Bhutan

Basic health Indicators including the U.N. Millennium Development Goals

                               ANNEX-1

Country reported Data for Basic Health Indicators including health related MDG Indicators

Sources:

1.      Statistical Year Book (2002), Planning Commission, Thimphu.

2.      Annual Health Bulletin 2002, Deptt. of Health Services, Ministry of Health and Education

3.      A Report, National Health Survey 2000, Department of Health Services, Ministry of Health and Education

4.      General Statistics 2003, Policy Planning Division, Ministry of Education      

5.      Bhutan at a Glance, 2003, National Statistical Bureau

6.      Asian Development Bank: Bhutan-1999 Country Portfolio Review and Country Programming Confirmation for 2000 Mission, Memorandum of Understanding

7.      Annual Health Bulletin, 2003, Royal Government of Bhutan, Ministry of Health

8.      National Accounts Statistics Report 2002, National Statistical Bureau, Royal Government of Bhutan

9.      WHO Core Indicators, 2005

10.   National Health Accounts for Bhutan, Summary NHA Indicating for World Health Report 2001

11.   SEARO MEMORANDUM: “Reorganization of Health Infrastructure of the Royal Government of Bhutan”, 28.06.2000

12.   Corrigendum: Royal Government of Bhutan, Ministry of Health, Bhutan

13.   WHO, The World Health Report, 2005

14.   UNDP, Human Development Report, 2004

15.   Fact Sheet, Population and Housing Census of Bhutan, 2005

16.   Annual Health Bulletin 2006, Royal Government of Bhutan, Ministry of Health , Thimpu, Bhutan

17.   World Population Prospectus. Revision 2004

18.   Annual Health Bulletin 2007, Royal Government of Bhutan, Ministry of Health , Thimpu, Bhutan

19.   WHO, World Health Report 2006

20.   Millennium Development Goals, Progress Report 2005, Bhutan

21.   South-East Asia Region EPI Fact Sheet 2005

Annex-2

Millennium Development Goals

Bhutan's Development Context and Overall Progress towards MDG Targets

Bhutan is a low income country, and its economy is essentially an agrarian one with 79 percent of the people dependant on agriculture and livestock rearing for their livelihood. At 34 percent of the GDP in 2002, agriculture ² still remains the single largest contributor to the national economy, though this has been declining steadily over the years. The fast growing modern sector, comprising manufacturing, industry, energy and services, today accounts for a major portion of the GDP, and is expected to dominate the economy in the future. The further developments of hydropower and energy-intensive industries are viewed as strategic key elements in unlocking the economic potential of the country and serve as the engines of growth. Tourism is also being increasingly regarded as an important sector as the industry provides more diversity to the economic base and generates valuable foreign exchange and employment opportunities in the country. Based on anticipated performance of these sectors, GDP is forecasted to continue growing rapidly at 7-9 percent annually, well into the next decade. Bhutan has also made significant progress in improving the levels of human development over the decade. This was largely achieved because of the Royal Government of Bhutan’s (RGoB's) strong commitment to the principle of development as social transformation and its translation into action through sizeable social sector investments. These social investments are now projected to constitute 24 percent of all capital and recurrent expenditures in the Ninth Five Year Plan.

The significant investments in the social sector have greatly contributed to the overall progress towards attaining the MDG. Bhutan is well on track to achieve several of the MDG Targets, some possibly even before 2015. However, as progress with regard to many of the MDG Targets is assessed in relation to the country's own past national context and since they are not in themselves the highest achievable goals but rather the minimum, the country should not be complacent. There is tremendous scope and need for further improvements in human development in absolute and qualitative terms. Additionally, achieving the MDGs by 2015 would require at the least, sustained, and preferably, higher levels of internal effort and external support as social development increments become progressively more difficult to attain.

The various MDGs relating to poverty, educational attainments, maternal and child health, high-risk diseases and environmental sustainability, are in themselves high priority development themes for Bhutan. National development targets as reflected in the Ninth Plan and the Bhutan Vision 2020 often exceed or closely match MDG Targets. Thus there is strong national political commitment and a generally positive policy environment. However, the overall situation with regard to the data and monitoring environment at both the sectoral and national levels are regarded to be weak and in need of strengthening.

KEY DEVELOPMENT INDICATORS

Sources: Statistical Yearbook of Bhutan 2001, Bhutan National Human Development Report 2000 and National Health Survey 2000.

 ² The agriculture sector includes agriculture, livestock, forestry and logging.

The progress made towards achievement of health related MDGs is given here:

GOAL1: ERADICATE EXTREME POVERTY AND HUNGER

Status and Trends

There is no evidence of widespread hunger in Bhutan, though some studies indicate the incidence of transient food insecurity and seasonal hunger in certain parts of the country, particularly during the planting and harvesting period between May and July.

Food Insecurity: While there is no hunger in the country, some gewogscharacterised by their poor accessibility occasionally face partial food insecurity particularly relating to grain deficit. The reasons attributed are low cropping intensity and crop productivity, labour shortages, small sized land holdings, inadequate irrigation, damage by predators, pests and plant diseases, poor storage, and insufficient food stocks. Among these, the factor of land holding size appears to have the most impact on food security. The poor utilisation of food, including the diversion of food grain to brew alcohol also contributes to the situation of household food insecurity.

An emerging trend that has significant bearing on food security and nutritional sufficiency is that food procurement appears to be shifting from farm production to purchases from the market and that there are perceptible changes in dietary patterns. Climatic changes and natural calamities, as elsewhere, have as well a significant impact on the food supply situation. Even then, these may be considered exceptions and not indicative of a problematic or widespread situation. Given this, it is considered that the target of halving the numbers of those suffering from malnutrition would be a more relevant and appropriate target for Bhutan.

Percentage of underweight and stunted Under-5 Children

Malnutrition: Levels of grade one or mild malnutrition among children have fallen from 32 percent in 1993 to 18 percent in 1997 (Bhutan National Human Development Report 2000). Third degree or severe malnutrition was minimal though not entirely absent. The percentage of under-5 children who were underweight has been halved from 38 percent in 1989 to 19 percent in 2000 and the MD target can be considered already achieved. The progress with regard to the category of under-5 children who suffer from stunting is currently on track. However, as the increments become progressively more difficult to attain, reductions to the levels desired will require significant and sustained interventions. The target of 28 percent can be potentially attained by 2015. In both situations, there are no major gender differences in the nutritional status, and where differences exist, girls are better off.

The micronutrient deficiency situation has improved considerably over the decade. Iodine Deficiency Disorders (IDD) which were once widely prevalent in the country, reflected in the high total Goitre rate at 65 percent, has reduced to a 14 percent prevalence with salt iodination close to 100 percent. With the regular monitoring and evaluation of the Iodine Deficiency Disorders Control Programme (IDDCP to ensure timely interventions, IDD prevalence should be reduced even further to minimal levels. A nationwide study of vitamin A deficiency confirms a sub-clinical vitamin A prevalence of 2.6 percent. Iron deficiency anaemia, however, is regarded as a major public health problem, particularly among pregnant women.

The steady improvements in child nutrition are directly attributable to the Nutrition Programme initiated in 1985. Through the programme and subsequent nutrition interventions, several community based nutrition initiatives promoting household kitchen gardens, enhancing livestock rearing and food production were carried out successfully.

Challenges

Food insecurity and malnutrition are more prevalent in the eastern parts of the country and there is a need for increased attention to these areas. Likewise, certain sections of the population are particularly vulnerable to malnutrition, such as children and women, particularly those from lower income groups. The levels of awareness and education are poorer in those regions and among such vulnerable groups. This serves to accentuate the problem.

In terms of women's nutrition, about one fifth of women of childbearing age are malnourished with a high number of them suffering from nutritional anaemia. Under the Ninth Five Year Plan, the health objective is to reduce nutritional anaemia in pregnant women by half to 30 percent, which will pose a significant challenge. Additionally, available figures indicate a very high prevalence of low birth weights, the best indicator of the extent of malnutrition in women and children. Furthermore, the practice of exclusive breastfeeding becomes more and more uncommon, and breast milk substitutes are increasingly made use of. While these specific malnutrition related challenges must them be addressed directly, dealing with these constraints with an integrated and multi-faceted approach will in itself pose a significant challenge.

Supportive Environment

Achieving food security has always been an important national policy objective, particularly in the context of an essentially agrarian economy with around 79 percent of its people dependent on agriculture.

The Ninth Five Year Plan acknowledges that the overall nutritional status of the population is unsatisfactory and emphasizes the need for improvements. The sectoral policy also specifically identifies a target of reducing Protein-energy Malnutrition (PEM) in under-­five children from 40 percent to 26 percent and to eliminate micronutrient deficiencies by 2007.

Nutrition gaps will be addressed further through the development of a National Nutrition Policy and Integrated Nutrition Information, Education and Communication (IEC) plan. A breast-feeding policy has recently been formulated and launched with a code for marketing of breast milk substitutes.

The successful Nutrition Programme in the communities, which includes promoting school agriculture and kitchen gardening, is to be continued and enhanced further. The new programme cycle is to be closely linked with the Child Care and Development Programme (CCDP) and the multi-­sectoral effort underway to improve nutrition through increasing food production and diversity, and improving food grain storage.

Advocacy activities have been greatly strengthened with the engagement of the monk body in highlighting nutritional deficiencies. 1996 was further designated the Nutrition Action Year with various thematic activities staged across the country.

Monitoring and Evaluation Environment:

GOAL 4: REDUCE CHILD MORTALITY

Source: National Annual Health Bulletins: 1990 & 2000

* Liner extrapolation for 1990

Status and Trends

Child mortality, both for under-five and infants, has decreased steadily over the past decade. Under-five and infant mortality rates have both declined by about 32 percent from 1990 to 2000. Attaining the M DG targets to reduce infant and under-five mortality by 2015 appears to be potentially achievable, but will still depend greatly on the levels of interventions maintained, including extending coverage to groups which are difficult to reach.

Acute Respiratory Infections (ARI, including pneumonia) were consistently the leading direct cause of child morbidity and mortality for under-five children. The other major causes for under five child mortality and poor health were diarrhoeal diseases and helminthic infestation, besides inadequate care practices relating to breast feeding, appropriate complimentary feeding, hygiene and sanitation, and care in illness. Incidences of ARI, diarrhoea, dysentery and worm infestation have however reduced progressively over the years. While the direct causes of infant mortality are unclear and need more in depth analysis and systematic studies, it is perceived that closing the knowledge, altitude and behaviour gaps in safe hygienic practices at birth, better nutritional practices and improved sanitation and hygiene conditions, would help further reduce infant mortality.

The significant progress in reducing infant mortality and under-five mortality were largely possible through the expansion of primary health care coverage, control of communicable diseases, particularly measles and tuberculosis, improved nutrition and hygiene, enhanced oral rehydration therapy usage, and the highly successful immunization programme.(See Box)

As early as 1991, Bhutan had achieved universal child immunization (UCI) with 84 percent coverage of all infants vaccinated with the six antigens of BCG, diphtheria, tetanus, pertussis, poliomyelitis, and measles. Hepatitis B immunization was introduced later in 1996, in line with the global immunization policy. The notable public health milestone of UCI was achieved in spite of the great difficulties of the accessibility to children in very remote communities, through the Expanded Programme on Immunization (EPI) provided by the effective network of health units and outreach clinics. Under the EPI programme, Hib burden assessment was carried out and in view of the finding that 44 percent of all meningitis occurs among under-five children, the Hib vaccine is to be approved for introduction until 2005. A nationwide review of the EPI coverage and cold chain system will also be undertaken to access the achievements, constraints and future needs.

No cases of polio have been reported for more than a decade, with the country enjoying a zero-polio status since 1986. From this it appears that the national goal of eradicating polio by 2005 can be achieved. However, the risk of the virus resurfacing in the country cannot be ruled out entirely as the wild-polio virus is still widely prevalent in the region. Polio immunization and sub-­immunization therefore continues to be administered, particularly in the border areas, to cover those missed out, and to bolster the immunities of those already immunized. Additionally, no deaths from neonatal tetanus have been reported since the mid 1990s and it is expected to be eradicated by 2005.

While there is a lack of confirmatory investigations on reported measles cases, recent figures indicate a rise in the incidence of measles. In the 1980s, measles cases dropped significantly, but during the 1990s, there were periodic measles outbreaks with 460 cases in 2000, as compared to 84 in 1999. While measles is still endemic to the country, the mortality arising from measles decreased significantly and no measles deaths have been reported since the mid 1990s.

Challenges

The main challenge in attaining further reductions in child mortality would be to expand primary health care coverage and nutrition, immunization and other relevant health care services to the unreached, marginalized and groups who live in very remote regions. The rugged and inaccessible terrain poses a severe constraint in terms of both the costs and logistics involved in the delivery of health services.

The further reduction of child mortality will depend considerably on how successfully the issues of LBW and other causes of perinatal mortality are addressed through appropriate interventions. Reductions in child mortality rates are also dependant on qualitative improvements in sanitation and hygiene, clean water supply, education and awareness, maternity and primary health care, which require continued and sustained efforts and interventions across several sectors. Tackling the challenge of developing effective inter-sectoral linkages and integrated approaches is likely to have a significant influence on the progress of improving child health in the country.

Impact studies also indicate very low levels of awareness and insufficient knowledge about the spread of diarrhoeal and respiratory infections, the major causes of child mortality. While this has long been identified as a constraint, there is considerable scope for improvement in the levels of information and education among communities on prevention and basic treatment of these illnesses.