Evaluating the effect of village health workers on hospital admission rates and their economic impact in the Kingdom of Bhutan.

BACKGROUND: Village health workers (VHWs) in Bhutan play an all-encompassing role in supporting the health of their communities. Recent reports from the Bhutan Ministry of Health have indicated a sharp reduction in the number of working VHWs. As such, our work attempts to estimate the cost saved and the number of averted hospital admissions onto the Bhutanese healthcare system and the individuals who are served by these health workers. METHODS: We utilized a dataset from the Bhutan Ministry of Health which encompassed over 95% of all reported disease cases within the nation. We examined the impact that VHWs have on hospital admission rates for eight diseases of interest by using multiple multivariate logistic regression models. Our model allowed us to estimate the potential disease cases averted when the average number of VHWs per health center is increased by one unit. Lastly, we utilized the 2011 "A Costing of Healthcare Services in Bhutan" to estimate the cost saved attributed to VHWs. RESULTS: An average one unit increase of VHWs per health center is associated with a decrease in hospital and clinic admission for diarrhea, dysentery, wound care, depression/anxiety, dental caries, and skin infection, while a non-significant increase was observed for scabies and conjunctivitis. These findings translate to 4604 outpatient visits averted, with $28,637 saved, and 78 inpatient visits averted, with $10,711 saved. These values sum to a total of 4682 yearly averted admissions at health centers, with a total cost savings of $39,348 yearly. Additionally, we estimated a yearly savings of $13,348 in transportation costs and a total of $20,960 saved in wages to the community members that VHWs serve. CONCLUSIONS: VHWs serve as a source of cost-savings for the Kingdom of Bhutan and also act as an economic buffer for more vulnerable communities. The cost-savings associated with these health workers is likely to become more pertinent as the nation begins to develop and healthcare costs increase. It is imperative that proper action be taken to retain these health workers as every VHW who leaves the program increases healthcare costs onto the Bhutanese government.

Determinants of Neonatal Mortality in Bhutan: A Case-Control Study.

More than half of Bhutan's under-five mortality is attributed to neonatal deaths. Despite this, there is a lack of local evidence on determinants of neonatal mortality. It is critical to generate new evidence to accelerate interventions to achieve sufficient reduction of neonatal mortality rate in line to sustainable development goal target 3.2. Thus, this study was aimed at exploring determinants of neonatal mortality in Bhutan. A case-control study was performed with reported neonatal deaths from hospitals and primary health centers between 2018 and 2019. A total of 181 neonatal deaths were included as cases along with three corresponding controls. Epidata and STATA were used for data management and analysis, respectively. A multivariable model was fitted to identify determinants of neonatal mortality. History of obstetric complications (odds ratio [OR] = 3.53; 95% confidence interval [CI] = 1.48-8.42), intrapartum complications (OR = 3.86; 95% CI = 1.71-8.74) gestational age (OR = 8.07; 95% CI = 2.89-22.52), and Apgar 1 minute (OR = 4.40; 95% CI =1.83-10.59) were associated with neonatal death. Therefore, quality of care during pregnancy and childbirth besides promoting supportive family environment is essential to reduce neonatal mortality.

Prevalence, Pattern, and Factors Associated With Self-reported Disability Among the Bhutanese Population: A Secondary Data Analysis of Population and Housing Census.

We analyzed the Population and Health Census of Bhutan (PHCB) 2017 to assess the prevalence and pattern of self-reported disability among people aged ≥15 years and the associated factors. The PHCB 2017 used the Washington Group Short Set on Functioning questionnaire to assess the disability ("lot of difficulty" or "cannot do at all") in seeing, hearing, mobility, cognition, self-care, and communication. Of the 536 443 persons included in the analysis, 384 101(71.6%) were aged <45 years, 283 453(52.8%) were men, and 206 103(38.4%) were from the rural area. The prevalence of any self-reported disability was 2.8%, among whom 34.2% reported multiple disabilities. The disability prevalence (any) was significantly higher among people aged ≥65 years, illiterate, economically inactive, permanent residents, residing in a rural area, and from central and eastern regions of the country compared with their respective counterparts. Further research on access to rehabilitation and linking with social protection schemes for the disabled is required in this country.

Dietary behavior of school-going adolescents in Bhutan: Findings from the global school-based student health survey in 2016.

OBJECTIVES: Bhutan is experiencing a dual burden of undernutrition and overnutrition among adolescents. Understanding dietary behavior is vital to designing evidence-based interventions to improve adolescent nutrition and prevent non-communicable diseases in adults. The aim of this study was to assess the pattern of dietary behavior and associated sociodemographic, behavioral, and metabolic risk factors among school-going adolescents in Bhutan. METHODS: The Bhutan Global School-based Student Health Survey 2016 studied students in grades 7 to 11 (N = 7576), sampled from 50 schools, randomly selected based on probability proportional to enrollment size, using a standardized self-administered questionnaire. Consumption of adequate fruits and vegetables (each at least twice daily, or a combination of at least five times daily), high-protein food at least twice weekly) in the past 30 d, no fast food in the past week, and no carbonated/sweetened drinks in the past 30 d were studied. Weighted prevalence of dietary behaviors and adjusted prevalence ratio (95% confidence interval) for factors associated with them were calculated. RESULTS: Of 5809 students from 13 to 17 y of age comprising 3255 (56%) girls and 3184 (54.8%) day students, 1166 (20.1%) were underweight, 1655 (28.5%) were tobacco users, and 1349 (23.2%) were alcohol users. Adequate fruit and vegetable intake, high protein consumption, not consuming fast foods and carbonated beverages were reported by 29.6%, 31.8%, 9.6%, and 14.9%, respectively. Being a day student, sex, and not reporting health risk behaviors were significantly associated with any healthy dietary behavior. CONCLUSION: Healthy eating behavior was low among Bhutanese adolescents. Policies influencing availability, affordability, and acceptability of healthy diets through peer-led, school- and community-based interventions are required to promote adolescent health and prevent non-communicable diseases.

A Cross-Sectional Survey Analyzing Community Perception and Utilization of Village Health Workers Stratified by the Urban-Rural Divide Within the Kingdom of Bhutan.

Village health workers (VHWs) serve as an integral health resource for many resource limited nations, including the Kingdom of Bhutan. As such, we aimed to identify community perceptions as well as utilization rates and types with relation to VHWs based on the urban-rural divide. Our team conducted a randomized survey of 429 community members in 14 villages within the Western region of Bhutan. Our findings indicate VHWs in rural communities are requested for their services twice as much as their urban counterparts. More specifically, urban VHWs are utilized 2.5 times more for general community services, while rural VHWs are utilized more for accessing medications. Additionally, our research indicates a need to increase training of VHWs as well as overall program promotion relating to the specific services that VHWs can provide. These investigations indicate the importance of differentially allocating resources, programming, and training based on the urban-rural divide.

Limited Secondary Transmission of the Novel Coronavirus (SARS-CoV-2) by Asymptomatic and Mild COVID-19 Patients in Bhutan.

As the COVID-19 pandemic continues, there is growing concordance and persisting conflicts on the virus and the disease process. We discuss limited transmissibility of the virus by asymptomatic and mild cases of COVID-19 patients in Bhutan. We followed up the secondary transmission of SARS-CoV-2 in the contacts of asymptomatic and mild COVID-19 patients in Bhutan. Bhutan had 33 confirmed COVID-19 cases in the country as of May 29, 2020. Of these, 22 (67%) were females. Except the first two cases (American tourists), the rest were Bhutanese living outside the country. The mean age of the Bhutanese patients was 26.3 (range 16-33) years. Close contacts of 27 of the 33 cases were followed up for signs and symptoms and COVID-19 positivity. The first two cases had 73 and 97 primary contacts, respectively, and equal number of secondary contacts (224). From the third case, a mandatory 21-day facility quarantine was instituted, all primary contacts were facility quarantined, and there were no secondary contacts. In total, the 27 cases had 1,095 primary contacts and 448 secondary contacts. Of these, 75 individuals were categorized as definite high-risk contacts. Secondary transmission occurred in seven high-risk contacts. Therefore, the overall secondary transmission was 9.0% (7/75) and 0.6% (7/1,095) among the high-risk and primary contacts, respectively. No transmission occurred in the secondary contacts. In contrast to several reports indicating high transmissibility of SARS-CoV-2 in contacts of confirmed cases, the mostly young, asymptomatic, and mild cases of COVID-19 in Bhutan showed limited secondary transmission.