Low salaries and safety issues keeping foreign doctors away: Health Ministry

The Ministry of Health has identified salaries and staff safety as the key issues driving “shortages” in the number of trained medical staff coming from abroad to work at hospitals in the Maldives.

Permanent Secretary at the Ministry of Health Geela Ali said that authorities were in the process of trying to recruit a number of medical specialists from across the region, adding that efforts were needed to overcome the various “issues” limiting interest from foreign professionals in coming to the Maldives.

The comments were made as Dr Mohamed Habeeb, presently in charge of Indira Gandhi Memorial Hospital (IGMH) in Male’, last week raised concerns in local media about a serious shortage of doctors, which he said was having a major impact on services.

IGMH Media Correspondent Zeenath Ali explained to Minivan News today that although paediatric services had been suspended temporarily at IGMH three months ago due to a lack of qualified staff, the services were now operating as normal.

“Previously, we had an issue with the numbers of doctors due to some resignations and contracts finishing,” she said of the difficulties faced three months ago.

Zeenath added that while the issue of having no paediatric staff had since been resolved, IGMH has requested assistance from the Health Ministry in recruiting additional medical specialists to meet patient demand in the capital.

Despite this high demand for medical services, she said IGMH had not since been forced to terminate entire services at the hospital as a result of staff numbers.

“We have four paediatricians presently working at the hospital. But it remains difficult on the international market to try and attract paediatricians to join us,” she said.

According to Zeenath, IGMH has also requested that additional anaesthesiologists be hired to meet the hospital’s present workload. She added that the Ministry of Health was said to be working on recruiting more staff to cope with patient demand.

Speaking about these recruitment efforts, Health Ministry Permanent Secretary Geela said there was presently a shortage of medical staff at hospitals and health centres across the country as a result of ongoing issues – not least in the basic salary packages offered by the state.

“We have been running adverts to try and find qualified staff across the region, but so far we are not seeing adequate response from other countries,” she said.

Geela claimed that salary was among the most prevalent issues authorities had identified as being responsible for shortages in medical staff, with the government pledging to raise wages from January 2014 should the proposals gain parliamentary approval.

“This will allow us to offer better salaries from 2014 and we hope there will be more interest internationally,” she said.

Staff safety

Another challenge for attracting foreign medical staff was ensuring the safety of staff, particularly in the outer atolls.

Geela said that the Health Ministry could not alone ensure safer working environments for foreign medical staff, with wider support from the government and public needed.

“We need a societal approach to try and combat this problem. When we place staff on islands, community support is required to make sure they are looked after,” she said.

Threats

IGMH’s orthopaedic department temporarily ceased working last month after a group of people allegedly threatened a member of staff who had refused to provide a doctor’s note for overseas treatment through the Maldives’ nationwide health insurance scheme, ‘Aasandha’.

A patient, who asked for the doctor’s recommendation to receive medical treatment abroad, was first told by IGMH that such a recommendation could not be made because his injury could be treated in the hospital, according to a statement issued by IGMH.

The hospital claimed the man then refused treatment from IGMH before coming back to the hospital with a group of 10 men who threatened to attack the doctor, stating that he too would have to seek medical treatment through ‘Aasandha’ if he did not write the recommendation note.

The hospital at the time said it was considering the use of police officers maintain security on site following concerns about threats of violence to staff.

Minivan News reported in September 2012 on the alleged widespread intimidation, fraud and “substandard” treatment by patients, health authorities, local staff and the country’s courts faced by expatriate medical professionals in the Maldives.

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Indian teachers request transfer, quit posts after Kumundhoo school attack

Almost a dozen Indian teachers on Kumundhoo in Haa Dhaalu Atoll have either resigned from their posts or requested transfers to another island following the assault of a colleague on school premises last week, diplomatic officials have confirmed.

Diplomatic sources said Indian High Commissioner Rajeev Shahare was meanwhile in the process of arranging talks with Maldivian education authorities to discuss the issue of teacher safety.

The Indian High Commission in the Maldives told Minivan News it received requests from eight Indian nationals currently working as teachers on Kumundhoo to be transferred to another island over concerns about their safety.

According to the commission, two other expatriate teachers on the island have also handed in their resignation after physics teacher Neelakantan Pappukutty Subash Kumar was assaulted in the school on May 14 by an angry mob accusing him of hitting a student in the chest.

One expatriate teacher on the island, who has since handed in their resignation, was also claimed to have received minor injuries trying to prevent the assault, an Indian diplomatic official told Minivan News this week.

Despite the concerns about teacher safety, the high commission said yesterday (May 19) that the response of the education ministry had so far been “positive” in terms of their handling of the attack on the Indian national.

Kumundhoo Island Councilor Ali Anwar claimed on May 15 that islanders had destroyed a a power distribution unit outside the school to cut off its electricity, before then entering and attacking the teacher, despite efforts by staff to try and prevent the assault.

So far eight suspects are being held in police custody over the attack, police confirmed today.

After being initially hospitalised after the assault, Kumar’s condition is not thought to be critical.  The high commission has claimed the teacher was now waiting for the Education Ministry to renew his work visa that expired last month, so that he can be returned to India for treatment.

A “mutual time” was also being sought for High Commissioner Shahare to meet with the country’s education officials to discuss the issue of “better security” for expatriate teachers.

Minivan News was awaiting a response from the Ministry of Education at time of press.

Ongoing concerns

Despite the high commission’s praise for the education ministry this week, one Indian diplomatic source said following the attack that the injured teacher’s treatment continued to highlight ongoing concerns over the Maldives’ treatment of foreign workers.

These concerns were said to be based around issues such as the retention of passports and travel documents by private and state employers.

“The fact remains that [Kumar’s] work permit has not been renewed. He was a government employee –  they should have renewed his documents before they expired, not afterwards,” the diplomatic source said last week.  ”This [issue] has been going on for over one and a half years now.”

A senior Indian doctor in the Maldives has also previously alleged that expatriate professionals regullarly  face intimidation and fraud in the country from employers and the public.

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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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