Human Resources, infrastructure, and supply systems for refractive error care in Bhutan: A WHO RESAT Analysis

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However, there has been limited assessment of how existing resources support equitable access to refractive error (RE). This study assesses the readiness of Bhutan’s RE service infrastructure, workforce distribution, and supply systems using the WHO Refractive Error Services Assessment Tool (RESAT) Methods: A cross-sectional situational analysis was conducted using a mixed method approach between March and July 2025. The assessment covered all 36 public eye-care facilities and 33 optical outlets across 20 districts. Data were collected through structured facility questionnaires, onsite field verification, and key-informant interviews. Quantitative findings were summarized descriptively and triangulated with qualitative data using framework analysis under three RESAT components: (1) service delivery, (2) human resources for eye health (HReH), and (3) health technology and supply. Results: Data were collected from all 36 public eye-care centres (100%) and 32 of 33 optical shops (97%) across Bhutan. Refractive-error (RE) services were available in 95% of districts but in only 14% of all health facilities, reflecting limited integration into primary health care. Optical outlets covered 65% of districts, with one-third located in Thimphu, indicating strong urban bias. All eye centres were adequately equipped for refraction, though maintenance delays were common due to the lack of biomedical capacity. The eye-health workforce comprised 102 professionals, of whom 89% were urban-based. Optometrists and ophthalmologists were exclusively urban, while only 17% of technicians served in rural hospitals. Optical services relied almost entirely (> 90%) on imported lenses and frames from India, with high transport costs inflating retail prices. Qualitative insights highlighted weak referral adherence, urban–rural inequities, and dependence on external supply chains. Conclusion: This analysis shows that Bhutan has made notable progress in integrating refractive-error (RE) services within its universal health-care system. However, inequitable workforce distribution, lack of local optometry training, and weak optical supply chains threaten sustainability. Strengthening human-resource capacity, embedding RE in the essential health package, and ensuring sustainable financing will be key to achieving universal effective RE coverage by 2030. Bhutan refractive error human resources infrastructure health system RESAT optical services Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The World Health Assembly resolution on Integrated People-Centred Eye Care (IPEC) and the WHO’s SPECS 2030 initiative emphasize effective refractive error coverage (eREC) as a key indicator for universal eye-health, targeting a 40-percentage-point increase by 2030 [ 1 , 2 ]. Achieving these targets will require strengthening the foundational building blocks of eye-care systems-trained human resources, well-distributed infrastructure, and a reliable health-technology and supply system [ 3 ]. In low- and middle-income countries (LMICs), deficiencies in these components often perpetuate inequities in access and quality of care [ 4 ]. The Lancet Global Health Commission on Global Eye Health highlighted that scaling up refractive care depends on sustained investment in human resources, infrastructure, and technology supported by robust policy, governance, and financing [ 5 ]. These findings point out that RE correction is not just a clinical intervention but a system function requiring integrated and scalable service delivery. However, integrating eye care into health systems in a low-resource setting remains challenging due to scarce resources, competing priorities, and the need for ongoing support [ 6 ]. Bhutan, a small Himalayan LMIC with a population of approximately 0.78 million, provides a unique setting to examine these systemic dynamics. Guided by the philosophy of Gross National Happiness (GNH), Bhutan provides free universal health care through a publicly financed health system delivering care from the community to tertiary levels[ 7 ]. Eye health has been integrated since the establishment of the Primary Eye Care Program (PECP) in the 1980s [ 8 ]. Through this integration, refraction and other ophthalmic services are now available in almost all district and referral hospitals. However, the readiness of these facilities has not been systematically evaluated. In Bhutan, existing studies have assessed the burden of refractive error among adults and school-aged children [ 9 , 10 ]. However, there remains a critical evidence gap regarding system capacity, including the distribution of health centers, human resources, equipment, and supplies required to deliver RE services equitably. This gap is particularly salient as the forthcoming National Eye Health Strategy 2025–2030 aims to align with WHO’s frameworks for IPEC and the SPECS 2030 initiative [ 11 ]. To address this gap, we conducted the first nationwide situational analysis of refractive-error services in Bhutan using the WHO Refractive Error Services Assessment Tool (RESAT) [ 12 ]. The present analysis focuses on three interlinked components: service delivery, human resources, and health-technology and supply to assess the availability, distribution, and operational readiness of RE services. By doing so, the study identifies operational strengths and critical gaps and informs actionable policy priorities to strengthen Bhutan’s readiness to achieve the 2030 eREC target. Methods Study design This study is part of a nationwide situational analysis of refractive-error services in Bhutan, conducted between March and July 2025, using the WHO RESAT. RESAT is a structured framework designed to assess the status of refractive-error services at national or subnational levels and monitor progress. The tool is organised around eight core components aligned with the six WHO health system building blocks, ensuring a comprehensive systems-based assessment. This study adopted a cross-sectional, mixed-methods design integrating quantitative facility-readiness data and qualitative stakeholder insights. Three RESAT components were examined: (1) service delivery, (2) health workforce, and (3) health-technology and supply. The service delivery domain assessed how refractive error services are integrated within the public health system, their referral networks, service locations, and the mix of public–private provision. The workforce domain examined the composition, distribution, and training of personnel delivering refractive care. The health technology and supply domain evaluated the availability, accessibility, and functionality of equipment essential for diagnosing and managing refractive error. Complementary analyses on other RESAT components are reported separately. Setting Bhutan is a lower-middle-income, landlocked Himalayan kingdom in South East Asia with an estimated population of 777,224. The country has a decentralized, three-tier health-care system. By 2025, there were 36 public eye centers across 20 districts distributed across 20 districts; one national referral center, two regional referral hospitals, four cluster hospitals, 18 district hospitals, and 11 ten-bedded hospitals. Additionally, 33 optical shops operated across 13 districts. Together, these facilities formed the sampling frame for the study. Study population and sampling All 36 public eye units in all 20 districts were included, ensuring complete national coverage. Each facility was represented by the Head of the eye-care unit (ophthalmologist, optometrist, or ophthalmic technician). The optical-outlet survey comprised all 33 licensed optical shops in Bhutan. Purposive sampling was used to recruit stakeholders for the key informant interview (KII). This methodological design followed RESAT guidelines, thereby ensuring both rigor and inclusivity in the selection process. Component A For the desk review, sources were selected based on relevance, credibility, and timeliness, prioritizing materials published between 2000 and 2025. The review covered national eye-health policies, program reports, and peer-reviewed literature on refractive-error services in Bhutan. Secondary data were obtained from national surveys, including the National Health Survey and Bhutan Living Standards Survey, as well as reports from the World Bank and National Statistical Bureau. Component B: Questionnaire-based survey A nationwide questionnaire survey covered all 36 eye centres and 33 optical outlets, assessing infrastructure, equipment, and service delivery. The heads of the facilities were invited to participate. To ensure data accuracy, six eye centers and three optical outlets were verified through site visits by two investigators (IPS and NTL). Component C: Key Informant Interview (KII) Using purposive sampling, 19 participants with expertise in RE service delivery were recruited for KII, guided by the WHO RESAT stakeholder framework.The qualitative component captured perspectives across RESAT domains. Participants included the Ministry of Health's Primary Eye Care Program Officer (n = 1), an international donor agency representative (n = 1), a Disabled People Organization representative (n = 1), ophthalmologist including the Head of apex center (n = 2), optometrists including the Chief Optometrist of apex center (n = 2), an ophthalmic technician (n = 1), optical shop owners (n = 2), PHC health assistants (n = 2), a health teacher (n = 1), a teaching institute representative (n = 1), individuals with refractive error (n = 3), and parents of children with refractive error (n = 2). Recruitment occurred via Ministry of Health networks using email and telephone, with snowball sampling to identify additional informants. Eligibility required at least two years of professional experience in eye care or related health services in Bhutan. Data Collection Procedures​ The RESAT questionnaire and interview tool was used for data collection [ 12 ]. No new questionnaire or tool was developed. (a) Desk-Based Review A systematic desk review synthesized secondary data on refractive error services in Bhutan, using national health policies, reports (e.g., National Standard for Ophthalmology Services, Bhutan Eye Health Strategy 2018–2023), and Primary Eye Care Program data. Peer-reviewed articles from PubMed, Google Scholar, and Scopus were identified using keywords like "refractive error Bhutan" and "eye care services Bhutan." Grey literature from WHO, IAPB, and NGOs was also examined. Of 140 records screened, 42 Bhutan-specific studies (2000–2025) met inclusion criteria and were analyzed using a standardized RESAT template. (b) Questionnaire-based survey of eye health facilities and opticals A structured questionnaire, adapted from sections 3 to 5 of RESAT covering service delivery, workforce, technology, and supplies, was administered to designated heads of eye care services in participating health facilities. Data was collected through self-administered online surveys (Google Forms), supplemented by follow-up telephone calls to clarify responses where necessary. The survey remained open for four weeks, during which periodic reminders were issued to maximize response rates. (c) Key Informant Interviews Semi-structured interviews (30–45 minutes) were conducted in English, either in person or virtually. Small group discussions (2–3 participants) were used where appropriate. To ensure rigour, all participants provided consent, and anonymity was maintained. Data analysis Quantitative data from surveys were summarized using descriptive statistics and presented in tables and figures. Qualitative data from interviews and desk reviews were analyzed thematically using NVivo software, following a deductive coding approach guided by the RESAT framework. Two researchers coded data independently, resolving discrepancies through consensus. Triangulation between quantitative and qualitative findings was applied to enhance validity and contextual interpretation, thereby strengthening the comprehensiveness and robustness of the overall situational analysis. Ethical Considerations Ethical approval was obtained from the Research Ethics Board of Health (REBH), Ministry of Health, Bhutan (Ref: REBH/Approval/2023/003) and the Biomedical Research Ethics Committee (BREC), University of KwaZulu-Natal, South Africa (Approval no: BREC/00004482/2022). Administrative clearance was granted by the Policy and Planning Division, Ministry of Health, Bhutan. The study followed WHO ethical standards and adhered to national and institutional protocols. Although non-clinical assessments typically do not require formal ethical approval under RESAT, informed consent was obtained from all participants to ensure voluntary participation, withdrawal rights without consequences, and confidentiality. No personal identifiers were collected, data were stored securely, and no incentives were provided to the participants. The study adhered to the Declaration of Helsinki. Results Data were obtained from 36 eye-care centers (100%) and 32 optical shops (97%) across Bhutan Service delivery Refraction services In Bhutan, all 36 public health facilities provide eye care, including RE services: one apex center, two regional referral hospitals, four cluster hospitals, 18 district hospitals, and 11 ten-bedded hospitals. No private or NGOs facilities provide refraction services. Public eye health centers also manage community vision screening, school eye-health programs, and outreach surgical camps. According to Bhutan Health Service Standards, 2019, general ophthalmology services, which include refraction services, are mandated to be available at all 10-bedded hospitals [ 13 ] However, only 65% of hospitals (36 of 55) and 14% of all health facilities (36 of 257) provided eye-care services ( Table 1 ) . Primary health centers are limited to ocular first aid and awareness activities. Bhutan’s RE services demonstrate broad geographic reach, available in 19 of 20 districts (95%) ( Fig. 1 ) . Table 1 Availability of eye care, including refractive error services across levels of health facilities in Bhutan, 2025. Sl .no Health facilities General health service Eye health, including RE service Percentage 1 JDW National Referral Hospital (JDWNRH) 1 1 100.0 2 National Traditional Medicine Hospital 1 0 0.0 3 Regional Referral Hospitals (RRH) 2 2 100.0 4 District Hospitals (DH) 28 20 71.4 5 10 Bedded Hospital 31 13 41.9 6 Primary Health Centers 194 0 0.0 Total 257 36 14.0 The service-output data were limited, with 21 health facilities reporting spectacle-dispensing volumes. The average number of spectacles dispensed was 37 per month. All public facilities offer vision screening and basic refraction, though contact-lens and low-vision services are available to tertiary and referral hospitals. The services in different levels of eye care facilities and comparison of eye-health and general-health service coverage in Bhutan is shown in Fig. 2 . Refractive surgery services are not currently available in the country. Ready-made near vision spectacles and contact lenses are available both over the counter and through prescription by qualified eye health professionals. There is no empirical research to investigate the perceived barriers to accessing refractive error care. Routine quality-assurance audits are absent, limiting evaluation of service performance. Bhutan's referral system directs patients from lower to higher-level eye care facilities, but there are enforcement challenges. It leads many to bypass initial care levels and seek services directly at advanced facilities, reducing system efficiency. Optical services In Bhutan, there are 33 optical shops across 13 districts, representing a coverage of 65% (13 out of 20 districts). The distribution of services was uneven, with the majority of outlets concentrated in urban centres. Thimphu has 11 outlets (33%), Mongar and Gelephu each have 3 (9%), reflecting limited access in rural districts (Fig. 3 ). Among the 32 surveyed optical facilities, most (72%, n = 23) were established between 2011 and 2020, marking the period of rapid expansion during this period. 16% (n = 5) opened after 2020, while only 3%(n = 1) predated 2000. Qualitative insights: Service delivery Health-staff interviews underscored limited refractive service coverage in lower-level facilities. “Apart from treating common eye infections, we are not trained to check vision or give spectacles. We simply refer to higher centers.” – -a PHC health assistant (HA) This observation aligns with RESAT findings: while all 36 public centers offer refraction, only 65% of hospitals provide eye care, and primary centers provide minimal or no RE services. Participants highlighted urban bias in optical access: "We prescribe spectacles everyday from our OPD, but most of them come back without spectacles requesting for eyedrops, as there are no optical shops in our district. People have to travel to other districts or border towns to buy a pair of spectacles”-ophthalmic technician, district hospital. ‘I came to Thimphu to get my eye power checked.I prefer to come here because I don’t get good choices of frames and contact lenses in our district’. -a patient with refractive error. These observations confirm RESAT’s quantitative data, revealing optical coverage in only 65% of districts, underscoring the uneven distribution and accessibility of optical care. Referral challenges were also noted “Patients often bypass district hospitals, though there are eye care services, and come straight to the referral hospital.” -an ophthalmologist. These qualitative findings complement the quantitative evidence of weak referral adherence and service fragmentation. Health workforce Eye-health personnel in Bhutan include ophthalmologists, optometrists, ophthalmic technicians, and nurses. All are licensed under the Bhutan Qualifications and Professional Certification Authority (BQPCA). under the Medical Act of Bhutan (2002). No HReH are employed in the private sector. Table 2 presents the national and facility-level distribution of HReH.. Table 2 Distribution and Urban-Rural Allocation of Eye Health Human Resources in Bhutan, 2025 HReH Category Total, n (%) Ratio (Pop: 777,224) National Eye Center, n (%) Regional Hospitals, n (%) District Hospitals, n (%) 10-Bedded Hospitals, n (%) Urban–Rural Distribution Ophthalmologist 17 (16.7) 1 : 45,719 8 (47.1) 6 (35.3) 3 (17.6) 0 (0.0) 100% Urban Optometrist 13 (12.7) 1 : 59,778 4 (30.8) 4 (30.8) 5 (38.4) 0 (0.0) 100% Urban Ophthalmic Technician 65 (63.7) 1 : 11,958 16 (24.6) 11 (16.9) 27 (41.5) 11 (16.9) 83.1% Urban · 16.9% Rural Ophthalmic Nurse 7 (6.9) 1 : 111,032 7 (100.0) 0 (0.0) 0 (0.0) 0 (0.0) 100% Urban Total 102 (100.0) — 35 (34.3) 21 (20.6) 35 (34.3) 11 (10.8) — Overall, 89.2% of HReH are urban-based, despite only 37.8% of the population living in urban areas. Rural districts (62.2% of population) are served by just 10.8% of personnel. Ophthalmologists, optometrists, and ophthalmic nurses are entirely based in urban areas (100%), while only 17% of technicians serve in rural ten-bedded hospitals. Rural eye care is often provided by general health workers with limited refractive error training. Bhutan’s ophthalmologist and optometrist ratios meet WHO benchmarks (1:50,000) for general eyecare but are inadequate for RE services. Government efforts focus on equitable deployment, particularly in underserved rural areas, supported by accessible infrastructure. However, no productivity or performance indicators exist for RE staff. Establishing monitoring frameworks and refresher training could enhance quality and efficiency. Refraction training in Bhutan is primarily delivered through the ophthalmology and ophthalmic technician programs at KGUMSB, while optometrists are trained abroad due to the absence of an in-country program. Ophthalmic nurses receive only short-term, non-refractional training (Table 3 ). Table 3 Training of human resources for eye health (HReH) for refractive error services in Bhutan HReH Category Training Programme Year Started / Upgraded Entry Requirement Duration Curriculum Focus on Refraction Training Requirements Graduates per Year (n) Recruited per Year (n) Ophthalmologist Postgraduate Degree in Ophthalmology (KGUMSB) 2014 MBBS 4 years Integrated into comprehensive clinical training Residents must perform ≥ 500 independent refractions [25] 2–3 2–3 (All graduated from KGUMSB) Optometrist Bachelor of Optometry (Overseas; no in-country training) - 12th Standard (Science) 4 years (India) + 1-year internship (Bhutan) Comprehensive training in refraction, optics, and vision science Clinical rotations in all core optometry disciplines 4–6 1–2 Ophthalmic Technician Diploma in Primary Eye Care (KGUMSB) 1987 (Certificate); upgraded to Diploma in 2020 10th Standard (1987–2005); 12th Standard (General) since 2006 2 years (pre-2020); 3 years including 1-year public health foundation (post-2020) Refraction covered in 3 of 6 semesters; extensive hands-on practical training Mandatory field postings and continuous practical assessment 5–8 5–8 (All graduated from KGUMSB) Ophthalmic Nurse Ophthalmic Nursing (Short-term, in-service training) Not formalized General Nursing and Midwifery (GNM) < 6 months Limited to vision assessment; no structured refraction component Short-term in-house training within ophthalmology wards (as required) Not specified Recruited as per need Table 4 shows that between 2010 and 2025, 114 eye health professionals joined public service, with 89.5% retained. The attrition for other opportunities was 7%, driven mainly by optometrists (18.7%). Ophthalmic technicians had the highest retention (94.2%), while ophthalmic nurses showed the greatest separation (30%), mostly due to retirement. Table 4 Recruitment and separation patterns of among human resources for eye health (HReH) in Bhutan (2010–2025) HReH Category Total Entered in Public Service Retained in System, % (n) Separated, % (n) Retired, % (n) Departed for Other Opportunities, % (n) Ophthalmologist 19 89.5 (17) 10.5 (2) 5.3 (1) 5.3 (1) Optometrist 16 81.3 (13) 18.7 (3) 0 (0) 18.7 (3) Ophthalmic Technician 69 94.2 (65) 5.8 (4) 1.4 (1) 4.3 (3) Ophthalmic Nurse 10 70.0 (7) 30.0 (3) 20.0 (2) 10.0 (1) Total 114 89.5 (102) 10.5 (12) 3.5 (4) 7.0 (8) There are no structured deployment programs for new graduates to underserved districts. While the BQPCA mandates continuing medical education (CME) for all professionals, no specific CPD guidelines exist for refractive-error management. Similarly, systematic quality audits and performance appraisals are lacking. The hospital quality control units ensure that refractive error personnel adhere to standardized procedures and protocols. Limited task-sharing occurs, with some health assistants and school health teachers trained for basic vision screening in schools. Qualitative insights: Health Workforce Participants repeatedly emphasized urban–rural workforce disparities. “We manage common eye problems in the PHC, because the eye care team are mostly in the higher centers. We refer most of the cases to those centers.” - PHC health assistant. “We try to place our limited staff across districts, but it’s difficult with so few of us.” - Head, National Eye Center. The RESAT quantitative outputs substantiate this finding, indicating that all ophthalmologists and optometrists (100%) are concentrated in urban areas and only 17% of technicians in rural facilities Stakeholders also identified training bottlenecks. “As the only institute producing allied health professionals, we are limited by our own challenge of HR and infrastructure. We do not have training programs for optometrists and the ophthalmic technician training also needs to compete with other categories of allied health’. -a teaching institute representative. Health technology and supply Infrastructure and Equipment All public eye centers (100%) have dedicated refraction rooms, and essential equipment for vision assessment and refraction services. Similarly, all optical outlets had near vision charts, lensometers, and interpupillary (IPD) rulers ( Fig. 4 ) . However, equipment for edging and fitting spectacles exists only in optical outlets, not in public facilities. Ophthalmic equipment for public facilities is procured through the national procurement system, but spectacles are excluded. The Biomedical Division of the Ministry of Health oversees the maintenance and calibration of the equipment. However, with the exception of the national referral hospital, biomedical technicians lack expertise to repair ophthalmic equipment. Optical Supply Chain Bhutan does not produce optical products domestically. Ready-made spectacles and single vision lenses are available in all optical practices surveyed across the country. However, multifocal lenses and progressive lenses were available in 60.6% (n = 20) and contact lenses in 36.7% (n = 12) opticals. However, myopia management lenses and refractive surgery options were unavailable. India was the predominant supplier for both spectacle lenses and frames, reported by 90.6% (n = 29) and 96.9% (n = 31) of opticals, respectively. Thailand was the second most common source for frames (31.3%, n = 10), followed by China (12.5%, n = 4), Nepal (9.4%, n = 3) and Italy (9.4%, n = 3). Import taxes Spectacle lenses (glass or other materials) and contact lenses are tax-exempt. Frames, mountings and sunglasses incur 10% customs duty and 5% sales tax. Imports from India are exempt from customs duty under the bilateral Free Trade and Commerce agreement; a 5% sales tax still applies [ 13 ]. Imported optical products may be dispensed without prior approval from government authorities. Within the public health sector, there is no centralized system to negotiate or regulate procurement prices for spectacles. Furthermore, aside from routine monitoring activities, no periodic surveys are conducted to assess the availability of essential refraction equipment and spectacles within the public health system. The infrastructure required to support effective refractive error services is largely in place. Advanced refraction equipment is widely accessible at tertiary eye care facilities and is also present in several secondary-level facilities, thereby enabling a reasonable capacity for the provision of high-quality refractive error management. Qualitative insights: Health technology and supplies Stakeholders reported overall satisfaction with the availability of eye health infrastructure in urban health centers; however, persistent deficiencies were identified in rural facilities. “ We have all the equipment here for refraction, but if one important piece of equipment, for example if a retinoscope breaks down, we don’t have the capacity to repair it. We have to wait for the next round of procurement cycle which takes around 6 months to get a replacement.’ -an ophthalmic technician, District hospital This highlights the fragility of maintenance systems despite adequate infrastructure. Optical retailers reported high dependency on imported optical products, particularly from India. They highlighted challenges due to transport costs and stock limitations: While import tariffs were not regarded as a significant constraint, stakeholders emphasized that high transportation costs constitute the major contributing factor to elevated spectacle prices. “ We sometimes face difficulty in providing spectacles on time, as we can’t stockpile all glass powers and have to import them from India. That also have to make a bulk purchase and it takes around 2–3 weeks.” - an optical shop owner 1. “We are comfortable with taxes. Transport costs are our main problem; small orders make per-lens prices very high.” - an optical shop owner 2. Staff further reported limited availability of specialized lenses, which aligns with survey findings indicating that multifocal lenses are available in only 60% of optical practices, while contact lenses are offered in only 37%. Discussion Bhutan has formally committed to the WHO SPECS 2030 initiative [ 14 ]. This nationwide situational analysis, presents the first comprehensive assessment of Bhutan’s RE service delivery system using RESAT. It provides an integrated understanding of service availability, human resources, technology, and supply. To the best of our knowledge, this is the first national-level application of the WHO RESAT. Overall, the findings reveal that Bhutan has made notable progress in establishing geographically accessible and well-equipped eye health centers. Nonetheless, persistent systemic challenges including workforce shortages, urban–rural disparities, and limited access to optical services continue to impede the equitable and sustainable delivery of refractive care. Service Delivery and System Integration Service delivery in eye health demonstrates notable strengths. RE services are available in 36 public eye health centers, reaching 95% of districts, a level of geographical coverage rarely observed in lower-middle-income countries. This level of accessibility surpasses that of comparable LMICs, such as Nepal, where approximately 40% of the population remain without access to basic eye care services [ 15 ] This achievement could be attributed to the country’s policy of integrating eye health into its primary health care through the Primary Eye Care Programme (PECP). Despite this, inequities in distribution persist as most RE services remain concentrated in hospitals. Only 14% of health facilities provide RE services, reflecting limited integration of RE care within the primary health care (PHC) network. The analysis highlights gaps in horizontal integration and referral compliance. Primary-health centres provide minimal refraction or spectacle services, forcing many patients to bypass lower-level facilities and seek care directly from secondary and tertiary centres. Strengthening task-sharing and expanding refraction services to primary-care levels through trained health assistants, school health coordinators, or tele-optometry could mitigate this imbalance [ 16 ]. Optical outlets are disproportionately concentrated in urban areas, with 33% located in Thimphu, while only 65% of districts are covered, necessitating rural residents to travel considerable distances to obtain spectacles. This urban–rural divide reflects service delivery patterns documented across South Asia and other LMICs, where uneven distribution of resources contributes to untreated visual impairment [ 17 ]. Strengthening gatekeeping functions and integrating basic refraction into PHC packages, possibly through task-sharing or tele-refraction, could enhance efficiency and early detection. The lack of systematic quality-assurance mechanisms and limited service-output monitoring further constrain the system’s ability to evaluate and improve performance. Regular audits of refraction accuracy, spectacle delivery timelines, and patient satisfaction would align Bhutan’s quality-assurance processes with WHO’s IPEC framework and ensure sustained improvement in eREC. Human Resources for Eye Health Bhutan meets the WHO benchmark ratio for ophthalmologists (1 : 50 000); however, the optometrist-to-population ratio (1 : 59 778) remains insufficient for population-based refractive-error management. This deficit is compounded by the high attrition rate (18.7%) and the absence of a domestic optometry training program, which necessitates reliance on foreign education, predominantly in India. Optometrists are uniquely trained for refraction, contact-lens fitting, and low-vision rehabilitation, domains essential for achieving the eREC target. Evidence indicates that countries with fewer optometrists tend to have higher rates of blindness and are often characterized by lower GDP per capita [ 18 ]. The human resource for eye health (HReH) analysis reveals a pronounced urban–rural disparity. Nearly 90% of HReH are concentrated in urban areas, serving only 37.8% of the national population. Ophthalmologists and optometrists are entirely located in urban areas, while only 16.9% of ophthalmic technicians serve in rural hospitals. This maldistribution undermines equitable RE service delivery and leaves rural communities reliant on minimally trained general health workers. Such inequities mirror broader LMIC trends, where workforce concentration in urban centres exacerbates access barriers for vulnerable populations [ 19 ]. It also underscores the difficulty of retaining professionals in remote areas, similar to Nepal [ 20 ]. Ophthalmic technicians form the backbone of service delivery at district and 10-bedded hospitals. This cadre provides a scalable entry point for task-sharing in refraction. Upgrading the diploma curriculum to manage advanced refraction and ophthalmic dispensing, and introducing refraction-focused continuing professional development (CPD) pathways could enhance both competency and career satisfaction. Retention analysis indicates profession-specific vulnerabilities: while ophthalmic technicians show high stability (94.2%), optometrists (18.8%) and ophthalmic nurses (30%) experience notable attrition, driven by external opportunities and retirement, respectively. To strengthen the HReH for refractive services, Bhutan should prioritise the recruitment and deployment of optometrists to all hospitals with 10 or more beds, while simultaneously mandating RE-specific continuous professional development (CPD) for primary care health workers. Additionally, lessons may be drawn from task-sharing approaches in comparable LMICs, such as Ethiopia, where community health workers have been successfully trained to conduct basic vision screening [ 21 ]. Infrastructure, Equipment, and Supply Chains The health technology and supply assessment reveal that public facilities in Bhutan are adequately equipped: all eye centers (100%) have a dedicated refraction room and essential equipment for basic refraction services. However,the absence of spectacles from the list of essential medical supplies results in inconsistent provision, often dependent on external donation. Delays in equipment repair due to lack of biomedical competence in repairing ophthalmic equipment and long procurement cycles reported to take several months compromise service reliability. Similar bottlenecks have been observed in other resource-limited contexts, emphasizing the need for decentralized maintenance capacity and preventive servicing protocols [ 22 ].Building decentralized biomedical maintenance capacity and adopting preventive-maintenance schedules would reduce downtime and enhance service continuity. The optical service landscape shows notable expansion, particularly after 2010, but remains heavily urban-skewed with only 65% of districts having optical outlets. Bhutan could support entrepreneurship in opening and operating optical shops in rural districts. Optical-supply chains are almost entirely import-dependent. About 90–97% of lenses and frames sourced from India, are subject to minimal taxation, substantially lower than most LMICs [ 23 ]. While import taxes are minimal, high transportation costs and the absence of bulk procurement inflate retail prices, limiting affordability especially for rural populations. It echoes global evidence that economic, rather than geographic, barriers often drive unmet refractive needs [ 24 ]. Furthermore, cumbersome import procedures and fragmented regulatory requirements discourages suppliers. The lack of in-country manufacturing or centralized procurement of spectacles also creates a disconnect between diagnosis and correction, a recurrent challenge in LMICs. Bhutan could employ public–private partnerships models to establish a national optical-supply strategy encompassing pooled procurement, local assembly, and public-sector dispensing points. To address these supply-side constraints, Bhutan may consider policy measures such as negotiating bulk procurement agreements, Inclusion of spectacles in Essential supplies list, developing local maintenance and technical capacity, and streamlining the importation process for spectacles and related accessories. Policy and Programmatic Implications Bhutan’s commitment to the WHO SPECS 2030 initiative offers a pivotal opportunity to transform RE services from a vertical program into an integrated, system-wide service. Policy focus should now shift toward embedding RE within the primary health care (PHC) package, supported by task-sharing models involving health assistants, school health coordinators, and tele-optometry to expand equitable access. Establishing an in-country optometry training program is essential to mitigate workforce shortages and reduce reliance on foreign education. Recruitment of at least one optometrist per district hospital, coupled with structured continuing professional development (CPD) for all cadres, will enhance quality and retention. Strengthening biomedical-maintenance capacity through decentralized repair hubs and preventive-maintenance schedules would minimize equipment downtime and sustain service delivery. Equally important is the creation of a National Optical-Supply Strategy that integrates pooled procurement, local assembly, and inclusion of spectacles in the essential-supplies list to improve affordability and rural access. Dedicated financing, public–private partnerships, and routine monitoring aligned with SPECS 2030 indicators will ensure accountability and progress. Strengths, Limitations, and Future Directions The utilization of the standard WHO RESAT framework, a mixed-methods design, nationwide coverage(100% of eye centers and 97% of optical outlets), full (100%) facility response, and the inclusion of diverse stakeholders substantially enhance the methodological rigor and validity of this study. Nonetheless, certain limitations must be acknowledged. These include reliance on purposive sampling for stakeholder selection and the dependence on self-reported facility-level data, which may introduce reporting bias.Service output data (e.g., number of spectacles dispensed) were incomplete, constraining productivity analysis. While the RESAT framework provides a structured and systematic basis for analysis, it does not incorporate quantitative eREC measurement. Furthermore, the cross-sectional design limits the ability to infer longitudinal trends or causal relationships over time. Future research should focus on patient perspectives and the economic burden of uncorrected refractive error, alongside longitudinal monitoring of workforce retention. Evaluating pilot models of primary-level refraction, tele-optometry, and community spectacle distribution could inform scale-up strategies. Conclusion This situational analysis reveals that Bhutan has made remarkable progress in establishing nationwide RE services within its universal health-care framework. The study highlights both commendable achievements; universal service availability, high workforce retention, and functional infrastructure demonstrate that system integration is possible even in resource-constrained contexts. However, sustainability challenges persist due to inequitable workforce distribution, absence of local optometry education, and challenges to optical access, and supply-chain sustainability. Addressing these will require a deliberate policy shift toward system-level reforms. Sustained financing, robust monitoring aligned with WHO SPECS 2030 indicators, and multisectoral partnerships will be crucial. It will also require embedding RE services within the essential health package, embracing task-sharing models, increasing the pool of optometrists, ensuring equitable distribution of HReH, and strengthening optical supply chain mechanisms. Finally, adopting innovative financing approaches such as piloting public-private partnerships or implementing cross-subsidy models, could enhance affordability and accessibility of spectacles, particularly for disadvantaged populations. Through strategic planning, Bhutan has the potential to meet the eREC targets and establish itself as a regional exemplar for LMICs in the region. Declarations Clinical trial number Not applicable. Ethics approval and consent to participate Ethical approval for the study was granted by the Research Ethics Board of Health (REBH), Ministry of Health, Bhutan (Ref: REBH/Approval/2023/003), and the Biomedical Research Ethics Committee (BREC) of the University of KwaZulu-Natal, South Africa (Approval No: BREC/00004482/2022). In addition, administrative clearance was secured from the Policy and Planning Division of the Ministry of Health, Bhutan. Consent for publication Not applicable. Competing interests All authors declare no competing interests. Funding No funding was received for this work. Author Contribution IPS is the study’s principal investigator. IPS, KSN and KPM conceptualized the protocol, and study design. IPS, NTL, DW and SP participated in study implementation including data collection. NTL, DW and SP provided technical guidance. KSN, KPM, NTL and DW were involved in the interpretation of the finding and validated the data. IPS drafted the manuscript and all authors critically reviewed the draft manuscript and approved the final version. Acknowledgement The authors thank the staff of GKCW National Eye Center, Thimphu for helping with data collection. The authors also express gratitude to the study participants for their time and cooperation. Data Availability The dataset(s) supporting the conclusions of this article is(are) included within the article (and its additional file(s)). References World Health Organization. Integrated people-centred eye care, including preventable vision impairment and blindness. WHA73.4. Geneva: WHO. 2020 Aug 3. Available from: https://apps.who.int/gb/ebwha/pdf_files/WHA73/A73_R4-en.pdf [cited 2025 Oct 10]. World Health Organization. WHO SPECS 2030 [Internet]. Geneva: WHO. 2024 May 15 [cited 2025 Oct 10]. Available from: https://www.who.int/initiatives/specs-2030 Keel S, Mueller A. WHO SPECS 2030 - a global initiative to strengthen refractive error care. Community Eye Health. 2024;37(122):6–7. Epub 2024 May 15. PMID: 38827975; PMCID: PMC11141117. Elam AR, Aguwa U, et al. Disparities in Vision Health and Eye Care. Ophthalmology. 2022;129(10):e89–113. Burton MJ, Ramke J, Marques AP, et al. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020. Lancet Glob Health. 2021;9(4):e489–551. 10.1016/S2214-109X(20)30488-5 . Lee L, Moo E, Angelopoulos T, Dodson S, Yashadhana A. Integrating eye care in low-income and middle-income settings: a scoping review. BMJ Open. 2023;13(5):e068348. 10.1136/bmjopen-2022-068348 . PMID: 37236663; PMCID: PMC10230923. Ministry of Health Bhutan. National Health Policy [Internet], Bhutan. MOH; 2025 Jan [cited 2025 Oct 10]. Available from: https://moh.gov.bt/wp-content/uploads/2025/01/National-Health-Policy.pdf Lepcha NT, Sharma IP. Primary eye care in Bhutan: achievements and challenges. Community Eye Health. 2021;34(113):s11–2. Epub 2022 Mar 1. PMID: 36033415; PMCID: PMC9412122. Sharma IP, Lepcha NT, Lhamo T, Ellwein LB, Pokharel GP, Das T, et al. Visual impairment and refractive error in school children in Bhutan: The findings from the Bhutan School Sight Survey (BSSS 2019). PLoS ONE. 2020;15(9):e0239117. 10.1371/journal.pone.0239117 . Bourne RRA, Cicinelli MV, Selby DA, et al. Effective refractive error coverage in adults: a systematic review and meta-analysis of updated estimates from population-based surveys in 76 countries modelling the path towards the 2030 global target. Lancet Glob Health. 2025;13(8):e1396–405. 10.1016/S2214-109X(25)00194-9 . World Health Organization. Bhutan charts new course for eye health by 2030 [Internet]. Geneva: WHO. 2025 Jul 16 [cited 2025 Sep 16]. Available from: https://www.who.int/news-room/feature-stories/detail/bhutan-charts-new-course-for-eye-health-by-2030 World Health Organization. Refractive error situation analysis tool (RESAT). Geneva: WHO; 2025 [cited 2025 Oct 10]. Available from: https://www.who.int/publications/i/item/refractive-error-situation-analysis-tool-%28-resat%29 Ministry of Health. Health Service Standard (HSS) [Internet]. Thimphu: Royal Government of Bhutan, Ministry of Health; 2019 [cited 2025 Sep 11]. Available from: https://moh.gov.bt/wp-content/uploads/2025/01/Health-Service-Standard_2019.pdf Ministry of Finance, Royal Government of Bhutan. Bhutan Trade Classification and Tariff Schedule 2022 [Internet]. Thimphu: Ministry of Finance; 2022 [cited 2025 Aug 14]. Available from: https://www.mof.gov.bt/wp-content/uploads/2022/06/BhutanTradeClassificationTariffSchedule2022.pdf World Health Organization. Bhutan charts new course for eye health by 2030 [Internet]. Geneva: WHO. 2025 Jul 16 [cited 2025 Sep 11]. Available from: https://www.who.int/news-room/feature-stories/detail/bhutan-charts-new-course-for-eye-health-by-2030#:~:text=%C2%A9,eye%20health%20for%20the%20country.%E2%80%9D Gurung R, Oli RU. Primary eye care in Nepal: current situation and recommendations for integration. Community Eye Health. 2021;34(113):s13–4. Epub 2022 Mar 1. PMID: 36033419; PMCID: PMC9412118. Muma S, Naidoo KS, Hansraj R. Proposed task shifting integrated with telemedicine to address uncorrected refractive error in Kenya: Delphi study. BMC Health Serv Res. 2024;24(1):115. 10.1186/s12913-024-10618-8 . PMID: 38254104; PMCID: PMC10801974. Ravilla T. Inequities in eye care in South Asia. Community Eye Health. 2016;29(95):S01–3. PMID: 28289325; PMCID: PMC5340109. Naidoo K, Govender-Poonsamy P, Morjaria P, Block S, Chan V, Yong A, Bilotto L. Global mapping of optometry workforce. Afr Vis Eye Health. 2023;82(1):8. https://doi.org/10.4102/aveh.v82i1.850 . Das T, Keeffe J, Sivaprasad S, et al. Capacity building for universal eye health coverage in South East Asia beyond 2020. Eye. 2020;34:1262–70. https://doi.org/10.1038/s41433-020-0801-8 . Kandel H, Adhikary R, Gyawali R. Allied eye health professionals in eye care services in Nepal. Community Eye Health J 33 110, 2020 (published online 21 April 2021). Kentayiso TW, Nkoane NL, Matlhaba KL. Primary eye care service provision ability of mid-level healthcare providers in southern Ethiopia. Afr Vis Eye Health. 2024;83(1):a931. https://doi.org/10.4102/aveh.v83i1.931 . Thapa R, Yih A, Chauhan A, Poudel S, Singh S, Shrestha S, Tamang S, Shrestha R, Rajbhandari R. Effect of deploying biomedical equipment technician on the functionality of medical equipment in the government hospitals of rural Nepal. Hum Resour Health. 2022;20(1):21. 10.1186/s12960-022-00719-y . PMID: 35246155; PMCID: PMC8895523. Frontier Economics; International Agency for the Prevention of Blindness. Glasses for All: Improving Supply to the Poorest – A Supply-side Market Brief. [Internet]. 2024 [cited 2025 Sep 11]. Available from: https://www.iapb.org/wp-content/uploads/2024/02/Supply-side-market-for-glasses.pdf International Agency for the Prevention of Blindness. Innovative approaches to the provision of refractive error services: a position paper of the IAPB Refractive Error Working Group. September 2021. Available from: https://www.iapb.org/wp-content/uploads/2021/12/2021-REWG-position-paper_Innovative-approaches.pdf Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 19 Mar, 2026 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 13 Jan, 2026 Reviews received at journal 23 Dec, 2025 Reviews received at journal 18 Dec, 2025 Reviews received at journal 13 Dec, 2025 Reviewers agreed at journal 12 Dec, 2025 Reviewers agreed at journal 12 Dec, 2025 Reviewers agreed at journal 12 Dec, 2025 Reviewers invited by journal 12 Dec, 2025 Editor assigned by journal 08 Dec, 2025 Editor invited by journal 21 Nov, 2025 Submission checks completed at journal 19 Nov, 2025 First submitted to journal 19 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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17:03:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":239553,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of eye-health and general-health service coverage in Bhutan, 2025\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8065415/v1/8f68309c9febf2c2b43a1992.png"},{"id":98538124,"identity":"d0bdac1b-99d0-40be-a469-5a70ba25cce5","added_by":"auto","created_at":"2025-12-18 17:03:04","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":162949,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of Eye Centers and Optical Shops in Bhutan, 2025\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8065415/v1/399d07d9e7d2f502310617bd.jpeg"},{"id":98625694,"identity":"03b7fd18-44c2-4193-a358-af8c29166c26","added_by":"auto","created_at":"2025-12-19 17:09:16","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":92894,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAvailability of the infrastructure and equipment for the management of refractive errors, including for screening and testing\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8065415/v1/89d67758c64ead25c24c16ca.png"},{"id":105223363,"identity":"cc6b9627-3c55-4d25-a507-640adbaf5e85","added_by":"auto","created_at":"2026-03-23 16:05:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2063181,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8065415/v1/e151f4e5-d639-4340-9d1f-64344731416e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Human Resources, infrastructure, and supply systems for refractive error care in Bhutan: A WHO RESAT Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe World Health Assembly resolution on Integrated People-Centred Eye Care (IPEC) and the WHO\u0026rsquo;s SPECS 2030 initiative emphasize effective refractive error coverage (eREC) as a key indicator for universal eye-health, targeting a 40-percentage-point increase by 2030 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAchieving these targets will require strengthening the foundational building blocks of eye-care systems-trained human resources, well-distributed infrastructure, and a reliable health-technology and supply system [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In low- and middle-income countries (LMICs), deficiencies in these components often perpetuate inequities in access and quality of care [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Lancet Global Health Commission on Global Eye Health highlighted that scaling up refractive care depends on sustained investment in human resources, infrastructure, and technology supported by robust policy, governance, and financing [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These findings point out that RE correction is not just a clinical intervention but a system function requiring integrated and scalable service delivery. However, integrating eye care into health systems in a low-resource setting remains challenging due to scarce resources, competing priorities, and the need for ongoing support [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBhutan, a small Himalayan LMIC with a population of approximately 0.78\u0026nbsp;million, provides a unique setting to examine these systemic dynamics. Guided by the philosophy of Gross National Happiness (GNH), Bhutan provides free universal health care through a publicly financed health system delivering care from the community to tertiary levels[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Eye health has been integrated since the establishment of the Primary Eye Care Program (PECP) in the 1980s [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Through this integration, refraction and other ophthalmic services are now available in almost all district and referral hospitals. However, the readiness of these facilities has not been systematically evaluated.\u003c/p\u003e \u003cp\u003eIn Bhutan, existing studies have assessed the burden of refractive error among adults and school-aged children [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, there remains a critical evidence gap regarding system capacity, including the distribution of health centers, human resources, equipment, and supplies required to deliver RE services equitably. This gap is particularly salient as the forthcoming National Eye Health Strategy 2025\u0026ndash;2030 aims to align with WHO\u0026rsquo;s frameworks for IPEC and the SPECS 2030 initiative [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo address this gap, we conducted the first nationwide situational analysis of refractive-error services in Bhutan using the WHO Refractive Error Services Assessment Tool (RESAT) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The present analysis focuses on three interlinked components: service delivery, human resources, and health-technology and supply to assess the availability, distribution, and operational readiness of RE services. By doing so, the study identifies operational strengths and critical gaps and informs actionable policy priorities to strengthen Bhutan\u0026rsquo;s readiness to achieve the 2030 eREC target.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study is part of a nationwide situational analysis of refractive-error services in Bhutan, conducted between March and July 2025, using the WHO RESAT. RESAT is a structured framework designed to assess the status of refractive-error services at national or subnational levels and monitor progress. The tool is organised around eight core components aligned with the six WHO health system building blocks, ensuring a comprehensive systems-based assessment. This study adopted a cross-sectional, mixed-methods design integrating quantitative facility-readiness data and qualitative stakeholder insights.\u003c/p\u003e \u003cp\u003eThree RESAT components were examined: (1) service delivery, (2) health workforce, and (3) health-technology and supply. The service delivery domain assessed how refractive error services are integrated within the public health system, their referral networks, service locations, and the mix of public\u0026ndash;private provision. The workforce domain examined the composition, distribution, and training of personnel delivering refractive care. The health technology and supply domain evaluated the availability, accessibility, and functionality of equipment essential for diagnosing and managing refractive error. Complementary analyses on other RESAT components are reported separately.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eBhutan is a lower-middle-income, landlocked Himalayan kingdom in South East Asia with an estimated population of 777,224. The country has a decentralized, three-tier health-care system. By 2025, there were 36 public eye centers across 20 districts distributed across 20 districts; one national referral center, two regional referral hospitals, four cluster hospitals, 18 district hospitals, and 11 ten-bedded hospitals. Additionally, 33 optical shops operated across 13 districts. Together, these facilities formed the sampling frame for the study.\u003c/p\u003e\n\u003ch3\u003eStudy population and sampling\u003c/h3\u003e\n\u003cp\u003eAll 36 public eye units in all 20 districts were included, ensuring complete national coverage. Each facility was represented by the Head of the eye-care unit (ophthalmologist, optometrist, or ophthalmic technician). The optical-outlet survey comprised all 33 licensed optical shops in Bhutan. Purposive sampling was used to recruit stakeholders for the key informant interview (KII). This methodological design followed RESAT guidelines, thereby ensuring both rigor and inclusivity in the selection process.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eComponent A\u003c/strong\u003e \u003cp\u003eFor the desk review, sources were selected based on relevance, credibility, and timeliness, prioritizing materials published between 2000 and 2025. The review covered national eye-health policies, program reports, and peer-reviewed literature on refractive-error services in Bhutan. Secondary data were obtained from national surveys, including the National Health Survey and Bhutan Living Standards Survey, as well as reports from the World Bank and National Statistical Bureau.\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eComponent B: Questionnaire-based survey\u003c/h3\u003e\n\u003cp\u003eA nationwide questionnaire survey covered all 36 eye centres and 33 optical outlets, assessing infrastructure, equipment, and service delivery. The heads of the facilities were invited to participate. To ensure data accuracy, six eye centers and three optical outlets were verified through site visits by two investigators (IPS and NTL).\u003c/p\u003e\n\u003ch3\u003eComponent C: Key Informant Interview (KII)\u003c/h3\u003e\n\u003cp\u003eUsing purposive sampling, 19 participants with expertise in RE service delivery were recruited for KII, guided by the WHO RESAT stakeholder framework.The qualitative component captured perspectives across RESAT domains. Participants included the Ministry of Health's Primary Eye Care Program Officer (n\u0026thinsp;=\u0026thinsp;1), an international donor agency representative (n\u0026thinsp;=\u0026thinsp;1), a Disabled People Organization representative (n\u0026thinsp;=\u0026thinsp;1), ophthalmologist including the Head of apex center (n\u0026thinsp;=\u0026thinsp;2), optometrists including the Chief Optometrist of apex center (n\u0026thinsp;=\u0026thinsp;2), an ophthalmic technician (n\u0026thinsp;=\u0026thinsp;1), optical shop owners (n\u0026thinsp;=\u0026thinsp;2), PHC health assistants (n\u0026thinsp;=\u0026thinsp;2), a health teacher (n\u0026thinsp;=\u0026thinsp;1), a teaching institute representative (n\u0026thinsp;=\u0026thinsp;1), individuals with refractive error (n\u0026thinsp;=\u0026thinsp;3), and parents of children with refractive error (n\u0026thinsp;=\u0026thinsp;2). Recruitment occurred via Ministry of Health networks using email and telephone, with snowball sampling to identify additional informants. Eligibility required at least two years of professional experience in eye care or related health services in Bhutan.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Collection Procedures​\u003c/h2\u003e \u003cp\u003eThe RESAT questionnaire and interview tool was used for data collection [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. No new questionnaire or tool was developed.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e(a) Desk-Based Review\u003c/h3\u003e\n\u003cp\u003eA systematic desk review synthesized secondary data on refractive error services in Bhutan, using national health policies, reports (e.g., National Standard for Ophthalmology Services, Bhutan Eye Health Strategy 2018\u0026ndash;2023), and Primary Eye Care Program data. Peer-reviewed articles from PubMed, Google Scholar, and Scopus were identified using keywords like \"refractive error Bhutan\" and \"eye care services Bhutan.\" Grey literature from WHO, IAPB, and NGOs was also examined. Of 140 records screened, 42 Bhutan-specific studies (2000\u0026ndash;2025) met inclusion criteria and were analyzed using a standardized RESAT template.\u003c/p\u003e\n\u003ch3\u003e(b) Questionnaire-based survey of eye health facilities and opticals\u003c/h3\u003e\n\u003cp\u003eA structured questionnaire, adapted from sections 3 to 5 of RESAT covering service delivery, workforce, technology, and supplies, was administered to designated heads of eye care services in participating health facilities. Data was collected through self-administered online surveys (Google Forms), supplemented by follow-up telephone calls to clarify responses where necessary. The survey remained open for four weeks, during which periodic reminders were issued to maximize response rates.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e(c) Key Informant Interviews\u003c/h2\u003e \u003cp\u003eSemi-structured interviews (30\u0026ndash;45 minutes) were conducted in English, either in person or virtually. Small group discussions (2\u0026ndash;3 participants) were used where appropriate. To ensure rigour, all participants provided consent, and anonymity was maintained.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eQuantitative data from surveys were summarized using descriptive statistics and presented in tables and figures. Qualitative data from interviews and desk reviews were analyzed thematically using NVivo software, following a deductive coding approach guided by the RESAT framework. Two researchers coded data independently, resolving discrepancies through consensus. Triangulation between quantitative and qualitative findings was applied to enhance validity and contextual interpretation, thereby strengthening the comprehensiveness and robustness of the overall situational analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e was obtained from the Research Ethics Board of Health (REBH), Ministry of Health, Bhutan (Ref: REBH/Approval/2023/003) and the Biomedical Research Ethics Committee (BREC), University of KwaZulu-Natal, South Africa (Approval no: BREC/00004482/2022). Administrative clearance was granted by the Policy and Planning Division, Ministry of Health, Bhutan.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e The study followed WHO ethical standards and adhered to national and institutional protocols. Although non-clinical assessments typically do not require formal ethical approval under RESAT, informed consent was obtained from all participants to ensure voluntary participation, withdrawal rights without consequences, and confidentiality. No personal identifiers were collected, data were stored securely, and no incentives were provided to the participants. The study adhered to the Declaration of Helsinki.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eData were obtained from 36 eye-care centers (100%) and 32 optical shops (97%) across Bhutan\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eService delivery\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003eRefraction services\u003c/h2\u003e \u003cp\u003eIn Bhutan, all 36 public health facilities provide eye care, including RE services: one apex center, two regional referral hospitals, four cluster hospitals, 18 district hospitals, and 11 ten-bedded hospitals. No private or NGOs facilities provide refraction services. Public eye health centers also manage community vision screening, school eye-health programs, and outreach surgical camps.\u003c/p\u003e \u003cp\u003eAccording to Bhutan Health Service Standards, 2019, general ophthalmology services, which include refraction services, are mandated to be available at all 10-bedded hospitals [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e13\u003c/span\u003e] However, only 65% of hospitals (36 of 55) and 14% of all health facilities (36 of 257) provided eye-care services \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Primary health centers are limited to ocular first aid and awareness activities. Bhutan\u0026rsquo;s RE services demonstrate broad geographic reach, available in 19 of 20 districts (95%) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAvailability of eye care, including refractive error services across levels of health facilities in Bhutan, 2025.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSl .no\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth facilities\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneral health service\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEye health, including RE service\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJDW National Referral Hospital (JDWNRH)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNational Traditional Medicine Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRegional Referral Hospitals (RRH)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistrict Hospitals (DH)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e71.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 Bedded Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e41.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary Health Centers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e194\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e257\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe service-output data were limited, with 21 health facilities reporting spectacle-dispensing volumes. The average number of spectacles dispensed was 37 per month. All public facilities offer vision screening and basic refraction, though contact-lens and low-vision services are available to tertiary and referral hospitals. The services in different levels of eye care facilities and comparison of eye-health and general-health service coverage in Bhutan is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eRefractive surgery services are not currently available in the country. Ready-made near vision spectacles and contact lenses are available both over the counter and through prescription by qualified eye health professionals.\u003c/p\u003e \u003cp\u003eThere is no empirical research to investigate the perceived barriers to accessing refractive error care. Routine quality-assurance audits are absent, limiting evaluation of service performance. Bhutan's referral system directs patients from lower to higher-level eye care facilities, but there are enforcement challenges. It leads many to bypass initial care levels and seek services directly at advanced facilities, reducing system efficiency.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eOptical services\u003c/h2\u003e \u003cp\u003eIn Bhutan, there are 33 optical shops across 13 districts, representing a coverage of 65% (13 out of 20 districts). The distribution of services was uneven, with the majority of outlets concentrated in urban centres. Thimphu has 11 outlets (33%), Mongar and Gelephu each have 3 (9%), reflecting limited access in rural districts (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAmong the 32 surveyed optical facilities, most (72%, n\u0026thinsp;=\u0026thinsp;23) were established between 2011 and 2020, marking the period of rapid expansion during this period. 16% (n\u0026thinsp;=\u0026thinsp;5) opened after 2020, while only 3%(n\u0026thinsp;=\u0026thinsp;1) predated 2000.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eQualitative insights: Service delivery\u003c/h2\u003e \u003cp\u003eHealth-staff interviews underscored limited refractive service coverage in lower-level facilities.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Apart from treating common eye infections, we are not trained to check vision or give spectacles. We simply refer to higher centers.\u0026rdquo; \u0026ndash; -a PHC health assistant (HA)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e This observation aligns with RESAT findings: while all 36 public centers offer refraction, only 65% of hospitals provide eye care, and primary centers provide minimal or no RE services.\u003c/p\u003e \u003cp\u003eParticipants highlighted urban bias in optical access:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"We prescribe spectacles everyday from our OPD, but most of them come back without spectacles requesting for eyedrops, as there are no optical shops in our district. People have to travel to other districts or border towns to buy a pair of spectacles\u0026rdquo;-ophthalmic technician, district hospital.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I came to Thimphu to get my eye power checked.I prefer to come here because I don\u0026rsquo;t get good choices of frames and contact lenses in our district\u0026rsquo;. -a patient with refractive error.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e These observations confirm RESAT\u0026rsquo;s quantitative data, revealing optical coverage in only 65% of districts, underscoring the uneven distribution and accessibility of optical care.\u003c/p\u003e \u003cp\u003eReferral challenges were also noted\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Patients often bypass district hospitals, though there are eye care services, and come straight to the referral hospital.\u0026rdquo; -an ophthalmologist.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThese qualitative findings complement the quantitative evidence of weak referral adherence and service fragmentation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eHealth workforce\u003c/h2\u003e \u003cp\u003eEye-health personnel in Bhutan include ophthalmologists, optometrists, ophthalmic technicians, and nurses. All are licensed under the Bhutan Qualifications and Professional Certification Authority (BQPCA). under the Medical Act of Bhutan (2002). No HReH are employed in the private sector. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the national and facility-level distribution of HReH..\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution and Urban-Rural Allocation of Eye Health Human Resources in Bhutan, 2025\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHReH Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRatio (Pop: 777,224)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNational Eye Center, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRegional Hospitals, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDistrict Hospitals, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10-Bedded Hospitals, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUrban\u0026ndash;Rural Distribution\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOphthalmologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 : 45,719\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8 (47.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6 (35.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3 (17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100% Urban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOptometrist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13 (12.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 : 59,778\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5 (38.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100% Urban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOphthalmic Technician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65 (63.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 : 11,958\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16 (24.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11 (16.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e27 (41.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e11 (16.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e83.1% Urban \u0026middot; 16.9% Rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOphthalmic Nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 : 111,032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100% Urban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e102 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35 (34.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21 (20.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35 (34.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e11 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOverall, 89.2% of HReH are urban-based, despite only 37.8% of the population living in urban areas. Rural districts (62.2% of population) are served by just 10.8% of personnel. Ophthalmologists, optometrists, and ophthalmic nurses are entirely based in urban areas (100%), while only 17% of technicians serve in rural ten-bedded hospitals. Rural eye care is often provided by general health workers with limited refractive error training.\u003c/p\u003e \u003cp\u003eBhutan\u0026rsquo;s ophthalmologist and optometrist ratios meet WHO benchmarks (1:50,000) for general eyecare but are inadequate for RE services. Government efforts focus on equitable deployment, particularly in underserved rural areas, supported by accessible infrastructure. However, no productivity or performance indicators exist for RE staff. Establishing monitoring frameworks and refresher training could enhance quality and efficiency.\u003c/p\u003e \u003cp\u003eRefraction training in Bhutan is primarily delivered through the ophthalmology and ophthalmic technician programs at KGUMSB, while optometrists are trained abroad due to the absence of an in-country program. Ophthalmic nurses receive only short-term, non-refractional training (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTraining of human resources for eye health (HReH) for refractive error services in Bhutan\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHReH Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraining Programme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYear Started / Upgraded\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEntry Requirement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDuration\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCurriculum Focus on Refraction\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTraining Requirements\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGraduates per Year (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eRecruited per Year (n)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOphthalmologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostgraduate Degree in Ophthalmology (KGUMSB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMBBS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIntegrated into comprehensive clinical training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eResidents must perform\u0026thinsp;\u0026ge;\u0026thinsp;500 independent refractions [25]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2\u0026ndash;3 (All graduated from KGUMSB)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOptometrist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBachelor of Optometry (Overseas; no in-country training)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12th Standard (Science)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 years (India)\u0026thinsp;+\u0026thinsp;1-year internship (Bhutan)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eComprehensive training in refraction, optics, and vision science\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eClinical rotations in all core optometry disciplines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOphthalmic Technician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiploma in Primary Eye Care (KGUMSB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1987 (Certificate); upgraded to Diploma in 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10th Standard (1987\u0026ndash;2005); 12th Standard (General) since 2006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 years (pre-2020); 3 years including 1-year public health foundation (post-2020)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRefraction covered in 3 of 6 semesters; extensive hands-on practical training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMandatory field postings and continuous practical assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5\u0026ndash;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5\u0026ndash;8 (All graduated from KGUMSB)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOphthalmic Nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOphthalmic Nursing (Short-term, in-service training)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot formalized\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGeneral Nursing and Midwifery (GNM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLimited to vision assessment; no structured refraction component\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eShort-term in-house training within ophthalmology wards (as required)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eRecruited as per need\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows that between 2010 and 2025, 114 eye health professionals joined public service, with 89.5% retained. The attrition for other opportunities was 7%, driven mainly by optometrists (18.7%). Ophthalmic technicians had the highest retention (94.2%), while ophthalmic nurses showed the greatest separation (30%), mostly due to retirement.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRecruitment and separation patterns of among human resources for eye health (HReH) in Bhutan (2010\u0026ndash;2025)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHReH Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal Entered in Public Service\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetained in System, % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSeparated, % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRetired, % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDeparted for Other Opportunities, % (n)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOphthalmologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e89.5 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.5 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.3 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOptometrist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81.3 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18.7 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e18.7 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOphthalmic Technician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e94.2 (65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.8 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.4 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.3 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOphthalmic Nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70.0 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.0 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.0 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10.0 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e89.5 (102)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.5 (12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.5 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7.0 (8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere are no structured deployment programs for new graduates to underserved districts. While the BQPCA mandates continuing medical education (CME) for all professionals, no specific CPD guidelines exist for refractive-error management. Similarly, systematic quality audits and performance appraisals are lacking. The hospital quality control units ensure that refractive error personnel adhere to standardized procedures and protocols. Limited task-sharing occurs, with some health assistants and school health teachers trained for basic vision screening in schools.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eQualitative insights: Health Workforce\u003c/h2\u003e \u003cp\u003eParticipants repeatedly emphasized urban\u0026ndash;rural workforce disparities.\u003c/p\u003e \u003cp\u003e\u003cem\u003e \u0026ldquo;We manage common eye problems in the PHC, because the eye care team are mostly in the higher centers. We refer most of the cases to those centers.\u0026rdquo; - PHC health assistant.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We try to place our limited staff across districts, but it\u0026rsquo;s difficult with so few of us.\u0026rdquo; - Head, National Eye Center.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe RESAT quantitative outputs substantiate this finding, indicating that all ophthalmologists and optometrists (100%) are concentrated in urban areas and only 17% of technicians in rural facilities\u003c/p\u003e \u003cp\u003eStakeholders also identified training bottlenecks.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;As the only institute producing allied health professionals, we are limited by our own challenge of HR and infrastructure. We do not have training programs for optometrists and the ophthalmic technician training also needs to compete with other categories of allied health\u0026rsquo;. -a teaching institute representative.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eHealth technology and supply\u003c/h2\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003eInfrastructure and Equipment\u003c/h2\u003e \u003cp\u003eAll public eye centers (100%) have dedicated refraction rooms, and essential equipment for vision assessment and refraction services. Similarly, all optical outlets had near vision charts, lensometers, and interpupillary (IPD) rulers \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. However, equipment for edging and fitting spectacles exists only in optical outlets, not in public facilities.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOphthalmic equipment for public facilities is procured through the national procurement system, but spectacles are excluded. The Biomedical Division of the Ministry of Health oversees the maintenance and calibration of the equipment. However, with the exception of the national referral hospital, biomedical technicians lack expertise to repair ophthalmic equipment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eOptical Supply Chain\u003c/h2\u003e \u003cp\u003eBhutan does not produce optical products domestically. Ready-made spectacles and single vision lenses are available in all optical practices surveyed across the country. However, multifocal lenses and progressive lenses were available in 60.6% (n\u0026thinsp;=\u0026thinsp;20) and contact lenses in 36.7% (n\u0026thinsp;=\u0026thinsp;12) opticals. However, myopia management lenses and refractive surgery options were unavailable.\u003c/p\u003e \u003cp\u003eIndia was the predominant supplier for both spectacle lenses and frames, reported by 90.6% (n\u0026thinsp;=\u0026thinsp;29) and 96.9% (n\u0026thinsp;=\u0026thinsp;31) of opticals, respectively. Thailand was the second most common source for frames (31.3%, n\u0026thinsp;=\u0026thinsp;10), followed by China (12.5%, n\u0026thinsp;=\u0026thinsp;4), Nepal (9.4%, n\u0026thinsp;=\u0026thinsp;3) and Italy (9.4%, n\u0026thinsp;=\u0026thinsp;3).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eImport taxes\u003c/h2\u003e \u003cp\u003eSpectacle lenses (glass or other materials) and contact lenses are tax-exempt. Frames, mountings and sunglasses incur 10% customs duty and 5% sales tax. Imports from India are exempt from customs duty under the bilateral Free Trade and Commerce agreement; a 5% sales tax still applies [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eImported optical products may be dispensed without prior approval from government authorities. Within the public health sector, there is no centralized system to negotiate or regulate procurement prices for spectacles. Furthermore, aside from routine monitoring activities, no periodic surveys are conducted to assess the availability of essential refraction equipment and spectacles within the public health system.\u003c/p\u003e \u003cp\u003eThe infrastructure required to support effective refractive error services is largely in place. Advanced refraction equipment is widely accessible at tertiary eye care facilities and is also present in several secondary-level facilities, thereby enabling a reasonable capacity for the provision of high-quality refractive error management.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eQualitative insights: Health technology and supplies\u003c/h2\u003e \u003cp\u003eStakeholders reported overall satisfaction with the availability of eye health infrastructure in urban health centers; however, persistent deficiencies were identified in rural facilities.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWe have all the equipment here for refraction, but if one important piece of equipment, for example if a retinoscope breaks down, we don\u0026rsquo;t have the capacity to repair it. We have to wait for the next round of procurement cycle which takes around 6 months to get a replacement.\u0026rsquo; -an ophthalmic technician, District hospital\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThis highlights the fragility of maintenance systems despite adequate infrastructure.\u003c/p\u003e \u003cp\u003eOptical retailers reported high dependency on imported optical products, particularly from India. They highlighted challenges due to transport costs and stock limitations:\u003c/p\u003e \u003cp\u003eWhile import tariffs were not regarded as a significant constraint, stakeholders emphasized that high transportation costs constitute the major contributing factor to elevated spectacle prices.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWe sometimes face difficulty in providing spectacles on time, as we can\u0026rsquo;t stockpile all glass powers and have to import them from India. That also have to make a bulk purchase and it takes around 2\u0026ndash;3 weeks.\u0026rdquo; - an optical shop owner 1.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We are comfortable with taxes. Transport costs are our main problem; small orders make per-lens prices very high.\u0026rdquo; - an optical shop owner 2.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eStaff further reported limited availability of specialized lenses, which aligns with survey findings indicating that multifocal lenses are available in only 60% of optical practices, while contact lenses are offered in only 37%.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eBhutan has formally committed to the WHO SPECS 2030 initiative [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This nationwide situational analysis, presents the first comprehensive assessment of Bhutan\u0026rsquo;s RE service delivery system using RESAT. It provides an integrated understanding of service availability, human resources, technology, and supply. To the best of our knowledge, this is the first national-level application of the WHO RESAT.\u003c/p\u003e \u003cp\u003eOverall, the findings reveal that Bhutan has made notable progress in establishing geographically accessible and well-equipped eye health centers. Nonetheless, persistent systemic challenges including workforce shortages, urban\u0026ndash;rural disparities, and limited access to optical services continue to impede the equitable and sustainable delivery of refractive care.\u003c/p\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eService Delivery and System Integration\u003c/h2\u003e \u003cp\u003eService delivery in eye health demonstrates notable strengths. RE services are available in 36 public eye health centers, reaching 95% of districts, a level of geographical coverage rarely observed in lower-middle-income countries. This level of accessibility surpasses that of comparable LMICs, such as Nepal, where approximately 40% of the population remain without access to basic eye care services [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e15\u003c/span\u003e] This achievement could be attributed to the country\u0026rsquo;s policy of integrating eye health into its primary health care through the Primary Eye Care Programme (PECP). Despite this, inequities in distribution persist as most RE services remain concentrated in hospitals. Only 14% of health facilities provide RE services, reflecting limited integration of RE care within the primary health care (PHC) network. The analysis highlights gaps in horizontal integration and referral compliance. Primary-health centres provide minimal refraction or spectacle services, forcing many patients to bypass lower-level facilities and seek care directly from secondary and tertiary centres. Strengthening task-sharing and expanding refraction services to primary-care levels through trained health assistants, school health coordinators, or tele-optometry could mitigate this imbalance [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOptical outlets are disproportionately concentrated in urban areas, with 33% located in Thimphu, while only 65% of districts are covered, necessitating rural residents to travel considerable distances to obtain spectacles. This urban\u0026ndash;rural divide reflects service delivery patterns documented across South Asia and other LMICs, where uneven distribution of resources contributes to untreated visual impairment [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Strengthening gatekeeping functions and integrating basic refraction into PHC packages, possibly through task-sharing or tele-refraction, could enhance efficiency and early detection.\u003c/p\u003e \u003cp\u003eThe lack of systematic quality-assurance mechanisms and limited service-output monitoring further constrain the system\u0026rsquo;s ability to evaluate and improve performance. Regular audits of refraction accuracy, spectacle delivery timelines, and patient satisfaction would align Bhutan\u0026rsquo;s quality-assurance processes with WHO\u0026rsquo;s IPEC framework and ensure sustained improvement in eREC.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eHuman Resources for Eye Health\u003c/h2\u003e \u003cp\u003eBhutan meets the WHO benchmark ratio for ophthalmologists (1 : 50 000); however, the optometrist-to-population ratio (1 : 59 778) remains insufficient for population-based refractive-error management. This deficit is compounded by the high attrition rate (18.7%) and the absence of a domestic optometry training program, which necessitates reliance on foreign education, predominantly in India. Optometrists are uniquely trained for refraction, contact-lens fitting, and low-vision rehabilitation, domains essential for achieving the eREC target. Evidence indicates that countries with fewer optometrists tend to have higher rates of blindness and are often characterized by lower GDP per capita [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe human resource for eye health (HReH) analysis reveals a pronounced urban\u0026ndash;rural disparity. Nearly 90% of HReH are concentrated in urban areas, serving only 37.8% of the national population. Ophthalmologists and optometrists are entirely located in urban areas, while only 16.9% of ophthalmic technicians serve in rural hospitals. This maldistribution undermines equitable RE service delivery and leaves rural communities reliant on minimally trained general health workers. Such inequities mirror broader LMIC trends, where workforce concentration in urban centres exacerbates access barriers for vulnerable populations [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. It also underscores the difficulty of retaining professionals in remote areas, similar to Nepal [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Ophthalmic technicians form the backbone of service delivery at district and 10-bedded hospitals. This cadre provides a scalable entry point for task-sharing in refraction. Upgrading the diploma curriculum to manage advanced refraction and ophthalmic dispensing, and introducing refraction-focused continuing professional development (CPD) pathways could enhance both competency and career satisfaction.\u003c/p\u003e \u003cp\u003eRetention analysis indicates profession-specific vulnerabilities: while ophthalmic technicians show high stability (94.2%), optometrists (18.8%) and ophthalmic nurses (30%) experience notable attrition, driven by external opportunities and retirement, respectively. To strengthen the HReH for refractive services, Bhutan should prioritise the recruitment and deployment of optometrists to all hospitals with 10 or more beds, while simultaneously mandating RE-specific continuous professional development (CPD) for primary care health workers. Additionally, lessons may be drawn from task-sharing approaches in comparable LMICs, such as Ethiopia, where community health workers have been successfully trained to conduct basic vision screening [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eInfrastructure, Equipment, and Supply Chains\u003c/h2\u003e \u003cp\u003eThe health technology and supply assessment reveal that public facilities in Bhutan are adequately equipped: all eye centers (100%) have a dedicated refraction room and essential equipment for basic refraction services. However,the absence of spectacles from the list of essential medical supplies results in inconsistent provision, often dependent on external donation. Delays in equipment repair due to lack of biomedical competence in repairing ophthalmic equipment and long procurement cycles reported to take several months compromise service reliability. Similar bottlenecks have been observed in other resource-limited contexts, emphasizing the need for decentralized maintenance capacity and preventive servicing protocols [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e22\u003c/span\u003e].Building decentralized biomedical maintenance capacity and adopting preventive-maintenance schedules would reduce downtime and enhance service continuity.\u003c/p\u003e \u003cp\u003eThe optical service landscape shows notable expansion, particularly after 2010, but remains heavily urban-skewed with only 65% of districts having optical outlets. Bhutan could support entrepreneurship in opening and operating optical shops in rural districts.\u003c/p\u003e \u003cp\u003eOptical-supply chains are almost entirely import-dependent. About 90\u0026ndash;97% of lenses and frames sourced from India, are subject to minimal taxation, substantially lower than most LMICs [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. While import taxes are minimal, high transportation costs and the absence of bulk procurement inflate retail prices, limiting affordability especially for rural populations. It echoes global evidence that economic, rather than geographic, barriers often drive unmet refractive needs [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Furthermore, cumbersome import procedures and fragmented regulatory requirements discourages suppliers. The lack of in-country manufacturing or centralized procurement of spectacles also creates a disconnect between diagnosis and correction, a recurrent challenge in LMICs. Bhutan could employ public\u0026ndash;private partnerships models to establish a national optical-supply strategy encompassing pooled procurement, local assembly, and public-sector dispensing points.\u003c/p\u003e \u003cp\u003eTo address these supply-side constraints, Bhutan may consider policy measures such as negotiating bulk procurement agreements, Inclusion of spectacles in Essential supplies list, developing local maintenance and technical capacity, and streamlining the importation process for spectacles and related accessories.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePolicy and Programmatic Implications\u003c/h3\u003e\n\u003cp\u003eBhutan\u0026rsquo;s commitment to the WHO SPECS 2030 initiative offers a pivotal opportunity to transform RE services from a vertical program into an integrated, system-wide service. Policy focus should now shift toward embedding RE within the primary health care (PHC) package, supported by task-sharing models involving health assistants, school health coordinators, and tele-optometry to expand equitable access. Establishing an in-country optometry training program is essential to mitigate workforce shortages and reduce reliance on foreign education. Recruitment of at least one optometrist per district hospital, coupled with structured continuing professional development (CPD) for all cadres, will enhance quality and retention. Strengthening biomedical-maintenance capacity through decentralized repair hubs and preventive-maintenance schedules would minimize equipment downtime and sustain service delivery. Equally important is the creation of a National Optical-Supply Strategy that integrates pooled procurement, local assembly, and inclusion of spectacles in the essential-supplies list to improve affordability and rural access. Dedicated financing, public\u0026ndash;private partnerships, and routine monitoring aligned with SPECS 2030 indicators will ensure accountability and progress.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eStrengths, Limitations, and Future Directions\u003c/h2\u003e \u003cp\u003eThe utilization of the standard WHO RESAT framework, a mixed-methods design, nationwide coverage(100% of eye centers and 97% of optical outlets), full (100%) facility response, and the inclusion of diverse stakeholders substantially enhance the methodological rigor and validity of this study. Nonetheless, certain limitations must be acknowledged. These include reliance on purposive sampling for stakeholder selection and the dependence on self-reported facility-level data, which may introduce reporting bias.Service output data (e.g., number of spectacles dispensed) were incomplete, constraining productivity analysis. While the RESAT framework provides a structured and systematic basis for analysis, it does not incorporate quantitative eREC measurement. Furthermore, the cross-sectional design limits the ability to infer longitudinal trends or causal relationships over time. Future research should focus on patient perspectives and the economic burden of uncorrected refractive error, alongside longitudinal monitoring of workforce retention. Evaluating pilot models of primary-level refraction, tele-optometry, and community spectacle distribution could inform scale-up strategies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis situational analysis reveals that Bhutan has made remarkable progress in establishing nationwide RE services within its universal health-care framework. The study highlights both commendable achievements; universal service availability, high workforce retention, and functional infrastructure demonstrate that system integration is possible even in resource-constrained contexts. However, sustainability challenges persist due to inequitable workforce distribution, absence of local optometry education, and challenges to optical access, and supply-chain sustainability.\u003c/p\u003e \u003cp\u003eAddressing these will require a deliberate policy shift toward system-level reforms. Sustained financing, robust monitoring aligned with WHO SPECS 2030 indicators, and multisectoral partnerships will be crucial. It will also require embedding RE services within the essential health package, embracing task-sharing models, increasing the pool of optometrists, ensuring equitable distribution of HReH, and strengthening optical supply chain mechanisms. Finally, adopting innovative financing approaches such as piloting public-private partnerships or implementing cross-subsidy models, could enhance affordability and accessibility of spectacles, particularly for disadvantaged populations. Through strategic planning, Bhutan has the potential to meet the eREC targets and establish itself as a regional exemplar for LMICs in the region.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eClinical trial number\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the study was granted by the Research Ethics Board of Health (REBH), Ministry of Health, Bhutan (Ref: REBH/Approval/2023/003), and the Biomedical Research Ethics Committee (BREC) of the University of KwaZulu-Natal, South Africa (Approval No: BREC/00004482/2022). In addition, administrative clearance was secured from the Policy and Planning Division of the Ministry of Health, Bhutan.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eAll authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eNo funding was received for this work.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eIPS is the study\u0026rsquo;s principal investigator. IPS, KSN and KPM conceptualized the protocol, and study design. IPS, NTL, DW and SP participated in study implementation including data collection. NTL, DW and SP provided technical guidance. KSN, KPM, NTL and DW were involved in the interpretation of the finding and validated the data. IPS drafted the manuscript and all authors critically reviewed the draft manuscript and approved the final version.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe authors thank the staff of GKCW National Eye Center, Thimphu for helping with data collection. The authors also express gratitude to the study participants for their time and cooperation.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe dataset(s) supporting the conclusions of this article is(are) included within the article (and its additional file(s)).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Integrated people-centred eye care, including preventable vision impairment and blindness. WHA73.4. Geneva: WHO. 2020 Aug 3. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://apps.who.int/gb/ebwha/pdf_files/WHA73/A73_R4-en.pdf\u003c/span\u003e\u003cspan address=\"https://apps.who.int/gb/ebwha/pdf_files/WHA73/A73_R4-en.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [cited 2025 Oct 10].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO SPECS 2030 [Internet]. Geneva: WHO. 2024 May 15 [cited 2025 Oct 10]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/initiatives/specs-2030\u003c/span\u003e\u003cspan address=\"https://www.who.int/initiatives/specs-2030\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeel S, Mueller A. WHO SPECS 2030 - a global initiative to strengthen refractive error care. Community Eye Health. 2024;37(122):6\u0026ndash;7. Epub 2024 May 15. PMID: 38827975; PMCID: PMC11141117.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElam AR, Aguwa U, et al. Disparities in Vision Health and Eye Care. Ophthalmology. 2022;129(10):e89\u0026ndash;113.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurton MJ, Ramke J, Marques AP, et al. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020. Lancet Glob Health. 2021;9(4):e489\u0026ndash;551. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2214-109X(20)30488-5\u003c/span\u003e\u003cspan address=\"10.1016/S2214-109X(20)30488-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee L, Moo E, Angelopoulos T, Dodson S, Yashadhana A. Integrating eye care in low-income and middle-income settings: a scoping review. BMJ Open. 2023;13(5):e068348. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2022-068348\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2022-068348\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 37236663; PMCID: PMC10230923.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health Bhutan. National Health Policy [Internet], Bhutan. MOH; 2025 Jan [cited 2025 Oct 10]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://moh.gov.bt/wp-content/uploads/2025/01/National-Health-Policy.pdf\u003c/span\u003e\u003cspan address=\"https://moh.gov.bt/wp-content/uploads/2025/01/National-Health-Policy.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLepcha NT, Sharma IP. Primary eye care in Bhutan: achievements and challenges. Community Eye Health. 2021;34(113):s11\u0026ndash;2. Epub 2022 Mar 1. PMID: 36033415; PMCID: PMC9412122.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma IP, Lepcha NT, Lhamo T, Ellwein LB, Pokharel GP, Das T, et al. Visual impairment and refractive error in school children in Bhutan: The findings from the Bhutan School Sight Survey (BSSS 2019). PLoS ONE. 2020;15(9):e0239117. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0239117\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0239117\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBourne RRA, Cicinelli MV, Selby DA, et al. Effective refractive error coverage in adults: a systematic review and meta-analysis of updated estimates from population-based surveys in 76 countries modelling the path towards the 2030 global target. Lancet Glob Health. 2025;13(8):e1396\u0026ndash;405. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2214-109X(25)00194-9\u003c/span\u003e\u003cspan address=\"10.1016/S2214-109X(25)00194-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Bhutan charts new course for eye health by 2030 [Internet]. Geneva: WHO. 2025 Jul 16 [cited 2025 Sep 16]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/feature-stories/detail/bhutan-charts-new-course-for-eye-health-by-2030\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/feature-stories/detail/bhutan-charts-new-course-for-eye-health-by-2030\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Refractive error situation analysis tool (RESAT). Geneva: WHO; 2025 [cited 2025 Oct 10]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/refractive-error-situation-analysis-tool-%28-resat%29\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/refractive-error-situation-analysis-tool-%28-resat%29\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health. Health Service Standard (HSS) [Internet]. Thimphu: Royal Government of Bhutan, Ministry of Health; 2019 [cited 2025 Sep 11]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://moh.gov.bt/wp-content/uploads/2025/01/Health-Service-Standard_2019.pdf\u003c/span\u003e\u003cspan address=\"https://moh.gov.bt/wp-content/uploads/2025/01/Health-Service-Standard_2019.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Finance, Royal Government of Bhutan. Bhutan Trade Classification and Tariff Schedule 2022 [Internet]. Thimphu: Ministry of Finance; 2022 [cited 2025 Aug 14]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mof.gov.bt/wp-content/uploads/2022/06/BhutanTradeClassificationTariffSchedule2022.pdf\u003c/span\u003e\u003cspan address=\"https://www.mof.gov.bt/wp-content/uploads/2022/06/BhutanTradeClassificationTariffSchedule2022.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Bhutan charts new course for eye health by 2030 [Internet]. Geneva: WHO. 2025 Jul 16 [cited 2025 Sep 11]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/feature-stories/detail/bhutan-charts-new-course-for-eye-health-by-2030#:~:text=%C2%A9,eye%20health%20for%20the%20country.%E2%80%9D\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/feature-stories/detail/bhutan-charts-new-course-for-eye-health-by-2030#:~:text=%C2%A9,eye%20health%20for%20the%20country.%E2%80%9D\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGurung R, Oli RU. Primary eye care in Nepal: current situation and recommendations for integration. Community Eye Health. 2021;34(113):s13\u0026ndash;4. Epub 2022 Mar 1. PMID: 36033419; PMCID: PMC9412118.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuma S, Naidoo KS, Hansraj R. Proposed task shifting integrated with telemedicine to address uncorrected refractive error in Kenya: Delphi study. BMC Health Serv Res. 2024;24(1):115. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-024-10618-8\u003c/span\u003e\u003cspan address=\"10.1186/s12913-024-10618-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 38254104; PMCID: PMC10801974.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRavilla T. Inequities in eye care in South Asia. Community Eye Health. 2016;29(95):S01\u0026ndash;3. PMID: 28289325; PMCID: PMC5340109.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaidoo K, Govender-Poonsamy P, Morjaria P, Block S, Chan V, Yong A, Bilotto L. Global mapping of optometry workforce. Afr Vis Eye Health. 2023;82(1):8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4102/aveh.v82i1.850\u003c/span\u003e\u003cspan address=\"10.4102/aveh.v82i1.850\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDas T, Keeffe J, Sivaprasad S, et al. Capacity building for universal eye health coverage in South East Asia beyond 2020. Eye. 2020;34:1262\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s41433-020-0801-8\u003c/span\u003e\u003cspan address=\"10.1038/s41433-020-0801-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKandel H, Adhikary R, Gyawali R. Allied eye health professionals in eye care services in Nepal. Community Eye Health J 33 110, 2020 (published online 21 April 2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKentayiso TW, Nkoane NL, Matlhaba KL. Primary eye care service provision ability of mid-level healthcare providers in southern Ethiopia. Afr Vis Eye Health. 2024;83(1):a931. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4102/aveh.v83i1.931\u003c/span\u003e\u003cspan address=\"10.4102/aveh.v83i1.931\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThapa R, Yih A, Chauhan A, Poudel S, Singh S, Shrestha S, Tamang S, Shrestha R, Rajbhandari R. Effect of deploying biomedical equipment technician on the functionality of medical equipment in the government hospitals of rural Nepal. Hum Resour Health. 2022;20(1):21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12960-022-00719-y\u003c/span\u003e\u003cspan address=\"10.1186/s12960-022-00719-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 35246155; PMCID: PMC8895523.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrontier Economics; International Agency for the Prevention of Blindness. Glasses for All: Improving Supply to the Poorest \u0026ndash; A Supply-side Market Brief. [Internet]. 2024 [cited 2025 Sep 11]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.iapb.org/wp-content/uploads/2024/02/Supply-side-market-for-glasses.pdf\u003c/span\u003e\u003cspan address=\"https://www.iapb.org/wp-content/uploads/2024/02/Supply-side-market-for-glasses.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Agency for the Prevention of Blindness. Innovative approaches to the provision of refractive error services: a position paper of the IAPB Refractive Error Working Group. September 2021. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.iapb.org/wp-content/uploads/2021/12/2021-REWG-position-paper_Innovative-approaches.pdf\u003c/span\u003e\u003cspan address=\"https://www.iapb.org/wp-content/uploads/2021/12/2021-REWG-position-paper_Innovative-approaches.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bhutan, refractive error, human resources, infrastructure, health system, RESAT, optical services","lastPublishedDoi":"10.21203/rs.3.rs-8065415/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8065415/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eBhutan has achieved near-universal access to primary health care, with eye health integrated into the national health system. However, there has been limited assessment of how existing resources support equitable access to refractive error (RE). This study assesses the readiness of Bhutan\u0026rsquo;s RE service infrastructure, workforce distribution, and supply systems using the WHO Refractive Error Services Assessment Tool (RESAT)\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA cross-sectional situational analysis was conducted using a mixed method approach between March and July 2025. The assessment covered all 36 public eye-care facilities and 33 optical outlets across 20 districts. Data were collected through structured facility questionnaires, onsite field verification, and key-informant interviews. Quantitative findings were summarized descriptively and triangulated with qualitative data using framework analysis under three RESAT components: (1) service delivery, (2) human resources for eye health (HReH), and (3) health technology and supply.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eData were collected from all 36 public eye-care centres (100%) and 32 of 33 optical shops (97%) across Bhutan. Refractive-error (RE) services were available in 95% of districts but in only 14% of all health facilities, reflecting limited integration into primary health care. Optical outlets covered 65% of districts, with one-third located in Thimphu, indicating strong urban bias. All eye centres were adequately equipped for refraction, though maintenance delays were common due to the lack of biomedical capacity. The eye-health workforce comprised 102 professionals, of whom 89% were urban-based. Optometrists and ophthalmologists were exclusively urban, while only 17% of technicians served in rural hospitals. Optical services relied almost entirely (\u0026gt;\u0026thinsp;90%) on imported lenses and frames from India, with high transport costs inflating retail prices. Qualitative insights highlighted weak referral adherence, urban\u0026ndash;rural inequities, and dependence on external supply chains.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThis analysis shows that Bhutan has made notable progress in integrating refractive-error (RE) services within its universal health-care system. However, inequitable workforce distribution, lack of local optometry training, and weak optical supply chains threaten sustainability. Strengthening human-resource capacity, embedding RE in the essential health package, and ensuring sustainable financing will be key to achieving universal effective RE coverage by 2030.\u003c/p\u003e","manuscriptTitle":"Human Resources, infrastructure, and supply systems for refractive error care in Bhutan: A WHO RESAT Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-18 17:02:59","doi":"10.21203/rs.3.rs-8065415/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-13T06:27:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-23T10:45:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-18T13:31:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-14T00:09:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"290673076318750696583483831684960471818","date":"2025-12-13T03:14:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"281704592092473999549276682434361725535","date":"2025-12-13T01:09:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"335897486239079817579406036602859419505","date":"2025-12-12T18:16:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-12T12:40:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-08T14:54:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-21T12:12:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-19T17:44:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-11-19T17:40:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8a4b5411-e2da-42bf-bffc-2648a68f806e","owner":[],"postedDate":"December 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T16:01:50+00:00","versionOfRecord":{"articleIdentity":"rs-8065415","link":"https://doi.org/10.1186/s12913-026-14400-w","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2026-03-19 15:58:50","publishedOnDateReadable":"March 19th, 2026"},"versionCreatedAt":"2025-12-18 17:02:59","video":"","vorDoi":"10.1186/s12913-026-14400-w","vorDoiUrl":"https://doi.org/10.1186/s12913-026-14400-w","workflowStages":[]},"version":"v1","identity":"rs-8065415","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8065415","identity":"rs-8065415","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}