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Health Sy Health Systems in Transition Vol. 7 No. 2 2017 s t ems in T r ansition Vol. 7 No. 2 2017 The Kingdom of Bhutan Health System Review The Asia Pacific Observatory on Health Systems and Policies (the APO) is a collaborative partnership of interested governments, international agencies, The Kingdom of Bhutan Health System Review foundations, and researchers that promotes evidence-informed health systems policy regionally and in all countries in the Asia Pacific region. The APO collaboratively identifies priority health system issues across the Asia Pacific region; develops and synthesizes relevant research to support and inform countries' evidence-based policy development; and builds country and regional health systems research and evidence-informed policy capacity. ISBN-13 978 92 9022 584 3 Health Systems in Transition Vol. 7 No. 2 2017 The Kingdom of Bhutan Health System Review Written by: Sangay Thinley: Ex-Health Secretary, Ex-Director, WHO Pandup Tshering: Director General, Department of Medical Services, Ministry of Health Kinzang Wangmo: Senior Planning Officer, Policy and Planning Division, Ministry of Health Namgay Wangchuk: Chief Human Resource Officer, Human Resource Division, Ministry of Health Tandin Dorji: Chief Programme Officer, Health Care and Diagnostic Division, Ministry of Health Tashi Tobgay: Director, Human Resource and Planning, Khesar Gyalpo University of Medical Sciences of Bhutan Jayendra Sharma: Senior Planning Officer, Policy and Planning Division, Ministry of Health Edited by: Walaiporn Patcharanarumol: International Health Policy Program, Thailand Viroj Tangcharoensathien: International Health Policy Program, Thailand Asia Pacific Observatory on Health Systems and Policies i World Health Organization, Regional Office for South-East Asia. The Kingdom of Bhutan health system review. Health systems in transition. Vol-7, Number-2 ISBN 978-92-9022-584-3 (NLM classification: WA 540.1) © World Health Organization 2017 (on behalf of the Asia Pacific Observatory on Health Systems and Policies) All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from SEARO Library, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: [email protected]). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization 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 the World Health Organization 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 the World Health Organization be liable for damages arising from its use. The views expressed in this publication are those of the authors and may not necessarily represent the decisions or policies of the World Health Organization. Printed in India ii Contents Preface .................................................................................................. xi Acknowledgements ............................................................................. xiii List of abbreviations ............................................................................. xv List of glossary ................................................................................... xxii Abstract ............................................................................................. xxiii Executive summary ............................................................................xxiv Chapter 1 Introduction ........................................................................... 1 Chapter summary ........................................................................................ 1 1.1 Geography and sociodemography....................................................... 2 1.2 Economic context ................................................................................ 6 1.3 Political context ..................................................................................10 1.4 Health status ......................................................................................13 1.5 Natural and human-induced disasters ..............................................21 Chapter 2 Governance.......................................................................... 23 Chapter summary .......................................................................................23 2.1 Overview of the health system ...........................................................25 2.2 Historical background ........................................................................28 2.3 Health-care organization ...................................................................29 2.4 Decentralization and centralization ...................................................31 2.5 Policy and planning ............................................................................35 2.6 Intersectorality ...................................................................................38 2.7 Health information management ......................................................41 2.8 Regulation ..........................................................................................42 2.9 Patient empowerment .......................................................................49 Chapter 3 Financing ............................................................................. 53 Chapter summary .......................................................................................53 3.1 Health expenditure .............................................................................54 3.2 Sources of revenue and financial flow ...............................................59 3.3 Overview of the public financing schemes ........................................62 3.4 Voluntary health insurance ................................................................69 3.5 Other financing mechanisms .............................................................70 3.6 Payment mechanism .........................................................................72 iii Chapter 4 Physical and human resources ............................................ 75 Chapter summary .......................................................................................75 4.1 Physical resources .............................................................................76 4.2 Human resources ...............................................................................88 Chapter 5 Provision of services ......................................................... 101 Chapter summary .....................................................................................101 5.1 Public health ....................................................................................102 5.2 Patient pathways ..............................................................................111 5.3 Primary/ambulatory care .................................................................114 5.4 Inpatient care ...................................................................................119 5.5 Emergency care................................................................................122 5.6 Pharmaceutical care ........................................................................125 5.7 Rehabilitation/intermediate care .....................................................130 5.8 Long-term care ................................................................................132 5.9 Services for family/informal carers .................................................132 5.10 Palliative care ...................................................................................133 5.11 Mental health care ...........................................................................133 5.12 Dental care .......................................................................................136 5.13 Complementary alternative medicine (CAM) and traditional medicine ..................................................................137 5.14 Health services for specific populations ..........................................140 5.15 Disaster risk management for health (DRM-H) ..............................142 Chapter 6 Principal health reforms ................................................... 148 Chapter summary .....................................................................................148 6.1 Analysis of recent major reforms ....................................................149 6.2 Future development .........................................................................161 Chapter 7 Assessment of the
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