STO raises credit limit for IGMH, resumes supplying medicine

The State Trading Organisation (STO) has raised the credit limit for the government-operated Indira Gandhi Memorial Hospital (IGMH) and resumed providing medical supplies and medicine.

STO Managing Director Shahid Ali told CNM today that the credit limit has been raised to MVR5 million (US$324,254) following assurances by the Finance Ministry.

While local media had reported that STO had stopped providing medicine to IGMH, Shahid explained that the government-owned company was unable to provide further supplies after the credit limit was reached this morning. The hospital owes STO for purchases dating back to 2011, he noted.

However, IGMH Responsible Officer Dr Mohamed Habeeb claimed that the STO stopped providing supplies “every other week or two weeks” citing the credit limit.

“STO has stopped providing medicine and medical supplies today saying we have run out of credit. But what can we do? It is the Finance Ministry that pays,” he was quoted as saying.

Shahid Ali had told parliament’s Finance Committee recently that the company was facing financial constraints due to unpaid debts in excess of MVR600 million from other government-owned companies.

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Doctors raise concerns over medicine shortages

Medical doctors, for the second time in 2012, have publicly expressed concern over medicine shortages in the Maldives.

In addition to official routes of raising concerns with relevant authorities, doctors have brought the issue of essential drugs shortage to the public’s attention and appealed to the government and the legislature through social media.

Dr Abdulla Niyaf, Chief Medical Officer and Senior Pediatric Consultant at ADK Hospital, has repeatedly expressed concern about the issue, specifically noting the recurrent problem of stock shortages in essential drugs such as neostigmine and phenobarbitone.

“As a paediatrician, we go in after each birth or cesarean to check on the newborn, full of concern that something might happen to the baby. If, say, the child’s heart malfunctions, and we are out of adrenaline, then there is nothing more that even us doctors can give,” explained Niyaf to Minivan News.

Niyaf said that the systematic issue of running out of stock of critical drugs was very serious, posing risks to the lives of many. He said that it is a huge concern as a doctor that he would be unable to provide immediate medication to patients who are in crucial need of specific medicines, due to complications with stock renewal.

Niyaf further said that he had previously sat down to discuss the matter with the State Trading Organisation (STO), the sole company licensed to import controlled drugs, and other relevant authorities. The answer had always been that the suppliers were facing issues of licensing, permits, delays in customs and so on.

“For how long can we, as doctors, keep listening to these justifications? All I want is for the issue to be resolved and for patients to have the chance of getting the best possible medical attention,” Niyaf said, expressing concern that the relevant authorities had so far not been able to resolve the issue.

Dr Faisal Saeed, another practicing doctor, told Minivan News that the matter was “a very real concern”.

“It is true that many medicines are often out of stock, but that doesn’t lessen the gravity of the problem. I don’t believe it is an option to be ever out of stock. What will any patient do if a critical medicine is unavailable at the time they most need it?”

Saeed further confirmed that there was a current shortage, stating: “As doctors, we worry about this. If something happens, it is we who must take responsibility. Our question is, when this country runs out of medicine, who is to be held accountable? Who will take responsibility for this?”

Dr Fathimath Nadhiya stated that the issue of shortages of even the most essential drugs has been a longstanding concern for a long period of time, further saying that if shortages were such an issue in the capital island Male’, then the loss must be felt even more harshly at remote island health facilities.

“Hospitals and health centres store the minimum required amounts of critical medicines at any given time. But we are not aware who carries the oversight responsibility to check whether this minimum is always maintained,” Nadhiya said.

She further spoke of her worry that with the lack of monitoring, island health facilities may have an even harder time to obtain many of the critical medicines. She said that in many islands, there were only one or more pharmacies run by private businessmen, who would prioritse medicine supplies not based on their medical importance, but rather on their sales statistics.

Ahmed Afaal, Managing Director of ADK, has also expressed concern on the matter on social media network, Twitter. He sent a message to President Dr Mohamed Waheed Hassan, urging him to look into the matter, stating that “tomorrow we may have to stop surgeries [because of an] injection neostigmine shortage. The only supplier is out of stock. Please help.”

Not yet a “doomsday scenario”: government

While many practicing clinicians have expressed concerns on the matter, the government denies the issue is as serious as claimed by the doctors.

“Checked with Health Minister and STO MD. There is no reason to worry about medicines,” President Waheed said,  in a short statement on Twitter.

Minister of Health, Dr Ahmed Jamsheed, backed the statement, saying at a press conference on Sunday that “although some social media messages on Twitter by practicing doctors may make the public dread a doomsday scenario, things aren’t all that bad yet”.

Jamsheed however did confirm that medicine shortages were a recurring problem in the health sector, stating that the Ministry of Health was planning to start a programme with the assistance of UNOPS and WHO to create a procurement/supply chain management system. Jamsheed said he believed that all the current concerns would be addressed and found a solution to through this programme.

“There is a common misconception that I would like to clarify. Although people usually assume otherwise, the health sector has never been involved in importing and supplying medicines. This is left to the private sector and the government-owned company STO,” Jamsheed explained.

“What we are seeing is that those responsible are not able to sufficiently supply medicines. I think we need to change this system if we are to find a solution. If we are to get a permanent solution, then we must make supplying medicines to patients the responsibility of the service provider, regardless of who imports it.”

Although some local practitioners say that the complaint is that the first choice medicines are unavailable, Jamsheed alleged that some of the complaints were because brands of medicine preferred by an individual doctor were not widely for sale.

“If there is an emergency, then the routine is that hospitals or the government flies in the medicine from neighbouring countries at the earliest,” Jamsheed said.

“If those staff in medical facilities who are responsible for these tasks are able to perform their jobs correctly, then it wouldn’t come to such a critical stage where provision of services are interrupted,” he stated.

Meanwhile, some doctors who spoke to Minivan News rejected the idea that emergency stocks were a solution, insisting that stock records ought to better kept and that patients in critical conditions do not have the option of waiting for medicine stocks to be flown in.

Legislative intervention

Maldives Democratic Party (MDP) MP Ibrahim Rasheed ‘Bonda’ submitted an emergency motion to the parliament on Monday, calling on the legislature to take action to “immediately resolve” the problem of medicine shortages.

Rasheed claimed that this failure to provide critical “life-saving medicines” to patients in crucial need of them was causing loss of lives.

“When practising doctors take the initiative to raise concerns, we realised the gravity of this problem. We then researched the issue in depth,” Rasheed told Minivan News.

“Millions of rufiya worth medicines need to be disposed of due to the failure to manage stocks. The stock is still managed manually. There is also a lot of corruption involved in the procurement and supply of medicines,” he said.

“There are permanent parliament committees within whose mandate this issue will fall. The problem is there are already a large number of pending bills that need to be worked on by these committees. We are now discussing within our party to determine what the most effective course of action will be,” Rasheed said.

During the one hour debate that ensued after the submission of the motion, Dhivehi Rayyithunge Party MP Ahmed Mohamed claimed that health services in his constituency had deteriorated, calling the condition of health care provision “regrettable”.

Progressive Party of Maldives (PPM) MP Adam Ahmed Shareef stated that health centres in the constituency he represented did not have the capacity for “the most basic tests”, adding that the pharmacy was managed by the women’s committee.

STO Spokesperson Ismail Sadiq was unavailable to speak to Minivan News this afternoon, and was not responding to calls.

Minivan News was not able to contact the Director General of Maldives Food and Drug Authority, Shareefa Adam, as her phone was switched off up to the time of press.

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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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Antibiotics “most misused drug in the Maldives”: ADK COO

Over-prescription and sale of over-the-counter antibiotics is leading to a rise of resistant super-bugs, the World Health Organisation (WHO) has warned, with the Maldives no exception.

“Antibiotics are the most misused drugs in the country,” ADK Chief Operating Officer Ahmed Jamsheed told Minivan News today. “People are becoming resistant, and in certain cases they might not even need the antiobiotics.”

The WHO is discussing the overuse of antibiotics and growth of superbugs at the 64th meeting of the Regional Committee for South-East Asia, in Jaipur this week.

Director General Dr Margaret Chan said, “we have taken antibiotics and other antimicrobials for granted. And we have failed to handle these precious, yet fragile medicines with appropriate care. The message is clear. The world is on the brink of losing its miracle cures.”

Jamsheed said he has seen patients with headaches prescribed with powerful antibiotics, such as ciprofloxacin. He says a lack of systematic supervision allows pharmacists, who are not educated in medicine, to give antibiotics to anyone who asks regardless of a prescription.

“We have a very rudimentary diagnostic capacity in the Maldives,” said Jamsheed. “Hospitals and physicians are not properly monitored, and patients have a lot of independence to choose the drug they want. There are few national guidelines.”

According to Jamsheed, hospital diagnoses are compromised by inadequate facilities. He said that as organisms  mutate, doctors are not able to keep up. Bacteria samples are usually outsourced, and communication can take weeks. “In some cases, we may not be able to recognise and diagnose a disease until we’ve already lost a few patients,” he said.

Superbugs, or super bacterium, are bacteria that carry several resistant genes and are difficult to treat. When a disease is inappropriately or excessively treated with antibiotics, the body develops an immunity which encourages the bacteria to grow stronger.

Dr Chan said many non-communicable diseases, such as heart disease and cancers, are triggered by “population ageing, rapid unplanned urbanization, and the globalisation of unhealthy lifestyles.”

Chan also noted that “irrational and inappropriate use of antimicrobials is by far the biggest driver of drug resistance.” As communities become more drug resistant, treatments could become more complicated and costly.

ADK Managing Director Ahmed Affal said education was important. “There is an increasing number of antibiotics being prescribed in the Maldives, and we need to talk more. Research shows that there will be problems, as organisms become more resistant.”

Affal said that the majority of cases at ADK are fevers and infections, although heart disease, hypertension, and renal infections are on the rise. “Antibiotics are commonly used for lung infections, and sometimes are given as a preventative measure,” he said.

Speakers at the WHO conference suggested that climate change could accelerate the growth of superbugs. Jamsheed told Minivan News that Maldivians could be more at risk for dengue fever and chikungunya, as well as viral diseases. He predicted that if these diseases were to become more common, the misuse of antibiotics would increase as well and people would become more drug resistant.

“The Maldives is not isolated,” Jamsheed said. “We import almost everything, and any bacteria that is growing elsewhere in the region and the world will certainly be transmitted here.”

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Khalifa Foundation to create Maldives Distance Medical Services

Deputy Chairman of UAE’s Khalifa Foundation, Ahmed Juma Al-Zaabi, signed an agreement with State Minister of Foreign Affairs, Ahmed Naseem, to grant the Maldives Distance Medical Services, reports Miadhu.

The foundation has many humanitarian initiatives around the world, aiming to fund sustainable projects that create jobs and raise standards of basic services like health and education in aid recipient countries.

The Khalifa bin Zayed Distance Medical Services project will include a network of 35 sites across the Maldives. The nursing department at the faculty of medicine will be named after Sheikh Khalifa.

The project will have a central base and several outposts. Doctors at the main centre will overlook reports made by nurses in the outposts and prescribe treatment. It is expected the service will provide medical attention to over 350,000 persons a year, according to Miadhu.

The grant will train local doctors, technicians and biotechnology specialists.

Chairman of the foundation, Sheikh Mansour bin Zayed Al-Nahyan, said the project fits well with the foundation’s strategy to not only assist but build infrastructure which will improve living standards and create jobs.

He added the different outposts would ease the logistics in health care for distant islands.

Minister Naseem said the grant would improve living conditions for thousands of people living in the islands and remote regions of the country which are difficult to access.

It would also train hundreds of medical and nursing staff, Naseem added.

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