Health Care

Do not have even faintest idea that I belong to the medical profession. My interest in medicine evaporated on the day  when I choose engineering in IIT Kharagpur over medicine after my high school graduation. Despite such low-key file storage in my head’s hard disk on medical matters, I can neither avoid visiting doctors nor having medicines.  So it is all about my medical treatment experiences in all those world-standard hospitals including Makati Medical Center  (Manila, Philippines), Shifa International (Islamabad, Pakistan), United Family Hospital (Beijing, China), Pyathai 2 Hospital (Bangkok, Thailand) and Bumrungrad International (Bangkok, Thailand). I am not that sickly a person visiting all these hospitals regularly enabling me to write this. Most of my visits were for annual medical check-ups, and few for treatments. I have my own impression either way of each hospital which I consider beyond my moral principle to disclose here.

For all patients medical treatment means full recovery from illness. It can only happen if the disease is diagnosed properly, treatment and post-treatment advice/care are given appropriately.  Generally patients have no idea of proper diagnosis, appropriate treatment and post-treatment advice/care. Also patients normally cannot differentiate if the treatment is for symptoms or problems. For doctors, it varies I guess. While I think most of the government hospital doctors (typically with doing-you-favor attitude) diagnosed, treat and advise patients on their illness considering also patients’ identity, personality, behavior, attitude, outfit etc., my experience in private hospitals is the following.

During one of my annual medical check-ups, doctor discovered that I was suffering from hernia and needed to be operated.  All justifications that operation being minor involving only local anesthesia, doctor having experience in operation etc.... were explained to me. I was also reminded that since I was with the Asian Development Bank and had insurance coverage, it would be good if I decided to do the operation.  There it was, the financial aspect of the diagnosis. First, slicing and stitching my body scared me to death. Second, the doctor did not even mention non-surgical treatment. And, why was he advising operation which should, in fact, be the last option? Was the recommendation for operation more associated with cost rather than diagnosis and appropriate treatment? I had to consult few more doctors and decide on appropriate treatment. Thereafter I have had several cases where doctors asked if I had insurance coverage for treatment. Even if it was not intended to associate with the type and level of treatment, I had already learnt to do basic research on my illness and discount appropriately  the impact of market forces in medical treatment through critical dialogue with doctors on diagnosis, treatment and post-treatment services. This I find is very important. It’s my life! It is not intended to be derogatory to medical profession but give a perspective on impact of privatization.

Bangkok  occupies more and more prominent place as being medical destination for the people all over the world in addition to being tourist and shopping paradise. The reasons quite simply are Thai hospitality and care, world-class equipment and facilities, and well trained professionals in addition to its tropical climate, location and cost effectiveness compared with medical care in developed countries (MRI: $350 in Bangkok, against $1,080 in the US). The right strategy calls for focusing on what you are good at and excelling in it, and  Thais are good at it. The reasons,  in addition to being a prestige issue for some, why more and more Bhutanese are heading to Bangkok for treatment . While it is so, illusion that Bangkok treatment being always perfect ensuring full recovery from illness is bit far fetched. For that matter anywhere in the world, I guess.

More recently I went to Bangkok for treatment of my back pain. The diagnosis included X-ray, MRI (magnetic resonance imaging) and evaluation by spine surgeon.  The problem was identified and I was given the choice: non-surgical treatment (medicine plus physiotherapy) or surgery, Lumbar Laminectomy (LL).

The human back comprises of many interlocking bones, discs, ligaments, tendons, nerves and more I suppose. The LL surgery involving two inches cut including lamina (bone) from one or more vertebrae is bound to have higher risk of destabilizing the spinal cord. I opted for non-surgical despite surgeon's recommendation for appropriateness of LL for full cure. The non-surgical treatment for about a month had no impact on my back pain what-so-ever. What do I do? I was back researching how best to treat my back. I came across new spine surgery procedure using endoscope, least invasive to date I read, called Endoscopic Lumbar Disectomy (ELD). Since ELD was done with very small incision (less than 2 cm) and on an out-patient basis (in west), I opted for ELD in another Bangkok hospital.  I asked the surgeon there regarding appropriateness of ELD vis-à-vis LL.  He told me they did not do LL anymore because ELD was least invasive, patients got back to  normal situation after about three months and more or less had no possibility of back destabilization. Why was LL appropriate on me earlier? Good question!

After my ELD I was back in Thimphu. Unfortunately, Thimphu weather deteriorated - snows at hilltops and severe cold wind sweeping through all afternoons. This adversely affected my fresh surgery. I had nerve inflammation. I wrote back to the surgeon for anti-inflammatory drugs. The Thai surgeon could not have given me cold weather post-surgery advice when he had only experienced tropical climate. The environment in Bhutan is different from the one  in Thailand. Then there were other issues: different drug brand names, lack of post-surgery physical examination and others with regard to difficulty in giving post-treatment care/advice.  I am fortunately now on my regular golfing days.

While I point out my real life experience for the readers to understand briefly pros and cons of overseas medical treatment along with impact of privatization on medical services, I see the other extreme that the loose free-medical-care-for-all policy on standstill from its sectoral inception flawed with never-ending issues relating to purchase and shortage drugs; counterfeit drugs; dilapidated hospitals/basic health units; shortage of doctors; non-operational medical equipment and you name it.  For balanced and sustainable development;  social, political and economic progress have to move ahead hand-in-hand. The economic reform makes no sense if a sector is on standstill. Isn’t it time to reform health care accounting the cost of mismanagement and overseas treatment (Nu 50-60 lakhs for couple of weeks in Bangkok hospital seems normal),  and allowing careful private sector participation including for health insurance for effective health coverage? I think it is, keeping in mind also that a pure free market model simply cannot work in providing health care!

What Retirement?

The retirement age of ADB (Asian Development Bank) is 60. I did not give much attention to it during induction briefing. As I approached 60, I asked myself, what retirement? Unproductive after 60? Whatever, I do not like the word! Isn’t the impression of a retiree generally physically fragile, mentally corroded and at times fairly inactive soul? If light-skinned with supposedly plenty of cash to spare, a person hanging around and taking pleasure of slack-life in southeast Asia. So I refuse to use the word, retirement – too laidback a word when my desire for getting better and base of curiosity are crisp.

 A year before approaching the magic number 60, I some what excitedly looked forward to life after ADB as a relocated and settled person: with full time at my disposal, playing golf, reading books, meeting relatives and friends and traveling around and taking life easy. As I approached more closer to 60, I read articles about people going under depression because of not being able to adjust their life styles. Nearer, I started to look back. The reflections were mainly of having to leave nicely adjusted work style, ethics and environment, and cross over to new mode. On the very next day of my 60th birthday, I wondered why I did not go to work while I was still on top-form in every sense of the word. I wrote my parting email to my ADB colleagues in Beijing:

“In pursuit of ….Happiness in the land of Gross National Happiness, the overarching philosophy guiding the Bhutan's development policy, based on four pillars: (i )sustainable economic development; (ii) preservation and promotion of culture and tradition; (ii) conservation of environment; and (iv) good governance. Development planners may argue if the high priority for culture and tradition, and conservation (preservation + protection) of environment will counter-balance in reality the high material aspiration of human being.

But still, for me a place worth spending my life after more than 19 years of ADB service.

The field of development excites me. I could not have asked for more than spending my last five years in China, where the real actions and huge events including Olympics, 60th Anniversary, and Shanghai Expo took place.

To you, I would like to express my deep appreciation for the many shared moments of friendship, learning and good work, and say what a pleasure it has been knowing and working with you!

And, thank you for your good words and birthday cakes and wishes.

Sangpa

PS: Try not to become a man of success, but rather try to become a man of value - Albert Einstein”

           For about a year, relocation and settlement, golf, relatives and friends, books, internet, travel around Bhutan and "take-it-easy" filled my days. By some definition, a man of success? Well, to an extent, many here would say yes! Did I try too hard for it sacrificing my man-of-value virtues? I say no but do not know what the others' say. To me a person of value means you are of value to your own existence first, and then to the existence of others. How do you get to that? One way is through inspiration.

“ We have a strong, committed parliament today, but my worry is in the future, whether our best and brightest people will come forward in order to serve the nation through politics.” His Majesty Jigme Khesar Namgyel Wangchuk, 17 Dec 2011.

This is a strong message from the King to the Bhutanese youth. But the youth of today need to be influenced, that takes effort and years for setting some kind of trend. For them trend is their friend. So, is politics the proper arena for initiating such a influence-thread (which I am not at all sure) and pursuing my values? I mean, my individual values, the way I look at it. I studied civil engineering instead of political science, have no experience in, and am not trying to make a career out of politics. And, I am no good at talking something without meaning it. But I am looking for platform, a political platform, to make some contribution for the good of the people and country - serve the nation in the words of His Majesty. Will it make me a politician? It does not bother me either way. Because it will not affect my values, certainly not in five years, as long as I am within the periphery of my own man-of-value virtues.

The value contribution is not about solving all the problems, not even finding answers to critical ones. If found, well and good. The contribution can come in a smallest form to make a difference down the road. It may be in terms of avoiding small mistakes or influencing correct decision making: good ideas do not die, and have no date for expiration. But good ideas need deep space and mature environment to blossom. My main concern!

Debt-to-GDP

Debt-to-GDP measures the financial leverage of an economy. “The debt can make a country effectively bankrupt. The total debt outstanding at the end of fiscal year ending in June 2011 was estimated at Nu 58.7 billion equivalent representing 80.9% (increase from 66.6% in 2009-10) of GDP of which 47% was rupee debt and 37.9% was foreign debt for convertible currency”…. my concern on country’s debt situation in my blog of 8 April 2012 . The external debt in FY2010-11 was Nu 58.7 billion while its nominal GDP  (total value of goods and services produced at market prices minus imports) recorded  Nu 72.0 billion.

Now it is reported that country’s external debt as of June 2012 has reached  Nu 76.0 billion, an increase of  Nu 17.4 billion (about 30%) from FY2010-11 while GDP for FY 2011-12 is yet to be released.  With such external debt increase, it would not be a surprise to see the debt to nominal GDP ratio going beyond 100% in future.

The nominal GDP for FY 2011-12 would have also increased, taking into account both prices and production increases over the year. If the production of goods and services did not increase during the year, then the entire growth is attributed to an increase in prices alone. So the growth does not reflect any real increase in the production of goods and services.

Of the total rupee debt of Nu 45.0 billion (59% of the total debt), hydropower debt amounts to Nu 32 billion (71% of total rupee debt), and  the short-term liability stands at Nu 13.0 billion (29% of rupee debt)

The short-term liability comprises GOI line of credit: Rs 6 billion; State Bank of India and Punjab National Bank Borrowings: Rs 5.1 billion; and Dungsam Cement debt: Rs 1.8 billion (increased from Rs 1.5 billion in June 2010). 

The convertible currency debt also increased to Nu 30.9 billion (41% of the total debt) from Nu 24.5 billion.

We may take comfort from the fact that the hydropower debt of Nu 32.0 billion (42% of of Nu 76.0 billion) is “self liquidating" with supposedly firm long-term sales contract, and most of the convertible currency debt of Nu 30.9 billion is concessional with easy amortization schedule spread over longer period.

A large portion of the increase in debt is attributed to hydropower loans. The debt increase is likely to continue exponentially for years ahead to complete both ongoing and new hydropower projects (see table below) and to meet other obligations.

Hydropower Projects
Sl.No.	Projects	Capacity MW	Start	Completion	Mode	Work Status
A.  Completed Projects
1.	Chukha Hydropower Plant	336	1979	1988	Bilateral	Completed            (GOI loan liquidated)
2.	Kurichu Hydropower Plant	60	1994	2002	Bilateral	Completed
3.	Tala Hydropower Plant	1,020	1997	2007	Bilateral	Completed
4.	Basochu Hydropower Plant	64	2002	2008	Bilateral (Austria)	Completed
Total		1,480
B.  New Projects
1.	Punatsangchhu-I	1,200	2009	2015	Bilateral	Advance Stage
2.	Mangdechhu	720	2010	2017	Bilateral	Initial Stage
3.	Punatsangchhu-II	990	2010	2019	Bilateral	Initial Stage
4.	Sankosh Reservoir	4,060	2011	2020	Bilateral	Yet to Start
5.	Kuri-Gongri	1,800	2012	2020	Bilateral	Yet to Start
6.	Amochhu Reservoir	620	2012	2018	Bilateral	Yet to Start
7.	Kholongchhu	650	2012	2018	Joint Venture	Yet to Start
8.	Chamkharchhu-I	670	2012	2018	Joint Venture	Yet to Start
9.	Wangchhu	600	2012	2018	Joint Venture	Yet to Start
10.	Bunakha Reservoir	180	2012	2018	Joint Venture	Yet to Start
11.	Nikachhu	208	2012	2017	Druk Green	Yet to Start
12.	Khomachhu	327	2014	2017	Druk Green	Yet to Start
13.	Rotpashong	918	2012	2019	Druk Green	Yet to Start
14.	Gamri	102	2013	2017	Druk Green	Yet to Start
15.	Dagachhu	114	2009	2013	Druk Green	Advance Stage
Total		13,159			Druk Green
Source: Druk Green Power Corporation Limited

Of the 14 new projects (leaving Dagachu aside), 10 projects were identified for the development of 10,000 MW by 2020 under Government of India - Royal Government of Bhutan Framework Agreement. Of which six projects were selected for  bi-lateral funding and remaining four (Kholongchhu, Chamkharchhu-I, Wangchhu Reservoir and Bunakha Reservoir), under joint venture funding by government corporations of Bhutan and India. The remaining four (Nikachhu, Khomachu, Rotpashong and Gamri) are to be developed by Druk Green Corporation out of its own resources.

The Druk Green has estimated that the total investment required for developing 14 projects (excluding Dagachu) as around Nu 190.0 billion.

The World Bank and IMF are of the view that  “a country can be said to achieve external debt sustainability if it can meet its current and future external debt service obligations in full, without recourse to debt rescheduling or the accumulation of arrears and without compromising growth.”  High external debt obviously is believed to have harmful effects on an economy.

Some economists believe that economic growth begins to suffer when a country's debt-to-GDP ratio exceeds 90%.

Also, there is a difference between external debt nominated in domestic currency, and external debt nominated in foreign currency. A nation can service external debt nominated in domestic currency by tax revenues, but all of the money used to service foreign currency debt has to come from a country's balance of payment transfers.

At this point can we afford financial recklessness? Absolutely not !  “The credit works on an economy like steroids on the body of an athlete: you need ever larger injections to maintain the effect”  says Edward Chancellor, global strategist, GMO (investment management firm).