A quality of care assessment for women of childbearing potential with epilepsy in Bhutan: An observational study.

BACKGROUND & OBJECTIVE: In lower-middle income countries such as Bhutan, the treatment gap for epilepsy is over 50% as compared to a treatment gap of less than 10% in high-income countries. We aim to analyze the quality of epilepsy care for women of childbearing potential in Bhutan using the Quality Indicators in Epilepsy Treatment (QUIET) tool, and to assess the usefulness of the tool's section for women with active epilepsy (WWE) in the Bhutanese setting. METHODS: A prospective convenience cohort was enrolled in Thimphu, Paro, Punakha, and Wangdue, Kingdom of Bhutan, in 2022. Bhutanese women of childbearing potential at the time of enrollment (18-44 years old) were evaluated for the diagnosis of active epilepsy and underwent a structured survey-based interview with Bhutanese staff. Participants were surveyed on their epilepsy, pregnancy, and antiseizure medicine (ASM) histories. The clinical history and quality of epilepsy care of adult WWE were assessed using a section of the QUIET tool for women, an instrument originally developed by the U.S. Department of Veterans Affairs to analyze the quality of epilepsy care for American adults. RESULTS: There were 82 Bhutanese WWE of childbearing potential, with mean age of 30.6 years at enrollment (range 18-44, standard deviation (SD) 6.6) and mean age of 20.3 years at epilepsy diagnosis (range 3-40, SD 8.0)). 39 % (n = 32) had a high school or above level of education, and 42 % (n = 34) were employed. 35 % (n = 29) reported a seizure within the prior week, and 88 % (n = 72) reported a seizure within the prior year. 49 % (n = 40) of participants experienced > 100 lifetime seizures. All but one participant took antiseizure medications (ASMs). At enrollment, participants presently took no (n = 1), one (n = 3), two (n = 37), three (n = 25), four (n = 11), or over five (n = 5) ASMs. The most common ASMs taken were levetiracetam (n = 40), phenytoin (n = 27), carbamazepine (n = 23), phenobarbital (n = 22), and sodium valproate (n = 20). 61 % of all WWE took folic acid. Of the 40 previously pregnant WWE, eight (20 %) took folic acid during any time of their pregnancy. 35 % (n = 29) used betel nut (doma, quid) and 53 % (n = 21) of pregnant WWE used betel nut during pregnancy. CONCLUSIONS: Based on data about WWE participants' ASM, supplement, and substance use, our study identified the high use of first generation ASMs (including valproate), frequently in polytherapy, and betel nut use as treatment gaps in women of childbearing potential age with active epilepsy in Bhutan. To address these gaps for locations such as Bhutan, we propose modifications to the QUIET tool's "Chronic Epilepsy Care for Women" section.

Rural-urban inequalities in health care utilization in Bhutan: a decomposition analysis.

BACKGROUND AND OBJECTIVE: On the trajectory towards universal health coverage in Bhutan, health equity requires policy attention as significant disparities exist between urban and rural health outcomes. This paper examines health services utilization patterns, inequalities and their socio-economic determinants in rural and urban areas and decomposes the factors behind these differences. METHODS: We used the Bhutan Living Standard Survey 2017 to profile health services utilization patterns and equalities. We employed two different decomposition analyses: decomposition of mean differences in utilization using the Oaxaca-Blinder decomposition framework and differences in the income-related distribution in utilization using recentered influence function regressions between rural and urban areas. RESULTS: Significant differences exist in the type of outpatient services used by the rural and urban population groups, with those living in rural areas having 3.4 times higher odds of using primary health centers compared to outpatient hospital care. We find that the use of primary health care is pro-poor and that outpatient hospital resources is concentrated among the more affluent section of the population, with this observed inequality consistent across settings but more severe in rural areas. The rural-urban gap in utilization is primarily driven by income and residence in the eastern region, while income-related inequality in utilization is influenced, aside from income, by residence in the central region, household size, and marriage and employment status of the household head. We do not find evidence of significant mean differences in overall utilization or inequality in utilization of inpatient health care services. CONCLUSIONS: While the differences in average contacts with health services are insignificant, there are prominent differences in the level of services availed and the associated inequality among rural and urban settings in Bhutan. Besides, while there are obvious overlaps, factors influencing income-related inequality are not necessarily the same as those driving the utilization gaps. Cognizance of these differences may lead to better informed, targeted, and potentially more effective future research and policies for universal health coverage.

Remote support of an external quality assessment program in 10 laboratories in Bhutan, Uganda, and Malawi: Pathologists Overseas experience between 2009 and 2017.

OBJECTIVES: This article describes Pathologists Overseas (PO) experience supporting external quality assessment (EQA) programs in 10 clinical laboratories across 3 countries between 2009 and 2017. METHODS: Laboratories were enrolled in the condensed chemical pathology EQA program provided by the Royal College of Pathologists of Australasia Quality Assurance Program. Participants were given an initial 2- to 4-day in-person training, followed by 1 year of active feedback on performance via emails or phone calls by a PO volunteer. RESULTS: There were 2 performance metrics: percentage of reported results as a measure of compliance and percentage of acceptable reported results as a measure of accuracy. Laboratories demonstrated high compliance with result reporting, with medians of 69.9%, 71.7%, and 81.3% before, during, and after feedback, respectively. Concomitant medians for the percentage of acceptable reported results were 41.2%, 57.3%, and 53.5%, respectively. Six laboratories had low performance in terms of accuracy at baseline (<60%). Active feedback improved the percentage of acceptable reported results for these lower-performing laboratories. CONCLUSIONS: External quality assessment programs can be successfully adopted long term by laboratories in low-resource settings. Active feedback requires significant time and effort but could be especially beneficial for laboratories with poor baseline performance.

Assessment of exposure to pesticides and the knowledge, attitude and practice among farmers of western Bhutan.

An estimated 69% of the population of Bhutan is engaged in agriculture. Farmers are exposed to a wide variety of pesticides during the preparation, transport, storage, mixing and application of pesticides posing a significant health risk. A controlled cross-sectional study of farmers in selected sites of Bhutan was conducted to characterize the level of exposure to pesticides and assess their knowledge attitude and practice on the safe handling of pesticides. A total of 399 participants were enrolled in the study comprising of 295 exposed farmers and 104 healthy and unexposed controls. A structured investigator administered questionaries was used to assess their Knowledge, Attitude and practice, and their blood samples were taken for measuring Acetyl Cholinesterase enzyme activity level. There was a significant difference between the Acetyl Cholinesterase enzyme inhibition of exposed and non-exposed control groups observed in the study (P < 0.001). Of the total of 295 farmers, 62 (21.01%) had severe enzyme inhibition of >30% as compared to the unexposed group. Safety practices of handling pesticides were low. The most common symptoms self-reported were headache (OR 1.08, 0.60-1.93) and neurological problems like forgetfulness, lack of concentration (OR 1.12, 0.50-2.48) and increased tiredness (OR 1.075, 0.52-2.19) that were significantly associated with the enzyme inhibition. In addition, we record a very low level of knowledge (17.0%), a fair attitude (63.0%) and poor practice (35.0%) on the safe handling and management of pesticides. This pilot study provides indication of exposure to pesticides in the selected sites of the country. Furthermore, it provides evidence for public health interventions by identifying the exposure patterns and pathways of individuals most at risk in the farming communities of the country. Surveillance and bio-monitoring programs are deemed necessary.

Refugee Family Health Brokers' (FHBs') Experiences with Health Care Providers: A Thematic Analysis.

BACKGROUND: The resettlement and post-resettlement quality of life of refugees is often marred by chronic health/mental health conditions. To adequately care for refugees suffering these conditions, a promising strategy is the use of refugee Family Health Brokers (FHBs). FHBs are safe and trusted family members functioning as intermediaries between one's family and health care providers. Although FHBs are known to positively influence health care utilization in their families, little is known about them and this aspect of their family caregiving role and experiences, particularly with health care providers, necessitating further research. METHODS: Fourteen Bhutanese and three Bosnian refugee FHBs participated in a 2-hr focus group discussing their experiences with health care providers after being surveyed about their FHB role. RESULTS: Thematic analysis yielded five themes centered around perceptions, knowledge, communication, behavior, and responsibilities reflective of FHBs' experiences, which can be understood as symptoms of existing structural inequalities. CONCLUSIONS: FHBs primarily conveyed problems, struggles, and dilemmas they experienced more so than rewarding aspects of being an FHB. Suggestions are provided on how to avert these negative experiences from occurring and becoming barriers to developing allyship with FHBs in the context of existing structural inequalities.

Catastrophic health care expenditure and impoverishment in Bhutan.

Monitoring financial hardship due to out-of-pocket spending on health care is a critical determinant of progress towards universal health coverage. This study investigates the occurrence, intensity and determinants of catastrophic health expenditure and impoverishment in Bhutan using three rounds of the cross-sectional Bhutan Living Standard Surveys carried out in 2007, 2012 and 2017. We use a composite financial hardship measure defined as households experiencing either catastrophic health expenditure or impoverished/further impoverished due to health spending or both. We calculated concentration indices to examine socio-economic inequalities. We used logistic regression to examine the factors associated with financial hardship. We find that, in the context of a significant increase in living standards, there is a sharp increase in the incidence of catastrophic health expenditure (using 40% of capacity to pay) and impoverishment (based on equivalized average food-share-based poverty line) between 2007 and 2017. In 2017, catastrophic health expenditure was estimated at 0.51%, impoverishment at 0.32% and further impoverishment at 1.93% of the population, cumulating to financial hardship affecting 2.55% of the population. Financial hardship particularly burdened rural dwellers and poorer households. Transportation costs almost doubled the risk of facing financial hardship. Households that were poor, had an unemployed head, were larger and had more elderly members had higher odds of financial hardship. This evidence should prompt policy and programmatic interventions to support Bhutan's progress towards universal health coverage.

Assessment of competencies in the prevention and control of chronic diseases and their influencing factors among health assistants in Bhutan: a cross-sectional study.

BACKGROUND: The morbidity and mortality of chronic diseases are increasing worldwide. The literature confirms that the prevention and control of chronic disease necessitates a robust primary health care system with a competent health care workforce. Studies on competencies in the prevention and control of chronic diseases and their determinants among health assistants (HAs) in Bhutan are scarce. This cross-sectional survey aimed to examine the level of competencies and investigate the factors influencing competencies in the prevention and control of chronic diseases among HAs. METHODS: The sample consisted of 330 HAs who were recruited through simple random sampling. A validated and reliable self-administered questionnaire was used to collect data through a web-based Google Form. Data were analysed using descriptive statistics and multiple regression analysis. RESULTS: The findings showed that the mean summed competency score was 191 (SD = 25.7). Approximately 96% of the participants perceived that they were competent in the prevention and control of chronic diseases. The multiple regression analysis indicated that work environment (ß = 0.473), sex (ß = 0.126), location of the health facility (ß = - 0.114), and organizational support (ß = 0.117) affected competencies in the prevention and control of chronic diseases by 31.4% with statistical significance (R2 = 0.314) (p < 0.05). CONCLUSIONS: This study suggested that improving the number of staff and availability of learning resources, considering training for both sexes, especially female primary health care workers, enhancing mentorship and supervision in rural areas, and establishing the recognition and encouragement of primary health care workers are needed.

District flood vulnerability assessment using analytic hierarchy process (AHP) with historical flood events in Bhutan.

Flood hazards are common in Bhutan as a result of torrential rainfall. Historical flooding events also point to flooding during the main monsoon season of the year, which has had a huge impact in many parts of the country. To account for climate change patterns in flood hazards in Bhutan, 116 historical flood events between 1968 and 2020 for 20 districts were retrieved and reviewed. The preliminary review revealed that the frequency of flood occurrence has increased by three times in recent years. In this study, seven flood vulnerability (FV) indicators were considered. Five are the attributes of historical floods, classified into a number of incidents for flood events, fatalities, affected population, and infrastructure damages including economic losses. Additionally, the highest annual rainfall and existence of a flood map were other two indicators considered. Using historical data, flood hazard and impact zonation were performed. The analytic hierarchy process (AHP) method was employed to derive a multi-criteria decision model. This resulted in priority ranking of the seven FV indicators, broadly classified into social, physical/economic, and environmental. Thereafter, an indicator-based weighted method was used to develop the district flood vulnerability index (DFVI) map of Bhutan. The DFVI map should help researchers understand the flood vulnerability scenarios in Bhutan and use these to mediate flood hazard and risk management. According to the study, FVI is very high in Chhukha, Punakha, Sarpang, and Trashigang districts, and the index ranges between 0.75 to 1.0.

Assessing public financing for nutrition in Bhutan, Nepal and Sri Lanka.

The objective of this study was to assess public financing for nutrition in Bhutan, Nepal and Sri Lanka to identify limitations of available data and to discuss policy implications. A variant of the Scaling Up Nutrition Movement methodology was used. Budget allocations and expenditures for relevant government ministries during 2012-2018 were identified. Nutrition-related line items were tagged using definitions of nutrition-specific and nutrition-sensitive interventions. Data were aggregated by year and calculated in constant United States dollars (USD). Expenditures by year were presented as a proportion of gross domestic product and general government expenditures. The percent utilization of budget allocations and proportion of funding from central government sources were determined. Per capita expenditures on nutrition-specific interventions varied from USD 1.08-8.76 and for nutrition-sensitive interventions varied from USD 20.22-51.20. Nutrition-specific expenditures as a percent of gross domestic product ranged from 0.08% in Sri Lanka in 2017% to 0.34% in Nepal in 2016. The median utilization rate was 64% for nutrition-specific and 84% for nutrition-sensitive interventions. Nutrition-specific funding financed by the central government was 90.7% in Bhutan and 99.4% in Sri Lanka. This study revealed the need to prioritize and invest in evidence-based interventions, including balancing investments in nutrition-specific versus -sensitive interventions. Challenges in estimation of nutrition expenditures and cross-country comparison were also observed, highlighting the need for appropriate nutrition line item tagging and standardized systems for data collection.

Community-Led Health Promotion Groups in a Bhutanese-Nepali Refugee Community.

This practice note reports on the work of the Namaste Community Health Partnership, an academic-community partnership established to address health disparities in a metro-area Bhutanese-Nepali refugee community in the western United States. Partners worked together to develop, implement, and evaluate a culturally-tailored health promotion program where Bhutanese-Nepali individuals led weekly walking groups and shared health promotion information and behavior change tools with community participants. The program was implemented with approximately 70 community members across two metro-area neighborhoods and two adult day care centers serving elders. Evaluation strategies included documenting walk attendance, tracking engagement with health promotion goals, and focus group discussions with program participants. Once enrolled, most participants consistently attended walks and achieved weekly goals-some even increased walking frequency beyond program requirements. Participants provided positive feedback about having a community leader and reported learning new information and enjoying participating with other community members. Challenges and lessons learned included difficulties engaging younger adults from the community, concerns about signing research consent forms, cultural norms discouraging the distribution of individual research participation incentives, variability across groups in preferences for program activities, and barriers to administering survey-based evaluation instruments. This academic-community partnership built capacity in the local Bhutanese-Nepali community, produced culturally relevant health programming, and trained and employed community members as health educators and physical activity leaders. The program resulting from this work has the potential to improve health knowledge and chronic disease prevention practices and ultimately reduce health disparities in an underserved refugee community.

Distributive health literacy and medication management: A longitudinal qualitative study with Bhutanese former refugees in Tasmania.

ISSUE ADDRESSED: Tasmania, Australia is home to a population of Bhutanese former refugees who have resettled since 2007. Their refugee journey and disrupted education opportunities have resulted in gaps in literacy in their primary language (Nepali), and many suffer one or more chronic conditions (ongoing communicable or noncommunicable diseases (NCDs)). This research explored how this community perceives chronic conditions and managed their medication using the concept of distributed health literacy. METHODS: A longitudinal qualitative method was used whereby 15 former refugees and their carers were interviewed 3-4 times over 9 months. Data were thematically analysed using a hybrid approach of inductive and deductive coding and theme development. RESULTS: Four themes related to distributed health literacy were identified. These were "barriers to medication literacy and adherence," "support people as health literacy mediators," "understandings of chronic disease" and "strengthening distributed health literacy." Participants described managing relatively low levels of knowledge about their chronic conditions and medications by appointing support people who acted as health literacy mediators. This resulted in interactions with health professionals, information gathering and medication use being enacted collectively between family members. Carers felt responsible for supporting others who were new to the Australian health system to learn new skills in addition to assisting with tasks such as informal interpreting. SO WHAT?: Interventions to improve the health literacy of former refugees should focus on collective critical health literacy action rather than just the functional health literacy of individuals. Health literacy mediators are a vital form of support for former refugees managing chronic conditions, so must be included in education and support programs.

Repatriation of Bhutanese During COVID-19 Pandemic: The Unspoken Economic Burden of COVID-19 on the Bhutanese Government.

Protecting the citizens who are living abroad has been a challenge for many countries during the current COVID-19 pandemic. In Bhutan, since the start of the pandemic, it has repatriated its citizens living and working abroad and putting them into a 21-day state-sponsored quarantine. They were also tested for COVID-19 on reverse transcription polymerase chain reaction (RT-PCR) that was funded by the government. While this measure is a blessing for its people, for the government it is a huge economic challenge.

Spatio-temporal patterns of childhood pneumonia in Bhutan: a Bayesian analysis.

Pneumonia is one of the top 10 diseases by morbidity in Bhutan. This study aimed to investigate the spatial and temporal trends and risk factors of childhood pneumonia in Bhutan. A multivariable Zero-inflated Poisson regression model using a Bayesian Markov chain Monte Carlo simulation was undertaken to quantify associations of age, sex, altitude, rainfall, maximum temperature and relative humidity with monthly pneumonia incidence and to identify the underlying spatial structure of the data. Overall childhood pneumonia incidence was 143.57 and 10.01 per 1000 persons over 108 months of observation in children aged < 5 years and 5-14 years, respectively. Children < 5 years or male sex were more likely to develop pneumonia than those 5-14 years and females. Each 1 °C increase in maximum temperature was associated with a 1.3% (95% (credible interval [CrI] 1.27%, 1.4%) increase in pneumonia cases. Each 10% increase in relative humidity was associated with a 1.2% (95% CrI 1.1%, 1.4%) reduction in the incidence of pneumonia. Pneumonia decreased by 0.3% (CrI 0.26%, 0.34%) every month. There was no statistical spatial clustering after accounting for the covariates. Seasonality and spatial heterogeneity can partly be explained by the association of pneumonia risk to climatic factors including maximum temperature and relative humidity.

Addressing Challenges in Health Technology Assessment Institutionalization for Furtherance of Universal Health Coverage Through South-South Knowledge Exchange: Lessons From Bhutan, Kenya, Thailand, and Zambia.

Health Technology Assessment (HTA), a tool for priority setting, has emerged as a means of ensuring the sustainability of a Universal Health Coverage (UHC) system. However, setting up an effective HTA system poses multiple challenges and knowledge exchange can play a crucial role in helping countries achieve their UHC targets. This article reports the results of the discussion during a preconference session at the 2019 HTAsiaLink Conference, an annual gathering of HTA agencies in Asia, which supports knowledge transfer and exchange among HTA practitioners. As part of this discourse, 3 main HTA challenges were identified based on experiences of selected countries in Asia and Africa, namely Bhutan, Kenya, Thailand, and Zambia: availability of funding, building technical capacity, and achieving buy-in among stakeholders for successful translation of HTA research into UHC policy. The potential solutions identified through this South-South engagement included establishing a legal mandate for HTA, building local technical capacity through partnerships and enhancing strategic communication with stakeholders to increase awareness, among others. South-South Knowledge Exchange can therefore be instrumental in sharing lessons learned from common challenges and offer potential solutions to address capacity building initiatives for HTA in LMICs.

Medical, transportation and spiritual out-of-pocket health expenditure on outpatient and inpatient visits in Bhutan.

Understanding the determinants of out-of-pocket health expenditure (OOP) is important for achieving and sustaining universal health coverage, as well as ensuring that no one is left behind. Focusing on major types of spending, including healthcare-related transportation and spiritual expenses, this study analyses OOP on outpatient and inpatient visits in Bhutan, using a two-part model and data from the nationally representative 2017 Bhutan Living Standards Survey. While OOP based on standard estimates is relatively low in Bhutan, the survey data show that expenses for healthcare-related transportation and spiritual ceremonies are substantive and by far exceed other components of OOP. Demographic, socio-economic, geographic and morbidity-related factors are found to affect the probability of incurring medical, transportation and spiritual OOP, as well as amounts spent. Disaggregating healthcare-related spending into its key components further reveals that living in rural areas increases the probability of incurring expenses for transportation and spiritual ceremonies, but decreases the odds of experiencing positive medical expenditure. Monthly equivalised household expenditure, functional disability, frequency of visits and length of stay are positively associated with total OOP, especially for transportation and spiritual expenses. Going to a public primary healthcare provider for the first outpatient visit, on the other hand, significantly decreases likelihood and amount of medical, transportation and spiritual OOP. These key results highlight the importance of understanding context-specific drivers of healthcare-related spending. In Bhutan, the financial burden particularly impacts respondents in rural areas and those with higher needs for healthcare services. A clear implication of the findings is that primary care and gatekeeping mechanisms need to be strengthened, especially considering that cost pressures have been growing which could lead to higher OOP in the future. Moreover, closer examination of the role of spiritual practices in the provision of health services is needed.

Distress and Resilience in Resettled Refugees of War: Implications for Screening.

There is little work published about predictors of specific trajectory types of distress in refugees of war during early resettlement in a host country. Data about distress (Refugee Health Screener-15 (RHS-15)) and possible predictors of distress were collected at the domestic medical examination (T1) within 90 days of arrival and the civil surgeon examination (T2) 11-16 months after T1 for refugee groups from three countries (COU). Descriptive, correlative, analyses of variance, and regression techniques were used to determine trajectory type and their predictors. A higher percentage (7.3%) were distressed at T2 than at T1. By group, the Bhutanese became more distressed, the Burmese became less distressed, and Iraqi's continued to have high distress. A regression model showed gender, loss, post-migration stress, and self-efficacy to be significant predictors of trajectory type (R2 = 0.46). When the T1 RHS-15 score was added to the model, observed variance increased (R2 = 0.53) and T1 RHS score accounted for the majority of variance (r = 0.64, p < 0.001), with post-migration stress accounting for markedly less (ß = 0.19, p = 0.03). Loss and self-efficacy became less significant. Loss was, however, a strong predictor of delayed and chronic distress trajectory type. These data suggest that screening for distress should occur at least twice during resettlement to detect those with initial distress and those with delayed distress. Screening should be coupled with identifying other social determinants of health and a comprehensive assessment to determine the need for intervention for secondary prevention (i.e., reducing delayed distress) and treatment (reducing chronic distress).

Dengue risk assessment using multicriteria decision analysis: A case study of Bhutan.

BACKGROUND: Dengue is the most rapidly spreading vector-borne disease globally, with a 30-fold increase in global incidence over the last 50 years. In Bhutan, dengue incidence has been on the rise since 2004, with numerous outbreaks reported across the country. The aim of this study was to identify and map areas that are vulnerable to dengue in Bhutan. METHODOLOGY/PRINCIPAL FINDINGS: We conducted a multicriteria decision analysis (MCDA) using a weighted linear combination (WLC) to obtain a vulnerability map of dengue. Risk factors (criteria) were identified and assigned with membership values for vulnerability according to the available literature. Sensitivity analysis and validation of the model was conducted to improve the robustness and predictive ability of the map. Our study revealed marked differences in geographical vulnerability to dengue by location and season. Low-lying areas and those located along the southern border were consistently found to be at higher risk of dengue. The vulnerability extended to higher elevation areas including some areas in the Capital city Thimphu during the summer season. The higher risk was mostly associated with relatively high population density, agricultural and built-up landscapes and relatively good road connectivity. CONCLUSIONS: Using MCDA, our study identified vulnerable areas in Bhutan during specific seasons when and where the transmission of dengue is most likely to occur. This study provides evidence for the National Vector-borne Disease Control programme to optimize the use of limited public health resources for surveillance and vector control, to mitigate the public health threat of dengue.

Barriers to Institutional Delivery Services in Districts With the Lowest Institutional Delivery Coverage in Bhutan.

Bhutan aims to achieve 100% institutional delivery coverage. While evidence indicates improved institutional delivery coverage over the years, coverage in some of the districts is only 49%. This study was aimed at exploring barriers to institutional delivery in three low-coverage districts. In-depth qualitative interviews and six focus group discussions were conducted in December 2015. The analysis was done as per the Braun and Clarke's 6-phase guide to doing thematic analysis. This study sheds light on 15 barriers for institutional deliveries, which include hesitancy to seek health care when the pregnancy is out of wedlock, the restriction of alcohol consumption at health centers, fear of hypothermia in cold places, pastoralism, health care providers shortage, lack of maternity waiting home and food, distance, difficult terrain, lack of transportation services, and financial constraints. Some of these barriers could be unique to Bhutan. The coverage could be improved considerably if the recommendations in this article are implemented.

Do social accountability approaches work? A review of the literature from selected low- and middle-income countries in the WHO South-East Asia region.

Governance failures undermine efforts to achieve universal health coverage and improve health in low- and middle-income countries by decreasing efficiency and equity. Punitive measures to improve governance are largely ineffective. Social accountability strategies are perceived to enhance transparency and accountability through bottom-up approaches, but their effectiveness has not been explored comprehensively in the health systems of low- and middle-income countries in south and Southeast Asia where these strategies have been promoted. We conducted a narrative literature review to explore innovative social accountability approaches in Bangladesh, Bhutan, India, Indonesia, the Maldives, Myanmar and Nepal spanning the period 2007-August 2017, searching PubMed, Scopus and Google Scholar. To augment this, we also performed additional PubMed and Google Scholar searches (September 2017-December 2019) to identify recent papers, resulting in 38 documents (24 peer-reviewed articles and 14 grey sources), which we reviewed. Findings were analysed using framework analysis and categorized into three major themes: transparency/governance (eight), accountability (11) and community participation (five) papers. The majority of the reviewed approaches were implemented in Bangladesh, India and Nepal. The interventions differed on context (geographical to social), range (boarder reform to specific approaches), actors (public to private) and levels (community-specific to system level). The initiatives were associated with a variety of positive outcomes (e.g. improved monitoring, resource mobilization, service provision plus as a bridge between the engaged community and the health system), yet the evidence is inconclusive as to the extent that these influence health outcomes and access to health care. The review shows that there is no common blueprint which makes accountability mechanisms viable and effective; the effectiveness of these initiatives depended largely on context, capacity, information, spectrum of actor involvement, independence from power agendas and leadership. Major challenges that undermined effective implementation include lack of capacity, poor commitment and design and insufficient community participation.