Résumé
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.