Like all South Asian nations, tuberculosis is a major threat in Bhutan, but fortunately it has a well established network of health facilities that provides free care and covers 90 per cent of the population.
Dr. Ugen Dophu, Director, Public Health Department, Ministry Of Health, Bhutan, shares the secrets of the programme’s success. Some of the success of the programmes are the special initiatives to tackle the disease among the productive age group of 15-49 years, and the challenges it faces. The pressing challenges are the shortage of trained health workers to monitor DOTS treatment in rural areas and a lack of state-of-the-art lab facilities. Steps to address these vulnerabilities are already underway in the form of organising regular and rigorous training for frontline health workers and other initiatives, all with technical assistance from the World Health Organization and the financial support of the Global Fund.
Questions: What are the conditions of the average tuberculosis (TB) patient in Bhutan? Typically, where do they hail from and what kind of challenges they face?
Answer: In Bhutan there is no specific community where the incidence of TB is more, and patients more or less come from all parts of the country. Like in any other South Asian country, TB here too is more prevalent in the 15-49 years age group and more in males than females.
Sixty-nine per cent of Bhutanese survive on subsistence farming and so for people from rural and remote areas there are many challenges in battling TB: First, daily DOTS (Directly Observed Treatment Short course) is a challenge as s/he cannot come to the health facility everyday. That’s why we admit a sputum positive TB patient in the hospital for two months to ensure that the medication is administered properly.
Another problem is that of patients being misled by local or traditional healers. To deal with this the Ministry Of Health met with these healers and requested them to refer anybody with a cough for more than two weeks or with chest pain or blood in sputum to our health facility for sputum microscopy.
Question : With a population of around 700,000 people, Bhutan has an annual incidence rate of 91 cases of all forms of TB per 100,000 population. While the case detection rate has been steadily increasing, the treatment success rate is an impressive 89 per cent. How has Bhutan achieved this?
Answer: The TB control programme in Bhutan is meeting the WHO standards. This has been possible due to the commitment of health workers. The concept of Gross National Happiness has been ingrained into all Bhutanese citizens – that while wealth is important, more than wealth happiness is important. So people work for the community. They sacrifice their time; they even sacrifice the opportunities for other earnings.
Another reason for this success rate is the well established network of health facilities that provide free care and cover 90 per cent of our population. Now our focus is on the remaining 10 per cent, which are moving populations like the nomads. For them, we conduct seasonal health activities – immunisation, TB check ups, chronic disease check ups and family planning services. The district health team goes and informs them of these camps where we immunise children, educate them on HIV, and if someone has symptoms of TB then we do a sputum smear and send it down to the district hospital. Further treatment is taken from there.
Question: There have been notable gains in the achievement of DOTS coverage. What are the gaps that you still perceive in this regard?
Answer: The main problem is the retirement of health workers. The programme has not been able to keep up with updating the new health workers, especially when it comes to giving a clear understanding of how DOTS works. While the intensive phase – first two months – of the treatment is taken seriously, the continuation phase is lax and that is where there is some concern.
Question: In the battle against TB, how critical are lab facilities and what is Bhutan’s plan of action in this regard?
Answer: Bhutan has 29 hospitals, 187 Basic Health Units (BHUs) and 440 outreach clinics and lab facilities. Unfortunately, we cannot expand like other South Asian countries.
Training a laboratory technician for highly technical tests like sputum microscopy takes a lot of effort and money. After training they have to do at least 10 sputum smear tests a day to keep their skills up to date. But in Bhutan even some of the district hospitals don’t have that kind of workload. So, the skill of the technician has every chance of going down. While at the basic level this kind of expansion is impractical for us, we do have sputum microscopy facility in all the district hospitals.
Since there are more patients visiting the BHUs and outreach clinics we have trained the staff on how to get a good sputum sample, how to make a good smear and then safely transport it to the district hospital.
Our worry is basically for those BHUs that are very far away from the hospitals – perhaps a week’s journey from the district hospital. For those few remote BHUs we have invested in training the health workers there in sputum microscopy in spite of the case load being low.
Question: Is multi-drug resistance (MDR) a problem when it comes to addressing TB in Bhutan?
Answer: A majority of our patients are receiving good ATT (Anti TB Therapy) drugs and most are under the supervision of a health worker so multi-drug resistance is not really a problem right now. There are only about 13-14 cases a year of MDR-TB. We have an on-going study on the prevalence of MDR-TB that will give us a better understanding of the magnitude of the disease.
Question: Data on TB prevalence shows that in Bhutan the productive age group of 15 to 49 years has been affected. How do you focus on this group? Any highlights on treatment of women?
Answer: A sputum positive TB patient of the 15-49 age group is admitted to the hospital for at least two weeks. When the patient expresses the need to get back to his/her work we let them go but a BHU staff who lives near the patient’s house is briefed and medicine has to be given to the patient at home, at least in the intensive phase, or the patient is instructed to come to the BHU. There is also a follow up sputum examination done by the BHU staff.
If the BHU is far away from the village then a staff member trains the Village Health Worker to properly administer the medicine. We call it modified DOTS. Women are also dealt with in the same manner – in the urban areas we have no problem in getting women to come to the DOTS centres. But in rural areas it may be a problem so either the patient is instructed to come to the BHU or she gets her daily dose from the Village Health Worker.
Question: How has the Global Fund grant and WHO’s technical assistance helped the TB programme in Bhutan?
Answer: WHO’s input has helped us build the capacity of the country to manage the programme; we have been able to technically build the capacity of our health workers too. In fact, only WHO provides us technical assistance for the TB programme. Both the Global Fund and technical assistance from WHO has helped us streamline our programme.
We have inefficiencies in the system, especially in procurement and prescription of drugs, and we want to sort this out so that even if there is no Global Fund the government can take over and sustain. We are supplying first-line TB drugs but for MDR-TB we are still dependent on the Global Fund, which also helps in procuring crucial lab supplies and training of the health workers.
Question: The TB-HIV interface has posed a lot of problems in other countries. How is Bhutan faring?
Answer: Bhutan’s TB-HIV collaborative activities are poor. As a step to changing this we have initiated an exchange of information between the two programmes – the HIV programme will keep the TB programme informed on the number of positive people and whether anyone has been diagnosed with TB. We also have a lot of ground to cover in the educational aspect – TB patients know about TB but they may have little idea about HIV transmission.
Question: Bhutan has undertaken IEC (Information Education Communication) activities on TB to improve community awareness. Do shed some light on these programmes?
Answer: The TB programme is very aggressive in its IEC activities – awareness has been created at the institution level and we are also collaborating with the local healers in villages in this regard. In the urban centres, we have collaborated with pharmacies. They have been instructed to refer suspected cases for sputum microscopy to the hospitals. At the village-level, the Village Health Workers (VHWs) ensure that people with symptoms of TB visit the BHU.
Each district conducts meetings with these partners and briefs them on TB. Leaflets and pamphlets are provided on basic information about TB – like ‘what is TB? How it is spread? How to identify a patient?’
For VHWs, these topics are included in their curriculum. Training is given for 14 days in general health aspects and this is followed up with a five-day refresher course every year.
Question: What kind of support are you providing in training of frontline health workers to help them create an empowering environment?
Answer: We have a comprehensive TB manual that deals with epidemiology, identifying signs and symptoms of TB, treatment guidelines, and so on. The programme also organises trainings on how to use this manual effectively. We have a Training of Trainers (TOT) programme. At least every two to three years the retraining of the health workers is organised.
The laboratory technicians and the para-medical workers are trained on how to collect a good sputum sample, on how to make a good smear, and so on. For lab techs the training is conducted every year.