But per capita spending on health has increased

Bhutan’s per capita spending on health was Nu 7,512 during the year 2015 -16, about Nu 500 more than the previous fiscal year, according to the recent National Health Accounts (NHA) study.

While the NHA for the fiscal years 2014-15 and 2015-16 is the third such study carried out in the country, it is the first to cover consumer characteristics such as age, sex and illness related patterns in health expenditures.

Going by the age, the sick person of 65 years and above had the highest per capita current health expenditure (CHE) of about Nu 10,000 and Nu 12,000 in 2014-15 and 2015-16. Managing the health problems of children under five years is next with per capita health expenditure of more than Nu 8,000 in both the financial years.

Health secretary, Dr Ugen Dophu said as people age, Non-Communicable Diseases (NCD) and chronic long-term disease are more likely to occur and so it costs the government more to treat them.

In both the financial years, the state spent around Nu 1.6B, the highest on NCD which is about 35 percent of the CHE. Managing infectious diseases cost around Nu 1.2B (26 percent).

Reproductive conditions, which include childbirth and related care consumed 16 and 18 percent of the current expenditure in respective fiscal years.

The study also found that managing health problems among females were slightly more expensive. Of the total expenditure of Nu 5.3B and Nu 5.8B in 2014-15 and 2015-16, expenditure on capital formation, which is investment made on capital assets, accounted for Nu 709M and Nu 918M respectively.

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, which dropped to 3.9 percent of the GDP in 2015-16.

Dr Ugen Dophu said spending on health should not be less than 5 percent of the GDP.  “Less than five is not good for the people of Bhutan. It means we are spending less on health.”

He said the government argues that it gives an annual budget of 6 to 8 percent of the GDP to health sector but that is after including the contributions from the donors. “If the spending, excluding the donors, is at least five percent of the GDB, then we will have more money to spend on health.”

Currently, BHU grade I do not have equipment like X-ray, ultrasound and dental chair because of lack of fund, he said.

While most countries spend more than 8 percent of their GDP on health, he said the government may not be able to give at par with other developing countries. “However, if the government can give at least 5 percent of the GDP for health, then there will be enough money to buy equipment, train health workers, and develop guidelines and SOPs. When we don’t have money, all these activities are stuck,” he said.

For a country like Bhutan, Global health experts recommend allocating around 5 percent of the GDP and about 8 percent of the total government budget on health to ensure quality in health care services.

The total CHE and expenditure on capital formation borne by the government was about 2.8 and 2.6 percent of the GDP respectively.

The major cost drivers, according to the study were inpatient care constituting 49 and 58 percent of the CHE, followed by outpatient care constituting 13 and 24 percent in 2014-15 and 2015-16.

Preventive care, ancillary services such as laboratory investigations, and purchasing medical goods constituted the rest.

Dzongkhag wise, Thimphu reported the highest CHE, followed by Chukha, Mongar and Sarpang. The study states that this is because of the location of major hospitals in these dzongkhags.

Of the health care providers, hospitals used about 68 and 73 percent of the current expenditure in both the fiscal years. More than 36 percent of the current expenditure was utilised by primary health care institutions in both the financial years.

Expenditure of Jigme Dorji Wangchuck National Referral Hospital accounted 17.2 percent of CHE in 2014-15 and 21 percent in 2015-16.

In both the years, the state has been the principal financier of the health system in Bhutan with a contribution of about 70 percent. Households’ contribution to CHE was about 20 percent in both and rest of the world’s contribution was about 5 percent. The study states that household expenditures exclude transport costs, and expenditure reported to be incurred on rimdo and puja.

WHO provided financial and technical support for the study.

Dechen Tshomo