The fine print of free health care: public responsibility

The Maldives’ Aasandha scheme realised a dream held by many citizens around the world – free health coverage. But it has also put a spotlight on the Maldivian public’s prodigious appetite for medical care.

“The launching of Aasandha has challenged the two hospitals in Male’, pushing them to their limits with frenzied ‘patients’ (or should I call them customers?) flooding and packing the hospitals,” wrote public health expert and Chief Operating Officer at Male’s ADK hospital, Dr Ahmed Jamsheed, in a January 16 blog post.

Observing that ADK has seen a 50 percent increase in specialist consultations and a 100 percent increase in demand for basic services, Dr Jamsheed describes the hospital as “overwhelmed.”

During the first 14 days of the Aasandha scheme, 41,000 individuals sought health care at ADK – 11 percent of the country’s population – costing the scheme millions and raising serious concerns over its sustainability, Dr Jamsheed observed.”

“In the absence of an ongoing epidemic, statistically and epidemiologically speaking, it is unlikely that so many people would be sick needing health care simultaneously,” he said.

The Aasandha scheme, a public-private partnership with Allied Insurance, was implemented on January 1, 2012. The public rush for national identity cards, a necessary ticket to free medical treatment, foreshadowed the scheme’s popularity.

Speaking today to Minivan News, Dr Jamsheed said limited information on Aasandha’s financial structure has led the public to exaggerate their medical needs.

“A lot of people seem to be of the mindset that they need to spend all of their Rf100,000 (US$6500) yearly allowance. Many don’t understand that if they don’t spend that cautiously they’ll be in trouble when something really does go wrong, especially if they have no way of settling the bill once they go over the limit.”

Pointing to the Maldives Inland Revenue Authority’s (MIRA) publicity of last year’s Goods and Services Tax (GST) initiative, Dr Jamsheed indicated that the integrity of universal coverage depends on an informed public. “A lot of political statements haven’t captured the scheme’s real meaning,” he said.

While Maldivians have a yearly allowance for health services, Jamsheed pointed out that funds for the scheme come from taxes. “If people exceed their allowance, the government could decide it has to raise the allowance. That would mean raising taxes,” he said.

“In a way the previous Madhaana scheme, where patients co-shared the cost, was useful in limiting unnecessary hospital visits and prescription charges,” he added.

Medical professionals have commented on what they describe as the population’s reflexive hypochondria. One doctor reports recently seeing a patient who boasted of visiting four doctors in one day. This author was once advised to seek medical advice for a pimple “because of the pain”.

Aasandha appears to prove the business rule that low prices attract public interest applies even to medical services – many Maldivians talk about being encouraged to go to the hospital simply because treatment is free.

Moreover, with no value placed on a consultation, Dr Jamsheed reports that many appointments are not being kept, an “injustice” which is creating delays. He adds that without a referral system, medical specialists are unnecessarily overwhelmed.

While some doctors may recommend advanced procedures to pad their profits, “what is more evident and frequent is the number of requests, pressure and time demand from patients and their family on doing medically unadvised or unnecessary investigation. Perhaps they don’t realise that this practice drains ‘their’ valuable money or funds in the insurance system, to which they would have to rely to get critical service when ‘needed’!”

A previous article by Minivan News reported that medical equipment and staff training doesn’t support effective diagnoses. In addition, hospitals and physicians are not properly monitored. Although the government has asked the people to treat the privileges of the Aasandha scheme responsibly, systemic reforms remain.

Noting that Maldivians “seem to demand rights rather than take responsibility,” Dr Jamsheed said he believed the desire for medical consultations had historical roots.

“When doctors began going to the islands in the 1980s and ‘90s, their services were promoted as a superior way of dealing with health issues. Then specialist doctors arrived. People saw this gradual improvement and right now the mentality is that for anything they need to see a specialist,” he explained. “It’s something we’ve subconsciously promoted.”

CEO of Indira Gandhi Memorial Hospital (IGMH) Cathy Waters echoed Dr Jamsheed’s observation that the number of ‘no-show’ appointments had increased. She reported that the hospital has seen a slight but steady increase in visits, prompting plans to allow more clinic appointments in February.

“Things have been calm, but steady,” she said. “Even before the Aasandha scheme people were coming to see doctors regularly for small things, often not understanding how those afflictions can be self-limiting,” she added.

Waters agreed that a lack of public education about minor illnesses and home care was an issue. “It’s important that people understand when to go to a doctor,” she said. Waters added that IGMH is considering developing a referral system to control patient access to specialists.

In addition to poor public responsibility and medical awareness, Jamsheed suggests that Aasandha’s broad coverage could also encourage abuse from within the system.

Under the scheme’s fee-for-service payment model, services are separately paid. Favoring quantity over quality, the method is an incentive for physicians to provide more, often unnecessary, treatments. According to Jamsheed, “this cannot be (significantly) avoided unless there is an effective and efficient regulatory system with full cooperation of the hospital management and responsible doctors. We all know that we don’t have this  ‘ideal’ scenario in the Maldives.”

The government’s own track record regarding health care doesn’t engender confidence – last year an Education Ministry taskforce took over the  response to a dengue outbreak from the Health Ministry.

“There is lack of clarity on policy directions and plans,” Jamsheed writes. “The Government keeps on changing policies, which causes difficulty in managing and uncertainty for the future.”

This year the Maldivian government has pledged to build new medical facilities, including hospitals and pharmacies, to provide better medical care within the atolls. While the Health Ministry has said space and staff shortages are an ongoing concern, Jamsheed and Waters agreed that the current rise in patient visits on Male’ should be addressed through education and reform within the medical system, rather than physical expansion.

“The rise in patient visits is slight but steady,” said Jamsheed. “We need to study the trend before making large financial investments.”


12 thoughts on “The fine print of free health care: public responsibility”

  1. So Minivan News will publish anything but news about the protests that have been held by the opposition for the past 10 nights in Male'.

  2. Why yes.

    Minivan News is one of the few news organizations that is openly owned and operated by members of the President's own family.

    I guess our country has a long way to go before even thinking of considering itself democratic in the Western sense of the word.

    Minivan news - the name is just so apt because it's just so deliciously ironic.

  3. This is a typical example of Nasheed's government wanting to fulfill the pledges without due care and diligence. He should know just as well as anyone else that unchecked, unmonitored, unstudies insurance scheme will not work anywhere in the world and in Maldives it will be like throwing a piece of meat into enclosure of a group of hungry lions.

    We need to strengthen the institutions. Build the character of the people (not just educate), Bring social and legal order in the society. Nasheed will fail at everything unless he gets his priority right before attempting the expensive and ambitious projects however sincere his intentions are.

  4. Tsk Tsk, If minivan is so biased why they hell do you not only read it every day but also feel the need to comment on every article, and if Minivan is so biased why the hell do they publish your stupid narrowminded embittered comments? Stop sitting on your brain man!

  5. When i saw minivan news for the first time, i thought it was Mini-Van-News. No joke. I saw the google url first and thought oh why, this is cool, news about mini vans.

    Really no joke.

  6. To Sheikh Imran Abdullah
    Again you have Jewish & Christianity phobia?Its time to visit psychiatric department to continue treatment/

  7. I don't think its professional and right for Dr Jamsheed to criticize the MAldivians way of using the Asandha scheme. Its been just only a month the scheme came into effect and naturally you would expect to see people making use of a service which has just started new for the first time in the country. The doctors shouldn't be in any position to criticize about this scheme. Their job is to see their patients and provide them the necessary care. Monitoring and updating or advicine, what ever you may call, about this scheme to the Maldivians should entirely be the role of the Health Ministry. The doctors and other health staff should not poke thier noses in the sustainability of this project. They will get their salaries whether people seek use of this asandha scheme or not. Yes, there might be people who misuse this scheme, but who will suffer if they misuse, the people themselves. If they run out of their limit of Rf 100,000 its they who will not have the medical service covered by asandha. So Dr Jamsheed, don't try to spill hot oil on something which has just begun and just started. Let the people realise themselves their responsibilities and you are not the right person to complain. If you are tired of seeing more patients becuase of the asandha scheme, just say it to your boss and resign if you don't want to see more patients. You did resign from IGMH for been less paid, so I guess have some moral values not to forward your legs infront of others luck.

  8. @Vagun;

    I comment on Minivan because it is biased. I feel I have a moral duty as a Maldivian citizen to have my voice heard on Minivan which advertizes half-truths, exaggerations and outright distortions regarding the Maldivian people to the outside world.

    Thank you very much.

  9. @Yasir

    The doctors themselves will suffer if the patients misuse their apportioned insurance. Here's how that works. Mr. Ibrahim (a classic Maldivian hypochondriac) who without reaslising that the 100 thousand allowed under Aasandhu is not all to have consultations with the doctor, goes through his insurance within the first six months of the year, if not sooner. Then, without realizing that he has used up his allowance, he will go to see the doctor and find out that he now has to pay for the same services he had till then taken for granted. At which point he will typically get angry at the hospital, the healthcare system, and the government at large for not giving him enough. Unfortunately for Mr. Ibrahim, he will end up having to beg, borrow or even steal the money to pay for his medical bills during the rest of the year. And would likely end up broke should he find himself in a position of actually being sick. An through all of this, it will be the doctor and the hospital staff that will bear the brunt of his illwill, as they would be the only people he meets directly in the healthcare system. So it's right that a doctor should be concerned for his patients' plight. And all plights need not necessarily be medical in nature. And all plights need not be here in the now either. So instead of bashing Dr. Jamsheed, perhaps we ought to commend him for highlighting something that most public officials would rather not.

  10. I think Yasir's argument is rather valid on some points, but if Dr. Jamsheed is in a position to have an opinion, then by all means.

    Let the people realize that it is a huge waste of their time.

    I am someone who wholeheartedly appreciates the Universal Health Care system, because I have absolutely no money to spend on escalating health problems that I have been living with for more than two years.

    It was a moment of triumph for me, that rapidly turned into disillusion, as I have been to the hospital nearly 5 times to be turned down for a specialist consultation. Basically, in the end, if I stick around any longer to get medical attention via Aasandha, it might cost me a lot more than just an arm and a leg, literally.

    You see, it is crucial that Dr. Jamsheed et. al. understand that a lot of those people have not been to the hospitals simply because they cannot afford to battle things like brain tumors and imbalanced endocrine systems on their own, and that they'd jump at the first chance they get to live a little while longer, even if it is in this strife-ridden hell that is marketed as heaven on earth.


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