With a shifting burden towards noncommunicable diseases and population aging, Bhutan faces emerging challenges in health. The country already continues to address high rates of malnutrition and disparities in access to maternal and child health services. To respond to evolving challenges, and to develop a more resilient and future-fit health system, the Royal Government of Bhutan has partnered with the World Bank to assess the current status and identify strengths and opportunities within the existing primary health care (PHC) system.
Measurement is essential to strengthening health systems
The Ministry of Health of Bhutan and the World Bank, supported by funding from the Government of Japan and The Global Fund, undertook and recently launched four comprehensive assessments. This marked Bhutan as a pioneer in primary healthcare measurement within the South Asia region. These assessments delve deep into the intricacies of Bhutan’s healthcare system, identifying strengths, weaknesses, and opportunities for growth.
- The Primary Health Care Performance Initiative (PHCPI) report sheds light on Bhutan’s PHC system's strengths and gaps. It forms the foundation for actionable policy recommendations aimed at bolstering the nation's healthcare system.
- The Service Delivery Indicators (SDI) health survey measures key primary health care domains in Bhutan, including foundations (workforce, policies, and management); processes of care (competent care systems and patient experiences); and person-centered outcomes (user confidence in the system and personal medical costs).
- The Bhutan Healthcare Costing Analysis assesses the cost of delivering health services at a sample of different levels of facilities, and how this may have changed over time.
- The Issue Brief Series on Sustainable Health Financing in Bhutan identifies financing efficiency and sustainability of public financing as key emerging challenges, and underscores the importance of investing in primary health care to improve value for money.
“The SDI survey not only provide critical insights into the quality of health service delivery in the country, it also is very timely for the 13th Five-Year Plan baseline.”
Lyonpo Tandin Wangchuk
Honorable Minister, Ministry of Health
Despite progress, challenges remain in service delivery
While the assessments reveal solid progress in PHC service delivery, they also unveil persistent challenges.
- Patient satisfaction: Patients are highly satisfied with their primary health care, with 95%rating the quality of facilities as good or very good. Patients were least satisfied with travel time to the facility and wait time at the facility before being seen by a provider.
- Infrastructure availability: While electricity and water access are near universal, they are often interrupted. Only 11% of facilities had uninterrupted electricity and 39% had uninterrupted water supply over the course of the three months prior to the survey. 70% of facilities in Bhutan have any internet connectivity, but only 17% had uninterrupted internet. Less than 25% of the facilities had a ramp and 13% had a handicap-accessible toilet. Only 23% of facilities had a fire extinguisher available, and less than 3% had a fire alarm/smoke detector.
- Service availability: There is broad availability of services for most high priority maternal and child health and noncommunicable diseases, however, readiness for emergent health priorities is more limited. Availability of cervical cancer screening, mental health services and detoxification and rehabilitative services are lacking especially at the primary facility level.
- Primary health care workforce issues: Almost 100% of providers are satisfied with the meaningfulness of their work, yet dissatisfaction with administrative burden, growth opportunities, and work demands is higher, particularly among doctors.
- Diagnostic and treatment accuracy: In clinical simulation cases conducted as part of the SDI health survey, Bhutan’s health care providers accurately diagnosed childhood diarrhea and pneumonia 98% of the time, compared to only 69% for childhood stunting, and few providers were able to comprehensively manage simulated intrapartum emergency cases. Performance on the clinical simulation case for mental health was lowest, with only 64% of providers correctly diagnosing depression.
- Continuity of care: Only 40% of patients reported usually receiving care at the same facility, and 21% reported bypassing a more convenient facility to receive care, primarily in order to receive more specialized services.
“Bhutan has always placed a strong emphasis on the importance of primary health care. Much of our success in health care is attributed to our strong foundation and dynamism in primary health care. The current PHCPI, SDI, and health financing assessments are timely to check the level of urgency required to align with the importance accorded to primary health care as a foundation of a strong health system in Bhutan.”
Tashi Penjor
Chief, Policy and Planning Division, Ministry of Health
