The price of healthcare in the south

A team of retired Royal Air Force personnel are trying to raise money to help a small community in the Indian Ocean gain access to the vital healthcare they need to subsist. Inspired by this group’s determination to help this impoverished community in the Maldives – a land oft-associated with luxury – Donna Richardson travelled to the Addu region to uncover the real state of medical care on an island that used to enjoy free, first class medical care while the island was a Cold War staging post.

Because of its geography, it is easy to cover up the poverty-stricken side of the Maldives’s inhabited islands. The Maldives is seen as a luxury holiday resort destination, but in fact there is hardly a place where the contrasts between rich and poor are so pronounced. While millionaires sup their cocktails, the indigenous peoples barely scrape by on a dollar a day and many are priced out of the most basic medical care because of the rising cost of health.

The RAF have long left Addu Atoll (‘RAF Gan‘) in the Maldives where they were stationed during the 1970s, but for some servicemen such as Richard Houlston and Larry Dodds, Addu has remained close to his heart. Upon returning to the island during a memorial visit last March, he saw first hand how locals are suffering and denied access to even the most basic of medical care. He decided to see how he can help a community which he loves dearly. Along with a former colleague Phillip Small, they have been trying to establish a Gan Medical Fund to help to raise awareness of the issues the island faces, provide medical equipment, and eventually if there is enough funding when it takes off, to train the future generation of doctors.

When British Forces left the region, the hospital as well as the expertise and knowledge also vanished (allegedly the equipment all moved to Male), and with the establishment of a dictatorial government regime, Addu stepped ten steps back in terms of their medical facilities.

Based in the south of the country, Hithadhoo Regional Hospital (HRH) is the main public provincial health care facility providing curative public health services and is the only government hospital in the province. The hospital is located in the capital of the south atoll, in the furthest corner of Addu Atoll, and covers seven districts over two atolls. It serves 50,000 patients, including the inhabited islands of Hulhumeedhu and Fuvahmulah, but has only 50 beds.

Lack of funding, limited expertise and treatment for only those who can afford it – this is the picture of government health in Addu, but things are improving, according to the new director of the recently-formed Southern Healthcare Corporation Hussein Rasheed.

“The biggest challenges are most of all the lack of equipment, then patient load, then the quality of doctors, but we are changing things,” Hussein Rasheed said.

Now run under the 100 percent government-shared trust, the hospital also hopes to leverage revenue from the new national health insurance schemes to cover its costs and to help raise vital cash for the departments.

For some years now medical facilities for those living in Addu Atoll and its far-flung neighbour, Fuvahmulah, in Nyaviyani Atoll have been overstretched and in short supply. Many of the problems are hereditary. The aging 26-year-old hospital building is a relic of the Gayoom regime. It is in bad shape, with crumbling walls, unstable voltage, barely enough beds and no air-conditioning. Post operative patients swelter in temperatures akin to a sauna and the hospital is in desperate need of improvement. There are plans to build a new 100-bed hospital with a government loan and charity funding, but it will take a year to secure the funding and then to find a site.

Due to its previous funding constraints, HRH is currently understaffed and runs more like a general surgery practice found in most developed countries. Although it does have practically all the departments required to make it a hospital, most areas are understaffed and in need of vital equipment from donors and charities. As a public hospital it is appealing to charities and non governmental organisations to help it to serve its community and restore public confidence in its services.

At present there is still not enough basic equipment for the hospital to function. It was not even able to provide basic X-rays at the time we visited. Since the last one blew up due to faulty voltage in the building, a new X-ray machine was purchased but has stood in a box because of the risk of damaging the new equipment.

While HRH does have basic outpatient clinics including dental, ear nose and throat (ENT), gynecology, internal medicine, ophthalmology, orthopedics, paediatrics, reproductive health, diagnostics imaging services, and ultrasound scanning and physiotherapy services, there are not enough specialists to staff these departments or the right equipment to provide full services under these remits.

Previously most equipment was donated by NGOs and charities such as World Health Organisation, United Nations Children’s Fund, JICA and the Japanese as well as the Chinese and Australian governments. They have pledged to continue to work with the Ministry of Health and Family to procure equipment.

But the hospital urgently needs a CT scanner, MRI machine and incubators plus vital surgical instruments such a chest stapler and cannulas for performing tracheotomies. Each and every department needs more equipment.

Two rusty ambulances sit grounded on the parking lot. All gifted by various NGOs and nations, these vehicles need parts which are unavailable in the Maldives. One is a Japanese vehicle donated by the Japan Council of International Schools (JCIS) which requires expensive parts, and the other is a converted minibus with the seats relaxed to make room for stretchers.

Two more vehicles sit rusting in the garage. While these are in better shape they need parts and technicians to service them. The only functioning ambulance is an old ‘green goddess’ type vehicle gifted by the Australian government, which is used infrequently.

The Casualty and Accident and Emergency unit has just two beds. A serious road traffic victim was brought here just last week had to be transported to Male’ by Maldivian Air Taxi at his own cost. In cases such as this, if there are no seats, or medical insurance does not cover the patient, they simply cannot receive the vital care they need. It becomes a ‘pay and display’ system of healthcare.

Even the labour suite is ill-equipped for delivering babies. One small baby was fighting for his life in intensive care at the time of visiting. The infant’s parents said they could not afford the transportation to give birth in Male‘. The hospital urgently needs an incubator and does not even have a paediatric ventilator to aid distressed infants.

While the hospital does have an operating theatre with one operating room there are no specialist surgeons to perform vital operations and just two general surgeons.

Collectively this means that the hospital is unable to function to full capacity and the public is losing confidence in the medical care available in the atoll. While there is a surgical theatre, there are only two qualified general surgeons whose knowledge extends only to hernias and small operations.

These conditions and the need for basic equipment are urgent issues and the hospital is appealing for outside help and funding to solve these shortages.

A question of confidence

Another challenge the hospital faces isthe need to restore public confidence in its services. Facing huge waiting lists, patients with serious health conditions opt to travel to Male’ or India for treatment if they can afford it, and the hospital stays stuck in a rut. Yet these ‘health tourists’ face great perils amidst cases of organ trafficking and alleged substandard treatment in southern India.

A young girl from Hithadhoo told us how her family were forced to sell their car and personal possessions to pay for her mother to go to India for a leg operation. Her brother also has eye problems and needs to attend regular eye clinics, which the hospital does not yet have, although there are plans to introduce under the Madhana health scheme.

“My mother suffers from arthritis and rheumatism and needed to go to India for treatment,” she said.

“She was very ill and needed treatment and we have lost faith in the hospital here in Hithadhoo so we decided to go to India where the treatment is better value for money.”

Travelling for medical treatments is a costly business. Patients must pay for the airfare, accommodation and treatment, but people believe that the care they receive overseas is better and so the cycle of health tourism continues.

One of the ways that Hithadhoo Regional Hospital wants to counter this health tourism is to introduce ‘telemedicine’, whereby customers can be confident that their results will be seen by qualified medical specialists from around the world, and also to introduce visiting surgeons and hold specialist surgery days.

Rasheed admitted: “People are not happy with the level of care. Right now we don’t meet the basic requirements so many people decide to go to Male’ for treatment and when they don’t see any difference in services, they go to India.”

He warned of the dangers of travelling abroad to India for treatment. The practice of medical tourism there is not regulated and patients organise the travel plans themselves.

“While there are many good quality doctors in India, there are also huge problems with cheating in India, particularly in the south,” he said. “Someone recently went to India for surgery and ended up having a kidney removed. Health tourism is a very risky business,” he added.

Another patient told how his father in-law has been regularly travelling to India to receive palliative care for lung cancer. Put simply, there is no care of this type available in the Maldives.

Until now talk of cancer has been taboo, although cancer and heart disease are some of the biggest killers in the Maldives. But with no oncology or cardio department, or even an ECG machine, many people are forced to travel farther afield to receive treatment. In the past, limited information has been available about preventative measures so many people die earlier than they should.

There is no palliative care in the islands and only limited care for cancer patients even in Male’, and no facilities to perform open heart surgery or brain surgery.

Rasheed himself is interested in studying more about cancer and its causes to help to inspire health promotion campaigns and attract more doctors to the region.

In its favour, HRH does have an ISO-certified laboratory which is fairly advanced and offers some patient services including intensive care units and neonatal intensive care departments.

The hospital is also working on its health promotion,  including child immunisation and growth monitoring, vector control, food hygiene and sanitation, disease surveillances and epidemic control, family planning, sexual transmitted disease clinic and turboculosis and leprosy control.

The hospitals’ three-year plan includes building a new hospital within a year, improving services in all areas, focusing on preventative health and education and introducing exchange programmes for doctors to visit the hospital and to partner with the private hospital in the region.

Rasheed said he has removed some of the ‘dead wood’ and de-motivated staff from HRH and replaced them with more high-energy staff. He hopes to turn the hospital’s reputation around in three years.

“When I took over the hospital here, we inherited a bad system, de-motivated staff and dated equipment,” he said. “In the past the doctors here were neglecting the needs of the patients. They knew they could do operations, but they were so de-motivated that they decided they could not do it and on many occasions we sent patients away,” he revealed.

These conditions and the need for basic equipment are urgent issues and the hospital is appealing for outside help and funding to solve these shortages.

There is also a need to distribute medicines for psychiatric patients, improving antenatal care and introducing an electronic record keeping system. At present patients with mental health issues are being released into the community without proper care and attention.

In addition, some elderly patients who have been abandoned by their families have taken up residence in the hospital.

However, things are starting to improve at the hospital after a change of management. Over the last three months since taking over the hospital trust, Rasheed has been making major strategic changes. In part this is due to a government reorganisation, which has placed all Maldivian hospitals under a new structure – which will operate more like a business, taking fees and charges from patients covered by the health insurance system.

“In the last couple of months we have managed to improve the level of confidence – for example, allocated a special day for general surgery where we have seen a couple of hernia patients, and we have been getting some good feedback. News spreads through word of mouth here,” he added.

With a limited budget to hire qualified doctors, the hospital is considering hiring visiting practitioners and surgeons. They are also appealing for the humanitarian services of voluntary, retired or semi-retired surgeons and specialist doctors to spend some time at the hospital in exchange for free accommodation, air fare and a share of commission from the profits gained from the operations they perform.

In the last month, the hospital hired a new Maldivian surgeon, a former classmate of Rasheed, who has performed basic operations. Just the other week they performed two hernia operations and feedback from the local community has been quite positive, according to Rasheed.

The two surgeons, Dr Fuammi Moustaffa and Abdulla Adsa, admitted that they were limited to small cases because of lack of equipment. Their remit includes appendicitis, hernia operations, cyst and gall bladder removal.
“We want to do more, but we don’t have the equipment or the specialists to perform other operations,” admitted Dr Moustaffa.

In January, the Israeli Eyes from Zion charity visited the hospital and removed cataracts from patients. There are plans for more visiting practitioners over the next few months.

Due to increasing demand for tertiary services in the provinces, with more funding it is planned to develop a specialised service centre for trauma treatment and the development of their service portfolio, as well as to improve provision of quality health care services.

The areas that they want to focus on include advanced diagnostic services such as MRI, telemedicine and treatment of kidney/renal conditions (including dialysis services) and establishing a provincial Emergency Medical Service (EMS) to international standards.

The hospital needs full time paramedics, fully-fledged ambulances, development of intensive care services and the development of a provincial medical emergency coordination centre.

Meanwhile, there is a private hospital called IDMC (run by the Simdi group) aimed at paying customers and those under the Madhana health scheme, such as civil servants. This hospital, run by Mariyam Shakeela, a former Hithadhoo resident, aims to provide first class medical care, but also requires more doctors to propel it to national standards. The hospital is currently campaigning to become an NGO called the Hawwa Trust to help alleviate some of HRH’s problems.

Eventually, once the basics are in place, Addu wants to develop medical tourism to attract patients to the Maldives. But for now this ambitious plan is limited until they come up to scratch on the other areas which are seriously lacking.

Donna Richardson is a freelance travel writer based in the Maldives.

For more information on Hithadhoo Regional Hospital visit www.shsc.com.mv