Health sector unprepared for potential HIV outbreak, warns HRCM

The health sector is unprepared for a potential outbreak of HIV in the Maldives in the absence of prevention programmes and specialised care for population groups at risk, the Human Rights Commission of Maldives (HRCM) has warned.

“[The Health Protection Agency] mandated with HIV/AIDS prevention/control is not adequately funded and lacks capacity to lay down such a system,” reads the HRCM’s submission for the UN Human Rights Council’s Universal Periodic Review.

“There are no prevention services for high risk groups, increasing the risk of spreading HIV. High risk factors including sharing of needles to inject drugs, high sexual activity among adolescents and youth could contribute to an increased prevalence of HIV/AIDS. It is alarming that there is no screening system for HIV/AIDS and STI in the prison system; considering some of the identified HIV patients go in and out of prison as repeated offenders.”

In May, the health ministry issued new guidelines on preventing the transfer of HIV from mother to child while the Health Protection Agency warned of an HIV “time bomb.”

A series of protests over regional healthcare services occurred earlier this year after it was revealed that the state-run Indira Gandhi Memorial Hospital (IGMH) had transfused HIV positive blood to a patient in February due to an alleged technical error.

The HRCM report also noted that health services were “not easily accessible and available in atolls and lack healthcare professionals such as gynaecologists and paediatricians.”

“Public has no trust in the healthcare system due to many avoidable health incidents and sensitive medical information of patients being leaked,” the report stated.

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President Yameen to personally oversee health sector

With additional reporting by Daniel Bosley

President Abdulla Yameen has announced that he will personally oversee the Maldives’ health sector until it overcomes its current problems.

“When things don’t get done, it is the president elected by the people who has to bear responsibility. But the democratic way is to delegate the work and let others do it. And doing things through institutions and offices,” local media quoted Yameen as saying in Addu City yesterday (August 11).

“If everything has to be done by the president, then we can just pay the president a large salary, send everyone else home and the work will be done. But we have offices and departments because we don’t want to do that.”

Speaking at a Progressive Party of Maldives (PPM) rally, Yameen alleged that, despite a lot of developments having been brought to the health sector during Gayoom’s administration, no investments have been made during President Mohamed Nasheed’s time in office.

The Ministry of Health has been headed by Defence Minister Colonel (retired) Ahmed Nazim after former minister Dr Mariyam Shakeela’s renomination was rejected by the Majlis last month, and had fallen under the oversight of Vice President Dr Mohamed Jameel Ahmed.

In an interview with Haveeru earlier this week, Dr Shakeela alleged that she had received threats and intimidation prior to her departure, suggesting that political opponents wished to remove her in order to benefit from corrupt development deals.

“When things fail, all the complaints are targeted to the president and in the end it is whoever is elected to the post of president that needs to carry the responsibility for everything,” President Yameen told local media.

“Therefore, I have decided that although the sector was not overseen by me previously, I am going to run the health sector directly under my oversight until it overcomes its current hurdles,” he continued.

Corruption claims

Dr Shakeela – whose time in office was marked by a number of high profile mishaps within the sector – told Haveeru that she had not been provided adequate powers to carry out the changes required.

“When I was given the post, some people said this can’t be done by bringing in someone from far outside after we worked hard to bring this government,” she was quoted as saying.

“So from the start there were some people who were bent on showing that I was a failure.”

The state-owned Indira Gandhi Memorial Hospital (IGMH) – long criticised for lack of qualified doctors and inadequate medical facilities – transfused HIV positive blood to a patient in February due to an alleged technical error.

In June, Fuvahmulah councillors called for Shakeela’s resignation after a case of stillbirth, an interrupted caesarean, and the death of a soldier on the island. A few weeks after, over 300 protestors demonstrated in Haa Dhaal Kulhudhuffushi over deteriorating conditions at the regional hospital.

Responding to Shakeela’s interview this week, PPM parliamentary group leader Ahmed Nihan told Minivan News that acting minister Nazim was carrying out “tremendous” work in the sector – work he is confident Dr Shakeela could not have done.

Nihan argued that the removal of Dr Shakeela was an example of good democratic practice after PPM members became dissatisfied with her performance.

On Monday (September 11) the ministry was reported to have signed an agreement with Sunshell Maldives Pvt Ltd for the MVR1.2 million (US$77,821) renovation of Hithadhoo regional hospital.

Yameen yesterday also praised acting health minister Nazim’s performance, saying he was “working very actively and conducting some very important work”.

He said that Nazim regularly deliberates with him on health sector issues, implementing his suggestions.

“I am therefore confident that with the current minister, I will be able to bring about the changes I desire in even the atoll level hospitals,” said Yameen.

The president is visiting Feydhoo and Hithadhoo islands in the southern atoll to examine ways in which the government’s development agenda can be implemented.

In addition to inaugurate a road construction project in Feydhoo, Yameen announced a land reclamation project to be started on the same island next year, as well as a atoll-wide sewerage project to begin this year.

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Three bills sent to committee

Three bills submitted on behalf of the government by Progressive Party of Maldives (PPM) MPs were sent to committee for further review at today’s sitting of parliament.

While a bill on health professionals was accepted unanimously with 77 votes in favour, a bill on the health sector was also accepted unanimously with 74 votes in favour and three abstentions.

Legislation on the Communications Authority of Maldives (CAM) submitted by PPM MP Saud Hussain was accepted with the unanimous consent of 74 MPs.

The bill outlines rules governing telecommunications and postal services and proposes allowing CAM to set prices for telecommunication services, license telcos and ensure a competitive market.

If passed into law, a five-member board would be instituted to head CAM, which would function under a ministry.

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Pro-government MPs reject Dr Shakeela’s re-nomination as health minister

Dr Mariyam Shakeela failed to secure parliamentary consent today after MPs of the ruling Progressive Party of Maldives (PPM) and ally Maldives Development Alliance (MDA) voted against approving her as Minister of Health.

Of the 73 MPs in attendance, 61 voted against endorsing her reappointment to the cabinet while 11 voted in favour and one abstained.

PPM reportedly issued a three-line whip against approving Shakeela following a secret ballot at a parliamentary group meeting this afternoon.

The health ministry has been under fire following a series of protests over regional healthcare services and mishaps in Malé.

The state-owned Indira Gandhi Memorial Hospital (IGMH) – long criticised for lack of qualified doctors and inadequate medical facilities – transfused HIV positive blood to a patient in February due to an alleged technical error.

In June, Fuvahmulah councillors called for Shakeela’s resignation after a case of stillbirth, an interrupted caesarean, and the death of a soldier on the island. A few weeks later, over 300 protestors demonstrated in Haa Dhaal Kulhudhuffushi over deteriorating conditions at the regional hospital.

Shakeela was up for parliamentary approval today for a second time after President Abdulla Yameen modified her initial portfolio as Minister of Health and Gender.

During a debate today on a report by the independent institutions committee – which narrowly recommended endorsing her appointment – PPM MP Mohamed Musthafa accused Shakeela of reversing a decision by the previous minister to raise wages for doctors under a 48-hour work week.

He claimed that Shakeela had reduced working hours to 45 hours and lowered salaries.

“The consequence was all specialists working at IGMH and doctors in hospitals in the atolls and health centres leaving the Maldives,” he said, adding that the health minister should bear responsibility for the alleged exodus.

Musthafa suggested that “circumstances have changed” since President Yameen nominated Shakeela for the post.

MPs of the opposition Maldivian Democratic Party (MDP) also voted against the health minister while Jumhooree Party (JP) MPs voted in favour.

MDP MP Rozaina Adam accused the health ministry of taking measures against health sector employees who provide information to opposition MPs. Such workers were threatened with dismissal and accused of “pestering” the government, she claimed.

Rozaina also strongly objected to the committee being unable to interview Shakeela due to a Supreme Court ruling.

JP MP Hussain Mohamed meanwhile noted that appointing cabinet ministers was a prerogative of the president, suggesting that the parliament’s confirmation role was a formality.

The party decided to endorse her as Shakeela’s reappointment implied that the president must have had confidence in her ability to implement his health policy, he said.

Health policy

Meanwhile, at a press conference yesterday, Shakeela said that the health sector had been strengthened despite “pressure” from elements within the government.

Shakeela insisted that she would not resign in the face of “obstacles and challenges” and said that President Yameen had not asked her to do so.

Shakeela contended that she had inherited a health sector “in ruins” with limited human resources and crumbling health centres and medical equipment.

She alleged that senior officials “within the system” were “obstructing” the ministry’s efforts.

Shakeela said she would “respect” the PPM MPs’ decision, but insisted that it would not be based on her performance.

Defending her track record, Shakeela said the ministry has formulated and submitted legislation to parliament on health services, health professionals, medical negligence, and medical devices.

The administrative framework of the health sector had been reviewed and revised, she said.

Shakeela said 70 percent of infrastructure had been damaged when the current administration took office, which has commenced repair work on 24 health centres at a cost of MVR14.1 million (US$914,397) while projects for repairing a further 49 centres were in the tendering process.

Contracts have been signed for constructing an 11-storey building for IGMH and upgrading the dialysis unit, she continued, adding that efforts were also underway to upgrade the Vilimalé health centre to a hospital.

Moreover, the ministry was purchasing equipment to upgrade the Hithadhoo and Kulhudhufushi regional hospitals to tertiary level, she said.

Among other ongoing projects were a quarantine facility and halfway house in Hulhumalé, a maternity waiting home in Kulhudhufushi, and newborn care centres.

A project to repair speedboats was also underway, Shakeela said, which has seen 13 out of 28 speedboats resume service. Four sea-ambulances have also been launched to fulfil a PPM campaign pledge, she noted.

While only 42 of 199 ambulances were functioning when she assumed office, Shakeela said 110 were now being used.

Noting that 80 percent of employees in the health sector were expatriates, Shakeela said the government was finding it hard to recruit professionals from overseas due to loss of confidence in the health sector by foreign workers.

A four-year long term plan for the health sector was being implemented, she noted.

Work has also begun on integrating a general practitioners service with the government’s ‘Aasandha’ health insurance scheme, Shakeela said.

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Resigning not the solution: Health Minister Dr Shakeela

Resigning in the wake of last week’s transfusion of HIV positive blood to a patient is not the solution to problems in the health sector, Health Minister Dr Mariyam Shakeela told MPs on the government oversight committee on Friday (February 28).

Dr Shakeela told the opposition-majority oversight committee that “human error” was to blame for the incident at the government-run Indira Gandhi Memorial Hospital (IGMH), as the lab technician reported the blood as negative despite the machine showing otherwise.

“My resignation isn’t going to solve this. I could resign if that is the case. My resignation is not going to solve it. That’s why I am saying, what is the solution? The solution is all of us cooperating and working together to improve the system,” she said.

Shakeela added that she had been receiving text messages calling for her resignation.

Asked by opposition Maldivian Democratic Party (MDP) MP Ahmed Hamza if she accepted “full responsibility without any excuses” for the incident, Shakeela replied that she accepts responsibility for “providing benefits” to whomever it was owed.

The ministry would attempt to explain to the public that the incident occurred due to “human error,” she stressed, adding that she did not think members of the public would stop visiting the government-run tertiary hospital.

As the donor was found by the patient, Shakeela stressed that the blood sample did not come from the hospital’s blood bank. The donor was not previously registered as an AIDs patient.

The government was ready to take whatever measures were necessary to restore public confidence, she added.

The minister also denied that there was a cover-up, or that the revelation to the media was prompted by leaked information.

Shakeela urged MPs to consider the mishap as “a one-off” incident caused by a mistake.

“Don’t think that this will keep happening to us all the time. We are taking steps for example to try and go to a fully automated system, to improve it and reduce human mistakes,” she said.

ISO standards

Upon learning of the incident on February 19, Shakeela said she informed the World Health Organisation (WHO), seeking advice and assistance following an emergency meeting with high-level officials at the Health Ministry.

The Health Ministry acted in line with international best practices, she said, and immediately launched independent inquiries.

The incident was revealed to the media shortly after receiving a draft report from an independent committee, she added, noting that further investigations were taking place to identify shortcomings at the hospital.

The machines at IGMH were state of the art whilst the standard operating procedures (SOPs) and protocols were at international standards, she noted.

Health Ministry Director General Dr Sheeza Ali meanwhile revealed that the laboratory was presently not “ISO certified”.

“But we are starting work during this year towards ISO certification. It is likely that we might not reach the latest [standards] as we might not be able to fulfil all the requirements,” she said.

Budget constraints

While the Health Ministry had asked for a “realistic budget” of MVR4 billion, Permanent Secretary Geela Ali said the budget approved by parliament had only MVR2.5 billion earmarked for the health sector.

Of the MVR2.5 billion annual budget, Geela noted that MVR1.8 billion was allocated for the National Social Protection Agency (NSPA).

Shakeela meanwhile told MPs that the health sector was in disarray, with crumbling infrastructure and facilities due to insufficient funds allocated in the state budget for many years.

“If we look at machinery, a screw comes loose from the machine and it falls on the head of the patient who is taken into the operating theatre,” she said.

Moreover, attracting qualified foreign doctors was “very difficult” as the salary of doctors in the Maldives has not kept pace with pay rises for doctors in the South Asian region, she explained.

Due to the budget constraints, Shakeela said the ministry was seeking foreign assistance, and that machinery and equipment were “on the way”.

In response to complaints regarding the budget, MDP MPs on the committee pointed out that health policy was formulated by the government while the state budget was proposed by the Finance Ministry, reviewed by a budget committee controlled by the ruling coalition, and approved by the government majority in parliament.

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State budget of MVR 16.9 billion for 2013 presented to parliament

Finance Minister Abdulla Jihad submitted an annual state budget of MVR 16.9 billion (US$1 billion) for 2013 (Dhivehi) to parliament today, proposing a raft of measures to raise revenue and reduce spending.

Of the proposed MVR 16.9 billion of government spending, more than 70 percent was recurrent expenditure, Jihad noted in his budget speech (Dhivehi).

“As in other years, the highest portion of recurrent expenditure is expenditure on [salaries and allowances for government] employees,” Jihad explained. “That is 48 percent of total recurrent expenditure.”

As total expenditure would outstrip projected revenues of MVR 12.9 billion (US$836 million), Jihad said the resulting deficit would be plugged with MVR 971 million (US$62 million) as budget support and MVR 1.3 billion (US$84 million) from Treasury bill (T-bill) sales.

Of the MVR 971 million in budget support, MVR 671 million (US$43 million) was expected as foreign loan assistance, Jihad explained, with the rest to be made up from “domestic finance.”

New measures proposed to raise revenue is expected to account for MVR 1.8 billion (US$116 million) in income, Jihad said.

Jihad further claimed that the budget deficit at the end of 2013 would be MVR 2.3 billion (US$149 million), half the deficit in the current year.

On revenue forecasts, Jihad revealed that income from taxation would account for MVR 9.1 billion (US$590 million) while MVR 3 billion (US$194 million) was expected from other sources, such as resort lease rents, dividends from government companies and profits from the Maldives Monetary Authority (MMA).

On social and economic programmes, Jihad said MVR 2.5 billion (US$162 million) was allocated to the education sector, MVR 1.7 billion (US$110 million) for strengthening the judiciary, MVR 1.5 billion (US$97 million) for improving health services, MVR 2 billion (US$129 million) for social security and welfare and MVR 5.5 billion (US$356 million) for infrastructure projects in the atolls.

A public sector investment programme (PSIP) was formulated with MVR 3.1 billion (US$201 million), Jihad said, with MVR 1.5 billion (US$97 million) from the state budget, MVR 21 million (US$1.3 million) from domestic loans, MVR 1.2 billion (US$77 million) as foreign loans and MVR347.6 million (US$22.5 million) as free aid.

The PSIP projects include construction and repairs of harbours in 14 islands, establishing sewerage systems in 11 islands, water systems in three islands, 1,500 housing units in eight islands, 21 new mosques and upgrading the regional hospitals in Kulhudhufushi and Addu City to tertiary level.

Meanwhile, according to the latest figures from the Finance Ministry, government spending as of November 22 stands at MVR 10.9 billion (US$706 million), while revenues of MVR 8.5 billion (US$551 million) have been collected so far this year.

Jihad said in parliament today that total spending in 2012 is expected to be MVR 16.5 billion (US$1 billion) while revenues would be MVR9.4 billion (US$609 million).

The revenue forecast in the 2012 budget was however MVR 11 billion (US$713 million).

“At the end of 2012, the state’s budget deficit is estimated to be at MVR 4.3 billion (US$278 million). That is 12.6 percent of GDP,” Jihad revealed.

Revenue raising and cost-cutting measures

A recent mission from the International Monetary Fund (IMF) urged the government to implement a raft of measures to raise revenues, advising that strengthening government finances was “the most pressing macroeconomic priority for the Maldives.”

Finance Minister JihadEchoing the IMF concerns, Jihad told MPs that rising public debt was “a major challenge to the country’s economy,” revealing that the state’s debt would increase to MVR 31 billion (US$2 billion) by the end of 2013 – 82 percent of GDP.

If the deficit spending trend continues, Jihad warned that the Maldives would face severe difficulties in securing development loans and financial assistance.

Taking the IMF recommendations on board in formulating the budget, Jihad proposed a number of revenue raising and cost-cutting measures,

  • Review government subsidies to target assistance to the needy
  • Freeze hiring “as much as possible”
  • Reforming the universal health insurance programme ‘Aasandha’
  • Reducing the number of councillors and board members of government companies
  • Reducing expenditure for trips from government offices to the atolls
  • Reduce government expenditure on rent for government offices
  • Reduce overseas trips by government employees
  • Amending the Pension Act to abolish “double pension”
  • Reversing import duty reductions
  • Hiking T-GST (Tourism Good and Services Tax) to 15 percent from July 2013
  • Introducing GST for telecom services (currently exempt from the tax)
  • Introducing GST for oil
  • Increasing airport service charge for foreigners from $18 to $30
  • Amending the law on revenue stamps
  • Abolishing 22 loss-making government companies

Jihad appealed to MPs to approve the measures and warned of “bitter consequences for the whole nation” should deficit spending continue in the future.

The Finance Minister urged MPs to “put aside political differences and prioritise national interest” in recognising that the country could not “indefinitely” spend beyond its means.

“We have to accept that these measures will affect all of us to some extent,” he said. “However, if we do not begin taking these measures, we might have to face more severe difficulties as a result of steps we would be forced to take.”

Monetary policy

According to projections by the MMA, said Jihad, the current account deficit is expected be higher than 2012 by 15 percent.

The current account deficit is projected to widen to 28 percent of GDP in 2013, Jihad said.

Collaborative efforts from different sector would be needed to “solve the balance of payments problem facing the country,” Jihad added, as the imbalance in the foreign exchange market has been building for many years, resulting in a parallel or “black market” for dollars.

Policies have been proposed to increase exports and expand small businesses, Jihad said.

Following the submission of the budget today, a joint committee of the parliament’s Finance Committee and Economic Committee would convene to review the proposed budget before it is put for a vote.

The budget debate has meanwhile been scheduled for December 4, 5 and 6, Speaker Abdulla Shahid said today.

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Malé Health Services Corporation established

President Mohamed Nasheed has established Malé Health Services Corporation Limited, a government-owned company with one hundred percent government shares.

The company was formed to “ensure economic and social development” and to provide “adequate health care” for Maldivians.

The corporation will establish and maintain health care facilities in the Malé region.

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Health Minister says government-owned corporations are a good step for health sector

Minister of Health and Family Dr Aminath Jameel has said there will be no loss to the government if health employees have to work under corporations, reports Haveeru.

The government is planning on managing Indira Gandhi Memorial Hospital (IGMH), regional hospitals and health centres, under 100 percent government-owned corporations.

The minister said employees will be protected under the Employment Act and Pension Law.

Dr Aminath said employees would not lose their rights and the Health Ministry would regulate the corporations under its regulatory mechanism.

She added that the health sector framework would be amended and salaries are expected to increase.

The minister added that bringing health services closer to the people under corporations would solve the current problems the health sector is facing.

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