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Background Globally the prevalence of renal failure is on the rise. Kidney transplantation is the preferred and most affordable treatment for renal failure with improved health-related quality of life (HRQOL) compared to dialysis. Bhutan lacks kidney transplant facilities in the country, requiring referral to the neighbouring country. The HRQOL in kidney transplants in Bhutan has never been evaluated. The study aimed to investigate the relationships between different factors and HRQOL in kidney transplant recipients. Methods An observational study was conducted from January to July 2022. A kidney transplant recipient who underwent surgery until December 2021 and came for therapeutic drug monitoring (TDM) was recruited. Data on HRQOL were collected by face-to-face interviews using a structured questionnaire. A descriptive analysis wasused to describe sociodemographic characteristics and HRQOL. Factors affecting HRQOL were analysedusing Mann‒WhitneyU and Kruskal‒Wallis tests. Linear regression was used to assess the link between factors and HRQOL. Results One hundred kidney transplant recipients were recruited in this study. Of these, 25 of them did not have a formal education, and 48 are employed. 53.0 % of kidney failures were due to hypertension, and 62 of them had dialysis for less than one year. Overall, physical symptoms contributed to poor HRQOL with a mean ± SD score of 4.9 ± (1.0) and the appearance dimension of better HRQOL at a mean ± SD of 4.0 ± (1.3). Unemployment was significantly associated with poor physical symptoms, uncertainty/fear and emotional dimension. Physical symptoms and age were found to be positive and statistically significant (r = .321, PConclusion Hypertension is the leading cause of kidney failure in Bhutan. The physical symptoms are associated with poor HRQOL among transplant recipients affecting mostly the unemployed. Recipients who are employed and the related donor were found to have better HRQOL.

Background Globally the prevalence of renal failure is on the rise. Kidney transplantation is the preferred and most affordable treatment for renal failure with improved health-related quality of life (HRQOL) compared to dialysis. In Bhutan, due to the lack of kidney transplant facilities in the country, patients are frequently referred to a neighbouring country. The HRQOL in kidney transplants in Bhutan has never been evaluated. The objective of the study was to investigate the relationships between different factors and HRQOL in kidney transplant recipients. Methods An observational study was conducted from January to July 2022. A kidney transplant recipient who underwent surgery until December 2021 and came for therapeutic drug monitoring (TDM) was recruited. Data on HRQOL were collected by face-to-face interviews using a structured questionnaire. A descriptive analysis was used to describe sociodemographic characteristics and HRQOL. Factors affecting HRQOL were analysed using Mann‒Whitney U and Kruskal‒Wallis tests. Linear regression was used to assess the link between factors and HRQOL. Results One hundred kidney transplant recipients were recruited in this study. Of these, 25 of them did not have a formal education, and 48 are employed. 53.0 % of kidney failures were due to hypertension, and 62 of them had dialysis for less than one year. Overall, physical symptoms contributed to poor HRQOL with a mean ± SD score of 4.9 ± (1.0) and the appearance dimension of better HRQOL at a mean ± SD of 4.0 ± (1.3). Unemployment was significantly associated with poor physical symptoms, uncertainty/fear and emotional dimension. Physical symptoms and age were found to be positive and statistically significant (r = .321, PConclusion Hypertension is the leading cause of kidney failure in Bhutan. The physical symptoms are associated with poor HRQOL among transplant recipients affecting mostly the unemployed. Recipients who are employed and the related donor were found to have better HRQOL.

The potential of trees to adapt to drier and hotter climates will determine the future state of forests in the wake of a changing climate. Attributes connected to trees’ hydraulic network are likely to determine their ability to endure drought. However, how a tree's architectural attributes relate to its drought tolerance remains understudied. We set out to quantify the relationship between tree structural complexity and drought tolerance. We used terrestrial laser scanning (TLS) to scan 71 trees of 18 species and generated 3D attributes of each tree. We constructed quantitative structure models (QSMs) to characterize the branching patterns of all study trees. Additionally, the box-dimension approach from fractal analysis was used to assess overall structural complexity of the trees. Three measures of xylem safety, i.e., the water potential at 12%, 50%, and 88% loss of hydraulic conductance (P12, P50, P88), were measured to characterize drought tolerance of the trees’ hydraulic systems, completed by data on specific hydraulic conductivity (Ks). Our findings revealed a significant relationship between the structural complexity (Db) and the three measures of xylem safety as well as Ks. Tree species with low structural complexity developed embolism-resistant xylem at the cost of hydraulic efficiency. Our findings also revealed that the Db had a more pronounced and significant relationship with branch hydraulic safety and efficiency than all other tested structural attributes. Our findings indicate that the Db is a robust and easy-to-measure descriptor of tree architecture that relates to important branch hydraulic properties of a tree.

The burden of overweight and obesity in children and adolescents has increased, especially in developing countries, posing a significant health challenge. Data on factors influencing overweight amo...

This study examined the bio-demographic, socioeconomic, environmental, and health-related determinants of infant mortality in the Kingdom of Bhutan. The nationally representative dataset of the 2012 National Health Survey (NHS), Ministry of Health of Bhutan, was used. Cox proportional hazards regression from survival analysis, accounting for the complex study design of the NHS, was performed using a stepwise approach to identify the determinants associated with infant mortality. The weighted infant mortality rate from November 2009 to October 2011 was 34 per 1,000 live births. Children born to uneducated mothers (aHR=2.27; 95%CI=1.16-4.47) and mothers who experienced domestic violence during pregnancy (aHR=4.24; 95%CI=1.45-12.41) were more likely to die before reaching their first birthday. Those infants born in households that used solid fuel were 2.16 times (95%CI=1.21-3.85) more likely to die than their counterparts. Relative to those born in the central region, children born in western (aHR=6.13; 95%CI=2.84-13.20) and the eastern (aHR=5.13; 95%CI=2.81-9.35) regions had a greater risk of dying. The results showed that education, domestic violence experience, solid fuel use, and region of residence are the key determinants of infant mortality in Bhutan. Policies that facilitate education and empowerment of women, prevent domestic violence, reduce solid fuel use, and equitable regional socioeconomic development policies may help accelerate the reduction of child mortality.

Leishmaniasis is a neglected tropical disease with an annual estimated 700,000 to 1 million new cases globally. The diseases affect the rural community and people living in poverty. It is transmitted by female phlebotomine sand-fly; a tiny 2–3 mm long insect vector. Along with the regional countries, Bhutan has embarked on the elimination goal. However, several challenges lies ahead on its path to elimination. There is no elimination strategy and actions. The reporting, surveillance system, control and prevention mechanisms are inadequate. Further, there is lack of knowledge among the health care providers that impedes elimination goals. Therefore, if Bhutan is serious about its elimination goal, all the gaps and current challenges needs to be addressed appropriately. Keywords: Bhutan; Elimination; Leishmaniasis.

This article describes an atypical case of post-kala-azar dermal leishmaniasis associated with complications due to delayed diagnosis and poor case management. The grave consequences of the prolonged disease process that continued for over 2 decades with eventual healing included facial disfigurement, visual impairment, and mental distress both to the patient and the family. The persistent infection within the skin over a lengthy period with likely increased risk of infection spread in the community highlights its potential negative impact on the ongoing leishmaniasis elimination program in the Indian subcontinent. Bhutan is a member of the leishmaniasis elimination network in Asia, and the government continues to invest in maintenance of the national healthcare system. The case study reveals the gaps in the healthcare system with hardships faced by a patient to access quality healthcare and poor patient outcome used as proxy indicators. It also points to the need to enhance access to healthcare to ensure early diagnosis and effective treatment for leishmaniasis patients including those who live in remote areas, in order to achieve the planned disease elimination targets. It also points towards the key challenges faced by a resource poor nation such as Bhutan in achieving universal health coverage and reaching the set goals for disease elimination. The findings underscore the need for a careful review of the national health care system and to address the deficiencies.

Background The COVID-19 pandemic has reaffirmed an all-knowing truth—that health is central in the 2030 Sustainable Development Agenda. To fully control the infection in a community, accurate testing of suspected cases along with effective tracing and appropriate treatment (3Ts) is still crucial to slowing transmission of COVID-19 virus This study explored factors that influenced COVID-19 testing in Bhutan. The lessons learned from this study could serve as a roadmap to strengthen the current respond to COVID-19 and for future outbreaks, particularly in low- and middle-income countries. Methods The study employed an exploratory qualitative design. Data collection methods included interviews with key informants with a purposively selected sample of 20 participants. The interview findings were augmented by reviewing both published literature and unpublished documents.For the analysis of qualitative interviews, a hybrid approach of inductive and deductive coding and theme development was conducted to analyze findings. A tailored version of the WHO Health System Framework incorporating the Essential Public Health Function was used to guide data interpretation. Results Political will through the influence and leadership of the King of Bhutan played a crucial role in raising attention to the problem, and provision of adequate financial and technical relief to ensure that all people irrespective of their socioeconomic status do not pay to get tested of COVID-19. A compassionate leadership, Whole of Society approach is backed by the scientific community, functional health systems and community-based approaches, use of information technology for awareness creation and improved surveillance system, and fast-tracked COVID-19 testing service delivery. Conclusion Bhutan’s success relied greatly on multi-sectoral and systematic approach during policy design, implementation and monitoring, and active collaborative efforts involving consultation and engagements with a broad range of local (community members), national and global actors for accelerated COVID-19 testing. These efforts were made possible through improved health governance and leadership at all levels of the society.

BACKGROUND Knowing the number of persons at risk for sexually transmitted diseases (STDs) and their risk behaviors are needed to allocate limited resources, set targets for prevention and care activities, gauge the reach of programs, and assess their impact. Female sex workers (FSWs) are a population at high risk for STD worldwide; little is known about FSW in Bhutan. METHODS We conducted a community-based survey and population size exercise of FSW in Bhutan. The survey used a hybrid venue-based/peer-referral sampling method. Population size estimation methods were key informant mapping, census and enumeration, unique object multiplier, and capture-recapture. RESULTS Of 517 women surveyed, 67.5% provided sex for money in the last year. Compared with FSWs at venues, FSWs referred by peers were more likely to have sex with alcohol (80.1% vs. 51.5%, P < 0.001) and more paying partners (mean, 3.5 vs. 2.0; P = 0.001), and less likely to have tested for an STD (28.3% vs. 51.0%, P < 0.001) or have outreach worker contact (27.6% vs. 41.5%, P = 0.007). The estimated number of FSWs in the 9 districts was 353 (95% confidence interval, 345-362). Extrapolation to the whole country projected 597 (417-777) FSWs nationally. CONCLUSIONS Our estimate of the number of FSW in Bhutan corresponds to 0.71% of adult urban women, a figure in line with other countries in South and Southeast Asia. Our data highlight the need for outreach beyond venues where women are employed to reach FSW at higher risk for STD but who have less access to interventions.

Introduction: As per the Annual Health Bulletin, 2017, alcohol related liver disease is the leading cause of death in Bhutan. There were 190 deaths due to harmful use of alcohol in 2016 and alcohol liver disease (ALD) incidence was 46 per 10,000 people. Community action to reduce harmful use of alcohol in the communities is one of the strategies being implemented in Bhutan. However, the impact of such community action is not assessed in the country. Therefore, this pilot study was conducted in two gewogs (sub-district) of Trashiyangtse dzongkhag to assess the short-term effects of this community action to reduce alcohol use. Methods: This pilot study involved one intervention and one control community. The interventions were developed and implemented in consultation with the community by empowering them for monitoring to ensure effectiveness of the intervention. The data were collected pre and post-intervention in both the gewogs through repeated cross-sectional surveys. Results: The practice of offering tshogchang decreased from about 99% to about 50% after the intervention. Practice of children drinking alcohol decreased by 6.83%. The average monthly spending on alcohol reduced from about Nu. 418 to about Nu. 97, and the amount of grains used for brewing decreased from about 34 Kg to 18 Kg, after the intervention. Conclusion: This study found that the community action is effective in bringing positive impacts in reducing harmful use of alcohol in community. Therefore, expansion of such community action in other communities in Bhutan with similiar context is strongly recommended..

Introduction: Breastfeeding is one of the most natural and best forms of preventive medicine for the newborns. Lack of optimal breastfeeding contributes to about over million preventable child deaths every year. Despite numerous benefits of breastfeeding and continuous efforts to improve breastfeeding practices, breastfeeding rates are far from optimal. Problems faced by lactating mothers while breastfeeding are main reason leading to non-exclusive breastfeeding or early termination of breastfeeding. This descriptive study is aimed at examining breastfeeding problems among women visiting Lactation Management Unit [LMU] at Bhutan’s national referral hospital in Thimphu. Methods: Data of all 2751 women-infant pair visiting Lactation management unit of Jigme Dorji Wangchuck National Referral Hospital with breastfeeding problems were double entered into Epi Data (version 3.1). Using STATA, descriptive statistical analyses were carried to examine common breastfeeding problems among the lactating mothers. Exclusive breastfeeding rates were also examined among the group. Results: The commonest types of breastfeeding problem were nipple sore (60.8%), incorrect breastfeeding techniques (12.9%), and nipple problems (8.2%). Teenage, first timers, caesarean delivery, preterm infants, underweight infants, and mothers with full time paid job were more likely to suffer from breastfeeding problems. Conclusion: Breastfeeding interventions for timely correction of breastfeeding techniques early in postnatal units could warrant prevention of up to 73.7% breastfeeding problems and thus, promoting exclusive breastfeeding and preventing early termination of breastfeeding.

Introduction: Excessive use of internet can lead to "Internet Addiction". A sharp rise in the number of internet users among adolescents in Bhutan have been observed lately which could have potential side-effects on their health. The aim of this study was to find the prevalence of internet addiction and psychological co-morbidities among the secondary school-going adolescents. Methods: This is a descriptive cross-sectional quan-qual sequential mixed method design with a quantitative component and qualitative component. The study was conducted between 1st May and 30st November 2017 conducted in twelve schools across Bhutan after taking ethical clearance was from Research Ethics Board of Health of Bhutan. Data were doubleentered in EpiData Entry, validated and imported into STATA version 12.0 for analysis. Point estimate at 95% CI was calculated along with frequency and proportion for binary data. Results: Among 721 adolescents from twelve selected schools, prevalence of internet addiction was 248 (34.440%) at , 95% Confidence Interval (31-38%). Out of A total of 586 (81%) preferred smartphone for internet use with 388 (54%) actually using it. Depression and anxietywere the associated psychological co-morbidities seen along with internet addiction. Internet addiction was high among those using internet at home, using smartphone for internet access, social networking and night time internet use were associated with internet addiction. Boredom, stress/anxiety and peer pressure were triggers of internet use. Internet addiction also affected academic performance, social interactions and sleep. Conclusions: Prevalence of internet addiction among adolescents in Bhutan is high comparing to previous standard data which requires immediate attention.

In 2018, Bhutan reported 54 cases of malaria, of which six were indigenous, 14 introduced and 34 imported. Considering the continuous reduction in the number of indigenous cases, Bhutan plans to eliminate malaria by 2025 under the Bhutan Malaria Elimination Strategy. The study was conducted to assess the presence of asymptomatic plasmodial infection in both, Bhutanese population living in malaria-risk areas and in migrant workers to guide the elimination strategies. A cross-sectional study was conducted from April to May 2016 in 750 Bhutanese people and 473 migrant workers. Plasmodium falciparum and Plasmodium vivax infections were investigated by using a rapid diagnostic test (RDT) and the polymerase chain reaction (PCR). Prevalence of asymptomatic plasmodial infection based on PCR was 0.27% (95% CI: 0.05–1.07%) among Bhutanese people with a mean age of 43 years old. The proportions of males and females were 45% and 55%, respectively. Among migrant workers, the prevalence of asymptomatic plasmodial infection was 0.42% (95% CI: 0.07–1.69%) with a mean age of 30 years old. The majority of migrant workers were from the neighboring Indian State of West Bengal (57.51%), followed by Assam (12.26%). RDT in both study groups did not detect any plasmodial infection. The presence of a low prevalence of asymptomatic plasmodial infection indicates that the current elimination strategies and interventions are effective.

Background Sedentary behaviour is shown to be associated with cardiometabolic health including obesity, and mental health. This study examined the factors associated with sedentary behaviour among Bhutanese adolescents. Methods The nationally-representative dataset of the Bhutan Global School-based Health Survey conducted in 2016 was analysed in this study. Multiple logistic regression using the backward elimination approach was performed to identify the factors associated with sedentariness. The analysis accounted for the complex survey design of the national survey. Results The weighted prevalence of sedentary behaviour among Bhutanese adolescents was 29.12%. The multivariable analysis showed that higher grades, being a day student, consumption of soft drinks and fast foods, substance use, feeling lonely and suicidal behaviour were associated with higher odds of sedentary behaviour. Short duration of sleep was associated with reduced odds of sedentariness, whereas longer duration with increased odds. In the girls’ sample, higher grade, student type, fast food intake, physical activity, longer sleep duration, substance use, and suicidal thought were the factors predicting sedentariness. Among boys, higher grade, soft drink and fast food consumption, physical activity, short sleep duration, smoking and drug use, and loneliness were the significant factors. Conclusions The results suggest plausible gender differences in the factors influencing sedentariness among adolescents of Bhutan. Gender-specific policies such as those aimed to reduce substance abuse, increase access to mental health services, and promote healthy lifestyles and behaviours are needed to reduce the adverse impacts of sedentary behaviour. Interventions targeting students in higher grades and day students may yield larger gains.

Introduction: Research Ethics Board of Health (REBH), established in 2009, is the only ethics review board in Bhutan. The REBH was certified by the Strategic Initiative for Developing Capacity in Ethical Review (SIDCER), Forum for Ethical Review Committees in the Asian and Western Pacific Regions (FERCAP) in 2010 and recertified in 2013, and it received the Federal Wide Assurance (FWA) from the Office for Human Research Protections (OHRP), USA, in 2010 and in 2013. All researchers conducting health related research in Bhutan have to seek prior ethical clearance from REBH under the requirements of the National Health Policy 2011. Objective: The article aims to describe the performance of REBH, its standard and review procedure. Methods: A descriptive study of records and database of REBH from 2009 to 2015. Results: As of December 2015, the REBH has received 227 protocols with an average of 32 protocols per year. The median number of days for the initial review was 21 days (Min 0 days; Max 85 days). The median duration for approval of protocols from the date of receiving the application was 48 days. The average number of times the protocols were reviewed before issuing the approval letter was 2. Conclusions: There has been a progressive increase in the number of protocols submitted to REBH. This indicated an increasing research culture in Bhutan. It takes about one and half months to get an approval from REBH; therefore, researchers have to consider the time required for ethical clearance process while planning research projects.

Background: Urine sampling may offer a less invasive solution than cervical sampling to test for human papillomavirus (HPV) for HPV vaccine impact monitoring. Methods: Paired samples of urine and exfoliated cervical cells were obtained for 89 women with history of high-risk (HR) HPV-positive normal cytology in Bhutan. Urine sampling protocol included self-collection of first-void urine immediately into a conservation medium and procedures to optimize DNA yield. Colposcopical abnormalities were biopsied. Two HPV assays were used: a multiplex type-specific PCR (E7-MPG) and a less analytically sensitive GP5+/6+ PCR followed by reverse line blot. Results: HPV positivity for 21 types common to both assays was similar in urine and cells by E7-MPG (62.9% and 57.3%, respectively, p = 0.32) but lower in urine by GP5+/6+ (30.3% and 40.4%, p = 0.05). HPV6/11/16/18 positivity did not significantly differ between urine and cells by either assay. Sensitivity of urine (using cells as gold standard) to detect 21 HPV types was 80% and 58% for E7-MPG and GP5+/6+, respectively, with specificity 61% and 89%. HPV type distribution in urine and cells was similar, regardless of assay. The 5 detected CIN3+ were HR-HPV positive in cells by both assays, compared to 4 and 3 by E7-MPG and GP5+/6+, respectively, in urine samples. Conclusion: For the monitoring of vaccine impact, we demonstrate validity of a urine sampling protocol to obtain HPV prevalence data that are broadly comparable to that from cervical cells. However, detection of HPV in urine varies according to assay sensitivity, presumably because low level infections are frequent.

In 2012, chikungunya virus (CHIKV) was reported for the first time in Bhutan. IgM ELISA results were positive for 36/210 patient samples; PCR was positive for 32/81. Phylogenetic analyses confirmed that Bhutan CHIKV belongs to the East/Central/South African genotype. Appropriate responses to future outbreaks require a system of surveillance and improved laboratory capacity.

The Bhutan National Pharmacovigilance Centre (NPC) became an official member of the WHO Programme for International Drug Monitoring in December 2014; however, the number of adverse drug reactions (ADRs) reported is very low (50 reports per 773,722 inhabitants over 10 years). Surveys of healthcare professionals (HCPs) in similar countries have indicated that adequate knowledge of both ADRs and ADR reporting is likely to increase the number of ADR reports submitted.The aim of this study was to investigate the level of knowledge of both ADRs and ADR reporting among HCPs, including traditional medicine practitioners.A cross-sectional survey was conducted, using a validated self-administered questionnaire. The questionnaires were distributed to 670 HCPs, including clinical doctors, nurses, pharmacists and traditional medicine practitioners from four referral hospitals. The survey consisted of 12 questions pertaining to ADRs and 10 questions pertaining to knowledge of ADR reporting. The collected response was then analysed descriptively and results presented as mean ± standard deviation (SD) using SPSS version 20.The overall response rate was 434 (65 %) questionnaires, with HCPs consisting of clinical doctors (94, 22 %), nurses (257, 59 %), pharmacists (52, 12 %) and traditional medicine practitioners (31, 7 %). The overall mean ± SD score with regard to the level of knowledge of ADRs was 6.52 ± 2.81 out of a maximum score of 12, among which clinical doctors scored 7.48 ± 2.95, nurses 6.15 ± 2.47, pharmacists 8.15 ± 2.49 and traditional medicine practitioners 4.13 ± 3.18. The mean ± SD score with regard to the level of knowledge of ADR reporting among HCPs was 3.94 ± 1.89 out of a maximum score of 10, among which clinical doctors scored 3.93 ± 1.81, nurses 3.75 ± 1.74, pharmacists 5.00 ± 1.81 and traditional medicine practitioners 4.00 ± 1.77.Clinical doctors and pharmacists have better knowledge of ADRs than nurses and traditional medicine practitioners, while knowledge of ADR reporting was low for all HCPs surveyed.

Background Over the last decade, Bhutan has made substantial progress in controlling malaria. The country is now in an elimination phase, aiming to achieve no locally transmitted malaria by 2018. However, challenges remain and innovative control strategies are needed to overcome these. The evaluation and user acceptance of a robust surveillance tool applicable for informing malaria elimination activities is reported here. Methods The Bhutan Febrile and Malaria Information System (BFMIS) is a combination of web-based and mobile technology that captures malariometric surveillance data and generates real time reports. The system was rolled out at six sites and data uploaded regularly for analysis. Data completeness, accuracy and data turnaround time were accessed by comparison to traditional paper based surveillance records. User acceptance and willingness for further roll out was assessed using qualitative and quantitative data. Results Data completeness was nearly 10 % higher using the electronic system than the paper logs, and accuracy and validity of both approaches was comparable (up to 0.05 % in valid data and up to 3.06 % inaccurate data). Data turnaround time was faster using the BFMIS. General user satisfaction with the BFMIS was high, with high willingness of health facilities to adopt the system. Qualitative interviews revealed several areas for improvement before scale up. Conclusions The BFMIS had numerous advantages over the paper-based system and based on the findings of the survey the Vector-Borne Disease Control Programme has taken the decision to incorporate the BMFIS and expand its use throughout all areas at risk for malaria as a key surveillance tool. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1105-0) contains supplementary material, which is available to authorized users.

Additional file 5. Perceived usefulness of the BFMIS.

Bhutanese g.so-ba-rig-pa [pronounced as So-wa Rig-pa], or Bhutanese traditional medicine, is one of the rich cultural heritages and oldest tertiary education sectors in Bhutan. It was initially taught in the monastic institutions that were established by Zhabdrung Ngawang Namgyal in 1616. A separate g.so-ba-rig-pa medical dispensary was established only in 1968 after the Third King, Jigme Dorji Wangchuck, introduced the health integration policy in 1967. Since then, g.so-ba-rig-pa medicine has expanded its services by establishing 54 traditional medicine centers alongside allopathic hospitals and basic health units in the country. Today, it has become a reservoir of knowledge and employment for Drungtshos [traditional physicians] and smen-pas [traditional clinical assistants], a cradle of health and cure for patients, and a source of income for farmers and herbal traders through medicinal plant programs. The Faculty of Traditional Medicine (FoTM) under the Khesar Gyalpo University of Medical Sciences of Bhutan is the pillar of these developments as its graduates form the core human resources of the system. This chapter describes the historical aspects of the Bhutanese g.so-ba-rig-pa medical education system and highlights its present practices including policy, governance, institutional and structural developments, teacher and student recruitments processes, curriculum development, teaching learning methods, types of degree courses offered, changes in learning tools and resources, internships, and the student assessment system. It also discusses the scope and the challenges of the FoTM and recommends the ways forward for achieving its long-term sustainability as a tertiary education provider.

The Himalayan Kingdom of Bhutan is rapidly changing, but it remains relatively isolated, and it tenaciously embraces its rich cultural heritage. Despite very limited resources, Bhutan is making a concerted effort to update its health care and deliver it to all of its citizens. Healthcare services are delivered through 31 hospitals, 178 basic health unit clinics and 654 outreach clinics that provide maternal and child health services in remote communities in the mountains. Physical access to primary health care is now well sustained for more than 90% of the population. Bhutan has made progress in key health indicators. In the past 50 years, life expectancy increased by 18 years and infant mortality dropped from 102.8 to 49.3 per 1000 live births between 1984 and 2008. Bhutan has a rich medical history. One of the ancient names for Bhutan was 'Land of Medicinal Herbs' because of the diverse medicinal plants it exported to neighbouring countries. In 1967, traditional medicine was included in the National Health System, and in 1971, formal training for Drungtshos (traditional doctors) and sMenpas (traditional compounders) began. In 1982, Bhutan established the Pharmaceutical and Research Unit, which manufactures, develops and researches traditional herbal medicines. Despite commendable achievements, considerable challenges lie ahead, but the advances of the past few decades bode well for the future.

Background The medicinal plants and the associated Bhutanese traditional medicine (BTM) are protected by the country’s constitution and receive both government support and acceptance by the wider public. More than 1000 medicinal plants are described in the BTM but currently collects only 300 species for daily formulations of BTM. These medicinal plants have been one of the drivers of the ‘Gross National Happiness (GNH)’ and biodiscovery projects in Bhutan. However, no review covering the systematic evaluations of the contributions of medicinal plants and the BTM to the GNH and biodiscovery exist till date. Methods This paper, therefore addresses this information gap. It is based on the review of the existing traditional and scientific literature, government websites and policy documents. The descriptions and discussions of the paper is straightened, authenticated and enhanced by the data collected through the informal discussions with the BTM practitioners and also through the authors’ many years of practical observations of the impact of the medicinal plants programs and the BTM practices in Bhutan. Results This paper found the following: a) the medicinal plants generates income to the farmers elevating their living standard and the economic status, b) it serves as the bulk ingredients of the BTM facilitating the provision of free traditional health care services to the patients, c) helps the conservation of medicinal plants and their pristine environment through recognition of their spiritual, social and economic values, d) preserves the rich BTM cultural heritage, and e) guides the biodiscovery projects based on their ethnobotanical information. The paper also identified the challenges and research gaps, and recommends appropriate strategies that can help secure the sustainable future of the medicinal plants, the BTM and the biodiscovery projects. Conclusions The medicinal plants play significant role in the country’s biodiscovery projects and the internationally renowned development policy of ‘Gross National Happiness’.

Background As per the World Malaria Report 2011, there was a 17% reduction in morbidity and 26% reduction in mortality in 2010, compared to 2000. In Bhutan, there were only 194 malaria cases in 2011 as compared to 5,935 cases in 2000. As the country moves towards an elimination phase, educating the community and empowering them on malaria prevention and control is imperative. Hence, this study was conducted to elucidate the effectiveness of the community-directed educational intervention on malaria prevention and control in malaria-endemic areas of Sarpang district, Bhutan. Methods This quasi-experimental study design was conducted using both qualitative and quantitative data collection methods. In-depth interviews and focus group discussions were carried out in addition to household survey using a structured questionnaire conducted before and after the intervention. Intervention was conducted using community action groups, who were provided with training and which then developed action plans for implementation of interventions within their communities. Results The study resulted in a significant improvement in knowledge and attitude in intervention as compared to control during the post-intervention survey (p

The Himalayan Kingdom of Bhutan is rapidly changing, but it remains relatively isolated, and it tenaciously embraces its rich cultural heritage. Despite very limited resources, Bhutan is making a concerted effort to update its health care and deliver it to all of its citizens. Healthcare services are delivered through 31 hospitals, 178 basic health unit clinics and 654 outreach clinics that provide maternal and child health services in remote communities in the mountains. Physical access to primary health care is now well sustained for more than 90% of the population. Bhutan has made progress in key health indicators. In the past 50 years, life expectancy increased by 18 years and infant mortality dropped from 102.8 to 49.3 per 1000 live births between 1984 and 2008. Bhutan has a rich medical history. One of the ancient names for Bhutan was 'Land of Medicinal Herbs' because of the diverse medicinal plants it exported to neighbouring countries. In 1967, traditional medicine was included in the National Health System, and in 1971, formal training for Drungtshos (traditional doctors) and sMenpas (traditional compounders) began. In 1982, Bhutan established the Pharmaceutical and Research Unit, which manufactures, develops and researches traditional herbal medicines. Despite commendable achievements, considerable challenges lie ahead, but the advances of the past few decades bode well for the future.

This paper highlights on the current malaria situations in Bhutan and its challenges for future prevention and control strategies. In Bhutan, malaria affects more than half of the entire population, mostly residing in the southern districts bordering with Indian states of Assam and West Bengal. Over the past ten years, due to concerted efforts, the morbidity and mortality due to malaria has significantly declined. These preventive and control measures focused on the mass distribution of long lasting insecticidal treated nets, focal indoor residual spray and use of artemisinin-based combination therapies. However, considerable challenge lies ahead and research is needed to generate local evidence for sustainable elimination of malaria from Bhutan. The article should be of value and interest to planners, malaria programs and for future researchers on malaria in Bhutan.