Healthy Gross National Happiness

Indo-Bhutan International Conference On Gross National Happiness Vol 02, October 2013 Pages: 221-228

International Journal of Business Intelligents (IJBI) 221 www.ijbui.com

Healthy Gross National Happiness

Kezang Choden1, Sonam Tobgay2, Ugyen3 1Gaeddu College of Business Studies, Chukha: Bhutan 2Gaeddu College of Business Studies, Chukha: Bhutan 3Gaeddu College of Business Studies, Chukha: Bhutan

[email protected], [email protected],[email protected] Abstract There’s no pursuit to happiness; happiness is a state of mind but yet there are factors that define our level of happiness. Is money the only factor that makes us happy? The concept Gross National Happiness defines happiness as the balance between material and no material values. Health for example is one of the important factors that determine happiness. We cannot expect a sick person to be happy. His health recovery will make him happy. Health is one of the most important domains of four pillars of Gross National Happiness. Happiness of people in Bhutan is measured in terms of health, education, personal wellbeing, community vitality, living standards etc… The paper does not reveal any new study but contains few literature reviews of the studies that are conducted in the past on health and GNH. The paper also holds some important information related to health and Bhutan, concept of Gross National Happiness and health in general. 1. Introduction 1.1 Gross National Happiness: GNH is a holistic and sustainable approach to development which balances between material and non-material values with the conviction that humans want to search for happiness. 1.2 Objective of GNH To achieve a balanced development in all facets of life that is essential to our happiness. The goal of GNH is happiness. One of several means to achieve this goal is sustainable economic growth. GNH is a unique approach to national and global development. Gross National Happiness is a term coined by His Majesty the Fourth King of Bhutan, Jigme Singye Wangchuck in the 1970s. The concept implies that sustainable development should take a holistic approach towards notions of progress and give equal importance to non-economic aspects of wellbeing. The concept of GNH has often been explained by its four pillars: good governance, sustainable socio-economic development, cultural preservation, and environmental conservation. Lately the four pillars have

been further classified into nine domains in order to create widespread understanding of GNH and to reflect the holistic range of GNH values. The nine domains are: psychological wellbeing, health, education, time use, cultural diversity and resilience, good governance, community vitality, ecological diversity and resilience, and living standards. The domains represents each of the components of wellbeing of the Bhutanese people, and the term ‘wellbeing’ here refers to fulfilling conditions of a ‘good life’ as per the values and principles laid down by the concept of Gross National Happiness. 2. What the GNH Index reveal about happy people? Of the nine domains, Bhutanese have the most sufficiency in health, then ecology, psychological wellbeing, and community vitality. In urban areas, 50% of people are happy; in rural areas it is 37%. Urban areas do better in health, living standards and education. Rural areas do better in community vitality, cultural resilience, and good governance.



Figure 1:The glimpse of GNH

It is hard not to think about happiness in Bhutan, a Buddhist kingdom set high in the Himalayas between India and China. As the country has gradually opened itself to the West and its tourists' dollars, so it has projected and exported its philosophy of 'gross national happiness' (GNH), a belief that a society should be measured not simply by its material indicators but by the health, education and the contentedness of its people. The grass certainly grows green in Bhutan. There is free health care and free education and since 1980 life expectancy has increased by 20 years and per capita income by 450 per cent. Today, in terms of life expectancy, the amount of education received and income, Bhutan ranks above the average for South Asia. Health and Gross National Happiness: review of current status in Bhutan Worldwide, contemporary measures of the success of health development programs have been mostly in terms of the reduction of mortality and morbidity as well as increasing longevity. While these goals have yielded much-needed health improvements, the subjective outcomes of these improvements, as experienced by individuals and the communities, have not been considered. Bhutan, under the overarching policy of GNH, has provided due consideration to these subjective indicators. Here, we report on the current status of health and happiness in Bhutan as revealed by

conventional objective indicators and subjective GNH indicators. (Dophu) The current literature on health in Bhutan in relation to the GNH survey conducted by the Centre of Bhutan Studies has been reviewed. Bhutan has made great strides within a short period of modernization, as shown by both objective and subjective indicators. Tremendous challenges lie ahead to achieve the ultimate goal of health and happiness, and how Bhutan articulates its path to modernization may be a lesson for the rest of the world. Bhutan started its modern health system in 1961 with two hospitals, two doctors, and two nurses. During that period, the prevalence rates for tuberculosis and leprosy was up to 15 per 1000 population, and about 80% of the female population had goiter. Other diseases, such as diarrhea, venereal disease, and malaria were also rampant. Bhutan became a signatory to the Alma-Ata declaration in 1978. Since then, Bhutan has ascribed the utmost importance to the health of its people. In addition, Bhutan adopted Gross National Happiness (GNH), which puts the happiness of the population at the core of developmental policies. Article 9 of the Constitution of Bhutan prescribes that “the state shall strive to promote those conditions that will enable the pursuit of Gross National Happiness.” This noble philosophy has been debated in greater detail in various international seminars led by the Centre for Bhutan Studies and attracted much international attention. 3. Happiness as a development goal Happiness varies across individuals and cultures, despite being an ultimate goal for individuals in all human societies. This concept is embedded in most religions and cultures, but in contemporary times, the pursuit of happiness has been translated into an unwavering pursuit of economic growth. The concept of health and well-being has been the subject of discussion for a long time, and numerous studies have been



conducted on this subject. In recent years, psychologists and social scientists have made strides in research on subjective well-being, and some of the major achievements have been the development of models and measurement of subjective well-being. Despite much progress, it has been highlighted that there is a need for more studies on the subject of health and happiness. Further, despite the increasing amount of literature on health and well-being, happiness as a national goal has not always been pursued. The fourth king of Bhutan, His Majesty Jigme Singye Wangchuck, in 1974, realizing the mismatch in the trajectory of growth-oriented market economics as a developmental philosophy, formulated the concept of GNH. To this end, development should serve the total well-being of the people and economic development is only the means to achieve it. In Bhutan, happiness is considered as a public good, and it is the responsibility of the government to create an enabling environment for the pursuit of GNH, as enshrined in the constitution. GNH in Bhutan is based on four principles, i.e., sustainable and equitable economic development, conservation of the environment, preservation and promotion of culture, and good governance. The Centre for Bhutan Studies, as mandated by the Royal Government of Bhutan, has developed a GNH index under nine domains. As part of the government initiative of the GNH index, the Centre for Bhutan Studies conducted a survey based on these domains in December 2007–March 2008 in 12 districts of Bhutan. 4. Core demographic and health indicators in Bhutan Bhutan has already achieved some of its millennium development goals, including access to improved water and sanitation, and is on track to achieve the remaining goals. These achievements were commended by the international community, when the 5th World Health Assembly awarded its prestigious

Sasakawa Health Award to the Monger Health Services Development Project in 1997, and when the World Health Organization awarded its fiftieth anniversary award for primary health care to Bhutan in 1998. Although the Royal Institute of Health Sciences currently focuses on training nurses, paramedics, and public health practitioners, there are future plans to upgrade this into a nursing and medical college to meet the human resources required in Bhutan. These achievements were also acknowledged during the joint Bhutan-Danish International Development Agency health sector review. Sources of happiness for the Bhutanese population varied from financial security to travelling abroad. On a 10-point scale (1 = not a very happy person, 10 = a very happy person), the average happiness score was 6.2 for Bhutan residents. Both good health and access to the health infrastructure and facilities are considered important sources of happiness. In a GNH indicator survey, 25.5% of respondents reported their health as excellent/very good, 64.1% reported it as good, and 66.3% of men and 58.5% of women reported not having any mental or physical illness during the 30 days preceding the survey. Conversely, 10.7% of men and 13.4% of women reported illness lasting 14 days or more during the same time period. Long-term disability was reported by 12.6% of rural respondents and 4.4% of urban respondents. Happy life years, calculated as the product of life expectancy and happiness score, resulted in 40.7 years for Bhutan. 5. Twenty sources of happiness for Bhutanese people: For government performance in the 12 months preceding the survey, ratings of excellent were given by 73% of respondents for improving education, 72% for improving health services, 67% for protecting the environment, 57% for providing electricity, 49% for providing roads, 38% for fighting corruption,38% for creating jobs, and 37% for



reducing the income gap between rich and poor. Traditional Bhutanese medicine, known as “gso-ba-rig-pa,” is well integrated into the modern health care system. This form of traditional Buddhist medicine currently practiced in Tibet, Mongolia, and Bhutan, dates back about 2500 years. In Bhutan, this traditional service is available in all districts. In most districts, these two systems are located in the same hospital and people can choose either type of service to use. In addition, other forms of traditional remedies are also practiced. The survey showed that 78.1% of respondents consulted an astrologer for matters related to them and their family, with 13% of respondents consulting an astrologer as a first contact during an illness. Other culturally related health determinants included in the GNH survey were consumption of alcohol and chewing of “doma” (areca nut and betel leaf with a dash of lime giving a red color when chewed). Alcohol and doma are an integral part of Bhutanese tradition and culture, and are served during most ceremonies and rituals. These traditionally valued commodities may be consumed in excessive amounts causing untoward health effects. As per the annual health report, alcohol is one of the top ten causes of death in Bhutan. The GNH indicator survey showed that 61.5% of respondents reported consuming alcohol at some point of time, with 17.7% of drinkers reporting that they had been drinking most of the time in the previous 12 months. In a similar manner, 75.8% reported chewing doma at some point in time, of which 22.7% reported chewing doma on a daily basis. In contrast, only 17.6% of respondents reported having smoked tobacco at some point in their lives. Tobacco smoking is against Buddhist teaching. This indicates that health risk behaviors which are culturally acceptable are more prevalent than those that are culturally proscribed. Income has a strong correlation with happiness, although studies from developed

countries show that income has a saturation point and does not correlate with an increase in income. In economic terms, Bhutan has progressed from being one of the poorest countries in the 1980s to becoming one of the middle income economies of the world, with an annual average growth rate of 7.5% in its gross domestic product. However, Bhutan is still a poor state, with 23.2% of the population living below the poverty line, and per capita consumption of USD 24 per person per month. The socioeconomic disparity is evident, with the richest 20% of the national population consuming 6.7 times more than the poorest 20%. There is also an increasing trend of mental disorders, with increasing numbers of young people suffering from stress and anxiety-related disorders. The GNH indicator survey found that disparities prevail in all categories of socioeconomic status for most variables measured. The survey report showed that male gender, higher educational level, strong family bonds, good health, lack of suicidal tendency, and participation in sporting and religious activities, were some of the factors contributing to happiness. While women have a longer life expectancy, men are found to be healthier, less disabled, and happier than women. These finding are in general consistent with those of other studies. There is no pharmaceutical company in Bhutan, and medicines are centrally procured and distributed to the remote health centers every year. The availability of over 90% of essential drugs is maintained throughout the year. The Health Trust Fund was created in 1997 to sustain accessibility of these essential services by the people, with a current fund accumulation of USD 23.7 million. This would augment the funding requirement for sustainable supplies of essential drugs and vaccines to fulfill the constitutional mandate of providing free health care. Sustainable development is defined as “development that meets the needs of the present without compromising the ability of future generations to meet their own needs,”



encompasses social, economic, and environmental dimensions. The values generated from these important concepts can be used for active promotion of health and pursuit of happiness. Environmental preservation is one of the foundations of GNH, and in Bhutan, the constitution mandates that a minimum of 60% of land area must have forest coverage. Ecological degradation, ecological knowledge, and afforestation variables are measured under the environmental diversity domain. For sustainable and healthy development promoting happiness of the nation, all four dimensions of the GNH needs to be addressed in a balanced and integrated manner, and measured periodically as a developmental yardstick. Only then can health, happiness, and development flourish harmoniously

6. Progress and delivery of health care in Bhutan The Himalayan Kingdom of Bhutan is rapidly changing, but it remains relatively isolated, and it tenaciously embraces its rich cultural heritage. Despite very limited resources, Bhutan is making a concerted effort to update its health care and deliver it to all of its citizens. Healthcare services are delivered through 31 hospitals, 178 basic health unit clinics and 654 outreach clinics that provide maternal and child health services in remote communities in the mountains. Physical access to primary health care is now well sustained for more than 90% of the population. Bhutan has made progress in key health indicators. (Pelzom, 2011) In the past 50 years, life expectancy increased by 18 years and infant mortality dropped from 102.8 to 49.3 per 1000 live births between 1984 and 2008. Bhutan has a rich medical history. One of the ancient names for Bhutan was 'Land of Medicinal Herbs' because of the diverse medicinal plants it exported to neighboring countries. In 1967, traditional medicine was included in the National Health System, and in 1971, formal training for Drungtshos (traditional doctors)

and sMenpas (traditional compounders) began. In 1982, Bhutan established the Pharmaceutical and Research Unit, which manufactures, develops and researches traditional herbal medicines. Despite commendable achievements, considerable challenges lie ahead, but the advances of the past few decades bode well for the future. 7. Traditional Bhutanese medicine (gSo-BA Rig-PA): an integrated part of the formal health care services. Traditional medicine in Bhutan is known as gSo-ba Rig-pa and is one of the oldest surviving medical traditions in the world. Other medical systems, such as Chinese medicine, Indian Ayurvedic medicine, Unani medicine, Greco-Roman medicine and the country's rich cultures and traditions have greatly influenced the way traditional Bhutanese medicine evolved. However, Buddhist philosophy remains the mainstream of this medical system. gSo-ba Rig-pa's principles are based on the perception the human body is composed of three main elements: rLung ('Air'), mKhris-pa ('Bile') and Bad-kan ('Phlegm'). When these three elements are balanced in the body a person is said to be healthy. The pathophysiology is also different from other medical systems, and the close link to Buddhism is reflected in the spiritual dimensions and the perception that all suffering is caused by ignorance. The treatment of diseases includes behavioral modification, physiotherapy, herbal medicines, minor surgery and spiritual healing. This makes the traditional Bhutanese medicine a unique and holistic health care system. The traditional medicine is an integrated and recognized part of the formal health care services in Bhutan under the auspices of the Ministry of Health. The article highlights three main points which can be learned from the Bhutanese experience: (1) the strong tradition of herbal medicines within gSo-ba Rig-pa forms a unique opportunity to prospect for new leads for development of



pharmaceuticals, (2) the availability of the traditional medicine along with biomedicine broadens the health care choices for patients, and (3) the experiences of integrating two conceptually very different health care systems within one ministry contains important managerial lessons to be learned. 8. Health care services in Bhutan Bhutan’s modern health care development accelerated with the establishment of the Department of Public Health in the 1960’s and the opening of new hospitals and dispensaries throughout the country. However careful attention had always been given to traditional practice and the people’s perception of illness. This has ensured that modern healthcare services and indigenous medical services develop simultaneously. Herbal-based, traditional medicine is well established and integrated into the general health services and remains a popular form of healthcare. Access to traditional medicine in the country has been greatly increased with 31 traditional Drungtshos (Doctors) providing indigenous medical services in all Dzongkhags (Districts). Traditional medicine continues to hold an important place in the formal healthcare system as it not only adds an important dimension to the country’s system of healthcare, but also provides an alternative form of healthcare. An integrated healthcare delivery system was foreseen as an effective strategy to reach the scattered population in Bhutan’s rugged terrain. The declaration of Alma Ata in 1978 adopting a primary healthcare approach to achieve ‘Health for All’ has also served accelerate health service development in this direction. The government has maintained a system of complete free healthcare for not only the Bhutanese citizens but also all those who reside in the country. In 1961 there was hardly any modern facility in Bhutan. Today, the country has more than 29

hospitals, 160 Basic Health Units and 90 percent health coverage with basic services. The health status of the population has improved markedly, especially during the last 10 years. National surveys conducted in 1984, 1994, and 2000 showed a tremendous increase in the access to safe drinking water and dramatic decrease in mortality and morbidity. The population growth rate has been brought down from 3.1 percent in 1994 to 2.5 percent in 2000. Training for health-care assistants, nurses’ aides, midwives, and primary health-care workers is provided at the Royal Institute of Health Sciences associated with the Jigme Dorji Wangchuck National Referral Hospital, Thimphu, which was established in 1974. Graduates of the school are the core of the national public health system and helped staff the primary care basic health units throughout the country. Additional health-care workers are recruited from among volunteers to supplement primary health care. The most common diseases in the 1980s were gastrointestinal infections caused by waterborne parasites, mostly attributable to the lack of clean drinking water. The most frequently treated diseases were respiratory tract infections, diarrhea and dysentery, worms, skin infections, malaria, nutritional deficiencies, and conjunctivitis. In 1977 the World Health Organization (WHO) declared Bhutan a smallpox-free zone. In 1979 a nationwide immunization program was established. In 1987, with WHO support, the government envisioned plans to immunize all children against diphtheria, pertussis, tetanus, polio, tuberculosis, and measles by 1990. The government’s major medical objective by 2000 was to eliminate waterborne parasites, diarrhea and dysentery, malaria, tuberculosis, pneumonia, and goiter. Progress in leprosy eradication was made in the 1970s and 1980s, during which time the number of patients had

decreased by more than half, and by 1988 the government was optimistic that the disease could be eliminated by 2000. It was estimated

in 1988 that only 8 persons per 1,000 had access to potable water. Despite improved amenities provided to the people through



government economic development programs, Bhutan still faced basic health problems. Factors in the country’s high morbidity and death rates included the severe climate, less than hygienic living conditions, for example long-closed-up living quarters during the winter, a situation that contributes to the high incidence of leprosy, and smoke inhalation from inadequately ventilated cooking equipment. Nevertheless, in 1980 it was estimated that 90 percent of Bhutanese received an adequate daily caloric intake. Although there were no reported cases of acquired immune deficiency syndrome (AIDS), the Department of Public Health set up a public awareness program in 1987. With the encouragement of the WHO, a “reference laboratory” was established at the Thimphu General Hospital to test for AIDS and human immunodeficiency virus (HIV) as a precautionary measure. To further enhance awareness, representatives of the National Institute of Family Health were sent to Bangladesh in 1990 for training in AIDS awareness and treatment measures. The Government maintains a system of universal health care for all of its citizens. However, the number of Hospitals in Bhutan is limited, and some diseases, such as cancer cannot be treated in Bhutan. Patients that cannot be treated in Bhutan are taken to hospitals in India, and their treatment is paid for by the government of Bhutan 9. Conclusion Bhutan’s strides in improving the health and happiness of its population, as suggested by various indicators, are commendable. The GNH indicator survey was taken when the country was in transition to full parliamentary democracy, and these baseline indicators can be used as a developmental yardstick. Despite the achievements, as indicated by both subjective and objective measures, much still needs to be done to improve GNH in Bhutan. This includes elimination of poverty, narrowing the socioeconomic gap, fighting

emerging and re-emerging infectious diseases, and halting the increasing trend of mental and lifestyle-related diseases. Therefore, the manner in which the health system is remodeled to address these challenging issues within the context of the growing expectations of the modern Bhutanese population will affect happiness indicators, and how Bhutan strives for economic growth without compromising the well-being of its people could epitomize the modern developmental paradigm. Despite availability of ample information about health and well-being in general, our search yielded a paucity of published information on health and GNH in Bhutan. Hence, official websites, government and international reports, and consultancy reports constituted the bulk of the information discussed in this paper. 10. Acknowledgments This paper could not have been undertaken without the help and assistance of several people. There are many people to whom we owe sincere thanks for their assistance throughout the evolution of this paper. First of all, we the group members would like to extend our sincere thanks and gratitude to our Domain Leader Mr. Poonovalan K, for his full support and guidance in executing our project. Without his support, this project would be an incomplete one. In addition to all we also would like to thank our Director Sir, for giving us a wonderful opportunity for intereaction. We also would like to thank and extend our sincere gratitude to the members of Health domain for all th help and guidance. 11. References [1]Dophu, U. Health and GNH. [2]Pelzom, D. T. (2011). Progress and dlivery of health care in Bhutan. Thimhpu: Ministry of Health. [3]http://bhutanjournals.com/reference-education/health-care/health-care-services-in-bhutan/



[4]http://www.grossnationalhappiness.com/articles/ [5]http://www.guardian.co.uk/world/2012/dec/01/bhutan-wealth-happiness-counts [6]http://www.gnhbhutan.org/about/ [7]http://www.dovepress.com/health-and-gross-national-happiness-review-of-current-status-in-bhutan-peer-reviewed-article-JMDH

[8]http://www.yanatravel.com/about-bhutan/health [9]http://www.ncbi.nlm.nih.gov/pubmed/17539263 [10]http://www.ncbi.nlm.nih.gov/pubmed/21418446

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Healthy Gross National Happiness