Population-level cancer screening and cancer care in Bhutan, 2020-2023: a review.

Screening of cancers is an important intervention in reducing the incidence and mortality related to cancers. Bhutan is one small country that is witnessing an increasing incidence and mortality related to cancers. The government implemented a time-bound population-level screening for gastric, cervical and breast cancers from 2020 to 2023 with an overall coverage of 91.2% of the eligible population. Among 370,225 individuals screened for H pylori, 32.4% tested positive; among 53,182 who underwent upper gastrointestinal endoscopy and biopsy, 255 (0.07%) had gastric cancer. Among 10,749 tested for HPV DNA, 9.3% were positive; among 9887 evaluated with colposcopy and biopsy, 154 (0.13%) had cervical cancer. For breast cancer screening, 72,283 underwent clinical breast examination, 845 mammography and cancer was detected in 73 (0.10%) individuals. In this article, we review how Bhutan implemented a population-level cancer screening programme with on boarding of multiple stakeholders and the participation of people across all districts.

Assessing public health sector performance in Bangladesh: Implications for health systems strengthening and universal health coverage - A secondary data analysis.

The Ministry of Health and Family Welfare has established a health systems strengthening initiative for measuring the performance of public sector health facilities in Bangladesh. The objective of the performance management initiative is to establish routine systems for measuring and scoring health facility performance and promote best practices in public health service management. The performance initiative includes a set of assessments conducted across the four tiers of the public health sector. The findings of assessments demonstrate improvements in the quality of health services and a sharp increase in the utilisation of services across all tiers during the period 2017-2019. The performance management initiative has also identified areas for improvement in the supply-side health system readiness, including ensuring an adequate supply of human resources, essential medicines, and functioning medical equipment and technologies. This initiative outlines the need to systematically address the issue of high health workforce vacancy rates through effective human resource planning and management strategies. The reporting of these ongoing health systems successes and challenges through the performance management initiative in Bangladesh provides an opportunity to develop evidence-based policy reforms for strengthening supply-side health systems. The initiative results, particularly in the context of growing public demand for services, also justifies a monitoring and evaluation mechanism focusing on the quality and coverage of frontline health facilities and the development of more integrated health systems. The performance management initiative will facilitate the maintenance of essential health services while addressing emergency health needs and tracking progress towards achieving the Universal Health Coverage goal.

Informing investment in health workforce in Bangladesh: a health labour market analysis.

BACKGROUND: As the 2016 Global Strategy on Human Resources for Health: Workforce 2030 (GSHRH) outlines, health systems can only function with health workforce (HWF). Bangladesh is committed to achieving universal health coverage (UHC) hence a comprehensive understanding of the existing HWF was deemed necessary informing policy and funding decisions to the health system. METHODS: The health labour market analysis (HLMA) framework for UHC cited in the GSHRH was adopted to analyse the supply, need and demand of all health workers in Bangladesh. Government's information systems provided data to document the public sector HWF. A national-level assessment (2019) based on a country representative sample of 133 geographical units, served to estimate the composition and distribution of the private sector HWF. Descriptive statistics served to characterize the formal and informal HWF. RESULTS: The density of doctors, nurses and midwives in Bangladesh was only 9.9 per 10 000 population, well below the indicative sustainable development goals index threshold of 44.5 outlined in the GSHRH. Considering all HWFs in Bangladesh, the estimated total density was 49 per 10 000 population. However, one-third of all HWFs did not hold recognized roles and their competencies were unknown, taking only qualified and recognized HWFs into account results in an estimated density 33.2. With an estimate 75 nurses per 100 doctors in Bangladesh, the second area, where policy attention appears to be warranted is on the competencies and skill-mix. Thirdly, an estimated 82% of all HWFs work in the private sector necessitates adequate oversight for patient safety. Finally, a high proportion of unfilled positions in the public sector, especially in rural areas where 67% of the population lives, account only 11% of doctors and nurses. CONCLUSION: Bangladesh is making progress on many of the milestones of the GSHRH, notably, the establishment of the HWF unit and reporting through the national health workforce accounts. However, particular investment on strengthening the intersectoral HWF coordination across sectors; regulation for assurance of patient safety and adequate oversight of the private sector; establishing accreditation mechanisms for training institutions; and halving inequalities in access to a qualified HWF are important towards advancing UHC in Bangladesh.

Gender-neutral HPV elimination, cervical cancer screening, and treatment: Experience from Bhutan.

Cervical cancer is preventable and also curable when detected early and treated adequately, yet it remains a leading cause of morbidity and mortality among women. In Bhutan, cervical cancer is the most common cancer among women. Bhutan was the first country among the low- and middle-income economies to have instituted a national HPV vaccination program, in 2010, and has achieved >90% coverage. In 2019, Bhutan launched a cervical cancer elimination flagship program well ahead of WHO's launch of the global strategy for accelerated elimination of cervical cancer. Bhutan initiated vaccination of adolescent boys and adopted a gender-neutral vaccination program beginning September 2020 through its well-established network of primary healthcare centres. The flagship program aims to screen women aged 30-69 years with HPV testing using liquid-based cytology (LBC) as triaging for screen positive women. For women aged 25-29 years, LBC will be continued as per American Society of Colposcopy and Cervical Pathology guidelines. Colposcopy and treatment will be performed in camps to decrease loss of follow up of screen positive women. This program is also expected to improve early diagnosis of cervical cancer and provide timely and adequate cancer treatment and palliative care services. This article reviews the progress made and the challenges facing the 2030 cervical cancer elimination targets in Bhutan.

Rates and indications of caesarean section deliveries in Bhutan 2015-2019: a national review.

BACKGROUND: Bhutan has made much efforts to provide timely access to health services during pregnancy and increase institutional deliveries. However, as specialist obstetric services became available in seven hospitals in the country, there has been a steady increase in the rates of caesarean deliveries. This article describes the national rates and indications of caesarean section deliveries in Bhutan. METHODS: This is a review of hospital records and a qualitative analysis of peer-reviewed articles on caesarean deliveries in Bhutan. Data on the volume of all deliveries that happened in the country from 2015 to 2019 were retrieved from the Annual Health Bulletins published by the Ministry of Health. The volume of deliveries and caesarean deliveries were extracted from the Annual Report of the National Referral Hospital 2015-2019 and the data were collected from hospital records of six other obstetric centres. A national rate of caesarean section was calculated as a proportion out of the total institutional deliveries at all hospitals combined. At the hospital level, the proportion of caesarean deliveries are presented as a proportion out of total institutional deliveries conducted in that hospital. RESULTS: For the period 2015-2019, the average national rate of caesarean section was 20.1% with a statistically significant increase from 18.1 to 21.5%. The average rate at the six obstetric centres was 29.9% with Phuentsholing Hospital (37.2%), Eastern Regional Referral Hospital (34.2%) and Samtse General Hospital (32.0%) reporting rates higher than that of the National Referral Hospital (28.1%). Except for the Eastern Regional Referral and Trashigang Hospitals, the other three centres showed significant increase in the proportion of caesarean deliveries during the study period. The proportion of emergency caesarean section at National Referral Hospital, Central Regional Referral Hospital and the Phuentsholing General Hospital was 58.8%. The National Referral Hospital (71.6%) and Phuentsholing General Hospital reported higher proportions of emergency caesarean sections (64.4%) while the Central Regional Referral Hospital reported higher proportions of elective sections (59.5%). The common indications were 'past caesarean section' (27.5%), foetal distress and non-reassuring cardiotocograph (14.3%), failed progress of labour (13.2%), cephalo-pelvic disproportion or shoulder dystocia (12.0%), and malpresentation including breech (8.8%). CONCLUSION: Bhutan's caesarean section rates are high and on the rise despite a shortage of obstetricians. This trend may be counterproductive to Bhutan's efforts towards 2030 Sustainable Development Goal agendas and calls for a review of obstetric standards and practices to reduce primary caesarean sections.

Implementation of national action plans on noncommunicable diseases, Bhutan, Cambodia, Indonesia, Philippines, Sri Lanka, Thailand and Viet Nam.

By 2016, Member States of the World Health Organization (WHO) had developed and implemented national action plans on noncommunicable diseases in line with the Global action plan for the prevention and control of noncommunicable diseases (2013-2020). In 2018, we assessed the implementation status of the recommended best-buy noncommunicable diseases interventions in seven Asian countries: Bhutan, Cambodia, Indonesia, Philippines, Sri Lanka, Thailand and Viet Nam. We gathered data from a range of published reports and directly from health ministries. We included interventions that addressed the use of tobacco and alcohol, inadequate physical activity and high salt intake, as well as health-systems responses, and we identified gaps and proposed solutions. In 2018, progress was uneven across countries. Implementation gaps were largely due to inadequate funding; limited institutional capacity (despite designated noncommunicable diseases units); inadequate action across different sectors within and outside the health system; and a lack of standardized monitoring and evaluation mechanisms to inform policies. To address implementation gaps, governments need to invest more in effective interventions such as the WHO-recommended best-buy interventions, improve action across different sectors, and enhance capacity in monitoring and evaluation and in research. Learning from the Framework Convention on Tobacco Control, the WHO and international partners should develop a standardized, comprehensive monitoring tool on alcohol, salt and unhealthy food consumption, physical activity and health-systems response.

En 2016, les États membres de l'Organisation mondiale de la Santé (OMS) avaient élaboré et mis en œuvre des plans d'action nationaux sur les maladies non transmissibles conformément au Plan d'action mondial pour la lutte contre les maladies non transmissibles (2013­2020). En 2018, nous avons évalué l'état de l'application des interventions les plus avantageuses recommandées en matière de maladies non transmissibles dans sept pays asiatiques: le Bhoutan, le Cambodge, l'Indonésie, les Philippines, le Sri Lanka, la Thaïlande et le Viet Nam. Nous avons recueilli des données à partir de toute une série de rapports publiés et directement auprès des ministères de la Santé. Nous avons inclus les interventions qui concernaient la consommation de tabac et d'alcool, une activité physique inadéquate et une consommation de sel élevée, ainsi que les réponses des systèmes de santé, et nous avons identifié les lacunes et proposé des solutions. En 2018, les progrès étaient variables selon les pays. Les lacunes étaient largement dues à un financement inadéquat; des capacités institutionnelles limitées (malgré des unités dédiées aux maladies non transmissibles); une action inadéquate dans les différents secteurs au sein et en dehors du système de santé; et l'absence de mécanismes de suivi et d'évaluation standardisés pour orienter les politiques. Afin de combler ces lacunes, les gouvernements doivent investir davantage dans des interventions efficaces telles que les interventions les plus avantageuses recommandées par l'OMS, améliorer l'action dans les différents secteurs, et renforcer les capacités en matière de suivi et d'évaluation, mais aussi de recherche. En s'inspirant de la Convention-cadre pour la lutte antitabac, l'OMS et ses partenaires internationaux devraient élaborer un outil de suivi complet et standardisé sur la consommation d'alcool, de sel et d'aliments malsains, l'activité physique et la réponse des systèmes de santé.

Para 2016, los Estados miembros de la Organización Mundial de la Salud (OMS) habían elaborado y aplicado planes de acción nacionales sobre las enfermedades no contagiosas de acuerdo con el Plan de acción mundial para la prevención y el control de las enfermedades no transmisibles (2013-2020). En 2018, se evaluó el estado de implementación de las intervenciones recomendadas en siete países asiáticos en materia de enfermedades no contagiosas: Bhután, Camboya, Filipinas, Indonesia, Sri Lanka, Tailandia y Vietnam. Se recopilaron datos de una serie de informes publicados y directamente de los ministerios de salud. Se incluyeron intervenciones que abordaron el uso del tabaco y el alcohol, la actividad física inadecuada y la ingesta elevada de sal, así como las respuestas de los sistemas de salud, se identificaron las deficiencias y se propusieron soluciones. En 2018, el progreso fue desigual entre los países. Las deficiencias en la aplicación se debieron en gran medida a la falta de financiación, a la limitada capacidad institucional (a pesar de las dependencias designadas para las enfermedades no contagiosas), a la inadecuación de las medidas adoptadas en los diferentes sectores dentro y fuera del sistema de salud y a la falta de mecanismos normalizados de supervisión y evaluación que sirvieran de base a las políticas. Para subsanar las deficiencias en materia de aplicación, los gobiernos deben invertir más en intervenciones eficaces, como las recomendadas por la OMS, mejorar las medidas adoptadas en los distintos sectores y aumentar la capacidad de seguimiento y evaluación y de investigación. A partir de las enseñanzas del Convenio Marco para el Control del Tabaco, la OMS y los asociados internacionales deberían elaborar un instrumento de seguimiento normalizado y completo para el consumo de alcohol, sal y alimentos no saludables, la actividad física y la respuesta de los sistemas de salud.

Antibiotic resistance in Neisseria gonorrhoea and treatment outcomes of gonococcal urethritis suspected patients in two large hospitals in Bhutan, 2015.

INTRODUCTION: Gonorrhea is a major sexually transmitted infection (STI) globally with increasing trends. Despite limited data, gonorrhea remains an important public health problem in Bhutan. METHODS: A descriptive study was carried out in two Bhutanese hospitals; Jigme Dorji Wangchuck National Referral Hospital and Phuentsholing General Hospital in 2015. Patients suspected of gonococcal urethritis were sampled, treated and followed up at two weeks. Gonococcal isolates were identified and tested for antibiotic susceptibility by the Calibrated Dichotomous Sensitivity Test (CDS) method. RESULTS: Of the 524 patients, 2.3% (12) were females. Most (46.6%) patients belonged to the 26-35 years age group. About 58% were lost to follow up; 62% (277) of males and all (12) females. N. gonorrhoea was positive in 76% (398) of microscopy and 73.1% (383) by culture. Resistance against ciprofloxacin, penicillin, tetracycline and nalidixic acid were 85.1%, 99.2%, 84.8% and 99.7% respectively. Nearly all the isolates were sensitive to cefpodoxime, ceftriaxone and azithromycin. Sixty-seven percent (350) were treated with injection ceftriaxone alone, 32% (169) with ceftriaxone and oral doxycycline and 1% (5) with ceftriaxone, doxycycline and metronidazole. Probable treatment failure was seen only in one patient (0.5%). CONCLUSIONS: Gonococcal resistance to currently used antibiotics was low and there was a high clinical cure rate. Compliance to treatment guidelines need reinforcement addressing antibiotic regimen, tracing sexual partners and addressing the social stigma. National STI programs should be more women-friendly for effective management, prevention and control of STIs. Laboratories must adopt more reliable susceptibility testing methods, the Minimum Inhibition Concentration method.

Assessing the Knowledge, Attitudes, and Practices on Antibiotics Among the General Public Attending the Outpatient Pharmacy Units of Hospitals in Bhutan: A Cross-Sectional Survey.

We assessed the level of knowledge, attitudes, and practices on antibiotics through a questionnaire-based cross-sectional survey among the general public in Bhutan. Of the 692 participants, 52.6% (364) were females with a mean age of 34.2 years. More than half of the respondents showed unsatisfactory knowledge varying significantly from 23.1% to 69.6%. Cotrimoxazole (septran) was the least known while amoxicillin was the most known antibiotics assessed. Two-thirds of the responsents (267) knew that inappropriate use of antibiotics could lead to antimicrobial resistance and 89% (319) were aware of the need to complete the antibiotic courses. In bivariate analysis, satisfactory knowledge was associated with the education level of graduate and higher as compared with no education. This study revealed unsatisfactory knowledge and attitude but satisfactory practices on antibiotics use among participants. Efforts are needed to improve public awareness on antibiotics. Enforcement of regulations on sale of antibiotics over the counter needs a revamp.

Maternal and child health voucher scheme in Myanmar: a review of early stage implementation.

BACKGROUND: The Maternal and Child Health Voucher Scheme (MCHVS) was introduced in Myanmar to address the high rate of maternal and infant mortalities. It aimed to increase access to maternal and child health (MCH) services by skilled birth attendants (SBAs) and improve the health of pregnant women and their babies. A study to pilot a voucher scheme was implemented in May 2013 in Yedarshey Township. This paper provides a report on a mid-term review of the programme after 7 months of implementation to determine the outcomes of the programme and its impediments. METHODS: Quantitative and qualitative approaches were used. Secondary quantitative data were analysed in order to measure the coverage and utilisation of the programme. Semi-structured interviews were conducted in groups and individually with 79 key informants to explore qualitative information on voucher communication, beneficiary's identification, voucher distribution, and challenges for beneficiaries and providers under the MCHVS. RESULTS: The results showed that 63 % of eligible pregnant women who registered to the programme received voucher booklets, while the utilisation of most of the MCH services increased over time; in particular, delivery by SBAs increased significantly (P < 0.01) after implementing MCHVS. Overall, the programme was implemented well in terms of promoting and communicating the programme to people in Yedarshey Township. Although a number of targeted poor pregnant women were included in the programme, some beneficiaries were overlooked for a variety of reasons. Nevertheless, both providers and beneficiaries who experienced the MCHVS service utilisation were satisfied with the programme. The evaluation indicated several programme challenges, i.e. external and internal programme communication, voluntary voucher distributor recruitment, incentive and support for voucher distributors, beneficiary screening criteria, and approaches to increase access of services for pregnant women living in remote areas. CONCLUSIONS: Generally, the MCHVS pilot programme is a promising initiative to increase access to and utilisation of the MCH services for pregnant women and their babies in Myanmar. However, increasing coverage of the programme and overcoming the barriers should be considered as high-priority issues that need to be addressed.

Auxiliary midwives in hard to reach rural areas of Myanmar: filling MCH gaps.

BACKGROUND: Auxiliary Midwives (AMWs) are community health volunteers supporting the work of midwives, especially maternal and child health services in hard to-reach areas in Myanmar. This paper assessed the contributions of AMW to maternal and child health services, factors influencing their productivity and their willingness to serve the community. METHOD: The study applied quantitative cross-sectional survey using census method. Total of 1,185 AMWs belonging to three batches: trained prior to 2000, between 2000 and 2011, and in 2012, from 21 townships of 17 states and regions in Myanmar participated in the study. Multiple logit regression was used to examine the impact of age, marital status, education, domicile, recruitment pattern and 'batch of training', on AMW's confidence level in providing care, and their intention to serve the community more than 5 years. RESULTS: All AMWs were able to provide essential maternal and child health services including antenatal care, normal delivery and post-natal care. They could identify and refer high-risk pregnancies to larger health facilities for proper management. On average, 9 deliveries, 11 antenatal and 9 postnatal cases were performed by an AMW during the six months prior to this study. AMWs had a comparative advantage for longer service in hard-to-reach villages where they lived, spoke the same dialect as the locals, understood the socio-cultural dimensions, and were well accepted by the community. Despite these contributions, 90 % of the respondents expressed receiving no adequate supervision, refresher training, replenishment of the AMW kits and transportation cost. AMWs in the elder age group are significantly more confident in taking care of the patients than those in the younger groups. Over 90 % of the respondents intended to stay more than five years in the community. The confidence in catering services appeared to have significant association with a longer period of stay in AMW jobs as evidenced by the odds ratio of 3.5, compared to those reporting unconfident. CONCLUSIONS: Comprehensive support system and national policy are needed to sustain and strengthen the contributions of AMWs, in sharing the workload of midwives, particularly in hard-to-reach areas of Myanmar.

Diabetes prevention and care in the universal health coverage context: The example of Thailand.

Universal health coverage (UHC) is a key policy issue in countries of the World Health Organization (WHO) South-East Asia Region. However, despite projections of significant increases in burden, there is little protection against the financial risks associated with noncommunicable diseases (NCDs), including diabetes. Thailand achieved UHC of all 67 million of the population in 2002, under three public health insurance schemes. The country therefore provides a case-study on diabetes prevention and care in the context of UHC. Although the budget for the Thai Universal Coverage (UC) scheme, which covers nearly 80% of the population, increased significantly during 2003-2013, the proportion allocated to clinical prevention and health promotion declined from 15% to 11%. The financial case for investment in diabetes prevention is made, particularly with respect to a focus on primary care and the use of community volunteers. The UC scheme can expand to nearly 100% population coverage, with a comprehensive benefit package and financial risk protection. Although the rates of complications and fatalities in patients with diabetes have improved over the last few years, achievement of well-controlled fasting blood glucose for all patients is still the main challenge for further improvement. It is recommended that, in order to improve coverage of diabetes care and prevention, it is essential for countries in the WHO South-East Asia Region to include major NCD services, in particular primary prevention, in their UHC strategies. Since a resilient health system is key to UHC delivery, strengthening of the health workforce and infrastructure should be part of any action plan to prevent and control diabetes.