Hear, Listen, and Speak Programme in Bhutan using a Public Private Partnership model

This article is published in The South South Matchmaker 3, South South Network.

An overview of the development challenges in the country

Although the statistics showed two per cent (2%) of the Bhutanese population have hearing loss, the actual number is likely higher, especially the number of hearing loss cases in young children. The discrepancy results from gaps in knowledge, attitudes and practices around hearing loss in Bhutan. In addition, a wide range of ear disorders need to be accounted for, if not detected or attended to early on, they can result in acquired hearing loss. Since hearing loss is not visible, it often remains undetected and untreated in infants and children. As the acquisition of listening and spoken language skills in children is directly related to their hearing ability, such unaddressed hearing loss can cause irreversible and permanent negative impacts. For example, it can further develop into more adverse implications for many aspects of children's lives and their futures including cognition, education, mental health, interpersonal relationships and employment later in life.

Currently, only a relatively small population in Bhutan receive comprehensive screening, intervention, monitoring and evaluation. The programme aims to bring the needed technology and knowledge via an innovative public private partnership model to address this public health challenge and sustainably fill this gap in Bhutan’s public health system.

Concepts

This project provides an innovative and comprehensive solution to address the urgent needs of hearing care for children in Bhutan using a public private partnership model to harness comparative advantages from both public and private sectors for achieving collective social benefits. By leveraging this innovative model, the public health sector in Bhutan can strengthen their hearing care capacities with the support of private partners pertaining to knowledge, capacity building and technology. The role of the Technology Bank is to coordinate multi-sector project partners from the private sector and the Government to facilitate the access to the technologies and ensure the resources are mobilized at all stages. This includes the close collaboration with local UN agencies, especially the UN Resident Coordinator Office and UNICEF to ensure the alignment of the development needs and priorities for the country.

The model provides both knowledge and technology transfer needed to address the current gaps in hearing care in Bhutan. In this case, Medtronic Labs has provided technology transfer and its technical assistance to Bhutan; MED-EL/Austrian Development Agency have provided knowledge transfer by capacity building training to the local medical workers and awareness raising in the local communities and schools. For the sustainability of its outcomes, the project design focuses on the direct provision of equipment, training of care and maintenance providers, training-of-trainers, and establishment of mechanisms for sustained provision of care across the continuum. This also includes hearing screening equipment for instant screening, specifically the ViviSonic Diagnostic ABR and the REM Device Model Verifit 2 as seen below, professional development to strengthen Bhutanese capacity and expertise, and the establishment of early intervention and therapy services that ensure the continuum of care.

The project is also designed to strengthen the health system in Bhutan to ensure that the enhanced local technical and knowledge capacity can sustain the ongoing prevention and treatment for hearing loss in children of Bhutan upon the programme’s completion. This project is also aligned with and can be integrated into the national policy of Bhutan, such as the Gross Happiness Plan 2018-2023 and the National Policy for Persons with Disabilities. The project aims to provide the interventions required to address hearing loss and preventive ear disorders across the whole continuum of care for all Bhutanese children. The expected outputs of the projects by the end of 2024 are:

• All 110000 Bhutanese children aged 0-14 will be screened for hearing
• The establishment of the first earmold lab in Bhutan for the local production of ear molds for hearing aids
• Technical capacity building for healthcare workers, ENT specialists and clinicians with a focus on rural areas
• Capacity building in hearing loss knowledge and awareness raising for schools, communities and parents
• Development of rehabilitation capacity and empowerment for healthcare workers and families with children with hearing loss

Challenges

The project began its implementation in 2021 and due to the COVID-19 lockdown measures that were in place in the country, the implementation was slowed down, such as facilitating in-person training and the importation of equipment into Bhutan with appropriate authorisations. Regular and active communications between project partners are the key to addressing these challenges. The design of a Consortium has also helped the communications, joint advocacy and effective decision making in this large-scale, complex private-public partnership on public health implementing in a least developed country.

Furthermore, on the project implementation, initially, there is an unequal distribution of technologies and systems (audiological equipment and hearing screening technologies) in Bhutan. Thus, the project aims to have these systems accessible to all, helping to diagnose conditions and measure the prevalence of paediatric hearing loss and ear disorders more accurately, which in turn helps to support policy evaluation and development.

There is also currently a limited capacity of trained technicians and availability of screening, audiology and diagnostics equipment and hearing aids as well as a lack of capacity to produce ear molds and fit hearing aids for children aged 0-14. The programme has commenced with the training of audiologists and health workers to conduct screening and operate the diagnostics equipment. The main challenge for Bhutan is the limited capacity of the specialists and the programme enables specialists to analyse and interpret the digital data once uploaded, thus expanding the reach of their service and contributing to a better quality of life for the children. Challenges encountered in some areas are limited connectivity for the data to be transmitted immediately to the specialists. The programme was implemented both in hospital and school settings, and both Ministries of Health and Education had to integrate the programme into the existing comprehensive school programmes. The Technology Bank and Medtronic Labs had to organise a multistakeholder meeting to ensure the alignment of roles and responsibilities.

Potential for adaptability or replication

The public-private partnership model is replicable as evidenced by the current work of the Consortium on the ‘Beyond Bhutan’ project. The objective of this is to expand and replicate this model to the other least developed countries. The initial focus is on Malawi and a subsequent country-specific approach will be adapted to other LDCs.

The solution is an adaptation from another case study?

This is the first partnership between the UN Technology Bank and private sector entities addressing hearing care in a least developed country focusing on technology and knowledge transfer. The programme strengthens the Bhutanese public health service in using technology to empower and support people with disabilities and attain SDGs 1, 3, 4, 10 and 17.

Lessons learned

Since the project is currently in the first phase of its proposed activities, the lessons learned are seen to be the inequity of services available in Bhutan for hearing screenings, a reality that was exacerbated during the COVID-19 pandemic. Thus, early detection and intervention are key aspects of this project, which is further strengthened through high-end standard equipment that could be utilized. Capacity building is also seen to be one of the main factors that could inform higher audiological management, while the establishment of the ear mold lab and the subsequent plan for providing cochlear implants which have substantial potential to bridge the existing gaps within Bhutan. Close partnerships and coordination with the relevant government counterparts have also proved effective in ensuring smooth implementation of the project activities on the ground, while also displaying ownership and responsibility for the project’s success. Integrating the programme into the national health and education programmes reinforces sustainability and complements existing child-related programmes in Bhutan. The role of private-public partnerships has enabled Bhutan to leverage technology transfer for inclusive healthcare.