Bhutan - Multiple Indicator Cluster Survey - 2010

Publication date: 2010

BHUTAN Monitoring the situation of children and women Bhutan Multiple Indicator Survey 2010 NSB Bhutan Bhutan Multiple Indicator Survey 2010 Printed by KUENSEL corporation Ltd. (2011) National Statistics Bureau United Nations Children’s Fund United Nations Population Fund B hutan M ultiple Indicator Survey, 2010 The Bhutan Multiple Indicator Survey (BMIS) was carried out in 2010 by the National Statistics Bureau (NSB). Financial and technical support was provided by the United Nations Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA). The BMIS is a customized version of the Multiple Indicator Cluster Survey (MICS), which is an international household survey programme developed by UNICEF with add-ons of the Demographic and Health Survey (DHS) to suit the Bhutanese context . It was conducted as part of the fourth global round of MICS surveys (MICS4). The BMIS provides up-to-date information on the situation of children and women and measures key indicators to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed-upon commitments. Additional information on the global MICS project may be obtained from www.childinfo.org. Suggested citation: Bhutan Multiple Indicator Survey, March 2011. National Statistics Bureau, Thimphu, Bhutan. ISBN. No: 978-99936-28-09-5 Copyright © National Statistics Bureau, 2011 www.nsb.gov.bt Bhutan Multiple Indicator Survey, May 2011, National Statistics Bureau, Thimphu, Bhutan Bhutan Multiple Indicator Survey, 2010 National Statistics Bureau Royal Government of Bhutan UNICEF United Nations Children’s Fund UNFPA United Nations Population Fund May, 2011 ii iii Summary Table of Findings Bhutan Multiple Indicator Survey (BMIS) and Millennium Development Goals (MDG) Indicators, Bhutan, 2010 Topic MICS Indica- tor Number MDG Indicator Number Indicator Value CHILD MORTALITY Child mortality 1.1 4.1 Under-five mortality rate 69 per thousand 1.2 4.2 Infant mortality rate 47 per thousand NUTRITION Nutritional status 2.1a 2.1b 1.8 Underweight prevalence Moderate and Severe (- 2 SD) Severe (- 3 SD) 12.7 percent 3.2 percent 2.2a 2.2b Stunting prevalence Moderate and Severe (- 2 SD) Severe (- 3 SD) 33.5 percent 13.3 percent 2.3a 2.3b Wasting prevalence Moderate and Severe (- 2 SD) Severe (- 3 SD) 5.9 percent 2.0 percent Breastfeeding and infant feeding 2.4 Children ever breastfed 98.9 percent 2.5 Early initiation of breastfeeding 59.0 percent 2.6 Exclusive breastfeeding under 6 months 48.7 percent 2.7 Continued breastfeeding at 1 year 92.7 percent 2.8 Continued breastfeeding at 2 years 65.7 percent 2.9 Predominant breastfeeding under 6 months 66.8 percent 2.10 Duration of breastfeeding (Median) 24.2 months 2.11 Bottle feeding 11.5 percent 2.12 Introduction of solid, semi-solid or soft foods 66.7 percent 2.13 Minimum meal frequency 62.6 percent 2.14 Age-appropriate breastfeeding 66.0 percent 2.15 Milk feeding frequency for non-breastfed children 36.3 percent Low birth weight 2.18 Low-birthweight infants 9.9 percent 2.19 Infants weighed at birth 72.2 percent CHILD HEALTH Tetanus toxoid 3.7 Neonatal tetanus protection 73.0 percent Care of illness 3.8 Oral rehydration therapy with continued feeding 61.6 percent 3.9 Care seeking for suspected pneumonia 74.2 percent 3.10 Antibiotic treatment of suspected pneumonia 48.7 percent Solid fuel use 3.11 Solid fuels 39.5 percent WATER AND SANITATION Water and sanitation 4.1 7.8 Use of improved drinking water sources 96.1 percent 4.2 Water treatment 55.8 percent 4.3 7.9 Use of improved sanitation facilities (not shared) 58.4 percent 4.4 Safe disposal of child’s faeces 57.5 percent Handwashing 4.5 4.6 Place for handwashing (Water and soap are available) Availability of soap 80.9 percent 99.4 percent iv Topic MICS Indica- tor Number MDG Indica- tor Number Indicator Value REPRODUCTIVE HEALTH Contraception and unmet need 5.1 5.4 Adolescent fertility rate 59 per thousand 5.2 Early childbearing 15.3 percent 5.3 5.3 Contraceptive prevalence rate 65.6 percent 5.4 5.6 Unmet need 11.7 percent Maternal and newborn health 5.5a 5.5b 5.5 Antenatal care coverage At least once by skilled personnel At least four times by any provider 97.3 percent 77.3 percent 5.6 Content of antenatal care 87.9 percent 5.7 5.2 Skilled attendant at delivery 64.5 percent 5.8 Institutional deliveries 63.1 percent 5.9 Caesarean section 12.4 percent CHILD DEVELOPMENT Child development 6.1 Support for learning 54.2 percent 6.2 Father’s support for learning 51.3 percent 6.3 Learning materials: children’s books 6.4 percent 6.4 Learning materials: playthings 51.5 percent 6.5 Inadequate care 14.2 percent 6.6 Early child development index 71.5 percent 6.7 Attendance to early childhood education 9.5 percent EDUCATION Literacy and education 7.1 2.3 Literacy rate among young women 56.5 percent 7.2 School readiness 1.4 percent 7.3 Net intake rate in primary education 68.1 percent 7.4 2.1 Primary school net attendance rate (adjusted) 91.9 percent 7.5 Secondary school net attendance rate (adjusted) 55.0 percent 7.6 2.2 Children reaching last grade of primary 93.6 percent 7.7 Primary completion rate 90.1 percent 7.8 Transition rate to secondary school 88.7 percent 7.9 Gender parity index (primary school) 1.02 ratio 7.10 Gender parity index (secondary school) 1.03 ratio CHILD PROTECTION Birth registration 8.1 Birth registration 99.9 percent Child labour 8.2 Child labour 18.4 percent 8.3 School attendance among child labourers 86.5 percent 8.4 Child labour among students 18.8 percent Early marriage and po- lygamy 8.6 Marriage before age 15 6.7 percent 8.7 Marriage before age 18 30.8 percent 8.8 Young women age 15-19 currently married or in union 15.2 percent 8.9 Polygamy 5.0 percent 8.10a 8.10b Spousal age difference Women age 15-19 Women age 20-24 11.9 percent 13.3 percent Domestic violence 8.14 Attitudes towards domestic violence 68.4 percent v Topic MICS Indica-tor Number MDG Indica- tor Number Indicator Value HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN HIV/AIDS knowledge and attitudes 9.1 Comprehensive knowledge about HIV prevention 17.5 percent 9.2 6.3 Comprehensive knowledge about HIV prevention among young people 21.0 percent 9.3 Knowledge of mother- to-child transmission of HIV 56.2 percent 9.4 Accepting attitude towards people with HIV 27.9 percent 9.5 Women who know where to be tested for HIV 54.5 percent 9.6 Women who have been tested for HIV and know the results 9.8 percent 9.7 Sexually active young women who have been tested for HIV and know the results 13.3 percent 9.8 HIV counselling during antenatal care 53.9 percent 9.9 HIV testing during antenatal care 46.9 percent Sexual behaviour 9.10 Young women who have never had sex 96.4 percent 9.11 Sex before age 15 among young women 3.7 percent 9.13 Sex with multiple partners 0.3 percent 9.14 Condom use during sex with multiple partners 20.5 percent 9.15 9.16 6.2 Sex with non-regular partners Condon use with non-regular partners 1.4 percent 61.6 percent Orphaned children 9.17 Children’s living arrangements (Not living with biological parents) 7.4 percent 9.18 Prevalence of children with at least one parent dead 5.4 percent vi Table of Contents Summary Table of Findings iii Table of Contents vi List of Tables ix List of Figures xiii List of Abbreviations xiv Acknowledgements xvi Executive summary x v i i I. Introduction 1 Background 1 Survey Objectives 3 II. Sample and Survey Methodology 5 Sample Design 5 Questionnaires 5 Training and Fieldwork 7 Data Processing 7 III. Sample Coverage and the Characteristics of Households and Respondents 9 Sample Coverage 9 Characteristics of Households 11 Characteristics of Female Respondents 15-49 Years of Age and Children Under- five 16 Orphanhood 20 IV. Child Mortality 25 V. Nutrition 31 Nutritional Status 31 Breastfeeding and Infant and Young Child Feeding 37 Low Birth Weight 49 IV. Child Health 55 Neonatal Tetanus Protection 55 vii Oral Rehydration Treatment 58 Care Seeking and Antibiotic Treatment of Pneumonia 67 Solid Fuel Use 70 VII. Water and Sanitation 75 Use of Improved Water Sources 75 Use of Improved Sanitation Facilities 87 Handwashing 98 VIII. Reproductive Health 105 Fertility 105 Contraception 110 Unmet Need 113 Antenatal Care 117 Assistance at Delivery 123 Place of Delivery 126 IX. Child Development 129 Early Childhood Education and Learning 129 Early Childhood Development 138 X. Literacy and Education 143 Literacy among Young Women 143 School Readiness 145 Primary and Secondary School Participation 147 XI. Child Protection 159 Birth Registration 159 Child Labour 161 Early Marriage and Polygamy 166 Domestic Violence 174 Child Disability 177 XII. HIV/AIDS, Sexual Behaviour 181 Knowledge about HIV Transmission and Misconceptions about HIV/AIDS 181 viii Accepting Attitudes toward People Living with HIV/AIDS 190 Knowledge of a Place for HIV Testing, Counselling and Testing during Antenatal Care 192 Sexual Behaviour Related to HIV Transmission 198 Appendix A. Sample Design 207 Sample Size and Sample Allocation 207 Sampling Frame and Selection of Clusters 209 Listing Activities 210 Selection of Households 210 Calculation of Sample Weights 210 Appendix B. List of Personnel Involved in the Survey 213 Appendix C. Estimates of Sampling Errors 215 Appendix D. Data Quality Tables 240 Appendix E. MICS4 Indicators: Numerators and Denominators 252 Appendix G. Questionnaires 256 ix List of Tables Table HH.1: Results of household, women and under-five interviews 10 Table HH.2: Household age distribution by sex 11 Table HH.3: Household composition 14 Table HH.3. Household composition 15 Table HH.4: Women’s background characteristics 16 Table HH.5: Children’s background characteristics 19 Table HH.6: Children’s living arrangements and orphanhood 21 Table CM.1: Children ever born, children surviving and proportion dead by sex 26 Table CM.2: Child mortality 27 Table NU.1: Nutritional status of children 33 Table NU.2: Initial breast feeding 38 Table NU.3: Breast feeding 41 Table NU.4: Duration of breast feeding 43 Table NU.5: Age appropriate breast feeding 44 Table NU.6: Introduction of solid, semisolid or soft food 45 Table NU.7: Minimum meal frequency 46 Table NU.8: Bottle feeding 48 Table NU.9 Low birth weight infants 50 Table CH.1: Neonatal tetanus protection 56 Table CH.2: Oral rehydration solutions and recommended homemade fluids 59 Table CH.3: Feeding practices during diarrhoea 62 Table CH.4: Oral rehydration therapy with continued feeding and other treatments 65 x Table CH.5: Care seeking for suspected pneumonia and antibiotic use during suspected pneumonia 68 Table CH.6: Solid fuel use 70 Table CH.7: Solid fuel use by place of cooking 73 Table WS.1: Use of improved water sources 76 Table WS.2: Household water treatment 80 Table WS.3: Time to source of drinking water 83 Table WS.4: Person collecting water 85 Table WS.5: Use of improved sanitation facilities 88 Table WS.6: Shared use of sanitation facilities 91 Table WS.7: Disposal of child’s faeces 93 Table WS.8: Use of improved water sources and improved sanitation facilities 96 Table WS.9: Water and soap at place for handwashing 99 Table WS.10: Availability of soap 101 Table RH.1: Adolescent birth rate and total fertility rate 106 Table RH.2: Early childbearing 107 Table RH.3: Trends in early childbearing 109 Table RH.4: Use of contraception 111 Table RH.5: Unmet need for contraception 115 Table RH.6: Antenatal care provider 118 Table RH.7: Number of antenatal care visits 120 Table RH.8: Content of antenatal care 122 Table RH.9: Assistance during delivery 124 Table RH.10: Place of delivery 127 xi Table CD.1: Early childhood education 130 Table CD.2: Support for learning 132 Table CD.3: Learning materials 135 Table CD.4: Inadequate care 137 Table CD.5: Early child development index 139 Table ED.1: Literacy among young women 144 Table ED.2: School readiness 145 Table ED.3: Primary school entry 148 Table ED.4: primary school attendance 150 Table ED.5: Secondary school attendance 152 Table ED.6: Children reaching last grade of primary school 154 Table ED.7: Primary school completion and transition to secondary school 155 Table ED.8: Education gender parity 156 Table CP.1: Birth registration 159 Table CP.2: Child labour 162 Table CP.3: Child labour and school attendance 164 Table CP.4: Early marriage and polygamy 168 Table CP.5: Trends in early marriage 171 Table CP.6: Spousal age difference 172 Table CP.7: Attitudes toward domestic violence 175 Table CP.8: Child Disability 178 Table HA.1: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensive knowledge about HIV transmission 182 xii Table HA.2: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensive knowledge about HIV transmission among young people 185 Table HA.3: Knowledge of mother-to-child HIV transmission 188 Table HA.4: Accepting attitudes toward people living with HIV/AIDS 190 Table HA.5: Knowledge of a place for HIV testing 192 Table HA.6: Knowledge of a place for HIV testing among sexually active young women 194 Table HA 7: HIV counselling and testing during antenatal care 196 Table HA.8: Sexual behaviour that increases the risk of HIV infection 198 Table HA.9: Sex with multiple partners 201 Table HA 10: Sex with multiple partners (young women) 203 Table HA.11: Sex with non-regular partners 205 xiii List of Figures Figure HH.1: Population pyramid, Bhutan 2010 12 Figure CM.1: Under-five mortality rate by background characteristics, Bhutan 2010 28 Figure NU.1: Percent of children underweight, stunted and wasted by age groups, Bhutan 2010 35 Figure NU.2: Initial breastfeeding (within one hour and one day of birth), Bhutan 2010 40 Figure.NU.3: Percent of children weight below 2500 grams at birth by Dzongkhag, Bhutan 2010 52 Figure.CH.1: Neonatal tetanus protection (women with a live birth in the previous 24 months). 57 Figure CH.2: Oral rehydration solution (percentage of under-five children with diarrhoea who received ORS and recommended homemade fluids), Bhutan 2010 61 Figure CH.3: Oral rehydration therapy (percentage of under-five children with diarrhoea who received ORT), Bhutan 2010 64 Figure WS.1: Percentage of household population using improved source of drinking water by Dzongkhag, Bhutan 2010 78 Figure HA.1: Percentage of women aged 15-49 years with comprehensive knowledge about HIV/AIDS by different background characteristics, Bhutan 20101 187 Figure HA.2: Percentage of women aged 15-24 years who had sex before age 15 and who had sex in the last 12 months with a man 10 or more years older, Bhutan 2010 200 xiv List of Abbreviations AIDS Acquired Immunodeficiency Syndrome BMIS Bhutan Multiple Indicator Survey CEDAW Convention on the Elimination of all forms of Discrimination Against Women CPS Contraceptive Prevalence Survey CRC Convention on Rights of the Child CSDP Child Survival, Development and Protection CSPro Census and Survey Processing System DHS Demographic and Health Survey DSO Dzongkhag Statistical Officer GNHC Gross National Happiness Commission HH Households HIV Human Immunodeficiency Virus IMR Infant Mortality Rate JMP Joint Monitoring Programme LAM Lactational Amenorrhea Method LPG Liquefied Petroleum Gas MDG Millennium Development Goals MICS Multiple Indicator Cluster Surveys NSB National Statistics Bureau NGO Non Governmental Organization ORS Oral Rehydration Solution ORT Oral Rehydration Therapy xv PASW Predictive Analytics Software PHCB Population and Housing Census of Bhutan PSU Primary Sampling Unit RGoB Royal Government of Bhutan SAARC South Asian Association for Regional Cooperation SBA Skilled Birth Attendant SD Standard Deviation SPSS Statistical Package for Social Sciences UNAIDS United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund U5MR Under-five Mortality Rate UN United Nations WFFC World Fit For Children WHO World Health Organization xvi Acknowledgements The Royal Government of Bhutan has mandated the National Statistics Bureau (NSB) to collect data to provide strong evidence for equity-based planning and programming and also to monitor implementation progress towards international conventions. The National Statistics Bureau, in col- laboration with the UNICEF and UNFPA, conducted the Bhutan Multiple Indicator Survey (BMIS) in March 2010. The BMIS is a household survey designed to collect data related to the welfare of children and women. It is the first of its kind in Bhutan. The NSB collaborated with the Ministry of Health, the Ministry of Education, the Gross National Happiness Commission, the National Commission for Women and Children and other stakeholders to successfully complete the survey. The staff of NSB, Dzongkhag Statistics Officers, Dzongdag, Gup and Tsogpas and many other people took part in conducting the BMIS 2010. We appreciate the support given by the relevant ministries, agencies and individuals, and we want to thank everyone involved in the survey, the subsequent data analysis and in preparing the BMIS report. The Global MICS team of UNICEF defined the MICS protocols and methodology and in consultation with NSB staff customized the design to Bhutan’s context. The standardized MICS questionnaires, sample selection procedures and software for tabulations (provided by UNICEF) were useful for the survey and data analysis. Several UNICEF consultants trained NSB staff and others for the field work and in sampling, data processing, analysis and report writing. UNICEF also supported training for BMIS team members abroad. We sincerely thank UNICEF and UNFPA for their technical and financial support. xvii Executive Summary The National statistics Bureau conducted the Bhutan Multiple Indicator Survey between March and August, 2010. The survey’s main objective is to provide up-to-date information on the situation of children and women in Bhutan. The survey is also aimed at furnishing data required for monitoring progress towards the MDGs, the goals of A World Fit for Children and other international goals. It is hoped that the findings will serve as a basis for equity-based programming, as well as contribute towards the improvement of data and monitoring systems in Bhutan. It will also help to strengthen technical expertise in the design, implementation, and data analysis of similar surveys in future. Sample Coverage Of the 15,400 households selected for the sample, 14,917 were occupied. Of which, 14,676 house- holds were successfully interviewed for a household response rate of 98.4 percent. Within those interviewed households, 16,823 of the eligible women (aged 15-49) were identified. Of them 14,018 were successfully interviewed, yielding a response rate of 83.3 percent. The household interviews identified 6,457 children under-five. The questionnaires were completed for 6,297 of them with a response rate of 97.5 percent. Nutrition Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to re peated illness, and are well cared for, they reach their growth potential and are considered well nourished. Overall, 71.4 percent of children under the age of five were weighed at birth and approximately 9.5 percent of infants were estimated to weigh less than 2500 grams at birth. Anthropometric measurements were taken during fieldwork and almost one in eight children under five in Bhutan were moderately underweight (12.7%) and 3.2 percent were classified as severely underweight. More than one third of children (33.5%) were moderately stunted or too short for their age, out of which 13.3 percent were severely stunted. Wasting is a reflection of acute malnutrition and moderate wasting is estimated at 5.9 percent and severe wasting at 2 percent. Nationally, 59 percent of infants were breastfed within one hour of birth and 92.9 percent of them within one day of birth. Child Mortality Infant mortality rate (IMR) is the probability of dying before the first birthday expressed per 1,000 live births. The under-five mortality rate (U5MR) is the probability of dying before the fifth birthday expressed per 1,000 live births. The infant mortality rate was estimated at 47 per thousand and the under-five mortality rate at 69 per thousand using the North model. There is some difference between the probabilities of dying among males and females, with males having higher mortality rates. Infant and under-five mortality rates are lower in the Western and Central regions as compared to the Eastern region. As the education level as well as wealth index of the mother increases, the under-five mortality rate decreases xviii Child Health In total, some 25.1 percent of under-five children had diarrhoea in the two weeks preceding the sur- vey. The Oral Rehydration Therapy use rate was 85.4 percent nationally; the rate in urban areas was 86.6 percent and 84.9 percent in rural areas. Nationally, 6.9 percent of under-five children were reported to have had the symptoms of pneumonia during the two weeks preceding the survey interview. Of them, 74.2 percent were taken to an appro- priate health facility, while 0.2 percent were taken to traditional practitioners. Water and Sanitation 96.1 percent of the surveyed population had access to improved drinking water sources; 99.6 percent in urban areas and 94.8 percent in rural areas. Only 58.4 percent of the overall surveyed population lived in households with access to improved sanitation facilities. By area, it is 77.9 percent for urban households and 51 percent for rural house- holds. 56.9 percent of surveyed households reported using an improved water source and proper means of excreta disposal. The urban population was almost twice as likely (77.7%) to use an improved source of drinking water and sanitation compared to the rural population (49%). Reproductive Health The current use of contraception was reported by 65.6 percent of women currently married or in union. The most popular method is injectables used by 28.9 percent of the married or women in union. 11.7 percent of women in Bhutan had an unmet need for contraception. The demand for con- traception was less satisfactory among younger women. Doctors provided antenatal care to 37.8 percent of urban women, compared with 17.9 percent of rural women. The nurses or midwifes provided the antenatal care to 57.3 percent of urban women and 48.1 percent of rural women. 93 percent of women who had a live birth in the two years preceding the survey had their blood test taken; 94.7 percent had their blood pressure measured and 89.1 percent had a urine specimen taken. Around 32 percent of the births in the two years prior to the BMIS survey were delivered with the assistance of a nurse or midwife. Doctors assisted the delivery of 26.1 percent of births, while 1.8 percent of births were aided by traditional birth attendants (two years period prior to the survey in- terview). Coverage of antenatal care by skilled personnel was relatively high in Bhutan with 97.3 percent of women receiving antenatal care at least once during the pregnancy. More than nine in ten moth- ers (94.1%) received antenatal care more than once and more than seven out of ten of the mothers received antenatal care at least four times (77.3%) during the last pregnancy during the two years preceding the survey. Mothers from the poorest households and those with no education or primary education were less likely than the more advantaged mothers to receive ANC four or more times. For example, 64 percent of the women living in the poorest households reported four or more antenatal care visits, compared with 91.8 percent among those living in the richest households. Women less than 20 years of age, as well as women aged 35-49, were less likely to receive four or more antenatal care visits compared to women aged 20-34 years old xix Child Development In 18.9 percent of children under-five households, at least an adult member was engaged in an mini- mum of four activities that promoted learning and school readiness during the three days preceding the survey. The average number of activities that adults engaged with children was 1.9. Fathers’ involvement in such activities was significantly higher at 51.3 percent. The average number of activi- ties was 1.2. 14.6 percent of children aged 0-59 months who were living in households without their father. The proportion of under-five children who had three or more children’s books is 13 percent in urban areas, compared to 3.6 percent in rural areas. Just 10.2 percent of children aged 0-59 months were left in the care of other children younger than 10 years old, while 6.3 percent were left alone during the week preceding the interview. Combining the two care indicators, 14.2 percent of children were left with inadequate care during the week preced- ing the survey. Education 56.5 percent of women in the country between 15-24 years were found to be literate. There were ma- jor variations according to residential areas; 77.9 percent of women were literate in urban areas while it was 44.5 percent in rural areas. For children of primary school-entry age (age six), 70.7 percent were attending grade 1. It was higher in rural areas (71.4%) than in urban areas (68.8%). The net primary school attendance rate was 92.2 percent. Among the Dzongkhags, Bumtang had the highest net primary attendance rate (97.3%). The gender parity index for primary school was 1.02, indicating there was no difference in the atten- dance of girls and boys in primary school. Child Protection According to the findings, 99.9 percent of under-five children in the surveyed households had a birth registration document (registered with civil authorities or in possession of a health card). Nationally, child labour prevalence was found to be 18.4 percent. There was little male-female varia- tion, with 17.6 percent of males and 19.1 percent of females involved in child labour. In rural areas, 22.2 percent of children and in urban areas, 8.7 percent were involved in child labour. Student labourers refer to the children attending school who were involved in child labour activities at the time of the survey. Of the 84.7 percent of children (aged 5-14) who were attending schools, 18.8 percent were also engaged in child labour. Among the surveyed households, 7.5 percent of women aged 20-49 were married before their 15th birthday, while 30.8 percent of women aged 20-49 were married before their 18th birthday. 68.4 percent of women believed that a man was justified in hitting or beating his wife if the woman was not respecting the “family norms” such as going out without telling a husband, neglecting a child, burning the food or refusing to have sex with him. xx HIV 83.7 percent of the interviewed women aged 15-49 have heard of AIDS. However, only 51 percent of women knew the two main ways of preventing HIV transmission. 60.6 percent of women knew of having one faithful uninfected sex partner, 66.1 percent knew the importance of using a condom every time they had sex. Overall, 80.5 percent of women knew that HIV can be transmitted from mother to child. 97 percent of women received antenatal care from a health care professional for the last pregnancy, but only 53.9 percent of them were provided with information about HIV prevention. Overall, 17.5 percent of women aged 15-49 years old were found to have comprehensive knowledge of HIV. Both the education level and household wealth were positively correlated with the level of comprehensive knowledge. Comprehensive knowledge was also much more prevalent among young- er women, unmarried women and women in urban areas. In the Western region 24.1 percent have comprehensive knowledge as compared to the Central and Eastern regions (14.0 and 8.7 % respec- tively). 1 I. Introduction Background This report is based on the Bhutan Multiple Indicator Survey (BMIS) conducted in 2010 by the National Statistics Bureau (NSB). The BMIS is the customized version of the UNICEF’s Multiple Indicator Cluster Survey (MICS) with the addition of the Demographic and Health Survey (DHS) to suit the Bhutanese context. The survey provides valuable information on the situation of children and women in Bhutan, and was based, in large part, on the needs to monitor progress towards goals and targets emanating from recent international agreements: the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000, and the Plan of Action of A World Fit For Children, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. In signing these international agreements, governments committed themselves to improving condi- tions for their children and to monitoring the progress towards that end. UNICEF was assigned a supporting role in this task (see table below). 2 A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declara- tion and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance interna- tional cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and sub-national levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action (paragraph 61) also calls for the specific involvement of UNICEF in the prepa- ration of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant ac- tors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in imple- menting the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” Bhutan’s development planning, which is based on the philosophy of Gross National Happiness (GNH), is aimed at achieving broad-based and sustainable growth, improving the quality of life, en- suring the conservation of the natural environment, preserving the country’s rich culture and strength- ening good governance. The government is in the process of adopting 72 GNH indicators derived from nine GNH domains. These indicators will measure Bhutan’s genuine progress towards human development. These development objectives are pursued by the Royal Government to achieve a har- monious balance between material well-being and the spiritual, emotional and cultural needs of an individual and society. 3 Despite rapid economic growth and sustained development efforts, around one fourth of the country’s people, mostly from the rural areas, still continue to live below the poverty line. To reduce the poverty level the government has adopted a two pronged strategy. The first strategy is concerned with the continued use of conventional poverty reduction programmes/ initiatives implemented at the national level. It seeks to address the structural causes and factors con- tributing to poverty at the national level, using mainstream sectoral programmes through provisions of basic education, primary health care, nutrition and family planning, safe drinking water and sani- tation and shelter. The second strategy is concerned with targeted poverty reduction programmes/ initiatives implemented at the local, community or regional levels. It involves working directly with vulnerable groups, as well as identifying and addressing the limitations faced at the individual house- hold, community or local level. The government has been making tremendous efforts towards protecting and upholding the rights and well-being of children and women through various social and economic programmes and by adopting several international legislations. In this regard, the National Commission for Women and Children was established in 2004 with the mandate to advocate for new legislations and to co-ordinate with NGOs and civil society organizations on the implementation of welfare and counselling services for women and children, especially related to violence, abuse and exploitation. It is within this frame- work that the BMIS 2010 was conducted. Bhutan is a signatory to and ratified CEDAW in August 1981, and CRC in May 1990. Bhutan also signed the SAARC convention on Regional Arrangements for the promotion of welfare in South Asia and the SAARC Convention on preventing and combating trafficking in women and children for prostitution on January 5, 2002. This final report presents the results of the indicators and topics covered in the survey. However, the results of maternal mortality module will be published separately in sectoral thematic reports. Survey Objectives The primary objectives of the Bhutan Multiple Indicator Survey 2010 are as follows: • To provide strong evidence for equity-based programming and planning focused-based inter- ventions. • To provide up-to-date information for assessing the situation of children and women, including the identification of vulnerable groups and disparities in Bhutan. • To furnish data for monitoring progress for MDGs and other related international goals and to allow regional and global comparisons. • To strengthen the technical expertise in the design, implementation and analysis of such sur- veys. 4 5 II. Sample and Survey Methodology Sample Design The sample for the Bhutan Multiple Indicator Survey (BMIS) was designed to provide estimates for a large number of indicators on the situation of women and children, for urban and rural areas, for three regions and 20 Dzongkhags (districts). The Western region includes Chhukha, Gasa, Haa, Paro, Punakha, Samtse and Thimphu Dzong- khag; the Eastern region includes Lhuentse, Monggar, Pemagatshel, Samdrup-Jongkhar, Trashigang and Trashiyangtse Dzongkhag and the Central region includes Bumthang, Dagana, Sarpang, Trong- sa, Tsirang, Wangdue Phodrang and Zhemgang Dzongkhag. The urban and rural areas within each Dzongkhag were identified as the main sampling strata and the sample was selected in two stages. Within each stratum, a specified number of Chiwogs in the rural areas and Blocks in the urban areas were selected systematically with probability proportional to size. After household listing was carried out within the selected enumeration areas, a systematic sample of 20 households was drawn in each sample enumeration area. The sample was stratified by Dzongkhag, urban and rural areas, and is not self-weighting. Sample weights were used for generating the results. A more detailed description of the sample design can be found in Appendix A. Owing to a smaller base population in Gasa, only 200 households were taken for the survey compared to 800 households in other Dzongkhags; thus, the results pertaining to this Dzongkhag should be treated with caution. Questionnaires Three sets of questionnaires were used in the survey: 1) A household questionnaire to collect information on all de jure (usual residents) household members, the household, and the dwelling. 2) A women’s questionnaire administered in each household to all women aged 15-49 years. 3) Under-five children questionnaire administered to mothers or caretakers in the household. The Household Questionnaire included the following modules: • Household Listing Form • Education • Water and Sanitation • Household Characteristics • Child Labour • Disability1 • Handwashing 1 The BMIS was followed by a second stage disability assessment which will verify the disability data coming from the BMIS. A report showing the disability results from the second stage will be produced separately. 6 The Questionnaire for Individual Women was administered to all women aged 15-49 years living in the households, and included the following modules: • Women’s Background • Child Mortality • Desire for Last Birth • Maternal and Newborn Health • Contraception • Unmet Needs • Marriage/Union • Attitudes towards and Experience of Domestic Violence • Sexual Behaviour • HIV/AIDS • Maternal Mortality The Questionnaire for Children Under-Five2 was administered to their mothers or caretakers living in the household. The questionnaire was administered to mothers of under-five children; in cases where mothers were not present in the household, primary caretakers for the child were identified and inter- viewed. The questionnaire included the following modules: • Age • Birth Registration • Early Childhood Development • Breastfeeding • Care of Illness • Anthropometry The questionnaires were based on the MICS4 model questionnaire3 and customized to suit the local realities and needs. In order to include more indicators related to reproductive health and experience of domestic violence, some questions from the ICF Macro, Demographic Health Surveys (DHS) questionnaires were adopted into the BMIS questionnaire. The BMIS questionnaires were pre-tested in Chhukha, Paro, Samtse and Wangdue Dzongkhag in January 2010. Additional questions were added to the BMIS that are not part of the MICS4 model questionnaires and not part of DHS4. The questionnaires were modified based on the pre-test observations. The BMIS questionnaire is provided in Appendix G. Besides interviews, the place for hand-washing was observed and the weights and heights of children under-five years were measured. Details and findings of these measurements are included in the re- spective sections of the report. 2 The terms “children under-five”, “children aged 0-4 years”, and “children aged 0-59 months” are used interchangeably in this report. 3 The model MICS4 questionnaires can be found at www.childinfo.org 4 Additional questions on non-formal education, post natal care, family planning, domestic violence and food security were added as was requested by different sectors/agencies in the country. The report on these additional topics will be included in the thematic analysis on education, gender and health which will be carried out subsequently. 7 Training and Fieldwork Training for the listing operation of the selected Primary Sampling Units (PSU) for the Dzongkhag Statistical Officers (DSOs), supervisors and enumerators were conducted for a week in early March 2010. The actual field listing operation was implemented over a period of one month. Training for the fieldwork was conducted for 14 days in April 2010. It included lectures on interview- ing techniques and the contents of the questionnaires, and mock interviews between trainees to gain practice in asking questions. Towards the end of the training period, trainees spent one day practising interviews in Thimphu. The questionnaires were not translated from English to the local Bhutanese languages. However, since the interviewers would be asking the questions in local languages to re- spondents and not in English, in order to standardize how translations would be done, an effort was made to provide standard translations to all teams of Dzongkhag, Lhotshamkha and Sharchopkha. Forty two teams were engaged in field enumeration. Each team consisted of one supervisor, two interviewers, one editor, one measurer and one driver. The actual fieldwork began in April 2010 and concluded in August 2010. Data Processing Data was entered using the CSPro software in 25 micro-computers and the entry was carried out by 25 operators and three supervisors. In order to ensure quality control, all questionnaires were double en- tered and internal consistency checks were performed. Procedures and standard programs developed under the global MICS4 programme and adapted to the Bhutan questionnaire were used throughout. Data entry began a month after the start of data collection and was completed in September 2010. Data was analysed using the Predictive Analytics Software (PASW), the version 18 of SPSS software, and the model syntax and tabulation plans developed by UNICEF were used for this purpose. 8 9 III. Sample Coverage and the Characteristics of Households and Respondents Sample Coverage Of the 15,400 households selected for the survey, 14,917 were found to be occupied. Of these, 14,676 were successfully interviewed with a household response rate of 98.4 percent. In the interviewed households, 16,823 women (aged 15-49 years) were identified. Of these, 14,018 were successfully interviewed, yielding a response rate of 83.3 percent within interviewed households. In addition, 6,457 children under age five were listed in the household questionnaire. Questionnaires were com- pleted for 6,297 of these children, which corresponds to a response rate of 97.5 percent within the interviewed households. Overall response rates of 82.0 percent and 95.9 percent are calculated for the women’s and under-five’s interviews respectively (Table HH.1). The response rate for women and children under-five is higher in urban areas when compared with rural areas, but the response rate for households is same for both areas. The response rate for women is low (83%) because some of the women could not be found in the household during the interview time. The response rate for young women is particularly low since some of them were away studying in boarding schools and some were outside the country, though by definition they still qualify as a member of the household. For MICS4 household membership was defined on a de jure basis. Gasa has a very low response rate for women (55.1%); the reason for this could be attributed to younger women studying in other Dzongkhags, while other women tend to yaks in remote places making it difficult to contact them during the survey time. The children’s response rate is the highest in Pemagatshel (99.6%) and lowest in Gasa (85.2%). Owing to smaller base population in Gasa, only 200 households were taken for the survey compared to 800 households in other Dzongkhags, because Gasa was shown in the sampling frame as contain- ing a total of 727 households. Thus, the results pertaining to this Dzongkhag should be treated with caution. 10 TA B L E H H .1 : R E SU LT S O F H O U SE H O L D , W O M E N ’S A N D U N D E R -F IV E IN T E R V IE W S N um be rs o f ho us eh ol ds , w om en a nd c hi ld re n un de r 5 by r es ul ts o f th e ho us eh ol d, w om en ’s a nd u nd er -fi ve ’s in te rv ie w s, a nd h ou se ho ld , w om en ’s a nd u nd er -fi ve ’s r es po ns e ra te s, B hu ta n, 2 01 0 R eg io n R es id en ce D zo ng kh ag Total Western Central Eastern Urban Rural Bumthang Chukha Dagana Gasa Haa Lhuntse Mongar Paro Pemagatshel Punakha Samdrup jongkhar Samtse Sarpang Thimphu Trashigang Trashiyangtse Trongsa Tsirang Wangdi Zhemgang N um be r of H ou se ho ld s H ou se ho ld s S am pl ed 50 00 56 00 48 00 33 20 12 08 0 80 0 80 0 80 0 20 0 80 0 80 0 80 0 80 0 80 0 80 0 80 0 80 0 80 0 80 0 80 0 80 0 80 0 80 0 80 0 80 0 15 40 0 H ou se ho ld s O cc up ie d 48 72 54 07 46 38 31 92 11 72 5 77 6 76 5 76 9 18 9 78 5 77 5 77 5 78 4 77 6 78 7 75 8 79 1 77 9 77 1 76 6 78 8 77 2 78 0 75 8 77 3 14 91 7 H ou se ho ld s I nt er vi ew ed 48 06 53 27 45 43 31 42 11 53 4 76 9 74 9 74 8 18 0 76 4 76 1 77 2 77 8 75 5 78 2 73 9 79 0 76 5 76 3 75 5 76 1 76 8 76 9 74 1 76 7 14 67 6 H ou se ho ld re sp on se ra te 98 .6 98 .5 98 .0 98 .4 98 .4 99 .1 97 .9 97 .3 95 .2 97 .3 98 .2 99 .6 99 .2 97 .3 99 .4 97 .5 99 .9 98 .2 99 .0 98 .6 96 .6 99 .5 98 .6 97 .8 99 .2 98 .4 N um be r of W om en W om en E lig ib le 58 61 63 10 46 52 38 72 12 95 1 99 0 95 9 84 3 23 4 86 6 77 9 89 6 95 2 80 9 95 6 83 7 91 0 93 9 98 4 70 1 63 0 86 5 91 8 83 4 92 1 16 82 3 W om en In te rv ie w ed 50 41 51 81 37 96 34 87 10 53 1 80 8 86 9 70 0 12 9 73 9 63 3 73 4 79 5 58 3 79 3 64 5 80 2 83 6 91 4 60 6 59 5 69 2 79 3 65 4 69 8 14 01 8 W om en re sp on se ra te 86 .0 82 .1 81 .6 90 .1 81 .3 81 .6 90 .6 83 .0 55 .1 85 .3 81 .3 81 .9 83 .5 72 .1 82 .9 77 .1 88 .1 89 .0 92 .9 86 .4 94 .4 80 .0 86 .4 78 .4 75 .8 83 .3 W om en ’s o ve ra ll re sp on se ra te 84 .8 80 .9 79 .9 88 .6 80 .0 80 .9 88 .7 80 .8 52 .5 83 .1 79 .8 81 .6 82 .9 70 .1 82 .4 75 .1 88 .0 87 .4 91 .9 85 .2 91 .2 79 .6 85 .2 76 .7 75 .2 82 .0 N um be r of C hi ld re n U nd er 5 C hi ld re n un de r 5 E lig ib le 21 14 24 45 18 98 13 96 50 61 42 6 33 3 33 8 81 31 7 26 5 38 7 34 3 27 7 35 1 37 1 37 3 31 1 31 6 30 6 29 2 33 6 30 8 31 7 40 9 64 57 C hi ld re n un de r 5 M ot he r/ C ar et ak er In te rv ie w ed 20 55 23 74 18 68 13 67 49 30 41 5 33 0 32 6 69 31 3 26 4 37 9 32 8 27 6 34 3 36 0 36 0 30 7 31 2 30 0 28 9 32 1 29 6 30 7 40 2 62 97 C hi ld re sp on se ra te 97 .2 97 .1 98 .4 97 .9 97 .4 97 .4 99 .1 96 .4 85 .2 98 .7 99 .6 97 .9 95 .6 99 .6 97 .7 97 .0 96 .5 98 .7 98 .7 98 .0 99 .0 95 .5 96 .1 96 .8 98 .3 97 .5 C hi ld re n’ s o ve ra ll re - sp on se ra te 95 .9 95 .7 96 .4 96 .4 95 .8 96 .5 97 .0 93 .8 81 .1 96 .1 97 .8 97 .6 94 .9 96 .9 97 .1 94 .6 96 .4 96 .9 97 .7 96 .6 95 .6 95 .0 94 .7 94 .7 97 .5 95 .9 11 Characteristics of Households The weighted age and sex distribution of surveyed population is provided in Table HH.2. The dis- tribution is also used to produce the population pyramid in Figure HH.1. From 14,676 successfully interviewed households there were 67,320 people, of which, 33,375 were males, and 33,944 were females. TABLE HH.2: HOUSEHOLD AGE DISTRIBUTION BY SEX Percentage distribution of the household population by five-year age groups and dependency age groups, and number of children aged 0-17 years, by sex, Bhutan, 2010 Males Females Total Number Percent Number Percent Number Percent Age 0-4 3329 10.0 3185 9.4 6514 9.7 5-9 3736 11.2 3650 10.8 7386 11.0 10-14 3707 11.1 4181 12.3 7887 11.7 15-19 3349 10.0 3181 9.4 6530 9.7 20-24 2785 8.3 3187 9.4 5972 8.9 25-29 2752 8.2 3065 9.0 5817 8.6 30-34 2483 7.4 2512 7.4 4995 7.4 35-39 2037 6.1 2068 6.1 4105 6.1 40-44 1815 5.4 1729 5.1 3545 5.3 45-49 1571 4.7 1280 3.8 2850 4.2 50-54 1510 4.5 1873 5.5 3383 5.0 55-59 1275 3.8 1223 3.6 2498 3.7 60-64 964 2.9 908 2.7 1872 2.8 65-69 791 2.4 636 1.9 1427 2.1 70-74 594 1.8 567 1.7 1161 1.7 75-79 369 1.1 358 1.1 727 1.1 80-84 222 .7 201 .6 423 .6 85+ 85 .3 135 .4 220 .3 Missing/DK 3 * 5 * 8 * Dependency age groups 0-4 10771 32.3 11016 32.5 21787 32.4 15-64 20541 61.5 21027 61.9 41568 61.7 65+ 2060 6.2 1897 5.6 3957 5.9 Missing/DK 3 * 5 * 8 * Children and adult populations Children age 0-17 12847 38.5 12923 38.1 25770 38.3 Adults 18+ 20525 61.5 21016 61.9 41542 61.7 Missing/DK 3 * 5 * 8 * Total 33375 100.0 33944 100.0 67320 100.0 * An asterisk indicates that the percentage is calculated on fewer than 25 unweighted cases. 12 Table HH.2 shows the age and sex distribution of the surveyed population. The findings revealed that the percentage of population aged 0-4 years is 9.7 percent (10% male and 9.4% female) while the percentage of population aged 0-14 years is 32.4 percent (32.3% male and 32.5% female) and the percentage of population 65 years and older is 5.9 percent. The percentage of children 0-17 years is 38.3 percent. The total dependency ratio is found to be 61.7 percent (61.5% male and 61.9% female) which is an increase of 1.1 percent from the PHBC 2005 (60.6%). However, the average household size remains the same (4.6 persons). Figure HH.1: Population pyramid, Bhutan 2010. Data quality tables indicate that a disproportionally large number of women were reported to be aged 50 and a disproportionally large number of women were reported to be 14. This unexpected age pat- tern is likely to be caused by age heaping (on age 50 among female respondents), as well as the pos- sibility that some interviewers may have tried to avoid conducting interviewing with all women by recording the ages of women outside of the eligibility age range i.e. 15-49 years. 13 Table HH.3 - HH.5 provide basic information on the households, female respondents aged 15-49 years, and children under-five by un-weighted as well as weighted numbers. Information on the basic characteristics of households, women and children under-five interviewed in the survey is essential for the interpretation of survey findings. It can also provide an indication of the representativeness of the survey. Table HH.3 provides basic background information on the households: the sex of the household head, region, residence, number of household members and the education of household head. These background characteristics are used in subsequent tables in this report; the figures in the table are also intended to show the number of observations by major categories of analysis in the report. 14 TABLE HH.3: HOUSEHOLD COMPOSITION Percentage distribution of households by selected characteristics, Bhutan, 2010 Weighted Percent Number of households weighted unweighted Sex of household head Male 72.0 10568 9727 Female 28.0 4108 4949 Dzongkhag Bumthang 2.2 320 769 Chukha 10.1 1478 749 Dagana 3.7 548 748 Gasa .7 102 180 Haa 2.0 297 764 Lhuntse 2.5 364 761 Mongar 6.6 965 772 Paro 5.4 790 778 Pemagatshel 3.8 564 755 Punakha 3.5 515 782 Samdrup jongkhar 5.6 827 739 Samtse 11.2 1641 790 Sarpang 6.1 895 765 Thimphu 13.2 1932 763 Trashigang 8.5 1245 755 Trashiyangtse 3.0 444 761 Trongsa 2.1 315 768 Tsirang 3.2 473 769 Wangdue 4.3 624 741 Zhemgang 2.3 338 767 Region Western 46.0 6755 4806 Central 23.9 3512 5327 Eastern 30.0 4409 4543 Residence Urban 29.4 4320 3142 Rural 70.6 10356 11534 Number of household members 1 6.1 900 887 2 10.8 1586 1656 3 14.3 2094 2025 4 20.1 2943 2771 5 18.9 2773 2721 6 13.6 1999 1998 7 7.7 1133 1223 8+ 8.5 1248 1395 Education of household head None 63.1 9265 10077 Primary 14.5 2134 1898 Secondary + 22.3 3275 2698 Missing/DK * 2 3 Total 100.0 14676 14676 * An asterisk indicates that the percentage is calculated on fewer than 25 unweighted cases. 15 The weighted and unweighted numbers of households are equal, since sample weights were normal- ized (See Appendix A). The table HH.3 also shows the proportions of households with at least one child under 18, at least one child under-five, and at least one eligible woman aged 15-49. The table also shows the weighted average household size estimated by the survey. TABLE HH.3: HOUSEHOLD COMPOSITION Percentage distribution of households by selected characteristics, Bhutan, 2010 Weighted Percent Number of households weighted unweighted At least one child age 0-4 years 35.8 14676 14676 At least one child age 0-17 years 75.0 14676 14676 At least one woman age 15-49 years 81.9 14676 14676 Mean household size 4.6 14676 14676 16 Characteristics of Female Respondents 15-49 Years of Age and Children Under-five Tables HH.4 and HH.5 provide information on the background characteristics of female respondents aged 15-49 years and of children under age five. In both tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). In addition to providing useful information on the background characteristics of women and children, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. TABLE HH.4: WOMEN’S BACKGROUND CHARACTERISTICS Percentage distribution of women age 15-49 years by background characteristics, Bhutan, 2010 Weighted percent Number of women Weighted Unweighted Dzongkhag Bumthang 2.4 337 808 Chukha 11.1 1550 869 Dagana 3.6 509 700 Gasa .8 107 129 Haa 2.0 282 739 Lhuntse 2.2 307 633 Mongar 6.6 926 734 Paro 5.7 799 795 Pemagatshel 3.5 489 583 Punakha 3.6 506 793 Samdrup jongkhar 5.5 775 645 Samtse 11.1 1562 802 Sarpang 6.6 924 836 Thimphu 14.7 2054 914 Trashigang 6.7 940 606 Trashiyangtse 2.1 301 595 Trongsa 2.1 294 692 Tsirang 3.3 463 793 Wangdue 4.0 562 654 Zhemgang 2.4 331 698 Region Western 48.9 6861 5041 Central 24.4 3420 5181 Eastern 26.7 3736 3796 Residence Urban 31.7 4448 3487 Rural 68.3 9570 10531 17 Contd. TABLE HH.4: WOMEN’S BACKGROUND CHARACTERISTICS Percentage distribution of women age 15-49 years by background characteristics, Bhutan, 2010 Weighted percent Number of women Weighted Unweighted Age 15-19 14.6 2052 1974 20-24 17.9 2502 2435 25-29 19.4 2721 2651 30-34 15.8 2219 2261 35-39 13.2 1856 1872 40-44 11.1 1561 1651 45-49 7.9 1106 1174 Marital/Union status Currently married/in union 71.5 10029 10051 Widowed 1.6 218 223 Divorced 4.2 583 708 Separated .8 108 110 Never married/in union 22.0 3079 2925 Missing * 0 1 Motherhood status Ever gave birth 72.3 10132 10356 Never gave birth 27.7 3886 3662 Births in last two years Had a birth in last two years 16.9 2368 2465 Had no birth in last two years 83.1 11650 11553 Education None 61.2 8585 8903 Primary 12.0 1687 1716 Secondary + 26.7 3746 3399 Wealth index quintiles Poorest 17.3 2419 2617 Second 18.1 2533 2907 Middle 19.0 2659 2955 Fourth 21.7 3040 2876 Richest 24.0 3367 2663 Total 100.0 14018 14018 * An asterisk indicates that the percentage is calculated on fewer than 25 unweighted cases. 18 Table HH.4 includes information on the distribution of women according to Dzongkhag, region, residence, age, marital status, motherhood status, births in last two years, education 5and wealth index quintiles6 . Of the total women respondents aged 15-49 years, 68.3 percent lived in a rural area and 31.7 percent in an urban area. The largest segment of individual women respondents (19.4%) were in the age group of 25-29 years, followed by those in the 20-24 age group (17.9%) and the 30-34 age group (15.8%). The smallest segment of individual women respondents were found in the 40-44 age group (11.1%), and the 45-49 year-olds (7.9%). A large portion of the women respondents aged 15-49 were married (71.5%), while 6.5 percent were formerly married and 22 percent were never married. Slightly more than 70 percent of women aged 15-49 had given birth at least once in their lifetime. In the case of education, 61.2 percent of women aged 15-49 had never been to school, while 12 percent had primary schooling. Another 26.7 percent had completed their secondary and higher education. In terms of wealth index, it was found that 17.3 percent belonged to the poorest, while 24 percent to the richest quintile. Some background characteristics of under-five children are presented in Table HH.5. This includes the distribution of children by several attributes: Dzongkhag, region, residences, age, mother’s educa- tion and wealth. Regarding the surveyed under-five children (Table HH.5), 70.8 percent lived in rural areas, while 29.2 percent resided in urban areas. By age-groups, 9.6 percent were younger than six months, 9.9 percent were 6-11 months old, 19.6 percent were 12-23 months old, 21.2 percent were 24-35 months old, 20.3 percent were 36-47 months old, and 19.4 percent were 48-59 months old. 66.8 percent of mothers of children under-five years of age had never received any formal education. In terms of the wealth index status of the household, children under-five are spread quite evenly across all quintiles with 20.6 living in the poorest quintile. 5 Unless otherwise stated, “education” refers to educational level attended by the respondent throughout this report when it is used as a background variable. 6 Principal components analysis was performed by using information on the ownership of consumer goods,dwelling char- acteristics, water and sanitation, and other characteristics that are related to the household’s wealth to assign weights (fac- tor scores) to each of the household assets. Each household was then assigned a wealth score based on these weights and the assets owned by that household. The survey household population was then ranked according to the wealth score of the house- hold they are living in, and was finallydivided into 5 equal parts (quintiles) from lowest (poorest) to highest (richest). The as- sets used in these calculations were as follows: source of drinking water, type of sanitation facility, persons per sleep- ing room, type of floor, type of roof, type of wall, type of cooking fuel, household member assets(watch, mobile phone, bike, motor cycle/ scooter, car/truck, computer, bow, camera, VCR/VCD/DVD player, sersho gho/kira), ownership of bank account . The wealth in- dex is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to pro- duce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute pov- erty, current income or expenditure levels. The wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Rutstein and Johnson, 2004, Filmer and Pritchett, 2001, and Gwatkin et. Al., 2000. 19 TABLE HH.5: CHILDREN’S BACKGROUND CHARACTERISTICS Percent distribution of children under five years of age by background characteristics, Bhutan, 2010 Weighted percent Number of children Weighted Unweighted Sex Male 51.1 3216 3236 Female 48.9 3081 3061 Dzongkhag Bumthang 2.7 171 415 Chukha 10.3 648 330 Dagana 3.8 237 326 Gasa .7 43 69 Haa 1.9 121 313 Lhuntse 2.0 124 264 Mongar 7.4 466 379 Paro 5.4 337 328 Pemagatshel 3.4 214 276 Punakha 3.5 218 343 Samdrup jongkhar 6.5 410 360 Samtse 12.0 755 360 Sarpang 5.6 350 307 Thimphu 12.7 801 312 Trashigang 7.6 479 300 Trashiyangtse 2.7 169 289 Trongsa 2.1 133 321 Tsirang 3.0 186 296 Wangdue 4.1 261 307 Zhemgang 2.8 175 402 Region Western 46.4 2922 2055 Central 24.0 1513 2374 Eastern 29.6 1862 1868 Residence Urban 29.2 1841 1367 Rural 70.8 4456 4930 Age 0-5 9.6 603 608 6-11 9.9 626 640 12-23 19.6 1234 1288 24-35 21.2 1337 1339 36-47 20.3 1275 1278 48-59 19.4 1222 1144 Mother’s education None 66.8 4207 4244 Primary 12.4 781 834 Secondary 20.8 1309 1219 Wealth index quintiles Poorest 20.6 1294 1373 Second 18.4 1159 1359 Middle 19.0 1197 1302 Fourth 22.8 1438 1299 Richest 19.2 1208 964 Total 100.0 6297 6297 20 Orphanhood Children who are orphaned or living in vulnerable households may be at increased risk of neglect or exploitation. Monitoring the variations in different outcomes for orphans and vulnerable children and comparing them to their peers gives us a measure of how well communities and governments are responding to their needs. The frequency of children living with neither parent, mother only, and father only is presented in Table HH.6. About 79 percent of children aged 0-17 years in Bhutan live with their parents, while 11 percent live with their mother only, and 2.4 percent live with their father only. Almost one in thirteen children (7.4%) is living with neither parent and 5.4 percent of the children have at least one parent dead. The proportion of children not living with a biological parent is higher among girls (8.9%) com- pared to boys (6%) and increases significantly with the age of the child and with household wealth. It is also significantly higher in urban areas (10.1%) compared to rural areas (6.3%). In contrast, the rate of children having one or both parent dead is higher in rural areas and decreases with household wealth. 21 TA B L E H H .6 : C H IL D R E N ’S L IV IN G A R R A N G E M E N T S A N D O R PH A N H O O D Pe rc en t d is tr ib ut io n of c hi ld re n ag e 0- 17 y ea rs a cc or di ng to li vi ng a rr an ge m en ts , p er ce nt ag e of c hi ld re n ag e 0- 17 y ea rs in h ou se ho ld s n ot li vi ng w ith a b io lo gi ca l p ar en t a nd p er ce nt ag e of c hi ld re n w ho h av e on e or b ot h pa re nt s d ea d, B hu ta n, 2 01 0 Li vin g w ith ne ith er pa ren t Li vin g w ith m oth er on ly Li vin g w ith fa the r o nly To tal No t li vin g wi th a bio log ica l pa ren t [ 1] On e o r b oth pa ren ts de ad [2] Nu mb er of ch ild ren ag e 0-1 7 y ea rs Li vin g w ith bo th pa ren ts On ly fat he r ali ve On ly mo the r ali ve Bo th are ali ve Bo th are de ad Fa the r ali ve Fa the r de ad M oth er ali ve M oth er de ad Im po ssi ble to de ter mi ne Se x M ale 80 .4 .4 .4 4. 9 .3 8.4 2.6 1.2 1.2 .3 10 0.0 6.0 4. 9 12 84 7 Fe ma le 77 .5 .6 .9 7.0 .3 8.2 2.8 1.2 1.2 .2 10 0.0 8. 9 5. 9 12 92 3 Dz on gk ha g Bu mt ha ng 67 .6 1.0 .8 7.3 .4 16 .8 4.5 .7 .6 .3 10 0.0 9. 5 7.3 61 9 Ch uk ha 80 .0 .3 1.1 6.7 .3 5.0 3.1 2.3 1.2 .1 10 0.0 8.3 5. 9 26 31 Da ga na 81 .0 .6 .7 8.3 .3 5.3 2.5 .8 .5 .0 10 0.0 9. 9 4.5 99 3 Ga sa 76 .5 .5 .0 5.0 1.2 6. 9 7.1 .7 2.0 .0 10 0.0 6.7 10 .8 17 5 Ha a 77 .8 .3 .7 7.7 .3 8.7 1.3 1.8 1.1 .2 10 0.0 9. 1 3.8 50 0 Lh un tse 76 .6 .6 .9 3.1 .2 12 .0 4.6 .9 1.0 .2 10 0.0 4.8 7.2 58 5 M on ga r 73 .2 1.1 .7 4.4 .6 12 .8 4.7 .8 1.6 .1 10 0.0 6.7 8.6 18 43 Pa ro 73 .1 .5 .5 8.0 .7 13 .9 1.7 1.0 .4 .2 10 0.0 9. 7 3.8 13 97 Pe ma ga tsh el 81 .8 .1 .4 3.0 .5 8.4 3.0 .9 1.2 .7 10 0.0 4.1 5.3 94 2 Pu na kh a 69 .9 .5 .7 6.2 .5 14 .6 3.7 2.1 1.7 .1 10 0.0 7. 9 7.1 99 6 Sa md rup jo ng kh ar 84 .8 .5 .8 5.1 .1 4.8 2.2 .3 1.0 .3 10 0.0 6.5 4.6 16 67 Sa mt se 83 .9 .7 .7 6.5 .3 3.6 1.7 .8 1.3 .5 10 0.0 8.2 4.8 28 78 Sa rpa ng 77 .5 .3 .8 8.5 .0 7.7 2.3 1.3 1.3 .1 10 0.0 9. 8 4.8 15 18 Th im ph u 82 .4 .2 .8 6.7 .3 6.8 1.4 1.1 .2 .1 10 0.0 8.0 3.0 32 16 Tr ash iga ng 81 .0 .6 .5 3.6 .2 8.0 1. 9 .9 3.2 .2 10 0.0 4.8 6.4 20 86 Tr ash iya ng tse 79 .4 .6 .2 3. 9 .1 10 .0 3.3 .9 1.4 .1 10 0.0 4.8 5.8 65 4 Tr on gs a 72 .2 1.1 .4 6.5 .1 14 .1 3.6 1.1 .7 .1 10 0.0 8.1 6.0 58 1 Ts ira ng 81 .2 .1 .1 7.1 .1 6.7 2.2 1.1 1.2 .1 10 0.0 7.4 3.7 79 7 W an gd ue 70 .8 .5 .1 5.1 .5 14 .2 4.3 2.7 1.2 .5 10 0.0 6.3 6.8 10 30 Zh em ga ng 82 .5 .2 .4 2.8 .3 5.5 5.6 1.0 .7 1.2 10 0.0 3.6 7.1 66 4 22 C on td . T A B L E H H .6 : C H IL D R E N ’S L IV IN G A R R A N G E M E N T S A N D O R PH A N H O O D Pe rc en t d is tr ib ut io n of c hi ld re n ag e 0- 17 y ea rs a cc or di ng to li vi ng a rr an ge m en ts , p er ce nt ag e of c hi ld re n ag e 0- 17 y ea rs in h ou se ho ld s n ot li vi ng w ith a b io lo gi ca l p ar en t a nd p er ce nt ag e of c hi ld re n w ho h av e on e or b ot h pa re nt s d ea d, B hu ta n, 2 01 0 Li vin g w ith ne ith er pa ren t Li vin g w ith m oth er on ly Li vin g w ith fa the r o nly To tal No t li vin g wi th a bio log ica l pa ren t [ 1] On e o r b oth pa ren ts de ad [2] Nu mb er of ch ild ren ag e 0-1 7 y ea rs Li vin g w ith bo th pa ren ts On ly fat he r ali ve On ly mo the r ali ve Bo th are ali ve Bo th are de ad Fa the r ali ve Fa the r de ad M oth er ali ve M oth er de ad Im po ssi ble to de ter mi ne Re gio n W est ern 79 .8 .4 .8 6.8 .4 7.2 2.2 1.4 .9 .2 10 0.0 8.3 4.7 11 79 2 Ce ntr al 76 .5 .5 .5 6.8 .2 9. 5 3.3 1.3 .9 .3 10 0.0 8.1 5.6 62 02 E as te rn 79 .6 .6 .6 4.0 .3 9. 0 3.1 .8 1.8 .2 10 0.0 5.6 6.4 77 76 Re sid en ce U rb an 80 .2 .5 1.0 8.3 .3 5.5 1.7 1.7 .7 .1 10 0.0 10 .1 4.2 74 10 Ru ral 78 .4 .5 .5 5.0 .3 9. 4 3.1 1.0 1.4 .3 10 0.0 6.3 5. 9 18 36 1 Ag e 0-4 ye ars 84 .1 .2 .1 1.5 .1 11 .7 1.3 .6 .4 .2 10 0.0 1.8 2.1 65 14 5- 9 ye ar s 80 .9 .3 .6 5.4 .2 8.6 2.1 1.2 .7 .1 10 0.0 6.5 3. 9 73 86 10 -14 ye ars 76 .7 .8 .8 8.2 .5 6.3 3.4 1.6 1.6 .1 10 0.0 10 .3 7.1 78 87 15 -17 ye ars 71 .5 .9 1.4 9. 9 .6 6.2 4. 9 1.5 2.4 .7 10 0.0 12 .8 10 .3 39 83 W ea lth in de x q uin til es Po ore st 82 .0 .4 .4 3.0 .3 7. 9 3.5 1.0 1.3 .3 10 0.0 4.1 5.8 52 20 Se co nd 77 .3 .6 .2 3. 9 .3 10 .4 4.1 .9 2.1 .2 10 0.0 5.0 7.3 49 01 M idd le 75 .1 .6 .7 6.0 .3 11 .2 3.1 1.2 1.4 .2 10 0.0 7.6 6.1 50 28 Fo urt h 81 .1 .5 1.0 6.7 .4 6.4 2.0 1.3 .6 .1 10 0.0 8.6 4.5 54 95 Ri ch est 78 .9 .4 1.0 10 .1 .3 5.8 1.1 1.5 .6 .3 10 0.0 11 .8 3.5 51 27 To ta l 79 .0 .5 .7 6.0 .3 8.3 2.7 1.2 1.2 .2 10 0.0 7.4 5.4 25 77 0 [1 ]M IC S in di ca to r 9. 17 [2 ] M IC S in di ca to r 9. 18 23 24 25 IV. Child Mortality One of the Millennium Development Goals (MDGs) is the reduction of infant and under-five mor- tality. Specifically, the MDG 4 calls for the reduction in under-five mortality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. Measur- ing childhood mortality may seem easy, but attempts at using direct questions, such as “Has anyone in this household died in the last year?” give inaccurate results. Using direct measures of child mortality from birth histories is time consuming, more expensive, and requires greater attention to training and supervision. Alternatively, indirect methods developed to measure child mortality produce robust estimates that are comparable with the ones obtained from other sources. Indirect methods minimize the pitfalls of memory lapses, inexact or misinterpreted definitions, and poor interviewing technique. Infant mortality rate (IMR) is the probability of dying before the first birthday expressed per 1,000 live births. Under-five mortality rate (U5MR) is the probability of dying before the fifth birthday expressed per 1,000 live births. In MICS surveys, infant and under-five mortality rates are calcu- lated based on an indirect estimation technique known as the Brass method (United Nations, 1983; 1990a; 1990b). The data used in the estimation are: the mean number of children ever born for five year age groups of women from the age of 15 to 49, and the proportion of these children who are dead, also classified for five-year age groups of women (Table CM.1). The technique converts these data into probabilities of dying by taking into account of both the mortality risks to which children are exposed and their length of exposure of children to the risk of dying. The North model7 life table was used to estimate child mortality. The differences exist in definitions between the surveys and the registration systems and in the meth- odology of data collection. In all mentioned surveys, information about birth and child deaths were obtained from mothers. In contrast, the registration system requires that either a health worker or a family member take care to register the event of births and deaths. 7 Previous mortality estimates for Bhutan, for example those coming from the 2005 census have been based on the North model. The Inter-agency Group for Child Mortality (IGME) has also supported the use of the North mod- el for mortality calculations based on the relationship between adult and child mortality in Bhutan.However, there is also ev- idence to suggest that the West model may be an appropriate choice for Bhutan; the West model is used by all neighboring countries of Bhutan. The appropriate choice of model requires in-depth further analytical work but for con- sistency purposes with previous estimates the North model has been used in the BMIS. 26 TABLE CM.1: CHILDREN EVER BORN, CHILDREN SURVIVING AND PROPORTION DEAD Mean and total numbers of children ever born, children surviving and proportion dead by age of women, Bhutan, 2010 Mean number of children ever born Total number of children ever born Mean number children surviving Total number of children surviving Proportion dead Number of women Sex Male 1.119 15686 1.005 14094 0.102 14018 Female 1.064 14919 0.97 13595 0.089 14018 Region Western 1.876 12868 1.724 11829 0.081 6861 Central 2.283 7807 2.09 7148 0.084 3420 Eastern 2.658 9930 2.332 8712 0.123 3736 Residence Urban 1.656 7367 1.568 6975 0.053 4448 Rural 2.428 23238 2.164 20714 0.109 9570 Mother’s education None 2.879 24716 2.568 22047 0.108 8585 Primary 1.814 3061 1.714 2891 0.056 1687 Secondary+ 0.755 2829 0.734 2751 0.028 3746 Wealth index quintiles Poorest 2.822 6825 2.45 5926 0.132 2419 Second 2.587 6553 2.279 5772 0.119 2533 Middle 2.347 6239 2.112 5615 0.1 2659 Fourth/Richest[1] 1.715 10,988 1.619 10,376 0.056 6,407 Total 2.183 30605 1.975 27689 0.095 14018 [1] Fourth and richest quintile are clubbed together *By Dzongkhag is not shown because the number of unweighted observations are lower than 50 27 Table CM.2 provides estimates of child mortality. The infant mortality rate is estimated at 47 deaths per thousand, while the probability of dying under age 5 (U5MR) is around 69 deaths per thousand. These estimates have been calculated by averaging mortality estimates obtained from women aged 25-29 and 30-34. There is some difference between the probabilities of dying among males and fe- males with males having higher mortality rates. Infant and under-five mortality rates are lower in the Western and Central regions as compared to the Eastern region. There are also significant differences in mortality in terms of educational levels and wealth. As the education level, as well as wealth index of the mother increases, the under-five mortality rate decreases. Differentials in under-five mortality rates by selected background characteristics are shown in Figure CM.1. TABLE CM.2: CHILD MORTALITY Infant and under-five mortality rates, North Model, Bhutan, 2010 Infant Mortality Rate [1] Under-five Mortality Rate [2] Male 54 79 Female 40 58 Region Western 42 61 Central 42 61 Eastern 57 87 Residence Urban 31 41 Rural 54 81 Mother’s education None 51 77 Primary 42 61 Secondary+ 24 31 Wealth index quintiles Poorest 68 106 Second 58 88 Middle 50 74 Fourth/Richest 28 39 Total 47 69 [1] MICS indicator 1.2; MDG indicator 4.2 [2]MICS indicator 1.1; MDG indicator 4.1 *By Dzongkhag is not shown because the number of unweighted observations are lower than 50 *The reference period is 2006, North Model was assumed to approximate the age pattern of mortality in Bhutan. 28 A child born to the poorest family from rural areas and with uneducated mother has the highest chance of dying by the age of five compared to a child born to a rich educated family in urban area. Figure CM1: Under-five mortality rate by background characteristics, Bhutan 2010. 24 ! A! child!born! to! the!poorest! family! from! rural!areas!and!with!uneducated!mother!has! the!highest! chance!of!dying!by!the!age!of!five!compared!to!a!child!born!to!a!rich!educated!family!in!urban!area.! Figure!CM1:!Under"five!mortality!rate!by!background!characteristics,!Bhutan!2010.! ! ! ! ! ! ! ! ! ! ! 29 30 31 V. Nutrition Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an ad- equate food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential and are considered well nourished. Malnutrition is associated with more than half of all child deaths worldwide. Undernourished chil- dren are more likely to die from common childhood ailments, and for those who survive, have re- curring sicknesses and faltering growth. Three-quarters of the children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. A reduction in the prevalence of malnutrition will also assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children un- der age five. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is based on new WHO growth standards4. Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweigh, while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two stan- dard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three stan- dard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. 4 http://www.who.int/childgrowth/standards/second_set/technical_report_2.pdf8 http://www.who.int/childgrowth/standards/second_set/technical_report_2.pdf 8 32 Finally, children whose weight-for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are classified as severely wasted. Wasting is a reflection of acute malnutrition usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. In BMIS, weights and heights of all children under-five years of age were measured using anthropo- metric equipment recommended by UNICEF (www.childinfo.org). Findings in this section are based on the results of these measurements. Table NU.1 shows percentages of children classified into each of these categories, based on the an- thropometric measurements that were taken during fieldwork. Additionally, the table includes the percentage of children who are overweight, which takes into account those children whose weight for height is above two standard deviations from the median of the reference population, and mean z-scores for all three anthropometric indicators. 33 TA B L E N U .1 : N U T R IT IO N A L ST AT U S O F C H IL D R E N Pe rc en ta ge o f c hi ld re n un de r ag e 5 by n ut ri tio na l s ta tu s a cc or di ng to th re e an th ro po m et ri c in di ce s: w ei gh t f or a ge , h ei gh t f or a ge , a nd w ei gh t f or h ei gh t, B hu ta n, 2 01 0 W ei gh t f or ag e: W ei gh t fo r a ge : W ei gh t f or ag e: W ei gh t f or ag e: H ei gh t f or ag e: H ei gh t f or ag e: H ei gh t f or ag e: H ei gh t f or ag e: W ei gh t f or he ig ht : W ei gh t f or he ig ht : W ei gh t f or he ig ht : W ei gh t f or he ig ht : W ei gh t f or he ig ht : % b el ow - 2 sd [1 ] % b el ow -3 sd [2 ] M ea n Z- Sc or e (S D ) N um be r o f ch ild re n % b el ow - 2 sd [3 ] % b el ow - 3 sd [4 ] M ea n Z- Sc or e (S D ) N um be r o f ch ild re n % b el ow - 2 sd [5 ] % b el ow - 3 sd [6 ] % a bo ve +2 sd M ea n Z- Sc or e (S D ) N um be r o f ch ild re n Se x M al e 13 .3 3. 4 -.8 30 85 33 .4 13 .6 -1 .4 29 28 6. 2 2. 2 7. 5 .0 29 54 Fe m al e 12 .0 3. 0 -.8 29 86 33 .6 13 .1 -1 .4 28 78 5. 5 1. 9 7. 6 .0 29 09 R es id en ce U rb an 10 .5 3. 2 -.7 18 00 28 .0 14 .0 -1 .2 17 13 6. 5 2. 3 10 .0 .1 17 13 R ur al 13 .6 3. 2 -.9 42 71 35 .8 13 .1 -1 .5 40 93 5. 6 1. 9 6. 6 -.0 41 50 D zo ng kh ag B um th an g 9. 1 2. 7 -.6 16 5 21 .5 6. 0 -1 .0 15 6 3. 3 2. 0 3. 3 -.0 15 7 C hu kh a 14 .1 3. 3 -.9 62 5 27 .4 6. 4 -1 .0 61 7 10 .9 2. 2 2. 4 -.4 61 5 D ag an a 12 .4 2. 1 -.8 23 1 29 .0 10 .3 -1 .2 22 5 5. 5 1. 7 5. 1 -.1 22 7 G as a 3. 6 1. 5 -.4 37 31 .8 12 .1 -1 .2 37 3. 2 0. 0 5. 5 .4 38 H aa 9. 8 1. 4 -.8 11 8 30 .6 10 .7 -1 .4 11 8 3. 3 .4 4. 8 -.0 11 6 Lh un ts e 17 .7 6. 1 -1 .0 12 3 58 .9 41 .5 -2 .4 11 2 4. 3 .9 30 .9 1. 0 11 8 M on ga r 12 .0 3. 7 -.8 46 2 39 .7 13 .9 -1 .5 45 3 5. 5 2. 0 5. 6 .1 44 9 Pa ro 7. 5 1. 6 -.5 32 0 30 .1 9. 9 -1 .2 30 1 6. 9 2. 1 9. 2 .2 30 1 Pe m ag at sh el 19 .8 6. 6 -1 .1 19 6 44 .9 19 .1 -1 .8 15 8 2. 6 .2 17 .7 .6 16 7 Pu na kh a 11 .4 2. 0 -.7 20 3 20 .7 6. 2 -.9 19 3 4. 7 2. 2 3. 3 -.1 19 7 Sa m dr up jo ng kh ar 11 .0 2. 0 -.9 40 4 37 .4 12 .4 -1 .5 40 0 3. 4 2. 1 4. 7 -.1 40 3 Sa m ts e 13 .1 2. 0 -.9 73 0 28 .4 7. 5 -1 .2 71 2 4. 7 1. 5 2. 3 -.3 70 9 Sa rp an g 10 .9 1. 0 -.7 34 7 23 .2 6. 4 -1 .2 32 8 4. 4 1. 8 5. 0 .0 32 9 Th im ph u 11 .9 4. 7 -.8 78 5 37 .8 23 .2 -1 .7 72 2 6. 2 2. 9 15 .5 .3 71 8 Tr as hi ga ng 17 .7 6. 0 -.8 45 4 47 .2 27 .0 -1 .9 42 4 8. 8 2. 9 15 .6 .4 45 2 Tr as hi ya ng ts e 13 .6 1. 2 -.8 16 4 40 .3 15 .8 -1 .4 15 5 4. 8 2. 8 7. 8 .1 16 1 Tr on gs a 10 .3 2. 9 -.6 13 0 27 .2 9. 5 -1 .1 12 9 2. 6 .7 1. 9 -.0 13 0 Ts ira ng 12 .9 3. 3 -.9 17 8 28 .4 7. 2 -1 .3 17 5 5. 3 2. 3 3. 1 -.2 18 1 W an gd ue 11 .0 1. 3 -.7 23 7 28 .7 8. 2 -1 .3 23 1 3. 7 1. 8 2. 7 -.0 23 7 Zh em ga ng 15 .9 6. 1 -.8 16 5 42 .8 18 .6 -1 .7 15 8 8. 8 3. 3 11 .4 .2 15 6 34 C 0n td . T A B L E N U .1 : N U T R IT IO N A L ST AT U S O F C H IL D R E N Pe rc en ta ge o f c hi ld re n un de r ag e 5 by n ut ri tio na l s ta tu s a cc or di ng to th re e an th ro po m et ri c in di ce s: w ei gh t f or a ge , h ei gh t f or a ge , a nd w ei gh t f or h ei gh t, B hu ta n, 2 01 0 W ei gh t f or ag e: W ei gh t fo r a ge : W ei gh t f or ag e: W ei gh t f or ag e: H ei gh t f or ag e: H ei gh t f or ag e: H ei gh t f or ag e: H ei gh t f or ag e: W ei gh t f or he ig ht : W ei gh t f or he ig ht : W ei gh t f or he ig ht : W ei gh t f or he ig ht : W ei gh t f or he ig ht : % b el ow - 2 sd [1 ] % b el ow -3 sd [2 ] M ea n Z- Sc or e (S D ) N um be r o f ch ild re n % b el ow - 2 sd [3 ] % b el ow - 3 sd [4 ] M ea n Z- Sc or e (S D ) N um be r o f ch ild re n % b el ow - 2 sd [5 ] % b el ow - 3 sd [6 ] % a bo ve +2 sd M ea n Z- Sc or e (S D ) N um be r o f ch ild re n R eg io n W es te rn 12 .0 3. 0 -.8 28 17 30 .5 11 .8 -1 .3 27 00 6. 7 2. 1 6. 9 -.1 26 94 C en tra l 11 .7 2. 5 -.7 14 52 28 .1 9. 0 -1 .2 14 04 4. 8 1. 9 4. 6 -.0 14 18 Ea st er n 14 .6 4. 2 -.9 18 02 42 .8 19 .3 -1 .7 17 02 5. 5 2. 1 11 .0 .2 17 51 A ge 0- 5 10 .7 3. 5 -.2 58 7 21 .0 9. 5 -.3 52 5 15 .1 8. 4 13 .6 -.1 49 7 6- 11 8. 6 2. 4 -.3 61 5 16 .7 9. 3 -.5 58 9 10 .0 3. 3 10 .0 -.0 57 0 12 -2 3 11 .4 3. 4 -.8 12 02 35 .9 14 .6 -1 .5 11 39 6. 2 2. 0 8. 3 .0 11 58 24 -3 5 13 .8 2. 8 -.9 12 94 37 .4 16 .1 -1 .7 12 26 3. 3 1. 1 6. 8 .1 12 54 36 -4 7 15 .4 3. 7 -1 .0 12 21 40 .3 14 .1 -1 .7 11 96 4. 9 1. 1 6. 7 -.0 12 14 48 -5 9 13 .1 3. 1 -1 .0 11 53 34 .3 12 .1 -1 .6 11 31 3. 3 .7 4. 8 .0 11 69 M ot he r’ s e du ca tio n N on e 14 .4 3. 7 -.9 40 44 37 .4 14 .7 -1 .5 38 86 6. 1 2. 2 7. 0 -.0 39 37 Pr im ar y 11 .2 1. 9 -.8 75 0 30 .5 9. 1 -1 .3 72 6 4. 6 1. 4 6. 3 -.1 73 0 Se co nd ar y 8. 1 2. 3 -.4 12 77 22 .7 11 .4 -1 .0 11 93 5. 9 2. 0 10 .3 .2 11 96 W ea lth in de x qu in til es Po or es t 16 .1 4. 2 -1 .0 12 32 41 .4 14 .9 -1 .7 11 96 5. 1 1. 8 6. 2 -.1 12 17 Se co nd 16 .1 3. 4 -1 .0 11 06 39 .9 14 .9 -1 .6 10 39 6. 6 1. 9 7. 1 .0 10 66 M id dl e 14 .0 3. 1 -.8 11 50 38 .4 15 .6 -1 .5 11 07 6. 4 2. 6 8. 4 .1 11 21 Fo ur th 10 .3 3. 1 -.7 14 11 27 .6 10 .8 -1 .2 13 54 5. 7 1. 9 6. 3 -.0 13 50 R ic he st 7. 3 2. 1 -.4 11 71 21 .4 10 .9 -1 .0 11 10 5. 6 2. 1 10 .2 .2 11 10 To ta l 12 .7 3. 2 -.8 60 71 33 .5 13 .3 -1 .4 58 05 5. 9 2. 0 7. 6 .0 58 63 [1 ] M IC S in di ca to r 2 .1 a an d M D G in di ca to r 1 .8 [2 ] M IC S in di ca to r 2 .1 b [3 ] M IC S in di ca to r 2 .2 a, [4 ] M IC S in di ca to r 2 .2 b [5 ] M IC S in di ca to r 2 .3 a, [6 ] M IC S in di ca to r 2 .3 b 35 Children with incomplete birth dates (month and year) and children whose measurements are outside a plausible range are excluded from Table NU.1. Children are excluded from one or more of the an- thropometric indicators when their weight and height have not been measured, which ever is appli- cable. For example, if a child has been weighed but his/her height has not been measured, the child is included in underweight calculations, but not in the calculations for stunting and wasting. Percentages of children by age and reasons for exclusion are shown in the data quality tables DQ.6 and DQ.7. Overall 98 percent of children had both their weight and height measured (Table DQ.6). Table DQ.7 shows that due to incomplete dates of birth, implausible measurements, and missing weight and/or height, 4.1 percent of children have been excluded from calculations of the weight-for-age indicator, while the figures are 8.4 for the height-for-age indicator, and 8.4 for the weight-for-height indicator. Almost one in eight children under age five in Bhutan are moderately underweight (12.7%) and 3.2 percent are classified as severely underweight (Table NU.1). More than one -third of children (33.5%) are moderately stunted or too short for their age, out of which 13.3 percent are severely stunted. Figure NU.1: Percent of children underweight, stunted and wasted by age groups, Bhutan 2010 29 Children!with!incomplete!birth!dates!(month!and!year)!and!children!whose!measurements!are!outside!a! plausible! range! are! excluded! from! Table! NU.1.! Children! are! excluded! from! one! or! more! of! the! anthropometric! indicators! when! their! weight! and! height! have! not! been! measured,! which! ever! is! applicable.!For!example,!if!a!child!has!been!weighed!but!his/her!height!has!not!been!measured,!the!child! is!included!in!underweight!calculations,!but!not!in!the!calculations!for!stunting!and!wasting.!Percentages! of!children!by!age!and!reasons!for!exclusion!are!shown!in!the!data!quality!tables!DQ.6!and!DQ.7.!Overall! 98!percent!of!children!had!both!their!weight!and!height!measured!(Table!DQ.6).!Table!DQ.7!shows!that! due! to! incomplete! dates! of! birth,! implausible!measurements,! and!missing!weight! and/or! height,! 4.1! percent! of! children! have! been! excluded! from! calculations! of! the!weight"for"age! indicator,!while! the! figures!are!8.4!for!the!height"for"age!indicator,!and!8.4!for!the!weight"for"height!indicator.!! ! Almost! one! in! eight! children! under! age! five! in! Bhutan! are!moderately! underweight! (12.7%)! and! 3.2! percent!are!classified!as!severely!underweight! (Table!NU.1).!More! than!one! "third!of!children! (33.5%)! are!moderately!stunted!or!too!short!for!their!age,!out!of!which!13.3!percent!are!severely!stunted.!!! ! Figure!NU.1:!Percent!of!children!underweight,!stunted!and!wasted!by!age!groups,!Bhutan!2010! ! .0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 0"5 6"11 12"23 24"35 36"47 48"59 % Age!group! in!months Underweight! Stunting Wasting ! ! ! 36 Children in the Eastern region have the highest prevalence of stunting (42.8%) and are classified as critical, which requires targeted programme intervention. In contrast, the percentage of children with wasting is the highest in Western region (6.7%). Children whose mothers are uneducated and are from the poorest family had highest prevalence of stunting at 37.4 percent and 41.4 percent respectively, compared to educated mothers (22.7%) and from the richest family (21.4%). The age pattern shows a big jump in stunting and a smaller jump in underweight among children aged 12-23 months (Figure NU.1). This corresponds to the age at which many children cease to be breastfed and are exposed to contamination in water, food, and the environment in general. The higher level of underweight and stunting remain also among older age groups. The largest percentage of over-weight children is in the richest quintile (10.2%), in urban areas (10%) and in the Eastern region (11%). 37 Breastfeeding and Infant and Young Child Feeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients and is economical and safe. However, many mothers stop breastfeeding too soon and there are often pressures to switch to an infant formula, which can contribute to growth faltering and micronutrient malnutrition and is unsafe if clean water is not readily available. WHO/UNICEF have the following feeding recommendations: • Exclusive breastfeeding for the first six months • Continued breastfeeding for two years or more • Safe, appropriate and adequate complementary foods beginning at 6 months • Frequency of complementary feeding: two times per day for 6-8 month olds; three times per day for 9-11 month olds It is also recommended that breastfeeding be initiated within one hour of birth. The indicators related to recommended child feeding practices are as follows: Early initiation of breastfeeding (within one hour of birth) • Exclusive breastfeeding rate (< six months) • Predominant breastfeeding (< six months) • Continued breastfeeding rate (at one year and at two years) • Duration of breastfeeding • Age-appropriate breastfeeding (0-23 months) • Introduction of solid, semi-solid and soft foods (6-8 months) • Minimum meal frequency (6-23 months) • Milk feeding frequency for non-breastfeeding children (6-23 months) • Bottle feeding (0-23 months) 38 TABLE NU.2: INITIAL BREASTFEEDING Percentage of last-born children in the 2 years preceding the survey who were ever breastfed, percentage who were breastfed within one hour of birth and within one day of birth, and percentage who received a prelacteal feed, Bhutan, 2010 Percentage ever breastfed [1] Percentage who were first breastfed: Within one hour of birth [2] Percentage who were first breastfed: Within one day of birth Percentage who received a prelacteal feed Number of last-born children in the two years preceding the survey Dzongkhag Bumthang 95.0 37.5 80.1 15.4 69 Chukha 100.0 38.1 94.7 10.1 223 Dagana 99.3 43.9 91.2 8.4 100 Gasa (97.6) (63.8) (90.7) (10.2) 28 Haa 97.8 78.0 97.8 5.0 43 Lhuntse 95.5 89.3 89.3 2.6 47 Mongar 98.6 65.9 93.4 4.3 186 Paro 99.0 41.6 91.9 2.8 146 Pemagatshel 96.9 77.4 93.9 3.0 94 Punakha 99.1 64.2 94.3 9.8 100 Samdrup jongkhar 98.8 46.7 93.0 5.3 163 Samtse 100.0 52.1 89.9 17.2 221 Sarpang 99.1 66.9 95.1 6.8 132 Thimphu 100.0 70.5 97.3 4.8 298 Trashigang 97.4 51.6 92.4 8.1 161 Trashiyangtse 97.9 81.9 91.5 10.9 60 Trongsa 99.3 54.9 90.1 11.7 50 Tsirang 100.0 71.4 94.7 4.1 62 Wangdue 100.0 67.5 87.3 21.3 103 Zhemgang 99.5 81.0 95.1 1.9 82 Region Western 99.6 55.4 94.0 8.9 1059 Central 99.0 61.2 90.9 10.0 598 Eastern 97.9 62.7 92.7 5.7 711 Residence Urban 99.3 61.3 93.5 8.3 690 Rural 98.8 58.1 92.6 8.2 1678 Months since last birth 0-11 months 98.9 58.8 93.1 6.7 1168 12-23 months 99.0 59.3 92.6 9.7 1200 Assistance at delivery Skilled attendant 99.4 60.5 93.3 8.5 1528 Traditional birth attendant / Village health worker / Rela- tive / Friend 98.0 57.3 92.0 7.8 754 Other/Missing 99.2 49.5 91.5 6.7 86 39 Table NU.2 provides the proportion of children born in the last two years who were ever breastfed, those who were first breastfed within one hour and one day of birth, and those who received a pre- lacteal feed. Although a very important step in management of lactation and establishment of a physi- cal and emotional relationship between the baby and the mother, 59 percent of babies are breastfed for the first time within one hour of birth, while 92.9 percent of newborns in Bhutan start breastfeeding within one day of birth. From the Table NU.2 above and figure NU.2 below it is clear that there is little change in the early initiation of breast feeding between background characteristics. Whether the delivery took place in the health facility or at home, attended by a skilled professional or non-skill, in urban or rural area, in the east or west, in poor or hard to reach households, the difference doesn’t go beyond 7 percent at the most. The widest range is between the educational levels of mothers (8.2% between none and second- ary education) and Dzongkhag, with Bhumthang the lowest (37.5%) and Lhuentse the highest percent (89.3%) of breastfed children within one hour of birth. It is worth mentioning that the high percent of children who were breastfed within one day, with the highest percentage in Thimphu (97.3%) and Haa (97.8%) and lowest in Bumthang at 87.1 percent. The highest percent of pre-lacteal feed (feeding a baby prior to giving breastmilk/Colostrum) was observed in Wangdue (21.3%) and Samtse (17.2%) and lowest in Lhuentse (2.6%) and Zhemgang (1.9%). This finding needs further study. Contd. TABLE NU.2: INITIAL BREASTFEEDING Percentage of last-born children in the 2 years preceding the survey who were ever breastfed, percentage who were breastfed within one hour of birth and within one day of birth, and percentage who received a prelacteal feed, Bhutan, 2010 Percentage ever breastfed [1] Percentage who were first breastfed: Within one hour of birth [2] Percentage who were first breastfed: Within one day of birth Percentage who received a prelacteal feed Number of last-born children in the two years preceding the survey Place of delivery Public sector health facility 99.6 60.0 93.5 8.2 1492 Private sector health facility 100.0 35.6 100.0 0.0 3 Home 97.9 57.8 91.7 8.1 865 Other/Missing 90.6 27.4 90.6 16.2 8 Mother’s education None 98.9 56.8 92.5 7.7 1484 Primary 98.3 58.6 92.4 7.5 302 Secondary + 99.3 65.0 94.0 9.8 582 Wealth index quintiles Poorest 97.6 55.2 91.0 8.2 471 Second 98.8 57.9 91.7 8.8 448 Middle 99.7 61.4 94.3 7.3 475 Fourth 99.1 58.2 93.3 7.0 518 Richest 99.5 62.6 94.0 9.8 455 Total 98.9 59.0 92.9 8.2 2368 [1] MICS indicator 2.4 [2] MICS indicator 2.5 * Two unweighted cases for Birth Delivered in private health facility not shown and seven unweighted cases with missing place of delivery not shown * Figures in parenthesis indicate that the percentage is based on just 25 to 49 unweighted cases 40 It is assumed that the higher the proportion of mothers’ are being attended by skilled birth attendants (SBA) during delivery the more likely babies are to be breastfed within one hour. However, the per- centage difference for this indicator between SBA (60.5%) and traditional birth attendant (57.3%) is only 3.2 percent. Figure NU.2: Initial breastfeeding (within one hour and one day of birth), Bhutan 2010. 34 percent!of!children!who!were!breastfed!within!one!day,!with!the!highest!percentage!in!Thimphu!(97.3%)! and!Haa!(97.8%)!and!lowest!in!Bumthang!at!87.1%.!!!The!highest!percent!of!pre"lacteal!feed!(feeding!a! baby!prior!to!giving!breastmilk/Colostrum)!was!observed! in!Wangdue!(21.3%)!and!Samtse!(17.2%)!and! lowest!in!Lhuentse!(2.6%)!and!Zhemgang!(1.9%).!This!finding!needs!further!study.!! It!is!assumed!that!the!higher!the!proportion!of!mothers’!are!being!attended!by!skilled!birth!attendants! (SBA)! during! delivery! the! more! likely! babies! are! to! be! breastfed! within! one! hour.! However,! the! percentage!difference!for!this!indicator!between!SBA!(60.5%)!and!traditional!birth!attendant!(57.3%)!is! only!3.2%.!! Figure!NU.2:!Initial!breastfeeding!(within!one!hour!and!one!day!of!birth),!Bhutan!2010.! 59.0 62.6 58.2 61.4 57.9 55.2 65.0 58.6 56.8 27.4 57.8 35.6 60.0 58.1 61.3 62.7 61.2 55.4 92.9 94.0 93.3 94.3 91.7 91.0 94.0 92.4 92.5 90.6 91.7 100.0 93.5 92.6 93.5 92.7 90.9 94.0 .0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Total Richest Fourth Middle Second Poorest Secondary!+ Primary None Other/Missing Home Private!sector!health!facility Public!sector!health!facility Rural Urban Eastern Central Western Percentage!who!were!first!breastfed:!!Within!one!day!of!birth Percentage!who!were!first!breastfed:!Within!one!hour!of!birth! 41 In Table NU.3, breastfeeding status is based on the reports of mothers/caretakers of children’s con- sumption of food and fluids in the 24 hours prior to the interview. Exclusively breastfed refers to infants who received only breast milk (and vitamins, mineral supplements, or medicine). The table shows exclusive breastfeeding of infants during the first six months of life, as well as continued breastfeeding of children at 12-15 and 20-23 months of age. 48.7 percent of children aged less than six months are exclusively breastfed. By age 12-15 months, 92.7 percent of children are still being breastfed and by age 20-23 months, 65.7 percent are still breastfed. Exclusive breastfeeding has a strong correlation with education of the mother and the wealth index. The most prominent difference, however, is in relationship to the wealth index where the children living in the households falling in the poorest quintile are less likely to be exclusively breastfed (36.1%) than their peers from the richest quintile (65%). While children from the Eastern region are less likely to be exclusively or predominantly breastfed, they are more likely to continue to be breastfed at two years of age than children from the Western and Central regions. TABLE NU.3: BREASTFEEDING Percentage of living children according to breastfeeding status at selected age groups, Bhutan, 2010 Children 0-5 months Children 12-15 months Children 20-23 months Percent exclusively breastfed [1] Percent predomi- nantly breastfed [2] Number of children Percent breastfed (Continued breastfeeding at 1 year) [3] Number of children Percent breast- fed (Continued breastfeeding at 2 years) [4] Number of children Sex Male 47.3 67.1 297 93.0 187 68.1 196 Female 50.0 66.6 306 92.5 225 63.2 192 Region Western 55.1 67.9 304 94.7 182 61.6 167 Central 43.4 67.5 140 89.2 100 67.1 114 Eastern 41.2 64.2 159 92.5 130 70.5 107 Residence Urban 57.4 73.1 195 90.8 125 58.7 126 Rural 44.5 63.8 408 93.5 287 69.0 261 Mother’s education None 44.4 66.4 352 94.5 277 70.2 244 Primary 47.1 62.0 62 87.7 43 63.6 58 Secondary 57.3 69.2 188 89.8 92 54.2 85 Wealth index quintiles Poorest 36.1 64.4 115 96.1 82 77.2 65 Second 50.3 67.2 91 91.7 82 70.4 81 Middle 42.8 61.3 128 92.3 78 68.4 69 Fourth 47.1 67.2 129 96.3 79 58.2 103 Richest 65.0 73.5 139 87.7 90 57.6 70 Total 48.7 66.8 603 92.7 411 65.7 387 [1] MICS indicator 2.6 [2] MICS indicator 2.9 [3] MICS indicator 2.7 [4] MICS indicator 2.8 * By Dzongkhag is not shown because the number of unweighted observation are lower than 50 42 Table NU.4 shows the median duration of breastfeeding by selected background characteristics. Among children under age three, the median duration is 24.2 months for any breastfeeding, 2.4 months for exclusive breastfeeding and 4.1 months for predominant breastfeeding. The median dura- tion for exclusive breastfeeding is found higher in urban areas compared to rural and it is positively correlated with mothers’ education. Corresponding to the findings in Table NU.3, the median dura- tion of exclusive breastfeeding among children from the Eastern region is found to be lower than in other regions, while median duration of any breastfeeding is higher. The median duration of exclusive breastfeeding (0.7 month) is found lowest within the poorest wealth quintile. 43 TABLE NU.4: DURATION OF BREASTFEEDING Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Bhu- tan,2010 Median duration (in months) of Number of children age 0-35 monthsAny breastfeeding [1] Exclusive breastfeed-ing Predominant breastfeeding Sex Male 24.3 2.2 4.2 1922 Female 24.1 2.5 4.0 1878 Dzongkhag Bumthang 20.0 2.2 3.4 106 Chukha 24.4 2.9 4.7 370 Dagana 29.8 .9 4.9 152 Gasa (21.1) (0.0) (15.0) 28 Haa 21.4 2.2 2.5 71 Lhuntse 22.8 .5 4.6 79 Monggar 25.8 2.2 3.0 274 Paro 20.9 4.1 4.8 220 Pemagatshel 27.6 4.4 10.3 139 Punakha 23.1 1.2 1.8 141 Samdrup Jongkhar 27.4 .7 4.3 249 Samtse 21.9 2.3 3.7 399 Sarpang 26.3 2.9 4.2 209 Thimphu 22.6 3.4 4.2 515 Trashigang 25.9 1.4 6.2 273 Trashiyangtse 21.7 1.0 2.7 105 Trongsa 27.9 .7 2.2 80 Tsirang 31.1 1.6 5.0 116 Wangdue 22.9 2.5 3.0 155 Zhemgang 26.7 1.5 4.4 119 Region Weatern 22.4 2.9 4.1 1744 Central 25.6 2.0 3.9 936 Eastern 25.8 1.7 4.2 1119 Residence Urban 22.5 3.0 4.2 1130 Rural 25.5 2.0 4.0 2670 Mother’s education None 25.5 2.0 4.1 2476 Primary 23.3 2.3 4.2 457 Secondary+ 21.8 3.0 4.0 867 Wealth index quintile Poorest 28.1 .7 4.5 753 Second 27.1 2.5 4.1 692 Middle 24.5 2.0 3.8 755 Fourth 22.1 2.3 4.3 862 Richest 22.0 3.4 3.9 738 Median 24.2 2.4 4.1 3800 Mean for all children (0-35 months) 24.8 3.2 5.5 3800 [1] MICS indicator 2.10 * Figures in parenthesis indicate that the percentage is based on just 25 to 49 unweighted cases 44 The adequacy of infant feeding in children under 24 months is provided in Table NU.5. Different criteria of adequate feeding are used depending on the age of the child. For infants aged 0-5 months, exclusive breastfeeding is considered as adequate feeding, while infants aged 6-23 months are con- sidered to be adequately fed if they are receiving breast milk and solid, semi-solid or soft food. Thus 48.7 percent of 0-5 month infants are adequately breastfed through exclusive breastfeeding. The percentage of children 6-23 months old appropriately breastfed is higher in the Central region than in other regions. The correlation to the mothers’ education, wealth and urban-rural is quite the op- posite as for children 0-5 months old. Thus, the percentage appropriately breastfed 6-23 months old decreases with the mothers’ education and with wealth, and is lower in urban areas. TABLE NU.5: AGE-APPROPRIATE BREASTFEEDING Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Bhutan, 2010 Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed [1] Number of children Percent currently breastfeeding and receiv- ing solid, semi-solid or soft foods Number of children Percent appropriately breastfed [2] Number of children Sex Male 47.3 297 71.8 953 66.0 1250 Female 50.0 306 71.4 907 66.0 1213 Region Western 55.1 304 70.4 828 66.3 1132 Central 43.4 140 75.2 482 68.1 622 Eastern 41.2 159 70.1 550 63.6 709 Residence Urban 57.4 195 66.2 562 63.9 757 Rural 44.5 408 73.9 1298 66.9 1706 Mother’s education None 44.4 352 73.8 1179 67.1 1531 Primary 47.1 62 69.5 244 64.9 306 Secondary 57.3 188 66.6 438 63.8 626 Wealth index quintiles Poorest 36.1 115 76.5 359 66.7 474 Second 50.3 91 73.1 368 68.6 459 Middle 42.8 128 68.0 365 61.4 493 Fourth 47.1 129 72.2 410 66.2 539 Richest 65.0 139 67.9 359 67.1 497 Total 48.7 603 71.6 1860 66.0 2463 [1] MICS indicator 2.6 [2] MICS indicator 2.14 * By Dzongkhag is not shown because the number of unweighted observation are lower than 50 45 Adequate complementary feeding of children from six months to two years of age is particularly im- portant for growth and development and the prevention of under-nutrition. Continued breastfeeding beyond six months should be accompanied by consumption of nutritionally adequate, safe and appro- priate complementary foods that help meet nutritional requirements when breastmilk is no longer suf- ficient. This requires that for breastfed children, two or more meals of solid, semi-solid or soft foods are needed if they are six to eight months old, and three or more meals if they are 9-23 months of age. For children 6-23 months and older who are not breastfed, four or more meals of solid, semi-solid or soft foods or milk feeds are needed. Overall, 66.7 percent of infants aged 6-8 months received solid, semi-solid, or soft foods with higher levels among boys (69.7%) than girls (63.4%). (Table NU.6). TABLE NU.6: INTRODUCTION OF SOLID, SEMI-SOLID OR SOFT FOOD Percentage of infants age 6-8 months who received solid, semi-solid or soft foods during the previous day, Bhutan, 2010 All Percent receiving solid, semi-solid or soft foods[1] Number of children age 6-8 months Sex Male 69.7 180 Female 63.4 163 Residence Urban 66.7 100 Rural 66.7 243 Total 66.7 343 [1] MICS indicator 2.12 * Rest of the background characteristics are not shown because the number of unweighted observations are lower than 50 46 Table NU.7 presents the proportion of children aged 6-23 months who received solid, semi-solid or soft foods the minimum number of times or more during the previous day, according to breastfeed- ing status. (See the note in Table NU.7 for a definition of minimum number of times for different age groups). Overall, more than half of the children aged 6-23 months (62.6%) were receiving solid, semi-solid and soft foods the minimum number of times. A similar proportion of females (63.1%) were enjoying the minimum meal frequency compared to males (62.1%). Among currently breastfeeding children aged 6-23 months, more than half of them (64%) were re- ceiving solid, semi-solid and soft foods the minimum number of times. Among non-breastfeeding children, more than half of the children (53.6%) were receiving solid, semi-solid and soft foods or milk feeds four times or more. TABLE NU.7: MINIMUM MEAL FREQUENCY Percentage of children age 6-23 months who received solid, semi-solid, or soft foods (and milk feeds for non-breastfeeding children) the minimum number of times or more during the previous day, according to breastfeeding status, Bhutan, 2010 Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi-solid and soft foods the minimum number of times Number of children age 6-23 months Percent receiving at least 2 milk feeds [1] Percent receiving solid, semi-solid and soft foods or milk feeds 4 times or more Number of children age 6-23 months Percent with minimum meal fre- quency [2] Num- ber of children age 6-23 months Sex Male 63.1 825 38.3 55.4 128 62.1 953 Female 64.9 785 34.2 51.7 122 63.1 907 Age 6-8 months 61.9 343 39.6 39.6 6 61.6 349 9-11 months 56.3 274 91.4 91.4 3 56.7 278 12-17 months 63.7 561 54.6 62.2 63 63.5 624 18-23 months 70.9 431 28.8 50.3 179 64.9 610 Region Western 64.1 708 41.5 56.3 120 62.9 828 Central 64.8 417 35.7 60.1 65 64.2 482 Eastern 63.2 485 27.3 41.9 65 60.7 550 Residence Urban 61.7 474 40.2 56.4 88 60.8 562 Rural 65.0 1136 34.2 52.0 162 63.3 1298 Mother’s education None 63.2 1038 25.9 43.7 141 60.9 1179 Primary 63.0 210 22.1 37.5 34 59.5 244 Secondary 66.7 361 61.7 79.0 76 68.8 438 Wealth index quintiles Poorest 61.4 329 21.5 48.4 29 60.3 359 Second 63.3 325 30.3 54.8 43 62.3 368 Middle 65.5 309 29.1 47.5 56 62.7 365 Fourth 65.5 347 29.0 38.5 63 61.4 410 Richest 64.2 299 62.5 76.9 59 66.3 359 Total 64.0 1610 36.3 53.6 251 62.6 1860 [1] MICS indicator 2.15 [2] MICS indicator 2.13 * By Dzongkhag is not shown because the number of unweighted observation are lower than 50 47 The continued practice of bottle-feeding is a concern because of the possible contamination due to unsafe water and lack of hygiene in preparation. Table NU.8 shows that bottle-feeding is still preva- lent in Bhutan. 11.5 percent of children aged 0-23 months are fed using a bottle with a nipple. The prevalence of bottle-feeding is higher in the Western region (14.8%) among children 0-23 months when compared with the Central (9.9%) and Eastern (7.8%). The practice of bottle-feeding is higher among highly educated mothers, in richer households and in urban areas. 48 TABLE NU.8: BOTTLE FEEDING Percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Bhutan,2010 Percentage of children age 0-23 months fed with a bottle with a nipple [1] Number of children age 0-23 months: Sex Male 10.9 1250 Female 12.2 1213 Age 0-5 months 6.4 603 6-11 months 16.5 626 12-23 months 11.5 1234 Dzongkhag Bumthang 20.2 72 Chukha 14.2 248 Dagana 5.2 108 Gasa (6.0) 20 Haa 21.7 44 Lhuntse 11.8 47 Mongar 5.5 179 Paro 14.0 152 Pemagatshel 8.6 87 Punakha 12.6 102 Samdrup jongkhar 6.7 160 Samtse 10.7 234 Sarpang 14.1 142 Thimphu 18.7 332 Trashigang 10.9 164 Trashiyangtse 5.0 72 Trongsa 10.8 53 Tsirang 1.1 68 Wangdue 11.0 102 Zhemgang 4.7 76 Region Western 14.8 1132 Central 9.9 622 Eastern 7.8 709 Residence Urban 18.4 757 Rural 8.5 1706 Mother’s education None 7.4 1531 Primary 12.3 306 Secondary 21.3 626 Wealth index quintiles Poorest 4.7 474 Second 4.0 459 Middle 7.1 493 Fourth 17.2 539 Richest 23.2 497 Total 11.5 2463 [1] MICS indicator 2.11 * Figures in parenthesis indicate that the percentage is based on just 25 to 49 unweighted cases 49 Low Birth Weight Weight at birth is a good indicator not only of a mother’s health and nutritional status but also the newborn’s chances for survival, growth, long-term health and psychosocial development. Low birth weight (less than 2,500 grams) carries a range of grave health risks for children. Babies who were un- dernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother’s poor health and nutri- tion. Three factors are most impact: the mother’s poor nutritional status before conception, short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during the pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. One of the major challenges in measuring the incidence of low birth weight is that more than half of infants in the developing world are not weighed. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facili- ties, and those who are represent only a selected sample of all births. Because many infants may not be weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2,500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s re- call of the child’s weight or the weight as recorded on a health card if the child was weighed at birth5 . 9 For a detailed description of the methodology, see Boerma, Weinstein, Rutstein and Sommerfelt, 1996. 9 50 TABLE NU.9: LOW BIRTH WEIGHT INFANTS Percentage of last-born children in the 2 years preceding the survey that are estimated to have weighed below 2500 grams at birth and percentage of live births weighed at birth, Bhutan, 2010 Percent of live births: Number of live births in the last 2 yearsBelow 2500 grams [1] Weighed at birth [2] Dzongkhag Bumthang 11.4 73.4 69 Chukha 14.4 74.3 223 Dagana 8.4 62.6 100 Gasa (10.3) (63.7) 28 Haa (7.4) (90.5) 43 Lhuntse (10.1) (70.1) 47 Mongar 11.0 70.0 186 Paro 10.5 98.1 146 Pemagatshel 9.3 72.7 94 Punakha 9.1 88.0 100 Samdrup jongkhar 7.6 44.9 163 Samtse 11.7 65.1 221 Sarpang 7.7 73.7 132 Thimphu 8.2 99.4 298 Trashigang 9.0 47.0 161 Trashiyangtse 10.5 59.1 60 Trongsa 7.8 67.4 50 Tsirang 10.2 91.3 62 Wangdue 10.0 60.5 103 Zhemgang 8.1 44.6 82 Region Western 10.7 84.4 1059 Central 9.0 66.8 598 Eastern 9.4 58.5 711 51 In total, 72.2 percent of births were weighed at birth and approximately 9.9 percent of infants are estimated to weigh less than 2,500 grams at birth (Table NU.9). While there were little differences regarding low birth weight by region, there was some variation by Dzongkhag with lowest levels in Samdrup Jongkhar (7.6%) and highest levels in Chukha (14.4%) (Figure NU.3). The percentage of low birth weight does not vary much by urban and rural areas or by a mother’s education. However, the percentage of low birth weight is significantly higher among newborns in the poorest quintile (12.2%) compared to the richest quintile (7.3%). Contd. TABLE NU.9: LOW BIRTH WEIGHT INFANTS Percentage of last-born children in the 2 years preceding the survey that are estimated to have weighed below 2500 grams at birth and percentage of live births weighed at birth, Bhutan, 2010 Percent of live births: Number of live births in the last 2 yearsBelow 2500 grams [1] Weighed at birth [2] Residence Urban 8.5 93.8 690 Rural 10.4 63.3 1678 Education None 10.2 62.4 1484 Primary 10.3 73.5 302 Secondary + 8.7 96.3 582 Wealth index quintiles Poorest 12.2 43.9 471 Second 10.5 56.3 448 Middle 9.5 73.6 475 Fourth 9.8 88.2 518 Richest 7.3 97.3 455 Total 9.9 72.2 2368 [1] MICS indicator 2.18 * Figures in parenthesis indicate that the percentage is based on just 25 to 49 unweighted cases 52 Figure.NU.3: Percent of children weight below 2500 grams by Dzongkhag, Bhutan 2010. 46 Figure.NU.3: Percent of children weight below 2500 grams by Dzongkhag, Bhutan 2010. 11.4 14.4 8.4 10.3 7.4 10.1 11.0 10.5 9.3 9.1 7.6 11.7 7.7 8.2 9.0 10.5 7.8 10.2 10.0 8.1 9.9 .0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 % Dzongkhag 53 54 55 IV. Child Health Neonatal Tetanus Protection One of the MDGs is to reduce by three quarters the maternal mortality ratio, with one strategy to eliminate maternal tetanus. In addition, another goal is to reduce the incidence of neonatal tetanus to less than one case of neonatal tetanus per 1,000 live births in every district. A World Fit for Children goal is to eliminate maternal and neonatal tetanus by 2005. Prevention of maternal and neonatal tetanus is to assure all pregnant women receive at least two doses of tetanus toxoid vaccine. However, if women have not received two doses of the vaccine during the pregnancy, they (and their newborn) are also considered to be protected if the following conditions are met: • Received at least two doses of tetanus toxoid vaccine, the last within the prior three years; • Received at least three doses, the last within the prior five years; • Received at least five doses, the last within 10 years; • Received at least five doses during lifetime. Table CH.1 shows the protection status from tetanus of women who have had a live birth within the last two years. Figure CH.2 shows the protection of women against neonatal tetanus by major back- ground characteristics. Nationally, 73 percent of women had received sufficient protection against tetanus. There is little difference between urban and rural areas for the percentage of women who were protected against tetanus. 80.1 percent of women with secondary+ education were protected from tetanus compared to 71.3 percent of women with no formal education, and 68.2 percent of women with primary education. While regional differences are not very large. There are variations between Dzongkhag for tetanus protection coverage with approximately a 39 percentage point defer- ence between the best performing Dzongkhag and the worst performing Dzongkhag 56 TABLE CH.1: NEONATAL TETANUS PROTECTION Percentage of women age 15-49 years with a live birth in the last 2 years protected against neonatal tetanus,Bhutan, 2010 Percentage of women who received at least 2 doses during last pregnancy Percentage of women who did not receive two or more doses during last pregnancy but received: Protected against tetanus [1] Number of women with a live birth in the last 2 years 2 doses, the last within prior 3 years 3 doses, the last within prior 5 years 4 doses, the last within prior 10 years 5 or more doses during lifetime Residence Urban 51.7 22.6 .0 .1 .1 74.5 690 Rural 48.5 23.6 .2 .1 .1 72.4 1678 Dzongkhag Bumthang 43.7 29.3 .0 .0 .7 73.7 69 Chukha 45.6 15.0 .0 .0 .0 60.6 223 Dagana 40.7 18.6 .0 .0 .0 59.2 100 Gasa (32.8) (19.6) (.0) (.0) (.0) (52.4) 28 Haa 74.8 7.2 .0 .0 .0 82.0 43 Lhuntse 60.9 25.5 .0 .0 .0 86.4 47 Mongar 49.0 27.0 .7 .3 .0 77.0 186 Paro 58.1 10.9 .0 .0 .0 68.9 146 Pemagatshel 52.3 30.0 .8 .7 .0 83.8 94 Punakha 44.8 8.2 .0 .0 .0 53.0 100 Samdrup jongkhar 42.6 38.9 .0 .0 .0 81.6 163 Samtse 53.5 31.6 .0 .0 .0 85.1 221 Sarpang 50.3 41.2 .0 .0 .7 92.2 132 Thimphu 55.3 16.0 .0 .0 .0 71.3 298 Trashigang 40.5 15.5 .0 .0 .0 56.0 161 Trashiyangtse 52.1 27.1 .0 .0 .7 80.0 60 Trongsa 41.7 31.4 1.0 .0 .0 74.1 50 Tsirang 63.2 3.8 .0 .0 .0 67.0 62 Wangdue 48.3 30.3 .0 .0 .0 78.6 103 Zhemgang 39.7 37.6 .5 1.5 .0 79.2 82 Region Western 52.5 17.3 .0 .0 .0 69.8 1059 Central 46.8 29.0 .1 .2 .2 76.3 598 Eastern 47.1 27.4 .3 .2 .1 75.0 711 Education None 44.2 26.7 .1 .2 .1 71.3 1484 Primary 49.2 18.5 .2 .0 .1 68.2 302 Secondary + 62.9 17.2 .0 .0 .0 80.1 582 Wealth index quintiles Poorest 43.1 27.6 .0 .1 .2 71.1 471 Second 50.5 20.0 .4 .0 .0 70.9 448 Middle 48.3 21.3 .2 .1 .2 70.0 475 Fourth 49.6 25.8 .1 .2 .0 75.7 518 Richest 55.9 21.4 .0 .0 .0 77.2 455 Total 49.4 23.3 .1 .1 .1 73.0 2368 [1] MICS indicator 3.7 * Figures in parenthesis indicate that the percentage is based on just 25 to 49 unweighted cases 57 Figure.CH.1: Neonatal tetanus protection (women with a live birth in the previous 24 months), Bhutan 2010. 50 Figure.CH.1: Neonatal tetanus protection (women with a live birth in the previous 24 months), Bhutan 2010. 73.0 77.2 75.7 70.0 70.9 71.1 80.1 68.2 71.3 72.4 74.5 75.0 76.3 69.8 .0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Total Richest Fourth Middle Second Poorest Secondary + Primary None Rural Urban Eastern Central Western Protected against tetanus 58 Oral Rehydration Treatment Diarrhoea is the second leading cause of death among children under-five worldwide. Most diar- rhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – either through oral rehydra- tion salts (ORS) or a recommended home fluid (RHF) - can prevent many of these deaths. Prevent- ing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. The goals are to: 1) reduce by one half death due to diarrhoea among children under-five by 2010 compared to 2000 (A World Fit for Children); and 2) reduce by two thirds the mortality rate among children under-five by 2015 compared to 1990 (Millennium Development Goals). In addition, the World Fit for Children calls for a reduction in the incidence of diarrhoea by 25 percent. The indicators are: • Prevalence of diarrhoea • Oral rehydration therapy (ORT) • Home management of diarrhoea • ORT with continued feeding In the BMIS questionnaire, mothers (or caretakers) were asked to report whether their child had had diarrhoea in the two weeks prior to the survey. If so, the mother was asked a series of questions about what the child had to drink and eat during the episode and whether this was more or less than the child usually ate and drank. Overall, 25.1 percent of under-five children had diarrhoea in the two weeks preceding the survey (Ta- ble CH.1). Diarrhoea prevalence was similar in all regions, but with some variations at Dzongkhag levels, with the highest prevalence in Wangdue (36.3%) and the lowest prevalence in Pemagatshel (15.7%). The peak of diarrhoea prevalence occurs in the weaning period, among children aged 12-23 months. Less diarrhoea prevalence is found among children in the richest quintile (18.8%) and chil- dren of mothers with secondary or higher education (19.7%). 59 TABLE CH.2: ORAL REHYDRATION SOLUTIONS AND RECOMMENDED HOMEMADE FLUIDS Percentage of children age 0-59 months with diarrhoea in the last two weeks, and treatment with oral rehydration solutions and recom- mended homemade fluids, Bhutan, 2010 Had diar- rhoea in last two weeks Number of children age 0-59 months Children with diarrhoea who received: Number of children aged 0-59 months with diar- rhoea ORS (Fluid from ORS packet or pre-packaged ORS fluid) Recommended homemade fluids ORS or any recom- mended homemade fluid Rice water/ rice porridge Whey (Da- chu) Weak tea (Phekha) with salt Any recom- mended homemade fluid Sex Male 26.4 3216 60.6 31.8 15.8 36.1 58.0 81.1 850 Female 23.8 3081 61.3 34.5 14.1 34.1 57.4 79.8 732 Dzongkhag Bumthang 17.2 171 52.7 20.5 19.0 30.1 50.2 75.8 30 Chukha 30.0 648 46.9 33.2 14.9 29.4 49.3 70.9 194 Dagana 24.5 237 62.9 30.6 2.8 20.5 40.0 86.9 58 Gasa 21.4 43 * * * * * * 9 Haa 23.0 121 59.8 49.4 9.7 18.9 61.5 78.2 28 Lhuntse 30.4 124 84.7 46.5 48.8 72.1 83.7 90.7 38 Mongar 25.2 466 63.3 34.8 23.1 43.2 65.5 80.0 117 Paro 25.7 337 57.1 33.4 12.0 14.1 46.1 76.3 86 Pemagatshel 15.7 214 (54.4) (36.8) (11.6) (40.2) (60.3) (80.9) 34 Punakha 27.6 218 53.3 29.5 19.6 40.6 59.0 77.8 60 Samdrup jongkhar 20.2 410 54.6 19.5 13.9 27.4 50.8 87.0 83 Samtse 24.7 755 48.6 21.4 10.7 20.1 40.4 67.3 186 Sarpang 20.5 350 63.2 47.1 6.9 22.7 51.1 79.4 72 Thimphu 25.2 801 73.4 36.0 5.9 54.6 72.8 89.6 201 Trashigang 26.5 479 71.7 40.0 10.9 33.1 63.0 85.7 127 Trashiyangtse 25.6 169 56.4 35.8 16.6 35.5 62.1 80.9 43 Trongsa 23.4 133 53.0 38.0 44.8 49.2 74.0 83.4 31 Tsirang 21.2 186 67.7 40.3 14.3 23.1 52.0 77.7 39 Wangdue 36.3 261 75.7 29.6 26.2 41.9 66.0 89.9 95 Zhemgang 28.7 175 67.2 32.5 23.5 69.3 80.8 91.9 50 Residence Urban 25.3 1841 64.3 33.5 8.3 39.2 60.1 82.8 467 Rural 25.0 4456 59.5 32.9 17.8 33.5 56.7 79.5 1115 Region Western 26.2 2922 56.5 31.4 11.3 32.5 54.1 76.4 766 Central 24.7 1513 65.6 34.6 18.2 36.3 59.0 84.8 375 Eastern 23.7 1862 64.6 34.7 18.6 38.8 62.8 84.0 442 Age 0-11 29.8 1229 47.9 21.1 3.7 17.4 32.9 62.4 366 12-23 36.2 1234 63.6 32.9 15.7 36.5 59.5 84.8 447 24-35 24.3 1337 66.0 43.1 18.3 48.0 72.7 89.6 325 36-47 20.2 1275 71.1 36.7 21.0 37.9 68.1 87.9 258 48-59 15.2 1222 57.1 34.3 21.5 40.6 61.7 79.5 186 60 Table CH.2 also shows the percentage of children receiving various types of recommended liquids during the episode of diarrhoea. Since mothers were able to name more than one type of liquid, the percentages do not necessarily add to 100. About 60.9 percent received fluids from ORS packets or pre-packaged ORS fluids and 57.7 percent received recommended homemade fluids. Children of mothers with secondary education and children from the richest quintile are slightly less likely to receive oral rehydration treatment than other children. Approximately eight out of ten children with diarrhoea received one or more of the recommended home treatments (i.e., were treated with ORS or any recommended homemade fluid), while around two out of every ten children did not receive any treatment. Figure CH.2 shows differences in the treatment of diarrhoea by background characteristics as partly discussed above. Contd. TABLE CH.2: ORAL REHYDRATION SOLUTIONS AND RECOMMENDED HOMEMADE FLUIDS Percentage of children age 0-59 months with diarrhoea in the last two weeks, and treatment with oral rehydration solutions and recom- mended homemade fluids, Bhutan, 2010 Had diar- rhoea in last two weeks Number of children age 0-59 months Children with diarrhoea who received: Number of children aged 0-59 months with diar- rhoea ORS (Fluid from ORS packet or pre-packaged ORS fluid) Recommended homemade fluids ORS or any recom- mended homemade fluid Rice water/ rice porridge Whey (Da- chu) Weak tea (Phekha) with salt Any recom- mended homemade fluid Mother’s education None 26.5 4207 62.3 31.9 15.9 37.8 58.7 81.4 1114 Primary 26.9 781 60.6 33.9 18.5 32.3 56.7 80.9 210 Secondary 19.7 1309 55.3 37.2 8.1 25.9 54.4 76.2 257 Wealth index quintiles Poorest 26.3 1294 60.1 34.7 19.1 37.5 61.7 80.6 341 Second 25.0 1159 61.8 31.8 21.4 35.1 59.4 82.6 290 Middle 28.0 1197 59.9 31.0 16.1 39.3 56.4 80.5 336 Fourth 27.0 1438 64.6 32.6 9.6 35.9 57.7 82.4 389 Richest 18.8 1208 56.0 36.0 8.2 24.1 51.6 74.3 227 Total 25.1 6297 60.9 33.1 15.0 35.2 57.7 80.5 1582 * An asterisk indicates that the percentage is calculated on fewer than 25 unweighted cases * Figures in parenthesis indicate that the percentage is based on just 25 to 49 unweighted cases 61 Figure CH.2: Oral rehydration solution (percentage of under-five children with diarrhoea who received ORS or any recommended homemade fluids), Bhutan 2010. More than one third (39.4 %) of under five children with diarrhoea drank more than usual and for children of mothers with secondary education it was more than half (51.4%) and among children from the richest quintile (50.8%). 70.8 percent ate somewhat less, same or more (continued feeding), but 29.2 percent ate much less or ate almost none. 54 Figure CH.2: Oral rehydration solution (percentage of under-five children with diarrhoea who received ORS or any recommended homemade fluids), Bhutan 2010. More than one third (39.4 %) of under five children with diarrhoea drank more than usual and for children of mothers with secondary education it was more than half (51.4%) and among children from the richest quintile (50.8%). 70.8 percent ate somewhat less, same or more (continued feeding), but 29.2 percent ate much less or ate almost none. 80.5 74.3 82.4 80.5 82.6 80.6 76.2 80.9 81.4 79.5 82.8 84.0 84.8 76.4 .0 20.0 40.0 60.0 80.0 100.0 Total Richest Fourth Middle Second Poorest Secondary Primary None Rural Urban Eastern Central Western ORS or any recommended homemade fluid 62 TA B L E C H .3 : F E E D IN G P R A C T IC E S D U R IN G D IA R R H O E A Pe rc en ta ge d is tr ib ut io n of c hi ld re n ag e 0- 59 m on th s w ith d ia rr ho ea in th e la st tw o w ee ks b y am ou nt o f l iq ui ds a nd fo od g iv en d ur in g ep is od e of d ia rr ho ea , B hu ta n, 2 01 0 H ad d ia r- rh oe a in la st tw o w ee ks N um - be r o f ch ild re n ag e 0- 59 m on th s D rin ki ng p ra ct ic es d ur in g di ar rh oe a: Ea tin g pr ac tic es d ur in g di ar rh oe a: N um be r of c hi ld re n ag ed 0 -5 9 m on th s w ith d ia r- rh oe a G iv en m uc h le ss to dr in k G iv en so m ew ha t le ss to dr in k G iv en ab ou t t he sa m e to dr in k G iv en m or e to dr in k G iv en no th in g to d rin k M is s- in g/ D K To ta l G iv en m uc h le ss to ea t G iv en so m ew ha t le ss to ea t G iv en ab ou t t he sa m e to ea t G iv en m or e to ea t St op pe d fo od H ad ne ve r be en gi ve n fo od M is s- in g/ D K To ta l Se x M al e 26 .4 32 16 11 .1 15 .7 32 .8 39 .0 1. 2 .3 10 0. 0 18 .0 34 .9 26 .1 9. 8 6. 3 4. 8 .1 10 0. 0 85 0 Fe m al e 23 .8 30 81 10 .8 18 .6 28 .8 39 .9 1. 7 .1 10 0. 0 18 .4 33 .1 28 .3 9. 4 5. 6 5. 2 .0 10 0. 0 73 2 D zo ng kh ag B um th an g 17 .2 17 1 2. 0 12 .9 29 .3 53 .8 2. 0 .0 10 0. 0 5. 4 32 .2 29 .1 21 .5 6. 3 5. 6 .0 10 0. 0 30 C hu kh a 30 .0 64 8 12 .8 20 .5 29 .1 35 .8 1. 8 .0 10 0. 0 22 .2 37 .8 22 .5 9. 9 0. 0 7. 5 .0 10 0. 0 19 4 D ag an a 24 .5 23 7 4. 8 14 .7 49 .6 30 .9 .0 .0 10 0. 0 12 .2 21 .9 48 .5 12 .6 1. 3 3. 5 .0 10 0. 0 58 G as a 21 .4 43 8. 2 27 .6 5. 5 48 .8 9. 9 .0 10 0. 0 * * * * * * * * 9 H aa 23 .0 12 1 1. 1 11 .8 32 .5 53 .2 1. 5 .0 10 0. 0 20 .5 33 .6 27 .6 13 .3 0. 0 5. 0 .0 10 0. 0 28 Lh un ts e 30 .4 12 4 29 .6 28 .6 24 .0 11 .7 4. 5 1. 6 10 0. 0 24 .1 33 .9 26 .7 13 .7 0. 0 1. 6 .0 10 0. 0 38 M on ga r 25 .2 46 6 19 .6 17 .4 28 .7 31 .8 1. 1 1. 3 10 0. 0 38 .8 38 .2 13 .7 0. 0 6. 8 2. 4 .0 10 0. 0 11 7 Pa ro 25 .7 33 7 4. 0 15 .9 25 .3 54 .7 .0 .0 10 0. 0 7. 3 50 .5 26 .9 7. 3 4. 3 3. 8 .0 10 0. 0 86 Pe m ag at sh el 15 .7 21 4 4. 0 2. 9 56 .5 31 .3 5. 3 .0 10 0. 0 (1 3. 2) (3 4. 1) (4 2. 5) (3 .4 ) (1 .8 ) (4 .9 ) (.0 ) (1 00 .0 ) 34 Pu na kh a 27 .6 21 8 .0 8. 1 28 .6 60 .2 3. 1 .0 10 0. 0 1. 4 30 .3 28 .6 18 .8 17 .5 3. 4 .0 10 0. 0 60 Sa m dr up jo ng kh ar 20 .2 41 0 4. 5 12 .5 49 .4 31 .9 1. 7 .0 10 0. 0 8. 2 32 .8 49 .4 6. 2 1. 6 1. 8 .0 10 0. 0 83 Sa m ts e 24 .7 75 5 6. 7 27 .3 33 .5 32 .5 .0 .0 10 0. 0 17 .7 30 .4 35 .5 11 .1 3. 1 2. 2 .0 10 0. 0 18 6 Sa rp an g 20 .5 35 0 9. 6 4. 0 49 .6 35 .1 1. 7 .0 10 0. 0 26 .1 29 .5 22 .3 3. 4 11 .4 7. 3 .0 10 0. 0 72 Th im ph u 25 .2 80 1 20 .2 6. 3 13 .2 59 .0 1. 3 .0 10 0. 0 25 .3 24 .0 15 .5 15 .7 14 .5 5. 1 .0 10 0. 0 20 1 Tr as hi ga ng 26 .5 47 9 20 .2 15 .8 22 .4 40 .5 1. 1 .0 10 0. 0 21 .5 36 .5 16 .9 7. 9 6. 1 11 .0 .0 10 0. 0 12 7 Tr as hi ya ng ts e 25 .6 16 9 4. 2 36 .0 34 .7 25 .1 0. 0 .0 10 0. 0 5. 5 53 .7 30 .4 6. 7 0. 0 3. 7 .0 10 0. 0 43 Tr on gs a 23 .4 13 3 9. 4 24 .7 34 .8 29 .6 1. 5 .0 10 0. 0 18 .2 33 .0 36 .7 9. 5 1. 2 1. 5 .0 10 0. 0 31 Ts ira ng 21 .2 18 6 11 .8 11 .1 34 .4 36 .9 3. 9 1. 9 10 0. 0 24 .0 27 .3 29 .1 5. 6 0. 0 12 .0 1. 9 10 0. 0 39 W an gd ue 36 .3 26 1 3. 9 22 .7 32 .3 39 .4 1. 8 .0 10 0. 0 8. 4 39 .3 28 .4 9. 7 10 .6 3. 5 .0 10 0. 0 95 Zh em ga ng 28 .7 17 5 4. 9 29 .9 43 .7 21 .5 .0 .0 10 0. 0 3. 3 40 .1 39 .4 7. 3 6. 8 3. 1 .0 10 0. 0 50 63 C on td . T A B L E C H .3 : F E E D IN G P R A C T IC E S D U R IN G D IA R R H O E A Pe rc en ta ge d is tr ib ut io n of c hi ld re n ag e 0- 59 m on th s w ith d ia rr ho ea in th e la st tw o w ee ks b y am ou nt o f l iq ui ds a nd fo od g iv en d ur in g ep is od e of d ia rr ho ea , B hu ta n, 2 01 0 H ad d ia r- rh oe a in la st tw o w ee ks N um - be r o f ch ild re n ag e 0- 59 m on th s D rin ki ng p ra ct ic es d ur in g di ar rh oe a: Ea tin g pr ac tic es d ur in g di ar rh oe a: N um be r of c hi ld re n ag ed 0 -5 9 m on th s w ith d ia r- rh oe a G iv en m uc h le ss to dr in k G iv en so m ew ha t le ss to dr in k G iv en ab ou t t he sa m e to dr in k G iv en m or e to dr in k G iv en no th in g to d rin k M is s- in g/ D K To ta l G iv en m uc h le ss to ea t G iv en so m ew ha t le ss to ea t G iv en ab ou t t he sa m e to ea t G iv en m or e to ea t St op pe d fo od H ad ne ve r be en gi ve n fo od M is s- in g/ D K To ta l R eg io n W es te rn 26 .2 29 22 10 .8 16 .7 25 .4 46 .0 1. 2 .0 10 0. 0 18 .3 32 .8 24 .9 12 .3 6. 8 4. 9 0. 0 10 0. 0 76 6 C en tra l 24 .7 15 13 6. 4 17 .0 40 .0 34 .9 1. 5 .2 10 0. 0 13 .9 32 .5 32 .6 9. 1 6. 6 5. 1 .2 10 0. 0 37 5 Ea st er n 23 .7 18 62 15 .1 17 .7 33 .1 31 .9 1. 7 .5 10 0. 0 21 .7 37 .5 26 .3 5. 5 4. 0 5. 0 0. 0 10 0. 0 44 2 R es id en ce U rb an 25 .3 18 41 11 .1 10 .5 26 .9 49 .8 1. 6 .1 10 0. 0 17 .8 28 .5 26 .9 13 .1 9. 3 4. 3 0. 0 10 0. 0 46 7 R ur al 25 .0 44 56 10 .9 19 .8 32 .7 35 .1 1. 4 .2 10 0. 0 18 .4 36 .4 27 .2 8. 2 4. 5 5. 2 .1 10 0. 0 11 15 A ge 0- 11 29 .8 12 29 9. 8 12 .9 43 .1 31 .6 2. 7 .0 10 0. 0 10 .8 24 .8 30 .9 7. 1 7. 4 18 .8 .2 10 0. 0 36 6 12 -2 3 36 .2 12 34 10 .3 16 .8 27 .8 44 .1 .9 .0 10 0. 0 19 .0 36 .7 24 .2 10 .2 8. 2 1. 7 0. 0 10 0. 0 44 7 24 -3 5 24 .3 13 37 15 .3 16 .6 25 .4 41 .5 .3 .9 10 0. 0 21 .8 42 .1 23 .6 10 .2 2. 2 .1 0. 0 10 0. 0 32 5 36 -4 7 20 .2 12 75 11 .9 18 .1 27 .2 42 .4 .5 .0 10 0. 0 25 .2 30 .0 26 .1 12 .5 5. 6 .6 0. 0 10 0. 0 25 8 48 -5 9 15 .2 12 22 5. 9 25 .1 29 .6 35 .9 3. 5 .0 10 0. 0 15 .0 37 .6 34 .2 8. 3 4. 9 .2 0. 0 10 0. 0 18 6 M ot he r’ s e du ca tio n N on e 26 .5 42 07 11 .7 19 .3 31 .1 35 .9 1. 7 .3 10 0. 0 20 .1 35 .9 24 .4 8. 7 5. 6 5. 1 .1 10 0. 0 11 14 Pr im ar y 26 .9 78 1 9. 6 14 .9 30 .8 43 .4 1. 2 .0 10 0. 0 10 .8 33 .0 33 .9 10 .7 8. 2 3. 4 0. 0 10 0. 0 21 0 Se co nd ar y 19 .7 13 09 8. 8 9. 1 30 .5 51 .4 .2 .0 10 0. 0 15 .9 26 .8 33 .2 12 .9 5. 7 5. 4 0. 0 10 0. 0 25 7 W ea lth in de x qu in til es Po or es t 26 .3 12 94 12 .4 22 .9 34 .7 28 .6 1. 2 .2 10 0. 0 20 .4 36 .9 28 .2 6. 3 3. 2 4. 8 .2 10 0. 0 34 1 Se co nd 25 .0 11 59 15 .5 22 .6 29 .1 31 .9 1. 0 .0 10 0. 0 19 .1 40 .7 26 .5 5. 8 4. 6 3. 3 0. 0 10 0. 0 29 0 M id dl e 28 .0 11 97 8. 4 16 .3 34 .9 37 .6 2. 3 .5 10 0. 0 12 .9 33 .6 25 .5 13 .7 7. 8 6. 5 0. 0 10 0. 0 33 6 Fo ur th 27 .0 14 38 9. 2 12 .2 27 .8 49 .4 1. 3 .2 10 0. 0 20 .6 30 .1 25 .4 11 .6 8. 6 3. 7 0. 0 10 0. 0 38 9 R ic he st 18 .8 12 08 9. 8 10 .8 27 .3 50 .8 1. 2 .0 10 0. 0 17 .7 28 .8 31 .5 10 .0 4. 7 7. 4 0. 0 10 0. 0 22 7 To ta l 25 .1 62 97 11 .0 17 .0 31 .0 39 .4 1. 4 .2 10 0. 0 18 .2 34 .1 27 .1 9. 6 6. 0 5. 0 .0 10 0. 0 15 82 * A n as te ris k in di ca te s t ha t t he p er ce nt ag e is c al cu la te d on fe w er th an 2 5 un w ei gh te d ca se s * Fi gu re s i n pa re nt he si s i nd ic at e th at th e pe rc en ta ge is b as ed o n ju st 2 5 to 4 9 un w ei gh te d ca se s 64 Table CH.4 provides the proportion of children aged 0-59 months with diarrhoea in the last two weeks who received oral rehydration therapy with continued feeding, and the percentage of children with diarrhoea who received other treatments. Overall, 73.6 percent of children with diarrhoea received ORS or increased fluids, and 85.4 percent received ORT (ORS or recommended homemade fluids or increased fluids). Combining the information in Table CH.3 with those in Table CH.2 on oral rehydra- tion therapy, it is observed that 61.6 percent of children received ORT and, at the same time feeding was continued, as is the recommendation. There are significant differences in the home management of diarrhoea by background characteris- tics. In the Western region, 58.9 percent received ORT and continued feeding, while it is higher for the Central (66.7%) and Eastern (61.9%) regions. Seven out of ten 0-11 month old children with diarrhoea in the last two weeks received oral rehydration therapy while in the other age groups more than eight out of ten with diarrhoea in the last two weeks received it. About 10 percent of children with diarrhoea are not given any treatment or drug, with more than double that figure (23.1%) for 0-11 month old children. Figure CH.3: Oral rehydration therapy (percentage of under-five children with diarrhoea who received ORT), Bhutan 2010. 57 Table CH.4 provides the proportion of children aged 0-59 months with diarrhoea in the last two weeks who received oral rehydration therapy with continued feeding, and the percentage of children with diarrhoea who received other treatments. Overall, 73.6 percent of children with diarrhoea received ORS or increased fluids, and 85.4 percent received ORT (ORS or recommended homemade fluids or increased fluids). Combining the information in Table CH.3 with those in Table CH.2 on oral rehydration therapy, it is observed that 61.6 percent of children received ORT and, at the same time feeding was continued, as is the recommendation. There are significant differences in the home management of diarrhoea by background characteristics. In the Western region, 58.9 percent received ORT and continued feeding, while it is higher for the Central (66.7%) and Eastern (61.9%) regions. Seven out of ten 0-11 month old children with diarrhoea in the last two weeks received oral rehydration therapy while in the other age groups more than eight out of ten with diarrhoea in the last two weeks received it. About 10 percent of children with diarrhoea are not given any treatment or drug, with more than double that figure (23.1%) for 0-11 month old children. Figure CH.3: Oral rehydration therapy (percentage of under-five children with diarrhoea who received ORT), Bhutan 2010. 85.4 82.6 88.2 85.6 86.1 83.5 84.1 87.6 85.3 83.5 90.5 93.8 88.5 71.6 84.9 86.6 87.1 88.1 83.2 .0 20.0 40.0 60.0 80.0 100.0 Total Richest Fourth Middle Second Poorest Secondary Primary None 48-59 months 36-47 months 24-35 months 12-23 months 0-11 months Rural Urban Eastern Central Western ORT (ORS or recommended homemade fluids or increased fluids) 65 TA B LE C H .4 : O R A L R EH Y D R AT IO N T H ER A PY W IT H C O N TI N U ED F EE D IN G A N D O TH ER T R EA TM EN TS Pe rc en ta ge o f c hi ld re n ag e 0- 59 m on th s w ith d ia rr ho ea in th e la st tw o w ee ks w ho re ce iv ed o ra l r eh yd ra tio n th er ap y w ith c on tin ue d fe ed in g, a nd p er ce nt ag e of c hi ld re n w ith d ia rr ho ea w ho re ce iv ed o th er tr ea tm en ts , B hu ta n, 2 01 0 C hi ld re n w ith d ia rr ho ea w ho re ce iv ed : O th er tr ea tm en t: N ot g iv en an y tre at - m en t o r dr ug N um be r of c hi ld re n ag ed 0 -5 9 m on th s w ith di ar rh oe a O R S or in cr ea se d fl ui ds O RT (O R S or re co m - m en de d ho m em ad e fl ui ds o r in cr ea se d fl ui ds ) O RT w ith co nt in ue d fe ed in g [1 ] Pi ll or sy ru p: A nt ib io tic Pi ll or sy ru p: A nt im o- til ity Pi ll or sy ru p: Zi nc Pi ll or sy ru p: O th er Pi ll or sy ru p: U nk no w n In je ct io n: A nt ib i- ot ic In je ct io n: N on - an tib io tic In je ct io n: U nk no w n In tra ve - no us H om e re m ed y/ H er ba l m ed ic in e O th er Se x M al e 73 .3 86 .7 63 .0 14 .3 .3 .4 .3 7. 2 1. 7 .0 .8 .0 3. 6 11 .6 9. 6 85 0 Fe m al e 74 .0 83 .9 60 .0 13 .9 .9 1. 3 .6 7. 6 1. 2 .0 .6 .0 3. 5 12 .1 12 .0 73 2 D zo ng kh ag B um th an g 73 .2 88 .0 71 .5 6. 9 .0 .0 .0 2. 9 .0 .0 .0 .0 2. 0 8. 9 12 .0 30 C hu kh a 58 .8 77 .9 57 .9 27 .5 .0 .0 .0 4. 0 2. 7 .0 .0 .0 5. 3 19 .6 12 .1 19 4 D ag an a 78 .3 93 .1 77 .0 16 .1 .0 1. 4 .0 31 .3 .0 .0 .0 .0 2. 2 2. 7 5. 7 58 G as a 65 .2 81 .2 47 .6 8. 9 .0 .0 .0 .0 .0 .0 .0 .0 0. 0 3. 8 18 .8 9 H aa 72 .8 79 .0 62 .5 11 .7 .0 .0 .0 6. 4 2. 5 .0 .0 .0 4. 9 7. 5 15 .6 28 Lh un ts e 85 .9 90 .7 73 .3 23 .9 2. 9 .0 .0 1. 1 1. 2 .0 .0 .0 0. 0 1. 6 7. 7 38 M on ga r 68 .9 81 .2 43 .6 0. 0 1. 2 1. 4 .0 9. 6 2. 1 .0 1. 6 .0 4. 0 4. 3 17 .8 11 7 Pa ro 79 .2 87 .2 75 .1 25 .4 1. 4 .0 1. 5 3. 7 1. 4 .0 .0 .0 1. 0 16 .3 9. 6 86 Pe m ag at sh el 66 .3 80 .9 70 .4 11 .2 1. 5 .0 .0 2. 2 6. 1 .0 .0 .0 9. 5 0. 0 16 .3 34 Pu na kh a 80 .6 88 .0 69 .1 35 .8 .0 .0 .0 .9 1. 9 .0 .0 .0 7. 8 15 .4 8. 6 60 Sa m dr up jo ng kh ar 69 .3 92 .8 81 .2 6. 5 .0 .0 .0 .9 .0 .0 1. 8 .0 1. 7 37 .0 6. 1 83 Sa m ts e 63 .6 75 .0 55 .9 1. 1 .0 3. 6 .0 11 .9 .0 .0 .0 .0 4. 1 20 .9 15 .4 18 6 Sa rp an g 71 .5 81 .3 47 .9 5. 4 5. 5 .0 .0 8. 1 .0 .0 .0 .0 3. 7 5. 6 18 .0 72 Th im ph u 88 .7 93 .3 52 .7 25 .2 .0 1. 9 1. 7 6. 9 .9 .0 1. 9 .0 5. 5 9. 1 4. 1 20 1 Tr as hi ga ng 83 .2 91 .2 55 .2 0. 0 .0 .0 .0 1. 2 5. 0 .0 1. 3 .0 1. 3 2. 9 8. 4 12 7 Tr as hi ya ng - ts e 63 .9 82 .2 78 .0 15 .8 .0 .0 .0 0. 0 .0 .0 1. 3 .0 0. 0 4. 6 16 .7 43 Tr on gs a 64 .2 85 .8 67 .0 1. 5 .0 .0 .0 26 .1 .0 .0 3. 2 .0 1. 7 8. 1 9. 8 31 Ts ira ng 74 .3 84 .2 53 .8 7. 9 .0 .0 3. 3 25 .2 .0 .0 .0 .0 7. 8 3. 6 10 .9 39 W an gd ue 83 .6 90 .6 71 .1 19 .4 .0 .0 1. 5 9. 2 .0 .0 .8 .0 .7 4. 6 6. 3 95 Zh em ga ng 73 .6 91 .9 80 .7 14 .6 1. 0 .0 .0 3. 0 3. 0 .0 .0 .0 1. 0 15 .9 8. 1 50 66 C on td . T A B LE C H .4 : O R A L R EH Y D R AT IO N T H ER A PY W IT H C O N TI N U ED F EE D IN G A N D O TH ER T R EA TM EN TS Pe rc en ta ge o f c hi ld re n ag e 0- 59 m on th s w ith d ia rr ho ea in th e la st tw o w ee ks w ho re ce iv ed o ra l r eh yd ra tio n th er ap y w ith c on tin ue d fe ed in g, a nd p er ce nt ag e of c hi ld re n w ith d ia rr ho ea w ho re ce iv ed o th er tr ea tm en ts , B hu ta n, 2 01 0 C hi ld re n w ith d ia rr ho ea w ho re ce iv ed : O th er tr ea tm en t: N ot g iv en an y tre at - m en t o r dr ug N um be r of c hi ld re n ag ed 0 -5 9 m on th s w ith di ar rh oe a O R S or in cr ea se d fl ui ds O RT (O R S or re co m - m en de d ho m em ad e fl ui ds o r in cr ea se d fl ui ds ) O RT w ith co nt in ue d fe ed in g [1 ] Pi ll or sy ru p: A nt ib io tic Pi ll or sy ru p: A nt im o- til ity Pi ll or sy ru p: Zi nc Pi ll or sy ru p: O th er Pi ll or sy ru p: U nk no w n In je ct io n: A nt ib i- ot ic In je ct io n: N on - an tib io tic In je ct io n: U nk no w n In tra ve - no us H om e re m ed y/ H er ba l m ed ic in e O th er R eg io n W es te rn 72 .4 83 .2 58 .9 20 .1 .2 1. 4 .6 6. 4 1. 3 .0 .5 .0 4. 7 15 .8 10 .4 76 6 C en tra l 75 .7 88 .1 66 .7 11 .9 1. 2 .2 .7 14 .2 .4 .0 .5 .0 2. 5 6. 6 9. 9 37 5 Ea st er n 73 .8 87 .1 61 .9 5. 7 .7 .4 .0 3. 3 2. 6 .0 1. 3 .0 2. 5 9. 5 11 .8 44 2 R es id en ce U rb an 78 .8 86 .6 60 .0 19 .7 .8 1. 8 .7 8. 1 1. 1 .0 1. 2 .0 3. 6 10 .1 10 .7 46 7 R ur al 71 .4 84 .9 62 .3 11 .8 .5 .4 .4 7. 1 1. 6 .0 .5 .0 3. 5 12 .6 10 .7 11 15 A ge 0- 11 60 .7 71 .6 48 .9 6. 6 1. 2 .9 1. 1 6. 6 1. 4 .0 1. 3 .0 1. 3 9. 4 23 .1 36 6 12 -2 3 76 .4 88 .5 63 .1 17 .5 .5 1. 3 .3 6. 9 1. 8 .0 1. 2 .0 4. 2 13 .0 8. 2 44 7 24 -3 5 81 .5 93 .8 70 .9 15 .5 .0 .7 .0 5. 3 1. 2 .0 .1 .0 3. 6 13 .6 5. 4 32 5 36 -4 7 80 .2 90 .5 61 .6 16 .3 .6 .7 .0 8. 7 1. 4 .0 .0 .0 5. 8 12 .5 3. 4 25 8 48 -5 9 69 .0 83 .5 66 .8 15 .3 .3 .0 1. 1 12 .0 1. 1 .0 .4 .0 3. 2 10 .0 11 .7 18 6 M ot he r’ s e du ca tio n N on e 72 .3 85 .3 59 .3 13 .7 .6 .8 .2 7. 5 1. 6 .0 .4 .0 4. 2 12 .2 10 .6 11 14 Pr im ar y 77 .3 87 .6 71 .2 11 .2 .2 .0 2. 3 6. 6 1. 1 .0 0. 0 .0 2. 6 9. 5 7. 6 21 0 Se co nd ar y 76 .1 84 .1 63 .7 18 .5 .7 1. 5 .0 7. 7 1. 2 .0 2. 8 .0 1. 5 12 .4 13 .7 25 7 W ea lth in de x qu in til es Po or es t 69 .1 83 .5 60 .9 8. 2 .7 .7 .4 11 .2 .8 .0 .5 .0 4. 5 12 .7 12 .3 34 1 Se co nd 72 .0 86 .1 64 .6 13 .5 .0 .6 .0 6. 8 2. 0 .0 .8 .0 3. 0 8. 9 10 .7 29 0 M id dl e 70 .5 85 .6 61 .5 12 .7 .5 .7 1. 6 5. 2 2. 2 .0 .0 .0 5. 4 10 .6 11 .0 33 6 Fo ur th 78 .9 88 .2 60 .8 18 .0 .8 .6 .2 8. 1 .3 .0 .9 .0 1. 9 12 .2 7. 5 38 9 R ic he st 78 .0 82 .6 60 .4 19 .3 .8 1. 7 .0 4. 5 2. 6 .0 1. 7 .0 2. 9 15 .6 13 .2 22 7 To ta l 73 .6 85 .4 61 .6 14 .1 .6 .8 .5 7. 4 1. 5 .0 .7 .0 3. 6 11 .9 10 .7 15 82 [1 ] M IC S in di ca to r 3 .8 * A n as te ris k in di ca te s t ha t t he p er ce nt ag e is c al cu la te d on fe w er th an 2 5 un w ei gh te d ca se s 67 Care Seeking and Antibiotic Treatment of Pneumonia Pneumonia is the leading cause of death in children and the use of antibiotics in under-fives with sus- pected pneumonia is a key intervention. A World Fit for Children goal is to reduce by one-third the deaths due to acute respiratory infections. Children with suspected pneumonia are those who had an illness with a cough, accompanied by rapid or difficult breathing and whose symptoms were NOT due to a problem in the chest and a blocked nose. The indicators are: • Prevalence of suspected pneumonia • Care seeking for suspected pneumonia • Antibiotic treatment for suspected pneumonia • Knowledge of the danger signs of pneumonia 68 TA B L E C H .5 : C A R E S E E K IN G F O R S U SP E C T E D P N E U M O N IA A N D A N T IB IO T IC U SE D U R IN G S U SP E C T E D P N E U M O N IA Pe rc en ta ge o f c hi ld re n ag e 0- 59 m on th s w ith su sp ec te d pn eu m on ia in th e la st tw o w ee ks w ho w er e ta ke n to a h ea lth p ro vi de r an d pe rc en ta ge o f c hi ld re n w ho w er e gi ve n an tib io tic s, B hu ta n, 2 01 0 H ad su sp ec te d pn eu m on ia in th e la st tw o w ee ks N um - be r o f ch ild re n ag e 0- 59 m on th s C hi ld re n w ith su sp ec te d pn eu m on ia w ho w er e ta ke n to : A ny a p- pr op ria te pr ov id er [1 ] Pe rc en ta ge o f ch ild re n w ith su sp ec te d pn eu m on ia w ho re ce iv ed a nt ib i- ot ic s i n th e la st tw o w ee ks [2 ] N um be r of c hi ld re n ag e 0- 59 m on th s w ith su sp ec te d pn eu m on ia in th e la st tw o w ee ks P ub lic se ct or : H os pi ta l Pu bl ic se ct or : B as ic he al th un it Pu bl ic se ct or : Sa te lli te cl in ic Pu bl ic se ct or : V ill ag e he al th w or ke r Pu bl ic se ct or : O ut re ac h cl in ic Pr iv at e ph ys ic ia n Pr iv at e ph ar - m ac y R el at iv e / Fr ie nd Sh op Tr ad iti on al pr ac tit io ne r O th er Se x M al e 7. 9 32 16 36 .6 37 .6 .0 1. 1 .8 .6 .0 2. 7 .8 .3 .0 76 .1 49 .8 25 3 Fe m al e 5. 9 30 81 29 .2 40 .4 .0 2. 5 .0 .0 .2 1. 8 .0 .0 1. 2 71 .5 47 .3 18 2 R eg io n W es te rn 6. 6 29 22 43 .2 25 .4 .0 1. 0 .0 .8 .2 4. 6 1. 1 .4 .0 70 .4 55 .6 19 4 C en tra l 6. 3 15 13 29 .6 50 .7 .0 1. 1 2. 1 .0 .0 .3 .0 .0 .0 80 .7 50 .1 95 Ea st er n 7. 9 18 62 23 .3 48 .7 .0 3. 0 .0 .0 .0 .6 .0 .0 1. 4 75 .0 38 .9 14 7 R es id en ce U rb an 4. 4 18 41 61 .3 12 .8 .0 .8 .0 .0 .0 5. 1 2. 5 .0 .0 74 .1 58 .4 81 R ur al 7. 9 44 56 27 .2 44 .7 .0 1. 9 .6 .4 .1 1. 7 .0 .2 .6 74 .2 46 .5 35 4 A ge 0- 11 5. 3 12 29 31 .2 37 .8 .0 .0 3. 1 .0 .6 .0 .0 .0 .0 72 .2 50 .3 65 12 -2 3 6. 5 12 34 28 .0 45 .3 .0 3. 9 .0 .0 .0 1. 1 .0 .0 .0 76 .6 61 .6 80 24 -3 5 7. 0 13 37 32 .8 39 .9 .0 1. 2 .0 .0 .0 2. 9 .0 .8 .0 71 .9 44 .7 93 36 -4 7 7. 8 12 75 42 .8 33 .3 .0 2. 7 .0 1. 5 .0 .0 .0 .0 .0 80 .3 54 .5 10 0 48 -5 9 7. 9 12 22 30 .8 38 .5 .0 .5 .0 .0 .0 6. 7 2. 1 .0 2. 2 69 .3 35 .0 97 M ot he r’ s e du ca tio n N on e 7. 7 42 07 28 .4 44 .4 .0 2. 2 .6 .0 .0 1. 6 .0 .2 .7 75 .0 41 .9 32 3 Pr im ar y 7. 7 78 1 40 .1 20 .6 .0 .4 .0 .0 .0 1. 4 3. 4 .0 .0 61 .1 69 .6 60 Se co nd ar y 4. 0 13 09 57 .6 25 .0 .0 .0 .0 2. 8 .8 7. 9 .0 .0 .0 84 .3 66 .9 52 W ea lth in de x qu in til es Po or es t 10 .1 12 94 15 .6 43 .9 .0 4. 4 .0 .0 .0 3. 1 .0 .0 1. 6 63 .6 40 .6 13 1 Se co nd 7. 7 11 59 28 .7 49 .6 .0 1. 1 2. 3 .0 .0 .8 .0 .0 .0 80 .6 46 .8 89 M id dl e 6. 0 11 97 29 .5 49 .1 .0 .0 .0 .0 .0 1. 6 .0 1. 0 .0 77 .6 61 .5 72 Fo ur th 6. 9 14 38 52 .1 25 .0 .0 .0 .0 .0 .0 4. 1 2. 1 .0 .0 76 .5 44 .6 99 R ic he st 3. 6 12 08 61 .4 15 .7 .0 1. 4 .0 3. 4 .9 .0 .0 .0 .0 81 .8 65 .6 44 To ta l 6. 9 62 97 33 .5 38 .8 .0 1. 7 .5 .3 .1 2. 3 .5 .2 .5 74 .2 48 .7 43 5 [1 ] M IC S in di ca to r 3 .9 [2 ] M IC S in di ca to r 3 .1 0 * B y D zo ng kh ag is n ot sh ow n be ca us e th e nu m be r o f u nw ei gh te d ob se rv at io n ar e lo w er th an 5 0 69 Table CH.5 presents the prevalence of suspected pneumonia and, if care was sought outside the home, the site of care. 6.9 percent of children aged 0-59 months were reported to have had symptoms of pneumonia during the two weeks preceding the survey. Of these children, 74.2 percent were taken to an appropriate provider, with the vast majority being taken to a public sector hospital (33.5%) or a public sector Basic Health Unit (38.8%). Table CH.5 also presents the use of antibiotics for the treatment of suspected pneumonia in under- fives by sex, age, region, residence, and socio-economic factors. In Bhutan, 48.7 percent of under-five children with suspected pneumonia had received antibiotics during the two weeks prior to the survey. The percentage was higher in urban areas (58.4%), while the percentage declines to only 38.9 percent in the Eastern region. The table also shows that antibiotic treatment of suspected pneumonia is very low among the poorest households (40.6%), among children whose mothers/caretakers have no edu- cation (41.9%), and among children 48-59 months old (35%). 70 Solid Fuel Use More than three billion people around the world rely on solid fuels (biomass and coal) for their basic energy needs, including cooking and heating. Cooking and heating with solid fuels leads to high lev- els of indoor smoke, a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is products of incomplete combustion, including CO, polyaromatic hydrocarbons, SO2, and other toxic elements. Use of solid fuels increases the risks of acute respiratory illness, pneumo- nia, chronic obstructive lung disease, cancer, and possibly tuberculosis, low birth weight, cataracts, and asthma. The primary indicator is the proportion of the population using solid fuels as the primary source of domestic energy for cooking. TABLE CH.6: SOLID FUEL USE Percentage disribution of household members according to type of cooking fuel used by the household, and percentage of household mem- bers living in households using solid fuels for cooking, Bhutan, 2010 Percentage of household members in households using: Solid fuels for cooking [1] Number of household membersElectricity Liquefied Petroleum Gas (LPG) Kerosene Coal Wood Straw/ Shrubs/ Grass No food cooked in household Other Total Dzongkhag Bumthang 22.7 32.1 .0 .0 45.2 .0 .0 .0 100.0 45.2 1605 Chukha 23.4 37.8 .0 .2 38.6 .0 .0 .0 100.0 38.7 6863 Dagana 10.6 11.1 .1 .1 77.8 .2 .0 .0 100.0 78.2 2541 Gasa 37.9 5.0 .0 .2 56.9 .0 .0 .0 100.0 57.1 484 Haa 44.4 39.6 .6 .0 15.3 .0 .1 .0 100.0 15.3 1312 Lhuntse 49.8 3.1 .1 .1 46.9 .0 .0 .0 100.0 46.9 1564 Mongar 28.7 14.4 .1 .6 56.3 .0 .0 .0 100.0 56.8 4741 Paro 48.6 45.8 .2 .0 5.5 .0 .0 .0 100.0 5.5 3776 Pemagatshel 18.7 15.7 .1 .3 65.2 .0 .0 .0 100.0 65.5 2627 Punakha 73.8 13.8 .0 .0 12.4 .0 .0 .0 100.0 12.4 2549 Samdrup jongkhar 34.3 12.7 .1 .2 52.7 .0 .0 .0 100.0 52.9 3892 Samtse 25.5 12.8 .4 .3 61.0 .1 .0 .0 100.0 61.3 7530 Sarpang 29.1 35.9 1.0 .0 34.0 .0 .0 0.0 100.0 34.0 4127 Thimphu 47.1 52.1 .0 .0 .6 .0 .0 .2 100.0 .6 8372 Trashigang 65.6 2.5 .0 .0 31.9 .0 .0 .0 100.0 31.9 5266 Trashiyangtse 48.9 11.5 .0 .4 39.2 .0 .0 .0 100.0 39.5 1711 Trongsa 23.6 21.8 .1 .3 54.2 .0 .0 .0 100.0 54.5 1510 Tsirang 6.3 15.4 .0 1.4 76.9 .0 .0 .0 100.0 78.3 2208 Wangdue 52.0 16.7 .1 .4 30.4 .4 .0 .0 100.0 31.2 2841 Zhemgang 29.1 7.0 .1 .5 63.3 .0 .0 .0 100.0 63.7 1800 Region Western 38.7 34.1 .2 .1 26.8 .0 .0 .0 100.0 27.0 30887 Central 26.1 21.3 .3 .3 51.9 .1 .0 .0 100.0 52.3 16631 Eastern 41.7 9.9 .1 .3 48.1 .0 .0 .0 100.0 48.3 19801 71 Contd. TABLE CH.6: SOLID FUEL USE Percentage disribution of household members according to type of cooking fuel used by the household, and percentage of household mem- bers living in households using solid fuels for cooking, Bhutan, 2010 Percentage of household members in households using: Solid fuels for cooking [1] Number of household membersElectricity Liquefied Petroleum Gas (LPG) Kerosene Coal Wood Straw/ Shrubs/ Grass No food cooked in household Other Total Residence Urban 44.5 52.9 .4 .1 2.1 0.0 0.0 0.0 100.0 2.2 18500 Rural 33.4 12.8 .1 .3 53.3 .0 .0 .0 100.0 53.6 48820 Education of household head None 35.2 13.8 .1 .3 50.6 .0 .0 .0 100.0 50.9 44415 Primary 40.4 25.0 .3 .0 34.2 .0 .0 .1 100.0 34.3 10129 Secondary + 37.9 57.9 .3 .0 3.8 .0 .0 .0 100.0 3.8 12763 Missing/DK * * * * * * * * * * 13 Wealth index quintiles Poorest .1 0.0 .0 .2 99.7 .0 .0 .0 100.0 99.9 13461 Second 27.7 2.2 .1 .6 69.4 .0 .0 .0 100.0 70.0 13468 Middle 62.4 14.2 .4 .3 22.5 .1 .0 .1 100.0 22.8 13466 Fourth 61.2 34.1 .4 .0 4.4 .0 .0 .0 100.0 4.4 13462 Richest 30.9 68.7 .0 .0 .3 .0 .0 .0 100.0 .3 13462 Total 36.5 23.9 .2 .2 39.3 .0 .0 .0 100.0 39.5 67320 [1] MICS indicator 3.11 * An asterisk indicates that the percentage is calculated on fewer than 25 unweighted cases 72 In more than a third of the household population (39.5%) of Bhutan, the main source of fuel for cooking is solid fuels. Use of solid fuels is very low among the household population in urban areas (2.2%), but very high in rural areas, where more than half of the household population (53.6%) are us- ing solid fuels. Differentials with respect to household wealth and the educational level of the house- hold head are also significant. The findings show that use of solid fuels is very uncommon among household population in the Western region, and among the richest. The table also clearly shows that the overall percentage is high due to high level of use of wood for cooking purposes. Solid fuel use alone is a poor proxy for indoor air pollution, since the concentration of the pollutants is different when the same fuel is burnt in different stoves or fires. Use of closed stoves with chimneys minimizes indoor pollution, while open stoves or a fire with no chimney or hood means that there is no protection from the harmful effects of solid fuels. Solid fuel use by place of cooking is depicted in Table CH.7. The table shows that of household members using solid fuels for cooking 36.7 percent cook in a separate building, 34.2 percent in a separate room used as kitchen, and 25.3 percent cook elsewhere in the house. 73 TABLE CH.7: SOLID FUEL USE BY PLACE OF COOKING Percentage distribution of household members in households using solid fuels by place of cooking, Bhutan, 2010 Place of cooking: Number of house- hold members in households using solid fuels for cooking In a separate room used as kitchen Elsewhere in the house In a separate building Outdoors Other Total Dzongkhag Bumthang 31.0 68.1 .4 .5 .0 100.0 725 Chukha 44.7 22.2 32.1 .5 .5 100.0 2659 Dagana 22.4 17.9 57.0 2.5 .2 100.0 1986 Gasa 44.9 55.1 0.0 .0 .0 100.0 277 Haa 16.8 69.2 13.4 .0 .6 100.0 201 Lhuntse 21.9 45.7 31.3 1.1 0.0 100.0 734 Mongar 29.3 14.6 40.8 15.1 .2 100.0 2695 Paro 65.9 18.3 10.9 4.3 .7 100.0 206 Pemagatshel 37.7 21.4 40.5 .5 .0 100.0 1721 Punakha 47.4 25.7 24.2 2.2 .6 100.0 316 Samdrup jongkhar 32.6 38.0 29.0 .3 .0 100.0 2058 Samtse 51.3 14.2 26.9 7.4 .2 100.0 4617 Sarpang 10.5 19.7 69.8 .0 .0 100.0 1401 Thimphu (81.5) (.0) (.0) (18.5) (.0) (100.0) 50 Trashigang 12.0 43.1 44.2 .7 .0 100.0 1682 Trashiyangtse 38.7 21.3 39.2 .9 .0 100.0 677 Trongsa 35.4 47.9 14.7 1.6 .5 100.0 823 Tsirang 8.3 16.9 74.0 .7 .0 100.0 1728 Wangdue 73.4 16.1 5.5 .0 5.0 100.0 885 Zhemgang 35.7 32.9 30.8 .5 .1 100.0 1147 Region Western 48.5 19.9 26.7 4.6 .3 100.0 8325 Central 26.6 26.8 45.0 1.0 .6 100.0 8696 Eastern 28.6 28.7 37.9 4.7 .1 100.0 9567 Residence Urban 45.3 27.5 25.7 1.5 .0 100.0 399 Rural 34.0 25.3 36.9 3.5 .3 100.0 26190 Education of household head None 33.9 27.0 35.1 3.6 .4 100.0 22621 Primary 36.5 13.6 47.1 2.6 .2 100.0 3475 Secondary + 30.5 30.2 38.7 .6 .0 100.0 486 Missing/DK * * * * * * * Wealth index quintiles Poorest 30.0 32.8 33.1 3.8 .4 100.0 13450 Second 36.8 19.5 40.2 3.2 .3 100.0 9429 Middle 39.8 13.4 43.5 3.1 .2 100.0 3077 Fourth 56.7 10.5 32.4 .5 .0 100.0 589 Richest 51.9 48.1 .0 .0 .0 100.0 44 Total 34.2 25.3 36.7 3.4 .3 100.0 26589 * An asterisk indicates that the percentage is calculated on fewer than 25 unweighted cases * Figures in parenthesis indicate that the percentage is based on just 25 to 49 unweighted cases 74 75 VII. Water and Sanitation Safe drinking water is a basic necessity for good health. Unsafe drinking water can be a significant carrier of diseases such as trachoma, cholera, typhoid, and schistosomiasis. Drinking water can also be tainted with chemical, physical and radiological contaminants with harmful effects on hu- man health. In addition to its association with disease, access to drinking water may be particularly important for women and children, especially in rural areas, who bear the primary responsibility for carrying water, often for long distances. The MDG goal is to reduce by half, between 1990 and 2015, the proportion of people without sustain- able access to safe drinking water and basic sanitation. The World Fit for Children goal calls for a reduction in the proportion of households without access to hygienic sanitation facilities and afford- able and safe drinking water by at least one-third. The list of indicators used in MICS is as follows: Water • Use of improved drinking water sources • Use of adequate water treatment method • Time to source of drinking water • Person collecting drinking water Sanitation • Use of improved sanitation facilities • Sanitary disposal of child’s faeces For more details on water and sanitation and to access some reference documents, please visit the UNICEF childinfo website http://www.childinfo.org/wes.html. Use of Improved Water Sources The distribution of the population by source of drinking water is shown in Table WS.1 and Figure WS.1. The population using improved sources of drinking water are those using any of the following types of supply: piped water (into dwelling, compound, yard or plot, public tap/standpipe), tube well/ borehole, protected well, protected spring, and rainwater collection. Bottled water is considered as an improved water source only if the household is using an improved water source for other purposes, such as hand-washing and cooking. 76 TA B L E W S. 1: U SE O F IM PR O V E D W AT E R S O U R C E S Pe rc en t d is tr ib ut io n of h ou se ho ld p op ul at io n ac co rd in g to m ai n so ur ce o f d ri nk in g w at er a nd p er ce nt ag e of h ou se ho ld p op ul at io n us in g im pr ov ed d ri nk in g w at er so ur ce s, B hu ta n, 2 01 0 M ai n so ur ce o f d rin ki ng w at er To ta l Pe rc en t- ag e us in g im pr ov ed so ur ce s o f dr in ki ng w at er [1 ] N um - be r o f ho us e- ho ld m em - be rs Im pr ov ed so ur ce s U ni m pr ov ed so ur ce s Pi pe d in to dw el l- in g Pi pe d in to co m - po un d Pi pe d to ne ig h- bo r Pu bl ic ou td oo r ta p Pr o- te ct ed w el l Sp rin g R ai nw a- te r c ol - le ct io n B ot tle d w at er U np ro - te ct ed w el l U np ro - te ct ed sp rin g Ta nk er - tru ck C ar t w ith sa m ll ta nk / dr um Su rf ac e w at er (r iv er ,st re am , d am , la ke ,p on d, ca na l,i rr ig at io n ch an ne l) O th er D zo ng kh ag B um th an g 28 .1 55 .5 2. 6 9. 1 .1 4. 1 .0 .0 .0 .2 .0 .0 .2 .0 10 0. 0 99 .6 16 05 C hu kh a 39 .1 39 .9 13 .4 .5 .0 .8 .0 .0 .0 3. 2 .0 .0 3. 1 .0 10 0. 0 93 .7 68 63 D ag an a 6. 0 74 .3 4. 3 7. 1 .4 2. 0 .0 .0 .4 .8 .0 .0 4. 4 .4 10 0. 0 94 .1 25 41 G as a 7. 0 23 .2 3. 3 26 .4 6. 0 4. 1 .0 .0 .5 9. 0 .0 .0 20 .5 .0 10 0. 0 70 .0 48 4 H aa 55 .4 41 .4 .6 2. 1 .1 .5 .0 .0 .0 .0 .0 .0 0. 0 .0 10 0. 0 10 0. 0 13 12 Lh un ts e 4. 9 65 .0 4. 7 23 .4 .0 0. 0 .0 .0 .4 .0 .0 .0 1. 5 .0 10 0. 0 98 .1 15 64 M on ga r 18 .0 74 .7 2. 4 1. 3 .0 2. 4 .3 .0 .1 .8 .0 .0 .1 .0 10 0. 0 99 .0 47 41 Pa ro 35 .7 49 .7 6. 9 2. 0 1. 6 .5 .0 .0 .1 .6 .3 .4 2. 1 .0 10 0. 0 96 .4 37 76 Pe m ag at sh el 7. 2 67 .6 12 .1 6. 3 1. 8 1. 2 .1 .0 .0 .4 .0 .0 3. 3 .0 10 0. 0 96 .2 26 27 Pu na kh a 20 .9 50 .0 4. 9 14 .6 .3 .3 .1 .0 .5 2. 6 .0 .0 5. 5 .3 10 0. 0 91 .0 25 49 Sa m dr up jo ng kh ar 16 .1 72 .0 8. 8 0. 0 .0 .4 .0 .0 .0 1. 2 .0 .0 .8 .6 10 0. 0 97 .3 38 92 Sa m ts e 20 .4 65 .3 4. 7 4. 0 .1 .9 .0 .0 1. 2 2. 2 .0 .0 1. 0 .2 10 0. 0 95 .4 75 30 Sa rp an g 30 .1 46 .7 14 .3 4. 4 .0 1. 2 .0 .0 .1 1. 3 .0 .1 1. 8 .1 10 0. 0 96 .7 41 27 Th im ph u 72 .4 26 .3 .9 .3 .0 .0 .0 .2 .0 .0 .0 .0 0. 0 .0 10 0. 0 10 0. 0 83 72 Tr as hi ga ng 8. 6 70 .7 4. 0 9. 9 2. 5 2. 8 .0 .0 .4 .5 .0 .0 .6 .0 10 0. 0 98 .6 52 66 Tr as hi ya ng ts e 13 .4 76 .8 5. 8 .5 .0 .9 .0 .0 .5 1. 3 .0 .0 .8 .0 10 0. 0 97 .4 17 11 Tr on gs a 17 .1 42 .8 4. 8 29 .3 .3 .5 .0 .0 .1 1. 3 .0 .0 3. 7 .1 10 0. 0 94 .8 15 10 Ts ira ng 10 .9 80 .4 4. 2 .2 .0 .0 .0 .0 .1 1. 7 .0 .2 2. 0 .1 10 0. 0 95 .8 22 08 W an gd ue 17 .3 41 .9 6. 8 22 .4 .1 1. 6 .0 .0 .3 1. 3 .0 .0 8. 4 .0 10 0. 0 90 .0 28 41 Zh em ga ng 10 .1 41 .1 21 .0 18 .6 .1 .2 .0 .0 .0 1. 2 .0 .0 7. 8 .0 10 0. 0 91 .0 18 00 77 C on td . T A B L E W S. 1: U SE O F IM PR O V E D W AT E R S O U R C E S Pe rc en t d is tr ib ut io n of h ou se ho ld p op ul at io n ac co rd in g to m ai n so ur ce o f d ri nk in g w at er a nd p er ce nt ag e of h ou se ho ld p op ul at io n us in g im pr ov ed d ri nk in g w at er so ur ce s, B hu ta n, 2 01 0 M ai n so ur ce o f d rin ki ng w at er To ta l Pe rc en t- ag e us in g im pr ov ed so ur ce s o f dr in ki ng w at er [1 ] N um - be r o f ho us e- ho ld m em - be rs Im pr ov ed so ur ce s U ni m pr ov ed so ur ce s Pi pe d in to dw el l- in g Pi pe d in to co m - po un d Pi pe d to ne ig h- bo r Pu bl ic ou td oo r ta p Pr o- te ct ed w el l Sp rin g R ai nw a- te r c ol - le ct io n B ot tle d w at er U np ro - te ct ed w el l U np ro - te ct ed sp rin g Ta nk er - tru ck C ar t w ith sa m ll ta nk / dr um Su rf ac e w at er (r iv er ,st re am , d am , la ke ,p on d, ca na l,i rr ig at io n ch an ne l) O th er R eg io n W es te rn 41 .8 44 .2 5. 7 3. 1 .3 .6 .0 .1 .3 1. 7 .0 .1 2. 0 .1 10 0. 0 95 .8 30 88 7 C en tra l 18 .2 54 .5 8. 9 11 .6 .1 1. 3 .0 .0 .2 1. 2 .0 .0 4. 0 .1 10 0. 0 94 .5 16 63 1 Ea st er n 12 .3 71 .6 5. 8 5. 7 .9 1. 7 .1 .0 .2 .7 .0 .0 1. 0 .1 10 0. 0 98 .0 19 80 1 R es id en ce U rb an 69 .9 23 .1 3. 1 3. 1 .0 .3 .0 .1 0. 0 .1 .0 .0 .2 .0 10 0. 0 99 .6 18 50 0 R ur al 11 .1 66 .8 7. 8 7. 0 .6 1. 4 .0 .0 .4 1. 7 .0 .0 2. 9 .1 10 0. 0 94 .8 48 82 0 E du ca tio n of h ou se ho ld h ea d N on e 13 .5 65 .0 7. 7 7. 4 .7 1. 2 .0 .0 .4 1. 4 .0 .0 2. 6 .1 10 0. 0 95 .4 44 41 5 Pr im ar y 31 .2 51 .4 6. 4 4. 7 .1 1. 3 .0 .0 .0 2. 1 .1 .0 2. 7 .0 10 0. 0 95 .0 10 12 9 Se co nd ar y + 72 .3 22 .1 2. 6 2. 1 .0 .4 .0 .1 .0 .2 .0 .0 .2 .1 10 0. 0 99 .5 12 76 3 M is si ng /D K * * * * * * * * * * * * * * * * * W ea lth in de x qu in til es Po or es t .1 72 .1 8. 8 8. 2 .7 1. 8 .1 .0 .8 2. 8 .0 .0 4. 3 .3 10 0. 0 91 .8 13 46 1 Se co nd 1. 8 74 .1 8. 2 7. 9 .8 1. 6 .0 .0 .2 2. 2 .0 .1 2. 9 .1 10 0. 0 94 .6 13 46 8 M id dl e 4. 7 73 .7 8. 4 7. 7 .4 1. 4 .0 .0 .3 1. 0 .0 .0 2. 4 .1 10 0. 0 96 .2 13 46 6 Fo ur th 39 .8 46 .1 6. 6 5. 2 .3 .5 .0 .0 .0 .4 .0 .1 1. 0 .0 10 0. 0 98 .4 13 46 2 R ic he st 90 .0 8. 0 .7 .7 .1 .1 .0 .1 .0 .0 .1 .0 .2 .0 10 0. 0 99 .8 13 46 2 To ta l 27 .3 54 .8 6. 5 6. 0 .5 1. 1 .0 .0 .3 1. 3 .0 .0 2. 2 .1 10 0. 0 96 .1 67 32 0 [1 ] M IC S in di ca to r 4 .1 ; M D G in di ca to r 7 .8 * A n as te ris k in di ca te s t ha t t he p er ce nt ag e is c al cu la te d on fe w er th an 2 5 un w ei gh te d ca se s 78 Overall, 96.1 percent of the population is using an improved source of drinking water – 99.6 percent in urban areas and 94.8 percent in rural areas. There are only small regional differences with 94.5 percent of the population in Central region getting its drinking water from an improved source com- pared to 95.8 percent in the Western region and 98 percent in the Eastern region. The source of drinking water for the population varies by region (Table WS.1). In the Western and Eastern regions, 91.7 and 89.7 percent respectively uses drinking water that is piped into their dwell- ing, yard or neighbour’s place. In contrast, only about 81.6 percent of those residing in Central region have piped water. In Gasa Dzongkhag more than two out of ten household members use surface wa- ter as the source of drinking water, therefore, the use of improved drinking water sources at 70 percent is much lower compared to the other Dzongkhags. Figure WS.1: Percentage of household population using improved source of drinking water by Dzongkhag, Bhutan 2010. 70 Overall, 96.1 percent of the population is using an improved source of drinking water – 99.6 percent in urban areas and 94.8 percent in rural areas. There are only small regional differences with 94.5 percent of the population in Central region getting its drinking water from an improved source compared to 95.8 percent in the Western region and 98 percent in the Eastern region. The source of drinking water for the population varies by region (Table WS.1). In the Western and Eastern regions, 91.7 and 89.7 percent respectively uses drinking water that is piped into their dwelling, yard or neighbour’s place. In contrast, only about 81.6 percent of those residing in Central region have piped water. In Gasa Dzongkhag more than two out of ten household members use surface water as the source of drinking water, therefore, the use of improved drinking water sources at 70 percent is much lower compared to the other Dzongkhags. Figure WS.1: Percentage of household population using improved source of drinking water by Dzongkhag, Bhutan 2010. 99.6 93.7 94.1 70.0 100.0 98.1 99.0 96.4 96.2 91.0 97.3 95.4 96.7 100.0 98.6 97.4 94.8 95.8 90.0 91.0 96.1 0.0 20.0 40.0 60.0 80.0 100.0 120.0 % Dzongkhag 79 Use of in-house water treatment is presented in Table WS.2. Households were asked of ways they may be treating water at home to make it safer to drink – boiling, adding bleach or chlorine, using a water filter, and using solar disinfection were considered as proper treatment of drinking water. The table shows water treatment by all households and the percentage of household members living in households using unimproved water sources but using appropriate water treatment methods. About 56 percent of the household population used a proper method to treat their drinking water. Cal- culated by area, 54.7 percent of rural and 98.6 percent of urban household members properly treated the water. Disparities exist between the educational levels of the household head and between the wealth quintiles. It is more likely for a household to treat the water properly in the wealthier house- holds, and in those with household head with primary, secondary education or above. Most of the households (74.8%) boil the drinking water as it is a cost effective way of treatment. 80 TA B L E W S. 2: H O U SE H O L D W AT E R T R E AT M E N T Pe rc en ta ge o f h ou se ho ld p op ul at io n by d ri nk in g w at er tr ea tm en t m et ho d us ed in th e ho us eh ol d, a nd fo r ho us eh ol d m em be rs li vi ng in h ou se ho ld s w he re a n un im pr ov ed d ri nk in g w at er so ur ce is us ed , t he p er ce nt ag e w ho a re u si ng a n ap pr op ri at e tr ea tm en t m et ho d, B hu ta n, 2 01 0 W at er tr ea tm en t m et ho d us ed in th e ho us eh ol d N um be r o f ho us eh ol d m em be rs Pe rc en ta ge o f ho us eh ol d m em - be rs in h ou se ho ld s us in g un im pr ov ed dr in ki ng w at er so ur ce s a nd u si ng an a pp ro pr ia te w at er tr ea tm en t m et ho d [1 ] N um be r o f ho us eh ol d m em be rs in ho us eh ol ds u si ng un im pr ov ed dr in ki ng w at er so ur ce s N on e B oi l A dd b le ac h / ch lo rin e St ra in th ro ug h a cl ot h U se w at er fi lt er So la r d is in fe ct io n Le t i t s ta nd a nd se ttl e O th er D on ’t kn ow D zo ng kh ag B um th an g 17 .8 73 .5 .9 1. 1 20 .3 .0 12 .6 .0 .0 16 05 10 0. 0 6 C hu kh a 6. 8 81 .8 .4 1. 2 34 .9 .1 13 .1 .0 .0 68 63 70 .6 43 0 D ag an a 9. 7 89 .2 .0 .0 12 .6 .0 2. 4 .0 .0 25 41 85 .7 15 0 G as a 23 .4 53 .7 .0 5. 5 3. 4 .0 30 .8 .0 .0 48 4 30 .6 14 5 H aa 4. 0 94 .0 .0 1. 0 29 .1 .0 7. 2 .0 .0 13 12 * . Lh un ts e 51 .7 40 .3 .0 1. 9 8. 4 .0 15 .9 .0 .0 15 64 16 .6 30 M on ga r 33 .2 63 .6 .4 1. 0 15 .6 .0 3. 2 .0 .0 47 41 (2 2. 9) 46 Pa ro 7. 9 71 .7 .2 .7 28 .1 .2 22 .7 .0 .0 37 76 58 .1 13 5 Pe m ag at sh el 29 .1 63 .6 .6 4. 5 9. 4 1. 5 24 .3 .0 .0 26 27 74 .2 99 Pu na kh a 23 .7 58 .2 .0 1. 9 25 .3 .1 13 .5 .0 .0 25 49 34 .6 22 8 Sa m dr up jo ng kh ar 32 .5 60 .7 .4 2. 8 13 .9 .0 5. 2 .0 .0 38 92 31 .1 10 4 Sa m ts e 11 .1 85 .5 .0 1. 2 17 .2 .0 3. 0 .0 .0 75 30 70 .1 34 5 Sa rp an g 11 .5 83 .7 .1 7. 5 16 .0 .0 .4 .0 .0 41 27 80 .1 13 6 Th im ph u 1. 8 95 .2 .3 1. 1 60 .1 .0 1. 1 .0 .0 83 72 * . Tr as hi ga ng 20 .5 67 .5 .0 .7 9. 5 .0 18 .4 .0 .0 52 66 (5 7. 3) 76 Tr as hi ya ng ts e 33 .2 63 .4 .1 .7 11 .9 .0 2. 8 .0 .0 17 11 66 .3 45 Tr on gs a 29 .3 45 .3 .1 2. 5 18 .1 .2 36 .7 .0 .0 15 10 32 .7 79 Ts ira ng 5. 5 93 .5 .0 .2 9. 2 .0 .6 .0 .0 22 08 86 .1 93 W an gd ue 9. 9 66 .3 .1 1. 3 14 .2 .1 32 .1 .0 .0 28 41 51 .0 28 3 Zh em ga ng 55 .5 42 .6 .0 .8 11 .6 .0 2. 0 .0 .0 18 00 7. 6 16 3 81 C on td . T A B L E W S. 2: H O U SE H O L D W AT E R T R E AT M E N T Pe rc en ta ge o f h ou se ho ld p op ul at io n by d ri nk in g w at er tr ea tm en t m et ho d us ed in th e ho us eh ol d, a nd fo r ho us eh ol d m em be rs li vi ng in h ou se ho ld s w he re a n un im pr ov ed d ri nk in g w at er so ur ce is us ed , t he p er ce nt ag e w ho a re u si ng a n ap pr op ri at e tr ea tm en t m et ho d, B hu ta n, 2 01 0 W at er tr ea tm en t m et ho d us ed in th e ho us eh ol d N um be r o f ho us eh ol d m em be rs Pe rc en ta ge o f ho us eh ol d m em - be rs in h ou se ho ld s us in g un im pr ov ed dr in ki ng w at er so ur ce s a nd u si ng an a pp ro pr ia te w at er tr ea tm en t m et ho d [1 ] N um be r o f ho us eh ol d m em be rs in ho us eh ol ds u si ng un im pr ov ed dr in ki ng w at er so ur ce s N on e B oi l A dd b le ac h / ch lo rin e St ra in th ro ug h a cl ot h U se w at er fi lt er So la r d is in fe ct io n Le t i t s ta nd a nd se ttl e O th er D on ’t kn ow R eg io n W es te rn 8. 2 83 .2 .2 1. 2 35 .0 .1 8. 6 .0 .0 30 88 7 58 .2 12 83 C en tra l 17 .1 74 .0 .2 2. 5 14 .4 .0 10 .8 .0 .0 16 63 1 55 .6 91 0 Ea st er n 30 .6 62 .2 .3 1. 8 11 .9 .2 11 .4 .0 .0 19 80 1 48 .7 39 9 R es id en ce U rb an 2. 6 90 .2 .4 2. 2 55 .6 .0 3. 3 .0 .0 18 50 0 98 .6 68 R ur al 22 .4 68 .9 .1 1. 5 10 .9 .1 12 .5 .0 .0 48 82 0 54 .7 25 24 E du ca tio n of h ou se ho ld h ea d N on e 22 .9 67 .9 .2 1. 7 11 .5 .1 12 .7 .0 .0 44 41 5 49 .3 20 22 Pr im ar y 9. 2 84 .2 .0 1. 3 25 .3 .1 7. 3 .0 .0 10 12 9 77 .2 50 5 Se co nd ar y + 2. 6 91 .1 .4 2. 1 62 .1 .1 2. 8 .0 .0 12 76 3 92 .3 65 M is si ng /D K * * * * * * * * * * * * W ea lth in de x qu in til es Po or es t 35 .5 57 .5 .0 .8 .7 .2 9. 5 .0 .0 13 46 1 49 .5 11 09 Se co nd 26 .6 64 .8 .0 1. 7 2. 4 .1 14 .9 .0 .0 13 46 8 55 .0 73 1 M id dl e 15 .6 74 .5 .1 1. 2 9. 0 .0 16 .6 .0 .0 13 46 6 57 .5 50 6 Fo ur th 5. 5 86 .5 .3 2. 3 30 .9 .0 7. 1 .0 .0 13 46 2 81 .2 21 5 R ic he st 1. 7 90 .6 .6 2. 5 72 .7 .2 1. 8 .0 .0 13 46 2 (1 00 .0 ) 30 To ta l 17 .0 74 .8 .2 1. 7 23 .2 .1 10 .0 .0 .0 67 32 0 55 .8 25 92 [1 ] M IC S in di ca to r 4 .2 * A n as te ris k in di ca te s t ha t t he p er ce nt ag e is c al cu la te d on fe w er th an 2 5 un w ei gh te d ca se s * Fi gu re s i n pa re nt he si s i nd ic at e th at th e pe rc en ta ge is b as ed o n ju st 2 5 to 4 9 un w ei gh te d ca se s 82 The amount of time it takes to obtain water is presented in Table WS.3 and the person who usually collected the water in Table WS.4. Note that these results refer to one roundtrip from home to drink- ing water source. Information on the number of trips made in one day was not collected. Table WS.3 shows that for 93 percent of households, the drinking water source is on the premises. For 5.1 percent of all households, it takes less than 30 minutes to get to the water source and bring water, while 1.9 percent of households spend 30 minutes or more for this purpose. In rural areas more households spend time in collecting water compared to those in urban areas. For users of improved drinking water sources, a higher 1.2 percent of households in the Eastern region spend 30 minutes or more for getting water compared to the Central and Western regions (0.9 and 0.3% respectively). However, for users of unimproved drinking water sources, a lower 0.6 percent in the Eastern region spend 30 minutes or more for getting water compared to the Central and Western regions (1.5 and 1.4% respectively). Thus, in the Eastern region it is easier to find unimproved drinking water sources close by, and more difficult to find improved drinking water sources close by compared to the other regions. 83 TA B L E W S. 3: T IM E T O S O U R C E O F D R IN K IN G W AT E R Pe rc en t d is tr ib ut io n of h ou se ho ld p op ul at io n ac co rd in g to ti m e to g o to so ur ce o f d ri nk in g w at er , g et w at er a nd r et ur n, fo r us er s o f i m pr ov ed a nd u ni m pr ov ed d ri nk in g w at er so ur ce s, B hu ta n, 20 10 Ti m e to so ur ce o f d ri nk in g w at er To ta l N um be r o f ho us eh ol d m em be rs U se rs o f i m pr ov ed d ri nk in g w at er so ur ce s U se rs o f u ni m pr ov ed d ri nk in g w at er so ur ce s W at er o n pr em is es Le ss th an 3 0 m in ut es 30 m in ut es o r m or e M is si ng /D K W at er o n pr em - is es Le ss th an 3 0 m in ut es 30 m in ut es o r m or e M is si ng /D K D zo ng kh ag B um th an g 88 .2 7. 8 3. 4 .1 .0 .4 0. 0 .0 10 0. 0 16 05 C hu kh a 92 .7 1. 0 .0 .0 .7 2. 7 2. 8 .0 10 0. 0 68 63 D ag an a 87 .8 6. 0 .3 .0 .6 2. 8 2. 5 .0 10 0. 0 25 41 G as a 55 .3 11 .2 1. 6 1. 8 1. 7 19 .5 8. 9 .0 10 0. 0 48 4 H aa 99 .3 .3 .4 .0 .0 .0 0. 0 .0 10 0. 0 13 12 Lh un ts e 98 .0 .0 .1 .0 1. 2 .3 .4 .0 10 0. 0 15 64 M on ga r 95 .4 1. 7 1. 9 .0 .5 .1 .4 .0 10 0. 0 47 41 Pa ro 94 .0 1. 6 .8 .0 .7 1. 8 1. 1 .0 10 0. 0 37 76 Pe m ag at sh el 90 .7 5. 1 .5 .0 .5 1. 7 1. 6 .0 10 0. 0 26 27 Pu na kh a 86 .2 4. 9 .0 .0 2. 7 5. 4 .7 .1 10 0. 0 25 49 Sa m dr up jo ng kh ar 97 .3 .0 .1 .0 1. 7 .4 .6 .0 10 0. 0 38 92 Sa m ts e 93 .4 1. 5 .5 .0 1. 7 .9 1. 9 .0 10 0. 0 75 30 Sa rp an g 93 .9 2. 6 .2 .0 1. 1 .7 1. 6 .0 10 0. 0 41 27 Th im ph u 99 .9 .1 0. 0 .0 .0 .0 0. 0 .0 10 0. 0 83 72 Tr as hi ga ng 86 .2 9. 9 2. 5 .0 .1 1. 2 .1 .0 10 0. 0 52 66 Tr as hi ya ng ts e 97 .2 .2 .0 .0 .6 .9 1. 1 .0 10 0. 0 17 11 Tr on gs a 80 .4 12 .9 1. 5 .0 1. 1 2. 3 1. 8 .0 10 0. 0 15 10 Ts ira ng 95 .6 .1 .0 .1 1. 9 1. 3 1. 0 .0 10 0. 0 22 08 W an gd ue 70 .2 18 .6 1. 3 .0 2. 3 6. 3 .9 .4 10 0. 0 28 41 Zh em ga ng 88 .8 1. 2 .8 .1 3. 0 3. 4 2. 6 .0 10 0. 0 18 00 84 C on td . T A B L E W S. 3: T IM E T O S O U R C E O F D R IN K IN G W AT E R Pe rc en t d is tr ib ut io n of h ou se ho ld p op ul at io n ac co rd in g to ti m e to g o to so ur ce o f d ri nk in g w at er , g et w at er a nd r et ur n, fo r us er s o f i m pr ov ed a nd u ni m pr ov ed d ri nk in g w at er so ur ce s, B hu ta n, 20 10 Ti m e to so ur ce o f d ri nk in g w at er To ta l N um be r o f ho us eh ol d m em be rs U se rs o f i m pr ov ed d ri nk in g w at er so ur ce s U se rs o f u ni m pr ov ed d ri nk in g w at er so ur ce s W at er o n pr em is es Le ss th an 3 0 m in ut es 30 m in ut es o r m or e M is si ng /D K W at er o n pr em - is es Le ss th an 3 0 m in ut es 30 m in ut es o r m or e M is si ng /D K R eg io n W es te rn 94 .1 1. 4 .3 .0 .9 1. 8 1. 4 .0 10 0. 0 30 88 7 C en tra l 86 .8 6. 8 .9 .0 1. 4 2. 5 1. 5 .1 10 0. 0 16 63 1 Ea st er n 93 .1 3. 7 1. 2 0. 0 .7 .8 .6 .0 10 0. 0 19 80 1 R es id en ce U rb an 97 .9 1. 5 .2 .0 .1 .1 .2 .0 10 0. 0 18 50 0 R ur al 89 .8 4. 2 .9 .0 1. 3 2. 3 1. 6 .0 10 0. 0 48 82 0 E du ca tio n of h ou se ho ld h ea d N on e 90 .4 4. 1 1. 0 .0 1. 3 2. 0 1. 2 .0 10 0. 0 44 41 5 Pr im ar y 91 .4 3. 3 .2 .1 .9 1. 9 2. 2 .0 10 0. 0 10 12 9 Se co nd ar y + 98 .1 1. 2 .1 .0 .1 .2 .2 .0 10 0. 0 12 76 3 M is si ng /D K * * * * * * * * * 13 W ea lth in de x qu in til es Po or es t 85 .7 4. 9 1. 1 .0 2. 5 3. 2 2. 5 .1 10 0. 0 13 46 1 Se co nd 88 .6 4. 6 1. 3 .0 1. 4 2. 6 1. 4 .0 10 0. 0 13 46 8 M id dl e 90 .8 4. 9 .5 .1 .7 1. 7 1. 3 .0 10 0. 0 13 46 6 Fo ur th 95 .6 2. 4 .4 .0 .2 .8 .6 .0 10 0. 0 13 46 2 R ic he st 99 .4 .2 .2 .0 .0 .0 .2 .0 10 0. 0 13 46 2 To ta l 92 .0 3. 4 .7 .0 1. 0 1. 7 1. 2 .0 10 0. 0 67 32 0 * A n as te ris k in di ca te s t ha t t he p er ce nt ag e is c al cu la te d on fe w er th an 2 5 un w ei gh te d ca se s 85 TA B L E W S. 4: P E R SO N C O L L E C T IN G W AT E R Pe rc en ta ge o f h ou se ho ld s w ith ou t d ri nk in g w at er o n pr em is es , a nd p er ce nt d is tr ib ut io n of h ou se ho ld s w ith ou t d ri nk in g w at er o n pr em is es a cc or di ng to th e pe rs on u su al ly c ol le ct in g dr in ki ng w at er us ed in th e ho us eh ol d, B hu ta n, 2 01 0 Pe rc en ta ge o f ho us eh ol ds w ith ou t d rin k- in g w at er o n pr em is es N um be r o f ho us eh ol ds Pe rs on u su al ly c ol le ct in g dr in ki ng w at er N um be r o f ho us eh ol ds w ith ou t d rin k- in g w at er o n pr em is es A du lt w om an (a ge 1 5+ y ea rs ) A du lt m an (a ge 15 + ye ar s) Fe m al e ch ild (u nd er 1 5) M al e ch ild (u nd er 1 5) D K M is si ng To ta l D zo ng kh ag B um th an g 11 .9 32 0 72 .1 19 .6 3. 1 1. 7 3. 5 .0 10 0. 0 38 C hu kh a 5. 6 14 78 (5 7. 0) (3 7. 3) (5 .6 ) (.0 ) (.0 ) (.0 ) (1 00 .0 ) 83 D ag an a 11 .5 54 8 77 .5 15 .7 2. 9 2. 8 1. 1 .0 10 0. 0 63 G as a 38 .0 10 2 83 .1 16 .9 .0 .0 .0 .0 10 0. 0 39 H aa .6 29 7 * * * * * * * 2 Lh un ts e .7 36 4 * * * * * * * 2 M on ga r 4. 3 96 5 (6 5. 3) (3 2. 1) (2 .7 ) (.0 ) (.0 ) (.0 ) (1 00 .0 ) 42 Pa ro 5. 3 79 0 (5 8. 1) (3 4. 6) (5 .2 ) (2 .0 ) (.0 ) (.0 ) (1 00 .0 ) 42 Pe m ag at sh el 8. 9 56 4 88 .9 11 .1 0. 0 0. 0 (.0 ) (.0 ) (1 00 .0 ) 50 Pu na kh a 9. 5 51 5 72 .6 22 .3 2. 2 2. 2 .8 0. 0 10 0. 0 49 Sa m dr up jo ng kh ar 1. 4 82 7 * * * * * * * 11 Sa m ts e 4. 6 16 41 (6 2. 8) (2 4. 8) (2 .7 ) (7 .0 ) (2 .6 ) (0 .0 ) (1 00 .0 ) 76 Sa rp an g 4. 9 89 5 (5 9. 8) (3 9. 4) (0 .8 ) (.0 ) (.0 ) (0 .0 ) (1 00 .0 ) 44 Th im ph u .1 19 32 * * * * * * * 3 Tr as hi ga ng 12 .5 12 45 79 .1 17 .8 3. 1 .0 .0 .0 10 0. 0 15 6 Tr as hi ya ng ts e 2. 2 44 4 * * * * * * * 10 Tr on gs a 17 .2 31 5 82 .6 11 .8 3. 4 2. 2 .0 .0 10 0. 0 54 Ts ira ng 2. 1 47 3 * * * * * * * 10 W an gd ue 28 .4 62 4 86 .6 7. 9 2. 7 1. 9 .2 .6 10 0. 0 17 7 Zh em ga ng 8. 7 33 8 87 .1 11 .5 1. 4 .0 .0 .0 10 0. 0 29 86 C on td . T A B L E W S. 4: P E R SO N C O L L E C T IN G W AT E R Pe rc en ta ge o f h ou se ho ld s w ith ou t d ri nk in g w at er o n pr em is es , a nd p er ce nt d is tr ib ut io n of h ou se ho ld s w ith ou t d ri nk in g w at er o n pr em is es a cc or di ng to th e pe rs on u su al ly c ol le ct in g dr in ki ng w at er us ed in th e ho us eh ol d, B hu ta n, 2 01 0 Pe rc en ta ge o f ho us eh ol ds w ith ou t d rin k- in g w at er o n pr em is es N um be r o f ho us eh ol ds Pe rs on u su al ly c ol le ct in g dr in ki ng w at er N um be r o f ho us eh ol ds w ith ou t d rin k- in g w at er o n pr em is es A du lt w om an (a ge 1 5+ y ea rs ) A du lt m an (a ge 15 + ye ar s) Fe m al e ch ild (u nd er 1 5) M al e ch ild (u nd er 1 5) D K M is si ng To ta l R eg io n W es te rn 4. 3 67 55 65 .1 27 .9 3. 5 2. 6 .8 .0 10 0. 0 29 3 C en tra l 11 .8 35 12 79 .5 15 .4 2. 5 1. 7 .6 .3 10 0. 0 41 6 Ea st er n 6. 2 44 09 77 .7 20 .1 2. 2 .0 0. 0 .0 10 0. 0 27 1 R es id en ce U rb an 1. 9 43 20 63 .6 23 .5 4. 3 5. 6 1. 6 1. 4 10 0. 0 81 R ur al 8. 7 10 35 6 75 .7 20 .2 2. 6 1. 1 .4 .0 10 0. 0 89 9 E du ca tio n of h ou se ho ld h ea d N on e 8. 3 92 65 76 .4 19 .0 2. 8 1. 1 .5 .1 10 0. 0 76 8 Pr im ar y 7. 0 21 34 71 .8 23 .5 2. 2 2. 2 .3 .0 10 0. 0 14 9 Se co nd ar y + 1. 9 32 75 61 .1 30 .9 3. 3 4. 0 .7 .0 10 0. 0 64 M is si ng /D K * 2 * * * * * * * * W ea lth in de x qu in til es Po or es t 11 .7 27 62 76 .1 18 .3 3. 8 1. 0 .8 .0 10 0. 0 32 3 Se co nd 9. 6 28 49 75 .6 21 .3 2. 1 1. 0 0. 0 .0 10 0. 0 27 3 M id dl e 8. 3 29 92 74 .4 22 .6 1. 3 1. 4 .3 .0 10 0. 0 24 7 Fo ur th 3. 9 30 87 73 .0 17 .4 3. 9 4. 1 .7 .9 10 0. 0 12 0 R ic he st .5 29 86 * * * * * * * 16 To ta l 6. 7 14 67 6 74 .7 20 .4 2. 7 1. 5 .5 .1 10 0. 0 98 0 * A n as te ris k in di ca te s t ha t t he p er ce nt ag e is c al cu la te d on fe w er th an 2 5 un w ei gh te d ca se s * Fi gu re s i n pa re nt he si s i nd ic at e th at th e pe rc en ta ge is b as ed o n ju st 2 5 to 4 9 un w ei gh te d ca se s 87 Table WS.4 shows that for the majority of households (74.7%), an adult female is usually the person collecting the water, when the source of drinking water is not on the premises. Adult men collect wa- ter in 20.4 percent of cases, while for the rest of the households, female or male children under age 15 collect water (4.2%). Use of Improved Sanitation Facilities Inadequate disposal of human excreta and personal hygiene is associated with a range of diseases including diarrhoeal diseases and polio. An improved sanitation facility is defined as one that hygieni- cally separates human excreta from human contact and is not shared by more than one household. Improved sanitation can reduce diarrheal disease by more than a third, and can significantly lessen the adverse health impacts of other disorders responsible for death and disease among millions of children in developing countries. Improved sanitation facilities for excreta disposal include flush or pour flush to a piped sewer system, septic tank, or latrine; ventilated improved pit latrine, pit latrine with slab, and composting toilet. Table WS.5 identifies the proportion of household members using each different type of sanitation facilities. In rural areas, the population is mostly using pit latrines without slabs (37.6%) or with slabs (22.1 %). In contrast, the most common facilities in urban areas are flush toilets with connection to a septic tank without soak pit (58.5 %) or with soak pit (15.7 %). 3.4 percent of the households were without any toilet facility at all. Most of these households are in the rural areas. According to Population and Housing Census of Bhutan (PHCB), 2005, the improved sanitation coverage in Bhutan was 84.2 per cent. The WHO / UNICEF Joint Monitoring Programme (JMP), 2010 reports the improved sanitation coverage of Bhutan at 65 percent. The discrepancy between the PHCB and BMIS is due to the difference in usage of definition of improved sanitation coverage. BMIS has followed the definition of JMP, which segregates pit latrines with slab and without slab. It categorizes pit latrine without slab as un-improved sanitation facility, where as in PHCB, 2005 all pit latrines were counted as improved sanitation facility. 88 TA B L E W S. 5: T Y PE S O F SA N IT AT IO N F A C IL IT IE S Pe rc en t d is tr ib ut io n of h ou se ho ld p op ul at io n ac co rd in g to ty pe o f t oi le t f ac ili ty u se d by th e ho us eh ol d, B hu ta n, 2 01 0 Ty pe o f t oi le t f ac ili ty u se d by h ou se ho ld To ta l N um be r of h ou se - ho ld m em be rs Im pr ov ed sa ni ta tio n fa ci lit y U ni m pr ov ed sa ni ta tio n fa ci lit y O pe n de f- ec at io n (n o fa ci lit y, b us h, fi el d) Fl us h to ile t Fl us h to se pt ic ta nk (W ith ou t so ak p it) Fl us h to p it (la tri ne ) Fl us h to u n- kn ow n pl ac e/ no t s ur e/ D K w he re Fl us h to se p- tic ta nk (w ith so ak p it) Ve nt ila te d Im pr ov ed P it la tri ne (V IP ) Pi t l at rin e w ith sl ab C om - po si ng to ile t Fl us h to so m e- w he re el se Pi t l at rin e w ith ou t sl ab /o pe n pi t Lo ng dr op la tri ne B uc k- et O th er M is si ng N o fa ci lit y, B us h, Fi el d D zo ng kh ag B um th an g 2. 9 15 .1 .9 .0 13 .2 .0 58 .7 .0 .0 6. 2 1. 2 .3 .0 .0 1. 5 10 0. 0 16 05 C hu kh a .5 54 .5 8. 7 .0 3. 6 .2 18 .5 .0 .3 8. 4 .7 .0 .0 .0 4. 6 10 0. 0 68 63 D ag an a 2. 8 14 .7 .9 .0 11 .0 .0 11 .7 .0 .5 54 .4 .5 .0 .0 .0 3. 6 10 0. 0 25 41 G as a .5 9. 2 .0 .0 1. 4 .0 50 .0 .0 .0 36 .3 .0 .0 .0 .0 2. 6 10 0. 0 48 4 H aa .0 32 .1 2. 2 .0 26 .8 1. 5 5. 0 .0 .3 14 .0 17 .9 .0 .0 .0 .2 10 0. 0 13 12 Lh un ts e .9 7. 7 2. 4 .0 1. 9 .4 26 .4 .0 .6 55 .6 1. 2 .0 .0 .0 2. 9 10 0. 0 15 64 M on ga r 9. 2 10 .4 1. 2 .0 5. 6 .0 14 .2 .0 .0 56 .7 0. 0 .0 .0 .1 2. 5 10 0. 0 47 41 Pa ro .1 47 .2 .7 .0 7. 6 .0 28 .1 .4 .0 11 .3 1. 1 .0 .0 .0 3. 4 10 0. 0 37 76 Pe m ag at sh el 1. 8 22 .4 1. 9 .0 1. 6 .0 5. 6 .0 .1 55 .2 1. 9 5. 4 .0 .0 4. 3 10 0. 0 26 27 Pu na kh a .1 28 .7 2. 5 .2 6. 6 .0 26 .5 .1 .4 29 .9 .5 .0 .4 .0 4. 2 10 0. 0 25 49 Sa m dr up jo ng kh ar 6. 0 30 .9 10 .6 .0 1. 8 .8 13 .4 .0 .0 31 .0 .3 .0 .0 .0 5. 3 10 0. 0 38 92 Sa m ts e .1 41 .6 11 .2 .0 3. 6 .0 8. 4 .4 .5 29 .2 .5 .0 .3 .0 4. 1 10 0. 0 75 30 Sa rp an g 1. 1 46 .9 8. 4 .0 7. 0 .9 1. 0 .0 .4 30 .6 1. 0 .8 .0 .0 1. 9 10 0. 0 41 27 Th im ph u 19 .5 42 .7 4. 0 .0 16 .5 2. 8 5. 5 .0 .0 7. 9 .1 .1 .4 .0 .5 10 0. 0 83 72 Tr as hi ga ng .1 7. 3 1. 5 .0 11 .9 .0 33 .8 .0 1. 0 39 .4 .0 .1 .2 .0 4. 8 10 0. 0 52 66 Tr as hi ya ng ts e .0 14 .3 21 .2 .0 1. 9 .0 32 .1 .0 .0 24 .8 .2 .0 .0 .0 5. 4 10 0. 0 17 11 Tr on gs a .8 14 .9 9. 7 .0 4. 5 .0 28 .8 .0 .3 35 .6 .4 .0 .1 .0 5. 0 10 0. 0 15 10 Ts ira ng .1 19 .6 41 .7 .0 3. 9 .0 1. 9 .1 .1 28 .7 .0 .0 .0 .1 3. 7 10 0. 0 22 08 W an gd ue .2 28 .6 .2 .0 4. 2 .0 38 .3 .0 .1 24 .7 1. 4 .0 .0 .0 2. 4 10 0. 0 28 41 Zh em ga ng .1 27 .2 4. 1 .0 1. 1 .1 10 .4 .4 .2 47 .0 3. 7 .0 .0 .0 5. 8 10 0. 0 18 00 89 C on td .T A B L E W S. 5: T Y PE S O F SA N IT AT IO N F A C IL IT IE S Pe rc en t d is tr ib ut io n of h ou se ho ld p op ul at io n ac co rd in g to ty pe o f t oi le t f ac ili ty u se d by th e ho us eh ol d, B hu ta n, 2 01 0 Ty pe o f t oi le t f ac ili ty u se d by h ou se ho ld To ta l N um be r of h ou se - ho ld m em be rs Im pr ov ed sa ni ta tio n fa ci lit y U ni m pr ov ed sa ni ta tio n fa ci lit y O pe n de f- ec at io n (n o fa ci lit y, b us h, fi el d) Fl us h to ile t Fl us h to se pt ic ta nk (W ith ou t so ak p it) Fl us h to p it (la tri ne ) Fl us h to u n- kn ow n pl ac e/ no t s ur e/ D K w he re Fl us h to se p- tic ta nk (w ith so ak p it) Ve nt ila te d Im pr ov ed P it la tri ne (V IP ) Pi t l at rin e w ith sl ab C om - po si ng to ile t Fl us h to so m e- w he re el se Pi t l at rin e w ith ou t sl ab /o pe n pi t Lo ng dr op la tri ne B uc k- et O th er M is si ng N o fa ci lit y, B us h, Fi el d R eg io n W es te rn 5. 5 43 .5 6. 1 .0 8. 8 .9 14 .3 .2 .2 16 .1 1. 3 .0 .2 .0 3. 0 10 0. 0 30 88 7 C en tra l 1. 1 27 .1 9. 2 .0 6. 4 .2 18 .2 .1 .2 32 .9 1. 1 .2 .0 .0 3. 1 10 0. 0 16 63 1 Ea st er n 3. 7 15 .3 5. 1 .0 5. 4 .2 20 .6 .0 .3 44 .0 .4 .7 .0 .0 4. 2 10 0. 0 19 80 1 R es id en ce U rb an 11 .2 58 .5 3. 7 .0 15 .7 1. 1 4. 0 .0 .1 4. 3 .2 .2 .1 .0 .8 10 0. 0 18 50 0 R ur al 1. 1 20 .8 7. 7 .0 4. 0 .3 22 .1 .1 .3 37 .6 1. 3 .3 .1 .0 4. 4 10 0. 0 48 82 0 E du ca tio n of h ou se ho ld h ea d N on e 2. 0 19 .9 6. 5 .0 4. 8 .5 22 .6 .1 .3 37 .2 1. 2 .3 .0 .0 4. 4 10 0. 0 44 41 5 Pr im ar y 3. 3 42 .7 10 .3 .0 8. 3 .8 10 .5 .0 .2 20 .3 .8 .3 .2 .0 2. 3 10 0. 0 10 12 9 Se co nd ar y + 10 .7 61 .1 3. 8 .0 14 .8 .4 3. 3 .0 .2 4. 5 .2 .1 .2 .0 .6 10 0. 0 12 76 3 M is si ng /D K .0 30 .9 .0 .0 .0 .0 49 .2 .0 .0 19 .9 .0 .0 .0 .0 .0 10 0. 0 13 W ea lth in de x qu in til es Po or es t .1 1. 4 9. 4 .0 .5 .0 21 .3 .1 .3 58 .4 .6 .0 .0 .0 7. 8 10 0. 0 13 46 1 Se co nd .7 9. 8 9. 1 .0 1. 0 .1 28 .3 .2 .3 43 .8 1. 3 .4 .2 .0 4. 7 10 0. 0 13 46 8 M id dl e 1. 9 19 .7 7. 9 .0 4. 8 .6 27 .4 .1 .3 31 .4 1. 8 .6 .0 .0 3. 3 10 0. 0 13 46 6 Fo ur th 3. 0 54 .8 5. 8 .0 16 .1 1. 5 7. 6 .0 .3 8. 4 1. 0 .3 .2 .0 .9 10 0. 0 13 46 2 R ic he st 13 .6 70 .0 .6 .0 13 .8 .2 1. 0 .0 .0 .4 .1 .2 .0 .0 .0 10 0. 0 13 46 2 To ta l 3. 9 31 .2 6. 6 .0 7. 2 .5 17 .1 .1 .3 28 .5 1. 0 .3 .1 .0 3. 4 10 0. 0 67 32 0 90 Access to safe drinking-water and to basic sanitation is measured by the proportion of population using an improved water source and improved sanitation facility. MDGs and WHO / UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation classify households as using an un- improved sanitation facility if they are using otherwise acceptable sanitation facilities, but sharing a facility between two or more households or using a public toilet facility. As shown in Table WS.6, 58.4 percent of the household population is using an improved sanitation facility without sharing with other households. Use of a shared facility is not very common among households using an unimproved facility. Only 8.1 percent of households use an improved toilet facil- ity that is shared with other households. Rural households are less likely than urban households to use a shared improved toilet facility (5% and 16.4%) respectively. 91 TA B L E W S. 6: U SE A N D S H A R IN G O F SA N IT AT IO N F A C IL IT IE S Pe rc en t d is tr ib ut io n of h ou se ho ld p op ul at io n by u se o f p ri va te a nd p ub lic sa ni ta tio n fa ci lit ie s a nd u se o f s ha re d fa ci lit ie s, b y us er s o f i m pr ov ed a nd u ni m pr ov ed sa ni ta tio n fa ci lit ie s, B hu ta n, 2 01 0 Im pr ov ed sa ni ta tio n fa ci lit y: N ot sh ar ed [1 ] Im pr ov ed sa ni - ta tio n fa ci lit y: Pu bl ic fa ci lit y Im pr ov ed sa ni - ta tio n fa ci lit y: 5 ho us eh ol ds or le ss Im pr ov ed sa ni ta - tio n fa ci lit y: M or e th an 5 h ou se ho ld s U ni m pr ov ed sa ni ta tio n fa ci l- ity : N ot sh ar ed U ni m pr ov ed sa ni ta tio n fa ci lit y: Pu bl ic fa ci lit y U ni m pr ov ed sa ni ta tio n fa ci lit y: 5 ho us eh ol ds o r l es s U ni m pr ov ed sa ni ta - tio n fa ci lit y: M or e th an 5 h ou se ho ld s O pe n de fe ca tio n (n o fa ci lit y, b us h, fi el d) To ta l N um be r o f ho us eh ol d m em be rs D zo ng kh ag B um th an g 80 .3 1. 0 8. 2 1. 4 6. 1 .0 1. 2 .4 1. 5 10 0. 0 16 05 C hu kh a 76 .2 .1 6. 6 2. 9 8. 3 .1 .8 .2 4. 6 10 0. 0 68 63 D ag an a 37 .3 .3 3. 5 .0 54 .1 .3 .9 .0 3. 6 10 0. 0 25 41 G as a 57 .6 1. 6 .6 1. 3 34 .5 1. 0 0. 0 .8 2. 6 10 0. 0 48 4 H aa 60 .0 .0 7. 6 .0 30 .6 .0 1. 6 .0 .2 10 0. 0 13 12 Lh un ts e 36 .1 .4 3. 1 .0 55 .6 .4 1. 4 .0 2. 9 10 0. 0 15 64 M on ga r 37 .3 .6 2. 7 .1 56 .0 .3 .5 .0 2. 5 10 0. 0 47 41 Pa ro 76 .1 .1 6. 9 1. 0 11 .6 .2 .6 .1 3. 4 10 0. 0 37 76 Pe m ag at sh el 31 .4 .0 1. 8 .0 62 .3 .1 0. 0 .0 4. 3 10 0. 0 26 27 Pu na kh a 53 .8 .2 10 .5 .2 24 .6 .0 6. 0 .5 4. 2 10 0. 0 25 49 Sa m dr up jo ng kh ar 52 .0 .2 10 .3 1. 0 30 .2 .2 .7 .1 5. 3 10 0. 0 38 92 Sa m ts e 53 .7 .5 10 .1 1. 2 28 .2 .0 2. 0 .3 4. 1 10 0. 0 75 30 Sa rp an g 57 .8 .5 6. 4 .6 31 .9 .2 .6 .0 1. 9 10 0. 0 41 27 Th im ph u 75 .1 .5 13 .5 1. 9 5. 7 .0 2. 6 .2 .5 10 0. 0 83 72 Tr as hi ga ng 52 .1 .3 1. 8 .3 37 .1 .2 3. 4 .0 4. 8 10 0. 0 52 66 Tr as hi ya ng ts e 65 .9 .3 3. 0 .4 23 .3 .8 .7 .2 5. 4 10 0. 0 17 11 Tr on gs a 50 .9 1. 0 6. 2 .6 33 .8 .5 2. 0 .1 5. 0 10 0. 0 15 10 Ts ira ng 63 .9 .2 3. 0 .2 28 .5 .0 .3 .2 3. 7 10 0. 0 22 08 W an gd ue 65 .4 .1 5. 0 .8 22 .9 .2 3. 0 .2 2. 4 10 0. 0 28 41 Zh em ga ng 40 .5 .1 2. 5 .2 49 .7 .4 .8 .0 5. 8 10 0. 0 18 00 92 C on td . T A B L E W S. 6: U SE A N D S H A R IN G O F SA N IT AT IO N F A C IL IT IE S Pe rc en t d is tr ib ut io n of h ou se ho ld p op ul at io n by u se o f p ri va te a nd p ub lic sa ni ta tio n fa ci lit ie s a nd u se o f s ha re d fa ci lit ie s, b y us er s o f i m pr ov ed a nd u ni m pr ov ed sa ni ta tio n fa ci lit ie s, B hu ta n, 2 01 0 Im pr ov ed sa ni ta tio n fa ci lit y: N ot sh ar ed [1 ] Im pr ov ed sa ni - ta tio n fa ci lit y: Pu bl ic fa ci lit y Im pr ov ed sa ni - ta tio n fa ci lit y: 5 ho us eh ol ds or le ss Im pr ov ed sa ni ta - tio n fa ci lit y: M or e th an 5 h ou se ho ld s U ni m pr ov ed sa ni ta tio n fa ci l- ity : N ot sh ar ed U ni m pr ov ed sa ni ta tio n fa ci lit y: Pu bl ic fa ci lit y U ni m pr ov ed sa ni ta tio n fa ci lit y: 5 ho us eh ol ds o r l es s U ni m pr ov ed sa ni ta - tio n fa ci lit y: M or e th an 5 h ou se ho ld s O pe n de fe ca tio n (n o fa ci lit y, b us h, fi el d) To ta l N um be r o f ho us eh ol d m em be rs R eg io n W es te rn 67 .6 .3 9. 7 1. 6 15 .6 .1 2. 0 .2 3. 0 10 0. 0 30 88 7 C en tra l 56 .5 .4 5. 0 .5 32 .9 .2 1. 2 .1 3. 1 10 0. 0 16 63 1 Ea st er n 45 .7 .3 3. 9 .3 43 .9 .3 1. 3 .0 4. 2 10 0. 0 19 80 1 R es id en ce U rb an 77 .9 .5 13 .6 2. 3 3. 4 .1 1. 3 .1 .8 10 0. 0 18 50 0 R ur al 51 .0 .3 4. 2 .5 37 .6 .2 1. 7 .1 4. 4 10 0. 0 48 82 0 E du ca tio n of h ou se ho ld h ea d N on e 50 .5 .3 4. 9 .7 37 .1 .2 1. 8 .1 4. 4 10 0. 0 44 41 5 Pr im ar y 62 .3 .5 11 .7 1. 4 20 .1 .1 1. 2 .4 2. 3 10 0. 0 10 12 9 Se co nd ar y + 82 .7 .4 9. 4 1. 6 3. 5 .2 1. 3 .2 .6 10 0. 0 12 76 3 M is si ng /D K 49 .2 .0 .0 30 .9 19 .9 .0 .0 .0 0. 0 10 0. 0 13 W ea lth in de x qu in til es Po or es t 31 .6 .1 1. 0 .1 57 .6 .2 1. 6 .0 7. 8 10 0. 0 13 46 1 Se co nd 47 .3 .2 1. 6 .2 43 .4 .3 2. 1 .2 4. 7 10 0. 0 13 46 8 M id dl e 50 .6 .5 10 .0 1. 3 30 .8 .2 2. 9 .3 3. 3 10 0. 0 13 46 6 Fo ur th 68 .0 .7 17 .4 2. 7 8. 5 .2 1. 5 .1 .9 10 0. 0 13 46 2 R ic he st 94 .5 .2 4. 0 .6 .6 .0 .1 .0 .0 10 0. 0 13 46 2 To ta l 58 .4 .3 6. 8 1. 0 28 .2 .2 1. 6 .1 3. 4 10 0. 0 67 32 0 [1 ] M IC S in di ca to r 4 .3 ; M D G in di ca to r 7 .9 93 TA B L E W S. 7: D IS PO SA L O F C H IL D ’S F A E C E S Pe rc en t d is tr ib ut io n of c hi ld re n ag e 0- 2 ye ar s a cc or di ng to p la ce o f d is po sa l o f c hi ld ’s fa ec es , a nd th e pe rc en ta ge o f c hi ld re n ag e 0- 2 ye ar s w ho se st oo ls w er e di sp os ed o f s af el y th e la st ti m e th e ch ild p as se d st oo ls , B hu ta n, 2 01 0 Pl ac e of d is po sa l o f c hi ld ’s fa ec es To ta l Pe rc en ta ge o f c hi l- dr en w ho se st oo ls w er e di sp os ed o f sa fe ly [1 ] N um be r o f c hi l- dr en a ge 0 -2 y ea rs C hi ld u se d to ile t / la tri ne Pu t / R in se d in to to ile t o r l at rin e Pu t / R in se d in to dr ai n or d itc h Th ro w n in to ga rb ag e (s ol id w as te ) B ur ie d Le ft in th e op en O th er Ty pe o f s an ita to n fa ci lit y in d w el lin g Im pr ov ed 20 .5 44 .6 26 .4 4. 3 .9 2. 6 .9 10 0. 0 65 .0 25 34 U ni m pr ov ed 14 .5 30 .9 41 .1 2. 4 .6 8. 7 1. 8 10 0. 0 45 .4 11 29 O pe n de fa ca tio n 3. 0 12 .9 40 .9 7. 7 7. 2 23 .5 4. 9 10 0. 0 15 .9 13 5 D zo ng kh ag B um th an g 10 .5 29 .5 52 .7 5. 8 .0 1. 0 .5 10 0. 0 40 .0 10 6 C hu kh a 25 .2 44 .5 16 .5 5. 2 4. 2 4. 0 .5 10 0. 0 69 .7 37 0 D ag an a 19 .8 37 .0 28 .7 2. 0 .0 12 .5 .0 10 0. 0 56 .8 15 2 G as a (1 5. 4) (3 1. 2) (3 3. 3) (1 2. 0) (.0 ) (8 .1 ) (.0 ) (1 00 .0 ) (4 6. 6) 28 H aa 25 .4 42 .5 18 .9 10 .6 .5 2. 0 .0 10 0. 0 68 .0 71 Lh un ts e 8. 7 39 .4 25 .6 26 .0 .0 .3 .0 10 0. 0 48 .1 79 M on ga r 9. 1 35 .1 39 .2 .4 2. 1 12 .6 1. 6 10 0. 0 44 .2 27 4 Pa ro 13 .5 48 .7 29 .4 2. 1 .0 6. 4 .0 10 0. 0 62 .1 22 0 Pe m ag at sh el 11 .4 53 .8 24 .4 4. 2 .0 4. 4 1. 8 10 0. 0 65 .2 13 9 Pu na kh a 16 .1 32 .0 43 .4 3. 2 .0 3. 8 1. 5 10 0. 0 48 .1 14 1 Sa m dr up jo ng kh ar 9. 8 30 .9 39 .1 2. 6 2. 3 10 .9 4. 6 10 0. 0 40 .7 24 9 Sa m ts e 24 .4 43 .4 22 .0 3. 4 .8 2. 5 3. 3 10 0. 0 67 .8 39 9 Sa rp an g 29 .1 43 .1 18 .9 1. 2 .0 5. 8 1. 9 10 0. 0 72 .2 20 9 Th im ph u 26 .4 59 .3 10 .4 3. 2 .5 .0 .3 10 0. 0 85 .6 51 5 Tr as hi ga ng 13 .3 18 .5 49 .6 3. 1 1. 7 13 .0 .7 10 0. 0 31 .8 27 1 Tr as hi ya ng ts e 11 .1 22 .7 60 .6 3. 4 .0 1. 1 1. 0 10 0. 0 33 .8 10 5 Tr on gs a 16 .9 17 .7 56 .4 2. 5 .0 4. 9 1. 6 10 0. 0 34 .6 80 Ts ira ng 4. 7 42 .2 44 .9 4. 5 .0 3. 0 .7 10 0. 0 46 .9 11 6 W an gd ue 18 .1 26 .9 45 .8 6. 7 .7 .7 1. 1 10 0. 0 45 .0 15 5 Zh em ga ng 14 .2 21 .9 60 .8 1. 3 .0 1. 1 .8 10 0. 0 36 .1 11 9 94 C on td . T A B L E W S. 7: D IS PO SA L O F C H IL D ’S F A E C E S Pe rc en t d is tr ib ut io n of c hi ld re n ag e 0- 2 ye ar s a cc or di ng to p la ce o f d is po sa l o f c hi ld ’s fa ec es , a nd th e pe rc en ta ge o f c hi ld re n ag e 0- 2 ye ar s w ho se st oo ls w er e di sp os ed o f s af el y th e la st ti m e th e ch ild p as se d st oo ls , B hu ta n, 2 01 0 Pl ac e of d is po sa l o f c hi ld ’s fa ec es To ta l Pe rc en ta ge o f c hi l- dr en w ho se st oo ls w er e di sp os ed o f sa fe ly [1 ] N um be r o f c hi l- dr en a ge 0 -2 y ea rs C hi ld u se d to ile t / la tri ne Pu t / R in se d in to to ile t o r l at rin e Pu t / R in se d in to dr ai n or d itc h Th ro w n in to ga rb ag e (s ol id w as te ) B ur ie d Le ft in th e op en O th er R eg io n W es te rn 23 .0 47 .8 20 .1 4. 0 1. 2 2. 8 1. 1 10 0. 0 70 .8 17 44 C en tra l 17 .7 32 .9 40 .5 3. 3 .1 4. 5 1. 0 10 0. 0 50 .6 93 6 Ea st er n 10 .7 31 .6 40 .9 4. 1 1. 5 9. 3 1. 9 10 0. 0 42 .3 11 18 R es id en ce U rb an 23 .3 54 .0 15 .6 4. 7 .5 1. 3 .6 10 0. 0 77 .4 11 30 R ur al 15 .9 33 .2 37 .9 3. 5 1. 3 6. 7 1. 6 10 0. 0 49 .0 26 68 M ot he r’ s e du ca tio n N on e 17 .2 35 .3 34 .8 3. 1 1. 3 6. 7 1. 7 10 0. 0 52 .5 24 74 Pr im ar y 18 .9 36 .1 36 .0 2. 9 .0 4. 7 1. 3 10 0. 0 55 .0 45 7 Se co nd ar y 20 .3 52 .6 18 .6 6. 5 .9 .9 .2 10 0. 0 72 .9 86 7 W ea lth in de x qu in til es Po or es t 11 .2 28 .6 42 .1 3. 5 2. 2 9. 4 3. 2 10 0. 0 39 .7 75 3 Se co nd 12 .4 30 .4 43 .1 3. 0 1. 2 8. 4 1. 6 10 0. 0 42 .8 69 2 M id dl e 13 .9 30 .5 43 .5 3. 7 1. 2 6. 1 1. 2 10 0. 0 44 .4 75 4 Fo ur th 26 .0 44 .8 22 .7 3. 5 .0 2. 3 .6 10 0. 0 70 .8 86 2 R ic he st 25 .4 61 .5 6. 7 5. 5 .7 0. 0 .0 10 0. 0 87 .0 73 8 To ta l 18 .1 39 .4 31 .3 3. 8 1. 0 5. 1 1. 3 10 0. 0 57 .5 37 98 [1 ] M IC S in di ca to r 4 .4 * Fi gu re s i n pa re nt he si s i nd ic at es th at th e pe rc en ta ge is b as ed o n ju st 2 5 to 4 9 un w ei gh te d ca se s 95 Safe disposal of a child’s faeces is disposing of the stool by the child using a toilet or by rinsing the stool into a toilet or latrine. Disposal of faeces of children 0-2 years of age is presented in Table WS.7 which shows that 57.5 percent of households safely disposed of children’s faeces. The rural-urban variation was very significant: only 49 percent of rural households compared to 77.4 percent of urban households followed the safe procedures. Safe procedures were least common in the Eastern region (42.3 %) followed by the Central region (50.6 %) and the Western region with a high 70.8 percent. There was a strong positive correlation between the safe disposal of a child’s faeces and both the education of mother and economic status of households. In its 2008 report6, the JMP developed a new way of presenting the access figures, by disaggregating and refining the data on drinking-water and sanitation and reflecting them in a “ladder” format. This ladder allows a disaggregated analysis of trends in a three rung ladder for drinking-water and a four- rung ladder for sanitation. For sanitation, this gives an understanding of the proportion of population with no sanitation facilities at all, of those reliant on technologies defined by JMP as “unimproved,” of those sharing sanitation facilities of otherwise acceptable technology and those using “improved” sanitation facilities. Table WS.8 presents the percentages of the household population by drinking water and sanitation ladders. The table also shows the percentage of household members using improved sources of drink- ing water and sanitary means of excreta disposal. About 56.9 percent of the surveyed household population reported using an improved water source and sanitary means of excreta disposal. The ur- ban population was almost twice as likely (77.7 %) to use an improved source of drinking water and sanitary means of excreta disposal compared to the rural population (49 %). As expected, the use of improved sources of drinking water and improved sanitation facilities also strongly correlates with the education level of household head and wealth index of household. The richest quintile is more than three times more likely to use improved drinking water sources and improved sanitation facilities than the poorest quintile. The Western region is more likely to use im- proved sources of drinking water and improved sanitation facilities when compared to the Central and Eastern regions. There are great variations between the dzongkhags, with Pemagatsel and Lhuentse having the lowest, about 30 percent each, and Thimphu and Bumthang having the highest, above 75 percent. 10 WHO/UNICEF JMP (2008), MDG assessment report - http://www.wssinfo.org/download?id_ document=1279 10 96 TA B L E W S. 8: D R IN K IN G W AT E R A N D S A N IT AT IO N L A D D E R S Pe rc en ta ge o f h ou se ho ld p op ul at io n by d ri nk in g w at er a nd sa ni ta tio n la dd er s, B hu ta n, 2 01 0 Pe rc en ta ge o f h ou se ho ld p op ul at io n us in g: N um be r o f h ou se - ho ld s Im pr ov ed d rin ki ng w at er [1 ] U ni m pr ov ed dr in ki ng w at er To ta l Im pr ov ed sa ni ta tio n [2 ] U ni m pr ov ed sa ni ta tio n To ta l Im pr ov ed d rin ki ng w at er so ur ce s a nd im pr ov ed sa ni ta tio n Pi pe d in to dw el lin g, p lo t or y ar d O th er im - pr ov ed Sh ar ed im pr ov ed fa ci lit ie s U ni m pr ov ed fa ci lit ie s O pe n de fe ca tio n D zo ng kh ag B um th an g 83 .7 15 .9 .4 10 0. 0 80 .3 10 .5 7. 7 1. 5 10 0. 0 79 .9 16 05 C hu kh a 79 .1 14 .7 6. 3 10 0. 0 76 .2 9. 7 9. 5 4. 6 10 0. 0 71 .7 68 63 D ag an a 80 .3 13 .8 5. 9 10 0. 0 37 .3 3. 7 55 .3 3. 6 10 0. 0 36 .2 25 41 G as a 30 .2 39 .8 30 .0 10 0. 0 57 .6 3. 5 36 .3 2. 6 10 0. 0 41 .6 48 4 H aa 96 .8 3. 2 .0 10 0. 0 60 .0 7. 6 32 .2 .2 10 0. 0 60 .0 13 12 Lh un ts e 70 .0 28 .1 1. 9 10 0. 0 36 .1 3. 5 57 .4 2. 9 10 0. 0 35 .8 15 64 M on ga r 92 .6 6. 4 1. 0 10 0. 0 37 .3 3. 3 56 .9 2. 5 10 0. 0 37 .0 47 41 Pa ro 85 .4 11 .0 3. 6 10 0. 0 76 .1 8. 1 12 .4 3. 4 10 0. 0 74 .5 37 76 Pe m ag at sh el 74 .8 21 .5 3. 8 10 0. 0 31 .4 1. 8 62 .5 4. 3 10 0. 0 29 .8 26 27 Pu na kh a 70 .9 20 .1 9. 0 10 0. 0 53 .8 10 .9 31 .1 4. 2 10 0. 0 51 .2 25 49 Sa m dr up jo ng kh ar 88 .1 9. 3 2. 7 10 0. 0 52 .0 11 .5 31 .3 5. 3 10 0. 0 51 .1 38 92 Sa m ts e 85 .7 9. 7 4. 6 10 0. 0 53 .7 11 .7 30 .5 4. 1 10 0. 0 52 .8 75 30 Sa rp an g 76 .8 19 .9 3. 3 10 0. 0 57 .8 7. 5 32 .8 1. 9 10 0. 0 56 .5 41 27 Th im ph u 98 .8 1. 2 .0 10 0. 0 75 .1 15 .9 8. 4 .5 10 0. 0 75 .1 83 72 Tr as hi ga ng 79 .3 19 .3 1. 4 10 0. 0 52 .1 2. 4 40 .7 4. 8 10 0. 0 51 .6 52 66 Tr as hi ya ng ts e 90 .2 7. 2 2. 6 10 0. 0 65 .9 3. 7 25 .0 5. 4 10 0. 0 64 .4 17 11 Tr on gs a 59 .9 34 .9 5. 2 10 0. 0 50 .9 7. 8 36 .3 5. 0 10 0. 0 49 .7 15 10 Ts ira ng 91 .4 4. 4 4. 2 10 0. 0 63 .9 3. 4 29 .0 3. 7 10 0. 0 62 .8 22 08 W an gd i 59 .2 30 .9 10 .0 10 0. 0 65 .4 5. 9 26 .2 2. 4 10 0. 0 61 .0 28 41 Zh em ga ng 51 .1 39 .8 9. 0 10 0. 0 40 .5 2. 8 50 .9 5. 8 10 0. 0 39 .3 18 00 97 C on td . T A B L E W S. 8: D R IN K IN G W AT E R A N D S A N IT AT IO N L A D D E R S Pe rc en ta ge o f h ou se ho ld p op ul at io n by d ri nk in g w at er a nd sa ni ta tio n la dd er s, B hu ta n, 2 01 0 Pe rc en ta ge o f h ou se ho ld p op ul at io n us in g: N um be r o f h ou se - ho ld s Im pr ov ed d rin ki ng w at er [1 ] U ni m pr ov ed dr in ki ng w at er To ta l Im pr ov ed sa ni ta tio n [2 ] U ni m pr ov ed sa ni ta tio n To ta l Im pr ov ed d rin ki ng w at er so ur ce s a nd im pr ov ed sa ni ta tio n Pi pe d in to dw el lin g, p lo t or y ar d O th er im - pr ov ed Sh ar ed im pr ov ed fa ci lit ie s U ni m pr ov ed fa ci lit ie s O pe n de fe ca tio n R eg io n W es te rn 86 .1 9. 7 4. 2 10 0. 0 67 .6 11 .6 17 .8 3. 0 10 0. 0 65 .7 30 88 7 C en tra l 72 .6 21 .9 5. 5 10 0. 0 56 .5 5. 9 34 .5 3. 1 10 0. 0 54 .8 16 63 1 Ea st er n 83 .8 14 .2 2. 0 10 0. 0 45 .7 4. 5 45 .6 4. 2 10 0. 0 45 .0 19 80 1 R es id en ce U rb an 93 .1 6. 5 .4 10 0. 0 77 .9 16 .3 5. 0 .8 10 0. 0 77 .7 18 50 0 R ur al 78 .0 16 .9 5. 2 10 0. 0 51 .0 5. 0 39 .6 4. 4 10 0. 0 49 .0 48 82 0 E du ca tio n of h ou se ho ld h ea d N on e 78 .5 17 .0 4. 6 10 0. 0 50 .5 5. 9 39 .1 4. 4 10 0. 0 48 .9 44 41 5 Pr im ar y 82 .6 12 .5 5. 0 10 0. 0 62 .3 13 .6 21 .8 2. 3 10 0. 0 59 .6 10 12 9 Se co nd ar y + 94 .5 5. 0 .5 10 0. 0 82 .7 11 .4 5. 2 .6 10 0. 0 82 .5 12 76 3 M is si ng /D K 50 .8 49 .2 .0 10 0. 0 49 .2 30 .9 19 .9 .0 10 0. 0 49 .2 13 W ea lth in de x qu in til es Po or es t 72 .2 19 .6 8. 2 10 0. 0 31 .6 1. 2 59 .4 7. 8 10 0. 0 30 .0 13 46 1 Se co nd 75 .9 18 .6 5. 4 10 0. 0 47 .3 2. 0 46 .0 4. 7 10 0. 0 45 .2 13 46 8 M id dl e 78 .4 17 .8 3. 8 10 0. 0 50 .6 11 .9 34 .1 3. 3 10 0. 0 48 .1 13 46 6 Fo ur th 85 .9 12 .5 1. 6 10 0. 0 68 .0 20 .8 10 .3 .9 10 0. 0 67 .0 13 46 2 R ic he st 98 .2 1. 6 .2 10 0. 0 94 .5 4. 7 .7 .0 10 0. 0 94 .3 13 46 2 To ta l 82 .1 14 .0 3. 9 10 0. 0 58 .4 8. 1 30 .1 3. 4 10 0. 0 56 .9 67 32 0 [1 ] M IC S in di ca to r 4 .1 ; M D G in di ca to r 7 .8 [2 ] M IC S in di ca to r 4 .3 ; M D G in di ca to r 7 .9 98 Handwashing Handwashing with water and soap is the most cost effective health intervention to reduce both the in- cidence of diarrhoea and pneumonia in children under five. It is most effective when done using water and soap after visiting a toilet or cleaning a child, before eating or handling food and, before feeding a child. Monitoring correct hand washing behaviour at these critical times is challenging. A reliable alternative to observations or self-reported behaviour is assessing the likelihood that cor- rect hand washing behaviour takes place by observing whether a household has a specific place where people most often wash their hands, and observing if water and soap (or other local cleansing materials) are present at a specific place for hand washing. Water and soap availability is higher for the Western region, higher level of education of the household head, wealthier households and urban areas. In Bhutan, 97.6 percent of the households had a specific place for hand washing, while 1.9 percent households could not indicate a specific place where household members usually wash their hands and 0.1 percent of the households did not give a permission to see the place used for handwashing (Table WS.9). Of those households where place for handwashing was observed, more than two-thirds (80.9%) had both water and soap present at the designated place. In 8.7 percent of the households, only water was available at the designated place, while 8.2 percent of the households had soap but no water. The remaining 2.2 percent of households had neither water nor soap available at the desig- nated place for hand washing. Interestingly, among the dzongkhags, Paro has the largest percent of observed households without both

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