A situational overview of acupuncture services in Bhutan

Kezang Tshering1, Nidup Dorji2 

1Faculty of Traditional Medicine, Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan

2Faculty of Nursing and Public Health, Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan

Corresponding author: Kezang Tshering, Faculty of Traditional Medicine, Thimphu, Bhutan.

Email: udkeza@gmail.com

DOI: https://doi.org/10.47811/bsj.0023060621

ABSTRACT

Acupuncture, a cornerstone of Traditional Chinese Medicine (TCM) has gained global recognition as an effective therapeutic health intervention. It is now practised in over 100 countries worldwide. The modality has evolved significantly from its ancient origins with stone needles to contemporary practice using sterile, disposable stainless-steel needles of varying specifications. In Bhutan, acupuncture was formally integrated into national healthcare services in 2014 through the National Traditional Medicine Hospital in Thimphu, initially delivered by Drungtshos (traditional medicine physicians) trained in Mongolia. While demonstrating significant therapeutic benefits, particularly for pain management and neurological disorders with minimal side effects, acupuncture service accessibility remains limited to the National Traditional Medicine Hospital, depriving acupuncture services outside of the capital city. Despite its recent introduction, patients’ demand for acupuncture has grown steadily, and is attributed to increasing public awareness and successful health education initiatives. With Bhutanese practitioners now receiving advanced training both domestically and internationally, there is a significant potential to expand acupuncture services to regional and district hospitals. This planned decentralisation aligns with Bhutan’s commitment to holistic healthcare and promises to enhance treatment accessibility nationwide, positioning acupuncture as an increasingly important component of the country's integrative medical system

Key words: Acupuncture therapy; Chronic Pain; Health Services; Integrative Medicine; Patient Satisfaction; Traditional Medicine;


INTRODUCTION

Acupuncture is a therapeutic practice that involves the insertion of filiform stainless steel needle into specific points on the body. The term “acupuncture” comes from the Latin word acu meaning “needle,” which reflects its focus on using needles during the process of puncturing or pricking. Simply put, acupuncture means puncturing with a needle. Acupuncture is an ancient Chinese medical technique used to treat pain and various other diseases. In modern practice, the thin filiform stainless needles of varying sizes are commonly used, based on scientific research and advancements. The needles are carefully inserted into specific points known as meridians or acupoints, at precise depths to achieve therapeutic purposes.

Acupuncture is well-recognized for its effectiveness in alleviating both acute and chronic pain, as well as neurological disorders. Although there are numerous theories to explain how acupuncture works, the pain reduction is believed to occur through stimulation of the central nervous system or brain, which triggers the release of natural painkillers in the body, such as endorphins and encephalins. Additionally, acupuncture helps to restore balance to the body’s vital energy.

An acupuncturist is expected to blend ancient wisdom and modern knowledge and skills to effectively practice acupuncture and provide safe and holistic care. Furthermore, it is essential for the acupuncturist to master the basic theories of Traditional Chinese Medicine including Yin, Yang, Qi, the five elements, and diagnostic principles prior to delving into acupuncture channels or meridians. An acupuncturist is also expected to understand the principles of cosmos functions and the relationship between external natural elements and the internal organs of the body and the interdependency of the channels/meridians. These foundational principles share similarities with those of Bhutanese traditional medicine.

Acupuncture and moxibustion flourished beyond China with the cultural exchanges between China and the foreign countries such as in Korea, Japan, Vietnam, in Southeast Asia and India. It was also introduced to Europe in the 17th century [1]. Western institutions and universities started studying the clinical effects of acupuncture for a range of illnesses and integrating it into their curricula. In the Sowa Rigpa texts, acupuncture is briefly mentioned under the section on invasive therapies, although it is not discussed in detail. This article describes the benefits of acupuncture and the introduction of acupuncture services in Bhutan.

GLOBAL BURDEN OF DISEASE AND ACUPUNCTURE

The Global Burden of Disease (GBD) framework highlights the significant impact of diseases, injuries, and health challenges worldwide. GBD identifies chronic conditions such as low back pain, neck pain, migraine, stroke, anxiety and depression, osteoarthritis, and chronic lung diseases as the leading contributors to global disability.Acupuncture therapy is inreasingly recognized as a complementary treatment for many of these high-burden health conditions. Although systematic reviews remain inconclusive [2], numerous clinical and experimental studies have demonstrated the effectiveness and safety of acupuncture therapy [3], showing promising benefits in the treatment of Parkinson’s disease [4], as well as improvements in lung function and quality of life [5]. Studies have also shown clinical benefits and safety option of acupuncture therapy for depression [6] and pain management [7]. In paediatric populations, acupuncture therapy has shown promising efficacy in the management of cerebral palsy, nocturnal enuresis, tic disorders, amblyopia, and pain reduction [8].

TRADITIONAL MEDICINE AND ACUPUNCTURE SERVICE IN BHUTAN

The National Traditional Medicine Hospital in Thimphu, the apex hospital for Traditional Medicine, offers a wide range of services, including an outpatient department, therapies like moxibustion, gold needle therapy, bloodletting, acupuncture, herbal steaming, hot oil compression, hot and cold compressions, Sorig yoga, and Sorig massage. Five eliminative therapies are among the primary services offered in the inpatient department.

Acupuncture service was started in Bhutan in 2014 by a few Drungtshos trained in Mongolia. The service was only implemented at National Traditional Medicine Hospital in Thimphu due to a shortage of personnel resources and subject-matter expertise. As more Drungtshos and other health professionals received training on acupuncture from other countries such as China, patients’ treatment has significantly improved in recent years.

Acupuncture offers a low-cost, high-impact intervention for chronic pain and neurological disorders, reducing reliance on expensive pharmaceuticals or surgeries [9]. In Bhutan’s resource-constrained system, scaling acupuncture could alleviate financial burdens in treating non-communicable diseases that account for 71% of deaths in Bhutan [10]. Existing evidence supports that acupuncture can be used as an adjunctive therapy to manage hypertension [11], is safe and effective for patient with gouty arthritis [12] and management of diabetes neuropathic pain [13].

UTILIZATION OF ACUPUNCTURE SERVICES

Acupuncture therapy is relatively new to Bhutanese. However, it is gaining popularity with National Traditional Medicine Hospital’s increased initiatives, advocacy, and campaign. The number of patients using acupuncture services are increasing as the therapy has minimal side effect with immediate result. People from all over the nation travel to the capital to receive acupuncture treatment only available at the National Traditional Medicine Hospital.

The number of patients receiving acupuncture services has increased in just two years, according to reports from 2023 and 2024 (Table 1). In 2023 and 2024, a total of 18519 and 22238 patients, respectively, came to NTMH for acupuncture treatments. In 2024 alone, the number of patients increased by 3719. This shows that more people in the nation are becoming aware of acupuncture treatment.

STANDARD OPERATING PROCEDURE FOR ACUPUNCTURE

Acupuncture services are mostly offered at the outpatient department during regular hospital visiting hours. Currently, only the traditional acupuncture is offered in separate rooms for men and women by four acupuncturists serving at National Traditional Medicine Hospital. As indicated below, it is run in accordance with the Standard Operating Procedure established by the hospital administration:

  1. Every instrument for the therapy should be kept ready by 8.45 am by therapy assistant and keep he kidney tray and needles ready. Details of the patients must be reflected clearly in the acupuncture service registry.
  2. Therapy assistant should ask the patients to take off their shoes, lead them to their respective gender rooms, and arrange their positions as per the disease
  3. The acupoints will be prescribed by the licensed acupuncturist and the therapy accordingly.
  4. Before needling on the points, patient should be asked about their history on receiving the therapy. Swab meridians with cotton soaked in spirit to control infection.
  5. Insert needles in the respective meridians, keep for 30 minutes, and tonify or drain based on the disease. (Figure 1)
  6. After 30 minutes of therapy, therapy assistant will assist the acupuncturist in pulling off the needles and putting them in a safe place. Depending on the severity of the disease, therapy should be applied continuously for a period of one to two weeks as per the directives of the acupuncturist.
  7. If patient faints in between the therapy, immediately remove the needles and let the patient rest, drink water and resume the therapy.
  8. After the needles are removed, if the patient bleeds, therapy assistant will clean it and let the patient rest.

    9. Challenges faced at National Traditional Medicine Hospital Acupuncture Department

    Lack of adequate human resource with skills and expertise coupled with fewer acupuncturists in the country affects the provision of effective acupuncture services. Currently, the acupuncture services are provided solely at National Traditional Medicine Hospital. Patients from remote parts of the country travels to avail acupuncture services at National Traditional Medicine Hospital. Financial difficulties are exacerbated if patients have no one to turn to while availing service at National Traditional Medicine Hospital in the capital city.  We believe that in the future, there may be more number of patients preferring acupuncture over pharmaceuticals due to its safety profile such as stronger belief in efficacy, fewer perceived barrier, and support from social circles and providers [14, 15]. With more acupuncturists gradually joining the system, the service will be available in the regional and district hospitals. Expanding acupuncture services to district hospitals would also reduce travel burdens, and greatly benefit particularly the older adults and patients from low-income groups. Where necessary, such as reaching acupuncture service to the remotest populations such as Lunana who faces geographic and financial barriers, mobile camps or clinics could ensure equitable access.

    Likewise, the infrastructure setting for acupuncture therapy merits development to meet public and time demand. For instance, installing exhaust fans in the acupuncture rooms to remove smoke utilizing moxibustion would make the environment safer as inhaling moxa smoke can be dangerous for both patients and medical staff. There is also a need to up date the standard operating procedure and protocol on time to provide efficient and upgraded service. In the future, the acupuncture room environment must be planned to comply with health and safety regulations.

    Table 2.  Services availed at the Acupuncture Department of the National Traditional Medicine Hospital between 2023 and 2024.
    Month 2023 New, 2024 Old, 2024 Total
    2024
    0–8 years 9–50 years ≥60 years 0–8 years 9–50 years ≥60 years
    Male Female Male Female Male Female Male Female Male Female Male Female
    Jan 1036 81 17930 70 281678 129 2351683
    Feb 961 58 12420 42 243 551 87 197 1322
    Mar 1441 84 149 41 58 470 885 216 311 2214
    April 1181 71 154 36 68 265 678 128 212 1612
    May 1265 72 131 33 38 382 745 195 229 1825
    Jun 1134 1 67 102 26 35 4 334 662 152 215 1598
    July 1741 1 98 186 52 624 400 854 241 260 2158
    Aug 2216 2 1 87 190 45 62 8 274 889 173 252 1983
    Sep 2478 127 224 50 58 450 773 160 198 2040
    Oct 1508 86 183 44 81 445 737 200 331 2107
    Nov 1726 78 150 71 63 367 640 272 317 1958
    Dec 1832 109 192 52 70 333 567 159 256 1738
    Total 18519 41 1018 1964 500 707 16 4244 8659 2112 3013 22238
    Source: Record Section, National Traditional Medicine Hospital, 2025
     

    RECOMMENDATIONS FOR ENHANCING ACUPUNCTURE SERVICES

    Currently at National Traditional Medicine Hospital, the patient is allowed to receive only one therapy per day. One patient cannot receive two or multiple therapies in a day, and this has negative impact to patients. In the existing practice, a patient can receive one therapy for a week and then opt for other therapies in the following week if the prescribed therapy is ineffective. However, in other countries such as in China, acupuncture is usually combined with moxibustion, electric acupuncture, cupping and tuina. There is a need to adopt the culture of using acupuncture with other therapies such as the massage, cupping, hot oil compression and other therapies in our setting. The combination of two or more therapies per day would mean time saving, more convenient, and better patient outcome.

    Furthermore, as acupuncture is gaining popularity, there are opportunities for the young Sowa Rigpa practitioners to become an acupuncturist. In fact, starting in July 2025, the Faculty of Traditional Medicine at Khesar Gyalpo University of Medical Sciences of Bhutan has started a three-year MD program in acupuncture and moxibustion. This will be a huge relief to public and the young Drungtshos to boost traditional medicine in Bhutan. Additionally, in the future, acupuncture therapy may be utilised in wellness and spa centres, as well as rehabilitation facilities nationwide. Short-term acupuncture exchange programs could be instituted to facilitate exchange and enhancement of knowledge and skills on acupuncture.

    CONCLUSION

    Acupuncture is a common treatment in the traditional Chinese medical system that is utilized in more than 100 nations worldwide. Known for its safety, portability, and minimal side effects, acupuncture is especially effective in managing pain and neurological disorders. Despite being relatively new to Bhutan's healthcare system, the number of patients seeking acupuncture treatments each year has been steadily increasing as a result of health education campaigns and growing awareness. With continued advocacy, acupuncture's role in Bhutan's healthcare system is poised for further growth.


    Declarations

    Ethics approval and consent to participate.

    Not applicable

    Consent for publication

    Written informed consent sought from the patient to use the image


    Competing interests

    The authors declare no competing interests.

    Funding

    There was no funding for this article.


    Availability of data materials

    The dataset is available from the corresponding author after approval from the Ministry of Health, Royal Government of Bhutan


    Author contributions

    Conceptualization, Formal analysis, Resources, Data curation, Writing – original draft, Writing – review & editing, Visualization: KT

    Methodology, Software, Validation, Resources, Writing – original draft, Writing – review & editing, Visualization, Supervision – ND

    Received: 13 April, 2025   Accepted: 14 August, 2025   Published online: 18 September, 2025

    References

    1. Chon TY, Lee MC. Acupuncture. Mayo Clinic Proceedings. Elsevier Ltd; 2013. pp. 1141–1146. doi:10.1016/j.mayocp.2013.06.009.
    2. Allen J, Mak SS, Begashaw M, Larkin J, Miake‐Lye I, Beroes‐Severin J, et al. Use of Acupuncture for Adult Health Conditions, 2013 to 2021: A Systematic Review. JAMA Netw Open. 2022;5: E2243665. doi:10.1001/JAMANETWORKOPEN.2022.43665.
    3. Liu Y, Zhao L, Chen F, Li X, Han J, Sun X, et al. Comparative efficacy and safety of multiple acupuncture therapies for post stroke cognitive impairment: a network meta‐analysis of randomized controlled trials. Front Neurol. 2023;14: 1218095. doi:10.3389/FNEUR.2023.1218095/BIBTEX.
    4. Xue H, He HX, Wu D, Fan WH, Li YX. An overview of systematic reviews of acupuncture for Parkinson’s disease. Front Neurosci. 2024;18: 1415008. doi:10.3389/FNINS.2024.1415008/BIBTEX.
    5. Fan S, Zhang Z, Wang Q. Efficacy of acupuncture therapy for stable chronic obstructive pulmonary disease: A systematic review and meta‐analysis. Medicine. 2023;102: e33537. doi:10.1097/MD.000000000003353.
    6. Chen B, Wang CC, Lee KH, Xia JC, Luo Z. Efficacy and safety of acupuncture for depression: A systematic review and meta‐analysis. Res Nurs Health. 2022;46: 48. doi:10.1002/NUR.22284.
    7. Qin C, Ma H, Ni H, Wang M, Shi Y, Mandizadza OO, et al. Efficacy and safety of acupuncture for pain relief: a systematic review and meta‐analysis. Supportive Care in Cancer. 2024;32. doi:10.1007/S00520024-08971-9.
    8. Yang C, Hao Z, Zhang LL, Guo Q. Efficacy and safety of acupuncture in children: An overview of systematic reviews. Pediatr Res. 2015;78: 112–119. doi:10.1038/PR.2015.91.
    9. Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H, Foster NE, et al. Acupuncture for Chronic Pain: Individual Patient Data Meta‐analysis. Arch Intern Med. 2012;172: 1444–1453. doi:10.1001/ARCHINTERNMED.2012.3654.
    10. Ministry of Health. Annual Health Bulletin. Thimphu: Policy and Planning Division, Ministry of Health; 2024. Available:https://moh.gov.bt/ wp‐content/uploads/2025/01/Annual‐Health‐Bulletin‐2024.pdf.
    11. Zhao XF, Hu HT, Li JS, Shang HC, Zheng HZ, Niu JF, et al. Is Acupuncture Effective for Hypertension? A Systematic Review and Meta‐Analysis. PLoS One. 2015;10: e0127019. doi:10.1371/JOURNAL.PONE.0127019.
    12. Lu WW, Zhang JM, Lv ZT, Chen AM. Update on the Clinical Effect of Acupuncture Therapy in Patients with Gouty Arthritis: Systematic Review and Meta‐Analysis. Evidence‐Based Complementary and Alternative Medicine. 2016;2016: 9451670. doi:10.1155/2016/9451670.
    13. Li X, Liu Y, Jing Z, Fan B, Pan W, Mao S, et al. Effects of acupuncture therapy in diabetic neuropathic pain: A systematic review and meta‐analysis. Complement Ther Med. 2023;78: 102992. doi:10.1016/J.CTIM.2023.102992.
    14. Liou KT, Trevino KM, Meghani SH, Li QS, Deng G, Korenstein D, et al. Fear of analgesic side effects predicts preference for acupuncture: a cross‐sectional study of cancer patients with pain in the USA. Supportive Care in Cancer. 2021;29: 427–435. doi:10.1007/S00520‐02005504‐Y/METRICS.
    15. Bao T, Li SQ, Dearing JL, Piulson LA, Seluzicki CM, Sidlow R, et al. Acupuncture versus medication for pain management: a cross‐sectional study of breast cancer survivors. Acupuncture in medicine : journal of the British Medical Acupuncture Society. 2018;36: 80. doi:10.1136/ACUPMED‐2017‐011435.