Transforming Bhutan’s Healthcare: A New Framework for Evidence-Based Decision-Making

Bhutan's Ministry of Health, in collaboration with HITAP and UNDP, has introduced an innovative Health Technology Assessment (HTA) framework to advance evidence-based healthcare decision-making. The framework addresses resource allocation challenges, enhances capacity-building, and aligns healthcare policies with national priorities to ensure sustainable and equitable health outcomes.

Bhutan’s Ministry of Health, in collaboration with Thailand’s Health Intervention and Technology Assessment Program (HITAP) and supported by the UNDP-led Access and Delivery Partnership (ADP), has taken a monumental step by introducing a revamped Health Technology Assessment (HTA) framework. This initiative is aimed at advancing evidence-based healthcare decision-making as the nation works towards achieving universal health coverage (UHC). The updated framework reflects Bhutan’s determination to align with global best practices while addressing its unique challenges. Developed through extensive stakeholder consultations, reviews of international guidelines, and iterative revisions, the framework is poised to optimize resource allocation and improve healthcare delivery across the country.

Tackling Longstanding Challenges in Health Technology Assessment

Bhutan’s foray into institutionalizing HTA began with the establishment of the Essential Medicines and Technology Division in 2008, later renamed the Health Intervention and Technology Assessment Division (HITAD). Initial HTA guidelines, introduced in 2013 and revised in 2018, paved the way for decisions like the introduction of pneumococcal conjugate and rotavirus vaccines into national immunization programs. However, progress was hindered by persistent challenges, including limited technical expertise, insufficient funding, and a disconnect between HTA outcomes and procurement processes. Bhutan’s small market size further weakened its negotiating power in health technology procurement, while the absence of a streamlined link between evidence generation and purchasing decisions compounded these issues.

Recognizing these barriers, Bhutan’s Ministry of Health launched efforts to overhaul the HTA framework. The revamped framework integrates lessons learned from past experiences and incorporates innovative strategies to address these obstacles effectively. This includes aligning HTA processes with national fiscal cycles, enhancing prioritization mechanisms, and fostering collaborative partnerships for evidence generation.

Innovations in the Updated HTA Framework

A defining feature of the new HTA framework is its integration with Bhutan’s budgetary and procurement cycles. This alignment ensures timely allocation of resources, with health technology prioritization finalized early in the fiscal year to facilitate seamless budgeting. The framework employs a three-point scoring system to prioritize health technologies based on criteria such as potential cost savings, impact on reducing international referrals, and alignment with national health strategies. Technologies addressing high-priority health system challenges, such as reducing financial burdens from cross-border referrals, receive greater attention.

The framework also introduces the Price Threshold Determination Group (PTDG), a key mechanism to bridge the gap between HTA findings and procurement decisions. Comprising representatives from Bhutan’s Health Trust Fund, Health Financing Division, and other relevant bodies, the PTDG ensures that procurement aligns with HTA recommendations. This group negotiates prices for non-cost-effective technologies based on thresholds derived from HTA evaluations, thereby maximizing value for money and strengthening Bhutan’s bargaining position.

Another innovation is the framework’s emphasis on collaboration in evidence generation. HITAD can now commission research from local institutions such as the Khesar Gyalpo University of Medical Sciences of Bhutan and the Royal University of Bhutan, as well as from international research agencies. This approach ensures the timely availability of high-quality evidence while addressing gaps in technical capacity. Capacity-building strategies include workshops, structured HTA courses at universities, and international internships, laying the foundation for sustainable HTA practices in Bhutan.

Stakeholder Engagement and International Best Practices

The participatory approach to developing the updated HTA framework has been a cornerstone of its success. Stakeholder consultations in 2022 and 2023 involved policymakers, healthcare professionals, patient representatives, and pharmaceutical companies. These sessions identified strengths and weaknesses of previous HTA processes, clarified stakeholder roles, and mapped out strategies to overcome barriers. Drawing on successful HTA models from Thailand, the Philippines, Singapore, and the UK, Bhutan tailored its framework to reflect international best practices while ensuring contextual relevance.

The framework also outlines rapid assessment protocols for public health emergencies, enabling timely and evidence-based decision-making during crises. This feature underscores Bhutan’s commitment to building a resilient healthcare system capable of responding dynamically to evolving challenges.

Transforming Healthcare Decision-Making in Bhutan

The updated HTA framework is expected to have far-reaching impacts on Bhutan’s healthcare system. By aligning resource allocation with national priorities and budget cycles, it ensures that interventions are both cost-effective and equitable. Strategic price negotiations and improved evidence generation capacity will enhance the system’s ability to make informed, impactful healthcare decisions. Monitoring and evaluation mechanisms are integrated into the framework, allowing for continuous assessment of health technologies and ensuring they deliver intended outcomes.

International collaboration has been instrumental in Bhutan’s HTA journey. Partnerships with HITAP and networks like HTAsiaLink have provided technical expertise, training, and co-research opportunities. Financial support from ADP has been crucial in institutionalizing HTA, emphasizing the importance of aligning external support with domestic priorities. Moving forward, Bhutan plans to build internal capacity through local universities and dedicated funding, ensuring the long-term sustainability of evidence-informed policymaking.

A Model for Evidence-Based Policymaking in Low-Resource Settings

Bhutan’s HTA journey offers valuable lessons for other countries navigating similar challenges in institutionalizing evidence-based healthcare decision-making. The framework’s development process demonstrates the importance of engaging diverse stakeholders, aligning HTA initiatives with political and fiscal cycles, and leveraging international partnerships. While challenges remain, Bhutan’s approach highlights the potential for tailored solutions to address local needs effectively. By fostering collaboration, investing in capacity-building, and capitalizing on political opportunities, Bhutan has established a strong foundation for achieving sustainable and equitable healthcare outcomes. The initiative not only strengthens Bhutan’s health system but also serves as a model for other low- and middle-income countries striving to optimize their healthcare resources. With its comprehensive and innovative framework, Bhutan is well-positioned to enhance its healthcare system and contribute to the global dialogue on evidence-based healthcare policymaking.