EDITORIAL

https://doi.org/10.47811/bhj.212

Bhutan's demographic turning point: family support and youth retention

Tshewang Gyeltshen^1,2

¹Department of Global Health Policy, School of International Health, The University of Tokyo, Japan

²National Medical Services, Royal Government of Bhutan, Thimphu, Bhutan

Corresponding author:

Dr. Tshewang Gyeltshen

Bhutan's demographic transition, marked by a decline in fertility alongside emerging population ageing and changing migration patterns, has moved from a distant projection to an immediate policy concern. For a country of fewer than 0.8 million people, even modest changes in population dynamics can have large consequences for the future workforce, the health system, and intergenerational support. National reporting for 2024 places total fertility at approximately 2.0 births per woman, near or slightly below replacement level, while international model-based series estimate fertility at a lower level in recent years^1,2. The precise estimate differs by source, but the direction is unambiguous: fertility has fallen sharply from the five to six children per woman recorded in the early 1990s.

Bhutan's declining fertility rate should first be understood as a reflection of the country's remarkable development achievements. Bhutan has achieved major gains in survival, maternal and child health, education, and access to contraception. The policy challenge is therefore no longer the continuation of population growth, but understanding and responding to a society where fertility rate has reached near-replacement levels, families are smaller, young adults spend longer periods in education, and social and economic circumstances increasingly influence decisions around marriage and childbearing. A rights-based response must start from this reality. The aim should not be to pressurise people to have children, but to create an environment where couples can realise their own reproductive aspirations by addressing the social, economic and structural barriers that may prevent them from having the families they already want.

A second demographic pressure is the growing emigration of young, educated Bhutanese. The World Bank has highlighted a rapid increase in migration, including a marked rise in Bhutanese residents in Australia between 2020 and 2024, many of whom are university educated and of prime working age³. This trend has important demographic consequences because emigration reduces the population in the life stage associated with partnership formation, childbearing, career development, and contribution to public service. It also affects systems that support families, particularly health and education. Efforts to address low fertility must therefore go beyond reproductive choices and include strategies to support the young Bhutanese.

Global evidence also suggests that low fertility should not be interpreted simply as a decline in the desire to have children. Rather, it often reflects a gap between people's reproductive intentions and their ability to achieve them. The UNFPA highlights that fertility challenges are shaped by constrained reproductive choices, driven by factors such as economic insecurity, rising housing costs, work-family pressures, delayed partnership, and unequal distribution of caregiving responsibilities⁴. This perspective is especially relevant with Bhutan's Gross National Happiness philosophy, wherein the focus must be on strengthening the conditions that enable family support, rather than promoting fertility through demographic coercion.

The strongest policy response would combine family support with strategies to retain youth. Evidence from high-income settings suggests that sustainable fertility responses require structural solutions rather than transactional ones. A systematic review of experimental and quasi-experimental studies found that subsidised childcare can increase fertility, whereas one-time birth payments and universal cash transfers often influence the timing of births without substantially changing the overall number of children⁵. For Bhutan, this highlights the need for affordable childcare and creche services, particularly in urban areas where dual-career couples are concentrated. Childcare should not be viewed only as a fertility intervention. It also supports women's continued employment, and supports early childhood development.

Paid parental leave is another structural solution. It should include a dedicated, non-transferable portion for fathers, together with job protection and flexible return to work arrangements. Evidence on gender equity and fertility suggests that childbearing becomes more compatible with modern employment when the costs of care do not fall disproportionately on women⁶. Paternal leave is therefore not symbolic. It changes expectations in households and workplaces, and it signals that childrearing is a shared social responsibility rather than a private burden carried mainly by mothers.

Housing support is another key factor. Young couples are unlikely to have their first or additional child when they face insecure housing, high rents, or limited access to finance. Targeted support, such as subsidised housing or mortgage support for young families, could address these barriers to family formation.

Fertility care is another area that requires attention. As education lengthens and the mean age at childbearing increases, difficulty with conception becomes more common. Domestically accessible and subsidised fertility services, including intrauterine insemination and in-vitro fertilisation services, could help couples achieve their desired final size when they face biological or financial barriers. These services should be offered as part of reproductive health care, and not as a pressure to reproduce.

Youth retention must be addressed in parallel. Improving public-sector career progression, strengthening opportunities in the private-sector, recognising overseas qualifications, and creating credible return pathways for Bhutanese overseas can help retain the reproductive-age population as well as the professional workforce needed to support families. This is particularly important for sectors such as health and education, where workforce losses have consequences that extend beyond demography.

Two cautions are necessary. First, family policies typically have modest and slow effects. Bhutan should not expect any single intervention to restore fertility quickly. Second, adaptation to a smaller and older population must occur alongside these interventions. These will require investments in age-friendly health care systems, and carefully considered labour migration. However, inaction would be the weakest option. Bhutan still has time to soften the demographic transition by adopting a strategy that supports families, retains youth, and protects reproductive choices within a coherent national strategy.

REFERENCES

1. Ministry of Health. Annual Health Bulletin 2025. Thimphu: Policy and Planning Division, Ministry of Health, Royal Government of Bhutan; 2025. Available from: https://moh.gov.bt/wp-content/uploads/2025/08/Annual-Health-Bulleti-2025.pdf

2. World Bank. Fertility rate, total (births per woman) - Bhutan. World Development Indicators. Accessed 8 June 2026. Available from: https://data.worldbank.org/indicator/SP.DYN.TFRT.IN?locations=BT

3. World Bank. Bhutan Development Update, Spring 2025: Bridging the Future - Addressing Challenges and Harnessing Opportunities of Migration. Washington, DC: World Bank; 2025. doi:10.1596/43419. Available from:https://openknowledge.worldbank.org/entities/publication/2b21a5f5-cf72-4ada-b9a0-afbba1573236

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