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Indian Journal of Community Medicine

The Impact of Community-oriented Primary Care in Trongsa Dzongkhag, Kingdom of Bhutan

Author(s): D.K. Nirola, G. Tshering, J. Brodie, M.K. Huntington

Vol. 31, No. 1 (2006-01 - 2006-03)

D.K. Nirola1, G. Tshering2, J. Brodie3, M.K. Huntington4

Introduction

To preserve Bhutan’s independence, Jigme Dorji Wangchuck led the country to join the world community. A farsighted leader, realized that once the culture and environment were lost, they would be unrecoverable. For this reason, he instituted a process of carefully planned development. This plan has been continued by his son, His Majesty Jigme Singye Wanchuck, whose coronation in 1974 marked the first time that a significant number of foreign visitors entered the kingdom. The motto of this development program is the enhancement of the ‘Gross National Happiness’ rather than gross domestic product.

In 1961, coinciding with the first Five Year Plan of socioeconomic development, the Royal Government of Bhutan introduced modern health services in the country. Since that time, life expectancy of the Bhutanese people has risen from 48 to 66 years, with similarly impressive decreases in maternal and infant mortality also noted. Health care is delivered in an integrated system, with community-level basic health units (BHU) representing the initial point of encounter for most patients. Increasingly complicated cases are referred to the Dzongkhag (District), Regional and National hospitals, sequentially. There are now 28 hospitals, over 150 BHUs, and nearly 500 outreach clinics staffed by over 2000 health care professionals at various levels. Care in the districts is provided by village health workers, health assistants, dental assistants, nurses (including midwifery) and generalist physicians. Subspecialist physician consultation is available only at the Regional referral hosptial level and higher. Ancillary services include trained laboratory technicians, pharmacy assistants, and indigenous Drungtsho (herbalist) practitioners1. There are no private hospitals or private medical practitioners in Bhutan. The Ministry of Health and Education and Department of Health receive regular, quite comprehensive epidemiological reports from the District Medical Officers, and undertake regular health surveys. A recent collaboration with DANIDA, a Danish development assistance program, has resulted in the introduction of a state-of-art electronic health management information system, with personal computer-based systems present at each District hospital. This should further improve the quality of public health information available in the nation.

Community-oriented Primary Care (COPC) is a model of health delivery elucidated by Kark and Kark after their experiences in South Africa2. Recognizing the futility of a curative-based approach to health care, they developed a system consisting of (a) Defining the community to be served; (b) Assembling the health care team, which includes community leaders as well as health care professionals; (c) Identifying common conditions in order to make a ‘community diagnosis’; (d) Instituting interventions to decrease the prevalence of these target conditions in the community; and (e) Evaluating the efficiacy of these interventions, adapting them if they are ineffective and expanding to new problems if the original ones are effectively addressed. This approach treats the community as the patient and develops primary care physicians with a public health perspective. It has been successfully applied in many settings worldwide.

This paper reports the effective application of COPC principles in a district in rural Bhutan.

Methods

Defining the community

Trongsa Dzongkhag covers a total area of approximately 1500km2, and ranges in altitude from 1500m to 3000m and located in the inner Himalayan region. The Mangude Chhu River flows through the center of the Dzongkhag dividing it roughly in half. Most of the settlements are along the river. Subsistence farming is primarily of wheat, barely, maize and millet; rice is grown in some parts of the Dzongkhag. Because of the poor socio-economic standards of the general public and the difficult terrain, it is a challenge to deliver health services effectively.

The Dzongkhag is divided into 5 geogs, viz., Drakteng, Nubi, Langthil, Korphu, and Tangsibji. The total population is made up of 11,511 individuals composing 1899 households. The population is primarily ethnic Mandhep, with significant Sharchop and Tibetan representation as well. Additional demographic information is depicted in Table I. Five Renewable Natural Resources extension centers, one high school, constitute the Dzongkhag educational system. In terms of health infrastructure, there are five BHUs and a District Hospital. The hospital is currently located in an old, converted school. Additionally, outreach clinics (ORC) are conducted by the various health centers at twenty-two sites throughout the Dzongkhag, thirteen of which have permanent buildings.

Table I: Trongsa Demographic Data, 2000.


  Dzongkhag National
Total Population 11,511 657,584
Population (0-14 years)% 37.3 42.1
Population (15-64 years)% 55.2 53.7
Population (65+ years)% 7.5 4.2
Annual Population growth% 2.1 2.5
Crude birth rate 26.8 34.09
General fertility rate/1000 women 111.1 142.7
Crude death rate 6 8.64
Infant mortality rate 13 60.5
Maternal mortality rate 0 2.55
Prenatal care (per 100 pregnant women) 95 NA
Deliveries attended by trained personnel (%) 46 23.66
Contraceptive prevalence rate (%) 38 30.7
Households with access to safe water (%) 84 77.8
Households served with adequate sanitary facilities (%) 91 88.0

The health care team

The District Health Supervisory Officer (DHSO) is supervisory official in charge of planning, regulatory aspects, and overall logistical implementation of health activities occurring at the Dzongkhag level. He is the individual ultimately responsible to the government for the smooth functioning of the health facilities under his administration.

All activities related to the District hospital are under the direction of the District Medical Officer (DMO). This generalist physician provides technical advice to the DHSO on all healthrelated activities and coordinates the Dzongkhag-level health staff training programs in addition to his primary responsibility of providing acute curative and rehabilitative health care services at the hospital and its associated outpatient department. Also staffing the District hospital are the nurses and nurse midwives, whose primary responsibilities are the nursing care of inpatients and provision of maternity care, respectively. In the outpatient department, a dental hygienist provides basic dental care (including fillings), and a laboratory technician and pharmacy assistant provide supporting services in their respective disciplines. Rounding out the District hospital personnel are the Drungtsho and sMenpa, who provide traditional herbal remedies. As there are currently no x-ray facilities, there is no radiology technician stationed in Trongsa.

The Health Assistants are in charge of the BHUs and are directly responsible to the DHSO. They provide the primary health care services to the population within the service area of the BHU. As the head of the team at the BHU, the Health Assistant organizes the ORC, maternal-child health clinics (MCH), and other health activities planned in his jurisdiction. Assisting and under the direction of the Health Assistants are the Basic Health Workers, who provide basic care in the villages.

Various community members are intimately involved in the planning and execution of public health programs in their areas. This is organized by the Village Health Development Committee in each community. The technical backup is provided by the skilled manpower from the local governmental personnel, with the public health engineer posted under the Dzongkhag engineering sector being primarily responsible for many of the projects. Health education in incorporated into the school system, as well. The community further helps in construction and maintenance of all public health projects and ORC buildings.

Community Diagnosis

As the result of the through record keeping and reporting required by the Health Department, a fairly clear picture of the epidemiology in the Dzongkhag is available. A comparison of the most common diagnoses in the year 2000 at the BHU and at the hospital is presented in Table II. In each setting, acute respiratory infection is by far the most common problem. This was not always the situation, however.

Table II: Ten most common outpatient diagnoses in Trongsa, 2000.

Rank Hospital Patients Number % of cases BHU Number % of cases
(n = 8714) (n = 17579)
1 Cough and cold 1569 18 Cough & cold 3164 18
2 Other Skin diseases 610 7 Headache 1934 11
3 Peptic ulcers 437 5 Diarrhea/Dysentery 1582 9
4 Conjunctivitis 436 5 Skin diseases 1231 7
5 Dysentery 349 4 Conjunctivitis 1230 7
6 Diarrhea 348 4 Peptic ulcers 1055 6
7 Injury 261 3 Fever, unknown origin 703 4
8 Fever, unknown origin 174 2 Others, NOS 527 3
9 Pneumonia 88 1 Injuries 352 2
10 Worms 87 1 Diseases of teeth & Gums 176 1

Tables III and IV present the pattern of diseases presenting at each setting for 1991, with a comparison to the data for 1999. This comparison will be discussed later. The most common illnesses in 1991 were gastrointestinal infections. Viral, bacterial, protozoan, and helminthic infections represented approximately 25% of the total morbidity seen at both the hospital and BHU. Acute respiratory infections (ARI) and skin diseases were also very significant contributors to morbidity in the population. These three conditions made up nearly half of the illnesses treated in Trongsa. It was based on these patterns that the health interventions were planned.

Intervention

Gastrointestinal infections

In that the bulk of the morbidity in the area is the direct result of waterborne diseases, development of a safe water supply and proper sanitation was a high priority. These issues were addressed as part of the national Rural Water Supply and Sanitation Program (RWSS). This program began in 1974 under UNICEF and was expanded in 1989 with funding from the European Economic Community.

As education regarding the source of these illnesses was disseminated, the Village Health Development Committees would contact the Dzongkhag engineering sector and the public health engineer would dispatch a team to identify potential water sources for the village. When a suitable source was located, the Dzongkhag would provide necessary materials and technical advice, while the community provided all the labor to construct proper spring boxes, distribution systems, and public taps. Following the completion of the system, the community assumes responsibility for its maintenance, utilizing trained Water Caretakers.

Related RWSS undertakings are the propagation of the use of sanitary latrines (both pit latrines and flush commodes), their proper location and construction, and use of household garbage pits.

Acute respiratory infection

The first step in addressing ARI represents an educational emphasis directed toward the training of mothers/caretakers, health workers, and other stake-holders in the recognition of ARI, appropriate treatments, and timely referral of severe cases. A tobacco-free initiative was also introduced and intensified after a resolution was passed in the National Assembly in the mid – 1990s. Trongsa Dzongkhag has been recognized as tobacco-free Dzongkhag by the Health Department. This makes the sale of tobacco illegal in the Dzongkhag. Additionally, drawing an association between tobacco abstinence and the practice of Buddhism (Bhutan’s predominant faith) appears to be an effective strategy.

A final educational intervention is the smokeless kitchens initiative. In most homes in Trongsa, cooking occurs over woodfired stoves. Efforts to encourage proper construction of these appliances, and the substitution of bottled gas stoves when possible, aim at minimizing exposure to the airborne irritants that increase risk for ARI development.

Additional Programs

Although the preceding interventions are the main focus of this report, it should be noted that educational endeavours addressing good personal hygiene, immunization, safe childbirth, and sexually-transmitted disease prevention were also instituted as part of the overall public health promotion.

Results

Evaluation and Adaptation

Several mechanisms are in place by which the effectiveness of public health interventions is monitored. These include (a) submission of monthly, quarterly and annual health reports by the BHUs to the DHSO; (b) regular visits by the DHSO to the health centers to monitor the progress in implementation of programs; (c) biannual strategic review and planning meetings between the health personnel and the DHSO; and (d) submission of quarterly and annual health reports by the DMO and the DHSO to the national Health Department (the compilation and analysis of which was greatly enhanced by the addition of the new Health Information Management System). While each of the above measures contribute to the overall quality assurance, it is from the latter that the most significant data may be derived. Tables III and IV demonstrate the change in the patterns of morbidity between 1991 and 1999.

The access to safe drinking water for the rural population has increased from about 70% to 84% and the latrine coverage has increased to 91%. Diarrhea and dysentery used to be the most common cause of morbidity; it now ranks third. Improvements in the quality of drinking water in rural areas has led to a significant decrease in the caseload of water borne diseases in the rural community. However, there continue to be frequent outbreaks of water borne diseases, especially among the Trongsa school students during the rainy season every year, attributable to the poor quality of drinking water being supplied to the town of Trongsa. These urban cases are responsible for the majority of the cases in the Dzongkhag.

To address the Trongsa city water supply problems, a survey for a World Bank urban water supply project was recently completed. With the implementation of this project, it is anticipated that the situation will be remedied. Continuing vigilance to maintain the purity of the water supply will be necessary.

Table III: Patterns of morbidity in Trongsa District Hospital1,3

  Hospital, 1991 Hospital, 1999
Total % Total %
Bacterial/amoebic enteritis 449 6.48 242 2.90
Viral enteritis 909 13.11 486 5.83
Tuberculosis 13 0.19 1 0.01
Children’s diseases 70 1.10 8 0.10
Tonsilitis 34 0.49 164 1.97
Scabies 173 2.50 33 0.40
Hepatitis 5 0.07 0 0.00
Malaria 34 0.49 3 0.04
Gonorrhea 57 0.82 53 0.64
Intestinal worms 335 4.84 178 2.05
Other infections 5 0.07 171 2.05
Neoplasms NR NR 0 0.00
Endocrine/metabolic/nutrition 63 0.91 51 0.61
Anemia 44 0.63 60 0.72
Mental disorders NR NR 0 0.00
Diseases of the eye 393 5.77 326 3.91
Diseases of the ear 205 2.96 208 2.49
Diseases of nervous system 54 0.78 21 0.25
Diseases of circulation 43 0.62 77 0.92
Acute respiratory infection 1211 17.46 1640 19.66
Other respiratory diseases 130 1.87 173 2.07
Diseases of teeth and gums 268 3.87 1600 19.18
PUD/gastritis 426 6.14 694 8.32
Other digestive diseases 60 0.87 0 0.00
Diseases of urinary system 126 1.81 104 1.25
Diseases of male genitalia 6 0.09 7 0.08
Diseases of breast 9 0.13 13 0.16
Diseases of female genitalia 37 0.54 22 0.26
Diseases of pregnancy, birth puerperium 39 0.56 0 0.00
Diseases of skin 1042 15.03 715 8.57
Diseases of musculoskeletal 136 1.96 197 2.36
Acute abdomen 1 0.01 0 0.00
Fever of unknown origin 12 0.17 389 4.66
Headache 197 2.84 388 4.65
Other signs and symptoms 35 0.50 11 0.13
Injuries 279 4.02 305 3.66
* NR: Nor reported
** Total number of patients treated were 6900 in 1991 and 8340 in 1999.

Table IV: Patterns of morbidity in Trongsa BHUs1,3

  BHUs, 1991 BHUs, 1999
Total % Total %
Diarrhea/dysentery 1276 16.1 1591 9.93
Cough and cold 1805 22.8 3614 22.56
Pneumonia * * 168 1.05
Helminthic infestation 609 7.7 755 4.71
Skin infection 884 11.2 1346 8.40
Malaria * * 5 0.03
Fever of unknown origin 238 3.0 1149 7.17
Conjunctivitis 838 10.6 1163 7.26
Otitis media 119 2.5 438 2.73
Nutritional deficiency 245 3.1 304 1.90
Peptic ulcer syndrome 291 3.7 961 6.00
Diseases of teeth and gums 157 2.0 378 2.36
UTI/nephritis 189 2.4 207 1.29
Injuries 187 2.4 489 3.05
STD 159 2.0 34 0.21
Childhood diseases 66 0.8 79 0.49
Disease of female genitalia 28 0.4 21 0.13
Headache NR NR 2210 13.80
Complication of pregnancy 19 0.2 ** **
Other 733 9.3 1107 6.91
* ‘Pneumonia’ included with ‘cough’, and ‘malaria’ included with ‘FUO’ in 1991
** not reported separately for BHU, included in Hospital report in 1999.

Unfortunately, the percentage of patients treated for ARI appears to have remained fairly steady, or even increased slightly, since 1991. Part of the reason for this lies in the lower rate of adoption of the ARI-directed interventions, compared with the RWSS measures. An increased attention to the initiatives addressing this condition will be necessary to decrease morbidity.

The immunization coverage has been maintained at above 95%. Annual immunization days are conducted successfully with nearly 100% coverage of the target population consistently. Continued diligence in this area is also warranted. Morbidity associated with childbirth has significantly diminished, as a testament to the success of the reporductive health initiatives. Cases of sexually transmitted diseases have remained steady, however, suggesting there is still room for improvement.

Discussion

The apparent improvement in the indicators of health here presented could be due to any one, or a combination, of several factors.

In an environment undergoing rapid and significant development, such as the Kingdom of Bhutan has, invariably these will be differences in the quality of data collection and reporting over the course of the near-decade covered the present study. A change in reporting patterns could very well influence the measures of health of the community independently of any actual improvement or deterioration of the health of the populace. Such differences in reporting could either accentuate or mask any real changes in the community’s health status.

Similarly, altered utilization of the health care system could artificially alter health indicators. For example, seeking care for minor illnesses which would have previously been untreated could alter the case mix seen at the health care facilities, skewing the distribution of presenting cases in a way unrelated to actual changes in disease prevalence. The data presented here clearly shows a 20% increase in the number of patients treated in Trongsa. It is unlikely that this represents an increase in total disease burden of the community, but rather, an increase in utilization of health care resources. Economic bias of data is also a possibility. Although healthcare is provided free of charge to all by His Majesty’s Government, other economic considerations matter. For example, the expense of travel to the healthcare facility and the loss of wages due to absence from work may bias the case mix toward illnesses that are perceived as serious enough to warrant such financial sacrifice. Increased accessibility to health care, as has been occurring in Bhutan, can counteract this but introduces the potential for bias in the oppsite direction. Bias could conceivably be induced by unscrupulous reporting of artifically inflated data out of a desire to demonstrate ‘good outcomes’. However, the Royal Government regularly rotates the personnel assigned to each dzongkhag, and any such fraudulent data would be rapidly apparent to the successors. While the authors of this report believe the changes reported herein represent real and meaningful improvements in the health status of Trongsa Dzongkhag as a result of the interventions described, the potential for confounding from the above sources of bias must be borne in mind.

Development in the health sector has produced manifold changes in the quality of life over the past decades. Notabele accomplishments include the significant increase in the overall life expectancy, a reduction in the infant mortality and maternal mortality and morbidity rates (1,3), changing patterns of disease, enhanced access to a safe water supply, and greater awareness of health and sanitation issues. These achievements, brought about by the thoughtful development of services, must now be sustained and complemented with continued quality improvement and further expansion. Several steps are planned.

Significant construction is underway to help meet the basic health infrastructure needs of the Dzongkhag. Trongsa Hospital is at present a 20-bed hospital lacking proper infrastructure, with minimal laboratory capabilities, no x-ray facilities, and inadequate space. A new hospital is under construction and scheduled for completion in 2003-2004. This facility is designed with the necessary infrastructure to be a fully equipped and staffed 20-bed hospital, on par with other district hospital in Bhutan. An additional BHU is currently under construction and scheduled to open later this year. Three more ORC communities have plans to erect permanent buildings.

Training of staff is another pressing need. Several BHUs are currently understaffed, especially in terms of midwifery, a situation that must be remedied in the near future. This will be accomplished both through Dzongkhag-level training and training at the Royal Institute of Health Services. Additional staff for the hospital will also be assigned as the services expand upon completion of the construction program. A need recently identified by the Ministry of Health, applicable throughout the nation, is for continuing medical education for the DMOs. A pilot project utilizing expatriate peer tutors in Trongsa was recently undertaken and may be expanded. In spite of the overall good coverage of the Dzongkhag by primary health care services, there remain a few pockets which don’t have easy access to current or planned BHUs. Villages may be quite remote from each other. While preventative outreach services are difficult to provide in these areas, it is geographically impossible to cater to the entire geog in terms of acute curative services. Travel time from a village to the nearest health center can take well in excess of four hours of rigorous trekking over the mountains. Some villages are entirely inaccessible during the rainy season. While these areas don’t have the population density to justify BHU placement, alternative solutions are being explored, including options such as seasonal posting of staff to the remote areas.

Conclusion

The application of COPC principles in Trongsa Dzongkhag has produced readily apparent improvements in the health and welfare of the region’s population. As most of the public health interventions and evaluation mechanisms occur at the national level, similar improvements may be seen throughout Bhutan’s Dzongkhags (though, of course, the target diseases differ between the cold, mountainous north and the tropical south). The success of COPC principles in Bhutan adds to positive track record of this approach to health care4-10. This report strengthens the case for their more widespread application.

References

  1. Department of Health Services, Ministry of Health and Education. Annual Health Bulletin. Thimphu, Bhutan: The Ministry, 1999.
  2. Kark SL, Kark E. An alternative strategy in community health care: community-oriented primary health care. Isr J Med Sci 1983; 19:707-13.
  3. Department of Health Services, Ministry of Social Services. Annual Health Bulletin. Thimphu, Bhutan: The Ministry, 1991.
  4. Longlett SK, Kruse JE, Wesley RM. Community-oriented primary care: historical perspective. J Am Board Fam Pract 2001; 14:54-63.
  5. Nevin JE, Gohel MM. Community-oriented primary care. Primary Care 1996; 23:1-15.
  6. Wright RA. Community-oriented primary care. JAMA 1993; 269:2544-47.
  7. Kark SL, Kark E, Abramson JH. Commentary: in search of innovative approaches to international health. Am J Public Health 1993; 83:1533-6.
  8. Tollman S. Community-oriented primary care. Br Soc Med 1991; 32:633-42.
  9. Nutting PA. Community-oriented Primary Care: from Principle to Practice. Albuquerque, New Mexico: University of New Mexico Press, 1990.
  10. Mullan F Community-oriented primary care. NEJM 1982; 307: 1076-78.

1 Dzongkhag Hospital, Trongsa, Kingdom of Bhutan.

2 Department of Health, Thimphu, Kingdom of Bhutan.

3 International Programs, WIcare, 3318 Woodward Drive, Franklin, WI, USA

4 Department of Family Medicine, University of Cincinnati, Cincinnati, OH, USA

E-mail: [email protected]

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