Bhutan making its people healthier, happier by beating noncommunicable diseases

Monks are promoting healthy diets and physical activity. Finance officials are taxing tobacco and alcohol. Local health workers are dispensing heart disease and diabetes care virtually on the doorsteps of villagers.

In Bhutan, protecting people from cardiovascular and lung diseases, cancers, and diabetes is a national priority. It has put in place a national plan, linking all sectors, from health to finance and education, to prevent and control these noncommunicable diseases (NCDs).

It is also the first country in the WHO South-East Asian Region to implement WHO’s package of essential noncommunicable (WHO PEN) disease interventions for primary health care in low-resource settings nationwide.

The impetus is clear. NCDs cause over half of all deaths in Bhutan. Over a quarter of the population has hypertension. Traditional eating habits include three daily high-salt meals and consumption of alcohol, which increase the risk of NCDs. Tobacco use and increased sedentary behaviour compound the threat. And, until recently, remote villagers struggled to access medicines.

“People here used to call NCDs the ‘silent killer’,” says Buddhist monk Lopen Pasang, health coordinator of Bhutan’s approximately 12 000 strong monastic community. “Monks were especially susceptible. Their diet was heavy in salt, sugar, and fats and they became sedentary. All this led to increased obesity, hypertension, diabetes, and other NCDs.”

Taking action on NCDs is feasible

In 2018, Bhutan rolls out a new 5-year socio-economic plan, which prioritizes NCD prevention and control across all sectors.

WHO PEN helps health-workers assess patients for major risk factors, like hypertension and high blood glucose, and offer treatment for people at high risk for heart attacks, strokes and other complications. It focuses on flagging disease threats early, and promotes prompt and improved care to increase chances of better health outcomes.

“Bhutan’s work on heart disease prevention and control, in particular, serves as a model for others to follow,” says WHO’s Dr Cherian Varghese, who is helping design and implement a new initiative known as Global Hearts. This initiative, being developed by WHO, the United States Centers for Disease Control and Prevention and partners, is supporting a group of countries to scale up heart disease management, salt reduction, and tobacco control in the way Bhutan has done.

Dr Karma Lhazeen, director of public health at Bhutan’s Ministry of Health, says by using screening, counselling, and treatment, backed by vigorous follow-up, there have been positive results in hypertension control. “In the districts where we piloted WHO PEN, the proportion of people with hypertension fell from 42% to 21%,” she says. “There were improvements in other conditions too, including diabetes.”

In 2014, Bhutan undertook a nationwide surveillance campaign, following WHO’s STEPwise approach to collect, analyse and disseminate health data, to get a clearer picture of the scale of the NCD problem. And the results were staggering: 39% of people were overweight or obese, 36% had raised blood pressure, and half were not engaged in vigorous physical activity. One in three people with high blood pressure received no treatment.

The findings triggered a new national action plan for NCDs.

All Bhutanese receive free healthcare. Under Bhutan’s new plan 53% of finances and materials to address NCDs will sit at district level – compared to 30% previously – giving more power for local decision-making.

Bhutan also zeroed in on the main risks contributing to NCDs. Tax on alcohol increased by 100% and districts are implementing a WHO-backed alcohol control plan. Strong tobacco laws ban production, sale and use in public places of the deadly product, and taxation is high. There is strong promotion of physical activity.

Political commitment is key to beating NCDs

“The government’s response to NCDs has been very encouraging,” says Tshering Dhendup, WHO’s NCDs focal point in Bhutan. “There is high-level political commitment.”

And such commitment is key.

Earlier this year, Prime Minister Tshering Tobgay met the WHO-led UN Interagency Task Force on NCDs, during which he stressed: “NCDs are a growing concern in Bhutan. As we live longer and enjoy greater prosperity, we are also succumbing to lifestyle diseases.”

NCDs prevention and control is central to Bhutan’s plans for a sustainable future. This is in line with the 2030 Agenda for Sustainable Development, aimed at eradicating poverty, promoting peace, and leaving no one behind. The Agenda also targets a one third reduction in premature deaths from NCDs by 2030.

Bhutan is one of several countries selected by WHO to receive integrated support to fast-track progress on achieving the 9 global NCD targets, including to reduce premature death from NCDs by 25% by 2025, and the NCD-related targets in the 2030 Agenda. This support has been another key ingredient in Bhutan’s progress to date.

Dr Lhazeen says: “Addressing NCDs helps our country’s development because by investing a small amount for prevention, primary, and secondary care, there will be huge savings from avoiding the high costs associated with NCD control.” Pasang the monk, himself a diabetic who had suffered from hypertension, concludes:

“I am witnessing a change in the health of monks and the broader community. Today, the younger generation of monks are well aware of the need to eat a healthy diet, avoid alcohol use, and be physically active. Their lives have improved.”