BHUTAN Assessment of capacities using SEA Region Benchmarks for Emergency Preparedness and Response
SEA-EHA-22-BHUTAN Assessment of capacities using SEA Region Benchmarks for Emergency Preparedness and Response Bhutan
Summary Report BHUTAN BHUTAN Background and vulnerability to disasters Bhutan is a mountainous country covering an area of 38 394 km 2 situated between the two Asian giants viz. China in the north and India in the east-south-west. The country is susceptible to a multitude of natural hazards being located largely in the high-risk seismic zones of IV and V. Hospital and health facilities are among the most vulnerable during disasters and each year due to damages, hospital and health units face difficulties in delivering health services to the public, especially to the affected communities. The two recent earthquakes of 21 September 2009 and 18 September 2011 have damaged a total of 64 health facilities (hospitals/basic health units/out-reach clinics). Reportedly, 12 deaths and 62 injuries were caused to the people and losses are estimated at more than Nu 600 million. With increasing impacts of climate change, there is the impending risk from glacial lake outburst floods (GLOFs). Bhutan has 2674 glacial lakes, of which 25 have been identified as potentially dangerous. The threat from GLOFs is increasing as temperatures rise due to global warming and cause glaciers to retreat at a rapid and unprecedented rate. High growth of settlements and agricultural practice in low-lying areas, inadequate building practices, overcrowding and fragile economy are factors that increase the population s vulnerability to disasters. Bhutan is also vulnerable to seasonal hazards such as landslides, flashfloods, windstorms, fire on human settlements, forest fires and emerging diseases. Mortality due to road crashes is also marked as one of the highest in the countries of South-East Asia Region. With an ever increasing number of vehicles and high road density, there is an increasing vulnerability of population to road disasters. 5
Assessment of Capacities using SEA Region Benchmarks for Emergency Preparedness and Response Methodology To assess Bhutan s emergency preparedness and response, one-day preliminary meeting on 1 February 2013, three-day workshop from 18 20 February 2013, and two-day finalization meeting from 16 17 May 2013 were held. The meetings and workshop were organized in collaboration with WHO by the Emergency Medical Services Programme under the Ministry of Health. The preliminary meeting was conducted to sensitize and orient key stakeholders on the South-East Asia Region (SEAR) Benchmarks, identify additional stakeholders and a core working group to facilitate the workshops. During the workshop, the participants and stakeholders were briefed and oriented on the SEAR Benchmarks, followed by a group discussion on indicators and questionnaires and scoring. The stakeholders were divided into four groups of policy and legislation; capacity-building; community preparedness and response; and health surveillance and early warning based on the field of their work. Scoring was done accordingly and groups rotated in turn to review and evaluate the scorings by the other groups. Final scoring was based on the average of all four ratings by different groups. The finalization meeting was conducted to review and revalidate the assessment and scoring. Each group presented their findings and changes. Relevant documents such as the Disaster Management Act 2012; Health Sector Emergency Contingency Plan; and Bio-Security Policy of the Kingdom of Bhutan 2010 were referred during the meetings and workshop. Multisectoral representation was ensured at all the workshops and meetings with the participation of professionals and representatives from different international and government agencies/organizations/ nongovernmental organizations (NGOs), academic institutions, local government including from health facilities at various levels. The meetings and workshop produced a comprehensive report with key findings and recommendations, which will help to develop policy strategies and plans of action to strengthen the emergency preparedness and response (EPR) programme of the health sector. This is a preliminary assessment and this will be an ongoing process that will be applied in a periodical manner after further adoption of the recommendations. Findings: Achievements and gaps 1.1 Policy and legislation BENCHMARK 1: Legal framework, coordination mechanism and organizational structure Achievements At the national level in the health sector, there are strong national policies on EPR (further strengthened with DM Act) Sectoral approach drills and simulation (flood, H5N1) were conducted. Multi-hazard mitigation planning teams should be constituted and should be functional. No clear guidelines for the EPR coordination committee were developed. Roles and responsibilities of EPR focal points not clearly delineated. All sectors do not have standard operating procedures (SOPs) for EPR. BENCHMARK 2: Regularly updated action plan and SOPs for disaster preparedness and response 6
Summary Report BHUTAN Achievement Some sectors (health, Bhutan Agriculture and Food Regulatory Authority (BAFRA), livestock) have some contingency plans for EPR. At the national level, the emergency contingency plan is yet to be developed. No HV maps are available. BENCHMARK 3: Emergency financial, physical and regular human resource allocation and accountability procedures established Achievement Some form of budget and staff needs for EPR are provided through programme support and pooling of staff. At the national level, the emergency contingency plan is yet to be developed and made operational. EPR focal points/units are not instituted at all levels and sectors. BENCHMARK 4: Rules of engagement (including conduct) for external humanitarian agencies based on needs established Achievements Rules of engagement with United Nations (UN) agencies exist. Some form of coordination at national level exists. Comprehensive rules and regulations with all international agencies (not just UN) are not established. 1.2 Community preparedness and response BENCHMARK 5: Community plan for mitigation, preparedness and response developed, based on risk identification and participatory vulnerability assessment and backed by a higher level of capacity Achievements Communities can access the budget from dzongkhag* and national level during emergencies. Health assistants are trained to some extent to assess the health risks in the community. Geology and mines have developed capacity to carry out GLOF risk and vulnerability assessment. Tools and guidelines are in place to assess the risk. Risk and vulnerability assessments were done on Vector-borne Diseases Control Programme and action plan implemented. Health officials always participate while preparing the plans at the community level. Disaster Management Act is in place. There is no capacity to assess and identify risk at the community. There is no capacity at the community level to prepare mitigation, preparedness and response plans. No plans have been prepared at the community level in terms of preparedness, risk and vulnerability assessments. *dzongkhag is an administrative and judicial district of Bhutan 7
Assessment of Capacities using SEA Region Benchmarks for Emergency Preparedness and Response BENCHMARK 6: Community based response and preparedness capacity developed, supported with training and regular simulation/mock drills Achievements Mock drills have been done at dzongkhag level. Safety drills were held in all schools. Community health workers and volunteers are trained in first-aid activities. Some basic emergency supplies are kept at basic health units (BHUs). Emergency kits (search and rescue and first aid) are supplied to districts which can be used in communities during disasters and emergencies. Sufficient number of training courses were not offered to get impactful results. Training needs were offered only at subnational (dzongkhag) level and not at community level. There is insufficient number of staff. Emergency kits at both dzongkhag and gewog* level are inadequate. BENCHMARK 7: Local capacity for emergency provision of essential services and supplies (shelters, safe drinking water, food, communication) developed Achievements Inventory system for essential supplies and equipment is in place. Medical transport arrangement is in place. Existing facilities (BHUs) can be used during emergencies. There are good road networks across the country. The ambulance system is managed effectively and efficiently through the Health Help Centre using free hotline # 112. Safe drinking water and communication coverage across the country is over 90%. Budgetary support mechanisms during emergencies are reflected in the Disaster Management Act. There are mechanisms through contingency plans to pull the resources from regional and district hospitals during emergencies. Health and livestock sectors have expertise in maintaining the quality of water and sanitation, food and air during disasters/ emergencies. There are no strategically identified locations of health facilities for essential supplies and services. There is a shortage of human resources. Disasters either at national, district or gewog levels of governments are not properly declared. Absence of large public halls and scattered settlements are reasons for inadequate shelters. The number of medical utility vehicles for transport of essential supplies and equipments is not enough. Expertise in maintaining the quality of water and sanitation, food safety and air during disasters is not available. *gewog is a group of villages in Bhutan 8
Summary Report BHUTAN 1.3 Capacity building BENCHMARK 8: Advocacy and awareness developed through education, information management and communication (pre-, during and post-event) Achievements Education and information on EPR are disseminated out through mass media, social gatherings. Education in emergencies and safe school initiative are ongoing. State health information and management system (HIMS) is in place. There is gap in early warning and there is a need to strengthen it. Disaster-specific messages are not developed for water and sanitation, shelter and food security. Health concerns need to be integrated in the curriculum of the monastic schools, vocational training institutes and in the colleges of Royal University of Bhutan (RUB) as well as included in the non-formal education (NFE) curriculum to teach the community. Information management for other sectors on recent snowfall and status of road connectivity needs to be coordinated by the Department of Disaster Management (DDM). The recently endorsed DM Act, 2013 would have additional information-sharing mechanism and procedures. Media houses should disseminate information on safety measures and the scale of disaster needs to be shared with the public- pre-emergency, during emergency and after emergency in a proactive mannwe. Information management system and alert mechanism need to be established and made available to public. BENCHMARK 9: Capacity to identify risks and assess vulnerability at all levels established Achievements Vulnerability assessment on MCH, EPI and nutrition is done to identify ongoing emergencies such as zhemgang. Information and Communication Technology (ICT) is used in hazard zonation of Glacial Lake Outburst Flood (GLOF) and seismic mapping Need assessment has been completed, while gap assessment is yet to be completed. A multi-hazard zonation map, vulnerability assessment tools and capacity map have to be prepared for all sectors and it should be consolidated. There is very limited capacity at the district level on vulnerability and risk assessment. Rapid response teams exist- but their capacities on assessment of vulnerabilities need to be enhanced. ICT should be used to develop risk assessment BENCHMARK 10: Human resource capabilities continuously updated and maintained Achievements Education in emergency, search and rescue, civil defence and firefighting has been established. 9
Assessment of Capacities using SEA Region Benchmarks for Emergency Preparedness and Response For water and sanitation, a draft preparedness and response contingency plan has been prepared, but not been implemented yet. ToR for health system functions in emergencies is in draft form. Institutional capacity on EPR needs to be enhanced. Royal Institute of Health Sciences (RIHS)/ University of Medical Sciences (UMS) need to develop and finalize training module and guidelines. Strategic plan to reach all the health workers is needed. Emergency preparedness and response training programme needs to be incorporated in training curricula. EPR training must be carried out at all levels (national, district and gewog) BENCHMARK 11: Health facilities built/modified to withstand the forces of unexpected events Achievements Hospitals, health facilities and other buildings are designed, approved and built with seismic resilient features for Zone V of IS Zonation Map. Construction is usually supervised by engineers. IS Codes relevant to the Bhutanese context need to be adapted. There is a need to develop design and good construction guidelines for all types of buildings such as rammed earth buildings, masonry buildings, timber frames, reinforced cement concrete (RCC) frames and steel structures for all types of use. Buildings should be designed for hazards such as fire and flood and the codes need to be strictly enforced. Lifeline infrastructure such as water supply, electricity and road access should have backup plans. 1.4 Health surveillance and early warning BENCHMARK 12: Early warning and surveillance systems for identifying health concerns established Achievements Health surveillance: Institutional structures and facilities for surveillance are in place. Surveillance for most communicable and noncommunicable diseases is institutionalized. Guidelines for notifiable diseases surveillance along with on-line reporting system is in place. Most districts have rapid response teams (RRT) formed. Involvement of other sectors: Health is a key stakeholder in the DDM framework. National response plans and joint decisionmaking exist for few zoonoses such as avian influenza, rabies and anthrax. All pharmacies and clinics in the private sectors are legally obligated to participate in times of emergencies. Some activities are being carried out to ensure water safety, food safety and security (water and food testing). 10
Summary Report BHUTAN Early warning system: Flood/GLOF warning system is in place. Resources: Personal protective equipment/tamiflu stockpiling for avian Influenza is done in identified health facilities. Resources (human/ logistics) get mobilized within 2 7 days after an event. Emergency preparedness and response (EPR) is limited to few communicable and noncommunicable diseases. Integration of EPR with health surveillances is still lacking. Efficiency of the existing surveillance is in question. There is little or no coordination/information exchange or joint decision-making process in times of emergencies. Functionality of the rapid response teams and its members is questionable. Except for the leading sectors, preparedness in other sectors is minimal. Early warning system except for few hazards (flood, GLOF) is not in place. There is no assessment of surveillance and response system. Reliability of communication channels is questionable. There is a lack of training manuals/modules for health workers and volunteers on risk communication. There is inadequate budget for emergency relief (DDM Act to be referred for clarification). There is inefficient waste management system in rural settings even though the National Solid Waste Management Act (2010), Rules and Regulations 2012 are in place. There is no national contingency plan. Human and financial resources are inadequate. Summary of Results Benchmark Group Number of indicators National Cumulative score of indicators Percentage Policy and legislation 37 31.5/74 42.57 Community preparedness and response 33 24/66 36.36 Capacity building 34 33/68 48.53 Health surveillance and early warning 12 8/24 33.33 11
Assessment of Capacities using SEA Region Benchmarks for Emergency Preparedness and Response Conclusion The participants were involved in critically reviewing all the 12 SEAR Benchmarks for EPR, including the indicators and tried to identify achievements and gaps in each of the four Benchmarks groups. Although there is some progress, there is room for intervention and improvement across the four benchmark areas. Accordingly, recommendations were made by the participants. Policy and legislation BENCHMARK 1: Legal framework, coordination mechanism and organizational structure All legal provisions related to EPR from various acts (and sectors) should be compiled and aligned with the DM Act, including sensitization of DM Act to other stakeholders. In the DM Act, health sector-related emergency preparedness is incorporated; however, related rules and regulations specific to EPR may be formulated. Article 33 of the Constitution may be referred and emergency medical service strategy reviewed and appropriately amended. Health Policy 2010 should be reviewed in line with Disaster Management Act 2013. The Health Sector Contingency Plan for emergencies and disasters should be finalized. BENCHMARK 2: Regularly updated action plan and SOPs for disaster preparedness and response A National contingency plan should be developed and SOPs/guidelines in line with the DM Act should be drawn up by all the sectors. Institution of Periodic meetings of the stakeholders and EHA focal points should be instituted. Health Vulnerability maps should be developed on priority basis. The Health Policy 2010 and contingency plan are in line with WHO guidelines, but should be revised and aligned with the DM Act, if required. BENCHMARK 3: Emergency financial, physical and regular human resource allocation and accountability procedures established Budget provisions must be made available as enshrined in the DM Act. Further WHO and other international organization support on EPR should be provided through United Nations Development Assistance Framework, Bhutan. Sectors concerned, in collaboration with Gross National Happiness Commission (GNHC) should explore external funding sources to fund EPR. 12
Summary Report BHUTAN With the enactment of the DM Act, the EPR at dzongkhag and gewog level should be constituted, for which technical and financial support is required. The existing EHA focal point at the MOH should be trained and units strengthened to respond effectively. At the dzongkhag level, EHA focal point needs to be identified and trained accordingly. BENCHMARK 4: Rules of engagement (including conduct) for external humanitarian agencies based on needs established The rules of engagement for involvement of national and international agencies (besides UN agencies) in times of emergency should be reviewed and expanded. Further, other national and international emergency protocols can be expanded and rectified. Community preparedness and response BENCHMARK 5: Community plan for mitigation, preparedness and response developed, based on risk identification and participatory vulnerability assessment and backed by a higher level of capacity Specific sectors need to conduct vulnerability mapping of risk areas in the country including the community. The community and stakeholders at all levels need to be trained and sensitized. Impactful capacity development needs of the community health workers have to be offered. Community level plans in the future for health emergencies including other sectors should be drawn up. Community health workers should be identified as one of the stakeholders in various stages of community planning. BENCHMARK 6: Community-based response and preparedness capacity developed, supported with training and regular simulation/mock drills Vulnerable community-based mock drills and simulation need to be instituted in all areas after the vulnerability mapping. Adequate training should be provided to both health workers and volunteers in the community. Adequate number of emergency kits should be supplied. 13
Assessment of Capacities using SEA Region Benchmarks for Emergency Preparedness and Response BENCHMARK 7: Local capacity for emergency provision of essential services and supplies (shelters, safe drinking water, food, communication) developed Deployment of adequate human resources should be ensured in places where health facilities are identified as strategic locations. Strategically located BHUs should be identified and equipped with essential and critical EPR items. Refresher courses for the community health workers should be conducted at regular intervals. There must be an official notification of any disaster or emergency of public health concern in the country. Operational plans for food, water, sanitation and shelter should be developed for emergencies. Capacity-building BENCHMARK 8: Advocacy and awareness developed through education, information management and communication (pre-, during and post-event) Advocacy and risk communication strategy/ plans should be developed and awareness created. BENCHMARK 9: Capacity to identify risks and assess vulnerability at all levels established Risk and vulnerability assessment tool including post disaster assessments needs to be developed. Procedures need to be instituted at all levels to identify risks and assess vulnerability. Capacities should be developed at various levels. BENCHMARK 10: Human resource capabilities continuously updated and maintained Emergency and response plans should be developed in all health facilities. All the health facility staff need to be trained in response procedures and their own responsibilities, and regular safety drill should be implemented. Channels of communication to receive or disseminate information should be set up to strengthen early warning. Information management for other sectors needs to be coordinated by DDM. 14
Summary Report BHUTAN BENCHMARK 11: Health facilities built/modified to withstand the forces of expected events Higher building standards should be developed for health facilities. The quality of construction and materials used for health facilities should be strictly monitored. Training on the fixing and abating of non-structural hazards and for continued functionality of critical emergency facilities should be provided to Health Infrastructure Development Division (HIDD) and maintenance staff. Vulnerability assessment of all health facilities should be conducted. Non structural mitigation measures should be conducted as a priority in identified health facilities. Health surveillance and early warning BENCHMARK 12: Early warning and surveillance systems for identifying health concerns established Strengthening surveillance system Adequate number of designated surveillance officers should be identified. New/refresher training on surveillance should be conducted for health workers at district and Basic Health Units (BHU) levels. Capacity for data management and analysis should be built at all levels. Existing surveillance systems should be assessed. Rapid response team Terms of reference should be developed for each member of the team. Emergency Medical Services (EMS) draft to be finalized and implemented in all the districts. Roles and responsibilities according to the Water Act need to be strengthened. Clear cut guidelines should be developed on food safety issues in the times of emergencies. Strengthening communication among stakeholders The Bhutan Info Comm and Medical Authority (BICMA) Act directives for the implementation of communication plan during emergencies should be enforced. Communication plans should be developed for all levels of health facilities for health related emergencies. Budget and release mechanism Relevant ministries should keep aside emergency response/disaster budget with clear roles and responsibilities. Mechanisms to release and mobilize funds during emergencies should be developed. Strengthen information-sharing system Integrated disease surveillance systems during disasters should be developed. Waste management system Waste management should be in line with the National Waste Management Act. 15
Assessment of Capacities using SEA Region Benchmarks for Emergency Preparedness and Response Annex 1 Summary of Action Plan At the end of the workshop, action plans were developed against each benchmark. This will enable the programmes and stakeholders concerned to follow up and work towards fulfilment of the action plans outlined as under: Benchmark Action / Recommendation Relevant Indicator When? Who? Benchmark 1: Legal framework, coordination mechanism and organizational structure Compilation of all legal provisions related to EPR from various acts (and sectors) aligned with DM Act Sensitization of DM Act to other stakeholders All indicators 2013 2014 DDM with other key sectors Development of rules and regulations for DM Act to align with other Acts and provisions Benchmark 2: Regularly updated action plan and SOPs for disaster preparedness and response Development of DM and contingency plan inclusive of recovery strategy and development of SOPs/guidelines by all the sectors All indicators 2013 2015 MoH with relevant sectors Identification and training of health EHA focal points Periodic meeting of the stakeholders and focal points Benchmark 3: Emergency financial, physical and regular human resource allocation and accountability procedures established Budget provision as per the DM Act Exploration of external funding sources to fund EPR activities All indicators 2013 2015 MoH, DDM, MoF, GNHC 16
Summary Report BHUTAN Benchmark Action / Recommendation Relevant Indicator When? Who? Benchmark 4: Rules of engagement (including conduct) for external humanitarian agencies based on needs established Review and expansion of the rules of engagement for involvement of other international organizations and national NGOs and agencies (besides UN agencies) in terms of emergency All indicators 2013 2015 MoH with other key sectors Review and rectify other emergency protocols Benchmark 5: Community plan for mitigation, preparedness and response developed, based on risk identification and participatory assessment and backed by high level of capacity. Vulnerability and risk mapping of the communities Capacity building of the community to respond to any emergencies and disasters Enhancing awareness on emergency preparedness Preparation of community plans for mitigation, preparedness, and response Community assessment of risks and vulnerabilities recognizes and reflects specific public health concerns. Community preparedness and response plans reflect assessed risks to public health and specific health sector vulnerabilities and capacities. 2014 2015 2014 2014 2014 2015 MoH, MoAF, Community, Department of Geology & Mines, DLG and DDM MoH (HPD) and DDM Ministry of Health, DDM and dzongkhag Health Sector Benchmark 6: Community based response and preparedness capacity developed, supported with training and regular simulation/mock drills. Deployment of adequate number of trained staff to health centres identified as potentially vulnerable and at risk. Periodic simulations and mock drills in the community Provision of adequate number of emergency kits in the community Training of staff of essential community level facilities. Training for community volunteers focusing on firstaid and their role in core public health interventions. 2014 2015 2014 2015 2014 2015 Ministry of Health DDM, DLG, MoE, MoH DDM, MoH, GNHC 17
Assessment of Capacities using SEA Region Benchmarks for Emergency Preparedness and Response Benchmark Action / Recommendation Relevant Indicator When? Who? Benchmark 7: Local capacity for emergency provision of essential services and supplies (shelters, safe drinking water, food, communication) developed. Identification of strategically located health centres for essential supplies and services A system of official declaration of any disasters in the country Food, shelter, water and sanitation plans in place Essential supplies for health response prepositioned in strategic locations. Supplies and transportation means identified and plans in place for emergency distribution of emergency supplies 2015 2013 2014 MoH, dzongkhag and DDM DLG, dzongkhag, gewog and DDM MoH, MoWHS, MoAF, MoHCA Benchmark 8: Advocacy and awareness developed through education, information management and communication (pre-, during and post-event) Development of communication strategy and action plan on EPR covering all public health areas (other sectors by relevant ministries, in collaboration with health) B8, S1, In-1, 3, 4 B8, S2, In-1 By 2014 HPD (MoH) supported by EMS and DDM PPD (MoH) Benchmark 9: Capacity to identify risks and assess vulnerability at all levels established Development of multi-hazard zonation map, vulnerability and capacity assessment tools and mechanism B9, S1, In-1, 2, 3 B9, S2, In-1 By 2015 MoH and DDM, DGM Benchmark 10: Human resource capabilities continuously updated and maintained Development and finalization of training strategy, module and guidelines and incorporation into training curricula. B10, S1, In-1, 2 B10, S2, In-1, 2 By 2014 RIHS and MoH Benchmark 11: Health facilities built/modified to withstand the forces of unexpected events Guidelines for RCC and steel structures Risk and vulnerability assessment of all health facilities and non structural mitigation on equipments and hospital emergency plan B11, S1, In-1, 3 B11, S2, In-1, 3, 4 By 2015 By 2015 Led by MoWHS and supported by MoH MoH (EMS) 18
Summary Report BHUTAN Benchmark Action / Recommendation Relevant Indicator When? Who? Benchmark 12: Early warning and surveillance systems for identifying health concerns established. Formation of RRT in all districts with proper training and TORs Integration of health related EPR surveillance specific to potential epidemic diseases into the health surveillance system- Development of standards and impart trainings Assessment of existing early warning systems for GLOF/flood Assessment of the existing surveillance systems Institution of water quality monitoring as per the Water Act and Quality Control guidelines S1, In 2 S1, In 3 S1, In-4 S2, In 1 S1, In 5 S1, In 5 S2, In 3/4 2014 2014 2014 2015 2014 2014 2015 MoH, DDM MOH DHMS, DGM, DDM MoH, LG, DOLS,MOA MoH, BAFRA, City Corporation, NEC MoH, MoE, City Corporation, NEC, MoHCA, BAFRA MoH, MoAF, MoIC Development of guidelines for sanitation, hygiene and food safety Development and implementation of effective risk communication strategy 19
The WHO South-East Asia Region Benchmarks for Emergency Preparedness and Response Framework with its standards and indicators, are used to assess the existing capacities of countries in emergency risk management with a focus in the public health area. Grouped into four categories (legal, community, capacity building, early warning), the benchmarks provide a comprehensive view of emergency risk management in the area of health in the country. This summary report reflects at a glance the status of the country against the standards and indicators under corresponding benchmarks. Assessments are held in the national context with some adaptation and translation of the tools. This assessment in Bhutan was led by WHO Country Office with the support of Emergency and Humanitarian Action unit of WHO s Regional Office for South East Asia in partnership with the Emergency Medical Services Programme under the Ministry of Health with participation of other stakeholders such as UN agencies, NGOs and civil society working in the relevant sectors. The identified gaps in the assessment become the key priority areas for WHO, the Ministry of Health and partners to the addressed. World Health House Indraprastha Estate, Mahatma Gandhi Marg New Delhi - 110002, India Telephone: +91-11-23370804, 23309444 Fax: +91-11-23370197 Website: www.searo.who.int/eha SEA-EHA-22-Bhutan