Bhutan: When Environment Drives Public Health Policies
June 15, 2007
by Barbara Crossette
From its cold, high Himalayan valleys to the belt of semitropical terrain facing the tea plantations of northeastern India, the isolated, landlocked kingdom of Bhutan presents public health officials with environmental challenges every day. More than a fifth of the country’s 700,000 people live in remote hamlets more than fours hours’—and sometimes up to seven days’—walk from the nearest road. Modern health care has been a distant luxury.
Yet Bhutan, in the three decades following the seminal 1978 Alma-Ata International Conference on Primary Health Care, has transformed a society marked by a high incidence of respiratory disease and astronomical levels of maternal mortality into a South Asian healthcare success story few would have predicted. No one starves in Bhutan. Childhood malnutrition and maternal deaths have dropped. Dramatically. Both the Alma-Ata meeting and the 1994 Cairo Conference on Population and Development provoked quick responses from the Bhutanese, who set to work to rethink national welfare in their traditional Buddhist nation. That meant a holistic approach to well-being, and the safeguarding and upgrading of traditional healing combined with modern medicine. The health system, they decided, would be adapted to their own environment, from the village up.
Bhutan’s small-scale projects, replicated across a mountainous country slightly larger than Switzerland, could work with relevant modifications in many other environments, given the right government planning and support, international experts say. The Bhutanese health system, described by the World Health Organization (WHO) as “one of the best programs in South-East Asia,” won WHO’s 50th anniversary award for primary health care in 1998.
How did the Bhutanese do it?
Health service planning started from the bottom up, said Gado Tshering, Bhutan’s Secretary of Health. Sixty percent of the health budget goes to prevention, including near-universal immunization, health education services, and quality of the environment at home and in the neighborhood. To pay for this, Bhutan, a non-industrialized, largely agrarian and pastoral country with a per capita gross national product of about $875 (or up to $1,900 if calculated in purchasing power parity), has bolstered its limited financial resources with loans from the Asian Development Bank, help from other international agencies and institutions as well as a health trust fund that the Bhutanese hope will eventually provide income from a capital base of at least $24 million. Donors and partners—among them Denmark, India, UNICEF, the UN Population Fund, the World Bank, and WHO—are confident that in Bhutan, projects are carefully planned and money well spent.
In 2004, the Bhutanese spent 4.6 percent of its gross domestic product (GDP) on health care with the government providing for 64.2 percent of that amount according to the WHO. By comparison, India spent 5.0 percent of its GDP on health, but the government provided a far smaller share of that amount (17.3 percent).1 Bhutan’s health infrastructure includes 176 basic health units at the village level, 485 smaller community outreach clinics, and 29 district or national hospitals, all but a few still relatively rudimentary. One problem that persists is the shortage of doctors, who must be trained abroad, as well as other medical personnel to staff health facilities at ideal levels.
“From the very beginning in Bhutan, the health care system was based on primary health care, which means our focus is on prevention of disease, promotion of good health, rehabilitation of people—and a lower focus on the curative side,” said Gado Tshering, who studied medicine in India and Thailand and recently received a fellowship from Harvard to visit medical institutions in the United States. “All health care is free. That includes not only treatment, but also we give food to the family while the patients are admitted in the hospital.”
Occasionally, medical supplies can run short because of distribution hurdles in the rugged landscape. In a small basic health unit in the Phobjikha Valley, about 100 miles from Thimphu, the Bhutanese capital, the health assistant in charge, Yonten Gyeltshen, a trained paramedic, not a doctor, said that there are days when he and Savitri Pradhan, the unit’s midwife, both get called away—often on foot—to remote farms or hamlets for emergencies and have to close the clinic.
Their colleague, Pema Tashi, who runs a traditional medicine office in the same building—following a countrywide Bhutanese policy—showed me an unused computer still in its box on the floor, unworkable because the solar panel on the roof did not produce enough electricity to run it, and there is no other source of power. All three of the unit staff bemoaned shortages of various supplies, including medications, caused by erratic deliveries.
Local problems notwithstanding, in barely two decades since King Jigme Singye Wangchuck—the last Bhutanese monarch to rule with near absolute power before the country embarked on a transition to democracy this year—began to modernize the kingdom, the Bhutanese health system has registered substantial gains in international terms, and has begun to pull ahead of other nations in South Asia, including India, on some health indicators.
The latest United Nations Development Program’s Human Development Report (2006) shows a life expectancy of 63.4, about on a par with India at 63.6, and fractionally above Bangladesh and Nepal. Bhutan’s percentage of underweight children under five years of age is 19 percent; India’s is 47 percent, with Bangladesh and Nepal at 48 percent. The under-five mortality rate in Bhutan has been reduced by 55 percent, from 166 deaths per 1,000 in 1990 to 75 deaths per 1,000 in 2005, and the numbers continue to drop. Maternal mortality, which stood at a staggering 770 per 100,000 live births in 1984, dropped to around 400 in 1994 and has been more than halved since then, the government says. India’s maternal mortality ratio is still hovering around 400, according to UNICEF.
In landlocked Bhutan, 95 percent of households use iodized salt, compared with 57 percent in India, according to UNICEF’s State of the World’s Children 2007. In the same report, Bhutan has immunization/vaccination rates above 93 percent for tuberculosis, DPT, polio, measles and hepatitis, slightly better than Bangladesh and well above Indian rates. In South Asia, only Sri Lanka tops Bhutanese figures with near-100 percent immunization.
Nutritional concerns are added to the preventive mix. Malnutrition is now, proportionately, much lower than in India and approaching the levels of Thailand, according to WHO figures. In Bhutan, where 19 percent of children under 5-years-old are moderately or severely underweight (3 percent severe), only 3 percent are considered wasted (substantially below median weight for height) and 4 percent stunted (substantially below median height for age).2 In Thailand, a far more prosperous and developed country, 18 percent of the children under-5 are underweight (2 percent severe), 5 percent wasted and a far higher share stunted (13 percent).
In recent years, Bhutan’s disease patterns have begun to change with better health care, environmental improvements, and general development, part of a global trend as countries develop and health improves. Respiratory infections and diarrheal diseases, which until recently were always at the top of morbidity and mortality figures, are being edged out by illnesses usually associated with more urbanized societies and developed countries, Gado Tshering said. “In the last five years or so we have seen that noncommunicable diseases like hypertension, diabetes, gout, accidents, trauma, cancers, heart diseases, mental problems have come up.”
That in turn reveals new problems, as the Bhutanese, who now have access to television and the Internet in many places, turn away from the better aspects of traditional living and seek a more modern life. “People are eating the wrong food, not doing exercise,” he said. “So we are equally worried on that front.” So far, the country has largely escaped HIV/AIDS, though more travel to countries like India and Thailand have prompted health officials to include information on avoiding the virus in education programs.
Put out the Cooking Fire, Banish the Cows
“Our prevention of diseases depends on how good the environment is,” Gado Tshering said. “And when I say environmental care, if we are able to provide fresh air, clean drinking water, keep the green trees around people, then they are much healthier.” The environment needs work, indoors as well as outside.
In April 2007, the World Health Organization reported that in 21 developing countries, indoor air pollution from cooking and heating fires made with solid fuels accounted for nearly 5 percent of all deaths and diseases, with the brunt of the impact falling on women and children. Worldwide, WHO said, cooking fuels such as coal, biomass, dung, wood and crop residues, are one of the 10 biggest threats to public health. The agency found that indoor air pollution caused or contributed annually to 1.2 million deaths in 11 countries: Afghanistan, Angola, Bangladesh, Burkina Faso, China, the Democratic Republic of the Congo, Ethiopia, India, Nigeria, Pakistan, and Tanzania.
The authors of Disease Control Priorities in Developing Countries, 2nd edition, write that better surveillance is necessary to determine relationships between the environment and deaths, diseases, and disabilities that may be linked to it. However four challenges complicate environmental public health surveillance, the experts say. These challenges are having the ability to link specific environmental causes to adverse outcomes, the insufficiency of data collected for other purposes in providing a case definition for a condition caused by an environmental agent, public alarm out of proportion to the hazard, and the need for biological markers that are increasingly critical to judging environmental exposure. Moreover, standards and surveillance methods vary from country to country.
“As we invest in understanding the enlarging threats in our global environment,” the experts write, we must overcome these challenges and establish improved surveillance systems. The health of our global community depends on the investment.”
To correct household environmental factors detrimental to health, the Bhutanese health ministry zeroed in on the burning of wood for cooking and heating, and became a strong supporter of the government’s rural electrification program, based on a combination of small hydroelectric systems, solar power or, where feasible, connections to an expanding national power grid. Even before the push for rural electrification, which is heavily subsidized and which some Bhutanese believe was an extravagance in such a sparsely populated country, programs taught village householders how to make smokeless clay stoves.
The switch to electricity has helped improve health. Where the rural electrification program has reached villages, the rate of respiratory infections has dropped. This is the case, regardless of whether the home is powered by solar or water power. Children and adults who sleep in a house where less wood is burned than before contract fewer respiratory infections.
With electricity, even if limited to a few hours a day, Bhutanese villagers have begun to buy rice cookers and electric kettles produced elsewhere in Asia. Although there have been some tragic accidents involving children unaware of the dangers of electrical power, generally health officials are pleased with the switch to electric cooking. “We found that there’s a double effect,” Gado Tshering said. “One, the pollution in a house is reduced. Secondly, we know that the environment around the house, has become more green.”
In semitropical or tropical areas of the country, insecticide-impregnated bed nets to prevent malaria and other mosquito-borne diseases are distributed free, with support from the Global Fund to Fight AIDS, Tuberculosis and Malaria. Local people are taught to dispose of standing water to deal with conditions in the hot Indian border region, where mosquitoes breed. Recently, malaria has also been found farther north in a temperate zone, causing new concern.
Even in a country with crystal-clear mountain streams bubbling down over rocks, water could be risky. “Eight years ago, only 50 to 55 percent of the people had access to safe drinking water,” Gado Tshering said. “Now 87 percent of people in this country have safe drinking water—but [for] the remaining 13 percent [it] is very tough.” Nomads such as yak herders and the remotest of farming villagers are hard to reach, he explained.
With campaigns to provide cleaner water came projects to build sanitary latrines and to get people to wash their hands frequently. Local clinics, the basic health units known as BHUs, display large posters showing hand-washing techniques.
Different kinds of latrines have been built. First were deep-pit latrines, over which people could erect simple structures for privacy. Now with more villages supplied with water, people have begun building flush latrines, encouraged by the government. Some of these are attached to houses. Government officials offer advice, but ask villagers to choose, build and maintain their own toilets, as they are expected to care for newly installed water pumps and pipes. “If we provide it they say, it is the government’s water, and they never take care,” he said. “Now we say, it is the community’s water, please take care.”
Villagers have also been enlisted to dig pits for trash, even more important now that plastic bags and bottles are finding their way into the hills and mountain valleys. Living with animals is discouraged. “Take them out and make the cowshed, don’t have them in your house,” is the message, Gado Tshering said. “Cows have to be in the cowshed, pigs in the piggery.” Yaks roam free in the hills, watched by herders.
Safeguarding Tradition, Bucking the Experts
Stories of Bhutanese insistence on doing things their way are legion among aid experts who know the country. As in many poor, underdeveloped nations, the Bhutanese sometimes have more confidence in local healers than in modern medicine. The health system has from the start incorporated and never demeaned traditional practices and herbal medicines in the name of modernity. Clinics and hospitals have traditional practitioners on the staff. In Phobjikha, the herbal doctor, Pema Tashi, said that he dealt mostly with joint aches, headaches, dizziness, ulcers and blood pressure. He refers anyone needing more complex modern medical care to colleagues down the hall.
The cultivation and safe processing of indigenous medical plants has been a matter of national policy since 1967. Starting with two Tibetan-trained practitioners, the traditional medicine services of Bhutan developed into a system that includes a traditional hospital as well as a network of traditional doctors or pharmacists known as compounders. There is a national training center and a pharmaceutical production and research facility.
In the process of creating a health system tailored to its needs, the Bhutanese have wrestled with decisions common to many other developing nations, and they have made some unpopular and controversial decisions. They have considered and rejected, against the advice of the World Bank according to the Bhutanese secretary of health, imposing user fees in this largely subsistence economy.
“One of the reasons we get free health care is because 69 percent of our people are in rural areas, and [many] of these people are below the poverty line,” said Gado Tshering. “They don’t have cash in hand. They have rice, they have butter, they have cheese and all. But if you tell them to give even one ngultrum [the Bhutanese currency] they will not have it.” Bhutan sets the poverty line at about 62 cents (25 ngultrum) per person per day. The UNDP considers about 32 percent of the people, mostly in rural areas, to be below this line—poor in cash terms, though not destitute, homeless or hungry. In self-sufficient Bhutan, monetary figures do not always accurately reflect actual living standards.
“They go for alternative therapies, like they go and see a monk or an astrologer or a neighbor,” Gado Tshering said. “They can give just two, three eggs or whatever—local alcohol. But not to us, you see.” If fees were imposed, people would delay seeking medical help until it might be too late, he said. “If there’s a cost, it’s going to be a deterrent. But in an urban area, where people have access to cash, that’s okay.”
Bhutan has also bucked a strong international preference for enhancing skilled birth attendance both at home and in facilities by aiming to have all babies delivered in health centers. “One of the major problems in our reproductive health is that Bhutan still has a very high maternal mortality [ratio],” the health secretary said. “Our ratio [in 2000] was something like 255 per hundred thousand live births. By the end of another five years we want to bring it in under 100.” The current maternal mortality ratio is estimated to be between 160 and 170.
The major causes of a high maternal mortality rate include bleeding during pregnancy, untreated infections and unexpected complications or emergencies that cannot be handled at home, Gado Tshering said. Health care may be days away by foot along mountain trails. “So now we are making a policy broadly called 100 percent institutional delivery, which many donors like UNICEF were arguing is not right,” he stated. He does not want to debate international policies. “For Bhutan, this is right,” he said.
The Bhutanese hope to eliminate 80 percent to 90 percent of maternal deaths this way. Where possible or necessary, a woman’s husband and mother are given a place to stay near the clinic, which makes her feel comfortable. At the basic health unit in Phobjikha, a woman had given birth in the morning of the day I visited and had already left by the afternoon because her home was relatively close—but not before the midwife had signed off. Had a Caesarean section or other procedure been necessary, the woman would have been sent to a regional hospital.
Family planning is encouraged, and fertility is down. Parents are told, “When the first child goes to school, you plan for the second,” said Gado Tshering, adding that a very wide variety of planning methods and contraceptives are available free of cost. When parents reach the maximum family size they feel they can support, they often opt for sterilization, but now more often a tubectomy for the mother rather than a vasectomy for the father. The Bhutanese are still analyzing this trend.
The World Intrudes
Like many other developing countries, Bhutan also faces potentially catastrophic results of global warming as glaciers begin to melt and at the same time, winter snowfall diminishes. The future, Bhutanese fear, holds both disastrous floods in some places and water shortages in others.
Bhutan is in many ways blessed environmentally, giving it a head start among some other poor nations. There is no desertification. There is no starvation. More than 70 percent of the land is forested and the government has, according to the World Wildlife Fund, which works here, “one of the most ambitious conservation plans the world has ever seen.” By early 2007, the country had exceeded its target of ozone reduction by banning the import of all appliances with chlorofluorocarbons.
But because Bhutan is not immune to global warming, caused largely by industrial countries, this looming threat poses terrifying possibilities including death on a massive scale. Glacial lakes tucked in icy walls among the peaks that separate the country from Tibet have begun to send water cascading into the valleys below. A UN-backed report from the World Glacier Monitoring Service said in January 2007 that mountain glaciers around the world melted between 2000 and 2005 at 1.6 times the average loss rate of the 1990s and three times that of the 1980s.
This is one environmental problem that the Bhutanese can only watch unfold, not fix. Already one devastating glacial flood in 1994 wiped out high-altitude villages and badly damaged the famed Punakha dzong, the fortress-monastery that was once the country’s capital.
“We have done everything to preserve our environment, but global warming does not recognize international boundaries,” said Nado Rinchhen, Bhutan’s deputy environment minister. “Global warming is a very serious concern.” Ten or 15 years ago, he said, Thimphu could expect frost in October and snow from November into spring. “Now people grow vegetables even in winter,” he said. “Even a layman can say there is climate change.”
All the money invested by a poor country in improving lives and creating a healthy environment for the Bhutanese could be in jeopardy, Nado Rinchen said. “What is being done to us - Bhutan had nothing to do with it. We are the victims.”
1 World Health Statistics 2007, World Health Organization Statistical Information System. www.who.int/whosis/database/core/core_select.cfm as accessed on 8 June 2007.
2 Technically speaking, the definition of wasting is below minus two standard deviations from median weight for height of the reference population, and the definition for stunting is below minus two standard deviations from median height for age of the reference population.
Sign up to receive periodic email updates from DCPP