CEO of Indira Gandhi Memorial Hosptial (IGMH), Cathy Waters, left the Maldives on Friday after more than a year at the helm of the country’s largest hospital. Waters, along with Nursing Director Liz Ambler and Medical Director Rob Primhak were recruited in January 2011 by UK-based NGO Friends of Maldives (FOM) and the Maldives High Commission to improve the quality of local healthcare. Ambler and Primhak have also left. Minivan News spoke to Waters prior to her departure.
Waters provided detailed briefing notes on the state of the hospital to accompany this interview (English)
JJ Robinson: What was the state of the hospital at the time of your departure?
Cathy Waters: There are now systems and processes in place so key decisions can be made. People know how to make those decisions and know where the systems and accountability now lie. Patients may not see that initially as a benefit, but we were making sure the foundation and systems were right.
I’m confident those in now in place. Clinical systems to ensure patient care are now there, and there are things such as a proper patient complaint system.
Equally we have introduced a zero tolerance policy to protect staff. We’ve noticed the number of verbal and violent attacks against staff has gone up. I don’t know why – but certainly over the last few months we’ve seen an increase in violence against staff. Now if you go into IGMH you’ll see posters and leaflets in Dhivehi and English.
JJ: One of your main innovations was the introduction of triage. Was this a hard concept to introduce?
CW: Maldivians tend to panic about things you or I would describe as fairly minor healthcare issues. If you were to cut your finger and it bled, you would probably hold a tissue on it, wrap something around it and deal with it yourself. Here, people panic at the slightest bit of blood.
A really good example of this was when we had some of the casualties coming in from the recent protests. A little bit of blood and people wanted to bypass the triage and go straight into the emergency room, when perhaps all they needed was to put a wad of padding over it and have it stitched up in time. There was no urgency about it, but people panic.
The most challenging part has been persuading people that they don’t need to be in the actual emergency room – that it’s acceptable to wait if it’s not something urgent. That has been so difficult to get across. But it is working, and was brought into place in November 2011. Now it’s been in place for a few months we know there are alternations we need to make it more effective.
JJ: You said earlier that you’ve had politicians ringing you up to bypass triage and go straight to emergency?
CW: Absolutely. I think they see it as their right to get access to treatment and the [in-patient] rooms really quickly, and I think in the past that’s why the triage system has failed, because people back down and say ‘OK, come straight to the emergency room.’
We’ve stuck to our principles and said we have to do this properly, because if we start letting politicians in or whoever just because they think they should be in, the whole purpose falls apart. very clear stick to principles.
JJ: Were you able to train triage staff to the point where they could resist that pressure?
CW: Yes, we had to do quite a lot of work, and there’s still a lot to do. We had instances when there were quite a few people waiting and instead of being triaged, they were just waiting for treatment. Then the doctors said let’s just cancel triage and let people into the emergency room. That defeats the whole purpose.
It’s about explaining to people. The most difficult area was when parents come in with children they believe are very sick, when actually it’s not urgent and they just need to see a doctor. But they panic, and that’s the area with the biggest problems. A lot of it is education and helping people realise that they don’t always need to come to hospital – that there are straightforward, basic things they can do.
JJ: How has the Aasandha scheme (universal healthcare) impacted IGMH?
CW: Now Ashanda has been opened to ADK and private health clinics, it’s created major problems for IGMH, because we still have loads of patients coming to IGMH, but we also know that those patients are also going to ADK and private clinics. The dilemma for us is that a lot of the private clinics are run by doctors who work in IGMH. That a fairly difficult area.
JJ: So the doctors end up working less at IGMH?
CW: They would probably argue this, but I would say the difficulty for us is commitment. The average Maldivian doctor will get a third of his income from IGMH, and two thirds from a private clinic. There is a huge incentive for them to do more and more private clinics.
For example, anecdotally a doctor in IGMH may see 6-20 patients in a clinic session. Apparently some of those doctors are seeing 70-75 patients in the same session at a private clinic.
It’s a big problem and the government needs to think about it. If you want doctors to be 100 percent committed to IGMH, you need to do something about increasing their salaries or minimising the amount of time they can do private work.
JJ: How sustainable do you think universal healthcare is in its current incarnation? Does there need to be a monetary barrier to entry?
CW: My view is that it was introduced far too quickly without thinking about what checks and balances needed to be in place. Some patients have already spent their Rf 100,000 (US$6500) entitlement. People see it as their right to spend Rf 100,000, and there wasn’t a public education campaign beforehand so people understand how to use it properly.
There are reports of people going from clinic to clinic and seeing more than one doctor in a day. If they’re not quite happy with what they got from one doctor, they’ll go to the next.
At IGMH the number of non-attendances for appointments has increased because people aren’t paying for it any longer. The patient doesn’t feel they are losing anything, although they are because they are using up their Rf 100,000. We have gaps in our clinics because patients have suddenly got an appointment at a private clinic quicker. And of course we have to work on our appointment system and how people access the hospital.
JJ: We have previously reported on tensions between local and foreign doctors over pay and allowances, such as accommodation. Were these resolved?
CW: It’s still an issue. The problem is that there are lots of inequities. Expat doctors get accommodation, Maldivian doctors don’t. But Maldivian doctors have the ability to do private work, which the expat doctors don’t, so there are some tensions.
Having said that, there are teams of doctors who work really well together. One of the things we have been doing is making sure the clinical heads of department meet once a fortnight, to try and make sure people are working together.
JJ: You have spoken about a contract IGMH had with the State Trading Organisation (STO) to supply medical equipment and consumables, at four times the going rate. What was behind this?
CW: The contract was initiated well before I started at IGMH. It was done for good reasons because there were huge problems with supplying medical equipment, but what we found was that we were paying hugely over the odds for goods we were receiving. Some of the issues with supply are still there, but generally speaking it has radically improved.
We had to do a lot of work on our side. Doctors had been stockpiling, so we have to educate them now that there is no need to stockpile, because it is increasing our expenditure.
It was also a major battle to understand our financial situation. When I first started people were spending money left, right and centre, and there was no financial control. Now we are are very clear about where we are – we don’t like where we are, because it’s not a very good financial position – but at least we know where we are. We are trying to enact a financial recovery plan, but we haven’t been able to go as far with it as we’d like.
JJ: What about the Indian promises to pump money into IGMH? Did you feel they were persistently interested in it?
CW: They came and pledged this money a considerable time ago. The project was supposed to start in April, but it slipped and slipped. It desperately needs to happen. The building is old and bursting at the seams, it is not able to cater to the needs of patients it has, and when it rains it leaks like a sieve. Things like the electric wiring are very old – it all needs to be redone.
JJ: You initially signed for another year, but mentioned concerns about job stability. How did things change at the hospital after the recent political turmoil? Should that be affecting a hospital?
CW: I don’t think it is – the Finance Ministry said, the same as the previous government, that we could not change salaries or appoint new people. So we have vacancies and we have to hold those [closed], with the exception of clinical staff. We argued that we needed to replace senior doctors if they leave. But we are carrying an excess of admin staff we desperately need to reduce. But the previous government stopped us doing that. To enable us to become a more effective organisation we need to do that.
JJ: What was it like working at the hospital, personally? Did you face challenges as a foreigner?
CW: Our chairman said it was not about me as a foreigner, it was about management. There was a general resistance to administration, which I detest. We have tried to bring together management and clinical staff, so we have a stronger team. What was happening before was that you would have different departments working in silos. Yes there’s been resistance – I came in with different ideas, trying to bring in a different style of working, empower staff to make decisions and come up with the solutions. They have the answers.
The language barrier was very frustrating. I was very vocal about not being politically driven, and saying what I thought. But at senior meetings in the Ministry of Finance they would always make a big thing about saying ‘Sorry, we are holding this meeting in Dhivehi’ – even though these were senior people with a good understanding of English.
At one particular meeting they spent most of the meeting slagging off IGMH. Fortunately I had taken another member of staff who was frantically writing things down. They would ask for a response but I couldn’t argue as I didn’t know what had been said. I found it really frustrating and I felt they used it sometimes.
JJ: You said you were keen for a Maldivian to take over after your departure? Is that capacity available locally?
CW: I think that given another six months we would have had a number of people ready to take it on. I had appointed a director of operations, who potentially could.
I made clear in my final comments to the new health ministers that they need to get the right person, and not necessarily make a political appointment, because it is such a key job driving change in the health system. Ultimately it’s their choice, though.
JJ: What do you feel like you’ve got out of the experience personally?
CW: I think I’ve become much more tolerant and patient, and politically aware – with a small and a large ‘P’. Diplomacy skills have been honed greatly. I also had my eyes opened about living in a small place where everyone knows everyone else. If someone was in the same classroom as the President, they think nothing about calling the President and telling him what they think of you.
It also really opened my eyes to the complete lack of confidentiality. People don’t think twice about leaking highly confidential information to whomever.
JJ: What are the top three areas the hospital needs to focus on right now?
CW: Firstly, getting to a stable financial footing, be that through the health insurance scheme, although it is not bringing in enough to allow IGMH to stand on its own two feet.
Secondly, the government needs to decide whether IGMH is a public or a private hospital. That’s a fairly difficult tension they need to resolve.
Third, let whoever is running IGMH run it, and have the confidence to run it, and stop all the political interference. That was the number one frustration – not being allowed to get on and do my job. We’d have a plan, then something completely unrelated would come in from the side and stop something I tried to enact. It was so difficult to keep people motivated when that happened.
There are some fantastic staff at IGMH. Liz the nursing director was also leaving, and we had an amazing leaving do, in traditional Maldivian dress. There are some really special people there.
If I can add a fourth priority: to continue to try and change the work ethic so people only take sick leave when they are genuinely sick.
Some of the senior team are very good, and have taken no sick leave – I haven’t had a day off sick the whole time I’ve been at IGMH. It never crossed my mind to take sick leave unless I was genuinely sick. But people just take loads of sick leave – they see it as their right.
I will miss it. It’s been a fascinating experience.
Biographical note: Cathy Waters arrived at IGMH in Feburary 2011, first as General Manager, and then CEO. In June/July 2011 she was asked to take on the role of Managing Director of the Male’ Health Services Corporation (MHSC). She has 32 years experience working in health care and health care systems, and has previously worked in the UK’s NHS as a CEO and as a Director of a small consultancy company specialising in organisational development and change management.