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.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~