Human resources, infrastructure, and supply systems for refractive error care in Bhutan: A WHO RESAT analysis.

backgroundBhutan has achieved near-universal primary health care coverage, with eye health structurally integrated into its publicly financed health system. However, the extent to which existing resources enable equitable access to refractive error (RE) services has not been systematically evaluated. This study assesses the readiness of Bhutan’s RE service infrastructure, workforce distribution, and health technology and supply systems using the WHO Refractive Error Services Assessment Tool (RESAT).

methodsA nationwide cross-sectional situational analysis was conducted between March and July 2025 using a mixed-methods design guided by the WHO RESAT framework. The assessment covered all 36 public eye-care facilities and 33 licensed optical shops across 20 districts. Data were collected through structured facility questionnaires, targeted site verification, and key-informant interviews with stakeholders. Quantitative findings were summarized using descriptive statistics and triangulated with qualitative insights through framework analysis under three RESAT components: (1) service delivery, (2) human resources for eye health (HReH), and (3) health technology and supply.

resultsData were obtained from all 36 public eye-care centres (100%) and 32 of 33 optical shops (97%) nationwide. RE services were available in 95% of districts but in only 14% of all health facilities, indicating limited primary-level integration. Optical shops operated in 65% of districts, with one-third concentrated in Thimphu, reflecting strong urban concentration. All public eye centres were equipped with essential refraction equipment; however, maintenance delays were reported due to the lack of biomedical capacity. The HReH comprised 102 professionals, of whom 89% were deployed in urban areas. Ophthalmologists and optometrists were exclusively urban-based, while only 17% of ophthalmic technicians served in rural hospitals. Optical services relied almost entirely (> 90%) on imported lenses and frames from India, with transport costs contributing to higher retail prices. Qualitative insights highlighted weak referral adherence, urban-rural inequities, and supply-chain vulnerability.

conclusionBhutan has made notable progress in integrating RE services within its universal health-care system. However, urban workforce concentration, absence of domestic optometry training, and reliance on imported optical supplies challenge equitable and sustainable service delivery. Strengthening workforce capacity, primary-level integration, and supply-chain resilience will be essential to achieving universal effective RE coverage by 2030. CLINICAL TRIAL NUMBER: Not applicable.