The termination of an agreement between the Ministry of Health and Family with Indian company Apollo Hospitals Enterprises to manage and develop the Indira Gandhi Memorial Hospital (IGMH) cost the government US$150,000, the Ministry of Finance and Treasury’s audit report for 2010 has revealed.
The audit report (Dhivehi) made public on Thursday (June 6) flagged an advance payment of US$ 150,000 from the finance ministry’s special budget to Apollo Hospitals as 20 percent of a transition management fee under the “management and development agreement” (MDA) signed on January 23, 2010.
Auditor General Niyaz Ibrahim contended that the payment was made by the finance ministry in violation of budgetary rules and accounting principles, adding that expenses of another office or institution should not be included in the finance ministry’s financial statement.
Moreover, the privatisation of the government hospital was not overseen by the privatisation committee as stipulated in public finance regulations amended in late 2009, the audit report noted.
The secretariat of the privatisation committee, which functioned under the Ministry of Economic Development, informed auditors that interested parties were invited to submit detailed proposals for developing IGMH in a public-private partnership deal in January 2009.
However, none of the detailed bids met the criteria set by the health ministry and the privatisation project was scrapped.
Following a visit by then-President Mohamed Nasheed to India, Health Minister Dr Aminath Jameel told the press on January 25, 2010 that Apollo was awarded the project because none of the bidders fit the criteria.
Apollo was chosen following consultation with the Indian government and based on legal advice, she added.
However, in August 2010, the Male’ Health Services Corporation – which operated IGMH – advised the health ministry against proceeding with the privatisation deal as Apollo’s proposal was not financially feasible for the government-owned health corporation.
On September 30, 2010, the health ministry informed Apollo that the government has decided to scrap the project since the necessary financial capital had not been arranged.
The audit report also noted that a transition management agreement and an operation management agreement that was required under the MDA was not signed in the stipulated 180-day period.
“Therefore, the US$ 150,000 paid to Apollo Hospitals under the MoU [Memorandum of Understanding] signed with IGMH in 2010 was a waste of funds with no benefit to the state,” the audit report stated.
It added that the loss was incurred as a result of “inadequate planning” before hastily signing the MoU without obtaining legal advice, considering the financial burden on the state and determining a source of capital.
The Auditor General recommended asking the Anti-Corruption Commission (ACC) to determine whether any state official abused their authority in awarding the project to Apollo Hospitals without a bidding process.
Among eight other cases highlighted in the report where expenses were made ostensibly in violation of public finance law, the audit revealed that in 2007 the government incurred a loss of MVR 30.8 million (US$1.9 million) after paying for 150,000 copies of the Quran Dhivehi translation with numerous errors.
The audit report noted that the project was awarded to Novelty Printers without a bidding process through the tender evaluation board.
Moreover, an advance payment of 85 percent of the contracted amount was made to Novelty Printers in violation of existing regulations, the audit discovered.
In June 2010, the Fiqh Academy decided to destroy the copies printed in 2007 as the errors could not be easily corrected. The decision was made following a year-long review by scholars of the academy.
The audit discovered that the errors in the final version were not present in the proofed copy approved by the President’s Office in 2007 – during the final years of former President Maumoon Abdul Gayoom’s reign – suggesting that Novelty was responsible for the errors.
Novelty Printers wrote to the President’s Office in November 2008 apologising for the printing errors, which they explained occurred due to a problem in the computer file used to make the printing plates.
The audit also discovered that Novelty was paid the remaining 15 percent of the contracted amount in May 2010 after a state minister at the finance ministry approved the payment.
The state minister sent a memo to the budget section falsely claiming that the government had received all 150,000 copies, the audit report noted.
The Auditor General recommended that the ACC should investigate the culpable official for alleged corruption and that the state should either recover the MVR 30 million paid to Novelty or demand 150,000 copies without errors.
The audit report also noted that the government was ordered by the Civil Court in January 2010 to pay US$119,616 as compensation for a former deputy general manager of the Maldives National Shipping Line (MNSL) for unlawful termination in 2002.
The Auditor General recommended legal action against the government officials responsible for incurring the financial loss by unlawfully sacking the MNSL deputy manager in 2002.
The audit further revealed that in 2009 and 2010 the finance ministry paid US$ 4 million to two American companies under a “settlement agreement” while arbitration proceedings were ongoing in Singapore.
In 2006, a consortium formed by the International Medical Group and Sirius International Insurance Corporation was awarded a contract to provide health insurance for government employees.
The companies sought arbitration in Singapore following a contract dispute with the now-defunct Ministry of Higher Education, Employment and Social Security. However, the US$4 million settlement was reached out of arbitration in May 2009 by the new government that took office in November 2008.
The settlement was paid out of the finance ministry’s special budget in 2009 and 2010.
The Auditor General recommended “a thorough investigation” to recover the financial loss incurred by the government as a result of the contract.
The audit report also contended that the finance ministry had not undertaken “adequate efforts” to recover MVR 51.4 million (US$3.3 million) owed to the government as loan repayments as of December 2010.
The loans worth a total of MVR 69.4 million (US$4.5 million) were provided to select individuals by the President’s Office from 1992 to 2006 under special privileges afforded to then-President Gayoom.
The loans were given with a six percent interest rate to be paid back within two to five years, the report found, noting that the repayment period would have lapsed in 2011 for the most recent loans.
However, in a letter sent to the finance ministry on November 6, 2008 – five days before Gayoom left office – the repayment period was extended to five years.
As the loans were given to senior officials of the outgoing government, the audit report contended that the decision to extend the repayment period amounted to corruption.
The Auditor General therefore asked for an investigation by the ACC into the extension and recommended that the finance ministry file court cases to recover the unpaid amounts.
Cathy Waters is the new Chief Executive of Indira Gandhi Memorial Hospital (IGMH), the main hospital in the Maldives. She is one of three foreign medical experts brought out by the UK-based Friends of Maldives NGO and the Maldives High Commission to improve the country’s standard of medical treatment, alongside Medical Director Dr Rob Primhak and Nursing Director Liz Ambler.
JJ Robinson: How did your role at IGMH come about?
Cathy Waters: I’ve been on holiday to the Maldives many times, but it’s been a very different experience living and working here, compared to the sanitised version [of the country] you get at the resorts.
I knew nothing about Friends of Maldives – instead a friend of mine sent me an advert in the Health Services Journal, and said “This is the job for you.” I thought it was interesting, was interviewed in December and found myself out here very quickly, in February.
My background is 28 years working in the UK’s National Health Service (NHS), starting as a clinical nurse and working my way up. For the last 15 years I’ve been working in management, and the last eight as Chief Executive of a primary care trust, which commissions health care services.
I’ve had lot of exposure training and working in hospitals, as well as the broader healthcare system. I left the NHS three years ago and worked in a small management consultancy in the UK, which involved going into companies that were facing problems, and working with them to solve those and bring about change.
My last big contract involved working with big local authority in London than needed a transformational change. In reality it meant making significant savings – we had to make 80 people redundant.
JJR: What was your understanding and knowledge of what the position involved before you arrived?
CW: I understood that IGMH is one of five entities that comes under the umbrella of the Male’ Heath services Corporation (MHSC), IGMH being the largest entity, at about 90 percent.
I knew they needed to make significant changes to patient care, and the overall environment for patients. I knew IGMH needed change, which was part of attraction for me as it was somewhere I could utilise all the skills I had to bring about that change.
I also knew it was a hospital that people care passionately about. There’s a real sense that it belongs to the community and that we should be providing high quality services.
One of the things I noticed early on was that staff morale was very low, and people were unsure about what was happening with the organisation and had all sorts of concerns about the future. One of the things I did when I started was observe what going on and try to be very visible as a chief executive, spending time with the doctors and in the labour ward.
A new executive nurse director Liz Ambler is already here, and a Medical Director Dr Rob Primhak will be joining in July, so together we want to be able to demonstrate importance of management staff and clinical teams working closely together. We need to break down some of those barriers and reduce the divide between management and clinical services.
JJR: You arrived three months ago on the tail end of the collapse of the Apollo deal, a 15 year agreement signed in January 2010 with India’s Apollo Hospital Group to manage IGMH. What actually happened?
CW: I did read about Apollo. My understanding was that they wanted to bring about significant change but they wanted significant resources to do that, and that wasn’t an option. One of the things I’m very clear about is that we need to bring about significant change, but within the existing budget. That might involve reviewing everything we do as an organisation.
Unless we can find resources elsewhere we have to work within the budget we’ve got. That’s quite a challenge, because previously there may not have been the same budgetary controls [there are now]. We have to be careful how we utilise our very precious resources.
JJR: What parallels have there been so far with your earlier experience?
CW: Working in an organisation where there are significant financial challenges, and working in an organisation where patient needs are very clearly evident. The population is very vocal about what they want and need – some of that is about manging expectations.
One of the things I know we need address is that people can’t access doctors as quickly as they want. We need to increase outpatient appointments. At the same time there is no system of triage, or prioritisation of the emergency room, which we are now developing.
JJR: It’s true that many people claim the quickest way to get an appointment is to have the mobile number of a friendly doctor.
CW: We have a Maldivian ER consultant in training who is coming back to develop a triage system and ensure those patients who need to be urgently seen are seen straight away, or that those with minor ailments are seen by someone else, or not as quickly.
From what I understand there isn’t a word in Dhivehi that translates into ‘urgent’. We have quite a lot of work to do to make sure patients get to the right place at the right time.
One thing common to people working in the NHS and IGMH is that staff are passionate about what they do. We have to channel that in a positive way. We need to engage staff in decisions rather than it being a top-down management style.
This means helping them to be part of the decision making process, which can be difficult to get your head around. The key groups are patients and staff – happy patients mean staff are pleased they are doing a good job, equally, happy staff are more likely to perform well.
Sometimes it’s very simple stuff – such as saying ‘Thank you, well done.’ I don’t think that’s happened here very often. It doesn’t take a lot to say thank you.
The work that went into planning for mass causalities for the Friday of the recent protests was great. It was a really great example of working as a team and getting everything ready for an influx of casualties.
I recognised the hard work that had gone in so I made sure I came in on the Friday and was part of what was going on, so staff felt supported, and afterwards I wrote a thank you memo. Simple stuff like that makes people feel valued for what they are doing.
JJR: What have been some of the key cultural challenges?
CW: There is a very, very different work ethic to the UK. Some of the things I’ve found very different and very frustrating are about how people manage their time, and motivating people to work. That’s a huge issue.
Getting people to plan ahead and put processes together is challenging. One exciting project is expanding the intensive care unit – I said we need a proper process and justification of the expansion, a proper plan about how we are going to do this. For me there’s a discipline to this, but it’s not always the way things have been done.
Also different and very distinct to IGMH is the lack of use of email – staff still attempt to use memos. I’m trying to encourage the use of email, and encourage people to think ahead and write agendas for meetings.
JJR: On other side of the cultural question, what has been the reaction among staff to a foreigner coming in as a top-level manager?
CW: Inevitably there’s been a degree of suspicion at someone new coming in, at someone from the UK coming in and imposing their views. For me what has been important is how we work with people and lead. I firmly believe that how you lead is important – working with staff, rather than telling them what to do. You do need boundaries and parameters, but people need a sense of direction, and permission to do things themselves.
The other issue is that my contract is for a year with the possibility of extending to two years. Whatever I do, I will feel I’ve failed if I haven’t managed to find someone in IGMH to transfer leadership skills to, and leave a positive legacy. The worst thing would be for me to do would be to go back to the UK and for things to tumble down. That would be an absolute failure on my part.
JJR: How did these obstacles come across? Were there initial difficulties?
CW: People have been very accommodating and very welcoming. I’ve convinced people that they don’t need to stand up when I walk into the room, which was very traditional, and I don’t expect people to call me “ma’am”. People generally been very welcoming. There’s been a few challenges with language barriers, although this has proved less of a problem than I thought it would be. I have very good support in meetings- I might do an overhead presentation, and it is translated into Dhivehi. Unfortunately I’m failing miserably at learn Dhivehi words. Generally people have been helpful and make sure I’m involved in what’s going on.
JJR: What are some of the unique characteristics of the Maldivian hospital-going public?
CW: They are very demanding, and very quick to blame the doctors if things go wrong. Inevitably in a hospital things go wrong, by the very nature of the work we do. And because IGMH is the country’s main hospital, we inevitably get the more complicated and high-risk cases. People are quick to be cutting.
Equally the general public should demand good care, and rightly get that care.
We need to work to enhance communication. One of the things I’ve noticed that is quite different from UK is that different departments still work in silos. We’re trying to break down these silos and get people to work across the organisation.
JJR: There has previously been conflict and misunderstandings between Maldivian doctors and foreign doctors working at the hospital, amid the cultural challenges of having a high turnover of foreign medical staff. Is this something you have observed?
CW: It fascinating that the hospitial talks about ‘Maldivian doctors’ and ‘foreign doctors’ as though they are completely different. Part of the problem I think for the Maldivian doctors who are very dedicated and are here for the duration is that they don’t get some of the benefits expatriate doctors get, such as support with their accommodation. Inevitably that brings some degree of conflict.
Expat doctors are also here for a short time, and I’m making a huge generalisation, but the commitment of some of them may not be as high as that of the Maldivian doctors. Some of that is the sort of contract we have for expatriate doctors, and that needs to be reviewed. Some of the expatriate doctors see IGMH as a staging post to get broader experience and go off to somewhere else, which must be quite annoying for the Maldivian doctors.
We’re trying to move to a position where as much of the workforce as possible is Maldivian, but inevitably that takes time.
JJR: What about the training of local staff, such as nurses?
CW: We have a good relationship with the Faculty of Health, and more Maldivian nurses are coming back into the system. Liz [Ambler] is very keen on in-service training to make sure we are training effectively, and Dr Rob [Primhak]’s background is in education so I’m sure he’ll be keen to ensure high standards of education and training when he starts in July. It’s an area we’re developing.
JJR: How have you found living in Male’?
CW: We’ve settled in well. My husband is semi-retired; he used to be a director of Mental Health Services. He’s made a decision not to work at the moment – he’s a diver and he’s doing his diver master training and really enjoying it.
One of my worries at the hospital is that we haven’t got the facilities to care for patients at the acute stages of mental health problems, and we haven’t necessarily got the right staff.
JJR: What do you think of the relationship the hospital has with the community, and what did the outcry over the widely reported ‘baby decapitation’ incident tell you about that relationship (the head of a deceased newborn had to be surgically removed during labour after its shoulders became stuck during delivery, endangering the mother).
CW: I had only been here a few weeks when that happened. Without going into the details, what surprised me was how quickly quite confidential details about the patient and the case were spreading like wildfire across Male’.
Understandably there was a lot of anger and concern, and fear generated. One of the key learning points for IGMH was how we need to handle that more effectively with the media – we didn’t handle that very well at all. It’s in the hands of lawyers now – it was a tragic and very unfortunate case, and a very emotive situation. From the hospital’s perspective we did all the necessary investigations that we needed to do.
JJR: Does it come back to this recurring mistrust of doctors?
CW: That’s one of the things I’ve picked up on – there is this mistrust. We still have to rebuild that, because we have some fantastic doctors and clinical staff in IGMH, and inevitably when we have high profile cases like that it creates more damage for the medical profession, which bore the brunt of that incident. We need to be more proactive about how we talk about some of the great things that happen in the hospital.
I’m not sure Male’ is ready for it, but I’d like to start a patient involvement group – a number of people from the community who work with us to improve what we do in the hospital. We do that a lot in the UK, but I’m not sure people here would be interested in doing that yet. It does help people understand the challenges we face as an organisation on a daily basis.
The President has appointed an envoy to work with the hospital. He has already brought through some significant changes in terms of the environment. It’s looking much better when people come in, and the outpatient area is now air-conditioned.
We need to focus on what we need to do to implement quality of care and improving access – there are hundreds of things need to do, but have to manage expectations.
One of the things we want to introduce is catering – at the moment patients’ relatives have to bring food in for them. That’s so different to the UK – nutrition is so important to a patient’s recovery. We want to try and introduce a catering service before the end of the year, so patients get a better service.
JJR: What are the hospital’s key strengths and weaknesses at the moment, aside from the shortage of mental health support you mentioned earlier?
CW: One area we do need to improve on is diagnostic capacity, and tools for helping diagnose. We are going to get a mammogram machine, which will have the facility to do biopsies, and we are going to get an MRI scanner which will improve diagnostics.
One of the key problems we have is access to equipment and medical consumables. We’ve put new processes and deals in place which will hopefully improve that, but I didn’t realise until I lived here that absolutely everything has to be imported. We are reliant on things coming in a timely way, and I don’t think that just affects us.
We also have a hospital kindly donated by the Indian government, but inevitably the building itself is in need of renovation. It was fit for purpose then but with the influx of people living in Male’ the need for services is huge. We have 500-600 patients a day, sometimes more, and the building is almost too small now. We have to look at how we take care of it and develop a more modern facility.
One of our big concerns in relation to the operating theatre is lack of anaesthetists. We have to pay a premium for them to come, as there’s international shortage. That’s a real problem for delivering key services.
Those are some of the key areas. We have a good team paediatricians, and a very busy but effective neonatal intensive care unit with 20 cots.
JJR: Is it difficult to attract people to come and live and work in the Maldives?
CW: I think it’s becoming more difficult now because of the dollar situation, and the cost of accommodation in Male’. The MHSC provides accommodation to doctors as part of their package, but nevertheless food prices and living expenses are going up.
A big problem is paying people in rufiya – the expats who come and work in the Maldives want to send part of their salary home but banks are struggling to enable them to send dollars. That seems to be a very major problem at the moment.
The big thing is making sure there is the right commitment from expatriates to stay and make a positive difference. There’s got to be some way of making the working conditions right for the Maldivian doctors as well. They are the life of the organisation, and we are dependent on making sure they don’t move elsewhere.
We are in the process of expanding inpatient facilities, and renovating the old staff quarters into more private facilities. We will have 56 beds finished in late summer, and we have also signed an agreement with the 11 storey building next to IGMH to provide 72 beds. This time next year we will have a significant increase in the number of beds, but that brings its own problems, such as where we are going to get staff. We’re trying to make sure there is joined-up thinking going on.
The agreement between India’s Apollo Group and the Maldives government to manage Indira Gandhi Memorial Hospital (IGMH) has stalled, after the private healthcare giant failed to submit a required operational management agreement by the July deadline.
“We were supposed to receive a plan by the end of July,” said State Health Minister Dr Abdul Bari. “They required additional information which we have provided.”
The operations management agreement was to be submitted following a situational analysis of the hospital.
That agreement said that both parties were required to cement the deal and sign the 12 year management agreement by the end of July.
Dr Bari said the government had requested an update from Apollo, but insisted the hospital’s future was not in limbo.
Managing Director of IGMH Mohamed Zubair said the hospital was not preparing for a management change, but noted that the deal “has neither failed nor succeeded. It is yet to be decided.”
“Apollo is an expert group and would bring a lot of benefits to the people,” he said. “They have the capacity to raise the existing standards. But even if they do not come we will continue trying to improve services.”
However the delay was making “little investments” more difficult, he said.
Apollo has previously estimated that it will need to spend US$25 million to bring the hospital up to global standards.
Chairman of the privatisation committee Mahmood Razee said following announcement of the agreement in January that one of the first changes to be made by Apollo would be to management.
“The major issue was that the management structure [at IGMH] was not working properly, this led to high costs and some services and medicines not being available. The overall quality of service went down,” he said.
Apollo also signalled its intentions to make 80 percent of hospital employees Maldivian over a 15 year period, although it was unclear as to how this would be achieved given the lack of medical higher education facilities in the country.
In April, a series of alleged blunders at the hospital – including wrong injections being given, a woman who claimed to have had a vein sewn into her skin and parents of a suicidal adolescent who complained their son suffered a motorbike accident and was discharged after being given an IV – highlighted a system under pressure.
Earlier this month the victim of a stabbing told Minivan News that doctors at IGMH had stitched his wound and sent him home, “but I did not feel well. I was having difficulty breathing, but since they said I was fine, I thought I was fine,’’ he said.
“Later, I realised air was spreading inside my body and my back, chest, neck and arms were puffing up. Doctors at ADK said that I had been stabbed in the lungs and that one of my lungs had stopped functioning. They said if I had been any later the air would have reached my brain and they would not have been able to help me.”
IGMH was originally gifted to the Maldives by the government of India.