WHO Country Cooperation Strategy Bhutan 2009–2013 docx

WHO
Country Cooperation Strategy
Bhutan
2009–2013
WHO Country Cooperation Strategy 2009-2013
ii
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WHO Library Cataloguing-in-Publication data

World Health Organization, Regional Office for South-East Asia.
WHO country cooperation strategy Bhutan: 2009-2013.
1. Health Status - statistics and numerical data. 2. Delivery of Health Care.
3. Health Planning. 4. International Cooperation.
5. Strategic Planning. 6. Bhutan.
ISBN 978-92-9022-391-7 (NLM classification: WA 540)
Bhutan
iii
Contents
Foreword v
List of acronyms vi
Message from the Honourable Minister, Ministry of Health, Royal
Government of Bhutan viii
Executive summary ix
1 Introduction 1
2 Health and development challenges 3
2.1 The country and the people 3
2.2 Stage of development 4
2.3 Health situation 5
2.4 Health systems 10
2.5 Major issues and challenges in the health sector 13
3 Development cooperation and partnerships: Technical assistance,
aid effectiveness and coordination 16
4 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
5 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
WHO Country Cooperation Strategy 2009-2013
iv
6 Implementing the Strategic Agenda 34
6.1 The Country Office 34
6.2 The Regional Office and headquarters 35
References 36
Annexes
1. Ministry of Health Organigram 37
2. Reference tables 38
3. Alignment of WHO Strategic Agenda/directions with the Tenth Five Year Plan
for the health sector and UNDAF outcome 42
Bhutan
v
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
Foreword
WHO Country Cooperation Strategy 2009-2013
vi
AC assessed contribution
AEFI adverse effects/events following immunization
AFP acute flaccid paralysis
AI avian influenza
AIDS acquired immune deficiency syndrome
ARI acute respiratory infection
BHTF Bhutan Health Trust Fund

BHUs basic health units
CAP consolidated appeal process
CCA Common Country Assessment
CCM Country Coordinating Mechanism
CCS Country Cooperation Strategy
DD diarrhoeal diseases
DOTS directly observed treatment, short-course
DRA Drug Regulatory Authority
DVED Drugs, Vaccines and Equipment Division
EmOC emergency obstetric care
GATS General Agreement on Trade in Services
GAVI Global Alliance for Vaccines and Immunization
GDP gross domestic product
GEF Global Environment Facility
GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria
GNH Gross National Happiness
GNM general nurse midwife
GPW General Programme of Work
GSM Global Management System
HA health assistant
HIV human immunodeficiency virus
HMN Global Health Matrix Network
IDD iodine deficiency disorder
IHR International Health Regulations
IMCI Integrated Management of Childhood Illnesses
IMR infant mortality rate
IT information technology
JE Japanese encephalitis
MDGs Millennium Development Goals
MDR multidrug resistance

MMR maternal mortality ratio
MoH Ministry of Health
MOSS minimum operating security standard
NCD noncommunicable diseases
NGO nongovernmental organization
List of acronyms
Bhutan
vii
NHA National Health Account
NIPPP national influenza pandemic preparedness plan
NITM National Institute of Traditional Medicine
NPO National Professional Officer
ORCs out-reach clinics
PHC primary health care
PRSP Poverty Reduction Strategy Paper
RB regular budget
RGoB Royal Government of Bhutan
RIHS Royal Institute of Health Sciences
RSTA Road Safety and Transport Authority
RWSS rural water supply and sanitation
SARS severe acute respiratory syndrome
SEAR South-East Asia Region
SEARO Regional Office for South-East Asia (of WHO)
STI sexually transmitted infections
SWAp sector-wide approach
TB tuberculosis
TRIPS Trade-Related Aspects of Intellectual Property Rights
UCI universal child immunization
UN United Nations
UNDAF United Nations Development Assistance Framework

UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
VC voluntary contribution
VHW village health workers
WB World Bank
WFP World Food Programme
WHO World Health Organization
WR WHO Representative
WTO World Trade Organization
WHO Country Cooperation Strategy 2009-2013
viii
Message from the Honourable Minister,
Ministry of Health, Royal Government of Bhutan
Bhutan
ix
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:
Executive summary
WHO Country Cooperation Strategy 2009-2013
x
Public health policy development:  Though most of the elements of the
National Health Policy are in place they are scattered and compartmentalized
in different units.
Acute shortage of qualified human resources for health:  There is a shortage
of especially doctors and nurses at all levels of the health system to ensure
quality services in health facilities and to undertake outreach activities. It is a
cross-cutting issue for the health sector that affects management, delivery of

services and quality assurance.
Further strengthening of the health system:  Challenges in this regard include:
(i) the improvement of the health information system; (ii) the identification
and implementation of a sustainable health financing system to cope with
the rapidly rising health costs along with the rise in demands of the better
educated population for more sophisticated services; (iii) the promotion of
operational research in health; and (iv) steadily reaching out to the unreached,
who constitute 5% to 10% of the population.
Further reducing child health mortality, especially its perinatal component 
and maternal mortality: Acute respiratory infection (ARI) and diarrhoeal
diseases (DD) continue to be the major causes of morbidity despite tangible
improvements in community water supplies and sanitation facilities. Bhutan
has made tremendous progress in reducing maternal mortality by half in the
last 10 years, but current maternal mortality rates (estimated in 2007 at 255
per 100 000 live births) are still high.
Communicable diseases prevention and control:  Tuberculosis case detection
and completion of treatment using the DOTS strategy have significantly
improved in Bhutan. However, greater efforts are required to prevent and
control multidrug resistance (MDR). Although Bhutan is considered a low-
prevalence country for HIV/AIDS with the epidemic mainly prevalent through
heterosexual transmission in the 15–24-year age group, it is likely that there
are undetected infections in the population. Cases of malaria have decreased
significantly over the recent years but there are still focal outbreaks causing
morbidity and mortality. With the first outbreak of dengue in Bhutan in 2004,
prevention and control activities for this and other vector-borne diseases such
as malaria, Japanese encephalitis (JE), kala azar and leishmaniasis need to be
intensified.
Noncommunicable diseases prevention, care and support:  Bhutan faces a
double burden of disease with a rising trend of noncommunicable diseases.
The response of the primary health care model needs to consider this rising

trend and the associated risk factors. Commendable efforts have focused on
tobacco control culminating in a ban on the sale of tobacco products in Bhutan.
However, alcohol abuse remains a major risk factor for noncommunicable
Bhutan
xi
diseases and substance abuse is a potential problem in the country. Community-
based mental health programmes require more resources to intensify activities,
and lack adequately trained mental health professionals. Injuries are also an
increasing cause of morbidity in Bhutan. Disabilities, especially related to vision
and hearing, are a growing concern in the country and programmes are needed
to strengthen rehabilitation, especially at the community level. Oral health
programmes require strengthening, especially through primary oral health care
and the school health programme.
Promotion of healthy environment:  Bhutan is committed to sustain and
expand its promotional efforts to control pollution in urban areas and homes.
A proper assessment of occupational hazards, especially in industries, needs to
be carried out to initiate preventive and management measures. A multisectoral
approach is needed to strengthen and ensure food safety. New concerns are
emerging with regard to climate change and its influence on health, especially
the risk of glacial lakes melting. Climate change may also alter the ecosystem
leading to a spurt in internal migration and affecting the availability of plants
used for traditional medicines.
Bhutan has achieved impressive results in terms of water supply and basic 
sanitation coverage. The current challenge is to ensure the functionality of
existing water systems, the quality of water, as well as to expand facilities to
reach the unreached and achieve universal water coverage, which usually is
expensive and requires new approaches. Assessments may also be required
regarding the use of sanitary facilities.
Emergency preparedness and response – National Influenza Pandemic 
Preparedness Plan (NIPPP) and implementation of the International Health

Regulations (IHR) 2005: Bhutan is a country prone to natural disasters since it
is located in a highly active and fault-prone seismic area. In addition, climate
change increases the risk of glacial lakes melting and overflowing. Many
activities conducted under the avian influenza workplan are common to IHR
implementation. This should offer opportunities for resource mobilization for
IHR implementation and will strengthen the capacity of the country to deal
with epidemic diseases, including avian influenza.
The present Country Cooperation Strategy (CCS) is based on the WHO guiding
principles for work at the country level, in line with the principles of ownership,
alignment and harmonization in accordance with the 2005 Paris Declaration on Aid
Effectiveness which was reaffirmed in the Accra Agenda for Action. It is firmly anchored
in the country’s unique social, cultural and spiritual development system based on the
Gross National Happiness philosophy that gives the highest priority to the people’s
physical, mental and spiritual well-being within a safe and secure environment. This CCS
is a tool that will guide the entire WHO Secretariat’s work in Bhutan. It aims to create
a flexible dialogue platform to work with all partners in health at the country level.
WHO Country Cooperation Strategy 2009-2013
xii
As Bhutan incorporated in its Constitution the mandate for the State to provide
free basic health care to each Bhutanese citizen, WHO is aligning its cooperation in
the 2010–2013 cycle with the priorities of the Tenth Five Year Plan (FYP) through the
following six Strategic Priorities, aligned with its core functions, that form the Strategic
Agenda of the CCS.
The main focus of cooperation is identified under each of the Strategic Priorities,
which are as follows.
Strategic Priority 01: Support the review, strengthening and
consolidation of health policies into a National Health Policy
Support the development of the National Health Policy document. 
Strategic Priority 02: Support strengthening the process of
development of human resources for health

Revision of the Human Resources Development Master Plan for Health based 
on national health priorities.
Key support to the implementation of the Human Resources Development 
Master Plan.
Strategic Priority 03: Contribute to the strengthening of the health
system
Fostering the efficient use of health information at all levels of the health 
system.
Development of options for sustainable health system financing. 
Improved management of decentralized health services and facilities. 
Norms and standards and quality assurance for basic health care scaled up 
towards universal coverage.
Expanding the roles of the community in supporting the health system. 
Research to support the health system. 
Strategic Priority 04: Foster the improvement of maternal health, child
health and nutrition according to the MDGs 3, 4, and 5
Improvement of the nutritional status of the population. 
Further reduction of child mortality and improvement of child health. 
Further improvement of maternal health with emphasis on reduction of maternal 
mortality.
Bhutan
xiii
Strategic Priority 05: Help reduce the burden of disease through key
interventions focusing on Health Promotion and risk factors with a
multisectoral approach
Prevention and control of communicable and emerging diseases. 
Noncommunicable diseases prevention, care and support, emphasizing health 
promotion and behaviour changes, and support for mental health.
Ensuring a healthy environment (water, sanitation, food safety, occupational 
health and climate change).

Emergency preparedness and response, including the reduction of the 
vulnerability of health facilities.
National Influenza Pandemic Preparedness Plan (NIPPP) and implementation 
of the International Health Regulations (IHR) 2005.
Strategic Priority 06: Enhance partnerships and resource mobilization
for health
Provide support to the coordination of partners in health. 
Resource mobilization. 
The Country Cooperation Strategy will guide the entire gamut of WHO cooperation
with the Kingdom of Bhutan during the period 2009–2013. The WHO Country Office
will use this flexible instrument to guide its operational planning and mobilize the
necessary technical expertise from its Regional Office as well as from Headquarters
and other sections of the Organization. WHO will also contribute to disseminate the
unique health achievements made by the country.
Bhutan’s unique environment, culture, and its preserved way of living that carefully
contribute to “Gross National Happiness” are attracting the world’s attention. The
country can play a special role in contributing to shaping the regional and global agenda,
and in exporting best practices and knowledge in specific domains such as the integration
of traditional and allopathic medicine, the development of herbal medicines, and the
successful development of health systems, based on primary health care with specific
emphasis on community participation.

Bhutan
1
1 — Introduction
Bhutan has officially planned and implemented two rounds of the Country Cooperation
Strategy already although none of these documents were published. The first round
was prepared in early 2000 and was used as a guideline for the formulation of the
2000–2001 and 2002–2003 workplans for the country. The second round was prepared
in early 2003 and that formed the framework for the World Health Organization’s

work in Bhutan during the 2004–2005 and 2006–2007 biennium. Those rounds of
CCS were prepared by teams consisting of representatives from WHO headquarters,
the Regional Office for South-East Asia and the Bhutan Country Office in consultation
with the Ministry of Health.
Both WHO and the Royal Government of Bhutan felt the need for another revision
the CCS because there had been several changes both at the global level and in the
country since the previous round.
As WHO entered into its 11th General Programme of Work (GPW) from 2006
incorporating the new global health agenda based on the changing health situation,
its priorities changed. Such priority shifts, too, had to be incorporated in the CCS that
forms the framework for WHO’s work at the country level.
For the country, the latest population figures and other key development indices
were firmly established by the 2005 National Population and Housing Census. Prior
to 2005, the population figures were not authenticated and disaggregated data for
population was not available for the different age groups and districts. The 2005 census
gives reliable figures that help in better assessment of the situation and planning.
Secondly, there have been major changes in the political arena over the last few
years. The National Constitution of Bhutan was drafted and the country adopted
the democratic system beginning with the formation of political parties during 2007,
followed by elections in 2008. The Fourth Druk Gyalpo abdicated and handed the
throne to his son, the Fifth Druk Gyalpo. An office has opened for public accounts at
the national level and corruption watchdogs have been put in place and the auditing
system bolstered. All these developments will have a bearing on WHO’s work in this
country.
Thirdly, there have also been marked improvements in the health status of the
country. Although the major priorities still remain the same, there have been a shift in
WHO Country Cooperation Strategy 2009-2013
2
other priorities for health. For example, the Millennium Development Goals (MDGs)
have now become important considerations for planning, and other priorities have

also emerged after review of the health sector’s performance during the Ninth Five
Year Plan (2002–2007), but due to transition of the Government, the Ninth Plan now
ends on 30 June 2008 instead of 30 June 2007.
Fourthly, up until the Eighth Five Year Plan (1997–2002), the country was more
concerned with expansion and coverage of health services. Quality issues have become
more important starting with the Ninth Five Year Plan (2002–2008). The Tenth Five
Year Plan is now concerned with reaching out to the yet unreached and ensuring the
quality of services. Reaching the last pockets of the unreached population would cost
considerably more and balancing cost efficiency against coverage and quality while
at the same time ensuring sustainability is going to be more difficult than before. All
these national concerns also need WHO consideration since it will be one of the major
contributors to national health in the Tenth Plan.
Further, the macroeconomic initiative has highlighted the need to plan health
interventions focusing on the poor. During the Tenth Plan, the Ministry of Health plans
to allocate more resources to the districts than in the past. This entails capacity-building
in the districts to cope with additional work and funds.
Finally, the Tenth Five Year Plan (1 July 2008 to 30 June 2013) will be the first
development plan to be implemented by the new democratic government. Hence,
the need to develop a viable cooperation framework during this particular Plan period
is viewed as crucial for WHO.
In view of all this, the CCS for Bhutan had to be formulated afresh to take into
account the changing priorities and provide a strong framework for WHO and the
Government of Bhutan to cooperate and work for the people during the early years
of representative government.
The CCS discussion process was initiated with the visit of a technical staff from
WHO SEARO in December 2006. This was followed by the preparation of a draft CCS
document by the WHO Country Office through extensive consultations with WHO
SEARO, headquarters and resident offices of UNDP, UNICEF, UNFPA, WFP on the
one hand and the Ministry of Health and the Netherlands Development Organization
(SNV), in the light of the Tenth Five Year Plan, on the other hand.

Bhutan
3
2 — Health and development challenges
2.1 The country and the people
Bhutan consists of 20 districts lying on the south-facing slopes of the eastern Himalayas.
Hence the topography is rugged with altitudes ranging from that of the Indian plains
to heights of over 24 000 feet. Health problems ranging from tropical diseases to
respiratory illnesses from the cold climate have been recorded in the country, which
has a total population of 672 425 (2005 census).
Till the Population and Housing Census conducted in 2005, the population of
the country was only based on estimates. The 2005 census revealed the calculated
total population of 672 425, which includes 37 443 persons with a non-permanent
residence.
Figure 2.1: Population pyramid, Bhutan 2005

Source: Population and Housing Census of Bhutan, 2005.
Per cent of population
WHO Country Cooperation Strategy 2009-2013
4
The census calculated the population growth rate at 1.3% as indicated in the age
pyramid (Figure 2.1) showing a decrease in the number of births over the last 15 years.
However, 46 per cent of the population is aged between 5 and 24 years indicating that
health and development efforts need to intensify support for children, adolescents and
the young. The census calculated life expectancy at 66.1 years, which was a dramatic
increase since 1960 when life expectancy was only 37 years.
2.2 Stage of development
The overall education level of the people has improved over the years. The 2005
National Population Census revealed a literacy rate of 69.1% for males and 48.7%
for females, with a higher literacy in urban areas. GDP growth has averaged 7.0% per
annum since 1980. However, the Bhutanese economy is fragile and highly dependent

on the hydropower industry. Between 1980 and 2004, this industry was the major
contributor to GDP growth although agriculture remains the source of income for the
majority of the population.
Rural electrification has led to an increase in power-intensive industries. Besides
industry, tourism also plays an increasingly important role in the country’s economy.
This sector not only generates foreign exchange but also has employment opportunities
for the educated youth. The number of tourists visiting the country has been increasing
rapidly from 6300 in 2003 to about 13 600 in 2005. The government intends to promote
this sector in the years to come.
In 2007, net primary school enrolment was 83.7% with gender parity with 85.4%
of those enrolled in grade 1 completing grade 7 (MDG book, p. 40). This has led to a
rapid increase in the number of educated graduates not yet matched by employment
opportunities both in the public and private sectors. The national unemployment
rate increased from 1.8% in 2003 to 2.5% in 2004. The 2005 census calculated the
unemployment rate at 3.1% for ages 15 years and above. This is a grave concern as
unemployed youth may engage in activities that jeopardize their own health and welfare
as well as that of other people.
In 2007 it was also estimated that 23.2% of the population lived below the poverty
line (MGD book, p.30) and Bhutan’s Tenth Five Year Plan targets a reduction of the
same to 15% by 2013. However, there is a considerable gap between urban and rural
areas as well as different regions of the country as seen in Table 2.1. It is estimated
that 98% of the poor live in rural areas (MDG book, p. 35). The poverty rate in 2004
increased markedly across the country from west to east. While the poverty rate in the
western region was 19%, it increased to 30% in the central region and to half of the
population (49%) in the eastern region.
Bhutan
5
Table 2.1: Quantitative indicators of poverty
Poverty
rate (% of

people)
Poverty rate
(% of
households)
Poverty gap
index
Severity
index
Whole country 32 25 0.086 0.031
Urban 4 3 0.007 0.002
Rural 38 32 0.105 0.038
Region
Western 19 13 0.046 0.016
Central 30 22 0.066 0.021
Eastern 49 40 0.147 0.056
Source: PAR, 2004
Map of Bhutan

2.3 Health situation
The health situation in Bhutan has improved significantly as revealed by the four national
surveys conducted in 1984, 1994, 2000 and 2005, as seen in Table 2.2 below:
WHO Country Cooperation Strategy 2009-2013
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Table 2.2: Overview of major trends revealed by the four national surveys
Health status indicator
Year
1984 1994 2000 2005*
Total fertility rate NA 5.6 4.7 2.5
Crude birth rate (per 1000 population) 39.0 39.9 34.1 20.0
Crude death rate (per 1000 population) 13.0 9.0 8.9 7.0

Population growth rate in % 3.0 3.1 2.5 1.3
Infant mortality ratio (per 1000 live births) 103.0 70.7 60.5 40.1
Under-5 mortality rate (per 1000 live births) 162.0 96.9 84.0 61.5
Maternal mortality ratio (per 100 000 live
births)
770.0 380.0 255.0 NA
Births attended by trained health staff NA 10.9 23.6 49.1
* Population & Housing Census 2005
Bhutan’s Tenth Five Year Plan places considerable importance on the achievement
of the Millennium Development Goals (MDGs). Considerable progress has already
been made towards achieving the MDG targets for the health sector, and Bhutan has
targeted to go beyond the MDG targets during the Tenth Five Year Plan. The MDG
plus targets include other priority indicators for health.
The causes of death for 2005 (Figure 2.2) show that Bhutan is clearly experiencing
an epidemiological transition with a reduction in deaths due to communicable diseases.
Only about a quarter of deaths are caused by communicable diseases while cancer
and heart diseases account for 31% of deaths. Accidents and other related causes
are responsible for about 18% of deaths. As with other countries in this stage of
epidemiological transition, mortality due to noncommunicable diseases and injuries is
likely to increase in the coming years while efforts to control communicable diseases
must be sustained.
Health of infants and children
The reduction of infant and under-5 mortality rates over the last 15 years has been
impressive with the country’s infant mortality rate and under-5 mortality rate at 40.1
and 61.5 respectively in 2005. However, these rates are not uniform throughout the
country. Table 1 in Annex 2 shows that the districts of Samdrupjongkhar and Trashigang
have an IMR above 60. Under-5 mortality rates are also about 80 in these two districts
along with Chukha. This indicates that further reduction in mortality rates will depend
on improving services to select specific districts and areas.
Bhutan

7
Figure 2.2: Causes of death in 2005 (excluding 33% other causes)
1%
6%
1%
9%
2%
5%
9%
4%
16%
1%
9%
19%
5%
3%
10%
Diarrhoea
TB
malaria
Cancer
diabetes
Meningitis/encephalitis
heart disease
Cerebro-vascular
diseases
other circulatory
diseases
common cold
pneumonia

alcohol liver diseases
Other kidney,
UT/Genital Disorders
pregnancy related
Injuries&trauma

Source: Annual Health Bulletin 2009
Reducing infant mortality entails making further concerted efforts at closing the
knowledge, attitude and behaviour gaps in safe hygienic practices at birth, better
nutritional and improved sanitation and hygiene. In addition, it appears that a majority of
infant deaths occur during the first month after birth, which emphasizes the importance
of interventions to reduce neonatal mortality.
Reproductive health and safe motherhood
Despite the tremendous achievements made in improving maternal health, the maternal
mortality ratio (MMR) still remains high. The primary health-care system has resulted in
high coverage of antenatal care (ANC). Table 2 in Annex 2 shows that 71% of pregnant
women have at least three ANC visits, although coverage is not even. The districts of
Dagana and Trashiyangtse less than 50% figures for the ANC visit.
However, the most important factor going against the reduction of MMR is the
considerable distance to health-care facilities and the varying coverage of deliveries
assisted by health professionals. In 2007, only 51% of deliveries were assisted by health
professionals and this rate was below even 30% in Lhuentse and Trashiyangste districts.
The Ministry of Health has attempted to increase the number of women who go to
WHO Country Cooperation Strategy 2009-2013
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health facilities for delivery. While the overall rate of deliveries in health facilites was
46% in 2007, six districts had rates of less than 20% of the same. Increasing deliveries
in health facilities for these districts will be a challenge for the health system.
The population pyramid emphasizes the fact that Bhutan has a young population with
the majority in the reproductively fertile age groups. Total fertility rate is on the decline

but measures need to be continued to prevent unplanned pregnancies. In addition,
important reproductive health diseases, such as cervical cancer and sexually transmitted
diseases including HIV/AIDS, are an increasing risk to reproductive health. These require
appropriate health promotion efforts and programmes focused on them.
Communicable diseases
While communicable diseases still remain a cause of morbidity and mortality, there
has been steady improvement over the last 20 years. Tuberculosis cases have dropped
from 4232 cases in 1990 to 874 in 2007. Malaria remains a problem especially in the
districts bordering India, although the number of cases has dropped from 22 126 in
1990 to 793 in 2007.
Sexually transmitted infections (STIs) have yet to be controlled and the number
of HIV/AIDS cases is increasing over the last ten years, with 144 cumulative cases in
2008. Since most of the HIV cases detected in recent years were contracted several
years ago, there is the danger of it unknowingly spreading to many sex partners in the
interim between contracting and detection.
Acute respiratory infection and diarroheal diseases remain the two major causes of
morbidity despite improvements in water supply and sanitation facilities in communities.
Finally, high coverage of immunization has been maintained by the country since the
achievement of UCI in the Eighties. No case of polio has been detected since 1982.
Nutrition
Despite the improved nutritional status achieved over the last two decades, malnutrition
and micronutrient deficiencies are still major health problems, especially among children
and pregnant women. The percentage of under-5 children who are underweight
has decreased from 38% in 1989 to 19% in 2000 (MDG book, p. 34). In 2007, the
overall percentage of underweight children visiting health clinics was 10%. The rate
of underweight children was highest in Trashiyangtse district (16%) while three other
districts had 13% (see Table 1 in Annex 2).
Micronutrient deficiencies in Bhutan are related to iron, iodine and vitamin A. The
programme to reduce iodine deficiency (normally a major problem in high-altitude
areas) has been virtually eliminated through strict control of the distribution of non-

iodized salt. Vitamin A deficiency does not appear to be a major problem because
of the routine distribution of large doses of vitamin A during immunization visits. A
Bhutan
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study in 2003 estimated that 28% of men, 55% of women and 81% of children were
anaemic due to iron deficiency (UNICEF, A Situation Analysis of Children and Women
in Bhutan, 2006). Severe anaemia during pregnancy is a special concern because of
its relation to maternal mortality. Routine supplementation with iron and folate tablets
is normally indicated.
A sedentary lifestyle is gradually overtaking the hardworking agricultural workers
and the average diet has improved. However, the traditional Bhutanese fondness for
fatty food has led to an increase in cases of obesity. Recent assessments have revealed
that obesity is now a public health concern in Bhutan.
Noncommunicable diseases
Noncommunicable diseases now account for more deaths than communicable
diseases (Figure 1). Although there has been no in-depth assessment, the trend in
admissions at the National Referral Hospital (Figure 2.3) shows that the proportion of
noncommunicable diseases is steadily increasing.
Figure 2.3: Distribution of hospital admissions by types of NCD

Source: Health Sector Review 2007
The major risk factors include alcohol consumption along with the use of tobacco
and betel nuts. The use of narcotic drugs and other substances among adolescents are
also on the rise. Although the general pace of life in Bhutan is not stressful and people
are more spiritual, psychiatric and anxiety-related problems have not spared them.
Mental health problems are becoming more serious as the country modernizes. The
community-based mental health programme is now being developed to provide basic
services for mental health problems.
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Emergency medical services
Bhutan is no exception when it comes to natural and man-made disasters. The
last few decades have witnessed the loss of precious life and property due to
flash floods, landslides, earthquakes and traffic accidents. As cases of severe acute
respiratory syndrome (SARS), avian influenza and influenza A occur in the Region,
Bhutan too has to prepare itself to deal with such problems. Although the country
has a good network of health-care facilities, most of them are ill equipped to deal
with such emergencies in an organized and rapid manner. As disasters can occur
unexpectedly, being prepared is the only way to deal with them.

Rural water supply and sanitation (RWSS)
The high number of diarrhoea and skin infection incidences makes the water supply
and sanitation programme assume crucial importance.
Bhutan’s water supply and sanitation coverage extends to more than 85% and
90% of the population respectively. From ethical and equity angles, it is critical that the
unreached 10% to 15% of the population has to be covered. The cost of reaching out
to the last far-flung population pockets comes to much higher. The demand-responsive
approach, as opposed to the earlier supply-driven approach, has contributed to the
enhancement of ownership and increased prospect of sustainability. The supply of
water and sanitation facilities needs to be seen as an integrated package along with
other public health activities.
2.4 Health systems
Policy and financing
The philosophy of economic development in Bhutan is based on the principle of Gross
National Happiness (GNH) delivered through the following four areas:
Sustainable and equitable socioeconomic development. 
Conservation of the environment. 
Preservation and promotion of culture. 
Promotion of good governance. 
While putting people at the centre of development, sustainable socioeconomic

development is not possible without giving due priority to health. The Government sets
aside an average of 10% – 11% of the national allocation annually for health. During
the Ninth Five Year Plan, the health sector received a 16.6% increase over the original
budget. To ensure equity, a pro-poor strategy of providing free basic health-care services
for all citizens has been adopted by Bhutan. The Government-donor funding ratio of
allocation so far is approximately 60:40.