Colorectal Cancer in Bhutan: Identifying Health System Gaps and Priorities

ABSTRACT

Background

Colorectal cancer (CRC) is an emerging public health concern in Bhutan, a lower‐middle‐income country with a geographically challenging terrain and limited specialised oncology services. As the country undergoes an epidemiological and economic transition, CRC numbers are steadily increasing. While Bhutan has made progress in cancer control through national programmes, CRC has not been a priority cancer, and health system readiness for its screening and management remains unclear. This study aimed to assess CRC care delivery in Bhutan and identify systems gaps using the World Health Organisation's health system building blocks framework.

Methods

A qualitative study was conducted using semi‐structured interviews with key stakeholders involved in cancer care delivery. Interviews were conducted in person or via secure virtual platforms and analysed using inductive thematic analysis and deductive coding guided by the WHO health systems framework until thematic saturation was reached. A comprehensive document review of publicly available CRC‐relevant services was also performed to complement the interview data collected. In total, twenty stakeholders including clinicians, policymakers, nurses and traditional medical practitioners were interviewed.

Results and Discussion

The results reflected key health system challenges including workforce shortages due to overseas migration, limited subspecialty training, and inadequate technical expertise within policymaking structures. Infrastructure constraints such as intermittent connectivity and power outages affected the functionality of the national electronic Patient Information System. CRC services remain highly centralised at tertiary hospitals, resulting in financial and geographic barriers for patients from remote districts. Medicine shortages, constrained health financing, and reliance on overseas referrals further limit service capacity. Sociocultural factors, including reliance on informal healers and delayed care‐seeking behaviours, also contribute to late presentations.

Conclusion

Strengthening CRC care requires coordinated health system reforms and Bhutan's experience offers important lessons for small health systems seeking to strengthen cancer care amid resource constraints and complex sociopolitical contexts.

Patient and Public Involvement Statement

Neither patients nor the public were involved in the development, analysis or writing of this study.

1. Introduction

Cancer is a leading cause of morbidity and mortality worldwide, with an estimated 19.3 million new cases and 10.0 million deaths globally in 2020 [1]. While previously concentrated in high‐income settings, cancer incidence and mortality are rising across low‐ and middle‐income countries (LMICs), driven by population ageing, epidemiological transition toward non‐communicable diseases, and improved detection [2]. These trends have profound implications for health systems that are often constrained by limited resources, workforce shortages, and fragmented care pathways. In this context, population‐level cancer prevention and early detection strategies have emerged as critical public health interventions to reduce premature mortality and improve equity in access to care [3].

Bhutan, a small lower‐middle‐income country in the Eastern Himalayas with a population of approximately 790,000, exemplifies many of these challenges [4]. Despite a nationally administered three‐tier health system that provides healthcare free of cost at the point of service, Bhutan's cancer burden has increased steadily. Between 2014 and 2018, over 2700 new cancer cases were reported, with age‐adjusted incidence rates of 76.4 per 100,000 among males and 101.7 per 100,000 among females [5]. Cancers now rank as the third leading cause of mortality in Bhutan, following cardiovascular disease and alcohol‐related liver disease. Among men, gastric, oesophageal, liver, and lung cancers predominate, while cervical, gastric, breast, thyroid, and ovarian cancers are most common among women [5].

Addressing this growing burden is directly aligned with Sustainable Development Goal (SDG) 3.4, which calls for a one‐third reduction in premature mortality from NCDs by 2030 [6]. However, cancer control in Bhutan faces significant structural and contextual challenges. While diagnostic confirmation and limited oncological services are available at the three referral hospitals (one national referral hospital and two regional referral hospitals), the country has historically lacked key specialist services, including medical oncology, haemato‐oncology, and radiation therapy [7]. Consequently, many patients requiring advanced cancer treatment are referred to India, incurring substantial financial, social, and logistical implications for both patients and the state [5].

In response to these challenges, the Royal Government of Bhutan adopted the Bhutan Cancer Control Strategy 2019–2025, a comprehensive national framework designed to reduce cancer incidence and mortality while improving quality of life for patients [8]. The strategy prioritises leadership and governance, cost‐effective prevention, evidence‐based screening and early detection, people‐centred service delivery, integrated palliative care, and strengthened surveillance and research. Implementation has been coordinated through the National Cancer Control Programme (NCCP) established in 2020. However, the impact of these reforms has not been formally evaluated, and persistent gaps in cancer care delivery remain. As the 2019–2025 strategy period concludes, there is a pressing need to characterise residual health system gaps and identify evidence‐informed approaches to strengthen cancer care delivery for Bhutan's population.

2. The Health Flagship Programme: A Landmark National Effort in Cancer Detection and Treatment (2020–2023)

As part of its NCCP, Bhutan implemented a nationwide cancer screening programme from 2020 to 2023 under the Twelfth Five‐Year Plan. The programme targeted gastric, cervical, and breast cancers due to their high burden and potential for early detection, aiming to improve screening coverage and ensure linkage to diagnosis and treatment (Appendix S1) [9].

Beyond screening, the Health Flagship Programme strengthened the health system by expanding diagnostic infrastructure, decentralising services, and building workforce capacity. Programme data were integrated into national digital platforms such as District Health Information Software 2 (DHIS2) and the Electronic Patient Information System (ePIS), supporting improved cancer surveillance [9]. However, challenges remain, including limited oncology specialists, lack of in‐country radiotherapy, and uneven access to palliative care. Emerging cancers such as colorectal cancer (CRC) were not prioritised.

Although Bhutan has historically prioritised gastric, cervical, and breast cancers, emerging national data indicate a rising incidence of CRC, likely reflecting broader epidemiological transitions associated with population ageing, changing lifestyle factors [10]. The increasingly worrying numbers are reported in Figure 1 and Table 1 below. The absence of population‐based colorectal cancer screening and limited research on system readiness further constrain timely detection and effective management.

FIGURE 1.

Map of frequency of colorectal cancers detected in individual districts.

TABLE 1.

Epidemiology of colorectal cancer cases from 2018 to 2024 in Bhutan.

District	Frequency	Percentage
Bumthang	6	3.3
Chukha	10	5.5
Dagana	7	3.8
Gasa	1	0.5
Haa	2	1.1
Lhuentse	9	4.9
Mongar	14	7.7
Paro	7	3.8
Pema Gatshel	15	8.2
Punakha	4	2.2
Samdrup Jongkhar	13	7.1
Samtse	14	7.7
Sarpang	14	7.7
Thimphu	7	3.8
Trashi Yangtse	5	2.7
Trashigang	28	15.4
Trongsa	4	2.2
Tsirang	6	3.2
Wangdue Phodrang	7	3.8
Zhemgang	7	3.8
No information	2	1.1
Total	182	100.0

Therefore, the research objectives of this paper are to comprehensively explore Bhutan's CRC care delivery and develop evidence‐informed policy recommendations to improve service delivery through a validated health systems framework.

3. Contextualising the CRC Numbers

To contextualise the emerging CRC burden, we present recent case counts compiled by the primary data custodian and co‐author (Dr Prabhat Pradhan, Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Thimphu), with district‐level distribution summarised in Figure 1 and Table 1. The numbers from each district were collated from patients who presented to JDWNRH (total number screened as the denominator) and screened based on their clinical presentations.

4. Health System Building Blocks

Improving cancer screening and management often goes beyond clinical care and into the realm of the health system. The World Health Organisation's six health system building blocks were founded in 2007 and provide a standard framework for evaluating health systems [11]. The building blocks include health financing, workforce, information systems, service delivery, medicines and equipment and governance and leadership. This framework frames cancer care services as a system‐wide challenge rather than a purely clinical problem making this an appropriate framework to understand the health systems factors affecting CRC care delivery in Bhutan. A detailed explanation of the framework can be found in Appendix S2.

To this end, this research seeks to comprehensively explore colorectal cancer (CRC) care delivery in Bhutan and develop evidence‐based policy recommendations to improve CRC service delivery through exploring stakeholder perspectives on the health system landscape for effective CRC service delivery in Bhutan using the WHO health system building blocks framework.

5. Materials and Methods

5.1. Study Design

This qualitative study was conducted between September and December 2025 using semi‐structured in‐depth interviews with key stakeholders following the Consolidated criteria for reporting qualitative studies (COREQ): 32‐item checklist (Appendix S3). An open‐ended interview approach allowed participants to share experiences and motivations in the delivery of colorectal cancer (CRC) services. Participants included a diverse group of professionals such as nurses, physicians, policymakers, civil society members, and public health professionals who were directly or indirectly involved in CRC care, such as the delivery of CRC health services in various clinical settings or CRC‐relevant policy implementation. Due to the limited healthcare workforce in Bhutan, where some specialties or policy areas may have only a single representative, participant anonymity was protected by reporting only broad roles, gender, and a de‐identified index in the results. Interviews were supplemented by a comprehensive document review of publicly available technical reports, policy briefs, and research publications on CRC in Bhutan from government websites and scientific databases (Appendix S4).

5.2. Sample Size

A purposive sampling approach was used to recruit participants from a colonoscopy training camp at JDWNRH organised by a Singapore surgical team and meetings during the same period attended by CD. These meetings were for the purposes of establishing the continuity of future colonoscopy training camps and research collaborations between Singapore and Bhutan. Participants had no prior relationship with the primary researcher. Recruitment occurred both in Bhutan and remotely after the training camp, using snowball sampling and publicly available institutional contacts.

The main on‐the‐ground recruitment site was JDWNRH, as most of the healthcare workers directly involved in CRC‐related work would have been present at the coloscopy training camp conducted. Having a modestly sized healthcare workforce, the camp allowed recruitment of the majority of healthcare workers directly involved in CRC services. Recruitment continued until thematic saturation, where collecting and coding more data derived no further themes, resulting in twenty participants with no dropouts.

5.3. Inclusion Criteria

The inclusion criteria for this study were: (a) above the age of 18 years, (b) who are involved or have expertise in cancer care services delivery, (c) consented to audio recording or note taking during the interview, and (d) able to converse in basic English.

5.4. Data Collection

Data collection was conducted either in person in Bhutan or remotely from Singapore via secure platforms (Zoom or Microsoft Teams). In‐person interviews were conducted by CD in a private setting at participants' convenience. The topic guide deployed was developed to elicit responses pertaining to the research question, covering the domains of clinical operations, health systems and health policy broadly, while permitting space for professional reflections (Appendix S5). Interviews lasted 20–60 min and were audio recorded and transcribed verbatim. Transcripts were de‐identified using random codes. If recording was declined, handwritten notes were taken and later de‐identified. Field notes were collected when appropriate, and no repeat interviews were conducted.

5.5. Analysis Plan

Audio recordings were transcribed verbatim by CD. Member checking was not performed. Transcripts were analysed using both inductive thematic analysis and deductive analysis guided by the WHO health systems building blocks framework using NVivo version 12 (QSR International). The research team followed the six‐step thematic analysis approach by Braun and Clarke seen in Figure 2 [12]. CD first familiarised himself with the transcripts, coded data relevant to the research question, and organised codes into themes aligned with the WHO framework. To enhance trustworthiness, coding disagreements were discussed with two co‐coders (EE, SY) until consensus was reached. Coders independently analysed selected transcripts and compared results to improve inter‐rater reliability. Coding comparisons were conducted via Zoom, and iterative discussions continued until thematic saturation—where collecting and coding more data derived no further themes—was achieved and final themes were agreed upon.

FIGURE 2.

Summary of key steps taken from analysis to manuscript writing.

6. Results

6.1. Participant Characteristics

Sample characteristics are noted in Table 2 below. Given Bhutan's small health care workforce and prior absence of organised CRC activities, our interviewees who were recruited from doctors attending the CRC camp and who currently provide CRC services likely represent the views of most clinicians managing CRC in Bhutan.

TABLE 2.

Summary of sample characteristics.

Parameter	Category	Frequency	(%)
Gender	Male	15	75
	Female	5	25
Role	Clinician	10	50
	Nurse	3	15
	Traditional medicine practitioner	1	5
	Policymaker	2	10
	Civil society	1	5
	Pharmacist	1	5
	Public health researcher	1	5
Sampling method	Purposive	14	70
	Snowball	6	30

6.2. Main Findings

The results, which are applicable not only to CRC but can be broadly associated with other cancers, are derived through the WHO health systems building blocks, forming the main themes, with the lack of private sector and cultural beliefs and practices as additional themes that fall outside the building blocks that emerged due to their contextual relevance to the local setting and research question. The subthemes were developed by grouping related codes into higher‐order conceptual categories, which were subsequently organised under the overarching themes described below.

6.2.1. Theme 1: Building Block of Information Systems

6.2.1.1. Subtheme 1.1: Implementation of a National‐Level Information System

Bhutan has made leaps toward improving its health information systems. It has rolled out an interoperable system termed Electronic Patient Information System (ePIS), which was piloted in 2015 and fully operationalised in 2023. It enables health care providers to trace a patient's journey (including CRC patients) across all care interfaces using a unique national health identifier.

So what I enter here (district hospital), some doctor in the National Referral Hospital can see it. Whatever I'm writing or whatever I'm putting out, whatever I'm reporting, he can see it. And whatever happens there also, I can see it from here. But we need to have that particular set of ID for that. We have UH (universal health) ID so unique health ID so what we call every person when they visit the hospital, they get that ID so if we have that ID on we can see it right now. (D3, clinician, male)

6.2.1.2. Subtheme 1.2: Connectivity Infrastructure Hinders Health Information Transfer

Despite the nationwide rollout of the electronic Patient Information System (ePIS), persistent connectivity issues, intermittent power outages, and lack of backup power in some areas, which are often due to geographic and climatic conditions, continue to limit its optimal functionality and may delay health service delivery including CRC care.

For information technology, Bhutan has rolled out the locally developed ePIS system since 2023. Despite the supposed full penetration for all districts up to all the BHU (basic health unit) levels, we still face issues with electricity and internet connection, which inhibit the collection and accessibility of patient data. Sometimes it is also seasonal as the power might go out more often in certain seasons (especially monsoon season). Power outages and also the slow servers are the main things for our IT systems that need to be resolved. (D1, clinician, female)

6.2.2. Theme 2: Building Block of Health Workforce

6.2.2.1. Subtheme 2.1: Migration of Healthcare Workers Overseas

Participants attributed the health provider attrition to limited in‐country professional development opportunities and comparatively lower remuneration relative to overseas positions. This outmigration places additional strain on the remaining workforce within the public healthcare system, exacerbating workload pressures and service gaps. Notably, providers depart despite the presence of financial‐bonding arrangements intended to retain these personnel, suggesting that current retention mechanisms may be insufficient.

Because if you cannot secure a future in your own country, you will have to go out right? So we need to understand that if we want people to stay here we have to enable. So yes, irrespective of the inflow and outflow (of manpower), I still feel that because there are still people who are staying here. Look after those people and ensure they are trained appropriately. They (Ministry of Health and Royal Civil Service Commission) keep saying the right people in the right job. (D5, clinician, female)

The amount that they get paid in somewhere, like Singapore, somewhere like Australia and the United States. They can pay the bond off in about 2 to 3 years. So they opt to go out and pay the bond rather than stay back. (D9, clinician, female)

6.2.2.2. Subtheme 2.2: Lack of Training and Time for Public Health and Medical Research Among Healthcare Professionals

Using data is essential for informing policy decisions. Health research into cancer epidemiology like CRC emergence patterns provides critical insights into population health dynamics. However, limited training and insufficient opportunities for health workers to engage in data analysis and research constrain the translation of available information into evidence‐based policymaking, thereby hindering optimal health system planning and response.

I personally have some data but I don't have time to clean the data and I don't know how to analyse it well enough to publish. I do feel that the lack of research training for clinicians and lack of time hinders us a lot when coming to research and using data for policy decisionmaking. (D1, clinician, female)

6.2.2.3. Subtheme 2.3: Low Uptake of Certain Critical Medical Specialties Critical for CRC Diagnosis and Treatment

Certain medical specialties attract greater interest than others; however, effective cancer diagnosis relies heavily on pathology services. In Bhutan, pathology has historically remained an undersubscribed specialty despite initiatives to increase its appeal.

We are encouraging young doctors to develop their vision […] This is something we have like last year, we have a scholarship under the Ministry to undertake training in pathology but since we introduced this spot, no one was interested. (D2, clinician, female)

6.2.2.4. Subtheme 2.4: Lack of Technically Trained Policymakers

A lack of long‐term technical experts dedicated to specific programmes within the Ministry of Health has limited optimal implementation of national public health programmes, as expertise is often borrowed on an ad hoc basis.

I think there are multiple levels to this issue and it is not new, we tend to face it every time a new programme is started. I think at the ministry level, there is a lack of strong technical guidance and there is no designated technical expert who knows how to guide the implementation of the programmes as the ministry only has programme officers. But they work very hard, but we need the experts to ensure that implementation is smooth and sustainable. Now, the experts are only involved when needed. (D1, clinician, female)

6.2.3. Theme 3: Building Block of Medicines and Equipment

6.2.3.1. Subtheme 3.1: Lack of Chemotherapy Medications for CRC

Bhutan relies heavily on imported chemotherapeutic agents, primarily from India. The local pharmaceutical manufacturing industry is absent because of Bhutan's small market size. This contributes to intermittent stockouts of essential CRC medicines.

“We do have shortages (chemo drugs) because we totally have to depend on India. So we do have shortages.” (PH1, pharmacist, male)

I don't think we are in the position to manufacture our own medicine and at the same time we are not in the capacity to do that, but until we are able to capture the market (Bhutan has a small market), we will not be able to compete with our neighbouring countries […] So it is solely driven by the market. And so I don't think we will be able to compete. So as long as we are not able to compete with the market, I don't think it makes sense for us to start manufacturing medicine in the country. (PH1, pharmacist, male)

6.2.3.2. Subtheme 3.2: Medicine Supplies Need to be Projected for the Year Which Leads to Potential Shortfalls

The procurement of medicines is generally performed on an annual basis, which risks potential shortfalls when demands rise unexpectedly.

When you talk about medicines, we have to make sure that whatever we quantify, it has to actually last for the whole year. So even if you try to contact the Royal Bhutan Consulate office, we do not have allocated budget because when you try to procure medicines which are in essential medicine list, you are given a budget one time. And we have to make sure that whatever is being approved, we have to make sure that, uh, we are able to procure all the medicines within that allocated budget. So it's very difficult for us to go for extra procurement in terms of essential medicines. (PH1, pharmacist, male)

6.2.4. Theme 4: Building Block of Leadership and Governance

6.2.4.1. Subtheme 4.1: Political Will for Cancer Policy Was Prominent in the Previous Government due to Presence of More Clinicians

Political leadership plays a critical role in shaping health policy priorities. The presence of clinicians in the former parliament, including the former prime minister, contributed to the underlining cancer screening and management as a national priority and facilitated the implementation of nationwide cancer programmes in the form of the Health Flagship Programme.

So at the screening level what the previous government did was that they had a flagship programme against the top three cancers and together with the media, that really boosted the screening. Otherwise before that it was fairly erratic and unorganised and we really didn't have much to work with. So after that the government would give a lot of funding because I think there were several doctors in there to see to it. (D3, clinician, male)

6.2.4.2. Subtheme 4.2: Competing Priorities at the Policy Level

Bhutan continues to face significant competing priorities at the policy level due to the dual burden of communicable and non‐communicable disease. Rising burden of lifestyle related disease such as diabetes mellitus, hypertension and hyperlipidaemia strain adequate resource allocation for CRC and other cancers.

Any programme is budget related. So you already know that during the Flagship programme, there was huge budget so we could focus on a certain type of cancer. Now the programme is more focused on the non‐communicable diseases like diabetes, hypertension, heart disease and all. So priorities mostly on that now at present. So it is more budget related. Now the focus on cancer as come down a little bit. The sustainability is the problem now. So once this NCD programme is over, nobody is there to look after that. They will focus on other things. Priority keeps on shifting. (D6, clinician, male)

6.2.4.3. Subtheme 4.3: Lack of Co‐Creation of Policies Around Stakeholders

There is limited co‐creation of policies, with insufficient incorporation of perspectives from the full range of relevant stakeholders.

You know, they (Ministry of Health) consult with one or two (clinicians) I think. But overall, all of them already decided, okay, this time we will have a Flagship programme on breast and gastric cancer and they just do it. Even though I think they consult one or two people I think, but we need to sit together, especially they have to sit with the clinicians. (P1, policymaker, male)

6.2.5. Theme 5: Building Block of Service Delivery

6.2.5.1. Subtheme 5.1: Model of Cancer Care Delivery Limited to Higher‐Level Hospitals

CRC care concentrates at the tertiary hospitals because lower‐level health facilities lack diagnostic and management capacities. Most CRC cases are therefore referred to tertiary centres for definitive management. Following completion of surgery and chemotherapy at referral hospitals, CRC patients are typically co‐managed across different levels of care to support follow‐up and continuity of treatment.

So once I have done all the staging and everything (at cluster hospital) then I refer to onco surgery or neoadjuvant chemo or anything required. So my point is that my further investigation is that I refer the patient to the surgeon in JDWNRH but there are certain districts, I think some of the districts who do the surgery as well (for emergent cases only), but most of the time we send the patients to JDWNRH. (D10, clinician, male)

After the chemo, he comes back to me (at cluster hospital) for follow‐up. They receive the chemo, the complete dose there, and then after that, they follow‐up with me here. Yeah. So the tumour markers, scopes and CT scans are all done in my hospital. (D7, clinician, male)

6.2.5.2. Subtheme 5.2: Cancer‐Related Services Are Still Referred Overseas

Patients with advanced or complex cancers are referred overseas, primarily to India, for further specialised treatment when local management capacity is insufficient.

Most of them are referred to India for further management as in Bhutan, they cannot do interventional radiology and advance cancer surgeries as well. The cancer services here in Bhutan are limited, but sending the patients to India costs the government a lot of money every year. We need to do something about this. (D1, clinician, female)

If the cancer, if the cancer patient is diagnosed locally, I mean, the cluster hospital and district hospital, they do send to JDWNRH and referral hospital for the confirmations and all. If the referral hospitals are able to manage and treat them, they usually treat and manage there on their own. But if it was much more aggressive, massive (cancer), they are not able to treat or manage then they usually refer to overseas hospital (in India) and all. (N1, nurse, male)

6.2.5.3. Subtheme 5.3: Palliative Care Services Are Present for End Stage CRC Patients

Palliative care is a key component of management for terminal illnesses. Bhutan provides a home‐based model of palliative care to support patients and families at the end of life.

Now there is one palliative care doctor for the entire Bhutan that helps the nurses together at the Kidu building which we are at, as well as at JDWNRH which started only last year. We offer homebased palliative care services and a team of nurses and the doctor will go house to house for selected patients. (D1, clinician, female)

6.2.5.4. Subtheme 5.4: Cancer‐Related Advocacy Services Are Ad Hoc

Cancer advocacy efforts are episodic and not implemented in a sustained, longitudinally coordinated manner. It fails to consistently reach all segments of the population, despite the use of traditional communication channels.

Advocacy keeps on happening especially when you have some special days like cervical cancer day, breast cancer day, haematological cancer days. During these days there are some celebration actually. And some of the experts go on the media and talk for an hour. So those things are there but it is on a small scale, like the Bhutan Cancer Society celebrates World Cancer Day but it doesn't cover the whole nation, it is just a small region (certain districts) only. It is published in the media, newspapers and sometimes they speak on the TV and these things do happen now and then. (D6, clinician, male)

6.2.6. Theme 6: Building Block of Health Financing

6.2.6.1. Subtheme 6.1: Constrained Financial Resources Limit Medicine and Equipment Supply

Constraints imposed by a limited health budget restrict the procurement of novel CRC therapeutics and adequate medical equipment, forcing overseas referrals for procedures unavailable in the country.

It is a free health system here number one, for general health providers because our drugs available in our hospitals, we don't have the good ones, we only have the old ones, especially the antibiotics also we don't have the latest generation. We only have the older generation ones, since the patient is not paying and the government is giving everything so it is hard for them to afford also. And second, we don't have all the equipment also, so for complicated patients we have to refer out (overseas to India). Even our surgical department we also refer a lot of patients outside. Because it is not initiated here, we are giving a lot of money when referring the patients. (D8, clinician, male)

6.2.6.2. Subtheme 6.2: Donor‐Driven Financing Is Not Sustainable

Bhutan supplements government funding with external donor support. While local champions actively advocate for support from international partners, sustained dependence on external financing underscores the need to re‐evaluate Bhutan's health financing model to ensure long‐term sustainability and resilience.

I think there's not enough as at the national level being like financially still reliant on foreign aid. That's why I'm saying it's a very un‐systematised. So it depends on the personal will of people at this key point areas. And let's say if there's a very bright and energetic programme officer in the ministry, let's say we have one very strong lady in the vaccine programme, she would find money from UNICEF you know, and then do a capacity building training. But then subsidies become an issue because there isn't enough money. (D3, clinician, male)

6.2.7. Theme 7: Lack of Private Sector

6.2.7.1. Subtheme 7.1: Lack of Private Sector Leads to Leakage of Funds Overseas

The absence of a regulated private sector leads to lost revenue from prospective medical tourism and increased outflow of healthcare spending by Bhutanese seeking care abroad. Developing a regulated domestic private healthcare sector could help address this potential revenue‐generating opportunity.

Many patients are going outside Bhutan on their own expense, so I think if they can spend that much outside, they will be able to spend in our own country also that will benefit them in many ways by just treating in our country […] this can become revenue for the country instead. (T1, traditional medicine practitioner, male)

6.2.7.2. Subtheme 7.2: Proposed Private Sector Needs to be Well Regulated to Prevent Removal of Manpower From Public Sector

There is a need to adopt a balanced regulatory approach that allows healthcare providers to engage in both public and private practice in order to retain the limited workforce capacity within the public sector as the private sector expands. Carefully designed dual‐practice arrangements with correct regulation may help prevent workforce attrition from public institutions while supporting broader system sustainability.

We need private practice not on a large scale but to give people choices that is one and the other thing is to decongest what we have here so that people who cannot afford can be looked after here (public healthcare facilities). It also doesn't mean that it has to be different sets of people. Same people here, if you are off you can work there (private sector) but service should not suffer here (public sector). That should be very distinguished as we don't have enough people. You open private practice and say that they only work in private and not in government (public sector) then we will be short at both levels. (D5, clinician, female)

6.2.8. Theme 8: Cultural Beliefs and Practices

6.2.8.1. Subtheme 8.1: Local Healing Practices Cause Delayed CRC Treatment and More Harm

The presence of unregulated local healers practising without formal accreditation or scientific oversight may contribute to delays in seeking formal medical care for CRC. In some cases, it has led to clinical deterioration due to unproven local healing interventions, which are distinct from the regulated and thriving Traditional Medicine.

There is one (local practice) that keeps drinking water called hydrotherapy. So if the person is obstructed [intestinal obstruction from CRC] then you will perforate […] So if you have people still doing it in Thimphu and these are people with more education […] then we have these bone fixers who can fix fractures […] (N2, nurse, male)

6.2.8.2. Subtheme 8.2: Culturally Obedient Population

The Bhutanese population is noted to be highly receptive to medical advice and this can lead to high uptake in national cancer screening and treatment programmes.

Our patients are very, very, very receptive […] Uh, let's say you are having PR (per rectal) bleeding or you are having an uncontrolled habit that might be cancer. You need to go get screened. They will be coming to screen if we can teach the information. Patients are very receptive. (D10, clinician, male)

6.2.8.3. Subtheme 8.3: Population With a Relatively High Pain Threshold

A perceived higher tolerance for pain among segments of the Bhutanese population may contribute to delayed care‐seeking behaviour. This underscores the need for targeted public education initiatives that emphasise recognition of CRC red flag symptoms and encourage earlier presentation to healthcare services.

Actually, we are a very sturdy people and our pain threshold is higher. I tell you our pain threshold is higher because our older people they have worked and worked so hard despite they being sick and only when they cannot move then they come into the hospital […] But I'm not saying that all the Bhutanese are like that as we also have some people whose pain threshold is sub‐zero. But majority we can stand pain and rather not talk about it. Maybe we need people to say that it is okay to say that you are sick and you feel pain. Because if it is something small it is okay, and you can be happy that you don't have something serious but if it is something serious you can nip it in the bud. (D5, clinician, female)

7. Discussion

This study shows that challenges in colorectal cancer screening, diagnosis, and management in Bhutan extend beyond the WHO health system building blocks, reflecting deeply embedded sociocultural norms, geographic constraints, and political priorities. Addressing the rising incidence of CRC requires a systemic approach beyond technical health sector reforms. Figure 3 summarises the themes, subthemes, and policy recommendations identified to address these health system gaps.

FIGURE 3.

Summary of themes, subthemes and policy recommendations to address health system gaps.

7.1. Health Information Systems and Data‐Informed Policymaking

The recent implementation of an integrated, national‐level information system significantly bolsters evidence‐based planning for CRC services, replacing the once fragmented data system. However, seasonal power outages (e.g., during the monsoon) can disrupt data collection and transferability in some vulnerable areas. This is particularly concerning for patients requiring emergent evacuations (e.g., bowel perforation from obstruction due to CRC) from remote districts where rapid access to patient histories is critical for earlier intervention.

Strengthening communication infrastructure will yield benefits beyond CRC care and the health sector. Enhanced connectivity can support more effective health information systems and catalyse broader economic development in Bhutan. Reliable communication networks are widely recognised as essential drivers of growth, trade and social inclusion [13]. Moreover, an interoperable information system that transmits data across all care levels will enable efficient data collection. This increases analytical capacity and allows for accurate estimation of disease burden including CRC, service utilisation, and outcomes, which can inform policymaking and resource allocation [14].

However, participants emphasised that although staff often collect data on CRC and other cancers, there is insufficient training among health personnel and policymakers to analyse and translate these data into actionable policy. Targeted capacity building in epidemiological analysis and health systems research will enable data‐driven decision‐making. Improved use of data is particularly important in Bhutan, where competing national priorities necessitate efficient allocation of constrained resources.

7.2. Workforce Capacity and Distribution

Health workforce constraints remain a major bottleneck in CRC care in Bhutan. Participants reported staff losses to overseas migration, limited subspecialty training, and few incentives for cancer‐related research, weakening service capacity. Expertise in CRC‐related surgical procedures is also concentrated at the tertiary centre, JDWNRH, with limited systems to retain clinicians in underserved districts. This centralisation raises equity concerns, as patients from remote and lower socioeconomic backgrounds must incur additional travel and lodging costs to access care, worsening disparities in cancer services [15].

Uneven interest across medical specialties creates bottlenecks in diagnostic capacity, particularly in pathology. Addressing this may require workforce strategies such as compulsory rotations to increase exposure, targeted training with dedicated funding, and stronger integration of technical expertise into health policymaking to strengthen diagnostic services.

Participants also described the ad‐hoc engagement of technical experts to support Ministry of Health officials on a piecemeal basis may limit sustained collaboration and long‐term co‐creation of policy. Addressing this gap requires deliberate workforce planning, including a dedicated evidence‐to‐policy translation unit within the Ministry to institutionalise technical expertise and support continuous, evidence‐informed policymaking.

To mitigate workforce loss from low remuneration, a pay‐for‐performance (P4P) reimbursement model could be progressively introduced within Bhutan's public health system. Designers of such a model should link incentives to clearly defined context‐appropriate performance indicators to complement and not undermine existing equity‐oriented principles [16]. Integration with ePIS would enable performance metrics to be grounded in patient‐centred outcomes such as CRC treatment completion, adherence to clinical pathways, and timely follow‐up rather than service volume alone.

7.3. Medicines, Equipment, and Service Delivery Constraints

Gaps in chemotherapy availability for CRC, intermittent stockouts of essential medicines, and weak forecasting mechanisms expose CRC patients to treatment delays and interruptions, reflecting broader supply chain vulnerabilities rather than isolated procurement failures. These challenges are compounded by Bhutan's constrained fiscal capacity, which restricts the procurement of newer and often costly cancer therapeutics. Addressing the fiscal elements for securing crucial CRC‐required medicine supply chains is elaborated in subsequent paragraphs.

CRC services remain largely centralised, necessitating patients from remote mountainous regions to incur substantial out‐of‐pocket costs for transport, accommodation, and lost income due to limited or non‐existent oncology capacity at lower‐level facilities. Although healthcare is free at the point of service in Bhutan, transport subsidies are generally limited to emergency cases.

Bhutan's terrain amplifies geographic inequities, as travel to tertiary centres for CRC services is often logistically difficult and financially burdensome. Decentralised service delivery models, including tele‐oncology and shared care between specialists and primary care teams, may help to reduce these access barriers while maintaining quality of care. However, implementing these models requires improving digital health literacy among patients, primary care providers and community health workers [17]. Additionally, employing integrated information systems connected with supply chain interfaces can enable accurate projections of annual medication forecasting and maintain a buffer stock to withstand health system shocks to reduce instances of stockouts.

7.4. Governance, Political Economy, and Competing Priorities

Bhutan's governance landscape has shifted dramatically since its transition to democracy in 2008. The Ministry of Health retains a strong central role for health, with the National Cancer Control Programme, which was established in 2020, leading cancer‐specific initiatives. Between 2020 and 2023, the Health Flagship Program achieved remarkable success, screening over 90% of the eligible population for three common cancers of stomach, cervical and breast [5].

Governance‐related challenges intersect with Bhutan's broader political and institutional context. Although political commitment to cancer care increased during the previous general election, partly because clinicians entered government, CRC services still compete with infectious diseases, other NCDs and economic development for political priority [18].

Participants noted that the monarchy's central role in governance can influence the pace of financing reforms. Many viewed free healthcare as a key strength of Bhutan's health system, aligned with the country's Gross National Happiness mandate [19]. These dynamics highlight the need for multi‐sectoral governance structures, such as a national cancer advisory council, to support policy coordination, stakeholder engagement, and prioritisation within limited fiscal space. Constitutional recognition of CRC and other preventable chronic diseases as national priorities could help secure sustained funding and long‐term political commitment [20].

7.5. Health Financing Sustainability and the Role of the Private Sector

Bhutan's predominantly tax‐funded, free‐at‐point‐of‐care health system faces sustainability challenges, as the cost of CRC and cancer care as a whole trends upwards. To mitigate inefficient spending as chronic diseases costs rise, Bhutan could establish a health technology assessment (HTA) unit housed within the aforementioned evidence‐to‐policy translation unit to optimise resource allocation toward cost‐effective interventions (so‐called “best buys”) [21].

Recently, in 2023, Bhutan transitioned to lower‐middle‐income status, causing a decline in donor funding, which further intensified fiscal pressures. In the midst of multiple competing priorities, government budget allocations and taxation alone are unlikely to sustain an expansion of CRC services writ large. Participants highlighted the potential role of compulsory, pooled health insurance schemes calibrated to individuals' socioeconomic status as a means of enhancing financial sustainability without undermining equity principles. Although Bhutan offers universal health coverage, its financing mechanisms remain limited and increasingly strained, relying largely on modest tax revenues from civil servants and government budget allocations. In addition, the Bhutan Health Trust Fund, which historically acts as a key source of financing for essential medicines, is diminishing. This raises concerns about the long‐term sustainability of pharmaceutical procurement for CRC and other disease conditions. Exploring alternative financing strategies, such as progressive taxation and the carefully regulated expansion of a domestic private healthcare sector could strengthen fiscal capacity and bolster the health system's financial resilience [22].

A well‐regulated private sector could complement public services by expanding diagnostic and treatment capacity. Currently, private provision is minimal, with only a handful of diagnostic centres offering basic imaging and endoscopy [23]. Carefully opening the market to private actors could help retain healthcare workers, reduce outbound medical travel, prevent financial leakage overseas, and improve efficiency through competition. However, this would require strong regulatory frameworks to safeguard quality, affordability, and alignment with national health goals [24].

7.6. Sociocultural Beliefs, Health Literacy, and Care‐Seeking Behaviour

Cultural beliefs and practices emerged as significant determinants of delayed CRC presentation. Participants reported that local informal healers (distinct from the formally trained traditional medicine practitioners) remain influential, particularly among older populations [25]. Harmful practices, such as hydrotherapy in patients with bowel obstruction due to CRC, may worsen outcomes and delay definitive care. Participants recommend engaging training local healers to recognise red‐flag symptoms for CRC and other diseases, and referring patients rather than marginalising these actors. Partnership models linking local healers, traditional medicine practitioners, and allopathic providers may offer culturally acceptable pathways to earlier diagnosis [26].

Despite generally high obedience of the population to public directives, which may facilitate high screening uptake as seen in the National Flagship programmes, poor health literacy and a perceived “high pain threshold” contribute to delayed care‐seeking [9]. Targeted education on CRC symptoms and screening benefits is essential. Advocacy initiatives must be opportunistic, community‐based, context‐specific and tailored to local needs. Collaboration with civil society organisations such as the Bhutan Cancer Society to co‐create CRC advocacy and health education campaigns that are palatable to the various districts in Bhutan is good starting grounds [27]. Being a predominantly Buddhist population, monasteries can also be partnered for similar purposes [28].

Despite high national smartphone penetration, participants noted limited social media engagement in remote communities, reflecting a digital divide that limits technology‐based health communication [17]. Lower digital health literacy, language barriers, and low trust may further widen disparities in CRC awareness and service use. Hybrid CRC outreach combining digital communication with community‐based engagement may improve overall population penetration. The National Health Flagship Programme demonstrates the value of integrating education with screening, though its logistical demands highlight the need for more scalable and sustainable approaches moving forward.

7.7. Strengths and Limitations

To our knowledge, this is the first qualitative study examining colorectal cancer in Bhutan from a health systems perspective. Participants included individuals directly involved in CRC management and policymaking at the national level, providing insights from key actors shaping service delivery and strategy. While the findings capture diverse perspectives within the health sector, CRC service implementation extends beyond it. Future research should include stakeholders from sectors such as health finance and infrastructure to provide a more comprehensive systems view. Further studies should also explore the qualitative aspects of implementing a formal CRC screening programme when it comes into fruition to better guide operational changes on the ground to suit the needs of the local system.

Nevertheless, the present findings may have broader applicability to other LMICs confronting similar challenges in cancer care delivery, especially when afflicted with a dual burden of disease (infectious and non‐communicable) in the advent of ageing population structures [29]. The gaps might not be novel: an evolving information system gearing toward integration across interfaces, outflow of health workers, lack of medicines, equipment and expertise, competing policy priorities for funding, infant integrated cancer and palliative care models and strained purse strings are items that have persisted in many LMICs which can be iteratively overcome with the recommendations set forth in our paper [30, 31]. However, these health system improvements take time and need to be iteratively tailored with careful alterations to make policy decisions retrofitted to the needs of the population and health system to which they serve.

8. Conclusion

Improving CRC outcomes in Bhutan requires coordinated reforms beyond the health sector, addressing financing sustainability, governance, sociocultural norms, and geographic inequities. Investments in data systems, workforce capacity, decentralised services, regulated private sector engagement, and culturally grounded advocacy are essential. Bhutan's experience offers lessons for other small health systems strengthening cancer care amid fiscal constraints and sociopolitical complexity.

Author Contributions

Chuan De Foo: conceptualization, investigation, funding acquisition, writing – original draft, methodology, validation, visualization, writing – review and editing, software, formal analysis, project administration, data curation, supervision, resources. Sonam Yoezer: methodology, validation, formal analysis, data curation. Tashi Dendup Wangdi: writing – review and editing, data curation. Prabhat Pradhan: writing – review and editing. Yun Le Linn: writing – review and editing. Chong Tsung Wen: writing – review and editing. Elliot Eu: writing – review and editing, data curation, validation. Vanessa Yik: writing – review and editing. Jia Lin Ng: writing – review and editing. Jeremy Tian Hui Tan: writing – review and editing. Fung Joon Foo: writing – review and editing. Evelyn Wong: writing – review and editing. Taufique Joarder: writing – review and editing, supervision.

Funding

This study was funded by the SingHealth SMSTDA Grants: 2025/SMSA/000013/P and 2025/SMSA/000072. This was also supported by the SingHealth Surgery Academic Clinical Programme Grant Award and the SingHealth Duke‐NUS Global Health Institute.

Disclosure

Reflexivity statement: The lead coder (CD), trained in clinical medicine and public health with interests in health systems and clinical care, acknowledges that his clinical background may influence interpretation of participants' narratives. To mitigate potential bias, CD used open‐ended questioning, practised active listening during interviews, engaged in reflexive memo‐writing during analysis, and grounded interpretations in the data. The writing involved Bhutanese counterparts who were all deeply involved in colorectal cancer care delivery and health systems reform for the country. This research prioritised inclusivity and equitable collaboration, with three female authors and three authors based in Bhutan. The team comprised individuals across a range of career stages, from junior to senior positions, spanning clinical medicine and health systems research. Ongoing collaboration with Bhutanese counterparts is planned, including return visits to support continued partnership, co‐development of future research, and transfer of research skills. These efforts aim to promote equitable authorship, strengthen local research capacity, and ensure sustained, locally relevant impact.

Ethics Statement

Ethics approval was obtained from the National University of Singapore, Institutional Review Board (NUS‐IRB) and the Khesar Gyalpo University of Medical Sciences of Bhutan, Royal Government of Bhutan before starting the study. This study was approved under NUS‐IRB‐2025‐509 and PN/2025/059.

Consent

Informed consent was obtained prior to commencing the qualitative data collection with the participants. The participants could withdraw at anytime with no consequences on their part. Participants also had no vested interests in the research.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix S1: Summary of key actions and outcomes of the National Flagship Programme.

Appendix S2: Summary of the WHO health systems building blocks.

Appendix S3: Consolidated criteria for reporting qualitative studies (COREQ): 32‐item checklist.

Appendix S4: Summary of document review.

Appendix S5: Interview guide.

Data Availability Statement

The qualitative data underlying this article cannot be shared publicly to protect privacy and confidentiality of participants. Deidentified data may be shared on reasonable request to the corresponding author.