Am. J. Trop. Med. Hyg., 104(2), 2021, pp. 441–445 doi:10.4269/ajtmh.20-1416 Copyright © 2021 by The American Society of Tropical Medicine and Hygiene Perspective Piece The Gross National Happiness Framework and the Health System Response to the COVID-19 Pandemic in Bhutan Thinley Dorji* Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan; Kidu Mobile Medical Unit, His Majesty’s People’s Project, Thimphu, Bhutan Abstract. Bhutan is a lower-middle–income country with limited tertiary-care health infrastructure and shortage of human resources. The country’s response to the COVID-19 pandemic is guided by the principle of Gross National Happiness (GNH), which prioritizes the well-being and happiness of people over conventional socioeconomic indicators. The king’s leadership and government’s decisions based on public health science helped in the control of the pandemic and reduce economic losses. The government implemented some unique and unconventional public health measures such as facility quarantine for those with high-risk exposure, an increase in quarantine period to 21 days, free testing and treatment, and population-based screening tests. Early and extensive contact tracing, extensive testing, effective communications, zoned travel restrictions, and adoption of physical distancing and hygiene measures limited COVID-19 transmissions within the country. Community participation from voluntary groups and civil society organizations helped deliver non-health services while hospitals provided uninterrupted routine health services through its primary healthcare network. All COVID-19 cases were treated in hospitals, and the country has had zero reported COVID-19 deaths. This article describes how the concept of GNH provided the framework for the government to respond to this pandemic. INTRODUCTION higher population located in the capital city Thimphu and in the southern districts that share a porous border with India. As Bhutan is a small Himalayan country that partly shares a COVID-19 spread around the world, the health system in porous border with the northeastern part of India, the latter Bhutan was evaluated and simulated against mathematical with 10 million cases of COVID-19 with grossly underreported fi 1 models of disease spread even before the rst case was de- deaths. As of December 7, 2020, 430 cases of COVID-19 tected in the country. In 2020, there were 48 hospitals, 186 were detected in Bhutan and has had zero reported deaths primary health centers, and three municipality health centers (Figure 1). The country with a limited number of human re- that covered more than 95% of the population within 3 hours sources and tertiary-care infrastructure aims to limit the local of travel.3 – spread and prevent COVID-19 related deaths as its primary Every hospital established flu clinics that were standalone ’ goal. The country s response to the impacts of the COVID-19 and separate from the main hospital infrastructure to screen pandemic is guided by the framework of Gross National for influenza-like illness and COVID-19, and designated sep- Happiness (GNH), which is an overall policy guide for Bhutan. arate facilities to isolate COVID-19 cases. Apart from the Royal Gross National Happiness was introduced in the 1970s to Centre for Disease Control in Thimphu, reverse transcription guide development toward building conditions that enhance (RT)-PCR testing facilities were newly established in four other people’s happiness and well-being.2 The conceptual frame- geographically strategic locations (regional referral hospitals work of GNH is based on four pillars: sustainable and equitable in Monggar and Gelegphu, and general hospitals in socioeconomic development, environmental conservation, Phuentsholing and Dewathang) to provide timely access to preservation and promotion of culture, and good governance; tests. The existing intensive care facilities at the three tertiary nine domains: psychological well-being, health, time use and hospitals were strengthened with additional equipment and balance, education, cultural diversity and resilience, good human resource. In Phuentsholing, the second most populous governance, community vitality, ecological diversity and resil- town and an economic hub in the south along the borders with ience, and living standards; and 33 indicators contributing to the India, new intensive care setup and RT-PCR testing facilities GNH index. Table 1 describes the domains and indicators of were established. COVID-19 antibody and antigen tests are GNH measurement.2 This article discusses how the country’s available at all levels of hospitals. health policy and system responded to the challenges and im- Human resources. The country has limited doctors, nurses, pacts of the COVID-19 pandemic in Bhutan, and is interpreted and technologists, and no infectious disease specialists, within the GNH domains of health, psychological well-being, virologists, or immunologists. In 2020, there were 376 doctors good governance, and community vitality. and 1,364 nurses with a ratio of 5.6 doctors and 18.4 nurses per 10,000 population.3 After the detection of the first GROSS NATIONAL HAPPINESS DOMAIN: HEALTH COVID-19 case in March 2020,4 human resources were reappropriated according to the population at risk. Addi- Infrastructure. Bhutan’s population of 0.7 million is scat- tional doctors, nurses, and laboratory technologists were tered across mountainous terrain in 20 districts with relatively deployed in high-population areas such as Thimphu, Paro, and Phuentsholing. Fifty doctors undergoing postgraduate training outside the country (13.3% of total registered in the * Address correspondence to Thinley Dorji, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan, or Kidu Mobile Medical country) were recalled, and 25 newly graduated doctors, Unit, His Majesty’s People’s Project, Gongphel Lam, Thimphu 11001, nurses, and technologists were recruited through a fast- Bhutan. E-mail: [email protected] tracked process.5 Given the lack of adequate doctors and 441 442 DORJI and enforcing physical distancing of crowds in hospitals and public places. Health services: Routine and COVID-19 services. The country provided uninterrupted routine services such as im- munization, maternal and child health services, and treatment of other chronic conditions such as diabetes, hypertension, tuberculosis, and HIV, demonstrating its commitment to pri- mary health care. Healthcare service delivery and routine outpatient services were redesigned to ensure continued ac- cessibility while preventing cross-contamination with poten- tial COVID-19 patients. To limit hospital visits, 54 flu clinics were established in physically separate locations that con- ducted passive surveillance and COVID-19 testing for all influenza-like illness, whereas hospitals initiated mobile de- livery of services and adoption of innovative measures such as FIGURE 1. The number of COVID-19 cases in Bhutan from March to designating drop-in places for delivery of medicines including December 7, 2020 reported by the Ministry of Health, Royal Govern- contraceptives.7 After an increasing number of COVID-19 ment of Bhutan. cases were detected in several districts in the south, all in- patients and attendants were tested for COVID-19 antigen and RT-PCR before admission in hospitals. nurses trained in critical care, 77 doctors and 255 nurses were COVID-19 cases are treated at four designated centers to trained in the management of intensive care units.6 concentrate the cases and rationalize the use of staff and The Royal Centre of Disease Control engaged students personal protective equipment: the Jigme Dorji Wangchuck from the Faculty of Nursing and Public Health, Khesar Gyalpo National Referral Hospital in Thimphu, Phuentsholing Hospi- University of Medical Sciences of Bhutan in running the RT- tal, Central Regional Referral Hospital in Gelegphu, and PCR tests. Volunteers from the De Suung Guardians of Peace Eastern Regional Referral Hospital in Monggar (Table 2). As of were engaged in monitoring of persons in quarantine facilities November 20, 2020, 491 health staff were deployed for 304 COVID-19 patients, with a health staff to patient ratio of 1.6:1.6 According to the National COVID-19 Treatment Guideline, all COVID-19 cases including those asymptomatic are ad- mitted and treated in hospitals followed by 2 weeks of facility TABLE 1 The nine domains and 33 indicators that measure Gross National de-isolation and require at least two negative RT-PCR tests 8 Happiness in Bhutan2 before discharge from de-isolation. Domain Indicators Health finances and resources. The free healthcare ser- vices are funded by the government with a budget allocation of Psychological well-being Life satisfaction – Positive emotions 3.6 6.9% of gross domestic product per year, and essential Negative emotions medicines and vaccines are procured through the Bhutan Spirituality Health Trust Fund.9 For the fiscal year 2020–2021, the gov- Health Self-reported health ernment allocated Nu 6,438 million (United States dollar Healthy days [USD] 87 million) for the health sector, an increase of 11% Disability 10 Mental health compared with the previous year. Time use Work A special COVID-19 fund was created with government allo- Sleep cation of budget and donations from citizens and international Education Literacy organizations.11 All COVID-19 testing and treatment are provided Schooling Knowledge free of cost by the government, and there is no out of pocket Value expenditure; COVID-19 vaccines