Bhutan is confronting a public health shift characterized by an aging population and a transition from communicable to noncommunicable diseases (NCDs), which now account for 69 percent of all deaths in the country.[1] As of 2019, 28 percent of the population was hypertensive, 11 percent obese, and 22.2 percent of youth used tobacco.[2] The average daily salt intake of 8.3 grams per person surpassed WHO recommendations, and unhealthy practices like increased alcohol consumption and chewing of doma (betel leaf and nuts) were on the rise.[3]  To address this, the Service with Care and Compassion Initiative (SCCI)[4] was launched in 14 districts, adapting the WHO package of essential noncommunicable (WHO PEN) disease interventions for primary health care.[5] Focused on hypertension and diabetes, Ministry of Health standardized treatment protocols in primary healthcare settings. Early data, including the 2023 pulse survey[6], suggest progress in healthcare delivery and reporting, particularly for hypertension and diabetes. These efforts align towards the Dhaka call of action [7] to achieve at least 50 000 people on protocol-based management of hypertension and diabetes to achieve universal health coverage.

How did Bhutan, with the support of WHO, achieve this?

In 2010, Bhutan pioneered the PEN program in South-East Asia, with initial success in controlling blood pressure and diabetes observed at pilot sites in Bumthang and Paro.[8] To accelerate progress, the Service with Care and Compassion Initiative (SCCI) was rolled out across four districts in 2018 and 2019 - Punakha, Wangduephodrang, Tsirang, and Zhemgang. A 2019 biennial health conference resolved to expand SCCI to 20 districts. This expansion was implemented through a partnership where district health sectors implemented interventions under the guidance of the Ministry of Health (MoH) and clinical support from Khesar Gyalpo University of Medical Sciences of Bhutan (KGUMSB).

The SCCI model employs multifaceted strategies including the "7 Rs" – robust team building, reaching out to provide home-bound services, refills of medicines, recall and reminders, responsive referrals, reliable and people-centred laboratory diagnosis, and real-time monitoring and supportive supervision. Additionally, it emphasizes the "3 Cs" of care - comprehensive, collaborative, and continuum.[9] To operationalize the strategy, established SCCI districts were paired with, and mentored, new districts. Primary Health Centers (PHCs) facilitated access to medication refills and coordinated patients’ laboratory appointments with hospitals. Health assistants, supported by a well-structured micro-plan, provided home-based services, and a multidisciplinary team, including a doctor, laboratory technologist, pharmacist, and NCD focal point, conducted biannual mentoring and supervision visits.[10]

^{The WHO team conducts a field visit to understand the modality of home-bound care in Punakha, Bhutan.}
Photo credit: WHO Bhutan

The COVID-19 pandemic in 2020 necessitated a shift to remote training for health workers. WHO Bhutan provided technical and financial support to the Khesar Gyalpo University of Medical Sciences of Bhutan to develop online PEN training modules and virtual equipment was distributed to 49 hospitals for district training. By 2023, health workers in 14 districts had been trained in a hybrid onsite and online format.

To further standardize care, the hypertension and diabetes protocol was officially launched on 21 September 2023. This aligned with Bhutan’s national goal of managing 50 000 patients with these conditions by 2025. WHO conducted biannual visits with local government officials and SCCI health workers, assessing progress using a checklist developed jointly with the Ministry of Health. These visits led to recommendations for continuous improvement, which were reassessed in subsequent visits.  The scope of mentoring gradually expanded beyond NCDs, to include HIV, maternal and child health, infection control, and community-based interventions. 

To enhance monitoring, WHO, the MoH, and KGUMSB established reporting mechanisms incorporating both manual registers and a comprehensive national Google-based database. These mechanisms tracked key health indicators, such as hypertension and home-based care, and facilitated quarterly and annual assessments at all healthcare facilities, including PHCs. The NCD division of the MoH reviewed the reports, providing comprehensive feedback. WHO supported the implementation of the recommendations, thereby improving healthcare services.

“We have created an efficient patient workflow spanning reception to exit at the pharmacy outlet in our hospital after the introduction of SCCI in 2021. The team responsible for providing noncommunicable services is trained to screen and manage the cases. All the cases are recorded and followed up to ensure timely care. We have also networked well with the primary health centres so that the patients don’t have to come to the hospital for medicine refills. The laboratory blood tests for those patients under PHC catchment are conducted through appointments to avoid inconveniences to the patients.”

- Kinley Dorji, NCD focal point, Bumthang Hospital, Bhutan

SCCI has transformed healthcare delivery, especially in managing hypertension and diabetes. Within health facilities there have been improvements in access to medicines, transportation, service documentation, referral processes, and patient flow.[12][13] Patients are now proactively screened for NCD-related risks during healthcare visits, with assessments including Body Mass Index (BMI), blood pressure, and blood sugar levels. Depending on their risk profile, they are then either initiated on a treatment plan or provided with personalized medical advice. To further enhance community access, the WHO has also supplied bags and essential equipment for the transportation of medicines to home-bound patients who are provided care in their homes. 

“As a person living with mobile disability – with lower limbs lacking mobility but having functional upper half of the body due to congenital paraplegia - and hailing from remote Barshong village, my dream of becoming an independent individual became alive as I enrolled into the SCCI in 2019. I became one of the beneficiaries of this initiative since I had hypertension during intensive screening in my community. I have not only received timely medical care but with the support of healthcare workers, local government officials and parents, I had undergone a six-month long tailoring in Thimphu which has helped me to set up a tailoring shop in Tsirang.”

- Jitshuen, 40, hypertensive patient, Barshong Gewog, Bhutan

Despite these advancements, challenges persist, such as the lack of designated NCD focal points, inadequate monitoring and reporting mechanisms, funding shortages, the need to improve the integration of indicators into the Health Management Information System (HMIS), and the development of more effective referral pathways. Addressing these issues is crucial for the continued improvement of NCD care and services and their successful integration into primary health care.