In matters of health 1
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ISBN 978-92-9022-776-2 Cover: The Trashichhodzong and the Gyalyong Tshokhang are the sources of the country’s national laws and policies. Photo: Kinley Wangmo Printed in Bhutan In matters of health Towards equitable health system, work of WHO in Bhutan, 2019 Foreword
hutan’s achievement in public health has been decisions and policies continue to play a vital role. exceptional. In 2019, Bhutan committed to eliminate cervical cancer The achievements are a combined effort by 2030. The same year, the kingdom became one of the first and merit of far-sighted leadership of our nations in the southeast Asia region to gain Hepatitis B control successive monarchs, focused not only on status, before the regional target primaryB health care but also on balanced development, which of 2020. has, in turn influenced the sustainable socio-economic growth. These are only a few The achievements are also attributable to WHO, a long-term examples of how decisions are partner in facilitating the course of Bhutan’s health care system. crucial part of the health care WHO’s partnership has stimulated generation, translation system. and dissemination of valuable public health knowledge. Norms Unique to Bhutan is the right and standards have not only been established, but monitoring to health services, both modern and implementation assistance have been provided too. Its and traditional medicines, which effort in shaping research agenda has resulted in positive the Constitution guarantees and changes as Bhutan strives for sustainable institutional capacity nurtured wisely by our monarchs. growth. The government will continue the legacy of according high The Organization assisted in making decisions, putting priority to equitable and universal access to free health care policies in place and implementing it on the ground. services. WHO’s partnership, as always, remains crucial. However, in the face of rising health expenditure, changing lifestyle and disease pattern, inadequate human resources, Dechen Wangmo changing political environment, evolving health care needs, Health Minister international health obligations, new health technologies, Foreword
uch of Bhutan’s policies are guided at and national policies have been crafted, a key function by its philosophy of Gross National of the Organisation that informs Member States of health Happiness, the four pillars that prop up policy options drawing on global expertise and experience. the nine domains that forms the base. As part of its service, the Organization continues to Health is one of the domains with promote and assist the bearingsM on rest of the eight. country in improving Little wonder that it is a service provided free to access, quality and use people, at least at the point of care, by the state that claims of medical products and responsibility of creating the sort of environment conducive technologies, which for its citizens to pursue happiness. The belief is, happiness eventually go on to of an individual is so contagious as to spread to the families, supporting management the community they live in and to the society ultimately. and governance of the A global community that it has come to represent, health system. World Health Organization has always aspired to fulfill the As Bhutan copes with diversity it brings in terms of knowledge and experience new challenges, grapples for Bhutan to draw from, so it can make informed policy with the existing and introduces new programmes and decisions on health. initiatives to improve health services, we will continue being As this report indicates, through the many trainings, the partner we are seen as, in the country’s aspirations for seminars and studies it supports for health and its allied better health care services and system. agencies, technically and in pecuniary terms, WHO has been a major partner in strengthening Bhutanese health system. It provides technical assistance and helps meet Dr Rui Paulo de Jesus international health standards for the country. WHO Representative Through such activities, decisions have been arrived
Introduction
he publication presents some of the significant emerging issue of suicide also received more focus from health works of WHO in 2019 to aid Bhutan’s progress sector and recognised the role of suicide gatekeepers. in achieving Sustainable Development Goals and The emergency contingency plan and the setting up of an Universal Access to Health Services. emergency medical team, which is underway, are some initiatives The book, in a gist, captures WHO’s work in exhibiting Bhutan’s commitment to Emergency preparedness, the 2019,T documented under five sections – Universal coverage, next section. Happiness and wellbeing, Emergency preparedness, Effective While universal access to health services is at the services and In partnership. forefront, effectiveness of the services cannot come second. Under Universal coverage, major milestones were attained Pharmaceutical management and standardisation of medical with Bhutan achieving Hepatitis B control status, its commitment equipment are some of the key initiatives highlighted under to eliminate cervical cancer by 2030 and the first World Patient Effective services section. Safety Day observed. The last section, In partnership, is about the Organization’s Happiness and wellbeing, the core principles of Bhutanese numerous collaborations with various government and development agenda, present initiatives taken to care for the international agencies to help realise the country’s national health elderly and the young. A patient centered PEN HEART package goals and objectives. was also initiated across health centres in the country. The Healthy nation: OpeningSound policy decisions photo bring about improved health systems that ensure a healthy future In matters of health 9
Photo: Kinley Wangmo Contents
Universal health coverage Eliminating cervical cancer 14 Adequate staffing 16 Patient safety at the core 18 Improved hypertension services 20 Part of the whole 23 Raising awareness 24 A status of Hepatitis B control 26 Expelling parasitic worms 28 E-sourcing health information 30 En route to malaria free status 32
Health and wellbeing Patient centered PEN HEARTS package 36 Legally sound 38 Gatekeeping suicide 39 Post trauma counseling 41 Neonatal deaths - how and why ? 42 Tackling alcohol locally 45 Healthy ageing 46 Effective services Baseline study for WASH 48 Mother and child go online 70 Real-time food safety surveillance 50 Assessing health technology 73 Tobacco use drops among youth 52 Assessing impacts from development 74 Scanning radiology equipment 76 Shortcut to treating TB 78 Emergency preparedness Supporting eye care service 81 To better manage laboratories 56 Roping in youth in their matters 82 Meeting international health regulations 56 Learning to code 84 For health security 59 Stronger as one 85 Risk communication 60 Assembling an emergency medical team 61 Preparing basic health emergencies 63 In partnership The flu shot 64 Committed to ending HIV 88 Updated SOP to rein on diarrheal disease 66 Global Health diplomacy 92 Heavy metal exposure 67 People’s healthcare 94 On the drafting board 96 Universal health coverage
14 In matters of health
Eliminating cervical cancer
hen 37-year-old Dechen received workers were trained in cervical cancer a call from a hospital nurse in screening at PGIMER in India. Two Thimphu informing her of the gynecologists were trained in colposcopy and papW smear result reading negative for cervical related procedures at Chulalongkorn University, cancer, she was relieved, before being impressed Thailand. with the service. She had undergone the WHO continues to support health ministry procedure two days ago. in strengthening capacity of health workers The last time the mother of two children did to help achieve cervical cancer elimination. Bhutan a pap smear, she had to wait for about a month Bhutan has been in the forefront of secondary for the result. Back then, in 2014, the sample prevention of cervical cancer since the late ‘90s. committed to had to be sent to Kolkata, India for test. Today, it The health ministry took the lead in formulating eliminate cervical is done at the laboratory of the national referral the first guideline in cervical screening in 1999. hospital. The National Health Policy assures cancer by 2030 In recent years, cervical cancer screening has comprehensive quality maternal and child been ramped up and in February 2019, Bhutan health care services. Similarly, the National committed to eliminate cervical cancer by 2030 Reproductive Health Strategy (2018-2023) at the 144th session of the WHO executive prioritises cervical cancer as one of the vital board. components towards achieving optimal sexual Following the commitment, 10 health and reproductive health services. In matters of health 15
Photo: Rinzi Om Dorji/WHO
Up North: Health Minister Dechen Wangmo with WHO Representative Dr Rui Paulo de Jesus in Laya at the launch of cervical cancer elimination campaign 16 In matters of health
Adequate staffing
pilot Workload Indicators of WISN. Of many, some of the positions level technical seminar on Strengthening Staffing Need (WISN) was included in the assessment were specialist Health Workforce Governance Towards conducted in various health technicians, medical officers, dental and Universal Health Coverage in Bhutan. The centresA across the country to assess clinical surgeons, clinical and staff nurse, WISN report was endorsed during the staffing requirements. health assistants and pharmacists. seminar with a way forward. WISN is a method to determine WISN was recommended during the One significant recommendation was staff shortages and surpluses, workload 4th biennial health conference, 2017. the implementation of WISN in all health pressures and other health systems Some of its key findings were facilities across the country to improve weaknesses. Based on the findings, key that primary care services required human resource forecasting and planning. recommendations are provided. WHO strengthening and staff roles had to be In the past, levels of service delivery, first published the WISN user manual in aligned with health centre needs. population densities and health worker 1998. The findings were presented to the to bed ratio were used for determining Hospitals in Thimphu, Mongar, ministry’s Human Resource Committee staff requirement. Seeking scientific Phuentsholing, Trashigang and Basic and during the 5th biennial health methodology, the ministry, with WHO Health Units I and II in Kanglung, Paro conference. assistance adopted WISN. and Punakha were assessed as part of the It was also presented during the high- In matters of health 17
staffing needs: Senior nurses attend to patients during a routine child immunisation programme at Hongtsho outreach clinic
Photo: Rinzi Om Dorji/WHO 18 In matters of health
Patient safety at the core
o strengthen and improve patient safety, the Hospital effect, rolling out various activities, which called for a re-look at Management and Administration Transformation patient safety and derived commitments to make patient safety (HMAT) was rolled out in all hospitals and Basic a reality in the country. HealthT Unit I. A two-day national symposium was organised in Thimphu This is expected to improve efficiency of the management to discuss patient safety issues. Key recommendations like and accountability in the clinical setting including medical reinforcing existing policies and standard operating protocols ethics. were made. Health Care Standard for Quality Assurance (BHSQA) was For awareness, landmarks like the national memorial initiated and implemented in most health facilities. Standard chorten and Buddha Dhordhenma, were lit up in orange on the operating procedures (SOPs) and good clinical practice evening of Patient Safety Day. Photo booths were stationed at guidelines were also developed. various locations. The country also observed World Patient Safety Day, A national hotline, 1414, for patient complaints was also bringing together health professionals, policy makers, launched. academics, legal professionals and other relevant regulatory The 72nd session of the World Health Assembly endorsed authorities to discuss and deliberate on patient safety. 17 September as World Patient Safety Day and in the SEA- The day was observed at eight health centres in strategic region, the Regional Strategy on Patient was adopted during the locations and with high workload. The day led to a rippling 68th session of the Regional Committee. In matters of health 19
ON THE EVE: City landmark like the Buddha Dordenma statue is lit up to mark World Patient Safety Day. Inset: On the day, photo booths were placed at various locations in Thimphu
Photos: Rinzi Om Dorji/WHO 20 In matters of health
Improved hypertension prevention services
ealth workers across 39 health facilities of of monitoring and coaching, evidence-based practice and Blood pressure Wangduephodrang and Zhemgang were access to medicine and technology were in place. of adults trained on early detection, prevention, Bhutan was one of the few countries in the South- 28% have high BP treatment,H improved stroke registry and strengthening East Asia Region, where non-physician primary health hypertension information system. care workers, or Health Assistants (HAs) are authorised of high BP patients were The two districts, according to Public Health to screen and prescribe first-line anti-hypertensive 20% not on medication Division’s Deputy Chief Programme Officer Pemba medicines. HAs, therefore, underwent two to three-year of population had their BP Yangchen, were identified for the training because of basic health science training. 83% measured by a health worker higher cases of hypertension there. Besides, they also HA’s were recognised as the core health workforce took into consideration the scattered health facilities providing health care across the nation’s 211 Basic Health Dietary Salt Intake and logistical challenges of the two districts. Units (BHU) in the 20 districts. BHUs are a five-bed Although hypertension services continued, she primary health care centre staffed with two to three HA’s. Mean population salt intake for an adult Bhutanese said the 2016 Package of Essential Noncommunicable Hypertension continues to be the leading risk factor 8.3 grams/day Diseases (PEN) clinical audit highlighted gaps in PEN of Cardiovascular Diseases (CVD). About 37.5 percent and, therefore, the PEN HEART model was adopted to of the country’s population suffer hypertension. As per of adults drink salted tea address the deficiencies. WHO estimates, Bhutan has been witnessing a growing 45% in their home “Health workers in each district were trained on the trend of Noncommunicable Diseases (NCD), which revised PEN HEART protocol, which entails modules on accounts for 69 percent of the total deaths, a majority Source: STEPS Survey, 2019 healthy lifestyle counselling,” she said, adding the system caused by CVD. In matters of health 21
KEEPING IN CHECK: In a day, the Lifestyle Related Disease Unit of the national referral hospital sees close to 40 patients coming to check blood pressure readings Photo: Kinley Wangmo HELPING H22AND: AIns part matters of the of health hospital’s service, a staff of the national referral hospital attends to a patient
Photo: Kinley Wangmo In matters of health 23
Part of the whole
he country now has a National regarding the need and demand for assistive Action Plan for People Living devices for people living with disabilities in with Disabilities. the country, what limited data the health TDrawn up in consultation with relevant ministry gathered indicated a strong need agencies, the action plan, through provision for assistive products. Today, only a limit- of assistive technologies and products, will ed number of people with disabilities have Number of ensure, in the long-term, meaningful par- access to them. impairment by types ticipation of people with disabilities in the According to the 2019 Annual Health Hearing impairment 3 029 country’s socio-economic development. Bulletin, which gathered door-to-door Visual impairment 2 129 As its member state and party to the 71st information by households on impairment World Health Assembly resolution that ad- by types – hearing, visual, physical, speech Multiple impairments 1 535 opted assistive technology, Bhutan was man- and multiple impairments – showed hearing Speech impairment 1 339 dated to develop, implement and strengthen impairment as being the highest at 3 029 Physical impairment 1 126 policies and programmes to improve access cases. Visual impairment followed at 2 129 to assistive technology. reported cases, 1 535 reported having mul- Likewise, as a member state also of the tiple impairments, 1 339 speech impairment UN, it was party to SDGs endorsement and 1 126 physical impairment. Source: of ensuring accessibility, affordability and Artificial limbs, communication aids, 2019 Annual Health Bulletin availability to assistive products, which in hearing aids, memory aids, pill organisers, broader scope defines the universal health software, spectacle and wheelchair and mo- coverage. bility aids are among a few assistive prod- Despite lack of official record or study ucts and technology lists. 24 In matters of health
Raising awareness
One effective method of educating and creating awareness among Bhutanese is the use of election boards, located strategically in all 205 gewogs (blocks) as a medium for communicating key public health messages. WHO in collaboration with health ministry came up with this simple and tested method of disseminating public health messages nationwide. A new poster, focusing on key public health issues, is up every two months.
EFFECTIVE COMMUNICATION: A woman pauses to read HIV advocacy material on an election board outside district administration office in Thimphu
Photo: Kinley Wangmo In matters of health 25 26 In matters of health
A status of Hepatitis B control
hutan was one of the first nations provided during infancy. to gain the Hepatitis B control Studies conducted among five-year- status in the WHO South-East olds in the four countries showed high AsiaB Region. immunisation rates, indicating Hepatitis The other countries in the Region that B prevalence among children in these age received similar recognition for slimming groups being less than one per cent. Viral hepatitis, Hepatitis B prevalence under one percent Children across the 11 countries in the among five-year-olds, were Bangladesh, region, under their national immunisation kills more than Nepal and Thailand. programmes, received three doses of the WHO announced this in July 2019, days Hepatitis B vaccines in their first year of 400000 people in before the World Hepatitis Day themed life. The vaccine, which prevents Hepatitis the region a year “Invest in eliminating Hepatitis” and much B infection in infancy goes on to reducing before the regional target of 2020, as a part chronic infections and liver cirrhosis or of the South-East Asia Regional Vaccine cancer in adulthood. Action Plan. Viral Hepatitis, although preventable, The status was arrived at following kills more than 400 000 people in the review and verification of childhood Region a year. Today, close to 90 million immunisation data of the four countries, people in the region suffer from chronic which revealed consistent Hepatitis B liver diseases that spikes cases of liver vaccine coverage – more than 90 percent – cancer and cirrhosis. In matters of health 27
Photo: SEARO/WHO
Another milestone: Health Minister Dechen Wangmo receives the WHO citation for Hepatitis B control from WHO Regional Director Dr Poonam Khetrapal Singh and WHO HQ Chef de Cabinet Dr Bernhard Schwartländer. 28 In matters of health
Deworming to eliminate STH
revalence of Soil Transmitted Helminth burden by strengthening control and prevention (STH) among school children in of its prevalence, for which capacity building Bhutan dropped from 16.5 percent in of school health coordinators was deemed 2003P to 1.4 percent in 2017, according to the critical. The idea was to maintain the low rate latest study. by increasing efforts to eliminate the burden of When the first study was carried out in 1985, STH through capacity building of key persons the prevalence rate was between 20 and 70 involved with children percent. The country began school deworming With WHO support, more than 80 health programme in 1989 with single-doze of officials and coordinators from various districts Albendazola (medication used to treat a variety across the country were engaged in developing of parasitic worm infestations) administered manuals, strategies for greater awareness every six months to school children. It picked creation. It was done through media and pace to extend coverage to 98 percent as of 2003. monitoring and evaluating STH prevalence in a Although STH infections do not necessarily few select schools. cause death among children, increasing evidence Regionally, STH prevalence among school indicate impairment in mental and physical children was lowest in the west at 0.6 percent, development, deficiencies of micronutrient, 1.4 percent in the country’s central region and including iron, all of which lead to poor learning 2.3 in the east. ability and absenteeism in schools. The country intends to eliminate STH In matters of health 29 PRE TEEN SCHOOLERS: Primary school students of Tang, a remote valley in Bumthang return home after school Photo: Kinley Wangmo 30 In matters of health
E-sourcing health information
n an effort to make health information available DHIS2 is a free and open source health from one source, various e-platforms of the management data platform the Health Information health ministry were integrated with the Systems Programme (HISP) developed. BhutanI Health Management and Information System The BHMIS has improved since the inclusion of (BHMIS). DHIS2 as the main platform for collection of routine BHMIS consists of various information sources with information. DHIS2 was initiated in 2014, and after District Health Information Software 2 (DHIS2) serving four years of implementation, the system was used by as the main platform for collection of routine health hospitals and BHU I with Internet connectivity. information. These systems not only help in service delivery The Mother and Child Health (MCH) tracking but also reduce mortality, morbidity and disease system and Malaria tracking system was also integrated burden. However, due to lack of Internet facilities and in DHIS2. equipment, many health centres still report routine According to health officials the e-health strategy is health information using paper-based forms. to have a single source of data to avoid duplication and In keeping with the effort towards digitisation of to support data validation and quality of information. health information, the government targets to connect To aid this initiative, the WHO supported web- all health facilities with Internet in the 12th FYP based BHMIS (DHIS2) application rollout and user (current plan period). training for Basic Health Unit II with Internet access A digitised health information system is expected to and also training of trainers on ICD 11 coding of increase reliability and availability of data for planning diseases. The training also included familiarisation of and programmatic interventions. the DHIS2 mobile app. In matters of health 31
ONLINE TRACKING: The Mother and Child Health tracking system was integrated with BHMIS
Photo: Kinley Wangmo 32 In matters of health
On track to malaria free status
ith only two cases of indigenous The National Committee for Disease malaria cases recorded in 2019, Elimination was briefed on the process of Bhutan is on track to eliminating WHO certification for malaria elimination, the malaria.W key principles involved. WHO also conducted In 2016, WHO included Bhutan in a group training for the malaria programme and of 21 countries with potential to eliminate malaria technicians. malaria by 2020. The Organization continues to provide The numbers dropped from 39,852 cases support in various areas of the government’s and 62 deaths in 1994 to just six indigenous response to malaria. In the past two years, cases in 2018 and two in 2019. By 2020, it hopes WHO has recruited and deployed two malaria to have no case. technicians in two remote places with history If the zero status is sustained for three of malaria outbreak. The technicians assist the consecutive years, Bhutan will be eligible National Malaria Programme in conducting to apply for WHO certification for malaria intervention and surveillance works. elimination. Achieving malaria free status will be another To support this endeavour, WHO conducted significant milestone in the history of Bhutan’s a review of the malaria surveillance system. It modern health system. assessed the current status of the surveillance system and provided recommendations for the last mile. In matters of health 33
CONTROL MEASURES: Mosquito nets were distributed to residents of Jomotshangkha, Samdrupjongkhar, one of the malaria hotspots in the country 34 In matters of health
Health and wellbeing In matters of health 35 36 In matters of health
Patient-centered PEN HEARTS pack
hutan was one of the first an acceptable quality of care, even in capacity. countries in the South-East Asia resource-poor settings. These tools enable Technical working members and WHO Region to pilot the WHO Package early detection and management of staff from SEARO office conducted a five- of EssentialB Noncommunicable (PEN) cardiovascular diseases, diabetes, chronic day training of trainers at the national level disease interventions. respiratory diseases and cancer to prevent for representatives from the districts in It was piloted in two districts in 2010, life threatening complications. March 2019. and in 2013 it was scaled up across the Acting on the PEN clinical audit 2016 The representatives developed a country to promote early detection findings, a PEN HEARTS package focusing prototype plan for conducting patient- and increase access to equitable NCD on integrated approach to management centered PEN HEART for their districts. services. The focus was on early detection of NCDs was introduced in Punakha and The patient-centered approach also involves and screening of common NCDs like Tsirang. family members, who are expected to be hypertension and diabetes. A cohort monitoring of control rates for agents of change in tackling NCDs. However, in 2016, a PEN clinical audit hypertension and diabetes at health facility Treatment modality underwent was carried out, which found consultations and national levels will be set up. Peer reorientation and brief interventions on focused on symptoms and disease coaching programme and learning network alcohol and tobacco use was integrated and pathology. Health workers were also found to provide evidence based management for CVD risk charts assessed. tuned out of treatment protocols and NCDs will be introduced. An NCD triage room or corner was lacked skills to add or intensify treatment For a baseline for the PEN HEARTS introduced with registers to track all patient for NCDs like hypertension and diabetes. project, a rapid assessment was conducted within their jurisdiction. Health care The WHO PEN is an innovative in February 2019 using rapid baseline workers are now committed to calling up and action-oriented set of cost-effective assessment form to document available patients and follow up on drug adherence. interventions that can be delivered to services, infrastructures and human In matters of health 37
Photo: Kinley Wangmo
FOLLOW UP: Patients outside the Lifestyle Related Diseases Unit of JDWNR hospital wait for check up 38 In matters of health
Legally sound
ome 40 medical and health professionals were brought up to speed on the National Health Policy. The policy, the outline for which was drafted withS support from WHO around July 2019, was taken up for Blood and Blood Products Regulations of Bhutan dissemination for medical and health professionals. It was in keeping with the Royal Civil Service Commission’s Tobacco Control Amendment Act 2014 mandate to all legal officers of various government agencies to disseminate information on laws and create legal awareness among National Health Policy various government departments and divisions. Considering it was mostly medical and health professionals The Medicine Act of the Kingdom of Bhutan in the border towns who dealt with legal issues and even faced court charges, the health ministry’s legal unit decided they be Bhutan Medicine Rules and Regulations sensitised and made aware of various legal provisions concerning the profession. National Blood Policy Bhutan Besides guiding medical and health professionals on legal matters, awareness on provisions in various laws pertaining to the profession helped prevent them from any possible legal perils emerging from the profession. In matters of health 39
Gatekeeping suicide
nderstanding the importance of Police recorded a total of 361 suicide deaths. gatekeeping in suicide prevention, The proportion of suicide deaths among all deaths 20 participants representing various was 4.5 percent, higher than the corresponding sectorsU like health, police, education, De-Suung and proportion of 1.4 percent in the low middle-income monastic community were trained as trainers. countries and occurred among the most productive WHO country office provided technical and age groups. About 87 percent of deaths occurred financial support to establish the national capacity of within the age group of 15-40 years. trainers. Since suicide attempts result in enormous cost to The training was aimed at developing knowledge, the health care, family and individuals, due to injury attitudes and skills to identify those at risk and make and disability, it is a public health concern in the referrals. country. The government committed to addressing In Bhutan, suicide and mental disorder was suicide prevention as a top public health priority. recognised as a growing public health concern. The Following recommendations of the WHO and the government endorsed a three-year National Suicide National Suicide Prevention Action Plan, the training Prevention Action Plan in 2015. of trainers for suicide prevention was conducted in Suicide was among the top six leading causes of November to develop national capacity. The training deaths in Bhutan. WHO data (2017) indicated that will be rolled out across the country within the 2018- 2.11 percent of the total deaths in the country were 2023 Plan. from suicide. From 2009 -2013, the Royal Bhutan 40 In matters of health
BUILDING CAPACITY: Frontline health workers and emergency medical responders undergo a post trauma counseling training
Photo: Rinzi Om Dorji/WHO In matters of health 41
Post trauma counseling
ith assistance from WHO, 60 emergency Globally, trauma is one of the leading causes of frontline health workers like emergency death between 1-44 years. In Bhutan, with increasing medical responders (EMRs) and nurses trauma cases, need for prompt and standard care is all in emergencyW departments from various health the more critical. facilities across the country were trained in post trauma In addition, medical emergencies due to counseling during public health emergencies. Noncommunicable Diseases (NCDs) are becoming a The first of its kind in the country, the training was burden for the health system. NCDs like stroke, acute conducted to build capacity of health workers to provide coronary syndrome, diabetic complications and alcohol psychological care besides medical treatment to patients liver diseases are some of the conditions requiring and others affected by traumatic events like disasters, immediate care. accidents or deaths. Emergency Medical Services Division under Prior to this, only indirect classes and sessions Department of Medical Services is identified as the covered psychological aspects of post trauma treatment. nodal agency to improve trauma care and emergency The training will further strengthen emergency services in the country. The health ministry medical services in the country. identified health facilities to be established as medical Allied health professionals, volunteers, De-Suups and emergency and trauma centres during the current other social workers are also expected to be trained. Five-Year Plan. 42 In matters of health
Neonatal deaths- how and why?
n what could be a first of kind, the intended to determine that. The health public health division of the health facilities reported more than 100 neonatal ministry carried out a retrospective mortality in 2018 and it was crucial to find studyI of neo-natal mortality in the country. out how and why they occurred, to identify Retrospective, because the study was gaps. The findings from the study would based on 2018 data registered with Mother be critical in defining key interventions to and Child Health (MCH) using the enhance and ensure health of newborns in Maternal, Perinatal, and Neonatal Deaths the country. Surveillance Response (MPNDSR) guideline. The sample, the study considered, Although neonatal deaths was a major constituted live newborns in health facilities contributor to the proportion of under-five – 27 hospitals including three referrals, 23 mortality, the country was wanting of a study BHU I, 185 BHU II and 45 sub-posts – that that considered the factors and characters reported neonatal mortality between 1 associated with neonatal mortality. January and 31 December 2018. The study conducted around August In matters of health 43
AN INFANT’S PROGRESS: A health staff weighs an infant at the MCH in Gelephu Regional Referral Hospital
Photo: Kinley Wangmo 44 In matters of health
Photo: Kinley Wangmo
COMMON PLACE: Alcoholic brews are ubiquitous in almost all restaurants and hotels in the country In matters of health 45
Tackling alcohol locally
n the absence of a national law, a bylaw to in the existing alcohol policy. control illegal sale of alcohol and reduce The country’s culture around drinking, its STEPS survey its consumption among people in rural ubiquity in all shapes, types and sizes across shops Respondents 6,000 plus communities,I was what some 5 000 elected local extending into the far reaches of the country gave leaders decided on. the country the notoriety of being one of the biggest, Current drinkers – 43% It does not stop there, local leaders also decided globally, in terms of the number of alcohol outlets Former drinkers – 16% to strictly implement the provisions of the bylaw compared with the size of its population. The study Lifetime abstainers – 41% that prescribes against exposure of underage to pointed out one liquor outlet per 98 Bhutanese above alcohol, sale of alcohol in grocery shops and healthy 15 years. Choice of alcohol substitute for alcohol at any religious or social What that means? Alcohol spawned diseases, among drinkers functions. particularly pertaining to liver, continues to be The decision was arrived at during an awareness one of the top five causes of deaths in the country Beer – 45% campaign that health ministry officials conducted that drains more than Nu 30 million of the public Ara – 24% among gups, mangmis and tshogpas of the four resources in treating alcohol-related ailments and Other home districts of Dagana, Lhuentse, Mongar and resolving social issues of deeper consequences. brewed alcohol – 15% Samdrupjongkhar. Studies in the past revealed that it was mostly Wine – 9% It was based on a WHO supported study, which people residing in rural areas, with low socio- delved into the country’s alcohol pricing and taxation economic and education background, who were most Spirit – 8% policies to conclude low adherence to it, both among vulnerable to alcohol abuse. Source: STEPS 2019 alcohol sellers and consumers, to control its sales and Therefore, the involvement of local leaders, reduce consumption. community representatives, including health The study pointed out two fundamental workers, women associations and religious leaders shortcomings – a method to contain rapid and was imperative in countering the deep-seated social uncontrolled growth of outlets and effective taxation – malaise that is alcohol. 46 In matters of health [ ] Healthy ageing
o homogenise the WHO Catering to this section of the population, citizens through periodic or annual health Integrated Care for Older People the health ministry in collaboration with checkup, under the overall supervision of (ICOPE) guidelines with the Kyoto University, initiated the community the Elderly Care Programme, under the existingT community based elderly care based elderly care programme through health ministry. programme in the country, healthcare a pilot project in Khaling, Trashigang in Of many, the checkup comprises workers were trained in ICOPE guidelines. 2010. screening for geriatric problems like With both ICOPE guidelines and The programme was rolled out drinking, depression, diabetes, dental, the elderly care programme focusing on nationwide through training of health hypertension, visual, hearing and urinary healthy ageing, it required the ongoing personnel in Basic Health Units and other incontinence. Once the assessment is programme to undergo a complete health facilities. done, follow up is carried out to manage review so gaps could be identified and the The National Health Assembly relevant conditions and prevent or delay ongoing programme modified accordingly. approved WHO’s global strategy and complications. For the review and to introduce the action plan on ageing and health in The WHO ICOPE package of tools offer concept of ICOPE, a two-day training 2016. As a tool, among others, an ICOPE an approach that helps key stakeholders of trainers was organised, followed by a guideline was developed in 2017. in health and social care to understand, three-day training. By providing evidence-based tools design and implement person-centred and Participants from hospitals across and guidance specific to every level of coordinated model of care. the country and Royal Society for Senior care, ICOPE helps health systems support The ICOPE handbook assists healthcare Citizens (RSSC) attended the trainings. healthy ageing and maximise older workers to develop a personalised care With increased life expectancy the people’s intrinsic capacity and functional plan that includes multiple interventions elderly population has been increasing ability. to manage cognitive decline, limited over the years. Today, five percent of the The community elderly programme mobility, malnutrition, visual impairment, Bhutanese population are over 60 years. in Bhutan assesses the health of elderly hearing loss and depressive symptoms. In matters of health 47
AGING GRACEFULLY: The health ministry of Bhutanese instituted a programme to screen ailments associated with old age for population are appropriate interventions [ over 60 years ]
Photo: Kinley Wangmo 48 In matters of health
Baseline study for WASH
ore than 90 percent of the 218 health disruption in the health facilities. facilities across the nation’s 20 districts Lack of baseline information, health officials said have access to piped drinking water, impeded the WASH sectors to set national targets of which,M an impressive 88 percent reported having that conformed with Sustainable Development Goals access to 24-hour water supply. that stipulates achievement of safe drinking water The findings from the national baseline survey and sanitation and hygiene by 2030. of Water, Sanitation and Hygiene (WASH) in health “Aligning the baseline study with SDGs could help centre facilities, however, pointed out issues of water set realistic national targets under the 12th Plan,” a disruption with 57 percent reporting about it and 11 health official said. percent that faced shortage during monsoons. Likewise, the study also revealed that 99 percent The survey that Public Health Engineering of the toilets in the health centre facilities surveyed Division of the health ministry undertook, with joint were pour flush. It stated that 13 percent were financial support from WHO, UNICEF and SNV, connected to sewer network and 49 percent had according to health officials was long overdue for septic tank with soak pit. focused intervention to address water shortages and In matters of health 49
HYGIENE: Though abundant, management of water from the sources through distribution channels to the outlets remain a challenge
Photo: Kinley Wangmo 50 In matters of health
Real-time food safety surveillance
he country’s disease control and food sample collection and transportation, BAFRA regulatory authorities can maintain inspectors will collect five instant food products an efficient food safety surveillance fortnightly from identified urban centres and withT the real-time online surveillance system transport them to Royal Centre for Disease FoodSIMS (Foodborne Disease Surveillance Control (RCDC) for microbiology analysis and Information Management System) developed in generate a report. It will be used to build an July 2019. efficient food safety surveillance data. The system allows for regular update of food In 2014, food poisoning was identified as samples collected from hotels, restaurants and one of the notifiable diseases in the country bakeries from the major towns of Gelephu, Paro, and was integrated into the National Early Phuentsholing and Thimphu. Warning and Surveillance Response. Lack of Along with the development of the such a robust system in the past limited relevant online system, Bhutan Agriculture and Food authorities to event-based and syndromic Regulatory Authority (BAFRA) food inspectors reporting of foodborne illnesses. Although from the identified towns were given their own that served its function of facilitating efficient user ID to load information into FoodSIMS. sharing of resources for core surveillance and They were trained on its use to strengthen support functions, it fell short of capturing data reporting mechanism as part of integrated on foodborne illnesses and systemic laboratory- surveillance system under NEWARS. based foodborne surveillance system. With the hands-on training on food In matters of health 51 TRADITIONAL BUFFET: Just about all favorite Bhutanese cuisine arrayed at a local restaurant
Photo: Kinley Wangmo 52 In matters of health
Tobacco use drops among youth
n the last six years, tobacco use of Smoking and Health of United States been the target of tobacco companies. among youth dropped by almost 10 Centers for Disease Control and Prevention So far four GYTS have been conducted. percent from 30.3 percent in 2013 to (CDC), in collaboration with countries The earliest survey was carried out in 2004 22.2I percent in 2019 according to the latest representing the six WHO regions, aims and thereafter in 2009 and 2013. Global Youth Tobacco Survey. to present a comprehensive tobacco The survey will help determine This decrease was attributed mainly prevention and control information on prevalence of tobacco use among youth to the drop in use of smokeless tobacco, young people. aged 13-15 years and 16-17 years. Other which reduced from 24.3 percent in 2013 It is a global standard to systematically related indicators include smoking to 12.5 percent in 2019. monitor tobacco use among youth and and smokeless, ever and current use, However, data analysis indicated not track key tobacco control indicators. It is secondhand smoking, cessation, access and much change in prevalence of cigarette a nationally representative school-based availability, marketing, and knowledge and smoking among youth, although it showed survey of students aged between 13 and attitude by sex. significant reduction in exposure to 15 years. Many countries have started to The GYTS data would prove critical tobacco smoke, both indoors and outdoors. widen the age range to 13-17 years and in to base policy measures and guide Students who used tobacco increased GYTS 2019, Bhutan too widened the age suitable interventions and strategies for from 16.5 percent in 2013 to 17.3 percent range for the survey. tobacco-free initiatives in Bhutan. It and those who smoked cigarettes increased There is scientific evidence that tobacco would also provide a baseline measure for from 14.0 percent to 14.7 percent. consumption will cut short more lives than monitoring and evaluating tobacco control The survey, developed by the tobacco- other Noncommunicable Diseases. Seen as programmes to assess progress in achieving free initiative (TFI), WHO and the office tomorrow’s customers, the youth have long a reduced prevalence of tobacco use. In matters of health 53
Tobacco users among students (13-15 years)
2013 23.2% female | 39% male
2019
13.5% female | 31.2% male
Source: GYTS 2013 & 2019 54 In matters of health
Emergency preparedness In matters of health 55 56 In matters of health
Chief Laboratory Officer Binay Thapa was the first RCDC laboratory To better technician to undergo WHO conducted IATA training in Maldives and Geneva. Association certified, he trains postal and health officials on IATA protocol. With assistance from WHO, around 30 laboratory technicians manage from across the country were trained in mid-2019. laboratories Meeting international health regulations he Royal Centre for Disease Control (RCDC) developed a manual to guide implementation he Royal Centre for Disease certification comes in. of quality management system across health Control (RCDC) deals with It is all about safe handling and laboratoriesT in the country. numerous disease samples, transportation of infectious disease A standard was necessitated to ensure uniformity in fromT something as contagious as a samples for tests in laboratories in managing laboratories to ensure better and quality outcomes. common flu to those as infectious as other countries. Every country has its Deriving from the manual, several Standard Operating H1N1 types. Some disease samples own regulations and standards to meet Procedures (SOPs) were developed with experts from various that require further verification and when air-transporting disease samples laboratories in RCDC. characterisation for genetics and anti- and every airline has its own policies. The centre will implement the system and carry out genetics have to be sent to Bangkok and With new diseases emerging and with activities aligning with the manual and guided by SOPs. sometimes as far as the US. ever greater risks of disease outbreaks, The overall benefit of a standard quality management The swiftest means to transport conforming to international standards system is in the coordination and direction it provides these samples and receive them is by is crucial. laboratories for sustained improvement and efficiency, besides air and this is where International Therefore, it is imperative that helping meet customer and regulatory requirements. Air Transport Association (IATA) laboratory technicians know and In matters of health 57
understand regulations and policies in different countries regarding transport of disease samples. It is for the safety of people handing them at source and those receiving at the other end. Packaging of the samples, by their volume and storage requirements, is crucial for different disease types categorised by how infectious they are. For a centre that carries out studies of disease samples and keeps contact with reference laboratories outside the country, IATA certification is must. Just as we send disease samples for verification and characterisation to labs outside the country, we have samples sent to us to test our competency so we stay relevant and up to global trends. IATA certification is upgraded every two years. Photo: Kinley Wangmo 58 In matters of health
GEARING UP: As part of emergency response operations, medical camp kit are set up at Mongar for hands on training In matters of health 59
For health security
Health National Action Plan The JEE Tool consists of four thematic for Health Security (NAPHS) areas of prevent, detect, respond, and other was drafted to accelerate the IHR-related hazards and points of entry. It implementationA of International Health covers 19 technical areas with specific targets Regulations (IHR) 2005. It was based on and performance indicators. the joint external evaluation (JEE), 2017, Some of the technical areas include recommendations. national legislation and financing, NAPHS is a five-year planning process to antimicrobial resistance (AMR), food safety, accelerate implementation and enhancement biosafety, national laboratory system, real of IHR core capacities focusing on the One time surveillance, emergency response Health and all hazards approach. operations and risk communications. The action plan also captured all ongoing In Bhutan, adequate national preparedness initiatives in a country along policies and legislation are in place that with a country governance mechanism for recognise and provide the necessary emergency and disaster risk management. basis for implementing IHR 2005. The A three-day workshop was conducted legal provisions concerning water, food, with technical assistance from WHO for medical assistance, disaster management, national technical heads for JEE and other trade-related procedures, immigration stakeholders, to familiarise them with and customs have all facilitated effective NAPHS tools. implementation. 60 In matters of health NATURAL DISASTERS: The very source of the rivers that nourish valley’s downstream can also be cause of calamities
he health ministry with relevant stakeholders developed the Health Emergency and Disaster Contingency Risk PlanT (HEDCP) 2016 for the health sector. It was felt necessary in view of natural hazards like earthquakes, landslides, seasonal communication flash floods, forest fires and glacial lake outburst floods (GLOF) the country was vulnerable to. It was also in consideration of the country being prone to disease outbreaks and other public health emergencies of international concern given
Photo: Kinley Wangmo In matters of health 61
its porous borders and growing number of travellers. Assembling an emergency Through the HEDCP and guideline, district health officers and medical superintendents, chief medical officers as media spokesperson as well as members of risk communication medical team team were identified. In addition, conforming with HEDCP nitiatives to establish a Bhutan for key members and partners to engage 2016 and SPEMS (2018-2023), emergency Emergency Medical Team (BEMT) by collectively to strengthen capacities in dealing medical services division developed risk mid-2020 have begun. with emergencies that require a national communication guideline. IThe team, which will take several months to and international emergency medical team Risk communication is a core component be trained and verified, will provide timely and response. It also provided a forum to discuss of the contingency plan and the Strategy Plan effective response to medical emergencies and and strengthen national EMT capacities in key for Emergency Medical Services (2018-2023). disasters in the country and beyond. areas. Communicating effectively during public Anticipating medical emergencies and Representatives from emergency and health emergency and disaster contributes to disasters in the country, and the probability of relevant professionals from health care facilities reduction of impact through promotion of getting overwhelmed, especially with limited attended the training. Representatives from positive and protective behavior. capacity, a training was provided to initial Royal Bhutan Army, disaster management To build capacity, a risk communication BEMT members with technical support from department, WFP and WHO country office workshop was conducted in Paro. District SEARO and BEMT mentors. also participated. health officers, medical superintendents and The three-day national emergency The group outlined steps necessary to chief medical officers, who were identified medical team training conducted in April activate and access emergency mechanisms, as risk communicators, applied mock in Paro focused on meeting the technical list clinical, logistical and other equipment communication and community engagement and documentary standards required for the required for BEMT. It also developed clinical principles in their preferred information verification emergency team. SOPs and other documents required for EMT channel during the workshop. They also The training provided opportunity deployment. practiced media skills needed during public health emergencies. 62 In matters of health
IN SESSION: A WHO emergency medical response expert trains cabin crew of a Bhutanese airline agency
Photo: Kinga Namgyel/WHO In matters of health 63
Preparing basic health emergencies
n efforts to institutionalise and Accordingly, in the 2018-19 fiscal year, a improve emergency preparedness workshop was conducted for health officials and response, including emergency of all Basic Health Unit (BHU) I, preparing medicalI services, the health ministry them to develop emergency contingency plan extended trainings to health personnel in for their own health facilities. basic health units. Besides Bhutan being known to sit on The Emergency Medical Services Division one of the most seismically active zones of (EMSD) was advised to sensitise health the world, growing numbers of casualties officials to develop emergency preparedness from disease outbreaks, natural disasters and plans of their own, rather than division trauma are an everyday reality. officials from the ministry going to individual As a part of emergency preparedness, health facilities to develop one. The logic was the EMSD began developing standardised that the health officials would best understand health facility emergency contingency plans situations within their jurisdictions and, (HFECP) for all health facilities, including therefore, were in the best position to device BHU I and BHU II for the five-year period. effective interventions. 64 In matters of health
The flu shot
t’s been less than six months since more than 70 health workers from various Tshering and Kunzang received health centres across the country on WHO their first flu shot, after the country immunisation manual and training them introducedI the vaccine around November to practice what the manual prescribed to last year. The couple from Trashigang, both implement the flu vaccine. in their 80s, living in Thimphu with their According to Royal Centre for Disease daughter and grandchildren, have stayed safe Control’s (RCDC) influenza surveillance, of the seasonal viral infection. seasonal flu occurs from December to March Although they do catch the flu once every in winters before turn of spring and between while, it is not so severe as to confine them to July and September. bed for days as in the past. The flu shots, it was decided, based on The couple were among the identified National Immunization Technical Advisory high-risk groups, falling in the category Group’s recommendation, to be administered of elderly population above 65 years, to be annually between November and December. administered the pneumococcal conjugate The campaign received more than Nu vaccines. Pregnant woman, those with six million in support from Task Force for chronic illnesses, children between six and 23 Global Health through Partnership Influenza months and health workers were among the Vaccine Introduction (PIVI) under US-CDC other high-risk groups. and Bhutan Health Trust Fund (BHTF) for The flu shot, though launched first in 88 000 doses of the flu vaccine. July 2018, was rolled out towards the end Annually, for the identified high-risk of 2019 coinciding with the newly elected population of 77 000 people, a budget of over government’s completion of one-year term in Nu eight million for more than 100 000 doses office. of the vaccine was estimated. With WHO’s support, it took familiarising In matters of health 65
FLU SHOT: Administered towards end of 2019, the vaccine will be an annual feature of the routine immunisation
Photo: Kinley Wangmo 66 In matters of health
Updated SOP to rein on diarrheal disease
o standardise methods for being a major cause of malnutrition. Diarrheal incidences isolation, identification of In Bhutan, it has been among the top bacterial pathogens, antibiotic 10 diseases causing morbidity, especially susceptibilityT testing and reporting of among children under five years old, 2015 - 20,803 diarrheal diseases, the standard operating according to annual health bulletins 2016 - 20,703 protocol (SOP) for diarrheal disease was from 2015-2018. updated. In 2017, second only to acute 2017 - 17,328 An initial workshop organised in respiratory infections, diarrhea was one 2018 - 16,435 Gelephu with 14 participants developed of the most notifiable diseases causing the SOP and was finalised during the morbidity of 41 396 Bhutanese across the secondary workshop of nine participants country. Under five years incidences in Paro. The SOP is expected to enable The SOP and guidelines in use programmatic interventions for were outdated and required review prevention and control of diarrheal 2015 - 2,004 and revisions, especially in the face of diseases through strengthened and increasing burden of diarrheal diseases uniform quality control measures 2016 - 1,755 on the health system. involved in testing. 2017 - 1,448 Diarrheal disease is one of the leading The SOP was also part of causes of childhood morbidity and strengthening emergency preparedness 2018 - 1,392 mortality in developing countries besides and response during disease outbreak. Source: Annual Health Bulletin, 2018 In matters of health 67
Heavy metal exposure
nformation, education and programme, in collaboration with health communications (IEC) materials on promotion division of the health ministry, risks associated with exposure to metal showed that among high-risk household wasI developed for metalsmiths and their contacts, 9.68 percent of adults and 41.67 family members. percent of children had high lead levels. The IEC materials also included ways to Likewise, 32.26 percent of adults and 41.67 reduce the ill effects. percent of children had elevated mercury Apart from that, metal artisans from levels. identified districts and institutes were The concern was more about greater informed of risks associated with their percentage of children exposed to elevated profession and brought up to speed on lead and mercury levels and the significant adequate precautions. knowledge gap among artisans, their The need for such advocacy and IEC employees and family members on the health materials was deemed necessary following risks associated with metal works. findings of a study on lead and mercury The initial education and awareness amounts in the blood of, not just metal campaign will continue, especially artisans, but people they employed and considering the need for greater advocacy on their family members, which revealed high chemical safety and hazards associated with percentage levels. lead and mercury and use of protective gears The study conducted in 2019 under and equipment to minimise metal exposure. Occupational Health and Chemical Safety
Photo: Kinley Wangmo 68 In matters of health
Effective services In matters of health 69 70 In matters of health
Mother and child go online
ago Dem, a senior health for Dago and others working in the Real time data punching, however, assistant working with mother and child units across the she said was challenging, given the outreach services at country, this is a step taken to assure the unreliable Internet facility. The theD Gyaltsuen Jetsun Pema mother that migration of MCH information, number of cases healthcare workers and child hospital in the capital, visits from registers to an online system, had to attend to, particularly in various communities around the doesn’t experience hiccups. the mother and child hospital, was city’s periphery. She takes vaccination The online MCH tracking system sometimes overwhelming and it was and family planning services to the has unique numbers of mothers and easier to note information in the people residing there. children under five years. It tracks the register. Along with health services, she health and development of children In 2019, as part of scaling up the takes a register, where she notes down and their immunisation records. MCH services in the country, the details of mothers and their children The information can be accessed reproductive health programme and the vaccines they are given. Back by mother and child units across the carried out training on web-based at the hospital, she enters the details country. If a family moves to another MCH tracking system. It included the in mother and child tracking register district, the new health facility can training on information system and before punching the same details track the mother and child online. revised handbook for primary health online on the Mother and Child Dago Dem said the new system care in two districts of Trashigang Health (MCH) tracking portal. would present a true picture of the and Dagana. While the workload has increased country’s immunisation status. In matters of health 71
EASE OF TRACE: Senior health assistant, Dago Dem, enters details of a mother and child into the online MCH tracking system Photo: Kinley Wangmo 72 In matters of health
UNDER THE SCANNER: A radiology technician monitors a cross sectional images of a patient inside the CT scan Photo: Kinley Wangmo In matters of health 73
Assessing health technology
ome 30 health clinicians and technicians EMTD partnered with a team comprising officials were trained on Health Technology from Health Intervention Technology Assessment Assessment (HTA), an evaluation of Programme (HITAP), Thailand and PATH, USA investmentS on health technology and how it justifies to develop HTA capacity for representatives from the cost based on its services. relevant agencies under the health ministry. The rationale was that such assessments help A weeklong sensitisation on HTA processes and policy makers arrive at evidence-based decisions stakeholder consultation meeting on the current on optimising the use of health technology and study with regard to the economic evaluation of resources. Rotavirus Vaccine was carried out for decision It began with Essential Medicines and Technology makers between 5 May and 11 May 2019. Division (EMTD) conducting economic evaluation In the process of training health officials on of Rotavirus vaccine triggered by the proposition of HTA, the ministry, besides obtaining data on the Vaccine Preventable Disease Programme (VPDP) economic evaluation of Rotavirus vaccine, was also for the introduction of new technologies. VPDP able to update cost of health infrastructure, human intended to include Rotavirus vaccine into the resource and their associated pay and allowances. routine immunisation schedule and make it available The previous health economic evaluation of for children under one year. pneumococcal vaccine was also updated. 74 In matters of health
Adverse impacts of development
o include adverse health impacts from national projects, such as hydropower and mining, in the district environment screening tool, was one of the outcomes of the three-day workshopT on Health Impact Assessment (HIA) held in Bumthang in October last year. More than 50 participants comprising district health and environment officers were sensitised on the importance of HIA to prevent, mitigate and manage negative health impacts from development projects, especially the major ones like mining and hydropower. District health and environment officers agreed to take up health concerns emanating from development projects with relevant authorities during development and environment meetings. However, participants expressed the need for capacity building of district health officers to implement HIA in the districts. HIA, in a broad sense, seeks to discern the negative health impacts from national policies, programmes and projects and work towards balancing both interests. In matters of health 75
DEVELOPMENT IMPACTS: Rishore coal mine in Dewathang, Samdrupjongkhar
Photo: Phuntsho Wangdi 76 In matters of health
Scanning radiology equipment
lightly over half, 44, of the 83 diagnostic Quality assurance tests were conducted to ensure radiology equipment tested for quality made it effective services and safety to both the public and through. In terms of healthcare centres, eight out service providers. Apart from that, it was also meant to of 35S identified for the radiation test survey passed. A build capacity of bio-medical engineers and users with certified Radiation Safety Office conducted the tests. regard to QA and survey of radiation equipment. A periodic Quality Assurance (QA) test of diagnostic The WHO supported the 45-day activity the Bio- radiology equipment and radiation survey for health Medical Engineering Division of the Department of facilities was felt critical in the face of growing number Medicinal Supplies and Health Infrastructure carried of people availing of diagnostic radiology services like out. It determined the number of functional radiology X-ray, Computed Tomography (CT) Scan, C-arm, Dental equipment and the resource the survey generated. IOPA and OPG. In matters of health 77
ON THE RAY: A patient in Thimphu hospital undergoes an x-ray investigation
Photo: Kinley Wangmo 78 In matters of health
Shortcut to treating TB
ne noticeable feature about However, the shorter prescribed the revised guideline on drug- medication was only for MDR-TB patients, resistant TB was the shorter previously untreated under the second-line medicalO treatment course for multi-drug- drugs treatment. The second-line drugs for resistant tuberculosis (MDR-TB). TB treatment was reserved for MDR-TB, Launched on World TB Day in extensively drug-resistant tuberculosis, or March 2019, the new guideline, which resistance to first-line therapy. included a comprehensive set of WHO The shorter medical regimen, recommendations for medication and comprising seven different drugs during care of drug resistant TB, shortened its intensive treatment and four in the course treatment from existing 20 months to 11. of the treatment, was recommended The consolidated guidelines also include for children, adults and HIV patients policy recommendations on culture diagnosed with MDR-TB through monitoring of patients, the timing of laboratory test confirmation. anti-retroviral therapy in multi-drug and Besides reducing the length of rifampicin-resistant tuberculosis (MDR/ treatment, the shorter regimen is said to RR-TB) HIV patients, use of surgery for be tolerable, effective and less expensive in patients receiving MDR-TB treatment and terms of treatment per patient. optimal models of patient support and care. In matters of health 79
HANDLING MEDICINES More than 130 pharmacy technicians and pharmacists from around the country received training on accurate quantification, appropriate storage, maintaining inventory, rational dispensary and safe disposal of expired medicines in May
Photo: Kinley Wangmo 80 In matters of health
EYE EXAM: An ophthalmic technician in Paro sees to a case Photo: Kinley Wangmo In matters of health 81
Prevalence of Supporting cataract blindness
Cataract as cause of eye care blindness
CSC for cataract service blind Good visual outcome of cataract surgery ith improved standard of living and increased life expectancy, 0 20 40 60 80 100 one emerging public health concernW for Bhutan is low vision and avoidable 2018 2019 blindness. Vision impairment and age-related eye diseases not only affect economic and social impairment due to refractive errors. trained about 40 ophthalmic staff on cataract, opportunities but also reduce quality of life The challenges become more pronounced glaucoma and refractive error screening, low and increases risk of death secondary to injury, as Bhutan gears towards achieving the goals of vision assessment and management and basic trauma and accident. Vision 2020: Right to sight and global action life skills training. With limited health care workers and plan 2014-2019 for prevention of avoidable Participants recommended that low vision capacity, the eye care services have backlog blindness and visual impairment. assessment be incorporated and practiced at of cases of avoidable blindness, emerging To build capacity of health workers in the all levels of eye care services and to provide challenges of non-avoidable eye diseases eye department, WHO provided assistance and a separate station for low vision services at and an increasing trend of childhood visual experts from LV Prasad Eye Institute, India, national referral hospital in Thimphu. 82 In matters of health
Roping in youth in their matters
cting on the findings of global school health counseling time, about three to four minutes, and is proven survey (GSHS) 2016, teacher and counselors were effective. It has two models, 5As (Ask, Advise, Assess, Assist sensitised on the issues of tobacco, betel quid, and Arrange) for tobacco users willing to quit and 5Rs alcohol,A carbonated drinks and junk food. (Relevance, Risks, Rewards, Roadblocks and Repetition) for To create awareness and advocate safe and healthy habits the unwilling. WHO supported training of trainers over the years. The training of trainers (ToT) was conducted for three This culminated into a roll out training of 20 school days. It started with presentation of key findings from the counselors and youth group leaders in Wangduephodrang by GSHS 2016, which establishes key baselines on students’ three master trainers on brief intervention model. health risk and protective factors. The findings set the tone The intervention was based on WHO FCTC article for the ToT, informing participants on the high prevalence of 14 guideline, developed for a clinical setting and used the risk factors and the roles they need to play to prevent and interchangeably as brief advice. The primary purpose of a control them. brief tobacco intervention is to help patients understand risks Most people vulnerable to the risk factors tend to develop of tobacco use and the benefits of quitting and motivating the habit in early adolescence. Therefore, empowering young them to quit. people with the correct health education and skills to make The intervention is considered feasible given the minimal healthy decisions early in life is of utmost importance. In matters of health 83
Current alcohol drinkers Survey findings 33% 16% Male Female
29.4% Tobacco users 55.2% Tried smoking tobacco before 14 years 24.7% Current smokers 83% Tried quitting 49.7% Exposure to second- hand smoke 66.2% Betel quid users
Source: GSHS, 2016 84 In matters of health
Learning to code
t was agreed among members states during the World Health Assembly to adopt the revised International Classification of Diseases, 11th revisionI (ICD 11) from ICD 10 from 1 January 2022. To understand morbidity and mortality trends and their causes is at the heart of mapping programmes and health services, allocate resource and disease prevention. ICD 11 is useful in clinical recording, primary care, patient safety, antimicrobial resistance and resource allocation. In Bhutan, lack of capacity to implement it thwarted the use of ICD codes. However, HMIS used a customised version of the ICD coding, an adaptation from ICD 10. ICD 11 coding will be the foundation for disease classification in the electronic patient information system, meaning it will also determine the success of ePIS besides a doctor’s ability to code the morbidity and mortality cases correctly. The need for training health workers, doctors, medical record officers and HMIS staff was necessary for the implementation of ICD 11 coding in the country. With technical assistance from WHO, a training was conducted to generate a pool of health experts on coding diseases using ICD 11. In matters of health 85
Stronger as one
clear framework now defines the purpose from relevant agencies worked on strengthening of “One Health” committees at the collaboration in responding to infectious zoonotic national, district and municipal levels outbreaks, information sharing, surveillance and risk to effectivelyA prevent and control transmission of mitigation for emerging and re-emerging zoonotic diseases from animals to humans. threats. The One Health concept was operational since In so doing, a clear strategy to implement one the government’s endorsement of Bhutan One Health health activities among relevant stakeholders in the Strategy Plan in 2017. Taking queue from WHO’s One 12th Plan was developed. Health concept, led by the two ministries of health Cooperation among agencies of public health, and agriculture, relevant agencies like the National animal health and environment was critical in Environment Commission, disaster risk management controlling transmission of infectious diseases from of home and cultural affairs ministry, royal university animals to humans and One Health concept paved of Bhutan and Bhutan Food Regulatory Authority the way. united to take up relevant roles in prevention and Human and animal health are interlinked, which control of zoonotic diseases. also means endemic human diseases have their What this meant was, besides primarily effecting origins at the human-animal-ecosystem interface. implementation of One Health and strengthening Studies indicate that more than 60 percent known interventions through concerted efforts to prevent human pathogens originate from animals and about and control zoonotic diseases, it also saved resources 75 percent emerging infectious diseases are zoonotic by curbing duplication of programmes. in nature. The framework was a culmination of WHO- The other decision during the conference was the funded fourth National One Health Conference need to establish a secretariat for One Health. held in Paro around December 2019. Participants 86 In matters of health
In partnership In matters of health 87 88 In matters of health
Committed to ending HIV
o create awareness on HIV detected in 1993 and over the years the control programme. and STIs, educate people on its numbers increased to 687 cases. The Royal Decree on HIV/AIDS His transmission and prevention, While the number of reported cases Majesty The Fourth King issued in 2004, sensitiseT them on associated stigma and is small compared with those of other calling for Bhutanese to help prevent discrimination, and to show solidarity, countries in the region, it is still of public the pandemic and provide care and various stakeholders came together on health concern given the country’s small compassion to those infected, serves as World AIDS Day. population. the guiding principle. The national programme focuses on The perception of HIV is expected to Her Majesty The Queen Mother, advocacy and awareness, behavior change change through voluntary counseling, Sangay Choden Wangchuck, the UNFPA communication, condom promotion tests being made available in all district Goodwill Ambassador continues to and distribution and enhancing hospitals and HISC and soon in BHUs. advocate on prevention of HIV, visiting information base on the epidemic. It also Treatment is available and with better communities and meeting people. advocated blood screening to ensure compliance, HIV would be treated like To create awareness and to break the safety, integrating management of STIs hypertension or diabetes. stigma against people living with the into primary health care, improving The political will and commitment disease, a network of HIV positive people, its treatment and setting up voluntary towards ending the AIDS epidemic by called Lhak-Sam, now a CSO, came counseling and testing facilities. 2030 remains strong. Five years before the forward in September 2009. Today, the country has 522 people first case was detected, the government living with HIV/AIDS. The first case was established a national STI and HIV/AIDS In matters of health 89
Photo: Rinzi Om Dorji/WHO
VOLUNTARY TESTS: A district medical official draws blood from a De-Suup in Samtse where the World AIDS Day was observed 90 In matters of health About HIV/AIDs About HIV/AIDS
Mode of transmission 642 38 3 3 1 About HIV/AIDs Blood Other Sexual route Mother to child Intravenous drug use (probable) transfusion
Mode of transmission Total people living Distribution by sex Modes of diagnosis 642 38 3 3 1 with HIV/AIDS: Blood• Medical screeningOther 165 Sexual route Mother to child Intravenous drug use (probable) transfusion• Ante natal check up 62 • Total PLHAs put on ART* 555 359 • Blood donor screening 36 • Total died on ART* 57 Male • Survey 44 • Total living on ART* 498 • Construction site screening 25 • Bhutanese national living Total people• living Contact tracing 201 outside with HIV/AIDS 01 Distribution by sex Modes of diagnosis 328with HIV/AIDS:• Voluntary testing 154 • Non Bhutanese who returned to their country 31 • Medical screening 165 Female • Ante natal check up 62 • Total PLHAs put on ART* 555 • Total death (including 359 • Blood donor screening 85.2%36 of the cases are• Total died on ART* 57 four non Bhutanese) 133 within the age range of Male • Survey 44 • Total living on ART* 498 • Total people living with 15-49 years • Construction site screening 25 • Bhutanese national living HIV/AIDS in the country 522 • Contact tracing 201 outside with HIV/AIDS 01 *Antiretroviral therapy Data: Lhak-Sam 328 • Voluntary testing 154 • Non Bhutanese who returned to their country 31 Female • Total death (including 85.2% of the cases are four non Bhutanese) 133 within the age range of • Total people living with 15-49 years HIV/AIDS in the country 522
*Antiretroviral therapy Data: Lhak-Sam About HIV/AIDs In matters of health 91
Mode of transmission 642 38 3 3 1 Blood Other Sexual route Mother to child Intravenous drug use (probable) transfusion
Total people living Distribution by sex Modes of diagnosis with HIV/AIDS: • Medical screening 165 • Ante natal check up 62 • Total PLHAs put on ART* 555 359 • Blood donor screening 36 • Total died on ART* 57 Male • Survey 44 • Total living on ART* 498 • Construction site screening 25 • Bhutanese national living • Contact tracing 201 outside with HIV/AIDS 01 328 • Voluntary testing 154 • Non Bhutanese who returned to their country 31 Female • Total death (including 85.2% of the cases are four non Bhutanese) 133 within the age range of • Total people living with 15-49 years HIV/AIDS in the country 522
*Antiretroviral therapy Data: Lhak-Sam 92 In matters of health
Global health diplomacy
The health ministry, with support from WHO, conducted a three-day workshop on Global Health Diplomacy in Thimphu from 31 July to 2 August. Pitching a country’s position on a particular health issue, sourcing potential funding and effectively proposing a health cause, all in utmost diplomacy, was one of the core trainings, Bhutanese health officials and those from its allied agencies received during the workshop. Resource persons from International Health Policy Programme and Thai Health Promotion Foundation also updated participants on a broad range of global health issues and technical aspects related to the functions of WHO’s governing bodies. The objective of the workshop was to enable health officials and others from relevant agencies to understand and learn about the key aspects of global health diplomacy. In matters of health 93
1. Workshop on global health diplomacy: (* ) 94 In matters of health
People’s healthcare
s is the case with most policies in driven, in that, services should be taken to the the country, even in health, it was people as a way to prevent diseases than wait to decided during the Fifth Biennial treat patients as they visited healthcare facilities. HealthA Conference, that its services should be For instance, for patients suffering chronic centred around people. illnesses, health workers would visit them, carry Besides meeting the aspirations of the out regular checks and provide medicines, people, especially those in the remote parts instead of patients visiting health centres. of the country, who walked for days to the That way, health workers across the country’s nearest health facilities, it fell in line with the numerous health units would know the government’s commitment to take healthcare communities they served and understand their services closest to the people as possible. patients and disease patterns. Broadly, the two chimed with the World Likewise, a team of doctors would visit Health Organization’s (WHO) Framework communities to provide specialised services for on Integrated People-centred Health Services quality healthcare at minimal cost. adopted during the 69th session of the World “For a nation that fully funds healthcare Health Assembly. services, we cannot take the same model or During the conference held around same way of doing business,” the health minister September, Health Minister Dechen Wangmo had said. had said healthcare needed to be demand- In matters of health 95 PEOPLE-CENTRIC HEALTHCARE: A demand driven health service is the way to go
Photo: Rinzi Om Dorji/WHO 96 In matters of health
On the drafting board
n the nation’s sustained efforts to improving its consultation with its programme officials, would have health services and facilities across 20 districts, sketched out the biennial health activities and against the World Health Organization (WHO) country it the estimated costing. Thereon, the Gross National officeI in Thimphu plays a crucial facilitator. Happiness Commission would review the programmes It does so by supporting the health ministry and its al- to weigh them against the country’s Five-Year Plan and lied agencies through numerous health advocacies, train- the government’s identified priorities for the sector. Past ings, programmes, workshops and global best practices. these tests, a two-year plan is drawn up. But how does the Organization determine the areas The health ministry implements the country’s of support for the country? How does it prioritise health planned health programmes with WHO providing both activities? How does it ensure its contribution to the technical assistance and financial support. health sector aligns with the national goals and its over- WHO ensures that each of its supported activities all vision? meet the expected outcomes and objectives the various The drawing board is a good start. departments of the health ministry proposes to the Sustainable Development Goals (SDG) 2030 as the Organization. basis, health minsters of 194 WHO Member States de- For implementation of activities, different pro- velop the General Programme for Work (GPW). Budget grammes in the ministry send the proposal to Policy is allocated for the programmes decided on, following and Planning Division (PPD). The division aligns the which work plans are prepared. sector plan, sectoral priorites and relevances of activities Health ministers of the southeast Asia regional to avoid duplication within sectors, relevant agencies committee, comprising 11 nations, including Bhutan, and other development partners. It then reaches WCO, endorse the programme budget. which ensures the proposals carry the value for money, Meanwhile, within the country, WHO Coun- in accordance with regional resolutions that have to do try office and health ministry’s planning division, in with recent updates or developments. In matters of health 97
Biennial meet: Representatives from the health ministry and relevant agencies share a light moment amid discussions on 2020-2021 health plans and programmes
98 In matters of health Bhutan Team
Dr Rui Paulo de Jesus Dr Lobzang Dorji Rinzi Om Dorji Thinley Wangmo
Jigme Lhendup Kinga Namgyel Thukten Ugyen Wangchuk In matters of health 99
Tashi Minjur Sonam Yangchen Wangchuk Sonam Wangdi
Sonam Jamtsho Dawa Penjor Dechen Choden Kencho Wangdi 100 In matters of health