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

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.