Creating an enabling environment for delivering maternal nutrition interventions in Bhutan
Laigden Dzed is a Senior Programme Officer in the Nutrition Programme, Ministry of Health, Bhutan.
Vandana Joshi is the Health and Nutrition Specialist for UNICEF Bhutan.
Loday Zangpo is a Programme Officer in the Nutrition Programme, Ministry of Health, Bhutan.
Tashi Tshomo is a Programme Officer in the Reproductive, Maternal and Newborn Health Programme, Ministry of Health, Bhutan.
Chandralal Mongar is a Health and Nutrition Officer for UNICEF Bhutan.
The Kingdom of Bhutan is located in the eastern Himalayas, landlocked between the Tibet Autonomous Region of China in the north and India on the other three sides. The latest census shows the population of Bhutan to be a little over 700,000 people1. Average life expectancy in the country has risen from 37 years in the 1960s to over 70 years in 20171. Much of the improvement in the health status of the Bhutanese people can be attributed to the inception of modern health care systems in the early 1960s, when Bhutan introduced universal access to healthcare2.
This article explores the factors in Bhutan, including access to healthcare, policy shifts and optimising service delivery, that have created an environment that is conducive to delivering maternal nutrition interventions.
Policies and strategies relating to the nutrition care of women
Universal healthcare, as mandated by the constitution, covers all health services (curative, promotive, preventive and rehabilitative) and is delivered at all levels (primary, secondary and tertiary). This means that there are no direct or indirect cost implications (financial barriers) for women in accessing pregnancy, delivery and postnatal care services. Antenatal services are provided ‘on the doorstep’ and a referral system (including airlift) is available for all women for institutional deliveries.
The most important development plan, the Government’s 12th five-year plan (2019-2023), is aligned with World Health Assembly global targets (2025) on maternal and child nutrition.
However, the most recent strategy document the National Reproductive Health Strategy of Bhutan (2018-2023) highlights the need to improve accessibility of maternal nutrition and health services, with a focus on quality and reach of services particularly in hard-to-reach areas and for nomadic populations, with the latter comprising 15% of the population3.
Delivering maternal nutrition services
The creation of a single service delivery platform for maternal and child health (MCH) services, designed by and sitting under the Ministry of Health (MoH), enables uniformity in the service package being delivered across Bhutan. Furthermore, maternal nutrition services are well integrated into the overall MCH package, so that mothers automatically receive these when seeking other maternal and child health services. All pregnant women are registered during the first trimester in the MCH clinic and receive a unique identification number to keep track of the total number of pregnant women in a catchment area. More importantly, this enables health facilities to follow up with mothers if they miss scheduled services, which has proven useful in supporting mothers to complete the recommended number of ANC and PNC visits.
Maternal nutrition packages
The ANC service package includes supplementation for iron, folic acid and calcium; screening and management of pre-existing health conditions such as maternal anaemia; monitoring the progression of the pregnancy, including foetal growth; health promotion (maternal nutrition counselling); and birth preparation. These services are delivered over the course of the recommended eight or more visits, a policy that was adopted in 2009 (long before the WHO recommendations in 2017). Currently, ANC coverage in pregnant women has reached 91% and PNC coverage (complete) is 87%4.
During the four mandatory postnatal visits, mothers are monitored for complications and supplemented with vitamin A, iron and folic acid. Counselling on maternal, infant and young child nutrition is also provided, with an emphasis on exclusive breastfeeding. Mothers are screened for anaemia and the growth of the infant is regularly monitored. In Bhutan, the prevalence of anaemia is lower in pregnant women (27.3%) than women of reproductive age and there is no severe anaemia among pregnant women, which has been attributed to high coverage of prenatal iron and folic acid (IFA) supplementation interventions5. However, the prevalence of anaemia among women of reproductive age (34.9%) still constitutes a public health problem5.
Health workers working in MCH services complete a three-year health assistant training, which includes midwifery, usually at the country’s medical university. Nutrition is one of the main pre-service components of this training course. Health workers also undergo continuous in-service training to ensure that they remain up-to-date with the latest developments in maternal nutrition and acquire mandatory continuing medical education (CME) credit points for periodically updating their practice license.
Two to three health assistants are posted at each basic health unit (BHU) and are the primary health providers responsible for antenatal, postnatal and delivery care for pregnant women. They also conduct monthly outreach clinics. This cadre receive periodic supervisory visits from district health officials and national programme officers, but there is no specific supervisory cadre available for health assistants.
Traditionally in Bhutan, maternal nutrition has been viewed as an intervention that concerns only the MoH. At the service delivery level, however, the district Multi-Sectoral Task Force (MSTF) and Community Based Support System (CBSS), comprising relevant agencies in the districts and communities, have been coordinating and delivering multiple interventions, including advocacy for maternal nutrition interventions, for many years. It is therefore not uncommon to see non-health officials promoting ANC and PNC care at the sub-national level.
The importance of a cross-sector approach in improving nutrition is increasingly recognised at the national and policy level; as seen, for example, in the recent combining of nutrition targets in the agriculture sector’s five-year plan (2019-2023). A formal inter-sector coordinating mechanism is being developed to implement the updated Food and Nutrition Security Strategy and Action Plans.
Data for decision-making
Data for decision-making on maternal nutrition interventions are generated through the health system’s routine data and information system and through routine periodic surveys. Maternal nutrition indicators, including IFA supplementation (antenatal and postnatal); calcium supplementation (antenatal); postnatal vitamin A supplementation; nutrition counselling; and weight monitoring during pregnancy, are recorded on a web-based District Health Information System (DHIS2). This enables each district health office to generate data that can be aggregated at the national level and used to track coverage; the MoH publishes an Annual Health Bulletin based on this information.
The recent introduction of an online MCH tracking system will also enable decision-makers to access real-time data that can be used for improving MCH programming. The system has been piloted in over 50 health facilities and is due to be scaled up to all health facilities in Bhutan by 2020.
The integrated approach in delivering maternal nutrition as part of the MCH service packages has had immense benefits, especially in terms of resource-sharing and programme coverage. However, there are remaining challenges to be addressed, since just two out of five pregnant women complete the recommended eight ANC visits and the odds of a child being malnourished in Bhutan rises inversely with the number of ANC visits6. Efforts are underway, including advocacy campaigns involving the community to improve the coverage of MN services. Proposals for utilising the conditional cash transfer scheme are being considered, through increased coverage of ANC, PNC and infant and young child feeding counselling.
The upcoming Food and Nutrition Security Strategy (2019-2023) will give increased focus to the multi-sector approach to improve maternal nutrition interventions by providing a platform for greater involvement by other sectors. In addition, ongoing efforts to develop a preconception care package for women that includes all the vital services, such as health screening, supplementation and counselling, aim to improve maternal nutrition and birth preparation. Government workers are now entitled to extended maternity benefits (six months paid maternity leave with flexi-time working thereafter). The enabling environment is mostly in place: the next step for Bhutan is to continue improving the quality and coverage of existing maternal nutrition interventions.
1National Statistics Bureau of Bhutan (2017); Population and Housing Census of Bhutan (2018).
2Sharma J, Zangpo K, Grundy J. Measuring universal health coverage: a three-dimensional composite approach from Bhutan. WHO South-East Asia Journal of Public Health. 2014;3(3):226-37.
4National Statistics Bureau of Bhutan. Bhutan Living Standards Survey Report (BLSS 2017). 2017.
5Nutrition Programme. National Nutrition Survey (NNS). Ministry Of Health; 2015.
6Aguayo VM, Badgaiyan N, Dzed L. Determinants of child wasting in Bhutan. Insight from nationally representative data. Public Health Nutrition. 2016;20(2):315-24.
More like this
Addressing maternal nutrition service delivery gaps in Afghanistan: Policy and programming opportunities
View this article as a pdf Dr Zakia Maroof is a Nutrition Specialist working with UNICEF Afghanistan. Dr Homayoun Ludin is an Afghan doctor working with the Ministry of...
Delivering care to address a double burden of maternal malnutrition in Sri Lanka
View this article as a pdf Dr Irosha Nilaweera is a Consultant Community Physician for the National Programme for Maternal Care, Family Health Bureau, Ministry of Health, Sri...
Addressing micronutrient gaps to reduce anaemia in Bhutan’s young children: Early experiences in home fortification
View this article as a pdf Laigden Dzed is Deputy Chief Programme Officer in the Nutrition Programme, Ministry of Health, Bhutan. Hari Prasad Pokhrel is a Senior Nutritionist...
FEX: Improving maternal nutrition in South Asia: Implications for child wasting prevention efforts
View this article as a pdf Lisez cet article en français ici By Zivai Murira and Harriet Torlesse Zivai Murira is Nutrition Specialist at United Nations Children's...
Resource: Women's nutrition: A summary of evidence, policy and practice including adolescent and maternal life stages
Please scroll down for links to download the Executive Summary (also available in French) and full report Lisez cet document d'information technique en français ici...
FEX: Can Care Groups influence health seeking behaviours? Results of an impact evaluation in north-eastern Nigeria
By Dieynaba S N'Diaye, Erin Elizabeth Harned, Maya Israeloff-Smith, Stephanie Stern, Main M Chowdhury, Ngozi Odichinma Omenazu and Armelle Sacher Dieynaba N'Diaye is a...
FEX: Nutrition Exchange (NEX) South Asia: Maternal nutrition
View this article as a pdf In its first-ever regional issue, Nutrition Exchange has partnered with the United Nations Children's Fund (UNICEF) Regional Office of South Asia...
FEX: Nutrition Exchange South Asia issues on maternal nutrition and complementary feeding
View this article as a pdf Nutrition Exchange (NEX)1 recently developed two regionally focused editions exploring maternal nutrition and improving young children's diets in...
Nepal’s success story: What helped to improve maternal anaemia?
View this article as a pdf Dr Ram Padarath Bichha is Director of the Family Welfare Division, Department of Health Services, Ministry of Health and Population, Nepal. Kedar...
FEX: Improving maternal nutrition in South Asia: Implications for child wasting prevention efforts
This is a summary of a Field Exchange 'views' article that was included in issue 63 - a special edition on child wasting in South Asia. The original article was authored by...
FEX: Integrating nutrition and antenatal care: a reproductive health perspective
Sarah Neusy is an Obstetrician-Gynecologist and Reproductive Health Advisor with Save the Children UK. I read with a great interest Mike Golden's article.1 His view makes a...
Providing maternal nutrition services at sub-national level in Punjab Province, Pakistan
View this article as a pdf Dr Khawaja Masuood Ahmed is the National Coordinator for Nutrition and for the National Fortification Alliance in the Ministry of Health, Pakistan....
FEX: Effectiveness of programme approaches to improve the coverage of maternal nutrition interventions in South Asia
View this article as a pdf Summary of research1 The nutritional status of women before and during pregnancy and after delivery has far-reaching consequences for maternal...
Strengthening nutrition information systems to improve maternal nutrition in Bangladesh
View this article as a pdf Dr Mustafizur Rahman is Line Director of the Institute of Public Health and Nutrition, Bangladesh. Dr Zeba Mahmud is Alive & Thrive Programme...
Harnessing the potential of India’s medical colleges to bring maternal nutrition services to scale
View this article as a pdf Dr Sebanti Ghosh is Programme Director with Alive & Thrive (A&T), India. Dr Kaushal Kishore is a member of the Indian Administrative Service (IAS)...
FEX: Building the ‘enabling environment’ via a multi-sector nutrition platform to scale up micronutrient supplementation
By Paula Quigley, Emmanuel Sokpo and Kate Godden Dr Paula Quigley is a public health professional with over 25 years of international experience in health programme design,...
FEX: Delivery of maternal nutrition interventions at scale and mainstreaming into the health system in Bangladesh
View this article as a pdf Lisez cet article en français ici By Deborah Ash, Zeba Mahmud, Kristen Kappos, Santhia Ireen and Thomas Forissier Deborah Ash is Project...
FEX: Improving complementary feeding practices through a comprehensive health systems strengthening approach: experiences from Egypt
View this article as a pdf Naglaa Arafa is a Nutrition Officer for UNICEF in the Egypt Country Office. Moataz Saleh is a Nutrition Specialist for UNICEF in the Egypt Country...
Combining a mid-day meal, health service package and peer support in Karnataka State, India
Combining a mid-day meal, health service package and peer support in Karnataka State, India View this article as a pdf Uma Mahadevan is Principal Secretary in the Department...
FEX: Integrating nutrition services into mobile health teams: Bringing comprehensive services to an underserved population in Afghanistan
View this article as a pdf Lisez cet article en français ici By Ahmad Nawid Qarizada, Maureen L. Gallagher, Abdul Qadir Baqakhil and Michele Goergen Ahmad Nawid...
Reference this page
Laigden Dzed, Vandana Joshi, Loday Zangpo, Tashi Tshomo and Chandralal Mongar (). Creating an enabling environment for delivering maternal nutrition interventions in Bhutan. Nutrition Exchange Asia 1, June 2019. p12. www.ennonline.net/nex/southasia/maternalnutritionbhutan