argumentative essay on covid 19 in bhutan

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A content Bhutanese monk spins a prayer wheel. Despite its high level of poverty, Bhutan's response to COVID-19 was exemplary.

How Bhutan Tamed COVID-19

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Few nations in the world have handled the COVID-19 pandemic as well as Bhutan, the small Himalayan kingdom of a little more than 700,000 people. As much of the world struggles to contain the infectious delta variant of the virus, Bhutan has already begun looking to a post-COVID future. 

Almost all eligible people, including teenagers, have been vaccinated — no minor feat for a mountainous country (much of which remains unreachable by paved roads) with limited medical and economic resources. Health workers trekked for days at altitudes of more than 12,000 feet above sea level in order to vaccinate the remotest corners. The health ministry, during the second vaccination campaign in July, dispatched almost 5,000 health workers to 1,217 separate locations in order to vaccinate Bhutan’s population. Thousands of volunteers from all walks of life assisted with the push via a program called  Desuung  (“Guardians of Peace”), initiated by Bhutan’s King Jigme Khesar Namgyal Wangchuck to encourage active citizenship. 

Not that everything has been easy for Bhutan. After patient zero — an American tourist — was diagnosed with COVID-19 in March 2020, tourism, one of the country’s main revenue streams, was halted immediately, impacting the 50,000 people employed in the sector. Following the closure, the government quickly adopted an economic contingency strategy that included a tourism stimulus plan amounting to about $3.8 million. Tourism employees were reassigned to work in infrastructure, product development, waste management, agriculture, and research.  

 As elsewhere in the world, schools and colleges in Bhutan were shut down. Education in Bhutan experienced a paradigm shift with the incorporation of technology, moving online and to national TV. Volunteer teachers camped at schools in the capital and taught students from the studios of the national broadcaster. Google Classrooms became the norm. Despite concerted efforts by the government to ensure equitable access, including providing free student data packages, there was a digital divide that saw many students being left behind. Not everyone had access to a smartphone or a television or a good internet connection. COVID-19 revealed both shortcomings as well as opportunities in the education sector. 

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What ensured Bhutan’s success, though, was tremendous public trust in the country’s leadership. The king established a royal relief fund and trekked across the country to provide comfort and support to workers on the frontlines of the pandemic, as well as ordinary folk. Under his leadership, financial institutions deferred loans and waived off interest payments. 

 Bhutan’s COVID success story can also be attributed to the fact that the prime minister and foreign minister are doctors, and the health minister is a public health specialist. The government maintained clear channels of communication with the media and the people in order to check misinformation. Government officials delivered daily press briefings on television as well as on Facebook in the early days of the pandemic. The health ministry and the prime minister’s office updated their social media pages daily, even addressing public concerns live, while WhatsApp groups were created to provide journalists and social media influencers with access to officials in order to share information and engage in fact checking.  

So far, the country has seen only three deaths from COVID-19: one in 2020 and two in 2021. All three victims had underlying health conditions. The total number of COVID cases recorded was around 2,600 as of December 2021. Bhutan’s health infrastructure may not rival the world’s wealthiest countries, but that mattered little to the elderly American tourist who was patient zero. After he was flown back to the U.S., doctors there credited Bhutanese medical care with saving his life. 

 What accounts for Bhutan’s good fortune during the COVID-19 pandemic? Besides good leadership and careful planning, many Bhutanese will claim — with confidence — that the true answer is divine intervention. Life in Bhutan is entwined with ritualistic Buddhist tradition: The government consulted with the central monastic body for the optimal date for the rollout of vaccines, which were then blessed upon arrival at the airport. A 30-year-old woman, born in the year of the monkey, was chosen as the nation’s first vaccine recipient on March 27, 2021, a day astrologists determined was particularly auspicious. Nationwide daily prayers for protection have also taken place at monasteries since the beginning of the pandemic. 

 But the likelier explanation for Bhutan’s success is far more mundane: good old-fashioned competent government — a resource that countries with far more wealth and power have so often struggled to harness. 

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Namgay Zam is an independent multimedia journalist and producer as well as the executive director of the Journalists’ Association of Bhutan. She is an Asia 21 Young Leader and a Fulbright Humphrey Fellow. Zam is passionate about social justice, mental health, and equal rights.

Two Years of Bhutan’s Pandemic Response

Paro, Bhutan - February 12, 2021 - Health check before a Buddhist prayer ceremony. 

Holger Kleine/Shutterstock.com

Bhutan has gone through four significant outbreaks of COVID-19 since March 2020. The first outbreak occurred in August 2020 (35th epi week), the second in December 2020 (52nd epi week), the third in May 2021 (21st epi week, attributable to the Delta variant), and the ongoing wave since December 2021 on account of the Omicron variant. As of April 9, 2022, over 40,629  persons tested positive for COVID-19 (22,592 males; 18,037 females; and 2,127 children<5 yrs),  31,424 persons have recovered (17,819 males and 13,605 females) and fourteen deaths are reported (6 males and 8 females).

Bhutan has been an exemplar nation in the South-Asia Region in launching a strong health sector emergency response to COVID-19. As soon as the first case was detected in Bhutan in March 2020, surveillance activities were immediately strengthened in all 20 districts with addition of district-based Case Investigation and Contact Tracing (CICT) teams. The IDA financed COVID-19 Emergency Response and Health Systems Preparedness Project in the amount of US$5 million was prepared and expeditiously approved by the Bank’s Board of Executive Directors on April 17, 2020. With the IDA financing, 50 hospitals and 184 primary health centers were provided with testing equipment, RT-PCR and Antigen Test Kits, consumables, hygiene products and PPE. Intensive Care Units were prepared in 4 COVID centers (total of 54 beds) to manage COVID-19 patients needing critical care. Capacities of 5 laboratories for COVID-19 testing were strengthened. Isolation, triage and treatment centers were established in designated hospitals and public health centers. Approximately 45,000 population above 12 years old (6 percent of the population) received primary series Moderna vaccines and another 135,000 population above 18 years old (18 percent of the population) received their booster dose of Moderna vaccine, also financed by IDA. Mass-, mid- and print-media were leveraged to create awareness of public health measures to manage COVID-19 as well as demand for testing, treatment and vaccination services. Over 4,756 awareness campaigns were launched, including a COVID-19 dashboard, video and radio spots, posters, pamphlets, travel advisories and social media campaigns. Hotline 1010 was set up for public service-related information dissemination, Hotline 112 for sharing health related information and advice and Hotline 1414 to address grievances related to health and COVID-19 related services. Trainings of health administrators and workers were conducted in COVID-19 prevention and treatment measures, social and behavior change communication, and to ensure compliance with social and environment safeguards requirements. Supervision visits were conducted to monitor and strengthen the health response to COVID-19, including progress with the minor civil works financed by the project.

With the support of the World Health Organization (WHO), United Nations Children’s Fund (UNICEF), the Global Alliance for Vaccines and Immunizations (Gavi), the World Bank and ADB, Bhutan established one of the world’s most effective vaccination campaigns. As of February 28, 2022, 98.4% of eligible population >12 years of age were provided first dose of COVID-19 vaccine and 94.5% of eligible population >12 years were fully vaccinated. Additionally 88.6% of eligible population >18 years of age received their first booster dose. Bhutan also initiated vaccination of children 5-11 years of age with approved vaccines. As of March 11, 2022, 96.1% of the children 5-11 years were provided the first dose of approved pediatric COVID-19 vaccines.

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Overcoming COVID-19 in Bhutan: Lessons from Coping with the Pandemic in a Tourism-Dependent Economy

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This publication assesses the Government of Bhutan’s financial relief measures for the most affected people, as well as programs and other interventions to address the impact of the coronavirus disease (COVID-19) pandemic.

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• A rapid and coordinated response to COVID-19 in Bhutan

Bhutan’s first reported COVID-19 case was imported in March 2020. The government reacted quickly to contain the case but new importations remained a considerable risk. Bhutan shares long land borders with India and China and has a relatively low density of health workers; only 370 medical doctors, 1500 nurses, and 700 community health workers serve a population of 760 000 people. Rapid transmission of COVID-19 in Bhutan would threaten to quickly overwhelm the health system as an inevitable consequence. Fortunately, years of infectious disease preparedness activities conducted by the government with technical and financial support from WHO prepared Bhutan to rapidly detect and respond to COVID-19. Bhutan’s rapid, harmonized response prevented thousands of COVID-19 infections and saved hundreds of lives. From 2020-2021, 2660 COVID-19 cases and four deaths occurred in Bhutan, a lower disease burden than many other countries.

Photo Credit : © WHO Country Office, Bhutan

Photo Caption : Tabletop simulation exercises in Phuntsholing, Bhutan.

How did Bhutan do it, and how did the WHO Secretariat support Bhutan?

• By investing in preparedness – In the months preceding the first COVID-19 case arriving in the country, WHO had provided financial and technical support to strengthen screening procedures at Paro International Airport. Thermal scanners were installed to monitor the body temperatures of arriving passengers, and COVID-19 simulation exercises were conducted to develop, assess and test functional capabilities of emergency systems, procedures and mechanisms to respond to COVID-19. In the years preceding the pandemic, the WHO Country Office provided technical expertise to the Ministry of Health to develop the health emergency contingency plan, strengthen International Health Regulation core capacity, and upgrade biosafety laboratory capacity from level 2 to level 3. WHO had also placed medical camp kits around the country to ensure continuity of primary health care services. When COVID-19 arrived, the camps were quickly converted into flu clinics as part of the COVID-19 response.
• By deploying a prompt, evidence-based response – The WHO Country Office updated and shared technical guidelines and strategies with the Ministry of Health, enabling a response that was based on the latest evidence and support from the daily epidemiological situation analysis. WHO was the only organization in the Government of Bhutan’s Technical Advisory Group for the COVID-19 response.
• By assessing the readiness of the health system and ensuring the availability of COVID-19 trained health workers – Bhutan assigned and trained workers to lead the frontline response using WHO protocols. WHO delivered gowns, gloves, goggles, and hundreds of thousands of medical masks to those on the frontline. In June and July 2020, WHO provided financial support for weekly trainings on the proper use of personal protective equipment.

Photo Caption : WHO delivering personal protective equipment for COVID-19 in Bhutan.

• By strong, coordinated, strategic action that was developed and communicated through timely simulation exercises – In June and July 2020, the WHO Country Office and the WHO Regional Office for South-East Asia provided funding and technical expertise to the Government of Bhutan for nationwide tabletop simulation exercises. Conducted in strategically important areas (five high risk border areas and the capital city), they tested standard operating procedures for pandemic management and identified and addressed gaps to strengthen the pandemic response plan. The 70 national and subnational level officials in attendance were left better equipped to implement COVID-19 protocols as a coordinated team. As one elected city council member expressed, “Attending the tabletop simulation exercise was an enriching experience. During the lockdown, I felt like I could easily communicate with other task force members and support my community. Before the exercise, I did not know how to work with others on the task force. We were ready with standard operating procedures but did not know exactly how to implement them.”

“The simulation exercise was carried out in a very timely manner. We tested the different roles and responsibilities needed for coordinating internal and external partners and the community. It helped us to identify gaps and fix them to strengthen our response. A clear understanding of logistics was necessary to ensure we could provide food, water, and medical services to people during lockdown.”

Thinley Norbu

Chief Program Officer, Department of Disaster Management

Bhutan’s successful response to COVID-19 stems from years of preparedness in addition to a rapid, strongly coordinated, and well-led response. His Majesty, the King of Bhutan, has been at the forefront of the response since the emergence of SARS-CoV-2, building national solidarity through strong and invested leadership. WHO’s activities to support the government by strengthening Bhutan’s preparedness and coordination received praise from Bhutan’s Prime Minister and Health Minister. The WHO Country Office has been recognized by the United Nations in Bhutan with a certificate for “Facilitating delivery in the time of COVID-19".

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An Exemplary National COVID-19 Vaccination: Lessons from Bhutan

Sangay phuntsho.

1 Vaccine Preventable Diseases Program, Ministry of Health, Thimphu 11001, Bhutan

Tshokey Tshokey

2 Jigme Dorji Wangchuck National Referral Hospital, Thimphu 11001, Bhutan; moc.oohay@yekohst_cod

Mongal Singh Gurung

3 Research Ethics Board of Health, Ministry of Health, Thimphu 11001, Bhutan; tb.vog.htlaeh@gnurugsm

Sonam Wangdi

4 Policy and Planning Division, Ministry of Health, Thimphu 11001, Bhutan; tb.vog.htlaeh@idgnawmanos

5 WHO Country Office, Thimphu 11001, Bhutan; tni.ohw@sidgnaw

Sonam Wangchuk

6 Royal Centre for Disease Control, Ministry of Health, Thimphu 11001, Bhutan; tb.vog.htlaeh@kuhcgnaws

Associated Data

All data have been presented in the manuscript and raw data are available on request from the corresponding author.

Vaccination remains a key public health intervention against the COVID-19 pandemic. However, vaccine distribution and coverage are variable between countries due to access and implementation issues. Vaccine inequity was evident with some countries having no access to the vaccines while others have initiated multiple booster doses. We share Bhutan’s approach to COVID-19 vaccination and lessons learned during the successful conduct of a nationwide vaccination program. As of 12 December 2021, 80.3% of the Bhutanese population have received at least one dose of COVID-19 vaccine and 77.0% have received at least two doses. Considering age groups, 97.2% of adults (18 years) have received at least one dose and 93.6% have received at least two doses. The first dose coverage for the adolescents 12–17 years was 99.7% and second dose coverage was 92.3% since some were not yet due for their second dose at the time of writing this report. The well-established existing national immunization program was especially useful in the implementation of the national COVID-19 vaccination program. The Bhutan Vaccine System, a digital platform for registration and monitoring of vaccination, was rapidly developed and extensively utilized during the campaign. The selfless leadership of the king, the government, and prior detailed planning with multi-sectoral collaboration and coordination, was the key in this exemplary vaccination program. Bhutan has successfully vaccinated children between 5–11 years with high coverage and no serious issues. Many adults have also received first and second booster doses, based on their risks and preferences.

1. Introduction

An outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia was first reported in Wuhan, China, in late 2019. By the end of 2021, the virus has spread to 222 countries, infecting at least 281.808 million individuals, and killing more than 5.411 million people globally [ 1 ]. Although multiple public health measures and other mitigation strategies have prevented the massive transmission of SARS-CoV-2, it is unlikely that the world will return to its pre-pandemic normalcy until safe and effective vaccines were rolled out with high global vaccination coverage [ 2 ]. The first COVID-19 vaccinations started in early December 2020 and at least 13 different COVID-19 vaccines across four platforms have been approved for Emergency Use Authorization (EUA) by the respective country’s regulatory authorities till then [ 3 ]. In addition, by the end of 2021, there were 195 COVID-19 vaccines under pre-clinical development and 126 under various stages of clinical development [ 4 ]. At the time of writing this article, 58.1% of the world’s population have received at least one dose of COVID-19 vaccine, of which only 8.4% were in low-income countries, and a total of 9.1 billion doses were administered [ 5 ]. However, the global figure indicates huge inequalities between countries, continents, and income groups, and vaccine doses have so far been distributed unevenly among the low-income countries particularly those across Africa [ 6 ]. Months after availability of vaccines, countries still faced difficulties in allocating vaccines equally and ethically [ 7 ]. While several countries were struggling to reach the 40% coverage target by the end of 2021, other countries have vaccinated well beyond this threshold and also initiated extensive booster doses [ 8 , 9 ].

Bhutan started planning for COVID-19 vaccination since July 2020 and developed deployment plans, conducted cold chain assessment, human resource mapping, electronic recording and reporting system for real-time vaccination coverage, and AEFI monitoring. Under the benevolent guidance of His Majesty the King and the oversight of the Government, Bhutan conducted two rounds of nationwide COVID-19 vaccination campaigns achieving high coverage. Booster doses have also been provided to the eligible population. This report shares Bhutan’s experiences on conducting the nationwide COVID-19 vaccination rollout.

This study was conducted by a group of officials from the Bhutan Ministry of Health (MoH) closely involved in the planning, procurement, training, vaccination, and monitoring of the country’s COVID-19 vaccination campaign. It involved the review and analysis of official plans, guidelines, standard operating procedures, field reports, facts and figures maintained by the national vaccine program, and the day-to-day records of events during the national vaccination campaign. Data are presented as frequencies and proportions.

Administrative approval was granted by the MoH Policy and Planning Division, and ethics approval was waived by the Research Ethics Board of Health. There is no utilization of identifiable individual information and informed consent was not required.

3.1. Bhutan’s Health System

Bhutan is a small country with about 750,000 people living in twenty districts. Medical care, including medicines and vaccines, are provided free of cost by the government as mandated by the constitution [ 10 ] and there are no private hospitals. These free services are provided through a three-tier system; (i) Primary health centers, sub-posts, and outreach clinics (ORCs) at the primary level, (ii) district or general hospitals at the secondary level, and (iii) regional and national referral hospitals at the tertiary level. Traditional and allopathic medicine services are fully integrated and delivered under one roof. At the grassroots level, village health workers (VHWs) play a key role in taking the basic health services to the people. There are 51 hospitals including referral hospitals and 186 primary health centers.

3.2. Bhutan’s Existing Immunization Program

Bhutan started the Expanded Program on Immunization (EPI) in 1979 with six vaccines (BCG, DTP, TT, OPV, and measles). Subsequently, several new vaccines have been introduced and integrated into the routine immunization program considering the national disease burden, financial implications, and health infrastructure. Recently introduced vaccines include hepatitis B, rubella, Hemophilus influenzae B, human papillomavirus (HPV), inactivated polio virus, mumps, pneumococcal (PCV), and seasonal influenza vaccine. Currently, Bhutan has 13 different vaccines in the EPI program.

Bhutan achieved Universal Child Immunization (UCI) in 1991, sustained neonatal tetanus elimination since 1994, received polio free certification in 2014, measles elimination certification in 2017, and hepatitis B control certification in 2018. The country has a well-established immunization program and has sustained high routine immunization coverage above 90% for the last several years [ 11 ]. Bhutan has conducted several nationwide vaccination campaigns in the past, including National and sub-national Immunization Days (NIDs/SNIDS) in early 1990s, and recently for measles and rubella, HPV and flu vaccination campaigns. Further, continued mop-up campaigns for measles and polio are carried out on regular interval in view of national, regional, and global elimination and eradication goals. Taking cue from all these experiences, Bhutan did not foresee many challenges in rolling out COVID-19 vaccines.

3.3. Early Planning through Programmatic Approach

Bhutan started planning the nationwide vaccination long before COVID-19 vaccines were even approved. The plan was to rapidly mobilize, distribute, and complete the nationwide vaccination campaign within a short period of time. The National guideline for COVID-19 vaccination was adapted from the WHO guideline 12 on COVID-19 vaccination programs and AEFI reporting and management. All health workers were trained in this guideline before the national campaign. Health workers nationwide were adequately trained on the COVID-19 vaccination, and Adverse Events Following Immunization (AEFI) management and reporting. Vaccine cold chain storage capacity readiness assessment for all available COVID-19 vaccines were conducted and accordingly additional procurements were made in preparation for nationwide COVID-19 vaccination rollout. A dedicated risk communication and media team was established at the MoH and the Prime Minister’s Office (PMO). These two teams carried out rigorous public advocacies and awareness including sensitization of the media, local government officials and religious leaders on vaccination. They were able to adequately address vaccine hesitancy and gained adequate public trust and confidence in the vaccine and vaccination services. Bhutan only used vaccines that were granted Emergency Use Authorization (EUA) by the World Health Organization (WHO) and subsequently by the country’s Drug Regulatory Authority (DRA). These included Covishield, AstraZeneca, Moderna, Pfizer, and Sinopharm vaccines. A majority of these vaccines were donated by India, USA, European Nations, China, and the global COVAX facility, and some were purchased by the government.

3.4. National COVID-19 Vaccine Deployment Plan (NVDP) and Allocation Framework

In June, 2020, the WHO, GAVI, and the Coalition for Epidemic Preparedness Innovations (CEPI) launched the COVAX Facility and Advance Market Commitment (AMC) with the goal of ensuring rapid equitable access to safe and effective vaccines to all countries, regardless of income level. Bhutan also joined the GAVI COVAX AMC facility. With the confidence accorded by this facility in getting access to COVID-19 vaccine supply, Bhutan started planning for the deployment under different situations. As per the guideline from WHO [ 12 ] and guidance from the National Technical Advisory Group (NITAG), Bhutan developed comprehensive a National Vaccine Deployment Plan (NVDP) and allocation framework prioritizing the high-risk groups based on risk assessment [ 13 ]. The risk-based criteria were developed to prioritize the specific population groups for the vaccination, which includes risk of acquiring infection, severe morbidity and mortality, socio-economic impact, and risk of transmitting to others. These criteria were applied to specific population groups through a scoring matrix and phase-wise vaccination was recommended in the context of shortage of vaccine supplies initially. Phase one included high-risk healthcare workers, active front line workers, elderly 60 years and above, and people with chronic medical conditions. Phase two included passive front line workers and students 12 years of age and above, and staff in the schools and institutions, and phase three was for children less than 12 years and pregnant women. Although the registration and vaccination of pregnant women was encouraged, the final decision to get vaccinated was left to the individual. Children were to be vaccinated whenever the authorization was granted to the specific age-groups. The rest of the population who were not included under any of the above criteria were to be vaccinated in the fourth phase. The plan was kept dynamic, and changes were made whenever necessary based on evolving vaccines accessibility and availability, which helped in the smooth roll out of the vaccination campaign. Unlike most countries, Bhutan got adequate vaccine supplies for the entire eligible population for both first and second dose and rolled them out within a week without having to implement the phased manner which was initially envisaged and planned.

3.5. Bhutan Vaccine System (BVS)

In preparation for the COVID-19 nationwide vaccination, the MoH developed the Bhutan Vaccine System (BVS) specifically for the COVID-19 vaccination management. The BVS ( https://bvs.moh.gov.bt , accessed on 1 June 2022) is a web-based portal aimed at ensuring quality data collection for evidence-based planning and management of the COVID-19 vaccination program. Months before the vaccination campaign, the BVS was operationalized, and all the eligible individuals were encouraged to pre-register their details online. However, those who could not pre-register were provided registration on site on the day of the vaccination at the respective vaccination posts. Information thus collected through BVS was used for data driven vaccination campaign planning (particularly vaccine distribution and designation of vaccination posts) and real-time monitoring of vaccination coverage and AEFI monitoring during the campaign. The BVS feature included registration, pre-screening, vaccination planning and scheduling, dashboard with vital information, real-time AEFI data and vaccination report generation, vaccine stock inventory, and a feature to self-generate a vaccination certificate with a QR code. The registration in the system was purely voluntary in nature and basic demographic information, such as name, age, gender, identity card numbers, and addresses were collected. The BVS was a game changer for the COVID-19 vaccination program in the country.

3.6. Vaccination Posts and Floor Plan during COVID-19 Vaccination

Based on registration information of the eligible population in BVS, 1227 vaccination posts were set up in health facilities, schools, community centers, private dwellings, or temporary sheds across the country for the nationwide vaccination campaign. The schools that were identified as vaccination posts remained closed during the vaccinations. The MoH deployed more than 3600 health professionals to conduct pre-screening, vaccination, and AEFI observation and management during the campaign. In addition, about 4800 volunteers (Desuups: guardians of peace) were also deployed for crowd management, on-site registration, ensuring COVID-19 protocols were followed, and ushering the vaccinated individuals to the observation rooms and guiding their exit after fingernail marking to ensure people do not get double vaccination. This detailed pre-planning ensured smooth and seamless implementation of the campaign. Further, to ensure good vaccination coverage of all the eligible population within the allotted time frame of one-week, inter-district movements (except for emergency travels) were restricted. Most importantly, all these vaccination posts adhered to COVID-19 preventive and safety protocols with strict monitoring and supervision by the respective health workers, the national supervisors and officials from the Drug Regulatory Authority (DRA). The processes involved during the vaccination are depicted in Figure 1 .

Algorithm for vaccination process.

3.7. Nationwide COVID-19 Vaccine Distribution

The distribution of the vaccines commenced immediately upon arrival and lot release by the DRA. Vaccines were transported either by road in refrigerated vans, domestic flights and helicopter services, as per the distribution plan ( Figure 2 ). The helicopter services were critical in shipping vaccines to the hard-to-reach places where there is no motor road access.

Vaccine transport and distribution plan.

3.8. Launch of the Vaccination Campaign

Bhutan is a religious and spiritual country where astrology plays a significant role in the lives of the people. The government in consultation with the national astrologers chose an auspicious day (and time) in the Bhutanese calendar to launch the first nationwide vaccination campaign. The auspicious day fell on the 27 March 2021. Astrologers also recommended that the two auspicious people (the first dose vaccinator and the vaccinee) should be both females born in the monkey year and 30 years of age. Accordingly, on 27 March 2021, at 9.30 a.m., the campaign was launched in one of the vaccination posts in the capital city (Thimphu) followed by the launches in other districts.

3.9. AEFI Reporting and Management

The MoH developed AEFI monitoring and management of the BVS in line with the WHO guideline on COVID-19 vaccination program and AEFI reporting and management and trained all health workers on the guideline [ 14 ]. During the vaccination campaign, two or more vaccination posts had a mobile doctor deployed to guide, supervise, monitor and manage any AEFIs. As a precaution, all individuals were pre-screened for any risk factors before vaccination and were mandatorily kept under observation for at least 30 min after receiving the injection. For the convenience of the vaccinees, especially for those who reside away from health centers, prophylactic antipyretic (paracetamol) tablets were distributed after completing the 30-min observation. The NITAG and Regional Immunization Technical Advisory Group (RITAG) members were trained on COVID-19 vaccines AEFI management and stationed in the hotline centers during the campaign to monitor and provide technical guidance in addition to reviewing all the reported AEFI cases in BVS on a daily basis.

3.10. Target Population and Data Analysis

The target population was calculated based on the 2021 resident population of Bhutan which was estimated by the Civil Registration and Vital Statistics System (CRVS) of Bhutan and National Statistics Bureau (NSB). The population estimate included foreigners currently residing in the country and Bhutanese citizens who were out of the country. The vaccination data, including socio-demographic characteristics (age, sex, occupation, place of residence) and self-reported information on existing health conditions, allergies, and disability(s), were collected through BVS during the registration. AEFIs were collected during and/or after the vaccination. The data collected through BVS were exported and cleaned using EpiData software for missing values and outliers. The analysis utilized the cleaned data set after removing the duplicate entries and incorporating missing information which were re-validated through phone calls.

3.11. Vaccination Coverage

The vaccination coverage for different age cohorts for the first and second doses is shown in Figure 3 . The overall population coverage was 80.3% and 77.0% for the first and second dose, respectively. In the adult population (18 years and above) the first dose coverage was 97.2% and second dose 93.6%. In the adolescents between 12 and 17 years, the first dose coverage was 99.7% and second dose 92.3%, respectively. As per the global vaccination status in December 2021, Bhutan stood at 14th highest share of fully vaccinated for COVID-19 vaccination coverage among the countries in the world [ 5 ].

COVID-19 vaccination coverage for the first and second doses.

3.12. AEFIs Reported during the Vaccination Campaign

AEFI cases were reported on a real-time basis through the BVS and managed immediately. The causality assessment was conducted by the national experts for all the serious AEFIs reported using the WHO causality assessment tool. The summary of number of minor and serious AEFIs reported against each vaccine type is shown in Table 1 below.

Adverse Events Following Immunization rate for the first and second dose against different vaccines.

1 Per 1000 vaccinated people; 2 Per 100,000 vaccinated people.

3.13. Vaccine Wastage Rate

Vaccine wastage is a huge concern due to the global shortage of COVID-19 vaccines and the cost implications. As per the WHO, vaccine wastage is calculated as:

• Vaccine usage rate = Number of doses administered/Number of doses issued × 100, and
• Vaccine wastage rate = 100 − vaccine usage rate

The overall wastage rate was 9.8% (n = 51,233 doses), with the wastage rate of 1.4% ( n = 7382 doses) during the first dose vaccination campaign and 8.4% ( n = 43851 doses) during the second vaccination campaign. The main reasons for the wastages were due to the short vaccine expiry date (85.1%), opened vials discarded after vaccination sessions (13.7%), broken vials (0.12%) and others (1.12%). Vaccine wastage rate was comparatively lower than the WHO acceptable wastage rate of 15% for multi dose vials containing 10 or more doses per vial [ 15 ].

3.14. Vaccine Hesitancy in Bhutan

As countries initiated vaccinations, vaccine hesitancy was a big issue. Reports on the COVID-19 vaccines being produced within short span of time, fake news, and widespread circulation of untrue information on social media most likely worsened vaccine hesitancy. Frank anti-vax is not known in Bhutan. The timely and effective risk communication and continued awareness program by the MoH and the PMO through various platforms (local government, monastic institutions, media houses, NGOs, social media influencers, etc.) were critical in reducing vaccine hesitancy and maximizing the vaccine uptake. A vaccine hesitancy online survey conducted prior to vaccination in the country in mid 2020 ( n = 7476), revealed about 58% of the respondents would definitely take the vaccine and 27% would probably take it if it were made available. About 4% said they would not take the vaccine and 11% were undecided. However, when the actual vaccine arrived and the nationwide campaign started, many people chose to get vaccinated. Although the survey showed a significant number of unwilling or undecided people, during the campaign, most people took the vaccines, perhaps due to wide availability of the vaccine at the doorstep and increasing local and global confidences in the vaccines by the time vaccines were rolled out in the country.

3.15. Estimated Vaccination Program Cost

The estimated vaccine delivery costs (excluding vaccine costs) for the first and second dose cost per fully vaccinated individual is summarized in Table 2 . The combined overall program cost for the first and second dose was USD 0.995 million ( First dose: USD 0.661 million, Second dose: USD 0.334 million ). The high program cost for the first dose was due to capacity-building of the health workers, cost for the BVS development, and procurement of immunization supplies and equipment which were not required during the second dose. These estimated costs were generated from records maintained by the Vaccine Preventable Disease Program with the assistance of the Ministry’s Administration and Finance Division.

Cost distribution by activity and cost per fully vaccinated, Bhutan, 2021.

4. Discussion

The first and the subsequent nationwide COVID-19 vaccination campaigns carried out in Bhutan are hailed as an example to the international community. Of all the things that contributed to this exemplary program is the leadership of the King, Prime Minister’s office, and the health and foreign ministries, together with detailed prior planning with a multi-sectoral collaborative approach and support provided by all relevant stakeholders. Building on an existing strong foundation of a national immunization program and experiences in conducting the nationwide vaccination campaigns in the past has helped health workers, districts, and central planners to implement the nationwide campaign successfully. Further, the use of the BVS for planning and vaccine distribution, real-time vaccination progress tracking and monitoring, and AEFI reporting and management was instrumental. The timely and effective risk communication and continued awareness program by the MoH and the PMO through various platforms were critical in reducing vaccine hesitancy and maximizing the vaccination coverage. The needs-based update in the vaccine deployment plan according to the real-time status update has helped minimize unforeseen challenges and allowed for smooth roll out of the vaccination campaign.

Post-vaccination campaign reviews and Inter-Action Review (IAR) meetings with relevant stakeholders, including representatives from the field after the first dose, were essential in making necessary improvements for the subsequent vaccination programs. For instance, during the first dose of adult vaccination, it was learned that some individuals who were alcohol dependent had stopped drinking a few days back prior to their vaccination schedule date, and this led to reporting of some alcohol withdrawal seizures adverse events at vaccination posts or at home after vaccination. Such adverse events were not reported during the second dose campaign after advocacy was carried out. During the first dose campaign, there were four incidences of people who received double doses of the vaccine, and with re-enforcement of proper procedures this was reduced to two incidences during the second campaign. Further, the implementation and experiences gained during the COVID-19 vaccination campaigns has contributed immensely to strengthening the overall immunization system in the country. The real-time immunization data management through BVS and overall cold chain capacity in the country has been strengthened. Building on the COVID-19 vaccines initiatives and to embrace the digital solution, all future vaccines are to be incorporated into BVS. To start with, the seasonal influenza vaccination for 2021 was already integrated into the system and HPV is planned in 2022, and subsequently all other childhood vaccines are to be administered using BVS. One of the strategies that has impacted in achieving high coverage is conducting a catch-up vaccination program after the campaign as a last mile to reach the maximum number of people, and also home-based and quarantine facility-based vaccination services. However, this approach was found to be time consuming and resource intensive.

The COVID-19 pandemic, which is probably the most devastating one in the last 100 years after Spanish flu, mandated the speedy evaluation of the multiple approaches for competence to elicit protective immunity and safety to curtail unwanted immune-potentiation which plays an important role in the pathogenesis of this virus [ 16 ]. The current COVID-19 pandemic has urged the scientific community internationally to find answers in terms of therapeutics and vaccines to control SARS-CoV-2 [ 17 ]. The United Nations and the WHO launched a strategy to vaccinate 40% of the world’s population against COVID-19 by the end 2021 and 70% by mid 2022 [ 17 ]. The earlier goal to vaccinate 10% of every country’s population by the end of September 2021 has fallen short, with 56 countries, mainly in Africa and the Middle East, unable to meet the target [ 17 ]. The vaccine production from various manufacturing companies has reached 1.5 billion doses per month and it is not a supply problem anymore but it is an allocation problem [ 17 ]. On the contrary, Bhutan has successfully vaccinated 80.2% of the overall population with a first dose and 76.8% with a second dose. Many have received booster doses. Children between 5–11 years have also been vaccinated without any issues. The COVID-19 vaccines must be a global public good and COVID-19 vaccines should contribute significantly to the equitable protection and promotion of human well-being among all people of the world. Safe and effective vaccines are a game-changing tool, and fair and equitable access to every country is of utmost importance to protect the people. Critics have argued that the high vaccination coverage in Bhutan is possible due to its relatively smaller population (less than one million people). However, it is noteworthy that many smaller countries more economically advanced than Bhutan have not be able to achieve the same results.

5. Limitations

This study was conducted after the completion of the second dose vaccination campaign in the country, and the data including the coverage for the subsequent doses, as well as vaccination for the children, are not included in this work.

6. Conclusions

Bhutan has achieved a high vaccination coverage for both doses and boosters within a short time. This was attributed to the great leadership and detailed early programmatic planning. Utilization and building on the strong existing vaccination systems can aid in rapid national vaccination campaigns in outbreaks and pandemics. Digitalization of the current EPI program through the adoption of the BVS will contribute to the success of routine vaccination program in Bhutan.

Acknowledgments

The authors would like to thank the MoH Management, National Immunization Technical Advisory Group (NITAG) members, COVID-19 vaccination data team and all other stakeholders involved in the vaccination campaign for their guidance and support. And the authors thank the Ministry of Health for bearing the article processing charges.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, S.P., T.T., M.S.G. and S.W. (Sonam Wangchuk); methodology, S.P., T.T., S.W. ([email protected]), S.W. ([email protected]), M.S.G. and S.W. (Sonam Wangchuk); software, S.P., T.T., M.S.G. and S.W. (Sonam Wangchuk); validation, S.P., T.T., M.S.G. and S.W. (Sonam Wangchuk); formal analysis, S.P., T.T., M.S.G., S.W. ([email protected]), S.W. ([email protected]) and S.W. (Sonam Wangchuk); investigation, S.P., T.T., M.S.G., S.W. ([email protected]), S.W. ([email protected]) and S.W. (Sonam Wangchuk); resources, S.P., T.T., M.S.G., S.W. ([email protected]), S.W. ([email protected]) and S.W. (Sonam Wangchuk); data curation, S.P., T.T., M.S.G., S.W. ([email protected]), S.W. ([email protected]) and S.W. (Sonam Wangchuk); writing—original draft preparation, S.P., T.T.; writing—review and editing, S.P., T.T., M.S.G., S.W. ([email protected]), S.W. ([email protected]) and S.W. (Sonam Wangchuk); visualization, S.P., T.T., M.S.G., S.W. ([email protected]), S.W. ([email protected]) and S.W. (Sonam Wangchuk); supervision, S.P., T.T. and S.W. (Sonam Wangchuk); project administration, S.P. and S.W. (Sonam Wangchuk); funding acquisition, S.P.; All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The administrative clearance for this paper has been granted by the Ministry of Health, Royal Government of Bhutan, and the ethical clearance was exempted by the Research Ethics Board of Health, Bhutan.

Informed Consent Statement

Informed consent was waived since this study was undertaken as a routine public health monitoring activity and there was no direct patient interaction and/or intervention.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

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• Published: 05 January 2022

The COVID-19 vaccination campaign in Bhutan: strategy and enablers

• Tsheten Tsheten   ORCID: orcid.org/0000-0002-8071-5721 1 , 2 ,
• Phurpa Tenzin 3 ,
• Archie C. A. Clements 4 , 5 ,
• Darren J. Gray 1 ,
• Lhawang Ugyel 6 &
• Kinley Wangdi 1  

Infectious Diseases of Poverty volume  11 , Article number:  6 ( 2022 ) Cite this article

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Bhutan has reported a total of 2596 COVID-19 cases and three deaths as of September 15, 2021. With support from India, the United States, Denmark, the People’s Republic of China, Croatia and other countries, Bhutan was able to conduct two rounds of nationwide vaccination campaign. While many countries struggle to overcome vaccine refusal or hesitancy due to complacency, a lack of trust, inconvenience and fear, escalated in some countries by anti-vaccine groups, Bhutan managed to inoculate more than 95% of its eligible populations in two rounds of vaccination campaign. Enabling factors of this successful vaccination campaign were strong national leadership, a well-coordinated national preparedness plan, and high acceptability of vaccine due to effective mass communication and social engagement led by religious figures, volunteers and local leaders. In this short report, we described the national strategic plan and enabling factors that led to the success of this historical vaccination campaign.

Bhutan, a small landlocked country with a total area of 38,394 km 2 , is nestled in the Eastern Himalayas between India and China. The current population of the country is projected at 756,129 with a sex ratio of 110 males to 100 females. The majority (62%) of the population lives in rural areas. The median age is 26.5 years with an overall life expectancy of 70.3 years [ 1 ].

The coronavirus disease 2019 (COVID-19) in Bhutan was first confirmed on 5 March 2019, in a 76-year-old tourist [ 2 ]. Subsequently, there were sporadic cases and localized outbreaks in different parts of the country [ 3 ]. As of 15 September 2021, there were 2,596 confirmed cases and three deaths in the country (Fig.  1 ).

Source: World Health Organization)

Daily reporting of COVID-19 cases from the beginning of the pandemic and the time period of nationwide vaccination rounds, Bhutan, 2021 (

The vaccination program in Bhutan was introduced as a part of the global initiative to eradicate smallpox [ 4 ]. Whilst diphtheria, pertussis and tetanus (DPT), oral polio vaccine (OPV) and Bacillus Calmette-Guerin (BCG) vaccines were introduced in few districts in 1976, Bhutan launched its expanded programme on immunization (EPI) in 1979 to develop and expand immunization services to achieve Universal Childhood Immunization [ 4 ]. At present, Bhutan provides vaccines against tuberculosis, hepatitis B (hepB), poliomyelitis, diphtheria, tetanus, pertussis, haemophilus influenza type b (hib), measles, mumps and rubella. According to the 2020 EPI report, Bhutan has achieved more than 80% coverage for all vaccines in 20 districts without a single case of vaccine dropout for the pentavalent vaccine (DPT-hib-HepB) [ 5 ]. Recently, Bhutan expanded its national immunization schedule by introducing vaccines against human papilloma virus (2010), pneumonia (2019) and influenza (2020) [ 6 ].

Vaccination is one of the most cost-effective ways of preventing infectious diseases, currently saving 4–5 million deaths every year [ 7 ]. Notwithstanding the progress of vaccines, far too many people have insufficient access to vaccines particularly in developing countries due to inadequate resources [ 8 ]. To make the situation worse, vaccination coverage remains suboptimal due to the high level of vaccine hesitancy related to complacency, barriers to accessing vaccines, a lack of trust in government authorities, misinformation, and fear of adverse effects following immunization [ 9 ]. Here, we aimed to provide our perspectives on the drives that enabled high coverage of the COVID-19 vaccination campaign in Bhutan.

Vaccination strategy

Bhutan conducted its first nationwide COVID-19 vaccination round with the inoculation of the Covishield vaccine (Oxford-AstraZeneca) on 27 March 2021 coinciding with an auspicious day of the local astrological belief (Fig.  1 ). For the first round, Bhutan received a total of 550,000 doses of Covishield vaccine (Oxford-AstraZeneca) from India through the vaccine Maitri initiative as a goodwill gesture of friendship between the two countries. Of the total 496,044 eligible population aged ≥ 18 years, 478,829 were vaccinated across 1,217 vaccination centres in 3 weeks of the campaign, achieving a vaccination coverage of 96.5% [ 1 , 10 ] (Fig.  2 ).

Source: Ministry of Health Facebook page)

Distribution of vaccination posts/centres across 20 districts during the COVID-19 vaccination campaign in Bhutan, 2021. The figure in the circle indicates the number of vaccination posts set up in each district (

Due to a massive surge in cases and a shortage of vaccine supply in India, Bhutan sought support from other countries to provide vaccines, including the United States (500,000 doses Moderna and 5,850 doses of Pfizer-BioNTech vaccine), Denmark (250,000 doses of AstraZeneca vaccine), Croatia, Bulgaria and others (~ 100,000 doses of AstraZeneca vaccine), and the People’s Republic of China (50,000 doses of Sinopharm vaccine). Similar to the first COVID-19 vaccination round, the second round kicked off on the auspicious day of 20 July 2021 (Fig.  1 ). However, during this campaign, Bhutanese had the option to choose other brands such as Moderna, Pfizer-BioNTech, and Sinopharm vaccines. A cumulative total of 473,715 people were vaccinated within 2 weeks, covering 95.6% of the eligible adult population [ 11 ]. Of those vaccinated, 95% received heterologous vaccines and the remaining received homologous vaccines [ 12 ].

Enablers of vaccine uptake

Enabling factors that led to high vaccination coverage in Bhutan are described below.

Strong leadership

The Prime Minister and the Health Minister guided and led the COVID-19 National and Regional Task Force committees responsible for planning and implementing all COVID-19 related initiatives. Perhaps, unique to Bhutan is the leadership role played by His Majesty the Fifth King, Jigme Khesar Namgyel Wangchuck. His Majesty worked together with the government in encouraging and inspiring the public to take COVID-19 vaccines. His Majesty has also visited the diverse geographical terrains in the mountainous northern borders and the hot and humid southern borders. During these royal visits, His Majesty visited and supervised vaccination posts to ensure vaccine toolkits and other necessary resources are put into place for the safe vaccination of the population.

Vaccination planning

Planning of the National vaccination campaign began soon after the start of the pandemic, at a time when vaccine trials were initiated in other countries. The Bhutan Vaccine System (BVS) ( https://bvs.moh.gov.bt/ ) was developed and successfully implemented to digitally enumerate the eligible population for vaccination. In addition, BVS was used to select the number of vaccination posts, their locations and automatic generation of vaccine certificates for the vaccine recipients. BVS also provided an important platform to follow up with the registered individuals and encourage them for the vaccination program. This system is managed by the Ministry of Health (MoH) and is user-friendly, leading to a high proportion of people being registered in it.

For the elderly and those individuals with mobility issues, home-based vaccinations were arranged. To overcome the physical barriers of rugged, mountainous terrain and to maintain a proper cold chain of the vaccine during the transportation process, vaccination services were facilitated by the Royal Bhutan Airlines and the Bhutan Helicopter Services Limited. This meant that vaccines were available in all the vaccination posts.

Vaccine communication

A massive public education programme was undertaken using appropriate vaccine communication strategies including pamphlets, advertisements on the national television channel (BBSTV) and radio, press briefs, and notices on the Facebook page of the MoH and the Prime Minister’s Office (PMO). The Prime Minister, Foreign Minister, and Health Minister regularly provided updates to alleviate any fear of vaccination. Further, the benefits of COVID-19 vaccination were discussed on BBSTV by vaccine experts and epidemiologists.

Health and religion

The Central Monk Body of Bhutan ( Zhung Dratshang ) and other monastic organizations led by spiritual masters ( Rinpoches ) played a pivotal role in building trust in COVID-19 control through vaccination and other means. The specific times of the vaccination rounds were fixed according to the advice of the Zhung Dratshang based on astrological beliefs. Through religious discourse and teachings, these organizations were able to inspire people with otherwise anti-vaccine sentiments, along with the population at large, to accept the vaccine.

Social engagement

A large volunteer workforce, known locally as Desuups ( www.desuung.org.bt ), came forward to facilitate the organization of vaccination rounds and other activities to control COVID-19 [ 3 ]. Founded by the Fifth King, Desuup trainees undergo a value-based personal development program to encourage volunteerism for community services and play an active role in building the nation. During the vaccination campaign, Desuups were deployed in every vaccination post and supported conducting online registration and verification of vaccine recipients, and ensuring compliance with the COVID-19 safety protocol. The armed forces, foresters and customs officials were also deployed to support the vaccination campaign as well as during the COVID-19 pandemic to maintain law and order in strategic locations such as crowded places and along the border to prevent illegal immigrants. It is interesting to note that many people, after receiving the vaccine, described their positive experiences on their social media platforms and the MoH web page, encouraging people to get vaccinated.

There are a few limitations worth noting in this study. Firstly, opinions expressed in this study could have been influenced by the researcher’s perception and understanding of the vaccination campaign. Secondly, inferences were based on the vaccination data from open sources such as the Facebook page of the MOH and the PMO. Authors believe these are credible sources with reliable information.

Conclusions

Adequate vaccination is the most important long-term solutions in the fight against COVID-19. Bhutan’s high coverage of COVID-19 vaccine is attributed to strong leadership, a well-coordinated national preparedness plan, regular communication strategies and successful social mobilization. Despite high vaccination coverage, the COVID-19 containment measures such as social distancing and handwashing have to be continued to limit the spread of COVID-19, particularly in the context of new emerging coronavirus variants and low vaccine coverage in neighbouring countries. Additional rounds, including booster doses, might be necessary for the continued protection of the population.

Availability of data and materials

The dataset used and in the current study were available on the WHO website ( https://covid19.who.int/table ).

Abbreviations

Bhutan Broadcasting Service Television

Bhutan Vaccine System

Coronavirus disease 2019

Ministry of Health

Prime Minister Office

United Nations Development Programme

Village Health Worker

World Health Organization

National Statistical Bureau. Dzongkhag Population Projections, 2017–2027. 2017.

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Tsheten, T., Tenzin, P., Clements, A.C.A. et al. The COVID-19 vaccination campaign in Bhutan: strategy and enablers. Infect Dis Poverty 11 , 6 (2022). https://doi.org/10.1186/s40249-021-00929-x

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What the world can learn from Bhutan’s rapid COVID vaccine rollout

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Nearly half the world’s population has received at least one dose of a COVID-19 vaccine. But figures vary widely between countries. Many low and middle-income countries have barely started their vaccination campaigns.

But the tiny Himalayan nation of Bhutan isn’t one of them. By the end of July, it had fully vaccinated 90% of its adults. Despite having few doctors and nurses, across just three weeks in the summer it delivered a second vaccine dose to nearly every adult in the country. This is a remarkable success story for one of the least developed countries in the world.

Health minister Dechen Wangmo credits solidarity, Bhutan’s small size and its science-based policymaking for its success. Its achievement highlights how logistical challenges and vaccine hesitancy can be overcome.

Donations are crucial

Bhutan’s success wouldn’t have been possible without international cooperation. Its first vaccines were donated by India . By March 2021, India had sent 450,000 doses of the AstraZeneca vaccine, enough to give all eligible adults in Bhutan their first dose in the spring.

But getting hold of second doses was a challenge. India’s second wave soon arrived, causing it to prioritise domestic immunisations and ban vaccine exports . Bhutan’s immediate source of doses had dried up, while India’s mounting caseload over the border posed a rapidly increasing infection risk.

After a tense wait, 500,000 doses of the Moderna vaccine came from the US through Covax , the vaccine-sharing initiative. An additional 250,000 doses of the AstraZeneca vaccine came from Denmark, followed by supplies of AstraZeneca, Pfizer and Sinopharm vaccines from Bulgaria, Croatia, China and other countries.

Planning makes the logistics work

Distribution was another big part of the puzzle. Bhutan is remote. Land access is only possible on a few roads from India. The Covax vaccines arrived by air at Paro International Airport. One of the most challenging landings in the world, Paro sits in a deep valley. The surrounding peaks are as high as 5,500 metres.

Domestic transport is also challenging. Bhutan’s population of almost 750,000 is scattered over an area roughly the size of Switzerland. Not all of the mountainous country is accessible by road.

Because of this, the health ministry had to plan in detail how to get all adults their first and second doses as quickly as possible. This involved extensive field visits to remote districts, to map where people were and identify possible vaccination sites. The visits also established ways of supplying these sites – by road, air or even on foot for the most inaccessible areas.

Schools, monasteries and other public buildings were used as vaccination centres. Keeping vaccines sufficiently cold at smaller locations could be challenging, so district hubs were created across the country to store vaccines and coordinate distribution to smaller sites as doses were needed. Domestic flights and a helicopter shuttle service were used to move doses around the country.

And a digital platform – the Bhutan Vaccination System – helped speed up the rollout of second doses. It allowed people to pre-register online before receiving their jab and so not waste time filling in personal details at the vaccine centre.

User research was also central to Bhutan’s planning phase . The health ministry ran online conferences with healthcare workers and authorities at district and village level to highlight expected challenges. Simultaneously, the ministry mobilised and trained healthcare workers to vaccinate and monitor patients.

But with only 376 doctors in the country, the planning phase soon identified a shortage of medical personnel. So 50 registered doctors known to be studying overseas were recalled .

Nurses and healthcare workers were supported by the “ Guardians of the Peace ” – a part volunteering, part national service programme that has been run in Bhutan for the last decade and has 4,500 members. These guardians encouraged people to get vaccinated and helped manage vaccine centres.

Set a good example

Good leadership has also been a hallmark of Bhutan’s vaccine rollout. There are high levels of trust in the country’s political leaders. This has been helped during the pandemic by the government having two doctors and two public health experts in its 11-member cabinet . The prime minister and the health minister have spent substantial time on the national response to COVID-19.

The role of King Jigme Khesar Namgyel Wangchuck should also not be underestimated. While Bhutan became a constitutional monarchy in 2008, transitioning to having a democratically elected government, the king is still much revered. His presence has been felt throughout the country, as he has travelled to remote settlements to oversee protection measures.

One such journey was a five-day trek to meet and thank healthcare workers. Leading by example, he quarantines in a hotel whenever he returns to the capital.

Bhutan’s politicians also engaged with the public to overcome vaccine hesitancy. A survey studied the public’s concerns, with the government’s response focusing on communicating the science behind the vaccine. Uptake was promoted by social media influencers and television and film personalities.

Cultural sensitivity was also crucial to ensuring public support. For example, Buddhist monks determined when to roll the vaccines out and picked the most auspicious time (the majority of the population is Buddhist). Monks also determined that the first dose should be administered by a women and given to a women born in the Year of the Monkey.

Not every country can achieve what Bhutan has. Having a small population and high trust in authorities facilitated this rollout. But Bhutan demonstrates that a fast and equitable vaccine rollout is possible in low and middle-income countries.

What’s clear is that the international community has to work together on the provision of vaccines. Support may also be needed to manage distribution, as getting doses to remote parts of the world’s least developed countries is a huge challenge. Bhutan, though, should offer encouragement that meeting it is possible.

• Coronavirus
• Coronavirus insights
• COVID-19 vaccine rollout

Economics Editor

Deputy Vice-Chancellor (Indigenous Strategy and Services)

Director and Chief of Staff, Indigenous Portfolio

Chief People & Culture Officer

Lecturer / senior lecturer in construction and project management.