Health in Bhutan is one of the government's highest priorities in its scheme of development and modernization. Health and related issues are overseen by the Ministry of Health, itself represented on the executive Lhengye Zhungtshog (cabinet) by the Minister of Health. As a component of Gross National Happiness, affordable and accessible health care is central to the public policy of Bhutan.[1][2][3][4]
The Constitution of Bhutan charges the Royal Government with ensuring a "safe and healthy environment," and with providing "free access to basic public health services in both modern and traditional medicines".[5]:5:2(d),9:21
The Human Rights Measurement Initiative[6] finds that Bhutan is fulfilling 85.5% of what it should be fulfilling for the right to health based on its level of income.[7] When looking at the right to health with respect to children, Bhutan achieves 91.8% of what is expected based on its current income.[8] In regards to the right to health amongst the adult population, the country achieves only 80.7% of what is expected based on the nation's level of income. [9] Bhutan falls into the "bad" category when evaluating the right to reproductive health because the nation is fulfilling only 84.1% of what the nation is expected to achieve based on the resources (income) it has available.[10]
The Ministry of Health has provided universal health care in Bhutan since the 1970s. Health care infrastructure and services are planned and developed through Five Year Plans (FYP) of the Ministry of Health.[11] The third democratically appointed Health Minister, Lyonpo Dechen Wangmo, is the head of the Ministry of Health.[12]
Two major pieces of Bhutanese legislation establish a framework for personnel and medicines. The Medical and Health Council Act of 2002 incorporates the Medical and Health Council as a legal entity to regulate medical schools, courses, and professional credentials.[13] The Medicines Act of 2003 establishes the Bhutan Medicines Board and Drugs Technical Advisory Committee. The Act authorizes several subsidiary organizations, including the Bhutanese Drug Regulatory Authority, Drug Testing Laboratory, and teams of Drug Inspectors. These agencies have rulemaking and law enforcement authority on drugs, medicines, and even price controls, but must operate within the laws of Bhutan.[14] Both pieces of legislation contain offenses germane to their subject matter, supplementing the Penal Code.[13]:VIII[14]:IX
These hospitals and smaller facilities were supported by 3,756 Ministry of Health employees in thirteen categories: 244 doctors; 957 nurses; 92 nurse's assistants; 505 "health workers;" 35 Dzongkhag Health Officers and Assistants; 41 drungtshos (traditional physicians); 52 smenpas (traditional physicians); 12 pharmacists; 79 pharmacy assistants and technicians; 13 lab technologists; 549 other technicians and assistants; and 1,601 administrative and support staff.[1]:iii
Emergency and health hotline
On May 2, 2011, Bhutan launched its telephonic Health Help Centre (HHC), which had proved successful over the prior two months. The HHC number is 112. The HHC provides two services: Emergency Response and the Healthcare Helpline, both accessible through landed and mobile phones. Emergency responses are served by 61 ambulances in 37 locations with 59 emergency medical technicians around the kingdom, equipped with GPS and GIS technology. The Healthcare Helpline dispenses medical advice.[15]
Funding
The cost and availability of health care facilities – some of which operate on a 24-hour basis – is a subject of discussion in Bhutan. Issues of affordability and sustainability have called into question Bhutan's proposed funding schemes.[16]
Health issues
An outhouse in Bhutan. Over 90% of Bhutanese have access to basic sanitation.
As of 2009, most Bhutanese had access to potable drinking water (83%) and basic sanitation (91%). Widespread health concerns included diarrhea (2,892 per 10,000 people) and pneumonia (1,031) among children under age 5; skin infections (1,322); conjunctivitis (542); hypertension (310); and intestinal worms (170). Less widespread were diabetes (38 per 10,000 people); alcohol-related liver disease (23); and cancer (17). Incidence of malaria and tuberculosis was generally low, at 10 and 15 cases per 10,000 people, respectively.[1]:iii,4–5
Influenza, including H1N1 ("swine flu") and H5N1 ("bird flu") strains, are present in Bhutan. As of 2009, there were 6 confirmed cases of H1N1, none of which was fatal. Bird flu, however, has resulted in at least one outbreak in Phuntsholing and remains a "serious concern" of the Ministry of Health.[1]:5
In 2011, there were 246 reported cases of HIV, representing just over 0.3% of the population.[17] Through 2010, infection rates remained modest though increasing, totaling 185 reported cases, or 0.1% of the population. The Ministry of Health attributed climbing numbers to promiscuity, drug use, and the prevalence of HIV/AIDS in neighboring countries.[1]:4
Maternal and child healthcare
As of 2008, 90% of the population were covered by the government's immunization regimen.[1]:iii In 2010, the Ministry of Health noted a growing trend of unsafe abortions among Bhutanese women (466 in 2003; 1,057 in 2009), apparently performed in neighboring India, contributing to Bhutan's high maternal mortality rate.[1]:3
In 2011, Bhutan had a maternal mortality rate of 200 per 100,000. This is compared with 254.9 in 2008 and 1145.4 in 1990. The under 5 mortality rate, per 1,000 births was 81 and the neonatal mortality as a percentage of mortality under 5 years was 43. In Bhutan the number of midwives per 1,000 live births was 15 and the lifetime risk of death for pregnant women was 1 in 170.[18]
Food safety
Bhutan regulates public health and safety in regards to food under the Food Act of 2005.[19] The Food Act establishes the National Food Quality and Safety Commission and the Bhutan Agriculture and Food Regulatory Authority ("BAFRA"), both of which are overseen by the Ministry of Agriculture. While the Ministry of Agriculture is singularly authorized to author regulations under the Food Act, the Minister of Agriculture may delegate authority to ministries responsible for health, trade, and customs.[19]:§§ 3–9,88
The National Food Quality and Safety Commission is chaired by the Minister of Agriculture and comprises ten additional members from various relevant government ministries and agencies regulating agriculture, health, commerce, home affairs, legal affairs, and the environment.[19]:§ 10 The Commission formulates the government's food policy, while the BAFRA is responsible for advising and implementing the Commission's policies, including health and safety inspections.[19]:§§ 15–21,33–52
BAFRA inspectors have broad authority to search, document, test, and seize food wherever it is transported, stored, prepared, or served; inspectors may also destroy unsafe food when it poses a "clear and present danger for human health or the environment".[19]:§§ 39–49 The Act further establishes health guidelines for businesses that serve or trade in food, including provisions allowing for food testing,[19]:§§ 53–58 and defines government authority in regulating food imports and exports.[19]:§§ 61–67 The Food Act, like other Bhutanese legislation, defines relevant offenses and penalties for failing to conform to proscribed laws and regulations.[19]:§§ 58–87
Tobacco
Tobacco sale and consumption is actively discouraged by the government of Bhutan through education, economic, and penal incentives. The Tobacco Control Act bans the sale of tobacco, taxes imports, and places restrictions on quantities individuals may possess.[2]:§§ 11–17 The Act also authorizes the Tobacco Control Board, through the Tobacco Control Office, to provide cessation programs in health facilities and to work with rehabilitation centers in diagnosing and counseling tobacco dependence.[2]:§§ 22–23
The Tobacco Control Office is occupied by the Bhutan Narcotic Control Agency and headed by its executive director. The Office acts as the agent of the Board responsible for coordinating most of the actual implementation of Bhutan's tobacco policy.[2]:§§ 29–32 The Ministry of Health, Ministry of Economic Affairs, Ministry of Finance, Ministry of Education, and Ministry of Home and Cultural Affairs are all responsible for implementing the laws in the Act and the policies of the Board in specified arenas.[2]:§§ 33–37,42
Alcohol
In 2011, the government passed its Alcohol Control Regulation, which imposed up to three times the previous taxes on alcohol. As a result, alcohol sales have dropped and prices have risen.[20] Alcohol consumption among students has risen in the recent past, resulting in several expulsions from Bhutan's elite Sherubtse College.[21]
Ara, the traditional alcohol of Bhutan, is most often home made from rice or maize, either fermented or distilled,[22] and may only be legally produced and consumed privately. Ara production is unregulated in both method and quality, and its sale has been prohibited in Bhutan since a severe crackdown. However, because Ara returns far more profit than other forms of maize, many Bhutanese farmers have pressed for legal reform.[23] The Bhutanese government, meanwhile, is intent on discouraging excessive alcohol consumption, abuse, and associated diseases through taxation and regulation.[24][25]
Through government efforts to reduce ara production and consumption in Lhuntse District, eastern Bhutan, locals conceded something should be done to curb the distinctly eastern Bhutanese tradition of heavy drinking. The government's strategy is to reduce ara production and consumption gradually until it is eliminated. Alcoholism and ara production have been notable topics of political discussion Bhutan, especially at the local level.[26] Ara, however, is also culturally relevant for its religious and medicinal uses.[27][28]
Narcotics and treatment
Bhutan regulates drugs – from pharmaceuticals to narcotics – through the Narcotic Drugs and Psychotropic Substances and Substance Abuse Act 2005 ("Narcotics Act").[4] Its stated legislative purpose is "to ensure that drugs are available exclusively for medical, veterinary and scientific purposes." To this end, the Narcotics Act emphasizes education and treatment as means of combatting illegal drug use.[4]:§§ 35–42 The Act sets forth a fivefold schedule for substances under which Schedule I includes the most restricted substances and Schedule V includes substances "liable for abuse but [not falling] under International control."[4]:§§ 3–6,i–v
To address drug-related issues, the Narcotics Act creates the Narcotics Control Board and the Narcotics Control Agency. The Narcotics Control Board, made up entirely of government appointees and chaired by "a relevant Cabinet Minister," is responsible for formulating drug policy,[4]:§§ 59–63 while its ancillary Narcotics Control Agency is chiefly responsible for implementing the Board's policy and advising the Board.[4]:§§ 64–79 The Narcotics Act provides enforcement and investigation powers to drug enforcement agencies, including the Royal Bhutan Police and Narcotics Control Agency.[4]:§§ 70–86 Under the Narcotics Act, every person and entity is subject to inspection by competent authorities.[4]:§§ 26–30,70–71
The Narcotics Act mandates drug treatment under the auspices of the Narcotics Control Board and punishes repeat offenders and those who otherwise fail to abide by the terms of treatment.[4]:§§ 50–53 The Board is bound to ensure treatment, rehabilitation, and social reintegration of drug-dependent persons, through interventions, counseling, and detoxification; it is thus required by law to maintain adequate personnel and institutions to provide such services.[4]:§§ 38–39 Records of treatment must be kept confidential.[4]:§ 56 Persons dependent on drugs are subject to compulsory treatment and rehabilitation; those who refuse to submit voluntarily must be confined in criminal custody.[4]:§§ 36–55
The Act authorizes courts to impose treatment as part of sentencing in cases related to drugs, and provides for probation-like "periodic attendance before a panel for review and evaluation of treatment and progress." Successful compliance with such a regimen allows courts to discharge other penalties related to narcotics, such as prison terms and fines.[4]:§§ 44–47,57[29] The Narcotics Act further sets forth about a dozen offenses and penalties regarding compliance with the Act, further supplementing the Penal Code.[4]:§§ 90–103
The Bhutanese media, for its part, have recognized dire societal problems resulting from and associated with substance and alcohol abuse. In response, the Bhutan Observer has encouraged religious and community support for those seeking recovery.[30]
Bhutan's suicide rate was 16.2 per 100,000 people in 2011. This figure ranks the kingdom as the 20th-highest suicide rate in the world, and the 6th highest in the Asia-Pacific region.[31]
Since 2011, the number of recorded deaths has increased by around 50% for the years 2012 and 2013,[32] which clearly places the Himalayan Kingdom among the countries with the highest suicide rates in the world. Bhutan is currently rated at number five in the Asia Region.[33] While no clear indications are given for Bhutan's high rate of suicide, lack of job opportunities, an extremely high percentage of broken families and a high rate of domestic violence are considered to be major contributing factors.
Bhutanesehealth care development accelerated in the early 1960s with the establishment of the Department of Public Health and the opening of new hospitals and dispensaries throughout the country. By the early 1990s, health care was provided through twenty-nine general hospitals (including five leprosy hospitals, three army hospitals, and one mobile hospital), forty-six dispensaries, sixty-seven basic health units, four indigenous-medicine dispensaries, and fifteen malaria eradication centers. The major hospitals were in Thimphu, Geylegphug, and Trashigang. Hospital beds in 1988 totaled 932. There was a severe shortage of health care personnel with official statistics reporting only 142 physicians and 678 paramedics, about one health care professional for every 2,000 people, or only one physician for almost 10,000 people.
Training for health care assistants, nurses' aides, midwives, and primary health care workers was provided at the Royal Institute of Health Sciences associated with the Jigme Dorji Wangchuck National Referral Hospital, which was established in 1974. Graduates of the school were the core of the national public health system and helped staff the primary care basic health units throughout the country. Additional health care workers were recruited from among volunteers in villages to supplement primary health care.[34]
The government has maintained a system of universal health care for its citizens. However, the number of Hospitals in Bhutan has been limited, and some diseases, such as cancer cannot be treated in Bhutan. Patients that cannot be treated in Bhutan are taken to hospitals in India, and their treatment is paid for by the government of Bhutan.[34]
The most common diseases in the 1980s were gastrointestinal infections caused by waterborne parasites, mostly attributable to the lack of clean drinking water. The most frequently treated diseases were respiratory tract infections, diarrhea and dysentery, worms, skin infections, malaria, nutritional deficiencies, and conjunctivitis. In 1977 the World Health Organization (WHO) declared Bhutan a smallpox-free zone. In 1979 a nationwide immunization program was established. In 1987, with WHO support, the government envisioned plans to immunize all children against diphtheria, pertussis, tetanus, polio, tuberculosis, and measles by 1990. The government's major medical objective by 2000 was to eliminate waterborne parasites, diarrhea and dysentery, malaria, tuberculosis, pneumonia, and goiter. Progress in leprosy eradication was made in the 1970s and 1980s, during which time the number of patients had decreased by more than half, and by 1988 the government was optimistic that the disease could be eliminated by 2000.[34]
It was estimated in 1988 that only 8 persons per 1,000 had access to potable water. Despite improved amenities provided to the people through government economic development programs, Bhutan still faced basic health problems. Factors in the country's high morbidity and death rates included the severe climate, less than hygienic living conditions, for example long-closed-up living quarters during the winter, a situation that contributes to the high incidence of leprosy, and smoke inhalation from inadequately ventilated cooking equipment. Nevertheless, in 1980 it was estimated that 90 percent of Bhutanese received an adequate daily caloric intake.[34]
Although there were no reported cases of acquired immune deficiency syndrome (AIDS) through the early 1990s, the Department of Public Health set up a public awareness program in 1987. With the encouragement of the WHO, a "reference laboratory" was established at the Thimphu General Hospital to test for AIDS and human immunodeficiency virus (HIV) as a precautionary measure. To further enhance awareness, representatives of the National Institute of Family Health were sent to Bangladesh in 1990 for training in AIDS awareness and treatment measures.[34]
Pema Dorji, a doctor of traditional Bhutanese and Tibetan medicine, the first person to institutionalize traditional medicine in Bhutan
Further reading
Dorji, Tandi; Melgaard, Bjorn (2012). Medical History of Bhutan:chronicle of health and disease from Bon times to today. Thimphu: Centre for Research Initiatives.
Taee, Jonathan (2017). The Patient Multiple: An Ethnography of Healthcare and Decision-Making in Bhutan. Berghahn Books.
Related Research Articles
Bhutan's early history is steeped in mythology and remains obscure. Some of the structures provide evidence that the region has been settled as early as 2000 BC. According to a legend it was ruled by a Cooch-Behar king, Sangaldip, around the 7th century BC, but not much is known prior to the introduction of Tibetan Buddhism in the 9th century, when turmoil in Tibet forced many monks to flee to Bhutan. In the 12th century, the Drukpa Kagyupa school was established and remains the dominant form of Buddhism in Bhutan today. The country's political history is intimately tied to its religious history and relations among the various monastic schools and monasteries.
Thimphu is the capital and largest city of Bhutan. It is situated in the western central part of Bhutan, and the surrounding valley is one of Bhutan's dzongkhags, the Thimphu District. The ancient capital city of Punakha was replaced by Thimphu as capital in 1955, and in 1961 Thimphu was declared as the capital of the Kingdom of Bhutan by the 3rd Druk Gyalpo Jigme Dorji Wangchuck.
Jigme Singye Wangchuck is a member of the House of Wangchuck who was the king of Bhutan from 1972 until his abdication in favor of his eldest son, Jigme Khesar Namgyel Wangchuck, in 2006.
Jigme Dorji Wangchuck was the 3rd Druk Gyalpo of Bhutan.
Lhuntse District is one of the 20 dzongkhag (districts) comprising Bhutan. It consists of 2506 households. Located in the northeast, Lhuntse is one of the least developed dzhongkhags of Bhutan. There are few roads, the first gas station was opened in September 2005, electricity is not well distributed, and the difficult terrain makes distribution of social welfare problematic. Despite its favourable climate, farming is hindered by the lack of infrastructure.
Dechencholing Palace is located in Thimphu, the capital of Bhutan, 4 kilometres (2.5 mi) to the north of the Tashichho Dzong and 7 kilometres (4.3 mi) north of the city centre. It was built in 1953 by the third king of Bhutan Druk Gyalpo Jigme Dorji Wangchuck.
Jigme Khesar Namgyel Wangchuck is the Druk Gyalpo of the Kingdom of Bhutan. After his father Jigme Singye Wangchuck abdicated the throne in his favor, he became the monarch on 9 December 2006. A public coronation ceremony was held on 6 November 2008, a year that marked 100 years of monarchy in Bhutan.
Changlimithang Stadium is a multi-purpose stadium in Thimphu, Bhutan, which serves as the national stadium. It is predominantly used for football matches and is the home of the Bhutan national football team, other national selections and number of Thimphu-based football clubs. The stadium also regularly plays host to women's football, archery tournaments, minifootball and some volleyball matches. The stadium was initially constructed in 1974 for the coronation of the fourth Druk Gyalpo Jigme Singye Wangchuck, but was completely refurbished in 2007 in advance of the coronation of the fifth Druk Gyalpo Jigme Khesar Namgyel Wangchuck. Floodlighting was added to the football pitch in 2009 and an evergreen turf was laid in 2012, to coincide with the start of the first season of the National League. Located 2,300 meters (7,500 ft) above sea level, the stadium is one of the highest in the world. It has raised numerous controversies in footballing circles, as its significant altitude affects the absorption of oxygen in the human body, offering considerable advantage to the home teams who are more accustomed to such conditions.
The development of Bhutanese democracy has been marked by the active encouragement and participation of reigning Bhutanese monarchs since the 1950s, beginning with legal reforms such as the abolition of slavery, and culminating in the enactment of Bhutan's Constitution. The first democratic elections in Bhutan began in 2007, and all levels of government had been democratically elected by 2011. These elections included Bhutan's first ever partisan National Assembly election. Democratization in Bhutan has been marred somewhat by the intervening large-scale expulsion and flight of Bhutanese refugees during the 1990s; the subject remains somewhat taboo in Bhutanese politics.
The following outline is provided as an overview of and topical guide to Bhutan:
Pema Dorji was a Bhutanese doctor (drungtsho) of traditional Bhutanese and Tibetan medicine, was the first person to institutionalize traditional medicine in Bhutan. He was the founding director of the National Indigenous Medicine Hospital and of the Institute of Indigenous Medicine in the capital Thimphu, and the key person behind the establishment of the Health Department's indigenous clinics and dispensaries in all 20 districts of Bhutan which make available free treatment and medicine to all the citizens of Bhutan.
The National Referral Hospital is the main hospital of Bhutan, located in the capital of Bhutan, Thimphu. Since it was established in 1972, the hospital has been supplying free basic medical treatment as well as advanced surgeries and emergency services to citizens from all over the country. It provides the most sophisticated health evaluation and management services in the country. Recently the hospital has added CT and MRI diagnosis equipment and improved lab services. The hospital has a library with many current textbooks.
The national symbols of Bhutan include the national flag, national emblem, national anthem, and the mythical druk thunder featured in all three. Other distinctive symbols of Bhutan and its dominant Ngalop culture include Dzongkha, the national language; the Bhutanese monarchy; and the driglam namzha, a seventeenth-century code on dress, etiquette, and dzong architecture. Natural symbols of Bhutan are its national flower, the Himalayan blue poppy; its national tree, the Himalayan cypress; its national bird, the raven; and its national animal, the takin.
The Tobacco Control Act of Bhutan was enacted by the Parliament of Bhutan on 6 June 2010 and came into force on 16 June. It regulates tobacco and tobacco products, banning the cultivation, harvesting, production, and sale of tobacco and tobacco products in Bhutan. The act also mandates that the government of Bhutan provide counselling and treatment to facilitate tobacco cessation. Premised on the physical health and well being of the Bhutanese people – important elements of Gross National Happiness – the Tobacco Control Act recognizes the harmful effects of tobacco consumption and exposure to tobacco smoke on both spiritual and social health.
Public holidays in Bhutan consist of both national holidays and local festivals or tshechus. While national holidays are observed throughout Bhutan, tsechus are only observed in their areas. Bhutan uses its own calendar, a variant of the lunisolar Tibetan calendar. Because it is a lunisolar calendar, dates of some national holidays and most tshechus change from year to year. For example, the new year, Losar, generally falls between February and March.
Ara, or Arag, is a traditional alcoholic beverage consumed in Bhutan. Ara is made from native high-altitude tolerant barley, rice, maize, millet, or wheat, and may be either fermented or distilled. The beverage is usually a clear, creamy, or white color.
The wedding of Jigme Khesar Namgyel Wangchuck, King of Bhutan, and Jetsun Pema took place on 13 October 2011 at the Punakha Dzong in Punakha, Bhutan. The current King of Bhutan, Jigme Khesar Namgyel Wangchuck, married Jetsun Pema, who became Queen Ashi Jetsun Pema Wangchuck. Both are descendants of the 48th Druk Desi of Bhutan and 10th Penlop of Trongsa, Jigme Namgyal.
HIV/AIDS in Bhutan remains a relatively rare disease among its population. It has, however, grown into an issue of national concern since Bhutan's first reported case in 1993. Despite preemptive education and counseling efforts, the number of reported HIV/AIDS cases has climbed since the early 1990s. This prompted increased government efforts to confront the spread of the disease through mainstreaming sexually transmitted disease (STD) and HIV prevention, grassroots education, and the personal involvement of the Bhutanese royal family in the person of Queen Mother Sangay Choden.
Dasho Dawa Dem was a bureaucrat in the Kingdom of Bhutan. She held positions in various government branches, namely the Royal Secretariat, the Thimphu District Administration, the Ministry of Foreign Affairs, and the Royal Advisory Council, in an official career spanning two decades, from 1965 to 1985. She helped establish the National Women's Association of Bhutan in 1981 was appointed its secretary in 1985. She retired in 2009 and died in 2018.
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