The health systems of the Kingdom of Bhutan and the development of a nationwide distance in-service training system for health human resources using ICT / 国際保健医療

Introduction  In-service training is an incentive to work and improve the quality of services of health human resources. In-service training for health human resources requires multi-sectoral efforts across relevant institutions, including the Ministry of Health (MOH), which is responsible for policy, and higher education institutions, teaching hospitals, etc.  The only national medical university of Bhutan, KGUMSB has developed a nationwide distance in-service training system using ICT, which had been prepared during the COVID-19 pandemic. Prior studies have reported that there are benefits to the use of ICT for in-service training in low- and middle-income countries to compensate for resource shortages.  In January 2023, a Memorandum of Understanding (MOU) was signed between the MOH and KGUMSB, etc. to cooperate and collaborate in the in-service training of health human resources across Bhutan.  This paper provides an overview of Bhutanese health systems and introduces how to establish a nationwide in-service training system by connecting central and regional health institutions through distance education using ICT, in the case of Bhutan.Methods  Participant observation, online interviews with stakeholders from KGUMSB, MOH, JICA, and documentary researches were conducted till July 2023.Results  ICT environment and simulation training center at KGUMSB and two regional referral hospitals (teaching hospitals) developed. KGUMSB developed facilities and systems for distance education (digital education equipment, learning management system, etc.), training of trainers, and distance education content. In addition, the MOU for in-service training was signed between the MOH, KGUMSB, etc.Conclusion  Through the efforts of KGUMSB, a specialized institution for health human resource development in Bhutan, to develop a distance education system, the MOU was concluded with MOH, and a nationwide in-service training system for health human resources was formed. For this system to work, in low- and middle-income countries with limited resources, a collaboration between the MOH, medical university, and teaching hospitals is essential.

A new species and four newly recorded species of black flies (Diptera: Simuliidae) from Bhutan

@#Simulium (Simulium) thimphuense sp. nov. is described from a pupa and a mature larva in Bhutan. This new species is placed in the S. multistriatum species-group, and is characterized by the pupal gill with eight thread-like filaments divergent basally at an acute angle when viewed laterally and the cocoon slipper-shaped with several small openings anterolaterally. Four species of Simulium (Simulium) are newly recorded from Bhutan: S. barraudi Puri in the S. multistriatum species-group, S. nodosum Puri in the S. nobile species-group, S. chiangmaiense Takaoka & Suzuki in the S. striatum species-group and S. himalayense Puri in the S. variegatum species-group. Our study increases the number of black fly species known from Bhutan from 18 to 23.

Normal CD4 Count in Healthy Voluntary Blood Donors in the Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan

Aim: This study aimed to estimate the normal CD4 counts in healthy Bhutanese blood donors. Study Design: A prospective descriptive study. Place and Duration of Study: This study was carried out in the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Thimphu, between July 2015 to April 2016. Methodology: We recruited healthy blood donors in the JDWNRH collecting demographic characters and blood samples from consenting donors. Blood samples were analyzed using the BD FACS count system. Results: A total of 413 healthy blood donors, 288 (69.7%) males with a mean age of 27.3 years (18-62 years) were enrolled. Ethnically, 351 (85.0%) were northern and 62 (15.0%) were southern Bhutanese. The mean CD4 count was 668.3 cells/µl (range 259 -1591 cells/µl) and the median was 663 cells/µl. Females had significantly higher counts (p=0.004) and CD4 counts also significantly increased with increasing age but these differences were numerically small. Ethnicity did not produce significant differences in the CD4 count. In about 21% of the participants, counts were below the reference ranges and published data for Indians and Caucasians but comparable to other Asian, Middle East and African population. Conclusion: Upon validation with a larger study, a somewhat different CD4 cutoff may be required for the Bhutanese population. However, within the Bhutanese population, a single reference count may be advocated for adults disregarding the negligible numerical differences between age groups and gender.

Survey and Phylogenetic Analysis of Rodents and Important Rodent-Borne Zoonotic Pathogens in Gedu, Bhutan

Rodents are well-known reservoirs and vectors of many emerging and re-emerging infectious diseases, but little is known about their role in zoonotic disease transmission in Bhutan. In this study, a cross-sectional investigation of zoonotic disease pathogens in rodents was performed in Chukha district, Bhutan, where a high incidence of scrub typhus and cases of acute undifferentiated febrile illness had been reported in people during the preceding 4–6 months. Twelve rodents were trapped alive using wire-mesh traps. Following euthanasia, liver and kidney tissues were removed and tested using PCR for Orientia tsutsugamushi and other bacterial and rickettsial pathogens causing bartonellosis, borreliosis, human monocytic ehrlichiosis, human granulocytic anaplasmosis, leptospirosis, and rickettsiosis. A phylogenetic analysis was performed on all rodent species captured and pathogens detected. Four out of the 12 rodents (33.3%) tested positive by PCR for zoonotic pathogens. Anaplasma phagocytophilum, Bartonella grahamii, and B. queenslandensis were identified for the first time in Bhutan. Leptospira interrogans was also detected for the first time from rodents in Bhutan. The findings demonstrate the presence of these zoonotic pathogens in rodents in Bhutan, which may pose a risk of disease transmission to humans.

Scrub typhus in Bhutan: a synthesis of data from 2009 to 2014.

Scrub typhus is an acute, febrile illness, caused by the bacterium Orientia tsutsugamushi, that affects millions annually in the endemic Asia-Pacific region. In untreated cases, the case-fatality rates range from 6% to 35%. In Bhutan, there was a probable outbreak in Gedu in 2009, which resulted in heightened awareness of the disease. Nevertheless, information on scrub typhus in Bhutan is limited and scattered and the epidemiology has yet to be established. To report the current picture of scrub typhus in Bhutan, this review gathered data from scholarly databases, surveillance reports, the Annual health bulletin, research publications and laboratory test reports from hospitals. The weight of evidence indicates an increasing burden of scrub typhus since the Gedu incident, coupled with increased awareness and testing. Another outbreak in a rural primary school in 2014 resulted in two deaths. More hospitals now have testing facilities and laboratory-confirmed cases have been increasing since 2009, with seasonal trends. This review highlights the need for in-depth surveillance and reporting, increased awareness among health-care workers, and initiation of prevention and control programmes in the country.

An approach to diabetes prevention and management: the Bhutan experience.

Bhutan has been witnessing a trend of increasing diabetes in recent years. The increase is attributed to a rise in risk factors such as overweight, high blood pressure, unhealthy diet and sedentary lifestyle among the population. To address the rising burden, the health-services response has been to establish diabetes clinics in all hospitals and grade one basic health units. People visiting the health centres who have high risk factors and symptoms for diabetes are screened using the World Health Organization cut-off level for blood glucose. They are then classified into prediabetes and diabetes. Accordingly, diet, medicine and physical activity are recommended as per their body mass index. To improve prevention and control of noncommunicable diseases, which include diabetes, the country piloted the WHO Package of Essential Noncommunicable (PEN) disease interventions for primary health care in low-resource settings in 2009, to promote early screening, treatment and follow-up, and adopted it in 2013. The WHO PEN has now been successfully integrated into the primary health-care system nationwide. It is planned that diabetes clinics will be upgraded to NCD clinics.

Prevalence and socio-cultural determinants of domestic violence among married women in Thimphu, Bhutan.

Introduction: Domestic violence is a public health problem all over the world, yet its prevalence is under-reported in a pervasive “culture of silence”. Bhutan is not likely to be an exception; however, data on the prevalence, forms and determinants of domestic violence are scant. The purpose of this study is to measure the prevalence and characterize factors associated with domestic violence among women in Thimphu, Bhutan’s capital. Methods: A population-based, household cross-sectional survey was conducted in January-May, 2012. A multistage sampling method was used to obtain a representative sample of 300 married women. The chi-square test was used to identify factors associated with increased likelihood of experiencing the four forms of domestic violence. Results: The overall prevalence of any domestic violence was 44%. By type of violence, the most common was emotional (36%), followed by control (30%), physical (20%) and sexual (14%). Sexual violence was reported more often by young adolescent women. Women from urban areas reported more emotional violence compared to women from rural areas. Women agreed with many situations in which force might be used by their husbands and with many of the traditional roles of women in society. Nonetheless, many women objected to the use of force in many situations and rejected certain constraining roles of women. Conclusions: This study supports the importance of advocacy for education and programs to prevent and mitigate harm from domestic abuse experienced by women in Bhutan.

Prevalence, determinants and outcomes of unplanned pregnancy and perspectives on termination of pregnancy among women in Nganglam, Bhutan.

Introduction: The objectives of this cross sectional study were to determine prevalence, determinants, and outcomes of unplanned pregnancy among women in Nganglam, a town in southeastern Bhutan. It also gauged opinions of women and healthcare providers towards abortion. Methods: A total of 683 women attending health clinics were consecutively interviewed using a semi-structured questionnaire. The core group for analysis was 490 women who indicated their recent pregnancy as planned or unplanned. Percentages, χ2 tests, and multivariate logistic regression analyses were used to determine prevalence and differences in unintended pregnancy by demographic characteristics. Results: The prevalence of unplanned pregnancy was 20.2%. Higher education, employed status of partner, higher parity, and non-use of contraceptives significantly increased the odds of unplanned pregnancy. Over half (58.4%) of the women said they knew someone to have crossed Indian borders to avail abortion services. Overall, 23% women supported legal abortion but majority (64%) were ambivalent. Given specific circumstances, both participants and health care providers supported some scenarios (life of mother, severe anomaly in fetus, rape and incest, maternal mental health) and opposed some circumstances as reasons for abortion (desired number of children met, contraception failure, not wanting to marry, poverty). Conclusions: One in five women in our setting in Bhutan experienced unplanned pregnancy. Programs to promote family planning are required among populations most at risk for unplanned pregnancy. Awareness programs are required to encourage use of effective contraceptive methods among Bhutanese women.

A Prospective Hospital-based Surveillance to Estimate Rotavirus Disease Burden in Bhutanese Children under 5 Years of Age

As part of efforts to develop an informed policy for rotavirus vaccination, this prospective study was conducted to estimate the burden of rotavirus diarrhea among children less than 5 years old attended to the Department of Pediatrics, Jigme Dorji Wangchuk National Referral Hospital (JDWNRH), Thimphu, Bhutan. The duration of the study was three years, extending from February 2010 through December 2012. We estimated the frequency of hospitalization in the pediatric ward and dehydration treatment unit (DTU) for diarrhea and the number of events attributable to rotavirus infection among children under 5 years of age. During the study period, a total of 284 children (1 in 45) were hospitalized in the pediatric ward, and 2,220 (1 in 6) in the DTU with diarrhea among children residing in the Thimphu district. Group A rotavirus was detected in 32.5% and 18.8% of the stool samples from children hospitalized in the pediatric ward, respectively. Overall, 22.3% of the stool samples were rotavirus-positive, and the majority (90.8%) of them was detected in children under 2 years of age. From this study, we estimated that the annual incidence of hospitalization in the pediatric ward and DTU due to rotavirus diarrhea was 2.4/1000 (95% CI 1.7–3.4) and 10.8/1000 (95% CI 9.1–12.7) children, respectively. This study revealed that rotavirus is a major cause of diarrhea in Bhutanese children in Thimphu district and since no study has been performed previously, represents an important finding for policy discussions regarding the adoption of a rotavirus vaccine in Bhutan.

Measuring universal health coverage: a three-dimensional composite approach from Bhutan.

Background: In the early 1960s, the Kingdom of Bhutan began to develop its modern health-care system and by the 1990s had developed an extensive network of health-care facilities. These developments, in tandem with wider social and economic progress encapsulated in the Gross National Happiness concept, have resulted in major gains in child survival and life expectancy in the past 50 years. In order to sustain these gains, the country has identified a constitutional and healthpolicy mandate for universal access to health. Methods: Based on analysis of the literature, and qualitative and quantitative health data, this case study aims to provide an assessment of universal health coverage in Bhutan, and to identify the major challenges to measuring, monitoring and sustaining universal coverage. Results: The study reveals that the wide network of primary and secondary care, reinforced by constitutional and policy mandates, ensures high population coverage, as well as wide availability and accessibility of care, with significant levels of financial protection. This achievement has been attributable to sustained state investment in the sector over past decades. Despite this achievement, recent surveys have demonstrated gaps in utilization of health services and confirmed associations between socioeconomic variables and health access and outcomes, which raise important questions relating to both supply- and demand-side barriers in accessing health care. Conclusion: In order to sustain and improve the quality of universal health coverage, improved measurements of service availability at subnational levels and of the determinants of pockets of low service utilization are required. More rigorous monitoring of financial protection is also needed, particularly in relation to rates of public investment and the impact of out-of-pocket costs while accessing care. These approaches should assist improvements in quality and equity in universal health coverage, in the context of ongoing epidemiological, demographic and social transition.

Psychoactive substance use by psychiatric patients in the National Referral Hospital, Bhutan: a retrospective analysis.

Background: The costs to the individual and to society of psychoactive substance use is of growing concern in Bhutan. This study aimed to assess the relation between the demographic variables of patients admitted to the National Referral Hospital for first-time detoxification and the psychoactive substances used. Methods: The demographic variables and types of psychoactive substance used by 284 substance users were reviewed. Data were collected through patients’ history sheets and admission registers, and analysed through descriptive statistics, one-way analysis of variance and independent t test. Results: The commonest psychoactive substance used was alcohol, followed by cannabis, nitrazepam, dextropropoxyphene, glue (inhaled) and chlorphenamine/ pseudoephedrine/codeine-containing cough syrup. Only 14% of participants were aged 45 years or older. Most patients used more than one substance; the mean number of psychoactive substances used was highest among males, individuals aged 15–24 years and those who were unemployed. Conclusion: Among patients admitted for first-time detoxification, harmful use of alcohol is the most common, followed by cannabis and illicit prescription drugs. Preventive measures should be prioritized on a need-based strategy. The findings of this study indicate that some of these preventive measures should be focused on males, unemployed groups and youth, and should involve raising awareness of harmful use of substances and the services available to treat substance use disorders.

Package of essential noncommunicable disease (PEN) interventions in primary health-care settings of Bhutan: a performance assessment study.

Background: A World Health Organization (WHO) package of essential noncommunicable (PEN) disease interventions was piloted in two districts of Bhutan by non-physician health workers. They conducted risk assessment among patients aged over 40 years who visited the outpatient department of health institutions. Blood glucose was also measured among those who were overweight/ obese (body mass index ≥23 kg/m2) or had a high waist circumference (>80 cm in women and >90 cm in men). Appropriate counselling, treatment and referral were provided to the patients. The performance of the PEN project in detecting and managing noncommunicable diseases (NCDs) and their risk factors was assessed. Methods: All health institutions of Paro (one district hospital and three basic health units [BHUs]) and Bumthang districts (one district hospital and four BHUs), were included in the PEN pilot assessment study. All patients who had presented to the clinics in the pilot districts from 1 June to 31 August 2012 constituted the study population. The data were collected from the clinical form, supervisor’s report and monthly report of the PEN project. The characteristics of patients with an NCD at registration and at the third follow-up visit were compared in a before–after analysis. Absolute changes in the characteristics of patients were computed for those who had completed the required followups during a 3-month assessment period. Results: In a 3-month period, 39 079 patients had attended clinics in the pilot districts. About 10% of the clinic attendees (3818/39 079) were aged over 40 years; of these, 22.6% (864/3818) had a high blood pressure, and 49.7% (1896/3818) were overweight/obese or had a high waist circumference. Screening of overweight/ obese/high waist circumference cases revealed that 26.1% (494/1896) had high blood sugar levels. Out of the 896 patients who were registered on PEN protocols, 13% had >20% risk of developing cardiovascular diseases (CVDs) in next 10 years as per the WHO/International Society of Hypertension risk-assessment charts. Among 444 who had three follow-up visits, high 10-year-CVD risk (>20%) had declined from 13% to 7.3%. Among 400 persons with hypertension, use of medication increased and high blood pressure declined from 42.3% to 21.5%. Among 115 persons with diabetes, use of anti-diabetes medication increased and high blood sugar declined from 68/100 to 51/100. Conclusion: Implementation of the PEN intervention in the primary health-care setting of Bhutan led to improvement in blood pressure and diabetes control, and reduction in CVD risk.

A prospective hospital based surveillance to estimate rotavirus disease burden in Bhutanese children under 5 years of age

To develop aninformed policy for rotavirus vaccination, this prospective study was conductedto estimate the burden of rotavirus diarrhea among children less than 5 years oldattending the Department of Pediatrics, Jigme Dorji Wangchuk National ReferralHospital (JDWNRH), Thimphu, Bhutan. The duration of the study was three years, extendingfrom February 2010 through December 2012. We estimated the frequency of hospitalizationin pediatric ward and Dehydration Treatment Unit (DTU) for diarrhea and thenumber of events attributable to rotavirus infection among children under 5years of age. During the study period, a total of 284 children (1 in 45) werehospitalized in pediatric ward, and 2,220 children (1 in 6 children)  in Dehydration Treatment Unit (DTU) withdiarrhea among children residing in the Thimphu district. Group A rotavirus was detected in 32.5% of the stoolsamples from the hospitalized children in pediatric ward and 18.8% in DTU withdiarrhea. Overall, 22.3% of the stool samples were rotavirus-positive, and the majority(90.8%) of them was detected in children under 2 years of age. From this study,we estimated that the annual incidence of hospitalization in ward and DTU s dueto rotavirus diarrhea was 2.4/1000 (95% CI 1.7–3.4) and 10.8/1000 (95% CI9.1–12.7) children, respectively. This study revealed that rotavirus is a majorcause of diarrhea in Bhutanese children in Thimphu district and represents animportant finding to policy discussions regarding the adoption of a rotavirusvaccine in Bhutan since no study has been performed previously.

Monitoring medicines use to support national medicines policy development and implementation in the Asia Pacific region.

Critical to the successful implementation of a national medicines strategy is evaluation of the policy and ongoing monitoring of medicine use. Methods for monitoring medicines use within countries vary depending on the country and its stage of medicines policy development and implementation. In this paper, we provide four case studies on monitoring medicines use to support national medicines policy development and implementation. Cases come from Bhutan, Indonesia, Malaysia and the Republic of Korea.

Mental health care in Bhutan: policy and issues.

The Royal Government of Bhutan pursues and promotes a policy of providing well integrated, equitable, cost-effective and balanced health services consisting of preventive, promotive, curative and rehabilitative programmes through its primary health care system. The government has accorded high priority to social sectors like health and education. However, there are serious concerns regarding the quality of care provided to persons with mental disorder, who on this account are subjected to stigma, discrimination and human rights abuses. This article aims to analyse, examine and highlight the policy and issues of the mental healthcare system in Bhutan. It focuses on the mental healthcare system with reference to services, policies and issues and to advocate for better policy development for mental health.

The pattern of psychiatric admissions in a referral hospital, Bhutan

Background: Mental illnesses are becoming a public health issue in all countries. However, data in most of the developing countries including Bhutan are scarce. This study aimed to explore the trends of admissions in the psychiatric ward of a referral hospital in Thimphu city of Bhutan. Method: The study employed a retrospective analysis method. The data were obtained from the patient admission register of the psychiatric ward to capture distribution by age, gender, occupation, nationality, clinical diagnosis, and length of stay in the ward. International Classification of Diseases (ICD) 10th Revision was used for classification of the diseases. Descriptive statistics were used to describe the pattern of patient admissions. Demographic characteristics of the sample were crosstabulated with clinical diagnosis and chi-square test was used to test statistical significance. Results: In the psychiatric ward 1336 patients were admitted over a seven-year period. In 2004- 05, 127 patients were admitted, which increased to 376 in 2010-11. Higher numbers of males (64.1%, 856) were admitted than females (35.9%, 480). Mental and behavioural disorders due to psychoactive substance use were the most common (45.5%) reason for admission. Among the admitted patients, 18.8% had no job or were dependents. A large number of patients were from Thimphu District (10.8%) and 42% of the patients stayed for one to two weeks in the hospital. Conclusions: Psychiatric admissions were found to be increasing every year. Alcohol and drug use disorders were the most frequent diagnosis leading to hospitalization. Attention must be paid to increasing the in-patient services for psychiatric patients.

Prescribing pattern of higher generation antibiotics in the out-patient setting in Bhutan hospitals

Background: The emergence of antibiotic resistance is a complex problem contributed by the interplay of various parties such as prescribers, patients or health settings. In particular, prescribers play a vital role in the use of antibiotics both in rational prescribing of drugs and influencing patients on the appropriate use. Objectives: Determine the appropriateness of the higher generation antibiotics (cephalosporin and flouroquonolone groups) in the out-patient setting of Bhutan hospitals. Materials and method: A cross-sectional study was conducted in three referral hospitals of Bhutan where the prescriptions were collected from the pharmacy. All prescriptions containing higher generation antibiotics were selected based on the appropriateness using a modified Medication Appropriateness Index. Three hundred thirty three prescriptions containing higher generation antibiotics were analyzed. Results: The use of antibiotics was common with 37.1% of the prescriptions containing antibiotics out of which 14% were higher generation antibiotics. When assessed on the appropriateness of the prescription, 55.9% of the prescriptions containing higher generation antibiotics were prescribed inappropriately. In addition, only 47.1% of the prescriptions had appropriate indications for higher generation antibiotics. Conclusion: There is a widespread inappropriate use of higher generation antibiotics in Bhutan.

A search for Goji Berry: Lycium Barbarum in Bhutan and its relative.

The Goji Berry flourished in the valleys of the Himalayas especially Tibet for thousands of years and have been the secret of longevities of the people who ate them. Some internet sources also report that wolfberries have been used in traditional Chinese Medicine for at least 2,000 years. Whatever it is, one thing is clear that the Goji Berry is known in Asia as an extremely nutritious food and have been extensively eaten raw, consumed as juice or wine, brewed into an herbal tea or prepared as a tincture, eaten as salads and used widely in other culinary preparations. Its leaves are made into tea. The berries are believed to enhance immune system function, improve eyesight, protect liver, boost sperm production and improve circulation, among other good health effects. Goji Berry root bark is also good for inflammation and some types of skin diseases. The Goji Berry was first reported to grow in Tibet but its habitat has been successfully duplicated and now it is propagated popularly in many countries like USA, Canada, Europe, Australia, Japan and primarily in Tibet and China. Since Bhutan also falls within Himalayan region, it was suspected that the same species must have been dwelling here too. Because the berry is highly nutritious, it comes with many medicinal uses, and has high economic value. ITMS looked for its possible whereabouts in Bhutan. The search, although didn’t yield any positive findings, a close relative of Goji Berry was found growing in Punakha. This is called Lycium armatum. This paper discusses about the search for Goji Berry and its literature findings.

Bio-prospecting in Bhutan: Its Scope and Challenges.

Natural products have been an important source of pharmaceutical products, cosmetics, nutraceuticals, fragrances, veterinary products, organic pesticides and many more. Many of the modern drugs that are currently available are the natural products derivatives. Since the diseases are scourging the mankind and its allies, there is urgent need for new drugs. There is also increasing demands for cosmetics, nutraceuticals, fragrances and other organic products. From these perspectives, there is huge potential for bioprospecting worldwide. For Bhutan, while there is a challenge in terms of funding the bioprospecting activities, there are lots of scopes for bioprospecting initiative. This is because; Bhutan is rich in biodiversity and also rich in traditional medical knowledge. These two critical factors supported by the reliable collaborators would make bioprospecting in Bhutan a success. Thus, this paper presents the scopes and challenges of bioprospecting in Bhutan.