Healthcare in Bhutan

Bhutan's healthcare system provides free medical services to all citizens, a principle enshrined in the Constitution of Bhutan (2008), which mandates that "the State shall provide free access to basic public health services in both modern and traditional medicines." This commitment makes Bhutan one of the few countries in the world — and the only one in South Asia — to guarantee universal free healthcare as a constitutional right. The system is entirely publicly funded, with no user fees charged at any level of the government health network, and is administered by the Ministry of Health under the overall development framework of Gross National Happiness.^[1]

Since the introduction of modern medicine in the 1960s — when Bhutan had virtually no formal healthcare infrastructure — the country has achieved remarkable improvements in health indicators. Life expectancy at birth increased from approximately 37 years in the 1960s to 71.8 years by 2022. The infant mortality rate declined from over 200 per 1,000 live births in 1960 to approximately 25 per 1,000 by 2023. Maternal mortality dropped from an estimated 1,000 per 100,000 live births to approximately 89 per 100,000, though this remains above WHO global targets. Immunisation coverage exceeds 95 per cent for most childhood vaccines, placing Bhutan among the highest-performing countries in the region.^[2]

Three-Tier Healthcare Structure

Bhutan's healthcare delivery system is organised in a three-tier hierarchical structure designed to provide coverage across the country's challenging mountainous terrain. At the base are the Basic Health Units (BHUs), which number approximately 210 and are staffed primarily by health assistants and nurses. BHUs provide primary healthcare services including maternal and child health, immunisation, basic emergency care, health education, and treatment of common illnesses. Each BHU serves a catchment area of several villages, and community health workers called Village Health Workers (VHWs) extend the reach of BHUs into remote settlements. Outreach clinics are conducted regularly to serve populations living far from BHU facilities.^[1]

The second tier consists of 20 district hospitals, one in each dzongkhag (district), providing inpatient care, surgical services, laboratory diagnostics, and specialist outpatient consultations. District hospitals typically have 20 to 50 beds and are staffed by general physicians, nurses, laboratory technicians, and pharmacists. Some larger district hospitals offer specialist services in obstetrics, paediatrics, and general surgery. Patients who cannot be treated at BHU level are referred upward to their respective district hospital.^[3]

The apex of the system is the national referral hospitals. The Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) in Thimphu, established in 1972 and named after the third King, is the country's largest and most advanced healthcare facility with over 350 beds and the widest range of specialist departments, including cardiology, neurology, oncology, nephrology, orthopaedics, and intensive care. The Eastern Regional Referral Hospital in Mongar serves the eastern dzongkhags and has approximately 80 beds, while the Central Regional Referral Hospital in Gelephu serves the southern region. These referral hospitals handle complex cases that exceed the capacity of district hospitals.^[4]

Traditional Medicine Integration

A distinctive feature of Bhutan's healthcare system is the formal integration of traditional medicine (Sowa Rigpa, also known as gSo-ba Rig-pa) alongside modern biomedicine. The National Traditional Medicine Hospital in Thimphu, established in 1967, serves as the apex institution for traditional medicine, and traditional medicine units operate in 22 locations across the country, often co-located with district hospitals or BHUs. Traditional medicine in Bhutan draws from Tibetan medical traditions and uses herbal medicines, acupuncture, moxibustion, spiritual healing practices, and hot stone baths as therapeutic modalities.^[5]

The government established the Faculty of Traditional Medicine at Khesar Gyalpo University of Medical Sciences of Bhutan (KGUMSB) to train traditional medicine practitioners through a formalised five-year degree programme. The Menjong Sorig Pharmaceuticals (MSP) manufactures traditional medicines using locally sourced medicinal plants, and the government has invested in the cultivation and conservation of medicinal plant resources. Patients in Bhutan are free to choose between modern and traditional medicine, and many use both systems complementarily. Research into the efficacy of traditional medicines is an emerging priority, with collaborative studies between KGUMSB and international partners.^[6]

Health Workforce and Challenges

Bhutan faces a significant health workforce shortage, particularly of physicians. The doctor-to-patient ratio stands at approximately 0.4 physicians per 1,000 population — below the WHO recommended minimum of 1 per 1,000 and substantially below the ratios in neighbouring countries such as India (0.7) and Sri Lanka (1.0). The shortage is especially acute in rural dzongkhags, where many district hospitals rely on a single doctor or on visiting specialists from Thimphu. Nursing ratios are somewhat better at approximately 1.3 nurses per 1,000 population, though rural postings remain difficult to staff and retain.^[2]

Training capacity has expanded with the establishment of KGUMSB, which graduated its first cohort of Bhutanese medical doctors in 2013. Prior to this, all Bhutanese physicians were trained abroad — primarily in Sri Lanka, Bangladesh, India, and Thailand — on government scholarships. KGUMSB now produces approximately 30 to 40 doctors per year, but this output cannot yet replace the country's reliance on foreign-trained physicians or meet growing demand, particularly as non-communicable diseases (NCDs) increase. Specialist training remains almost entirely abroad, as no postgraduate medical programmes exist in Bhutan.^[7]

The disease burden is shifting. While Bhutan has made substantial progress against infectious diseases — malaria has been nearly eliminated, and tuberculosis incidence is declining — non-communicable diseases now account for the majority of mortality. Cardiovascular disease, cancer, chronic respiratory diseases, diabetes, and mental health disorders are rising, driven by urbanisation, changing dietary patterns, increasing alcohol consumption, and sedentary lifestyles. Mental health services remain severely underdeveloped, with only a handful of psychiatrists serving the entire country.^[3]

Overseas Referrals

When patients require treatment that exceeds the capacity of Bhutanese hospitals — including advanced cardiac surgery, organ transplantation, complex oncology protocols, and certain neurosurgical procedures — the government funds overseas referrals, primarily to hospitals in India. The Overseas Patient Referral Programme is managed by a committee at JDWNRH and sends several hundred patients annually to institutions including the All India Institute of Medical Sciences (AIIMS) in New Delhi, Apollo Hospitals, Christian Medical College Vellore, and Tata Memorial Hospital in Mumbai. The government bears the full cost of treatment, travel, and accommodation for both the patient and an accompanying attendant.^[4]

This programme, while essential for patient welfare, represents a substantial and growing financial burden. The annual cost of overseas referrals has been estimated at approximately Nu 800 million to Nu 1 billion (US$10–12 million), equivalent to a significant share of the national health budget. The government has been working to reduce referral volumes by expanding domestic specialist capacity — including the construction of a new 300-bed hospital in Thimphu and the development of satellite diagnostic centres — but the gap between domestic capacity and clinical demand remains wide. Some patients face long waiting times for referral approval and travel logistics, and the process can be logistically challenging for rural patients who must first travel to Thimphu for committee evaluation.^[8]

Health Financing and Sustainability

Healthcare expenditure in Bhutan is approximately 3.5 to 4 per cent of GDP, with the majority funded through government general revenue supplemented by bilateral and multilateral development assistance (from WHO, UNICEF, the Global Fund, India, Japan, and other donors). There are no health insurance premiums or out-of-pocket fees at public facilities. However, the sustainability of free universal healthcare is an increasingly pressing concern as costs rise due to the NCD transition, expanding infrastructure, pharmaceutical procurement, overseas referrals, and salary costs for a growing health workforce. The 13th Five Year Plan (2024–2029) identifies health financing reform as a priority, with discussions around possible contributory health financing mechanisms, though the government has reaffirmed that basic services will remain free.^[9]

References

1. Ministry of Health, Royal Government of Bhutan. "Health Services." moh.gov.bt.
2. World Health Organisation. "Bhutan Country Profile." who.int/countries/btn.
3. WHO South-East Asia Region. "Bhutan Health System Review." Health Systems in Transition, Vol. 7, No. 2. WHO IRIS.
4. Jigme Dorji Wangchuck National Referral Hospital. "About JDWNRH." jdwnrh.gov.bt.
5. Ministry of Health. "Traditional Medicine in Bhutan." moh.gov.bt/traditional-medicine.
6. World Health Organisation. "Traditional, Complementary and Integrative Medicine." who.int.
7. Khesar Gyalpo University of Medical Sciences of Bhutan. "About KGUMSB." kgumsb.edu.bt.
8. "Overseas referrals continue to strain health budget." Kuensel. kuenselonline.com.
9. Gross National Happiness Commission. "13th Five Year Plan." gnhc.gov.bt.