Q&A: Former CEO of IGMH Cathy waters

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.


Q&A: Cathy Waters, CEO Indira Gandhi Memorial Hospital

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.

IGMH was gifted to the Maldives by the Indian government

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.