Creating an enabling environment for delivering maternal nutrition interventions      in Bhutan

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Laigden Dzed is a Senior Programme Officer in the Nutrition Programme, Ministry of Health, Bhutan. 

Vandana Joshi is the Health and Nutrition Specialist for UNICEF Bhutan.

Loday Zangpo is a Programme Officer in the Nutrition Programme, Ministry of Health, Bhutan.

Tashi Tshomo is a Programme Officer in the Reproductive, Maternal and Newborn Health Programme, Ministry of Health, Bhutan.

Chandralal Mongar is a Health and Nutrition Officer for UNICEF Bhutan.

Background

The Kingdom of Bhutan is located in the eastern Himalayas, landlocked between the Tibet Autonomous Region of China in the north and India on the other three sides. The latest census shows the population of Bhutan to be a little over 700,000 people¹. Average life expectancy in the country has risen from 37 years in the 1960s to over 70 years in 2017¹. Much of the improvement in the health status of the Bhutanese people can be attributed to the inception of modern health care systems in the early 1960s, when Bhutan introduced universal access to healthcare².

This article explores the factors in Bhutan, including access to healthcare, policy shifts and optimising service delivery, that have created an environment that is conducive to delivering  maternal nutrition interventions.

Policies and strategies relating to the nutrition care of women

Universal healthcare, as mandated by the constitution, covers all health services (curative, promotive, preventive and rehabilitative) and is delivered at all levels (primary, secondary and tertiary). This means that there are no direct or indirect cost implications (financial barriers) for women in accessing pregnancy, delivery and postnatal care services. Antenatal services are provided ‘on the doorstep’ and a referral system (including airlift) is available for all women for institutional deliveries.

The most important development plan, the Government’s 12th five-year plan (2019-2023), is aligned with World Health Assembly global targets (2025) on maternal and child nutrition.

However, the most recent strategy document the National Reproductive Health Strategy of Bhutan (2018-2023) highlights the need to improve accessibility of maternal nutrition and health services, with a focus on quality and reach of services particularly in hard-to-reach areas and for nomadic populations, with the latter comprising 15% of the population³.

Delivering maternal nutrition services

The creation of a single service delivery platform for maternal and child health (MCH) services, designed by and sitting under the Ministry of Health (MoH), enables uniformity in the service package being delivered across Bhutan. Furthermore, maternal nutrition services are well integrated into the overall MCH package, so that mothers automatically receive these when seeking other maternal and child health services. All pregnant women are registered during the first trimester in the MCH clinic and receive a unique identification number to keep track of the total number of pregnant women in a catchment area. More importantly, this enables health facilities to follow up with mothers if they miss scheduled services, which has proven useful in supporting mothers to complete the recommended number of ANC and PNC visits.

Maternal nutrition packages

The ANC service package includes supplementation for iron, folic acid and calcium; screening and management of pre-existing health conditions such as maternal anaemia; monitoring the progression of the pregnancy, including foetal growth; health promotion (maternal nutrition counselling); and birth preparation. These services are delivered over the course of the recommended eight or more visits, a policy that was adopted in 2009 (long before the WHO recommendations in 2017). Currently, ANC coverage in pregnant women has reached 91% and PNC coverage (complete) is 87%⁴.

During the four mandatory postnatal visits, mothers are monitored for complications and supplemented with vitamin A, iron and folic acid. Counselling on maternal, infant and young child nutrition is also provided, with an emphasis on exclusive breastfeeding. Mothers are screened for anaemia and the growth of the infant is regularly monitored. In Bhutan, the prevalence of anaemia is lower in pregnant women (27.3%) than women of reproductive age and there is no severe anaemia among pregnant women, which has been attributed to high coverage of prenatal iron and folic acid (IFA) supplementation interventions⁵. However, the prevalence of anaemia among women of reproductive age (34.9%) still constitutes a public health problem^5.

Capacity-development efforts

Health workers working in MCH services complete a three-year health assistant training, which includes midwifery, usually at the country’s medical university. Nutrition is one of the main pre-service components of this training course. Health workers also undergo continuous in-service training to ensure that they remain up-to-date with the latest developments in maternal nutrition and acquire mandatory continuing medical education (CME) credit points for periodically updating their practice license.

Two to three health assistants are posted at each basic health unit (BHU) and are the primary health providers responsible for antenatal, postnatal and delivery care for pregnant women. They also conduct monthly outreach clinics. This cadre receive periodic supervisory visits from district health officials and national programme officers, but there is no specific supervisory cadre available for health assistants.

Inter-sector coordination

Traditionally in Bhutan, maternal nutrition has been viewed as an intervention that concerns only the MoH. At the service delivery level, however, the district Multi-Sectoral Task Force (MSTF) and Community Based Support System (CBSS), comprising relevant agencies in the districts and communities, have been coordinating and delivering multiple interventions, including advocacy for maternal nutrition interventions, for many years. It is therefore not uncommon to see non-health officials promoting ANC and PNC care at the sub-national level.

The importance of a cross-sector approach in improving nutrition is increasingly recognised at the national and policy level; as seen, for example, in the recent combining of nutrition targets in the agriculture sector’s five-year plan (2019-2023). A formal inter-sector coordinating mechanism is being developed to implement the updated Food and Nutrition Security Strategy and Action Plans.

Data for decision-making

Data for decision-making on maternal nutrition interventions are generated through the health system’s routine data and information system and through routine periodic surveys. Maternal nutrition indicators, including IFA supplementation (antenatal and postnatal); calcium supplementation (antenatal); postnatal vitamin A supplementation; nutrition counselling; and weight monitoring during pregnancy, are recorded on a web-based District Health Information System (DHIS2). This enables each district health office to generate data that can be aggregated at the national level and used to track coverage; the MoH publishes an Annual Health Bulletin based on this information.   

The recent introduction of an online MCH tracking system will also enable decision-makers to access real-time data that can be used for improving MCH programming. The system has been piloted in over 50 health facilities and is due to be scaled up to all health facilities in Bhutan by 2020.

Remaining challenges

The integrated approach in delivering maternal nutrition as part of the MCH service packages has had immense benefits, especially in terms of resource-sharing and programme coverage. However,  there are remaining challenges to be addressed, since just two out of five pregnant women complete the recommended eight ANC visits and the odds of a child being malnourished in Bhutan rises inversely with the number of ANC visits⁶. Efforts are underway, including advocacy campaigns involving the community to improve the coverage of MN services. Proposals for utilising the conditional cash transfer scheme are being considered, through increased coverage of ANC, PNC and infant and young child feeding counselling.    

Next steps

The upcoming Food and Nutrition Security Strategy (2019-2023) will give increased focus to the multi-sector approach to improve maternal nutrition interventions by providing a platform for greater involvement by other sectors. In addition, ongoing efforts to develop a preconception care package for women that includes all the vital services, such as health screening, supplementation and counselling, aim to improve maternal nutrition and birth preparation. Government workers are now entitled to extended maternity benefits (six months paid maternity leave with flexi-time working thereafter). The enabling environment is mostly in place: the next step for Bhutan is to continue improving the quality and coverage of existing maternal nutrition interventions.

Footnotes

¹National Statistics Bureau of Bhutan (2017); Population and Housing Census of Bhutan (2018).

²Sharma J, Zangpo K, Grundy J. Measuring universal health coverage: a three-dimensional composite approach from Bhutan. WHO South-East Asia Journal of Public Health. 2014;3(3):226-37.

³www.cia.gov/library/publications/the-world-factbook/geos/bt.html

⁴National Statistics Bureau of Bhutan. Bhutan Living Standards Survey Report (BLSS 2017). 2017.

⁵Nutrition Programme. National Nutrition Survey (NNS). Ministry Of Health; 2015.

⁶Aguayo VM, Badgaiyan N, Dzed L. Determinants of child wasting in Bhutan. Insight from nationally representative data. Public Health Nutrition. 2016;20(2):315-24.