ANNUAL HEALTH BULLETIN 2004 - Ministry of Health

ROYAL GOVERNMENT OF BHUTAN
MINISTRY OF HEALTH
THIMPHU : BHUTAN
ANNUAL
HEALTH BULLETIN
2004

Table of Contents
General lnj'orllflltion
Foreword .1
Map showing health infrastructure 2
Structure of the Health Ministry 3
Health

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This Annual Health Bulletin, 2004 is the 24th in the series of publications brought
Qut regularly as a media on Bhutan health services ..It is a source of basic information on
health services delivery system recorded routinely and compiled on annual basis.
This publication selVes as a periodical progress report and provides feedback on the ongoing
activities of programme implementation. It is also intended to facilitate effective monitoring
of health programmes and ensure appropriate interventions for better management of health
services. Traditionally, this publication has therefore been our humble attempt towards
meeting the basic requirements of data and information for planning and setting priorities in
health. To make this system an effective tool, constant efforts are being pursued to improve it
through appropriate and timely reviews. However, we would still require continued cooperation
of all interested readers, particularly within health, in providing us feedback with
comments and suggestions for further improvement of this bulletin.
Looking back at the progress of health activities during 2004, considerable
improvement has been observed. This is evident from the fact that one can see an increasing
coverage of health services as revealed by the disease patterns over the years. There has been
very little or minimum cases of any disease outbreak this year and that the risk of deaths or
mortality has declined significantly. It is also observed that the attendance at the outpatient
services is significantly on the rise. This may be attributed to the ongoing health awareness
campaigns effectively reaching the grassroots and 'as a result the general population is
becoming much more aware of their own health needs, thus seeking care.
However, it is also evident from the records that problems do persist in many areas of
health that need further attention. From both the global perspective and country situations, we
are not only aware of the emerging problems but also seriously concerned with the rising
trend of non-communicable diseases. There is also the challenge of preparing and managing
disasters both man-made and natural. These altogether call for a closer look and require
different strategies to tackle the situation in an environmentally friendly manner.
In order to strengthen arid improve the district health system, the year 2004 has seen a
major shift in the policy of health administration by introducing District Health Officer
(DHO) who will manage overall public health aspects in the community. However, only 3
regions have been identified at the initial stage viz, Trashigang, Zhemgang and Chhukha for
East, Central and the Western regions respectively. This change is expected to bring about
improvement in the quality of services through fulltime involvement of the current DMOs in
their clinical profession and not having to deal with administrative burdens.
In conclusion, let me express my appreciation to all those who are involved in health
services development in Bhutan. Our deep gratitude is due to the development partners,
government agencies and to the health workers for their dedicated services whose collective
efIorts have been a source of inspiration for health in creating a conducive and progressive
life for the Bhutanese people.
Secretary
Ministry of Health

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National Referral Hospital
JDWNRH
Outside
Bhutan
T ••• •••
Eastern Region Central Region Western Region
Referral Hospital Referral Hospital Referral Hospital
Mongar Gaylephu JDWNRH, Thimphu
,
L
Dzongkhag Hospitals
(District Hospitals)
Community Health Units
_.1
:.........................................
t........................................ :
Basic Health
( BHU)
Units
Outreach Clinics
(ORC)
......... ....

Health Management Information System (HMIS)
Flow of Information
INFORMATION
MANAGEMENT
1. Monthly/Annual data
aggregated at BHU
level in electronic fom1
(by the end of next
month of past quarter)"-
2. Intra-district personnel
transfer information
(immediate)
3. District and lower level
disease outbreak
infomlatioll
(immediate)
4. Other immediate
renarts
1. National Level Indicators
2. Health Bulletins
•••
~/
calculat~ I Produces /
HEALTH
INFORMATION
UNIT
\
DISTRICT
OFFICE
(DHSO)
1. Feedback rep0l1 (quarterly)
2. Other infonnation on demand
Health Staff information
from Personnel Section of
Health, MoH .
1. Staff
Database
2. Vital statistics
database
3. Service Statistics
database
4. Facility Codes
1. BHUIHOSP
Service Statistics
database
2. HOSPIBHU wise
household
intonnation
1. Monthly Activitv
Report
2. Monthly
Morbidity report
3. Immediate
/
[HOSP-IT~.~AJ-~--
1. Feedback report (Quarterly)
2. Other infonnation on demand
''A
tl·
Monthly BHU reports (by 15 'of next month)
Village Level Arumal Household Survey (by] 5 th of March)
Immediate reports on notifiable dIseases
District level
mdicators
Community Health
Unit*
! Calculates
BASIC HEALTH UNIT ----------------~
(BHU)
Some BHU level
mdlCators
BHU Collects ORC service
informatlOn
/
[iRes
BHU Collects Vlllage mfonnatlOn
through annual survey & rural water
supply inspection reports
fVote: Some "enical programmes (e.g. TB and Lepros}) reports are directly sent to respecti,'"
programme head quarters.
• Community JIcalth UnU (C"HU) sends same informatioll to DHSO as sent by BNUs. Morbiditv
dl1/afrom CIIUIORCs managed by hospitals are added to the hospital l/wrbiditl ,[a!{/...

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Population 56205 63890 ,8847
Male 27747 30440 33489
Female 28458 33450 35358
Life Expectancy at birth (years) NA 66.1 66.1
Sex ratio (Males per 100 females) 103- 105.1 106.6
Dependency ratio 80 91.7 77.4
-
General Fertility Rate 170 172.7 142.7
Total Fertility Rate NA 5.6 4.7
Crude Birth Rate (per 1000 population) 39 39.9 34.1
Crude Death Rate (per 1000 population) 13 9.0 8.6
Population Growth Rate 3 3.1 2.5
Infant Mortality Rate (per 1000 live births) 103 70.7 60.5
Under-5 Mortality Rate (per 1000 live borths) 162 96.9 84.0
Matemal.mortality ratio (per 1000 live births) 8 3.8 2.6
Trained Birth attendance (%) NA 10.9 23.6
:.'-I!

Health facilities and manpower, 2004
A. Human Resource
Number of doctors (including non-nationals)
Doctors per 10,000 population
Ratio of doctors to hospital bed
No. of Drungtshos (Indigenous physicians)
No. of sMen as (Indi enous com ounders)
District Health Supervisory Officers (DHSO)
RSc. Nurses
General Nurse Midwife/Staff Nurses (GNM)
Auxiliary Nurse Midwife (ANM)
Assistant Nurses
Health Assistants (HA)
Basic Health Workers (BHW)
Ratio of nurses to hospital bed
Nurses er 10,000 ulation
Lab. Technicians
Dental TechnicianslHygienist
X-Ray Technicians
Pharmacy Technicians
O.T. Technicians
Eye Technicians
Other Technicians
Compounders/Para medical workers
Malaria workers
135
1.8
1: 8
31
26
23
12
183
140
175
201
171
1:2
6.8
106
48
32
79
23
29
29
22
47
Type of facility
Number/Indicator
Number ofhospitals* 29
Number of Basic Health Units (BHUs)* 176
Indigenous hospital 1
Indigenous Units 21
Training institutes (including NIFH, Gaylegphug) 3
Outreach Clinics (ORC)* 476
Total hospital beds 1068
Hospital bed per 10,000 population 14.0

Activities
The Royal Institute of Health Sciences as mandated in its vision and mission statements
continues to produce relevant and well trained mid level health human resource for the
Health Ministry. 71 pre service trainees graduated during the year. They include 18
GNMs, 17 HAs, and 36 technicians bringing the total number of graduates to over 1500
since its establishment as the Health School in 1974. 15 senior health assistants
completed the one year Diploma in clinical management course and will soon be posted
as Assistant Clinical Officers. The second batch of 16 senior staff nurses were also
awarded their Bachelor's Degree in Nursing early this year after completing the two year
conversion program conducted at RIHS in collaboration with La Trobe University,
Australia. The Bachelor of Nursing conversion program has been a grand success with
the targeted number of 30 staff nurses getting their Bachelor's degree. 2 scholarships
were awarded for the second time by the Vice Chancellor at the Faculty of Nursing, La
Trobe University.
78 new trainees were recruited in the 2004-2005 academic session, 22 GNMs, 19 HAs
and 37 technicians. Majority of candidates are with class 12 pass qualification. This is an
encouraging trend as we have trainees who are not only better qualified but are also more
mature and with better prospects for further training. The total number of trainees as of
today stands at 194 with 104 males and 90 female. This is near the maximum capacity
that RillS can handle.
4 new faculty members have been inducted into the RIHS. 3 more have re joined after
completing their Masters. There are 22 full time faculty members (8 with Masters, 3
undergoing Masters, 7 with Bachelors and the rest with Diploma or certificates) and 20
support staff. We also have 1 JOeV IT lecturer and one UNV midwifery lecturer on a
two year contract but whose terms are nearing their end.
While both quantity and quality in terms of qualification and experience has improved
significantly in the last few years, the faculty position is slil1 far from optimum if RIHS is
to impart quality training and handle the increased inti.J(c of both pre service and in
service training. We urgently need one more doctor to teach the clinical aspects, one
community health specialist, one health educator or communication expert and at least 4
nursing lecturers. The faculty also needs to be trained ;md updated on subject specific
knowledge, teaching methodologies and best practices. In this regard, many of the faculty
members had the opportunity to attend a teaching methodology workshop at NRTI,
Lobesa organized by RUB with expertise from NIF. A few of the staff also had
opportunities to attend trainings or workshops outside the country. With the
Government's approval of payment of remuneration to part time or visiting lecturers, the
faculty position and the quality of training is expected to Improve significantly with the
greater enthusiasm and participation of the doctors, nurses and technologist from the
JDWNRH and programme personnel from the Ministry.

Formal handing over of the Institute to the RUB has been delayed due to some
teclmicalities, but RillS is actively participating and interacting with the University in the
academic area and all efforts are being made to meet and institute the University's
requirements and standards.
Future Directions
• The Institute is gearing towards becoming a College of Nursing and Health
Sciences and begin to offer Bachelor' Degree in Nursing under the auspices of the
Royal University of Bhutan.
• The other training programs are also expected to be up graded to Diploma level.
• The Institute is also expected to take greater role in continuing education activities
by conducting in service trainings, workshops and up gradation courses.
• Faculty development in terms of quality and quantity would be one major activity
for the future. We need faculty with subject specific expertise at Masters level as
well as the requisite number and trained in teaching and learning methodologies.
• We also need to develop the research capabilities of the faculty so that the
Institute can conduct research in clinical as well as in the education field to
improve the training aspects at RIHS.
• The infrastructure will have to be upgraded and expanded to accommodate the
increasing number of students and staff every year.

The structure for QAS has been institutionalized in the Health Department during the
mid_8 th FYP since 1998 as one of the major component of the Health Care Division
under the Health Department.
With the commencement of the Ninth five Year Plan, the concepts of Quality
Assurance in Health Care have been outlined and a policy document on Quality
Assurance and Standardization was developed and disseminated to the health care
settings. With the bifurcation of the Ministry the quality assurance program has been
instituted as the QAS Division under the Department of Medical Services in 2003. In
view of the mandates and roles with other Departments and Divisions,' it has been
recently placed directly under the Ministry of Health.
The government has set poli~ objectives to improve and standardize the health care
needs of the country for the 9 FYP, which the Quality Assurance and Standardization
Division is mandated to operationlise the standardization of services and supplies in the
Ministry of Health.
Quality is the central issue in health care today. Rising expectations of the people and
patient safety advances in medical and diagnostic technology, competition in the health
care industry, and escalating costs have put quality of care center stage. There is a
growing realization that quality improvement is essential for enhancing efficiency and
effectiveness of health services both in the public and private sectors.
• By the end of the 9 th Five Year Plan, there will be a Nationwide Quality Assurance
System with clear policies and indicators that are practical and realistic.
• To establish structures and processes in the Ministry of Health to ensure continuous
improvement in the quality of health care through development and use of
appropriate health technologies.
• To develop an understanding of the concepts of quality and its importance in
health care.

• To develop skills in planning and implementing quality assurance programmes
in the health centers.
• To learn quality improvement processes, tools and managerial skills.
• To develop an understanding of standards and indicators of quality.
• Development and institutionalization of standard operative procedures
• To develop basic skills in the assessment and measurement of quality.
• Achievement of optimal utilization of resources (bnth human and material)
• Ensuring safety and
• Achieving consumer satisfaction.
A) Quality Assurance is a systematic and planned approach to defining, designing,
assessing, monitoring, and improving the quality of health services on a continuous
basis.
o
o
The development of guidelines for practice (standard operative
procedures) / benchmark.
Standardization of services, staffing levels, equipment and supplies
across health facilities.
1. Focus on the client: Focus on clients not only involves the external clients
(patients) but also the internal clients (organizational members)
2. Focus on systems and processes: QA focuses on arrangements of organizations,
people, materials and procedures associated with a particular function or
outcome, which consists of inputs, processes and outputs. These steps are
directed at achieving one goal or output from the system that encompasses the
processes.
3. Focus on Measurement: The collection and analysis of data are important in
QA as they ensure objectivity for quality improvement.
4. Focus on Teamwork: Teams are important to QA as the processes consist of
interdependent steps executed by different people, which involve clarifying and
incorporating the insights and needs of the clients into health care delivery.
Quality Assurance and Standardization Division is responsible for the development
and implementation of national policy/ guideline on QA in coordination with the
HTQC. The areas that must be addressed include:

• Establishment of goals and strategies in the health care plans according to the
priorities. .
• Legislation and nationwide coordination in implementing QA&S systerrl. in the
health care settings.
'
• Coordinate / facilitate to oversee and ensure that the health systems are
standardized, that the health facilities follow the minimum standards and quality
of services to the beneficiaries are ensured.
• Standardize the infrastructures, services, supplies and staffing pattern for all
health care settings in the ministry
The Joint Director, QA&S Division will spearhead and coordinate QA activities
through the HTQC and institutionalize the QA&S in the health care system.
Taking into account the geographical and communication barriers, three support
structures are proposed; National, Regional and District.
District level: District QA teams headed by DMOs and DHSOs based at district
hospitals.
QA teams will be formed at each level, which the individual will have a continuing
responsibility for the quality of their work in their own facility. QA teams will meet at
regular intervals to discuss and consider the quality issues and improving the overall
quality of the services they provide. Within the QA & S structure, some of theses teams
will take on additional responsibility of providing support to the less quality performing
districts or the Regional QA teams supporting the districts in their region and districts
supporting the BHUs in their region.

As a general principle QA responsibilities should be decentralized as far as possible,
consistent with the ability of lower levels to take decisions and manage the QA
implementation in their own area.
The proposed QA teams at various levels:
• National QA teams: Lead by Joint Director, QASD
• Regional QA teams: Lead by Superintendents
• District QA teams: Lead by DMO
• BOO QA teams: Lead by DHSO
• Review and discuss their prior quality problems at their level and develop
quality management plans.
• Conduct and coordinate the QAS training in their respective areas.
• Submit the annual work plans to the QASD.
• Submit quarterly reports to the J1, Director, QASD for feedback and for
effective monitoring and evaluation.
The Joint Director, QASD coordinates QA activities through the HTQC. The HTQC
forum discusses the priority issues for quality improvements and standards setting and
for developing policy on how quality of care issues should be taken forward within the
health services as a whole. This body is comprised of a broad representation of
personnel committed to assessing quality of care at all levels and their roles and
functions are:
To provide leadership and advocacy for QA & S in Bhutan
To assess priorities for quality improvement and standards setting
To maintain an equitable and appropriate distribution of health technology
and human resources at each level of the health services.
To promote and enhance the skills of health staff in quality improvement of
health care.
To review progress on quality improvements nationally
The health care authorities at the Regional and District levels will put quality assurance
in focus by establishing goals and policies in their own priority health care areas and
ensure that they are incorporated in the health care plans of their service centers. As part
of each plan, the authorities will ensure that each health care institution takes part in

quality assurance activities and reports the results of its efforts. Another important task
is the facilitation of interdisciplinary and inter-institutional cooperation. The formation
of QA teams at the regional level will greatly facilitate in handling this work.
The training on Quality Assurance and Standardization was planned in three phases.
The first phase of the training was conducted with help of external assistance. The
participants included only the in charges / heads of the sections of the health facility.
The second phase of the QAS training is being conducted at each health facility
including all the health professionals, administrative and support staff too, not
disturbing the daily routines of the facility.
The third phase of the training would be focused on the BHUs, which will be starting
soon after the completion of the second phase.
Monitoring the progress of the implementation of the training and the development of
the national QA & S support structure, which is already in place.
This monitoring will assess the performance of the QA&S system both in terms of
process and out come, that is in the operation of the QA&S system and the
improvements made across the districts and referral hospitals in quality indicators,
particularly those related to the national priority quality issues.
This will compare base-line measures of quality indicators for the priority issues with
the same indicators 3 years later.
Statistical analysis of changes in average values for district quality indicators and
analysis of variation between districts will be conducted. In this way it will be possible
to me;sure whether the gap in performance between poorer and stronger districts
reduces in time.

The National Traditional Medicine hospital, ITMS has carried out the General administration and
Management works on shedule as follows:-
1. Procurement of office equipments and other activities
2. Monitoring and management trips to dzongkhag Traditional Medicine Units.
3. Therapy extension works completed
4. Workshop on Incorporating Traditional information system into BHMIS conducted
5. Draft finalization of Traditional diseases classification
6. Finalized forms for treatment and Therapy activities ofNTMH
7. Publication of Traditional diseases classification (TDC) book, register and forms are
under process
8. Documentation and information unit for the lTMS established
9. Planned and initiated lTMS museum developement programmes
~ OThe Traditional Physicians and sMenpas have carried out the out-Teach-services in
religious centres at Phajodeng, Tango, Cheri, Dodedrag, Lhongtsho goenpa, Tashigang
goenpa and Thadrag goenpa.
• Cunducted quarterly staff meeting and monthly clinical meeting of NTMH, ITMS to
review the activities and improved the traditional medical services.
o
To study the nature and the specifice therapeutic uses of hot spring and minerals, National
Traditional Hospital (NTMH) has been conducted survey of hot springs and minerals in
Duedmang, Zhemgang Dzongkhag and Ge1ephu, Sarpang dzongkhag and Chuzom, near
Rabkhey zam in Wangdi dzongkhags.
o No specialized training for Dungtshos and sMenpas to upgrade their knowledge and
skills.

SN Cases Male Female Total
1 New case 8121 7207 15328
2 Old case 9292 7553 16845
Total 18413 14760 32448
SN Therapies Number
1 gTar (Blood letting) 117
2 bSreg (Moxibition) 21
3 sPra-gden-gSer-Khab (Acupreasure gold needle) 16806
4 dNgul-Khab (Acupreasure silver needle) 1233
5 IChag-tshug (Iron rnoxibition) 105
6 Snurn-Tshug (Oil rnoxibition) 374
7 Me-bum (Cupping) 1
8 rNgab-ra 13
9 sLang-dug (Steam application) 3197
10 Slang-lums (Stearn bath) 2448
11 Chu-lums (Herbal bath) 2326
12 sNa-sJyong (Nasal irrigation) 202
13 bShel-sKyug 1
14 rNa-sNyum 15

HospitaJlUnit
No. of out-patients treated
N••w Old Total
Indigenoushosnital 15603 16845 32448
Indigenous units:
TrashiganQ: 2517 745 3262
Trongsa 2829 2182 5011
Bumthang 2476 2463 4939
Punakha 3156 2418 5574
Haa 1952 2095 4047
Mongar 3068 1659 4727
Gaylegphug 1565 790 2355
SamdrubjJongakhar 1775 854 2629
PemagatsheI 1696 687 2383
Yebi1abtsa 1120 1403 2523
Paro 7176 3481 10657
T rashiyangtse 166 133 299
Lhuntse 1939 879 2818
Dagana 1642 415 2057
Tsirang 1565 790 2355
Samtse 1717 993 2710
Wangdiphodrang 3518 2730 6248
Chhukha 1397 950 2347
Gasa 919 310 1229
Riserboo 0 0 0
Phobjikha 53 74 127
Total: 57849 42896 100745

1. The National Institute of Traditional Medicine has published an academic calendar.
2. The field training for first year Dungtsho and Phannacy trainees has been
conducted in central and regional hospital and BHUs.
4. As per the training curriculum, field training trips for identification of Hig'l and
Low altitude medicinal plants have heen conducted for the 3 rd year s1\knpa
trainees in Lingshi Dungkhag and Trongsa Dzongkhag.
5. The amendment of training curriculum for Dungtshos and sMenpas has been
completed.
6. The trainees of National Institute of Traditional Medicine have been awarded 2 nd
prize of Guru Nangsi Z.,lnoen statue 28" on His Majesty's hirth anniversary 11 th
November 2004, in debate competition within Institutes of Royal University of
Bhutan, organized by Dzongkha Development Authority, MoE.
7. The National Institute of Traditional Medicine has published an evaluation hand
hook to enhance the quality of knowledge and skills dnd improvement of
disciplines for Institute.
TraditionalHospitallUllits
Drungts-,;;;-r-S~~~~~p-;;----
- . -L .
Indi~enous Hosnital, Thimphu 14 _li_____
Indigenous Units:
Bumthang 1 J____
Chhukha -- ~-- 1 1 -------
Dallana
- --'------ 0 _____ 1 ____ .
Gasa
.."--
1 1
Haa 1 1 ---
Lhuntse 1 .____ l~ ___
MonQar 1 _____ 1.___
Paro 1 1
---"
PemaQatshel 1 1
Punakha
-- 0 1
Samdrubiom!khar 0 1
Samtse 1 1
Gavlenhu (Saroanll) 1 1
TrashiQanQ" 1 1
Trashivam!tse --
1 1
TronQ:sa 1 1
Tsiranl.! 1 1
Baio (WanQ:diuhodrang) 1 1
Yebilantsa (ZhemQ:nag) 1 1
Riserboo 1
.. .-
0
Phobiikha 0 1
Total 31 26

1. Production, Supply and sales of Traditional Medicine
1. Total production output of 1692.265 Kilogram
2. Total sales of worth Nu. 3,55,493.425 from the commercial products.
2. Research and Quality Control
I) QC on Imported RM completed
2) R & D Work on product development
3) Quality Standards and test protocol under compilation
3. Training
o Pharmacology and his Assistant have undergone Immuno-modulating
studies at Mahidol University, through World Bank funding.
o Undergone training on basic running and maintenance of Tea packing
machine
1) Construction of Green house at Lingshi - Tender has been floated twice
and rejected by the committee.
2) Refurbishment and structural amendment to the Marketing section and
existing manufacturing unit ~ HIDP is drawing up design and awaits
the site plan from the City co-operation.
3) Expansion of Production and Storage area - awaits the Site plan and
Tapa survey from the City Co-operation and Department of Survey.
o
o
o
Preparation of Overall Work Plan and Annual Work Plan for EC MP
Project II completed Head PRU and many staff were intensely
involved)
First Steering Committee Meeting held
New Component Manager Appointed

Introduction
The laboratory services, preferably be called national laboratory services grew up side
by side along with development of preventive and curative health services in Bhutan
since the inception of planned development in the early sixties. With a very modest
beginning, there are now various levels of laboratories in the country provid :ng from
very basic services in basic health units (BHUs) to sophisticated tests and equipments
providing wider range of services at the National Referral Hospital laboratory at
Thimphu. Except at the central level where there is a separate public health laboratory
(PHL), public health laboratory activities are appropriately merged with clinical
laboratories at the district hospitals and BHUs.
Organization
The clinical laboratory services in the country are under the administrative umbrella of
the Health Care and Diagnostic (HCD) Services division under the Department of
Medical Services (DMS). The head of Pathology and Laboratory Services unit at
JDWNR Hospital, Thimphu is technically responsible for the overall guidance and
supervision of the laboratory activities in the country.
At present the JDWNR hospital laboratory is headed by a pathologist and assisted by
about 66 technologists and technicians. The regional referral hospitals have 4-6
technicians and 1-2 technicians man the Dzongkhag hospitals. A few of the BHU-I are
manned by one laboratory technician.
The laboratory services organization is pyramidal in shape viz the Central Laboratory at
Thimphu forming the apex and the BHU laboratories forming the base. The
intermediate level laboratories are those of the two regional referral hospitals at
Gelephug and Mongar and twenty-six other district hospitals across the country.
At the central level, there is one public health laboratory, administratively under the
Department of Public Health.
Vision
To provide excellent laboratory services essential for patient care and diseases
intervention with accurate, reliable and timely laboratory results and information.
Mission
• Upgrade and equip the Central Laboratory in terms of technology and human
resources and make it comparable to any accredited laboratory in the region.
• Upgrade the Regional Referral Hospital laboratories and make them equipped
enough to act as the regional referral laboratories
• Equip all district hospitals and grade I BHU laboratories with basic laboratory
•• services like biochemistry, hematology and blood transfusion.
• Develop different laboratory specialties in terms of personnel and services as
required.

Strategies
• Develop and rationally utilize laboratory technologists and technicians.
• Expand pathology, biochemistry and microbiology services at regional referral
and Dzongkhag hospitals including culture facilities.
'. Introduce frozen section services, immunochemistry, cytochemistry,
electrophoresis, and upgrade blood transfusion services in referral hospital
laboratories.
• Standardize levels of diagnostic tests done at different levels of laboratories
• Establish a Laboratory Quality Assurance (LQA) Unit under the technical
supervision of Central Laboratory at JDWNR Hospital.
• Establish a structured sample referral system from the Dzongkhag to NRHIRRH
laboratories.
• Streamline coordination and centralized planning and procurement of laboratory
equipments and supplies for the laboratories.
• Streamline and strengthen pre-service training oflab technicians at RIHS.
• Establish a computerized laboratory information system.
Present Status
A : M annower:
Class of Professional Existin Actual Shortage Remarks
g requirement
Pathologist 2 5 3 1 expatriate, 1
under traininl!
Microbiologist 0 3 3 1 MT doing
Micro No MD
Biochemist 0 3 3 Urgent
requirement
Blood bank MO
Medical Technolom.st
Medical Lab. Technicians
1 3 2
4 20 16
84 150 66
B: Existing Services: JDWNR Hospital
• Surgical pathology services catering to the whole country
• Cytopathology services performing gynecological, non-gynecological
cytology and fine needle aspiration cytology (FNAC) services
• Immunohistochemistry services providing 20 basic antibodies for
immunochemistry services.
• Biochemistry and Immunology services form the bulk of laboratory
activities. The unit also analyses and reports referred samples from the
districts and RRH especially hormones and tumor markers
• Microbiology services with facility for culture and sensitivity. Often
supports the DoPH in outbreak responses and diseases surveillance
activities.

• Hematology services for routine analysis and bone marrow studies.
• Flow cytometry installed in hematology unit now for CD 4+ and CD8+ T
lymphocytes count to support anti-retroviral therapy.
• Parasitology and urinanalysis services
• Blood Transfusion services with facilities for packed cells, platelets, fresh
frozen plasma transfusion.
• Pre-service and in-service training of health workers in laboratory
techniques
• Support public health programs in cervical screening, STD/HIV, CDD
activities,
• Conduct and support operational research
• Disease outbreaks responses
Most of the district hospitals and all the RRHs now have basic biochemistry,
hematology and immunology (rapid methods) services. The two RRHs and three other
hospitals have blood storage facilities too.
Cervical Pap smear screening services is available in Mongar, Samtse and Gelephug,
though smear collection can be done almost nationwide now.
Basic Health Units I with laboratory technicians have the capability to do tests similar
to the district hospitals. BHUs-II do only urine for sugar and protein, blood for MP,
parasites, hemoglobin and stool microscopy besides sputum for AFB and salt analysis
for iodine contents.
Activitie and achievements in the ast few vears
Patholo and Lab. Services 2004 JDWNRH
Laborator Sections -t--'Iotal tests
1
2
3
..i _
s
6
7
8
9
Microbiology
_lJ~(i8{2__
Hematolo
. __J.2{2.910
Clinical lab.
i. 31,171_
Histo atholo & C 010 _~2,552
Immunology
._.__i._.24~581
Hormone and Body fluids analysis .JL480
Blood bank·
__ 130.i.887
ANC sam les . 10685
Biochemist 236093
I

I
I
I
---~-~
J
,_J
15,000
i
10,000
I
T
I
C Hormone and Body
Fluids Analysis
5,000
Total Tests Performed in 2004 at JDWNRH,
".,.. ••. , tlfl41. ••• IJWf
D Hormone and Bod
Fluids Analysis

• Since 2000, annual intake of laboratory technician trainees at RlliS has been
increased to 10 every year (previous intake was 3-4 annually)
• Immunochemistry facility has been introduced in JDWNR Hospital from
2004
• Biochemistry services at JDWNR hospital has been greatly enhanced with
installation of another automated analyzer and one immunology analyzer.
• Histopathology and cytology services at JDWNRH has improved with
introdudion of automated tissue processors, cytocentrifuges and automated
stainers.
• Blood bank facilities in Thimphu, Mongar and Gelephug have greatly
improved with provision of blood bank refrigerators, plasma expressors and
more technicians trained in blood transfusion. One medical officer has
joined the blood bank after a diploma in transfusion medicine. Blood policy
has been drafted and standard operating procedure (SOP) manual developed
and distributed to all hospitals.
• Microbiology services with culture facility are available in Thimphu,
Mongar and Gelephug. Microbiology unit at JDWNR Hospital has installed
Bac Tee Alert 3D automated blood culture system, thus shortening the time
required for culture sensitivity.
• A cervical Pap smear programme has been launched covering many of the
districts in the country.
Issues and Constraints
• There is an acute manpower shortage at all levels in the laboratory services.
There is an urgent need to train more lab personnel and upgrade existing
technicians to diploma level in various specialties oflaboratory services.
• The training of technicians at RillS needs to be better streamlined by creating a
faculty at RlHS responsible for training laboratory technicians. Alternatively,
teaching members may be identified from the existing manpower in the JDWNR
Hospital laboratory with' designated responsibilities.
• The role of Central Laboratory at JDWNRH in upgrading and supporting other
laboratories should be properly defined.
• Most of the laboratories in the districts run out of reagents in the middle of the
year. Equipments break down and services are hindered frequently. There is a
need to strengthen the supplies and maintenance system of health equipments by
HERM unit.
• There is no system of quality check of laboratory activities in the districts as
well as some private laboratories in the country. A Quality Assurance unit has
to be established at JDWNR Hospital laboratory, which will then bring all other
laboratories in the country under the QA system.
• Surgeries are carried out in many hospitals in the country without the intraoperative
pathology consultations. There is need to start frozen section services
at least in the NRH and RRH pathology units.

Hospital associated infections (HAIs) is a major cause of mortality, increased morbidity
and emotional stress in hospitalized patients in the developing countries. These account
for significant economic loss and additional burden to health care institutions. WHO
studies have shown that HAIs are reported from hospitals in the Eastern Mediterranean
(11%) and South East Asia (10%) regions. It has also been estimated that at any time
over 1.4 million people worldwide suffer from infectious complications acquired in the
hospitals. In Thailand it was estimated that HAIs cost more than US $ 40 million every
year. ]berefore, the need for efficient infection control program in all health care
settings and capacity building for health care workers have been highlighted due to
CUlTent increase in trends in infectious diseases and sometimes life threatening
infections like severe acute respiratory syndrome (SARS) and reemerging diseases like
plague and tuberculosis. An infection control program helps to put various practices for
prevention of spread of infections. Lack of infection control practices facilitates the
transmission of infections from patients to health care workers, other patients and
attendants. Therefore, it is important for all health care workers, patients and family
members, friends and close contacts to adhere to the infection guidelines strictly. It is
also imperative for health care administrators to ensure implementation of the infection
control program in health care facilities. Therefore, Ministry of Health developed a
National Infection Control and Healthcare Waste Management Programme, based on an
assessment of representative sample of healthcare facilities and stakeholder
consultations, in October 2004 under Department of Medical Services.

The vision of IC&HWM program is to strengthen and improve occupational
conditions and reduce disease transmission in health care settings.
health
• Training of health care workers in prevention and control of Hospital Acquired
Infections
• Advice on isolation procedures and infection control measures
• Investigation of outbreaks of Hospital Acquired Infections
• Monitoring of the Hospital Acquired Infections
• Infection control audit including inspection of waste disposal, laundry and
kitchen
• Monitor and advice on the safe use of the antibiotics
• Monitoring of the staff health to prevent staff to patient and patient to staff
spread of infections
• Development of clear national policies and guidelines on IC&HWM
• Establishment of the Multisectoral National Infection Control Committee at
the central level
• To form Infection Control Teams and Infection Control Nurses in hospitals
and BHUs
• Development and distribution of the standards and IEC materials
• Training of health workers on Infection Control and Health care waste
management
• Procurement of supplies and equipments for civil works for environmentally
sound treatment, disposal and management of hospital waste.
• Institution of system of segregation, safe collection, transportation and
disposal of waste with minimal contact with patients, health care workers
add general public.
• Regular reporting, monitoring and evaluation of implementation of Infection
Control and Waste management Plan
• Infection Control Committee has been formed at central level
• Infection control teams have been established in some Ozongkhag hospitals.
• Procurement of equipments and protective attires, needle cutters, construction of
pits at different hospitals is under process
• Revision of guideline for infection control for health care settings and training

mcdules is in progress
• IEC materials on Infection control and waste management -in progress
• Lack of awareness and knowledge on hospital acquired infections among health
workers and community
• No standards and guidelines on Infection control and hospital waste
management in the health facilities
• No standard and uniform waste disposal system
• Inadequate funds for procurement of supplies and equipments.
• Inadequate trained manpower for implementation ofthe activities
• To revise national guideline on Infection Control.
• To develop post exposure prophylaxis policies/guidelines against HN
infection in collaboration with the HIV/AIDS program.
• To develop training modules for Infection Control and Hospital Waste
Management
• To train health workers on Infection control and Hospital waste management
• To revive the infection control link nurses who were trained in 2002
• ,To standardize the waste disposal system for health care facilities at the
earliest
• To implement Infection control system in all the hospitals

Nursing services in Bhutan is the backbone of health care delivery system. This
category of health workers represents more than 50% of the health professionals. They
play very significant roles in providing health care services in the hospitals and at the
community level. Nursing is an essential element of health services.
Masters
4 (excluding 3 undergoing training)
Bachelor 15
General Nurse Midwife 165
Auxiliarv Nurse Midwife 140
Assistant Nurse 175
Total number of nurses 499
\
urses rame In SDeClaIze Ie s
Intensive care unit 13
Nurse anaesthetists 11
Dialvsis 5
ENT 2
Endosconic recention crvo nrocedure 2
OT mana!!ement 2 ,
Psvchiatrv nursin!! 2
Orthopedics nursing 2
Counselinl! 1
Audiolol!v
I
Burns 1
Neonatal intensive care unit
I
Pediatric nursinQ' 1
Nursim! administration
I
OncolollV nursin!! 1
TMT 1
Total 47
Mission statement
To maintain nurses and midwives as a dynamic professional workforce
providing quality health care and influencing health development to
promote the quality oflife for the people of Bhutan. .
Aims and objectives
The main aims and objectives of nursing services are the following:
• To ensure provision of high quality nursing care
• To maintain adequate and competent nursing staff
.- To provide educational opportunities which facilitate personal and
professional growth and development in order to improve the
quality of health care services.
I
I

Strategies
• Training of more nurses in specialized areas
• Periodic in-service trainings to update knowledge and keep pace in
skills as per the demands of the changing situations
• Strengthen supervision and staff appraisal
• Strengthen recording and reporting system
• Develop guidelines and manuals for effective management of
. .
nursmg servIces
Target
To train more nurses on different specialized fields so that nurses take
critical roles to provide quality health care and improve nursing services.
Issues and constraints
There is an acute shortage of nurses across the country.
Recommendations
• There is an urgent need to increase number and competence of
nursing staff to improve the quality of services as health care
delivery is highly labor intensive and the Bhutanese patients are
also becoming quality sensitive.
• Establishment of a strong system of continuing medical education
(CME) as nursing staff must be updated with new knowledge and
skills to keep pace with the dynamic needs/changes in the medical
field.
• There is a need to strengthen faculty and other infrastructure in the
RillS so that intake of nursing students can be increased.
• Training of more specialized nurses as demanded for expansion or
introduction of new services is on the rise.

Nilme of Hospit41s/ Bed Patients load,2004 No of Clinicians *2 NurslRf( . Sta iff'-- *3
----
BHUGr1 strength I lR- Out- Specia- GDMO ACO Present Approved
*1 patients patients lists
---
JDWNRH 200 19775 2,49,849 29 7 20 132 129
(15traineesl
Monggar 80 2437 21673 10 2 33 46
Samtse 60 1279 18792 3 2 1 21 30 --~-
Gidakom 60 369 11301 2 1 10 30 ---.
Dewathang 60 1036 13971 3 7 10
Lungtenphu 49 742 10334 1 3
Trashigang 40 819 12950 2 2 2 10 21
Yebilaptsa 40 613 9330 1 1 1 7 45
._-",_.
Wangdi,RBA 40 29600 1 1
-_._-
Paro 40 1794 27285 4 1 20 _ .._ ...
21
Gelephu 40 1818 30441 7 1 21
-
Bumthang 40 412 14419 1
-.
Punakha 40 1553 27042 1 1 14 21
Riserboo 30 596 8154 1 1 0 10
-
S/jongkhar 20 586 18262 1 1 7 21
Lhuntse 20 587 8157 2 1 5 10
T/yangtse 20 603 8726 1 1 5 10
--
Damphu 20 685 20326 2 1 9 10
Pemagatshel 20 654 17342 1 1 4 10
_._-
Tsimalakha 20 892 19439 1 1 1 13 10
Trongsa 20 144 4932 1 1 7 10
----
Sarpang 20 521 26094 1 1 20 4
Gedu,THPC
I
20 807 30642 3 +-- 11 4
Phuntsholing 20 1731 29155 2 2 15 21
- -
Tsimalakiha 20 8.92 19439 1 1 1 13 10
Haa,[IMTRA T] 12 6 1 1 0
-
Gomtu 12 1 4
Sipsoo 10 636 - 13215 1 4 4
Baja 10 12821 1 I
-+
1 10 4
Yongphula 10
---
Bali BHU I 10 297 9197 1 1 6 4
IBFH,Thimphu 5 1 1 0
Note: * 1. As 01'2004
*2. These figures keep on changing due to transfers, further trainings, etc.
*3. Total strength og GNM, ANM and AN together.

The Primary Eye Care Program was launched in 1987. Initially, Andheri Hilfe, a
German NGO had inputs in the field of human resource development and supply of
ophthalmic instruments and equipments. It also funded the construction of the 25-bed
eye hospital at Yebilaptsa, Zhemgang. The project successfully ended in April 2000.
From May 2000, the Himalayan Cataract Project, another NGO agreed to provide
necessary financial support to the program with focus on human resource development
and also to strengthen the facilities for eye care services by supplying instruments and
equipment for the three referral and some district hospitals. The support also extended
in eye care activities such as outreach clinics, eye camps, school health, development
and distribution of lEe materials, training of health workers etc. The project further
helped in broadening the scope and dimension of programme by providing
opportunities for networking with various institutions and ophthalmic experts in and
outside the region.
One of the notable achievements during this project period was a corneal ulcer study
where Village Health Workers in two Dzongkhags were trained in diagnosis and
treatment of corneal trauma under close supervision and monitoring by the programme.
The Himalayan Cataract Project has completed its commitment in April 2005 and again
signed a $ 0.5 million grant MOU with the government for five more years till June
2010.
'Status
Eye care services form part of the national health care delivery system and is integrated
with the existing primary health care services. These include eye health promotion
through education, prevention of blindness and visual impairment through early
screening and appropriate treatment of potentially blinding conditions and rehabilitation
of the incurable blind.
Secondary eye care services are provided in all referral hospitals where cataract surgery
and other ophthalmic microsurgery facilities are available. Facilities for YAG laser for
after cataract and glaucoma care and treatment of retinopathies have been introduced in
the national referral hospital, Thimphu. There are ophthalmic assistants in all district
hospitals who provide primary eye care services. There is an effective eye patients
referral system, which facilitates early interventions and better outcome of treatment.
Though there are indooT patients in all referral hospitals, only the Eye Department in
Thimphu and Yebilaptsa has 20 and 25 beds respectively for inpatients.
There are 4 national and an expatriate ophthalmologis:ts working in the country. There
are 26 ophthalmic assistants who are posted at different district hospitals and BHU
Grade 1.
There are self-financing optical shops functioning at eye department, Thimphu and
referral hospital, Mongar. High quality, low cost spectacles are provided free to students

Besides the routine curative care, ophthalmologists in the national referral hospital are
involved in training of ophthalmic assistants. Organizing mobile eye camps and other
community ophthalmic outreach clinics, conducting school eye health and refresher
course for health workers are their additional responsibilities.
No blindness survey has been conducted in Bhutan and hence magnitude of the problem
has stili not been ascertained. However, as per WHO estimate, prevalence of blindness
in Bhutan is estimated at 0.8% and cataract is still the leading cause of preventable
blindness. Corneal blindness due to eye infections following trauma and refractive
errors are also common especially in the younger population.
General: To prevl!/It and control major avoidable blindness, and to make essential
eye care available to all.
Specific objectives:
1. To provide primary eye care services to the whole country
2. To ensure availability and accessibility to effective eye care through referral and
rrW>bileye services to all that are in need.
3. To raise eye health status of the population by reducing ocular morbidity and
blindness through IEe, improved referral system, mobile and outreach clinics.
Strategies and activities
1. Human Resource Development
• Training of national ophthalmologists and technicians in country, m the
region and beyond
• Training of other relevant health personnel in basic eye care
• Training ofVHWs and community leaders in basic eye care
• Appropriate ophthalmic equipments and instruments will be procured and
supplied to health centers
• Provision of refraction services and supply of low cost spectacles to school
children and community regularly and during eye camps.
• Through regular eye camps, this will target the un-reached population with
particular emphasis on improving cataract surgical rate and health education
• Through provision of instruments, equipments and other supplies as
appropriate for out reach services
• Through provision of eye health education in schools in collaboration with
comprehensive school health program and to the community through VHW s
• Development and distribution of me materials, manuals and guidelines

• Development of an appropriate information system as an integral part of the
national health information system to facilitate monitoring and evaluation
• Development of guidelines and data collection tools.
• Periodic review of the program
• Inadequate national human resource in terms of number and technical
capacity
• Emergence of new conditions like glaucoma and diabetic retinopathy
• Difficult terrain for the needy to access services especially during mobile
camps and outreach activities.
• Inadequate advocacy/IEe for patients for availing services on time.
• Mobile eye camps to be scaled up to operate 3000 cataract cases per year so
as to clear the existing cataract backlog.
• Establishment of retinopathy and glaucoma services in the referral hospitals.
• Sustain provision of refractive services & low cost spectacles for target
population
• Support in IEe/advocacy activities of primary eye care program through
development and dissemination of appropriate communication materials and
strategies
• Utilization ofVHW network in corneal ulcer and other basic eye care in the
community through capacity building

Oral health is an important component of general health services in Bhutan. It has also
become clear now that causative or risk factors in oral diseases are often the same as
those implicated in major general diseases. Thus, oral health promotion .nd oral
diseases prevention should embrace what is termed "the common risk factor approach",
leading to the integration of oral health promotion" into a broader health promotion.
Diseases like oral cancers, pre-malignant lesions like sub-mucosal fibrosis, lichen
planus, luekoplakia etc. can also be prevented.
OHP started in the early eighties but due to manpower and financial constraints, nothing
significant was carried out. However, due to the widespread prevalence of oral diseases
across the population, oral health programme was recognized under the umbrella of
WHO assisted programmes. Doctors posted in dental units, who also have clinical
obligations, look after the programme. Till date there is no one appointed as programme
manager for oral health programme.
1. Oral surgeon: 1
2. Dental surgeons: National: 6, Expatriates: 4 .
3 are undergoing P.G. studies.
3. Dental hygienists: 32
4. Dental technicians: 14
5. Dental assistants: 2
The over all objective of the OHP is to provide basic oral health services to all the
Bhutanese people.
• Capacity building:
This is focused on the training of trainers, dental hygienists and dental auxiliary
staffs in basic community and preventive dentistry to update knowledge, skills
and confidence.
• Reaching the unreachedlhard to reach population
A team in 1999 and 2000 visited Gasa to carry out dental check up and
treatment. A team also visits Laya & Lingshi yearly for dental check up and
treatment.
• Promotion of awareness on common oral and peri:6dontal diseases, oral cancers
and basic dietary and social behavioral preventive measures through appropriate
IEC media.

Activities carried out
.• Organizing school oral health programme:
I Yearly a team checks up students and treat minor problems as well as impart
lEe on oral hygiene.
• Targeted interventions are regularly carried out on specified communities,
schools and monastic institutions by the Dzongkhags.
• Annual Art clinic for traumatic restorative technique
• National cleft lip and cleft palate survey is under analysis by Epidemiology&
Research unit under the PPD.
• Annual cleft lip and cleft palate camp is organized annually in collaboration
with WI project, which consists of an American plastic surgeon team.
Few proposals
• To carry out a national survey on oral health and DMFf (Decayed, Missing,
Filled up Teeth) data in collaboration with WHO to find out the awareness and
burden of oral diseases in the population.
• Fluoridation of water in schools and other institutions.
• Systematic evaluation of community OHP to ensure effectiveness of the
programme and incorporate corrective strategies and activities.
Few issues/constraints
1. Need more doctors to be trained, so that all the districts can be covered.
2. Need to send oral hygienists and technicians for continuing education and
refresher courses in clinical and preventive dentistry in regional institutes
3. Urgent need for proper funding for oral health program activities with ever
increasing morbidity like loss of teeth in early age groups, increasing number of
oral cancers and precancerous lesions of the mouth etc.
4. Support in conducting relevant research/studies for evidence based
interventions.

An X-Ray service in the country was started in the mid 1965 with a small 60 mA
machine in the old hospital in Langjuphaka. In 1974 old hospital was shifted t' present
location after which some development took place in the X-Ray unit through
installation of 1 500 mA and a small 60 mA X-ray machines. Besides these
installations, the radiology unit also started to train few X-ray technicians and darkroom
assistant in basic radiography. In 1975 some major development took place in the
District hospitals too by installation of X-Ray machines in Trashigang, Gelephug,
Samtse, Sarpang. Radiographers from outside fan all these machines.
In 1980 radiographer course was introduced in the radiology unit on a regular basis.
Contrast examinations like barium meal studies E.G. barium meal, barium enema,
barium follow through, IVU, OCG, HSG etc were also initiated. In 1985, all training
activities were handed over to the then Health School, (RlHS now) and the first batch of
qualified Radiographers graduated from the Health School in 1987. Every year about 6-
8 radiographers graduate from the RIHS. By 1989, the first national radiologist joined
the Radiology Department following which installation of X-Ray units in almost all
District Hospitals occurred. By 1990, almost all the contrast radiography examinations
were introduced such as urography, venography, T-tube cholangiof,Tfam,myleography
and sonography etc. By mid 1994, ultrasound facilities were introduced in the
JDWNRHospital.
By 1995, almost all the old X-ray machines in the JDWNRH and Districts hospital were
replaced by new and advanced X-Ray machines with I.I.TV monitor and fluoroscopy
facilities.
By mid 1996 another national radiologist joined the Radiology Department. By, 2004
almost all the District hospitals and BHU grade 1 were also equipped with X-Ray and
ultrasound facilities.
Now we have 2 national radiologists and 1 expatriate radiologist on contract. All
together, there are 33 radiographers working across the country.
Some recent milestones
• A color doppler and telemedicine system in the Radiology department were
installed in 2004.
• 2 staffs have been trained to handle the color doppler ultrasound machine.
• 1 Radiologist is undergoing CT&MRI training for 2 years in Thailand and 3
radiographers have already been trained in CT & MRI.
• Another 3 radiographers each has been trained in contrast radiography and
~ ultrasound.
• 1 radiographer underwent medical radiological technology trai:ling through
nCAin 1995.
• . At present, 1 radiographer is undergoing 2 years diploma course in ultrasound.

• There is proposal for the introduction of CT and MRI in JDWNRH and CT scan
services at ERRH, Mongar soon.
• Expansion and standardization of ultrasound services in the country.
• More radiologists and ultrasound technologists are under process for advanced
courses outside.
• There is an acute shortage of human resources in radiology services.
• Procuring and updating radiological equipments as per advances in the field is a
challenge
Maintenance of the existing equipments is often difficult and this hampers in the provision of

History
In the 1990s, radio telephonic linkages were established in order to connect the remote
Basic Health Units (BHUs) and hospitals that are scattered all over the country.
Telemedicine was incepted when Dr. H.Nakajima the then DG of WHO had an
audience with His Majesty the King, Jigme Singye Wangchuck in 1997. It was fUlther
strengthened when internet was introduced in the country in June, 1999.
The Telecommunication Development Bureau (BTD) of the International
Telecommunication Union (ITU) in 1999 started a pilot project on Multipurpose
Community Telecenter (MCT) wherein Telemedicine was one of the components. In
conjunction with the MCT project, a teleradiology project was initiated in 1999-2000
by connecting the district hospital at Jakar to the Jigme Dorji Wangchuck National
Referral Hospital (JDWNRH) in Thimphu. The X-Ray image and ECG image
transmissions were carried out successfully, thereby, demonstrating the applicability of
the technology.
In November 2000, the two major referral hospitals at Mongar in the east and the JDW
in the west were connected. Consultations in different fields of specialties like
Radiology, Dermatology, Medical, Orthopedics, Surgical, Pediatric, Psychiatry,
Pathology etc. were carried out and monitored monthly based on the consultation
reports. Soon Gelephug district hospital was also connected to the internet and thereby
provided with X-Ray digitizer and digital camera to carry out necessary telemedicine
consul tations.
In March 2003, the East Bhutan Tele-ECG' project was carried out in close
collaboration with the Tokai University of Medical Sciences, Japan through the
Japanese grant for Grassroot Projects (GGP). Necessary trainings were provided with
support of the TeIemedicine Society of Japan (TSJ). The Trashiyangtse and Lhuentse
sites were provided with multipurpose equipment with analyzer software for ECG,
Cardioechogram and Phonocardiogram. The connection bi:l ween these two hospitals
and the referral hospitals is done through the dial-up connection via the local PSTN.
Since there are only one cardiologist in the country, the doctors from these two sites
consulted cases to the APT 2 nd Opinion Center housed in Tokai University, Japan for
correct and prompt diagnosis.
Inorder to monitor and guide the development of the project, a Health Telematics
Taskforce was formed in April 2000 with personnel from the Ministry of Health,
hospitals and WHO country office under the chairmanship of the Director of
Department of Medical Services. It has been further strengthened with members
included from the Ministry of Information and Communication and other relevant staffs
from the Health Ministry.

In order to overcome some of the difficulties and constraints that the health sector is
facing, te1emedicine was always looked upon as an efficient and cost effective
alternative to ensure quality health care services to the Bhutanese population.
• To improve diagnostic capacity of District hospitals
• To reduce patient referrals by back stopping them through consultative management
• To provide a forum for continuing medical education (CME) in the Hospitals
• To improve Health Information System
The overall objective is to improve the quality of the life of the Bhutanese peoples especially ir
remote areas.
The past five-year plans have placed greater emphasis on the Primary Health Care approach anc
thus achieved the basic health coverage of about 90%. A major focus in the Ninth Plan i~
improvement in the quality of health care services with improvement of secondary and tertiaI)
care without compromising the primary health care approach. As such the objectives will directl)
contribute significantly to the overall national health policy objectives.
At present, there are five sites furnished with the neCessary telernedicine equipments
engaged in full swing teleconsultations. There were a total of 363 consultations since
September 2001 till Feb 2004 as is reflected in the pie chart below.
RadiOlogy
36%
As seen above, tele-radiology with 134 consultations (36%) is the most common
followed by Medical consultations (21%), then Dermatology (15%), Orthopedics and
Surgical follow with 9% and 6% respectively.

Some of the main constraints faced in the development of this important service are the
inadequate financial resources for infrastructure expansion to cover all the strategic
health centers. The expansion is also limited as there has to be coordination and
compatibility with the over all enhancement of the IT and telecom system in the
country. Inadequate capacity in terms of trained manpower is another constraint in the
overall drive for the enhancement of the telemedicine services in Bhutan.
As reflected, tele-radiology is very popular in Bhutan. Currently, film digitizer is used
to acquire digital image of the X-Ray film taken in a conventional machine. Use of
computerized radiology technology will be cost effective and convenient in the long run
as it will get rid of many recurrent expenses like reagents and chemicals as well as
reduce repeated exposure of patients to the X-Ray. Further, it will bring about faster
service and economize space. Therefore, the next step for the telematics project would
be to opt for a computerized radiology and go for digital radiographic equipment.
A grand master plan for the Bhutan Health Telematics Project needs to be developed
whereby an ideal, fully networked telematics is visualized with complete human
resource plans as well as equipments at each health care level drawn out.
Bhutan Health Te1ematics services has to progress in collaboration 'with the Bhutan
Telecom and its level of development. Hence it will take decades to achieve a fully
networked Telematics environment. Therefore, the study of possibility of wireless
communication for health and the telemedicine in particular is being explored.

Diabetes is one of the fast upcoming non~communicable diseases in Bhutan. There were
446 cases in 2001,701 in 2002,indicating a rising trend. In 2002 to 2003,diabetes
mellitus formed 1.5% of the referred cases outside and 2.45 of the referral expenditure.
2.4% of referred cases for the same year were for renal failure, incurring 13.8% of
overall referral cost. A significant number of these cases would be the sequel of
diabetes mellitus.
World Diabetes Foundation is an NGO that has granted US$ 390,000 as a grant for
establishment of diabetes health care services in Bhutan with the view to, improve
access to proper diabetes care by establishing diabetes clinics in the referral hospitals,
improve knowledge of diabetes management among the staff by training and giving the
general population information materials and organizing awareness campaigns. The
project period is from July 2005 to June 2008. Bangladesh Institute of Research and
Rehabilitation in Diabetes (BIRDEM), has been identified as the tutor institute for
training and other technical support.
To ensure optimal case management of diabetes mellitus, delay and prevent onset of
complications and delay onset of disease in potential diabetics.
To improve access to proper diabetes and hypertension care by establishing
clinics at tWoreferral hospitals.
To improve knowledge of diabetes and hypertension management among health
service providers.
To give general population information on diabetes and hypertension, their
prevention, by developing health information and communication materials,
campaigns!advocacy.
To involve relevant divisions in the establishment and streamlining of diabetes
and hypertension services i.e. JDWNRH, RIHS, Information, Communication
Bureau (ICB), Mongar referral hospital
Plans and activities
• Study tour for sensitizing relevant hospital administrators and care providers at
BIRDEM, Dhaka.
• Setting up of a diabetes and hypertension clinic at JDWNRH and by th~ end of
2006,one more clinic at ERRH, Mongar.
• Development and dissemination of mc materials/messages, development of
training materials, manuals/guidelines etc.
• Training of relevant health workers for management of diabetes & hypertension.
• To conduct a baseline survey for NCD risk factors in collaboration with DoPH.

Perinatal medicine services are going to be an important aspect of the Maternal and
Child Health (MCH) services in Bhutan. Morbidity data for 1999 in general and
maternal mortality data in 2001 and 2002 show that nearly half of the deaths o( ~urred in
health facilities and were from preventable causes. Basic maternity care facilities in
particular, the delivery unit, clinic areas including space for ultrasound services must be
built in all the health facilities. Also there can be no improvement in the reduction of
these morbidity and mortality status if perinatal care is based only in and around the
referral and larger hospitals in the country.
The Magee Family, a non-governmental organization based in the United Kingdom has
granted an amount ofUS$ 350,000 to the RGoB for establishment of perinatal medicine
services in Bhutan as a project for seven years. The project will support the building of
a new maternity unit with specific focus on perinatal services, human resource
development through trainings, procurement of supplies (a high resolution ultrasound
machine for JDWNRH, Thimphu) and developing an outreach obstetric referral system.
The outreach referral system will be enhanced by the use of ultrasound machines for
early detection of fetal abnormalities and maternal complications. Computerized record
system for perinatal services will also be enhanced through this project. The projected
has started in Isl January 2005 and will end in December 2012.
The Department of Medicine Services will be coordinating and implementing the
project with a gynecologist trained in perinatal medicine at the JDWNRH as the
technical advisor. A preliminary evaluation of the project will be performed at the third
year and the final evaluation of project goals and objectives will be carried out at the
end of the project period.
To prevent or reduce maternal and perinatal morbidity and mortality from high risk
factors during pregnancy or delivery by establishment of perinatal ultrasound scanning
services at the peripheral health centers and by having access through the referral
system of all high risk patients for specialized perinatal medicine services at JDWNRH.
This hospital will act as an effective base for perinatal medicine services in Bhutan.
• All high-risk pregnant women have access through referral system for quality
obstetric care at JDWNRH by setting up perinatal service base there.
• The development of laboratory support for perinatal medicine as an important
component of the new hospital.
• All pregnant women in labour at JDWNRH will have access to improved
delivery facilities and practices including effective pain relief in labour and

timely caesarian section in dedicated operating theatres and a High Dependency
unit appropriately staffed and equipped.
• Stalt high-risk satellite clinics backed up by perinatal ultrasound services in
Paro, Punakha and Phuntsholing hospitals.
• Develop clinical perinatal database and protocols for standardized services.
Through development of human resources to support the project and related
activities. Training and retraining of sonographers and technicians will be a
priority.
By purchasing essential equipments including a new high-resolution obstetric
ultrasound machine with full service contract and after sales service. Supplying
some selected BHUs in cold places with panel/kerosene heaters will be taken up
to facilitate institutional deliveries. Later on, all the BHUs must be covered from
other funding sources.
By establishing perinatal medicine services at JDWNRH to cater as referral and
training center.
Through establishment of regional and district high-risk obstetric ultrasound
services to support the referral process.
By improving the existing obstetric services with establishment of a high
dependency unit and introduction of epidural service for effective pain relief
during labour.

J!])cPJ, rmffil:mcPJ1Yfl
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Over the decades, since the planned development activities started, Bhutan has made noticeable
progress in improving the quality oflife of the people of Bhutan. This was possible because of the
coordinated and public orientated effort of the various sectors of government functionaries.
The contributions from the Health Sector are evident by the gradual and steady improvement in the
important health indicators like, life expectancy at birth, infant and under 5 mortality rates, maternal
mortality rates, access to Health Care Services ihcluding improvement in human resource etc.
Reproductive Health(RH) Care is one of the important programme in the Health Care Services
introduced in the country as early as 1971. The RH programme has played a critical role along with
other programs and activities in improving the quality of life of the people. Reduction in Maternal
Mortality Ratio, Infant mortality, improvement in fertility rates and gradual reduction in growth rates
are some of the notable achievements during these decades.
In this report, some planned and routine activities carried out in the year 2004 that has directly or
indirectly influenced the achievements of Reproductive health are discussed.
Immediate objectives for the year 2004.
1. To increase the access to reproductive health services.
2. To procure and supply essentials equipments/instruments and contraceptives.
3. To improve skill and knowledge of health workers.
4. To generate communities support to the programme and increase knowledge about
reproductive health.
5. To provide quality reproductive health services and increased utilisation of health
facilities.
Construction:
• Construction of 320RCs initiated
• Essential equipment for 24 ORCs procured and distributed to all newly constructed
ORCs.
• Contraceptives procured and distributed to all the dzongkhags. In addition
Emergency Contraceptive pills have been procured and will soon be distributed as per
the guidelines.
• Procurement of non-expendable medical equipment to the district hospitals.

• 11 new doctors trained on Basic EmOC
• Training of trainers on revised Midwifery Standard completed
• Training of trainers on reproductive tract infections(RTI)/sexually transmitted
infections(STn and post abortion management.
Training outside country:
• Training of 4 Nurses in giving Anesthesia in Bangkok for 13 months.
• Two doctors trained on Emergency Opstetric Care at CMC,Vellore,India
Development and printing:
• Posters and leaflets on five danger signs of pregnancy printed and distributed to the
dzongkhags
• Revision of National Medical Standard for Contraceptives Services and Cervical
cancer guidelines completed
• Development and printing of The Manual on Infertility Management and Standard
Guidelines for health workers on Management of Complications of Abortion.
a e . on aCeD!ve users or e vear an
Methods Total- 2003 2004
Tubectomv 1049 1364
VasectomY 4636 4919
IUD 25669 2111
OCP 14403 18807
DMPA 51027 40745
Considering the existing CPR (30.7%) and contraceptive method mix (VO -44%, TL - 10%, IUD -
11%, OCP ~ 11%, DMPA - 19% and condom - 4%), none of the method utilization as shown in the
table are consistent. The 2111 IUD users probably depict new users. For OCP about 5500 women are
expected to use the method with the total consumption of 66,000 cycles of OCPs, if all of them used
the method for 1 year. However only 15,89-0cycles ofOCPs were used during the year. The 40,745
DMPA users probably connotes total no. of DMPA injection given, because at the current rate (19
%) of DMPA users, about 38,000 injections are expected to be used in a year. Information on
permanent method users could not be retrieved.
The study carried out in 3 gewogs in the 3 different regions of the country gives a very faint idea
about current family planning service situation at community level. However, the findings may not
hold good for all the communities in the country. The compiled study report is attached.

A. Antenatal Care:
Table 2. ANC attendance 2002-2004
ANC
2002 2003 2004
Total new attendance 10.594 12587 13656
Total reDeat attendance 39451 37077 45148
Average No. of visit (no.oftimes) 3.7 2.9 3.3
During the year 13,815 women attended the clinic at least once and there were a total of 45,819
visits. The new attendance shows a significant improvement both in absolute numbers and
proportion attending ANC (63% of expected pregnant woman). Average no. of visits per woman
(3.3) also shows marginal improvement.
Incidence reported like abortion, PIH and APH are inconsistent and inconclusive. However abortion
remains to be the most common complications encountered during pregnancy. Anaemia though
encountered frequently during day-to-day practice are clumped in other group, therefore it is
impossible to comment on the trend.
2001 2002 2003 2004
Total attended deliveries - 6256 6290 7120
-
Normal deliveries 6028 --
j5580 5625 6173
Still birth 97 154 78 110
I
Neonatal death - - 23 55
Birth weight«2.5kQ) - - 218 303
~
Ceasarian Section - - 539 783
Assisted deliveries - - 126 164
The number of attended deliveries shows a significant improvement in absolute numbers in the year
2004. There were 7141 attended deliveries in the year, however no proportional increase is observed.
About 1 % of the attended births were stillbirths and 3% of babies born are below normal weight
(2.5kg). The caesarian section rate among attended deliveries is 11% and about 3% are assisted
vaginal deliveries (forceps and vacuum deliveries).

Type
of
-. .
complications 2001 2002 2003 2004
Total °/0 Total %- Total ___o/!!-~_ J!!t~--~---_
• I
Abortion 125 5.4 311 12.1 464 30.5 579 i 21.2
-._.~.. - ··1- -.~~
A.P.H 15 0.8 56 2.2 111 7.3 __11..8.. __..----±l
P.I.H 102 4.5 100 3.8 254 16.7 f---- 365 I
-
13.4
Anaemia 1983 88.2 2101 81.5
Henatitis 1 0.1
f------- -_. ---_ .._.
Malaria 6 0.3
----
Others 17 0.8 690 10.5 1663 6UL
Total 2249 100% 1519 I 27251 .....-
257[= ~~
I
---·T-----
LiQO~____ J
Complication _2001 2002 2003
Total °/0 ... Total % Total % Total 0/c,
I
Obstructed labour 41 17.6 100 12.7 80 11.4 I 222_ _18.3
Mal presentation 59 25.4 130 16.6 104 14.8j---ill 9.3
Prolonged labour/ I
runtured uterus 2 0.8 152 19.4 204 29.1 267 22.4
PPH 49 21.5 113 14.3 145 20.6 183 15.1
Retained Placenta Sl __ 34.2.. 288 36.8 249 35.5 332 27.4
Puemerl Sepsis -_._-- f-------- ----_. 93 7.7
I
Total 232
I
..~- .._~ 783 702 1210
Prolonged labour, PPH, obstructed labour and mal presentations are common problems encountered,
in order of frequency.
Information about post-natal care is not available. However problems/complications like retained
placenta and puerperal sepsis are quite common.
--
There were 15,380 new attendances and a total of 136,095 repeat visits with an average of9 visits by
each child. Repeat visits above the age of I year, though expected to be high, still remains low.
There are 150416 instances of weighing infants and children attending clinics. In about 17% of
instarl'ces, overweight was encountered and under nutrition in about 9% of instances. Severe
malnutrition is very rare. (Less than 1% of instances).

80%( 13011 infants) of estimated infants received all the vaccines provided within the first year of
birth. Dropout rates are within limits of accepted range (BeG to Measles = 6.3%, DPTI to DPT3 =
3.6%).
Among the vaccine preventable diseases in the year, 68 Measles and 22 Tetanus cases were reported.
Among the measles cases, majority of the cases were in above 5 yrs old population. Only one
Tetanus case under 5 years old population was reported, however it is not known whether it was
neonatal death or not.
Table 6. ¥carlv Cervical Cvtoloi!v. JDWNRII 2003 and 2004
Year Normal Inflamm ••tion
Nonpccific
Soccific Actipo Atrophic LSIL LSIL HSIL HSIL
nflammat
Cervlcitl
in BV TV Yeast mvcetes lHeroes • ASCUS AGUS HPV CINII IrIN HI Unsat
2003 1532 674 212 117 33 3 2 49 20 32 8 36 102 1 150
2004 3479 920 755 214 20 8 1 61 14 9 7 18 32 4 392
Year.
torm
..I -1ft n
Son-Specifi So •.•.ifi. Actlno Atrophic LSIL LSIL HSIL HSTL
nflammatoi
n BV TV Yeast mvcetes !Hero ••• r"rvicitis ASCl;S AGl:S HPV CINII £:1'.11I Unsat
2003 I S02 338 34 23 II II I 6 I 3 2 6 38 3 169
2004 I 2677 1003 472 125 13 4 6 21 2 7 2 20 2J 1 663
The number of screening at JDWNRH and the districts are increasing. The percentage of abnormal
smears at both JDWNRH and other centers are about 1% of the total slides examined.
Unsatisfactory slides, particularly from the districts are exceptionally high (13%).
Though the information on age of women is not available from the districts, looking at JDWNRH
records, it is revealed that majority of the women are in the age group 20-29 years of age.
Table 8. A
Age group
of women screened in 2004
Total Smear
20 - 29
30 - 39
40-49
50 and above

Complied
by: Dr. K.C Buragohain, JDWNRH, RHU
Mr. Sonam Wangdi,APO,RH
The programme would like to extend our gratitude for the guidance, help and co-operation from the
following officers and staff at different stages of this study.
1. DMOIDHSO Trashigang,Sarpang, and Punakha Dzongkhag
2. HAJANM/BHW- Kanglung, Norbuling and Kabesa BHUs
This report would not have been possible without the untiring efforts of the trainees and facilitators
of RH training conducted at Kanglung BHU, Gaylegphug NMCP training center and Punakha
hospital
Contraceptive prevalence rate and fertility rates are two critical indicators of quality of family
planning services provided to the communities. In many of the Health facilities there was an
observed lack of understanding about source of information and estimation of these indicators.
The RH training of the trainers in three regions- Kanglung for eastern region, Geylegphug for Central
region and Punakha for western region provided good opportunity to train the trainers as a part of the
training. It was felt tlult the same training CQu14be carri~ out when district level training is taken up
in respective district.
1. To train the participants on how to estimate Contraceptive Prevalence Rate and Fertility Rate.
2. To estimate Contraceptive Prevalence Rate and method use in these gewogs
3. To find out the common problems faced by the women while using the family planning
methods and reasons for not using.
At the time of the training it was not possible to visit each and every household in the areas of the
BHUs located in those gewogs. To make the study statistically significant for the areas the strategy of
thirty clusters randomized sample survey was adopted. Each household was considered to be a unit.
The households were arbitrarily numbered from the village household information available in the
BHUs of the area. The first household in each cluster was selected randomly and continued with next
nearest house till required numbers of women were interviewed. Seven women ofreprodYctive age
(15-49 years of age) from each cluster were interviewed for collection of information.
Standard tools to collect information was developed which contained information on total

population, family planning practices among women of reproductive age irrespective of their marital
status, reasons for not using contraceptive method, problems faced during use of methods and state
of fertility in the past 1 year.
The trainees were selected as surveyors and were trained on the survey methodology including
practical sessions in the form of a role-play. Each surveyor was assigned a minimum of 2 clusters
and was provided with a guide to identify the clusters.
The information so collected were tabulated and analysed manually to make it more user friendly.
The findings of the studies are discussed below.
a. Total households visited:
A total of 490 house holds, 140 in Norbuling, 168 in Kabisa and 182 in Kanglung gewog; were
visited to interviewed 635 women (210,212 and 213 women respectively at Kanglung , Norbuling
and Kabisa gewogs). On an average 1.3 women were interviewed per-house hold.
a e . AQe an sex Istn ution 0 enumerate ODU a on:
PODulation enumerated
Age Sex Kanglung Norbulingl Kabisal Total Percentage
Gratap Geog Chusegang Samazinkka
Geog
Geog
M 252 176 180 608 21.03
0-14 F 211 190 206 607 20.99
M 37 39 30 106 3.66
15 - 19 F 48 52 56 156 5.39
M 19 25 20 64 2.21
20-24 F 46 57 43 146 5.05
M 35 18 27 80 2.76
25 - 29 F 44 32 - 50 126 4.35
M 38 15 23 76 2.62
30 - 34 F 47 33 43 123 4.25
M 33 22 17 72 2.49
35 - 39 F 37 33 27 97 3.35
M 24 16 21 61 2.11
40-44 F 23 24 28 136 4.70
M 14 22 25 61 2.11
45 - 49 F 15 32 28 75 2.59
50 and > M 50 60 79 189 6.53
F 39 49 . 81 169 5.84
tl12 895 984 2891 100
Total
There was a total count of 2891people that were actually residing in the various hO'lseholds visited at
the time of survey. Among the occupants 1317 were males and rest (1574) were women
(female/I 000 male =1195). The major fraction of population belonged to age group 0-14 (42%).

About 30% (29.71%) of the population presently living in those area are women of reproductive age
(15- 49 years). Only about 12% of the population are 50 years or above.
a e . .!!e Istn uti on and ontraceptive use rate:
SI. Age
No. group No. of women interviewed Total Percentage
Klunv* N.lin!!** Kabesa*** Total Klun!! N.lin!! Kabesa
1 15-19 19 35 29 83 2 5 0 7 8.43
2 20-24 32 42 41 115 13 13 8 34 29.56
3 25-29 43 27 40 110 23 16 8 47 42.73
4 30-34 46 30 32 108 26 16 15 57 52.77
5 35-39 36 29 27 92 23 23 11 57 61.95
6 40-44 19 22 23 64 9 15 11 35 54.68
7 45-49 15 27 21 63 I 5 14 8 27 42.85
Total 210 212 213 635 101 102 61 264 41.57
During the study, all women interviewed irrespective of their marital status; were asked about their
current contraceptive practice. Out of the total 635 women interviewed 264 women were using
(41.57%) some modern method of contraceptive. Kanglung and Norbuling gewogs had a CPR of
48%; it was lowest at Kabisa gewog at 28%. The highest No. of acceptors are in the age group 35-
39 years(62%) and gradually declines with advancing age; only 43% of women of age group 45-49
years are using some form of contraceptive. The Contraceptive practice increases with increasing
age from 15 years to 35 years. It was found to be lowest (8.43%) in the age group 15-19 years.
d. Contraceptive Choice:
Table 11. Contracemtive meth 0d mIX .
SI.
No. Method Total number of user Total Percentage
N.lingl Kabesal
K.lun!! C/!!an!! Samazingkha
1 Condoms 0 2 0 2 0.76
2 Oral Pills 4 11 5 20 7.6
3 DMPA 60 29 22 112 42.58
4 ruCD 11 7 4 22 8.36
5 Vasectomy 22 29 23 74 28.13
6 Tubal Ligation 4 23 7 34 12.92
7 Others 0 0 0 0 0
Total 101 101 61 263 100

Among the modem methods of contraceptives, DMPA is the most widely used methods of
contraceptive (43%), followed by vasectomy 28%. Tubal ligation is used by about 13% of the
women. The use of oral pills and IUeD are 7.6% and 8.36% respectively. Only 0.76% of the women
are using male condom as a method of contraceptive. Use of any other methods of contraception was
not recorded at the time of study.
Three hundred seventy-one women who were non-users of contraceptive at the time of the study
were asked for reason for not using. Currently not married was the most common reason for not
using any methods (23%). Want more children (11.32%), Breast
feeding> 6 wks (9.16%) and pregnant(8.08%) are the other common reasons. About 5% of the
women interviewed were not using any methods as they were unable to conceive and another 5% of
the women were afraid of side effects. Attitude of the Health Worker and genders were not found to
be reason for not utilizing FP services.
Other reasons for not using F.P are divorced/separated, will not get pregnant, waiting for
menstruation, thinks method will not suit, missed date for injection, menopause and undecided.
Total number
SLNO Reasons of women Percentage
1 Unmarried 87 23.45
2 Sexuallv not active 7 1.88
3 Pre~ant 30 8.08
4 Breast feedinl!>6 weeks 34 9.16
5 Postoartum 4 1.07
6 Want more children 42 11.32
7 Not heard ofFP 3 0.8
8 Not able to conceive 20 5.39
9 Do not like 2 0.53
10 Afraid of side effects 17 4.58
II Health worker's attitude not friendlv 0 0
12 Male health worker 0 0
13 Others* 125 33.67
Total 371 100
* will not conceive due to age, Divorced/Separated, Will not get pregnant,
waiting for menstruation to return, thinks method will not suit her, missed
dates for injection, menopause, undecided etc.

discontinuation. Medical side effects following the use of the method were found to be the most
common cause for discontinuation (34%). Want another child is second most common causes of
discontinuation (22%). Other less common causes are divorced/separated, not able to report in time,
will not conceive, no time to go to the BHU etc. Reasons associated with misconception like
developing of cancer and uterus becoming abnormal after the use of contraceptives were also
recorded in some instances. In eight women reasons for discontinuation was not know.
Total
SI.NO Reasons for discontinuation Discontinued Percentage
I
1 Medical side effects 26 34.21
2 Want more children
.
17 22.36
3 Contracentive not available 0 0
4 Divorced/Senarated 6 7.89
5 Not able to renort in time 4 5.26
6 Others* 15 19.73
7 Unknown 8 10.52
Total 76 100
Among the method users, 54 women have faced some problem while using the method and majority
(83%) of the problems are because of Medical side effects. Only 2% of the users said that the Health
center is too far. Health workers attitude and gender of the Health workers were not found tobe of
any issue. Seven women (13%) faced other problem like husband not supportive and no co-operation
from other members of the family.
a e . ro ems ace IV con raceD' Ive users
SI.NO Tvne of Problem Total Nos
1 Side effects
2 Health center too far
3 Health workers attitude
4 Male Health worker
5 Others - -
Total
83.33
1.85
o
o
12.96
100
Fertility among different age group of wQmen was studied for a period of past one year. The fertility
rate was found to be highest in age group 25-29 years(248. 1411000 women) with gradual decline to
18.51/1000 women of the age group 45-49 years. The fertility rate for teenagers (13-19 years) was
found to be 71.43/1000 women. The next group of women where fertility is high (204.12/1000
women) is in the age group 20-24 years.

Table 15. Fertilitv status
S Age
No. of
women T~~al bi:T
Fertility
N Group interviewed in 1 vear Rate
N.LinQ Kabesa Total N.Limz Kabesa Total N.Linll Kabesa Mean
1 15-19 35 29 64 5 0 5 142.85 0 71.43
2 20-24 42 41 83 11 6 17 261.9 146.34 204.12
3 25-29 27 40 67 8 8 16 296.29 200 248.14
4 30-34 30 32 62 4 8 12 133.33 250 191.66
5 35-39 29 27 56 2 7 9 68.96 259.25 164.1
6 40-44 22 23 45 1 6 7 45.45 260.86 153.15
7 45-49 27 21 48 1 0 1 37.03 0 18.51
Looking at the ASFRs (age specific fertility rate) in these seven age groups the total fertility rate is
estimated to be 5.25 per woman. Fertility status was not studied at Kanglung gewog. Fertility in
younger age group was higher in Norbuling gewog and older age group was higher in Kabisa gewog.
5. Discussion:
The women of reproductive age during these three surveys represents more then 50% of the total
women interviewed .(TotaLwomen in--l6-49 yrs interviewed was 859 and total women in 15-49 yrs
was 635). The study gives us a picture of the current situation of contraceptive use in the studied
gewogs.
The male to female ratio is found to be marginally higher than the National ratio of 98: 100
(Statistical year book- 1997). As per the National Health Survey 0[2000, the ratio was found to be
94: 100. Another important finding is the no. of women of reproductive age residing in these
areas(30%). These aberrations are probably because of migration of adult male population to other
areas looking for better opportunities or for studies. Other findings like the age and sex distribution
are almost consistent with the existing averages.
The overall contraceptives prevalence in these three gewogs is found to be 41.57% of women of
reproductive age. This shows an overall improvement of 10% from 2000 National Health Survey
(30.7%). It was lowest in Kabisa gewog- 28%. A comparison of the age group wise contraceptive
prevalence with 2000 National Health Survey (NHS) is shown in the table below.
Table 16. Com arison of a
15 - 19
20-24
25 - 29
30 - 34
35 - 39
40-44
45 -49
Overall

The overall CPR improved to 46% if wornell not at risk of pregnancy are excluded from the
denominator. This group of women also includes women who are pregnant, post partum within 6
wks and wo~en who are in fecund. 46.57% CPR is comparable to any other developing country
though it is slightly lower. Contraceptive prevalence in teenaged girls, though looks improved, needs
further improvement. Also in the other extreme group (45 -49 yrs) it is low.
1. Contraceptive prevalence rate is far below the expected increase.
2. Contraceptive use by extremes of Reproductive age women is low.
3. Use of condom as a method of contraceptive is almost non-existent.
4. ruCD use as a method of contraception is not improving as expected.
5. Medical side effects are one of the common reasons for non-use or discontinuation of
contraceptives. Also it is the most common problem faced by the user.
6. Misconception about contraception like, may cause cancer ete are prevalent among some
users.
7. Infertility though not explicit is prevalent among 5 % ofF.P non-users.
8. Fertility rates are very high in cOJ;Ilparisonto similar countries in the region
9. Pregnancies among teenagers are common.
C,onclusion:
The study has attempted to give a picture of the status of Reproductive Health, in particular the
Family Planning aspect at the community level. Although the study has been carried out using only 3
gewogs, the findings reflects to some extend the situations that rest of the country is currently in.
With continuous support from the government, the situation seems to be improving as reflected by
the 46.57% CPR of the three villages. Although there is an increase in the CPR, it is still far behind
the target of 60% CPR to be achieved by the end of ninth five year plan.
6. Some Priority Issues:
Some issues, which are apparent from the report and also implied from reviews and observations
made during the year that needs to be addressed in priority basis, are mentioned below:
1. Low and Inadequate ANC attendance:- Approximately 63% of pregnant women are attending
ANC at least once and it is far below the target of 100% attendance that has to be achieved
by the end of ninth five year plan period. Ideally a pregnant woman must at least make 4
ANC visits.
2. Low institutional deliveries:- Institutional deliveries (Hospital and BHU deliveries) and
deliveries attended by a trained person constitute only about 32% of the total deliveries.
3. No policy support on Post-natal care- no information is collected on postnatal care at any
level except information on couple of complications. So routine monitoring is impossible.
4. Low Contraceptive Prevalence rate :- Contraceptive prevalence rate though shows gradual
improvement, is still low at about 41%.
Other issues related to F.P have been described in the study report.

5. Abortion Complication:- Though the incidence of complications following abortion is
not known, prevalence of abortion as a complication of pregnancy is very common.
6. Infertility and RTIs including STIs:- Though prevalence of infertility is not yet studied, from
the 3 gewog Family Planning study, it is revealed that quite a high number of women are
unable to conceive. Major causes are probably from the Reproductive tract infections (RTIs)
and sexually transmitted infections (STIs).
7. Low Cervical Cancer screening coverage:- Only 8% of target population could be screened in
the year 2004, which is inadequate for any impact on reduction of cervical cancer in the
communities.
8. Teenage Pregnancy and Contraceptive use:- Teenage mothers constitute about 15% of the
antenatal attendees. In some of these young mothers, the index pregnancy is already second
or third pregnancy.
Contraceptive prevalence in this group of women is negligible.

Expanded Program On Immunization (EPI)
The EPI was launched in the country on 15 th Nov. 1979 coinciding with International
Year of Child with an objective of reducing the seven- vaccine preventable disea 'es.
(TB, DiphtheIia, Pertussis, Tetanus, Polio and Measles) In December 1994, the tetanus
Toxiod vaccine for pregnant women was also introduced in to the program. In Mid
1996. Hep.B vaccine for all children under one year of age was introduced as an
integral component of EPI.
The EPI services been full integrated in to the general public health services mainly
with MCH/FP in particulars. It is delivered through existing Hospitals, BHUs and
ORCs. Over all Immunization services aimed for effective coverage with all seven
antigens aimed at all infants less than one year of age and to all pregnant women.
Goals for 9 th Five years plan.
• The goals of the EPI program is to reduce the seven vaccine preventable disease to a
level at which they are no longer public health problem by maximizing opportunity,
minimizing risk and increasing acceptability and reach of immunization program.
Objective of Program are:
• To sustain EPI coverage for all seven antigens at one above 90 percent for all
children under one year.
• To eradicate poliomyelitis by 2005
• 90% reduction of measles cases
• 95% reduction of deaths caused by measles
• To eliminate Maternal and neo-natal Tetanus by 2005
• To develop sustainability in the EPI program through national capacity building.
Strategies:
• Ensuring quality and vaccination safety
• Establishing and strengthening surveillance for all EPI disease
• Community mobilization
• National capacity development for ensuring sustainability
Program Status:
• Immunization coverage maintained above 85% under one year of age
• There are seven antigen under EPI programme.
• DPT -Hep.B combination vaccine introduced in 2003 nation wide through GAVI
support
• AFP surveillance conducted in 22 hospital in 2003
• Open Vial Policy for DPT-Hep.B, OPV and IT vaccine were introduced in
December 2003.
• Reusable Syringes were replaced by Auto Disable Syringes (AD syringes) for all
BPI vaccines in December 2003 through GAVI support

• EPI mid level management training was conducted for DMOs/DHSOs and primary
health workers from 2003 and on going activities.
• No. Cases ofMNT have been reported since 1994.
AFP Surveillance:
• Bhutan is a non-endemic country for poliomyelitis. The last case of clinically
compatible case of poliomyelitis was detected in 1986 in Tsirang Dzongkhag. But
due to its porous border with an endemic country, India, the risk of importation of
poliovirus is always there. Thus, in order to control measures, acute flaccid paralysis
(AFP) surveillance was initiated in later part of 1997.
• Since, 1997, 18 of AFP cases were reported and investigated and discard as nonpolio
by the national expert committee polio eradication.
During 2003 4 AFP cases was reported and active surveillance pick up one unreported
case of AFP from JDWNRH, Thimphu and stool result was inadequate because of late
collection and that case was referred to Kolkota for the further treatment. Now the case
has been investigated and discards as non-polio by the national expert committee.
Rubella.
Rubella was not a notifiable disease in the country. The new as well as the old hospital
and BHU reporting forms did not include rubella for routine reporting. No. Laboratory
testing facilities for rubella existed prior to April 2003. Though clinical suspicion of
rubella was made; there were no supportive diagnostic facilities.
Trongsa had an outbreak of febrile rash in 2003. This occurred in the municipality areas
as well as in some nearby villages. A total of five schools had the outbreak which had
laboratory confirmed rubella. There were six other Dzongkhags that reported similar
epidemics these were laboratory confirmed as rubella epidemic. In 2003 Public Health
Laboratory has received 179 sample of blood for analysis among which 35 samples
tested were from pregnant women from the outbreak area in Trongsa. All were negative
for rubella (IgM). These samples were tested for anti-measles IgM as well as antirubella
IgM.All the samples were negative for measles IgM. Fifty-five samples tested
positive for Rubella IgM among non-pregnant groups.

Sl. District BeG Measles DPT- OPV OPVO
No HenB3 3rd
1 Bumthang 301 283 297 289 303
2 Chukha 1540 1686 1688 1685 1398
3 Dagana 402 407 431 431 320
4 Gasa 50 56 57 57 45
5 Haa 176 231 229 229 149
6 Lhuntse 346 364 377 380 211
7 Mongar 996 848 889 923 639
8 Pam 416 556 622 622 383
9 P/Gatshel 298 319 277 277 196
10 Punakha 427 416 468 469 271
11 Samdrubi ongkhar 975 922 916 953 944
12 Samtse 1214 1187 1254 1261 831
13 Sarpang 986 937 899 925 704
14- rTItimphu 2819 1838 2012 2014 2701
15 Trashigang 1189 1106 1188 1188 843
16 Trashiyangtase 454 362 434 435 257
17 Tsirang 414 504 429 435 383
18 Trongsa 226 255 266 260 226
19 Wangdiphodrang 560 627 647 648 422
20 Zhemgang 373 360 340 341 371
Total 142162 13264 13720 13822 11597
90-~/
80-r; .
70 //
100-{ /,-
60- /
1
5°1/
401' .-
30 V;
:~~
O·
Measles
DPT-HepB3
Antigens

TB Control Program in Bhutan is fully integrated with general health care services at the
Dzongkhags since its inception in 1976. Replacement of Long course Chemotherapy (LCC)
by Short Course Chemotherapy (SCC) in a phased manner was initiated in 1988. Learning
from the experience of running the program, recommendations of review mission and
keeping in view, WHO's declaration of TB as a global emergency in 1994, Bhutan adopted
Directly Observed Treatment Short Course Chemotherapy (DOTS) strategy throughout the
country from 1997. At the end of 8FYP i.e within 4 years of implementation of DOTS
strategy, significant progress has been made in the control ofTB in Bhutan.
• To prevent death from TB among poor and vulnerable populations.
• To reduce mortality/morbidity and transmission ofTB until it is no longer a
Public Health Problem.
to intensify advocacy and awareness activities for TB prevention and increased
case detection rates
to improve capacity of health staff to detect and treat TB
to strengthen laboratory capacity to carry out drug sensitivity training and quality
assurance
to strengthen Program management and monitoring and evaluation at district and
national level.
Improving access to DOTS by decentralizing the availability of services and
easily accessible treatment with adequate drugs at all time with specific objective
as under.
• New smear positive case detection of 80% and cure more than 85%
• TB in HIV positive patient diagnosed timely and all such cases are promptly put
on DOTS.
• Multi drug resistant (MDR) does not increase in the country.
• Enhance DOTS utilization by making its accessibility/availability user friendly.
Strengthen diagnostic decentralization and follow up capabilities through
establishment of operational laboratory facilities at BHUs level.

Str~gthen the DOTS component of DOTS strategy by widening the spectrum of
DOTS providers through various means, including community involvement.
Formulate defined lEC strategies and intensify lEC activities covering patients,
communities, governmental extension agents, religious leaders, etc.
Organizing training, meetings, and visits for health personnel to enhance their
professional and operational skills under the overall ambit of capacity building.
Enhancing DOTS utilization by making its accessibility and availability user
friendly.
Field visits; meetings, monthly/ quarterly reports and patient referral system will be themajor
tools for monitoring the TB program activities and. district DOTS center's would
monitor at the BHU level to strengthen the TB program activities.
i) Present status in %: Baseline Target Achievement
(2000) (9FYP) (2003)
Case detection 69 75 73
Cure 66 85 76
Completed 21 5 11
Treatment success 87 90 89
Deaths 4 5 5
ii) No of case notified/treated all type: 2001 2002 2003 2004
Pulmonary Positive 442 447 428 406
Pulmonary negative 474 272 284 242
Extra Pulmonary 324 318 344 354
Total 1240 1037 1056 1002
V. Cohort Reports:
i) Laboratory reports: 2001 2002 2003 2004
5495 6014 6663 5781
378 416 443 418
6.84 6.92 6.65 7.23
1.78 2.16 2.09 1.64

According to cohort report, districts laboratory services are doing well.
However, it was noted that some districts laboratory needs to improve
diagnostic facilities and ensure quality control.
ii) Case finding report of new & re- 2001 2002 2003 2004
treatment cases:
New 353 364 360 356
Relapse 28 35 38 36
Failure 27 19 19 5
Retreat after Interruption 34 29 11 9
New pulmonary negative 474 272 284 242
New extra pulmonary 324 318 344 354
Total 1240 1037 1056 1002
Program suggests studying on relapse and failure including patient interruption during
continuation phase.
Hi) Report by gender (new smear positive cases only) 2001 2002 2003 2004
Male 196 209 199 203
Female 157 155 161 153
Total 353 364 360 356
iv. Smear conversion report at 2/3 months (%) 2001 2002 2003 2004
-~ --
New 68 71 80 86
Relapse ~-
72 52 72 85
Re-treatment (other than relapse) 71 62 55 80
According to smear conversion report at 2/3 months of treatment, it has proven that DOTS
during initial intensive phase is excellent. However, districts needs to update sputum status at the
end of 5 and 8 months of treatment to declare cure and to reduce MDR TB.
-

v. Treatment outcome (%) 2000 2001 2002 2003
Cured 66 72 71 78
Completed 21 14 10 11
Died 5 2 3 4
Failed 2 2 2 2
Interrupted treatment 0.5 1 1 0.7
Treatment success 87 86 86 89
Not known 5 6 5 3
According to cohort report, treatment outcome has increased from 66% to 78% In 2003.
However, we have long way to achieve the set target of 85% by the end of 9 FYP.
As of know, we have 26 MDR TB in Bhutan, which was clinically diagnosed and put on 2 nd line
drugs. However, GFATM support would bring improvement in terms of laboratory services
including drugs sensitivity testing in the near future.

ARI Control Activity was first launched in 1986 after the introduction of Mid-Level
Management Course on EPI, ARI & CDD at the then NIFH, Gayleyphug. ARI Programme is an
ongoing health activity. However, there was no Program Manager/ Program Officer identified for
coordinating the activities. Considering the high ART morbidity (27%), the Health Department gave
priority to ARI control activity, and therefore, in November 1992, Programme Manager for ARI
Control Activity was appointed.
A booklet titled "ARI IN CHILDREN" on management and control of ARI based on WHO
Standard Case Management protocol was developed in 1993. The peripheral health workers were
then given short in-service training on ARI case management in Hospitals and BHUs. The activities
were carried out by the Dzongkhag health staff as routine health care services in their respective .
districts, the technical back up and support in terms of training, supplies and resource mobilization
was, how eYer, done by the central program.
The Programme is under the introduction of IMCI approach that would further strengthen the
integrated activity of ARIlCDD/EPI including early childhood care and development. The concept of
IMCI is to bring the inter-rdated programme activities together to have a cost effective and efficient
health system
Present status:
ARI rank as highest in terms of morbidity/mortality in the country. However, pneumonia
caseload seems to be reducing according to the morbidity/mortality report as given below.
Case load of ARI morbidity & mortality reported from BHUs & hospitals:
ARI MORBIDITY REPORT FROM BHUS IN %
Diseases 1997 1998 1999 2000 2001 2002 2003 2004
COUQh& Cold 24.48 23.50 24.29 23.66 21.56 27.44 32.75 32.41
Pneumonia 2.84 2.3 2.22 2.01 1.68 1.44 1.51 1.14
Diseases 1997 1998 1999 2000 2001 2002 2003 2004
Coullh & Cold 14.96 14.02 15.65 16.16 14.92 20.66 29.00 27.96
Pneumonia 6.17 6.83 7.63 6.95 6.9 0.9 1.34 1.18
Diseases 1997 1998 1999 2000 2001 2002 2003 2004
CouQ:h & Cold 24.48 23.50 24.29 23.66 21.56 17.80 17.45 17.13
Pneumonia 2.84 2.3 2.22 2.01 1.68 3.01 2.81 2.45

~~::; ...~~.:=---- ."'
0
Diseases 1997 1998 1999 2000 2001 2002 2003 2004
Cou{!h& Cold 14.96 14.02 15.65 16.16 14.92 24.50 23.54 24.71
Pneumonia 6.17 6.83 7.63 6.95 6.9 2.7 3.05 2.82
• To bring down pneumonia cases and deaths due to pneumonia at the manageable level
implementing IMCIIECCD strategy and intervention of research activity.
• IMCI approach applied 100%
• Reduction of ARI episode to below 3%
• Reduction of under 5 pneumonia cases from 20% to below 15%.
• Reduction of under 5 deaths due to pneumonia from 10% to < 5%
• Over all reduction of IMR & U5MR by 20% of 2000 status.
1. Capacity building to improve the skills of HWs.
2. Provision of supplies to ensure drugs and equipment are reaches in time.
3. Enhance IEC activity & Community participation to create awareness.
4 Supervision/monitoring to ensure the implementation of IMCr activity.
5. Intervention of research activity to track down deaths due to
Pneumonia among U5 children.
6. Training ofDMOs/DHSOs/Sr. HWs on IMCI/ECCD.
1. Revised ARI guideline on "ARl IN CHILDREN", developed ARI flip chart and
pamphlet as IEC materials both in Dzongkhag and English version.
2. Developed and distributed guide book for health workers on ARI case management at
community level
.
3. Developed audio and videocassette as IEC materials both in English and Dzongkhag
version.
5. Program is concerned about the prevention and control of ARI at all health facilities.

Future directions:
1. The programme proposed to conduct research on ARl caseload and type as to
track down the causes so that appropriate intervention could be identified.
11. To determine the under-five morbidity and mortality rates and other social
factors affecting them, survey/research on IMCI activity impact will be carried·
out so as to identify an appropriate intervention for the growing problem.
Introduction of the IMCI concept is still premature and a full time technical focal person
is required to guide the integrated programs at the central level. However, the programme
activities are fully integrated within general health services integrating ARI, CDD and
EPI.

The National Control of Dirrhoeal Diseases Program was initiated in 1982 and program
because operational in 1984. The program was initiated in the Head Quarter because of the high
morbidity & mortality due to diarrhoeal diseases in the country.
Diarrhoeal diseases continue to be a major health problem affecting the survival of the children in
the country. As a program intensification process Bhutan in coordination with WHO had adopted a
new strategy "Integrated Management of Childhood Illness" in 2000. With this holistic approach
strategy the program expect to observe changes on reduction of morbidity & mortality in the future.
To reduce morbidity & mortality due to diarrhoeal diseases, through promotion of sanitation, hygiene
& proper case management practices.
1. To reduce deaths due to diarrhoea in children under five from 13.3% to less than 5%.
2. To reduce diarrhoeal incidence rate amongst five years of age from 21% to 10%.
3. To reduce number of episodes from 3.9 per year to less than 3 per year.
4. To enable people to become more self-reliant in prevention and management of diarrhoeal
diseases.
• Timely & equitable distribution /supply of CDD drugs & equipment.
• Strengthen capacity building for health workers including VHWs through in-service
pre-service training.
• Investigation of outbreak & use of containment measures mainly cholera &
gastroenteritis.
• Strengthen & integrate IMCIIECCD in communities to enhance knowledge & skills
required for childcare.
• Improve quality services by strengthening DTU/ORT & training of health workers,
VHWs, mothers & care givers,
• Enhance lEC activities & collaborate with relevant sectors like PHE, Health &
Religion & comprehensive School Health program.
• Conduct impact assessment & operational researches

Year Diarrhoea cases Dvsentrv cases
< 5 years > 5 years < 5 years > 5 years Total cases
renorted
2000 21991 50812 12170 34967 119940
2001 29499 65551 5028 13765 113843
2002 21191 46539 11296 26644 105670
2003 23608 46537 10940 24078 105163
2004 25730 46523 10072 22715 105040
• Printing of under five guidelines & flip charts
• Training of health workers on use of under five clinic guidelines & flip charts.
• Skj]] development training of mothers on prevention of diarrhoea & ARI with a focus on
exclusive breast-feeding & care of early childhood development.
• Training of health workers in 11 day IMCI
• Procurement of eDD/ARI drugs & equipment.
• Printing and Procurement of IMCI chart booklet & photo series.
• Printing of IMCI wall chart.
• Printing of IMCI modules.

Background
The Village Health Worker (VHW) system was first piloted in Bumthang by Helvetas in 1978.
Finding it imperative in facilitating primary health care delivery in the communities living in
scattered and difficult terrains, it was expanded to Trongsa, Thimphu, Wangdue Phodrang &
Lhuentse. And by mid 1980's the program was implemented throughout the country.
The VHWs selected by the communities themselves were given two-week long training on basic
preventive and promotive aspects of health care including First Aid and treatment of minor
ailments. The positive and discemable impact of the contributions made by VHWs over the years
is reflected in rapid health indicator improvements especially in communicable diseases of major
public health concern in the country. It has proved to be an important link between the health
service and the communities.
In 1993-94, the VHW program was evaluated with the objective to assess the utility and
necessity of the program. The evaluation findings indicated that VHWs were very useful i~
strengthening primary health care delivery system. Both the health providers and the
communities felt that VHW s should continue to function. As such, the Health Department
prepared a " Strategy Paper to Strengthen the VHW Programme," which was formally approved
in 1995.
The VHW program has received support from WHO through PHC project till 1992. From 1993
till today UNICEF has extended support for the program. At present, there are 1201 actively
functional VHW s throughout the country & need to train more concentrating in the resettlement
areas & also to replace the dropped out VHWs.
Rationale
The difficult land terrain coupled with sparse and scattered population dictated the need for
VHWs to assist health staff to provide health care to the un-reached communities thereby,
bringing wider health coverage. It was felt that such a category of people in the village would not
only serve as a two-way link between the health care providers and the communities but also
help to inculcate a sense of healthy living responsibilities in the communities.
Programme Objectives (9 th FYP)
1. Facilitate increased access to health care services in the country
2. Improve healthy life style of the communities through dissemination of appropriate health
information
3. Provide first aid and treatment for minor ailments
Strategies
1. Establish VHW selection/recruitment criteria,
2. Re-define their roles and responsibilities,
3. Impart regular training courses
4. Develop Monitoring & Evaluation tools, recording/reporting formats and guidelines/manuals
forVHWs
5. Strengthen monitoring and supervision ofVHW program activities
6. Institute supply and distribution system for first aid drugs and equipment

There are 1201 active VHWs in the country and program aims to retained this number through
regular refresher courses and other incentives like intra and inter-Dzongkhag study visits.
Training will be conducted for the 281 new VHW recruits. The ratio of male female VHW is 1:3
(male: female), the cumulative drOJ1outnumber is 1200 for the last 17 years.
81. Dzonkhag No. Trained Existing
No
(active)
1. BumthanQ 90 40
2. Chukha 131 74
3. Dal!ana 75 34
4. Gasa 29 14
5. Haa 47 22
6. Monl!ar 214 III
7. Lhuentse 87 42
8. Perna Gatshel 90 48
9. Paro 128 70
10. Punakha 92 48
11. SfJ onQ"khar 152 98
12. Samtse 314 154
13. Sam an!:? 150 60
14. Trashil!anl! 216 103
15. Tashi Yanlrtse 94 41
16. Tron!:?sa 89 47
17. Tsiranl! 115 51
18. Thimohu 98 40
19. W/ Phodranl! 115 60
20. Zheml!all{! 75 45
Total 2401 1201
There are 1201 functional VHWs in the country.
The implementation is fully decentralized since the inception.
A comprehensive training manual guideline for trainers has been developed The programme
was evaluated in 1993/1994
Strategy paper & information kit for the programme has been developed.
The DSA for VHW s during the training and refresher courses has been enhanced from
Nu=30/- to Nu=150/- per day.
A recognition certificate for VHWs was awarded to the programme by UNDP coinciding
with" International day for the Volunteers" in 2001.
The VHW s were provided with badges, & bags

Donor supported vertical programme.
Resource gap - insufficient financial support to maintain quality services through regular
services.
Recognition of VHW s for remuneration / incentive / compensation (packaging)~miformly
has been problem.
Retention / drop out I replacement of trained VHWs.
Community participation for ownership & sustenance.
Growing expectations & demands.
Multi-sectoral dimension for health development.
Regular refresher courses need to be maintained.
Adequate financial support for above and other non-financial incentives.
Vertical program I reprogramming within the decentralization policy.
Fixed target setting for better planning and monitoring.
Dzongkhag & Geog budgeting from regular resources.
Ownership building and sustenance by community in long run.
Recognition- remuneration & incentive packaging modalities for VHW s
All programs to recognize VHW as channel or a medium to reach the community and utilize
them optimally. Therefore all programs must coordinate to support fund to ensure regular
refresher & new trainings to reduce high dropouts.

STD/AIDS control program was established under the Department of Health in 1988
and the first case of AIDS was detected in 1993.
• As of 16 th February 2005 there are 72 HN positive cases
• The first mother to child transmission case was reported in 2001 .
• Total of 5 pregnant mothers were detected with HN infection.
• The mode of infection of all the detected cases is through heterosexual sex.
• Most of detected cases so far are through sentinel surveillance, contact tracing,
and medical checkup.
• The cases are distributed in all occupations with maximum in civil servants and
business peoples.
• According to gender there are 33 female and 39 male infected with HIV. The
ratio of female to male is (1:1.3).
• The current prevalence of HIV infection is 0.05%, which shows that Bhutan is
at early phase of epidemic.
1. To reduce transmission of HN infection through sexual, blood products, and
perennial and STIs.
2. To reduce risk of STI and HIV transmission through lEC and multi sector
approach.
3. To reduce morbidity and mortality associated with HIV/AIDS and STls.
4. VCT services and HIV surveillance system established in all districts.
1. Prevent sexual transmission through multi-sectoral approach and lEe
2. Prevent transmission through blood and blood products
3. Prevent vertical transmission
4. Counseling and care facilities established
5. Program Strengthening and management.
The National AIDS Committee was established in 1994 and the terms of reference
(TOR) are:
• Formulate policies on prevention and control of STDs and HN/ AIDS.
• Facilitate linking of national HIV/AIDS plan and policies with other important
policy making processes.

• Function as coordinating body in the national response to HIV/AIDS prevention
and control activities.
• Mobilize Active commitment and collaboration of publicly/private sectors, civil
societies and communities.
• NAC is now upgraded to NHAC with the RGOB approval during the 220 th
session of Coordination Committee Meeting of the council of ministers on
February 2, 2004.
Ministry of Health is in the process of formulating a comprehensive policy to address
the complex issue ofHN/AIDS. With the guidance ofNHAC and consultancy experts
on HIV/AIDS, the Ministry is looking for a comprehensive policy with in a year. The
existing policy framework and policy statements are as follows:
• Maintain confidentiality ofHN positive peoples.
• Practice Universal Precaution in all health care settings.
• Screen all blood and blood products.
• Provide ART to HN positive pregnant mothers.
• Implement program activities through Multi Sectoral Approach.
• Provide 100 % access to condoms.
• Avoid breast-feeding child ofHN positive mothers.
• Spouse/partners notification by infected is being encouraged, family which
health authority will disclose on hislher behalf.
• Address gender equality and human rights in all areas of care and support to
people living with HIV/AIDS.
• One needle one person
• Stronger call for a multi Sectoral taskforce
• Emphasize creating an enabling environment- policy, legal, social and culturalthat
will facilitate behavior change.
• Strengthen the preventive, promotive, services.
• Strengthen the treatment and care services- including counseling services,
screening in laboratory and blood bank services.
• Strengthen institutional capacity- more Voluntary Counseling and Testing
Centers (VCTC), human resources trained on treatment and management of
AIDS
• Continuing effective detection and management of Sexually Transmitted.
Infections (ST!) at primary health facilities.
• Making an enabling environment for HIV/AIDS patients- good policies, which
incorporates evidence based, and right based policies.
Trends in HN infection will be monitored through surveillance such as reporting of
STls, analysis of sentinel data and monitoring of RPR prevalence among antenatal
clinic attendees. Further, the program will monitor through:

1. Behavioral survey
ii. Progress Reports
Internal and external reviews of the program
lll.
At the national level, the National AIDS Commission, which is multi-sectoral in nature,
will be expanded to include a representative of the private sector. The National
HIV/AIDS Commission will continue to coordinate AIDS prevention efforts at the
district level.
• Lack of trained professionals particularly in voluntary counseling and
testing, surveillance and behavioral research.
• Stigmatization and discrimination.
• Porous border and increasing population mobility both within and outside
the country.
• Prevalence of HIV positive cases among the commercial sex workers.
• Rehabilitating HIV positive.
• Mobilizing adequate funding for HIV/AIDS preventin,.. "nd control program.
SI.No Profession No. of cases
1 Civil Servants 06
2 Corporate Employee 06
3 UN Employee 01
4 Business 12
5 Housewife 15
6 Farmers 05
7 Commercial Sex Workers 07
8 Others 4
9 Uniformed Personnel 11
11 Minor 05
Total 72
.

SI.No Gender No. of cases
1 Male 39
2 Femal 33
Total 72
Sl.No Gender No. of cases
I Male 13
2 Female 2
Total 15

The Gidakom district hospital under Thimphu Dzongkhag is the National Referral Centre
for Leprosy as well as TB in addition to its community health services. This hospital
therefore serves as the centre for rehabilitative services on district, regional and national
levels.
A total of 39 cases have been recorded in 2004 showing a 7% decline from last year.
While 14 cases were registered by Gidakom hospital for Western Region, 2 cases came
from Eastern region, 1 each from Mongar and Trashigang. There were 16 new cases
during the year out of which 7 were referred by health workers, 7 cases reported
themselves directly to the Lerposy workers and 2 cases were detected through contact
survey.
The prevalence rate for this year stands at 0.59/10,000 population and the case detection
rate at 0.24. The deformity rate was found to be at 25% compared to 38% last year. No
relapse case reported this year but 2 suspected cases were reported from Punakha who
are still kept under observation. No deaths reported this year.
Focal surveys were carried out in 4 selected endemic Gewogs under 2 districts of
Trashigang and Wangdiphodrang Le., Kangpara & Thrimshing, Nisho and Kazhi
Gewogs respectively.
. urvevs one
Type of Enumerated Examined Percentage New patients
Survev
found
Contact survey 50 372 62 2
Mass survev - - - -
Focal (village 5658 3936 69 Nil
survev)
Others - - - -
Category LL BL BB BT TT Total
Total at the end oflast year 11 20 7 4 - 42
+ New oatients detected 3 8 4 1 - 16
+ Transferred in etc. 4 5 3 - - 12
+ Relaose - - - - - -
+ Regained to control - - - - - -
- Released (RFf) 6 8 3 - - 21
- Death - - - - - -
- Lost to control - - - - - -
- Transferred out etc. 2 7 1 - - 10
Total at the end of this year 10 18 9 2 - 39

Background.
The National Malaria Eradication Programme (NMEP) launched in 1964, later renamed
as the National Malaria Control Programme (NMCP) in keeping with the Global
Malaria Control Strategy after realizing that eradication aim was indeed an
unachievable target, n~w renamed as Vector borne Disease Control Programme
(VDCP), besides malaria control has plans to start surveillance activities for other
vector borne diseases like Japanese encephalitis, Dengue fever I Dengue Hemorrhagic
fever to start with.
Malaria had been a serious problem even in the earlier days when the National Malaria
Eradication Programme was not initiated in Bhutan and has remained a priority
program especially in the border districts in the south. However, with the launching of
the program rapid control of the malaria situation was achieved.
The control strategy was centered on parasitic control with microscopy diagnosis and
anti-malarial drug treatment, and vector control strategy with IRS using DDT. In 1995
DDT was substituted by synthetic pyrethroid (Deltamethrine). Major change in the
control strategy took place in 1998 when IRS was replaced with Insecticide treated bed
net programme ( ITBN) in line with the Global Malaria Control Strategy. The first line
treatment policy for uncomplicated fa1ciparum malaria was changed from chloroquin to
SP compound in 1991 and then to Artesunate combination in 1999.
Program Goal.
Reduce malarial disease burden to a level where population residing in malarious areas
can lead a productive life thereby, contributing to the socia-economic development of
the country.
Main Program Objective.
Reduce malaria mortality by 25% by the end of 9 th FYP period.
Program Components.
1. Parasitic Control.
2. Vector Control.
3. Data Management.
Main Program Strategies.
1. Provision of diagnostic and treatment facilities as close to the communities as
possible to facilitate early diagnosis and prompt treatment (EDPT).
2. Selective and comprehensive use of insecticides for vector control.
3. Intensi fication of TECadvocacy activities.
4. Initiation of inter- sector collaborative vector control activities through
partnerships.
5. capacity development in terms of human resource.

The malaria trend has improved in the last few years compared to base year 1994.
Reviewing the last five years epidemiological data the reported number of confirmed
malaria cases were 5,935 in 2000,5982 in 2001,6511 in 2002 3806 in 2003 and 2670
in 2004. In 2004 the proportion of Plasmodium jalciparum malaria was 40% as
compared to P vivax malaria.
Malaria case load and Pf% trend from 1965
to 2004
YEAR
I·.. POSITIVE - Pf% i
The percentage of Pf cases has been constantly above 40% since 1994 reaching the
highest ever in 2002 with 54% and at 40% in 2004.
Malaria case load contributed by endemic dzongkhags (Fig 2 & 3)
95% of the country's malaria case load is contributed by the 5 endemic dzongkhags of
Sarpang, Samdrup Jongkhar, Samtse, Chukha and Zhemgang. For the first time Samtse
Dzongkhag has contributed maximum number of malaria cases of the country's
caseload in 2004. Malaria situation shows improvement in the last few years in all the
dzongkhags.

Malaria case load contributed by f"Ive malaria endemic Dzongkhag
&
other non-endemic Dzongkhags (2004)
Other Dzs.
5%
Chuk ha Oz..-,
7% .
Zhemgang
r 2%
Oz..
··~·· ••_Samtse Oz.
38"-0
Sarpang Oz.f
34%
0500)-
o o-
4(X» .E
lax>
oj
I
I

Top 20 Health Centers that contributed malaria
cases in the country in 2004
1. Sibsoo hospital 438
2 .Lhamoizinkha 289
3. Samtse hospital 223
4. Gelephu 205
5_Ghumauney BHU 191
6. Phuntsholing 160
7. Umling BHU 141
8. Sarpang hospital 136
9. Gomtu hospital 104
10. Jomotshangkha 100
11. Samdrup jongkhar 94
12. Samdrupcholing 62
13. Chengmari 61
14. Jigmeling BHU 55
15. Chuzargang 45
16. Deothang Hospital 38
17. Norbuling 37
18. Jompa 23
19. Gedu 20
20. DechilinglYebileptsa/
Panbang 18
Drug responses study is routinely carries out by the program. In 2003 the study had
been conducted with 117 patients in Chuzargang BHU and Umling BHU of Sarpang
Dzongkhag with Artesunate combination for uncomplicated falciparum malaria and the
adequate clinical response (ACR) was 98%. Therefore the current treatment regimen is
very effective.
Therapeutic efficacy studies with chloroquin for treatment of P vivax was also
conducted with 61 patients from Umling and Chuzargang BHU and the dequate clinical
response (ACR) was 95%. SO treatment for P vivax with Chloroquin is still very
effective in the population in the study areas.
Number of malaria deaths has reduced from 48 in 1994 to 05 in 2004 but the case
fatality rate has increased from 3 in 1994 to 4.6 in 2004 which is also a matter of
concern to the program

45
40
.. - .
Malaria mortality
35T
.c
rn
Q)
30-
~ 25-
o
(jj 20'
i:~t ..--._- .._~_~~ __ -_-_-_-.-. _-__ -=- •.....
_---.----__ ~-_~~~~.-4 ••••..
_.--._._---------._-_._---
_-_===..~-~.
I
1995
L DEATH ~ CFR/1000J
----.------
Issues and challenges ahead
1. Malaria transmission reduction is evident from the reduction of case load in
2004 as the ITBN coverage has increased; therefore, the vector control strategy
with ITBN is effective. If the population coverage can be increased further it
may be possible to halt and reverse the incidence of malaria by 2015 and thereby
achieve the Millennium Development Goal target 8. For that ITBN use has to be
advocated and advocacy sustained till behavior change of community is
affected.
2. The major issue is the constantly maintained Pf% above 40% for the last 5 years
and the case fatality rate in 2004 still about 4.6. To be able to bring malaria
mortality to zero would be a major challenge and all Pf cases need to be
followed up closely and drug sensitivity studies need to be decentralized to the
other endemic Dzongkhags so that treatment policy change if necessary can be
based on the report on the drug studies.
3. Focal Indoor Residual Spray (IRS) needs to be done at least once covering the
maximum transmission season in the forest fringe area, Pf dominant areas and
epidemic foci. Therefore cost of the vector control activities will remain high
inspite of reduction in case load in 2004.
4. Human Resource Development at program level, Dzongkhag level and the BHU
level still remains as major issue and there is need to build capacity of health
workers at all levels.
5. Community participants and inter-sector collaboration need to be further
strengthened for malaria control activities without their active participation
malaria control would be nearly impossible.

Background:
His Majesty's vision of 'Gross National Happiness as against Gross National Product'
is an inspiration and a guiding principle for the fonnulation of a comprehensive and
holistic program for the promotion and protection of mental health in Bhutan. Bhutan's
development has taken into consideration the broader issues of balancing development
with the safeguarding of the traditional values and the rich cultural and environmental
heritage of the country. However, it is possible that in the pursuit of material wealth and
comfort today, the people may jeopardise their psychological and spiritual well-being.
The launching of the National Community Mental Health Program in 1997 was timely
and in accordance with the development policy of the Royal government of Bhutan.
This also coincided with the launching of 8 th Five Year Plan. (1997-2002)
It is now widely accepted that community mental health programme is the key to the
prevention and promotion of mental health, treatment and rehabilitation of mentally ill
persons in their own communities. This approach is especially relevant to Bhutan in the
context of our well-developed primary health care services and limited number of
trained mental health professionals in the country.
Program Mandate
To improve and promote mental health/well-being of the Bhutanese CItIzen by
providing community based mental health care services to all needy citizens in all parts
of the country through integrated approach.
General objective.
Protection and promotion of Mental Health
Specific objectives.
Sensitize Health personnel at all levels to be able to provide mental health care along
with general health services.
To reduce burden of mental and neurological diseases, alcohol and drug dependence.
To strengthen integration of mental health care into the primary health delivery system
to cover entire country with health staff oriented to provide basic mental health care at
the community level.
To involve traditional and indigenous system of medicine in the mental health care.
Strategy:
Overall guiding strategies and approaches for community mental health would
be; identification of mental health activities at different level of health system.
Accordingly appropriate training and activities in mental health care identified for
different categories of health workers and other significant people in the community
such as the village health workers, religious community, police, teachers etc.
Areas/Component
11. Situational Analysis on prevalence of mental problems.
12. Capacity development for the health workers & Programme personnel.

13. Professional Human Resource Development.(HRD)
14. Exploration of Traditional Approach to Mental Health
15. Incorporation of Mental Health Component in RIHS curriculum.
16. Supply of essential Psychotropic Drugs to the health centers.
17. Involvement of education sector (school teachers/student) in promoting mental
health.
18. Recording & Reporting of potential mental cases through HMIS.
19. Advocacy/Awareness activities on mental health.
20. Supervision & Monitoring.
A pilot survey conducted in 3 Dzongkhags indicated prevalence of 30% ADS, 25%
Epilepsy, 18% Depression, 14% Mental Retardation, 6% Psychosis, 6% suicide. The
survey did provide some light on the Common mental problems and in terms of
Knowledge, Attitude and Practices towards it but will not represent the national
scenano.
This survey has been a learning experience for both health workers and community
leaders on mental health. It has brought to light that there is general lack of awareness
on the modem concepts of mental disorder and their management in our community.
1. Conducted advocacy and awareness activities and also IEC materials to sensitize
the general public on mental health issues.
2. Developed Mental Health Manual for primary health care workers.
3. Training of medical officers and orientation of Nurses were conducted and it is
one of the on going activities, which will be continued.
4. Trained one Psychiatrist and 3 Nurses in Psychiatric Nursing and one
psychiatrist and 2 nurses are undergoing training at present in India and
Bangladesh.
5. 3 Medical Officers and 3 ACOs trained on community mental health.
6. Conducted pilot survey in three Districts.
7. Collaborated with the education sector for student counseling services
8. including parents' awareness and education program.
9. Participated in train!ng and orienting the schoolteachers on mental health &
substance abuse during winter vacation.
10. Initiated a consultative meeting, identified focal group to coordinate the
exploration of traditional approach to mental health and developed a proposal
that will be piloted in the next fiscal year.
11. Incorporated essential indicators of mental disorders in HMIS.
12. Health workers in Paro, Bumthang, Chukha and Trashigang were trained on
basic mental health care.
13. Identified the mental health topic that will be incorporated in RlHS curriculum
very soon.

Human resource development proposed for the 9 FYP (2002-2007)
.Psychologist INo. Counselors SNos.
Psychistrist 2Nos. Psychiatric Nurse lONos
Psychiatric Social Worker INo.
Future direction
Consolidate on the activities that have been already embarked now.
Intensify Advocacy and IEC activities both at the national and community level.
Inclusion of mental health care as an integral part of primary health care in a1120
Dzongkhags.
Inclusion of mental health component in RIBS curriculum.
Community based rehabilitation and social reintegration of mentally ill people in the
community.
Exploration alternative/traditional approach to prevent and promote mental health of
our people.
Develop plans & policies to address the substance abuse problems in the country.
Establish a national resource centre to support the community mental health care. (or
strengthen the Day Care Centre/psychiatric Unit at JDWNRH)
Feed Back on HMIS quarterly report 2004.
It is encouraging to note that the Districts are now reporting mental disorders because
there was hardly any report before. The data cannot be interpreted on face value due to
following factors:
a) accuracy/validity of diagnosis is questionable as most health workers are
not trained and aware of mental disorders.
b) there could be repetition of cases i.e. every case attending hospital over
the year may be counted as cases and not individual patients.
c) there is a wide variation in number of cases in different districts- where
there is trained doctors and health workers, mental disorders cases are
reported more, and not that there are major differences in prevalence.
Also accessibility could be other factors.

The integration of Community Based Rehabilitation (CBR) programme within the PHe
was commenced in 1997 (8th FYP) with assistance from WHO. The Community Based
Rehabilitation (CBR) Programme was initiated as a pilot programme in Khaling Geog,
Trashigang Dzongkhag, using the infrastructure of the primary health care system for
service delivery. This was aimed at identifying the challenges to include rehabilitation
as the fourth major component of Primary Health Care. With the experience gained in
the Khaling pilot programme, the CBR activities were gradually extended to other
dzongkhags.
Surveys carried out in the pilot CBR Programme and household surveys in Bhutan have
estimated disability at 3.5%. These figures are only suggestive and are not definitive. A
more detailed survey of the different regions may be necessary to correctly assess the
extent and degree of disabilities and their causes, which will be carried out soon.
However, the pilot survey has highlighted the fact that people with speech and hearing
problems constitute the highest percentage of the disabled population, followed by
those with visual impairment.
People with disabilities are often more severely affected by and exposed to, hardships
and discrimination than other community members. The most common needs expressed
by people with disabilities are for functional skills in daily life activities (self care,
mobility, behaviour), educational needs (schooling, vocational training) and needs for
information about their disability. Another major concern of people with disabilities is
the need for income generating activities.
In Bhutan, many superstitions and misconceptions about disabilIty continue to be
prevalent. Services for early identification and intervention to prevent the progression
of impairments and disabilities are insufficient, as also the facilities for medical
rehabilitation, education, awareness, and employment generation. The terrain in the
country is another challenge for delivery of rehabilitation services.
However, the pilot Programme has also highlighted the fact that the goals of a
community-based programme cannot be achieved only through the interventions of the
health sector. An effort has been made in the pilot phase to form a National Coordination
Committee on' Disability (NCCD) in 1999. Since then, the Ministries of
Education and Employment has started developing a policy for inclusion of people with
disabilities along with the mainstream of Bhutanese population in reaslising the
development philosophy of Gross National Happiness (GNH).

The vision for the CBR Programme is that" Persons with Disabilities are able to attain
their fullest potential, become self -reliant and are active contributors to nation building
to the extent possible".
Towards this vision, DPR programme will seek to address the needs of all identified
disabled persons in the community through the following broad objectives:
1. Inclusion of disability prevention and rehabilitation as an integral part of primary
health care in an 20 dzongkhags;
2. Undertake Human Resource Development (HRD) in various aspects of
rehabilitation;
3. Develop Gidakom as National Medical Rehabilitation Resource Centre;
4. Diminish the overall impact of disability through awareness and provision of other
appropriate Institution & Community based rehabilitation interventions;
5. Develop activities on diabetes, hypertension and other Life Style Related Disorders
(LSRD);
6. Promote integration of children with disabilities into normal schools;
7. Facilitate the involvement of other sectors in disability prevention & rehabilitation
programmes through the multi-sectoral approach.
8. Promoting/Initiating Self Help Groups of People with Disabilities.
1. Coverage
Expansion of CBR programme to other districts.
Identification of children with speech and hearing disabilities has been initiated
in all schools.
Inclusion of disabled children into normal schools and special schools
2. Capacity building
Training of physiotherapy technicians (in & ex country)
20 Dzongkhag PHC workers (DMOs, DHSOs, HAs, ANMs, BHWs)
trained on CBR through in-service training courses;
Training of Trainer (TOT) on CBR in India for 8 health workers - DMOs,
DHSOs, PITs, RillS Lecturer & Programme Personnel
1 PIT for Diploma in Prosthetic & Orthotic Technician
1 PIT for Diploma in Speech & Language
2. Initiation of interventions
Provision of Assistive Devices and distribution - hearing aids, crutches,
wheel chairs, walkers etc.
Upgradation of Artificial Limb Workshop at Gidakom for producing
prosthesis/orthosis.
Physiotherapy units established in 15 hospitals.

Establishment of Audio logy Unit at JDW NRH.
Identification of Changzamtok, Changangkha & Drukgyel School as a pilot
school for integration of disabled children.
Identification of Draktsho Vocational Training Centre to promote vocational
training opportunities for persons with disabilities.
Conduct of mobile ENT camps in 4 regions.
Preparation of work-plan for CBR by respective BHUs
Formation of National Co-ordination Committee on Disability (NCCD)
concerns at National Level
Formation of rehabilitation committee at community level.
Incorporation of Disability Information Collection into HMIS. Annual
Household Survey 2004 indicates prevalence of disability at 2.6%.
Based on the need and experiences of the CBR programme, the nomenclature of CBR is
renamed as Disability Prevention & Rehabilitation (DPR), Mental Health & Substance
Abuse.

\di\ it~ Report for 1I00lpitals and Bill's, 200-t
13656 2nd Visit 12020 3rd Visit [ 101631More Visits 22965
--~
2125 Facility 4995 No. taken by forcepslvaccum '164
( hiltl ( link \ltt ,,,1.,11' l
Ild.JlII 1'l111i1i1i1'.I1illn (0-11 l11onlh,)
No. of children
with overweight
BCG 14162
rN;'-~-itb~~rm;'--;-~&ht- --------
Polio "0" 11597
~~~~.~~_:_::_:~_~~~::I _--_ .•••..
Measles 13264
INo. with malnutrition grade III
l
[IUD
~_~~~~
397 INo. fully immunised
Falllil, 1'.t1nllin~ (110.01 III \\ l.i", -.
-'---~---""---------
i
60 ORS:
----~--_._------,._-
55 DMPA:
239 Vit A capsules:
Hydroelorothlazld:
Hydralazine:
166 Iron tablets: 33
19 Polio vaccine: 41
223 Trvaccine: 45
-----_ .._---~-----_.-
58 Albendazole: 10
----------- ---
65 Rabies anti-venom: 530
56484
10496
f------------------ -~--------
IU_~ne:_ __ ~ ~834
[Stool: 8091
tHIV~=___=~===---===-=--13764
Caesarian
Section
General: Abdominal 760
2031 252
6534 38
1240 45
1112 0
------
901 20
750 0
649 0
X-Ray Chest: ------------------1----------------1 23225
x=-R;yE;tre~_ -ties: ------------ ----, ------- --- ---12497
~=:~=.:····t==~~;~1
Ultrasound Othen: 6260
____________________ L
_
1h'lllal ''IT\ In',
:_:_:_::_:~-Is_-:_- __-__-_ -_-=~3____ 1:~
Bill
•.•Oil"
:"'Hlin!:,;
[Extractions: 1 - - --------2-2200
i6124
l~~~I_O~hfr~~ -=-_-j_- 2_85_16--1

District ANC atte"dances Average
1st visit 2nd visit 3rd visit 4+ visit visit
Bumthang . 303 275 224 431 3.1
Chhukha 1710 1402 1233 3433 3.5
Dagana 358 259 175 144 1.6
Gasa 45 44 27 18 2.0
Haa 135 115 79 166 2.7
Lhuntse 341 250 173 199 1.8
Mongar 773 657 483 509 2.1
Paro 589 504 454 1262 3.8
Pemagatshel 292 237 166 191 2.0
Punakha 494 419 331 554 2.6
Samdrubjongkhar 1010 847 670 852 2.3
Samtse 1287 1153 1027 2069 3.3
Sarpang 997 843 774 1626 3.3
Thimphu 2393 2342 2237 8728 5.6
Trashigang 1035 974 795 793 2.5
Trashiyangtse 361 271 175 146 1.6
Trongsa 202 185 144 120 2.2
Tsirang 390 357 284 638 3.3
Wangdiphodrang 545 533 448 656 3.0
Zhemgang 396 353 264 430 2.6
Total 13656 12020 10163 22965 3.3

District
Deliveries attended at
Home Facility Total % attended
Bumthang 67 81 148 54.7
Chhukha 152 520 672 77.4
Dagana 134 32 166 19.3
Gasa 16 1 17 5.9
Haa 9 44 S3 83.0
Lhuntse 70 24 94 25.5
Mongar 223 183 406 45.1
Paro 45 314 359 87.5
Pemagatshel 53 31 84 36.9
Punakha 75 72 147 49.0
Samdrubjongkhar 176 225 401 56.1
Samtse 217 3S4 571 62.0
Sarpang 83 444 527 84.3
Thimphu 2S 1994 2019 98.8
Trashigang 282 256 538 47.6
Trashiyangtse 88 68 156 43.6
Trongsa 85 18 103 17.5
Tsirang 84 148 232 63.8
c
Wangdiphodrang 95 86 181 47.5
Zhemgang 146 100 246 40.7
Total 2125 4995 7120 70.2

Child attendances
Total
District Infants < 1year 1 -4 years new
New Old New Old
Bwnthang 306 2622 0 2253 5181
Chhukha 1571 8162 48 3845 13626
Dagana 412 2352 63 931 3758
Gasa 55 347 7 149 558
Haa 171 1585 0 1340 3096
Lhuntse 349 2331 13 1535 4228
Mongar 1016 7115 18 6841 14990
Pam 419 3977 2 2141 6539
Pemagatshe1 306 1848 50 1573 3777
Punakha 429 2488 2 1208 4127
Samdrubjongkhar 1005 5283 113 3819 10220
Samtse 1232 6868 65 1165 9330
Sarpang 999 5828 37 3594 10458
Thimphu 2801 11935 10 3258 18004
Trashigang 1162 7658 277 6949 16046
Trashiyangtse 491 2583 68 1492 4634
Trongsa 220 1766 20 1416 3422
Tsirang 427 3087 6 2333 5853
Wangdiphodrang 577 3394 92 1842 5905
Zhemgang 389 2718 3 3554 6664
Total 14337 83947 894 51238 150416

No. with No. with Nutrition levels Total Percent
District over normal Grade I Grade II Grade III malnou- malnouweight
weight rished rished
Bumthang 1291 3846 117 9 3 129 2.5
Chhukha 1474 11286 735 97 34 866 6.4
Dagana 934 2704 280 48 1 329 8.8
Gas a 0 568 13 0 0 13 2.3
Haa 728 1799 533 65 3 601 19.4
Lhuntse 768 2952 314 56 13 383 9.1
Mongar 2463 10863 1192 187 46 1425 9.5
Paro 885 5231 354 64 5 423 . 6.5
Pemagatshel 831 2475 381 31 9 421 11.1
Punakha 1509 3255 259 40 8 307 7.4
Samdrubjongkhar 2804 7553 800 146 19 965 9.4
Samtse 2085 6408 591 94 20 705 7.6
SaI-pang 1402 7918 961 153 24 1138 10.9
Thimphu 1824 1600-7 756 108 35 899 5.0
Trashigang 1373 12672 1532 334 91 1957 12.2
Trashiyangtse 539 3524 423 57 9 489 10.6
Trongsa 742 2260 110 10 1 121 3.5
Tsirang 879 3864 851 171 45 1067 18.2
Wangdiphodrang 1211 3790 514 111 14 639 10.8
Zhemgang 1022 4111 900 121 17 1038 15.6
Total 24764 113086 11616 1902 397 13915 9.3
~Gradelll
Grade I!
8% ~\----
~
/ i 0%
~------_ .. I

District IUD Cycles of DMPA Male Female Pieces of Total Percent
inserted Oral pills Injections sterilisation sterilisation condoms users users
Bumthang 6 102 351 72 6 3613 4150 0.4
Chhukha 78 2570 3627 399 24 334214 340912 31.9
Dagana 24 886 1277 408 19 17275 19889 1.9
Gasa 0 100 182 15 8 3109 3414 0.3
Haa 9 266 961 4 9 9427 10676 1.0
Lhuntse 13 351 783 196 17 16641 18001 1.7
Mongar 99 1204 4158 355 120 188153 194089 18.2
Paro 217 400 1494 424 215 22064 24814 2.3
Pemagatshel 196 708 1213 6 1 9777 11901 1.1
Punakha 19 686 2445 34 11 16882 20077 1.9
Samdrubjongkhar 192 1130 3704 563 111 26106 31806 3.0
Samtse 30 2155 2274 353 58 36743 41613 3.9
Sarpang 115 2147 2970 1049 362 59089 65732 6.2
Thimphu 429 2102 4234 433 210 65369 72777 6.8
Trashigang 81 1179 4624 172 15 77194 83265 7.8
Trashiyangtse 341 220 1195 0 1 6379 8136 0.8
Trongsa 17 85 429 169 31 9957 10688 1.0
Tsirang 134 1382 1895 6 37 33901 37355 3.5
Wangdiphodrang 26 415 1239 46 7 16294 18027 1.7
Zhemgang 85 719 1690 215 102 48492 51303 4.8
Total 2111 18807 40745 4919 1364 1000679 1068625 100.0
Vasectomy
7%
Oral Pills
28%
DMP A Injections
60%

District Admissions Patient Average
Hospital BHU days days
Bumthang 72 4 218 3.0
Chhukha 4256 142 15762 3.7
Dagana 91 144 224 2.5
Gasa 0 7 0 0.0
Haa 342 0 1609 4.7
Lhuntse 789 90 2461 3.1
Mongar 2687 502 15964 5.9
Paro 1568 73 4301 2.7
Pemagatshe1 610 30 2724 4.5
Punakha 472 26 2432 5.2
Samdrubjongkhar 2268 230 20050 8.8
Samtse 3325 213 14751 4.4
Sarpang 4466 265 11624 2.6
Thimphu 7947 65 58154 7.3
Trashigang 1682 532 9070 5.4
Trashiyangtse 644 143 4729 7.3
Trongsa 269 68 1470 5.5
Tsirang 849 42 2922 3.4
Wangdiphodrang 1279 136 4658 3.6
Zhemgang 1209 94 6767 5.6
Total 34825 2806 179890 5.2

Procedures Cases %
Caesarian section 783 4.6
General abdominal 3043 18.0
Gneral - others 6772 40.1
Orthopaedic extremities 1704 10.1
Orthopaedic others 1119 6.6
Gynaecology 1537 9.1
Ear, Nose & Throat 977 5.8
Eye 966 5.7
Total 16901 100.0
.~
I
Ear, Nose & Throat Eye Caesarian sectioll
GY;O"''''~' 6~% ~.~ : G",rol obdomm,l
18%
Orthopaedic others
7% ~~
O"h'P'

Services
Cases
Diagnostic procedures:
X-Ray chest 23225
X-Ray extremities 12497
X-Ray others 11391
Ultrasound: - Gynaecology/Obstretics 7894
- Abdomen 8693
- Others 6260
Dental services:
Prophylaxis 1585
Scaling 562
Fillings 16124
Extractions 22200
Others 28516
Laboratory examillations :
Haemoglobin 86309
Blood grouping 44436
Malaria slides 56484
TB sputum 10496
Urine 104834
Stool 8091
HN 13764
Surgery 13437
. Laboratory
e.r:aminations
Diagnostic
procedures

District Caesarian General General Orthopaedic Orthopaedic Gaeno- ENT Eye Total
section abdominal others extremities Others colof?Y
Bumthang 0 3 0 2 0 0 0 0 5
Chhukha 24 465 4325 149 207 25 127 57 5379
Dagana 0 0 0 0 0 0 0 0 0
Gasa 0 0 0 0 0 0 0 0 0
Baa 0 0 0 0 0 0 0 0 0
Lhuntse 0 0 0 0 0 0 0 0 0
Mongar 43 216 104 142 37 114 36 45 737
Paro 24 51 93 29 40 57 5 0 299
Pemagatshe1 0
,
0 27 8 3 0 0 11 49
Punakha 6 21 60 25 12 5 0 236 365
Samdrubjongkhar 25 168 239 95 67 45 53 4 696
Sarntse 54 93 199 99 57 39 2 5 548
Sarpang 62 213 551 153 39 114 34 8 1174
Thimphu 496 1785 392 662 314 1082 545 344 5620
Trashigang . 20 0 0 1 1 6 5 10 43
Trashiyangtse 0 0 44 0 0 0 0 0 44
Trongsa 0 1 35 2 0 0 0 0 38
Tsirang 7 0 0 24 0 8 1 0 40
Wangdiphodrang 0 11 685 311 325 8 169 223 1732
Zhemgang 22 16 20 2 17 34 0 23 134
Total 783 3043 6774 1704 1119 1537 977 966 16903
Percentage 4.6 18.0 40.1 10.1 6.6 9.1 5.8 5.7 100;0

District Haemoglobin Blood Malaria TB Sputum Urine Stool HIV Total
levels groupin~ slides
Bumthang 1222 557 101 138 1518 80 157 3773
Chhukha 10280 4345 7355 1513 11131 651 715 35990
Dagana 896 1485 49 43 1318 299 391 4481
Gasa 67 42 0 0 79 0 0 188
Haa 769 318 34 88 565 31 117 1922
Lhuntse 1262 602 36 84 1579 92 121 3776
Mongar 4564 3245 1055 1307 4314 524 892 15901
Paro 3283 1429 251 204 3633 270 239 9309
Pemagatshel 710 808 130 131 571 68 104 2522
Punakha 3165 1318 840 177 3113 148 259 9020
Samdrubj ongkhar 5672 1837 8718 658 8186 465 940 26476
Samtse 6639 1687 7597 558 6110 206 311 23108
Sarpang 7294 3134 25060 946 17652 291 749 55126
Thimphu 28779 16207 2643 3252 27169 4354 7843 90247
Trashigang 4114 4113 405 452 10457 194 346 20081
Trashiyangtse 1008 508 39 163 929 33 49 2729
Trongsa 866 443 91 28 602 54 56 2140
Tsirang 1507 369 468 143 1105 78 52 3722
Wangdiphodrang 2669 1421 586 562 3357 146 351 9092
Zhemgang 1543 568 1026 49 1446 107 72 4811
Total 86309 44436 56484 10496 104834 8091 13764 324414
Percentage 26.6 13.7 17.4 3.2 32.3 2.5 4.2 100.0

District X-ray X-ray X-ray Ultrasound Prophy- Scaling Fillings Extractions Others
chest extremities others GynlObs Abdomen Others {axis
Bumthang 157 202 13 0 0 0 13 0 330 522 550
Chhukha 2670 1549 891 191 229 81 382 55 2677 2660 5030
Dagana 0 0 0 0 0 0 13 0 229 376 207
Gasa 0 0 0 0 0 0 0 0 0 0 o •
Haa 0 0 0 0 0 0 28 6 290 201 377
Lhuntse 76 39 9 1 0 4 19 1 207 256 246
Mongar 1533 761 834 126 352 24 48 37 627 1401 1507
Para 309 249 175 25 3 0 64 3 1013 1095 1447
Pemagatshe1 80 61 32 0 0 0 22 1 76 341 380
Punakha 605 548 364 572 411 122 77 2 412 420 1270
Samdrubjongkhar 1579 724 653 185 235 122 81 0 587 1285 898
Samtse 740 786 382 110 15 0 167 48 487 677 282
Sarpang 2049 684 559 624 1157 87 69 22 1122 1779 1852
Thimphu 11841 5879 6773 5194 5757 5677 406 272 5898 7871 11018
I
Trashigang
416 254 219 721 323 134 66 91 1056 1590 957
Trashiyangtse 223 109 64 0 0 0 53 17 67 68 44
Trongsa 16 35 6 0 0 0 6 0 143 136 242
Tsirang 261 223 93 6 0 0 48 0 344 529 543
Wangdiphodrang 229 292 92 0 0 0 18 5 368 529 689
Zhemgang 441 102 232 139 211 9 5 2 191 464 977
Total 23225 12497 11391 7894 8693 6260 1585 562 16124 22200 28516

SN District HH access to HH having piped HH having drainage HH using garbage HH without separate HH safe
sanitary latrine water supply and foot path disposal pits animal shed from smoke
1 Bumthang 98.1 95.1 86.7 94.3 3.3 96.9
2 Chhukha 90.6 82.6 72.2 76.9 12.1 22.7
3 Dagana 83.9 56.9 28.1 79.0 45.6 70.1
4 Gasa 88.2 38.5 39.6 77.7 4.6 80.8
5 Haa 82.4 91.7 29.3 34.6 33.9 83.5
6 Lhuntse 88.8 89.0 49.9 62.5 23.0 57.6
7 Mongar 87.9 76.3 37.0 57.4 16.4 61.3
8 Paro 94.4 89.7 75.2 82.4 18.5 76.3
9 Pemagatshel 83.2 84.6 22.5 49.8 13.6 74.4
10 Punakha 90.1 74.6 22.7 82.7 6.6 47.3
11 Samdrubjongkhar 93.7 80.8 29.5 70.3 16.7 42.5
12 Samtse 85.2 68.1 28.0 53.4 9.8 66.3
13 Sarpang 87.7 83.6 46.8 60.3 35.7 63.1
14 Thimphu 82.3 79.5 34.8 37.4 10.7 72.3
15 Trashigang 91.9 85.7 29.7 46.2 17.0 30.4
16 Trashiyangtse 89.6 81.4 52.3 71.1 22.8 38.7
17 Trongsa 89.8 93.5 55.1 64.3 1.6 60.5
18 Tsirang 82.7 70.5 42.9 71.4 38.5 45.9
19 Wangdiphodrang 92.3 75.7 61.0 80.2 30.1 60.6
20 Zhemgang 91.4 84.9 72.1 60.9 26.0 64.5
Total 89.2 80.5 46.6 64.7 19.2 53.3

Outreach
Clinic
Tsimalakha Hospital
Phuntsholing Hospital
Gedu Hospital
Chhumay
Tang
Ura
Chhukha -I
Bongo,
Balujora *
Chabchha
Chongekha
Getana
Logcmna
Tala
Dungna
Dagana -I
Dagapela
Drujegang
Akhochin
Tshangkha
Lajab
Jurugang
Khagochen
Gasa
Lungnana
Laya
Damji
Bali
I
Dorithasa
Yangthang
Sangbekha
Autsho
Dungkhar
Gorsum (Ungar)
Ladrong
Menji
Nay
K.'loma
Patpachhu
1'angmach..'lu
''senkhar
7angkhar I I
______________________ , -J

Districts Hospitals Basic Health Units ORC
Mongar. Mongar Hospital Balam 55
Bumpazor
Chaskhar
Drametse
Gongdu (Dagsa)
Gyalpozhing - I
Junrni (Belam)
Lingrnethang
Kengkhar
Nagor
Ngatshang
Pangthang
Serzhong (Muhung)
Silarnbi
Thangrong
Tsakaling
Tsamang
Yadi
Yangbari
Banjar
Paro Paro Hospital Bitekha 26
.
Dawakha
Drugyal
Pemagatshel Pernagatshel Hospital Dungrnin 24
Yurung
Chhimong
Trhumchung
Punakha Punakha Hospital Kabisa 9
Shelngana
Samadingkha
Tshochasa
Talo (Mende gang)
Sarntse Sarntse Hospital Dorokha 8
Gomtu Hospital
Sibsoo Hospital
Dumtey
Tendu
Bara
Buka *
Chargaray *
Chengrnari
Ghumauney
Denchukha
Nainital
Sengt en
Panbari

Districts Hospitals Basic Health Units ORC
Samdrub Jongkhar S'Jongkhar Hospital Samdubchholing - I(Raitar) 28
Dewathang Hospital Nganglam - I
Dalim *
Jomotsangkha (Daifam)
Dechheling
\1artshala
~1injiwoong
Orong
Samrang *
Shingkharlauri
Gomdar
:t\orbugang
Chhokhorling (Kulikata)
Sarpang Sarpang Hospital Lhamoizingkha - I(Kalikhola) 12
Gaylegphug Hospital
Norbuling
Dovangaon
Jigmechholing (Surey)
Chhuzangang (Taklai)
Gongdara
JigmeEng
umling (Lalai) .
Nichula *
Maogaon *
Phibsoo
Manas
Thimphu JDWNR Hospital Dechhen Chholing-I 23
TBFHospital
Thinlegang
Gidakom Hospital
Ga)'llekha
Lungtenphug Hospital Lingzhi
Mutithang (Sattelitc clinic)
Jungzhinang
(Sattelite clinic)
i
I
I
I
i
I
I
I
I
Trashigang Trashigang Hospital Bartsham, Bidung 63
Riserboo Hospital
Bikhar, Chhangmi
Yonphula Hospital
Kanglung - I, Kangpara
Khaling, Mcrag
"
Nanong, Pasaphu
Phongmcy, Radi
Rangjung - I, Saktcn
Thungkhar, Thongrong
Tsangpo (Thrimshing)
Ozarong, Yabrang
Yangnyer, College Dispensary

Districts Hospital 13HU ORC
Trashi Yangtse Yangtse Hospital Jamkhar 22
Khem
Khamdang
Ramjar
Tomiyangsa
Yalang
Trongsa Trongsa Hospital Bemji 23
Kungarabten
Langthel (Tontophel)
Nabji
Trashiling
Zhangbi
Tsirang Damphu Hospital Khorsani 5
Mendegang (Lamidara)
Tsirangtoe (Tsirangdara)
Patalay
Danasey*, Burichhu*
Wangdi Phodrang Wangdi Hospital Bajo - I 25
(Tencholing)
Dangchhu
Kamichhu
Jalaula
Phobjikha
Samtegang
Sephu
Gaselo
Vma
Teki Agona
Zhemgang Yebilabtsa Hospital Panbang - I 33
Shemgang- I
Gomphu
Drogar
Goshing
Khomshar
Lelegang
Shingkhar
Buli
Edi*
Kagtong
Langdorbi
Pantang
Note: Hospital list excludes 1 hldigenous Hospital.
* Centres not functioning.

~
ICD Priority Health ProblemlDisease Under 5 Yean 5 Yean and older Referred Deaths
Code
Total
Male Female Male Female In Out No.
... « ;.LU .i. iii;iiiii. i:< Li·iiii;t ;...;:.: iii··: L< <
AOO· Cholera I I 9 16 27
AOI· Typhoid 113 87 951 997 2148 30 28 4
A02· Diarrhoea 12361 11950 24187 21041 69539 19 17 2
A03· Dysentery 4643 4711 12094 9662 31110 15 11 3
A15· Tuberculosis 23 38 571 461 1093 124 66 22
A33· Tetanus I I
A36· Diphtheria
A37· Pertussis
ASI· Early Syphilis 6 10 97 81 194 I
A54· Sexually Transmitted Disease, excluding HIV/AIDS I 6 1313 839 2159 6 3 I
A80· Polio
A82· Rabies I 11 4 16
'11•• 1
:::.:···::i •• ;;;·.·· c. i .i <

ICD Priority Health ProblemIDisease Under S Years S Years and older Referred Deaths
Code
Total
Male Female Male Female In Out No.
GOO* Meningitis/Encephalitis 23 29 145 162 359 11 28 21
G41* Epilepsy 35 22 465 376 898 11 to 3
GI0* Other Nervous inlcuding Peripheral Disorders 163 205 5172 6928 12468 37 65 6
Eye & Ear Disc_* .... )//,
HI0* Conjunctivitis 3084 3378 14353 17075 37890 12 21
H25* Cataract 13 17 341 317 688 17 18
HOO* Other Eye Disorders 1166 1287 11298 12499 26250 50 129 3
H65* Otitis Media 3172 3137 7162 6560 20031 18 75
H60· Other Ear Disorders 1129 1209 4273 4267 10878 26 71
J}i$e"eJor~ir~.latory System •••• ),f! ;;""';) '/;,(.: ......: .. /).... ,/,.', ..•.;..
) ..... ,;:. ): ,;;.;;;.
100· Rheumatic Heart Disease 17 20 438 496 971 31 40 14
110· Hypertension 6326 7869 14195 85 133 19
120· Ischaemic Heart Diseases 277 276 553 27 12 33
160· Cerebro-vascular Diseases I 2 108 62 173 8 9 24
126· Other Circulatory Diseases 93 98 1973 2243 4407 33 67 34
Res'tratery d.$elI . ;;,' ..... ;." .. ,.i···;./.)};, ....;..,
.. ',..
;... ; .., .)/ ......;,......; ...)..
JOO* Common Cold 27884 27977 98954 110048 264863 333 34 I
J02· Acute Pharyngitisrronsilitis 3399 3506 18863 20589 46357 29 40 I
Jl2· Pneumonia 4503 4506 2292 2044 13345 63 106 61
J01· Other Respiratory & Nose Diseases 3536 3408 12096 13111 32151 68 184 27
......
.
l)~of~J)igestivemt~~
....,'" ..) ..Y'i
> ).. )(. 'joY,;;'
••
K02· Dental Caries 731 832 13476 14579 29618 7 120
KOO· Diseases of Teeth & Gums 605 704 11099 11612 24020 II 80 3
K20· Peptic Ulcer Syndrome 176 372 25320 32843 58711 71 195 4
K35· Acute Appendicitis I 4 343 316 664 32 67
K70· Alcohol Liver Diseases 659 488 1147 63 70 69
K80* Gall Bladder Diseases 19 19 306 592 936 29 39 I
KIO· Other Diseases of the Digestive System 1905 1979 14606 15009 33499 127 223 37
: ..
Skill Discases ........
. ; .
LOO· Skin Infections 10463 10345 42647 35848 99303 57 121 3
L10· Other Disorders of Skin & Subcutaneous-tissues 4103 4067 20599 16890 45659 46 87 I
Distal" of Museulo-skelt:tal .ystelQ &CogeJI~"IDerormities "
MOO· Arthritis & Arthrosis 61 61 4564 4292 8978 29 37 2
M20· Other Musculo-skeletal disorders 591 672 23326 19621 44210 130 149 5
Genito-Uriaary distas"
N30· Cystitis 6 11 175 59! 783 3 2
N61· Infection of Breasts, including Puerperium I 10 715 726 14 5
-
N62· Other Disease of the Breast 2 3 29 144Q ]483 4 15
N70· Pelvic Inflammatory Disease 1710 1710 36 14
N91· Menstrual Disturbances :noo 3300 35 48
NOO· Other Kidney, UTI Genital Disorders 545 527 6799 1243] 20302 145 185 29
Pregnaney.
Childbirth aod Puerperium
••••••
--_._~_.~---,
--

ICD Priority Health Problem/Disease Under 5 Years S Years and older Referred Deaths
Code
Total
Male Female Male Female In Out No.
000· Abortions 579 579 32 24
013· Pregnancy Induced Hypertension 365 365 22 46
020· Ante-Partum Haemorrhage & Placenta Previa 118 118 12 34
032· Malpresentation 113 113 16 42
063· Prolonged Labour 267 267 32 97 I
064· Obstructed Labour 222 222 13 31 I
072· Post Partum Haemonhage 183 183 5 14 I
073· Retained Placenta 332 332 24 33
085· Puerperal Sepsis 93 93 8 4
010· Other complications of pregnancy 1663 1663 112 169 I
: .... i··i. iiC iii»i.i; .iii i·t .,·ii ... ···i· .
• •••••••••
,i .·.•:x :•• i·'i;
P05· Low Birth Weight 143 160 303 I 6 4
P95· Foetal Death & Stillbirth 63 47 110 3 3 35
P96· Neonatal Death 32 23 55 I 2 43
POO· Conditions Orginating in the Perinatal. Period 189 148 337 3 5 13
-
.JtunQU•••• .......... ' ' .. i;i'.· 7'.: ;; >i .Vii; ,>i··· :: >X..
• • ii'
Qoo· Malfotmations 35 34 32 35 136 I 5 2
MMies •• ~ ••• 'J.;i· i·"··· .. i·fi ••·;;·//iLi' ;ii ;iii i.,.··....,•.. ., hi .i /i;.';;;';'"
no· Bums and Corrosions 654 556 1418 1000 3628 20 26 5
SOO· Injuries & Poisoning 970 822 12334 4991 19117 62 183 13
VOl· Transport Accidents 43 40 1052 384 1519 41 120 II
W53· Bites & Stings 420 382 2944 2031 5777 17 31 2
WOO· Other External Causes of Injury 723 566 8509 4179 13977 96 109 10
Y96· Work Related Injuries 199 196 7449 3078 10922 87 112 4
Y40· Complications of Health Care 81 102 967 1023 2173 12 20 3
ZOO· ANC, Immunisation & Other counselling 2857 3145 9245 18560 33807 102 68
~d CIlSeS aU Cllll$eS
:: Total Old Cases all causes
Ed_·

~
~
Ii 8~
,
~ ~
cq
~ \-~
;(>t\
!t,
8 Col
~ ~
..~ \-
,~~
••
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:E
... 8"-4 "\
III ..,/~
:J
,
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'a
• .,~ ~
-~ ~'Col
.lie
...
~
III

~
~ ~
=::
Q("
:;l
~
~~
..:: ~ ,,~
~
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~
~ ~
5 ~«
.~ c.
~
ClI
a..
y' O''t,
liiI ?(>

Common cold
Skin indfections
Diarrhoea
Peptic UnIcer Syndrome
Acute Pharyngitis/Tonsilitis
Other Disorders of Skin & Subcutaneous-tissues
Other musculo-skeletal diseases
Conjunctivitis
Other Diseases ofthe Digestive System
Other Res iratory & Nose Diseases
Total
264863
99303
69539
58711
46537
45659
44210
37890
33499
32151
1130126
23.4
8.8
6.2
5.2
4.1
4.0
3.9
3.4
3.0
2.8
64.8
Other musculo-skeletal
diseases
~
~ Other Disorders of Skin & Subcutaneous-tissues
~
.!:3
~
Acute PharyngitisITonsilitis
10.00 15.00
Cases in %

ABER
ACO
AEFI
AFP
AGUS
AIDS
AN
ANC
ANM
APH
API
ARDS
ARI
ASCUS
BB
BCG
BHU
BHW
BL
BSC
BV
CBR
CDD
CPR
DANIDA
DEL
DHSO
DMO
DMPA
OOTS
DPT
DSA
DVED
ECCD
ECL
ELISA
EmOC
ENT
EPI
Annual Blood smear Examination Rate
Assistant Clinical Officer
Adverse Events Following Immunization
Acute Flaccid Paralysis
Aptical grandular cells of undetermined significance
Acquired Immuno Deficiency Syndrome
Assistant Nurse
Antenatal Clinic
Auxilliary Nurse Midwife
.Ante-partum Haemorrhage
Annual Parasite Incidence
Acute Respiratory Depression Syndrome
Acute Respiratory Infection
Atypical squamous cells of undetermined significance
Borderline Borderline
Bacilli Callmal Gurrina
Basic Health Unit
Basic Health Worker
Borderline
Blood Slide Collection
Bacterial Vaginalis
Community Based Rehabilitation Programme
Control of Diarrhoeal Diseases
Contraceptive Prevalence Rate
Danish International Development Assistance
Department of Employment and Labour
District Health Supervisory Officer
District Medical Officer
Depomedroxyprogesterone acetate
Direct Observation Treatment Services
Diphtheria, Pertussis and Tetanus
Daily Subsistence Allowance
Drugs, Vaccinces & Equipment Division
Early Child Care and Development
Eclampsia
Enzyme Linked Immuno Sorvent Assay
Emergency Obstretric Care
Ear, Nose and Throat
Expanded Programme on Immunization

FYP
GDMO
GNM
HA
HERM
HFA
HIU
HIV
HMIS
HPY
HSIL
HTN
HW
ICN
IDA
lDC>
IECH
IMCI
IMFAC
IMR
IRS
ITBN
ITMS
IUD
JDWNRH
JE
KAP
LSIL
MB
MCH
MDT
MMR
MOHE
MTP
NCCA
NCCPE
NID
NIFH
NITM
NMCP
NMEP
NPA
NTCP
NTTA
Five Year Plan
General Duty Medical Officer
General Nurse Midwife
Health AS3istant
Health Equipment Repair and Maintenance
Health For All
Health Information Unit
Human Immuno Virus
Health Management Information System
Human Papilloma Virus infection
High grade Squamous Intraepitheliallesion CH-II,CNIII ca-in-situ
Hypertension
Health Worker
International Conference on Nutrition
Iodine Deficiency Anaemia
Iodine Deficiency Diseases
Information, Education and Communication for Health
Integrated Management of Childhood Illness
Integrated Management during Pregnancy and Child birth
Infant Mortality Rate
Indoor Residual Spray
Insecticide Treated Bed Net
Indigenous Traditional Medicine Services
Intrauterine Device
Jigme DOlji Wangchuck National Referral Hospital
Japanese Encephalitis
Knowledge, Attitude and Practice
Low grade Squamous Intraepithelial/koilocytosis lesion CIN-I
Multi Bacillary
Maternal and Child Health
Multi Drug Therapy
Maternal i'1ortality Ratio
Ministry of Health and Education
Medium Term Plan
National CoordinatiQn committee on Disability
National Certification Committee for Polio Eradication
National Immunization Days
. National Institute of Family Health
National Institute of Traditional Medicines
National Malaria Control Programme
National Malaria Eradication Programme
National Plan of Action
National Tuberculosis Control Programme
National Technical Training Authority

OCP
OPD
OPV
ORC
ORT
OT
PEM
PHC
PHD
PIH
PNC
PPD
PPH
PTT
PUO
PUS
RBM
RCSC
RDT
RGoB
RHD
RHU
RIHS
RPR
RTI
SAARC
SNID
SPR
STD
STI
STP
TPF
TPHA
TT
TV
UNDP
UNFPA
UNICEF
VAD
VCT
VHW
VO
Oral Contraceptive Pills
Outpatient Department
Oral Polio Vaccine
Outreach Clinics
Oral Rehydration Therapy
Operation Theatre
Protein Energy Malnutrition
Primary Health Care
Public Health Division
Pregnancy Induced Hypertension
Post-natal Clinic
Policy and Planning Division
Post-partum Haemorrhage
Physiotherapy Technician
Pyrexia of Unknown Origin
Peptic Ulcer Syndrome
Roll Back Malaria initiative
Royal Civil Service Commission
Rapid Diagnostic Test
Royal Government of Bhutan
Rheumatic Heart Disease
Reproductive Health Unit
Royal Institute of Health Sciences
Rapid Plasma Reagin
Royal Technical Institute
South Asian Association for Regional Cooperation
Sub-national Immunization Days
Slide Positivity Rate
Sexually Transmitted Diseases
Sexually Transmitted Infection
Short T enn Plan
Total Plasmodium Falciparum
Treponema Pallidum Hearn Agglutination
Tetanus Toxoid
Trichomonas Vaginalis
United Nations Development Programme
United Nations Fund for Population Activities
United Nations International Children's Emergency Fund
Vitamin A Deficiency
Voluntary counseling & testing
Village Health Worker
Vasectomy Operation