Bhutan Battles Tuberculosis

The isolated kingdom builds a formidable health network

As with all South Asian nations, tuberculosis is a major threat in
Bhutan, but the kingdom has a well-established network of health
facilities that provides free care and covers 90 per cent of the

Until relatively recently an isolated,
poverty-stricken country, the kingdom is undergoing a remarkable
transformation under the direction of Jigme Singye Wangchuck, who
ordered its transformation into a democracy and then abdicated the
throne in favor of his son .Jigme Khesar Namyel Wangchuck. In attempting
to transform the economy, the former king ordered the formulation of
the concept of GNH – gross national happiness rather than GDP – gross
domestic product. With an economy dominated by agriculture and forestry,
Bhutan's per capita GDP is only US$5,000 for its 700,000 citizens. The
health system is part of that transformation.

In a one-on-one
interview, Dr Ugen Dophu, director of public health in Bhutan's Ministry
Of Health, shared the secrets of the program's success, the special
initiatives to tackle the disease among the productive age group of
15-49 years, and the challenges it faces – such as the shortage of
trained health workers to monitor DOTS – what health officials call
Directly Observed Treatment Short Course – in rural areas, and a lack of
state-of-the-art lab facilities.

Steps to address these
vulnerabilities are already underway in the form of organizing regular
and rigorous training for frontline health workers and other
initiatives, all with technical assistance from the World Health
Organization and the financial support of the Global Fund.

What are the conditions of the average tuberculosis patient in Bhutan?
Typically, where do they hail from and what kind of challenges they

A: In Bhutan there is no specific community where the
incidence of TB is higher, and patients more or less come from all parts
of the country. Like in any other South Asian country, TB here too is
more prevalent in the 15-49 years age group and more in males than

Sixty-nine per cent of Bhutanese survive on subsistence
farming and so for people from rural and remote areas there are many
challenges in battling TB: First, daily DOTS is a challenge as s/he
cannot come to the health facility everyday. That's why we admit a
sputum positive TB patient to the hospital for two months to ensure that
the medication is administered properly.

Another problem is that
of patients being misled by local or traditional healers. To deal with
this the Ministry Of Health met with these healers and requested them to
refer anybody with a cough for more than two weeks or with chest pain
or blood in sputum to our health facility for sputum microscopy.

With a population of around 700,000 people, Bhutan has an annual
incidence rate of 91 cases of all forms of TB per 100,000 population.
While the case detection rate has been steadily increasing, the
treatment success rate is an impressive 89 per cent. How has Bhutan
achieved this?

A: The TB control program is meeting WHO
standards. This has been possible due to the commitment of health
workers. The concept of Gross National Happiness has been ingrained into
all Bhutanese citizens – that while wealth is important, more than
wealth, happiness is important. So people work for the community. They
sacrifice their time; they even sacrifice the opportunities for other

Another reason for this success rate is the well
established network of health facilities that provide free care and
cover 90 per cent of our population. Now our focus is on the remaining
10 per cent, which are moving populations like the nomads. For them, we
conduct seasonal health activities – immunization, TB check ups, chronic
disease check ups and family planning services. The district health
team goes and informs them of these camps where we immunize children,
educate them on HIV, and if someone has symptoms of TB then we do a
sputum smear and send it down to the district hospital. Further
treatment is taken from there.

Q: There have been notable gains in the achievement of DOTS coverage. What are the gaps that you still perceive?
The main problem is the retirement of health workers. The program has
not been able to keep up with updating the new health workers,
especially when it comes to giving a clear understanding of how DOTS
works. While the intensive phase – first two months – of the treatment
is taken seriously, the continuation phase is lax and that is where
there is some concern.

Q: In the battle against TB, how critical are lab facilities and what is Bhutan's plan of action in this regard?
Bhutan has 29 hospitals, 187 Basic Health Units (BHUs) and 440 outreach
clinics and lab facilities. Unfortunately, we cannot expand like other
South Asian countries.

Training a laboratory technician for
highly technical tests like sputum microscopy takes a lot of effort and
money. After training they have to do at least 10 sputum smear tests a
day to keep their skills up to date. But in Bhutan even some of the
district hospitals don't have that kind of workload. So, the skill of
the technician has every chance of going down. While at the basic level
this kind of expansion is impractical for us, we do have sputum
microscopy facility in all the district hospitals.

Since there
are more patients visiting the BHUs and outreach clinics we have trained
the staff on how to get a good sputum sample, how to make a good smear
and then safely transport it to the district hospital.

Our worry
is basically for those BHUs that are very far away from the hospitals –
perhaps a week's journey from the district hospital. For those few
remote BHUs we have invested in training the health workers there in
sputum microscopy in spite of the case load being low.

Q: Is multi-drug resistance (MDR) a problem when it comes to addressing TB in Bhutan?
A majority of our patients are receiving good ATT (Anti TB Therapy)
drugs and most are under the supervision of a health worker so
multi-drug resistance is not really a problem right now. There are only
about 13-14 cases a year of MDR-TB. We have an on-going study on the
prevalence of MDR-TB that will give us a better understanding of the
magnitude of the disease.

Q: Data on TB prevalence shows that
in Bhutan the productive age group of 15 to 49 years has been affected.
How do you focus on this group? Any highlights on treatment of women?

A sputum positive TB patient of the 15-49 age group is admitted to the
hospital for at least two weeks. When the patient expresses the need to
get back to his/her work we let them go but a BHU staff who lives near
the patient's house is briefed and medicine has to be given to the
patient at home, at least in the intensive phase, or the patient is
instructed to come to the BHU. There is also a follow up sputum
examination done by the BHU staff.

If the BHU is far away from
the village then a staff member trains the Village Health Worker to
properly administer the medicine. We call it modified DOTS. Women are
also dealt with in the same manner – in the urban areas we have no
problem in getting women to come to the DOTS centres. But in rural areas
it may be a problem so either the patient is instructed to come to the
BHU or she gets her daily dose from the Village Health Worker.

Q: How has the Global Fund grant and WHO's technical assistance helped the TB programme in Bhutan?
WHO's input has helped us build the capacity of the country to manage
the program; we have been able to technically build the capacity of our
health workers too. In fact, only WHO provides us technical assistance
for the TB program. Both the Global Fund and technical assistance from
WHO has helped us streamline our program.

We have inefficiencies
in the system, especially in procurement and prescription of drugs, and
we want to sort this out so that even if there is no Global Fund the
government can take over and sustain. We are supplying first-line TB
drugs but for MDR-TB we are still dependent on the Global Fund, which
also helps in procuring crucial lab supplies and training of the health

Q: The TB-HIV interface has posed a lot of problems in other countries. How is Bhutan faring?
Bhutan's TB-HIV collaborative activities are poor. As a step to
changing this we have initiated an exchange of information between the
two programs – the HIV program will keep the TB program informed on the
number of positive people and whether anyone has been diagnosed with TB.
We also have a lot of ground to cover in the educational aspect – TB
patients know about TB but they may have little idea about HIV

Q: Bhutan has undertaken information education
communication) activities on TB to improve community awareness. Do shed
some light on these programs?

A: The TB program is very
aggressive in its education activities – awareness has been created at
the institution level and we are also collaborating with the local
healers in villages in this regard. In the urban centers, we have
collaborated with pharmacies. They have been instructed to refer
suspected cases for sputum microscopy to the hospitals. At the
village-level, the Village Health Workers ensure that people with
symptoms of TB visit the BHU.

Each district conducts meetings
with these partners and briefs them on TB. Leaflets and pamphlets are
provided on basic information about TB – like 'what is TB? How it is
spread? How to identify a patient?'

For health workers, these
topics are included in their curriculum. Training is given for 14 days
in general health aspects and this is followed up with a five-day
refresher course every year.

Q: What kind of support are you providing in training of frontline health workers to help them create an empowering environment?
We have a comprehensive TB manual that deals with epidemiology,
identifying signs and symptoms of TB, treatment guidelines, and so on.
The program also organizes trainings on how to use this manual
effectively. We have a Training of Trainers program. At least every two
to three years the retraining of the health workers is organized.

laboratory technicians and the para-medical workers are trained on how
to collect a good sputum sample, on how to make a good smear, and so on.
For lab techs the training is conducted every year.

(© Women's Feature Service)