Health sector surpasses expectations  but challenges, as always, remain

Dechen Tshomo

Vision 2020:   Health: Modern health care in Bhutan began in 1961 with two hospitals and 11 dispensaries coinciding with the first five-year Plan. Since then, the country has witnessed a significant evolution in health sector.

While Bhutan strived for the equitable distribution of services through free health care services, improving the quality of health care was one of the priorities in the Bhutan 2020 charted some twenty years ago.

Health Secretary Dr Ugen Dophu said major achievements in the health sector over the years are reflected as priorities in the document.

Increase in life expectancy at birth from 37 in 1960 to 70.2 in 2017 was one of the key achievements in the last two decades in the sector.

In terms of the delivery of health care services, there has been enormous progress. Mother and child health is one area that measures the nation’s health and remarkable achievement was made in the reduction of maternal and child mortalities.

According to the Annual Health Bulletin 2019, maternal mortality ratio (MMR) fell from 560 in 1990 to 89 in 2017, exceeding its Millennium Development Goals (MDG) target of 140. The health sector aims to reduce the ratio from 89 to 83 per 100,000 live births in the 12th Plan.

The infant mortality rate has been reduced from 60.5 in 2000 to 15.1 per 1,000 live births. The sector aims to further reduce it to less than 15 per 1,000 live births in the next five years.

Similarly, the under-five mortality rate per 1,000 live births is targeted to drop to 20.3 per 1,000 live births from 34.1. In 2000, under-five mortality was 84 per 1,000 live births.

The sector also aims to increase institutional delivery to more than the current rate of 93.40 percent and the percentage of the population who live three hours or less from the nearest health facility to more than 90 percent.

As of 2018, there are 32 hospitals, 23 BHU grade I, 185 BHU grade II and 551 out-reach clinics.

Extending the services to those living in the remotest parts of the country was another priority envisioned in the vision 2020 document.

Health Secretary Dr Ugen Dophu said that the coverage of health services in the country stands at 95.6 percent today. About 4.4 percent of the unreached population includes difficult to reach areas and nomadic population.

“We cannot give the service to these unreached population even if we construct a BHU in the area,” the secretary said.

However, this population have access to timely and quality services through land ambulance and helicopter services. A team of health professionals periodically visit these unreached population for preventive and promotion of health.

The proportion of the population that lives less than three hours from the nearest health facility increased by about six percent from 2000 (89 percent) to 2012 (95.8 percent), according to the national health survey reports.

As projected two decades ago, health sector has benefited enormously from technological advancement over the years.

While telemedicine has not been fully implemented due to challenges like poor internet connection and limited digital equipment, teleconsultation has picked up over the years.

In 2018 alone, 2,700 cases were consulted using telecommunication technology from 26 health facilities identified by the health ministry.

With the Digital Drukyul Flagship project in the 12th Plan, electronic communications and information system in health is expected to strengthen.

Three-tiered health care service delivery system is still visible with the main nodal points within the system having been further reinforced and with the health of Bhutanese firmly in the hands of Bhutanese health professionals, as envisioned.

In line with this, the document recommends according high priority to the training of health personnel to reduce dependence on expatriates and to ensure that the health of Bhutanese is in the hand of Bhutanese.

In terms of overall health manpower, Dr Ugen Dophu said there is no severe shortage except for the specialist and subspecialist.

“If the doctors had not resigned then we would have sufficient specialists. Some resign after completing their obligation period, that is where the shortage comes,” he said.

While the number of doctors increased to 228 in 2018 from 109 doctors in 1999, the country still faces a shortage of specialists. To address the shortage, the government is hiring specialist and subspecialist from other countries like Bangladesh.

Traditional medicine in Bhutan has also come a long way in the last decades.

The document aspired that Bhutan’s health system could rival the system existing in industrialised countries by 2020 and others would turn to Bhutan for advice on how knowledge of indigenous medicines can be integrated into the mainstream system of health care.

Dr Ugen Dophu said traditional medicine have different departments and it has strengthened in terms of new services and therapies. Collaboration between traditional and modern medicines are seen with the referral of patients from modern to traditional medicine practices, he said.

To address psychological wellbeing, traditional medical services and mental health services are offered by both allopathic and traditional medicines as a holistic approach to health and wellbeing.

The number of traditional health facilities has also increased from one indigenous hospital and 17 indigenous units with 31 drungtshos (Indigenous physicians) and 17 menpas in 2000 to 53 drungtshos and 113 smenpas as of 2018.

In the past five years, traditional health facilities increased from 53 to 66. Health officials said this indicates equal importance accorded by the government to both modern and traditional medicines to provide free access to basic public health services.

Besides introducing innovative methods of financing primary and specialised health care, the document recommends introducing user fees for medical services for those who can meet some of the costs of health care to address the issue of sustainability of providing free health care.

The Bhutan Health Trust Fund was established in 2000 to ensure a continued and timely supply of vaccines and essential drugs.

The Vision 2020 also recommends progressively privatising health services so that the growing number of people who can pay for the full cost of healthcare no longer receive it free of charge, with the introduction of supporting private health insurance. Except for private pharmacies and diagnostic centres, there are no private hospitals in the country.

Dr Ugen Dophu said privatisation of clinical health care services is difficult. “If we privatise the health services then the current health system will be distorted.”

The experts will be hired by the private hospitals and it will be difficult to maintain the quality of health services in government hospitals, he added.

To sustain, he said that the health ministry is aggressively carrying out health promotion and disease prevention activities. “The advocacy is expected to prevent communicable disease, non-communicable diseases, drug and alcohol abuse resulting in lesser number of people getting ill.”

Despite significant improvements in the population health indicators, challenges remain.

Dr Ugen Dophu said limited health financing is the major challenge the health sector faces. Bhutan’s spending on health has declined over the years. From 5.7 percent of gross domestic product (GDP) spent on health in 2000, spending on health dropped to 4.9 percent in 2003, and 4 percent in 2006.  It further dropped to 3.65 percent in 2010, and to 3.55 percent in 2012.

For the fiscal year 2014-15, the spending on health was 4 percent, which dropped to 3.9 percent of the GDP in 2015-16.

Dr Ugen Dophu said the spending on health in the 12th plan is about 3.5 percent of the GDP. “Spending on health should not be less than 5 percent of the GDP.

Rising incidences of NCDs and chronic diseases, rising healthcare costs, the triple burden of disease, human resource constraints especially at the tertiary care level, scattered and hard to reach settlements and poor health-seeking behaviour are some of the other challenges the sector has.

To ensure a healthier nation, the health sector’s priorities in the 12th Plan include providing access to equitable quality healthcare, reducing the incidence of non-communicable diseases (NCDs) and ensuring the sustainability of healthcare.

Health Minister Dechen Wangmo said as the country prepares for graduation from the least developed countries group, the focus should be on building a sustainable resilient health system.

This, Lyonpo said should be in line with improving health governance, building institution with minimal conflict of interest, investing in capacity building of its people so that there is expertise in the country and is self-sufficient in services without having to rely on referring patients abroad.

“If we have a very rare disease then we have to refer outside, otherwise we should be able to take care of most of the illnesses within the country,” Lyonpo said.

As the country moves forward, Lyonpo said a health system in line with the epidemiological transition is envisioned. “Beyond just health care, we want to focus on quality and comprehensive health care.”

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