Population and Development Situation Analysis Report

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POPULATION AND DEVELOPMENT
SITUATION ANALYSIS
BHUTAN 2010
Research & Evaluation Division, Gross National Happiness Commission
Thimphu, Bhutan

TABLE OF CONTENTS
CHAPTER ONE ...................................................................................................................................4
1. INTRODUCTION......................................................................................................................................4
CHAPTER TWO.................................................................................................................................11
2. POPULATION DYNAMICS ..................................................................................................................11
2.1 Population data sources ................................................................................................................................... 11
2.2 Population size and growth.............................................................................................................................. 11
2.3 Age and sex structure....................................................................................................................................... 11
2.4 Population density and spatial distribution ...................................................................................................... 14
2.5 Fertility levels, trends and determinants .......................................................................................................... 15
2.6 Mortality levels, trends and determinants........................................................................................................ 18
2.7 Disability ......................................................................................................................................................... 20
2.8 Urbanization and Migration............................................................................................................................. 21
CHAPTER THREE ............................................................................................................................25
3. POPULATION AND ENVIRONMENT................................................................................................25
3.1 Human activities and environment linkage...................................................................................................... 25
3.2 Population density ........................................................................................................................................... 25
3.3 Climate change and natural disaster ................................................................................................................ 25
3.4 Agriculture....................................................................................................................................................... 26
3.5 Livestock ......................................................................................................................................................... 26
3.6 Forests.............................................................................................................................................................. 27
3.7 Water ............................................................................................................................................................... 27
3.8 Minerals and Mining........................................................................................................................................ 28
3.9 Energy.............................................................................................................................................................. 29
3.10 Air............................................................................................................................................................... 30
3.11 Urbanization and the environment .............................................................................................................. 31
3.12 Biodiversity................................................................................................................................................. 32
CHAPTER FOUR...............................................................................................................................34
4. POPULATION AND THE ECONOMY................................................................................................34
4.1 Economic growth and population .................................................................................................................... 34
4.2 Demographic aspects of savings................................................................................................................. 35
4.3 Dependency ratio.......................................................................................................................................... 35
4.4 Positive impact of changing age structure- Window of opportunity ............................................................... 36
4.5 Labor force and its impact on the economy..................................................................................................... 36
4.6 Labor and Employment ................................................................................................................................... 37
4.7 MDG and social indicators .............................................................................................................................. 38
CHAPTER FIVE ................................................................................................................................40
5. POVERTY DIMENSION........................................................................................................................40
5.1 Poverty and population .................................................................................................................................... 40
5.2 Poverty levels and trends ................................................................................................................................. 40
5.3 Population and poverty differentials................................................................................................................ 41
5.4 Poverty and health ........................................................................................................................................... 41
5.5 Poverty and education...................................................................................................................................... 43
5.6 Migration and poverty ..................................................................................................................................... 43
5.7 Poverty and housing ........................................................................................................................................ 44
5.8 Urbanization and poverty ................................................................................................................................ 45
5.9 Youth and unemployment ................................................................................................................................ 45
5.10 Poverty and MDG goals.............................................................................................................................. 46
CHAPTER SIX ...................................................................................................................................48
6. REPRODUCTIVE HEALTH.............................................................................................................48
6.1 Health Care System in Bhutan......................................................................................................................... 48
6.2 Reproductive Health (RH)............................................................................................................................... 48
6.3 Safe Motherhood including EmOC ................................................................................................................. 49
6.4 Antenatal Care ................................................................................................................................................. 49
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6.5 Postnatal Care .................................................................................................................................................. 50
6.6 Newborn Care.................................................................................................................................................. 50
6.7 Maternal, infant and child mortality ................................................................................................................ 50
6.8 Family Planning............................................................................................................................................... 51
6.9 Morbidity, screening and prevention of cervical & breast cancer ................................................................... 53
6.10 Reproductive Tract Infections (RTIs) including STI/HIV .......................................................................... 54
6.11 Prevention and management of abortion complications ............................................................................. 55
6.12 Prevention and management of Infertility................................................................................................... 55
6.13 Adolescent Sexual Reproductive Health..................................................................................................... 56
6.14 Increasing Trend in Drug Abuse................................................................................................................. 56
6.15 Status of Health MDG goals ....................................................................................................................... 56
6.16 Reproductive health outcome versus economic status ................................................................................ 57
6.17 Quality and effectiveness in health care service delivery ........................................................................... 57
CHAPTER SEVEN.............................................................................................................................59
7. GENDER...................................................................................................................................................59
7.1 The Concept of Gender Mainstreaming........................................................................................................... 59
7.2 Gender concerns in development..................................................................................................................... 59
7.3 Sex composition, headship and property rights ............................................................................................... 59
7.4 Literacy and Enrolment in Schools.................................................................................................................. 60
7.5 Gender and health............................................................................................................................................ 61
7.6 Women and Poverty ........................................................................................................................................ 63
7.7 Labour force participation ............................................................................................................................... 64
7.8 Women in public and political life .................................................................................................................. 65
7.9 Birth, Marriage and Death Registration........................................................................................................... 66
7.10 Gender and Environment ............................................................................................................................ 66
7.11 Constitutional and Legal Provisions ........................................................................................................... 67
7.12 Government Institutions on gender issues .................................................................................................. 68
7.13 Data gaps in gender mainstreaming ............................................................................................................ 68
8. ANNEXURES .................................................................................................................................69
Additional tables ....................................................................................................................................................... 69
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CHAPTER ONE
1. INTRODUCTION
1.1 Country Background
Bhutan covers an area of 38, 394 sq. km and is largely mountainous with altitudes ranging
from 300 meters in the south to 7300 meters in the north. Of the total land area, 72.5 percent
is covered with forests which include 26 percent of land designated as protected areas and
9 percent as biological corridors (RNR, MoA). The country has a rich biodiversity and has
been declared as one of the ten global biodiversity ‘hotspots.’
The country is largely an agrarian economy with 79 percent of its population engaged in
agriculture and livestock farming. According to RNR statistics 2000, only about 7.8 percent
of the land is arable. Farm mechanization is limited by the steep terrain and traditional
farming practices are followed.
The form of government is that of a Democratic Constitutional Monarchy, which was
established in 2008. Administratively the country is divided into 20 Dzongkhags comprised
of 205 Gewogs.
Figure 1: Map of Bhutan
Source: National Land Commission Secretariat
1.2 Population and Development
Bhutan has made significant strides in economic, social, and demographic achievements
ever since the launch of planned development in 1961. All along the course of development,
owing to the mountainous terrain and limited natural resources, the perceived high growth
of population was considered as an obstacle to progress. Under such circumstances,
cautious policies and plans helped Bhutan succeed in achieving much of what has been
achieved without depleting its natural environment. For example, by opting for long term
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enefits to short term gains, agricultural reforms were introduced whereby, ‘Tseri’,
the traditional method of burning vast forest lands for cultivation purposes was abolished.
Such gains may not hold for long if the population continues to grow. Although population
growth has declined to 1.8 percent per annum, it is still high enough to offset development
gains. Recognizing the inter-linkage of population and development, the country needs to
continue with the integration of population policies effectively with development programs
within the framework of the country’s development philosophy of gross national
happiness.
Following the International Conference on Population and Development (ICPD) held in
Cairo in 1994, the Royal Decree on population planning was issued by His Majesty the
Fourth King in 1995. The Royal Decree on Population Planning states that:
“For the Royal Government of Bhutan, where the spiritual and temporal system exist in harmony:
To ensure continuing peace, prosperity and happiness for our people, to ensure successful
implementation of the Government’s policies and development plans, and to avoid complications of
the population explosions faced by other countries in the near future, it is very important for every
Bhutanese high and low, to understand and support the population planning activities initiated by
the health services.”
In the past, population related issues were confined largely to family planning and
reproductive health policies. Till date proper comprehensive population related research
and analysis has never been conducted which has constrained policy-making and planning
at all levels. The Vision 2020 set population reduction growth rates as: 2.08 percent per
annum by 2002, 1.63 percent by 2007 and 1.31 percent by 2012. It was also targeted to have
a comprehensive population policy in place by the end of the 8 th FYP (1997-2002) as per
Bhutan 2020: A Vision for Peace, Prosperity and Happiness.
The rationale for population research and analysis is that it is intricately linked to every
sector of development and is a major cross-cutting issue in all development plans. For
instance, a change in the age structure implies a change in the labor force structure,
adolescent, youth, and elderly composition, and this impact on resources and their
allocation and socio-economic services.
The conduct of demographic situation assessments underlines the importance of challenges
and opportunities that lie ahead with the event of changing population dynamics. It
provides an empirical basis for effective evidence-based planning and policy formulation.
Such assessments highlight the current situation of economic development, social issues,
employment, labor, agriculture, gender, adolescents and youth, reproductive health that
can be viewed through the perspective of changing population dynamics – fertility,
mortality and migration. The highlighting of future changes in the population dynamics
and linkages with other aspects of development would facilitate planners and policy
makers. It is also crucial for government agencies to be able to plan and make necessary
interventions based on demographic trends, to meet future challenges that would be
confronting the country.
Rationale for population research & analysis:
provide a clear picture of the challenges & opportunities as a result of changing population dynamics
effectively guide future national policies and decisions
integrate population issues into development
support evidence-based cross-sector planning
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improve coordination, research & data collection

As part of the GNHC/UNFPA Project on Preparation of the Population Perspective Plan
for Bhutan: the following population-related documents were prepared:
1. The Population Situation Analysis Report (PSAR) – focuses on carrying out a
situation analysis of the population dynamics, population and environment,
population and economy, the poverty dimension, reproductive health and
population and gender;
2. The Population Perspective Plan (PPP) - Based on the findings from the PSAR, the
PPP outlines the population policy context highlighting major population and
development issues and presenting the goals and strategies. The PP also includes a
proposal and strategies for the establishment of an institutional mechanism to
coordinate, monitor and implement the population policy.
3. PPP-Action Plan – An action plan has been prepared emanating from the goals and
strategies under the PPP. It includes activities, indicators and responsible
implementing and coordinating bodies.
Key Milestones in the formulation of the Population Documents
April 2008
May 2008
June to August 2008
October 2008
March 2009
April to May 2009
June to July 2009
August 2009
September to November 2009
December to February 2010
August 2010
Brainstorming session on population and development (Task
Force formation)
1 st Task Force meeting
Development of preliminary situation analysis report which
presented the current demographic situation of the country
Recruitment of consultant (further work on the situation analysis
report and population perspective plan in consultation with
sectors)
Stakeholder Workshop (development of action plans)
Bilateral discussions on the population action plans with major
sectors
Internal review of draft documents
Population Retreat (1 week)
Dissemination of draft documents for comments
Incorporation of feedback and comments and refinement of draft
documents. Draft documents ready for submission to GNH
Commission.
Presented to the GNH Commission.
1.3 Issues, Trends and Challenges
Demographic Challenges – The country faces declining but still high fertility and high
population growth rates, increasing but still limited level of contraceptive use, population
momentum, demographic bonus, rise in adolescent and youth population, slow but steady
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increase in older population, high level of rural to urban migration and skewed spatial
distribution of population and data gaps for development planning. Trend data on
demographic and population parameters is inadequate. The data quality and coverage
needs to be improved.
Current Trends:
The total population of Bhutan was 634,982 in 2005 comprising 52.5 percent males
and 47.5 percent females.
Sex ratio at birth is 101 males to every 100 females. Overall sex ratio is 111 males to
every 100 females. Chhukha Dzongkhag has the highest male to female sex ratio of
132 males for every 100 females.
The population is projected to grow from 757,000 in 2015 to 887,000 by 2030.
Population growth rate was 2.6 percent in 1984, 3.1 percent in 1994 and 1.8 percent in
2005 and fertility rates are declining - TFR in 2005 was 3.6 births.
Infant mortality rate (IMR) declined from 121 per 1,000 live births in 1984 to 41 in
2005.
Life expectancy at birth reached 66.3 years in 2005 from 49 years in 1984.
Population is expected to grow due to positive population momentum.
Dependency ratio significantly dropped to 61 percent in 2005. Increase in the
working age population leading to a demographic dividend if sound public policies
are put in place.
Proportion urban increased from 13 percent in 1985 to 30.9 percent in 2005. Annual
urban rate of growth until 2005 was 6 percent.
Population density increased from around 10 persons per square km to 16 persons
per sq km in 2005.
Internal migration will continue to be the most significant factor in determining the
rate of urbanization. The severe strain on urban facilities and services a key
challenge.
Environmental Challenges – Environmental issues include eroded hillsides, worn-out
farmlands, parched grasslands, polluted water, air and industrial pollution, water and
garbage pollution, loss of soil fertility and limited access to safe drinking water.
Current Trends:
Volume of solid waste, industrial waste and pollution of air will continue to be a
challenge. Solid waste – around 50 tonnes of solid waste produced per month in the
urban areas.
69 percent of the population lives in rural areas where the main source of livelihood
is agriculture and related activities.
Most agricultural lands are fragile, hilly, rocky and average per-capita land holding
is around 0.6 acres per person.
Yield of crops have decreased partly due to over-use of chemical fertilizers and wildlife
depredation of crops and livestock.
Increase of packaged food imports along with environmentally hazardous nondegradable
materials.
Mining industries doubled from 46 in 2002 to 91 in 2006. Industrialization and
mining activities leads to pollution, and loss of forests and natural habitat.
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Consumption of wood for construction and other uses increasing over
the years.
Without proper policies, population growth will lead to increasing pressures on the
environment further exacerbating poverty.
Number of persons per sq. km. of forest area is increasing indicating the extent of
pressure on forest with increasing population.
Around 16 percent of the households do not have access to safe drinking water.
Around 55 percent of households use wood for cooking.
Economy Challenges – The economy continues to evolve into a modern economy with a
decline in primary sector growth as against the tertiary and secondary sectors, largely
attributed to growth in the electricity and construction sectors. Growth in the
manufacturing and industrial base relatively slow.
Current Trends:
Real GDP increased from Nu. 1095 million in 1980 to Nu. 24,592.1 in 2003 and then to
Nu. 37,964.2 million in 2008.
Per capita income- US$ 1852.4 (Nu. 80,580.2).
Growth rate highest in 2007 (19.7 percent) due to commissioning of the Tala Hydro
Power project.
Significant changes in the structure of the economy - share of primary sector declining.
High growth in the mining and quarrying sector, indicating 74 percent growth over the
past one year.
The number of persons in the productive age group (15-64 years of age) is projected to
grow from around 395,000 in 2005 to 489,000 by 2015, an increase of 24 percent.
Unemployment rate ranged around 3 percent to 4 percent in the past decade.
Unemployment among the teenage youth (15-19) increased from 2.5 percent in 1998 to
7.2 percent in 2004. Similarly, unemployment for the 20-24 years age group increased
from 2.7 percent in 1998 to 4 percent in 2004 and to 11.4 percent in 2006. Employment in
the agriculture sector accounted for 43 percent of all employed in 2005 compared to 75
percent in 1999.
Out-migration from rural areas increase challenges posed due to inadequate labor.
A total of 5,214 persons employed in tourism sector, and around 35,000 tourists from
India and 21,094 from other countries arrived in Bhutan. Arrivals increased by around
22 percent over the past one year. Annual earnings of USD 29.8 million represent an
increase of 24.8 percent.
Gross enrolment ratio was 55 percent in 1990, 84 percent in 2004 that improved to 90.1
percent in 2005, indicating the possibility of achieving the second MDG goal. In 1985,
percentage of pupils in grade 1 surviving to grade 5 was 47 percent. By 2000, survival
from grade 1-5 increased to 82.3 percent and by 2005 survival rate improved to 84.2
percent.
Poverty Challenges – High rural poverty rates and key challenge of targeting the remotest
and poorest communities to reduce poverty levels.
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Current Trends:
The poverty level has decreased from 34 percent in 2000 to 31.7 percent in 2004 and
further to 23.2 percent in 2007.
Poverty levels declining at an annual rate of around 5 percent per annum. At that
rate, poverty incidence is estimated to reach 15 percent by 2015
Percentage of population below minimum level of dietary energy consumption
(2,124 kilocalorie-food poverty line) increased from 3.8 percent in 2004 to 5.9 percent
in 2007.
TFR for mothers of poorer households higher and TFR much higher among illiterate
mothers. Larger households invariably mean a competition for limited resources and
are an indicator of poverty.
In 2007, literacy among the non-poor was 60 percent while it was 40 percent among
the poor.
Higher IMRs noted for poorer households.
Among children below 5 years, respiratory infection is the highest with 40 percent of
total morbidity incidences while diarrhea represents 11 percent.
Primary GER in urban was 97.8 percent as against 87.1 percent in rural areas. School
attendance and enrolment is lower for poorer households than non-poor
households.
Yield of food grains has declined over the years.
Domination of a few large industries in the economy contributes to income inequality.
A Gini coefficient of 0.35 in 2007 suggests a fairly high in-equality.
Strong association of poverty to young dependency ratio with a correlation
coefficient of 0.62. Total dependency ratio decreased from 86.2 percent in 2000 to 60.6
percent in 2005.
Reproductive Health Challenges - Risky sexual behavior of adolescents, maternal mortality
and infant mortality rates, huge gap between knowledge and practice of contraception,
high incidence of mother and child malnutrition, HIV/AIDS and high risks of the disease
spreading, rising trend of abortions, reproductive tract infections and drug abuse.
Current Trends:
Teenage pregnancies (15-19 years) accounted for 11 percent of all births.
Hospitals in urban areas over-crowded, while in rural areas they are underutilized
and under-staffed.
The contraceptive prevalence rate increased from 18.8 percent in 1994 to 30.7 percent
in 2000 and to 43.6 percent in 2005. In 2000, 95 percent women between 15-49 years
reported of having heard of family planning and only 30.7 percent practiced it.
Trained attendance delivery increased from 57.1 percent in 2006 to 66.3 percent in
2008.
Many women and children suffer from deficiencies of micronutrients, notably iron
and Vitamin A, and up to 40 percent of children are stunted. Iron deficiency anemia
prevalence was 28 percent for men, 55 percent for women of child bearing age, and
81 percent for children under 3 years.
Increasing trend in STDs, and HIV/AIDS prevalence due to unsafe sexual practices
especially amongst adolescents and lack of health awareness.
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217 confirmed cases of HIV/AIDS as of July 2010. Prevalence highest among those
aged 15-45 years.
In 2007, complications of pregnancy were the top morbidity condition, followed by
diseases of the digestive system, respiratory and nose diseases, kidney, UTI/genital
disorders.
Lack of accurate data collection on abortion. Unconfirmed sources relate of illegal
and risky abortions outside the country.
Rising trend of cervical cancer cases.
Enhancing access and utilization of quality comprehensive RH services for all
women, men and adolescents remain a challenge.
Gender Challenges - Gender disparity in education, labor force participation, paid work,
and higher level occupations and the legislative and executive branches, data and research
gaps.
Current Trends:
Literacy rate among males is 69 percent and among females is 49 percent.
Female adult literacy rate is only half of that of males (38.7 percent and 62 percent
respectively).
Gross enrolment rate (GER) in 2005 for males was 92.1 percent and 88 percent
among females in primary schools. Enrolment gap between males and females
widens in the higher educational levels.
Menstrual and complications due to pregnancy are rising.
Based on 2007 morbidity data, diseases that afflicted more females than males are,
nutritional anemia (around three times higher), depression and mental disorders,
nervous and peripheral disorder, hypertension, peptic ulcer syndrome, gall bladder
disease, cystitis, kidney and genital disorders.
In urban areas female labor participation rate of 33.6 percent is much lower than
rural females (54 percent).
Over 76 percent females engaged as own account worker and unpaid family worker
while around 52 percent males worked as paid employees.
Women’s representation in decision making positions is low.
There is lack of data and research to understand gender particularly in relation to
specific diseases affecting women, nutrition, pregnancy, abortions, UTIs, education,
work and poverty.
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CHAPTER TWO
2. POPULATION DYNAMICS
2.1 Population data sources
The Population and Housing Census of Bhutan 2005 (PHCB 2005) is the main source of
population data. Other sources of data are from the various national surveys, censuses, and
administrative data, namely the National Health Surveys 1994 and 2000; Demographic
Survey 1984; the RNR Censuses; Bhutan Living Standard Surveys; Poverty Reports;
National Labor Force Surveys; Annual General Statistics Reports of the MoE, Annual
Health Bulletins and other data collected by various sectors and autonomous agencies. The
analysis of future population projections is sourced from the Population Projections,
Bhutan 2005-2030 which is based on the PHCB 2005 prepared by the National Statistics
Bureau (NSB).
The NSB is the central agency for the collection, production and dissemination of official
statistics. The respective line ministries and agencies are responsible for primary and
secondary data collection on areas directly relevant to their sectors. As such, the NSB and
sector agencies are key data sources.
Most of the sample surveys produce data at the national level. The conduct of well
coordinated and more frequent surveys that enable production of data at smaller
geographical levels such as the Gewog and village levels needs to be strengthened.
2.2 Population size and growth
According to the PHCB 2005, the total population of Bhutan was 634,982 persons. By 2015
and 2030 the population is projected to be 757,000 and 887,000 respectively (Population
Projections of Bhutan, 2005-2030, NSB). This shows an increase of 45 percent between 2005
and 2030
Between 1984 and 1994, the population grew steadily although the rate of growth slowed.
The annual population growth rate in 1984 was 2.6 percent (Demographic Health Survey
(DHS), 1984) which increased to 3.1 percent in 1994, mainly due to the then high level of
fertility against the sharp decline in mortality. In 2000, the population growth rate declined
to 2.6 percent (National Health Survey (NHS), 2000) and further to 1.8 percent in 2005
(PHCB 2005). During this period there was a swift decline in fertility against modest
improvements in mortality rates. The indirect method 1 was used for calculation of the
growth rates.
2.3 Age and sex structure
The age structure has a direct influence on population change. A classification of the
population by three broad age groups, shows that children aged 0-14 constitute a large
proportion of the total population. This proportion declined from 37.2 percent in 1984
1 The indirect measure of the total fertility rate utilizes the data on child ever born by women of 15-49 years of age.
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(Statistical Year Book (SYB) 1985) to 33.1 percent in 2005. It is expected to further
decline to 22.8 percent by the year 2030. The proportion of the elderly population (65+
years) was 4.3 percent in 1984 and 4.7 percent in 2005 and is estimated to increase to 6.6
percent in 2030.
Table 1: percentage distribution of the population by broad age group
Age group
2005 2030
Total Male Female Total Male Female
0 - 14 33.1 31.7 34.6 22.8 22.4 23.3
15-19 11.8 11.2 12.5 9.2 9.1 9.4
20-24 11.1 12.1 10.1 9.0 8.8 9.1
25-59 37.0 38.1 35.7 48.9 49.5 48.2
60-64 2.3 2.3 2.3 3.6 3.7 3.4
65 + 4.7 4.6 4.8 6.6 6.5 6.6
Total 100.0 100.0 100.0 100.0 100.0 100.0
Source: Population Projections, NSB 2005
The median age 2 of the population, as per the PHCB 2005 is 22 years. This implies that the
population will continue to increase in the near future as a result of a large proportion of
young population entering the reproductive age. The median age is expected to be 31 years
by 2030 which is indicative of a decrease in the proportion of young population.
A common measure of the sex composition of the population is the sex ratio or the number
of males per 100 females. The resident sex ratio in 2005 was 111 males per 100 females
which is attributed to the presence of a large expatriate male labor force employed in the
construction industry. The sex ratio at birth which is also termed as the secondary sex ratio
was 101 males for every 100 females in 2005. Generally, this sex ratio is normally assumed
to be 105 boys to 100 girls.
The ageing index 3 in 2005 was 14 percent. This means that there were 14 elderly persons for
every 100 children. The elderly population will continue to grow steadily with the
improvement in health status and increasing life expectancy.
The dependency ratio 4 provides a rough measure of the burden of dependency that the age
structure imposes on a population. A very significant aspect of rapid population growth is
the resultant problem of dependency burden. In 1985, the dependency ratio of 71 percent
(SYB 1985) was due to the large proportion of young population reflective of the period of
high fertility. With the decline in fertility in recent decades, the dependency ratio declined
to 61 percent in 2005. It is expected to further decline in the next two decades due to falling
fertility until the time when the proportion of elderly population will begin to increase.
2 The median age is the age at which the population is divided equally into two halves.
3 The ageing index is the ratio of elderly persons (65+ years) to every 100 children below the age of 15.
4 The dependency ratio is the ratio of children below 15 years of age and elderly population (65+ years) to the size of the
working population (15-64 years).
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The age structure and sex composition of the population is represented by the pyramids
for different periods of time in figures 2 (a), (b) and (c). The figures depicting the
distribution of population by age and sex are useful in the formulation of public policies
and determining development needs, challenges and opportunities before the country. The
sex structure of the population ascertains the specific requirements of the male and female
population.
Figure 2(a): Population Structure 1984
Figure 2(b): Population Structure 2005
Source: Demographic Health Survey, 1984 Source: PHCB 2005
Figure 2(c): Population Structure 2030
It is observed that the population pyramid in
1984 has a broad base representing a larger
proportion of population in the younger age
groups. This is indicative of the high level of
fertility during the 1980s. By 2005, the pyramid
shows the change in population structure
particularly at the base which starts to constrict.
The decline in fertility causes a narrowing of the
base of the population
Source: Population Projections, NSB 2007
structure. With fertility expected to continue to
fall in the next few decades, the pyramid in the year 2030 assumes a columnar shape with
the apex bulging. It happens due to the decline in the less than 15 population and increase
in the proportion of the working and the elderly population.
2.3.1 Population momentum
The term population momentum refers to the tendency of a population to continue to grow
beyond the time when replacement level fertility 5 is achieved. Population estimations
under two scenarios i.e. under the assumption that replacement level is achieved by 2012
and 2020 show that the population will continue to grow. If replacement level is reached by
5 Replacement level fertility is the level of fertility at which the population exactly replaces itself i.e. an average of 2.1
children per woman.
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2012, the population will still continue to grow and reach 920,000 in 2045. On the other
hand, if the replacement level is reached by 2020, the population size will increase to
around 992,000 by 2045. .
The initial stage of demographic transition is characterized by high birth and death rates.
Mortality declines much faster than fertility. This introduces a time lag between declines in
fertility and mortality so the growth rate is still high. As both births and deaths begin to fall
equally, the population will stabilize after achieving replacement level fertility.
2.3.2 Demographic bonus
Demographic bonus is defined as the economic opportunity presented by a large labor
force and a low dependency ratio. The overall dependency ratio in Bhutan in 1984 was 71
percent which declined to 61 percent in 2005, resulting in a large labor force as a
percentage of total population. This period of inflated labor population, offers the
opportunity for enhanced productivity and accelerated progress. This window of
opportunity offered by the population structure is termed as the demographic bonus. The
demographic bonus lasts for a short period of time until population aging sets in. When
not complemented by appropriate strategies, it may have negative implications.
2.4 Population density and spatial distribution
According to the PHCB 2005, the country’s population density was 16 persons per square
kilometer and it is estimated to increase to 23 persons per square kilometer by 2030. The
population density was highest in Thimphu Dzongkhag with a density of 54 persons per
square kilometer followed by Chhukha and Samtse each with densities of 40 persons per
square kilometer. On the other hand, Gasa Dzongkhag was the least populated with 1
person per square kilometer, followed by Lhuentse Dzongkhag with 5 persons per square
kilometer.
In 2005, around 31 percent of the total population of Bhutan resided in the urban areas.
Thimphu city is the largest urban center in the country accounting for about 75 percent of
the total urban population. The rapid increase in the proportion of population in the urban
areas is mainly due to the migration of population from the rural to urban areas.
The graph in Figure 3 shows uneven spatial distribution of population. Thimphu
Dzongkhag is the most populous with 15.5 percent of the country’s total population
followed by Chhukha with 11.7 percent of the country’s total population.
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Figure 3: Population distribution across Dzongkhags
2.5 Fertility levels, trends and determinants
According to the World Population Policies Report 2007 UNDESA the global total fertility
declined from 4.5 children per woman in 1970-75 to an estimated 2.6 children in 2005-2010.
Amongst the 150 developing countries, fertility has reached below replacement level in 28
of the countries while it remains above 5 children per woman in 27. In this respect, Bhutan
has a fertility rate heading for the replacement level fertility around the end of the next
decade. Over the past few decades there has been a consistent decline in the TFR which
declined from 5.6 in 1994 (NHS 1994) to 3.6 in 2005. The replacement level of 2.1 is
estimated to be reached by 2020.
Figure 4: Crude Birth Rate and Crude Death Rate
Prior to the population and housing
census in 2005 demographic data were
obtained from the national health surveys.
The crude birth rate (CBR) 6 estimates were
fairly high in the 80s and the 90s. At the
growth rate of 3.1 percent in 1994 the
population would have doubled in every
23 years.
Source: DHS 1984 &1994; NHS 2000; PHCB 2005
However, the CBR declined from 39.9 per 1,000 population in 1994 to 34.1 in 2000 and
further to 26.1 in 2005. This may be compared to the Crude Death Rate 7 (CDR) of 13.4 per
1000 population in 1984 that declined to 8.64 in 1994 and to 7 in 2005. The decline in the
CBR may be attributed to the improvement in school enrolment, particularly that of girls,
improved retention in schools and employment. There has been an increase in the
6 The number of births per 1,000 population.
7 The number of deaths per 1,000 population.
15

Table 3: TFR by household characteristics
Household/Mother's characteristics
TV/Video Possession
Source: PHCB 2005
TFR
Have TV/Video 1.99
Don't have TV/Video 2.9
Car Possession
Have car 1.7
Don't have car 2.7
Distance from road head
< 1 hour 2.42
1-3 hours 2.93
> 3 hours 3.01
It may be noted from table 3 that those mothers
residing less than 1 hour distance from the road
head has a lower TFR (2.4) as compared to those
living 1-3 hours away (2.9) and more than 3 hours
away (3.0). Similar observations may be made
under the economic status of the mother,
whereby there is a substantial gap in TFR
between those who possess television sets and
cars and those who do not.
2.5.3 Nuptiality
The term nuptiality refers to marriage and it relates to the study of unions or dissolutions of
marriage. Marriage is an important demographic event which influences the course of
population change. Female age at marriage and the proportion single in the reproductive
age group are important due to its impact on fertility.
The mean age at marriage can be estimated from the proportion single - Singulate Mean
Age at Marriage (SMAM) 9 . According to the PHCB 2005 the mean age at marriage was
21.8 years with the mean age at marriage in rural areas (21.3 years) slightly lower than the
urban areas (21.7 years). This signifies that a higher proportion of marriages occur in the
young ages.
Table 4: percent of population divorced, 2005-2007
Sex 1984 (SYB) PHCB 2005 BLSS 2007
Male 0.9 0.8 1.1
Female 2.7 2.1 3.2
Both sex 1.9 1.9 2.2
Table 4 presents the percentage of
divorced persons. The overall
percentage of divorced persons
increased from
Source: SYB 1984: PHCB 2005; & BLSS 2007.
1.9 percent in 1984 to 2.2 percent in 2007. The proportion divorced is over three times
higher for females (3.2 percent) than males (1.1 percent).
9 The singulate mean age at marriage is the average length of single life expressed in years among those who marry
before the age of 50.
17

Figure 6: Rural urban differences in the proportion of singles among females
Source: PHCB 2005
The figure above shows that the proportion of singles is higher for females in urban areas
than in rural.
The mean age at child bearing (MACB) is 26.9 years. In 2005, 11 percent of the total births
occurred to women in the age group 15-19 years. This is a high teenage pregnancy rate
which has implications on the health of the mother and child and may also be looked at in
relation to high infant and maternal deaths.
2.6 Mortality levels, trends and determinants
The estimates of crude death rates (CDR) based on past demographic and national health
surveys and the PHCB 2005 is given in table 2.5. The (CDR) declined from 19.3 deaths per
1000 population in 1984 to 7.7 deaths per 1000 population in 2005. In the same manner, the
Infant Mortality Rate (IMR) dropped from 102.8 infant deaths per 1000 live births in 1984 to
40.1 in 2005. The Under Five Mortality Rate (U5MR) declined two and a half fold during the
same period. As a result of improved health indicators, the overall life expectancy at birth)
increased significantly from 47.5 years in 1984 to 66.3 in 2005.
Table 5: Mortality indicators, Bhutan 1984-2005
Mortality Indicator 1984 2005
CDR (Crude Death Rate) 19.3 7.7
IMR (Infant Mortality Rate) 102.8 40.1
U5MR (Under Five Mortality Rate) 162.4 60.1
MMR (Maternal Mortality Rate) 7.7 2.55
Life Expectancy at birth 47.5 66.3
Male 45.8 65.7
Female 49.1 66.8
Source: SYB 1997; PHCB 2005
18

2.6.1 Age specific mortality
The Age Specific Death Rate (ASDR) describes the specific component of the overall crude
death rate. It pertains to the event of death in a specific age group.
Table 6: ASDR by age, 2005
Age group
CDR

Trashigang 3.7 9.4 8.6
Trashiyangtse 8.6 9.4 9.2
Trongsa 1.9 9.1 7.7
Tsirang 4.8 6.9 6.7
Wangdue 5.6 8.3 7.7
Zhemgang 3.0 7.2 6.4
Bhutan 5.3 7.9 7.1
Source: PHCB 2005; Based on annual birth in 1 year before census date
2.6.3 Morbidity levels, trends and determinants
The Ministry of Health keeps records of inpatients and outpatients who utilize services
from the health facilities. Morbidity data may be considered acceptably reliable as health
services are provided free by the government.
As per the Annual Health bulletin (AHB) 2008, admission in the Basic Health Units (BHUs)
rose by 3 percent compared to the previous year. Common cold still remains the most
prevalent health problem affecting the population. The general morbidity trend has been
similar over the past few years, both in adults and under 5 years. Similarly, for indoor
morbidity, complications of pregnancy continue to be the major cause for inpatient
admission. The number of pneumonia cases, however has decreased significantly from the
previous year when it was the fifth most common cause of indoor morbidity. On the other
hand, ear and eye problems, diseases of the circulatory and digestive systems, pregnancy,
child birth & peuperium, diarrhea and dysentery gained prominence.
Since the 1990s Acute Respiratory Infection (ARI) remained the foremost health problem
followed by diarrhea and dysentery. While ARI is still one of the top diseases, diarrhea and
dysentery dropped to the third position as early as 1995.
2.7 Disability
The Population and Housing Census of Bhutan define disability as “a functional limitation
in performing certain tasks/activities due to ongoing long term physical, mental and health
condition”. There were 21,894 (3.4 per cent) people of all ages with disability. As per Table
8, hearing (35.7 percent) and (23.5 percent) seeing were the most common disabilities.
Table 8: People with disability (PWD)
Findings from the PHCB 2005 reveal that
more males suffer from disability than
females. Disability in Bhutan is a rural
phenomenon. Its prevalence is noted at 3.4
percent of the total population (45.7
percent were females and 54.3 percent
males). Compared to the percent share of
the total population, males comprised 1.8
percent and females 1.6 percent. 2.4
percent were people with disability
acquired after birth, and 1 percent people with disability acquired since birth. The male to
female sex ratio among the PWDs was found to be 1.19, indicating that for every 100
females there were 119 males.
20

By residence type of the respondents, 1.4 percent of the total urban population and 4.4
percent of the total rural population are with disability. Disability acquired since birth as
well as after birth is more prevalent in rural areas than in urban areas.
Table 9: Disability in older population by age and sex (population over 60 years)
Age-group (%)
60-64 65-69 70-74 75-79 80+ Total (%)
Disability acquired since birth
Male 2.8 2.6 2.4 2.8 3.0 2.7
Female 2.2 2.4 1.8 1.9 1.8 2.1
Disability acquired after birth
Male 10.0 13.1 17.1 18.5 24.0 14.5
Female 9.3 11.8 15.2 19.4 24.8 13.9
Both Sexes 12.2 15.0 18.3 21.3 26.7 16.6
No. of Cases 1,781 1,704 1,598 1,118 1,176 7,377
Source: Bhattarai,Bholanath, 2010, Disability Patterns in Bhutan (based on PHCB 2005)
The prevalence of disability is observed to rise with age and is more prevalent in the elderly
population. As per the study on disability patterns in Bhutan which is based on the PHCB
2005, the total prevalence of disability above age 60 is higher among the males than females
in general, however, after age 75 disability is higher among the females. One reason for this
may be attributed to the longer life expectancy of women.
With respect to literacy levels amongst PWD, as per the PHCB 2005, 16.3 percent of the
PWD acquired since birth are literate while 27.9 percent of the PWD acquired after birth are
literate. The corresponding percent literate among those without disability is 60.9 percent.
From the total male PWD, 33.2 percent are literate and 14.3 percent of the total female PWD
are literate.
From the employment perspective, 51 per cent of the male PWD and 36.5 per cent of female
PWD are employed. Majority of the female PWD are engaged as unpaid family workers. As
such, gender disparities in literacy levels and employment exist and marked differences are
apparent in both these areas between PWD and those without disability. Findings from the
study on disability patterns in Bhutan also reveal that the proportion of never married
PWD is higher for both males and females in comparison to that of the able and total
population. About 62.7 percent of the males and 52.6 percent of females with acquired
disability since birth are never married. Further, a higher proportion of PWD in mental
functioning followed by speech impairment acquired since birth are never married. These
findings show that disability is a barrier for entering into marriage, especially for those
with disability since birth.
2.8 Urbanization and Migration
The definition of urban areas used in the PHCB 2005 was that provided by the Department of Urban
Development and Engineering Services (DUDES) 10 .
10 An area is declared as urban if the following criteria or 75% of the criteria are met:
a) A minimum population of 1,500 people;
b) A population density of 1,000 persons or more per square kilometer;
21

2.8.1 Urbanization
Figure 7: Population of larger cities
The urban population grew from 13
percent in 1984 to 31 percent in 2005
(BNUS 2008). The size of urban cities,
as shown in Fig 2.6, varies
considerably in population size.
Thimphu city being the largest city,
accounted for over 40 percent of the
total urban population. The second
largest town is Phuentsholing
accounting for around 11 percent of
total urban population. Several towns
Source: PHCB 2005
were small with only a few hundred
population. The proportion of urban population is estimated to grow to 60 percent by 2020
(BNUS 2008).
According to the PHCB 2005, the proportion of population that is urban is highest for
Thimphu Dzongkhag constituting 80.3 percent of its population; the second most
urbanized are Chhukha and Sarpang Dzongkhags, with 44.3 percent and 30.3 percent
respectively.
2.8.2 Migration
In the Human Development Report 2009, it is estimated that approximately 740 million
people are internal migrants almost four times as many as those who move internationally.
As per the PHCB 2005, migration is defined as a form of geographical mobility or spatial
mobility between one geographical area to another, generally involving a change of
residence from the place of origin to the place of destination. Internal migration 11 is
important in the population redistribution and urbanization. International migration 12 is
mainly confined to groups of project bound labor migrants.
The migration rates based on the PHCB 2005 are presented in Table 7. Thimphu dzongkhag
received the highest migrants with a positive migration rate of 2.3 percent, followed by
Chhukha, Paro and Punakha Dzongkhags. Zhemgang, Trashigang, Lhuentse and Tsirang
were the major places of origin of migrants with negative rates of migration.
c) More than 50% of the population should depend on non-primary activities;
d) The area of the urban center should not be less than 1.5 square kilometers; and
e) Potential for future growth of the urban center particularly in terms of its revenue base,
11 This refers to a change of residence within national boundaries, such as between states, provinces, cities, or
municipalities. An internal migrant is someone who moves to a different administrative territory.
12 International migration occurs when peoples cross state boundaries and stay in the host state for some
minimum length of time.
22

Table 10: Net migration by Dzongkhag
The high rate of migration to urban
areas may be explained by the
findings of the PAR 2007, that an
estimated 23.2 percent of the
population are poor. It states that
poverty in Bhutan is exclusively a
rural phenomenon with three in ten
persons in rural areas poor. By its
estimates, only less than 2 percent are
poor in the urban areas. The Rapid
Impact Assessment of Rural
Development, Planning Commission,
November 2007 (RIARD 2007) also
found that accessibility to services,
Source: PHCB 2005
particularly that of income generation
support was only 16 percent in the rural areas. At the same time, 35 percent of respondents
in rural areas faced food shortages during the year.
As per PHCB 2005, the highest proportion of migrants (31.5 percent) migrated for family
moves. Around 17 percent of the migrants moved for employment, 15 percent for
education and training, 11 percent due to marriage, 10 percent transfer of work, 3.4 percent
for resettlement, 7 percent staying as visitors to relations and the rest 7 percent were for
other unspecified reasons.
Chapter Highlights
The total population in 2005 was 634,982 persons. Males comprised 52.5 percent and females 47.5 percent of the
population resulting in a resident sex ratio of 111 males for every 100 females. Chhukha Dzongkhag has the highest
male to female sex ratio of 132 males for every 100 males.
Population grew at a rate of around 3.1 percent during 1994 which in 2005 declined to 1.8 percent. Although rate of
growth will gradually decrease, population size is expected to reach 757,000 persons in 2015, and will further climb
to 887,000 persons by 2030.
The population density was 16 persons per sq km in 2005. With the increase in population, density will increase to
23 persons per sq km by 2030.
The dependency ratio indicates the socioeconomic burden, which has declined to 61 percent in 2005. The growing
size of the working population (15-59 years) is responsible for the decline of dependency ratio. The median age of the
population is 22 years which is indicative of half the population being below 22 years of age. This implies that the
population growth rate is likely to increase in the near future as a result of the young age structure.
23

Elderly population (65+ years) increased from 4.3 percent in 1984 to 4.7 percent in 2005 which is expected to
increase to 7.2 percent by 2030 and will steadily grow with the improvement of health status and increasing life
expectancy. Aging index in 2005 was 14 percent.
The birth rate declined from 39.9 births per 1000 population in 1994 to 34.1 in 2000 that further dropped to 19.7 in
2005. Of the total 12,538 births, 11 percent representing 1,376 births occurred to teenage women in the age group
15-19 years.
Total fertility rate (TFR) declined from 6.5 in 1991 to 3.6 by 2005. The level of fertility varies by urban rural
residence and by Dzongkhag. The contraceptive prevalence rate has increased from 18.8 percent in 1994 to 30.7
percent in 2000. Over 83 percent women of age 10-19 years were single. The decline in the proportion of singles
among teenage women is partly responsible for fertility decline.
Life expectancy increased from 47.5 in 1984 to 66.3 in 2005. Improvement is noticed in the achievements made in
the IMR which declined from 102 in 1984 to 40.1 in 2005. In spite of the declining fertility and mortality, the
population will continue to grow due to the effect of population momentum.
To accurately assess the course of population change and effect on development there is dire need to fill demographic
data gaps, its trends, improve data quality, coverage and institute research.
24

CHAPTER THREE
3. POPULATION AND ENVIRONMENT
3.1 Human activities and environment linkage
Environment conservation is one of the four themes for achieving the national development
goal of Gross National Happiness (GNH). It has thus received consistent priority in the
country’s development process. Of the total land area, 72 percent is under forest cover; that
includes 29 percent protected areas and 9 percent biological corridor (10 th FYP, GNHC
2008-2013). Accelerated socio-economic activities and increased demand for resources of a
growing population pose pressure on environment.
Despite having the lowest population density in the region and a significant reduction in
the rate of population growth in the last decade, population growth is still one of the
biggest challenges faced by the country, with it’s associated impacts on the environment,
food security, nutrition, employment, balance of payments; and ability to continue to
provide services to a growing population. Meeting the development needs of a growing
population, with increasing incomes and changes in consumption patterns will exert
increasing pressure on the environment.
3.2 Population density
The density of population (number of persons per sq. km) in Bhutan is quite low at 16
persons per sq. km in 2005 and projected at 23 persons per sq. km. by 2030 (Population
Projections, NSB 2007). However, the skewed population distribution, the limited arable
land, and the topography continue to give rise to localized population pressure on the
environment.
As per the Bhutan Environment Outlook (BEO) 2008 most environmental problems are
localized and generally associated with high population density, urbanization and
industrialization. If the aggregate of arable land and land with human settlements are taken
as the denominator, the density of population increases to 200 persons per square
kilometer. Furthermore, the skewed population distribution shows that places like
Thimphu, Chhukha and Samtse have population densities ranging from 51 to 38 persons
per square kilometer square, which is well above the national average.
Going by the current trends of rural urban migration and urbanization, it seems population
distribution will continue to be skewed exerting pressure on the local environment
therefore adequate mitigation and adaptation measures would have to be put in place.
3.3 Climate change and natural disaster
Climate change and global warming is mainly due to increase in human activities to meet
the needs of a growing population. The major challenges faced by Bhutan will be on how to
manage its influence on climate change and how to adapt to it. According to the Bhutan
National Adaptation Programme of Action (NAPA) 2006, the most likely adverse impact of
climate change in Bhutan are increased Glacial Lake Outburst Floods (GLoF), and
landslides and flash floods caused by rainfall in areas with poor soil stability. The
Inventory of Glaciers in Bhutan (2001) has identified 24 out of 2,674 glacial lakes as having
25

the potential of causing GLoF. The NAPA also states that the most vulnerable sectors
are agriculture and hydropower due to their heavy dependence on monsoons and
temperature change patterns. The rural poor who depend directly on crops and livestock
have accordingly been identified as those likely to be most vulnerable to climate change.
Currently the agriculture sector provides livelihood to around 79 percent of the population
through income generation and employment, and hydropower continues to be the
backbone of the Bhutanese economy. Climate mitigation and adaptation activities will be
needed to meet the future needs of the population.
3.4 Agriculture
Agriculture is the primary occupation for the majority of people in Bhutan the proportion is
greater for the rural areas. However, food grains self sufficiency met through domestic
production stands at 65 percent against a target of 70 percent set in the 10 th FYP.
Although the CountrySTAT-Bhutan, showed that land under crop cultivation increased by
48.5 percent from 173,135.1 acres in 1999 to 233,187.76 acres in 2007, further increases may
be limited by the fact that only about 9 percent of the total land is arable. Furthermore, as
shown in table 3.1 the yield per acre exhibits a declining trend, and the average cropland
holding per capita which was estimated at 0.61 acres is expected to fragment further as a
result of the growing population. The steep slopes around the country also make for
unproductive agricultural lands.
Against this backdrop a major challenge in the future would be trying to feed the needs of a
growing population while preserving the existing environment. An increase in cropland
could result in loss of forest cover, land degradation and other associated impacts if not
done in a sustainable manner.
Table 11: Crop yield 1999-2007, Bhutan
Per Capita Yield (tonnes/acre)
Cereals 1999 2000 2002 2003 2004 2005 2006 2007
Paddy 0.55 0.87 0.48 0.55 0.69 0.65 0.67 0.65
Maize 0.49 0.78 0.50 0.59 1.32 0.96 0.72 0.71
Wheat 0.32 0.30 0.36 0.46 0.44 0.40 0.44 0.42
Barley 0.39 0.37 0.35 0.61 0.41 0.43 0.43 0.42
Buckwheat 0.23 0.20 0.18 0.14 0.24 0.25 0.26 0.23
Millet 1.00 0.03 0.04 0.04 0.02 0.03 0.26 0.25
All cereals 0.52 0.66 0.43 0.50 0.88 0.65 0.58 0.57
Source: CountrySTAT-Bhutan: http://www.rnrstat.bt/csbhutan/
3.5 Livestock
Livestock rearing is a critical source of income and livelihood for the rural people, with
almost every household owning cattle. Livestock is reared mainly for dairy products, meat,
draught power and dung production for manure. According to RNR Statistics (2005)
produced by the MoA, there were 338,847 cattle and 45,538 yaks, compared to 2003 this was
an increase of about 8 percent and 138 percent respectively. With 1,737 km 2 pastureland, the
26

density of cattle per square kilometer of pastureland was calculated at 191/ km 2 in
2003, this had increased to 221/km 2 in 2005. It is apparent that uncontrolled grazing will
lead to environmental degradation.
Given the integral role that livestock rearing plays in the livelihoods of the rural populace,
and its potential negative impact on the environment, it is critical to address the two issues
through sustainable management practices.
3.6 Forests
Bhutan has made a constitutional commitment to keep as a minimum 60 percent of its land
under forest cover at any point of time. As of 2005, 72.7percent of the land area was under
forest cover. Keeping this commitment will be a major challenge in the face of a growing
population with it associated demands for more agricultural land, fuel-wood and timber.
Currently the Department of Forest (DoF) and the Natural Resources Development
Corporation Limited (NRDCL) supply 284,000 m 3 of wood annually which is much below
the actual demand estimated at 769,000 m 3 per year. This is an indication of the immense
pressure imposed by the needs of a growing population on our forests. If left unchecked, it
may lead to illegal and unsustainable extraction practices, making areas susceptible to soil
and water erosion.
Due to the skewed population distribution, Thimphu has the highest population per sq km
of forest at 114 persons, and Gasa with least at 3 persons per sq km of forest, as result
pressure on forests are larger in areas with higher population densities.
Other challenges to preserving our forests arise from fires and clearing for infrastructure
development. Data from the DoF show that between 1999 and 2005 (2001 to 2003 there was
a decline) there were about 400 incidents of forest fires which destroyed almost 35,000
hectares of forest. More than 1,300 hectares of forest land have been cleared between 2001
to 2005 for various infrastructure development activities with roads and transmission lines
accounting for 70percent of it. Due to forest degradation and other factors about 95,430
hectares of land have been affected by landslides/soil erosion.
3.7 Water
The demand for water in Bhutan is primarily for hydropower generation, municipal and
rural domestic use, irrigation, industrial use, and livestock rearing and production. The
main sources for drawing water are the main stem rivers, tributary streams and rivers, and
sub-surface water. The long term mean annual flow of the entire country is estimated to
73,000 million m 3 ; and per capita mean annual flow availability is 109,000m 3 ; and per capita
minimum flow availability is 20,000 m 3 .
While the per capita availability of water is one the highest in the world, localized water
shortages and pollution occur due to the growing population and its skewed distribution,
poor planning and management, and access issues in some areas. The potential impact of
climate change on the glaciers and glacial lakes is also a major concern, as they constitute a
major source of water in Bhutan.
27

The quality of water at the macro level is in a very good state. However, localized pollution
problems occur due to unsanitary conditions, these are exacerbated in urban centers such
as Thimphu and Phuentsholing.
The PHCB 2005, revealed around 16 percent of the households in the country depended on
springs/pond/tube water for drinking. Amongst the Dzongkhags, Gasa had the highest
percentage of population with no access to piped water with 52percent falling under the
category, while Thimphu had the least at 3 percent. In the urban areas, 98 percent of the
households had piped drinking water compared to over 78 percent in the rural areas.
The water supply adequacy assessment carried out by Department of Energy (DoE) in 28
urban centers in 2002 revealed 11 towns experienced water shortages and an additional 7
towns were likely to experience the same by 2013.
A detailed water demand forecast exercise carried out by DoE for the preparation of
Bhutan’s Water Resources Management Plan estimated 422 million m 3 of gross
consumptive demand in 2002. This demand is forecasted to grow to 541 million m 3 by 2022.
Per capita consumptive water demand works out to 665 m 3 per year. Irrigation demand
accounts for 93 percent of the total demand. On the other hand, municipal demand
presently 2.3 percent is expected to increase to 3.7 percent by 2012 and 7 percent by 2022
with the growth of population. Non-consumptive water demand i.e. for hydropower
generation was estimated at 6,700 m 3 for 2002 and is forecasted to grow to 26,900 million m 3
by 2022 keeping in view the upcoming and potential hydropower projects in the future.
3.7.1 Water Pollution
As per the BEO 2008, domestic sewage is the main source of water pollution. Improper
disposal of waste oil and other vehicle effluents from workshops located close to rivers are
also a serious environmental concern, especially in places like Thimphu and Phuentsholing.
Out of 133 automobile workshops in the country, 67 are located in Thimphu and
Phuentsholing. Use of pesticides and herbicides in Bhutan are a potential source of water
pollution, with their use more than doubling between 1998/99 to 2004/05 i.e. from 125,311
kg to 280,995 kg. However, it has been estimated that 94 percent of the total volume of
herbicides and pesticides used in the country have no acute hazard as per the toxicity
classification of the WHO. There is the need to develop a comprehensive data and
information base to monitor the water pollution situation.
3.8 Minerals and Mining
Due to rapid industrialization and economic growth, the rate of production of minerals has
increased. Mining operations have a direct impact on the landscape and environment.
According to BEO 2008, mining, along with the chemical and cement production industries
contributed the most to air pollution. As of 2003 there were 47 mines and quarries
operating on a total land
28

Figure 8: Trend of mineral production, Bhutan
area graph of shows 644 hectares that (Department around 500,000 of Geology metric & Mines)
tonnes of limestone were produced in 2002
that increased to 600,000 metric tonnes in
2006. That is around one metric tonne of
limestone mined per capita. Although
slightly lower than limestone, dolomite
production since 2003 has grown at the
same rate as that of limestone. Its
production in 2006 is close to 500,000
Source: Department of Geology and Mines, 2003
metric tonnes. While the volume of gypsum
production is around 100,000 metric
tonnes per year, the rate of growth is same as
that of limestone and dolomite as shown in
Figure 8. Its production in 2006 crossed 200,000
metric tones. Production of coal increased
slightly during the period. Talc production increased at half the pace of other minerals. Its
production in 2006 was around 50,000 metric tones. Following the trends, it is likely that
mining operations may increase in the future, to meet the needs of a growing population,
increasing the likelihood of impacting the environment and landscape.
3.9 Energy
Population growth, and the associated changes in living standards and consumption
patterns have implications on amount and type of energy used ultimately determining its
impact on the environment. As per the Bhutan Energy Data Directory 2005 residential
energy use accounted for 48.7 percent of the total energy consumption, with the industrial,
transport, and commercial sectors accounting for 25 percent, 14.3 percent, and 10.3 percent
respectively.
The present energy supply in Bhutan is dominated by renewable energy. In 2005 the total
energy supply was estimated at 554,752 Tonnes of Oil Equivalent (TOE) against a total
demand of 392,467 TOE. Biomass and hydropower were the major sources in the energy
supply mix. The per capita energy supply for 2005 was estimated at 0.87 ToE 13 against a per
capita demand of 0.62 TOE. 14 For residential energy use, 91 percent of the demand was met
from biomass, the industrial sector was the largest consumer of electricity consuming 64.7
percent of the total, and oil was the dominant source in the transport sector.
It is apparent that the demand for energy and the source of supply will undergo changes.
The number of production and manufacturing industries had almost doubled between 2002
and 2006 (SYB 2007), and if the trend continues demand for electrical energy may increase.
Going by current trends (BEO 2008) vehicular numbers are expected to increase by 265
percent from that in 2005, which would bring about a drastic increase in oil consumption.
The residential sector (both rural and urban) is also expected to change their energy supply
13 This was 51 percent lower than the world average for the same year.
14 This was 65.7 percent below the world average for the same year.
29

mix, with the implementation of nationwide electrification programs, and the advent of
cheaper appliances in the market. The provision of clean, reliable and affordable energy
will be a major challenge associated with population growth.
Figure 9: Types of industries, 2002 -2006
3.10 Air
Source: Statistical Yearbook, 2007
The two largest contributing factors in urban areas are vehicular emissions and use of solid
fuels for cooking, heating and lighting.
According to the First Greenhouse Gas (GHG) Inventory produced by the NEC in 2000, the
vehicular source contributed 42.99 million kg (19 percent of total CO2 emissions). The
number of vehicles grew at an average rate of 7 percent 15 between 1990 to 2005, and future
scenarios project a further growth in vehicle numbers, bringing about increased CO2
emissions if left unchecked.
The GHG Inventory 2000 also found that 27.18 million kg of CO2 emissions were
contributed by the country’s domestic energy use i.e. from the use of fuel wood for cooking,
heating and lighting purposes. The PHCB 2005 showed 37.3 percent households used fuel
wood for cooking, 30.6 percent used electricity for cooking, while 25.6 percent used LPG.
Fuel wood use has however declined over the years with the availability of modern fuels
and electrical cooking and heating appliances and the access to electricity in most parts of
the country.
The industry sector is the largest source of CO2 in the country. According to the GHG
Inventory 2000, it contributed 133.69 million kg of CO2 (58 percent of total CO2 emissions).
Industries such as cement, chemical processing and mining contributed the most to air
pollution. In an assessment by NEC in 2001 of environmental management in selected
industries it was found that high levels of ambient dust and lack of pollutant emission
control system still persisted as serious concerns. The other pressures on the state of air
15 Average growth rate of 4.9 percent (1990-99) and 9 percent (2000-05)
30

quality include population growth, urbanization, forest fires and solid waste
generation and disposal.
3.10.1 Ambient air quality
Ambient air quality and monitoring has been done only in Thimphu. NECS recorded an
average respirable particulate matter (PM10) concentration of 24.5 μg/m 3, which is
considerably lower than the internationally set PM10 concentration levels of 50 μg/m 3 (US-
EPA) and 40 μg/m 3 (EU Guideline). On the basis of the PM10 concentration levels for
Thimphu it can be expected that the ambient air quality is much pristine in most other parts
of Bhutan except for industrial towns like Pasakha, Gomtu and Phuentsholing town.
The result of air pollution is the likely increase acute respiratory infection respiratory
infection among children and chronic respiratory diseases, cardiovascular and lung
diseases among adults with rapid urbanization, vehicular use and industrial expansion. For
every 10μm increase in diameter (PM10), health risks increase by 1.2 to 4.4 percent (Health
Environment and Sustainable Development, Ministry of Health, Yangon).
3.11 Urbanization and the environment
The urban population in Bhutan grew almost at the same rate with real GDP as seen in
Figure 10 between 1985 and 2005.
Figure 10: percent change in real GDP and Urban population
Source: Statistical Yearbook of Bhutan, NSB
There has been a sharp increase
in urbanization particularly
between 1995 and 2005. Due to
the consumption patterns and
modern lifestyles, the urban
population produces huge
amounts of air and water
pollution. Problems of waste
management and disposal arise
and urbanization has strong
bearings on provision of basic
amenities, quality of life,
environment, water and
sanitation, waste disposal and various other social and economic problems such as
unemployment, increasing crime rates, etc.
3.11.1 Solid Waste
Solid waste generation and disposal is an emerging environmental concern particularly in
the urban areas. According to a survey by RSPN in 2005, Thimphu and Phuentsholing
accumulated 36.7 and 24.7 metric tons (MT) of municipal solid waste respectively in a day
31

at the landfill sites. The per capita solid waste generation for Thimphu 16 was about
0.46 kg per day or 168 kg per annum and for Phuentsholing was 1.2 kg per day or 438 kg
per annum. In Thimphu alone there has been an increase in solid waste by 67 percent since
2003 (22 MT per day) and an alarming increase of 360 percent since 1994 (8 MT per day).
This indicated that daily solid waste generation increased at a rate of 8 percent each year
between 1994 and 2003 and then at an accelerated rate of 33 percent between 2003 and 2005.
Rapid urbanization, changing consumption patterns, and lack of civic awareness among the
Bhutanese is expected to bring about increases in solid waste generation particularly in
urban areas, exerting more pressure on the environment.
3.12 Biodiversity
Bhutan has been declared one of the top ten biodiversity hotspots in the world. The
country’s fauna includes more than 600 species of birds and 190 species of mammals, of
which 14 bird species and 26 mammal species are globally threatened according to the
International Union for Conservation of Nature’s (IUCN) Red List of threatened species.
Population growth has led to increasing pressure on biodiversity through over grazing,
excessive forest use, forest fires, infrastructure development, population growth and
urbanization. Between 1999-2003 the Department of Forests (DoF) recorded more than 2,600
offences of illicit timber extraction, fuel wood collection, and wildlife poaching and fishing
in the period 1999-2003. The main species targeted for poaching were musk deer (Moschus
chrysogaster) and Chinese Caterpillar Fungus (Cordyceps sinensis) as both are highly valued
for their medicinal value and have a lucrative market.
Human- wildlife conflict is also a growing concern in the country. Crop depredation by
wildlife such as wild boars, deer, monkeys, bears and elephants, is common and
widespread and is a constant source of farmers’ woes. A study by FAO and the royal
government estimated that the monetary value of crop damage by wild boar amounts to
more than Nu. 112 million every year. The RNR Statistics 2000 ranks crop damage by
wildlife as the most severe constraint faced by farmers. 30 percent of the households in the
vicinity of Jigme Singye Wangchuck National Park have reported loss of livestock to
predators.
Chapter highlights:
Although fertility is declining, the population will continue to increase due to population momentum and increase in
number of women in the reproductive age group. An effect of population increase is the increase in population density
that increased from around 10 persons per square km in 1985 to 16 persons per sq km in 2005.
Pace of development is also marked by the rapid urbanization which grew from 13 percent urban population in 1985 to
31 percent in 2005. Urban population grew at an annual rate of 6 percent until 2005. Migration from rural to urban
areas has been responsible for concentration of population making Thimphu a primate city overstretching services,
causing social problems, problems of solid wastes (around 50 tonnes/month) and pollution of water and air. Rapid
urbanization and population increase intensifies the pressure on forest and land for space.
16 As per PHCB 2005 the population of Thimphu was 79,185 and Phuentsholing 20,537
32

On the other hand, 69 percent of the population lives in rural areas. Per capita land holding is 0.6 acre and yield is
constrained by steep rocky terrain, loss of soil fertility and rampant crop destruction by wild animals. Yield of crops have
been declining for most cereals. To meet the growing need of food for the increasing population at the backdrop of the
decreasing crop yield, volume of food imports is expected to rise.
Manufacturing and mining industries has been gradually outpacing the agriculture sector as a major sector of the
economy. There were 46 mining industries in 2002 that doubled to 91 in 2006. Industrialization and mining activities
may cause loss of forests and natural habitat.
Consumption of wood for construction, fuel and other uses has increased over the years that have direct implications to
the forest and environmental degradation. Only about 45 percent households use electricity for cooking while around 55
percent households use wood.
As per the BLSS 2007, 23.2 percent of the total population lives below the poverty line and poverty is found to be a rural
phenomenon. Without proper policies, population growth will lead to increasing pressures on the environment further
exacerbating poverty.
With growing population, the need for water, both for agriculture and for drinking will increase. In 2005, around 16
percent of the households in Bhutan were without safe drinking water.
In Thimphu city alone there has been an increase in solid waste by 67 percent since 2003 (22 MT per day) and an
alarming increase of 360 percent since 1994 (8 MT per day). This means that daily solid waste generation increased at
the rate of 8 percent each year between 1994 and 2003 and then at an accelerated rate of 33 percent between 2003 and
2005.
The industry sector is the largest source of CO2 in the country, contributing to 133.69 million kg of CO2 (58 percent of
total CO2 emissions) and high levels of ambient dust and lack of pollutant emission control system in industries still
persist as serious concerns (NEC 2001).
33

CHAPTER FOUR
4. POPULATION AND THE ECONOMY
4.1 Economic growth and population
Over the past three decades, Bhutan has progressed well in terms of economic development
with an average GDP growth rate of over 8 percent. Sustained economic growth has been
primarily driven by large-scale hydropower development and the export of electricity to
India. The economy has experienced the highest growth rate coinciding with the
commissioning of the hydro power projects as illustrated in Figure 11.
Figure 11: Real GDP Growth: 1981-2008
35
Real GDP Growth: 1981-2008
30
25
20
15
Real GDP Growth
10
5
0
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2008
Source: NSB and Draft SGNH
Translating Bhutan’s development in terms of real GDP, it increased from Nu. 1,095 million
in 1980 to Nu.37,964.2 million in 2008. The nominal Gross National Product/Gross National
Income (GNI) in 2008 was estimated at Nu. 53,010.6 million or per capita income of over
Nu. 78,884.82.
Population growth and economic development are inversely related in terms of utility and
distributional aspects of the natural resources. However, the mode of economic growth to a
larger extent depends on economic dynamics i.e. production, consumption and savings/
investment patterns.
34

Similarly, variables of savings and investment influences growth of national
income. Bhutan has experienced steady growth in gross savings over the past years, Nu.
6,637.4 million in 2000 to Nu. 26,371.7 million in 2008 (National Accounts Report, NSB
2009).
4.2 Demographic aspects of savings
Savings at household and individual levels are determined by demographic characteristics
such as age composition, size & structure of household and occupational status of the
household members. High population growth increases propensity to consume, thereby
discouraging current savings, which has adverse effect on capital formation and economic
growth. On the other hand, the propensity to save increases, when the proportion of
population in labor force is larger than the population in dependency age cohort. As per
NSB’s projection, our economy will be witnessing 24 percent increase in labor force size
between 2005 to 2015. Therefore, if the government complements this with strategic policies
and investment models, the national income and saving rates will rise significantly.
At the national level, gross savings has been increasing steadily. For instance, in 2005 total
gross savings at national level was Nu. 13,854.7 million or per capita saving of Nu. 21,819
which increased to Nu. 31,585 (44.8 percent increase) in 2008.
One of the summary measures of age structure is the dependency ratio. The coefficient of
correlation between dependency and young dependency ratio vis-a-vis poverty is high as
indicated in Table 11. The Poverty Analysis Report (PAR) 2007 and PHCB 2005 highlighted
the correlation coefficient of 0.62 and 0.63 respectively. This is indicative of higher
consumption patterns and lower propensity to save as the number of dependents increases
in the household
4.3 Dependency ratio
Table 12: Dependency ratio and poverty level correlation
Indicator of age structure/
household size
Poverty and total dependency ratio
Poverty and young dependency
ratio
Poverty and old dependency ratio
Source: PAR 2007 and PHCB 2005, NSB
Correlation
Coefficient
Highly co-related
(0.62)
Highly co-related
(0.63)
Weakly co-related
(0.34)
The change in age structure is dynamic in nature, for it is constantly being shaped by the
changes in the components of population age cohort. Therefore, the demographic bonus
arising out of bulging adult population is momentary that will soon be taken over by the
increase in dependency ratio due to the increase in the proportion of old age people. The
young and the older population depend on the productivity of the working population.
35

The period when the dependency ratio is lowest is the time of opportunity offered by
the changing age structure as a result of demographic transition.
The total dependency ratio was estimated at 70.9 percent in 1984, which declined to 60.7
percent in 2005. The dependency ratio is expected to drop further down to 41.8 percent by
2030. If this projection holds true, there will be a positive environment in accelerating
economic growth, accompanied by enhanced savings at individuals and household level.
4.4 Positive impact of changing age structure- Window of opportunity
Figure 12: Age structure (2005 & 2030)
Demographic transition is a result of
change in population size, its structure and
composition, primarily due to change in
fertility and mortality rate. By 2030,
children between the ages 0-14 years are
expected to decline to 22.3 percent from
33.1 percent in 2005.
On the other hand, the elderly population
above 65 years is also expected to increase
from 4.7 percent in 2005 to 7.2 percent in
2030.
Source: PHCB 2005; Population Projections, NSB
The changing age structure is expected to:
1. Boost rapid economic growth due to increase in number of working-age population.
2. Enhance savings and capital formation due to increase in life expectancy. Basically,
the longer people live more will be saved for the post retirement period. As a result,
the rate of savings and capital formation will be enhanced, which, forms the precondition
for today’s world for rapid economic growth.
3. Boost domestic market due to increase in proportion of the population with capacity
to buy goods and services.
4.5 Labor force and its impact on the economy
As per the definition by the International Labor Organization (ILO), labor force is the
population who are economically active. The labor force, therefore, includes all individuals
who are employed as well as unemployed but looking for jobs. The employed are those
who work for wages, own account, profit and unpaid family work.
36

Other things remaining constant, the productivity of labor force will depend on
the size and skills of the existing labor force. Therefore, for policy decisions and human
resource planning, data on the existing labor force and projection for short-medium and
long term is essential. The Ministry of Labor and Human Resources as the central agency is
mandated to produce and project labor force data.
The labor participation rates of PHCB 2005 were applied to the already projected
population to arrive at future estimates of labor force, under the assumption that the rates
more or less remain constant during the projection period. The labor force size is projected
to increase from 256,895 persons in 2005 to 289,583 in 2010 (an increase of 32,688
individuals in the labor force). This will continue to grow to an estimated 318,688 by 2015,
an additional of 61,973 persons. Hence the economy needs to generate 24 percent increase
in employment opportunities by 2015.
The structure of our economy has been transforming swiftly with primary subsistence
agriculture economy being gradually overtaken by secondary sector, manufacturing and
service sectors. The share of primary sector in the economy dropped to 21.2 percent in 2008.
In this context, human resource planning is crucial, as the swiftly growing trend in
economic structural transformation will exert pressure for the need of skilled labor, which
may increase dependence on expatriate labor.
Figure 13: Sectoral composition of nominal GDP
Source: NSB
4.6 Labor and Employment
In 2005, the labor force participation rate, which is the ratio of economically active
population (15-64 years) to the total population, was 60.4 percent. The participation rate
among males was 72 percent, as compared to 48 percent among females. Labor
participation rate was also found to be higher in the rural areas (63 percent) than among
urban areas (54 percent).
As per PHCB 2005, only 3.1 percent of the total economically active population of 256,895
persons was unemployed. Unemployment in urban areas (4.7 percent) was twice higher
than in rural areas (2.4 percent). Females had higher unemployment rate (3.3 percent) than
their male counterparts (2.9 percent). In the urban areas, female unemployment rate (7.6
percent) was 111 percent higher than males (3.6 percent).
37

The youth population (15-24 years) had comparatively higher unemployment rate. Of the
total unemployed in 2005 (SEDI Report 2005, NSB), youth accounted for 55 percent.
Thimphu Dzongkhag recorded the highest youth unemployment rate of 12.6 percent, and
Lhuentse Dzongkhag the lowest youth unemployment rate with 1.3 percent.
Among the employed, 63 percent females were employed in agriculture sector as compared
to 33 percent among males (PHCB, 2005). Agriculture sector is the largest sector in the
employment of the labor force, with an overall 44 percent of all labor force working in this
sector.
Figure 14: Unemployment rate (2003-2009)
5
Unemployment rate
Unemployment rates
4
3
2
1
1.8
2.5
3.1 3.2
3.7
4
unemployment rate
0
2003 2004 2005 2006 2007 2009
Source: MoLHR
4.7 MDG and social indicators
The quality of the labor force is dependent on the education system and structure. In the
10 th plan, education sector is allocated 6.63 percent of the total plan outlay. The target is to
enhance basic net enrolment to near 100 percent with emphasis on quality and attainment
of higher education levels by students.
Literacy rate is an important indicator to analyze the improvements in education. The
overall literacy rate for Bhutan increased from 45 percent in 1994 to 59.5 percent in 2005
(PHCB 2005). Literacy among males (69.1 percent) is substantially higher than females (48.7
percent).
38

MDG goal 2 is to achieve universal primary education. Gross enrolment ratio was 55 percent in
1990, 84 percent in 2004 that increased to 90.1 percent in 2005. Retention level in schools has
improved from 47 percent in 1985 to 84.2 percent by 2005 (SYB, NSB data and PHCB 2005).
MDG goal 8, target 2 emphasizes to make available the benefits of new information technology
(IT). Information technology development is viewed as a tool to improve the overall development
efficiency. IT infrastructure and services have increased rapidly. Fixed telephone line service
increased from 4,052 in 1990 to 30,420 in 2004. In 2005, 17.1 percent of the households had fixed
telephones lines. Use of computers increased from an average of less than 1 computer per 100
persons in 2000 to 2.6 per 100 persons in 2005. Similarly, there were only 4 internet users for
every 1,000 persons in 2001 that increased to 12 in 2005. With an expanding network of mobile
phone connections all over the country, communications has by far crossed expectations and
targets.
Chapter highlights
The GDP at constant prices increased from Nu. 1,095.0 millions in 1980 to Nu. 20,111.8 in 2000 that increased to
31,672.8 million in 2006. In real terms, the economy has been growing at an annual rate of around 8 percent since 2000.
The highest growth has been observed in mining and quarrying, indicating 63 percent growth in 2006, electricity 35.3
percent and hotels and restaurants (32.2 percent).
The labor force population of age 15-64 years is projected to grow from around 395,278 in 2005 to 488,601 by 2015 an
increase of 23.6 percent within the decade.
The largest single sector contributing to the economy in 2007 was Agriculture (23 percent) which will continue to be the
largest sector providing employment.
Unemployment rate in 2005 was 3.1 percent. Unemployment among females was higher (3.3 percent) than among males
(2.9 percent).
High young dependency ratio is strongly associated with higher poverty level of Dzongkhags with a correlation
coefficient of 0.62. Total dependency ratio decreased from 86.2 percent in 2000 to 60.6 percent in 2005.
Out-migration from rural areas might cause loss of labor in villages. While majority of male labor force were employed in
paid jobs, contrastingly majority of the female labor force were engaged in unpaid jobs.
The fall in mortality as a result of improved health complemented by a corresponding decline in fertility normally leads to
increase in the size of labor force. As a result, Bhutan is going to experience a large increase in the labor force.
The labor force size will increase from 256,895 persons in 2005 to 289,583 in 2010 and continue to grow to an estimated
318,688 by 2015. This provides a window of opportunity that can boost economy if complemented by sound policies and
strategies.
39

CHAPTER FIVE
5. POVERTY DIMENSION
5.1 Poverty and population
The link between population growth and poverty is very uncertain and complex, there is
no solid empirical evidence which proves that population growth causes or exacerbates
conditions of poverty, poverty leads to population growth. However, most accept that there
is a causal connection between the two, operating in both directions, and efforts to address
both are mutually reinforcing. This is particularly relevant in the context of sustainable
development, where human development goals such as reproductive health and education
are of considerable importance. Bhutan’s development goals have always been pro-poor.
The reduction of poverty has always featured as an integral component of gross national
happiness and hence always been a primary objective of all development plans.
All plans have sought to address the multi-dimensional nature of poverty through broad
sector programs with massive investments in social sectors such as education, health,
roads, etc. While these broad based programs have improved living conditions and
ameliorated poverty, experience and lessons drawn from the implementation of the past
plans indicate that poverty reduction efforts could be better served, accelerated further and
complemented with specific and improved targeting. Hence, during the 10 th Plan broadbased
poverty reduction programmes are complemented with the introduction of targeted
poverty reduction programmes to bring down the proportion under poverty to 15 percent
from 23.2 percent (Poverty Analysis Report (PAR) 2007, NSB). Almost 25 percent of the
plan outlay has been allocated to the Health and Education sectors (10FYP Main Document,
GNHC).
5.2 Poverty levels and trends
The PAR 2007 estimated that 23.2 percent (146,100 people) of the population live under the
poverty line (Nu. 1096.14 per person/month), and 5.9 percent of the population (37,200
persons) live under the food poverty line (Nu. 688.96 per person/month). Of the total
population under poverty 98.1 percent were rural based and 1.9 percent resided in urban
areas, giving poverty in Bhutan a rural essence. It was estimated that 30.9 percent of the
people living in rural areas fell under the poverty line. The Gini coefficient was estimated at
0.352 at the national level (0.315 for rural and 0.317 for urban areas).
Table 13: Poverty incidence by area
Area
Poverty Headcount Subsistence Headcount
2004 2007 2004 2007
Urban 4.2
(0.7)
Rural 38.3
(2.8)
Bhutan 31.7
(2.3)
1.7
(0.4)
30.9
(1.0)
23.2
(0.8)
Source: PAR 2004 & PAR 2007
0.03
(0.03)
4.7
(0.9)
3.8
(0.7)
0.16
(0.10)
8.0
(0.5)
5.9
(0.4)
40

A comparison of PAR 2007 with PAR 2004 shows a decline in poverty rate from 31.7
percent to 23.2 percent 17 and a reduction in both rural and urban poverty. However, there is
an increase in the subsistence poverty level, indicating the need for strengthening efforts in
enhancing food security and nutrition levels especially in the rural areas.
5.3 Population and poverty differentials
The Rapid Impact Assessment of Rural Development 2008 (RIARD) confirmed that
although general quality of life has improved in the rural areas, substantial differences
between rural & urban areas still remain in terms of income poverty, access to social
services, basic amenities & economic opportunities. The PAR 2007 showed that 30.9 percent
of the rural people were poor as compared to 1.7 percent in the urban areas. 35 percent of
rural population reported food insufficiency, inadequate agricultural land, and
unproductive soils, as the main reasons for poverty.
On a regional basis, besides Thimphu, Dzongkhags with relatively larger population also
have higher levels of poverty. Poverty rates in the more populated Dzongkhags such as
Chhukha, Monggar, Samtse, Samdrupjongkhar and Trashigang are significantly higher
than in other Dzongkhags.
The PAR 2007 also observed that in rural areas, male headed households were poorer than
the female headed households. The depth and severity of poverty is also observed to be
higher among male-headed households.
5.4 Poverty and health
The relation between poverty and health is also multi-dimensional and with the linkage
operating in both directions. Poor health contributes to poverty and poverty perpetuates
poor health. Improving the health of the poor enables them to move out of poverty. The
poor health of individuals (particularly bread-earners) and households affect their welfare
and even leads to their breakdown as economic units. Further, the high fertility rates
among poorer sections of the society impact their income distribution aspects and
nutritional standards.
The PAR 2007 showed that generally access to health facilities was good across the country
with no significant difference between the poor and non-poor. However, the time taken to
reach these facilities was significantly higher for the rural areas, more so for the poor than
the non-poor. Majority of the women across the nation both poor and non-poor gave birth
between the ages of 20 and 29 years. While knowledge about contraceptives was higher
among the non-poor than the poor and in urban areas than in rural areas, the use of
contraceptives was slightly higher for the poor in both urban and rural areas. 18
The National Nutrition and Infant and Young Child Feeding Survey, Ministry of Health,
2008 findings revealed that the prevalence of stunting was high at 37 percent, underweight
11.1 percent, and wasting 19 was 4.6 percent (1.4 percent severely and 3.2 percent
17 The figures may not be directly comparable due to differences in sampling frame, geographic coverage, and
questionnaires of the two reports.
18 This may be partly due to the fact, that the poor use contraceptives for other purposes.
19 Wasting, or low weight for height, is a strong predictor of mortality among children under 5 (unicef.org/progress for
children/2007).
41

moderately). The rise in the prevalence of acute malnutrition or wasting from 2.6
percent in 1999 to 4.6 percent in 2010 is a concern. While the differences between sexes were
not significant, the difference in nutritional status between regions and place of residence
was statistically significant. The western region had more acute malnutrition (8.2 percent)
while the eastern had more chronic malnutrition or stunting (44 percent). An area of major
concern is that more than a third of our children have stunted growth. On the other hand,
the number of underweight children has gradually declined and the prevalence stands at
11.1 percent, a decrease by 9.8 percent from the 1999 baseline (AHB MoH 2010).
Table 14: Nutritional status at national, regional and by area
National
Level
East West Central Rural Urban
Wasting 4.6% 3.3% 8.2% 2.4% 5% 3.1%
Underweight 11.1% 10.7% 11.4% 11.2% 12.2% 7.3%
Stunting 37% 44% 33.8% 33.3% 38.8% 31.2%
Source: Annual Health Bulletin, MoH 2009
As per the AHB 2010, access to safe drinking water has increased from about 55 percent in
1990 to about 90 percent by 2007. Access to sanitation facilities has also increased from 67
percent to 87 percent. While the MDG target of halving by 2015, the proportion of people
without sustainable access to safe drinking water and sanitation, has been achieved,
continued importance must be given to the quality and sustainability of water and
sanitation schemes. According to the AHB 2010, from a total of 201,423 incidences among
children below 5 reported to health facilities, respiratory infections represented 45.5
percent, skin diseases 13.7 percent, diarrhea 10.9 percent and dysentery 4 percent of the
total.
5.4.1 Poverty, fertility and mortality
High or excessive fertility rates and high mortality rates lead to reduced investments in
development of household members especially children. This then fuels a vicious cycle of
poverty and poor health.
Demographic Trap:
One reason for the poverty trap is the demographic trap, when impoverished
families choose to have many children. This leads to families being unable to
invest in the nutrition, health and education of each child. High fertility rates in
one generation often lead to high fertility rates in the following generation. High
population growth leads to deeper poverty and deeper poverty contributes to high
fertility rates.
From the “End of Poverty” by Jeffrey Sachs.
As also highlighted by the PHCB 2005, high fertility and mortality is generally found
among poorer communities. A larger household size commonly means a competition for
limited household resources and normally an indicator of poverty. When fertility is higher,
the dependency ratio is higher which is noticed in poor households and communities. As
poverty is not only lack of income, it must be viewed with respect to other socioeconomic
status, such as education, literacy, health, security and mental wellbeing.
42

It is observed that TFR for mothers of households that did not possess a car was 1.7 while it
was 2.7 for households without a car. Fertility is noticed to be higher among the illiterate
(TFR of 3.07) than the literate women whose TFR is 1.98. In urban areas where accessibility
to socioeconomic services, opportunities of employment and wage levels are better, both
mortality and fertility are lower indicating a better socio-economic status.
The Infant Mortality Rate (IMR) in 2005 was 40.1 infant deaths per 1000 live births. Under
Five Mortality (U5M) was 60.6 (PHCB 2005). Infant mortality is lower among women of
higher socio-economic conditions. For instance, an estimated IMR for women with TV was
41 compared to 72 for mothers without TV. Similarly, women who used firewood to cook (a
proxy for lower economic status), the IMR was 75 while mothers who used LPG gas was 45.
Infant mortality is much lower in urban areas where the facilities and socio economic status
is much better as compared to that in rural areas.
In 2007, 50.9 percent of the total births were attended by health professionals. The
percentage of attendance is comparatively higher in urban areas (75.3 percent) than in the
rural areas (40 percent).
5.5 Poverty and education
The PAR 2007 revealed the poor have a much lower literacy than the non-poor, 52.8 percent
of the non-poor in rural areas were literate compared to 74.5 percent in the urban areas. In
both areas unaffordability and need to work were the main reasons for not going to school.
The high proportion of illiterate population is among the major causes of poverty in
Bhutan. As a determinant of poverty outcome of individuals and households, adult
illiteracy is of critical issue both for males and females. The total adult (age 15 years and
above) literacy in 2005 was 52.8 percent. The poor health among women is better explained
by the very low literacy rate among adult women. Adult literacy of 65 percent among men
is comparatively better than female adult literacy which stands at 38.7 percent. The youth
literacy rate (15-24 years) was 74.4 percent with male literacy higher than females at 80
percent and 68 percent respectively (Socio-economic and Demographic Indicators (SEDI)
2005, NSB 2008).
5.6 Migration and poverty
Rural-urban migration is a global phenomenon, with economic development and growth of
urban centers as key pull factors creating the mass movement of people from rural to urban
areas. According to PHCB 2005, migration occurred in both directions from urban to rural
and rural to urban areas, though the latter was more pronounced. Based on the lifetime
migration data, the total migration was 111,770 out of which 91,778 was rural to urban
migration and 19,992 was urban to rural migration. If this trend continues there will be
greater pressure on the urban areas and if not managed well, poverty levels will increase.
The reasons for rural-urban migration were mainly due to employment and higher
educational opportunities in urban areas, according to the Rural Urban Migration study by
PPD, MoA, 2005.
43

Figure 15: Net migration by Dzongkhag
Thimphu
39,770
Chhukha
15,480
Paro
7,377
Monggar
-7,453 Trashigang
-16,697
Zhemgang
-8,509
Source: PHCB 2005
Urban areas in Bhutan are witnessing very high growth rates straining urban
infrastructure, services, and other facilities. Thimphu for example is increasingly becoming
over-populated and stressed with associated urban problems such as, increased
delinquency and crimes, unemployment especially among the youth, lack of housing,
insufficient water and sanitation facilities, and strain on education, health and other public
services.
The study by MoA in 2005 indicated that migration impacts both the place of origin and
place of destination of migrants. In the place of origin generally the rural areas, lack of
manpower for agriculture and other work were expressed to be the problems. However,
remittance to the villages was said to be the main benefit. While in the urban destination,
migrants indicated an increase in their opportunities and livelihoods. 70 percent migrants
said their happiness had increased. The PAR 2007 estimated that of the total population
under the poverty line, 98.1 percent were rural based and 1.9 percent resided in urban
areas.
5.7 Poverty and housing
Shelter is a basic need, next to food and clothing. An individual spends nearly two-thirds of
life at home, and family formation and personality development takes place at home. Lack
of adequate housing facilities leads to increased social crimes, overcrowding, and exposure
to diseases like tuberculosis, malaria, measles, diarrhea, etc. due to lack of access to basic
facilities. It can adversely affect both physical and mental growth of an individual and can
also increase death and infant mortality rates. The need for housing is increasing with the
increase in population especially in the urban areas. The issue may be viewed in terms of (i)
44

present deficit ii) replacement of dilapidated units iii) future need resulting from
population growth and iv) future need resulting from urban growth. Besides population
growth, there is now a trend of nuclear families which increases the need for housing units.
The exact magnitude of the housing problem is not clearly known due to lack of complete
and reliable data. The PHCB 2005 showed 59 percent of households lived in their own
housing, while the rest lived in rented or other arrangements. At the current growth rate,
the demand for housing is expected to rise, especially in urban centers.
5.8 Urbanization and poverty
Urban poverty arises mainly because of the migration of job seekers into urban areas due to
concentration of resources and opportunities in these areas. The development of growth
centers across various regions may minimize the pressure on the existing urban centers.
According to PAR 2007, urban poverty was estimated at 1.7 percent a decline from 4.2
percent in 2003.
5.9 Youth and unemployment
Since the development of a country depends on the productivity of its citizens, the
productive employment of the youth is integral for the progress of the country. The United
Nations, for statistical purposes defines ‘youth’ as those persons between the ages of 15 to
24 years. According to BLSS 2007, youth accounted for 31 percent of the labor force.
Over the Ninth plan period, the labor force participation rate grew from 56.5 percent in
2001 to 67 percent in 2007 (BLSS 2007, NSB). However, youth unemployment grew from 2.6
percent in 1998 to 9.9 percent in 2007 (BLSS, NSB). Further, 24.7 percent of the urban youth
were unemployed as compared to 6 percent in rural areas (BLSS 2007).
Table 15: Youth Labor Force Participation Rate (LFPR) and unemployment trends
1998 2001 2004
Age
group
LFPR
(%)
Unemployment
rate
LFPR
(%)
Unemployment
rate
LFPR
(%)
Unemployment
rate
15-19 37.8 2.5 23.2 8.4 24.1 7.2
20-24 56.7 2.7 52.5 3.8 50.5 4.0
15-24 46.6 2.6 36.3 5.4 35.2 5.5
Source: LFS 1998, 2001, 2004
The youth are unduly affected by unemployment due to the lack of skills, qualification and
experience. Unemployment amongst teenage youth (15-19 years) increased from 2.5 percent
in 1998 to 7.2 percent in 2004. Similarly, unemployment in the 20-24 years age group
increased from 2.7 percent in 1998 to 4 percent in 2004 and 11.4 percent in 2006. The
increasing unemployment trend for this group is a major cause of concern.
With respect to employment trends, the agriculture sector accounted for 43 percent of the
total employment in 2007 showing a decline from 75 percent in 1999. On the other hand, the
industrial sector exhibited an increasing trend, accounting for 17 percent of those employed
as compared to only 5 percent in 1999. There has also been an expansion in the share of
employment in the service and industry sector.
45

5.10 Poverty and MDG goals
Bhutan’s development objectives are well in line with the MDGs. The primary objective in
the 10 th five year plan is poverty reduction, and all plans and programmes have been
formulated to reduce poverty.
MDG Goal 1: Eradicate extreme poverty and hunger
Target 1: Halve, between 1990 and 2015, the proportion of people living below the poverty line.
Target 2: Halve by 2015, the proportion of people who suffer from hunger.
The proportion of population living under the poverty line decreased from 36.3 percent in
2000 to 31.7 percent in 2004 and further to 23.2 percent in 2007. Between 2000 and 2007, the
poverty level declined at an annual rate of around 5 percent per annum. At that rate,
poverty incidence is estimated to drop to 15 percent by 2015 that will exceed the MDG
target of 20 percent.
While the target set for reducing underweight under 5 children has been achieved, the
reduction of under-height under 5 children and proportion of population below minimum
level of dietary energy consumption (2,124 kilocalories) still remains a challenge. While the
MDG target is 1.9 percent, the proportion of under-height under 5 children increased from
2.6 percent in 1999 to 3.8 percent in 2003 to 5.9 percent in 2007 (PAR, NSB 2007). The
proportion has slightly declined to 4.6 percent in 2010 (AHB, MoH 2010). This may be due
to the growing inequality of incomes between the rural and urban areas with lesser benefits
of economic growth going to the rural areas where 69 percent of the population lives.
Chapter Highlights
Proportion of population below poverty line reduced from 34 percent in 2003 to 23 percent by 2007, declining at an
average annual rate of around 5 percent per annum.
Percentage of population below minimum level of dietary energy consumption (2,124 kilocalorie) which stood at 3.8
percent in 2004 is observed to have hardly budged even by 2007 representing around 21,300 households still below food
poverty line.
Poverty has mainly been found to be confined to rural areas. It may therefore be interpreted in the perspective of
marginally low female employment in paid jobs, high illiteracy among females and remoteness from markets of the rural
settlements.
Yield of food grains have declined over the years. Domination of a few large industries to the economy might cause
income in-equality and provoke poverty. In 2007, Gini coefficient of 0.35 suggests a fairly high in-equality.
High fertility and mortality is generally found in among poorer communities. For instance, it is observed that in Bhutan,
TFR for mothers of households that did not possess a car was 1.7 while it was 2.7 for poorer households without a car.
TFR is much higher among the illiterate mothers (3.07) than the literate women (1.98).
Estimated IMR for households with TV was 41 compared to 72 for mothers without TV, so a lower birth rates among
better off families. For households that used firewood to cook, the IMR was 75 as compared to 45 among those that used
LPG.
Urban areas where accessibility to socioeconomic services, opportunities of employment, and wage levels better, both
mortality and fertility are lower indicating a better socio-economic status.
46

Primary GER in urban was 97.8 percent as against 87.1 percent in rural areas. It is expected that the school
attendance and enrolment is lower for poorer households than non-poor households. In 2007, literacy among the poor was
over 40 percent while among the non-poor it was 60 percent.
47

CHAPTER SIX
6. REPRODUCTIVE HEALTH
6.1 Health Care System in Bhutan
Health care services in Bhutan are rendered through a network of 31 hospitals, 181 Basic
Health Units and 518 outreach clinics. In addition, over 1,200 Village Health Workers
(VHW) serve as health volunteers in the communities (Annual Health Bulletin (AHB), MoH
2010). Furthermore, to strengthen and integrate the traditional medicine system with the
main health service, an indigenous hospital and 37 indigenous units covering all
Dzongkhags have been established.
6.2 Reproductive Health (RH)
Reproductive health service is an integral part of the primary health care system that
includes maternal and child health services, e.g. antenatal care, postnatal care,
immunization of children and pregnant women and family planning services. The
emergency obstetric and neonatal care (EmONC) services which were initially available
only at referral, regional and Dzongkhag hospitals, have now been expanded to Basic
Health Unit (BHU) levels, enabling easy access of EmONC facilities by the rural populace.
The key components of RH include the following:-
(i) Safe motherhood including emergency obstetric care (EmOC)
(ii) Newborn care
(iii) Family planning
(iv) Screening and prevention of cervical and breast cancer
(v) Reproductive tract infections (RTIs) including STI/HIV
(vi) Prevention and management of complications of abortion
(vii) Prevention and management of infertility
(viii) Adolescent sexual reproductive health (ASRH)
Important Milestones in Reproductive Health
1971- 34th National Assembly passed resolution on family planning (FP) services
1979-Adoption of primary health care approach and integration of FP into the general health care
system
1981: National Institute of Family Health (NIFH) established
1995: Royal Decree on Population Planning launched and intensification of FP & RH services
1996: His Holiness endorses “Buddhist perspective of FP”
1999: HM the Queen (UNFPA Goodwill Ambassador) advocacy efforts – taking FP and RH issues to a
higher level
2000: Introduction of basic and comprehensive EmOC centers
2003: Introduction of Competency Based Training (CBT) for health workers
48

6.3 Safe Motherhood including EmOC
Since 2005, institutional deliveries have improved considerably, for instance, it more than
doubled from 18.9 percent in 2000 (National Health Survey (NHS), MoH 2000) to 46 percent
in 2005 (PHCB 2005). Similarly, births attended by trained health personnel increased from
57.1 percent in 2006 to 66.3 percent in 2008 (AHB, MoH 2009). As per the Maternal Death
Review Report 2001-2008, Postpartum Hemorrhage (PPH) was found to be the main cause
of maternal deaths in the country. Therefore, strengthened and concerted efforts in
promoting institutional deliveries and other primary health care services would prevent
such pregnancy related deaths. It is equally important to equip health centers with basic
infrastructure and skilled professionals, together with programmes to enable easy access to
EmOC services across the country.
6.4 Antenatal Care
According to the NHS 2000, from the total number of women who gave birth, only 51
percent attended at least one antenatal clinic. The reasons for low Antenatal Care (ANC)
attendance were primarily due to women in earlier trimesters being uncertain or waiting
for their pregnancies to advance a little. The survey findings clearly indicate that that ANC
is tied to the period of gestation in that 72 percent of women in their third trimester
attended as compared to 46 percent in their second trimester and 16 percent in their first
trimester. ANC attendance has been increasing steadily from 2,291 in 2003 to 53,352 in 2008
and 55,586 in 2009 (AHB, MoH 2010). This has largely resulted in a decline of the maternal
mortality rate from 8 per 1,000 live births in 1984 to 2.55 in 2000. In view of the progress in
ANC attendance and institutional deliveries and with concerted efforts on increasing the
demand and provision of such services, the MDG target of 1.4 per 1,000 live births by 2015
will be achieved.
As observed in Table 15, pregnancy care services are improving. In 2009, 67.4 percent of
births were reported to be attended by trained health personnel vis-à-vis 23.7 percent in
2000. The percentage of deliveries attended at health facilities however, needs to be further
addressed as around 40 percent of deliveries still take place at home.
Table 16: Antenatal care attendance, 2003 and 2009
Type of care Number of attendance percentage
2003 2009 2003 2009
Antenatal care attendance
2,291 55,586* .. ..
Delivery attended at home
2,291 878 37.1 6.6
Delivery attended at hospital/BHU
3,883 8,133 62.9 60.9
*Antenatal care attendance in 2008 is the sum of first to fourth visit
Source: Information Section, MoH & AHB 2010, MoH
As per PHCB 2005, attendance of births by skilled health personnel is much lower in rural
areas (39.9 percent), than in urban areas (75.4 percent). Furthermore, the proportion of birth
attendance by skilled health personnel is higher for literate mothers (66.6 percent) vis-a-vis
illiterate mothers (40.7 percent).
49

As indicated in PHCB 2005, the level of education of mothers and trained birth
attendance are progressively correlated, whereby the percentage of births attended by
skilled health personnel increases with the level of education of mothers. The proportion of
births attended by skilled personnel of mothers with: below primary education were 49.3
percent; primary 59.6 percent; lower secondary 75.7 percent; middle secondary 87.8
percent; higher secondary 93.1 percent; diploma 94.0 percent; and undergraduates 95.8
percent. This fact indicates that the education level of mothers is a primary determining
factor for good child and maternal health.
6.5 Postnatal Care
The maternal death investigation report shows that the postpartum period is the most
crucial for the survival of the mother as most maternal deaths are caused by postpartum
hemorrhage (PPH). However, till date there is inadequate data on postnatal care.
Presumably, the causes for the death of women in the postpartum period could be due to
negligence on the part of the patient, inadequate or lack of awareness, information, facilities
and lack of proper information records at the health facility level. Given its significance in
reducing maternal and newborn mortalities and morbidities, there is need to design
interventions and proper information reporting and monitoring on postnatal care.
6.6 Newborn Care
Infant mortality rates are directly correlated to attendance of births by trained personnel
and proper antenatal care. In 1994, only 15.1 percent of total births were attended by skilled
personnel. As per the NHS 2000, MoH deliveries at home accounted for 78.3 percent (fourfifth
of all births). Of all the births at home, attendance by mother in-laws accounted for
33.4 percent, husbands 24 percent, other in-laws 11.1 percent, and VHWs only 0.2 percent.
Breastfeeding has a direct link to the nutritional status and health of a child. The findings
from the National Health Survey 2000 show that mothers introduced solid food and other
feeding practices too early on infants. Ideally, an infant must be breastfed at least for the
first six months after birth. It was also found that 42 percent of the mothers of infants (< 1
year) practiced exclusive breastfeeding.
6.7 Maternal, infant and child mortality
The maternal mortality ratio (MMR) declined by 54.5 percent from 5.60 per 1,000 live births
in 1990 to 2.55 per 1,000 live births in 2000. To achieve the MDG target, maternal mortality
must be further reduced by 45 percent to 1.40 per 1,000 live births by 2015. In the 10 th Plan,
an even more ambitious target of 1 per 1,000 live births has been set for achievement by
2013. PPH (post-partum hemorrhage) is one of the main causes of maternal mortality that
may be addressed through improved accessibility to quality emergency obstetric care
(EmOC) services.
Since 1990 the under-five mortality rate has declined from 123 per 1,000 live births by
almost half, to 61.5 in 2005. While the MDG target is to achieve 41 by 2015, the 10 th Plan
target is more ambitiously set at 30 per 1,000 live births by 2013. The major causes of underfive
mortality and morbidity are attributed to acute respiratory infection (ARI), diarrhea,
worm infestation and malnutrition. This is also attributed to the high teenage pregnancy
rate (11 percent as per PHCB 2005) whereby infants are born with low birth weight and are
highly vulnerable to neonatal deaths (Bhutan’s progress - Midway to the MDGs, 2008).
50

The infant mortality rate (IMR) declined from around 103 in 1984 and 90 in 1990 to 40.1 in
2005. The MDG target is to achieve a decline of 30 per 1,000 live births by 2015 and the 10 th
Plan target is to bring IMR down to 20 by 2013. Infant deaths are mainly caused by neonatal
mortality, infectious diseases such as diarrhea, respiratory infections and low birth weight.
The high morbidity and mortality especially of infants are associated with low level of
literacy, low income, poverty, and limited access to EmOC and skilled birth attendance.
Therefore, emphasis to improve child health should be focused in areas of low
socioeconomic status. Enhancing access to improved and quality health services in rural
areas would reduce issues related to child morbidity and mortality.
Malnutrition among women and children is also a common health problem in Bhutan. The
National Nutrition, Infant & Young Child Feeding Survey 2008 observes the prevalence of
stunting, underweight and wasting at 37 percent, 11.1 percent and 4.6 percent respectively.
Two major determinants of malnutrition are disease and inadequate diet. A multi-sectoral
approach needs to be adopted in order to address the low nutrition diet component.
The anemia prevalence rate was 54.8 percent among mothers of children between 6-60
months (A study on “Anemia among men, women and children in Bhutan 2003, MoH). The
report highlights Iron Deficiency Anemia as a common nutritional disorder and its
prevalence rate at 27.6 percent for men, 54.8 percent for women of child bearing age, and
80.6 percent for children under 3 years.
6.8 Family Planning
The contraceptive prevalence rate (CPR) increased to 43.6 percent in 2005 from 30.7 percent
and 18.8 percent in 2000 and 1990 respectively. The CPR among married women of
reproductive age has increased steadily from 23 percent in 1994 to around 43.5 percent in
2005. The CPR also varies by rural/urban residence and the education level of women.
CPR is higher in urban areas and among literate women than in rural areas & illiterate
women. Data also shows a huge gap between knowledge and use of contraception in that
although 95 percent of women reported to be aware of family planning methods, only 30.7
percent used contraception (NHS 2000).
Over the years, there has been a shift in the choice of contraceptive methods. For instance,
most methods used in the 1990s were intended to reduce birth rates. However, with the
emerging issues of HIV/AIDS in the country, condom use has increased substantially
exceeding 1.6 million in 2007.
51

Table 17: Contraceptive Methods among women (15-49 years)
The demand for contraceptives and
reproductive health commodities, as
depicted in Table 17 has increased
significantly between 1983 and 2007.
The demand for permanent
methods such as male and female
sterilization has also increased
substantially.
Source: AHB 2008; SYP NSB
In 1983, 170 IUD users, 1,599 cases of oral pills, 197 condom users and 577 vasectomies were
recorded. The high fertility in the late 70s and early 80s could be attributed to the lack of
reproductive health services.
Figure 16: Family planning users
Source: AHB, MoH
The contraceptive prevalence rate (CPR) excluding condom increased from 19 percent in
1995 to 31 percent in 2000. Permanent methods of family planning have increased eight fold
from 1994-2005. For instance, the number of vasectomy clients was 1,120 in 1990 that
increased to around 9,000 users in 2007. Over 1.6 million condoms were distributed in 2007
as compared to around only 6,000 in 2001.
By 2005, the CPR increased to 43.6 percent. In 2006 and 2007, it is difficult to determine the
CPR due to the inability to ascertain the exact number of condom users as the figures
represent distribution.
52

6.9 Morbidity, screening and prevention of cervical & breast cancer
Source: AHB, MoH 2008
Table 18: Number of neoplasmic
health conditions
Cervical cancer is a dominant
malignancy diagnosed in women in
the mid to late reproductive years.
More than half the cases are
diagnosed in later stages leading to
high mortality. While the treatment
for severe cases of cancer is not
available in the country, pre-invasive cancer
can be treated
effectively if detected through screening. The screening services are being provided to
women aged between 20-60 years to prevent the incidence of cervical cancer. The present
coverage of cervical cancer screening stands at 20 percent and is targeted to achieve 40
percent by the end of the 10 th Plan. In Table 18, the number of attendance in health facilities
show an increasing trend between 2003 and 2007 (AHB 2008).
6.9.1 Cervical and breast cancers
Women’s health concerns relate mainly to problems of morbidity and mortality i.e. diseases
that affect women almost exclusively, such as pregnancy, birth and fertility related and
malignant and non-malignant diseases of the reproductive organs (breast cancer, cervical
cancer, etc.). The diseases that are more frequent in women than in men are rheumatoid
arthritis and anemia, and diseases that manifest themselves differently in women (this
particularly applies to mental health problems where women bear the burden of
depression, anxiety and eating disorders).
Attendants
5000
4500
4000
3500
3000
2500
2000
1500
1000
500
0
Trend of hospital morbidity, Bhutan
Menstrual diseases
Pregnancy complications
2003 2004 2005 2006 2007
Year
Figure 17: Maternal morbidity trends
The number of cases of cervical cancer rose from 12 in
2003 to 70 cases in 2007 and 90 cases in 2009 (AHB
2010). Similarly, as shown in the graph, menstrual and
pregnancy complications are on the rise. Data on
hospital attendance (AHB 2008) show consistent rise in
complications of pregnancy as shown in Figure 17
besides diabetes, arthritis, depression and anxiety,
anemia and hypertension.
Source: AHB, 2007 MoH
53

6.10 Reproductive Tract Infections (RTIs) including STI/HIV
Year
Cases
2003 2290
2004 2159
2005 1797
2006 1575
2007 1339
Male ( percent) 59.2
Female ( percent) 40.8
Total ( percent) 100.0
Table 19: Reproductive morbidity
The number of attendance with reproductive morbidity
declined as indicated in Table 19. There were 2,290
cases in 2003 that declined to 1,339 in 2007. The number
of attendance with UTI cases increased by 134 percent
in 4 years time i.e. from 11,160 cases in 2003 to 26,133 in
2007 (AHB 2008).
Source: AHB, 2007 MoH
On the other hand, the cases of HIV/AIDS have been increasing in recent years. The first
cases were reported in 1993 and by April 2006 there were 83 confirmed cases. Between 1993
and July 2010, 217 persons were detected with HIV infection (National AIDS Control
Programme, DoPH, MoH). The distribution of HIV/AIDS cases by year shows an
increasing trend, particularly in recent years. For example, only one-third of HIV/AIDS
infected cases were reported during the 10-years following the detection of the first 2 cases
in 1993, but this number more than doubled during the past seven years (2003-2010) as
shown in Table 20.
Year Cases Cumulative
cases
1993 2 2
1994 1 3
1995 0 3
1996 4 7
1997 2 9
1998 0 9
1999 0 9
2000 9 18
2001 7 25
2002 15 40
2003 5 45
2004 23 68
2005 9 77
2006 24 101
2007 24 125
2008 19 144
Dec 2009 41 185
Jul 2010 32 217
Table 20: HIV/AIDS cases (1993-2010)
Out of the total of 217 cases, 107 are females and
110 are males. HIV/AIDS prevalence is the
highest among those aged 30-39 years and 91%
fall within the age range of 15-49 years. The
young people account for 50 percent of the people
infected and are a highly vulnerable group. By
occupational backgrounds, housewives comprise
28 percent of the detected cases followed by
business/private employees. The key mode of
transmission is through unsafe sexual practices
(90 percent) such as multiple partners, casual sex
and low condom use (National AIDS Control
Programme, DoPH, MoH).
Source: National AIDS Control Programme, DoPH, MoH
54

The risk factors of spreading are the rising level of substance abuse, commercial sex
becoming more common, perceived low level of condom use and an increasing number of
young population and low level of awareness and education about the various modes of
transmission. Of greater concern is that many people think HIV/AIDS can be cured. A
recent study on out of school youth found that 29 percent of respondents thought AIDS
could be cured. But even when people are aware of the dangers, they do not take
precautionary measures and there is a considerable gap between knowledge and practice.
Once the epidemic matures the chances for an increase in mother to child transmission are
higher and given the low use of condoms, transmission between partners is highly likely
(Common Country Assessment for Bhutan, 2006 UN).
Over 30 percent of the youth felt that they had totally adequate or just adequate knowledge
on sexual health (The Situation on Bhutanese Youth 2005-2006, YDF & MoE).
6.11 Prevention and management of abortion complications
According to the AHB, MoH 2010, hospital-based data indicate a rising trend in abortions
from 466 cases in 2003 to 1057 cases in 2009. In 1999, Medical Termination of Pregnancy
(MTP) was legalized. The MTP is accepted if two doctors certify that the pregnancy poses a
risk to the life or could cause grave injury to the physical or mental health of the mother.
Table 21: Number of cases by morbidity conditions
It is a known fact that abortions also
occur across the Indian border which
remains unreported. Although
abortions are illegal, a study on the
situational analysis of children
and women in Bhutan, 2002,
indicates that a growing number of
Bhutanese women seek abortion
services. Lack of awareness and
knowledge on sexual and reproductive
health, lack of skills to negotiate
unwanted sex or safer sexual health
relations and lack of parental guidance
place young girls at high risks of unwanted pregnancies and sexually transmitted
infections. (Adolescent Health and Development, a country profile Bhutan, 2008, MoH).
Abortion unless on medical grounds is illegal in Bhutan, irrespective of age of women. In
Bhutan it has been found that complications of pregnancy contributed to 50 percent of
maternal deaths and 11 percent of obstetric complications were due to abortions.
Understanding the extent of induced abortion is constrained by the absence of data and
research. Data on abortion in the morbidity records of the health facilities do not
differentiate whether it is induced or spontaneous abortion.
6.12 Prevention and management of Infertility
The extent of infertility prevalence is not known as the treatment services are not available
within the country.
55

6.13 Adolescent Sexual Reproductive Health
Risky sexual behavior such as, early marriage, teenage pregnancy, low use of contraception
and sexually transmitted diseases including HIV/AIDS are reported to be increasing
amongst adolescents. Adolescent fertility is considerably high, accounting for 11 percent of
all births in 2005 (PHCB 2005) which indicates high rate of maternity at younger ages. This
calls for concerted health service strategies to reduce teenage and unwanted pregnancies.
Legally, the minimum age of marriage for both girls and boys is 18 years. However, there
are evidences where the incidence of teenage pregnancies below the legal age is quite high.
Whether married or not, the desire to postpone birth would depend on the awareness and
education of girls on reproductive health. There is a need to make data available on unmet
needs of adolescents and youth, and strengthen family planning programmes by assessing
and using data on unmet need.
6.14 Increasing Trend in Drug Abuse
Crime incidents related to drugs/narcotics or substance abuse has been increasing over the
years. The Statistical Yearbook of Bhutan (SYB), 2007 shows increase from 23 cases in 2001
to 60 in 2005- tripled within four years time.
The Medicine Act of 2003 and Bhutan Penal Code 2004 provide some form of legal
framework and regulation on the use of medicine, drugs and alcohol. Knowing that the
alcohol and drugs have adverse social effect directly or indirectly, the law prohibits sale of
alcohol to underage and drugs without prescription and other abusive substance. A study
carried out in 2004 on alcohol reported that there was 1 bar for every 250 Bhutanese and 10
bottle of beer or sprit for every man, woman and child in Bhutan.
Goal 4: Reduce child mortality
Target 5: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate
6.15 Status of Health MDG goals
The under-five mortality rate (U5MR) declined from 84 in 2000 to 61.5 deaths per 1,000 live
births in 2005. The U5MR declined 5.7 percent per annum from 2000 to 2005. At this rate the
target of reducing the U5MR to 41 per 1,000 live births by 2015 is possible. The infant
mortality rate (IMR) decreased from 60.5 in 2000 to 40.1 deaths per 1,000 live births in 2005
and the MDG target is to reduce IMR to 30 by 2015. The immunization coverage has
Goal 5: Improve maternal health
Target 6: Reduce by three quarters between 1990 and 2015, the maternal mortality ratio
increased from 85 percent in 2000 to over 90 percent in 2009.The MDG target is to achieve a
coverage of more than 95 percent.
The MMR in 2000 was 2.55 maternal deaths per 1,000 live births and the results of PHCB
2005 indicated that the MMR had hardly made any significant gains between 2000 and
2005. At this rate, achieving the target of 1.40 per 1,000 live births by 2015 is a challenge.
Goal 7: Combat HIV/AIDS, Malaria and Other diseases
Target 7: Halt and begin to reverse the spread of HIV/AIDS
56

There were 38 HIV/AIDS cases in 2000 that increased to 140 in 2007 (AHB, MoH 2008),
which is an increase of 38.3 percent per annum. By 2010 the number of cases increased to
217. Hence, committed strategies to halt the HIV/AIDS epidemic are necessary. The
contraceptive prevalence rate (CPR) increased to 30.7 percent by 2000 from only 18.8
percent in 1990. The CPR (excluding condoms) rose to 43.6 percent in 2005 (estimated using
AHB, MoA data). Therefore, the target of 60 percent in 2015 appears to be achievable.
6.16 Reproductive health outcome versus economic status
The PHCB 2005 data indicate that reproductive health outcomes are related to the socioeconomic
background of households. For example, the total fertility rate (TFR) among
mothers of households possessing a car was 1.7, while it was 2.7 for poorer households
without a car. TFR is much higher among the illiterate mothers (3.07), who are usually
poor, than the literate women (1.98), who are usually better-off. Similarly, estimated infant
mortality rate (IMR) for households with TV was 41 per 1,000 live births, compared to 72
for households without TV. Households that used firewood to cook, reflected an IMR of 75
compared to 45 among those that used LPG. These findings call for special attention to
improving accessibility to health services including reproductive health & family planning
services and education to the poor.
6.17 Quality and effectiveness in health care service delivery
Having achieved primary health care targets, any further development in health care
services will depend on how well the health systems will cope with the emerging health
issues at the turn of morbidity transition. It implies both quantity in terms of medical,
technological, capital and human resources and quality in terms of services. Some major
challenges ahead are mortality levels particularly of maternal and child, non-communicable
lifestyle related diseases, emergency medical services and capacity development. To
improve health status further, health centers both at the urban and rural areas need to be
well equipped and updated with technology, equipment, materials, staffed with sufficient
numbers of well trained technical and professional staff, and efficient service delivery
mechanisms in place. Emphasis needs to be greater in rural areas where the existing
communication and transportation networks, settlement patterns, low level of awareness,
education, etc. currently pose as barriers for quality health service delivery.
Chapter highlights
The institutional delivery increased to 46 percent in 2005 (PHCB 2005) from 18.9
percent in 2000 (NHS 2000, MoH). Births attended by trained health personnel was
66.3 percent in 2008 an increase from 57.1 percent in 2006 [AHB, MoH 2009).
Postpartum Hemorrhage (PPH) was found to be the number one cause of maternal
deaths in the country
Antenatal care attendance by women in 2000 was 51 percent that increased to 70.1
percent by 2008. The percentage of deliveries attended by health personnel
increased from 62.9 percent in 2003 to 89.2 percent in 2008. Delivery at home
accounted for 78.3 percent (four-fifth of births of all the births) in 2000 (NHS
2000, MoH). Of all the births that took place at home, mothers-in-law attended to
33.4 percent of the births, husbands 24 percent, other in-laws 11.1 percent, and
Village Health Workers (VHW) only 0.2 percent.
In 2005, IMR was 40.1 per 1,000 live births. In 2000, only 42 percent of the
mothers of infants (< 1 year) practiced exclusive breastfeeding. Iron deficiency
57

anemia prevalence was 28 percent for men, 55 percent for women of child
bearing age, and 81 percent for children under 3 years.
Most commonly available services are IUD, oral pills, vasectomy, tubectomy and
condoms. In 2007, there were 31,734 users of various contraceptives, an increase
from 27,607 in 2006. In 2006 there were 83 confirmed cases of HIV and its
prevalence is the highest among persons aged 15-45.
In 2007, complications of pregnancy were the top morbidity condition, followed by
diseases of the digestive system, respiratory and nose diseases, kidney, and
UTI/genital disorders. Over the period there was a steady rise of cervical
cancer. The number of cases of cervical cancer rose from 12 in 2003 to 70 cases
in 2007, a six-fold increase over four years. Similarly, menstrual and pregnancy
complications are on the rise.
Maternal mortality improved from 3.08 per 1,000 live births in 1994 to 2.55 in
2000 after which it remained more or less the same.
In 2005, 11 percent of all births occurred to teenage mothers probably due to
lack of awareness among girls or due to unmet need.
The national Nutrition, Infant & Young Child Feeding Survey 2008 observes that
the prevalence of stunting was 37 percent, 11.1 percent underweight and 4.6
percent wasting.
Contraceptive prevalence rate (CPR) increased to 30.7 percent by 2000 from only
18.8 percent in 1990. CPR, (excluding condoms) rose to 43.6 percent by 2005.
Between 1993 and 2010, 217 persons were detected with HIV infection but
distribution of these cases by year shows an increasing trend, particularly in
recent years.
According to the annual health bulletin 2010, about 1057
were reported in 2009.
spontaneous abortions
58

CHAPTER SEVEN
7. GENDER
7.1 The Concept of Gender Mainstreaming
Gender mainstreaming has been defined as: “the process of assessing the implications for
men and women of any planned action, including legislation, policies and programmes, in
all areas and at all levels. The ultimate goal is to achieve gender equality” (E.1997.L.O.
Para.4. Adopted by the United Nations Economic and Social Council (ECOSOC) 17/7/97).
7.2 Gender concerns in development
All aspects of development affect both men and women’s lives, so there is a positive
relation to the status of gender and gender mainstreaming strategies.
No societal, legal, political and family institutions discriminate girls and women in Bhutan.
Nonetheless, women are comparatively behind men in many of the social, economic and
political spheres especially in education, employment and public decision-making (Gender
Pilot Study 2001 and Bhutan’s 7 th Report on the Convention on the Elimination of All forms
of Discrimination Against Women (CEDAW), 2007). Women constitute around half of the
country’s population and harnessing this huge potential in every aspect of development
will have great potential to accelerate development.
The country presented its 7 th CEDAW Report to the UN CEDAW Committee in June 2009.
The Concluding Comments and recommendations of the Committee to the Royal
Government of Bhutan (RGoB) highlighted areas of concern such as: strengthening of the
national machinery; under-representation of women in public and political life; addressing
all forms of violence against women including prostitution and trafficking and sexual
harassment in the workplace; elimination of stereotyping; ensuring equal access of girls and
women to all levels of education; improving access to general, mental and reproductive
health care; creating adequate job opportunities especially for rural women; eradicating
domestic child labor abuse; discouraging illegal underage marriage and polygamy; and
aligning the provision of child custody with the Convention.
7.3 Sex composition, headship and property rights
In 2005, the sex ratio at birth was 101 males per 100 females i.e. there were 101 males for
every 100 females which is testimony of the complete absence of discrimination based on
sex. The overall sex ratio of the general population is 111 males per 100 females. The excess
of males over females is mainly due to the presence of a large expatriate male labor force in
the country (PHCB 2005).
Of the total households, 28.2 percent were female headed while 71.8 percent had male
headship (PHCB 2005). As per the Bhutan Living Standard Survey (BLSS 2007), the
household head is defined as the main economic decision-maker and source of economic
support within the household. In rural areas, female-headed households were observed to
be less poor and the depth and severity of poverty was higher among male-headed
households. The survey also found that generally across age-groups of the household head,
59

the dependency ratio was higher for poor households. A higher proportion of
dependents in relation to income earners signify less consumption for each member.
Over 54 percent of the households were extended families i.e. members comprised of older
parents and other relations, whereby inheritance of property is equal and a matter of
convenience. In rural areas, most property was received through inheritance, with 60
percent inherited by females and 40 percent by males except in Trashigang and Monggar
where around 40 percent of women owned or inherited property (Gender Pilot Study,
2001).
7.4 Literacy and Enrolment in Schools
Adult literacy is very important in the context of the ability of men and women to
participate in employment opportunities that is directly linked to income and poverty. The
overall literacy rate was 59.5 percent, with female literacy of 49 percent and a much higher
rate of 69 percent among the males. Among the youth population (15-24 years), literacy for
females is 68 percent, a much lower rate than males which is 80 percent (Socio-Economic
Development Indicators (SEDI) Report, NSB 2008).
Figure 18: Adult literacy rates
Figure 19: Rural and urban adult
literacy rates
Source: PHCB 2005
Source: PHCB 2005
Figures 18 and 19 show adult literacy rates by sex for urban and rural areas. The adult
literacy rate for females is only half of that of males at 38.7 percent and 65 percent
respectively. The gap between male and female literacy is more in urban than in rural areas,
particularly beyond 20 years. Further, the literacy level of urban females, particularly after
age 20-24 years, is lower than literacy level of rural males.
60

Table 22: The Gross Enrolment Ratio by sex, and level of education
The Gross Enrolment Ratio (GER) at the primary school levels for both sexes is over 90
percent. The GER of 92.1 percent for males is higher than females
Source: PHCB 2005
Primary
Lower
Secondary
Middle
Secondary
Higher
Secondary
All
Schools
Male 92.1 68.8 53.1 39.3 74.1
Female 88.0 66.0 46.8 28.1 68.5
Both 90.1 67.4 49.9 33.7 71.3
(88 percent). The GER
decreases from primary
to the lower secondary up
to the higher secondary
levels both for males and
females.
The number of female students in schools increased over the years narrowing gender gaps.
In 1983, there were 13,924 girls and 29,858 males enrolled in schools, indicating a huge gap
between male and female enrolment (SYB, NSB, General Statistics, MoE). In 2005 however,
there has been a substantial improvement and the number of females were 65,509 against
70,116 male students. However, a grade-wise assessment of the population attending
schools and institutes reveals that the proportion of females after grade 10 decreases from
almost at par levels to as low as 31.3 percent at degree and beyond (PHCB 2005).
There are also regional differences in female enrolment in schools and the lowest female
enrolment rate is observed in Gasa (49.5 percent), followed by Samtse and Dagana
Dzongkhags. In Pemagatshel, the enrolment rate for males was 88.8 percent and 71.5
percent for females, the highest among the Dzongkhags (PHCB 2005).
7.5 Gender and health
In Bhutan, the maternal mortality is still high at 2.55 deaths per 1,000 live-births. There are
numerous women-related health issues which need to be addressed in order to achieve the
country’s global and regional targets. As per the PHCB 2005 and the annual health
bulletins, only around half the births are attended by skilled attendants; anemia is higher in
women than among men; contraceptive use is still low; high teenage pregnancy; HIV/AIDs
is increasing; pregnancy related morbidity is the highest inpatient attendance;
depression/anxiety is disproportionately higher among females than men; hypertension
affects more females than males; infant mortality is still high; and improving the quality of
health services for the growing population needs added attention and resources.
7.5.1 Morbidity and mortality
During the early 1980s, the Infant Mortality Rate (IMR) was over 103 infant deaths per 1,000
live births (SYB & AHB, MoH) that declined to around 71 by 1994. With improvement in
health coverage, the IMR continued to fall and by 2005 it declined to 40.1 per 1,000 live
births (PHCB 2005). The IMR has been declining at an annual rate of 2.9 percent since the
early 1980s.
The data on hospital attendance (AHB, 2008) show continuous increasing trend in cancer,
diabetes, arthritis, depression and anxiety, anemia, hypertension, menstrual and pregnancy
complications, all of which affect mostly women. Based on the 2007 morbidity data (AHB,
61

2008), diseases that afflicted more females than males are, nutritional anemia (around
three times higher), depression and mental disorders, birth and fertility, malignant and
non-malignant diseases of the reproductive organs (breast cancer, cervical cancer, etc.);
nervous and peripheral disorders, hypertension, peptic ulcer syndrome, gall bladder
disease, cystitis, kidney & genital disorders, etc.
7.5.2 Marriage, births and contraception
According to the PHCB 2005, around 11 percent of births occurred to teenage women
between 15 to 19 years. The percent of females divorced is much higher than males
especially in the rural areas as depicted in Figure 20.
Figure 20: Percentage divorced by sex
The proportion of singles at
different points of time or for
Different areas can indirectly
provide an idea about differences
in the marriage pattern.
A summary index, the Singulate
Mean Age at Marriage (SMAM)
derived from the proportional
distribution of single females
measures average age at marriage.
Average age at marriage for
females was 17.9 years in 1984
(Statistical Bulletin, CSO 1985) that
increased to 23.6 years in 2005.
Source: PHCB 2005
The increase in the average age at marriage can have a positive impact in the course of
fertility decline. A comparison of the proportion of single females for 1984 and 2005 is
shown in Figure 21. Rising enrolment and increasing girls’ higher education could be
responsible for the increase in average age of marriage at younger age groups.
Figure 21: Proportion single for females by
age group
The Mean Age at Child Bearing (MACB)
provides an indication of the average age at
which a woman would bear a child. The
average age at child bearing was 26.9 years.
Source: DHS 1984; PHCB, 2005
62

Figure 22: Number of first births by age-group
As shown by Figure 22, the highest number
of births occurred to women of 20-24 years
of age, followed by 15-19 years. Around 96
percent of all first births were concentrated
in the age group 15-29 years. Over 48
percent of first births were to women of age
20-24 years followed by about 28 percent at
age 15-19 years and more than 20 percent to
mothers of 25-29 years of age (PHCB, 2005).
Source: PHCB 2005
The Contraceptive Prevalence Rate (CPR) increased from 19 percent in 1995 to 30.7 percent
in 2000 as per the National Health Surveys, it further increased to 43.6 percent by 2005
(PHCB 2005). The most popular contraceptives are condoms and Depo-Provera/DMPA
injections. Condom distribution increased from 2,846 pieces in 1986 to about 1.5 million in
2008 (AHB, MoH, 2009). While the users of tubectomy, vasectomy and IUD have increased,
the use of pills is on the decline.
7.6 Women and Poverty
Poverty levels decreased from 31.7 percent in 2004 (PAR 2004) to 23.2 percent 2007, which
translates to around 146,100 persons living below the national poverty line i.e. persons
whose real consumption is below the total poverty line of Nu. 1,096.94 per person per
month. 5.9 percent of the total population lives below the food poverty line i.e. 37,300
persons whose per capita food consumption expenditure is below Nu. 688.96 per month.
Poverty is a rural phenomenon with 3 out of every 10 persons poor (30.9 percent) and in
urban areas less than 2 percent of the population is poor. A major proportion of rural
women are engaged in agriculture and as unpaid family worker, and more rural women
than men do not have any source of income (almost 15 percent of the rural working age
women) which renders women as more vulnerable. The PAR 2007 reveals that poverty in
households with one or more women is higher by as much as two times than those
households with male adults. Among the economically inactive 20 population that include
homemakers, 38.7 percent were males and a very high proportion of 61.3 percent were
females in 2005 (PHCB 2005).
The Rapid Impact Assessment of Rural Development Study 2007 (RIARD 2007) found that
35 percent of the respondents faced food shortages during the past one year and half of
them ran short of food for at least four months.
20 Persons who did not participate in producing goods and services in the past one week prior to census enumeration.
These persons include 15 years and above who are engaged in household duties in their own homes, students, disabled
and ill persons (PHCB 2005).
63

The RIARD 2007 further indicated that education is by far the most powerful
determinant of the lack of food in rural areas. Considering the lower literacy rates among
women in both rural and urban areas, women are more susceptible to poverty.
7.7 Labor force participation
Figure 23: Age specific economic activity rates by sex (PHCB 2005)
Activity rate
100.0
90.0
80.0
70.0
60.0
50.0
Age specific economic activity rates by sex, Bhutan 2005
Generally, women account for nearly half
the working age population. The overall
labor force participation 21 or activity
rates are substantially lower for females
compared to males.
40.0
The total labor force participation rate
30.0
was 60.4 percent (PHCB 2005). It is much
Male
20.0
higher among males (71.5 percent)
Female
10.0
compared to females (47.7 percent) and
-
this pattern is true in both the urban and
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 +
rural areas. In the urban areas, the female
Age group
participation rate is 33.6 percent while it
was 54 percent among males. The lower participation rate is partly due to low literacy
levels among women whereas urban employment requires certain level of education.
Women in rural areas were mostly engaged in non-skilled activities and farming. The level
of female labor participation slows down slightly at the age range of 30 to 34 years, which
may happen when females exit from economic activity to raise children and take care of the
home.
Percent
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
Unemployment rate, Bhutan 2005
compared to 33 percent among the males.
Source: PHCB 2005
Male
Female
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 + All
ages
Age group
Figure 24: Unemployment rate by
age-group and sex (PHCB 2005)
Female participation rises up to
55.3 percent at the age group 25 to
29 years but slightly decreases to
54.6 percent for the age group 30 to
34 years. The illiteracy rate among
females in the age group of 15 to 54
years, the prime working age, is
double that of the males, around 67
percent of females were illiterate as
In 2005, the unemployment rate for persons 15 years and above was 3.1 percent. The female
unemployment rate was 3.3 percent, comparatively lower than males at 2.9 percent. The
unemployment rate for females in the 19 to 24 age group is 8.1 percent which is much
higher compared to males at 5.9 percent (PHCB 2005). As per the recent Labor Force Survey
21 Labor force participation rate is the ratio between the labour force and the overall size of their cohort (national
population of the same age range).
64

conducted by the Ministry of Labor and Human Resources in 2009, the
unemployment rate for females increased from 3.8 percent in 2006 to 5.4 percent in 2009
and that for males remained at 2.6 percent.
7.7.1 Employment activities
As depicted in Figure 25 below, among the females a high proportion, 76 percent were
engaged as own account or unpaid family worker while among the males, 51.9 percent
were engaged as paid employees. 17.9 percent females worked as paid employees and a
negligible 0.7 percent as employers.
Figure 25: Employment status by sex
Source: PHCB 2005
As per the PHCB 2005, 62.8 percent females worked in the agriculture sector as compared
to a much lower 32.6 percent males.
7.8 Women in public and political life
Achieving the goal of equal participation of women and men in decision-making will
provide a balance that more accurately reflects the composition of society and is needed in
order to strengthen democracy and promote its proper functioning. Without the active
participation of women and the incorporation of women's perspective at all levels of
decision-making, the goals of equality, development and peace cannot be achieved (Beijing
Platform for Action, 1995). In Bhutan, the Constitution guarantees equal fundamental rights
to all its citizens.
While the government has given increasing importance to improving women’s
participation in public decision making, women remain under-represented. Women
comprise only about 14 percent of the members in the parliament, about 30 percent in the
civil service (with an even lower representation at higher levels), and 12.4 percent in the
judiciary (accounting for 3 percent of the Drangpons, 4.2 percent of Drangpon Rabjams and 30
percent as Registrars). Similarly, public offices at the local level are largely held by men.
Although around 50 percent of the registered voters are females, candidature to political
offices are largely males. In line with the National Plan of Action for Gender (NPAG), 2008
to 2013, measures for addressing the low participation of women in governance include
65

awareness raising and sensitization among key actors, capacity building through
leadership programmes targeted at women and reviewing of policies and legislation.
7.9 Birth, Marriage and Death Registration
Civil and vital registration systems are an important source of administrative data, as they
record the occurrence and characteristics of vital events – births, deaths and causes of
death, marriage, divorce, and adoption, etc. according to the laws, regulations, and legal
requirements of a particular country. This information generally constitutes an important
source of data disaggregated by sex and combined with other sources, they can also
provide gender-sensitive information which is vital for gender mainstreaming of policies,
plans and programmes. Further, they provide vital rates such as infant mortality, child
mortality, and maternal mortality rates. However, the completeness of coverage and the
accuracy are pre-requisites for the vital and civil registration systems information to be
relevant and reliable.
The Department of Civil Registration and Census under the Ministry of Home and Cultural
Affairs is responsible for vital recording and registration of marriages, births, and deaths.
Every couple is required to register their marriage and obtain marriage certificate from the
Court of Justice. Registration of birth is compulsory because of its importance of evidence
of an individual at different phases of life, particularly in enrolment in school, acquiring of
citizenship card, employment and pension. Births are required to be reported within 24
hours after birth. Death registration in the same manner is done by the local administration
office. A person’s life insurance benefits are paid by the government on production of death
certificates.
Simultaneously, births and deaths are also registered by the Ministry of Health in their
health institutions. These are useful for health administration and health interventions.
Birth registration cards obtained from hospitals are used while enrolling students for the
first time to ascertain the correctness of age. Death registration in hospitals are however
limited to the deaths in medical facilities.
Birth registration is presumably better than either of marriage or death. It is hard to actually
understand whether all marriages are registered. There is no study so far, that provide
information about the completeness of registration of marriages and deaths. The
institutional set up for registering marriage, births and deaths therefore needs to be
strengthened.
7.10 Gender and Environment
The main objective of incorporating gender in environment is to enable women and men to
perform their roles in the best cost effective methods that will conserve the environment,
accelerate sustainable development and consequently lead to the improvement in people’s
quality of life. As women in Bhutan are mainly engaged as agricultural workers, homemakers
and care-givers to the sick and elderly (Labor Force Survey 2009, MoLHR), they
play a crucial role in relation to the environment. As such, rural women play a vital role as
farmers and conservationists and are more reliant on the environment for their basic needs
such as food and water. Awareness and knowledge on a healthy environment within
households and the community needs to be integrated in sectoral plans and programmes.
66

Further, it is required to provide rural women dependent on agricultural
livelihoods, with environmental awareness and education on good practices in farming
which is directly related to food self sufficiency in families. Consequently, there is an
urgent need to adopt a gender-responsive approach towards environment policy making
and programming.
7.11 Constitutional and Legal Provisions
Constitutional guarantees of equality are important because of the principle of
constitutional supremacy that prevails in almost all the countries. Bhutan has specific
constitutional provisions on women’s right to be free from discrimination and other gender
related harmful practices.
The Constitution of Bhutan guarantees fundamental rights to all citizens of the country.
Article 7 (15) of the Constitution states, ‘all persons are equal before the law and are
entitled to equal and effective protection of the law and shall not be discriminated against
on the grounds of race, sex, language, religion, politics or other status’. More specifically,
the Principles of State Policy under Article 9 (17) states, ‘the state shall endeavor to take
appropriate measures to eliminate all forms of discrimination and exploitation against
women including trafficking, prostitution, abuse, violence, harassment and intimidation at
work in both public and private spheres’.
The equality of participation in politics is guaranteed by the Constitution under Article 15,
and under Article 7 - access and opportunity to join public service, right to equal pay for
work of equal value is assured.
The Electoral Law of Bhutan in article 13 states; ‘a person is eligible to vote in elections if
that person is at least 18 years of age on the date of the election’. The legal age for marriage
and to vote are both at 18 years.
There are no limitations on women’s freedom of movement and the right to work or to
participate in activities outside the home. The Chathrim for the National Workforce, 1994,
provides that all persons above 17 and below 65 years of age will be employed. Both men
and women are entitled to the same wages with equal opportunities and facilities for
employment. There are no restrictions imposed on women and girls regarding scholarships
for further education and travel abroad.
The concept of the 'head of households' is a relative one and household decision-making
depends on the capacity of the individual. There is no fixed appointment of roles to either
the wife or the husband.
According to the Marriage Act 2006, divorce can be initiated by either sex, and following a
divorce, the mother is given custody of the child till he/she attains 9 years after which the
child is given the choice of living with either parent. The law also provides for the support
of the child till the attainment of 18 years whereby the child (till the maximum of two
children) receives 20 percent of the monthly income of the father. In terms of wealth
accumulated after marriage, it is divided equally between the partners.
67

In the civil service a mother at birth of a child is entitled to 3 months paid maternity leave
while the father is given one week paternity leave.
No differentiation or discrimination exists in the allotment of pension rules; both males and
females receive the same proportion of pension. Upon the death of husbands before
retirement age, the surviving wife is entitled to the pension of her husband.
7.12 Government Institutions on gender issues
Bhutan ratified the Convention on the Elimination of all Forms of Discrimination Against
Women (CEDAW) in 1981. A Royal Decree issued in 1998 emphasized the importance of
women’s participation at all levels of government and society. Although women’s
participation in rural community meetings is as high as 70 percent their representation in
public decision-making at the national and local levels is low. The NCWC is the gender
machinery in the government.
Sensitization on gender equality & equity, setting up the institutional as well as legal
framework, media advocacy and awareness, coordination with various sectors and
institutions to develop protection mechanisms and coordination among agencies to
consolidate efforts and resources to strengthen the focus on gender issues are the various
strategies being adopted by the Government.
7.13 Data gaps in gender mainstreaming
Availability of information is key to generate gender sensitization and mainstreaming.
Comprehensive data on a wide range of gender related areas, particularly on to
participation in decision making, entrepreneurship, domestic violence, trafficking, drugs,
tobacco, etc. are not available.
There is a lack of data in women’s health and analytical capacity to conduct gender focused
research of the existing administrative data. The regular data collection of service facilities
of health, national sample surveys on economy, labor force surveys and other surveys need
to be engendered. Wherever possible, existing data should be compiled and analysed to
reflect gender concerns.
Chapter highlights
The sex ratio at birth was 101 which are within biological limits suggesting the absence of sex preference. Overall general
population sex ratio however was 111 males per 100 females indicative of an excess of males in the total population.
In 2005, over 56 percent among the females had never attended school/institute while it was 40 percent among males.
Illiteracy among females (51 percent) is much higher than that among males (31 percent).
Gross enrolment rate in primary levels for both sexes is over 90 percent, the GER for males is higher (92.1 percent) for
males than for females (88 percent).
In 2005, 65,509 female students were enrolled in schools as against 70,116 male students indicating very narrow gap
between male and female enrolment. The number of cohort survival show female retention is poorer and much less than
that for males.
Low level of nutrition suggested by higher proportion of females than males indicates unsatisfactory health for women.
68

Based on 2007 morbidity data, disease that afflicted more females than males are nutritional anemia (around three
times higher), depression and mental disorders, nervous and peripheral disorder, hypertension, peptic ulcer syndrome,
gall bladder disease, cystitis, kidney & genital disorder etc.
Overall labor force participation rate was 60.4 percent. Male participation rate of 71.5 percent was much higher than
female participation rate of 47.7 percent. Among females just 17.9 percent worked as paid employee and a meager 0.7
percent as employers whereas 51.9 percent males worked as paid employee and 1.7 percent as employers. Female
unemployment of 3.3 percent is slightly higher than males (2.9 percent).
However, improving enrolment and retention of girls in schools have led to proportion of teenage marriage rate for
females have declined 31 times for age 10-14 years between 1984 and 2005.
Of the total of 47 parliament elected members, only 4 were females representing 8.5 percent seats. Even in the civil
service, number of women in executive position is only a handful. Small case studies find that violence against women is
prevalent. There is lack of data and research to understand gender particularly in relation to specific disease affecting
women, nutrition, pregnancy, abortions, UTIs, education, work and poverty. Research in these areas must be taken as a
priority area.
Singulate Mean Age at Marriage (SMAM) is estimated indicate that the marriage rate has changed over time. Mean age
at marriage for females was 17.9 years in 1984 and a considerable increase is change occurred with SMAM of 23.6 years
of average age at marriage. Higher proportion of females at younger ages below age 25 was in single status in 2005 much
higher than their counterparts during the 1980s.
8. ANNEXURES
Additional tables
Table 1: Population by age group and sex, Bhutan 2005 - 2030
Age
group
2005 (PHCB 2005) 2030 (estd.)
Total Male Female Total Male Female
0-4 62,553 31,489 31,064 62,326 31,429 30,897
5-9 70,399 35,547 34,852 65,627 33,124 32,503
10-14 77,007 38,728 38,279 74,410 37,558 36,852
15-19 75,236 37,504 37,732 81,700 41,218 40,482
20-24 70,574 40,254 30,320 79,580 40,136 39,444
25-29 57,358 31,386 25,972 60,938 30,698 30,240
30-34 42,806 23,208 19,598 68,722 34,674 34,048
35-39 38,729 21,124 17,605 74,640 37,499 37,141
40-44 29,900 16,022 13,878 72,121 35,898 36,223
45-49 27,662 14,895 12,767 66,521 37,857 28,664
50-54 22,047 11,779 10,268 52,644 28,665 23,979
55-59 16,392 8,764 7,628 37,570 20,143 17,427
60-64 14,574 7,564 7,010 31,614 16,887 14,727
65-69 11,361 5,999 5,362 21,807 11,290 10,517
70-74 8,742 4,493 4,249 16,954 8,685 8,269
75-79 5,245 2,677 2,568 10,306 5,168 5,138
69

80+ 4,397 2,162 2,235 9,043 4,480 4,563
Total 634,982 333,595 301,387 886,523 455,409 431,114
Source: Population Projections, NSB 2007
Table 2: Year-wise projected population 2005-2030
Year Total Male Female
2005 634,982 333,595 301,387
2006 646,851 339,403 307,448
2007 658,888 345,298 313,590
2008 671,083 351,269 319,814
2009 683,407 357,305 326,102
2010 695,822 363,383 332,439
2011 708,265 369,476 338,789
2012 720,679 375,554 345,125
2013 733,004 381,582 351,422
2014 745,153 387,520 357,633
2015 757,042 393,324 363,718
2016 768,577 398,948 369,629
2017 779,666 404,347 375,319
2018 790,215 409,474 380,741
2019 800,154 414,293 385,861
2020 809,397 418,760 390,637
2021 818,370 423,085 395,285
2022 827,038 427,250 399,788
2023 835,379 431,247 404,132
2024 843,363 435,058 408,305
2025 850,976 438,679 412,297
2026 858,410 442,200 416,210
2027 865,662 445,626 420,036
2028 872,759 448,965 423,794
2029 879,707 452,224 427,483
2030 886,523 455,409 431,114
Source: Population projections, NSB 2007
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Table 3: percent population 1984-2030
1984 2005 2030
Age group
Males Females Total Male Female Total Male Female Total
0-4 12.0 12.8 12.4 9.4 10.3 9.9 6.9 7.1 7.0
5-9 13.3 13.5 13.4 10.7 11.6 11.1 7.1 7.3 7.2
10-14 11.5 11.3 11.4 11.6 12.7 12.1 8.0 8.2 8.1
15-19 10.0 10.2 10.1 11.2 12.5 11.8 9.0 9.4 9.2
20-24 8.8 9.2 9.0 12.1 10.1 11.1 9.4 9.7 9.5
25-29 7.8 7.9 7.8 9.4 8.6 9.0 6.8 7.1 6.9
30-34 6.7 6.4 6.6 7.0 6.5 6.7 7.4 7.7 7.5
35-39 5.8 5.5 5.7 6.3 5.8 6.1 7.9 8.0 7.9
40-44 5.1 4.9 5.0 4.8 4.6 4.7 7.7 7.5 7.6
45-49 4.5 4.3 4.4 4.5 4.2 4.4 7.3 6.7 7.0
50-54 4.2 3.9 4.0 3.5 3.4 3.5 6.4 5.7 6.1
55-59 3.2 3.1 3.2 2.6 2.5 2.6 5.1 4.5 4.8
60-64 2.8 2.7 2.8 2.3 2.3 2.3 4.0 3.6 3.8
65 + 4.3 4.4 4.3 4.6 4.8 4.7 7.2 7.3 7.2
TOTAL 100.0 100.0 100.0 100 100 100 100 100 100
Source: DHS 1984, PHCB 2005, Population Projections NSB 2007
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Table 4: Total population by urban rural residence and Dzongkhag 2005
Dzongkhag Persons percent
Urban Rural Total Urban Rural Total
Thimphu 79,185 19,491 98,676 80.2 19.8 100.0
Chhukha 32,926 41,461 74,387 44.3 55.7 100.0
Samtse 10,139 49,961 60,100 16.9 83.1 100.0
Trashigang 6,816 44,318 51,134 13.3 86.7 100.0
Sarpang 12,596 28,953 41,549 30.3 69.7 100.0
Samdrupjongkhar 10,964 28,997 39,961 27.4 72.6 100.0
Monggar 7,153 29,916 37,069 19.3 80.7 100.0
Paro 2,932 33,501 36,433 8.0 92.0 100.0
Wangdue 7,522 23,613 31,135 24.2 75.8 100.0
Tsirang 1,666 17,001 18,667 8.9 91.1 100.0
Zhemgang 3,386 15,250 18,636 18.2 81.8 100.0
Dagana 1,958 16,264 18,222 10.7 89.3 100.0
Trashiyangtse 3,018 14,722 17,740 17.0 83.0 100.0
Punakha 2,292 15,423 17,715 12.9 87.1 100.0
Bumthang 4,203 11,913 16,116 26.1 73.9 100.0
Lhuentse 1,476 13,919 15,395 9.6 90.4 100.0
Pemagatshel 2,287 11,577 13,864 16.5 83.5 100.0
Trongsa 2,695 10,724 13,419 20.1 79.9 100.0
Ha 2,495 9,153 11,648 21.4 78.6 100.0
Gasa 402 2,714 3,116 12.9 87.1 100.0
Total 196,111 438,871 634,982 30.9 69.1 100.0
Source: PHCB 2005
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Table 5: Estimated birth and death rates, growth rates and life expectancy
Year Birth rate Death rate
Growth
rate
Life
expectancy
1950-55 49.6 30.6 1.96 27.8
1955-60 46.5 30.5 1.60 33.8
1960-65 45.2 26.4 1.88 37.3
1965-70 44.7 23.9 2.10 39.8
1970-75 43.2 22.3 2.09 41.3
1975-80 41.0 20.6 2.04 43.3
1980-85 39.0 19.0 2.00 45.6
1984 39.1 13.4 2.57 47.5
1994 39.9 9.0 3.09 66.1
2000 a 34.1 8.6 2.55 66.2
2005 b 26.1 7.7 1.84 66.3
2010 b 25.2 7.3 1.79 68.9
2015 b 22.6 6.9 1.57 70.9
2020 b 17.9 6.5 1.14 72.4
2025 b 15.5 6.5 0.90 73.4
2030 b 14.5 6.8 0.77 74.2
(Note) : a = Estimated by linear interpolation; b= implied estimations
Table 6: CDR by urban rural residence, 2005
Dzongkhag Urban Rural Total
Bumthang 5.5 7.3 6.8
Chhukha 5.6 7.5 6.6
Dagana 4.8 7.9 7.5
Gasa 12.4 11.4 11.6
Haa 4.4 8.1 7.3
Lhuentse 2.7 8.9 8.3
Monggar 4.1 8.6 7.7
Paro 10.9 6.5 6.9
Pemagatshel 3.9 8.6 7.9
Punakha 4.8 8.0 7.7
Samdrupjongkhar 5.9 6.5 6.3
Samtse 8.2 7.7 7.8
Sarpang 4.1 5.9 5.3
Thimphu 5.3 8.3 5.7
Trashigang 3.7 9.4 8.6
Trashiyangtse 8.6 9.4 9.2
Trongsa 1.9 9.1 7.7
Tsirang 4.8 6.9 6.7
Wangdue 5.6 8.3 7.7
Zhemgang 3.0 7.2 6.4
Bhutan 5.3 7.9 7.1
Source: PHCB 2005; Based on annual birth in 1 year before census date
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