidden for use in foods. Reports of it being used on imported fish sounded off alarm. The country imports more than a thousand metric tonnes of three fish variety every year. Around the same time as the Indian media was rife with reports on the issue, BAFRA officials, sometime in July, tested two consignments of fish at Phuentsholing, the gateway and country’s trading hub, which tested positive for the chemical and were disposed of. In absence of a kit to test fish for formalin content, BA- FRA officials used one that tested vegetables for pesticides then, which actually did the job. As part of support from WHO, which BAFRA officials sought, the authority was provided a formalin test kit that could be used on 300 samples. BAFRA officials had asked Indian fish suppliers to the country to produce a certificate of reliability from Export Inspection Council (India’s export regulator) as a guaran- tee of safety. Three metric tonnes, the last fish consignment, after three months of absence in the Bhutanese market, was allowed in November, 2018. Checking fish for formalin Monitoring situations & assessing trends 89Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Situations and trends of diseases, outbreaks, mortality and morbidity require constant monitoring and assessment for a strong and dynamic health system 90 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Although the country has been certified polio free in 2014, almost 30 years since the last case was detect-ed in 1986, the health ministry is taking no chance of the status. With technical support from WHO, the ministry conducted the Acute Flaccid Paralysis (AFP) surveillance and its review meeting over 84 days, covering 28 hospitals with 17 partici- pants. With intention of chasing up any missed cases of AFP, the ministry designated surveillance officers in the districts to visit hospitals on monthly and quarterly basis to review admis- sion records and other relevant documents. AFP surveillance was established in the country in 1997 to rein in on cases of importation of Wild Polio from polio endemic countries, while simultaneously carrying out routine immunisation services. The Regional Commission for Certification of Poliomyeli- tis certified the country polio free in March 2014. According to Polio Endgame Strategy, AFP surveillance should continue until poliomyelitis is eradicated globally. MONITORING SITUATIONS & ASSESSING TRENDS A tab on polio The Vaccine Preventable Disease pro-gramme was about consolidating the numerous surveillance guidelines that were drawn for various disease specific vaccines in the past. A single integrated document, simple to comprehend and convenient to implement was the idea. That way, health workers could use it to administer vaccines of various types, besides preventing duplication of activities and saving on resources both human and financial. This program is intended to assist district health facilities, the first level in the health system with full-time staff multi-tasking, to provide various services. 91Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Sustaining status: Although the country has been declared polio free, it continues surveillance to ensure it stays that way 92 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 MONITORING SITUATIONS & ASSESSING TRENDS Ever since Bhutan donned the title of a measles free country in the WHO South East-Asia region, a rec-ognition earned in April 2017, the country ensured every effort added up to sustaining the humbling status. Health centres and district health rapid response team (DHRRT) across the country, with Royal Centre for Disease Control (RCDC) at the heart of it, were quick to respond to every case that signalled anything close to measles. There was also a need to worry as significant number of measles cases and outbreaks surfaced soon after. About 15 cas- es of measles from seven districts were recorded in 2018. But in these efforts, the teams felt short of skills to investi- gate cases and outbreaks, resulting in prolonged process that most likely caused additional transmissions. Besides, chal- lenges also remained in determining and classifying cases as indigenous or imported. Following recommendations from Regional Measles Verifi- cation Commission (RVC) in Delhi to strengthen case inves- tigation, assistance were sought from WHO for technical and financial support. Subsequently, in early November 2018, all members of the DHRRT from across the country met in Paro for a training aimed at strengthening their capacity to investigate more effi- ciently the vaccine preventable disease cases and outbreaks. According to an official with national disease surveillance and epidemiology unit of RCDC, the training would not just boost surveillance but also intercept transmission. As for the teams across the country, next time they sniff a case or an outbreak, they are all set to dig deeper and analyse the cause of outbreak, while also trying to understand the coverage and effectiveness of supplementary immunisation initiatives. To hold the title Initiatives to erase any possible cases of measles in the coun-try continued in 2018. WHO worked closely with the health ministry to build capacity of medical officers to investigate outbreaks, preparing them to conduct contact tracing to identify potential sources of infection, among others. Efforts to conduct vaccination to stop further transmission of measles continued. Surveillance was intensified to detect additional cases, while Outbreak Response Immunisation was also held in areas that reported measles. 93Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Stepped up surveillance: Relevant officials receive SMS and mail alerts during detection of cases 94 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 MONITORING SITUATIONS & ASSESSING TRENDS Bhutan experienced 42 foodborne disease outbreaks in the last five years, but lacked systematic data collec-tion or monitoring. To tackle this, a foodborne disease surveillance was initi- ated in 12 sentinel sites of Trashigang, Samdrupjongkhar, Mon- gar, Trongsa, Gelephu, Tsirang, Wangduephodrang, Punakha, Thimphu, Paro, Samtse and Phuentsholing based on geograph- ical representation. The surveillance will complement the diarrhoeal surveil- lance system, which is in its 10th year. Diarrhoeal studies based on the surveillance indicate that contrary to what is believed, diarrhoeal diseases occur more during winter. Besides bacterial and viral pathogens, food allergens are also suspected to be behind diarrhoeal outbreaks in the country. Diarrhoeal studies also indicate that about 30 percent of the patients have no bacterial or viral agents. Taking a ‘One Health’ approach, the foodborne disease sur- veillance also involved Bhutan Agriculture and Food Regulato- ry Authority (BAFRA). According to surveillance guideline, developed with support from WHO, BAFRA will collect at least five samples, twice a month from ready-to-eat restaurants, randomly, from the sentinel sites. These samples will be sent to Royal Centre for Disease Control’s food and nutrition lab where data will be generated. Food data and clinical data will be correlated to provide better insight into diarrhoeal diseases. Food data can help identify the source of contamination. The objective of the surveillance are to make predictions and to provide early warnings, identify vulnerable population, study if control programs are running effectively and generate reliable data for policy interventions. Feeding foodborne diseases database 95Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Determining source: Food samples will be collected for better insight into foodborne diseases, including identification of source of contamination 96 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 GLAAS approach: The assessment focuses on water, sanitation and hygiene initiatives to control incidence of WASH related diseases 97Road to SDGs: Encapsulating works of WHO in Bhutan 2018 This is perhaps the document to grab for those seek-ing comprehensive understanding of the country’s water situation, sanitation and health. Put together through an initiative called Global Analysis and Assessment of Sanitation and Drinking Water, or what is shorter known as GLAAS, the initiative weaves well in ensur- ing not just health but the sixth SDG pertaining to clean water and sanitation. This was the third participation for Bhutan in the global assessment, the first two being in 2014 and 2016. In preparing for this cycle, Public Health Engineering Division (PHED), Ministry of Health, took the lead to conduct consultative meetings in October 2018 with WASH stakehold- ers, policy makers and financing authorities, where survey questionnaires and relevant information were collected. Implemented by WHO, the survey lends focus on water, sanitation and hygiene investment to improve the health of population by specifically reducing incidence of WASH related diseases. It also enables policy and decision makers at all levels to access reliable information to make decisions in these areas. PHED officials said globally, resource allocation for WASH was limited compared to other sectors like education, health, agriculture and environment. GLAAS provides evidence for relevant sectors, including finance, via a forum called Sanitation and Water for All to seek commitments for increased resource allocations. According to officials, the forum has been successful in bring- ing about increased funds for WASH programmes over the years. What about WASH? MONITORING SITUATIONS & ASSESSING TRENDS 98 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Two hits: When religious sites perched on numerous hills and ridges meet the Bhutanese faith, the outcomes are spiritual and physical well being 99Road to SDGs: Encapsulating works of WHO in Bhutan 2018 With a torch-light shining in front of her, walking stick tapping against uneven path, Kesang Wang-mo struggles her way up rugged, ascending trail. The first rays have barely hit the ground and the 34-year-old is already drenched in sweat. Her body is sore from the previous two days arduous hike. With each stride, despite the limp, she inches closer to her spiritual mission – 108 rounds around the cracked ridge (Dra Karpo). Circumambulating the sacred site in Paro entails going around an entire ridge. One full circle consists of an uphill climb and as steep a descent, which lasts about 20 minutes for an average walker. It is said going around the holy site, blessed by Guru Rin- poche and many Buddhist masters over centuries, 108 times would redeem one from the sins of this life. It is possibly a convenient option to seek atonement from a depraved life one led. It is in such practices that many Bhutanese, by way of seeking spiritual pursuit, also engage in physical activities. Therefore, for someone like Kesang Wangmo, motivation works both ways. Having entered the realm of the overweights after her sec- ond childbirth, Kesang said her life turned obtuse. Fear of, one day, contracting lifestyle disease crept in. “Therefore, as I started exercising, I chose to blend it with spiritual practices,” she said. Circumambulating stupas, prostrations and pilgrimage to far-flung religious sites on weekends were some of the strategies she and her friends adopted. This time, as she strove for the 108 rounds, Kesang said it was one challenging endeavor she was committed to complet- ing. A person with average fitness and willpower would usually attain the required number in three days. But there are those who do it in two days and others who resign half way to return “some other day”. Returning to Kesang, the 34-year-old completed the rounds in three days, which was enough time to test the limits of her heart and contemplate on life, drawing analogies from the walk. MONITORING SITUATIONS & ASSESSING TRENDS Going around Dra Karpo 100 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 It’s almost midday and the second set of morning prayers are over at Zilukha nunnery in Thimphu. The nuns pour out of the temple, put on their sneakers and line up in the courtyard. A small portable sound box lets out an upbeat music and on the physical trainer’s instruction, the nuns warm up and stretch. A few minutes later, they are into the groove, doing high- knees and jumping jacks. The nuns, about 50 of them, have been taking aerobics classes for two years. They look forward to the classes, the reason they agree in unison, is the health benefits. “It has helped keep my blood pressure under control,” said Ngawang Lhamo, 52, adding that her joint aches no longer bothered her and she now walks the 40-steps staircase to the dining hall with ease. It has also helped her pray and rest better. The nuns get up early and start their morning prayers at 5am and break for lunch and dinner. After dinner, they pray again in their own rooms. Physical activity is almost non-existent. High blood pressure, high cholesterol and obesity are some of the diseases that irk the nuns. Trainer Dorji Tsheten, 29, of Dosten Fitness Consultancy Service advice the nuns on the importance of healthy diet. The aerobic classes are thrice a week and Dorji Tsheten seeks donations from individuals or friends to keep the classes at the nunnery going. He also organised a fund-raising drive to get a pair of sneakers each for the nuns. Dorji Tsheten became a fitness trainer in 2010, after suffer- ing from TB. “I was under medication but wanted to explore other ways to get healthier, so I browsed the Internet and read about the benefits of exercise.” After recovery, he trained in Thailand to become a fitness trainer and has, since, been an advocate for healthy living. Dorji Tsheten and his team of trainers also received aerobics training with support from WHO. MONITORING SITUATIONS & ASSESSING TRENDS For body and mind 101Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Rising from prayers: Fitness instructor Dorji Tsheten trains nuns at Zilukha nunnery in Thimphu Looking forward 103Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Some of WHO Bhutan’s key partners share thoughts and expectations, as they look forward to working closely in the coming years 104 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Health Minister Dechen Wangmo For Bhutan, this is our last Five-Year Plan as least developed country. As we graduate to a lower middle income economy, how we deliver health care services must change.  Our health care system must be transformed to make it relevant to the current needs and situation.   Today with improved access to information, technol- ogy, road accessibility and enhanced public awareness on health, we must work hard to transition to comprehensive and quality model of care. Disease patterns have changed and more complex issues like mental health diseases and disorders are emerging.  Health has to be featured in all policies since the com- plexity of providing quality and comprehensive health cannot be addressed by Ministry of Health alone.   To address these complexities and to keep health services sustainable, the system which was relevant few years back will have to be transformed with introduction of innovative and sustainable interventions. LOOKING FORWARD A relevant health care 105Road to SDGs: Encapsulating works of WHO in Bhutan 2018  Bhutan’s case is unique since basic health care services are free as enshrined in the Constitution. The tier system of Basic Health Units, district hospitals, regional and referral hospi- tals is exemplary and has worked well resulting in immense improvement in health outcomes. Health coverage in terms of accessibility is almost 90 percent, but there are limitations and challenges. We are still talking about two-hour walking distance as an indicator to assess basic health services, while every second is critical for a person who is unwell. We must improve access by strengthening the services be- ing delivered at each level of the health system. Efficiency has to be strengthened to improve delivery. We must be able to equip each health facility with comprehensive set of diagnos- tic equipment and adequate human resources. Health promo- tion and disease prevention will need greater emphasis. Quality health care will uphold trust of our people in our health system. For WHO, who has been a critical technical partner in development of Bhutan’s health system, this is an opportunity. We can work together, keeping in mind the context of our graduation from LDC and the issues of sustain- ability that arise.  WHO, with its global presence, network of expertise and a wealth of technical know-hows can guide us in transforming our health system into one that is befitting the 21st century.    Dechen Wangmo Minister Ministry of Health 106 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Technical benefactor LOOKING FORWARD In the day of modern medicines, the country finds itself plagued by what is called, triple burden diseases, a com-bination of communicable, noncommunicable, and new outbreaks or reemerging diseases. Most health budget is spent on curative health care, like diagnostics and treatment, which if we continue, as the trend is, diseases will overwhelm us. The ministry, with support from WHO is developing Re- source Allocation Guideline, which will look at allocation of health care expenditure in a manner that 70 percent goes into curative aspect of the health care and 30 percent on preventive. With help of WHO, we are also coming up with the Health Bill, which has been drafted a few times. Among others, the Bill discusses budget for health care, in that it looks to raising the amount for health care to Nu 5B from Nu 2.5B. It will be open for public feedback and comments, while simultaneously holding public consultations across 20 dzongkhags. WHO’s assistance will be valuable there as well. We are also working together with WHO in bringing about behavioral change among Bhutanese, especially in view of growing cases of lifestyle diseases. Although initiatives like open-air gym and aerobics have helped, we are looking at mass appeal and paradigm shift in people’s behavior that promotes healthy lifestyle. Rather than engaging in everyday programmes and activi- ties, we would appreciate WHO’s assistance in bringing about changes in the prevailing health system. For instance, with WHO’s support Bhutan has a very robust disease surveillance system. With RCDC at the centre of this program, we learn of disease outbreak in any part of the country and can according- ly respond. WHO is a technical body and they are fulfill- ing that part very well in Bhutan. Hereon, we would like WHO to continue support- ing us with technical assis- tance, help develop capac- ities of health workers to improve quality of care and services until they become sustainable. Of course, even after that, their assistance would still be required, but at levels much elevated. Dr Ugen Dophu Secretary Ministry of Health 107Road to SDGs: Encapsulating works of WHO in Bhutan 2018 WHO has been instrumental in establishing the med-icines regulatory system in Bhutan. As far as 1986, WHO has been helpful in establishing Essential Drugs Programme, which was in fact the beginning of the regula- tory system of Bhutan when there was none. Under the programme, WHO initiated and provided technical support for the development of national drug policy in 1987. Medi- cines management system, capacity building of its people, procure- ment, storage and monitoring followed suite. In early 2000, WHO helped draft the Medicines Act, which was then passed in 2003. The Drug Regulatory Authority (DRA) was established in 2004, to which it continues to provide technical sup- port. The impact of their assistance is felt most strongly in systems strengthening for effective governance of medicines, like making policies, guidelines and legislations; and institution of technical committees systems and processes, which are here to stay for a long time. DRA became autonomous in 2008. Although we have been receiving continuous support, we need first-level communication with WHO. That way the authority’s priorities are captured well within the health systems strengthening priority action plan. Even for WHO-supported budget release, we have to channel through the health ministry. We need WHO’s support to review and revise Medicines Act and Regulations to expand DRA’s ambit beyond just medicines. With advancing medical technologies and developments in medi- cal field, DRA’s changing mandate requires legisla- tions and regulations in many areas, mainly medi- cal devices, cosmetics and medical equipment. There is also need for assistance in strengthen- ing the capacity of various advisory committees and regulatory quality man- agement system, including DRA’s. WHO should continue playing the facilitating role and providing technical assistance in the pharma- ceutical field as and when required. Facilitating the authority Kinga Jamphel Drug Controller Drug Regulatory Authority LOOKING FORWARD 108 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Greater awareness Various international days were observed across the country, some as remote as the semi-nomadic community of Merak in Trashigang. Events, such as school quiz competition, blood donation drive and health talks, all intended at creating greater awareness on various diseases at different levels among diverse sections of the population were held. Observing international health days reaffirm WHO and health ministry’s commitment to tackling health issues at the root through sensitisation. 109Road to SDGs: Encapsulating works of WHO in Bhutan 2018 110 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Through the years 1995 Royal Decree on population planning issued 1946 World Health Organization established 1948 Constitution of WHO introduced 1978 Participated in the International Conference on Primary Health Care in Alma Ata, Kazakhstan 1979 Formally adopted the Alma Ata Declaration of ‘Health for All’ 1982-83 Biennium began with two programs and budget outlay of USD 250,000 1983 Basic agreement between WHO and Royal Government of Bhutan concluded. Country office established in Thimphu 1982 Bhutan formally joined WHO on March 8 1992 Royal Decree on sanitation and a latrine for each household issued 1986 Bhutan achieved polio- free status 111Road to SDGs: Encapsulating works of WHO in Bhutan 2018 1997 Leprosy eliminated 1998 Bhutan Health Trust Fund was launched on May 12 2000 The Royal Charter of Bhutan Health Trust Fund issued 2010 Tobacco Control Act of Bhutan passed by Parliament 2014 Bhutan certified polio free Today Priority public health agenda with USD 3M budget a year 2003 The Medicines Act of the Kingdom of Bhutan was endorsed and enacted on August 5 2017 Elimination of measles, three years earlier than regional target lll Bhutan conferred with World No Tobacco Award lll National Action plan on AMR developed 2018 Committed to Astana Declaration on Primary Health Care 112 Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Dr Rui Paulo de Jesus Sonam Jamtsho Dawa Penjor Sonam Yangchen Dechen Choden Tashi Minjur Team Bhutan 113Road to SDGs: Encapsulating works of WHO in Bhutan 2018 Thukten Rinzi Om Dorji Jigme Lhendup Kencho Wangdi Thinley Wangmo Kinga Namgyel Ugyen Wangchuk Wangchuk