HEALTH SECTOR NOTE. MINISTRY of FOREIGN AFFAIRS/DENMARK GROSS NATIONAL HAPPINESS COMMISSION/BHUTAN

MINISTRY of FOREIGN AFFAIRS/DENMARK GROSS NATIONAL HAPPINESS COMMISSION/BHUTAN Joint Evaluation: Danish-Bhutanese Country Programme 2000-09 HEALTH SECTOR NOTE Professor J Patrick Vaughan Oxford Policy Management Ltd. July 2010

Table of content 1. Introduction 1 2. Achievements during the 8 th Five-Year Plan 1997-2002 3 2.1 Background to developments in the health sector before 2000 3 2.2 HSPS2 and Danida support to the health sector 3 3. Background and objectives for the 9 th Five-Year Plan 2003-08 5 3.1 The overall objectives of the 9 th FYP 5 3.2 Agreement for Programme Support Phase 3 (HSPS3), 2003-08 5 3.3 Technical assistance to HSPS, Phases 1, 2 and 3 6 4. Achievements during the 9 th Five-Year Plan 2003-08 8 4.1 9 th FYP: Component 1: Budget Support 8 4.2 9 th FYP: Component 2: Capacity Building in Management and Monitoring 9 4.3 9 th FYP: Component 3: Rural Water Supply and Sanitation (RWSS) Programme 10 4.4 9 th FYP: Summary of progress towards policies, plans and targets 11 5. Background and objectives for 10 th Five-Year Plan 2008-13 13 5.1 Overall aim of the 10 th FYP 13 5.2 Agreement for Social Sector Programme Support (SSPS) 2008-13 13 5.3 Joint Denmark-Bhutan Review 2009 14 5.4 HRD and capacity building 14 5.5 Pro-poor policies and district health services 15 5.6 Performance monitoring and accountability 15 5.7 Health sector coordination mechanisms 16 5.8 Epidemiology and Research Unit, Policy and Planning Division, MoH 16 5.9 Summary: Assessment of progress against plans for the 10 th FYP 17 6. Analysis of indicators for progress in the health sector 19 6.1 ROACH Approach Results Oriented Approach to Capacity Change 19 6.2 Achievements as shown by health indicators 2000-09 19 6.3 Institutional developments in the health sector 2000-09 22 7. Cross-cutting issues and themes 23 7.1 Poverty and gender equity issues 23 7.2 Governance and rights to health 23 7.3 Effects of further decentralization in health 24 7.4 Future private sector involvement in the health sector 24 8. Overall assessment of Danish support to the health sector 25 8.1 Donor support to the health sector 25 8.2 Assessment of capacity building 25 8.3 Assessment of technical assistance 26 8.4 Changes in health service delivery 2000-09 26 8.5 Bhutan and Danish partner-donor harmonization and alignment 26 8.6 Summary of the Danish contribution to the health sector 2000-09 27 8.7 Contribution of Danish support to the achievements in the health sector 27 8.8 Prospects for sustainability 28 9. Recommendations to Danida on underpinning the health sector 29 9.1 What support should Danida provide to maximise effect? 29 9.2 Recommendations 29 References 33

Abbreviations and acronyms ADB Asian Development Bank BHMC Bhutan Medical and Health Council BHU Basic Health Unit BIMS Bhutan Institute of Medical Sciences BTN Bhutan Ngultrum (the national currency) DHSP District Health Service Programme DKK Danish Kroner FYP Five-Year Plan GFATM Global Fund Against AIDS, Tuberculosis and Malaria GOI Government of India GNH Gross National Happiness GNHC Gross National Happiness Commission HRD Human Resources Development HRP Human Reproduction Programme, WHO HSPS Programme Support ICDDRB International Centre for Diarrhoeal Disease Research Bangladesh IT Information Technology JDWNRH Jigme Dorji Wangchuck National Referral Hospital LOD Liaison Office of Denmark LT Long-Term (advisor) MDG Millennium Development Goals MoF Ministry of Finance MoH Ministry of Health MoHE Ministry of Health and Education NCD Non-Communicable Diseases ORC Out-Reach Clinic PAR Poverty Analysis Report PHC Primary Health Care RCSC Royal Civil Service Commission RGoB Royal Government of Bhutan ROACH Results Oriented Approach to Capacity Change RWSS Rural Water Supply and Sanitation SSPS Social Sector Programme Support 2008-13 ST Short-Term (advisor) STI Sexually Transmitted Infections TA Technical Assistance UNFPA United Nations Population Fund Unicef United Nations Children s Fund USD US Dollars VHW Village Health Worker WB World Bank WHO World Health Organization Bhutanese terms Dzongkhag Gewog District - cluster of gewogs (there are 20 in Bhutan) Administrative block (there are 205 in Bhutan)

1. Introduction This paper focuses primarily on presenting developments in the over the decade 2000-09 and in particular on the contribution made by Denmark (Danida) in supporting health development in Bhutan. It first examines the objectives of the Five-Year Plans for 1997-2002, 2003-08 and 2008-13 and then the achievements during the plan period, together with an assessment of the Danish contribution towards these achievements. Later sections examine trends towards improvements in health status indicators. This approach builds on the close alignment between the objectives in the Five-Year Plans and those for the health sector within the agreements made by Denmark for their support. The overall objectives of this evaluation were: To assess and document the relevance and effectiveness of Danish support to poverty reduction and democratisation in Bhutan 2000-09; and To consolidate and enhance the sustainability of the outcomes achieved through learning and adjustments to the cooperation during the last programme period 2008-13 and beyond. This paper focuses on the whole Bhutanese health system and analyses output, outcome and health impact or status indicators to see if there are significant trends over this decade. Selected indicators were examined that cover the three main areas of outputs or achievements by the FYPs, outcome indicators for population coverage by health services and public health programmes, and impact as measured by indicators of health status. Included are indicators for the provision of health facilities and staff, total number of patients diagnosed with selected diseases, population coverage of public health service interventions, and also for possible trends in impact as seen through changes in health status. Denmark has over the last two decades made country agreements with Bhutan which provided support to the following main sectors: - 1991-1996: Programme Support Phase 1 (HSPS1) - 1997-2002: Programme Support Phase 2 (HSPS2), Rural Water Supply and Sanitation (RWSS, from 2000), Environment and Natural Resource Management (ESPS), Urban Development (USPS) and Good Governance and Public Administration Reform (GG/PARP) - 2003-08: Programme Support Phase 3 (HSPS3), Environment and Urban Development (EUSPS), Good Governance (GG I) and Education (EdSPS) - Social Sector Programme Support (2008-13) (SSPS 2008-13), covering the education and health sectors, Good Governance (GG II), Environment and Urban Development (EUSPS). This paper focuses mainly on the health sector in the decade 2000-09 and, in particular, on the Programme Support Phases 1, 2 and 3 (HSPS), Rural Water Supply and Sanitation (RWSS) and the start of the Social Sector Programme Support (SSPS) in 2008. In the earlier FYPs the contributions made by the Danish Government were discrete and identified with specific project activities, often through earmarked funding. However, identification and attribution becomes more difficult with Danida s move to sector budget support in 2003 for the new Programme Support Phase 3 (HSPS3, 2003-08). 1

In supporting the 10 th FYP starting in 2008, the Danish Government made the Social Sector Programme Support agreement (SSPS 2008-13) with relies entirely on central budget support mechanisms, with no earmarked funds for separate health sector activities. This means that all Danish funding for the health sector is now fully included in the budgets of the MoH and it is not possible, therefore, to either identify or attribute any individual developments directly to this funding. Chapter 1 briefly summarises support during the 8 th FYP (1997-2002). Chapter 2 then examines the objectives for the 9 th FYP and the agreements made for the Programme Support Phase 3 (HSPS3) 2003-08. Chapter 3 looks in more detail at the achievements during the 9 th FYP 2003-08 and the Danish contributions made in those years. Chapter 4 presents the main objectives of the 10 th FYP for 2008-13 and the agreement for health sector support included under the Social Sector Programme Support (SSPS) 2008-13. Finally, it examines some of the early health sector achievements during 2008-09. Chapter 5 summarizes the evolution in Bhutanese health outcome indicators and health status indicators over the period 2000-09 to look for any significant trends. Chapter 6 examines the cross-cutting themes of gender, governance, decentralisation, and plans for privatisation in the 10 th FYP. Chapter 7 attempts an overall assessment of Denmark s contribution in supporting the health sector over the decade 2000-09. Chapter 8 finally makes recommendations for areas in the health sector that could benefit from Danish support during the final years of the 10 th FYP 2008-13. 2

2. Achievements during the 8 th Five-Year Plan 1997-2002 2.1 Background to developments in the health sector before 2000 Bhutan first became a priority for Danish development assistance in 1989 and for the 7 th FYP 1991-97 Denmark committed DKK 74.6 million to the Support Programme Phase 1 (HSSP1). This support focused mainly on strengthening planning and management, human resources development, health infrastructure, information technology, education and communications, and control of diseases. In June 1997 the Royal Government of Bhutan (RGoB) and the Government of Denmark signed an agreement for Programme Support Phase 2 (HSPS2) to be implemented simultaneously with the 8 th FYP for 1997-2002, with an allocation of DKK 120 million. In 1999 the RGoB also requested Danish support for a large Rural Water Supply and Sanitation (RWSS) project, which started in 2000 as a continuation of a previous Unicef financed programme. This had a separate budget of DKK 44.5 million and was due to be completed in 2005 but was later extended to 2007. Bhutan was an early adopter of the Primary Health Care (PHC) approach promoted by the World Health Organization (WHO) and Unicef in the late 1970s, which led in the 1980s to an ambition to expand local and rural health services in order to reach many underserved villages and households. This health policy relied mainly on Village Health Workers (VHWs), Out-Reach Clinics (ORCs), Basic Health Units (BHUs), and District Hospitals (DHs). The result today is a strong and reasonably equitably distributed PHC, with about 90% of the total population now within three hours walk of a health service unit. All government basic PHC and hospital services have remained free from formal charges. However, by the mid-1990s weaknesses in this PHC approach resulted in vertical health and disease control programmes being strengthened, including those for tuberculosis, leprosy, iodised salt, malaria, immunisations, and maternal and child health. However, the RGoB s general aim has continued to be to achieve greater equity in access to PHC basic health services by consolidation rather than by expanding these further. The Mid-Term Review of HSPS2 in April 2000 found that: Bhutan had made impressive progress in development of its health care system. Access to services had been expanded significantly. Quality of care in general is reasonable, with some deficiencies in the areas of essential drugs, referral system and supervision. It also noted that there were significant problems caused by a shortage in all categories of health workers. 2.2 HSPS2 and Danida support to the health sector Besides supporting PHC from early in HSPS2, Denmark began investing in urban water supplies, sanitation, sewage and waste disposal. It also noted concerns about the health consequences of rapid urbanisation and the increase in non-communicable diseases, mental ill-health and road traffic accidents (RTA). In HSPS2 Denmark supported the strengthening of health planning and management and human resources development (HRD) in the Ministry of Health and Education (MoHE) through technical assistance (TA). Denmark also expanded its support for HRD through overseas in-service training for short overseas visits and workshops, as well as for overseas certificates, diplomas, postgraduate Masters courses and medical specialist training. In 3

addition, Denmark directly supported with TA the capacity of the MoHE s Policy and Planning Department and its Epidemiology and Research Unit. Starting in HSPS2 Danida funded the construction and renovation of an additional 33 BHUs, two district hospitals and started the construction of the new headquarters building for the Ministry of Health in Thimphu. It had also supported five large urban drinking water supply and sewage projects in district towns through the RWSS programme. These projects were later extended into HSPS3 and all were finally completed by 2007. Denmark and India were the two largest donors to the health sector, while others included UNFPA, Unicef, WHO and ADB. The assessment of Danish support in 1999 (Mid-Term Review 2000) concluded that there was some degree of synergy and agreement between the RGoB health policies and the Danida support and that almost the entire Danish funding was included in the RGoB budgets and accounts. It then stated: This transparency makes for more efficient use of donor support. However, the evaluation also concluded that coordination between RGoB and donor agencies should be further strengthened in order to maximise their contributions. In 2001, a feasibility study of financial management by the RGoB in the health and education sectors commissioned by Danida recommended that future support to the health sector should include an element of budget support. The Joint Annual Sector Review of HSPS2 in 2002 concluded that the health sector was indeed ready for more broadly based financial budget support. 4

3. Background and objectives for the 9 th Five-Year Plan 2003-08 3.1 The overall objectives of the 9 th FYP These include the following: Improving the quality of life and income, especially of the poor Ensuring good governance Promoting private sector growth and employment Promoting cultural heritage and environmental conservation Achieving rapid economic growth and transformation. The 9 th FYP plan budget was for Bhutan Ngultrum (BTN) 70 billion of which 45% was recurrent expenditure. The RGoB s recurrent budget expenditure for the health sector throughout the period July 2002-June 2008 represented 11% of total government recurrent expenditure. In 2007, the final year of the original plan, the plan period was extended by one further year to allow for parliamentary debate to take place on proposals for the 9 th FYP by the newly elected National Assembly. The long-term objective for the health sector in the 9 th FYP was the attainment of a healthy living standard by the people within the broader framework of overall development of the country. The specific objectives were the following: Enhancing the quality of health services Targeting health services to reach the unreached Strengthening traditional medicine system and its integration with overall health services Enhancing self-reliance and sustainability of health services Intensifying human resource development for health and establish a system for continuing education Strengthening health management information systems and research and their use Intensifying reproductive health services and sustain population planning activities Promoting community based rehabilitation and mental health, and find innovative means to enhance the mental well-being of people Developing appropriate secondary and tertiary health care services, while maintaining the balance between primary, secondary and tertiary health care Intensifying the prevention and control of prevailing health problems, as well as the emerging and re-emerging ones. 3.2 Agreement for Programme Support Phase 3 (HSPS3), 2003-08 The Agreement between the Bhutanese and Danish Governments for the Programme Support Phase 3 (HSPS3) was closely aligned to the health sector objectives in the 9 th FYP, as set out above. The total Danish contribution to HSPS3 Components 1 and 2, shown below, were for DKK 82 million and for Component 3 a further DKK 44.5 over and above the agreed budgets for HSPS2 and HSPS3. The three components in HSPS3 were: 1. Component 1: Budget Support. This amounted to 74% of the total DKK 82 million, channelled to the Ministry of Finance (MoF) and disbursed as regular RGoB expenditure. 5

2. Component 2: Support to Capacity Building in Management and Monitoring. These funds were earmarked to the health sector. 3. Component 3: Support to the National Rural Water Supply and Sanitation (RWSS) Programme. These earmarked funds went to the Ministry of Health and Education (MoHE). The 9 th FYP Mid-Term Review Meeting of Central Sectors and Agencies was held in Thimphu in November 2004. It acknowledged that Danish support had enabled the satisfactory completion of the Trongsa and Trashigang hospitals, while other funds had helped with the expansion of works on Thimphu and Monggar hospitals. In 2005 MoHE was separated into two ministries and the newly established Ministry of Health (MoH) moved into its own new headquarters building in Thimphu which had been constructed with support from Danish funding. During the 9 th FYP the Bhutan health sector total budget was BTN 7,250 million for the six years 2002-08, made up of current expenditure BTN 4,461 million and capital expenditure of BTN 2,788 million being 11.2% and 6.3% of the gross national expenditure respectively. Donor funding, mainly by Denmark and India, contributed 22% to the total health sector expenditure. 3.3 Technical assistance to HSPS, Phases 1, 2 and 3 From 1991 to 2008 Denmark included a substantial contribution through technical assistance (TA) to support the Support Programmes Phases 1, 2 and 3. Table 1 below shows data for both short-term and long-term international advisers. Table 1: Danida technical assistance to Bhutan FYPs and to HSPS 1991-2008 Bhutan Five Year Plans 7 th FYP 1991-96 8 th FYP 1997-2002 9 th FYP 2003-08 1991-2008 Danida Programme Support TA Long-term Advisers Topics Covered TA Advisers: Numbers of Short-term, Long-term and Total months Total Programme Support Phase 1 and 2 (HSPS 1 and 2) Programme Support Phase 3 (HSPS3) Rural Water Supply and Sanitation (RWSS) Advisers: Short-term Long-term Health planners 3 CTA 2 Engineer 1 Quality Assurance 1 Economist 1 Research 1 Chief adviser 1 Economist 1 Inf. Techn. 1 Architect 1 ST: 0 LT: 5 Months: 147 6 - - - Senior Advisers 2 - - - ST: 2 ST: 4 Months: 164 ST: 1 LT: 0 Months: 10 ST: 3 LT: 1 Months: 47 ST: 6 LT: 0 Months: 6 ST: 13 LT: 4 Months: 129 ST: 3 LT: 1 Months: 40 ST: 8 LT: 9 Months: 317 ST: 14 LT: 4 Months: 139 ST: 6 LT: 2 Months: 87 0 6 22 28 5 5 5 15 Total TA months 147m 221m 175m 543m NB: Short-term is less than 12 months and long-term 12 months or more. The total TA for the HSPS 1, 2 and 3 and the RWSS amounted to 543 person months, or more than 45 years, equivalent to 2.5 full-time persons for each year from 1991 to 2008.

The TA for HSPS3 and RWSS alone amounted to a total of 226 person months or nearly 19 years, equivalent to more than three persons full-time for each of the six years. The TA was mainly for health planning, management and financing, as well as for human resources and information technology. There is a noticeable change over the period 1991 to 2009 in the way TA was used to support the health sector. Initially in HSPS1 the TA relied mainly on long-term advisers but by HSPS3 it had become less reliant on long-term and more reliant on short-term advisers. For the Social Sector Programme Support (SSPS) 2008-13 no TA is being paid for by Denmark directly for the health sector. Starting in 1991 the TA increased up to 2001 and it then remained at a high level for HSPS3 during 2003-07, although it declined rapidly after 2007. This reflected Danida s deliberate intention to reduce its direct TA as it switched to more sector budget support. In the health sector most TA under HSPS1 (1991-97) focused mainly on supporting health planning, health economics and financing, and public health engineering. While during HSPS2 (1997-2002) the TA supported engineering, construction of health facilities and infrastructure development. The focus during HSPS3 (2003-08) switched towards strengthening the Bhutanese capacity in senior management and a number of specialised technical issues. In conclusion, there is no doubt that Denmark s support to Bhutan through TA made a major contribution to, firstly, establishing a well developed and equitable system for primary health care throughout Bhutan and, secondly, underpinned the development of a strong and capable MoH that was well positioned to further develop the health system under democratisation and decentralisation. 7

4. Achievements during the 9 th Five-Year Plan 2003-08 4.1 9 th FYP: Component 1: Budget Support The total sector budget support amounted to 74% of the total DKK 82 million, channelled to the Ministry of Finance (MoF) and disbursed annually for regular RGoB expenditure to the MoHE, and later to the new MoH. Disbursement was slow over the first two and half years, with MoHE expenditure being only 34% of the total available. The RGoB Mid-Term Review of the 9 th FYP in late 2004 noted that the MoHE had achieved a number of significant health initiatives early in the implementation of HSPS3, including the establishment of the Bhutan Medical and Health Council, Drug Regulatory Authority and Bhutan Health Trust Fund, as well as the ratification of the WHO Convention on Tobacco Control and the banning of sale of tobacco products. The Danida Mid-Term Review also noted that reproductive health activities and advocacy on STI/HIV/AIDS had been intensified; the National Commission for HIV/AIDS had been revitalised and sentinel surveillance established in 15 sites in 13 dzongkhags; the Monggar Referral Hospital had been upgraded; national immunisation coverage had been maintained above 85%; equal emphasis was given to developing PHC as well as secondary and tertiary care services; the Human Resource Master Plan had been updated and published; and that construction of the JDW National Referral Hospital in Thimphu had been started. However, the Mid-Term Review in 2004 also highlighted a number of problems, including the continuing shortage of human resources, particularly of medical specialists; difficulties in achieving universal coverage by PHC services in hard to reach areas; need to strengthen curative and diagnostic capacities in district hospitals; need to strengthen central monitoring and supervision in the context of decentralisation of health services to dzongkhags and gewogs; and the increasing support required by dzongkhags for equipment and building maintenance. The Bhutan Joint Review was carried out in mid-2006 and involved the MoH, Danida and World Bank (WB), which had been supporting the HIV/AIDS programme from 2004. This Joint Review also noted that the health sector continued to be a high priority for the RGoB and that the MoH had made considerable progress with nearly all its 9FYP objectives. This Review expressed: confidence in the general priorities of the Government and do not find any very apparent problems in the proposed budget for 2006-07 (p. 8). Monitoring had been strengthened and there were now 16 health indicators and so far the 9 th FYP had reached targets for eight and was close for another three. The most recent and comprehensive review of progress is included in the Review 2007. The 2007 Review also examined the MoH s preparations for the forthcoming 10FYP that had tackling poverty as its top priority. As Bhutan was adopting decentralisation, the challenges for the MoH included how it continued to implement PHC while also expanding the secondary and tertiary health services and how it balanced this with strengthening its support for district health services, including district hospitals, under a more decentralised system. Other priorities identified were how to achieve a higher level of self reliance in financing and how to maintain the MoH s dedicated and valuable work force. In support of the MoH in its own development, the Review recommended that Danida make some specific inputs with short-term TA. 8

The Review 2007 looked at the development of the sector, with a special emphasis on progress during the 9 th FYP period (2002-07). It also undertook a strategic analysis of sectoral priorities for the forthcoming 10 th FYP. It also made an extensive analysis of health indicators and of trends and progress towards improvements. The review team concluded that there was good evidence for a steady improvement in many health status indicators and for a fall in the incidence of some common diseases over the decade since 1995. Following discussions with Bhutanese government officials and the MoH the review team also identified the following priorities for inclusion in the 10 th FYP: Possible privatisation of some health services and facilities Costs of treating some 7,000 patients abroad each year Cost-effectiveness and equity of expanding physical access to primary health care services in rural areas Emerging non-communicable diseases and strategies for their control New strategies on IT (information technology), procurement of medical supplies and equipment, and the continuing lack of sufficient number of trained health workers. 4.2 9 th FYP: Component 2: Capacity Building in Management and Monitoring Bhutan has formalised procedures for human resource development (HRD) of governmental staff which are managed by the Royal Civil Service Commission (RCSC). Earlier Danish support for training utilised earmarked funds for HRD in designated ministries, rather than as funds managed by the RCSC. Later these funds were incorporated into those for sector budget support and channelled to the GNHC and then to the Ministry of Finance (MoF). HSPS3 supported the MoE/MoH with significant funding for HRD which was guided by the Human Resources Master Plan for selection of health staff for overseas training. See Table 2 below for support to both short term overseas visits or courses and see Table 3 below for long term overseas higher level training involving certificate, diploma and postgraduate Masters courses. Short courses were completed in such fields as planning and financing, monitoring and evaluation, research methodology, health information, finance and accounts, IT management, and telemedicine and e-governance. In addition, Denmark also funded study tours to expose senior staff to international trends, share experiences and raise awareness amongst decision makers. Capacity development in HSPS3 also involved Certificate, Diploma and Masters level (long term) courses, including health policy and planning, health economics, public policy, HRD, financial management, IT, bio-statistics, information systems and management, and information security. Table 2 below shows that most of the staff attended short courses in India (39%) and the others in SE Asia and the Philippines. The numbers were relatively steady for years 2003-07 but were much higher for the last year 2008. The total time spent overseas was 450 weeks or 16 months, with the 185 staff each spending an average of 2.4 weeks away from Bhutan. The courses were mainly for training in health planning, technical building, management, engineering and computing/it. 9

Table 2: Health staff receiving overseas short-term study tours and training 2003 08 Countries for Study 2003 2004 2005 2006 2007 2008 Total India 13 12 8 5 13 22 73 SE Asia 11 5 7 1 5 29 58 Philippines 2 9 4 10 18 9 52 Europe 2 2 Total staff number 28 26 19 16 36 60 185 Total staff weeks 78 78 34 38 81 141 450 Source: LOD and MoH data. Table 3 below shows the steady decline in health staff receiving Danish funding for higher level training overseas during the 9 th FYP, from 11 in 2003 to one in 2008. No staff went for postgraduate Masters courses overseas in 2007-08 and only three doctors were sent for specialist training in 2003 and none after that. Each of the 32 staff on long term study spent an average of 14 months overseas, with 59% (19/32) attending postgraduate courses in Australia. These high level courses were mainly for diplomas and masters in infrastructure development, epidemiology and public health. The higher specialist training was in foetalmaternal medicine, cyto-pathology and prosthodontics. A total of 217 health sector staff benefited from this training over the six years of the extended 9 th FYP and HSPS3, made up of 185 who attended short overseas courses and 32 on longer term overseas courses, with an average of 31 and 5 staff being selected per year respectively. Both the short-term and long-term overseas studies were mainly paid for by specific projects as part of capacity development, but this support largely disappeared with Danida s switch to budget support in HSPS3. This accounts for the noticeable decline in numbers funded by Denmark in the final years of the 9 th FYP. Table 3: Health staff receiving long-term higher level training overseas 2003 08 2003 2004 2005 2006 2007 2008 Total Certificates, Diplomas 5 2 2 3 5 1 18 Postgraduate Masters 3 3 1 4 11 Medical Specialisation 3 3 Total Staff number 11 5 3 7 5 1 32 Total Staff months 189 66 48 98 54 6 461 Asia 4 1 2 2 1 10 Australia 6 2 3 5 3 19 USA 1 1 Europe 2 2 Source: LOD and MoH data. In conclusion, the Danish support clearly gave high priority to supporting the development of human resources in health by investing heavily in a wide range of mid-level and high level skills that were needed to underpin the 9 th FYP. This was done through the use of a formal planning process for HRD that was supported by Denmark and implemented through the RCSC. The development plan put a strong emphasis on establishing high level project implementation related skills and the development of a cadre of senior public health professionals. 4.3 9 th FYP: Component 3: Rural Water Supply and Sanitation (RWSS) Programme The national RWSS programme was first established in 2000 as a separate component with its activities based on the demand and support for implementation coming from 10

communities themselves, including for long-term maintenance. Funding then continued under HSPS3 as Component 3 with earmarked Danish funds until late 2007. The urban component was implemented in the five districts of Monggar, Samtse, Sarpang, Trashigang and Tsirang. The 2004 Mid-Term Review noted that the procurement of materials for the larger RWSS schemes had increased and recommended that the MoH sector should fully decentralise its management to dzongkhag and gewog for both budgets and activities, including for procurement and distribution of materials. The RGoB Mid-Term Review in 2004 also noted that the health sector should coordinate much more closely with other sectors at the dzongkhag level, particularly in terms of centrally executed programmes, as well as between the dzongkhags and gewogs for local planning and implementation. The RWSS programme had its own thorough technical review early in 2005, which found that the RWSS was on track to complete 494 new schemes. However, this review did express concerns about the long-term viability of relying on external financial and technical support and the need to integrate all public health engineering into regular public health activities when this component closed. The review also expressed concerns over the large discrepancies in coverage that remained between dzongkhags and the large number of local schemes requiring rehabilitation. In 2005 the implementation period for RWSS was extended to include the development of a computerised management information system supported by TA. The project finally closed in 2007. 4.4 9 th FYP: Summary of progress towards policies, plans and targets Achievements by Programme during HSPS3, (Component 1): 1. Danish funds were successfully channelled to the MoF and disbursed to the MoH for regular RGoB expenditure 2. The Bhutan Medical and Health Council Act (BHMC) 2002 and Bhutan Medicines Act 2003 were passed, enabling the Bhutan Medical and Health Council and the Drug Regulatory Authority to be established respectively 3. Ratification of the WHO Convention on Tobacco Control led to banning the sale of tobacco products from December 2004 4. Health Trust Fund was established in 2003 with a significant contribution from Denmark to match Bhutanese funds 5. Health activities and advocacy on STI/HIV/AIDS had been intensified and the National Commission for HIV/AIDS had been revitalised 6. Human Resources Master Plan had been updated and published 7. Construction of the JDW National Referral Hospital in Thimphu had been started. The Joint Review of the in 2004 also highlighted the following problems: 1. Continuing shortage of human resources, particularly of medical specialists 2. Difficulties in achieving universal coverage by PHC services in unreached areas 3. Need to improve curative and diagnostic capacities in district hospitals 4. Need to strengthen central monitoring and supervision in the context of decentralisation of health services to dzongkhags and gewogs 5. Increasing support required by dzongkhags for equipment and building maintenance. 11

The Bhutan Joint Review (carried out in mid-2006) and the Danish Health Sector Review (carried out in January 2007) both examined the development of the sector, with a special emphasis on progress during the 9 th FYP period (2002-07) and undertook a strategic analysis of sectoral priorities for the forthcoming 10 th FYP. The 2007 Review made an extensive analysis of health indicators and of trends and progress towards improvements and concluded that there was good evidence for a steady improvement in many health status indicators over the decade since 1995. Both Reviews also noted that the health sector continued to be a high priority for the RGoB and that the MoH had made considerable progress with nearly all its 9 th FYP objectives. Monitoring had been strengthened for 16 health indicators and that so far the 9 th FYP had reached targets for eight and was close for another three. Achievements in Capacity Building in Management and Monitoring (Component 2): HRD was based on the Human Resources Master Plan which guided the MoH s selection of health staff for overseas training. Main achievements were: 1. 217 health sector staff benefited from this training over the six years of the HSPS3 2. 185 staff attended short overseas training and 32 long term courses overseas 3. On average 31 staff were selected for short courses and five for longer courses each year 4. 39% of staff attended short courses in India and the others in SE Asia and the Philippines 5. Main topics for training were health planning, technical building, management, engineering and computing/it 6. Health staff receiving high level training overseas declined from 11 in 2003 to one in 2008 7. No staff went for postgraduate masters courses overseas in 2007-08 8. Only three doctors were sent for specialist training in 2003 and none after that 9. Most staff on overseas long-term study went for postgraduate courses in Australia, mainly for diplomas and masters in infrastructure development, epidemiology and public health. Achievements by Rural Water Supply and Sanitation (RWSS - Component 3): The national RWSS programme began in 2000 and was continued under HSPS3 until 2007 with earmarked funding. Achievements included: 1. Urban component implemented in Monggar, Samtse, Sarpang, Trashigang and Tsirang 2. Completion of 494 new rural water schemes 3. Many implementation activities were successfully decentralised to dzongkhags 4. Computerised management information system successfully developed by 2007. Concerns were expressed, however, about the long-term viability of relying on external financial and technical support and the need to integrate all public health engineering into regular MoH public health activities. Achievements in Preparing for the Forthcoming 10 th FYP: As Bhutan was adopting more decentralisation, the MoH faced the following challenges: 1. Implementation of PHC while also expanding secondary and tertiary health services 2. Strengthening support for district health services, including district hospitals 3. Achieving a higher level of self reliance in financing 4. Maintaining the MoH s dedicated and valuable work force. 12

5. Background and objectives for 10 th Five-Year Plan 2008-13 5.1 Overall aim of the 10 th FYP The aim of the 10 th FYP is to tackle poverty and to improve the quality of life of the people within the overall development philosophy of Gross National Happiness (GNH). Better health is seen as critical to achieving the goal of GNH and an important element in poverty reduction and the development of human capital. The new Constitution mandated the RGoB to provide free access to basic public health services in both modern and traditional medicine and to endeavour to provide security in the event of sickness... These rights were incorporated into the 10 th FYP and seen as a crucial element in tackling poverty because, as stated in the 10 th FYP, health investments have the greatest productivity benefits for and impact on the poor and low income groups. The 10 th FYP broad objectives also gave high priority for achieving the following: Millennium Development Goals (MDGs) for maternal and child health Continued development of the secondary and tertiary health services Control of both communicable and non-communicable diseases Improved access to primary health care services Further development of the country s human resources in health Enhanced traditional medicine services at all levels Sustainability and equity in the health care system. The 10 th FYP contained many of the previous priorities stated in the 9 th FYP. It also stated 15 specific guiding policy objectives, 16 strategies and 13 health sector targets. An important new emphasis in the 10 th FYP was the potential for supporting greater involvement of the private sector. These included private sector participation in: Tertiary medical care and the establishment of a five-star private hospital Provision of some private diagnostic and non-technical services Outsourcing some non-medical services Corporatising the Pharmaceutical and Research Unit of the National Institute of Traditional Medicine. The 13 targets were a mixture of indicators for health system provision, outputs, outcomes and for health status. 5.2 Agreement for Social Sector Programme Support (SSPS) 2008-13 The Social Sector Programme Support (SSPS) 2008-13 combines the support for both the health and education sectors, which are now designated as the Social Sector. The overall approach is seen as a continuation of the principle of budget support in the previous HSPS3. As was the case for HSPS3, the support is given as sector budget support. This SSPS support involves the three RGoB ministries, MoH, Education, and Labour and Human Resources (MoLHR) and covers the period from January 2008 to June 2013 providing a total of DKK 140 million. The SSPS 2008-13 agreement has three components: 1. Component 1: Social Sector Budget Support to Health and Education. This component accounts for 76% of the total Danish support. The funds are channelled twice annually 13

through to the GNHC and then to the MoF, which then disburses them as part of the regular RGoB budget to each ministry. 2. Component 2: Vocational Education and Training (VET). This has 11% of the support and is earmarked for the MoLHR, with most of it being reserved for capacity building. 3. Component 3: Technical Assistance and Management of the SSPS. This has 13% of the support and includes the costs of TA, part of the LOD, and joint reviews and studies. Only Component 1 is considered further in this report as Components 2 and 3 did not directly involve the health sector. It should be noted that SSPS has no earmarked funds for health sector activities and that all Danish funds for health are passed directly to the GNHC and then on to the MoF to be disbursed as regular budget to the MoH. This means that all Danish funds are now fully included in the budgets of the MoH and it is not possible, therefore, to either identify or attribute any individual developments directly to this Danish funding. 5.3 Joint Denmark-Bhutan Review 2009 This Review was carried out early in April 2009 and was the first that was genuinely Joint between the RGoB and donor partners that included Danida, Unicef, UNFPA and WB. This Review attempted to implement the principles in the Paris Declaration and the Accra Agenda for Action in the spirit of harmonization of donor review procedures with those of the RGoB, as well as alignment of donor priorities with those of the Bhutanese Government. The Review confirmed that the RGoB had sustained its focus on PHC and for an equitable expansion in both access to and use of basic health services and traditional medicine. It also noted that there were rising public expectations, increasing costs of health services, and that human resources development continued to be a crucial issue. The following sections identify some recent developments in the health sector: human resources and capacity building, pro-poor and district health services, performance monitoring, sector coordination, epidemiology and research support, and harmonization and alignment. 5.4 HRD and capacity building There have been several important developments in HRD. The GNHC now takes a lead role in liaison with the RCSC and the MoH and there is no funding ceiling to constrain the situation. HRD continues to be given high priority by the MoF, GNHC and the RCSC. Budget allocations for HRD in the MoH appear to have remained steady under the recent Danish SSPS budget support programme, despite the lack of specific or earmarked funds. However, the introduction of new training institutes for certificate and degree programmes in Bhutan will only help to resolve shortages in the long term. Following previous support from Danida, the RGoB now accepts its role in developing human resources in health. The MoH and RCSC today support the overseas training each year of 25 doctors, 10 degree nurses and five dentists, as well as small numbers of pharmacists, dieticians and technicians. Certificate level training of nurses, midwives and technicians continues to take place in Bhutan. The assistant nursing cadre will be phased out, with the best ones being offered training to upgrade to become general nurses and midwives. Others will be offered training to work in such specialist areas as intensive care units, burns units, emergency outpatients, and palliative care. 14

Newly graduated Bhutanese doctors are required to work for at least one year in Bhutan before applying for higher level specialist training. However, there are considerable difficulties in obtaining placements for this specialist training in India, Bangladesh, Sri Lanka, Myanmar, Thailand or Malaysia, as Bhutanese graduate doctors have not been successful in competing against nationals in the selection examinations. Bhutan may have to look to Singapore or Australia or put in place alternative arrangements. 5.5 Pro-poor policies and district health services The MoH is a relatively small ministry that has 22 programmes, serves 20 dzongkhags and coordinates 30 hospitals. To improve coordination with the dzongkhags, the MoH in June 2008 established the new District Health Service Programme (DHSP) to oversee district planning, including for staffing, training, supplies and construction. Human resources planning and employment, as well as purchase of drugs and maintenance of equipment, are still handled centrally whereas local deployment of staff is a matter for the district health teams. The MoH is focusing on improving staffing and facilities in all district hospitals so that each one will have at least three doctors and about a half of all BHUs will have one doctor and one clinical assistant. To overcome the present shortages of doctors, Bhutan has contracted 22 expatriate doctors from Myanmar for two years and a further 11 from Bangladesh and India. There has been clarification of responsibilities for the district health services, with the DHO being designated as in charge of all health sector planning and management, including for the district hospital and all public health activities, as well as primary health care facilities and all disease control programmes. At present only one dzongkhags does not have a district hospital but there are now two regional and one national referral hospitals. The MoH is determined that all districts should have a hospital and that they should all be able to offer basic emergency, outpatient and inpatient services, including delivery units, and be equipped with at least two ambulances for emergencies and transport for supervising BHUs and ORCs. It is planned to have traditional medicine units and basic diagnostic, x-ray and laboratory facilities in all district hospitals. 5.6 Performance monitoring and accountability External donor funding, including from the Governments of India and Denmark, is received and controlled by the GNHC which also has responsible for coordinating all capital expenditures, while the MoF handles the current budgets. The MoH has found this whole process to be more accountable and transparent than previously. The MoH also maintains that there has been no apparent reduction in the RGoB s budget commitment to the health sector under the SSPS arrangements for budget support. To strengthen the RGoB s financial management and accounting, the 10FYP includes the introduction of results based management based on the new National Monitoring and Evaluation System (NMES) developed by the GNHC. This will have three inter-linked webbased platforms for all government planning (PLaMS), budgeting (known as MYRB) and accounting (known as PEMS). Their implementation will require government staff at all levels to be trained. 15

The GNHC has responsibility for capital expenditure and how these funds flow to the MoH and to the dzongkhags. The MoH controls central recurrent expenditure for drugs, equipment and short-term training, while the GNHC controls the costs for long-term HRD, large buildings, vehicles and infrastructure. About 30% of the MoH s current budget funds are also decentralised to the districts for day-to-day implementation and management of health programmes. From the total MoH budget for 2008-09 of BTN 1763 million, about 70% is provided by the RGoB and 30% comes from donors, including the Governments of India and Denmark. Actual expenditure will probably be less than this total. About 56% of the total MoH budget for 2008-09 was allocated to the Directorate of Medical Services but this includes the costs for all hospitals and most of the capital expenditures. Of the remaining allocations, about 16% is allocated to services falling under the Directorate of Public Health and a similar amount to PHC. About 7% is allocated to the MoH secretariat. The total MoH budget for 2009-10 is expected to be less, at about BTN 1,411 million. 5.7 Health sector coordination mechanisms The Directorate for Public Health in the MoH is responsible for the central integration and organization of all prevention and public health programmes, while decentralised implementation is the responsibility of the dzongkhags, including programmes for mother, child and reproductive health services, immunisations, and training of birth attendants and VHWs. Important district communicable diseases control programmes include those for malaria and dengue in areas bordering India. A new MoH policy and strategy has recently been published for the prevention and control of the emerging non-communicable diseases (NCDs). The 10 th FYP supports constitutional reforms and further decentralisation which has implications for how the MoH coordinates with health activities in the dzongkhags and gewogs, including the new block grants. Under the 10 th FYP local governments are allowed to decide on local priorities and manage their own budgets for certain recurrent costs, which could introduce greater competition for funds between sectors at the district level. The dzongkhags are expected to finance most recurrent costs, including for salaries, small constructions and maintenance. However, the MoH will retain responsible for large capital construction, such as of larger hospitals and facilities, together with the selection, training and deployment of staff. 5.8 Epidemiology and Research Unit, Policy and Planning Division, MoH Denmark supported the development of this strategy unit under HSPS3. The Unit has responsibility for producing the evidence for policy making and services planning. It also oversees all research studies carried out by the different MoH programmes, as well as being responsible for maintaining ethical oversight and organizing training for research studies. The Unit makes available small grants of USD 5-7,000 to encourage district based studies. This Unit is currently under staffed. Besides the Head, a medically qualified epidemiologist, the Unit has only one statistician and one research assistant. For health economics it calls on help from two economists working elsewhere in the MoH. It also often seeks policy advice from the WHO and support from the International Centre for Diarrhoeal Disease Research in Dhaka for specialist laboratory facilities. The Unit is applying for a long term institutional 16

research strengthening grant from the Human Reproduction Programme at WHO Headquarters in Geneva. Examples of research studies it has conducted include: behavioural risks for transmission in HIV/AIDS, incidence of acute respiratory tract infections in young children, prevalence of tuberculosis, causes of delays for maternal deliveries, access to Pap smears, and the information in health messages for women. The unit has also undertaken health facility surveys for sexual transmitted infections and HIV, together with an evaluation of staff capacity and quality of services. 5.9 Summary: Assessment of progress against plans for the 10 th FYP The Joint Bhutan and Donor Review, carried out early in April 2009, concluded that the following progress had been achieved: 1. That the principles in the Paris Declaration and the Accra Agenda for Action in the spirit of harmonization and alignment are being implemented and Danish support is now closely in alignment with the RGoB s national priorities in the 10 th FYP. 2. The health sector was on track within SSPS and that it is broadly achieving the objectives within the 10 th FYP. 3. The GNHC is now responsible for coordinating all capital expenditures, while the MoF handles the current budgets. The MoH has found this whole process to be more accountable and transparent. There has been no apparent reduction in the RGoB s commitment to health, despite the fact that there are no earmarked funds for health and all Danish funding is now included in government budgets. About 70% of MoH budget is provided by the RGoB and 30% comes from donors, including the Governments of India and Denmark. 4. HRD continues to be given high priority by the MoF, GNHC and the RCSC, and there is no funding ceiling to constrain the situation. Budget allocations for HRD appear to have remained steady under the present budget support. Other HRD achievements include that each year 25 doctors, 10 degree nurses and five dentists receive overseas training. The new Bhutan Institute of Medical Sciences will soon be given university status and will include a new medical school. 5. The RGoB has sustained its focus on PHC and an equitable expansion in both basic health services and traditional medicine. The MoH has established a new District Health Service Programme to oversee district planning and management, which also focuses on staffing and facilities for all district hospitals. The DHO has been designated as being in charge of all district health activities, including for the district hospital. 6. To strengthen the RGoB s financial management and accounting, the 10FYP includes the introduction of results based management, based on the new National Monitoring and Evaluation System developed by the GNHC. It will have three inter-linked web-based platforms. 7. The GNHC has responsibility for capital expenditure and how these funds flow to the MoH and to the dzongkhags. The MoH controls central recurrent expenditure for drugs, equipment and short-term training, while the GNHC now controls the costs for longterm HRD, large buildings, vehicles and infrastructure. Of the recurrent budget funds 30% is for the running of decentralised health services in the districts, including for the day-to-day implementation and management of PHC and public health programmes. 17