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5. DEVELOPMENT OF
THE HEALTH SYSTEM
5.1 Health policies
and strategies
The
overall long-term objective of the Health Ministry is for, “attaining a
healthy living standard by the people living within the broader framework of
the overall development of the country”. There has been a shift from
expansion of services, which was emphasized in the earlier plans, to the
quality of services. It entails setting up of standards at various levels of
health care delivery system. Strategies have been evolved to reach the
un-reached through decentralization of planning and management systems; to
strengthen management information system, to develop research and their use
which leads logically to one of the Ministry’s most important objectives: intensifying
human resource development for health and establishing a system of continuing
education. To this end, the Ministry has developed the Master Plan for
Human Resource as a guide for developing human resource for health.
Intensification
of prevention and control of prevailing health problems and dealing with the
emerging and re-emerging ones require extra resources and efforts. The
Ministry has prepared itself in dealing with this problem. Other objectives
that have flowed from the previous plans are intensification of reproductive
health services and sustaining population planning activities; promoting
community-based rehabilitation, mental health, and finding innovative means
to enhance the mental well-being of the people; and maintaining balance
between primary, secondary, and tertiary health care so that the higher
levels of service can back up the needs created or problems identified by the
grass root level health care units.
The
Bhutan Medical and Health Council Act has been
passed by the National Assembly in 2002. Bhutan Medial and Health Council
secretariat was established in 2003 with council members appointed.
Millennium
Development Goals(MDGs)
Progress
made towards achievement of health related MDGs is
given at Annex-2
Related Links
 Policy and
Planning Division - Bhutan
Plan - WHO/SEARO
Health
Policy – WHO/HQ
5.2 Inter-sectoral
cooperation
Inter-sectoral coordination at different levels of the
Government is achieved through different ways. At the national level, the
Planning Commission coordinates the plans of various development sectors and
the Department of Aid and Debt Management of the Ministry of Finance
coordinates resource allocation. At the district level, the Dzongdag is the overall head for implementation of plans.
All the sector representatives at the district level function under the Dzongdag. Thus duplication of efforts is avoided and the
actions are coordinated.
Even at
the Department and programme level, there are a lot of coordination
mechanisms through Policy and Planning Division of the Ministries.
Additionally, individual programmes have their own coordination mechanism
with other concerned sectors. Malaria programme, for instance, has direct
coordination mechanism with the agriculture and municipal departments.
Similarly, environmental health programme liaises with the National
Environment Commission, Municipal Corporations of each district and even the
police force. The nutrition coordinates its efforts with the Agriculture,
Trade, and other relevant sectors. Further, there are the multi-sectoral task forces that also address the issues that
cut across many sectors.
5.3 Organization of the health system
The long
history of health services delivery in Bhutan is the introduction of
modern Allopathic system in early
part of the twentieth century with the arrival of the first batch of
Indian-trained physicians and paramedics, but its traditional medicare was introduced in the system from Tibetan in the
seventeenth century. Traditional
practitioners received formal training in Tibet
and apprenticed in Bhutan.
The
Department of Health Services was set up in 1960. At that time, there were
two hospitals and 11 dispensaries. All
of these facilities were staffed by doctors and nurses from other countries
and very few medical and paramedical personnel were available from local
people.
The
present development of modern health systems and health infrastructure
commenced in 196 with the beginning of the First Five-Year Plan. Basic health
units were established in certain areas from the early 1970s, but the main
expansion of infrastructure started in the 1980s. Despite the introduction of
western allopathic system, traditional medicine has retained a significant
role in the provision of health services in Bhutan. As the traditional medicine
practiced in Bhutan,
Sowa Rigpa, is a systematic field of knowledge, traditional
medical care is provide side by side with modern allopathic health care. It was recognized as the official
medical tradition and included in the national health system in 1967.These
two systems are now more or less integrated.
Modern
health services are delivered through a four-tiered network consisting of the
National Referral
Hospital, the Regional
Referral Hospitals,
District Hospitals and Basic Health Units to
outreach clinics at the community level.
The huge
infrastructure development in the past decade has resulted in a near optimum
level of health infrastructure at the primary level. The district and
regional referral hospitals have been significantly increased in number and
improved in capacity. However,
capacity in surgical and other specialized services is still sub-optimal at
the district and regional referral levels (Asian Development Bank:
Bhutan-1999 Country Portfolio Review and Country Programming Confirmation for
2000 Mission, Memorandum of Understanding).
The
health service system at the district and lower levels depend on the district
authorities for their administrative support and on the Health Department at
the centre for technical support. The basic health units submit their case
reports directly to the District Supervisory Officers. These officials
compile these reports and submit to the Health Department at the national
level. However, the diseases under strict surveillance like HIV,
Poliomyelitis, etc. that come under the notifiable
category are reported directly to the national level immediately.
In the
year 2000, a task force was instituted by the Royal Government to critically
review the structure of each Ministry and suggest ways to further strengthen
the civil service to become more efficient, accountable and transparent.
In the
restructured organogram, the Health Division has been renamed as “Health
Department”. There are five main
“Divisions” and various sections under each.
All the previous “Units” are upgraded to Divisions and each headed by
a Joint Director. The International Health division has been shown as a
separate “Section” by itself (SEARO MEMORANDUM: “Reorganization of Health
Infrastructure of the Royal Government of Bhutan”, 28.06.2000).
The Reorganization
Chart of Health Department [PDF 133 KB]
ORGANOGRAM
HEALTH DEPARTMENT (After reorganization)
The basis
for Bhutan’s
health care delivery system is the primary health care system starting with
518 outreach clinics and 176 basic health units at the community level. The
districts have the district hospitals set up under the three Regional Referral
Hospitals and one of these Regional
Referral Hospitals also serve as the National Referral
Hospital.
The
patients at the basic health unit level are referred to their respective
district hospitals for secondary or tertiary health care. The district
hospitals likewise refer to their respective Regional Referral Hospitals and
that in turn rely on the National
Referral Hospital.
As it is not yet possible to have very specialized health care in the
country, a good number of cases requiring such health care are referred
outside the country.
Related Links
Ministry of Health
Organogram– Bhutan
Health System
- WHO/SEARO
5.4 Managerial process
In line
with good governance policy, the Ministry of Health and Education was
bifurcated into two separate Ministries viz. Health Ministry and Education
Ministry in July 2003. (Please see the organogram in 5.3). With this
bifurcation, the structures under the Health Ministry were reorganized and
put under the Departments of Public Health and Medical Services. Each of
these Departments will then be able to direct the programmes related to their
respective areas without distractions from other commitments.
The
health services in the districts are directly under the administration of the
Dzongdag, district magistrate. The Health
Department provides technical support to the districts. The District Medical
Officers look after the hospitals and the District Supervisory Officers look
after the primary health care concerns in their respective districts. The
Basic Health Units at the community level are directly under the
administration of the District Health Supervisory Officer.
Related Links
General
Information – Bhutan
5.5 Health information system
Realizing
the importance of information in management, Health Information Unit was
established in 1983. Since then the Annual Health Bulletin was compiled on a
yearly basis and published. WHO has put in substantial support to develop the
Health Information System in the 1990s. During
1999-2000, the information system was reviewed and the Health Information
Management System was instituted with support from DANIDA. Presently HMIS is
being computerized and experimented.
The basic
health facilities have been given standardized reporting forms to report the
morbidity, mortality and other health data collected at that level. This is
compiled and consolidated every month and submitted to the District Health
Supervisory Officers who, in turn, compiles and submits to the national level
every quarter. At the national level the Health Information Unit compiles and
makes it available to all concerned. However, the human resource for the
Health Information Unit has to be further improved both in terms of expertise
and numbers to make the Health information System dynamic and helpful for a
ground reality-based planning for the future.
The flow
of health information at different levels along with feedback report may be seen from the flow
of information diagram (Annual Health Bulletin, 2003, Royal Government of
Bhutan, Ministry of Health).
Related Links
Information and Communication Bureau -
Bhutan
5.6 Community action
In order
to bridge the gap between the organized health service and the community, the
Government trains village health workers, who are chosen by the Communities themselves. As of 2000, there are 1500 village health
workers, who advocate health to the people and help in bringing the health
problem of the people in the communities to the government health workers.
They are also taught and allowed to dispense a few basic allopathic
medicines.
The
communities also look after the development schemes like those for drinking
water supplies in their own areas. The programme assists the communities by
providing them the necessary training.
There are
also the traditional faith healers, astrologers and religious leaders in the
community. The Ministry also takes the support of these respected people in
imparting specific health messages-ranging from the need to take iodized salt
to family planning – to the people in the communities along with their
routine work.
In
keeping with the principles of primary health care, it was seen necessary to
extend universal coverage of health services to the rural population and
encourage community participation in health activities and awareness. The
Village Health Workers (VHW) Programme was thus initiated in 1978. The VHWs are considered to be the important link between the
community and the Government in improving basic hygiene and sanitation,
prevention of vaccine preventable diseases, family planning, nutrition,
control of diarrhoeal diseases and prevention of sexually transmitted
diseases, including HIV/AIDS, especially for communities that do not have
easy access to health facilities.
5.7 Health research and technology.
To be able to carry out research for the health
sector so that there will be evidence-based health interventions; the country
has been building its research units. The Research Unit was formally
established in 1995. The key staffs are still being trained abroad.
Related Links
Research – WHO/HQ
Research
– WHO/SEARO
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