Cabinet consultations continue over hospital upgrade plans

The cabinet is working to finalise proposals for upgrading Kulhudhuffushi Regional Hospital and Addu City Regional Hospital in order to match the services provided at Male’s Indira Gandhi Memorial Hospital (IGMH) and better meet the challenges facing the country’s health sector.

The Ministry of Health was not able to detail the exact nature of these proposed upgrades when contacted by Minivan News, but said discussions would continue in cabinet over the next few days regarding the “improvements” required to the hospitals and the wider health sector.

According to the President’s Office, a steering committee of cabinet ministers has been drawn up to try and outline the direction of the hospital upgrades and identify present shortcomings within the country’s health services.  Efforts for combating the spread of dengue fever are also said to be a part of the discussions.


News report links Maldives to Indian health insurance scheme

The Maldives is reportedly among a number of nations showing interest in an Indian health insurance scheme designed to aid workers earning below the poverty line from significant hospital costs.

The India-based Economic Times newspaper on Friday (July 1) quoted Anil Swarup, Director General for Labour Welfare in Delhi, as claiming that delegations from countries like the Maldives, Nigeria and Bangladesh had sought technical guidance on potentially implementing and running the Rashtriya Swastya Bima Yojana (RSBY) scheme in their respective nations.

The claims were made during a state-level workshop on the insurance scheme that was held in India.

RSBY was launched back in 2007 as a partially state-funded insurance plan to protect low earning families in the country by covering medical charges of up to Rs 30,000 (US$642) after the claimant pays a initial Rs30 (US$0.67) registration fee, the news report added. About 25 states in the country are reported to have signed up to the scheme.


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

Cathy Waters is the new Chief Executive of Indira Gandhi Memorial Hospital (IGMH), the main hospital in the Maldives. She is one of three foreign medical experts brought out by the UK-based Friends of Maldives NGO and the Maldives High Commission to improve the country’s standard of medical treatment, alongside Medical Director Dr Rob Primhak and Nursing Director Liz Ambler.

JJ Robinson: How did your role at IGMH come about?

Cathy Waters: I’ve been on holiday to the Maldives many times, but it’s been a very different experience living and working here, compared to the sanitised version [of the country] you get at the resorts.

I knew nothing about Friends of Maldives – instead a friend of mine sent me an advert in the Health Services Journal, and said “This is the job for you.” I thought it was interesting, was interviewed in December and found myself out here very quickly, in February.

My background is 28 years working in the UK’s National Health Service (NHS), starting as a clinical nurse and working my way up. For the last 15 years I’ve been working in management, and the last eight as Chief Executive of a primary care trust, which commissions health care services.

I’ve had lot of exposure training and working in hospitals, as well as the broader healthcare system. I left the NHS three years ago and worked in a small management consultancy in the UK, which involved going into companies that were facing problems, and working with them to solve those and bring about change.

My last big contract involved working with big local authority in London than needed a transformational change. In reality it meant making significant savings – we had to make 80 people redundant.

JJR: What was your understanding and knowledge of what the position involved before you arrived?

CW: I understood that IGMH is one of five entities that comes under the umbrella of the Male’ Heath services Corporation (MHSC), IGMH being the largest entity, at about 90 percent.

I knew they needed to make significant changes to patient care, and the overall environment for patients. I knew IGMH needed change, which was part of attraction for me as it was somewhere I could utilise all the skills I had to bring about that change.

I also knew it was a hospital that people care passionately about. There’s a real sense that it belongs to the community and that we should be providing high quality services.

One of the things I noticed early on was that staff morale was very low, and people were unsure about what was happening with the organisation and had all sorts of concerns about the future. One of the things I did when I started was observe what going on and try to be very visible as a chief executive, spending time with the doctors and in the labour ward.

A new executive nurse director Liz Ambler is already here, and a Medical Director Dr Rob Primhak will be joining in July, so together we want to be able to demonstrate importance of management staff and clinical teams working closely together. We need to break down some of those barriers and reduce the divide between management and clinical services.

JJR: You arrived three months ago on the tail end of the collapse of the Apollo deal, a 15 year agreement signed in January 2010 with India’s Apollo Hospital Group to manage IGMH. What actually happened?

CW: I did read about Apollo. My understanding was that they wanted to bring about significant change but they wanted significant resources to do that, and that wasn’t an option. One of the things I’m very clear about is that we need to bring about significant change, but within the existing budget. That might involve reviewing everything we do as an organisation.

Unless we can find resources elsewhere we have to work within the budget we’ve got. That’s quite a challenge, because previously there may not have been the same budgetary controls [there are now]. We have to be careful how we utilise our very precious resources.

JJR: What parallels have there been so far with your earlier experience?

CW: Working in an organisation where there are significant financial challenges, and working in an organisation where patient needs are very clearly evident. The population is very vocal about what they want and need – some of that is about manging expectations.

One of the things I know we need address is that people can’t access doctors as quickly as they want. We need to increase outpatient appointments. At the same time there is no system of triage, or prioritisation of the emergency room, which we are now developing.

JJR: It’s true that many people claim the quickest way to get an appointment is to have the mobile number of a friendly doctor.

CW: We have a Maldivian ER consultant in training who is coming back to develop a triage system and ensure those patients who need to be urgently seen are seen straight away, or that those with minor ailments are seen by someone else, or not as quickly.

From what I understand there isn’t a word in Dhivehi that translates into ‘urgent’. We have quite a lot of work to do to make sure patients get to the right place at the right time.

One thing common to people working in the NHS and IGMH is that staff are passionate about what they do. We have to channel that in a positive way. We need to engage staff in decisions rather than it being a top-down management style.

This means helping them to be part of the decision making process, which can be difficult to get your head around. The key groups are patients and staff – happy patients mean staff are pleased they are doing a good job, equally, happy staff are more likely to perform well.

Sometimes it’s very simple stuff – such as saying ‘Thank you, well done.’ I don’t think that’s happened here very often. It doesn’t take a lot to say thank you.

The work that went into planning for mass causalities for the Friday of the recent protests was great. It was a really great example of working as a team and getting everything ready for an influx of casualties.

I recognised the hard work that had gone in so I made sure I came in on the Friday and was part of what was going on, so staff felt supported, and afterwards I wrote a thank you memo. Simple stuff like that makes people feel valued for what they are doing.

IGMH was gifted to the Maldives by the Indian government

JJR: What have been some of the key cultural challenges?

CW: There is a very, very different work ethic to the UK. Some of the things I’ve found very different and very frustrating are about how people manage their time, and motivating people to work. That’s a huge issue.

Getting people to plan ahead and put processes together is challenging. One exciting project is expanding the intensive care unit – I said we need a proper process and justification of the expansion, a proper plan about how we are going to do this. For me there’s a discipline to this, but it’s not always the way things have been done.

Also different and very distinct to IGMH is the lack of use of email – staff still attempt to use memos. I’m trying to encourage the use of email, and encourage people to think ahead and write agendas for meetings.

JJR: On other side of the cultural question, what has been the reaction among staff to a foreigner coming in as a top-level manager?

CW: Inevitably there’s been a degree of suspicion at someone new coming in, at someone from the UK coming in and imposing their views. For me what has been important is how we work with people and lead. I firmly believe that how you lead is important – working with staff, rather than telling them what to do. You do need boundaries and parameters, but people need a sense of direction, and permission to do things themselves.

The other issue is that my contract is for a year with the possibility of extending to two years. Whatever I do, I will feel I’ve failed if I haven’t managed to find someone in IGMH to transfer leadership skills to, and leave a positive legacy. The worst thing would be for me to do would be to go back to the UK and for things to tumble down. That would be an absolute failure on my part.

JJR: How did these obstacles come across? Were there initial difficulties?

CW: People have been very accommodating and very welcoming. I’ve convinced people that they don’t need to stand up when I walk into the room, which was very traditional, and I don’t expect people to call me “ma’am”. People generally been very welcoming. There’s been a few challenges with language barriers, although this has proved less of a problem than I thought it would be. I have very good support in meetings- I might do an overhead presentation, and it is translated into Dhivehi. Unfortunately I’m failing miserably at learn Dhivehi words. Generally people have been helpful and make sure I’m involved in what’s going on.

JJR: What are some of the unique characteristics of the Maldivian hospital-going public?

CW: They are very demanding, and very quick to blame the doctors if things go wrong. Inevitably in a hospital things go wrong, by the very nature of the work we do. And because IGMH is the country’s main hospital, we inevitably get the more complicated and high-risk cases. People are quick to be cutting.

Equally the general public should demand good care, and rightly get that care.

We need to work to enhance communication. One of the things I’ve noticed that is quite different from UK is that different departments still work in silos. We’re trying to break down these silos and get people to work across the organisation.

JJR: There has previously been conflict and misunderstandings between Maldivian doctors and foreign doctors working at the hospital, amid the cultural challenges of having a high turnover of foreign medical staff. Is this something you have observed?

CW: It fascinating that the hospitial talks about ‘Maldivian doctors’ and ‘foreign doctors’ as though they are completely different. Part of the problem I think for the Maldivian doctors who are very dedicated and are here for the duration is that they don’t get some of the benefits expatriate doctors get, such as support with their accommodation. Inevitably that brings some degree of conflict.

Expat doctors are also here for a short time, and I’m making a huge generalisation, but the commitment of some of them may not be as high as that of the Maldivian doctors. Some of that is the sort of contract we have for expatriate doctors, and that needs to be reviewed. Some of the expatriate doctors see IGMH as a staging post to get broader experience and go off to somewhere else, which must be quite annoying for the Maldivian doctors.

We’re trying to move to a position where as much of the workforce as possible is Maldivian, but inevitably that takes time.

JJR: What about the training of local staff, such as nurses?

CW: We have a good relationship with the Faculty of Health, and more Maldivian nurses are coming back into the system. Liz [Ambler] is very keen on in-service training to make sure we are training effectively, and Dr Rob [Primhak]’s background is in education so I’m sure he’ll be keen to ensure high standards of education and training when he starts in July. It’s an area we’re developing.

JJR: How have you found living in Male’?

CW: We’ve settled in well. My husband is semi-retired; he used to be a director of Mental Health Services. He’s made a decision not to work at the moment – he’s a diver and he’s doing his diver master training and really enjoying it.

One of my worries at the hospital is that we haven’t got the facilities to care for patients at the acute stages of mental health problems, and we haven’t necessarily got the right staff.

JJR: What do you think of the relationship the hospital has with the community, and what did the outcry over the widely reported ‘baby decapitation’ incident tell you about that relationship (the head of a deceased newborn had to be surgically removed during labour after its shoulders became stuck during delivery, endangering the mother).

CW: I had only been here a few weeks when that happened. Without going into the details, what surprised me was how quickly quite confidential details about the patient and the case were spreading like wildfire across Male’.

Understandably there was a lot of anger and concern, and fear generated. One of the key learning points for IGMH was how we need to handle that more effectively with the media – we didn’t handle that very well at all. It’s in the hands of lawyers now – it was a tragic and very unfortunate case, and a very emotive situation. From the hospital’s perspective we did all the necessary investigations that we needed to do.

JJR: Does it come back to this recurring mistrust of doctors?

CW: That’s one of the things I’ve picked up on – there is this mistrust. We still have to rebuild that, because we have some fantastic doctors and clinical staff in IGMH, and inevitably when we have high profile cases like that it creates more damage for the medical profession, which bore the brunt of that incident. We need to be more proactive about how we talk about some of the great things that happen in the hospital.

I’m not sure Male’ is ready for it, but I’d like to start a patient involvement group – a number of people from the community who work with us to improve what we do in the hospital. We do that a lot in the UK, but I’m not sure people here would be interested in doing that yet. It does help people understand the challenges we face as an organisation on a daily basis.

The President has appointed an envoy to work with the hospital. He has already brought through some significant changes in terms of the environment. It’s looking much better when people come in, and the outpatient area is now air-conditioned.

We need to focus on what we need to do to implement quality of care and improving access – there are hundreds of things need to do, but have to manage expectations.

One of the things we want to introduce is catering – at the moment patients’ relatives have to bring food in for them. That’s so different to the UK – nutrition is so important to a patient’s recovery. We want to try and introduce a catering service before the end of the year, so patients get a better service.

JJR: What are the hospital’s key strengths and weaknesses at the moment, aside from the shortage of mental health support you mentioned earlier?

CW: One area we do need to improve on is diagnostic capacity, and tools for helping diagnose. We are going to get a mammogram machine, which will have the facility to do biopsies, and we are going to get an MRI scanner which will improve diagnostics.

One of the key problems we have is access to equipment and medical consumables. We’ve put new processes and deals in place which will hopefully improve that, but I didn’t realise until I lived here that absolutely everything has to be imported. We are reliant on things coming in a timely way, and I don’t think that just affects us.

We also have a hospital kindly donated by the Indian government, but inevitably the building itself is in need of renovation. It was fit for purpose then but with the influx of people living in Male’ the need for services is huge. We have 500-600 patients a day, sometimes more, and the building is almost too small now. We have to look at how we take care of it and develop a more modern facility.

One of our big concerns in relation to the operating theatre is lack of anaesthetists. We have to pay a premium for them to come, as there’s international shortage. That’s a real problem for delivering key services.

Those are some of the key areas. We have a good team paediatricians, and a very busy but effective neonatal intensive care unit with 20 cots.

JJR: Is it difficult to attract people to come and live and work in the Maldives?

CW: I think it’s becoming more difficult now because of the dollar situation, and the cost of accommodation in Male’. The MHSC provides accommodation to doctors as part of their package, but nevertheless food prices and living expenses are going up.

A big problem is paying people in rufiya – the expats who come and work in the Maldives want to send part of their salary home but banks are struggling to enable them to send dollars. That seems to be a very major problem at the moment.

The big thing is making sure there is the right commitment from expatriates to stay and make a positive difference. There’s got to be some way of making the working conditions right for the Maldivian doctors as well. They are the life of the organisation, and we are dependent on making sure they don’t move elsewhere.

We are in the process of expanding inpatient facilities, and renovating the old staff quarters into more private facilities. We will have 56 beds finished in late summer, and we have also signed an agreement with the 11 storey building next to IGMH to provide 72 beds. This time next year we will have a significant increase in the number of beds, but that brings its own problems, such as where we are going to get staff. We’re trying to make sure there is joined-up thinking going on.


Islanders allege black magic performed in Maalhos School after students inexplicably start to faint

At least four students in North Ari Atoll Malhos have been taken to hospitals in Male’ after they mysteriously fainted.

Five students attending the school have experienced the unusual incident, but the fifth student’s condition was not as serious as the other four.

One male student, who was the first to experience the unusual effects, reportedly lost conscious and was brought Male’ for treatment after he was found in a hypoxic condition, characterised by a lack of oxygen in the blood supply.

Several days later another female student experienced the same condition and was brought Male’ for treatment.

Third student studying at the school fainted while she was at home yesterday, and remains hospitalised in Indira Gandi Memorial Hospital (IGMH).

‘’She fainted while she was at home and she was taken to the health centre immediately,’’ said a family member of the girl, no older than 14. ‘’She remained unconscious for more than two hours in the health centre.’’

The family member said the girl had not claimed to have observed anything unusual before suddenly fainting.

‘’She did not see or feel anything unusual before she just fainted like the others,’’ he said. ‘’The health centre advised her to come Male’ for more treatment and for necessary examinations.’’

He said that many tests conducted so far all showed the results as normal.

‘’It is very strange, we do not know what is going on,’’ he said.

He also said that the fifth student to experience the symptoms, who was of the same age and fainted yesterday, was brought Male’ with her.

‘’The other girl that was brought with her was in a far worse condition. She remained unconscious for more than three or four hours and she does not know what happened to her,” he said.

The family member said that more than four men were needed to hold the girl down when she became conscious, and people observed that she was extremely strong for a girl of her age.

‘’We are suspecting that this is something related to black magic practices,’’ he added.

Another islander, Ahmed Adil ‘Ahukko’, alleged that the cause of the fainting spells was the performance of black magic during the Local Councils Elections in an effort to win votes.

‘’Because it was the island school where the elections were held, the person who did it would probably do it to the school so that it has effect on anyone that enters there,’’ he claimed. ‘’Parents are very concerned and have expressed concern about it now.’’

Although the island is small and isolated with a population of only a few hundred, belief in black magic remains very common and many claim to be victims of such spiritual attacks.


RAF man says Gan reunion the inspiration for Addu Atoll hospital fund

A recent return to Gan for one former member of Britain’s Royal Air Force (RAF) has reportedly been the inspiration for a fund aiming to strengthen medical facilities on the island.

Richard Houlston, from Devon in the UK, spent a year of his RAF service in Addu Atoll between 1969 and 1970, where he worked to maintain transmission equipment to support a nearby British airbase operated from Gan, reports the Express & Echo newspaper, published in Exeter in the UK.

Speaking to the newspaper, Houlston said that the Gan Scholarship Fund, which hopes to raise about £10,000 (Rf202,664) to provide training and equipment in order to try and boost medical facilities in the area, was formed after a visit to the island by 28 airmen the island earlier this year.

After being greeted and looked after by the people of Addu Atoll during a visit, which also included time for a spot of diving, Houlston said the airmen were concerned by the standards of healthcare available to local people.

“There is a hospital on the island of Hithadhoo, where I was working, but it struggles to give anything more than a basic service,” he told the paper. “The closest proper hospital is in India, over 1,000 miles away.”
At present, Houlston said £1,600 (Rf32,000) has been raised for the fund.

The RAF were based at Gan from the early 1950s to the mid 1970s.


Government reportedly terminates Apollo-IGMH deal

The deal between the Maldives government and Apollo Hospitals to manage Indira Gandhi Memorial Hospital (IGMH) has fallen through, local media reported Health Minister Dr Aminath Jameel as saying on Tuesday.

“We had to terminate the agreement because they [Apollo] were unable to meet the terms and conditions stated in the agreement. Every agreement specifies deadlines to settle certain matters,” Dr Jameel reportedly said.

“We have also informed them [Apollo] that the agreement has been terminated.”

Senior staff at the Health Ministry and Chair of the Privatisation committee Mahmoud Razee told Minivan News they had not been informed of the deal’s collapse and had only heard media reports. Minivan News contacted Dr Jameel but she was unable to confirm the reports as she was “travelling in the islands.”

The government reportedly terminated the agreement with Apollo after the Indian hospital giant was unable to invest the agreed amount to develop the hospital.

Apollo had estimated that it would cost US$25 million to bring the hospital up to global standards. The group also revealed intentions to make 80 percent of its employees Maldivian over a 15 year period, although it was unclear as to how this would be achieved given the lack of medical higher education facilities in the country.

Apollo planned to offer orthopedics, cardiology, gastro, neurology, acute care and trauma specialities in the first phase of the privatisation deal, as well as set up and operate a cardiology unit within the year, the Health Ministry stated when the deal was first announced in January.

CEO of IGMH Zubair Mohamed was not responding to calls at time of press, but expressed concern when the deal stalled in July, stating that uncertainly over the arrangement was making “little investments” more difficult.

“Apollo is an expert group and would bring a lot of benefits to the people,” he told Minivan News at the time. “They have the capacity to raise existing standards. But even if they do not come we will continue trying to improve services.”

However the agreement stalled after the private healthcare giant failed to submit a required operational management agreement by the July 2010 deadline. Both parties were required to cement the deal and sign the 12 year management agreement by the end of July.


Letter on Hulhumale’ Hospital

Mr President,

I am writing you, Mr President, to inform you about the death of a student of Grade 9 at Ghaazy School Hulhumale’ on August 9, 2010.

According to the student’s parents, the student attended Hulhumale’ Hospital with severe chest pain on August 8, 2010. A doctor (an Indian national) prescribed medicines and sent her away without doing any of the investigations which are usually done by good doctors.

Since all chest pains are NOT normal, this doctor should have referred her to the physician who is also working at Hulhumale’ Hospital. But this doctor neither referred her to that physician nor did any investigation like an ECG or blood tests, from which a physician could normally identify whether it was a chest pain related to gas in the stomach or a heart-related problem.

So, therefore, I would like to inform you Mr President, that this is a problem which has to be solved without any further delay. I also like to mention that this is a very sad story, and that many people who seek medical treatment at this hospital feel that some doctors and nurses are so careless that they recently gave an expired injection (which was sold by a pharmacy) to a young child without noticing that it was expired. This means neither the pharmacist nor the nurse noticed that it was already expired.

This is not something we can correct by investing additional money BUT we can easily with proper supervision of the hospital manager. For this hospital it is much, much easier to solve such problems because the hospital manager is both a manager and a medical doctor.

Mr President, this email is intended to inform you about what is really happening in our beloved country so that our beloved President could keep it in mind even with the very tight and very busy, VERY IMPORTANT engagements at this critical time.


All letters are the sole view of the author and do not reflect the editorial policy of Minivan News. If you would like to write a letter, please email it to [email protected]


Maldivian journalist and blogger found unconscious on Raa atoll

Well-known Maldivian writer and blogger, Ismail Khilath ‘Hilath’ Rasheed, 34, has been found unconscious from a suspected drug overdose on an uninhabited island in Raa atoll, according to a Haveeru report in Dhivehi.

Hilath was found unconscious at a beach in Furaveri, a garden island where he had been staying since last Saturday. The caretaker of the island found him at the beach around 4:00pm last Wednesday, said the Haveeru report.

Haveeru noted that Hilath was being treated at Ugoofaru hospital, and his condition was improving.

Today Police Sub-Inspector Ahmed Shiyam said Hilath had been released from hospital and is now being held in police custody while police investigate the drug related-incident.

“We tried to keep him under house arrest but his family refused and asked that he be placed in police custody,” Shiyam said, adding that the court had ruled that Hilath could be held for seven days.

Hilath, a journalist of 10 years experience, is one of the most outspoken and controversial figures in the Maldivian ‘bloggosphere’ and is well known for being highly critical of Islamic fundamentalism in the Maldives.

In March he was the subject of death threats published on, a popular publishing platform that allows anyone to publish content in Dhivehi.

The threats were quickly removed from Muraasil following complaints, but not before receiving widespread attention.


20 year-old dies in speeding motorcycle accident

A 20 year-old man died yesterday afternoon when his speeding motorcycle crashed into a tree in Noonu Kendhikulhudhoo.

The attending doctor at Kendhikulhudhoo Health Centre said the man had died before reaching hospital.

Police reported the motorcycle was completely damaged and Manadhoo police are investigating the accident further.