‘Unlimited Aasandha’ scheme will be sustainable, says President Yameen

President Abdulla Yameen last night inaugurated the ‘Unlimited Aasandha’ universal health scheme, a presidential campaign pledge and part of his first hundred day programme.

Criticising the Aasandha service introduced by President Nasheed, Yameen said the new Aasandha will have no limit on the amount of money that can be spent or with regards to age categories.

“Today the state of Aasandha is that every one has one lakh rufiyaa limit. Without any regard to the illness the person has, how much has to be spent, it is over for them when the one lakh limit is reached,” Yameen said.

Yameen stated that the new scheme will be “sustainable and funded by the state budget”. Cabinet Minister Ahmed Adeeb has suggested that ‘Unlimited Aasandha’ and other enhanced social services will be financed through long term government bonds.

President Yameen noted that the following will be covered by the new ‘Unlimited Aasandha’ scheme;

  • Sports injuries – including surgical procedures and rehabilitation treatment for professional athletes
  • All accidents and emergencies that happen while abroad
  • Emergency transfer of patients from islands
  • Transportation tickets for medical escorts to travel abroad with patients under 18 and above 65 years
  • Organ transplants and any permanent medication that is required after such a surgery
  • Unlimited coverage for pregnant women
  • Free annual medical checkups for every citizen above 30 years of age, and for school children

Though persons with special needs are not exempted, their temporary, permanent, and physical aids will not be covered through the service, said Yameen. The president pledged to find a solution to this problem during the next Majlis.

As the ‘old’ Aasandha was reportedly abused by members of the public and even health care providers and pharmacies, Yameen urged all to use the service “in good faith”.

“This is a service that is spent from people’s money for all citizens. So everyone should use it responsibly”.

The new unlimited service is an upgrade from the existing Aasandha programme introduced by President Mohamed Nasheed which encountered a number of issues, particularly with regards to sustainability.

After reaching the brink of financial collapse in August 2012, small charges were introduced to the scheme at private clinics. The opposition Maldivian Democratic Party (MDP) suggested that Yameen’s Progressive Party of Maldives and the coalition alliance had deliberately sabotaged the service.

Financing the pledges

The government has also made assurances that it can fulfill its pledges to increase old age benefits and to pay fishermen an allowance of MVR10,000.

The MVR2,000 pension for individuals over 65 years of age was increased to MVR2,300 through an amendment to pension legislation, while President Yameen has pledged to further increase it to MVR5000 starting from 1 March 2014.

The pledge to pay MVR10,000 to every fisherman regardless with or without any catch had later been explained by the Minister of Fisheries and Agriculture as an insurance scheme whereby fishermen would pay a monthly premium of MVR500 (US$32) during the fishing season to gain MVR10,000 (US$ 650) during the off-season.

On Sunday, however, President Yameen said the insurance scheme for the fisheries and agriculture sector was just one of the pledges to have been achieved within the first 100 days and that the  MVR10,000 allowance would be provided for fisherman as promised starting next month.

The government will need to generate MVR1 billion (US$64.9 million) from investments this year to sustain the pension increase alone.

“The economic committee [a cabinet sub-committee] decided to utilise a long term finance instrument based on a long term bond and t-bills through seven to five years,” Minister of Tourism Ahmed Adeeb said at a President’s Office press conference yesterday.

Assuring that the model was capable of financing the increases, Adeeb said that funds could be increased through legislative changes, and suggested that the Maldives could combine various funds – such as housing fund, health insurance, and pensions – into a single fund.

“If you look at countries like Singapore, all these funds are the contained in a single fund,” he said, stating that as a small country it is a good financial model for the Maldives to create a single strong fund.

Budget deficit

Commenting on Adeeb’s proposals, Mahmud Razee – former economic development minister under Mohamed Nasheed’s administration – said that both T-Bills and bonds, even if it they long term, will increase the national debt.

“These are loans, and taking loans is acceptable to invest in to increasing productivity. But this is not such an investment, this is something the government is spending. Eventually people will have to bear the burden of this,” Razee said.

Referring to the proposal to combine funds, Razee said that if the government was serious about it they should establish the necessary legal mechanisms for such a system.

“When we talk about Singapore, we should know that they can do it because they have that level of savings. But that is not the case with us,” he said.

The money in the pension fund has been entrusted with the state by people who want pensions, and it should not be mixed with other funds, Razee argued.

Selling treasury bills and treasury bonds has been one of the main approaches the government has taken to finance the budget deficit over the past few years.

Last December, the central bank and regulator – the Maldives Monetary Authority (MMA) – advised the state to pay all due treasury bills and treasury bonds and to turn existing short-term debts into long-term ones.

In a 2013 report which described the Maldives as “spending beyond its means”, the World Bank noted that the government had spent over MVR900 million on Aasandha from a budget of just MVR720 million.

Suggestions regarding Aasandha include decreasing the cost of drugs predominantly used by the poorest segments of the population, limiting spending for overseas treatment, moving toward a more close-ended provider payment system, and targeting subsidies only at needier patients.

This year’s record MVR17.95 billion (US$ 1.6 billion) budget has a deficit of MVR1.3 billion (US$84.3 million). The People’s Majlis recently approved a number of revenue-raising measures, while the government has announced it is aiming to reduce expenditure and achieve a balanced budget within a year.


Government trials expansion of Aasandha to Maldivians in Sri Lanka, India

The government is this month expanding the Aasandha universal health insurance for Maldives nationals with resident visas in Sri Lanka and India to specific “empanelled” hospitals.

National Social Protection Agency (NSPA) Chair and State Minister State for Health Thoriq Ali Luthfee has said that to coincide with the Islamic Holy month of Ramadan, Maldives nationals residing in the two countries would now be covered for 397 surgical and medical procedures under the universal health scheme.

The coverage will be available at a set number of hospitals that have already been providing services under Aasandha in Sri Lanka and India.

The Aasandha universal health insurance program was introduced by former President Nasheed’s government in January 2012 and retained by President Waheed’s administration after the controversial transfer of power in February the same year.

The scheme, a public-private partnership with Allied Insurance, covers up to MVR100,000 (US$6500) in healthcare costs for Maldives nationals with valid national identity cards.

State Minister Luthfee claimed that the extension of the services to Maldivians residing in Sri Lanka and India was possible as a result of cutting systematic “waste” from the Aasandha system present from its inception under the previous government.

Healthcare challenge

The government has announced the launch of the new services at a time where health authorities have continued to come under criticism about limited health services being offered to patients domestically.

In June, President Waheed told staff at Indhira Gandhi Memorial Hospital (IGMH) in Male’ that his government was working to try and overcome “budgetary challenges” it has been facing in providing healthcare services.  The pledge was made amidst concerns about limited services at domestic health centres in the country.

Earlier the same month, the Ministry of Health had told Minivan News that insufficient salaries and concerns over staff safety were key issues driving “shortages” in the number of trained medical staff coming from abroad to work at hospitals in the Maldives, resulting in impacts to services.

However, despite economic difficulties facing the provision of health care in the Maldives at domestic hospitals and health centres, Luthfee said that Aasandha was funded and overseen by the NSPA under a separate budget budget to health finance – which was handled by the health Ministry.

He claimed that the outcome of extending Aasandha coverage for residents in Sri Lanka and India would need to be monitored to see if the system could be extended to for Maldivian expatriates in other parts of the world.


Luthfee claimed that one key consideration of the success of expanding Aasandha coverage would in whether Maldivians used the scheme “responsibly”.

Shortly after the launch of the scheme in January 2012, Health Minister Dr Ahmed Jamsheed – then Chief Operating Officer at Male’s ADK hospital – said the private health centre had been overwhelmed at the time by patients. He cited a 100 percent increase in demand for basic services in the first 14 days of the scheme.

Dr Jamsheed at the time contended that limited information on Aasandha’s financial structure was leading some members of the public to exaggerate their medical needs, with the mindset that all of their MVR100,000 allowance needed to be spent without regard for the system’s sustainability.

Luthfee claimed today that initial high pressure on the Aasandha system as a result of exaggerated medical needs had seemingly been tempered by greater accountability and a better understanding among the public of how the system was being financed.

“We have been able to balance this, partly through the use of a cost share agreement with private institutions participating in Aasandha,” he said.

Luthfee argued that the potential irresponsible use of universal medical care limiting services for the most in need was an issue initially seen in the early days of public healthcare systems all over the world – pointing to the early days of the UK’s National Health Service (NHS) model as one example.

He claimed that despite some of the challenges facing the system, Aasandha was now being operated in sustainable manner resulting from decreased costs to when the system was launched last year.  He claimed that despite the decreased costs, services offered through the scheme had not been compromised as a result.

Credit limits

Earlier this year, the Amrita Institute of Technology Hospital in Kochi, India, announced that it had been forced to impose a credit limit on services being offered to Maldivian nationals travelling for treatment under Aasandha.

As with other similar insurance schemes, the hospital at the time told Minivan News that it had been forced to control patient admittance as a result of over 7 million rupees (US$130,536) in unpaid charges.

Aasandha’s management said there had been some issues receiving money from the Finance Ministry to cover bills owed as a result of the insurance scheme last December – traditionally a “peak” period for Maldivians wishing to seek medical treatment abroad.

A spokesperson for the hospital could not be reached for comment today.

However, Cosmopolitan Hospital in Travandrum, India, one of several health centres “empanelled” under the Aasandha scheme, said it continued to offer medical services to Maldivian nationals under the programme.

The spokesperson added that he had not been made aware of any issues presently with payments or services being provided through the system.

Nawaloka Hospital, based in Colombo, Sri Lanka, which is also offers treatments under Aasandha, confirmed that it was not aware of any issues with payments being received for treatments and continued to provide medical services to Maldives nationals without any significant limitations.

Last July, the present government pledged that Aasandha would “not collapse”, despite the state owing four months of unpaid premium charges sought to cover medical treatments.


Maldives Journalists Association (MJA) drafting bill for minimum wage, health insurance

The Maldives Journalists Association (MJA) is drafting a bill to ensure journalists receive a minimum wage and health insurance.

MJA President Ahmed ‘Hirigaa’ Zahir told local media he expects Parliament to pass the bill, which would “ensure journalists can live without handouts”.

“We are saying that journalism is the fourth power of the nation. All other powers have security and everything else. Journalists are faced with grave threats. However, they don’t back down. Hence, such a bill is important,” Zahir said.

The MJA has previously worked to improve journalism in the Maldives, according to MJA Treasurer Adam Haleem.

“There are two institutions which parent the Maldives journalism. These are funded by the state budget. However, we could say that we work for perpetuity. We work without much of a budget. However, looking at the past two, four years, we have kept our eyes more open in media related areas. If a report is compiled by someone based on our work, I think that the work by MJA would take first place,” said Haleem.


Comment: The price of an expat life in the Maldives

As a Bangladeshi colleague was wheeled into the operating theatre of Indira Gandhi Memorial Hospital for emergency life-saving treatment, I knew where my thoughts should have been.

We seek to assure ourselves that even in a cynical commercial world, you cannot put a price on life. Is such a phrase anything more than sound logic for those in the privileged position to afford the finest Singaporean inpatient treatment, or the insurance to cover hundreds of thousands of dollars of emergency medical evacuation to tax-payer funded Western healthcare?

Life after all is precious. Yet all too often, the true value of precious things is rarely understood until it, or in this case they, are threatened or lost.

The introduction of the complex and troublesome Aasandha universal health insurance program this year by the government of former President Mohamed Nasheed, so far retained by President Dr Mohamed Waheed Hassan, has started a new era in Maldives healthcare.

Maldivians can now obtain treatment and surgery in their own country without relying on the vastness of their own wealth or savings, the kindness of friends, or the mercy of elected politicians and wealthy resort tycoons.

While the execution of such a system should always be open to scrutiny, there is much to be admired in the concept of ensuring every person in the country will be cared for when at their weakest.

But what of the country’s immigrant population? How are an ever-growing group of people in the Maldives – mainly in the form of unskilled workers from Bangladesh trafficked into the country – to be cared for?

For many of the foreign workers who make up a third of the country’s population, and are expected in coming years to equal the number of indigenous employees, the price of life can be counted down to the very last laari.

This is no more apparent when insurance companies can only reimburse treatments for foreign workers that have already been paid for – no matter the level of upfront expense.

What happens when companies or employers, whether out of negligence or limited finances, are unable to bare the initial costs needed for a life saving operation?

Who is there to purchase and provide these patients with the medicines and saline drips from for hospital staff to administer? In the absence of close friends and family, where is the assistance in journeying to a hospital toilet and what alternate options does a low-income expatriate have? In short, who is there to care?

The concern was born – not altogether altruistically – whilst spending Tuesday night sleeping on the floor of a post-operation ward at Indira Gandhi Memorial Hospital (IGMH) in Male’, in case a signature or saline drip was required.

Thankfully, he is well.

Barring “unexpected complications”, he will recover, as will the company’s finances once it is reimbursed from the employee’s insurance policy – only a recent mandatory requirement for obtaining a visa for foreign workers.

As a company representative, the initial costs for vital surgery, though not insignificant, can be reclaimed and more importantly, have to be met.

As an individual and friend, without the financial capabilities and resources of a company, the alternatives would otherwise be unthinkable.

A friend and room-mate of my colleague later explained that over half of his month’s wages were spent Tuesday morning on emergency medicines, scans and x-rays alone – all just to identify the scale of the problem – even before an operation. The price of life, I realise, is appallingly low for the wrong person.

In the wards, visiting hours are 24/7. Family members must maintain constant vigil over their bedridden loved-ones, taking full responsibility for everything from toilet assistance to buying and supplying hospital staff with needed medicines.

It is anyone’s guess how foreign workers – many of them far from home and family and unable to even afford the upfront deposit for treatment – are able to survive the system.

Ultimately my friend appears lucky. As the days pass, colleagues and acquaintances have, in either desperation or adversity, been transformed into an unusual though much appreciated surrogate family of makeshift nursing staff in the ward.

They have become well acquainted with pharmacies and their respective costs, and learned to recognise when saline solutions for drips are urgently in need of replacement. Some have even had to contemplate how best to preserve a friend’s dignity in toilet situations, that are not “always ideal” in maintaining a professional relationship.

Small blessings indeed.

Contemplating such a situation after days spent outside the operating theatres and waiting rooms of IGMH, perhaps there is much to be said for the hospital prayer room.

We are only human after all, but surely there are few times of feeling as completely powerless than when watching another person’s suffering.

Is it right then, that a person – regardless of skills or social standing – should amidst moments of extreme fear and anxiety have to pray for their economic, as well as physical well-being?

Surely some great deeds are not beyond human intervention.


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.”


Procedures to include private clinics in Aasandha underway

The government is working to modify the stipulation that private clinics will not be included in the universal health insurance scheme Aasandha, due to become active tomorrow, January 1.

President Mohamed Nasheed this morning announced that the government is trying to set procedural standards for including clinics in the scheme, Haveeru reports.

Health Minister Ibrahim Waheed told local media that, “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 added that clinics must upgrade their services to hospital standard in order to be included in the Aasandha scheme.

Details have not been revealed.

The Aasandha scheme does include provisions for Maldivians seeking medical treatment abroad, and offers financial support for those in need.


ID card unit swamped in anticipation of Aasandha scheme

The Department for National Registration is overwhelmed by the sudden increase in applications for national identity (ID) cards, ahead of the universal health insurance scheme which begins on January 1.

To be eligible for the “Aasandha” scheme which provides government-sponsored coverage up to Rf100, 000 (US$6,500) per year, a person must hold a valid ID.

The department typically experiences a rise in traffic during this time of year as Maldivians take advantage of the annual holiday (October to December) to make trips from islands to take care of necessary business and annual shopping in Male’.

Many are now rushing to the national registration office to renew expired ID cards or apply for new ones.

Assistant Director Abdullah Haleem is in charge of ID card operations at the department, and spoke to Minivan News regarding the matter.

“Since Sunday a lot of people have been coming in. It is very difficult to cater to the increased number of applicants because we lack resources and staff,” he said.

“It is difficult to estimate how many people are coming in. Everyday we are releasing 250 token for applicants. Many who queue up have to leave because they don’t get the token. Sometimes within an hour all tokens are over,” Haleem explained.

Minivan reporters observed that the office was crowded with men, women and children- as all chairs were taken, some stood desperately staring at the board displaying their token numbers.

A father waiting in the queue with his five year old daughter complained about the long hours of waiting, but he said it is “worth it” because his daughter would get free heath care once he had received the ID card.

Haleem also noted that it is mostly parents coming in this week to make ID cards for their children. In order to ease their burden, he said the office has decided to release additional tokens for children between 3:00pm and 4:00pm from Tuesday onward.

The office is usually open from 8:00am to 4:30. However, a staff member noted that they have to put in extra hours to meet the demand.

Meanwhile, bundles of application forms coming in from different atolls are piling up at the registration department.

“We have ID card application form collection centers in all the atolls. So those centers are sending in a lot of forms as well,” Haleem said, noting that the paperwork is “fairly simple”.

He said some applicants may not receive the card before January, however assured that the office is working hard to issue the cards as soon as possible.

The health insurance bill was submitted by Nolhivaram MP Mohamed ‘Colonel’ Nasheed and unanimously approved by with 72 votes on December 21, 2011. It was ceremoniously signed into law on December 22.

According to the bill, citizens receive government-sponsored coverage up to Rf100,000 (US$6,500) per year. The bill includes provisions for medical treatment abroad, and for 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 decision has caught the approving eye of Mexico’s government, which passed a similar bill eight years ago.

“Mexico and the Republic of Maldives are developing countries, but with our universal health insurance programs our people’s health care can be better than that of developed countries such as the United States,” read a statement.

Speaking to Minivan News at the time, President’s Office Press Secretary Mohamed Zuhair said that the program has challenged the government “to raise the standards of medical service and continuously improve the care available in the Maldives.”

The Aa Sandha plan coincides with discussions over renovating the procedure for prescribing medications and shifting from a brand-based market to generic drugs.

In a previous article, Minivan News reported that the current system is based more on the business interests of pharmaceutical importers than on the health needs of the community.

“The drugs that are imported are the ones they want to sell, not the ones we want to prescribe,” explained Medical Director at Male’ Health Service Corporation, Dr Robert Primhak.

Chief Operating Officer at ADK Hospital and former head of the Center for Community Health and Disease Control (CCHDC), Ahmed Jamsheed, added that the shift would benefit people physically and financially.

“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 at the time.


Health insurance should be free: MPs propose amendments to Bill

Parliament has proposed almost a hundred amendments to the National Health Insurance Bill, including a call for it to be made compulsory for locals and expatriates alike.

The bill currently requires workers to contribute 3.5 percent of their salaries to the scheme, however an amendment proposed by MP Yusuf Abdul Gafoor would require the government to pay insurance costs for everyone in the country, out of revenue derived from taxing tobacco products.

Haveeru reported that Maldivian Democratic Party (MDP) MP Mohamed ‘Colonel’ Nasheed had proposed a 1.5 percent employee contribution, with three percent paid by the employer. Dhivehi Rayyithunge Party (DRP) MP Rozaina Adam proposed that workers pay only 0.5 percent.

DRP MP Dr Abdulla Mausoom said the state should fund health insurance for all Maldivians through increased tax revenue, while expatriates should be charged.