ADK waste found on street

Waste from the ADK private hospital in Malé such as syringes, gloves, and blood samples has been found on nearby streets, reports newspaper Haveeru.

Residents of the neighbourhood informed the local daily that seeing waste lying on the street was a daily occurrence.

The items are often left behind when waste is taken away twice daily on a pickup, the residents explained.

“Test tubes are crushed underneath motorbikes and blood is seen, spilled on the street. They take away the waste in ordinary disposal bags. The place reeks of foul stench when they do,” a resident was quoted as saying.

ADK Managing Director Ahmed Afaal told the newspaper that while hazardous waste was disposed in Thilafushi under strict supervision, other materials not considered hazardous were taken out with regular trash.

He conceded the possibility of such waste having spilled out on the street.

“People involved in waste disposal in Malé are not professionals. Therefore items used in the hospital, though nonhazardous, could have spilled out on to the street. As there are no professionals providing waste disposal services, we are unable to dispose of the waste in the most efficient manner,” he was quoted as saying.

He added that the hospital – the largest private hospital in the Maldives – had not received any complaints regarding waste on the street.

“We try to do this properly, without any harm coming to locals. We will look into how that took place,” he said.

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ADK says co-payment will be available from next week

ADK hospital has announced that it will take co-payment from next week after the government decided to charge a co-payment from the national health insurance scheme, Aasandha, from private hospitals and clinics.

The company had previously stated that such services would be available from August 1.

The hospital’s Managing Director, Ahmed Afaal, told Haveeru today that, whilst negotiations with the government regarding collection of the payment were ongoing, the price of services at the hospital would not change.

The Aasandha company has said that that agreements for co-payment has been reached with eight other clinics although it has yet to release a price list, reported Haveeru. Over 60 private healthcare providers have applied for Aasandha coverage.

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Six-year old girl dies of dengue shock syndrome

A six year-old girl died at Male’s ADK hospital on Tuesday shortly after being admitted with dengue fever complicated by respiratory difficulties.

Referred to as ‘Dengue Shock Syndrome’, ‘Dengue Haemorhaggic Fever’, or ‘severe dengue’, this type of complication greatly increases the risk of death in cases as blood pressure drops to dangerous levels.

“The girl was brought in at 4:00pm, gasping, blue, in a critical condition and was taken to the intensive care unit where she died,” said the hospital’s Managing Director, Ahmed Afaal.

Afaal was not yet able to confirm the girl’s home island, but confirmed that there would be a thorough investigation into the case as it involved dengue.

Her death is the first dengue-related death to have been recorded this year. A record 12 deaths last year were mostly children suffering from similar complications. Instances of the disease have been rising steadily both within the Maldives and globally.

Health Minister Dr Ahmed Jamsheed he was unable to comment on the issue, as he said he was engaged in SAARC meetings. He did, however, say that a communicable diseases paper would be discussed at the meeting.

The Centre for Community Health and Disease Control (CCHDC) issued its first warning of the year on March 20, blaming the large amount of construction work in the capital and pools of stagnant water, which serve as breeding grounds for dengue-carrying mosquitoes.

According to the World Health Organisation (WHO) the specific type of insect that carries dengue, the Aedes Aegypti Mosquito, is unusual in that it bites during the daytime. Once infected, humans are the most prominent carriers of the dengue illness, passing the strain on to other mosquitoes when bitten.

The organisation estimates that between 50 and 100 million people a year are infected, with 40 percent of the world’s population at risk. It advises that dengue should be suspected whenever a high fever is accompanied by any of the two following symptoms: severe headaches, pain behind the eyes, muscle and joint pains, nausea, vomiting, swollen glands, a rash.

It can be difficult to distinguish from the milder Chikungunya disease that can last for up to five days. Even healthy adults can be left immobile by dengue for several weeks while the disease runs its course.

Prevention rather than cure

The government has attempted to raise awareness of the disease in order to prevent the spread of what remains an illness without a specific cure.

After last summer’s outbreak was labelled an epidemic by the government, the Maldives National Defence Force (MNDF) was drafted in to assist with spraying breeding sites, although it did encounter difficulties in accessing some sites.

Such instances led to calls from the now Health Minister Ahmed Jamsheed, head of the CCHDC at the time, for the introduction of a Health Protection Bill that would provide “sufficient resources to ongoing efforts on community education, awareness and health promotion, access to premises with mosquito breeding and legal action against those who do not comply with the law or regulations.”

At the time of last month’s warning Public Health Programme Coordinator for the CCHDC, Dr Fathmath Nazla Rafeeq shared her concerns over the lack of public attention to the Centre’s alerts.

“Since December [2010] we had warned about the increase in dengue cases. But most of the people don’t even remember. They assume that mosquitoes should be controlled if there is a dengue outbreak and everything will be okay when authorities spray fog,” Nazla observed. “Therefore, on most islands, its [mosquito control] is highly neglected. Once dengue starts to spread, people panic”.

She also added that another epidemic would be inevitable if the authorities did not consistently eradicate breeding areas.

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Protesters not covered under health insurance schemes: participation “high risk and voluntary”

State television journalist Moosa Naushad has had a successful operation in Colombo for injuries sustained during a protest on Male’ last week, and will return to the Maldives in a few days’ time, according to Maldives National Broadcasting Corporation (MNBC) Director Adam Shareef.

Naushad was attacked outside of MNBC by 15 people while covering an  opposition-led protest on January 23. The aggressors broke his hand and left him with fractures to his shoulder blades and feet, while MNBC editor Thoyyib Shaheem was tasered after trying to intervene. Both sides of the political spectrum blamed the other for the attack, with the opposition alleging that MDP activists mistook Naushad for a VTV reporter.

Since the nightly  protests began on Male’ over two weeks ago a number of journalists, activists and police officers have sought medical attention for related injuries. Although security personnel are covered by their employer, others have discovered that injuries sustained during a protest are excluded from coverage by most available insurance programs, including the government’s recently introduced Aasandha scheme for every Maldivian citizen.

“As far as I know, no insurance scheme in the Maldives would cover somebody injured during a protest,” said Allied Insurance and Aasandha Program Manager Ahmed Shabiq, pointing out that protests are considered high-risk and voluntary.

To fill the coverage gap, Naushad’s injuries have been treated with “a gift from the government, and some contributions from MNBC,” MNBC’s Shareef said. He added that the station tries to cover injuries other journalists have sustained while working, but said that there is no company insurance program.

Some hospital patients have been surprised to discover the caveat, and several have filed queries and complaints with Aasandha. Shabiq pointed out that “that policy is clearly listed in our exclusions section, printed in pamphlets and on the website. But I think people just aren’t aware of those details.”

However, “it’s not so easy to identify if someone was involved in a protest, and if they’re responsible for their injury.”

All injured individuals are treated on the assumption that they did not engage in high risk behavior until evidence to the contrary is presented. Shabiq claimed hospitals are asked to determine the individual’s level of involvement in any high-risk behavior, while another Allied official said police reports are used to clarify responsibility.

Private practitioner at Central Medical and Clinic, Dr Ahmed Razee, agrees with the policy: “Insurance should not cover intentional injuries. If you jump off the roof of a house you jump off the roof of a house!” he said.

However Dr Fathimath Nadia at Indira Gandhi Memorial Hospital (IGMH) believes the scheme’s policy leaves room for skepticism.

“I think injuries should be covered, but then again if you go to a protest I guess you have to expect that something could happen. But it’s difficult for a medical staff member to know if a person has been injured because of something they did or not.”

Dr Nadia suggested that the policy could have a preventative impact.

“At a protest you should expect that injuries could happen, so if you’re not going to be covered then maybe you won’t go, or you’ll be very careful,” she supposed.

In a separate case, Dr Nadia pointed out that some of the most important partnerships exist in the no-coverage grey zone.

“Three days ago I saw a 22 year-old boy who had had a diving accident. He needed a decompression chamber so we wanted to send him to Bandos but Bandos isn’t part of Aasandha so he wouldn’t be covered,” she explained, adding that the high cost of decompression chambers – of which only one of the Maldives’ five is not operated by a resort – effectively reserves them for the elite.

“It’s a problem, because we see a lot of dive- and sea- related injuries. The boy is now paralysed from his waist down, but what to do?”

However, Dr Nadia pointed out that Bandos had seen the boy and to her knowledge the family had kindly not been billed.

Health insurance programs around the world have their limits. The Maldivian public appears keen to find out first-hand just where those limits lie.

In a previous article Minivan News reported that hospital traffic had increased dramatically since Maldivians became eligible for up to Rf100,000 (US$6500) in free health care annually.

Public health expert and Chief Operating Officer at Male’s ADK hospital, Dr Ahmed Jamsheed, noted in a January 16 blog post that during the scheme’s first two weeks ADK had seen a 50 percent increase in specialist consultations and a 100 percent increase in demand for basic services.

In addition, 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 wrote, later noting that some patients are seeking multiple and even extraneous appointments.

At IGMH, Dr Nadia has also seen the appointment book fill up. She suggested that repeat appointments stem from a public belief that bi-monthly check-ups are merely proper maintenance – you can’t have too much of a good thing.

However, she noted that the validity of a person’s complaint could be hard to gauge. “It’s difficult to know if a person will receive correct medication from the pharmacy staff, and what they will do with that medication. We can’t follow them to find out,” she said.

In Dr Razee’s opinion, multiple visits to the doctor are important, even if only to put one’s worries to rest.

“Medically speaking, it’s not a waste of time or money,” he said.

“Many people are coming in with complaints that they couldn’t afford to address before. And they are seeing several doctors in succession because they want to get a second, even third, opinion, or they are looking for a doctor they feel comfortable with, or they were unable to tell everything in the short period of time they were first given with the doctor and they want to finish the story,” he said. “It’s normal human nature.”

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Aasandha scheme doesn’t cover private clinics

The treatment from private clinics will not be covered in the universal health insurance scheme “Aasandha” commencing on January 1, 2012.

State Minister Ibrahim Waheed said the “Aasandha” scheme will not include private clinics as the government wants to establish a mechanism that would allow patients to receive all kinds of treatment from a single place, according to Haveeru.

“We haven’t planned to include private clinics in Aasandha in 2012. The government doesn’t want everyone to set up clinics in their houses but rather wants the people to be able to receive treatment from a single place,” he was quoted as saying in Haveeru.

According to Aasandha website, the scheme will initially cover treatment from IGMH, ADK Hospital, IMDC Hospital in Addu and other hospitals and health centers currently operated by state owned health corporations.

Under the parliament-approved scheme, all Maldivian citizens will receive government-sponsored coverage up to Rf100,000 (US$6,500) per year, including further provisions to citizens who require further financial assistance.

Expatriate workers are also eligible for coverage providing their employers pay an upfront fee of Rf1,000 (US$65).

The Aasandha program was officially signed at Artificial Beach on December 22 with hundreds of Maldivian citizens in attendance.

Aasandha is a public-private partnership with Allied Insurance. Under the agreement, Allied will split the scheme’s shared 60-40 with the government. The actual insurance premium will be paid by the government, while claims, billing and public awareness will be handled by the private partner.

The service will cover emergency treatment, including overseas if the treatment is not available locally, inpatient and outpatient services, domestic emergency evacuation, medicine under prescription, and diagnostic and therapeutic services.

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Proposed switch to generic drugs would improve transparency of medical system, say doctors

A proposal currently under review would allow doctors to provide medication directly from health centers, bypassing the prescription process which often leads patients on a wild goose chase around Male’s pharmacies.

State Health Minister Ibrahim Waheed yesterday announced that the proposal is being discussed with health corporations, and that prescriptions could be ruled out by next June at the earliest.

He further suggested that a large pharmacy would be established in every atoll hospital, and would supply products to other health centers across the atolls.

Health Minister Aminath Jameel reportedly did not respond to most questions posed by MPs regarding health corporations at a committee meeting yesterday. Speaking to Minivan News today she said the proposal fell under the ministry’s remit but that she did not have the details and was unable to comment.

Other officials and offices at the Health Ministry had not responded to phone calls at time of press.

Generic drug-based systems which include hospital-centered distribution are commonly practiced in other countries, sources say.

The World Health Organisation supports the use of generic drugs, particularly in developing countries.

In a speech earlier this year, WHO Director General Dr. Margaret Chan said, “Generic products are considerably less expensive than originator products, and competition among generic manufacturers reduces prices even further. Generics serve the logic of the pocket. An affordable price encourages good patient compliance, which improves treatment outcome and also protects against the emergence of drug resistance.”

CEO of Indira Ghandi Memorial Hospital (IGMH) Cathy Waters said the hospital had not been officially informed of the proposal, but noted that pharmacies were generally not well-stocked and that there were multiple available brands.

Medical Director at Male’ Health Service Corporation Dr Robert Primhak said he “would welcome an improvement in pharmaceutical supply and prescribe system.”

According to Primhak, doctors currently prescribe drug brands rather than generic medications. Shifting to a generic drug-based system would mean that a list of nationally-approved drugs would be available for the first time in hospitals, clinics and pharmacies, a “major improvement” that would improve the medical system’s transparency.

However, such a shift would also require “robust quality control” and a centralised import and supply system, Primhak said.

These reforms could take the edge off of the medical import and supply business.

“There’s no business advantage in stocking medications that are not commonly used,” Primhak explained. “For example, a baby who is born with a heart problem needs a specific drug to keep a vessel open. We might get that case three times a year. But instead of stocking these specialised drugs which are only rarely used, the retailers prefer to stock common drugs and brands that will sell, because they know that they can get a turnover.

“The drugs that are imported are the ones they want to sell, not the ones we want to prescribe.”

MPs yesterday voiced concern that the proposed system would incur huge losses for pharmaceutical importers.

Minivan News asked Primhak if medical decisions in the Maldives were driven by business interests and ought to be re-directed towards serving the people. “Yes, to both points,” he said.

Chief Operating Officer at ADK Hospital and former head of the Center for Community Health and Disease Control (CCHDC), Ahmed Jamsheed, believes the proposed change would engender a stronger monitoring system by default.

“The new system would move towards generic drugs which would make it easier to monitor drug quality and standards, and bring down the price,” he said.

It would also improve patient convenience. “Now, a medication prescribed by a doctor in ADK may not be available in the hospital pharmacy, so the patient has to hop around to different pharmacies to get the prescription filled.”

Jamsheed believes the change would benefit the Maldives’ medical system but agrees that the focus should be on people, not corporations.

“Currently, there is a big network of pharmacies, most of which are privately owned. It is known that most pharmacies are poorly monitored, and the authorities are unable to control them. Many prescription-only drugs not meant for over-the-counter sale are actually available to anyone who asks. That carries a huge risk for the patient community.”

Usually, Jamsheed said, a small country like Maldives only needs one or two sources for importing the drugs. But he said the MPs have a point: standardised markets don’t foster high profit margins. “But at the end of the day, the government has to consider whether the system is best for the country and its people,” he observed.

Under the proposed 2012 state budget, Rf2 billion is allocated to the health sector; Rf638 million of that amount is to be used for developing mechanisms providing easy access to health care. Another Rf543 million is designated to developing atoll health centres under Public Private Partnership.

The budget also allots R720 million to the universal health insurance scheme, due to take effect in January 2012, while Rf100 million is to be spent on health corporations’ capital investments, which are made to improve their services.

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Maldives holds regional record as malaria-free zone

The Maldives holds South-East Asia’s record for being malaria-free. Meanwhile, the region is falling behind as one-third of affected countries show signs of eliminating the vector-borne disease over the next ten years.

Dr Robert Newman, director of the Global Malaria Program of World Health Organisation (WHO) said malaria control has improved significantly. “The world has made remarkable progress with malaria control. Better diagnostic testing and surveillance has shown that there are countries eliminating malaria in all endemic regions of the world.”

Malaria affects 40 percent of the world population. While the Maldives had a volatile track record in the 1970s, peaking at 1100 cases in 1976, virtually no cases of local origins have been reported since 1984.

Director General of Health Services Dr. Ibrahim Yasir said the only malaria cases have involved foreigners or Maldivians who have traveled to regions where the disease is endemic.

“A few times a year a foreigner might come who has been infected elsewhere, or in a recent case a Maldivian boat capsized near Africa and those on board contracted malaria and were treated here,” he said.

Yasir noted that the interiors of transport vehicles coming from malaria-infected locations are sprayed with a disinfectant to prevent accidental importing of the bug.

Certain countries that share regular traffic with the Maldives are showing worrisome resistance to malaria elimination.

According to an article published by Times of India today, Roll Back Malaria Partnership (RBM)’s latest report says that high rates in India, Indonesia and Myanmar have kept South East Asia’s malaria report rate stable while other regions see a declining report rate.

RBM’s report compares 5,200,000 probable and confirmed cases of malaria in 2000 in India against 5,000,000 in 2010. A WHO fact sheet, however, notes that 2 million fewer cases of death due to malaria were reported for the same time period.

Sri Lanka and Korea are in the pre-elimination phase.

Malaria elimination – the deliberate prevention of mosquito-borne malaria transmission resulting in zero incidence of infection in a defined geographical area – was first attempted at large scale during the Global Malaria Eradication Program from 1955 to 1972.

WHO certified 20 countries as malaria-free during this time, however in the 30 years that followed efforts to control the disease deteriorated and only four countries were certified.

During the 1970s, the Maldives successfully eliminated the malaria-carrying mosquito. It continues to combat the dengue-carrying mosquito, however, and several outbreaks have claimed 11 lives this year, making 2011 the worst year on record for dengue fatalities.

Among the factors that prevent the elimination of malaria, dengue and other viral diseases is the over-use of antibiotics. At the 64th meeting of the Regional Committee for South-East Asia in September, members suggested that overuse of antibiotics was making diseases harder to treat.

In 2010, WHO introduced a program combatting the reflexive practice of prescribing anti-malarials to any child with a fever. “Anti-malarial treatment without diagnostic confirmation means poor care for patients. It masks other deadly childhood illnesses, wastes precious medicines, hastens the inevitable emergence of drug-resistant parasites and makes it impossible to know the actual burden of malaria.”

In a previous interview with Minivan News, ADK Chief Operating Officer Ahmed Jamsheed called antibiotics “the most misused drug in the Maldives,” and warned that the trend could put Maldivians more at risk for dengue fever and chikungunya, as well as viral diseases.

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Antibiotics “most misused drug in the Maldives”: ADK COO

Over-prescription and sale of over-the-counter antibiotics is leading to a rise of resistant super-bugs, the World Health Organisation (WHO) has warned, with the Maldives no exception.

“Antibiotics are the most misused drugs in the country,” ADK Chief Operating Officer Ahmed Jamsheed told Minivan News today. “People are becoming resistant, and in certain cases they might not even need the antiobiotics.”

The WHO is discussing the overuse of antibiotics and growth of superbugs at the 64th meeting of the Regional Committee for South-East Asia, in Jaipur this week.

Director General Dr Margaret Chan said, “we have taken antibiotics and other antimicrobials for granted. And we have failed to handle these precious, yet fragile medicines with appropriate care. The message is clear. The world is on the brink of losing its miracle cures.”

Jamsheed said he has seen patients with headaches prescribed with powerful antibiotics, such as ciprofloxacin. He says a lack of systematic supervision allows pharmacists, who are not educated in medicine, to give antibiotics to anyone who asks regardless of a prescription.

“We have a very rudimentary diagnostic capacity in the Maldives,” said Jamsheed. “Hospitals and physicians are not properly monitored, and patients have a lot of independence to choose the drug they want. There are few national guidelines.”

According to Jamsheed, hospital diagnoses are compromised by inadequate facilities. He said that as organisms  mutate, doctors are not able to keep up. Bacteria samples are usually outsourced, and communication can take weeks. “In some cases, we may not be able to recognise and diagnose a disease until we’ve already lost a few patients,” he said.

Superbugs, or super bacterium, are bacteria that carry several resistant genes and are difficult to treat. When a disease is inappropriately or excessively treated with antibiotics, the body develops an immunity which encourages the bacteria to grow stronger.

Dr Chan said many non-communicable diseases, such as heart disease and cancers, are triggered by “population ageing, rapid unplanned urbanization, and the globalisation of unhealthy lifestyles.”

Chan also noted that “irrational and inappropriate use of antimicrobials is by far the biggest driver of drug resistance.” As communities become more drug resistant, treatments could become more complicated and costly.

ADK Managing Director Ahmed Affal said education was important. “There is an increasing number of antibiotics being prescribed in the Maldives, and we need to talk more. Research shows that there will be problems, as organisms become more resistant.”

Affal said that the majority of cases at ADK are fevers and infections, although heart disease, hypertension, and renal infections are on the rise. “Antibiotics are commonly used for lung infections, and sometimes are given as a preventative measure,” he said.

Speakers at the WHO conference suggested that climate change could accelerate the growth of superbugs. Jamsheed told Minivan News that Maldivians could be more at risk for dengue fever and chikungunya, as well as viral diseases. He predicted that if these diseases were to become more common, the misuse of antibiotics would increase as well and people would become more drug resistant.

“The Maldives is not isolated,” Jamsheed said. “We import almost everything, and any bacteria that is growing elsewhere in the region and the world will certainly be transmitted here.”

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Hospital blunders highlight health system failures

When Fathimath Sudhuna checked into ADK hospital last Friday feeling faint and dizzy, she did not expect it would cause her condition to worsen.

She was asked by a doctor to complete two medical tests: a sugar test and a cholesterol test. Her husband, Ibrahim Shaukath, took her to the hospital pathology for the tests and was asked to wait outside.

“It took a long time for her to come out – I had to ask the nurse why it was taking so long,” Shaukath said.

When she came out he asked her why it had taken so long: she replied that a nurse had given her the wrong injection.

“It was an injection that was supposed to be given to a 15 year old patient,” he said.

Fathimath’s condition deteriorated and she became unable to stand. Shaukath complained that the hospital’s management “did not take it seriously and tried to ignore it, saying it would be ‘all right’.”

”I am not saying this to harm the hospital,” he said. ”I just want to prevent it  from happening to another person.”

Managing Director of ADK Hospital Ahmed Afaal said the incident had been reported and the hospital was investigating. He said he had no information about the patient’s condition worsening after the incident, and was reluctant to speak to the media.

IGMH blunder

A person assisting with a birth at Indira Gandhi Memorial Hospital (IGMH) last week told Minivan News on condition of anonymity that surgeons had sewn one of the mother’s veins into her skin after an emergency cesarean to remove the baby.

”[The mother] told the doctors that she felt pain in the sewed area,” the assistant said, ”but the doctors did not care to look, they just said it would be all right.”

Three days later, when the woman removed the dressings on the wound, she discovered a red lump underneath.

”She ran to the hospital counter and yelled at them,” the assistant said. ”They started treating her and she was told the doctors had sewn a vein into her skin and blood was stuck in there.”

Another woman who also asked to remain anonymous told Minivan News that a doctor at IGMH had told her husband that he was a heart patient with a high risk of heart attack, and had treated him as such for two months.

Eventually the family sent him to India for medical treatment, where they found out “he did not have any problem with his heart.”

Yet another woman, who identified herself as Zainab, told Minivan News that her son, who was very weak after an attempted suicide and a motorbike accident, was sent home after a single IV.

”We begged them to keep him until he felt better,” she said, ”but they said he would be all right and told us to leave.”

She claimed that her son could not even walk when he was discharged.

Chief Executive Officer of IGMH Zubair Mohamed confirmed such cases had recently been reported to the hospital management.

”We encourage all our patients to complain at the Health Ministry when they face such problems,” Zubair said.

Zubair said everyday 99 per-cent of the patients left with no complaints.

”Doctors and nurses sometimes makes mistakes,” he said.

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