Map of BhutanMap of Bhutan
Different regionsDifferent regions
West
Central
East
C
W
southsouth
HEALTH EQUITY HEALTH EQUITY ANALYSIS OF BHUTANANALYSIS OF BHUTAN
1.1. Household levelHousehold level
2.2. Household member levelHousehold member level
3.3. Pregnancy and live birth level Pregnancy and live birth level
Data collection questionnaires
Schedule A: village folder SCHEDULE A: VILLAGE FOLDERDzongkhag….……….…………………..G1 Geog Code.……..… [][ ][ ][ ] V1 Size.……....….…… [][ ][ ][ ]V2 sample village code......... [ ][ ]
Var. ItemPlease tick in appropriate box for each item
CodeFor coder’s use
V3 Does the village have health care facility?1 [ ] yes 2 [ ] no
[ ]
V4 If no, what is the nearest health center facility?1 [ ]Hospital 2 [ ] BHU 3 [ ] ORC
[ ]
V5 What is the time needed to reach this facility by foot?[ ][ ]hrs [ ][ ]min
[ ][ ] [ ][ ]
V6 Does the village have an active VHW?1 [ ]yes 2 [ ]no
[ ]
1.Household level1.Household level
Sanitation (latrine) coverageSanitation (latrine) coverage Access to safe waterAccess to safe water Illness within the past one monthIllness within the past one month
Number of households sampled
TotalResidenceRural Urban
RegionsWestCentralEastSouth
Availability of health facilityNoYes
12,711 *
10,2512,460
4,342800
4,7752,794
7,0413,061
* Blown to 100,328 nationally
Stratifiers Stratifiers Latrine coverage Latrine coverage (%)(%)
Access to safe Access to safe water (%)water (%)
Illness within the Illness within the past one month past one month
(%)(%)
Overall Overall 88.8%88.8% 76.4%76.4% 18.0%18.0%
ResidenceResidence
UrbanUrban
RuralRural
RegionRegion
WestWest
CentralCentral
EastEast
South South
Health facilityHealth facility
NoNo
YesYes
Education Education
no educationno education
PrimaryPrimary
SecondarySecondary
highhigh
OccupationOccupation
StudentStudent
monksmonks
Govt. service/armed forcesGovt. service/armed forces
BusinessBusiness
FarmerFarmer
Unemployed Unemployed
othersothers
93.3%93.3%
88.0%88.0%
89.7%89.7%
95.8%95.8%
88.5%88.5%
85.8%85.8%
90.7%90.7%
87.6%87.6%
74.2%74.2%
87.7%87.7%
96.0%96.0%
96.8%96.8%
83.1%83.1%
88.7%88.7%
93.5%93.5%
90.6%90.6%
86.4%86.4%
91.5%91.5%
82.5% 82.5%
97.7%97.7%
72.6%72.6%
86.4%86.4%
81.7%81.7%
70.8%70.8%
70.2%70.2%
84.9%84.9%
70.7%70.7%
74.2%74.2%
87.7%87.7%
96.0%96.0%
96.8%96.8%
71.0%71.0%
70.1%70.1%
95.8%95.8%
94.6%94.6%
71.4%71.4%
88.9%88.9%
81.4% 81.4%
17.4%17.4%
18.0%18.0%
19.5%19.5%
18.5%18.5%
16.1%16.1%
18.8%18.8%
17.1%17.1%
18.4%18.4%
17.0%17.0%
16.4%16.4%
17.9%17.9%
12.9%12.9%
12.4%12.4%
12.4%12.4%
18.3%18.3%
13.0%13.0%
16.9%16.9%
19.8%19.8%
21.3% 21.3%
Latrine coverage in rural Latrine coverage in rural areas.areas.
2. Household member level2. Household member level
Modern contraceptive useModern contraceptive useAntenatal careAntenatal careDelivery care by trained health Delivery care by trained health
personnelpersonnelDelivery at the health facilitiesDelivery at the health facilities
Number of household members sampled
TotalGenderMaleFemaleAge<11-45-910-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-64>65EducationNo educationPrimarySecondary/ HighOccupationChild/studentsMonksGovt.service/Armed forcesBusinessFarmerUnemployedOthers
68,847
33,48935,358
9,7158,9537,0055,1444,6794,1363,7503,4903,1642,9922,3872,0793,664
52,47912,005
4,33429,111 1,468
2,743 1,581
29,052 3,624 1,260
16,44411,434
Contraceptive method Contraceptive method used by married womenused by married women
Almost 30.7% of the reproductive age Almost 30.7% of the reproductive age women who were married and not known women who were married and not known pregnant during the survey chose to use pregnant during the survey chose to use the modern methods of contraceptionthe modern methods of contraception
These include sterilization, pill, DMPA, These include sterilization, pill, DMPA, Vasectomy, IUD, and condom. Vasectomy, IUD, and condom.
Contraceptive methods Contraceptive methods practiced by the married practiced by the married womenwomen
Method of contraception Method of contraception
Antenatal careAntenatal care
The total number of women who had ANC at any The total number of women who had ANC at any
gestation periods was found to be gestation periods was found to be 51%;51%;
However, this should not be directly interpreted as the However, this should not be directly interpreted as the
proportion of the reach of antenatal services to proportion of the reach of antenatal services to
pregnant women. This is so as women in earlier pregnant women. This is so as women in earlier
trimesters either do not yet realize that they are trimesters either do not yet realize that they are
pregnant or that they may wait for the pregnancy to pregnant or that they may wait for the pregnancy to
advance a little before they decide to seek ANC. advance a little before they decide to seek ANC.
The analysis should tie the time of ANC to the period of The analysis should tie the time of ANC to the period of
gestation; hence it was divided into following three gestation; hence it was divided into following three
groups: 1-st, 2-nd, 3-rd trimesters (as the denominator)groups: 1-st, 2-nd, 3-rd trimesters (as the denominator)
ANC in 1st trimester ANC in 2nd trimester ANC in 3rd trimester
TotalAge15-1920-2425-2930-3435-3940-4445-49ResidenceUrbanRuralRegionsWestCentralEastSouthHealth facilitiesNoYesEducationNonePrimarySecondary/higherOccupationChild/studentsGovt.service/Armed forcesBusinessFarmerUnemployed
20.2%
15.5%26.3%20.5%15.8%13.7%0.0%0.0%
25.2%18.6%
27.8%0.0%
10.7%24.5%
21.2%18.5%
17.9%21.1%31.0%
0.0%24.6%0.0%
18.3%25.9%
48.1%
58.2%53.3%46.4%38.5%35.7%40.0%0.0%
68.8%42.5%
59.1%66.7%44.1%34.7%
36.8%63.3%
44.3%66.9%66.0%
75.0%58.5%76.0%41.2%56.5%
72.7%
73.9%72.2%82.3%73.7%54.6%59.1%
100.0%
93.9%67.8%
81.0%82.4%67.8%66.9%
64.7%84.7%
68.5%96.7%
100.0%
75.0%100.0%100.0%65.1%90.7%
Delivery care by trained Delivery care by trained health personnel health personnel and at health facilityand at health facility
The number of women who took delivery care The number of women who took delivery care from trained health personnel in 1996 was from trained health personnel in 1996 was found to be 19.6% which increased to 27% in found to be 19.6% which increased to 27% in the year 2000 , even though it shows some the year 2000 , even though it shows some increase, it is still a long way off from the target increase, it is still a long way off from the target of all births to be attended by trained of all births to be attended by trained attendants. attendants.
The number of women who took delivery at The number of women who took delivery at health facilities in 1996 was found to be 15.1% health facilities in 1996 was found to be 15.1% which increased to 23% in the year 2000, even which increased to 23% in the year 2000, even though it shows some increase, it is still a long though it shows some increase, it is still a long way off from the target of all births to be way off from the target of all births to be delivered at the health facilities. delivered at the health facilities.
By the latest year 2000
By trained health personnel Delivery at health facility
TotalAge15-1920-2425-2930-3435-3940-4445-49ResidenceUrbanRuralRegionsWestCentralEastSouthHealth facilitiesNoYesEducationNonePrimarySecondary/higherOccupationChild/studentsGovt.service/Armed forcesBusinessFarmerUnemployedOthers
27.3%
21.9%30.0%32.4%27.7%21.0%6.0%5.6%
62.9%18.5%
43.2%20.2%13.8%22.8%
16.5%42.0%
20.6%51.9%79.1%
35.7%87.8%57.1%14.8%51.8%39.3%
23.0%
18.8%25.1%27.4%22.9%19.4%3.0%5.6%
58.6%14.2%
40.5%11.5%8.0%
20.2%
13.4%35.9%
16.4%49.3%71.6%
33.3%77.2%58.7%11.2%45.7%34.2%
3. Pregnancy level3. Pregnancy level
Teenage pregnancyTeenage pregnancyBreast feedingBreast feedingUnder-five mortalityUnder-five mortality Infant mortalityInfant mortalityPlace of death of childrenPlace of death of childrenWant more children?Want more children?
Total number of live births in the last nine years
Total
Years of events200019991998199719961995199419931992
131,728 *
11,43412,00413,60014,68314,80216,00715,96916,49716,732
Women 15-49 years who gave live births(Pregnancy level data)
* Blown from 16,197 samples, included only non-missing data
Year 2000Year 2000 Teenage pregnancy (%)
Breast feeding (%)
TotalResidenceUrbanRuralRegionsWestCentralEastSouthHealth facilitiesNoYesEducationNonePrimarySecondary/higherOccupationChild/studentsGovt.service/Armed forcesBusinessFarmerUnemployedOthers
20.3%
18.0%20.8%
15.1%22.8%22.8%25.4%
21.1%19.2%
18.3%48.0%13.7%
92.9%2.5%28.7%20.5%17.0%48.4%
42.1%
41.7%41.8%
30.9%45.1%47.7%46.1%
40.4%43.5%
42.1%33.8%49.3%
50.0%38.4%38.0%41.4%43.7%40.2%
Under-five mortality (%) (1996)
Infant mortality (%)(1996)
Infant mortality (%)(2000)
TotalAge of mothers15-1920-2425-2930-3435-3940-4445-49ResidenceUrbanRuralRegionsWestCentralEastSouthHealth facilitiesNoYesEducationNonePrimarySecondary/higherOccupationChild/studentsGovt.service/Armed forcesBusinessFarmerUnemployedOthers
10.5%
0.0%11.5%9.5%
10.9%8.9%
10.2%16.6%
3.8%10.8%
9.4%14.2%13.8%5.7%
11.2%9.5%
11.3%7.5%0.0%
38.1%0.0%9.3%
11.5%8.1%0.0%
8.0%
0.0%9.2%6.0%8.6%9.0%3.8%
11.6%
3.8%8.7%
7.4%12.1%10.0%4.3%
8.6%7.1%
8.5%4.4%0.0%
38.1%0.0%9.3%8.7%6.2%0.0%
9.3%
12.7%8.2%8.1%8.1%9.4%
16.8%22.2%
5.0%10.4%
7.3%5.9%
12.6%8.8%
11.5%6.1%
9.8%5.3%7.9%
14.3%3.8%
11.0%10.6%5.9%
13.1%
By the latest year 2000
Place of death of children under age of five
Want more children?
Home Hospital
TotalAge of mothers15-1920-2425-2930-3435-3940-4445-49ResidenceUrbanRuralRegionsWestCentralEastSouthHealth facilitiesNoYesEducationNonePrimarySecondary/higherOccupationChild/studentsGovt.service/Armed forcesBusinessFarmerUnemployedOthers
81.9%
88.9%78.6%64.7%85.7%
100.0%100.0%
0.0%
44.6%86.8%
65.5%100.0%91.7%85.9%
85.0%78.5%
85.4%45.0%38.1%
100.0%64.3%
100.0%87.0%48.5%
100.0%
13.1%
11.1%21.4%17.3%14.3%0.0%0.0%0.0%
55.4%7.6%
20.9%0.0%8.3%
13.1%
7.5%21.5%
10.9%55.0%23.8%
0.0%35.7%0.0%8.7%
39.4%0.0%
22.9%
50.5%42.2%31.3%24.1%16.3%14.7%10.0%
19.5%25.8%
22.5%20.1%24.4%23.6%
29.0%20.5%
24.1%20.8%19.2%
33.5%17.8%14.7%28.7%21.7%11.7%
Teenage pregnancy Multivariable analysisMultivariable analysis
Odds Ratio P-value
Urban vs. Rural
West vs. East
Central vs. East
South vs. East
Primary vs. No education
Secondary-high vs. No education
Availability of health facility : Yes vs. No
Year 1997 vs. 1996
Year 1998 vs. 1996
Year 1999 vs. 1996
Year 2000 vs. 1996
.96
.77
.90
1.24
2.24
1.04
.80
1.10
.99
.92
1.04
0.686
0.000
0.352
0.003
0.000
0.732
0.003
0.232
0.950
0.338
0.591
Under-five death Odds Ratio P- value
Rural vs. Urban West vs. EastCentral vs. EastSouth vs. EastPrimary vs. No education Secondary-high vs. No educationAvailability of health facility: Yes vs. NoYear 1991 vs. 1990Year 1992 vs. 1990Year 1993 vs. 1990Year 1994 vs. 1990Year 1995 vs. 1990Year 1996 vs. 1990
1.64.85.78.46.57.28.87.96.88.94.95.99.97
0.0000.0190.0240.0000.0010.0000.0300.6840.2010.5390.6030.8890.787
Under-five mortalityMultivariable analysis
Infant deathOdds Ratio P-value
Rural vs. Urban
West vs. East
Central vs. East
South vs. East
Primary vs. No education
Secondary-high vs. No education
Availability of health facility : Yes vs. No
Year 1997 vs. 1996
Year 1998 vs. 1996
Year 1999 vs. 1996
Year 2000 vs. 1996
1.60
.78
.94
.49
.67
.57
.71
.85
.91
.99
1.17
0.009
0.018
0.677
0.000
0.054
0.042
0.001
0.186
0.458
0.943
0.211
Infant mortalityMultivariable analysis
Income Distribution by Country
RecommendationRecommendation The existing 2000 National Health Survey report has given an illustration The existing 2000 National Health Survey report has given an illustration
on the overall status of the population health. on the overall status of the population health.
This report added new information on the differential characteristics of This report added new information on the differential characteristics of
household status with respect to health conditions, woman and child household status with respect to health conditions, woman and child
health across geographic locations and socio-demographic stratifiers. health across geographic locations and socio-demographic stratifiers.
It is useful as a tool for monitoring and evaluation of health (in) equity of It is useful as a tool for monitoring and evaluation of health (in) equity of
the people of Bhutan over times. It sheds light on the target group of the people of Bhutan over times. It sheds light on the target group of
population whom the health policy should pay specific attention to. population whom the health policy should pay specific attention to.
For example, the eastern region was found worse than the others in For example, the eastern region was found worse than the others in
usage of contraceptive by married women (28.2%), delivery care by usage of contraceptive by married women (28.2%), delivery care by
trained health personnel (13.8%), delivery at the health facilities (8.0%), trained health personnel (13.8%), delivery at the health facilities (8.0%),
under-five mortality (12.7%), and infant mortality (12.6%). under-five mortality (12.7%), and infant mortality (12.6%). This is to This is to
reduce the gap in the area identified as health inequity reduce the gap in the area identified as health inequity
priority.priority.
RecommendationRecommendation One woman health issue that this analysis One woman health issue that this analysis
did not touch upon despite the available did not touch upon despite the available data (Schedule G) is data (Schedule G) is maternal mortalitymaternal mortality. . Since the mortality folder cannot be linked Since the mortality folder cannot be linked individually to the past pregnancy folder individually to the past pregnancy folder which contain individual live births and the which contain individual live births and the corresponding event years, the denominator corresponding event years, the denominator (i.e., number of live births) of the maternal (i.e., number of live births) of the maternal mortality ratio cannot be determined. mortality ratio cannot be determined.
RecommendationRecommendation Unfortunately, the analysis cannot deal with Unfortunately, the analysis cannot deal with
economic disparityeconomic disparity issue since there were issue since there were no quests on the economic status of the no quests on the economic status of the surveyed households. The economic well-surveyed households. The economic well-being can be captured using the questions being can be captured using the questions on regular consumption expenditures, asset on regular consumption expenditures, asset belonging and properties, and (in-cash and belonging and properties, and (in-cash and in-kind) incomes. Hence, this report in-kind) incomes. Hence, this report recommends the next health survey recommends the next health survey incorporates the economic-based incorporates the economic-based questionnaire items.questionnaire items.
RecommendationRecommendation The National Health Survey questionnaire for The National Health Survey questionnaire for health seeking health seeking
behavior has only the out-patient queriesbehavior has only the out-patient queries by days of illness and the by days of illness and the two sources of care. It will be more useful if the frequency of visits for two sources of care. It will be more useful if the frequency of visits for each particular type of care and the amount of household direct each particular type of care and the amount of household direct payment are also recorded. payment are also recorded.
The queries on in-patient care will be a useful complement if they are The queries on in-patient care will be a useful complement if they are also included in the survey. The inpatient questions should include (1) also included in the survey. The inpatient questions should include (1) frequency of admissions, (2) days of stay, and (3) payment made by frequency of admissions, (2) days of stay, and (3) payment made by the households for services and traveling costs. To allow for the the households for services and traveling costs. To allow for the relatively uncommon events, a recall period of 12 months should be relatively uncommon events, a recall period of 12 months should be used for the inpatient questions. used for the inpatient questions.
With these types of health service utilization data, a further analysis on With these types of health service utilization data, a further analysis on the equity in health utilization and public subsidy, so-called ‘benefit the equity in health utilization and public subsidy, so-called ‘benefit incidence analysis’ (i.e., whether the health resources are pro-rich or incidence analysis’ (i.e., whether the health resources are pro-rich or pro-poor) can be performed.pro-poor) can be performed.
Dzongkhag….…….…………..……………..G1 Geog Code.………….. [][ ][ ][ ] V1 Size…….……….…… [][ ][ ][ ]
V2 sample village code................ [ ][ ]HH1 Household Sr. No….……… [ ][ ][ ]HM1 Sr. No. of individual ……………..... []
Please note that this schedule is for a Recall Period of only ONE MONTH
HH member
HM1
HS1Open-ended
question. Record the most prominent symptoms as reported by the respondent. Will be coded later
How many days were you ill?
HS2
Where did you first advice/care? If so where?
HS31-none2-self3-traditional4-lama5-VHW6-BHU/ORC7-hospital8-other
Did you seek second advice/care?
If so where?HS40-no second care1-traditional2-lama3-VHW4- BHU/ORC5-hospital6-other
Who made decision to seek first care?
HS51-self2-head of HH3-spouse of head4-grandparents5-other relatives6-other
Why do you choose this particular caregiver (first)?
Open ended question. Answer will be narrative and to be coded before data entry. HS6
[ ][ ] [ ][ ][ ] [ ] [ ] [ ]
[ ][ ] [ ][ ][ ] [ ] [ ] [ ]
[ ][ ] [ ][ ][ ] [ ] [ ] [ ]
[ ][ ] [ ][ ][ ] [ ] [ ] [ ]
Please specify other (if any) for HS3, HS4 and HS5 in the space below also give the specific HM1 code.
SCHEDULE F: HEALTH CARE SEEKING BEHAVOUR FOLDER
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Thank you very ~~~~Thank you very much, for your kind much, for your kind attention and time.attention and time.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~