The government of Bhutan places huge importance on people’s health, one of the nine domains the small Himalayan kingdom measures in gauging its people’s happiness.
But despite free access to public health services and an expanding number of health facilities across the country, Bhutan still suffers from a multitude of health issues.
One of the government’s biggest concerns is the rising burden of noncommunicable diseases. An estimated 42.4 percent of the population consume alcohol, significantly higher compared with some of its neighbors that conducted similar surveys in the past five years. An estimated 28.6 percent of the population drink alcohol in East Timor, 19.8 percent in Myanmar, and 17.9 percent in Sri Lanka. Additionally, about 67 percent of the population in Bhutan are not consuming enough servings of fruits and vegetables, according to the country’s latest health bulletin. Instead, adult Bhutanese are eating more food high in salt content, averaging 9 grams a day, almost double the World Health Organization's recommended amount of less than 5 grams.
In 2015, health facilities in Bhutan reported NCDs as the top causes of mortality in the country, with liver disease associated with alcohol consumption topping the list.
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NCDs are the number one killer in Southeast Asia, causing the deaths of an estimated 7.9 million people annually. That’s more than 50 percent of total deaths in the region, as per the WHO’s estimation. Communicable diseases, in comparison, kill 5 million people in the region each year.
As in other countries, lifestyle changes are contributing to this unhealthy behavior in Bhutan. But tackling the problem of NCDs in the country requires a different kind of local and foreign assistance — one that recognizes the problem is partly due to globalization and partly due to culture.
An estimated 29 percent of men and 14 percent of women engage in heavy episodic drinking in Bhutan, according to a 2014 NCD survey in Bhutan. Dr. Nick Banatvala, senior adviser and team lead of the U.N. Interagency Task Force on the Prevention and Control of NCDs during its February mission in the kingdom, described this as drinking six or more glasses of alcohol in a day. By comparison, in neighboring countries such as Sri Lanka, Myanmar and East Timor, just 1 percent of women engage in heavy drinking.
The serving of alcohol and its consumption is part of Bhutanese customs and traditions. Alcohol is customarily served to guests and is part of the offerings made in ceremonies and rituals across the country.
But heavy drinking is becoming a problem. Widespread alcohol consumption in Bhutan has been associated with mental and behavior disorders, leading to domestic violence and road accidents.
Tobacco use — such as smoking and chewing — also remains a persistent challenge in Bhutan, despite a ban on the sale of tobacco in the country. Purchasing tobacco overseas comes with hefty taxes for a limit of 200 cigarettes per month, which has led to an emerging market in tobacco smuggling, particularly from neighboring India.
“It’s very difficult to get good clear figures, but we get the impression that about 34 percent of men and around 14 percent of women, at least according to WHO Bhutan statistics, are using tobacco,” Banatvala said.
The government of Bhutan has been working to address NCDs, Banatvala said. An upcoming five-year action plan currently being drafted by Bhutan’s Gross National Happiness Commission already includes some elements of NCDs, such as tackling diabetes and hypertension. It also addresses mental health and suicide, which are often linked alongside discussions on NCDs and are both priority issues as well in Bhutan, according to Banatvala.
The task force is in discussions with different stakeholders — from government ministries and U.N. agencies to members of civil society and the private sector in Bhutan — on the possibilities of increasing alcohol taxation as a means to curb its consumption, encouraging diversity in diet in schools, and working with the private sector on effective food labeling, for example.
Their work is cut out for them.
“We know that in governments, each ministry has its own language, its own incentives, its own behaviors and cultures,” Banatvala said. “So much of the NCD prevention is outside the hands of the ministries of health, [but] trying to get ministries to work with one another is tricky. So in our discussions, we’re looking at opportunities for win-win from both sides.”
Civil society has a significant role to play in terms of advocacy and ensuring government and private sector accountability, but civil society in Bhutan is not yet as developed as in other countries, Banatvala said.
But there is an opportunity for donors who are looking to help solve Bhutan’s NCD challenge. Donors such as India, which channeled over 70 percent of its 2016 foreign aid budget to Bhutan although much of this is for hydropower projects, can help introduce governments to evidence-based policy interventions that “really do work” in tackling NCDs, such as taxation. If the receiving government — in this case Bhutan — expresses interest in using it for their own purposes, donors can follow it up with technical assistance, or through partnerships with other governments that have implemented a similar initiative before, Banatvala said.
“I think life is very different from the days of HIV, TB and malaria,” he said. “The idea that you should have a big U.N. NCD or global fund for NCDs isn’t just going to work in this current environment,” he said.
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