TELEMEDICINE IN BHUTAN

By Clara Ng

Imagine a middle-aged Bhutanese man who sees a doctor at a rural clinic after coughing up blood for a week. The doctor runs basic tests but finds no clinical evidence of heart failure. He recommends the patient to a regional referral hospital. However, as an agrarian worker who survives by subsistence farming, the patient cannot afford the time and money to take a week off to travel to the hospital and back. He ignores his condition until it worsens to the extent that he requires emergency care, which ends up being catastrophically expensive.

Now, consider the same man who goes to the clinic under a new system. Instead of referral to a specialist hospital, the local health professional takes a chest x-ray and emails the image to a medical consultant in Japan. Within a day, the specialist replies with the proper diagnosis, albeit one that is unfamiliar to the rural doctor - aortic aneurysm. The doctor conducts his own research on the condition and provides adequate treatment for the patient¹.

For a nation that is categorized as "least developed" by socioeconomic factors, it may be surprising to know that the latter, more hopeful vision of healthcare is closer to reality than imagination. In fact, the advent of new technologies and their applications in healthcare have dramatically altered the provision of health services in Bhutan in the past decade.

Telemedicine is the use of telecommunications technology to deliver medical care. It offers an effective approach to optimize use of limited resources while mitigating time and distance barriers. Successful implementation of telemedicine, or telehealth, requires the involvement of the government, medical professionals, patients, and foreign institutions in creating a sustainable model for the introduction and development of an innovation that promises to change the basic foundations of healthcare.

Situational Analysis

As a sparsely populated country in a mountainous region, Bhutan is still in the developing stages with regards to infrastructure. Poor roads, combined with the rugged topographical nature of the land, have made transportation difficult. With approximately 80% of Bhutanese people living more than an hour's walk from the nearest road², high costs are incurred when bringing patients and medical equipment to and from remote locations. An ambulance may take over 20 hours going from east Bhutan to Thimphu, the nation's capital³. Bhutan's underdeveloped transportation network has serious implications not only on the timely provision of efficient health care, but also on equal access by rural and urban populations.

Aside from the socioeconomic gap arising from geographic location, Bhutan suffers from a shortage of health personnel. With only three formal medical training institutes⁴, the nation relies on community participation of village health workers as well as outside education of professionals⁵. The shortage of both general doctors (81) and certified specialists (22)⁶ is reflected in the staggering doctor-to-population ratio of 1:6557⁷. The government acknowledges that "even when the country wants to send national medical doctors abroad for specialization training, foreign doctors have to be recruited in their absence⁸." As a result of the inadequate supply of human capital and inability of professionals to properly identify and treat complex illnesses, approximately 150 patients are transferred abroad for specialized care each year⁹, thus further increasing health expenditures for a social welfare state that promises free care but is already strapped for funding.

In terms of organizational structure, Bhutan's healthcare system is composed of four tiers: one national referral hospital, two regional referral hospitals, 26 district hospitals, and a combined 607 basic health units and outreach clinics¹⁰. This pyramidal structure and heavy reliance on a single specialized hospital exposes the vulnerabilities of the system. Weak connections within and amongst the different levels could spell disaster for the entire network, especially because hospitals at the periphery (both structurally and geographically) are only trained in basic, non-specialized care. An unstable health network with poor coordination in the tiers would beg the question of sustainability and long-term capability to meet the healthcare demands of Bhutan's people.

The aforementioned factors make Bhutan a good candidate for the implementation of telemedicine. Bhutan's transportation difficulties and personnel shortages can be alleviated by innovative health technologies, while concerns of a unified and sustainable healthcare structure could be solved by the connectivity that e-health offers. The fact that Bhutan has limited experience in advanced computerization paves the way for the adoption of new technologies¹¹. Furthermore, because the country has a relatively small population (estimated 658,000 in 2000)¹², it can implement new telemedical trials without committing excessive resources or incurring huge risks. The process of piloting new services on a small scale and later expanding the scope has proven to be cost-effective and beneficial¹³. Finally, these existing demographic, socioeconomic, and healthcare structures are bolstered by overwhelming support from the government to create a positive environment in which telemedicine can thrive.

Telecommunications and E-health in Bhutan

Telemedicine has been introduced in Bhutan with the goal of exploiting three main uses: clinical (diagnostic and therapeutic), educational, and administrative¹⁴. As healthcare costs are rising and information technology costs are falling, the use of new technologies is expected to help contain the growth of healthcare expenditures while improving quality. Given the shortage of specialists in Bhutan's healthcare system, it is essential to modify the structure of the health network in such a way as to put resources to their best use. While telemedicine may not be a panacea for Bhutan's health-related woes, it can nonetheless have a profound influence on the health system's organization. Computerized handling of patient data can integrate Bhutan's stratified system by linking the four tiers of healthcare facilities. This connectivity will allow general peripheral hospitals to funnel cases through to district hospitals, which will then refer patients to the most specialized facilities as necessary¹⁵.

The major prerequisite for telemedicine is the existence of a telecommunications infrastructure, including components such as telephone lines, Internet connection, access to email, and satellite technology - the basic building blocks upon which physicians can become connected through a unified health system. The establishment and success of DrukNet, the sole Internet services provider in Bhutan, has led the government to boast of telecommunication as "one of the strongest assets in the infrastructure of the country¹⁶." Bhutan has followed these early accomplishments with the introduction of multipurpose community telecenters that seek to connect remote regions together from a social standpoint.

In the healthcare sector, teleradiology has emerged as the most popular application of e-health. The transfer of radiographic data from community clinics to larger hospitals allows for virtual interaction amongst healthcare providers in different locations. This transmission can come in the form of a digital x-ray image sent as an email attachment to the consultant. Resulting diagnoses have been shown in some developing countries to reduce unwarranted patient transfers and referrals by approximately 21%¹⁷. The East Bhutan tele-electrocardiogram project of 2003, which linked two district hospitals to Japan's Tokai University medical center, successfully facilitated tele-ECG consultation between countries. This novel communication technique conferred additional benefits of improved emergency care, cost savings, and timely diagnosis of potentially life-threatening illnesses¹⁸.

Due to these achievements, initial telemedicine trials in Bhutan have been met with positive feedback, resulting in strong backing by the Bhutanese people, government, and foreign organizations alike.

Government's Perspective

The Bhutan government is a major stakeholder in the implementation of telemedicine in the country. As the institution that bridges the gap between internal needs of the Bhutanese people and external influences of foreign organizations, the Royal Government of Bhutan must be responsive to the circumstances of all involved parties. In determining the course of development for the nation, head officials must balance cultural preservation with modernization. The government has been committed to using Gross National Happiness as the main determinant of success, thus effectively incorporating the citizens' desires and demands into its decision-making processes.

The goals delineated in Bhutan's Ninth Five Year Plan (FYP), to be implemented from 2002 to 2007, reflect the government's dedication to the improvement of healthcare through technology. Amongst the nation's healthcare priorities are expanding health services to remote populations, strengthening health management information systems, and intensifying prevention and control of emerging diseases. The government views information technology as a cost-effective strategy that will play a major role in bettering access and quality. While Bhutan pursues innovation and modernization, the government has not compromised its allegiance to cultural values. Another major plan of the ninth FYP is the continued integration of traditional medicine with general health services¹⁹. The Royal Government has successfully reconciled the previously conflicting extremes of old and new by incorporating traditional medical practices into Bhutan's procession towards a healthcare system that is increasingly dependent on novel technologies.

As the key actor in Bhutan's telemedical pursuits, the Royal Government is also in charge of acquiring funding and allocating resources for the project. Thus far, Bhutan has been largely dependent on foreign governments and non-profit organizations for financial resources. For example, the 2003 East Bhutan tele-electrocardiogram project was sponsored almost entirely by the Japanese Ministry of Foreign Affairs²⁰. Accordingly, the Royal Government must work to align its country's development targets with the incentives and plans of its generous donors. At the same time, Bhutan officials must understand that charitable funding is only temporary and must seek to build a stable infrastructure that can support the continuation and expansion of telemedicine even after money stops pouring in. The current donor contribution, which finances roughly 55% of Bhutan's capital expenditures, is expected to decrease in the coming years as Bhutan weans itself away from foreign dependence²¹. The Royal Government's responsibility to oversee the healthcare system's long-term success is outlined by the International Telecommunication Union's recommendation to developing countries: local leaders should "ensure the telemedicine services are self-sustaining… to avoid raising false expectations²²."

To address this financial problem, the Bhutanese government established a Health Trust Fund in 1998 with the hope of raising US$24 million to be spent on primary health services. Slightly over 40% of that goal ($10 million) has been reached thus far. The government is currently matching donor contributions dollar for dollar and has committed to subscribe up to half of the targeted figure. National revenues are expected to rise in the next 15-20 years as Bhutan reaps profits from both private investments and lucrative public projects²³. Alternative payment methods, including user fees, have also been introduced in response to the financing concerns.

Overwhelming optimism and faith in the potential of telemedicine has resulted in the highest political commitment to healthcare in the history of the Royal Government of Bhutan. The government has stipulated that telecommunication infrastructure will be vital for health improvement, which will subsequently pave the way for Bhutan's evolution into a knowledge based society. Officials hope that by developing sustainable financing mechanisms to support the education of health professionals and implementation of innovative technologies, all district hospitals will be connected by telemedicine in the coming years.

Medical Professionals' Perspective

The Bhutanese government plays a significant role in delineating the healthcare development model and acquiring the necessary funds to implement the plan. However, this is not possible without the human capital to bring about the desired changes. Consequently, the health personnel of Bhutan are important players in the telemedicine project. While the government provides the link between the Bhutanese people and outside institutions, it is the doctors who connect new technologies to their patients who are the main beneficiaries of telemedicine. Physicians must be comfortable with the new and innovative technologies that are implemented.

Expectedly, education is a vital component of telemedicine in Bhutan because medical professionals must learn how to use the new equipment. Thus, a mere presence of medical supplies is not enough because physicians must have the knowledge and more importantly the comfort to use them. Fortunately, Bhutanese health professionals have mirrored the government's enthusiasm over telemedicine. Currently, the limiting factor of telemedical growth is not the health professionals' receptivity of the new material, but rather, the medical education that is necessary to allow the technological equipment to be used effectively. Doctors have reacted positively to training sessions, although some trials like the East Bhutan tele-ECG implementation returned findings that the project schedule did not provide sufficient time for training of equipment and of simple operational procedures like how to send email attachments. In general, physicians have expressed a need for increased connectivity with fellow health experts in order to use these novel technologies well²⁴.

Interestingly, the overall attitude of Bhutanese medical personnel seems to contrast that of physicians in other developing nations. Studies have shown that computer illiteracy and technophobia have been major concerns for uncooperative clinicians in many countries²⁵. The "almost ubiquitous… low level of adhesion among physicians" in primacy care settings has been partially attributed to the lack of a coordinated system in which the autonomy of clinical decisions can coexist with the more regulated environment that telemedicine demands²⁶. Ironically, it may be the lack of specialized medical education in Bhutan that allows physicians to see telemedicine as an enhancing feature rather than a competitive element in their practice. The constantly developing nature of the Bhutanese health system has effectively cultivated an environment of change. Perhaps telemedicine will be met with greater resistance from doctors once implementation spreads to the rural areas of Bhutan, where there are likely to be more practitioners of traditional medicine.

Just as telemedicine will change the relationship between medical professionals and their practice in the health system, the introduction of computerization in the delivery of care will undoubtedly alter the traditional physician-patient dynamic. Telemedical technologies divert attention away from the face-to-face interaction between healer and patient. This personal relationship is given less focus in favor of a consultant's remote diagnosis, which is made possible by the electronic transmission of patient data. One theory proposes that the doctor who sees the patient will change from an autonomous health expert to a sympathetic listener who merely helps the patient weigh his or her treatment options²⁷. Under a telemedical framework, the responsibilities of the medical professional are split between the local doctor who conducts tests on the patient and the specialized consultant who uses the results of these tests to make a formal diagnosis. The healer-patient encounter thus shifts from a human relationship to a virtual contact facilitated by the electronic exchange of information²⁸. While it is too early to assess the response of Bhutanese medical professionals to the new physician-patient dynamic, this fundamental change will undoubtedly force health personnel to reevaluate their roles, goals, and incentives in the telemedical healthcare system.

Foreseeable Problems and Future Outlook

Bhutan's preliminary telemedical successes should be tempered by a sense of guarded optimism because the nation must recognize caveats that may threaten such pursuits in e-health.

While the advent of innovative computer systems and medical equipment has been welcomed by the healthcare system, Bhutan must be careful not to become too dependent on new technologies. During a power breakdown for example, Bhutan was forced to carefully reevaluate its heavy reliance on hydroelectric power. The unstable electric supply was later attributed to the annual dry season from November to April²⁹. Furthermore, an increased use of technology also raises the question of patient privacy because along with the conveniences of information sharing are dangers of fraud and data leakage. Until the security of medical records can be ensured, the growth of telemedicine may be halted³⁰. Bhutan must invest in backup infrastructure to protect the health information system from inevitable and uncontrollable failures.

Understandably, patients may be distrustful of the threats posed by new telematics and subsequently exhibit reluctance in adopting technological equipment in their health encounters. Bhutan's health system should strive to be patient-centered by presenting patients with choices but maintain the power to make the final decision. Telemedicine should enhance rather than replace existing medical practices. The main determinant of the progress of e-health should be "the pull of needs, not the push of supply³¹."

Flexibility should apply not only in dealing with patients' private concerns but also with the telemedical system itself. As Bhutan develops socially, politically, and economically, disease patterns will evolve as well. The changing epidemiology of illnesses thus serves as both a reason for e-health's introduction as well as a trigger for continued growth of the field. Telemedicine's ability to adapt should be monitored by a robust evaluation system that takes into consideration Bhutan's national values and objectives. Only through a standardized assessment model can the healthcare system achieve significant improvement in quality.

In the coming years, Bhutan must find an appropriate balance between following the recommendations of foreign organizations and independently developing a medical system on the basis of its national agenda. As the implementation of e-health is still in its early stages, it is essential for Bhutan to coordinate with other countries and collaborate on research to share experiences on the achievements and shortcomings of different telemedical models³². Only through an integrated approach to telemedical development can Bhutan learn from the experiences of others. At the same time, Bhutan must distinguish itself from the unique aspects of other countries' health systems. Due to contextual discrepancies, there is no single prototypical telehealth structure that can be successfully replicated throughout all countries. By carefully considering stakeholders' interests, external guidance, and national identity, Bhutan can come to reasonable decisions that will affect the expansion of telemedicine and determine its role in the future of the healthcare system.

References:

¹ Agus Subekti and others, "East Bhutan Tele-ECG Project" (International Telecommunication Union, 2003), 17-19, http://www.itu.int/itudoc/itu-t/workshop/e-health/s2-05.pdf (accessed November 10, 2007).

² Yongguo Zhao, Isao Nakajima, and Hiroshi Juzoji, "On-Site Investigation of the Early Phase of Bhutan Health Telematics Project," Journal of Medical Systems 26 (2002), 70, http://www.springerlink.com/content/n25r170713472314/fulltext.pdf (accessed November 5, 2007).

³ Isao Nakajima and others, "Telemedicine in the Land of Thunder Dragon - East Bhutan Tele-ECG Project" (Institute of Electrical and Electronics Engineers, Workshop on Enterprise Networking and Computing in Healthcare, 2003), 48, http://ieeexplore.ieee.org/iel5/8645/27395/01218717.pdf (accessed November 10, 2007).

⁴ "Health Infrastructure - 2005" (World Health Organization, Country Office for Bhutan, 2006), http://www.whobhutan.org/LinkFiles/Health_Information_HI-05.pdf (accessed December 16, 2007).

⁵ "Ninth Five Year Plan" (Royal Government of Bhutan, 2002), 77, http://www.pc.gov.bt/fyp/maindoc/5yp09_main.pdf (accessed December 10, 2007).

⁶ Zhao, 68.

⁷ Kinlay Penjor and Gaki Tshering, "Bhutan Health Telematics Project: Overcoming the Barriers" (Institute of Electrical and Electronics Engineers, Workshop on Enterprise Networking and Computing in Healthcare, 2004), 49, http://ieeexplore.ieee.org/iel5/9246/29313/01324467.pdf (accessed November 10, 2007).

⁸ "Ninth Five Year Plan," 81.

⁹ Subekti, 4.

¹⁰ Ibid.

¹¹ "Project Proposal for Building ICT Infrastructures for Rural Communities in Bhutan" (International Telecommunication Union, Telecommunication Development Bureau, 2003), 7, http://www.itu.int/ITU-D/ldc/documents/projects-2003/bhutan2.pdf (accessed December 10, 2007).

¹² Nakajima, "Telemedicine," 48.

¹³ Anthony Smith and others, "Telemedicine and Rural Health Care Applications", Journal of Postgraduate Medicine 51 (2005), 292 (accessed December 16, 2007).

¹⁴ Richard Wootton, "Telemedicine and Developing Countries - Successful Implementation will Require a Shared Approach," Journal of Telemedicine and Telecare 7 (2001), 2, http://www.uq.edu.au/swinfen/pdf/Swinfen_1-6.pdf (accessed December 10, 2007).

¹⁵ David Wright, "Telemedicine and Developing Countries." Journal of Telemedicine and Telecare 4 (1998): 4.

¹⁶ "Ninth Five Year Plan," 96.

¹⁷ Smith, 291.

¹⁸ Nakajima, "Telemedicine," 50.

¹⁹ "Ninth Five Year Plan," 79.

²⁰ Subekti, 21.

²¹ Penjor, 49.

²² "Recommendation SG 2/6-98: Impact of Telecommunications in Health Care and Other Social Services" (International Telecommunication Union, World Telecommunication Development Conference, 1998, revised 2001), http://www.itu.int/ITU-D/tech/telemedicine/recsg2_6.html (accessed December 15, 2007).

²³ Norbu Wangchuk, "Bhutan Health Trust Fund" (World Health Organization, Country Office for Bhutan, 2006), http://www.whobhutan.org/EN/Section4_32.htm (accessed December 10, 2007).

²⁴ Subekti, 15.

²⁵ Isao Nakajima and others, "Problems and Our Solutions for Implementing Telemedicine Systems," Journal of Medical Systems 23 (1999), 429, http://www.springerlink.com/content/k2rq202546532814/fulltext.pdf (accessed December 10, 2007).

²⁶ Elaine Tomasi and others, "Health Information Technology in Primary Health Care in Developing Countries: A Literature Review," Bulletin of the World Health Organization 82 (2004), 872, http://www.who.int/bulletin/volumes/82/11/tomasi1104abstract/en/index.html (accessed December 16, 2007).

²⁷ Adam William Darkins and Margaret Ann Cary, Telemedicine and Telehealth: Principles, Policies, Performance, and Pitfalls (New York: Springer Publishing Company, 2000), 49.

²⁸ Rashid L. Bashshur, Timothy G. Reardon, and Gary W. Shannon, "Telemedicine: A New Health Care Delivery System," Annual Review of Public Health 21 (2000), 618, http://arjournals.annualreviews.org/doi/pdf/10.1146/annurev.publhealth.21.1.613 (accessed November 10, 2007).

²⁹ Zhao, 74.

³⁰ Darkins, 43.

³¹ Michael Rigby, "Impact of Telemedicine Must be Defined in Developing Countries," British Medical Journal 324 (2002), http://www.bmj.com/cgi/content/full/324/7328/47/a (accessed December 10, 2007).

³² Mike Mitka, "Developing Countries Find Telemedicine Forges Links to More Care and Research," Journal of the American Medical Association 280 (1998): 1295, http://jama.ama-assn.org/cgi/reprint/280/15/1295 (accessed December 16, 2007).

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