The fine print of free health care: public responsibility

The Maldives’ Aasandha scheme realised a dream held by many citizens around the world – free health coverage. But it has also put a spotlight on the Maldivian public’s prodigious appetite for medical care.

“The launching of Aasandha has challenged the two hospitals in Male’, pushing them to their limits with frenzied ‘patients’ (or should I call them customers?) flooding and packing the hospitals,” wrote public health expert and Chief Operating Officer at Male’s ADK hospital, Dr Ahmed Jamsheed, in a January 16 blog post.

Observing that ADK has seen a 50 percent increase in specialist consultations and a 100 percent increase in demand for basic services, Dr Jamsheed describes the hospital as “overwhelmed.”

During the first 14 days of the Aasandha scheme, 41,000 individuals sought health care at ADK – 11 percent of the country’s population – costing the scheme millions and raising serious concerns over its sustainability, Dr Jamsheed observed.”

“In the absence of an ongoing epidemic, statistically and epidemiologically speaking, it is unlikely that so many people would be sick needing health care simultaneously,” he said.

The Aasandha scheme, a public-private partnership with Allied Insurance, was implemented on January 1, 2012. The public rush for national identity cards, a necessary ticket to free medical treatment, foreshadowed the scheme’s popularity.

Speaking today to Minivan News, Dr Jamsheed said limited information on Aasandha’s financial structure has led the public to exaggerate their medical needs.

“A lot of people seem to be of the mindset that they need to spend all of their Rf100,000 (US$6500) yearly allowance. Many don’t understand that if they don’t spend that cautiously they’ll be in trouble when something really does go wrong, especially if they have no way of settling the bill once they go over the limit.”

Pointing to the Maldives Inland Revenue Authority’s (MIRA) publicity of last year’s Goods and Services Tax (GST) initiative, Dr Jamsheed indicated that the integrity of universal coverage depends on an informed public. “A lot of political statements haven’t captured the scheme’s real meaning,” he said.

While Maldivians have a yearly allowance for health services, Jamsheed pointed out that funds for the scheme come from taxes. “If people exceed their allowance, the government could decide it has to raise the allowance. That would mean raising taxes,” he said.

“In a way the previous Madhaana scheme, where patients co-shared the cost, was useful in limiting unnecessary hospital visits and prescription charges,” he added.

Medical professionals have commented on what they describe as the population’s reflexive hypochondria. One doctor reports recently seeing a patient who boasted of visiting four doctors in one day. This author was once advised to seek medical advice for a pimple “because of the pain”.

Aasandha appears to prove the business rule that low prices attract public interest applies even to medical services – many Maldivians talk about being encouraged to go to the hospital simply because treatment is free.

Moreover, with no value placed on a consultation, Dr Jamsheed reports that many appointments are not being kept, an “injustice” which is creating delays. He adds that without a referral system, medical specialists are unnecessarily overwhelmed.

While some doctors may recommend advanced procedures to pad their profits, “what is more evident and frequent is the number of requests, pressure and time demand from patients and their family on doing medically unadvised or unnecessary investigation. Perhaps they don’t realise that this practice drains ‘their’ valuable money or funds in the insurance system, to which they would have to rely to get critical service when ‘needed’!”

A previous article by Minivan News reported that medical equipment and staff training doesn’t support effective diagnoses. In addition, hospitals and physicians are not properly monitored. Although the government has asked the people to treat the privileges of the Aasandha scheme responsibly, systemic reforms remain.

Noting that Maldivians “seem to demand rights rather than take responsibility,” Dr Jamsheed said he believed the desire for medical consultations had historical roots.

“When doctors began going to the islands in the 1980s and ‘90s, their services were promoted as a superior way of dealing with health issues. Then specialist doctors arrived. People saw this gradual improvement and right now the mentality is that for anything they need to see a specialist,” he explained. “It’s something we’ve subconsciously promoted.”

CEO of Indira Gandhi Memorial Hospital (IGMH) Cathy Waters echoed Dr Jamsheed’s observation that the number of ‘no-show’ appointments had increased. She reported that the hospital has seen a slight but steady increase in visits, prompting plans to allow more clinic appointments in February.

“Things have been calm, but steady,” she said. “Even before the Aasandha scheme people were coming to see doctors regularly for small things, often not understanding how those afflictions can be self-limiting,” she added.

Waters agreed that a lack of public education about minor illnesses and home care was an issue. “It’s important that people understand when to go to a doctor,” she said. Waters added that IGMH is considering developing a referral system to control patient access to specialists.

In addition to poor public responsibility and medical awareness, Jamsheed suggests that Aasandha’s broad coverage could also encourage abuse from within the system.

Under the scheme’s fee-for-service payment model, services are separately paid. Favoring quantity over quality, the method is an incentive for physicians to provide more, often unnecessary, treatments. According to Jamsheed, “this cannot be (significantly) avoided unless there is an effective and efficient regulatory system with full cooperation of the hospital management and responsible doctors. We all know that we don’t have this  ‘ideal’ scenario in the Maldives.”

The government’s own track record regarding health care doesn’t engender confidence – last year an Education Ministry taskforce took over the  response to a dengue outbreak from the Health Ministry.

“There is lack of clarity on policy directions and plans,” Jamsheed writes. “The Government keeps on changing policies, which causes difficulty in managing and uncertainty for the future.”

This year the Maldivian government has pledged to build new medical facilities, including hospitals and pharmacies, to provide better medical care within the atolls. While the Health Ministry has said space and staff shortages are an ongoing concern, Jamsheed and Waters agreed that the current rise in patient visits on Male’ should be addressed through education and reform within the medical system, rather than physical expansion.

“The rise in patient visits is slight but steady,” said Jamsheed. “We need to study the trend before making large financial investments.”