Bhutan

6. HEALTH SERVICES

6.1 Health education and promotion

The IEC programme supports in the promotion of all other health programmes. Earlier, The IEC activities were initiated but the IECH Bureau was formally established in 1991. Over the years, this programme, through the use of mass media and its own advocacy systems, has been able to educate the general public about health hazards and motivate the public to change gradually to a healthy life style. It also helps in developing health education materials for the other programmes and in documenting their progress.

School children are the most receptive of the IECH target groups. Their adoption to hygiene helps in motivating other family and community members to understand key role of a cleaner life style. The Division also runs a comprehensive health programme for school children.

Related Links

      Health Promotion, NCD - WHO/SEARO

      Health Education – WHO/HQ

      Health Promotion – WHO/HQ

6.2 Maternal and child health/family planning/adolescent health

Following the Alma Ata declaration of 1978, Bhutan has adopted the Primary Health Care (PHC) approach to the delivery of health care services.  Maternal and Child Health Care (MCH) was an important component of the Primary Care Package.  Health aspects of human reproduction have been addressed through MCH services.

Over the decades, important social and demographic changes have taken place and they have rendered the concept of MCH approach too narrow to address all concerns in this aspect of health.  In response to the changing situations a new broader concept of “Reproductive Health” has emerged that offers a more comprehensive and integrated approach to the current needs of all in human reproduction.

Elements of Reproductive Health

Taking into account the national capacities and available resources, the reproductive health package for Bhutan prioritized the following elements:-

     Family planning

     Safe motherhood

    Antenatal care

    Intra-natal care

    Post-natal care

     Prevention and management of complication of abortion

     Reproductive Tract Infection (RTI) Sexually Transmitted Infection (STI)

     Human Immune Deficiency Virus

     Prevention and management of infertility

     Child survival including care of the new born

     Cancer of reproductive tract and breast

Death during pregnancy and within 6 weeks following delivery is very common among women of reproductive age leading to individual, family and social tragedies.  The Government has recognized it and strategies have been evolved to address this problem.

The cause/causes of death vary between home and hospital deaths.  Major common causes of death of the women in pregnancy or in postpartum period are as follows:

      Postpartum haemorrhage (PPH) with retained placenta is the most common cause of deaths at home.  Out of the 19 women who died because of PPH with retained placenta, only 1 woman died in hospital. 

      Complication of septicaemia infection is second most common cause of maternal death.  There were 9 deaths due to septicaemia during the study period. 

      There were 6 maternal deaths because of Postpartum haemorrhage (PPH) without retained placenta and all 6 occurred at home.

      During the study period 5 women died because of prolonged obstructed labour either at home or on the way to hospital.

      Pregnancy Induced Hypertension (PIH)/Eclampsia accounted for 4 deaths during the study period.  Three women died of postpartum Eclampsia and one of ante-partum eclampsia.

      All the deaths except one included in this groups are hospital deaths.  There was one death each due to the following causes:

      (Bacterial/) meningitis/encephalitis

      RHD with multiple valve involvement with thrombo-embolism

      Symptomatic heart failure (no identified previous heart condition)

      Heart failure (3^rd pregnancy after replacement of mitral valve)

      Amniotic fluid embolism

      Multi organ failure

      Cerebro-vascular accident

During 2006, deliveries attended by qualified attendant were 57 percent (Annual Health Bulleting 2007). In maternal health, the maternal mortality ration (per 100,000 live births) was 560 in 1990 and 255 in 2000. In 2000, contraceptive prevalence was 31 percent.

Related Links

      Maternal Health Care Services - Bhutan

      Child Health and Nutrition - Bhutan

      Family Planning Services - Bhutan

      Adolescent Health - WHO/SEARO 

      Child Health and Development – WHO/SEARO

      Child and Adolescent Health and Development – WHO/HQ

      Gender, Women and Health – WHO/SEARO

      Maternal Health – WHO/HQ

      Reproductive Health - WHO/SEARO

      Reproductive Health - WHO/HQ

      Making Preg. safer - WHO/SEARO

      Making Preg. safer - WHO/HQ

6.3 Immunization

Epi was launched in 1979 with seven antigens. In 1988, the National Assembly passed a resolution, which directed the Health Sector to immunize all children. With continued effort Universal Child Immunization was achieved in 1991. Since then the immunization converge was maintained above 85%. Under one year of age overall Immunization services aimed for effective coverage with all seven antigens aimed at all infants less than one year of age and to all pregnant women (Annual Health Bulletin, 2003, Royal Government of Bhutan, Ministry of Health).

Multi-antigen National Immunization Days (NIDS) were carried out in 1995 (TT, Measles and polio). Since 1996 Sub-national Immunization Days (SNIDS) are carried out. Hepatitis B vaccine was introduced in 1996. Double antigen (Measles & Polio) SNID was carried out in 2000. In the subsequent SNIDS no Measles vaccine was given other than for routine immunization.  The coverage of EPI is shown in table given below:

Table: Bhutan National EPI Converge Evaluation Survey (CES), 20002).

The evaluation survey revealed that 89.7 percent of the children are fully vaccinated before their first birthday and 64.6 percent of the fully vaccinated children received valid dose. According to annual health bulletin 2007 of Bhutan shows the immunization coverage for all antigen is 90 percent

Related Links

      Immunization - Bhutan

      Immunization - WHO/SEARO

      Immunization - WHO/HQ

6.4 Prevention and control of locally endemic diseases

Sexually Transmitted Diseases/HIV/AIDS Programme

In Bhutan, so far 50 Positive cases have been diagnosed from about 86190 samples screened, which comprises sentinel population all over the country and also voluntary groups who come forward for testing.  Of these 50 HIV cases, 10 have died, 1 due to cerebral malaria and 9 due to ARC.

The programme on sexually transmitted disease started in 1988 with the preparation of a short-term plan of action for prevention and control of HIV/AIDS in Bhutan. Bhutan is one of the few countries where the HIV/AIDS control programme started much before the disease entered the country. The programme has well-charted strategies. Clinical screening of blood from sentinel sites and anti-natal clinics helped to screen the problem. A very strong advocacy programme through IEC helped to make the people and the communities aware of the problem and free distribution of condoms from health facilities helped in preventing the infection and controlling both.

As the disease has shown a rising trend in the recent years, the STD/AIDS programme was reviewed in 2002 to find out the reason and to adjust the control activities for dealing with the problem.

Besides HIV/AIDS, the other sexually transmitted diseases like gonorrhoea and syphilis are also under an effective control, presently.

Related Links

      HIV - WHO/SEARO

Tuberculosis Control Programme

According to 1993 survey, Annual Risk of Tuberculosis Infection (ARTI) in Bhutan is 1.5 percent.  Based on 1.5 percent ARTI, NTCP estimated to detect 75 sputum positive cases per 100,000 people and about 185 cases of all type of tuberculosis per 100,000 people.

According to the case finding indicators, it is below estimation with 360 (69%) with sputum positive cases are reported and 1026 cases of all type of tuberculosis.  Therefore, program encourages district health services to scale up with case detection rate from 69 percent to 80 percent by the end of 9^th Five Year Plan.

Tuberculosis is still a major public health concern despite enormous improvement in its control methods. The TB Control Programme was started in 1976. With technical guidance from WHO, DOTS system has been introduced in the country and medical doctors and nurses are now adequately trained in this method. Each hospital has a TB in-charge who is responsible for reporting of new cases and following up on treatment.

Keeping in view of WHO’s declaration of TB as a global emergency in 1994, Bhutan adopted Directly Observed Treatment Short Course Chemotherapy (DOTS) strategy throughout the country from 1997.  With the implementation of DOTS strategy, significant progress has been made in the control of TB in Bhutan.

Related Links

      TB - Bhutan

      TB - WHO/SEARO

      TB – WHO/HQ

Malaria Control Programme

Malaria caseload peaked in 1994 with 38901 cases and since then has declined by 90 percent in 2003 with 3806 cases.  The Slide Positivity Rate (SPR) declined from 39.9 in 1994 to 6 in 2003.  The Annual Parasite Incidence (API) also declined from 111.1 in 1994 to 7.2 in 2003.  Number of malaria deaths has reduced from 48 in 1994 to 15 in 2003 but the case fatality rate has increased from 3 in 1994 to 8.9 in 2003 which is also a matter of concern to the program (Corrigendum: Royal Government of Bhutan, Ministry of Health, Bhutan).

Perhaps the Malaria Control Programme is one of the oldest health programmes. It was introduced in 1964 with the full support of the Government of India. WHO has continued to provide the required technical support and helped the Government to strengthen programme management, including training and establishing an entomology unit for the programme. Vector control method has undergone substantial change since 1995. For all practical purposes, comparative analysis of malaria data has been worked out taking 1994 as the base year, because the Programme changed its control strategy from Indoor Residual Spraying (IRS) with DDT to Synthetic Pyrethroid which was meant to be a strategy for five years. The IRS was then discontinued in 1997 with the launching of the plan for insecticide treated bed net (ITBN) programme as per the recommendation of WHO in the context of the roll-back malaria (RBM) imitative.

Related Links

      TB - WHO/SEARO

      TB – WHO/HQ

Leprosy Control Programme

The Leprosy Programme was started in 1966 and was consolidated in 1982 and the Leprosy Mission and the Norwegian Santal Mission initially supported it. Initially, it was implemented as a vertical programme but it is now fully integrated into the general health service. While maintaining the achievements and working towards elimination, the Government is also working to strengthen the programme capacity.

According to the past records the number of leprosy cases came down from a total 40 to 33 in 2002.  The case detection rate was found to be 0.19 per 10,000 population and the prevalence rate at 0.50/10000 in 2002 as compared to 0.61/10000 in 2001.

Related Links

      Leprosy - WHO/SEARO

      CDS – WHO/SEARO

      Infectious diseases – WHO/HQ 

6.5 Prevention, control and management of common diseases and injuries

Related Links

     Department of Public Health - Bhutan

Integrated Management of Childhood Illness

Since diarrhoeal diseases and acute repository infections top the list of morbidity in health facilities, the programmes on Control of Diarrhoeal Diseases (CDD) and Acute Respiratory Infection (ARI) were started in 1982 and 1987, respectively. Since the initiation of the WHO’s Integrated Management of Childhood Illness (IMCI) strategy, these two programmes have been combined to form the IMCI Programme.

Community-Based Rehabilitation Programme

Although the Health Sector took up the community-based disability and rehabilitation programme only in early 1997, some initiatives were taken much earlier by the Education Department. The Education Department started the Zangley Muenselling School for the visually impaired in Khaling, Eastern Bhutan decades ago. The Health Sector has identified one hospital as rehabilitation centre and recently efforts have been made to develop this centre.

Mental Health Programme:

The Community Mental Health Programme was formulated in 1997 coinciding with the beginning of the 8^th Five-Year Plan. WHO and DANIDA played key role in its development by providing both financial and technical assistance. The programme is totally integrated into the general health service. A pilot mental health survey was conducted in 2002. The programme is being further strengthened through developing the key staff and health workers.

Survey carried out in the pilot CBR programme and household survey in Bhutan have estimated that there are about 21,000 persons with disabilities in the country, amounting to 3.5 percent of the total population of Bhutan.  These figures are only suggestive and not definitive.  A more detailed survey of the different regions may be necessary to correctly assess the extent and degree of disabilities and their causes in Bhutan.

In a quick survey of dzongkhag, it was found that 90 percent of the population had access to a health facility (including ORC, BHU or hospital) within 2 hours of walk as per revised redefining access in 1996.

Related Links

      NCD & MH - WHO/SEARO

      NCD - WHO/SEARO

      Mental Health - WHO/SEARO

      Mental Health - WHO/HQ

     Cancer – WHO/HQ