The health system in Bhutan over the past five decades has undergone remarkable growth, being mainly publicly financed, health services are available in a three-tier structure of primary, secondary and tertiary levels. Over time, the organisation of the health system has successfully evolved to integrate traditional and allopathic medical services, with village health workers providing an important bridge to promote public health programmes in an accessible manner to the community. As defined in the Constitution of Bhutan, health services are provided free with government revenue being the predominate source of financing allowing universal health care to be distributed equitably.
Despite limited accessibility with varied geographical terrain and isolated, rural populations, access to health care has seen a remarkable improvement. Furthermore, in the past 40 years Bhutan has risen as one of the top global performers in terms of advances in life expectancy reaching a peak of 71 years, outperforming neighbouring countries such as India and Nepal. However with these advances comes a new set of health challenges, with an increasing life expectancy causing a demographic transition with a larger proportion of the population being over the age of 65. This increasing the prevalence of noncommunicable diseases (NCDs) significantly. The rapid urbanisation and modernisation of Bhutan in recent decreased has also contributed to the rise in NCDs.
The burden of NCDs has risen also due to various evolving determinants in Bhutan these including societal and cultural, economic and political, and environmental. Over the past decade the evolution of these determinants has had a major influence on the health sector. For instance increasing social urbanisation has led to an increasingly sedentary lifestyle and modernisation has led to an increase in the consumption of high calorie, low nutritional foods, increasing rates of obesity. Hence, increasing rates of NCDs such as heart disease, chronic respiratory diseases, diabetes and hypertension. This is evident in the statistics displaying nearly 25% of the population has hypertension, and recent nutritional studies revealing 35% of the population is overweight. Furthermore, NCDs cause the highest percentage of disease burden in all age groups across Bhutan, and account for over 50% of all deaths, thus making them Bhutan’s greatest health challenges today.
ACCESS, EQUITY AND QUALITY OF CARE OF SERVICES
The accessibility of healthcare in Bhutan is an area of major growth, which first began humbly in 1961 with two hospitals, two doctors and two nurses. Tremendous progress has been made since then with the expansion of health facilities bridging gaps to many rural communities. This has led to almost 90% of the population being within 3 hours of travel to the nearest health facility. Furthermore, eight outreach clinics and seventeen village health workers (VHWs) have been provided per 10,000 population to provide basic health services at a primary level. Additionally, the implementation of VHWs as an aspect of the health system aids in overcoming any cultural accessibility barriers that might have otherwise existed with healthcare professionals. Overall there has been a surge in the utilisation of health services including both traditional medicine services and within the allopathic system, with efforts made over the last decade to expand service delivery points and enhance facilitation of cross referrals. This being from the allopathic system to increase the access and utilisation of traditional medicine.
The number of physicians and nurses has also been steadily rising in Bhutan, however there is still a shortage of medical specialists throughout the country. The distribution of doctors is sub-optimal with only 12 out of 20 districts meeting the government’s goals of stationing a minimum of three clinical doctors in each district. The majority of health infrastructure is focused in the eastern region in comparison to central and western areas and Bhutan still faces physical accessibility issues due to its geographical landscape of high mountains and deep valleys isolating remote communities.
The modernisation of Bhutan’s health system although providing significant improvement to the health of the Bhutanese , must now adapt to face the new challenges facing the evolving society of increasing sedentary lifestyle, increasing obesity and the consumption of a nutritionally deficit diet. The epidemiological transition occurring in Bhutan requires attention to ensure access to nutritional produce and education about lifestyle health. Additionally, with rapid urbanisation, it is estimated that by 2020 over half of Bhutan’s population will reside in urban areas, this leading to overcrowding, sanitation issues and increased pollution all adversely impacting health. Furthermore, Bhutan’s rapid urbanisation has had a significant impact on its agricultural yield with many people migrating from the countryside in search of jobs and education. Thus, agricultural lands are left unattended leading to shortages of fresh food creating chronic food insecurity in southern and eastern regions which also correlated with an increased rate of poverty in these area. Hence leading to an accessibility concern with food insecurity resulting in an insufficient dietary intake of nutritious foods required.
Bhutan has strived to achieve equity through the delivery of a three-tired health system. By providing these services free of charge universally, Bhutan strives for equitable distribution of health care resources irrespective of an individual’s socioeconomic status. However, despite this aim, health equity still proves a major concern in Bhutan with disparities evident throughout the access and utilisation of health services. There are discrepancies between health outcomes in rural and urban areas, income levels and amongst the eastern, central and western regions of Bhutan. In particular the population’s physical accessibility to the nearest health facility is significantly skewed with more wealthy residents being able to access health facilities faster.
Similarly, data shows a negative income gradient in regards to utilisation of services with the richer populations having greater access to and thus progressively using more health services in comparison to the poorer groups. Hence, despite universal coverage of health care with an equal opportunity for all to access, there is still an issue of equity with disparities existing for communities in remote areas lacking awareness of services, and therefore displaying a decreased utilisation of services. Additionally, out of pocket costs such as the money spent on transportation for individuals from isolated areas and medications required contributes to the effect of socioeconomic status on health equity.
PUBLIC HEALTH PROGRAMS ADDRESS THE ISSUE
Following a nationwide surveillance campaign in 2014, Bhutan was able to gain a somewhat clearer picture of issues surrounding NCDs with analysis of data revealing nearly 40% of the population were overweight or obese, 35% had hypertension and 50% were not physically active. These findings were able to spur the government into action with new action plans for NCDs being formed. An attempt was made to increase funding with an additional 20% of funds being allocated at a district level to allow decision making to occur locally. Efforts have also been made towards reducing the main risk factors contributing to NCD’s with the government placing a tax on alcohol and tobacco to decrease their utilisation. Additionally, in comparison to other neighbouring countries Bhutan has instated stronger tobacco bans and regulations regarding sales, imports and advertisement.
Currently, NCD prevention strategies mainly focus on addressing the impact of diet, lifestyle and traditional practices on health with an emphasis on prevention and control of risk factors through surveillance of prominent risks and analysis of disease trends. This method of approach moves away from disease specific interventions which would have a lesser impact when dealing with the management and reduction of NCDs cumulatively.
To combat these issues the government has created a set of objectives from which they have based their public health programs. These objectives include, stimulating public health action, promotion and disease preventing measures by reducing risk factors for NCDs. These risk factors originate from poor diet, lack of physical activity and alcohol and tobacco use. Increasing awareness and educating on these lifestyle factors is vital in order to have a positive and preventative health impact. Encouraging community based local action campaigns which are sustainable, effective and engaging is also important to control NCD risk factors. Similarly encouraging early detection and ensuring quality management of common NCDs such as diabetes, hypertension, heart disease and COPD needs to be achieved through an integrated approach within primary health care services.
To put these objectives into motion, the government has implemented a number of policies to address the issues surrounding prevention, diagnosis and management of NCDs. One of these policies implemented is the ‘National Policy and Strategy Framework on Prevention and Control of NCDs’. This policy takes a holistic approach towards NCDs with primary prevention being a main focus as well as equitable provision of care and treatment services. The implementation of this program is carried out by the National Committee for Lifestyle Promotion and Prevention of NCDs with the aim to include input from all sectors into the process with from health finance (increasing funding to public health programs) to education (delivery of community seminars on the risk factors of NCDs) .
Bhutan has also been the first country in the South-East Asian area to implement WHO PEN – WHO’s Package of Essential Noncommunicable Disease Interventions – for primary healthcare in a low resource setting. WHO PEN allows health professionals to be able to asses patients for risk factors such as high blood glucose levels and hypertension this helping to predictively recognise these disease threats. Thus promoting better health outcomes with improved care and preventive treatment offered for those at high risk of developing conditions such as cardiovascular disease, cerebrovascular disease and diabetes. The results from the implementation of WHO PEN in piloted districts have been promising with a decrease in the rates of hypertension from 42% to 21%.
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CRITIQUE
HEALTH SYSTEM REVIEW STRENGTHS AND WEAKNESSES
The publicly financed health system in Bhutan has proved a major organisational strength with the country’s constitution stating that “The state shall provide free access to basic public health services in both modern and traditional medicines”. Subsequently, not only citizens but non-nationals and visiting individuals are provided with free healthcare. With the entire population covered by universal healthcare under the public health system this provides equity throughout the system with a comprehensive range of services accessible for all.
Another innovation of the Bhutanese health care financing system is the establishment of the Bhutan Health Trust Fund (BHTF). This fund was created as a financial tool to be able to sustain the purchase of crucial components required for healthcare facilities. The primary objective being to ensure more specifically the supply of vaccines, needles, syringes and other essential medicines and equipment to health care facilities in a continued and timely manner. This is a definite strength of the financial system in Bhutan which in recent years has allowed the purchase of pentavalent vaccines and drugs.
However, currently Bhutan faces issues in maintaining their ability to provide free health care with the evolution of the health care system escalating health care costs. The sustainability of this system proves a challenge with increasing expenditures related directly to the rising incidence of NCDs in Bhutan. This is due to the fact that Bhutan lacks the facilities to treat NCDs such as diabetes and kidney failure, and hence these individuals must be treated abroad. In some cases upon recommendation from a committee of specialists, the country provides sponsored treatment abroad which increases transportation and accommodation costs among many other additional expenses. With increasing rates of NCDs there is a correlating increase in the number of patients who require treatment abroad, thus placing increased financial stress on the publicly funded health system. Sustaining these expenses long-term while maintaining immediate health costs required proves an imminent challenge for Bhutan. Resolving this problem will prove challenging in the future years and will require changes to be made to the financial system. Without a shift in health organisation and policy, the country may face serve consequences with the constitution’s guarantee of free health care placed in jeopardy. A review of the health system must take place in terms of financing and service delivery from an equitable and sustainable standpoint to be able to set limits for health care expenditure with essential costs defined. Systematic change needs to occur in order to be able to maintain universal health care in Bhutan for all.
Health service delivery is another one of the major barriers affecting the appropriate treatment of NCDs. Despite Bhutan’s aims to gradually integrate prevention and treatment of NCDs into their primary care system, the majority of patients who require treatment for NCDs are referred abroad to receive tertiary care. This includes treatments for diseases such as cancers, renal failure and chronic rheumatic heart disease which are among the top conditions referred abroad. Travelling abroad for treatment poses barriers for many patients as it greatly diminishes the accessibility of treatment in multitude of ways. Due to financial barriers a patient may be unable to access treatment if they cannot afford the required additionally travel expenses or the prolonged time away from their livelihood to physically access treatment in another country. Additionally traveling abroad may decreasing accessibility by posing a social barrier if an individual is unwilling to travel to an unfamiliar environment with different customs and social principles which they may feel uncomfortable with or intimidated by, and therefore be less likely to follow through with treatment. Furthermore, accessibility of a health care service is affected by the integration and interaction of different health departments and services, and hence if there is a breakdown between the administration and management structures of separate entities this diminishes the accessibility of resources. With treatment provided abroad evidently additional organisational barriers exist creating opportunity for breakdown in communication, and making adequate facilitation of healthcare services even more difficult with the added complication trying to coordinate patient referrals between countries.
Despite NCDs causing more than half of all deaths in Bhutan, the country to yet to develop a sustainable approach to develop the skills of health professionals in order to deal effectively with NCDs. Basic health units in Bhutan which deliver primary health care are comprised of a basic health worker, health assistant and an assistant nurse midwife who are not specifically educated or equipped to handle the treatment of NCDs. Additionally, training in NCDs is not included in the Village Health Worker program and hence they are not educated on and cannot educate the community on the prevalence and prevention of NCDs. This displaying another organisational barrier diminishing the accessibility of healthcare with village workers while able to communicate effectively with the community are unable to facilitate the education on prevention of NCDs.
However in general there is a chronic shortage of doctors and other health care professionals in the country this exacerbating the overall limited training and knowledge of health care workers in regards NCDs. Moreover it was reported in 2009 that fewer than ten physicians in Bhutan had specialised training in NCDs. With these ten physicians gaining their training in places such as India or Thailand, as currently in Bhutan there exists no training facility for an education in NCDs. Furthermore, there are no established international exchanges or other programs accessible to health workers for them to be able to fill this deficiency in training of NCDs. However recently, the government has taken action in an effort to build upon this weakness in their health system with the establishment of Khesar Gyalpo University of Medical Sciences of Bhutan (KGUMSB). This is the first medical university in Bhutan with faculties for medicine, traditional medicine and nursing and public health all combined into one institution. These three faculties aims to teach with a vision of sustained quality and patient centred care through innovative and integrated curriculum. The foundation of this university provides not only a space for vital learning and research networks to take place but the opportunity for Bhutan to achieve self-sufficiency with their own human health resources and specialised centres decreasing their need to outsource healthcare for their citizens to other countries. Additionally, recent policy has also been established to increase scholarship opportunities for medical education to address the shortage of physicians, as increasing the number of physicians will aid the accessibility of healthcare.
PUBLIC HEALTH PROGRAMS STRENGTHS AND WEAKNESSES
To address the increasing burden of NCDs Bhutan has established a ‘National Policy and Strategy Framework on Prevention and Controls of NCDs’. This policy providing a holistic approach for a program aimed at primary prevention and delegation of care and treatment services in regards to NCDs. The establishment of this policy in the community has been run by the National Steering Committee for Lifestyle Promotion and Prevention for NCDs. This committee formed in 2010 was launched by the ministry of health in conjunction with a similar program the ‘Lifestyle Related Diseases Program.’ While the creation of theses policy and programs is a step in the right direction, there is still much action to be taken from a political standpoint to ensure changes are enacted. Furthermore funding for these programs has been limited and yet are required to
Another barrier yet to be overcome is the major gaps in health surveillance of NCDs. Currently, a vital registration system exists to collect mortality information from patients who pass away in health care facilities. However, this registration system collects no data in regards to NCDs and their risk factors. Additionally, there is no information systematically recorded for any complications that may occur, the quality of health care and on health expenditures in relation to NCDs. With this surveillance information lacking, it is difficult to fully grasp the extent of the issue and therefore to be able to effectively manage it.
The development of a national NCD surveillance system would also be highly beneficial in reducing the prevalence and severity of NCDs. While some initial efforts have been implemented, there is currently little development towards a nation-wide system. A comprehensive surveillance system in both private and public sectors will assist the assembly of accurate information. Thus allowing systematic collection, analysis and distribution of data to be used to be used for the successful planning and implementation of public health programs. Without proper evaluation and investigation of data public health programs would not be able to efficiently target areas of need to improve the issue.
Despite the establishment of an essential drug program in 1987 created to monitor and evaluate the use of drugs, the program has not been implemented on a large scale with adequate entry. This deficit was recognised during the revision of the national drug policy in 2007 and yet a system is still in the process of being made to monitor the use and stock quantities of vital drugs – this inclusive of NCD drugs. Hence in order to be able to effectively treat NCD’s this barrier must be overcome, as the lack of data surrounding NCD drug use makes it difficult to a work out their accessibility.
STRATEGIES TO ADDRESS THE ISSUE
To improve the increasing burden of NCD’s in Bhutan many strategies will have to be implemented in order to bring about change in the society. Firstly, the delivery of health services should be upskilled. In order to improve the management of NCDs Bhutan should place a greater priority on the education and development of NCDs-related skills amongst its health workers. This includes increasing the number of workers trained to deal with NCDs as well as expanding their skill set. Additionally, facilities should be upgraded with basic diagnostic and management infrastructure to be able diagnose and treat patients. Hence, to be able to recognise the problem early diagnosis is critical in the plight to decreasing NCDs. Necessary NCD drugs should also be made more readily available and accessible for in particular those in rural areas and with low socioeconomic status.
Another strategy that can be used to help prevent and control NCDs is to increase participation in regional collaboration. This includes collaboration with other countries such as India and Nepal whereby sharing knowledge and exchanging experiences all countries involved will be benefited. Some possible area of collaboration within the region could be creating standardised and mandated food labelling policies in order to improve awareness and educated the community with the knowledge of the food composition of process foods. This would allow individuals to take a more active role in their nutrition and diet enabling them to be able to make their own educated decision in regards to their health. Collaboration could also be utilised to purchase essential medications needed to treat NCDs. This would work to increase the affordability of medications when bought in bulk while also increasing their accessibility. Furthermore, a collaborative regional health assessment institution would be beneficial to all countries involved to be able to compare and contrast the varied effectiveness of interventions utilised for NCDs.
Another area of the Bhutan heath system with the capacity to be improved by regional collaboration would be the opportunity for collaboration with education and training. In this area in particular Bhutan lacks the training facilities and programs for education in NCDs hence regional collaboration would allow the opportunity for different counties to be able to upskill and improve staffing in areas of health where they are specifically lacking to be able to cover a broader range of health issues.
Establishing a technological data base for patient correspondence to increase the opportunity and ease of access for patients seeking accessing treatment abroad. As presently in Bhutan many patients must travel abroad for the treatment of NCDs with this process being administratively and financially cumbersome. With the implementation of a shared patient records and databases this process could be streamlined further improving the accessibility of healthcare to those throughout the region.