Enhancing health system governance and citizen empowerment in Bhutan through the Bhutan Vaccine System (BVS): a mixed-methods study

Background: The Bhutan Vaccine System (BVS) was developed for the COVID-19 vaccination and later expanded to include influenza and HPV vaccinations. It represents a key national innovation in health system transformation, linking vaccination delivery with citizen engagement. This study assessed how the BVS strengthened vaccination monitoring, governance processes, and citizen empowerment in Bhutan. Methods: We used a convergent mixed-methods design integrating secondary analysis of BVS data with qualitative interviews. Quantitative data from the BVS were analysed by age, sex, and district. Qualitative data were drawn from 56 key informants comprising policymakers, health workers, and community members from six districts of Bhutan. Thematic analysis, guided by Potter and Brough's systemic capacity-building framework, identified enablers and barriers across performance, personal, workload, facility, and support capacities. Findings were integrated using a convergence framework to align quantitative trends with qualitative themes. Results: By December 2023, 91.6% of Bhutan's total population had received at least one COVID-19 vaccine dose, and 83.3% had received three or more doses. Policymakers and health workers reported that the BVS improved real-time monitoring, reduced administrative delays, and data visibility. Self-registration and downloadable digital certificate features of the BVS increased people's autonomy and trust. Key barriers included limited interoperability with other health-information systems, unreliable internet connectivity, reporting burdens, and insufficient user training and hardware. Conclusion: The BVS demonstrates how a digital platform can strengthen governance and empower citizens when integrated within primary health-care structures. Sustained investment in infrastructure, digital literacy, and interoperability will be critical to maintain these gains and to guide equitable digital-health governance across low and middle-income countries. Bhutan's experience offers practical lessons on how digital systems can advance both efficiency and equity in public health management.