The MoH report reveals- from a total of 208 deaths in 2003, it increased to 352 in 2009, which all are NCDs- alcohol liver disease, hypertension, heart diseases, diabetes, and cancers. The fact is that these NCDs are preventable with innovative public health approaches and responsive cooperation from people which would ultimately reduce the burden on the public health system and socio-economic condition of the country.
The medical reports on morbidity shows a rising trend of Non-Communicable Diseases in Bhutan, which poses a substantial health burden. During a Community-based survey conducted by the Ministry of Health (2007) in Thimphu, high prevalence of NCD risk factors was revealed. The survey indicated high prevalence of alcoholism, hypertension, and obesity. It also showed that about 66.6% of adults consumed less amount of recommended fruits and vegetables. Moreover, maximum people lived sedentary lifestyle, where 8.2% had high glucose level while 44.3% had raised cholesterol level.
Thus, with support from WHO, the Royal Government of Bhutan formulated policy for prevention and control of NCDs. They banned the sale of tobacco in public places. Smoking in public places was also prohibited. Further, with policy focused on health promotion and diseases prevention, numerous awareness campaign and advocacy programmes on importance of healthy diet and physical activity were adopted. Of all the initiatives, PEN project proposed by the WHO, and piloted in two districts of Paro and Bumthang is a new and efficient protocol integrated in our primary health system to combat NCDs.
“PEN project basically is prevention of NCDs and promotion of healthy life style like eating less salt, less oil, eating more vegetables, doing more exercise. Its protocol says it is a timely screening since early diagnosis can prevent early referrals of patients,” says Wangchuk Dukpa, senior programme officer under department of public health.
PEN stands for Package of Essential Non-Communicable Diseases interventions. The WHO developed PEN to provide technical guidelines for prevention of NCDs in Bhutan. PEN is a new concept and it is a consolidated type of protocol designed by the WHO, especially for screening and prevention of NCDs.
According to the MoH report, PEN intervention protocols are the tools to improve access of cost effective interventions to the community in the Low Middle Income Countries like Bhutan.
According to Wangchuk, PEN is a package of essential NCD intervention expounded by WHO, especially designed for low middle income country like ours. PEN is like some sort of protocol to give guidelines to health workers in peripherals in order to prevent NCDs, and carry out early diagnostics.
In 2009, health workers from 18 districts were sensitized on PEN intervention protocols. “The PEN was very new to Bhutan. In the first step, WHO experts came to Bhutan. We had meetings with many health workers. They discussed PEN in workshops, and later PEN was projected,” says Wangchuk.
With the financial and technical support from the WHO, PEN was initiated in two pilot districts of Paro and Bumthang, where staffs of Basic Health Units were trained in three day workshops.
“We did project to see how we can cope up with the guidelines drawn by the WHO. When we say project, we wanted to integrate this PEN intervention in our primary health system,” says Wangchuk.
To facilitate PEN project, additional equipment to measure blood glucose level and blood pressure were supplied to BHUs. WHO 10- year CVD risk prediction charts was provided along with making available of health education materials. To cater the basic needs of NCD patients, medicine supplies were increased in BHUs.
All NCD patients attending OPDs in health centers in pilot districts were registered and patients above 40 years were counseled on stopping smoking, reducing harmful use of alcohol, eating healthy food and enhancing physical activity. They were screened for high blood pressure, obesity, tested for blood sugar level. Those found to have hypertension and life style disease like diabetes were registered to keep a clinical record for future follow ups.
As a result of PEN intervention, with the support from the WHO, two pilots PEN intervention were successfully implemented in Paro and Bumthang. It was found that the PEN intervention protocols were user friendly were most of the health workers could adopt it. Here Wanchuk says, ‘Before some sort of life style related diseases screening were there. Now, with PEN, it is more organized and integrated in health system as a fundamental protocol to prevent NCDs.’
After the PEN intervention was projected, the efficiency of various health centers improved, building up the capacity of health workers. And increased community awareness on major NCD risk factors indicated a proportion of achievement in prevention NCDs particularly through this PEN intervention.
The Way Forward
At the Mid Term Review of RGoB, serious concerns on NCD trends were recognized, and therefore advocacy and awareness campaign on prevention of NCDs were rendered top priority.
National EDL for extension of drugs to the district hospitals and BHUs will be revised through putting up proposals to the National Drug Committee.
To enhance the capacity of health workers to diagnose mellitus at early stage, glucometer will be included in all BHUs.
The PEN protocol will be reviewed and made available to all health centers. It will be expanded and integrated in all Dzongkhags. The PEN integration protocol will be incorporated into RIHS curriculum.
The health workers of entire country will be trained on PEN protocol intervention to incorporate with existing PHC system in order to control and prevention of NCDs.
(Draft Background research by Medaimax for WHO Bhutan)