EDITORIAL
https://doi.org/10.47811/bhj.177
Corresponding author:
Karma Tenzin
karmatenzin9@gmail.com
INTRODUCTION
Healthcare has always been at the forefront of developmental policies in Bhutan since modernization in 1960s. The Constitution of Bhutan mandates “free access to basic public health service in modern and traditional medicines” embodying free health services as a fundamental right of every Bhutanese1. Removal of financial hardship while seeking health care, a primary tenet of the Universal Health Coverage (UHC), is a global pursuit for social security. As Bhutanese, we should be worrying the least about health and education, as both these services are provided free by the State. The extent of free health care provision ranges from fully lodged with free primary care to some of the highly specialized organ transplants through referrals at hospitals abroad. However, providing free services at the delivery point comes at a cost to the upstream national exchequer. Indeed, what is seen as free in the eyes of a service user at the corridors of a health facility has substantial background costs.
It must be acknowledged that healthcare resources are limited, and healthcare costs are escalating in the face of worsening population health. The recently concluded National Health Survey 2024 revealed the impending ill health of our population as more people are smoking and even less engaging in physical activity. Nearly one-third of adults are living with hypertension2. The situation is worsened as the country experiences a rapidly aging society (6.5% elderly population), ever rising cancer cases and road traffic accidents2. Equally concerning is the volatile situation of the health workforce with high attrition rates wherein 20% of nurses and 9% of doctors have left the service after the pandemic3.
The question of how we can sustain our free healthcare and maintain the quality in dynamic evolving situations of emerging diseases while balancing the pressure to remain abreast with technologies and the need for competent health workers is worrisome. As we confront the struggles to protect the health of our people, the quest for innovative solutions to retain a resilient and sustainable free health care should remain resolute. We propose three priority considerations to strengthen free health care for all.
1. Increasing health spending
Bhutan allocated 3.85% of its Gross Domestic Product (GDP) for the health sector, which is much lower than the 10% in Maldives, which is comparable to the health spending by countries part of the Organization for Economic Co-operation and Development4-6. For a strong and robust health system, the Bhutanese government must double the GDP allocation for the health sector. This is critical as Bhutan’s graduation from a least developed country to a low middle-income country, requires resource mobilization from internal revenue, which is in contrast to the past where the health sector benefitted from international donor support. Therefore, an efficient resource mobilization and prioritization for health care budget should remain adaptive. In addition to reliance on general pooled tax revenue for health care, the government should also prioritize introducing tax for health harming products.
2. Introduction of sin tax
Sin tax, a tax levied on goods and services that are considered harmful or costly to society, is a recommended global best practice, both as a public health intervention and a source of revenue. Sri Lanka imposes 77% tax on all brand of cigarettes while Colombia tripled cigarette costs and levied a 4% annual increase. This resulted in a 34% reduction in smoking as well as an increase in the revenue collection, contributing towards the financial sustainability of the UHC system7. Similarly, Bhutan must consider levying additional tax on alcohol, tobacco products and sugar sweetened beverages, which are classified as health harming products. Kuensel in its September 2024 issue reported that tobacco was among the top ten imported commodities with an import value of 1.4 billion ngultrums in 20228. Following the lifting of the import ban on tobacco during the COVID 19 pandemic, accessibility to tobacco could be controlled through price raise through additional tax. The Ministry of Economic Affairs approved 1,282 restaurants to sell liquor in just 10 days in June 20229. This comes amid concerns of alcohol liver disease claiming the highest number of lives in 2023 and 2024 (146 and 129 respectively)10.
3. Improving efficiency of primary health care
Enhancing access to primary care services for prevention and early intervention is crucial for a healthy population. Health systems should be able to detect and respond early to diseases that are associated with high disability adjusted life years such as cancer, diabetes, stroke, hypertension and alcohol use disorders10. Routine screening for these diseases at primary health care centers and strengthened access at the community level, especially for hard-to-reach population, can yield better health outcomes by preventing delay in diagnosis and its associated complex and expensive treatment costs11.
In Sri Lanka and Thailand, a primary care nurse visits houses in the community and maps health ailments in the family. Similarly, a sanitary inspector visits houses and establishments to inspect health hygiene practices. These are simple and low investment strategies with significant health system benefits. Our health system should consider prioritizing healthcare at the household level, by integrating family outreach as a unit of care and encouraging each individual to take responsibility of their own care.
The authors are mindful that while the above initiatives are advocated, routine clinical services must be maintained and upgraded as per the needs. However, prioritizing the above could be a smart way to sustain a robust and sustainable health system in long term.
REFERENCES
1. Royal Government of Bhutan. The Constitution of the Kingdom of Bhutan. 66p. [Full Text]
2. Ministry of Health, Royal Government of Bhutan. 5th National Health Survey Integrated Stepwise Household Survey 2023. Royal Government of Bhutan. 24 p. [Full Text]
3. Wangdi J. Health Minister addresses concerns over high healthcare worker attrition rates. Kuensel. March 2024. [Full Text]
4. World Health Organization. Bhutan Health data overview for the Kingdom of Bhutan. 2021. World Health Organization. [Full Text]
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7. World Health Organization Newsroom. Countries share examples of how tobacco tax policies create win wins for development of health and revenue. World Health Organization. 2021. [Full Text]
8. Wangdi J. Tobacco on the back burner: Skyrocketing import raises alarm. Kuensel. September 2024. [Full text]
9. Dema T. 1,282 restaurants approved to sell alcohol in 10 days. Kuensel. June 2022 [Full Text]
10. Ministry of Health. Annual Health Bulletin 2024. HMIS and Research Section, Policy and Planning Division, Ministry of Health, Royal Government of Bhutan. 2024; 175p. [Full Text]
11. Alcohol and Drug Foundation. Community-led and community-based prevention. Position paper. 2022; 9p. [Full Text]