Four bilateral agreements signed with Pakistan

The Maldives has signed four Memorandums of Understanding with Pakistan today during president Abdulla Yameen’s ongoing two-day state visit.

The MoUs were for mutual cooperation in healthcare, education, sports, and combating drug abuse.

President Yameen was accompanied by first lady Fathmath Ibrahim, speaker of parliament Abdulla Maseeh Mohamed, and cabinet ministers. The delegation is due to return tonight.

President Mamnoon Hussain hosted a banquet in honour of president Yameen last night. The pair held talks on strengthening bilateral ties earlier in the day.

“President Yameen thanked his Pakistani counterpart for the excellent hospitality extended to himself and his delegation,” said the president’s office.

“President Yameen also extended an invitation to President Mamnoon Hussain to visit the Maldives at his earliest convenience. At the meeting, both the leaders deliberated on enhancing trade and cultural exchanges, as well as expanding the scope of investment opportunities. Discussions were also held on supporting each other in the global arena.”

Yameen has also reportedly invited prime minister Mohamed Nawaz Shareef to attend an official function due to be held on July 26 to mark the golden jubilee of the Maldives’ independence.

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Kulhudhuffushi protests over “comatose” regional health service

Over 300 islanders staged a protest on Saturday on northern Haa Dhaal Kulhudhuffushi Island over deteriorating regional health services.

Protesters called for Health Minister Dr Mariyam Shakeela’s resignation outside the Kulhudhuffushi Regional Hospital, claiming services have deteriorated to “conditions never seen before in recent history.”

Kulhudhuffushi Island Council President Ali Mohamed said the hospital served over 60,000 people in the region, but lacked doctors and equipment.

Following the protest, doctors at the hospital refused to work today claiming they lacked an environment conducive for work. However, they resumed work at 10:30 am after the Kulhudhuffushi Island Council and Haa Dhaal Atoll Council intervened.

Meanwhile, the Haa Dhaal Atoll Council issued a statement on Thursday condemning “comatose” health care service at the hospital and warned it will hold serial protests until grievances are addressed.

In recent weeks, a woman had to be flown to Malé when doctors could not sew up an episiotomy following labor, an infant suffered damages to the head during a caesarean, and a child was stillborn despite routine checkups, the council claimed.

The Kulhudhuffushi regional hospital has not had a physician for seven months, and has only one gynecologist. Three gynecologists are needed to serve the northern atoll’s population, the council said.

The council also highlighted a severe lack of facilities on the island. The hospital has a dentist, but the dental chair has been broken for two years and three years have passed since the x-ray machine broke down, the council said.

Further, lack of antibiotic discs for culture and thyroid tests and lack of laboratory chemicals have hampered the hospital’s ability to conduct medical tests, the council said.

Healthcare infrastructure is dilapidated, surtains are old and hospital bedding is torn, the council said.

The state had only allocated MVR 1200 (US$ 77.8) for cleaning supplies for the year. When the funds are divided among the 13 islands, each health center receives MVR 7.69 per month (US$ 0.5) or enough to buy two bars of soap every month, the council said.

“The council calls on the Ministry of Health and all relevant authorities to recruit two more gynecologists, a physician, a cardiologist, ultra sound scanning machine, an x-ray machine, 4 ECD machines, two fetal Doppler and adequate supplies for and facilities in the twelve health centers in Haa Dhaal Atoll,” the statement read.

The council also claimed Shakeela had not failed to respond to repeated requests for a meeting.

In response, Shakeela told regional newspaper Kulhudhuffushi Online work is underway to improve regional health facilities and said the ministry is recruiting doctors to staff regional hospitals.

The Health Ministry is also in the process of purchasing a new x-ray machine and laboratory equipment for the Kulhudhuffushi hospital, she said. But the process will take time, as equipment is imported from abroad, she added.

The government in May announced it is seeking 225 additional doctors, and said it will place 91 medial officers in health centers across the country.

The Health Ministry has been under fire in recent weeks following a series of health scares.

On June 3, councilors of southern Fuvahmulah Island held a press conference blasting Shakeela for “worsening conditions” at the hospital.

Councilors alleged negligence in a series of medical incidents including a case of stillbirth and the death of a soldier on the island.

In February, the Indhira Gandhi Memorial Hospital in Malé transfused HIV positive blood to a patient due to an alleged technical error.

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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.

Monitoring

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.

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Rising religious fundamentalism, conservative thinking impacting women: Department of National Planning

Progress toward achieving gender equality has not kept pace with other development achievements in the Maldives, as reflected by the 12 percent of women who have suffered sexual abuse before the age of 15 while one in three have been the victim of violence, a Department of National Planning study has found.

The study examined how much human development progress has been achieved in the Maldives in terms of population and development, reproductive health and rights, gender equity, equality and empowerment of women as well as education during the period 1994 – 2012.

The “Maldives Operational Review for the ICPD Beyond 2014” study was conducted under the supervision of the Department of National Planning (DNP), in collaboration with the United Nations Population Fund (UNFPA), to determine whether the Maldives has met the 1994 Cairo International Conference on Population and Development (ICPD) thematic Programme of Action (PoA) goals.

The study found that “Despite impressive advancements in all development areas, the progress towards achieving gender equality and equity and the empowerment of women have not been the same.”

“Even though, the Maldivian Constitution guarantees equal rights and freedom for all Maldivians without any discrimination, prevailing traditions and socio-cultural norms have limited women’s participation in the workforce and in the community,” the study determined.

“The increasing level of religious fundamentalism and conservative thinking has worsened the situation,” it added.

Although the Domestic Violence Act 3/2012 was “a historical milestone for women in the country,” domestic violence and violence against women remains a “major concern” in the Maldives.

“One out of three females aged between 15-49 years has experienced some form of violence within their lifetime. Further, 12 percent of women reported having experienced sexual abuse before their 15th birthday,” the report stated. “Most of the time, the perpetrators are a close family member or intimate partner and the incidence goes unreported and undocumented.”

Victims to not receive appropriate and timely support, since domestic and sexual violence are perceived as a private matter and often go unreported, the study found.

Additionally, “Women continue to be stereotyped and underrepresented at professional decision making levels,” noted the report.

The low level of women being represented in senior level positions is partly due to the “high domestic burden on females,” with women heading 47 percent of households in the Maldives, one of the highest rates in the world, the study determined.

Although women are represented in the workforce, they are “mostly represented in stereotypical roles” such as education (72 percent), health (68 percent), manufacturing (65 percent) and agriculture (64 percent), said the report.

Meanwhile, 40 percent of young women remain unemployed, with 10.5 of the overall youth population being neither employed nor seeking to further their studies, the report added. Employment opportunities for many have been obstructed primarily due to inadequate employment opportunities as well as the mismatch between skills and job requirements.

The report also found that the number of women continuing their studies beyond secondary education is low compared to men. This disparity is the result of “limited access to educational institutions at the island level, domestic responsibilities and hesitance to allow females to study on another island.”

“Special affirmative actions are needed to create more employment and livelihood opportunities for women and to increase the number of women in public and political life,” stated the report.

Despite the Maldives achieving the Millennium Development Goal target to eradicate extreme poverty and hunger, malnutrition and anemia are still limiting women’s equality, equity and empowerment, noted the study.

“Poor nutritional status and anemia are significantly high among pregnant women and women of reproductive age, [which] puts them in high risk for maternal mortality,” the report found. “Malnutrition among women puts them in high risk during pregnancy and hinders their full participation in education, employment and social activities.”

Women – and young women’s – health is also at risk due to the lack of access to quality services, particularly in regard to sexual and reproductive health.

“With regard to reproductive rights, men often control decisions regarding women’s reproductive health, often based on religious and cultural grounds,” the report noted.

“[Furthermore,] the sudden growth of religious fundamentalism and conservative thinking is an emerging challenge, particularly for women and young girls,” the study stated. “There have been increase towards certain trends such as preference for home schooling and refusing vaccination and other medical services for women based on religious beliefs.”

Violence against women

Despite the extensive provisions in the Domestic Violence act, it has done little to curb the abuse of women, minors and other vulnerable people; the police, the judiciary and wider Maldivian society have made minimal progress addressing domestic violence and abuse, former Gender Minister and Chairperson the Hope for Women NGO, Aneesa Ahmed, recently told Minivan News.

Meanwhile, support for women’s equality has experienced a “significant drop” despite overall progress in improving the human rights situation nationally, a Human Rights Commission of the Maldives (HRCM) second baseline survey recently concluded.

“Despite the freedoms that the constitution has provided for women, attitudes towards women’s empowerment show a negative trend,” stated Andrew Cox, the former UN Resident Coordinator and UNDP representative in the Maldives.

“Alarmingly, the study also suggests that there has been a regression in people’s sensitivity towards domestic violence and gender based violence,” he added.

Male attitudes have become “more conservative” regarding women’s rights issues, whereas female views have become more supportive of rights in some areas, the report stated.

In a reversal from the 2005 human rights study, more women than men now consider it inappropriate for men to hit their wives. However, significant numbers of respondents stated where there was a “substantive justification” – as opposed to something trivial – “violence against wives was justified,” the report determined.

Both genders in the Maldives were also found to believe that in the husband/wife relationship, women should play a “subordinate role”.

In spite of this culturally conservative shift regarding women’s rights, an “overwhelming” 92 percent ofMaldivians believe that laws and systems to protect women from sexual assault should be reformed, according to the results of a survey conducted by Asia Research Partners and social activism website Avaaz.org.

Of those polled, 62 percent supported an outright moratorium on the practice of flogging, while 73 percent declared existing punishments for sexual crimes were unfair to women.

The international community has echoed this sentiment, particularly in regard to the recent
case in which a 15 year-old rape victim was sentenced to 100 lashes and eight months’ house arrest for a separate offence of fornication garnered substantial international attention and condemnation.

In March, an Avaaz petition calling for the repeal of the sentence and a moratorium on flogging in the Maldives collected more than two million signatures – a figure more than double the number of tourists who visit the country annually.

Currently, British couples are being asked to avoid the Maldives as a honeymoon destination to force the country’s government to overturn the conviction of the girl, who was given the draconian sentence after being raped by her stepfather, while UK Prime Minister David Cameron has been asked to intervene in the case, writes Jane Merrick for the UK’s Independent newspaper.

Maldivian Democratic Party (MDP) MP Eva Abdulla explained the current context of women’s rights in the Maldives to the publication.

“Consider the statistics on flogging: that 90 per cent of the cases are women. Consider the statistics on rape charges: 0 per cent success rate of prosecution, with the latest being the release of four men accused of raping a 16-year-old, on the grounds that there wasn’t enough evidence,” said Abdulla.

“The increasing religious fundamentalism followed by the attempts to subjugate women, both politically and otherwise, should be cause for alarm. This is a country of traditionally very strong women.

“However, increasingly, the Adhaalath Party, a self-claimed religious party which is in alliance with the current government, uses the religious card to scare off women. We women MPs are often threatened whenever we speak against the party,” she added.

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ADK hospital extends lease, signals US$23 million expansion

Male’s privately-owned ADK hospital has extended its lease by 50 years and announced a US$23 million to expand services.

The hospital’s Chairman Ahmed Nashid told local media the expansion project would be partly funded using a loan from the German Development Bank, and would double the hospital’s capacity.

The expansion will include four operating theatres, critical care facility, a senior citizen’s unit, cardiac laboratory, MRI machine and a power house, ADK Managing Director Ahmed Afaal told local media.

The hospital will also construct a health science school and grant 10 scholarships providing board and lodging for students coming to Male from the islands.

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Maldives no longer “tolerable” for foreign doctors, expatriate medical officer claims

Expatriate medical professionals working in the Maldives regularly face intimidation, fraud and “substandard” treatment from patients, health authorities, local staff and the country’s courts, a foreign medical officer working in the country has revealed.

The expatriate medical professional, who has worked in several posts across the country since 2009, revealed that along with widespread reneging on contracts and failing to deal with intimidation of expatriate medical staff, health officials had, in certain cases, not even checked whether foreign doctors were registered to practice medicine.

“Earlier there was a system of asking doctors for the registration of their basic medical degree (graduation degree) in their own country so as to register them in Maldives,” he told Minivan News. “This law was so compromised over the last two years that in one atoll alone, four unregistered doctors are to my knowledge still practising their absent skills here. Frankly speaking, they can kill anybody just by their lack of knowledge, but some get caught on occasion.”

Medical authorities have claimed they were aware of a number of concerns regarding doctor registration, a situation currently being reviewed in conjunction with the Maldives Medical Council. However, the Ministry of Health and Family denied that a fall in the number of doctors coming from India to practice in the Maldives was related to alleged treatment by authorities and patients on islands – instead noting improved pay rates currently offered in their home country.

However, raising concerns over a “deterioration” in the quality of healthcare being provided in some atolls during the last two years, the expatriate medical officer – who asked not to be identified – also detailed a number of issues over the treatment of foreign workers in the country.

According to the whistle-blower, there were growing concerns among skilled expatriates working in medicine and education in the Maldives that was losing the country its reputation as a “tolerable working place”.

Fewer doctors from India were coming to the Maldives year-on-year, the source observed, in part to what he called “public intolerance” of an imported non-Muslim work force.

“The overall behaviour of the Maldives Ministry of Health and Family and government has been negative. [There is also] an lack of availability of US dollars and the Bank of Maldives (BML) has banned issuing international ATM cards to expatriates,” he said. “Meanwhile, there has been an increase in the exchange rate of the US dollar, but no increase in the salary structure in Maldivian rufiya (MVR), meaning salaries are less than before. There are also instances in which the lawlessness of this country has led to the lack of punishment of Maldivian nationals even for heinous crimes like rape if the victim is an expatriate.”

“Violence”

Taking the example of Gaafu Alif (GA) Atoll, where the medical professional has had experience of working, he alleged “constant fear” and intimidation were regularly experienced by foreign healthcare professionals.

“Increasing instances of violence against expatriates is being reported from everywhere in Maldives,” he said.

On the island of GA Villingili, the medical professional claimed that one paediatrician from Pakistan working on the island was physically assaulted after failing to provide a referral letter demanded by some of his patients.

“I myself was on duty, so we had to make the legal documents for him. Afterwards nothing happened and [the doctor] left after just two days without the intention of continuing their contract. [The doctor] is still working in the Maldives, but somewhere else now,” he said.

“[Another doctor] from Uzebikstan also left GA Atoll because some local teenagers beat her two children. The matter became worse when she and her husband reacted with anger towards these boys. People were singing ‘We will kill you…’ on the roads whenever they came out. Ultimately [the doctor] requested for a transfer and is now working in Faafu Nilandhoo Atoll.”

The medical officer added that from his own experiences, skilled expatriate workers across the Maldives faced intimidation and sexual harassment on the islands, with cases such as expatriate teachers having to defend themselves in their own homes.

“I myself have heard some patients calling me or my colleagues their servants and threatening to do what he/she tells to, or else,” he said. “Interestingly, local staff never help in these situation a because they think we they will not be affected much because we don’t know Dhivehi. The situation becomes much more painful as many of us understand the language quite well. These are just glimpses only. And only of [GA] Atoll. Imagine what will happen if we collect together all the things which have gone wrong across the Maldives.”

The medical professional claimed there were also concerns about how authorities were treating doctors in the country, particularly in regards to contractual obligations such as agreements on wages and accommodation.

According to the source, a number of doctors had shared concerns about amendments made to their contractual agreements without their consent or knowledge once they arrive in the country – both in terms of salary and housing.

“When a doctor lands in Male’, only then [do authorities] reveal to him or her that actually this offer letter is an old one and now the salary structure is a little different. It is always like that. So many times they have done it that now people know about it unofficially and openly and make fun of it,” he claimed.

“Authorities write in their offer letter about free residence while working here. It is mentioned in this form of providing free residence or as much rufiya through a housing allowance, plus their people will help you find a place. They don’t, of course,” he said.

The medical officer claimed that he was personally provided with a housing allowance of MVR 3,000 ruifiya (US$195), assistance in finding accommodation had not been given.

However even upon finding accommodation, a former expatriate paediatrician from South Asia, who was living and working in GA atoll, was alleged to have been evicted from a property on one island by its owners with less than 24 hours notice after they found a tenant willing to pay better rent for the accommodation. The doctor left the island he was assigned after a month and a half due to being unable to find accommodation.

The medical officer added that authorities were ultimately failing to support skilled expatriate workers in favour of local staff who often had no medical or management training.

“It is an everyday story in this hospital and everywhere else in Maldives. Even at Indira Gandhi Memorial Hosptial (IGMH) [in Male’],” he claimed. “Far lower qualified local staff are working with a salary on par with far better qualified expatriate staff, and doing nothing on duty. It frustrates expatriates every single minute. It is not justifiable but local administration support it.”

The expatriate healthcare worker pointed to his own experiences in an atoll hospital, where he claimed trained nurses were having to clean the nappies of elderly patients due to the refusal of local sanitation staff – known as sweepers – to do so.

“This work is for local sweepers, but they often refuse to do it, forcing the staff nurses through equally arrogant management to perform the actions,” he claimed. “They don’t understand that a staff nurse, who has to administer injections and medicines to patients, will get their dress soiled by the excrement if they clean the stool of these patients, and in turn some patient only is going to receive it in returb as a hospital born infection.”

Healthcare provision

Beyond the treatment of expatriate health professionals, the medical officer highlighted a number of concerns about the operations of the nation’s hospitals, such as the impact of the launch earlier this year of the Aasandha universal health scheme.

The medical officer claimed that Aasandha had in fact led to a growing trend of pharmacies bringing in low cost “garbage” medicine to the country, on the grounds that the Aasandha budget was insufficient to acquire medicines from what the medical officer called “standard companies”.

“This in turn is is playing with the health of people by bringing introducing antibiotic resistance or uncompensated chronic diseases due to irregular and uncontrolled dosing of drugs,” he said.

“With the pricing of drugs, we write the number of tablets to be 12. The pharmacy gives seven or eight. Patients don’t know about these things. And as a result they come back to us with partial recovery and antibiotic resistance.”

The medical officer said that in order to try and overcome the limitation, doctors were having to recommend larger prescriptions to ensure a sufficient number of tablets were provided by the pharmacy, before asking patients to return to them to amend the amount they should be taking.

“This way the patient gets the needed amount of medicine, the dosing of which I correct myself after calling him/her back to me with the medicines. This practice is risky but at least I succeeded in managing my patients successfully,” he said.

According to the medical officer another key problem with Aasandha was the lack of public understanding concerning the scheme and entitlements of the public.

“They become very angry when we tell them that this or that medical condition is not covered by Aasandha. A lot of times they force the management to force us to fabricate a medical condition just to get Aasandha approval,” he revealed.

Soon after the scheme had been launched in January this year, Health Minister Dr Ahmed Jamsheed – then Chief Operating Officer at Male’s ADK hospital – said limited information on Aasandha’s financial structure had led the public to exaggerate their medical needs. He urged for a greater sense of public responsibility to prevent overwhelming the country’s health service.

However, calls to limit Aassandha have so far proved divisive in parliament and the present coalition government. Ahmed Thasmeen Ali, head of the government-aligned Dhivehi Rayyithunge Party (DRP), has previously been an outspoken critic of limiting the provision of universal healthcare at private premises.

The medical officer added that national healthcare provision had also been affected by the launch during the previous government of seven provincial health corporations designed to try and decentralise health care and budgets.

According to the expatriate medical officer, the establishment of the corporations was seen as an attempt by the former government to ensure the work of the Health Ministry was being controlled by government rather than opposition supporters already working within healthcare.

“Splitting the [work] of the Health Ministry into corporations was not a bad idea although it was more motivated by ability to acquire financial control rather than anything else,” he claimed. “The local governance had one thing positive; we could at least address our problems with our employers easily. They were accessible. Although they seldom made any difference, at least there was no frustration that I could not even talk to the authorities. Nowadays, no one can talk to the Mnistry of Health people as most of the time either they simply don’t pick the phone or you cannot connect to them.”

The medical officer said a growing sense of frustration and the shared of experiences of expatriates and healthcare professionals from across the South Asia region had seen the Maldives’ reputation as place to practice medicine tarnished in recent years.

“All these stories do reach [places like] India and I don’t feel that people will tolerate this much more. That’s why there is a constant decline in the number of people coming from somewhere like India to work here in whatever form,” he observed.

Indian High Commission concerned

Earlier this year, Indian High Commissioner Dynaneshwar Mulay raised concerns over the treatment of expatriates from across the South Asia region – particularly by the country’s police and judiciary.

Mulay claimed that alongside concerns about the treatment of some Indian expatriates in relation to the law, there were significant issues relating to “basic human rights” that needed to be addressed concerning immigrant workers from countries including Sri Lanka and Bangladesh.

Addressing the claims, Zaufishaan Abdulla Kamaludeen, Director of Human Resources for the Health Services Corporations, which is currently run under the Ministry of Health, said that while expatriate doctors had traditionally been sourced from India, it had become increasingly difficult to bring them to the Maldives.

Kamaludeen stressed that this change appeared mainly to be a result of more competitive rates of pay for medical staff in India compared to the Maldives

“There have been spikes in the salary packages being offered to doctors from India. This is maybe a reason why since about March 2012, when I joined the Health Ministry, we have been having difficulty getting Indian doctors to work here,” she claimed. “We have been getting many applications from doctors from Pakistan,” she added, stressing that medical personnel were also being sourced from countries like Myanmar to cover demand in the country.

Kamaludeen added that it was traditionally difficult to place expatriate doctors on islands in the country’s outer atolls, a situation he claimed was complicated by the tendency of healthcare professionals to network about their experiences.

However, she denied that the difficulties and complaints recevied staff were a result of intimidation or the attitudes of local staff and patients to foreign workers. Kamaludeen claimed that requests for transfers for most often related to “personal issues”.

“Mainly we get requests for transfer from islands relating to personal problems. These vary on a number of issues such as the availability of vegetarian food,” she claimed. “We also get requests from doctors wishing to work close with other doctors, so they don’t feel isolated on arrival.”

Kamaludeen added that another challenge with placing doctors had come from the set up of certain health corporations to pay skilled medical staff more than if they worked in another region.

“Doctors at times would demand to work for the corporations offering the highest pay,” she said. “Right now, a board has been established to try and harmonise salaries for staff working in different atolls.”

Addressing allegations that there had been issues with the registration of some expatriate medical staff to practice in the Maldives, Kamaludeen said that the ministry had been made aware of instances of doctors working with improper registration.

However, she said that in such cases the Maldives Medical Council had been immediately informed and a review was presently taking place on the issue.

Kamaudeen claimed the issue appeared to have arisen over a lack of awareness of the type of licensing required to practice n the Maldives.

“We have understood this to the result of a lack of information being provided from recruitment groups and agencies,” she said.

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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.

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The price of healthcare in the south

A team of retired Royal Air Force personnel are trying to raise money to help a small community in the Indian Ocean gain access to the vital healthcare they need to subsist. Inspired by this group’s determination to help this impoverished community in the Maldives – a land oft-associated with luxury – Donna Richardson travelled to the Addu region to uncover the real state of medical care on an island that used to enjoy free, first class medical care while the island was a Cold War staging post.

Because of its geography, it is easy to cover up the poverty-stricken side of the Maldives’s inhabited islands. The Maldives is seen as a luxury holiday resort destination, but in fact there is hardly a place where the contrasts between rich and poor are so pronounced. While millionaires sup their cocktails, the indigenous peoples barely scrape by on a dollar a day and many are priced out of the most basic medical care because of the rising cost of health.

The RAF have long left Addu Atoll (‘RAF Gan‘) in the Maldives where they were stationed during the 1970s, but for some servicemen such as Richard Houlston and Larry Dodds, Addu has remained close to his heart. Upon returning to the island during a memorial visit last March, he saw first hand how locals are suffering and denied access to even the most basic of medical care. He decided to see how he can help a community which he loves dearly. Along with a former colleague Phillip Small, they have been trying to establish a Gan Medical Fund to help to raise awareness of the issues the island faces, provide medical equipment, and eventually if there is enough funding when it takes off, to train the future generation of doctors.

When British Forces left the region, the hospital as well as the expertise and knowledge also vanished (allegedly the equipment all moved to Male), and with the establishment of a dictatorial government regime, Addu stepped ten steps back in terms of their medical facilities.

Based in the south of the country, Hithadhoo Regional Hospital (HRH) is the main public provincial health care facility providing curative public health services and is the only government hospital in the province. The hospital is located in the capital of the south atoll, in the furthest corner of Addu Atoll, and covers seven districts over two atolls. It serves 50,000 patients, including the inhabited islands of Hulhumeedhu and Fuvahmulah, but has only 50 beds.

Lack of funding, limited expertise and treatment for only those who can afford it – this is the picture of government health in Addu, but things are improving, according to the new director of the recently-formed Southern Healthcare Corporation Hussein Rasheed.

“The biggest challenges are most of all the lack of equipment, then patient load, then the quality of doctors, but we are changing things,” Hussein Rasheed said.

Now run under the 100 percent government-shared trust, the hospital also hopes to leverage revenue from the new national health insurance schemes to cover its costs and to help raise vital cash for the departments.

For some years now medical facilities for those living in Addu Atoll and its far-flung neighbour, Fuvahmulah, in Nyaviyani Atoll have been overstretched and in short supply. Many of the problems are hereditary. The aging 26-year-old hospital building is a relic of the Gayoom regime. It is in bad shape, with crumbling walls, unstable voltage, barely enough beds and no air-conditioning. Post operative patients swelter in temperatures akin to a sauna and the hospital is in desperate need of improvement. There are plans to build a new 100-bed hospital with a government loan and charity funding, but it will take a year to secure the funding and then to find a site.

Due to its previous funding constraints, HRH is currently understaffed and runs more like a general surgery practice found in most developed countries. Although it does have practically all the departments required to make it a hospital, most areas are understaffed and in need of vital equipment from donors and charities. As a public hospital it is appealing to charities and non governmental organisations to help it to serve its community and restore public confidence in its services.

At present there is still not enough basic equipment for the hospital to function. It was not even able to provide basic X-rays at the time we visited. Since the last one blew up due to faulty voltage in the building, a new X-ray machine was purchased but has stood in a box because of the risk of damaging the new equipment.

While HRH does have basic outpatient clinics including dental, ear nose and throat (ENT), gynecology, internal medicine, ophthalmology, orthopedics, paediatrics, reproductive health, diagnostics imaging services, and ultrasound scanning and physiotherapy services, there are not enough specialists to staff these departments or the right equipment to provide full services under these remits.

Previously most equipment was donated by NGOs and charities such as World Health Organisation, United Nations Children’s Fund, JICA and the Japanese as well as the Chinese and Australian governments. They have pledged to continue to work with the Ministry of Health and Family to procure equipment.

But the hospital urgently needs a CT scanner, MRI machine and incubators plus vital surgical instruments such a chest stapler and cannulas for performing tracheotomies. Each and every department needs more equipment.

Two rusty ambulances sit grounded on the parking lot. All gifted by various NGOs and nations, these vehicles need parts which are unavailable in the Maldives. One is a Japanese vehicle donated by the Japan Council of International Schools (JCIS) which requires expensive parts, and the other is a converted minibus with the seats relaxed to make room for stretchers.

Two more vehicles sit rusting in the garage. While these are in better shape they need parts and technicians to service them. The only functioning ambulance is an old ‘green goddess’ type vehicle gifted by the Australian government, which is used infrequently.

The Casualty and Accident and Emergency unit has just two beds. A serious road traffic victim was brought here just last week had to be transported to Male’ by Maldivian Air Taxi at his own cost. In cases such as this, if there are no seats, or medical insurance does not cover the patient, they simply cannot receive the vital care they need. It becomes a ‘pay and display’ system of healthcare.

Even the labour suite is ill-equipped for delivering babies. One small baby was fighting for his life in intensive care at the time of visiting. The infant’s parents said they could not afford the transportation to give birth in Male‘. The hospital urgently needs an incubator and does not even have a paediatric ventilator to aid distressed infants.

While the hospital does have an operating theatre with one operating room there are no specialist surgeons to perform vital operations and just two general surgeons.

Collectively this means that the hospital is unable to function to full capacity and the public is losing confidence in the medical care available in the atoll. While there is a surgical theatre, there are only two qualified general surgeons whose knowledge extends only to hernias and small operations.

These conditions and the need for basic equipment are urgent issues and the hospital is appealing for outside help and funding to solve these shortages.

A question of confidence

Another challenge the hospital faces isthe need to restore public confidence in its services. Facing huge waiting lists, patients with serious health conditions opt to travel to Male’ or India for treatment if they can afford it, and the hospital stays stuck in a rut. Yet these ‘health tourists’ face great perils amidst cases of organ trafficking and alleged substandard treatment in southern India.

A young girl from Hithadhoo told us how her family were forced to sell their car and personal possessions to pay for her mother to go to India for a leg operation. Her brother also has eye problems and needs to attend regular eye clinics, which the hospital does not yet have, although there are plans to introduce under the Madhana health scheme.

“My mother suffers from arthritis and rheumatism and needed to go to India for treatment,” she said.

“She was very ill and needed treatment and we have lost faith in the hospital here in Hithadhoo so we decided to go to India where the treatment is better value for money.”

Travelling for medical treatments is a costly business. Patients must pay for the airfare, accommodation and treatment, but people believe that the care they receive overseas is better and so the cycle of health tourism continues.

One of the ways that Hithadhoo Regional Hospital wants to counter this health tourism is to introduce ‘telemedicine’, whereby customers can be confident that their results will be seen by qualified medical specialists from around the world, and also to introduce visiting surgeons and hold specialist surgery days.

Rasheed admitted: “People are not happy with the level of care. Right now we don’t meet the basic requirements so many people decide to go to Male’ for treatment and when they don’t see any difference in services, they go to India.”

He warned of the dangers of travelling abroad to India for treatment. The practice of medical tourism there is not regulated and patients organise the travel plans themselves.

“While there are many good quality doctors in India, there are also huge problems with cheating in India, particularly in the south,” he said. “Someone recently went to India for surgery and ended up having a kidney removed. Health tourism is a very risky business,” he added.

Another patient told how his father in-law has been regularly travelling to India to receive palliative care for lung cancer. Put simply, there is no care of this type available in the Maldives.

Until now talk of cancer has been taboo, although cancer and heart disease are some of the biggest killers in the Maldives. But with no oncology or cardio department, or even an ECG machine, many people are forced to travel farther afield to receive treatment. In the past, limited information has been available about preventative measures so many people die earlier than they should.

There is no palliative care in the islands and only limited care for cancer patients even in Male’, and no facilities to perform open heart surgery or brain surgery.

Rasheed himself is interested in studying more about cancer and its causes to help to inspire health promotion campaigns and attract more doctors to the region.

In its favour, HRH does have an ISO-certified laboratory which is fairly advanced and offers some patient services including intensive care units and neonatal intensive care departments.

The hospital is also working on its health promotion,  including child immunisation and growth monitoring, vector control, food hygiene and sanitation, disease surveillances and epidemic control, family planning, sexual transmitted disease clinic and turboculosis and leprosy control.

The hospitals’ three-year plan includes building a new hospital within a year, improving services in all areas, focusing on preventative health and education and introducing exchange programmes for doctors to visit the hospital and to partner with the private hospital in the region.

Rasheed said he has removed some of the ‘dead wood’ and de-motivated staff from HRH and replaced them with more high-energy staff. He hopes to turn the hospital’s reputation around in three years.

“When I took over the hospital here, we inherited a bad system, de-motivated staff and dated equipment,” he said. “In the past the doctors here were neglecting the needs of the patients. They knew they could do operations, but they were so de-motivated that they decided they could not do it and on many occasions we sent patients away,” he revealed.

These conditions and the need for basic equipment are urgent issues and the hospital is appealing for outside help and funding to solve these shortages.

There is also a need to distribute medicines for psychiatric patients, improving antenatal care and introducing an electronic record keeping system. At present patients with mental health issues are being released into the community without proper care and attention.

In addition, some elderly patients who have been abandoned by their families have taken up residence in the hospital.

However, things are starting to improve at the hospital after a change of management. Over the last three months since taking over the hospital trust, Rasheed has been making major strategic changes. In part this is due to a government reorganisation, which has placed all Maldivian hospitals under a new structure – which will operate more like a business, taking fees and charges from patients covered by the health insurance system.

“In the last couple of months we have managed to improve the level of confidence – for example, allocated a special day for general surgery where we have seen a couple of hernia patients, and we have been getting some good feedback. News spreads through word of mouth here,” he added.

With a limited budget to hire qualified doctors, the hospital is considering hiring visiting practitioners and surgeons. They are also appealing for the humanitarian services of voluntary, retired or semi-retired surgeons and specialist doctors to spend some time at the hospital in exchange for free accommodation, air fare and a share of commission from the profits gained from the operations they perform.

In the last month, the hospital hired a new Maldivian surgeon, a former classmate of Rasheed, who has performed basic operations. Just the other week they performed two hernia operations and feedback from the local community has been quite positive, according to Rasheed.

The two surgeons, Dr Fuammi Moustaffa and Abdulla Adsa, admitted that they were limited to small cases because of lack of equipment. Their remit includes appendicitis, hernia operations, cyst and gall bladder removal.
“We want to do more, but we don’t have the equipment or the specialists to perform other operations,” admitted Dr Moustaffa.

In January, the Israeli Eyes from Zion charity visited the hospital and removed cataracts from patients. There are plans for more visiting practitioners over the next few months.

Due to increasing demand for tertiary services in the provinces, with more funding it is planned to develop a specialised service centre for trauma treatment and the development of their service portfolio, as well as to improve provision of quality health care services.

The areas that they want to focus on include advanced diagnostic services such as MRI, telemedicine and treatment of kidney/renal conditions (including dialysis services) and establishing a provincial Emergency Medical Service (EMS) to international standards.

The hospital needs full time paramedics, fully-fledged ambulances, development of intensive care services and the development of a provincial medical emergency coordination centre.

Meanwhile, there is a private hospital called IDMC (run by the Simdi group) aimed at paying customers and those under the Madhana health scheme, such as civil servants. This hospital, run by Mariyam Shakeela, a former Hithadhoo resident, aims to provide first class medical care, but also requires more doctors to propel it to national standards. The hospital is currently campaigning to become an NGO called the Hawwa Trust to help alleviate some of HRH’s problems.

Eventually, once the basics are in place, Addu wants to develop medical tourism to attract patients to the Maldives. But for now this ambitious plan is limited until they come up to scratch on the other areas which are seriously lacking.

Donna Richardson is a freelance travel writer based in the Maldives.

For more information on Hithadhoo Regional Hospital visit www.shsc.com.mv

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President Nasheed says improving tertiary education essential for country’s future

President Mohamed Nasheed said special measures are needed to increase the Gross Enrolment Ratio (GER) for tertiary education by 40 percent over the next five years.

The GER shows the levels of enrolment for primary, secondary and tertiary education.

President Nasheed said to increase the GER for tertiary education, reforms in the school system were needed, as well as an increase in secondary education. He said three out of four students took the commerce stream, resulting in limited opportunities for employment and higher education.

President Nasheed said passing the Maldives National University Bill was of utmost importance, as well as transferring research work from government offices to the national university.

The president added that it is crucial to start medicine courses in the Maldives, as 340 doctors are needed to provide quality healthcare. He said the government would provide loans for higher education outside the country, including 50 student loans for nursing and medicine courses.

President Nasheed said starting degree courses in areas such as architecture, quantitative surveying and town planning also needed to be started.

He noted that capacity building in the judiciary was another important area.

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