Building partnerships for One Health and better drug use in Bhutan

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Nestled between India and China, east of Nepal sits the Himalayan nation of Bhutan, home to just under 800,000 citizens. The country, which offers free education and health care to all Bhutanese, is also renowned for pioneering the concept of Gross National Happiness as a measure of the well being of the population.

According to government policies, Bhutan does not have private hospitals or a medical college. Instead, the country provides primary and secondary health care through public hospitals – tertiary care is provided through three referral centers and a national hospital in the capital Thimphu.

The Fleming Fund has been active in Bhutan since 2017 and its investments are centred around supporting good AMR governance and building AMR surveillance systems in the four main hospitals and their animal health equivalents.

Partnerships in the Laboratory

Since the grant’s inception, recipients say the Fleming Fund has helped build strong partnerships and improve drug use across the country. Ragunath Sharma, who works in bacteriology at Jigme Dorji Wangchuk National Referral Hospital in Thimphu said: “In Bhutan we are quite a small country - we know each other very well. Informally things happen, but with the Fleming Fund we are making a system, making things more formal.”

He says support from the Fleming Fund has standardised laboratory operating procedures and protocols across the whole country, meaning tests are run uniformly and staff can collaborate easily. He and his colleagues are also in the process of developing a quality management manual that will be rolled out nationally, further improving standardisation and cooperation.

Dr. Pem Chuki, who heads the stewardship programme at Jigme Dorji Wangchuk National Referral Hospital and is also a Fleming Fund Fellow, agrees that the programme has been critical to strengthening collaboration. She says historically there has been a lack of confidence in the data generated from laboratories, but that quality assurance and quality management improvements supported by the Fleming Fund will help restore confidence in testing results.

IT support from her Fellowship mentors at the University of Melbourne, has also helped. Because laboratory results, patient data and doctors’ notes all need to be linked together to develop an accurate picture of antimicrobial resistance and use, strong IT systems greatly enhance stewardship activities. Support from the Fleming Fund has provided hardware and software to collect and analyse AMR and antimicrobial use data.

One Health Partnerships

According to Pem and Ragunath, Fleming is also strengthening animal and human health partnerships. Both sectors are involved in national AMR governance decisions and recently instituted joint laboratory media preparation of blood agar from sheep blood.

Media preparation, is the process of mixing various substances to create an ideal environment for bacterial growth on a culture plate. Blood agar is prepared by the addition of fresh blood to an agar base. As sheep blood is more difficult to obtain, many laboratories use human blood discarded from blood banks. However, human blood does not support the growth of some bacteria and can pose a biohazard to laboratory workers. Ideally, sheep should be reared near a laboratory where technicians can regularly collect blood for the preparation of blood agar.

Support from Fleming Fund means sheep are now cared for by animal health practitioners for the purpose of providing blood to the microbiology laboratories in the vicinity.

“We are very close to the human health laboratory here, so we meet them frequently. We care for the sheep and then share with our colleagues in human health. This helps us to streamline our services,” said Dr N.K Thapa, Animal Health Specialist at the National Center for Animal Health.

He says improved cross-sector collaboration hasn’t just contributed to AMR work, but is having long-standing health system strengthening impacts. “During the COVID-19 response we shared equipment with human health colleagues - that would not have happened without existing sharing of resources. Now, compared to the past, we are having Technical Working Group meetings more frequently. We come together and discuss common issues and we are identifying what other resources could be shared,” he said.

The Fleming Fund will continue to support cross-sector collaboration in Bhutan until mid-2021, but according to Pem, Ragunath and Thapa the foundations of strong partnerships have already been built.