Fu­ture of Health Care

The health care in­fra­struc­ture may be bet­ter in the Mal­dives than many other coun­tries but there is still a long way to go.

Southasia - - FEATURE THE MALDIVES - By Sam­ina Wahid

This year marks the 50th an­niver­sary of the Mal­dives as a mem­ber of the United Na­tions. To com­mem­o­rate this his­toric oc­ca­sion, the UN in the Mal­dives un­veiled its “UN50 photo ex­hi­bi­tion” cap­tur­ing the de­vel­op­ment jour­ney of the Mal­dives over the past five decades, es­pe­cially health, and how the World Health Or­ga­ni­za­tion (WHO) has been a cru­cial part­ner through the years. The pho­tos and nar­ra­tive ex­hi­bi­tion cap­tured the Mal­di­vian govern­ment’s en­gage­ment with the WHO to pro­mote so­cio-eco­nomic de­vel­op­ment, ad­vance the health agenda, pro­tect the rights of chil­dren and ad­vo­cate gen­der equal­ity and women’s em­pow­er­ment.

Re­cent years have seen a ma­jor

ex­pan­sion of health ser­vice de­liv­ery in the coun­try with more fo­cus on cu­ra­tive health care. The Mal­dives has one of the best doc­tor-to-pop­u­la­tion ra­tios amongst its neigh­bors and other small is­land coun­tries. In 2005, there were 379 doc­tors with a doc­tor-to-pop­u­la­tion ra­tio of 1:775, while in 2010 there were 525 doc­tors with the doc­tor-topop­u­la­tion ra­tio of 1:609, mak­ing the physi­cian den­sity (per 1000 pop­u­la­tion) as much as 1.642.

Back in the 90s, the Mal­dives’ med­i­cal es­tab­lish­ment con­sisted of a cen­tral hos­pi­tal for males, four re­gional hospi­tals and 21 pri­mary health­care cen­ters. The sit­u­a­tion since has changed, given that the life ex­pectancy in the coun­try has gone up to 71 years for men and 72 years for women. The Mal­dives has also worked hard to meet the Mil­len­nium De­vel­op­ment Goals (MDGs) be­cause of which sev­eral im­mu­niza­tion pro­grams have been in­tro­duced there. As a re­sult, the in­fant mor­tal­ity rate has de­creased over the past years. Pre­vi­ously, 70 per cent of in­fant deaths were neona­tal deaths since a large num­ber of births were pre­ma­ture. To­day, how­ever, in­fant mor­tal­ity has con­sid­er­ably de­clined since tremen­dous pri­or­ity is given to ma­ter­nal health. The Min­istry of Health has con­ducted var­i­ous health pro­grammes such as the safe moth­er­hood pro­gramme to con­trol the Ma­ter­nal Mor­tal­ity Ra­tio (MMR).

The big­gest chal­lenge to­day is the pres­ence of Non-Com­mu­ni­ca­ble Dis­eases (NCDs), in terms of the num­ber of lives lost due to ill-health, dis­abil­ity and early death. NCDs re­quire spe­cial­ized and ex­pen­sive ser­vices, in­clud­ing health ex­perts, ma­chines and in­fra­struc­ture. There is a ma­jor dis­par­ity in the qual­ity of ser­vices avail­able to ad­dress NCDs be­tween the cap­i­tal, Malé and the is­lands. Many is­lands have im­pres­sive build­ings but the health re­sources are miss­ing. The qual­ity of ser­vice is largely con­strained by the lack of com­pe­tent doc­tors and nurses avail­able and their will­ing­ness to re­side in the is­lands. Other is­sues in­clude the lack of main­te­nance of in­fra­struc­ture and ma­chin­ery in the health fa­cil­i­ties on the is­lands.

An im­por­tant is­sue is the fair­ness or equal­ity of the coun­try’s health fi­nanc­ing ar­range­ments. The amount peo­ple pay for health care through the var­i­ous sources of fi­nanc­ing, out-of­pocket pay­ments, pri­vate in­sur­ance, so­cial in­sur­ance, and taxes — af­fects the amount of money they spend on things other than health care. The Mal­dives has seen health ex­penses ris­ing through the decades, as the trends in health ex­pen­di­ture for house­holds sug­gest and house­hold ex­pen­di­ture has in­creased at a much faster pace than govern­ment ex­pen­di­ture. As a re­sult, out-of-pocket ex­pen­di­ture for Mal­di­vian house­holds in 2011 reached 49 per cent of the to­tal health ex­pen­di­ture in the coun­try.

The grow­ing cases of NCDs and the age­ing pop­u­la­tion trends pose a ma­jor fi­nan­cial bur­den for the na­tional health ac­count. To ad­dress on­go­ing fi­nan­cial con­straints in the health sec­tor and po­ten­tial pres­sures in the fu­ture, ex­perts rec­om­mend that in­no­va­tive fi­nanc­ing schemes and the use of tech­nol­ogy be ex­plored. In­no­va­tive fi­nanc­ing can be ex­plored through es­tab­lish­ing part­ner­ships with the pri­vate sec­tor. ‘Health tourism’ is al­ready es­tab­lished in South Asia and the Mal­dives has the po­ten­tial to tap its nat­u­ral beauty, pris­tine en­vi­ron­ment and seren­ity to es­tab­lish it­self as a fu­ture desti­na­tion for well­ness and health tourism. This can re­duce the leak­ages in the health sec­tor caused by med­i­cal care sought abroad by the lo­cal peo­ple them­selves. An­other op­tion to ad­dress health fi­nanc­ing is to ex­plore the use of tech­nol­ogy in ser­vice de­liv­ery. One such chan­nel is telemedicine, which can help to ex­tend con­sul­ta­tions and ser­vice pro­vi­sions to re­mote lo­ca­tions. Un­for­tu­nately in the Mal­dives, de­spite heavy in­vest­ments, telemedicine has not been op­er­a­tional­ized.

Many ex­perts be­lieve that the strong foun­da­tions of pri­mary health care, which have been suc­cess­fully es­tab­lished in the Mal­dives over the past three decades, are dis­in­te­grat­ing as pri­mary health care is no longer the fo­cus of the health sec­tor. It is im­por­tant to strengthen and de­velop man­age­ment ca­pac­ity in the health sec­tor with im­proved re­port­ing and ac­count­abil­ity mech­a­nisms. There is a need to de­velop a com­mon vi­sion among health pro­fes­sion­als, pol­icy mak­ers and ser­vice providers on the pri­or­i­ties of the health sec­tor. Fur­ther­more, the health sys­tem needs to take into ac­count the emerg­ing health risks in the pop­u­la­tion. Cli­matere­lated health risks de­mand en­hanced com­mu­nity ac­tion and preven­tion. It is there­fore crit­i­cal that preven­tive health care be con­sid­ered a pri­or­ity and that pub­lic health ser­vices and pro­fes­sion­als be re­ori­ented to ad­dress the emerg­ing health is­sues in the Mal­dives. The writer is a free­lance jour­nal­ist who con­trib­utes reg­u­larly to var­i­ous lead­ing pub­li­ca­tions.

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