National Medical Services of Bhutan

The National Medical Services (NMS) of Bhutan is the umbrella structure for public healthcare delivery, organised and funded by the Ministry of Health. It is built around a three-tier referral pyramid that begins at the village level and ends at the apex referral hospital in Thimphu, with onward referral abroad for cases that cannot be treated within the country.^[1]

The system delivers a comprehensive package of services free of charge at the point of service to all Bhutanese citizens, in fulfilment of Article 9, Section 21 of the Constitution, which mandates the State to provide free access to basic public health services in both modern and traditional medicines. Services include referral outside the country, at State expense, for high-end therapies that are not available domestically.^[2]

The medical workforce is drawn from a mix of locally trained graduates of the Khesar Gyalpo University of Medical Sciences of Bhutan (KGUMSB) and Bhutanese doctors trained abroad, principally in India, Bangladesh, Sri Lanka and Thailand. As of 2024 Bhutan reported a doctor density of around 4.6 doctors per 10,000 population, well below the World Health Organization minimum benchmark.^[3]

Three-Tier Structure

The first tier is the Basic Health Unit (BHU), the entry point into the formal health system. BHUs are graded into BHU II at the village level — staffed by Health Assistants and offering primary curative care, antenatal care, immunisation, family planning and basic outpatient services — and BHU I, which is larger and offers a broader inpatient and outpatient service. Outreach Clinics extend BHU services to remote settlements, supported by Village Health Workers.^[1]

The second tier is the district hospital, located in each dzongkhag's administrative centre and serving as the nodal point of referral from BHUs in its catchment. District hospitals offer general medicine, obstetrics, paediatrics and basic surgery, with most also operating laboratory and imaging services.^[4]

The third tier comprises the two regional referral hospitals — at Mongar (eastern Bhutan) and Gelephu (south-central Bhutan) — and at the apex, the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) in Thimphu. JDWNRH provides all specialised services available domestically and serves as the final domestic referral point for the entire country.^[5]

Workforce and Training

For most of the twentieth century, Bhutan was wholly dependent on doctors trained abroad. The establishment of KGUMSB by an Act of Parliament in 2012, and the launch of its MBBS programme with a first intake of twenty-four students, was the first step towards domestic supply. By 2023 the university had produced 1,127 graduates across nursing, public health, traditional medicine and postgraduate medical specialties, and offered MD programmes in twelve specialties.^[6]

Recruitment and retention remain significant challenges. Reported attrition rates in 2024 included 3.5 per cent for medical doctors and 16 per cent for nurses, with much of the loss attributed to outward migration to Australia and other destinations as part of the broader Bhutan-to-Australia movement of skilled workers. Ministry of Health workforce planning has identified a continuing shortfall of General Duty Medical Officers, with around 195 GDMO posts targeted to be filled in the medium term.^[7]

Service Coverage

Bhutan reports universal childhood immunisation coverage at high levels, with diphtheria-pertussis-tetanus and measles-containing vaccines reported above 95 per cent in successive WHO and Ministry of Health reports. The country runs a nationally coordinated tuberculosis programme, an HIV/AIDS programme that combines testing, prevention and antiretroviral treatment, and an extending non-communicable disease programme reflecting Bhutan's epidemiological transition.^[1]

Cases that exceed domestic clinical capacity are referred abroad under the Royal Government's "Referral Abroad" policy, which routes patients principally to empanelled hospitals in India, with the cost fully met by the State. The system is widely cited in international health-policy literature as one of the most generous tax-funded universal coverage arrangements in South Asia, although it is increasingly under fiscal pressure.^[8]

Financing and Reform

Health services are financed principally through the central government budget under the Ministry of Finance appropriation, with additional contributions from the Bhutan Health Trust Fund (BHTF) and from external development partners. The BHTF was launched at the WHO headquarters in Geneva on 12 May 1998, with its Royal Charter issued by the Fourth King on 3 August 2000; it became an autonomous agency on 1 September 2018 when it was delinked from the Royal Civil Service Commission.^[9]

Since 2014 a mandatory health contribution of one per cent of basic salary in the formal sector has been transferred directly to the BHTF pool, providing a sustainability mechanism for primary health care. Discussions on a broader social health insurance scheme — initially piloted in 2018 — and on possible corporatisation of selected hospital services have remained politically contentious, given the constitutional principle of free access at the point of service.^[10]

References

1. Annual Health Bulletin — Ministry of Health, Royal Government of Bhutan
2. Healthcare and happiness in the Kingdom of Bhutan — PubMed Central
3. Bhutan HRH Country Profile, September 2024 — World Health Organization
4. Bypassing Primary Health Care in Bhutan — Prime Scholars
5. Jigme Dorji Wangchuck National Referral Hospital — Wikipedia
6. University Profile — Khesar Gyalpo University of Medical Sciences of Bhutan
7. Review Report of Human Resource challenges in Bhutan's health sector — Centre for Evidence-Based Policy Studies
8. Improving Sustainable Financing for Universal Health Coverage in Bhutan — Public Health Challenges, Wiley
9. About — Bhutan Health Trust Fund
10. Sustainability of Bhutan's Health Services — The Druk Journal