WHO Country Cooperation Strategy Bhutan 2009–2013 WHO Library Cataloguing-in-Publication data World Health Organization, Regional Office for South-East Asia WHO country cooperation strategy Bhutan: 2009-2013 Health Status - statistics and numerical data Health Planning Strategic Planning Delivery of Health Care International Cooperation Bhutan ISBN 978-92-9022-391-7 (NLM classification: WA 540) © World Health Organization 2010 All rights reserved Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from Publishing and Sales, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: publications@searo.who.int) The designations employed and the presentation of the material in this publication not imply the expression of any opinion whatsoever on the part of the World Health 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damages arising from its use This publication does not necessarily represent the decisions or policies of the World Health Organization Printed in India ii WHO Country Cooperation Strategy 2009-2013 Contents Foreword v List of acronyms vi Message from the Honourable Minister, Ministry of Health, Royal Government of Bhutan viii Executive summary ix Introduction Health and development challenges 2.1 The country and the people 2.2 Stage of development 2.3 Health situation .5 2.4 Health systems .10 2.5 Major issues and challenges in the health sector 13 Development cooperation and partnerships: Technical assistance, aid effectiveness and coordination 16 Past and current WHO cooperation .18 4.1 WHO country cooperation overview 18 4.2 Operational aspects of the implementation of the Strategic Agenda 18 Strategic Agenda for WHO cooperation .23 5.1 Guiding principles for WHO at the country level 23 5.2 Strategic Priorities and main focus for WHO cooperation .23 Strategic Priority #1 .24 Strategic Priority #2 .24 Strategic Priority #3 .25 Strategic Priority #4 .28 Strategic Priority #5 .29 Strategic Priority #6 .33 5.3 Strategic approaches based on WHO Core Functions 33 Bhutan iii Implementing the Strategic Agenda 34 6.1 The Country Office 34 6.2 The Regional Office and headquarters 35 References 36 Annexes Ministry of Health Organigram .37 Reference tables 38 Alignment of WHO Strategic Agenda/directions with the Tenth Five Year Plan for the health sector and UNDAF outcome 42 iv WHO Country Cooperation Strategy 2009-2013 Foreword This WHO Country Cooperation Strategy (CCS) 2009–2013 reflects the medium-term vision for the World Health Organization’s collaboration with the Royal Government of Bhutan (RGoB) in support of its national health strategies Bhutan has a robust and functional primary health-care delivery system Over the years, the Royal Government of Bhutan has taken several measures to improve the health infrastructure, human resource development and preventive health programmes These initiatives have resulted in significant improvement in the health outcomes and indicators However, in the context of the present demographic and epidemiological transition, Bhutan will face and need to address new health issues and challenges in the coming years The government’s Tenth Five Year Plan reflects these concerns and priorities which are expected to be taken up during 2009–2013 Strategic objectives and agendas identified in the CCS have been formulated in line with these priorities identified in the Tenth Five Year Plan while harmonizing with the work of other UN organizations and agencies and development partners The development of the CCS has also taken into consideration these aspects of the plan and a thorough analysis of health care trends and situations have been carried out Further, a wide range of consultations and dialogues has been conducted with the RGoB, UN agencies and other development partners in Bhutan which resulted in the formulation of Six Strategic Approaches in the CCS The Ministry of Health, RGoB and the WHO Country Office for Bhutan played a central role in the development of this CCS Extensive support and assistance was provided by the WHO Regional Office for South-East Asia (SEARO) and WHO headquarters in order for us to come out with this comprehensive strategic document I have the pleasure of presenting this Country Corporation Strategy document to the RGoB as well as to all our development partners This Strategy Document reflects our collaborative efforts in developing and nurturing the Health Service of Bhutan WHO will continue to work in collaboration with the Royal Government of Bhutan to further the attainment of Gross National Happiness for the people of Bhutan Dr HSB Tennakoon WHO Representative to Bhutan Bhutan v List of acronyms AC AEFI AFP AI AIDS ARI BHTF BHUs CAP CCA CCM CCS DD DOTS DRA DVED EmOC GATS GAVI GDP GEF GFATM GNH GNM GPW GSM HA HIV HMN IDD IHR IMCI IMR IT JE MDGs MDR MMR MoH MOSS NCD NGO vi assessed contribution adverse effects/events following immunization acute flaccid paralysis avian influenza acquired immune deficiency syndrome acute respiratory infection Bhutan Health Trust Fund basic health units consolidated appeal process Common Country Assessment Country Coordinating Mechanism Country Cooperation Strategy diarrhoeal diseases directly observed treatment, short-course Drug Regulatory Authority Drugs, Vaccines and Equipment Division emergency obstetric care General Agreement on Trade in Services Global Alliance for Vaccines and Immunization gross domestic product Global Environment Facility Global Fund to Fight AIDS, Tuberculosis and Malaria Gross National Happiness general nurse midwife General Programme of Work Global Management System health assistant human immunodeficiency virus Global Health Matrix Network iodine deficiency disorder International Health Regulations Integrated Management of Childhood Illnesses infant mortality rate information technology Japanese encephalitis Millennium Development Goals multidrug resistance maternal mortality ratio Ministry of Health minimum operating security standard noncommunicable diseases nongovernmental organization WHO Country Cooperation Strategy 2009-2013 NHA NIPPP NITM NPO ORCs PHC PRSP RB RGoB RIHS RSTA RWSS SARS SEAR SEARO STI SWAp TB TRIPS UCI UN UNDAF UNFPA UNICEF VC VHW WB WFP WHO WR WTO National Health Account national influenza pandemic preparedness plan National Institute of Traditional Medicine National Professional Officer out-reach clinics primary health care Poverty Reduction Strategy Paper regular budget Royal Government of Bhutan Royal Institute of Health Sciences Road Safety and Transport Authority rural water supply and sanitation severe acute respiratory syndrome South-East Asia Region Regional Office for South-East Asia (of WHO) sexually transmitted infections sector-wide approach tuberculosis Trade-Related Aspects of Intellectual Property Rights universal child immunization United Nations United Nations Development Assistance Framework United Nations Population Fund United Nations Children’s Fund voluntary contribution village health workers World Bank World Food Programme World Health Organization WHO Representative World Trade Organization Bhutan vii Message from the Honourable Minister, Ministry of Health, Royal Government of Bhutan viii WHO Country Cooperation Strategy 2009-2013 Executive summary The Kingdom of Bhutan is a fascinating, landlocked and mountainous country nestled in the eastern Himalayas, bordering China to the north and India to the south Partly due to its difficult geographical boundaries, Bhutan has always preserved its independence and its rich and unique cultural heritage has mostly remained intact over the ages The Bhutanese have developed a strong sense of common identity despite a mosaic of cultures with extraordinary ethnic and linguistic diversity The kingdom has recorded impressive achievements on many fronts over the last four decades and is one of the few countries where macroeconomic progress in terms of per capita GDP growth as well as the physical infrastructure in terms of improved communications and electrical connectivity has been matched by the social sector with provisions of free education and free health care, safe drinking water and basic sanitation Under the visionary leadership of its monarchs, Bhutan has challenged many traditional concepts of development with its unique development philosophy based on the principles of Gross National Happiness The monarchs’ long-term vision of democratization and decentralization has been implemented through a peaceful step-by-step devolution of power to the people that culminated in 2008 with the adoption of the Constitution of the Kingdom of Bhutan, making Bhutan the world’s youngest democracy Since the early 1960s the health status of the Bhutanese population has dramatically and consistently improved In 1978 Bhutan signed the Alma Ata Declaration and introduced the primary health care approach to build a modern health system in harmony with its traditional health services, including the manufacturing of traditional herbal medicines, along with a strong emphasis on community participation Village health workers are the link between the communities and the institutions of health system With over 90% health coverage with basic services, 90% access to clean drinking water and 88% basic sanitation coverage there has been a spectacular decrease in mortality and morbidity in recent years Life expectancy at birth has risen from 33 years in 1960 to 66 today WHO has a long-standing collaboration on health with the Royal Government of Bhutan In 2000 Bhutan started developing its first Country Cooperation Strategy A remarkable improvement was witnessed in the health sector during the 2000–2008 Bhutan is now close to achieving many of the health-related MDGs and has opted for “MDG-plus” during the Tenth Five Year Plan aiming to reach the MDGs and beyond by 2015 and also achieve other priority health targets While there has been considerable progress in health development, the country is still facing major challenges in terms of: Bhutan ix QASD Secretary Non-Communicable Disease Division Information & Communication Bureau Public Health Engineering Division * Programme: PEC, Oral Health Diabetes, Infection Control & others, eg Wlcare, HVO, Magee Project, Danchu, Institutional mechanisms Communicable Disease Division Public Health Laboratory Department of Public Health PPD Drug Regulatory Authority ICT Unit Bhutan Medical & Health Council Minister Health Care & Diagnostic Services HIDP DVED National Traditional Medicine Reg Ref Hospitals JDWNR Hospital Biomedical Engineering Services/HERM Department of Medical Services * Programmes/Projects AFD Bhutan Health Trust Fund Internal Audit MINISTRY OF HEALTH Annex-1 Ministry of Health Organigram Bhutan 37 Annex-2 Reference tables Table 1: Key indicators of infant and child health by district, 2005 Sl No District Live births Pop inder years Infant deaths Deaths to years IMR Under-5 mortality rate % low weight visits* 285 366 28.1 38.6 6% Bumthang Chukha 248 960 38 73 30.4 88.9 10% Dagana 435 031 17 39.1 59.8 13% Gasa 72 325 0.0 13.9 8% Haa 205 995 14.6 53.7 11% Lhuentse 321 582 16 49.8 62.3 11% Mongar 832 817 42 17 50.5 70.9 12% Paro 613 045 13 21.2 27.7 5% Pemagatshel 270 362 13 48.1 63.0 12% 10 Punakha 349 714 11 31.5 34.4 7% 11 Samdrupjongkhar 818 221 51 14 62.3 79.5 9% 12 Samtse 182 025 40 27 33.8 56.7 10% 13 Sarpang 830 401 45 21 54.2 79.5 12% 14 Thimphu 866 463 56 26 30.0 43.9 6% 15 Trashigang 082 082 68 25 62.8 86.0 13% 16 Trashiyangtse 426 939 13 30.5 42.3 16% 17 Trongsa 292 326 12 41.1 44.5 8% 18 Tsirang 384 944 23.4 36.5 8% 19 Wangdi 650 142 35 12 53.8 72.3 7% 20 Zhemgang 378 813 13 34.4 58.2 13%   TOTAL 12 538 62 553 503 269 40.1 61.6 10% Sources: Except for low-weight visits, all data are from Census of Bhutan 2005 * Number of underweight children divided by number of attending clinics (source: Annual Health Bulletin, 2008, page 78) 38 WHO Country Cooperation Strategy 2009-2013 Table 2: Utilization and coverage of basic health services by district % households visiting health facilities (2005) Coverage of measles immunizations (2007) % of deliveries with ANC visit (2007) % births attended by a health professional (2007) % of deliveries at health facilities (2007) Bumthang 90% 129% 64% 38% 32% Chukha 88% 131% 108% 50% 45% Dagana 93% 107% 45% 20% 16% Gasa 89% 111% 94% 59% 6% Haa 91% 105% 62% 24% 19% Lhuentse 92% 107% 58% 55% 47% Mongar 93% 110% 70% 64% 56% Paro 85% 114% 79% 74% 70% Pemagatshel 79% 188% 77% 57% 30% Punakha 96% 146% 65% 86% 73% Samdrupjongkhar 89% 149% 76% 56% 40% Samtse 86% 60% 83% 45% 38% Sarpang 95% 76% 76% 61% 56% Thimphu 90% 141% 65% 68% 68% Trashigang 91% 84% 64% 47% 35% Trashiyangtse 91% 116% 49% 25% 13% Trongsa 90% 115% 67% 13% 3% Tsirang 96% 152% 55% 43% 38% Wangdi 91% 122% 70% 33% 25% Zhemgang 91% 99% 71% 55% 18% Total 90% 115% 71% 54% 46% District Sources: 2005 Census and Annual Health Bulletin, 2008 Bhutan 39 Table 3: Health Facilities in Bhutan by district (2009) Sl no District Basic Health Units 2009 ORC 2009 Hospital Beds Inpatient days 2007 Bed occupancy rate 2007 Bumthang 14 Bumthang 20 441 47% Chukha 47 Tsimalakha 20 15 277 47% Phuentsholing 50 Gedu 20 Dagapela 20 244 3% Dagana 16 Gasa 13 Haa 15 IMTRAT 12 606 37% Lhuentse 11 33 Lhuentse 20 152 57% Mongar 24 57 Mongar RRH 150 19 005 35% Paro 27 Paro 40 059 48% Pemagatshel 12 33 Pemagatshel 20 312 59% 10 Punakha Punakha 40 401 51% 11 Samdrupjongkhar 36 Samdrupjongkhar 30 13 501 123% 12 Samtse 18 Samtse 20 15 532 85% Gomtu 20 Sipsu 10 Sarpang 10 12 091 47% Gelephu RRH 60 JDWNRH 350 80 699 47% IBF Hospital 10 Lungtenphu RBA 50 Gidakom 60 Trashigang 40 13 541 62% Riserboo 10 Yongphula RBA 10 13 14 15 Sarpang Thimphu Trashigang 10 19 11 19 57 16 Trashiyangtse 23 Yangtse 20 037 42% 17 Trongsa 19 Trongsa 20 092 15% 18 Tsirang 13 Damphu 20 794 52% 19 Wangdi 10 23 Tencholing RBA 40 662 18% 20 Zhemgang 14 38 Yebilaptsa 40 803 33% TOTAL 178 521   1232 213 249 47% Source: MoH report as of March 2009 2007 Inpatient days from Annual Health Bulletin, 2008 40 WHO Country Cooperation Strategy 2009-2013 Table 4: Implementation of the HRH Master Plan 2002–2006 Programme Planned Revised Completed Undertaking Recalled Total Super-Specialization 11 Specialization 22 38 18 25 Masters 42 28 18 46 PG Diploma 15 14 Diploma 23 55 29 33 62 Certificate 90 550 580 56 636 Grand total 156 711 648 140 792 Bhutan 41 42 WHO Country Cooperation Strategy 2009-2013  HR capacity enhanced MoH/01: Health Management and Development Programme  HR capacity enhanced MoH/01: Health Management and Development Programme  Provisions of the Bhutan Medicine Act 2002 enforced  Role and composition of the BHMC revised and all medical and Health professions registered  BMHC and DRA delinked from the Ministry and functions as an independent agency MoH/04: Sustainability, Regulatory and Monitoring Programme  Evidence-based decision enhanced MoH/01: Health Management and Development Programme Health Sector Tenth Five Year Plan strategic objectives/output Support to further strengthen the development of human resources for health Support for the review, consolidation and strengthening of health policies in a National Health Policy WHO Strategic Priority UNDAF outcome  Support the development of the National Health Policy document  Key support to the implementation of the Human Resources Development Master Plan for Health  Contribution to the revision of the Human Resources Development Master Plan for Health based on national health priorities  Capacity of RGoB to formulate and implement results-oriented policies and strategies that create an enabling environment for reproductive health, maternal and child health, STIs and HIV/AIDS, TB and malaria programmes strengthened WHO main focus Alignment of WHO Strategic Agenda/directions with the Tenth Five Year Plan for the health sector and UNDAF outcome Annex-3 Bhutan 43  Indigenous hospital services strengthened  Telemedicine services strengthened and expanded  Referral hospital management and services strengthened MoH/03: Diagnostic and Curative Services Programme  Health Trust Fund fully operationalized MoH/04: Sustainability, Regulatory and Monitoring Programme  Evidence-based decision enhanced MoH/01: Health Management and Development Programme  Referral hospital management and services strengthened MoH/03: Diagnostic and Curative Services Programme  Use of ICT strengthened  Evidence-based decision enhanced MoH/01: Health Management and Development Programme Health Sector Tenth Five Year Plan strategic objectives/output Contribute to the strengthening of the health system WHO Strategic Priority UNDAF outcome  Promotion of the efficient use of health information at all levels of the health system  Improved management of decentralized health services and facilities  Development of options for sustainable health system financing  Capacity of RGoB to formulate and implement results-oriented policies and strategies that create an enabling environment for reproductive health, maternal and child health, STIs, and HIV/AIDS TB and malaria programmes strengthened WHO main focus 44 WHO Country Cooperation Strategy 2009-2013  Evidence-based decision enhanced MoH/01: Health Management and Development Programme  Awareness on NCDs enhanced  VHW services strengthened MoH/02: Health Promotion and Disease Prevention and Control Programme  Quality and reach of health infrastructure improved MoH/03: Diagnostic and Curative Services Programme  Quality of laboratory services strengthened MoH/02: Health Promotion and Disease Prevention and Control Programme  QA instituted and capacity enhanced MoH/01: Health Management and Development Programme Health Sector Tenth Five Year Plan strategic objectives/output Contribute to the strengthening of the health system WHO Strategic Priority  Research to support the health system  Roles of the community in supporting the health system  Norms and standards and quality assurance for basic health care scaled up towards universal coverage WHO main focus  Capacity of RGoB to formulate and implement results-oriented policies and strategies that create an enabling environment for reproductive health, maternal and child health, STIs, and HIV/AIDS TB and malaria programmes strengthened UNDAF outcome Bhutan 45  Reproductive Health services enhanced MoH/02: Health Promotion and Disease Prevention and Control Programme  Enhanced immunization coverage & awareness on communicable diseases  ARI and diarrhoea incidence reduced MoH/02: Health Promotion and Disease Prevention and Control Programme  Nutritional status improved MoH/02: Health Promotion and Disease Prevention and Control Program Health Sector Tenth Five Year Plan strategic objectives/output Foster the improvement of maternal, child health and nutrition (MDGs 3, and 5) WHO strategic priority  Further improvement of maternal health with emphasis on reduction of maternal mortality  Further reduction of child mortality and improvement of child health  Improvement of the nutritional status of the population WHO Main focus  Capacity of RGoB to formulate and implement results-oriented policies and strategies that create an enabling environment for reproductive health, maternal and child health, STIs, and HIV/AIDS TB and malaria programmes strengthened UNDAF Outcome 46 WHO Country Cooperation Strategy 2009-2013  Hospital-based services improved and clinical care strengthened  Reduced hospital-acquired infections  Health facilities with timely and adequate medical supplies MoH/03: Diagnostic and Curative Services Programme  Awareness on NCD enhanced  School health advocacy strengthened  VHW services strengthened  Mental health services strengthened  Reduced incidence of disability MoH/02: Health Promotion and Disease Prevention and Control Programme  Incidence of zoonotic diseases reduced  Increased coverage of vector-borne diseases prevention and treatment  Halt & reverse the spread of HIV & STIs  TB & leprosy case detection and management strengthened MoH/02: Health Promotion and Disease Prevention and Control Program Health Sector Tenth Five Year Plan strategic objectives/output Help reducing the burden of diseases through key interventions focusing on health promotion and risk factors using a multisectoral approach WHO strategic priority  Noncommunicable disease prevention, care and support; emphasizing health promotion and behavior changes; and support for mental health  Communicable and emerging disease WHO Main focus  Capacity of the government to respond to prevention, care and treatment of HIV/ AIDS and STIs through multisectoral approach strengthened UNDAF Outcome Bhutan 47  Telemedicine services strengthened and expanded  At least two functional ambulances provided to all hospitals and paramedics introduced  Quality and reach of health infrastructure improved  Health facilities with timely and adequate medical supplies MoH/03: Diagnostic and Curative Services Programme  Effective control and response mechanism to health pandemic/disaster put in place MoH/02: Health Promotion and Disease Prevention and Control Programme  Nutritional status improved  Workers’ Health services strengthened  Alternative technologies for difficult & unreached areas introduced successfully  Water and sanitation programme sustained at over 90% MoH/02: Health Promotion and Disease Prevention and Control Program Health Sector Tenth Five Year Plan strategic objectives/output Help reduce the burden of diseases through key interventions focusing on health promotion and risk factors using a multisectoral approach WHO strategic priority UNDAF Outcome  Healthy environment (water, sanitation, food safety, occupational health and climate change)  Emergency preparedness and response including the reduction of the vulnerability of health facilities  Capacity of government to respond to prevention, care and treatment of HIV/ AIDS and STIs through multisectoral approach strengthened WHO Main focus 48 WHO Country Cooperation Strategy 2009-2013  Telemedicine services strengthened and expanded  At least two functional ambulances provided to all hospitals and paramedics introduced  Quality and reach of health infrastructure improved  Health facilities with timely and adequate medical supplies MoH/03: Diagnostic and Curative Services Programme  Quality of laboratory services strengthened MoH/02: Health Promotion and Disease Prevention and Control Programme Health Sector Tenth Five Year Plan strategic objectives/output Help reduce the burden of diseases through key interventions focusing on health promotion and risk factors using a multisectoral approach WHO strategic priority  National influenza pandemic preparedness plan (NIPPP) and the implementation of the International Health Regulations (2005) WHO Main focus  Capacity of government to respond to prevention, care and treatment of HIV/ AIDS and STIs through multisectoral approach strengthened UNDAF Outcome Bhutan 49 MoH/03: Diagnostic and Curative Services Programme MoH/02: Health Promotion and Disease Prevention & Control Program MoH/01: Health Management and Development Programme  Health Trust Fund fully operationalized MoH/04: Sustainability, Regulatory and Monitoring Programme MoH/04: Sustainability, Regulatory and Monitoring Programme MoH/03: Diagnostic and Curative Services Programme MoH/02: Health Promotion and Disease Prevention and Control Programme MoH/01: Health Management and Development Program Health Sector Tenth Five Year Plan strategic objectives/output Enhance partnerships and resource mobilization for health WHO Strategic Priority  Resource mobilization  Support to the coordination of partners in health WHO main focus  RGoB and community partnerships enhanced to promote utilization of health services UNDAF Outcome .. .WHO Country Cooperation Strategy Bhutan 2009–2013 WHO Library Cataloguing-in-Publication data World Health Organization, Regional Office for South-East Asia WHO country cooperation strategy Bhutan: ... Ministry 22 WHO Country Cooperation Strategy 2009-2013 — Strategic Agenda for WHO cooperation The WHO Strategic Agenda for cooperation with Bhutan is the core element of the Country Cooperation Strategy. .. Cooperation and Country Focus WHO country cooperation strategies: A guiding framework Geneva, 2005 (4) World Health Organization, Country Office for Bhutan WHO Country Cooperation Strategy, Bhutan