Accident or negligence?

We have just received news from a family member of a patient admitted in newborn ICU at IGMH about a terrible accident (?) that has befallen their loved one yesterday. This was a baby who was admitted along with his twin sister 4 days earlier because of premature birth. Family source tells us that baby was reportedly doing very well when something terrible happened.

According to the family member, on 27th February at around 9 in the evening the baby's father was called to the ICU because the baby's condition had worsened suddenly. There was a lot of commotion at that time with doctors and nurses giving various medications to the baby and doctors doing cardiac massage.

It was later revealed to the family that for an unexplained reason the child had bled out from an "un-clamped" central IV line! The doctors were unable to clearly say how much blood was lost and for how long the baby had bled. According to the family member, the baby was "white as snow" when the father saw the child and reportedly baby's heart had stopped beating for sometime.

Dr Shafiu had later explained to the family that there was significant blood loss and that baby had to be given urgent blood transfusion. The father is distraught that such a thing had happened because of carelessness in the ICU. The doctors had said that during the time when child had no heart beat, brain damage may have happened.

The family is also worried that their baby is looked after by a different doctor every day and the explanations by each are different. There seems to be no communication between the various doctors involved. No one person seems to be in-charge and no one seems to be particularly willing to give a reasonable explanation of what and how things happened.

Family is expected to make an official complaint to the IGMH office. They have been asked to wait till the office is open after the long weekend.

We at MMW fail to understand how a central line could be left un-clamped! Why was the bleeding not noted earlier and significant blood loss stopped?

Can this be called just an accident? Does this amount to negligence?

Latest updates:

• Baby survived the incident.
• As feared, baby has started to have fits.
• Today doctors have told family that brain injury is the likely reason for fits.
• Family have been warned that baby could be disabled for life with permanent brain damage.

Dhivehi beys: safety and regulations?

Dhivehi beys, the field of medical practice that has been practiced in Maldives as a traditional form of healing, has been acclaimed by many of its practitioners and critics of modern medicine as a "purist" form of medical therapy. We are sure that there would be many people who would support this argument. We are equally sure that there would be people who would question the legitimacy and effectiveness of current "Dhivehi beys verikan".

The roots of Dhivehi beys are lost to history. However the similarities it shares with homeopathic, ayurvedic and herbal therapy suggests that it is a medical practice derived from a combination of these fields of medicine. Our Dhivehi beys practitioners, especially the ones practicing in Male' seem to have also borrowed practices from modern western medicine as well.

As commented by a visitor, modern medicine has heavily borrowed and derived their drugs and medicaments from early herbal and homeopathic practitioners. They have arguably invested heavily into studying the agents and substances for their properties, characters and effect on the living beings to understand the safety and efficacy of its use in clinical settings. This is perhaps the areas where current Dhivehi beys products and medicaments lag in comparison.

Are "Dhivehi beys verin" doctors? Some of them seem to like the title rather much. One practitioner who has a growing business in Male' at his MM clinic likes to be referred to as doctor. He is to our knowledge not registered in Maldives as a doctor. The Maldives Medical Council answered our call and reported that he was not a doctor. Maldives Medical Association office was closed and their opinion was not available on this issue. The use of this title is of concern as many people might be misled by the title itself. While we do note that neither the clinic nor the prescriptions claim the title "Dr" the fact that the Title is used un-corrected by the clinic staff and patients is a serious concern.

(Other people apparently use the title too without having the necessary qualifications: Dental Hygienists in IGMH and in private practice use the title Doctor in public and therefore cause confusion as being equivalent to much higher trained dental surgeons).

The concoctions that are available from MM clinic are famous as being locally produced and "tested". One "veymui sharbat" is claimed to possess healing for almost all illnesses! None of the clinics products have any side effects; claims the "doctor" according to his patients. This is because they are from natural products. His claim: natural products don't have side effects.

There have been some allegations of misuse of modern pharmaceutical agents in medicaments produced by traditional practitioners. One prominent  internal medicine physician from IGMH, who spoke to us on condition of anonymity, alleges that there is concern among his colleagues that a large number of traditional concoctions contain crushed tablets of modern drugs. He specifically mentioned steroids and morphine as being used. He said that he makes these allegation based on observations he has made which included some renal patients showing signs of prolonged steroid use (Cushingoid features) and others showing opiate overdose signs.

These are very serious allegations. It is our wish that authorities look into these allegations as soon as possible.

There are some other very disturbing allegations as well. The doctor quoted his friends in Obstetric practice as having told him about a traditional practitioner in Villingili who carried out per vaginal examination of female patients either by himself or "using the husbands hand" to look for signs of pregnancy or illness! We are unable to verify these claims and therefore have not used the name of the practitioner; we would encourage patients and doctors with information to come forward and confirm the story to our readers, if they are indeed genuine. It is our understanding and belief that the said practitioner has no training in carrying out these delicate examinations and strongly condemn such practices if indeed they are happening.

We have been able to confirm that the traditional practitioner in Villingili is consulted by many young couples struggling to start a family. Some of the patients we spoke to described some treatments that were offered. These included use of herbal and home-made pastes to apply on the genitals, use of different sexual positions and use of disposable syringes to "inject" partners semen into the vagina for "artificial insemination". These techniques have so far, as described by the 2 young couples we spoke to, been unsuccessful in their cases.

We tried to contact Dr Ahmed Razee, who is apparently the chairperson of the "Dhivehi Beys veringe Jamiyyaa" regarding these practices. Unfortunately we have not been able to talk to him to get his reaction or expert opinion. We wonder why HE is the charperson anyway?

We believe that Dhivehi beys has a role to play in our medical system. We do not doubt that it has helped many patients find cures and alleviated of suffering, even in cases where modern medicine has failed to find cures. None the less, we would like to see this branch of medical practice to be more refined. We would like to see the the safety of the "medicaments" and concoctions established through proper scientific studies (and not just by anecdotal evidence).

We cannot afford to be duped by a wayward, unregulated and unsafe traditional medical practices. It is our wish that authorities look into the serious allegations that have been made and make an attempt to regulate this branch of medicine that so many Maldivian are turning to.

Child sexual abuse victims: abused and neglected [edited]

It was several years ago. I was waiting outside the door to our house waiting for my young daughter to be ready for school. I was considering the route to school that we'd have to take to keep my feet dry as I push my bicycle through the mud-puddled streets when a friend tapped my shoulder and began to tell me about the hot topic of the day. A couple of Maldivian teachers had been caught sexually abusing young girls in their private tuition sessions. To my horror one of them was my daughters teacher; Naseem sir! I was so horrified that I told my wife that our daughter was not going to school for a few days till we could be sure that our daughter was not a victim herself.

There was no help offered either by the school or any organisation to kids like my daughter, to see if they had suffered themselves. No assessment of counseling to help them get over the trauma of listening to stories of their best-friends having been made to do disgusting things by their teachers!

I took my daughter to Central Hospital to get help for her. I thought she needed more than the support we could offer ourselves. I had real fear that my daughter might have been a victim. She had been behaving very differently lately. She easily cried about things that happened at home, she stayed unusually quiet for her usual self, she ate much too little for her mothers liking and she had stopped socialising with her friends. But most frightening of all she had started to make a fuss about having to go to school. All that just a few weeks before the news of Naseem sir and his accomplice's sickening stories became public.

At the hospital there really wasn't anyone to help us. Dr Mohamed Ahmed's name was mentioned to us. We took our daughter to his clinic which used to be house at his residence just across the street from the hospital. He wasn't particularly helpful. He asked us to give our daughter a couple of pills, something to relieve the "transient depressive mood". It probably didn't help, but we followed his instructions carefully. It was years later with our daughter preparing for her O'L exams when she confided in her mother that she was "touched" by her teacher! To our horror, by then the scum-bag was back in Male' and nearly freely going about his life; Our daughters life destroyed by an experience that would almost certainly scar her for life.

It is worrying that the number of reported cases of child sexual abuse in Maldives has been in the rise in recent years. The past few years have seen horrific tales of sexual assault on children of either gender; especially at the hands of those people who are entrusted with their welfare.

I will not be discussing the different cases, why it is on the rise or why the punishment for such terrible crimes is so meager. That needs to be discussed and is one important area of social protection of child welfare that is neglected in Maldives. What I will be touching on, and hoping to open a discussion, is the lack of proper assessment and support mechanisms within our medical services to help those who have been victims of these grave crimes.

The situation has indeed improved since the times of my daughter. A child welfare service is now established at the ministerial level at Gender ministry, child protection services are being decentralised to the atolls, IGMH has established a Family Protection Unit to help improve identification, reporting and early case management and an improvement in the publics  understanding of the need to report and seek help.

All that said, our children are still not receiving adequate care and treatment to get over the effects of these atrocities committed against them. Many of these kids are never counseled at all. Their families are not taught about the danger signs that need to be looked for and certainly little if any is done to help kids get back to "being kids" again!

My daughters friend who were subjected to the most severe abuse lost their way in school, were unable to integrate into society and became social outcasts themselves. At least one of them has significant criminal records; especially linked to sexual criminal conduct.

I would be the first to agree that even with the best treatment and care a few children may never return to "normal" childhood, but with little or nothing done the chances are that our unfortunate kids are further "abused" by a system reluctant to invest in proper care for kids under going such traumatic and forever scarring experience.

The carers currently working in the field are too young themselves, having little more than a year of work experience (within our severely inadequate system) with no professional medical or psychological or psychiatric assistance or supervision. Fair enough, a psychologist has recently started clinical work at IGMH and a couple of Psychiatrists do lend their support to the management, but their involvement is insufficient. More than that, their skills and training don't necessarily give them the required skills to actually work in this very sensitive area. There isn't a single child psychiatrist in the country!

There are many areas of need in our health system. Building and expanding ICUs, improving health care provision in the atolls etc...are all important and perhaps even high on the priority list. But with the current trend of increasing child abuse and other forms of domestic violence isn't it time that we get better help available for our kids who do fall prey to Pedophiles in regaining their childhood innocence and providing them a way back to a life that is not scarred?

Report submitted by Mubeen Jaleel.

Child sexual abuse victims: abused and neglected.

It was several years ago. I was waiting outside the door to our house waiting for my young daughter to be ready for school. I was considering the route to school that we'd have to take to keep my feet dry as I push my bicycle through the mud-puddled streets when a friend tapped my shoulder and began to tell me about the hot topic of the day. A couple of Maldivian teachers had been caught sexually abusing young girls in their private tuition sessions. To my horror one of them was my daughters teacher; Naseem sir! I was so horrified that I told my wife that our daughter was not going to school for a few days till we could be sure that our daughter was not a victim herself.

There was no help offered either by the school or any organisation to kids like my daughter, to see if they had suffered themselves. No assessment of counseling to help them get over the trauma of listening to stories of their best-friends having been made to do disgusting things by their teachers!

I took my daughter to Central Hospital to get help for her. I thought she needed more than the support we could offer ourselves. I had real fear that my daughet might have been a victim. She had been behaving very differently lately. She easily cried about things that happened at home, she stayed unusually quiet for her usual self, she ate much too little for her mothers liking and she had stopped socialising with her friends. But most frightening of all she had started to make a fuss about having to go to school. All that just a few weeks before the news of Naseem sir and his accomplice's sickening stories became public.

At the hospital there really wasn't anyone to help us. Dr Mohamed Ahmed's name was mentioned to us. We took our daughter to his clinic which used to be house at his residence just across the street from the hospital. He wasn't particularly helpful. He asked us to give our daughter a coupleof pills, something to relieve the "transient depressive mood". It probably didn't help, but we followed his instructions carefully. It was years later with our daughter preparing for her O'L exams when she confided in her mother that she was "touched" by her teacher! To our horror, by then the scum-bag was backin Male' and nearly freely going about his life; Our daughters life destroyed by an experience that would almost certainly scar her for life.

It is worrying that the number of reported cases of child sexual abuse in Maldives has been in the rise in recent years. The past few years have seen horrific tales of sexual assault on children of either gender; especially at the hands of those people who are entrusted with their welfare.

I will not be discussing the different cases, why it is on the rise or why the punishment for such terrible crimes is so meager. That needs to be discussed and is one important area of social protection of child welfare that is neglected in Maldives. What I will be touching on, and hoping to open a discussion, is the lack of proper assessment and support mechanisms within our medical services to help those who have been victims of these grave crimes.

The situation has indeed improved since the times of my daughter. A child welfare service is now established at the ministerial level at Gender ministry, child protection services are being decentralised to the atolls, IGMH has established a Family Protection Unit to help improve identification, reporting and early case management and an improvement in the public's  understanding of the need to report and seek help.

All that said, our children are still not recieving adequate care and treatment to get over the effects of these atrocities committed against them. Many of these kids are never counselled at all. Their families are not taught about the danger signs that need to be looked for and certainly little if any is done to help kids get back to "being kids" again!

My daughters friend who were subjected to the most severe abuse lost their way in school, were unable to integrate into society and became social outcasts themselves. Atleast one of them has significant criminal records; especially linked to sexual criminal conduct.

I would be the first to agree that even with the best treatment and care a few children may never return to "normal" childhood, but with little or nothing done the chances are that our unfortunate kids are further "abused" by a system reluctant to invest in proper care for kids under going such traumatic and forever scarring experience.

The carers currently working in the field are too young themselves, having little more than a year of work experience (within our severely inadequate system) with no professional medical or pscychological or psychiatric assistance or supervision. Fair enough, a psychologist has recently started clinical work at IGMH and a couple of Psychiatrists do lend their support to the management, but their involvement is insufficient. More than that, their skills and training don't necessarily give them the required skills to acually work in this very sensitive area. There isn't a single child psychiatrist in the country!

There are many areas of need in our health system. Building and expanding ICUs, improving health care provision in the atolls etc...are all improtant and perhaps even high on the priority list. But with the current trend of increasing child abuse and other forms of domestic violence isn;t it time that we get better help available for our kids who do fall prey to Paedophiles in regaining their childhood innocense and providing them a way back to a life that is not scarred?

Announcement

We at MMW have received several emails requesting that we moderate the comments made in response to our posts. We have noted with disgust that few people who have used severely abusive words in commenting. While we do not condone these acts, we would like to allow free expression of opinions.

We understand that people on both sides of a discussion have much to say. Sometimes emotions run high and language is allowed to deteriorate. We have made a decision that we will be allowing a free hand at commenting at present. We reserve the right to change our stand on this issue at a later time.

It is our request that all individuals who comment on the blog refrain from using foul words. We would appreciate it very much if comments could be made in relation to the post. Kindly self moderate your comments.

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.

The essential drug list and health service outlets

We understand that with the assistance of WHO, senior level health service providers in the Maldives drew up and occasionally update a list of medications and consumables under the broad heading of Essential Drug List. Its been several years since the list was first created and the list has not been updated for a few years now.

The Essential Drug List names medications and consumables that are to be made available, as a prime responsibility of the Ministry of Health, at all health service outlets across the country at all times. These are basic requirements that need to be in place at all centers regardless of the geographical location within the archipelago. Recently we read about several hospitals and health centers running out of medical oxygen. When we were investigating the story we found out that many of the health posts and health centers that we were able to contact, also had some of the essential drugs missing.

Haa Dhaal Maavaidhoo has a health post but no doctor and no medications. The community health worker is unable to manage anything, even under the advice of properly trained doctors who he reaches by phone for assistance. Maavaidhoo health post is left decapitated because of lack of proper health service personnel. The island recently made the news in Maldives when few of its residents protested against the health conditions on the island.

Haa Alif Ihavandhoo has a health center and 2 small pharmacies managed by local businessmen. Recently, patients had to be transfered to Haa Dhaal Kulhudhufushi and Haa Alif Dhihdhoo because the doctor in the island said that he was unable to treat the cases because he had nothing more than Penicillin injections and some over the counter pain medications available for use. One case of epilepsy was transfered because they ran out of Diazepam. No routine anticonvulsant therapy was available.

We can also confirm that in moth Raa Alifushi and Rasgatheemu the health posts were until recently running on very little amount of medications. An asthmatic in Alifushi was referred to Ungoofaaru regional hospital because there was no ventolin in the island. The elderly patient had been keeping a stock of his own medications but ran out just at the time when his asthma had worsened. He survived the attack and has brought back a good stock of ventolin with him to Alifushi. Ventolin is listed on the Essential Drug List.

One young doctors from Alif Alif Rasdhoo atoll hospital reported to us that he and his colleagues receive calls from nearby islands when they are requested to take charge of cases because the doctors in the health centers don't have simple antibiotics to manage infections. The doctor fears that even mentioning his gender endangers him being identified as there are only four doctors working there including a gynecologist.

In Thaa Atoll Burunee the recently upgraded health center also reported a dire lack of medications and IV fluids. Sporadic cases of Dengue fever are seen in the island, especially among the Tsunami refugees. Not having IV fluids of the type needed in Dengue, the station doctor was unable to manage cases as best as possible.

These are some cases where we were able to identify issues of availability of even the essential drugs for basic health services. We wonder how many other islands and health centers would have similar problems. Even maintaining a supply of medications that MoH itself has declared as basic necessities for health service provision is not guaranteed.

We are also concerned about the lack of health service providers in a large number of islands. We do understand that MoH has made a renewed commitment to ensure that doctors are placed in many of these previously neglected island. This is promising, however, it comes to us as no surprise that many of the doctors currently working in the islands are mere novices who graduated from basic medical training less than 6 months before joining the Maldivian health sector! Their ability to work exclusively on their own in the very demanding conditions is highly questionable. This compounded with lack of medications and investigative capabilities leaves them and the public exposed to sad outcomes that we often hear about.

We ask the public to pressure the authorities to ensure that a basic health service guideline be established and minimal standard of health services to be provided to the islands be established. The Essential Drug List needs to be updated and provisions kept in place to ensure that all health facilities including the very basic ones have a ready supply of these medications.