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Health Hum Rights. 2016 Jun; xviii(ane): 193–208.

The Paradox of Happiness

Wellness and Homo Rights in the Kingdom of Bhutan

Benjamin Mason Meier

Acquaintance Professor of Global Wellness Policy at the University of North Carolina, Chapel Colina, NC, USA.

Averi Chakrabarti

Doctoral Educatee in the Department of Public Policy at the Academy of North Carolina, Chapel Loma, NC, USA.

Abstruse

The Kingdom of Bhutan is seeking to progressively realize the human correct to health without addressing the cross-cutting human being rights principles essential to a rights-based approach to health. Through a mural assay of the Bhutanese health system, documentary review of Bhutanese reporting to the United Nations human being rights system, and semi-structured interviews with health policymakers in Bhutan, this study examines the normative foundations of Bhutan's focus on "a more than meaningful purpose for evolution than just mere textile satisfaction." Nether this development paradigm of Gross National Happiness, the Bhutanese health arrangement meets select normative foundations of the correct to health, seeking to guarantee the availability, accessibility, acceptability, and quality of health intendance and underlying determinants of health. Notwithstanding, where Kingdom of bhutan continues to restrict the rights of minority populations—declining to address the ways in which human rights are indivisible, interdependent, and interrelated—additional reforms volition be necessary to realize the right to health. Given the standing prevalence of minority rights violations in the region, this written report raises research questions for comparative studies in other rights-denying national contexts and advancement approaches to accelerate principles of non-discrimination, participation, and accountability through health policy.

Introduction

Bhutan straddles two worlds: reforming health policy to ensure domestic happiness while denying human being rights to minority populations. Although the Bhutanese authorities has reformed its national health organisation 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 agreement of cultural relativism debates at the intersection of wellness and human rights, information technology is necessary to business relationship for those states that seek to meet public health goals while denying the larger interrelated ready of wellness-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 correct to wellness through national wellness 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-economical measures in evolution 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 amidst the happiest in the earth, the Bhutanese government has sought to enlarge the global evolution agenda to comprise notions of happiness. Yet, while Bhutan has sought to export its GNH Index to other nations, advancing GNH to widespread acclamation in the United Nations (United nations), it is simply beginning to interact with the UN human being rights organisation and to address criticism of its minority rights practices.

Where few have studied the means in which Bhutanese GNH policy comports with international man rights law, this commodity investigates the policies through which human rights norms and principles have been implemented in the transformation of Kingdom 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 Kingdom of bhutan'due south GNH approach to development. Primal to GNH, the side by side department outlines the rapidly changing Bhutanese health organisation and analyzes the ways in which this evolving system seeks to progressively realize several normative foundations of the homo correct to health. Withal, highlighting the government'south continuing neglect of principles of non-discrimination, participation, and accountability in the wellness system, the article then examines the contradictions through which Bhutan relies on a narrow vision of the correct to health without engaging human rights principles that might claiming land authorisation, focusing on select norms of the correct to health to the exclusion of minority rights. The article concludes that rights-based health advocacy in rights-denying states volition require public health advocates to sympathise this tension in realization of the correct to health, recommending additional cross-national research to understand how national policymakers engage the correct to health selectively while avoiding cross-cutting principles of human rights.

Kingdom of bhutan and the goal of Gross National Happiness

Nestled high in the Himalayas between India and China, Kingdom of bhutan'southward roots can exist traced to the 17th century, when Shabdrung Ngawang Namgyal, a Buddhist military leader from Tibet, secured control over virtually of the Druk Yul (Land of the Thunder Dragon) and adult Bhutan'southward dual religious/secular system of regime.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 land.2 Through the formalization of secular government, Penlops (regional fiefs) existed until 1907, when 1 Penlop was selected to be king over the entire state, marking the showtime of Kingdom of bhutan's hereditary monarchical arrangement of governance, now extended across five generations of kings.3 Despite the formal institution 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 Fundamental Monk Torso) sharing say-so over all matters of organized religion and state.4

In this small kingdom, there is substantial ethnic multifariousness: 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 upward nearly 80% of the population, with the Ngalong practice of Tibetan-mode 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 linguistic communication, is the official linguistic communication of the land, although many other Tibeto-Burman languages predominate in the key and eastern parts of the country and Nepali is spoken in the southward.7

This authorization of Ngalong/Buddhist/Dzongkha populations has often persisted to the detriment of ethnic, religious, and linguistic minorities.

Following a century of accented monarchy in Bhutan, King Jigme Singye Wangchuk stepped down from the throne in 2006, declared the state to exist a democracy, and handed over the reins of regime to his son, Jigme Khesar Namgyel Wangchuk. The young Wangchuk, the fifth Dragon King, oversaw the nation's showtime legislative elections in 2008, marking Bhutan's transition to a ramble monarchy.8 Where Kingdom of 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 construction has provided a basis to address Bhutan's policy focus on GNH, presenting "a new epitome based on man happiness and the wellbeing of all life forms as the ultimate goal, purpose and context of evolution."10

GNH was envisioned in Bhutan as a method of encouraging holistic development, redefining development equally the advancement of political, economic, social, and cultural goals. The enshrinement of happiness equally a policy goal tin be traced back to Bhutan's 1729 legal code, which stated that "if the Regime cannot create happiness (dekid) for its people, there is no purpose for the Government to be."11 With the third king declaring his primary intention to make the Bhutanese people "prosperous and happy," he focused on happiness in commemorating Bhutan's 1971 admission as a UN Member Land.12 Presently later on his accession to the throne in 1972, the fourth rex declared that he would reform Bhutanese policy "to accomplish economic self-reliance, prosperity and happiness."xiii Coining the term 'Gross National Happiness' (and proclaiming it morally superior to Gross National Product), he formalized happiness equally 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, ecology 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."fifteen Surveying its citizens to assess happiness, the government of Bhutan now distributes GNH surveys to "representative samples" to assess ix domains: psychological well-beingness, health, education, culture, time use, skillful governance, customs vitality, ecological diversity and resilience, and living standards.16 The GNH survey asks multidimensional questions on each of the domains, providing respondents an opportunity to rank their satisfaction on a scale from deeply unsatisfied to incredibly satisfied.17 Based upon these rankings, individuals tin be classified as unhappy, narrowly happy, extensively happy, and deeply happy; past examining amass happiness levels in the national GNH Index, the authorities tin reallocate resources to increase the proportion of happy people and decrease the "insufficiencies of the not-notwithstanding-happy people."xviii

Seeking to export this paradigm of happiness through global evolution discourse, Bhutan has repeatedly extolled its GNH Index throughout the globe, with the United nations General Associates supporting a 2011 resolution on "Happiness: Towards a Holistic Arroyo to Evolution."nineteen These efforts to promote GNH have provided the Bhutanese government with an oversized voice in the UN agenda, allowing this modest state to host a 2012 High-Level Meeting on "Happiness and Wellbeing: Defining a New Economic Paradigm."twenty The GNH model continues to resonate in UN development debates, with Bhutan held upwardly as a model for translating happiness into policy under the Sustainable Development Goals.21 As a reflection of Bhutan's global efforts to accelerate happiness in development, the UN General Assembly has declared March xx^th to be International Happiness Day.22

Health and human rights in Bhutan

Described ofttimes as "the last Shangri-La," a paradise on earth, the Bhutanese monarchy has endeavored to create a social club co-ordinate to Buddhist principles, seeking happiness through its national health organization. The authorities 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 admission to bones public health services in both modern and traditional medicines" and, drawing on the Universal Proclamation of Man Rights, shall "endeavor to provide security in the effect of sickness and disability or lack of adequate ways of livelihood for reasons beyond 1'southward control."23 Although Bhutan has not ratified many of the international treaties that codify a correct to health, health is recognized as 1 of the 9 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 then at the expense of minority populations. Where many states take been seen to violate individual rights in the pursuit of economic evolution, Bhutan has employed similarly violative ways to achieve its unique focus on development through national happiness.25 This focus on GNH, nevertheless, creates singled-out human rights challenges, with the government simultaneously:

seeking to uphold the economical and social rights of the nation to facilitate the spiritual, emotional, and cultural well-being of social club, 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 correct to health through the wellness system'due south GNH focus while undermining this rights-based effort through violations of cross-cutting human rights principles for non-discrimination and equality, participation, and accountability.

Kingdom of bhutan's rights-based health arrangement

Equally Bhutan'due south 2008 Constitution mandates universal access to health as part of the government's commitment to GNH, the first National Wellness Policy, launched in 2011 by the Ministry building of Health, authorized the regime to: "Build a healthy and happy nation through a dynamic professional wellness organization, attainment of highest standard of health by the people within the broader framework of overall national development in the spirit of social justice, and disinterestedness."26 The policy thereby frames the health organization in accordance with select normative obligations of the human correct to health, seeking to make wellness progressively bachelor, accessible, acceptable, and of sufficient quality.27

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 wellness.28 Pursuing a holistic health system, the Ministry has explicitly advocated this arroyo as a reflection of the WHO definition of health: "a state of complete physical, mental and social well-existence and not but the absence of affliction or infirmity."29 The health system seeks to realize this focus on "complete health" through both wellness care and determinants of health.

In coming together the Kingdom'south ramble obligation to provide "free access to bones public health services in both modern and traditional medicines" to its largely rural population, Village Wellness Workers (VHWs), Basic Health Units (BHUs) and Outreach Clinics (ORCs) oft provide the principal level of primary health intendance.30 Although the VHWs are not paid government employees, they serve as a valuable "free [sic] force to support the activities of the health system."31 The BHUs are the official source of principal 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 past these primary care facilities are referred to the formal infirmary system, comprised of the district hospitals (located in each of the state's twenty districts), the regional referral hospitals in Mongar (east Bhutan) and Gelephu (due south Bhutan), and the Jigme Dorji Wangchuk National Referral Hospital in Thimphu.

Beyond wellness care, the new Bhutanese Constitution also seeks to "ensure a condom and healthy environment," and the Ministry building of Health has employed this authority to achieve pregnant public health advancements through disease prevention and health promotion programs.34 Public health interventions accept led to the virtual disappearance of endemic goiter and leprosy, reduced the prevalence of vector-born diseases, achieved near-universal babyhood 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 auction of tobacco.36 Given this chief health care approach—providing customs-based health intendance and addressing underlying determinants of wellness—WHO has repeatedly praised Bhutan for the touch of its health system on the public'south health.37

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Bhutan Ministry of Health and WHO Country Office in Bhutan. Photograph: Benjamin Mason Meier.

The Ministry of Health plays a crucial leadership part in "nurturing" these health care and public health programs, working with foreign donors and international organizations to back up 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, fugitive duplication and overlaps, with each donor or development partner agile in preferred areas of assistance."39

Based upon Bhutanese regime programs and foreign health aid, health indicators in Bhutan have improved steadily, as seen in Table 1.

Table 1.

UN indicators cogitating of realization of the man correct to health.

	1970	1990	2012
Life expectancy at birth	36.9	52.5	67.nine
Maternal mortality rate (per 100,000 live births)	-	900	120^*
Babe bloodshed rate (per 1,000 live births)	-	92	36

Bhutan fares amend on many health indicators than its counterparts in the WHO Due south-E Asia Region, with considerably lower rates of maternal mortality (120 per 100,000 live births, compared to 190 for the region), HIV (142 per 100,000 people, compared to 185 for the region) and malaria (20 per 100,000 people, compared to 1,462 for the region).forty Even as the nation undergoes a larger "demographic transition"—with longstanding issues of undernutrition compounded past new problems of overconsumption—the regime has begun to focus on not-infectious disease, encouraging healthy diets and concrete activeness.41 With the kickoff national GNH surveys finding the greatest expressions of citizen happiness in the health domain, these wellness system reforms speak to the government'south efforts to implement certain norms of the right to health.

Mainstreaming the correct to health

The right to health, codified seminally in Commodity 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) and antiseptic expansively in Full general Comment fourteen of the Un Committee on Economic, Social and Cultural Rights (CESCR), is progressively realized through the Bhutanese health organisation's structures, processes, and outcomes.42 Establishing the legal construction of its wellness system under the 2008 Constitution, Bhutan has set out a range of laws to realize the determinants of health. Building from government processes to implement primary wellness care, Bhutan's National Health Program has laid out "detailed provisions clarifying what club can wait by way of health-related services and facilities."43 Heralding its improving public health outcomes, Bhutan has made enormous strides in reducing the risk of prevalent diseases, with major implications for the country'south public health. In accord with select normative foundations of the human being right to wellness, these implementation efforts for health care, disease prevention, and health promotion highlight Kingdom of bhutan'due south rights-based practices to guarantee wellness availability, accessibility, acceptability, and quality (AAAQ):

Availability: The right to health looks to whether there is a sufficient quantity of health facilities, goods, and services, and Bhutan has made progressive efforts to enhance wellness availability by increasing the number of health intendance personnel, developing its health education system, and ensuring essential medicines.44 Where Bhutan has long faced a pregnant shortfall of health intendance workers, with approximately half the amount that WHO guidelines recommend, it has seen a dramatic scaling upwardly in the by decade: from 50 doctors and 335 nurses in 2002 to 244 doctors and 957 nurses in 2014.45 Bhutan's National Mental Health Program seeks to clinch the availability of mental health care through the full general health care system, with additional resources through 63 psychiatric facilities, 1 mental health inpatient ward, two psychiatrists, and three psychiatric nurses.46 To further increment the availability of wellness services, Kingdom of bhutan is expanding its health education system, with the Royal Found of Health Sciences (RIHS) developing its first bachelor's caste programme in Public Health in 2010 and in Nursing and Midwifery in 2012.47 Although Bhutanese students previously studied abroad to receive avant-garde medical training, the Bhutanese government has worked with India to establish a new medical school, the University of Medical Sciences of Bhutan, which is developing programs in medicine, traditional medicine, nursing, and public health.48 While Bhutan continues to have a lower proportion of health personnel than other countries in the region, it spends (with support from foreign donors) far more per capita than its regional counterparts on health goods and services, with WHO estimating that essential medicines are now available to more than ninety% of the population.49
Accessibility: The Bhutanese wellness organisation seeks to aggrandize accessibility to health through a continuum of free services, with the tiers of the Bhutanese health organisation—the VHWs, BHUs, and hospitals—meeting international human rights standards to "have a mix of chief (community-based), secondary (district-based), and tertiary (specialized) facilities and services."50 Facilitating geographic accessibility in a state of scattered rural settlements and rugged mountainous roads, the primary wellness care arrangement is "reasonably equitably distributed" and, in accordance with the National Health Policy, can be accessed by 90% of citizens within a 3-hour walk (with the remaining 10% reached by ORCs).51 The VHW program exists principally to improve health education (information accessibility) in villages, with national trainings for VHWs to disseminate data on sanitation practices, family planning, and "the importance of cleanliness, immunization and a healthy diet."52 To ensure the standing affordability (economic accessibility) and "long-term sustenance" of these health services, the government in 1997 established the Kingdom of bhutan Wellness Trust Fund—with centralized government purchasing and matching foreign contributions—to finance vaccines and essential medications.53 Although there remains a standing shortage of specialists and supplies in the district hospitals, patients can exist referred to afar facilities for tertiary intendance, with the Bhutanese regime assuming all expenses for transporting patients and escorts, if necessary, outside of the country.54
Acceptability: Where the right to health seeks acceptability to cultural standards in public health systems, the Bhutanese health organization has been designed in line with the Buddhist traditions practiced by the majority of citizens.55 Combining elements from traditional medicine and modern medicine in all hospitals, information technology is common for patients to be referred between traditional and modern medical units. The traditional medical care practitioners—both Drungtshos (traditional doctors) and sMenpas (traditional compounders)—have been formally integrated into the national wellness organization and receive required training at the Institute of Traditional Medicine Services.56 In cases where modernistic medicine has challenged cultural behavior—for example, cancer is "an nigh taboo topic in the land" and often goes unreported because it is thought to exist a result of improper actions in this or a previous life—modern medical practitioners take worked with traditional healers to raise awareness, increase diagnoses, and expand treatment options.57 Beyond cultural acceptability, the wellness system also considers acceptability to afflicted communities, as seen where the regime'southward HIV programs accept sought to exist "responsive to the needs of the vulnerable and marginalized groups, peculiarly people living with HIV/AIDS, Men who accept sex activity with Men, Commercial Sexual activity Workers and Trans-genders."58
Quality: A health system realizing the right to wellness must secure "a level of quality consistent with medical and scientific standards."59 Although past international reviews have found that many of the health facilities in Bhutan are "of questionable quality," lacking even necessary equipment, these external reviews have taken note of recent upgrades and ended, based on Bhutan's level of development, that the "[quality of care in general is reasonable."60 Similarly, while the poor training of health workers is likely to touch the quality of wellness services, the grooming programs discussed above are likely to improve both the quantity and quality of trained workers in the years to come up. In creating regulatory institutions for the maintenance of health organization quality, the Bhutan Medical and Wellness Council Human action of 2002 regulates medical and health personnel, and the Bhutan Medicines Act of 2003 oversees the quality of medications.61 To guide health personnel in assuring the quality of medications, Bhutan has codified a National Drug Policy to bring near more than "rational prescribing" of modern medicines and created a Pharmaceutical and Inquiry Unit to standardize the research and development of traditional medicines.62

Fulfilling many of the central norms of the right to health, Kingdom of bhutan views GNH as a ground for the right to health, and, in turn, looks to the correct to health every bit necessary for GNH.

Engaging human rights in Bhutan

Still restrictions of homo rights in Bhutan stalk from its same GNH-based efforts to nautical chart a distinctive course for wellness and development, with the government viewing minority "overflowing" as a threat to the survival of the state and viewing restrictive citizenship policies equally necessary safeguards for the Bhutanese GNH system.63 Similar to the repressive efforts of other rights-denying states that have sought to forge a national identity through the exclusion of minority populations, Bhutan first established its "one nation, one people" policy in the 1990s as a means to frame the Bhutanese identity to realize its unique development objectives, justifying that:

The emergence of Kingdom of bhutan as a nation state has been dependent upon the joint of a distinct Bhutanese identity, founded upon our Buddhist behavior and values, and the promotion of a common linguistic communication. These accept been defining elements in our history and they have made it possible to unify the country and to achieve national homogeneity and cohesion among diverse linguistic and ethnic groups. This identity, manifest in the concept of 'one nation, one people', has engendered in u.s. the volition to survive every bit a nation state likewise equally the strength to defend it in the face up of threats and dangers.64

Rather than facilitating the multicultural national identity that had existed previously, this policy shift led to the persecution of non-Buddhist peoples, the mass exodus of minority populations, and the creation of large Bhutanese refugee populations outside of the Kingdom.65 Up to 100,000 Nepali-speaking Hindus (Lhotshampas) were expelled from the land throughout the 1990s—through trigger-happy repression, forcible eviction, or formal pressure level—making their mode to refugee camps in Nepal and thereafter excluded from Bhutanese citizenship and land ownership.66 Decried every bit a form of "ethnic cleansing," with emptied southern agronomical lands subsequently given to landless northern Bhutanese citizens, such violations of minority rights brought international condemnation on the Bhutanese government.67

Responding to this condemnation, Bhutan initially sought to close itself off from the international human rights system, arguing that information technology had never ratified either of the Un's man rights covenants: the International Covenant on Civil and Political Rights (ICCPR) and the ICESCR.68 By denying civil and political rights, the Bhutanese government sought to insulate itself from the ICCPR'due south protection of minority rights.69 Yet, with these seminal ICCPR protections evolving to get the universal corpus of minority rights under international law, Bhutan continued to be criticized for violating the rights of the Lhotshampa minority.lxx

Based upon the Full general Assembly's elaboration of minority rights in the 1992 Declaration on the Rights of Persons Belonging to National or Ethnic, Religious and Linguistic Minorities, the UN repeatedly questioned Bhutan's denial of rights through the exclusion of citizenship, get-go in the Committee on Human Rights and and then in the Human being Rights Quango.71 The Bhutanese regime has come to ratify the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) and the Convention on the Rights of the Child (CRC), reporting on women's and children's rights to international treaty monitoring bodies; however, where the government continues to fail the minority rights components of these adopted treaties, information technology has faced continuing international criticism—for instance, from the Committee on the Rights of the Child for denying minority children the correct to accept part in Lhotshampa culture, practise the Hindu organized religion, or use the Nepali linguistic communication.72

In spite of the promise of negotiations for the return of Lhotshampa refugees, very few refugees accept been naturalized as Bhutanese citizens or permitted to return to their homes in Kingdom of bhutan.73 Rather than engage these land tenure claims, Bhutanese authorities reports regularly exclude whatever mention of minority populations, linguistic differences, or cultural diversity.74 When Bhutan has been pressed on the homo rights of these excluded populations, the regime has viewed these issues through the lens of terrorism and criminality, arguing that "the problem of the people in the refugee camps in eastern Nepal is not a typical refugee situation, but one of highly complex nature, with its genesis in illegal immigration."75 With neither minority suffrage, contained media, nor ceremonious society, Bhutan continues to face international scrutiny for its violative policies.76

Despite this ongoing denial of minority rights, the Bhutanese regime has begun to engage human being rights as role of the Kingdom's transition to democracy. Proceeding toward commonwealth without crisis, struggle, or revolution, this unique democratic transition over the by decade was driven and guided by the monarchy, which yielded considerable power to elites in the legislative and judicial branches while solidifying the majority Buddhist/Drukpa/Dzonkha identity.77 Even every bit the Constitution has been criticized for its neglect of religious, linguistic, and ethnic diversity—and specifically for the standing exclusion of Lhotshampa refugees, reserving constitutional rights only to "citizens"—it has opened a space for human being rights discourse, with Bhutan now acknowledging that "without the enjoyment of all man rights, Gross National Happiness, to which information technology is also securely committed, cannot exist achieved."78

This democratic transition has led the government to limited a renewed commitment to the international human rights system, with the drafters of the Bhutanese Constitution noting that they were "specially influenced past South Africa's [constitution] . . . considering of its strong protection of homo rights."79 Engaging with the international homo rights system in the aftermath of this democratic transition, yet, has necessitated a purposeful effort to examine rights in isolation, looking to commonage development rather than private freedoms and noting that "respect for human rights such every bit rights to education, health and livelihoods complement abstract rights of equality before law."80 Through this prioritization of collective happiness (of the majority citizens) over individual freedoms (of minority populations), the government has argued that GNH "lays the framework for the protection, promotion and integration of human rights into the fabric of Bhutanese society."81

Participating in the United nations's Universal Periodic Review (UPR) procedure for the outset fourth dimension in 2009, the Bhutanese government focused on the strides it was taking to implement rights as office of the Kingdom'south nascent transition to republic. While largely addressing women's and children'due south rights, framed by its treaty commitments to CEDAW and the CRC, Bhutan reported on the progressive realization of health rights to these groups through the national master health care organisation.82 Only when pressed during its UPR presentation did the Bhutanese delegation concur "that equal importance must be accorded to civil and political rights, and economical, social and cultural rights."83 The interrelated rights of minority populations were raised repeatedly in the UPR procedure—in the land report and the state dialogue, leading to several concrete Working Group conclusions to address these cross-cut human rights concerns—yet few steps were taken to resolve this issue prior to Bhutan's second review in 2014.84

When Bhutan once more presented information to the Human Rights Council, its second UPR report (a) linked GNH to the promotion of economic and social rights, (b) included a separate section on the "Right to Health," and (c) noted tentative steps through which the transition to commonwealth had facilitated greater realization of civil and political rights.85 Repeatedly noting its deepening commitment to all human rights, the regime ended in both UPR reporting cycles that it will go along to consider the ratification of human rights instruments one time it has developed the institutions and capacity necessary to run into these homo rights obligations.

The paradox of human being rights realization in rights-denying states

Bhutan's GNH-driven health organization has met certain international obligations to progressively realize the correct to wellness—receiving scant criticism on wellness issues in advocate reports and few recommendations on its health system in either UPR reporting cycle—nonetheless Bhutanese health policy has still failed to run across cantankerous-cut man rights principles that underlie the right to health, including:

Equality and non-discrimination: With principles of non-discrimination ubiquitous across the international human rights arrangement, Bhutan has fabricated explicit its commitment to realize health without bigotry, only this delivery has fallen short with regard to minority populations. The government prioritizes women and children every bit "vulnerable groups" in national policy, in accordance with CEDAW and the CRC; notwithstanding, data indicate that health inequality in Bhutan flows mostly along geographic lines, with large and persistent regional disparities in admission to nutrient security, drink h2o, and health care.86 Although the government has attributed geographic inaccessibility to "the rugged and hard terrain" and "remoteness, sparse population and lack of reliable communication facilities," these regional disparities are strikingly like to the distribution of ethnic/religious/linguistic minorities, indicative of de facto (if not de jure) discrimination.87 Policies are needed to accost the specific barriers to wellness care and underlying determinants of health for minority populations, peculiarly the Nepali-speaking Lhotshampas in southern Bhutan, who remain marginalized in policy and vulnerable in practice.88 Where the government has non released disaggregated health data based on ethnicity, organized religion, or language, it volition be necessary for the government to understand these inequities through disaggregated indicators, developing a tailored response that prioritizes these minority groups in health policy.
Participation: Where a rights-based wellness organization must develop "institutional arrangements for the active and informed participation" of "all relevant stakeholders," Bhutan has long facilitated participation through a decentralized arrangement of governance, extended through the Constitution'southward say-so that:

Power and authorization shall be decentralized and devolved to elected Local Governments to facilitate the direct participation of the people in the development and management of their own social, economic and environmental well-being.89

Although this constitutional decentralization was specifically justified as a means of facilitating participation through district administration of the health system, such decentralization efforts have given rise to problems in the supervision and monitoring of health programs.xc In facilitating meaningful local participation beyond the GNH Survey, VHWs can provide a crucial link between communities and the health system, with trusted VHWs who are "living permanently in the community," and information technology will be crucial that VHWs come from the minority communities they serve.91 Ensuring minority voices in the health system, it will be additionally necessary to expand authorities authorization of minority civil society organizations in health. Replicating the success of organizations like Lhaksam, which represents HIV-positive populations and works with the Ministry of Health to reduce stigma, such mechanisms for ceremonious society participation in the health system tin assure acceptability in realization of the correct to health.92
Accountability: In facilitating accountability as a cross-cut human rights principle and key component of the right to wellness, Bhutan provides neither individual complaint mechanisms nor contained judicial regime.93 In the absence of a formalized adversarial ways of enforcing rights confronting the state, the Bhutanese government relies on its GNH Index to assess the realization of happiness. Nonetheless in assessing happiness, the GNH Surveys (on which almost 90% report themselves to be happy) have been criticized as highly subjective, reflecting habituation to persistent deprivations and imposing standards that may non reflect wellbeing.94 Further, although the GNH Alphabetize groups individual responses by sub-groups—disaggregating populations by age, district, gender, and occupation—this data disaggregation does not business relationship for ethnic/religious/linguistic minority groups, obscuring whatever footing for discrimination claims.95 While the Ministry building of Health has begun to administer National Health Surveys (NHS) to complement the GNH surveys, the Ministry building remains limited in its ability to compile and analyze data on the quality and effectiveness of the health sector.96 To provide boosted monitoring and evaluation mechanisms, the Ministry of Health has created the Bhutan Wellness Management and Information System (BHMIS) to assess information forwarded by each commune wellness function, and it will be necessary to evaluate information on minority groups under new versions of the District Health Information Arrangement (Druk HMIS).97

Although Bhutan has taken steps to progressively realize select norms of the right to health through its GNH arroyo to development, these efforts to clinch happiness through the wellness organization continue to violate the rights of minorities, impacting underlying determinants of health and undermining cantankerous-cutting human rights principles. This paradox raises an imperative to assess cross-cut human rights principles every bit interconnected obligations under the right to health, recognizing the means in which homo rights are indivisible, interdependent, and interrelated.

Without the unalloyed principles laid out by human rights, in that location can be no moral progress under international police force, withal such failures should non blunt health policy reforms in the management of greater humaneness and respect for the inherent dignity of the individual. Although scholars have noted a resistance to human rights in Southeast Asia, with some relativist authors arguing that "Asian" values are fundamentally unlike from "universal" human rights, it becomes articulate in this case that Bhutanese values in the wellness system overlap essentially with select norms of availability, accessibility, acceptability, and quality under the correct to health.98 Establishing a middle ground betwixt universality and relativism, the Bhutanese regime is non denying the beingness of norms that protect health merely rather constraining the norms included in its interpretation of the right to health, implementing certain norms of the correct to wellness in isolation while denying cross-cutting principles necessary to a rights-based approach to health. These issues must exist addressed equally Bhutan continues to piece of work with the international human rights system, analyzing the opportunities and limitations for human rights mainstreaming in the Bhutanese health system.

By acknowledging failures to implement a rights-based approach to health in Bhutan, this case study highlights the value of cross-cutting human rights principles in framing health system reforms. Bhutan has come to receive widespread approbation from human rights advocates for its failure to respect minority rights and implement homo rights protections, and where the Bhutanese government has come to view the international human being rights government with intense suspicion, such suspicions may shut off any formal advancement of the homo right to wellness, with current wellness policy documents often neglecting even to mention human rights. The Bhutanese regime's continuing violations of minority rights—while egregious in failing to run across the moral equality of all peoples—should not keep human rights advocates from working with policymakers in reforming the national health system to implement cross-cutting homo rights principles pursuant to state obligations under human correct to health.

Decision

Although Bhutan has steadfastly sought to blunt the influence of global forces, seeking its own unique class of evolution nether the GNH epitome, it would be a fault to presume that the international human right to wellness has no place in shaping a chop-chop evolving Bhutanese health system. Where the human rights organisation lacks a footing to prioritize human rights, it is necessary to report how different cultures navigate tradeoffs betwixt rights-based norms and principles in seeking to realize the right to wellness. The human right to health is transforming the world, and the homo rights community must sympathise the ways in which this international man right is implemented through national health systems, conceptualizing human rights implementation in states that deny the beingness of individual freedoms while seeking to realize public wellness. As the Bhutanese government moves beyond GNH and integrates itself further in the international human being rights arrangement, scholars must clarify the importance of cross-cut human rights principles to the man right to health—addressing universal threats to dignity, framing health system reforms, and assuring the highest attainable standard of health.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5070691/