Bhutan Health Journal
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Improving healthcare performance by focusing on individual productivity of healthcare provider and system thinking: a strategy proposal
Get PDFBhutan’s health system, despite its commendable achievements in past few decades, continues to face shortage of skilled healthcare professionals and quality issues in service delivery. While recruiting more professionals, advocating for population health, better patient experience and safety, healthcare provider wellness has been overlooked. As the recent pay revision receives warm welcome from the health fraternity, a sense of greater professionalism and responsibility will be expected. Yet, aforementioned challenges still remain. Life and aspirations of professionals, brought up and trained in society that provides free healthcare and education, will become more convoluted. Mentorship program for healthcare providers at the beginning of their career and institutionalizing enabling environment for their personal and professional development need to be looked into. Decisions to pursue specialization should be a result of genuine interest and not a presumed exit hallway from professional frustrations, nor a shortcut to hefty pay. A promising and congruous career pathway can improve job satisfaction among health care providers. Endeavors to improve healthcare service delivery are present at every level but lack of coordination hampers favorable outcome. Variation in healthcare is major cause of adverse healthcare outcome and it is also known that every system is perfectly designed to achieve the results it gets. After conceptualizing few desired outcomes, a strategy framework that leads to health system improvement through improved individual productivity and systemic reforms enhancing intra- and inter sectoral coordination, while using evidence-based practice and existing resources, is proposed
Prevalence and risk factors of pulmonary tuberculosis among people living with diabetes mellitus at the National Referral Hospital, Thimphu, Bhutan
Get PDFIntroduction: Diabetes mellitus (DM) is increasing the risk of pulmonary tuberculosis (PTB) with concern over the convergence of these two diseases. Although screening for PTB among people with DM has been recommended by WHO, it has not been implemented in Bhutan yet. Objective: The aim of this study was to determine the prevalence and risk factors of PTB among people living with DM at the National Referral Hospital (NRH), Thimphu, Bhutan.
Methods: This was a cross-sectional study conducted from 1st June – 9th October 2018. All 343 consenting DM patients were screened for PTB using the WHO recommended questionnaire and those with TB positive symptoms were tested for active PTB using sputum smear microscopy and Gene-Xpert. A descriptive statistical analysis was performed using SPSS 21.
Results: The prevalence of PTB among people living with DM was 0.87% (95% CI: 0.20-2.50).The mean age was 54.95 (± 13.2 years) and all were DM type II. The median duration of diabetes was 4 years (range of 0.1-40 years), an average level of HbA1c 7.47 (± 2.6), and median duration on DM medication was 4 years (range of 0.1-40 years) with the majority (88.9%) on oral hypoglycemic drugs. Good glycemic control (HbA1c< 7) was achieved by 39.4% of individuals. PTB risk factors included PTB positive symptoms (7.0%), prior PTB history (5.5%) and recent contact with PTB patient (5.0%). Additional known PTB risk factors were smoking (7.6%), alcohol use (4.1%) and low body mass index (1.5%).
Conclusions: Although the prevalence PTB was low, health education, proper case management and risk based screening for PTB among DM is recommended
Managing essential healthcare services during the first nationwide lockdown: experiences from a Regional Referral Hospital in Bhutan
Get PDFThe current COVID -19 pandemic has brought unprecedented burden on healthcare system throughout the world. While the pandemic has hijacked all attention and priorities, there is a significant concern that non-COVID essential healthcare services may be negleccted. Lockdowns have become an important public health measure to contain local outbreaks. We describe our experiences in ensuring the provision of essential healthcare services during the first nationwide lockdown. Adequate preparations with a well-thought of contingency plan , identification of roles, good communication system, 24 -hour hotline and a mobile clinic with the most essential services, form important components of essential healthcare services.  
Usefulness of Robson classification system to analyze caesarean section deliveries: a hospital based study
Get PDFIntroduction: World Health Organization recommends using the Ten-group Robson classification as a standard for assessing and reducing caesarean section (CS) rates. Our study aimed at analyzing CS deliveries using this system with the primary objective of examining the driving factors of increased risk for caesarean delivery.
Methods: A retrospective observational study was conducted in Mongar Regional Referral Hospital from 1st January 2016 to 31st December, 2018 recruiting all institutional deliveries and classifying each of them into 10 groups of Robson classification system based on six obstetric variables.
Results: There were 2337 deliveries, of which 804 were CS, contributing to a rate of 34.4%. More than three fourth (78.9%) of caesarean deliveries occurred in Groups 5, 4, 2 and 1. Previous CS was the highest contributor of CS rate and the most common indication.
Conclusion: Higher CS rate has been observed in our referral hospital, contributed largely by women with previous CS, induced labour and pre-labour CS. There is a need for implementation of Robson classification system in all tertiary hospitals
Evaluation of Work Place Based Assessment implementation in Postgraduate medical education at a Medical University in Bhutan
No full textIntroduction: The Postgraduate Medical Education has witnessed transition from traditional cognitive based to more competency-based learning globally. Khesar Gyalpo University of Medical sciences of Bhutan introduced Competency Based Medical Education (CBME) through implementation of work place-based assessment (WPBA) in June 2018. The primary objective of this initiative was to produce specialist of highest quality and cultivate competency and outcome based, yet learner centered curricula.
Methods: The evaluation was conducted in June, 2019. The mixed methods of data collection techniques were utilized such as survey, interview, and review of the documents and focus group discussion. It was to provide understanding of local challenges and needs in implementation of WPBA.
Results: A total of 90% of the faculty members and 40% of administrators evaluated were aware of the implementation of WPBA. Majority of the faculty felt that WPBA is beneficial to both faculty and the residents and all residents felt that it’s beneficial in terms of learning. OBGYN residents have been exposed to maximum numbers of WPBA at 20. The maximum numbers of WPBA activities were performed by residents of general practice department which stood at 56. Lack of time as hindrance of practice of WPBA was implicated by 28% of the faculty and 61% residents.
Conclusions: Despite WPBA being implemented for a short duration there is a high level of awareness and acceptability among both the residents and faculties as an effective teaching and learning tool
Characteristics of Helicobacter pylori infection in a National Referral Hospital in Bhutan
Get PDFIntroduction: Helicobacter pylori (H. pylori) is a bacterium causing chronic gastric infection and may cause gastric cancer. It was necessary to see the trend of infection, especially in symptomatic patients. This retrospective descriptive study was aimed to describe the characteristics of H. pylori infection in Bhutanese patients referred for an endoscopy to the National Referral Hospital, Thimphu.
Methods: The sample of the study was randomized 380 medical records of the patients who underwent upper gastrointestinal endoscopy and Rapid Urea Test for symptomatic dyspepsia and peptic ulcer. Data was collected using a survey form designed by the researchers. Data analysis was done using descriptive statistics and either Chi-square or Fisher’s exact test.
Results: The prevalence of H. pylori infection was very high (76.6%). The mean age of the infection was 42 with a range from 15 to 84 years. The highest prevalence of infection was observed in the age group 20-29 years (82.7%) and lowest in the oldest age group 70-84 years (66.7%). The analysis showed no significant difference in infection amongst age groups, gender, and endoscopic findings to the positive results at 5% significant level except for monthly prevalence (p<0.001). Gastritis was the commonest endoscopy finding (153/380) and gastro-duodenitis had the highest positivity rate (88.9%).
Conclusion: The prevalence of infection was relatively high compared with previous studies. Young and middle-aged adults had a high prevalence and this group needs to be given priority for screening and eradication treatment considering limited resources to prevent associated gastric cancer in Bhutan
Outcomes at the Neonatal Intensive Care Unit, Eastern Regional Referral Hospital, Monggar Bhutan: A Retrospective Cohort Study
Get PDFIntroduction: Globally, 2.6 million neonates die every year, with more than one third of these deaths occurring within 24 hours of birth. Most neonatal deaths are preventable. The scaling up of Neonatal Intensive Care Unit services in developing countries have shown to improve survival rates. This study aimed to determine the mortality rate, and correlate the general and clinical characteristics with the outcomes of neonates admitted in the NICU at the Eastern Regional Referral Hospital, Mongar, Bhutanfrom the year 2015 to 2017.
Methods: Demographic data, neonatal and maternal variables were extracted for all Neonatal Intensive Care Unit admissions from 2015 to 2017. Descriptive and analytical statistics were reported as frequencies, percentages, median, adjusted OR, 95% CI and p-values.
Results: The mortality rate was 12.31%. Neonatal jaundice (49.55%), neonatal sepsis (41.74%), and prematurity (32.43%) were the three most common diagnoses. The mortality among neonates with low birth weight (<2500 grams) was 3.68 times (adjusted OR 3.68; 95% CI: 1.39-9.77) higher than the mortality among the normal birth weight neonates and mechanically ventilated neonates were 35.85 times (adjusted OR 35.85; 95% CI: 13.12-97.87) more at riskof dying than those without mechanical ventilation. The main causes of mortality were neonatal sepsis (34.15%), prematurity (29.27%) and birth asphyxia (21.95%).
Conclusion: The mortality rate at the NICU, Eastern Regional Referral Hospital is 12.31%. The study recommends to establish intermediate phototherapy/Kangaroo Mother Care/special baby care unit in the hospital to improve the quality of new born car
Analysis of adverse drug reactions reported to national pharmacovigilance center of Bhutan
Get PDFIntroduction: Medicines prescribed for diseases often causes adverse drug reactions in patients ranging from mere inconvenience to permanent disability and death. This is because, most of the adverse drug reactions especially the serious and latent ones may not have occurred during the clinical trials and vulnerable populations like children, pregnant women and the elderly are not all included in clinical trial studies considering the ethical and safety issues.
Objectives: To study the demographic characteristics, types of adverse drug reactions and common drugs causing these reactions from the adverse drug reaction reports received by the national pharmacovigilance of Bhutan.
Methods: A total of 222 adverse drug reactions were received at the national pharmacovigilance center from January 2016 to May 2018 were analyzed retrospectively. The Drug Regulatory Authority is the national pharmacovigilance center of Bhutan and is a member to the International Drug Monitoring Program since 2014.
Results: 73% of adverse drug reactions occurred in adults while 13.5% occurred each in children and elderly. 48.7% of the total adverse drug reactions reports were caused by antibiotics out of which penicillin was the most common causal drug (32.4%). The most commonly reported adverse drug reactions was rashes (36.5%) followed by gastro-intestinal system disorder (14.9%).
Conclusions: Antibiotics are common causal drugs for adverse drug reactions. All categories of health professional must be encouraged to report adverse drug reactions. Active surveillance for drug safety monitoring especially for those of patients who are on antibiotics is recommended.
Uterine didelphys: diagnosis in late pregnancy
No full textIntroduction: Uterus didelphys is a rare mullerian duct anomaly (MDA) and often remains undiagnosed till pregnancy or delivery. Obstetric complications can arise especially if undiagnosed in labour with malpresentation or thick inelastic vaginal septum. Some presents with dyspareunia or dysmenorrhea in the presence of a varying degree of longitudinal vaginal septum. Rarely delayed diagnosis can lead to complications that include endometriosis, adhesions, infertility, etc
Timely adoption of newer evidences
No full textHow can such evidences help patients and the health system in Bhutan? Bhutan has a three-tiered health system that guides resource allocation such as the availability of medicines, testing facilities and placement of doctors. Warfarin is available only at the National and Regional Referral Hospitals through the Essential Medicines Essential Medicines List 20165. With improved socioeconomic conditions and easier access to transport, many patients bypass the referral system and access health in tertiary care centres for diagnosis of conditions and follow up treatment in nearest local hospitals. Doctors are now available in primary level hospitals leading to early diagnosis of medical conditions and prescription of wider ranges of medicines. SGLT2 inhibitors and novel oral anticoagulants can be made available for prescription through the Essential Medicines List at the primary care levels so that patients in rural areas have better disease outcomes in a context where there is relatively lesser monitoring available. Newer developments in medical science offers avenues and opportunities for the National Essential Medicines List play crucial roles in improving patient care and treatment outcomes within the context of the Bhutanese health system