Non-affordable health care and a welfare system in ruins? The socially vulnerable left to fend for themselves.

Thursday, February 14, 2008

Thousands of Maldivians apply for welfare assistance in financing essential treatment each year. The exact number and the total expenses have never been revealed by the concerned ministry in all the time it has been providing this social security assistance. Yesterday, 13th of February 2008, we visited IGMH during visiting hours to talk to patients and their relatives about welfare assistance.

Welfare assistance for the poor and needy

More than half of all in patients in the general wards at IGMH are on one or other form of welfare assistance. We counted 7 in ENT ward, 10 in Pediatric ward, 15 in Medical ward and 12 in Surgical ward as being on welfare assistance to pay for health care costs. A large majority of them are truly deserving and needy, while a few of them were individuals from well-to-do families with reasonable ties to powerful figures within the welfare system including the presidential palace, Theemuge.

We asked around and found out that no patient is refused a welfare assistance letter by treating doctors if one is requested by the family. Apparently some doctors, judging the financial capacity of families, even offer to give such a letter if they deem it necessary. Except for a rare few, none of these families are refused welfare assistance by the Ministry of Gender and Social Security either. They are each reportedly entitled to a weeks welfare assistance to cover the cost of hospital bed charges, investigations and medications that are available from STO pharmacy. (Some medications not available at STO have to be purchased by families on their own, at their own expense). This assistance obviously means a lot for the very needy, who still have to spend out of pocket for food and accommodation of patients attenders. The cost for that is terribly high as well.

Only a small minority of the really sick cases get to complete the treatment and leave the hospital during the period when welfare assistance IS available.The majority of them need further assistance and extension of welfare assistance to continue treatment. Ministry of Gender and Social Security is not so willing to continue assistance beyond the initial welfare assistance period. Some patients do get a final 7 days of assistance with the warning that further assistance would not be possible and that applications should not be send after this current period expires.

Some of the very needy patients are therefore left to beg, borrow or steal to continue medical care. Fortunately most people beg or borrow. Private businessmen frequently, but not  always, offer a few days of assistance or a lump-sum assistance of a US $ 100 to 200. Whatever they could get is accepted by many, as there really isn't much of a choice for them.

The not-so-needy getting assistance

The heavy expenses of medical care at IGMH and the cost of staying in Male' to assist the patient is much too high for most people to shoulder themselves. With the current welfare system a large number of the not-so-needy people get the assistance that could be best provided for the very needy, who have no other way of supporting the finances of medical care, especially when the course of the illness is long and treatment lengthy.

The families of senior level government officials and well-connected middle level civil servants get welfare assistance on an open budget, mostly thanks to the Theemuge welfare assistance. Surprisingly, these people are often flown out of the country for medical treatment that is available and competently delivered at the local institutions.

The Theemuge welfare budget came under great scrutiny during the recent budget proposal, but sadly our elected (and the unelected) members of the parliament refused to go the distance to merge welfare funds under one body to give better assistance. We do understand that a bigger budget does not necessarily mean better management, that is something that needs to be addressed separately as well.

Medical insurance cover

We have been taken for a ride recently by the authorities with stories of a government medical insurance scheme being in place within a few months. The very public arguments between powerful figures within the government establishment saw the collapse of the process and we are left to fend for ourselves and no closer to a medical cover that possibly would inherently be more fair for the needy.

Again, bickering among political rivals has destroyed an opportunity for the needy to find a way to get medical care in a dignified manner. But the medical insurance scheme would not mean an end to welfare assistance. The social security net would still be important, to ensure that the unemployed, self employed and people with special needs don't fall through the holes in the net.

Identifying the truly needy and assisting them

Who wouldn't want to get something free? Many financially able families currently opt for welfare assistance because it is possible to get that assistance regardless of their own financial capabilities. Everyone gets that assistance, why not them? It is the governments money, kind of their own!

Doing the right things does not seem to be a top priority. Social justice is a challenge.

In this situation a near fool-proof system of identifying the needy is essential. We understand that none of the systems in use in the different developed countries is effective in ensuring 100% uniformity, but the UK and US social security system could be studied to find out what would be a reasonable system for our situation. Professional bodies and organizations that have made a name providing such consultancy maybe sought through the assistance of international donor agencies and a "method" identified for Maldives. That is something that needs more thought and discussion; we have no simple solution. The solution will not be simple we are sure. However,  there will be a solution should we try hard enough to find one!

Medical care abroad

With the cost of medical care sky high in Male', many Maldivians including the poor find traveling to neighboring India a financially better option. The cost of traveling to Male' from an island, supporting family members to stay in rented apartments in Male', the cost of food and other personal expenses are all considered to be way to high. The small amount of money, often a life saving, could be wasted in Male' with not that much of a return in terms of improvement of the patients health!

For this reason, even the not-so-well-off families make the decision to travel to India for treatment by much senior doctors, with better medical diagnostic facilities, at a cheaper cost and with less expenses for the caretaker and other family members. This prospect has taken many Maldivians away from IGMH and other medical institutions in Maldives. Most of them probably fare well in India and return, at least in their own opinion, in better health.

Sadly, we must highlight the increasing number of cases where unnecessary treatments, investigations and other expenses have eaten into the limited finances available to family that they return home financially broke, terribly shaken and in worse health than they left in the first place. Illnesses close to spontaneous remission may do so despite the sometimes unnecessary treatment offered; the credit being given to the foreign stationed doctors medical acuity and skill.

Medical care abroad on welfare aid

The welfare assistance for treatment abroad is another area where social justice is at its poorest. The system in place is heavily misused by those entrusted with running it, monitoring it and executing its decision making.

Some very needy patients are refused welfare assistance to go abroad by medical professionals; because they feel that the treatment is possible in Maldives. This even when, reportedly curable and manageable conditions go uncured or uncontrolled for ages. When complication after the other diminishes the doctors and the family's confidence of ever being able to get over the illness.

Some chronic illnesses cannot be properly managed in Maldives (like cancers) and the only rational option is to travel abroad; even when it is for hope alone. Such cases are also refused assistance at various levels of the selection process. Sometimes it is the medical board at IGMH, while at other times even at their insistence the fund issuing agency refuses for no obvious reasons.

Even when the assistance is obtained, the assistance usually does not match the amount of expenses the treatment for which the patient is referred abroad. Regardless of the disease or medical condition, the government assistance is "return ticket for 2 people including patient and US $ 300". A patient going for cardiac surgery, renal transplant, chemotherapy or many other treatment need finances much bigger than this. This would amount to little help in such cases.

In the name of being fair, the Ministry of Gender and Social Security refuses to offer additional funds to special cases, unless of course there is an interest from a high ranking government official, minister or MP. Many patients have had to travel repeatedly, getting treatment in parts and portions because of this. Some have had to cut-short essential treatment and return to wither away and die.

Way forward? or continue direction-less as we do now?

We don't intend to say that we have a solution to all these issues. But we are not ready to give up by saying there is no way to do things properly. There must be a way. A more fair and equitable distribution of welfare assistance for the needy needs to be established.

If we do not see a solution that we can quickly employ, it is paramount that we look for one. An open discussion could throw more light on to how things could be done differently to get better results.

Our representatives in parliament, rather than using sickness in people in their constituency as a tool to "buy" votes, should look at the greater good of the people and work to address the unfairness of the current system, inadequacies in the current system and the lack of auditing, transparency and monitoring of procedures and processes.

I am sure readers have their own opinions on this issue. Have your say. Throw in your ideas.


Pachas said...

I don’t see any reason why Theemuge should have a welfare budget, except to spend for the president and his entire family plus his cronies and their families. Basically the welfare ministry budget and Theemuge welfare budget should be made to one and spend to develop hospitals and train medical and proper hospital admin staffs.

Hope we don’t start again another stupid argument about which country graduate docs are better or nurse vs docs arguments. I believe docs/nurses from the best institution can be bad. No one should generalize. Been good is a very individual thing. Moreover we should not try and practice the Indian subcontinent caste system where docs see nurses as inferior things and nurses see docs as fearful creatures. Both should work as a team for the betterment of patients. If docs consider nurses as ignorant and careless and nurses believe that they know better than the docs, I must say that both are wrong. Both are the best in their own fields. We should learn to respect each other and give credit. If not, in the argument, neither docs nor nurses will win, but definitely the patient loose.

xenon said...

Our health care system is designed in such a way that public have to beg the authorities for their medical needs. For example it’s almost impossible for a person from an island to get an appointment for consultation in IGMH. So he is forced to contact one of the several parliament members (belonging to DRP)who also hold high positions in IGMH admin to get a booking for a consultation. And if the patient needs admittion in hospital or wants to go abroad for treatment the MP provides him with that assistant from welfare budget in social security ministry or from Theemuge.
So the system is designed in such a way that the healthcare expenses are unbearable and the public is compelled to beg from the government. In return the public have to make sure that the people in high up remain elected to their posts. Fair deal huh?

Anonymous said...

Congratulation MMV for diverting and bringing different aspects of health care.

Obvioulsy the best way would be to go for universal medical insurance. The west depends on that rather then welfare.

Its true that lot of people who doesnt deserve it are on welfare. This could be avoided on having a welfare register. Income and socio-economic status would be taken into account before registering someone there.

Any person availing welfare services have to be already registered. This is similar to the sytem in some of the neighbouring countries where the colour of their ration card would indicate their socio-economic status.

Can the goverment come to an understanding with the neighbouring countries where by welfare patients can be subsidized in some way. Like cutting the government tax could go a long way in saving cost. Specuially for institutions like Regional Cancer Centre in India


Anonymous said...

We only talk about politicians who take advantage of the welfare system.

What about those in the medical profession? What about those doctors who gives certificates only if consulted in their private clinics?

What about those doctors who stoop down to the level of asking for sexual favours before giving an "abraod medical" certificate?

Huh..Unbeleivable right...but true

firey said...

sexual favours? thats is a load of bull! you can't name one person who has done it.

Anonymous said...

Infact I can name a few. I am not going to be pulled into this naming game. You ask around and you would know.

And then there are the guys who would have the chest exposed and plapated for clinical evalutaion of headache?

If you ask around there are many similar instances. I think MMV should look in to this. Or are they afraid that it will only expose a lot of internal medicine doctors?

fidhudous said...

off topic but can't help it.

anonymous, you call that sexual favours? surely sex means something different to you than the rest of us.

and btw, an examination of the chest could reveal a few causes of headache of cardiac origin!

Anonymous said...

It is a fact that many of us have become more prosperous over the years but even when a close relative is sick and has to go abroad tend to ask for welfare assistance.This is when they can very well afford to do it on their own.Then there is a mafia among us who spread all types of rumours to bring discredit to the work of some dedicated doctors in IGMH both foreign and local.The reason? Just to get more clients for their respective doctors in the Indian cities becos these middlemens( many of them Maldivian) living in cities like Thiruvananthapuram thrive on such clients.Now the common man is caught in between
and tend to go to great lengths to
go abroad 3 to 4 times a year just because some doctor in an indian hospital has asked him to do it.
Many times these reviews can be done very well in IGMH and other atoll hospitals.However many of these so called medical visits are simply business cum pleasure trips for the patients if not for those accompanying him.

Anonymous said...

I fail to see a cardiac casue of headache diagnosed by palpating the chest and without putting your steth. I guess you doctors are taught something special

But I guess this is besides the point. But the fcat id that doctors abuse the welfare system as much as the public by giving them favours and sending patients on pleasure cum medical trips as favours.

Anonymous said...

Anyone came come up with any sort of allegation in a forum like this. However if one is witness to such misconduct why not report it to the concerned authorities and let the doctor explain himself?

That said, it is the norm among doctors in IGMH (and elsewhere in Maldives) not to properly expose the patient during physical examination, apparently not embarrass the patient. The consequences some times are missed physical signs and diagnoses.

I really wonder how many doctors would do a complete examination of the chest with proper exposure in a patient with chest complaints? Or how many would listen to the heart/lung sounds with the stethoscope directly over the patient's skin?

Anonymous said...

Some countries have laws regarding the examination of a female patinet by a doctor of the opposite sex like mandatory presence of a female attendent. Even checking pulse agaisnt this could invite legal actions.

This would have prevented the doctors from sending out the clinical assistant when they "see" some "speicial" patients....

I am not aware of any such Law or regulation in IGMH. Are there??

Anonymous said...

looks like mmw does not have to make any allegations or expose anything. Even when they write a really good post like this; people argue and throw accusations of all sorts!

people have been waiting for an opportunity to make expose'. wonder how many stories mmw has received and are looking into!

Anonymous said...

If not seeing a breast has the likelihood of missing an important clinical sign then a truly professional doctor will go ahead and see it.This is just a very routine thing.If some of the excessive tuna eating non medical guys get a weired pleasure on seeing a young girls breast exposed then that is their problem.
It is just plain ignorance if they think that the attending doctor will have sexual gratification out of this.However if the patient suffers due to lack of examination and missing an important clinical sign then the same people will cry foul and try to hang the concerned doctor.These are the double standards with which the doctors have to live daily but kudos to many of them for carrying their work so professionaly inspite of all these allegations and cheap talk.

Anonymous said...

what does any of this have to do with improvin our current mismanagement of welfare and theemuge budget...get real and talk to the point!!

Anonymous said...

YAWNS.......... boring blog

Anonymous said...

Right. Boring blog and I bet the author of this blog must have had many of his/her relatives send on numerous occasions on theemuge/welfare budget.Such hypocrisy.

Anonymous said...

very boring. even the stats prove it.

a mere 420 comments in its first 57 days online.

OK, 421 including this one.

Anonymous said...

hey ppl only sensationalist stories create buzz..good luck MMW. its good u brought up topic. u cant help if others want to write only bad things abt ppl.. people have been having attention deficit n lack of space for speaking bravely... rather can throw stones at anyone by hiding.. be real men and women ... if u have issue bring it up with the person..

Anonymous said...

to the last anonymous:
very true and well said

Yasiph said...

pis...pis... its Ministry of Higher Education, Employment and... Social security. Welfare comes under Social Security and its been under Gender Ministry, Health and who knows where! Even from the ministry's name, you get the importance of the "Social security" within the policy makers(stake holders, cabinet or whatever) It has been QUITE a while the Social Security department has been thrown from ministry to ministry. Its about time they get a proper ministry of its own.

And I totally agree with you all that the welfare needs to be central and not shared with Theemuge. But then again, there are ppl concerned that they would get less if there is a single place for welfare.

On the other hand, could it be possible that the welfare tht Theemuge gives are actually from the President's expense ge baakee which he feels should be shared with the less and the needy? pls dont get me wrong, Im not at the office and I do not know even if its the real case.

Anonymous said...

If you think that sweet talk is going to bring any good then dream on.

Anonymous said...

Is there some one who really knows about health systems in our parliament?

Anonymous said...

IGMH has 3 of its staff in the Majlis. @ directors and 1 executive director. The health ministry have 2 more people in there as well.

That is a reasonable representation.

Do they know anything about our medical system? unlikely. They are totally lame! Useless.

Anonymous said...

to the last anonymous:

hello....these guys are the same ppl who is holding the development of igmh and our health system.

their representation in parliament is not for our igmh/health system but for drp.

we all have seen how many times igmh ED Alibe' (Noonu atoll MP for life) coming into doctors rooms demanding to see noonu atoll ppl. He'll always say that its his relative. I belive he is related to whole of noonu atoll. And we have seen many a times that when a doc decides for discharge of a noonu atoll patient, if the patient wants to stay admitted, say till a noonu atoll boat arrives to Male' for his/her transportation, he'll call up their popular MP and our infamous ED Alibe' for intrusion. Usually when the doc does does not budge from his decission of discharge, Alibe' will look for an easy catch like an expatriate doc (like Dr Sunil/Surgery Dept) to admit under him. Definitely he makes the previous doc's life a hell from admin side.

Yes they do know our health system very well. Thats why they survive. They were mostly community health workers and been warming their chairs since stone-age.

Anonymous said...

ya, some people make igmh a nursing home or an old folks home. even worse its also made into a cheap hotel to stay in Male'.

...and everyone says igmh has scarcity of beds to admit patients.

Anonymous said...

wow to the anonymous who explained that...abt alibe interference. that really happened like that in front of me one day n doc looked so disappointed and let down as the relatives of patient left with dirty looks at doc n nursing staff

Anonymous said...

I have been told that getting a room in IGMH require "connections" and that being on top of the queue is just not enough. Is this true?

We already heard about FA practising as a radiologist without a MD. Can MMW please confirm that all the other docs working as speiclaists are having post graduate degress in their respective fields. That they are not just roanu edhuru MBBS FA

Speaking of MBBS doctors I have a lot of faith in them. Some of them have attended to me and my family with lot of professionalism. Its becasue few of them over reach their limits that every bodys gets blamed. And sometimes they dont get the necessary support from the specialists. We blame them for not calling the speiclaist at the drop of a hat, but little do we realize they get hell from specialists for calling them on petty things. Ask any medical officer and they could name a few specialists who are notorious for this.

Give them some respect, after all they had spend a good five years studying medicine and passed stringent tests to reach this stage. And whatever we may say IGMH will collapse without medical officers.

Helath care is like chain and to be intact all the rings has to be strong. From the admin staff to the nurse to the MO to the specialist to the super spcialist. Even the sweeper counts cause he plays an important rols in infection control. Give everyone his due and lets not generalize and put people down..

robban said...

I think this might help. I dunno if this is updated now.

Anonymous said...

for the last anony...thank you!only few people appreciate that and your critiscm is inspiring and i really hope IGMH takes that into consideration...
i sure hope this blog be useful for concrete critism

Anonymous said...


Its just as I feared. Lots of doctors with just diplomas are acting as consultants. God knows how many of them do not have any post graduate diploma at all, let alone a degree......

MMW can u enlighten us pls

Anonymous said...

some peeple go to burma or some third d world cuntry whre cheap can get a certificate. Didn't Afeef do this?

Anonymous said...

to the last anony... why are so many people then going to show to dr afeef. i can assure u a majority of people who go to him come satisfied. like i said before u cannot judge someone by the certificates..when u go to india u have so many name boards on the doc door and u are all so impressed.. most of time u dont know what it means and a lot of it is not recognized.. but u still show to him and get well. whether the doc studied from 3rd world or 1st world or from the moon ultimately it is his knowledge and most importantly the way he interacts with ppl. i always say 90% of getting well depends on the way a doctor talks to his patients.. even if he gives excellent medicine patient wont be happy if he is rude. wont even believe in medicine n maybe not even take it.from the way u have singled out afeef i feel u have a personal thing against him.. can it be that u are another paeds doc? cheers

Anonymous said...


haleema-nurse said...

"We didn't need Michael Moore to tell us that the American health-care system is broken; it's been front-page news for so long, we're getting - well - sick of hearing about it. Yes, Americans pay too much for care that is anything but caring, for technology that does little more than prolong our agony, for hospitals from which we emerge sicker than we entered. Our infant mortality rate ranks barely above that of a Third World country, and millions of children lack basic preventive care. One hundred thousand people die each year from vaguely categorized "medical errors." And most notoriously, the nation's growing legion of uninsured - more than 45 million and counting - must depend for their very survival on the increasingly unlikely kindness of strangers.

The disparity in our health-care system is a national disgrace: How is it possible that in the flushest nation on earth - a land where Botox injections are served up on demand for the rich - so many fail to get the basics.

food for thought:
keep on grumbling

Anonymous said...

Raaje is a rich country. No reason why affordable health care health care should not be provided. America made a mistake. They privatized health care so much that it has become almost impossible to reduce the cost of health care. Maldives should learn and not go along the same path.

air head said...

but isn't it already way on that path?

did u know that some internal med docs and ortho docs charge 200 rf for a private consultation? and u can hardly ever get an appointment from IGMH for these docs..

so where does this leave us... well.. these ppl are robbing us in braod day light.. (well actually night but still wth the lights on...)

doctor ah dhekken beynumiyyaa IGMH ah dhaadhey ekamaku doctor ah dhakkan beynumiyyaa emeehun ge clinic ah dhaashey...

Anonymous said...

with the meagre salary they get, the working hours and the responsibility I think 200 is fair enough

After all you go to them by choice. Now there are so any doctors to choose from. You can always show in IGMH and if the doctor is not available you can always show in casuality. If you insist on showing to a particular doctor he must have something in him.....

You hesitate to pay him 200 rupees but will not hesisate to beat him up incase your loved one dies even if it is due to unavaodable circumstances......Such double standards

You wouldnt mind going abroad and show to any doctor whoes reputation you have no idea except for the fact that he workd in a big hospital and pay 200 dollarts but if it a Maldivian doctor 200 is too much.... such double standards

Anyway 200 is the amount set by the Ministry of Health and you also have to consider how much of that 200 the doctor takes home


air head said...

last i heard... the docs gets like 75% of what they get from seeing the patients in most of the clinics... and are u still in this planet... a simple ,mbbs doctor gets over 12000rf.. and that was before there was a salary increase recently for all gov labourers... so imagine how much a consultant will get, specially not that there is a salary increase...
i know that ppl will never be satisfied with what they earn ever...

but this is fukey boduvaru...

just think of all those poor ppl who wait for days to show to a specialist and when they can't get app's from IGMH have to see a specialist from those over rated clinics..

well for the rich ofcourse 200 is nothing.. they would rather go to their clinics than be seen in IGMH..

i dn't think IGMH can ever have an efficient no biased app system with the likes of alibe and them still in their seats..(who keeps half of the apps for himself so that he can give it to his friends and noonu atholhu relatives.. just like he does for the private rooms in IGMH..and this is not bull shit i know this first hand)

Anonymous said...


Even a Banghalhi takes more than MRF.1000 just to clean your junction and thats unskilled labour.

Why shouldnt a doctor take the just 200 after all what he does is highly skilled and its a very very responsible job. And anyway those who can afford need go to private clinics. Its the same in other countries, after all Maldives is a capitalist economy.

Infact you would be surprised at the amount of money doctors are making aborad. Thats why some of our doctors are not coming back. Like Ahamed Mohamed Didi and Shah Mahir.

Anonymous said...

The grass is alwasy greener on the other side. But the fact is that in maldives everyone has to be seen by a specialist for even a boil in his ass.

In the so called affluent western countires sometimes people have to wait for months before a speicalist consultation.

So much so it becomes cheaper and quicker for them to travel to asian countries for their medicals. This is the basis of so called medical tourism.

Here we bring the ceiling down even if we have to wait for 15 minutes outside a consultation room. Well if we demand VIP service we have accept VIP Fees. Nothing free in this world.

And since there are so many doctors to choose from both local and foreigners if a doc is able to command high fees he must be worth it... What do u say?


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