Progress and delivery of health care in Bhutan, the Land of the Thunder Dragon and Gross National Happiness

Progress and delivery of health care in Bhutan, the Land of the

Thunder Dragon and Gross National Happiness

Tashi Tobgay1, Tandin Dorji1, Dorji Pelzom1 and Robert V. Gibbons2

1 Bhutan Ministry of Health, Thimphu, Bhutan2 United States Army Medical Command, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand

Summary The Himalayan Kingdom of Bhutan is rapidly changing, but it remains relatively isolated, and it

tenaciously embraces its rich cultural heritage. Despite very limited resources, Bhutan is making a

concerted effort to update its health care and deliver it to all of its citizens. Healthcare services are

delivered through 31 hospitals, 178 basic health unit clinics and 654 outreach clinics that provide

maternal and child health services in remote communities in the mountains. Physical access to primary

health care is now well sustained for more than 90% of the population. Bhutan has made progress in key

health indicators. In the past 50 years, life expectancy increased by 18 years and infant mortality

dropped from 102.8 to 49.3 per 1000 live births between 1984 and 2008. Bhutan has a rich medical

history. One of the ancient names for Bhutan was ‘Land of Medicinal Herbs’ because of the diverse

medicinal plants it exported to neighbouring countries. In 1967, traditional medicine was included in the

National Health System, and in 1971, formal training for Drungtshos (traditional doctors) and sMenpas

(traditional compounders) began. In 1982, Bhutan established the Pharmaceutical and Research Unit,

which manufactures, develops and researches traditional herbal medicines. Despite commendable

achievements, considerable challenges lie ahead, but the advances of the past few decades bode well for

the future.

keywords Bhutan, national health programmes, delivery of health care, public health

Introduction

The Himalayan Kingdom of Bhutan is rapidly changing,

but it remains relatively isolated, and it tenaciously

embraces its rich cultural heritage. There are only one to

two flights a day at the lone airport in Paro, 60 km from

the capital city of Thimphu. There are no trains and only

three major roads that enter from India. Bhutan joined the

United Nations in 1971, tourism opened in 1974, and

television and internet arrived in 1999. After a century of

hereditary monarchy, it embarked on democracy in 2008.

Despite the changes, Bhutan is bound by its culture and

environmental ethic, visibly evident by the people wearing

traditional dress at work and in school, by small farms and

by the pristine wilderness. Like other aspects of life,

Bhutan’s health care is modernizing and at the same

maintaining strong ties to tradition.

Bhutan, also known as Druk-Yul or Land of the Thunder

Dragon, is extremely rugged and mountainous; it covers

approximately 38 394 km2 (about the size of Switzerland).

The altitude ranges from 75 m on the south-eastern border

with India to more than 7000 m in the Himalayas bordering

Tibet (Pommaret 2007). The country is divided into 20

districts. In 2005, the census counted 634 982 with popu-

lation density of approximately 16 people ⁄ km2. Although

the mountains leave only 8% of the land arable, 70% of the

people living in rural areas farm and raise livestock. In such

difficult terrain, travel and communication is a daunting

challenge. Roads and telephone networks were started in

the 1960s. As of 2009, more than 40 000 registered vehicles

ply 5363 km of roads. All districts have access to national

digital networks, and there are 149 439 mobile phone

subscribers (Bhutan National Statistics Bureau, 2009).

Bhutan’s per capita gross domestic product (GDP) was

1900 USD in 2009. Nearly half of the GDP is obtained

through selling hydroelectric power to India. Thirty per-

centage of the population live below the poverty line.

Bhutan is classified as a medium-developed country whose

human development index is 132 of 182 countries (United

Nations Development Program 2009; World Bank 2009).

Despite what is considered relative poverty, Bhutan

ranked 17th on the 2009 Happy Planet Index, ahead of

most of the developed world (White 2007; New Economics

Foundations 2009). Indeed, Bhutan may be most famous

Tropical Medicine and International Health doi:10.1111/j.1365-3156.2011.02760.x

volume 16 no 6 pp 731–736 june 2011

ª 2011 Blackwell Publishing Ltd 731

for the concept of Gross National Happiness and its four

pillars of good governance, sustainable development,

environmental conservation and preservation of culture

that guide government decisions.

In 1970, the fourth King of Bhutan, His Majesty Jigme

Singye Wangchuck, concerned about the consequences of

growth-oriented market economics and espoused the

concept, and since then, Bhutan has embraced Gross

National Happiness as its main developmental philosophy

(Ura 2009). The Centre for Bhutan Studies, mandated by

the Royal Government of Bhutan, developed the GNH

index under 9 domains: (i) psychological well-being, (ii)

time use, (iii) community vitality, (iv) culture, (v) health,

(vi) education, (vii) environmental diversity, (viii) living

standard and (ix) governance (Centre of Bhutan Studies

2008). The variables under each domain serve as a

yardstick of the developmental progress.

Bhutan is now a constitutional monarchy. In 2008, the

King introduced democracy and turned the monarchy over

to his son, the 5th King, His Majesty Jigme Khesar

Namgyel Wangchuck. The Country has been culturally

linked to Tibet since the 7th century, but when China took

control of Tibet in 1959, and after the Indo-China War in

1962, the Tibetan border was closed. Bhutan is the only

country whose official state religion is the Tantric form of

Mahayana Buddhism. Dzongkha is the official language,

but both Dzongkha and English are taught from elemen-

tary school, so English is widely spoken and used in

government. In addition, many dialects are spoken in the

different regions of the country.

Healthcare delivery

Despite very limited resources, Bhutan is making a

concerted effort to update its health care and deliver it to

all of its citizens. In 1961, Bhutan had only two hospitals,

11 dispensaries, three doctors (two Bhutanese and one

Scottish Presbyterian missionary), two nurses and 12

medicinal compounders (C.E. Taylor, unpublished obser-

vation). Bhutan became a signatory to the Alma-Ata

Declaration on Primary Health Care in 1978 (Bhutan

Ministry of Health 2009a) which affirmed health as a

fundamental human right and the attainment of the highest

possible level of health an important social goal. Since

then, Bhutan’s healthcare system has developed steadily.

Healthcare services, including referrals outside the country,

are provided at the nation’s expense. Health care is about

5.7% of the total planned budget (Gross National Happi-

ness Commission 2008), and the right to the free access to

the essential health services is anchored in the constitution.

Even visitors and tourists are provided free health care

within the kingdom should they need it.

Today, healthcare services are delivered through 31

hospitals, 178 basic health unit (BHU) clinics and 654

outreach clinics in all 20 districts and 201 subdistricts

(Table 1 and Figure 1) (Bhutan National Statistical Bureau

2005). Referral hospitals, district hospitals and BHUs refer

patients both to a higher level and back to the community

for monitoring and rehabilitative measures (Bhutan Min-

istry of Health 2009b). The national referral centre is a

350-bed hospital in Thimphu; another two regional refer-

ral hospitals are in Mongar in eastern Bhutan and in

Gelephu in the south. The national referral hospital has

most of the specialties of medicine and surgery, including

neurosurgery, and has MRI and CT scan facilities. The

regional referral hospitals have basic specialty facilities,

such as internal medicine, gynaecology and obstetrics,

paediatrics and orthopaedics. The South Asian Association

for Regional Cooperation (SAARC) Telemedicine and

Rural Telemedicine Projects was launched in April 200,

enabling consultation by the referral hospitals with tertiary

centres in India. District hospitals are built on the

backbone of one doctor, 4–5 nurses, one laboratory

technician and health assistants. These facilities have basic

diagnostic facilities comprising x-ray, complete blood

count, blood glucose levels and microscopic services for

diagnosing tuberculosis and malaria.

To make care more accessible, 178 BHUs are scattered

throughout the country. They are usually staffed with a

three health assistants who have completed 2 years of

training at the Royal Institute of Health Sciences (RIHS).

These frontline healthcare workers have been the backbone

of the primary care system in Bhutan since the inception of

modern health care (Berkeley 1979; Morris-Jones 1985).

The BHU caters to the communities for minor ailments,

assists at normal deliveries and takes care of prevention

and sanitation activities within the community. There are

no laboratory or radiological services in BHUs. Work has

begun to provide them with computers and internet

facilities and to train health workers on information

technology. To improve immunization and reduce mater-

nal and infant mortality, they organize outreach health

clinics once a month, where teams travel to remote

Table 1 Numbers of Bhutan’s healthcare facilities, doctors and

nurses

1977 1995 2000 2005 2008

Hospitals 10 26 29 29 31

BHUs 31 84 160 176 178

Doctors 52 112 109 145 171Nurses – – 443 534 567

BHU, basic health unit.

Tropical Medicine and International Health volume 16 no 6 pp 731–736 june 2011

T. Tobgay et al. Health care in Bhutan

732 ª 2011 Blackwell Publishing Ltd

communities to provide maternal and child health services.

Thus, care is delivered even to people who may find care

essentially inaccessible. Most trips to set up outreach

clinics require a few hours, but others may take a full day

or more. Each BHU has a catchment area, and there may

be two or more outreach clinics depending on the area.

Information and research

The Bhutan Health Management and Information System

(BHMIS) was established within the Ministry of Health to

keep computerized health data. Information is relayed

from the health facilities (BHUs, hospitals and referral

hospitals) through the district health office to the Ministry

of Health and entered into BHMIS. Depending upon the

information, the health facilities submit on a monthly,

quarterly, biannual or annual basis via the email or

through facsimile to the district health office, where reports

are compiled and forwarded to the MOH for entry into

BHMIS. There are many challenges in providing reliable,

credible and robust information. So far, the reliability of

the reported data has not been evaluated. Both the ministry

and the districts make little use of the data, and the

capacity of health staff to use data at the level it is

generated is poor, and many health staff are computer

illiterate. Neither the slow transfer of data does allow for

the timely reporting of outbreaks. New epidemics are

reported to the Department of Public Health by telephone

or urgent official mails by the district health office.

Research in Bhutan is still at an early stage, but there is

an interest in good research, and the first review board was

established in 2009 to review proposals for the scientific

and ethical issues. The board was quickly recognized by the

Forum for Ethical Review Committees in the Asian and

Western Pacific Region (FERCAP) and received a Federa-

tion-Wide Assurance number for the Protection of Human

Subjects for International Institutions from the United

States.

Medical education and training

The RIHS, established in 1974, is the country’s health

education institute and provides training for health assis-

tants, nurses and paramedics. In the absence of any other

health-related schools, the RIHS has been central to the

development of human resources for the Ministry of

Health for past 36 years. There are plans to upgrade the

nursing college and establish a medical college along with

other courses in public health to address the acute shortage

of human resources in Bhutan (Gross National Happiness

Commission 2008; Bhutan Ministry of Health 2009a).

Currently, there are 171 medical doctors in Bhutan who

have been mostly educated and trained in India, Bangla-

desh, Sri Lanka, Thailand, Myanmar and Nepal. As of

2008, along with these medical doctors, 567 nurses, 14

pharmacists, 10 laboratory technologists, and various

other technicians and basic health workers constituted a

total of 3414 healthcare personnel (Bhutan Ministry of

Health 2009b). To address the shortfall of healthcare

workers while they are training in foreign locations,

medical staff (mostly physicians) are recruited from

Myanmar, India and other countries. Volunteer healthcare

workers including Health Volunteers Overseas from USA

and other developed countries provide training and med-

ical services in Bhutan. Bhutan friendship associations

established in various countries also provide human

resources as well as infrastructure development and bud-

getary support.

Progress

In 2007, international consultants reviewed Bhutan’s

health sector development to assist with strategic planning

for the future (Enemark et al. 2007). They found that good

progress had been made on basic indicators, such as >90%

coverage of infant immunization, fewer low birthweight

newborns, more antenatal clinic attendance and less

dependence on external funding. The Ministry of Health

led national efforts to strengthen the training of primary

care providers and improve health information systems.

The ‘Child Health Card’, a tool to record birth date,

immunizations, medical records and growth chart, is issued

to all newborns and is especially important and effective

because the Ministry of Education requires it for school

admission (Bhutan Ministry of Health 2009b).

With the assistance from key partners such as the

Government of India, Danish International Development

Assistance, the United Nations and other government and

international agencies, Bhutan has made progress in health

indicators (Table 2). In the past 50 years, life expectancy

has risen by 18 years, and the infant mortality rate has

fallen from 102.8 to 49.3 per 1000 live births from 1984 to

2008 (World Health Organization 2009). Physical access

to primary health care is now well sustained over 90%

(Gross National Happiness Commission 2008). Through

strengthened prevention activities, Bhutan eliminated

iodine deficiency in 2003 and leprosy in 1997 (World

Health Organization 2003). The incidence of malaria and

tuberculosis has fallen: in 2008 there were only 329 cases

of malaria; in 1999 there were 12 591, and the number of

TB cases dropped from 1093 in 2004 to 921 in 2008.

Bhutan stands ahead of many countries in the WHO-

SEARO region in its efforts to reach the Millennium

Development Goals (MDG). The maternal mortality ratio




per 100 000 live births is 440 for Bhutan, 830 for Nepal,

570 for Bangladesh and 450 for India. The under five-

mortality rate for Bhutan is 81 per thousand live births,

one of the lowest in the region. Bhutan also is doing better

in MDG target 6 for malaria, TB and HIV (World Health

Organization 2010).

Universal child immunization against diptheria,

pertussis, tetanus (DPT), bacillus Calmette-Guerin (BCG),

measles, rubella, polio (OPV), and hepatitis B was

achieved in 1991 (Zangpo 2009). In 2009, Bhutan also

began providing human papilloma virus vaccine to all

high-risk girls. Bhutan was a recipient of the GAVI award

for 2009, for excellence of immunization coverage and

sustaining the immunization coverage rate over 90% for

the past 5 years (Gross National Happiness Commission

2008; Pelden 2009). The Essential Drugs Program under

the Ministry of Health has been able to deliver essential

drugs, vaccines and medical equipment to all health

facilities with availability of over 90% essential drugs

throughout the year (Dorji 2007). This is achieved through

careful selection of essential drugs needed to address the

major health needs by the National Drug Committee. All

drugs are centrally procured annually and distributed

throughout the country before the rainy season. There is

functional internal mobilization of supplies within districts

and then regions to reduce under and over supplies of

medicines. Health workers and the pharmacy staff are

trained on rational use of medicines. Currently, all essential

medicines and medical equipment are procured through the

government’s budget with minimal external assistance to

reduce the donor dependency. For sustainability, a Health

Trust Fund was created in 1997; returns from its invest-

ments are used to procure essential drugs and vaccines. As

of June 2009, it has accumulated a total amount of

23.7 million USD (Bhutan Ministry of Health 2009c).

Traditional medicine

Bhutan has a rich medical history. One of the ancient

names for Bhutan was ‘Land of Medicinal Herbs’ because

Table 2 Core demographic and health

indicators of Bhutan (Source National

Health surveys, 1984, 1994, 2000 andpopulation and housing census of Bhutan)

1984 1994 2000 2005 2008

Total fertility rate – 5.6 4.7 3.0 2.4

Population growth rate 2.6 3.1 2.5 1.3 1.3Infant mortality rate ⁄ 1000 live births 102.8 70.7 60.5 56.0 49.3

Maternal mortality ratio (per 100 000 live births) 770 380 260 440 –

Crude death rate ⁄ 1000 population 13.4 9.5 8.6 7.0 –Life expectancy – 49 66 65 66

Existing health facilities-2010Legend

NR Hospital

Gasa

Punakha

Thimphu Wangdue

ParoHaa

Samtse Chhukha

Dagana

Tsirang Sarpang

Zhemgang

Trongsa

Bumthang

Mongar

PemagatshelSamdrup Jongkhar

Trashigang

Yangtse

Lhuentse

RR Hospital

Hospital

BHU I

BHU

Figure 1 Map of Bhutan with location of

health facilities (in separate file).




of the diverse medicinal plants it exported to neighbouring

countries. Traditional medicine was influenced by the

Indian Ayurvedic and Chinese practices that came via Tibet

at least as far back as the 7th century. The practice includes

the theory of the three humours (bile, phlegm and wind),

the reading of pulses, herbal medicine and spiritual aspects

of healing. Uncertain composition and consistency of

herbal medicines (or supplements) and lack of functional

reporting of adverse events are of great concern (Goldman

2001; Marcus & Grollman 2002; Straus 2002). In 1982,

Bhutan established the Pharmaceutical and Research Unit

that manufactures, develops and researches traditional

herbal medicines. From more than 1000 formulations, 98

were selected for the unit to standardize and implement

quality control. The traditional medical services are well

integrated into the main healthcare system, and every

hospital has the traditional medical and modern medical

units under the same roof to enable patients to choose the

services they desire; often patients are referred between the

two services. In 1967, traditional medicine was included in

the National Health System, and in 1971, formal training

for Drungtshos (traditional doctors) and sMenpas (tradi-

tional compounders) began (Wangchuk et al. 2007). As of

2008, there are 36 Drungtshos and 54 sMenpas who are

trained at the Institute of Traditional Medicine Services in

Thimphu. In Bhutan, traditional medicine is a temporal

extension of ancient practice, but at the same time, modern

medicine is eagerly sought. This attitude allows the

venerated traditional system to collaborate with the

western medical system.

Challenges

Despite commendable achievements in primary care,

considerable challenges lie ahead. Bhutan is at the cross-

road of disease burdens from both communicable and

non-communicable diseases. Although the communicable

diseases are decreasing, cardiovascular, diabetes and men-

tal health diseases are on the rise. Development activities

such as urbanization and population migration could

create environments conducive to infectious diseases. The

widening socioeconomic gap is a growing concern, and

measures have been instituted to address land ownership,

rural income generation, education and scholarships for

rural citizens, and access to internet facilities. Such

development projects are in concordance with the princi-

ples of Bhutan’s overarching development philosophy of

Gross National Happiness which focuses on overall social,

cultural, environmental and economic developments rather

than a mere economic progress (Commission on Social

Determinants of Health (CSDH) 2008). Bhutan is extre-

mely concerned about the impact of tobacco on the health

of its citizens. The influence of Buddhism discouraged

tobacco farming and use, and tobacco control laws were in

force as early as 1729 (Ugen 2003). To our knowledge,

Bhutan is the first nation to make the sale of tobacco illegal.

The use of tobacco in public places is banned. Religious

institutions remain tobacco-free, and the majority of the

older generations abstain from using tobacco products.

Bhutan has a revered culture and medical history that

developed in relative isolation. Over the past few decades,

change has been rapid, and the government and people

strive to hold to their traditions while integrating beneficial

aspects of modern life. This is exemplified in a system that

stresses preventive measures, offers traditional and modern

health care side by side and endeavours to apply quality

standards to herbal medicine. Because of the rugged

country and sparse population, it is a challenge for Bhutan

to provide physical access to care, but great efforts are

made and priorities are set at a national level. Although

there is much progress to make, the advances of the past

few decades bode well for the future.

Acknowledgement and disclaimer

We express our gratitude to the Royal Government of

Bhutan, the Commission on Higher Education and

Ministry of Education of Thailand for their institutional

support. The opinions or assertions contained herein are

the private views of the authors and are not to be

construed as official, or as reflecting the views of the

Department of the Army, the Department of Defense or the

National Institute of Health.

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Corresponding Author Robert V. Gibbons, USAMC-AFRIMS, APO AP, 96546, USA. Tel.: +66 2 644 5644; Fax: +66 2 644 4760;

E-mail: [email protected]




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Progress and delivery of health care in Bhutan, the Land of the Thunder Dragon and Gross National Happiness