Colorectal Cancer in Bhutan: Identifying Health System Gaps and Priorities

Colorectal cancer (CRC) is an emerging public health concern in Bhutan, a lower-middle-income country with a geographically challenging terrain and limited specialised oncology services. As the country undergoes an epidemiological and economic transition, CRC numbers are steadily increasing. While Bhutan has made progress in cancer control through national programmes, CRC has not been a priority cancer, and health system readiness for its screening and management remains unclear. This study aimed to assess CRC care delivery in Bhutan and identify systems gaps using the World Health Organisation's health system building blocks framework.

A qualitative study was conducted using semi-structured interviews with key stakeholders involved in cancer care delivery. Interviews were conducted in person or via secure virtual platforms and analysed using inductive thematic analysis and deductive coding guided by the WHO health systems framework until thematic saturation was reached. A comprehensive document review of publicly available CRC-relevant services was also performed to complement the interview data collected. In total, twenty stakeholders including clinicians, policymakers, nurses and traditional medical practitioners were interviewed.

The results reflected key health system challenges including workforce shortages due to overseas migration, limited subspecialty training, and inadequate technical expertise within policymaking structures. Infrastructure constraints such as intermittent connectivity and power outages affected the functionality of the national electronic Patient Information System. CRC services remain highly centralised at tertiary hospitals, resulting in financial and geographic barriers for patients from remote districts. Medicine shortages, constrained health financing, and reliance on overseas referrals further limit service capacity. Sociocultural factors, including reliance on informal healers and delayed care-seeking behaviours, also contribute to late presentations.

Strengthening CRC care requires coordinated health system reforms and Bhutan's experience offers important lessons for small health systems seeking to strengthen cancer care amid resource constraints and complex sociopolitical contexts.

Neither patients nor the public were involved in the development, analysis or writing of this study.