A review of health and access to health information in Bhutan

The kingdom of Bhutan is situated in the Eastern Himalayas, between China (Tibet) to the north, the Indian States of Assam and West Bengal to the south and east, and Sikkim to the west. Located in the heart of the high Himalayan mountain range, and with a total area of about 38 394 square kilometres, Bhutan is a landlocked country surrounded by mountains. 1 The capital city of Bhutan is Thimphu. Bhutan had an estimated population of 734 3402 in 2003, although this figure varies depending on the source consulted. The 2005 World Health Report lists the population in 2003 at approximately 2. 25 million. 3 Seventy-nine per cent of the population lives in villages, and the mountainous geography of Bhutan means that many areas are not served by roads or highways. Indeed, the nearest road can very often be a day's walk away. The Bhutan Government controls all communications networks and it first introduced television in 1999, and then the Internet in 2000. Bhutan has a Gross National Income per capita of US760, 4 placing it in the World Bank's classification definition of a low-income country. 5 Life expectancy in Bhutan is 66. 1 years (males 66. 0 years; female 66. 2 year) ; child mortality (the probability of dying before the age of 5 years) is 85 per 1000 births for both males and females; adult mortality (the probability of dying between the ages of 15 and 59) is 261 per 1000 births for males and 202 per 1000 births for females. 6 The Bhutanese people have access to free health care. In 2003, there were 140 doctors, 501 nurses, 368 health technicians from varying specialties, and 358 other health workers. 7 There is no medical school in Bhutan and a shortage of medical personnel is a real problem. Bhutan relies on its neighbouring countries, Bangladesh, India, Myanmar, Sri Lanka and Cuba, for the education of doctors. The Royal Institute of Health Sciences in Thimphu trains nurses, midwives, health assistants, and technicians for pharmacy, dentistry, radiology, ophthalmology, ENT, orthopaedics, physiotherapy and surgical theatre. There is one national referral hospital in Thimphu, The Jigme Dorji Wangchuck National Referral Hospital8 and another three regional referral hospitals at Thimphu (Western Bhutan), Mongar (Eastern Bhutan) and Gelephu (Central Bhutan). There are also 29 district hospitals, 440 outreach clinics, and 172 basic health units (BHUs). 9 Each district, or dzongkhag, has a District Health Supervisor Officer (DHSO). Traditional medicine plays an important role in the Bhutanese health-care system. There is a National Traditional Medicine Hospital and Institute in Thimphu and 19 other traditional medicine units within hospitals around Bhutan. Access to health and medical information is very restricted in Bhutan as Internet access is expensive and there are no paid journal subscriptions at any of the health libraries. There are five health libraries in Bhutan and they all are in the capital Thimphu. It is both difficult and impractical for health workers to make regular visits to Thimphu to access information. The library of the RIHS serves the staff and students and provides a reference service to health workers at the National Referral Hospital as well as health workers from other health facilities. The library is unable to pay for any annual journal subscriptions but it does receive free journals from the World Health Organization (WHO) and the Regional Office for South-East Asia (SEARO). These include Bulletin of the World Health Organization and WHO Drug Information, both of which are available online. 10, 11 Nursing journals are supplied by both SEARO and the WHO country office in Bhutan. The RIHS also produces two periodical publications, The Royal Institute of Health Sciences Annual Report, and a journal called Mirror, which is published twice a year. Other free journals held in the library include the Thai Association Medical Journal. The RIHS also holds a number of WHO publications and acts as a WHO depository library. These publications include books and reports from the WHO headquarters in Geneva and the SEARO office in New Delhi. There is also a modest collection of monographs and provision for Internet access for library patrons. The library, which is staffed by two librarians, also has an inhouse catalogue, although this is not currently available on the Internet. This library houses a technical collection of monographs and reports but has no journal subscriptions, although the WHO–SEARO office does supply a large number of items. The library, which serves the staff of the ministry, does not have a website, but the Ministry of Health website12 gives information on health statistics, such as the number of surgical procedures carried out at the country's hospitals. The WHO Country Office in Bhutan has a WHO publications and documentation library. The WHO Library contains WHO reports, monographs and journals such as the Bulletin of the World Health Organization and WHO Drug Information. The library and documentation office houses publications from WHO in Geneva and SEARO. Jigme Dorji Wangchuck National Referral Hospital is the apex facility for the delivering of health-care services in Bhutan. It was established in 1972 as a general hospital. During 1994 the hospital expanded its services and was renamed Jigme Dorji Wangchuck National Referral Hospital. The hospital serves a population of almost 50 000, excluding referred patients from neighbouring dzongkhags and cases referred from 20 other districts hospitals. The hospital has built its strength around the provision of a wide range of almost 20 different specialty services13 and it serves as: national referral hospital (developed as a tertiary care centre for the whole country) ; regional referral hospital for the western dzongkhag hospitals; Thimphu dzongkhag hospital; teaching/training hospital—regularly involved in health promotional activities to support programmes; human resource pool and provider of technical backup for dzongkhag hospitals The library, which is staffed by three librarians, serves 50–60 doctors and over 400 nurses—the majority of health professionals in the country. There are no journal subscriptions and, consequently, the library relies on the Bulletin of the World Health Organization as well as donations from doctors. The library has the largest collection of medical textbooks in Bhutan and it also receives a number of WHO and SEARO publications. An Internet terminal is available and there are links to WHO, PubMed, and Health InterNetwork and Access to Research Initiative (HINARI). Traditional medicine is important in Bhutanese health care and this institute provides medical services and educates traditional doctors. Here, research is conducted on Bhutan's medicinal plants in order to identify those ingredients in centuries-old remedies in the hope of developing new health products. The institute has a library of recipes dating back to the introduction of Tibetan Buddhism around 1616. These have been collected from monasteries, where educated monks have retained most of the medical lore. Under the Ministry of Health, the Institute of Traditional Medicine Services (ITMS) has rapidly grown, from a single dispensary in 1967, to become a multi-functional organization. All 20 districts now have indigenous units attached to their hospitals. At national level, the institute currently has three sections, a Traditional Medical Hospital, a National Institute of Traditional Medicine, and a Pharmaceutical and Research Unit funded by the European Union (EU). 14 The Internet now plays an important role in accessing health information in Bhutan. There are a number of high-quality resources accessible to all health workers. Some of these are freely available and others are provided via journal access programmes. Bhutan is part of the SEARO region of the WHO and so has access to high-quality information from both the WHO Library in Geneva and the SEARO Library in New Delhi. Telecommunications infrastructure within Bhutan is allowing the Internet to connect Thimphu with the district hospitals and health-care units. These districts are geographically disconnected because of the nature of the physical geography of Bhutan's mountainous regions. There is a poor road network and many of the health-care units are accessible only by walking. Bhutan's communications networks are addressing this remoteness in terms of information access and there are a number of telemedicine projects underway. 15 Health-care workers in Bhutan have free access to the resources of the WHO via the WHO website (http: //www. who. int). These resources include the WHO Statistical Information System (whosis), 16 the WHO Library database (wholis), which contains more than 70 000 bibliographic records and 30 000 links to full-text documents, 17 and WHO online publications such as the World Health Report, the Bulletin of the World Health Organization, the Weekly Epidemiological Record, and WHO Drug Information. 18 The WHO SEARO library has a comprehensive information service that supports the member countries via the WHO Country Offices. The SEARO library hosts the Health Literature, Library and Information Services (hellis) Network database. 19 hellis contains a wealth of bibliographic and full-text information from journals and reports produced by the SEARO countries. hellis contains the Index Medicus South-East Asia Region (IMSEAR), individual indexes for Indonesia, Myanmar, Nepal, Sri Lanka, and Thailand. hellis also hosts a database of national research reports and hosts a small number of South-East Asian medical journals online. Doctors and health workers in Bhutan have access to medline via PubMed. PubMed now has over 1. 1 million freely available articles that do not require a subscription; these are retrievable by typing the search term ‘Free Full Text sb’ into the query box. Most of these 1. 1 million articles are from journals hosted by the free-articles listing of HighWire Press. 20 HINARI is a journals access programme from WHO that gives eligible countries access to over 3000 of the world's biomedical journals. 21 Access is via the HINARI website (http: //www. who. int/hinari) and there are direct links into publishers’ websites, portals, and databases such as PubMed, Cochrane, and cinahl. HINARI was launched in 2002 and now has over 70 publishers on board. There are 114 eligible countries and, of these, 104 have at least one registered institute. In September 2005, a country workshop was held at the RIHS campus with participants attending from health institutions all around the country. Bandwidth and connectivity at the major medical centres means that health-care workers have the opportunity to take advantage of the access opportunity provided by HINARI and open-access resources. However, training in the effective use of these resources, and awareness that access is available, is a challenge that needs addressing to carry forward the momentum from the September 2005 workshop. Geographical and financial barriers are the main constraints to accessing health information in Bhutan. The Internet plays an integral part in disseminating health information to workers who are, in the main, geographically disconnected from the main resources in the capital Thimphu. WHO provides most of the hard-copy publications and a wealth of online information via the WHO and SEARO websites. In addition to the WHO, publishers are making content available via open-access and journal-access programmes like HINARI. Implications for Practice There are very few print journals available in Bhutan. The availability of journals via HINARI and open-access sources need to be disseminated to health-care staff and training schools; Training health-care staff on how to access information available via the Internet needs to be a core component to any information skills training.