Health care perspective (Nurses' point of view)

Introduction

Bhutan is a small Kingdom situated between China and India. Health and education sectors received priority since the inception of planed development in the Kingdom; both services have literally been provided free of cost. The draft Constitution envisages “free access to basic public health services in both modern and traditional medicines” (Article 9(21), p. 15). This Paper seeks to identify the major health problems affecting the Bhutanese population and analyze selective strategies of the 9^th Five Year Plan (FYP). It also presents a panoramic view of the existing Bhutanese health care system, the challenges which lay ahead and the ways in which health care personnel in general and nurses in particular can contribute towards fulfilling the Royal wishes of maximizing the Gross National Happiness of our people.

Background

Health is defined as “a complete state of physical, mental and social well being and not merely the absence of the disease or infirmity” (WHO, 1948). Modern health care system came to Bhutan in the early 1960s with the launching of the 1^st FYP (1962-1967) during the reign of the third King. Beginning with the adoption of primary health care approach in 1978, Bhutan achieved a rapid improvement in the health care delivery to its population. Bhutan’s health care system is a blend of traditional and modern allopathic medicines. In congruence with the Royal Government’s planning policy the Ministry of Health set up its plans as, ‘Five Year Plan’. Accordingly, the 8^th FYP (1997-2002) aimed to achieve ‘health for all’ by the year 2000.

Major Health Problems

The predominant communicable diseases in Bhutan are tuberculosis, leprosy, malaria and Human Immuno Virus/Acquired Immuno Deficiency syndrome (HIV/AIDS). Non-communicable diseases are mental illness and lifestyle diseases, for instance hypertension and obesity. It is feared that people may become vulnerable to combination of communicable diseases like AIDS and Tuberculosis.

The prevailing top ten diseases are common cold, skin infection, peptic ulcer, other musculoskeletal diseases (other than arthritis and arthosis), acute pharyangitis/tonsilites, diarrhea, other disorders of skin, conjunctivitis, other diseases of digestive system excluding dental carries, diseases of teeth and gums, acute appendicitis, alcoholic liver disease and gall bladder disease, followed by antenatal check up/immunization (Annual Health Bulletin (AHB), 2006, p.9). The trends of morbidity among the children under five are the top three diseases, common cold, diarrhea and skin infections, causing 50 % of the total morbidity (AHB, 2006, p.7).  

In terms of mortality, the alcoholic liver disease contributed to 7.8 % of the total deaths in last three years. Postpartum hemorrhage is the leading cause of the maternal mortality followed by severe pre-eclampsia /eclampsia (AHB, 2006, p.7 & p.47). Due to strong patronage emanating from the Throne and Royal Government’s commitment, small pox has been eradicated in 1976/77; leprosy and iodine deficiency disease has been eliminated in 1997 and 2003 respectively.

Funding

As evident from the fund allocated, Royal Government continues to ensure that the provision of health services is not compromised. 22% of the national budget is allocated to the health and education sectors out of which 8.5% is allocated to the health sector (Wangchuk, N., http://www.whobhutan.org.htm). These sectors have also received the maximum grants aid since 1991 amounting to Nu.6.7 billion. Similarly, these sectors received the highest grants receipts amounting to Nu.945.2 million in 2005-06.  As a whole, health and education sectors received 17.40% of the total grants during 2005-06 which is comparatively the highest (Kuensel, 2007, March 24).

Lately, cost-sharing practices have been initiated in selective services (for instance, cosmetic dental and laparoscopic surgeries for removal of gall bladder stones) during the 8^th FYP in pursuance of the policies of self-reliance and sustainability; people are also charged for hire of cabins/private rooms in the hospitals. Monthly compulsory deduction at source of health contribution from civil servants is not a new practice. However, unlike Australian health care system there are not much cost “mutualisation in pharmaceutical” commodities (Duckett. P.9, 2004) in Bhutan; patients are required to buy certain drugs which are not in the essential drugs list as the last resort.  Initiating Health Trust Fund with the intended capital of US $ 24 million is aimed at providing free vaccines, one of the important health care services.

Organization

The Ministry of Health in an independent ministry headed by a minister and supported by a secretary. It has two Departments – the Department of Public Health and the Department of Medical Services, each headed by a director. There are other special units like Bhutan Medical and Health Council, Internal Audit Unit, Information Communication Unit, Legal Unit, Drug Regulatory Authority, Policy and Planning Division, Quality Assurance Division, and Administration and Finance Division. There is Institute of Traditional Medicine Services under the Department of Medical Services.

Health Care System

The Bhutanese health care system is founded on concept of primary health care based on the principles of equity, accessibility, acceptability and affordability. It is an integrated system catering primary health care to, ‘90% of the population’ (Statistical Yearbook of Bhutan, 2004). It functions through four-tiered system of (1) the Basic Health Units (BHUs), (2) the district hospitals, (3) the regional referral hospitals and (4) the national referral hospital.  Medical cases, for instance cancer, which can not be treated in the Kingdom, are referred to India.  

Health Assistants, Auxiliary Nurse Midwives and Basic Health Workers staff the BHUs. They take the health care services to the remote areas of the Kingdom through monthly out-reach clinics (ORC). The Village Health Workers serve as bridge between the community and the health workers.  The district hospitals are manned by one or more doctors and the national and regional referral hospitals provide selected specialized services. This is supplemented by traditional medicines; all the districts have indigenous units attached to the hospitals.

There is no method of measurement of the services in terms of inputs and outputs like that of Australia (Duckett 2004, p.2); the achievement of the health care services in Bhutan is analyzed at the end of the FYP as the targets are set at the beginning of the Plan.

Selected Strategies and their Implication on Nursing Services

The 9^th FYP witnessed significant milestones in the history of the Bhutanese health care system. The Plan saw achievement of almost all the goals set in the previous Plans. There has been a shift of focus from infrastructure development to providing the quality services at each tier of health care services delivery system as evident from the selected strategies discussed below.

I. Enhancement of the Quality of Health Services

One of the most important strategies of the 9^th FYP is the enhancement of the quality of health services. The introduction of quality assurance program saw all-round development; there is quality assurance team at every level of health care system. However, the standard of the quality assurance and their rules may vary depending on the local needs and circumstances.

Information technology, especially in a mountainous country like Bhutan plays a vital role in the enhancement of quality of health care services. A doctor in a remote hospital, for example, can confidently treat patients by consulting specialists either over the telephone or with the use of telemedicine facility. This will improve with the increasing coverage of the Kingdom by telecommunication services.

There is effort to ensure a consistent supply of all five important vaccines, namely, BCG, Measles, OPV3 and DPT- Hep B. We’ve achieved 90 % coverage in the immunization of children below one year. In 2005, there was 100 % BCG immunization.  Measles and Rubella (MR) vaccines have been introduced in 2006; the intensive campaign achieved 98 % coverage. Since then, MR vaccines are administered at 9^th and 24^th months (AHB, 2006, p.8).

Much has developed at infrastructure front too. The construction of regional referral hospital at Monggar and national referral hospital at Thimphu are nearing completion. The number of BHUs has also increased from 166 in 2002 to 176 in 2005. There are 485 ORCs serving as the main outlet of primary health care to the most interior parts of the Kingdom. There are 21 indigenous units (AHB, 2006, p.4). A CD4 level counting machine has been installed at Mongar regional hospital. At the diagnostic front, installation of Computed Tomography scan and Magnetic Resonance Imaging equipment has enhanced the quality of health services.  This will also save fund in terms of decreasing referrals outside the Kingdom in the long run.

The Medical and Health Council Act 2002 regulates legal and ethical matters pertaining to delivery of medical services. The Medicine Act 2002 ensures the quality, safety and efficacy of the medicines. However, with the increasing literacy of the population health personnel may play safe due to legal implications which may arise from medical negligence. Consequently, public may be fed with defensive services and complex statistics.

Being at the forefront of delivery of medical services, better infrastructure, state-of-the-art-technology, good legal framework and farsighted policies will facilitate the nurses to deliver better and faster health services.

II. Target Health Services to Reach the Un-reached.

Reaching the un-reached is yet another important strategy of the 9^th FYP.  Although we claim 90 % health coverage, existence of certain pockets of areas where health services have yet to reach can not be ruled out since Bhutan is a Baeyul (a hidden land) with rugged terrain and harsh climate. The nomadic population, floating population, religious population, groups’ not availing services and, communities not covered by health facilities are recognized as un-reached populations which are of rural setting and urban setting. Introduction of satellite clinics at the capital has been aimed at catering to such groups; besides faster delivery of services, it is expected to mitigate the patient load at the hospitals (Pelvar, S. Bhutan Times. 2007, April 8). The increased number of ORCs and creation of Sub-Posts is expected to take the medical services closer to the people in the far flung areas.

However, despite our full efforts and the best intentions, there may be more hidden and mysterious places like Yoserna (Tashi, T. Bhutan Time. 2007, March 25). One can only wonder about the diseases and epidemics afflicting these people; for instance sexually transmitted infections, one of the precursors of HIV/AIDS have not spared even remote Gasa. Thus, while the veracity of our claim for 90% health coverage may not be doubted, we should not cease to attempt to reach the un-reached.

III. Prevention and Control of Prevailing, Emerging and Re-emerging Health Problems.

Intensification of activities for the prevention and control of prevailing, emerging and re-emerging health problems is yet another important strategy of the 9^th FYP. This pertains to both the communicable and non-communicable diseases. HIV/AIDS, road traffic accidents, alcoholic liver diseases, hypertension, and lifestyle related diseases, rheumatic heart diseases, severe acute respiratory syndrome (SARS), hepatitis, cancers, meningitis, ageing, occupational health, substance abuse and avian flu are the emerging issues. Tuberculosis, dengue/dengue hemorrhagic fever and Japanese encephalitis are re-emerging diseases. Information, communication and education on avian flu are also disseminated (Namgay, S. Kuensel. 2007, February 28) since we not only import poultry products but raise it in traditional ways.  Further, due to rich biodiversity Bhutan provides roosting places to the migratory birds like black necked cranes which might carry the virus. Out breaks of dengue fever may be managed better if fund is instituted for the same.

Assistance and cooperation of the community is enlisted while combating the diseases. Comprehensive guidelines have been developed to take care and treat the opportunistic infections of the HIV/AIDS. The Anti-Retro Viral drugs are now available. People are trained for Voluntary Counseling and Testing (VCT). District Core Teams have been identified for the care of HIV/AIDS cases and, autonomous VCT centers have been opened at Thimphu and Phuntsholing.

If we are not vigilant, substances abuse may become public health problem with increasing number of young children getting inside the trap (Dema, K. Kuensel, 2007, March 3 & Wangmo, T. Bhutan Times, 2007, March 11). Frequent arrest of the drug peddlers and seizure of vast array of drugs by law enforcement agencies indicates that the Ministry should step up measures to curb the emerging problem.

The non-communicable diseases programs have also been intensified. Diabetic clinics have been opened in Thimphu and Mongar hospitals which are staffed by trained personnel. Papanicolaou (Pap) smear screening facilities for early detection of cervical cancer have also been extended to almost all the hospitals and BHUs.

Conclusion

Bhutan has made considerable progress in developing an integrated decentralized heath care system within relatively short span of time. There are continuous efforts to reach the un-reached parts of the Kingdom. At the same time, no effort is spared to improve the quality of the existing system, including - primary health care, disease control programs and needs of the disabled, the elderly and, the emotionally and mentally disturbed (Bhutan 2020, p. 55).

Traditional medicines have been nurtured as an alternative medicine. We are keeping abreast of developments in the medical world. Telemedicine is contributing to the quality and effectiveness of delivery of health care services especially in remote districts. We are also conscious of the cost and sustainability of free health services and the people are accordingly sensitized by levying charges on selected services.

Most importantly, people at the forefront of the health care system – the doctors, nurses and health workers are continuously trained, and the days may not be far when the our system is fully manned by Bhutanese. With strong leaderships of the successive monarchs, stable government and small population (672,425; AHB, 2006),  we can achieve  100%  coverage in the delivery of improved health care services in the near future, thereby  maximizing the  gross national happiness of our people.

References

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