*Population in 2020、GNI and life expectancy are updated based on UN's 2019 data.
*Medical information is based on WHO's 2017 report Mental Health Atlas-country profile.
The Kingdom of Bhutan, commonly known as Bhutan, is a constitutional monarchy in the interior of South Asia. Located on the southern slope of the eastern section of the Himalayas between China and India, The northwest is adjacent to Tibet, while the west, south and southeast connect with India. The valleys are deep and 71% of the land is covered by forests, resulting in a scattered distribution of population. Bhutan was a vassal state of ancient China and a protectorate of the British. In 1949, it signed a treaty of friendship with the Indian government and was protected by India. The country is clean and smoking is strictly forbidden throughout the country, and it is known as the pure land on earth. The King of Bhutan does not want the natural ecology and traditional culture to be disturbed by too many tourists and adopts a national lock-up policy. Therefore, tourists entering Bhutan must pay high fees, currently only 5,000 foreign tourists are allowed to enter the country each year.
Bhutan has a land area of 38,394 square kilometers, which is a little bit larger (6%) than that of Taiwan. However, because it is located in the southern Himalayas, most of the land is mountainous areas above sea level with 3,000 meters. Many of the people are engaged in agriculture and animal husbandry. Electricity output (Mainly is hydropower and takes 20% of the national GDP) and stamp sales are the main sources of the country’s income. The tourism industry has just been developed and will become one of the future economic sources.
There are 20 administrative districts in Bhutan, and each district has a main temple called "Dzong", which was a defensive fortress named Dzongbao in ancient times, and now inhabited by monks and government officials. In Bhutan, a kingdom with both the political and religious combination, furthermost, the biggest "Dzongbao" in the capital is undoubtedly the highest power center, in which the king and national supreme Buddhism leaders are all residing here.
The official languages are Dzongkha and English, and Tibetan and Nepali are also spoken. Most people (75%) believe in Tibetan Buddhism, and it is regarded as the country's religion, while some people (22,6%) believe in Hinduism, and the rest are minorities like Shamanism believers (1.9%).
Bhutan lacks a complete household registration system and the national population statistics are inaccurate, but the total population, as of 2018, does not exceed 0.8 million in total, and mainly divided into three races, including Thanglas, Ngalops and Lhotshampas. Most of the population is concentrated in the capital city of Simbu, a few are scattered in primitive river valleys or mountains, and many places are uninhabited. The WHO pointed out that Bhutan’s total medical expenditures accounted for 5.5% of total domestic production, and the government’s per capita medical and health expenditures were US$101.0, and also estimates that Bhutan's neuropsychiatric diseases account for 12.1% of the global disease burden. The overall mental health as percentage of the national total health expense is estimated on 0.3%, which is quite a small number anyhow.
According to the Constitution of the Kingdom of Bhutan, The country shall "provide basic public health services free of charge" to ensure that all the people can obtain fair and high-quality health services. The central health authority in Bhutan is the Ministry of Health (MoH), whose mission is to ensure sustainable, rapid, equitable, accessible, reliable and affordable health services for the people.
II. Mental health policy and system
Because it has the most rugged and uneven land in its territory, the inconvenience of transportation in Bhutan has led to low medical services. Bhutan has mental policies and plans, but no mental health legislation. State funds are mainly used to train health workers and provide essential psychiatric medicines, and the government provides free treatment including psychotropic medications. In recent years, the government has vigorously promoted the Bhutan's e-Government master plan, among them, there are the National e-Health strategy and action projects, The purpose is to use technology to empower medical personnel to use digital model to provide telemedicine services in order to overcome geographic restrictions and enhance people's health. With the support of the Asian Development Bank (ADB) and the World Health Organization (WHO), the first phase of the strategy has been completed, and the blueprint for the digital health information system is under way. The second phase of the strategy will be started during 2020-2023 and will include works in the following areas:
(1). Identity management of health manpower;
(2). Implement main index for the patients and safe patients' information system;
(3). All medical institutions can use the system.
Bhutan’s e-health care strategy has the potential to fundamentally change the provided health services, strengthen primary health care and promote the development of a "single health" public health surveillance system.
Bhutan has free universal healthcare, the health service organization is a four-level network consisting of national referral hospitals, regional referral hospitals, basic health units and local outreach clinics. The lower-level health service units mainly rely on the support of local authorities and administrative personnel, who in turn report to the national first-level health department. The Bhutanese government formulated the National Mental Health Policy in 1997, the policy includes the development of community mental health services, primary mental health care, human resources, patient and family participation in advocacy and promotion, across different groups, economic conditions, quality improvement and self-management and other issues, fair access to the scope of mental health services. Bhutan is currently implementing a five-year plan that focuses on continuing to improve health cares, such as, the increase of the manpower in the medical workers、 the raise of the people's expected life years、90% of the population who walk to the medical units can reduce the time for treatment to be less than 3 hours. The five-year plan allocates 8.5% of its national budget to the health sector.
In addition, Bhutan has established a National Health Trust Fund with a goal of reaching 24 million U.S. dollars. The Bhutanese government also promised to match all donations with the trust fund clearly. Currently, 60% of Bhutan's health care services are funded by foreign aid, which makes its stability unpredictable. Therefore, the Bhutan Health Trust Fund should hopefully be self-financing in case the foreign aid dropped out or unavailable. It is expected that the Bhutanese economy will be stabilized within the coming 15-20 years, so that the health sector in Bhutan can be financially independent by then.
III. Human Resources
The human resources working in mental health institutions are classified as follows: the formal psychiatrists (lack of information) should be very few, another 100 lay physicians but in the field of psychiatry are averagely 14.87 per 100,000 population, and 370 nurses (55.02 per 100,000) which include the ones having no special mental health training. Bhutan currently does not have any psychologists, social workers and occupational therapists.
Bhutan’s healthcare system includes modern and traditional healthcare, which is combined to maximize public healthcare services. There are several medical education centers in the country:
(1). Royal Institute of Health Sciences (RIHS) was established in the capital Simbu in 1974, and is a member college of the Royal University of Bhutan, it provides diploma and certificate programs for nurses, medical technicians and other primary health care workers;
(2). Institute of Traditional Medicine Services, which trains traditional medicine workers, provides a five-year bachelor's degree program for doctors, and a three-year diploma program for synthesizers who manufacture medicines;
(3). Khesar Gyalpo University of Medical Sciences of Bhutan (KGUMSB), a decentralized university, provides high-quality medical and health education to solve the shortage of healthcare personnel and to meet the long-term needs for training of health care persons at all levels (diploma, bachelor to doctorate degree, as well as providing continuing medical education and specialized short-term training), human resources and super professional centers that enable the country to plan health to improve the quality of health care services in the future.
IV. Mental health system and promotion
Bhutan's medical care and education are provided free of charge by the government. Most Dzong (districts) have at least one hospital and some smaller medical facilities. Although the number of medical units is acceptable, the overall medical equipment and manpower are insufficient. As of 2013, there were 32 hospitals across Bhutan. In addition to the 5 hospitals in the capital - Simbu, Chukha, Samtse and Trashigang have 3 hospitals each. Every other Tsongkha district has at least one hospital and some smaller medical facilities. Jigme Dorji Wangchuk National Referral Hospital is the largest public hospital in Bhutan. Teleconsultation service has been launched, where patients, even tourists, can get free basic medical care and advanced services such as surgery and emergency treatment. There are general practitioners, plenty of experts, laboratories and operating rooms, as well as diagnostic equipment such as Computed tomography (CT) and Magnetic Resonance Imaging (MRI).
Currently there are 5.1 physicians and 11.5 nurses per 10,000 people in urban areas, while the average level in rural areas is even worse, with only 0.2 doctors and 2.4 nurses per 10,000 people. The public sector has 1,078 beds and 145 physicians, including specialist physicians working in hospitals. There is no private health care service in Bhutan. In terms of primary health care, there are 35 physician-based units (i.e., 29 regional hospitals and 6 primary medical units) and 170 non-physician clinics or basic health units.
There are no psychiatric hospitals in Bhutan. There are 63 community psychiatric clinics and 100 inpatient beds, with an average of 14.9 beds per 100,000 population. Mental health outpatient facilities have an average of approximately 5,266 people per 100,000 population, or 783 patients. There is currently no information on all users who have received mental health outpatient treatment.
There is only one mental health day treatment facility in the country, but there are no day care medical units specifically for children and adolescents. The facility can treat 35 patients, and about 5.21 per 100,000 population. In day treatment, roughly half of the patients are women, and an estimated 29% are children or adolescents. Patients receive an average of 150 days of treatment per year.
In terms of mental health promotion, the Bhutanese government believes that it should be included in public education, so every year it organizes a "Mental Health Week" in conjunction with the "World Mental Health Day", which includes mental health education and professional training.
The National Guidance Committee promotes enhanced suicide prevention measures. Its operations include the cooperation between the health, education, monastery communities and police department, and to strengthen the capacity of gatekeepers and boost the suicide information system with the provision of a basis for policy making and decision-making. Suicide prevention activities have become the responsibility of local governments, which paved the way for the basic local level and various departments in the Kingdom of Bhutan.
V. Major issues, challenge, and opportunities
Because of the cold climate in Bhutan, many people have had the habit of chewing betel nuts since they were young, which result in an increasing rate of oral cancer. The medical resources in the country cannot afford the incurred expense, and therefore, the said cancer patients must travel to the neighboring country like India to obtain treatment.
According to Bhutan's 2015 National Happiness Index survey, 91.2% of Bhutanese believe that they are happy. However, the same survey also found that the mental health of its people has declined because of the increase of anxiety and frustration disorders. The analysis of domestic experts also indicates that the economic factors, interpersonal relationships, domestic violence, mental illness, etc., have caused the increase in the suicide rate. In Bhutan, 87% of suicides are between 15 and 40 years old, which currently makes the suicide rank sixth among the top ten abnormal causes of death in Bhutan.
Suicide and mental disorders are increasingly serious and becomes the public health problems in Bhutan, and it has caused the attention of the government. Therefore, it launched the first national suicide prevention plan in 2015. The three-year action plan took a holistic approach to make suicide prevention services the highest priority, including the strengthening policies, adopting social protection measures, mitigating risk factors and others related to its affected incidents, etc.
tient mental health in Bhutan include emotional and neurological disorders, mood disorders, substance abuse disorders and schizophrenia are the most common diagnoses. Alcohol has become the first killer for the middle-aged men, and also to women, in Bhutan, while the substance abuse is also a big issue for the young. Furthermore, more and more young people who graduated from the school can't get some appropriate jobs for themselves, which also lead to a major social problem. In short, the alcohol, substance and unemployment are not only the public health issue but also a threat to its medical services at this moment.
The resources and facilities currently available to treat drug abuse addiction are quite limited. The capital Simbu has a 15-bed rehabilitation center run by a NGO and an addiction recovery. But its function cannot respond to the existing demand for drug treatment and rehabilitation. Many of these addicts are attending rehabilitation centers in Sikkim and Darjeeling of India. For patients diagnosed with mental illness, there is a 10-bed ward in Simbu that administers the drug poisoned or drug-psychotic patients.
VI. Potential exchange issues
The Bhutanese government has begun to promote an integrated community mental health service program under the primary health care system, which is between traditional medical care (such as Dharma rule, meditation, yoga, etc.) and modern mental health professions. In this country, mental illness is still a taboo, and in addition, people usually prefer traditional "treatment" methods, while only a small number of patients go to the hospital for treatment. In summary, the training of mental health professionals, suicide prevention and drug addiction, etc., will be the topics of further exchanges with Bhutan in the future.