Alma-Ata Declaration and Bhutan

Bhutan was among the nations that signed the Declaration of Alma-Ata in 1978, a landmark international commitment to primary healthcare adopted at the International Conference on Primary Health Care, jointly convened by the World Health Organization (WHO) and UNICEF in Almaty, Kazakhstan (then Alma-Ata, Soviet Union) from 6 to 12 September 1978. The declaration articulated the principle that primary healthcare — defined as "essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible" — should form the foundation of every nation's health system. For Bhutan, a small Himalayan kingdom with a predominantly rural population and minimal modern health infrastructure at the time, the Alma-Ata commitment provided both a philosophical framework and a practical blueprint for expanding healthcare access across its mountainous terrain.^[1]

The declaration's impact on Bhutan was far-reaching. In the decades following 1978, the Royal Government systematically expanded the primary healthcare network, establishing Basic Health Units (BHUs) in every one of the country's twenty dzongkhags (districts), training cadres of community health workers, and enshrining the principle of free universal healthcare in national policy and ultimately in the Constitution of Bhutan.^[2]

Healthcare Before Alma-Ata

Prior to the mid-twentieth century, Bhutan had no modern healthcare system. The population relied entirely on traditional medicine — primarily Sowa Rigpa (gSo-ba Rig-pa), practised by drungtshos and local healers — supplemented by spiritual and ritualistic healing practices. The introduction of modern biomedical care began under the Third King, Jigme Dorji Wangchuck, who established the Department of Public Health and opened hospitals in Thimphu, Samtse, Trashigang, and Gelephu during the early 1960s. A small number of dispensaries and Basic Health Units were established in Trongsa and Bumthang in the early 1970s, but coverage remained extremely limited.^[3]

At the time of the Alma-Ata conference, Bhutan faced daunting health challenges. Life expectancy was low, infant and maternal mortality rates were high, and infectious diseases including malaria, tuberculosis, and leprosy were prevalent. The vast majority of the population lived in remote rural settlements accessible only by foot, making the delivery of healthcare services extraordinarily difficult.^[4]

Impact of the Declaration

Bhutan's commitment to the Alma-Ata Declaration catalysed a systematic expansion of primary healthcare infrastructure during the 1980s and 1990s. The Royal Government adopted primary healthcare as the central organising principle of national health policy, with a focus on preventive care, community-based health services, and equitable access. Key developments included:

Basic Health Units (BHUs): The government established BHUs as the primary point of healthcare delivery in rural communities. Each BHU was designed to serve a defined catchment population and was staffed by Health Assistants, auxiliary nurse-midwives (ANMs), and basic health workers (BHWs). By the late 1990s, BHUs had been established in all twenty dzongkhags, bringing healthcare within walking distance of most rural Bhutanese. Outreach clinics (ORCs) were added to serve the most remote settlements, with health workers trekking to communities that could not reach a BHU.^[5]

Free Universal Healthcare: The Alma-Ata principle of healthcare as a fundamental right reinforced Bhutan's existing policy of providing medical services free of charge. This commitment was formalised in the Constitution of Bhutan (2008), which states: "The State shall provide free access to basic public health services in both modern and traditional medicines." Today, healthcare at all levels — from BHU consultations to referrals at tertiary hospitals, and even treatment at empanelled hospitals outside the country for specialised therapies — is provided at no cost to Bhutanese citizens.^[6]

Community Health Workers: In alignment with the Alma-Ata emphasis on community participation, Bhutan trained village health workers to provide basic preventive and curative care, health education, maternal and child health services, and disease surveillance at the village level. This cadre of frontline workers became essential to extending the reach of the health system into communities far from any hospital or BHU.

Contemporary Health System

As of the 2020s, Bhutan operates a three-tiered health system. At the primary level are 179 Primary Health Centres (the successors to the original BHUs), 53 sub-posts, and 555 outreach clinics. The secondary level comprises 49 district and general hospitals, while the tertiary level includes three national referral hospitals. Traditional medicine services, provided through drungtsho-staffed units attached to district hospitals, operate in parallel with the modern biomedical system.^[7]

Health indicators have improved dramatically since 1978. Life expectancy has risen from approximately 40 years in the 1960s to over 70 years, infant mortality has fallen sharply, and previously endemic diseases have been brought under control. While significant challenges remain — particularly in delivering specialised care to remote populations and addressing emerging non-communicable diseases — Bhutan is widely regarded as a primary healthcare success story among low-income countries, and one that validates the vision articulated at Alma-Ata.^[8]

References

1. "Declaration of Alma-Ata." World Health Organization.
2. "Bhutanese Health and the Health Care System: Past, Present, and Future." The Druk Journal.
3. "Health in Bhutan." Wikipedia.
4. "Healthcare and happiness in the Kingdom of Bhutan." PMC, 2016.
5. "Overview." Ministry of Health, Royal Government of Bhutan.
6. "Health inequities in Bhutan's free healthcare system." Public Health Challenges, 2022.
7. "Overview." Ministry of Health, Royal Government of Bhutan.
8. "Healthcare and happiness in the Kingdom of Bhutan." PMC, 2016.