The Paradox of Happiness

The Kingdom of Bhutan is seeking to progressively realize the human right to health without addressing the cross-cutting human rights principles essential to a rights-based approach to health. Through a landscape analysis of the Bhutanese health system, documentary review of Bhutanese reporting to the United Nations human rights system, and semi-structured interviews with health policymakers in Bhutan, this study examines the normative foundations of Bhutan’s focus on “a more meaningful purpose for development than just mere material satisfaction.” Under this development paradigm of Gross National Happiness, the Bhutanese health system meets select normative foundations of the right to health, seeking to guarantee the availability, accessibility, acceptability, and quality of health care and underlying determinants of health. However, where Bhutan continues to restrict the rights of minority populations—failing to address the ways in which human rights are indivisible, interdependent, and interrelated—additional reforms will be necessary to realize the right to health. Given the continuing prevalence of minority rights violations in the region, this study raises research questions for comparative studies in other rights-denying national contexts and advocacy approaches to advance principles of nondiscrimination, participation, and accountability through health policy. Benjamin Mason Meier is an Associate Professor of Global Health Policy at the University of North Carolina, Chapel Hill, NC, USA. Averi Chakrabarti is a Doctoral Student in the Department of Public Policy at the University of North Carolina, Chapel Hill, NC, USA. Please address correspondence to the authors c/o Benjamin Mason Meier, Department of Public Policy, 103 Abernethy Hall, University of North Carolina, Chapel Hill, NC 27599. Email: [email protected] Competing interests: None declared. Copyright © 2016 Meier and Chakrabarti. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited. Health and Human Rights Journal HHr HHR_final_logo_alone.indd 1 10/19/15 10:53 AM B. M. Meier and A. Chakrabarti / papers,193-208 194 J U N E 2 0 1 6 V O L U M E 1 8 N U M B E R 1 Health and Human Rights Journal Introduction Bhutan straddles two worlds: reforming health policy to ensure domestic happiness while denying human rights to minority populations. Although the Bhutanese government has reformed its national health system in accordance with select norms of the human right to health, the continuing denial of universal equality stands as an impediment to a rights-based health system, with this failure to ensure cross-cutting principles of non-discrimination, participation, and accountability undercutting government efforts to realize the right to health. Advancing understanding of cultural relativism debates at the intersection of health and human rights, it is necessary to account for those states that seek to meet public health goals while denying the larger interrelated set of health-related human rights. Given international efforts to address health rights in rights-denying states, it is vital that human rights advocates recognize culturally specific limitations to realizing the right to health through national health policy. All policies in Bhutan seek to enhance Gross National Happiness (GNH). Based upon principles of Mahayana Buddhism, GNH focuses on the advancement of social harmony, preservation of national identity, and sustainability of natural environments. By emphasizing non-economic measures in development policy, looking beyond Gross Domestic Product, the Bhutanese GNH system surveys citizens to assess their holistic well-being. With Bhutanese citizens consistently found to be among the happiest in the world, the Bhutanese government has sought to enlarge the global development agenda to incorporate notions of happiness. Yet, while Bhutan has sought to export its GNH Index to other nations, advancing GNH to widespread acclaim in the United Nations (UN), it is only beginning to interact with the UN human rights system and to address criticism of its minority rights practices. Where few have studied the ways in which Bhutanese GNH policy comports with international human rights law, this article investigates the policies through which human rights norms and principles have been implemented in the transformation of Bhutan’s national health system. The opening section reviews the political history of Bhutan, introducing the governance reforms that have accompanied its recent democratic transition and the policy goals of Bhutan’s GNH approach to development. Central to GNH, the next section outlines the rapidly changing Bhutanese health system and analyzes the ways in which this evolving system seeks to progressively realize several normative foundations of the human right to health. However, highlighting the government’s continuing neglect of principles of non-discrimination, participation, and accountability in the health system, the article then examines the contradictions through which Bhutan relies on a narrow vision of the right to health without engaging human rights principles that might challenge state authority, focusing on select norms of the right to health to the exclusion of minority rights. The article concludes that rightsbased health advocacy in rights-denying states will require public health advocates to understand this tension in realization of the right to health, recommending additional cross-national research to understand how national policymakers engage the right to health selectively while avoiding cross-cutting principles of human rights. Bhutan and the goal of Gross National Happiness Nestled high in the Himalayas between India and China, Bhutan’s roots can be traced to the 17th century, when Shabdrung Ngawang Namgyal, a Buddhist military leader from Tibet, secured control over most of the Druk Yul (Land of the Thunder Dragon) and developed Bhutan’s dual religious/ secular system of government. 1 With Buddhism having long predominated in the region, introduced in the 8th century by the Indian monk Padmasambhava (Guru Rimpoche in Bhutan), Buddhist monks continued to hold theocratic authority over the new Bhutanese state.2 Through the formalization of secular government, Penlops (regional fiefs) existed until 1907, when one Penlop was selected to be king over the entire state, marking the beginning of Bhutan’s hereditary monarchical system of B. M. Meier and A. Chakrabarti / papers, 193-208 J U N E 2 0 1 6 V O L U M E 1 8 N U M B E R 1 Health and Human Rights Journal 195 governance, now extended across five generations of kings.3 Despite the formal establishment of democratic rule through the 2008 Constitution, Buddhism remains the “spiritual heritage” of this new constitutional monarchy, with the Druk Gyalpo (Dragon King) and Je Khenpo (leader of Central Monk Body) sharing authority over all matters of religion and state.4 In this small kingdom, there is substantial ethnic diversity: the Ngalong peoples (of Tibetan origin) are concentrated in the western and northern districts; Sharchops (originally from northern Burma and northeast India) are concentrated in eastern districts; and Lhotshampas (of Nepali origin) are concentrated in the southern foothills.5 The Ngalongs have long been politically dominant, reflected in the state’s: • religious makeup: Buddhists make up about 80% of the population, with the Ngalong practice of Tibetan-style Mahayana Buddhism permeating all aspects of Bhutanese life, although Hindu and Christian populations make up the majority of the south.6 • linguistic makeup: Dzongkha, the Ngalong language, is the official language of the country, although many other Tibeto-Burman languages predominate in the central and eastern parts of the country and Nepali is spoken in the south.7 This dominance of Ngalong/Buddhist/Dzongkha populations has often persisted to the detriment of ethnic, religious, and linguistic minorities. Following a century of absolute monarchy in Bhutan, King Jigme Singye Wangchuk stepped down from the throne in 2006, declared the country to be a democracy, and handed over the reins of government to his son, Jigme Khesar Namgyel Wangchuk. The young Wangchuk, the fifth Dragon King, oversaw the nation’s first legislative elections in 2008, marking Bhutan’s transition to a constitutional monarchy.8 Where Bhutan has traditionally delegated authority to the local level, the country is now administratively divided into 20 dzongkhags (districts) and 205 gewogs (blocks), with district-level development committees administering local projects and articulating local needs.9 This decentralized governance structure has provided a basis to address Bhutan’s policy focus on GNH, presenting “a new paradigm based on human happiness and the wellbeing of all life forms as the ultimate goal, purpose and context of development.”10 GNH was envisioned in Bhutan as a method of encouraging holistic development, redefining development as the advancement of political, economic, social, and cultural goals. The enshrinement of happiness as a policy goal can be traced back to Bhutan’s 1729 legal code, which stated that “if the Government cannot create happiness (dekid) for its people, there is no purpose for the Government to exist.”11 With the third king declaring his principal intention to make the Bhutanese people “prosperous and happy,” he focused on happiness in commemorating Bhutan’s 1971 admission as a UN Member State.12 Soon after his accession to the throne in 1972, the fourth king declared that he would reform Bhutanese policy “to achieve economic self-reliance, prosperity and happiness.”13 Coining the term ‘Gross National Happiness’ (and proclaiming it morally superior to Gross National Product), he formalized happiness as a national policy goal and a means to transform the Kingdom. To reorient the nation toward GNH—making happiness the official goal of all policies—the Bhutanese government has sought to realize equitable and sustainable socio-economic development, environmental conservation, cultural preservation, and good governance.14 This national commitment to GNH has been woven throughout the 2008 Bhutanese Constitution, which codified that: “The State shall strive to promote conditions that will enable the pursuit of Gross National Happiness.”15 Surveying its citizens to assess happiness, the government of Bhutan now distributes GNH surveys to “representative samples” to assess nine domains: psychological well-being, health, education, culture, time use, good governance, community vitality, ecological diversity and resilience, and living standards.16 The GNH survey asks multidimensional questions on each of the domains, providing respondents an opportuniB. M. Meier and A. Chakrabarti / papers,193-208 196 J U N E 2 0 1 6 V O L U M E 1 8 N U M B E R 1 Health and Human Rights Journal ty to rank their satisfaction on a scale from deeply unsatisfied to incredibly satisfied.17 Based upon these rankings, individuals can be classified as unhappy, narrowly happy, extensively happy, and deeply happy; by examining aggregate happiness levels in the national GNH Index, the government can reallocate resources to increase the proportion of happy people and decrease the “insufficiencies of the not-yet-happy people.”18 Seeking to export this paradigm of happiness through global development discourse, Bhutan has repeatedly extolled its GNH Index throughout the world, with the UN General Assembly supporting a 2011 resolution on “Happiness: Towards a Holistic Approach to Development.”19 These efforts to promote GNH have provided the Bhutanese government with an oversized voice in the UN agenda, allowing this small state to host a 2012 High-Level Meeting on “Happiness and Wellbeing: Defining a New Economic Paradigm.”20 The GNH model continues to resonate in UN development debates, with Bhutan held up as a model for translating happiness into policy under the Sustainable Development Goals.21 As a reflection of Bhutan’s global efforts to advance happiness in development, the UN General Assembly has declared March 20th to be International Happiness Day.22 Health and human rights in Bhutan Described frequently as “the last Shangri-La,” a paradise on earth, the Bhutanese monarchy has endeavored to create a society according to Buddhist principles, seeking happiness through its national health system. The government has long seen the need for a national health system as a means to GNH, with the 2008 Constitution making explicit that the government “shall provide free access to basic public health services in both modern and traditional medicines” and, drawing on the Universal Declaration of Human Rights, shall “endeavor to provide security in the event of sickness and disability or lack of adequate means of livelihood for reasons beyond one’s control.”23 Although Bhutan has not ratified many of the international treaties that codify a right to health, health is recognized as one of the nine domains of GNH, and the government has argued that it is implementing the right to health through GNH policy reforms.24 Yet even as Bhutan seeks to secure happiness through health policy, it has done so at the expense of minority populations. Where many states have been seen to violate individual rights in the pursuit of economic development, Bhutan has employed similarly violative means to achieve its unique focus on development through national happiness.25 This focus on GNH, however, creates distinct human rights challenges, with the government simultaneously: • seeking to uphold the economic and social rights of the nation to facilitate the spiritual, emotional, and cultural well-being of society, while • continuing to restrict the rights of minority populations to maintain a uniform national identity for this pursuit of happiness. The Bhutanese government thus presents a paradox in human rights realization, developing policies to fulfill the right to health through the health system’s GNH focus while undermining this rights-based effort through violations of cross-cutting human rights principles for non-discrimination and equality, participation, and accountability. Bhutan’s rights-based health system As Bhutan’s 2008 Constitution mandates universal access to health as part of the government’s commitment to GNH, the first National Health Policy, launched in 2011 by the Ministry of Health, authorized the government to: “Build a healthy and happy nation through a dynamic professional health system, attainment of highest standard of health by the people within the broader framework of overall national development in the spirit of social justice, and equity.”26 The policy thereby frames the health system in accordance with select normative obligations of the human right to health, seeking to make health progressively available, accessible, acceptable, and of sufficient quality.27 B. M. Meier and A. Chakrabarti / papers, 193-208 J U N E 2 0 1 6 V O L U M E 1 8 N U M B E R 1 Health and Human Rights Journal 197 The Bhutanese health system The Bhutanese Ministry of Health was established with the objective of bringing “GNH closer to a reality” through the realization of health.28 Pursuing a holistic health system, the Ministry has explicitly advocated this approach as a reflection of the WHO definition of health: “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”29 The health system seeks to realize this focus on “complete health” through both health care and determinants of health. In meeting the Kingdom’s constitutional obligation to provide “free access to basic public health services in both modern and traditional medicines” to its largely rural population, Village Health Workers (VHWs), Basic Health Units (BHUs) and Outreach Clinics (ORCs) often provide the principal level of primary health care.30 Although the VHWs are not paid government employees, they serve as a valuable “complimentary [sic] force to support the activities of the health system.”31 The BHUs are the official source of primary health care, providing basic medical care, maternal and child care services, and prevention interventions.32 These BHUs run ORCs, through which health personnel travel to geographically isolated villages.33 Cases that cannot be resolved by these primary care facilities are referred to the formal hospital system, comprised of the district hospitals (located in each of the country’s 20 districts), the regional referral hospitals in Mongar (east Bhutan) and Gelephu (south Bhutan), and the Jigme Dorji Wangchuk National Referral Hospital in Thimphu. Beyond health care, the new Bhutanese Constitution also seeks to “ensure a safe and healthy environment,” and the Ministry of Health has employed this authority to achieve significant public health advancements through disease prevention and health promotion programs.34 Public health interventions have led to the virtual disappearance of endemic goiter and leprosy, reduced the prevalence of vector-born diseases, achieved near-universal childhood immunization, and stemmed the flow of water-borne illness.35 To halt tobacco-related diseases, Bhutan became the first nation in the world to ban cigarette smoking and prohibit the production and sale of tobacco.36 Given this primary health care approach—providing community-based health care and addressing underlying determinants of health— WHO has repeatedly praised Bhutan for the impact of its health system on the public’s health.37 Bhutan Ministry of Health and WHO Country Office in Bhutan. Photo: Benjamin Mason Meier. B. M. Meier and A. Chakrabarti / papers,193-208 198 J U N E 2 0 1 6 V O L U M E 1 8 N U M B E R 1 Health and Human Rights Journal The Ministry of Health plays a crucial leadership role in “nurturing” these health care and public health programs, working with foreign donors and international organizations to support needed international assistance and cooperation in health initiatives.38 WHO has applauded the Bhutanese government for being “proactive in managing donor assistance within a well-defined framework, avoiding duplication and overlaps, with each donor or development partner active in preferred areas of assistance.”39 Based upon Bhutanese government programs and foreign health assistance, health indicators in Bhutan have improved steadily, as seen in Table 1. Table 1. UN indicators reflective of realization of the human right to health.