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

Background: Bhutan 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’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.