Country Profile: Bhutan (from opportunity found on IHD website!)
Sunday, 25 March 2007
A. Introduction to the country and region
Bhutan is a Himalayan Kingdom sandwiched between India and Tibet. It has never been colonized and until recently the country was inaccessible to all but the most venturesome travelers. Druk Air, the national airline, is the only airline allowed into the only airport at Paro. The first roads were built in the 1960s and this allowed Bhutanese to be able to travel more easily within their country. Bhutan is divided into three separate regions by high mountain ranges and these areas have developed separately in dress, customs and language. The religion of Bhutan is Buddhism and this pervades every aspect of their lives. There are no churches, mosques or temples but monasteries are the predominant buildings in every town and adorn mountain ridges overlooking the valleys. The whole country is very mountainous and farms are small and terraced. There is no major industry in the country but building and construction are booming. Hydro-electric power is exported to India, the major trading partner. Most people own their own homes and enough land to farm.
Very little machinery is used in agriculture, mostly a pair of oxen, manual labour and some roto-tillers. The construction workers are largely Nepali or Indian with the Bhutanese taking most of the Government jobs and farming. The whole feeling of the country is very spiritual, happy and welcoming. There are several foreign organizations working in Bhutan such as the UN, UNICEF, the World Bank and European agricultural organizations that both offer expertise and funding of projects. The Bhutanese are a very proud people and they take pains to preserve their culture. They wear traditional dress, revere the King and follow Buddhism faithfully. The King has promoted a philosophy of Gross National Happiness instead of Gross National Product. The four pillars of GNH are preservation of culture, ecological sustainability, fair and equitable economic growth and good governance. These policies are enshrined in the draft constitution which is due to be instituted in 2007. The King has also introduced the retirement age for the monarch of 65 years. He will retire in 2008 and the Crown Prince will become King. The tree-line in Bhutan is 13,000 ft. rather than 7,000ft in Canada and forest currently covers 72% of the country. The policy is for this never to be lower than 60%. The language of education is English and education is mandatory and free.
B. Population Health
On the whole the health status appeared good with no obvious mal-nutrition. The country is sparsely populated due to the mountainous terrain. Income is low and people manage by growing their own food and making their own clothes. Weaving is a common occupation of the women. I didn’t get to travel across the country but I did see a few mountain villages. The majority of houses in the cities have plumbing, but in the rural areas they use outdoor toilets. Milk seemed readily available. Water is usually boiled prior to drinking. Meat is eaten by many but not by all and chilies, cheese and red rice are the main staples. Leprosy and TB are not uncommon and malaria is only present in the southern lowlands. Polio is not an issue.
C. Health Care System
Health Care is totally free including drugs. Orthopedic surgery was good but total joint replacements are not done there. There are three pediatricians in the capital who were all excellent. Family members are responsible for most of the nursing care of patients in hospital, except the dressing of wounds and administration of medicines. Pressure sores are common, as is pneumonia. Thimpu, the capital, is home to the large general referral hospital but there are also smaller hospitals in the main cities in the country, which can cope with everyday medical conditions. Another district hospital is used for longer term conditions such as TB and Leprosy and there is some discussion around using this hospital as a rehabilitation centre for spinal cord injured clients. These hospitals are all government run but some other countries also support by providing some physicians and support staff. There is a two tier system in that there is a VIP room in the PT department as well as VIP rooms in the hospital for government officials and Lamas. The main difficulty is access to health services as the terrain is so difficult and some villages are as much as 4 days walk away from the nearest road. The plan of the Royal Government of Bhutan is to institute community based rehabilitation (CBR). Although CBR in Bhutan is still in its infancy it is the model that is being promoted. In fact there is a whole ministry concerned with developing CBR. There is a shortage of Bhutanese medical professionals. Patients requiring more advanced and specialist services are sent to India for treatment. The travel budget sometimes becomes depleted before the end of the fiscal year necessitating delays in transfers out. This can cause life threatening situations. There is a parallel indigenous health system, which concentrates on natural and herbal remedies. Patients often first access the Lama for medical care, then indigenous medicine and when all else fails, the western system at the National Referral Hospital. This can cause serious delays in receiving timely interventions in some critical conditions.
D. Disability and Rehabilitation
Inaccessibility is a major problem. Spinal cord injuries are becoming increasingly common with the development of narrow steep mountain roads. Even in Thimpu, the capital, the roads are steep and nearly all buildings, especially monasteries are accessed by steps. Walls separate many areas and in order for me to get from my house to the hospital, I had to climb a ladder over the wall. This is common all over Bhutan. Due to the terrain, it is very difficult to discharge and rehabilitate people with spinal cord injuries as wheelchairs are just not appropriate in this mountainous terrain. There is only one orthotist, who is from India, for the entire country. He also makes prostheses but is overworked so that people living in the East of the country probably have to wait a long time for services. Bhutan currently has only 3 local physiotherapists although another two more are being trained in India. There is no physiotherapy association as the profession is very young in Bhutan. In order to train as a physiotherapist they have to go outside of the country and the Government of Bhutan will provide funding for well qualified individuals to take their training in India. Physiotherapy is not well understood and does not get much respect. Much emphasis is put on the use of modalities as an adjunct to PT treatment. There is no speech therapy or occupational therapy although they did have one OT a few years ago. There is a vocational training school in Thimpu that mostly caters to those who are mentally challenged and hearing impaired. There is a two year physiotherapy technician program which is the main focus of the physiotherapy volunteer. This level is equivalent to physiotherapy assistants but they work independently once they have completed their two year program and several months of probation at the main teaching hospital. The students have had no medical background prior to starting their program but they gain a good grounding in anatomy and learn orthopedics, neuro and cardio-resp during two years of classes and ongoing clinical work. They also learn about women’s health and other skills that they need for working out in the distant regions. They also have a thorough training in electrotherapy.
E. Personal Experience
I was in Thimpu, the capital of Bhutan, from May to July 2006. I went with Health Volunteers Overseas (HVO), an organization that sends a physiotherapist every four months to teach physiotherapytheory and practice in a two year physio technician program. The role also includes support for the qualified physiotherapists and further development of the program together with the senior therapists. I found this position on the International Health Division website! Teaching follows a set curriculum and the HVO physiotherapist is responsible for setting and grading the exams. Apart from classroom teaching, we work alongside the students in the clinical setting in all areas of the hospital including a pediatric clinic. Once the students graduate from the program, they work for a few more months in the general referral hospital and they then are sent out to various districts across the country to provide services in these areas. HVO also sends orthopedic surgeons for one month each to work together with the Bhutanese orthopedic surgeons. The hospital was extremely busy and there were many people who had been in accidents with multiple trauma. A house is provided for the volunteer but otherwise the PT is responsible for airfare, food and other incidentals. The prospective PT is also required to become a member of HVO. The website is www.hvousa.org The organization is based in Washington but several Canadian physiotherapists have volunteered with HVO in Bhutan.
The Hospital has an ICU and orthopedic, medical, surgical and pediatric wards as well as an out-patient PT department and a pediatric outpatient clinic. There was a visiting orthotist and an outlying hospital with one PT technician that mostly comprised of leprosy, TB and SCI clients. Apart from the physiotherapy technician students, there are also students in several other disciplines trained under the auspices of the Royal Institute for Health Sciences, attached to the hospital.
The physiotherapy staff at the National Referral Hospital consisted of the department head who is a blind physiotherapist, two Indian trained PTs, 7 PT technicians and 7 students. The department head received his physiotherapy training in London, UK. He is currently at McMaster taking his Masters in Health Sciences. With the two Indian trained physiotherapists on staff the role of the HVO therapist is gradually changing to mentorship and further continuing education teaching as the local therapists gradually take on more of the student teaching role.
My main role was teaching the PT technician students, clinical teaching and supporting the pediatric clinic. There was also a weekly teaching session for the whole PT staff. In addition I shared ideas for CBR, conservative treatment of club foot and early intervention for neurological clients.
The work day started at 9am. The first hour was usually spent doing either orthopedic or pediatric rounds with the specialists and team. This was followed by clinical work and teaching with the students and graduated staff. There was then one hour of classroom teaching with the first year students followed by one hour teaching the second year students. The work day finished at 3pm. Much of the evening was spent preparing training notes and setting and marking the exams. It was a half hour walk into town where there was an assortment of restaurants or else the house was equipped with a kitchen and gas burner and there was a fantastic weekend market for the purchase of fresh vegetables.
Some successes of the ongoing HVO PT program include the excellent quality of the work being done in some of the districts. The concept of having PT services throughout the country by the ongoing training of these PT technicians is admirable. It is hoped that within a few years there will be enough fully qualified physiotherapists in the country to fully support these services.
One of the challenges was the reliance on modalities but this was too entrenched to alter. Another main challenge was the difficulty in discharge planning for SCI clients as there were so many natural obstacles: how to solve that? The concept of having VIP clients was different but was accepted as part of Bhutanese life.
F. Recommendations
I would strongly recommend this opportunity to volunteer in Bhutan. It is a well structured experience as you work to a set curriculum and English is the common language. The people are extremely helpful and friendly. Four months is a good length of time as it is sufficient for the volunteer to understand the culture and to complete some projects whereas it is short enough that the staff do not become dependent on the foreign volunteer. It is also easier for volunteers to make a commitment for this length of time. The volunteer will see all kinds of conditions and meet all kinds of challenges that would not be encountered back home. I saw several clients with worm infestations, many clients with peripheral neuropathies and one child with a severe snake bite to the neck. Fortunately, he recovered. It is difficult and expensive to visit Bhutan as a tourist as there is a required daily fee to be paid which is waived for the volunteer. Although Sundays are the only day off, it is possible to access the mountains on those days and have a fantastic Himalayan experience. It is a good idea to have some extra days at the end of the assignment in order to explore further into the interior. One should also take the opportunity to visit some of the PT technicians working in other districts to give them support and to see how community based rehabilitation works in these remote areas.
