Bhutan

4. HEALTH RESOURCES

4.1 Human resources for health

Along with the expansion of health infrastructure, human resources for the Health Sector have also been built steadily over the years, but the country still faces shortage of medical personnel with only 2 doctors per 10,000 population in 2005. Developing medical doctors is still very difficult as Bhutan has to depend on the neighbouring countries for medical education. Bhutan does not have any medical college. Candidates are sent to Bangladesh, India, Myanmar, and Sri Lanka for their MBBS course.

Table: Trends in HRD indicators

Other categories of middle and subordinate level human resource have been developed within the country at the Royal Institute of Health Sciences. This institute has got the WHO’s 50th Anniversary Award for Primary Health Care. It is the main contributor to the primary health care development in Bhutan in terms of human resource. The institute trains Health Assistants (HA), Basic Health Workers (BHW), Auxiliary Nurse Midwife (ANM), General Nurse Midwife (GNM), Assistant Nurse (NS), and technicians of various disciplines (laboratory, pharmacy, dental, x-ray, ophthalmology, physiotherapy, operation theatre). With the support of WHO, this institute is now affiliated to La Trobe University in Australia to train nurses at post-basic level.  

On the other hand, the National Institute of Traditional Medicines (NITM) trains both full-fledged traditional physicians, Drungtshos and the Menpas to support them.

In spite of the acute scarcity of human resource, Health Department successfully manages with adequate workforce of different categories who are well trained in various fields such as clinical, managerial and administrative fields both within and outside the country. The Royal Institute of Health Sciences (RIHS) and the Institute of Traditional Medicine Services (ITMS) are the two main institutes, where nurses, paramedical workers, technicians, drungtshos(traditional physicians) and menpas(traditional compounders) are trained. Although only pre-service training is imparted by these two institutes, both in-service and refresher courses, including up-gradation courses, have been given priority by the Department through the programmes.  

The RIHS has been able to conduct B.Sc. Conversion Course for Nurses in collaboration with the Australian La-Trobe University through affiliation. Established in 1974, RIHS has been the nation’s premier institute in the production of various categories of human resource that forms the backbone of the primary health care. The NITM is also committed to the training of the required human resource for traditional medical services and research in the traditional medicine.

The NITM has produced 36 drungtsos and 34 Menpas and the RIHS has trained 293 health assistants, 189 Auxiliary nurse midwives, 217 general nurse midwives, 263 basic health workers, 173 assistant nurses and 258 technicians of different categories as of 2002.

Bhutan has 2 doctors and 8 nurses per 10,000 population.  The ratio of nurses to hospital bed is 1:2 (Annual Health Bulletin, 2006, Royal Government of Bhutan, Ministry of Health).

Related Links

     Health Personnel - Bhutan

     Human Resources – WHO/HQ

     Human Resources – Bhutan

4.2 Financial resources for health – present and projected financial resources for the health system, health care finance and expenditure

An overview of the overall financial resources in Health Sector indicates that external assistance has played a major role in development of health services.  The share of external assistance has increased from 45.8 percent in 1995-96 to 65.0 percent in 1998-99 (budget estimate) of the total expenditure on Health in Bhutan (Asian Development Bank: Bhutan-1999 Country Portfolio Review and Country Programming Confirmation for 2000 Mission, Memorandum of Understanding)

In Bhutan, public sector (RGOB) provides finance to allopathic and indigenous medicine with the exception of small number of private pharmacies and diagnostic facilities as well as traditional healers.

Financing of health care is through 5 sources:

      Royal Government of Bhutan

      International aid

      Military

      Private firms

      Households

Public financing of health care is through a National Health Service financed by the RGOB through revenues and grants. The Government and donor financing of health services flow through National Budget and Aid Coordination Division.  Funds are then released to the Health Division and the Dzongkhags.  The Government expenditure (current prices) on health increased from 218.109 million Nu in 1995-96 to 331.574 million Nu in 1997-98.  In the financial year 1998-99 (budget), the Government of Bhutan provided 217.629 Nu which is just 35 percent of total health expenditure (budget) (Asian Development Bank: Bhutan-1999 Country Portfolio Review and Country Programming Confirmation for 2000 Mission, Memorandum of Understanding).

In Bhutan, total expenditure on health as percentage of GDP has increased from 3.8 percent in 1998 to 3.14 percent in 2003.  Bhutan government has recognized the importance of health sector. The public expenditure on health out of the total health expenditure was 84 percent in 2003 whereas, private expenditure on health as percentage of total expenditure on health was 16 percent in 2003 (WHO, the World Health Report, 2006).

Only 2.9 percent of total outlay for the First Plan (1962-1967) was earmarked for health, but the Government recognizes the importance of the social sectors. The current Government allocation for Health is around 10 percent of the total outlay, which comes to 3.1 percent of the GDP.

In the past Plan, donors played a significant role in supporting the health sector. However, to reduce the over dependence on donors, the Government is now taking steps to bear the major portion of the cost. On an average the Government now bears about 49 percent of the total outlay.

The main development partners in the health sector are Government of India, DANIDA, UNICEF, UNFPA, WHO.

Related Links

      Health Expense- Bhutan

4.3 Physical infrastructure for health

(Please distinguish where relevant between public, private for profit, and non-profit services)

The health service is provided through a four-tiered network consisting of a National Referral Hospital, Regional Referral Hospitals, District Hospitals and Basic Health Units.  There are total 641 health facilities, including 29 hospitals, 176 basic health units and 514 out-reach clinics at the community level. In addition to this, traditional medicine services are available in all the districts.

In Bhutan, around 1133 beds are available in hospitals. There were 17 hospital beds per 10,000 population. (Annual Health Bulletin 2007, Ministry of Health).

The health infrastructure expansion took place in the 1970s reaching the peak of expansion activities in the 1980s. In line with the Alma Ata Declaration, the country committed itself to establishing a relevant and cost-effective health care delivery system based on the primary health care approach. Despite the high cost of health care service delivery in a country with a population scattered thinly over the mountainous terrain, Bhutan has managed to establish a fairly uniform spread of Basic Health Units, District Hospitals, and Regional Referral Hospitals.

The district hospitals are the first-level referral institutions and are equipped to provide curative, promotive, preventive and emergency services.

The regional referral hospitals are the second level referral hospitals and provide services of specialists.

The infrastructure development in the past decade has resulted in a near optimum level of health infrastructure at the primary level (Asian Development Bank: Bhutan-1999 Country Portfolio Review and Country Programming Confirmation for 2000 Mission, Memorandum of Understanding).

There appear to be no reliable quantitative data on access to health service in Bhutan.  The 1994 NHS defined access as being within three hours’ walk of a care provider.  Using this definition, based on a sample of about 10 percent of the population, it was determined that 90 percent of the population had access to services.  In 1996, redefining access as being within two hours’ walk from a health facility (including ORC, BHU or hospital), it was estimated from a very quick survey of dzongkhag administrators that, again, 90 percent of the population had access However, distance to a health facility is one of important factors affecting access.

Services are free of charge in Bhutan and there appear to be no ‘informal’ payments required from the patient.  There are financial costs including the cost of transportation and the opportunity cost of visiting the services but these are not considered to be major barriers (Asian Development Bank: Bhutan-1999 Country Portfolio Review and Country Programming Confirmation for 2000 Mission, Memorandum of Understanding).

Related Links

     Department of Medical Services – Bhutan

      Health Infrastructure - Bhutan

4.4 Essential drugs and other supplies

The regulatory function is an essential part of public health systems.  It has relatively remained underdeveloped.   There is no systematic inventory of legal instruments related to health.  There is no system in place to ensure the participation of the health sector in the formulation of legal instruments related to health.  And there is limited enforcement of those laws, rules and regulations that exist.  However, the Medicines Act is being drawn up to regulate the medicines, drugs and other substances in the country, which was endorsed by the national Assembly in 2003.

The Ministry of Health and Education (MOHE) has formed an inter-ministerial standing committee to assume responsibility for coordination of public health regulation.  This committee will ensure that:

      Appropriate public health legal instruments have been drafted and passed by National Assembly,  and information about them is disseminated,

      Existing and future legal instruments with a bearing on health are compiled and catalogued,

      Health sector input is obtained in the drafting of legislation/regulation that is related to health, and

      Enforcement of regulations is strengthened (Asian Development Bank: Bhutan-1999 Country Portfolio Review and Country Programming Confirmation for 2000 Mission, Memorandum of Understanding)

The public drug supply system in Bhutan accounts for more than 90 percent of the expenditure on drugs.  It is the responsibility of Medical Supplies Unit (MSU) for supply, quality and other aspects of the management of drugs, non-drug supplies and equipment in the public sector.  It is divided into 4 sections: The Essential Drugs Program, the Drugs Section (EDP), the Non-drugs Section, and the Health Equipment Repair and Maintenance Unit (HERM).

The EDP, working within the MSU, aims to ensure a regular supply of safe, effective and need-based drugs of acceptable quality at reasonable cost.  Working with the Drugs and Non-drugs Sections, which are responsible for procurement and distribution, the EDP focuses on training of storekeepers and prescribers at all levels, and in selection of drugs for the national formulary.

Drugs are delivered once a year to hospitals and those BHUs which are accessible by road. For the majority of BHUs, drugs are delivered to drop-off points and from there transported by ponies and porters.

Related Links

     Department of Medical Services – Bhutan

     Human Resources – WHO/HQ