OVERALL ASSESSMENT AND STRATEGIC ISSUES

The health status of the Maldivian people has improved remarkably. Contributing to this success was the Government’s emphasis on preventive health, particularly the immunisation programme that was intensified to achieve a high coverage, resulting in the near elimination of polio and tetanus. No cases of diphtheria and whooping cough have been identified within the last decade. Among other communicable diseases, malaria has been eliminated and diarrhoeal diseases brought under control. Leprosy and filaria are also shortly expected to achieve zero transmission. The successes in this area and the resulting increased life expectancy have sharpened the focus on non-communicable diseases. Thus, the Maldives is now going through a phase of epidemiological transition, characterised by reduction in communicable diseases and emergence of non-communicable diseases.

Life expectancy in the Maldives has risen sharply, while infant mortality has declined steeply. However, maternal mortality and fertility have remained high. The population is about 244,814 (1995 Census), with an annual growth rate of 2.8%. Many islands being densely populated, there are serious concerns regarding the rapid population growth rate. Therefore, while reproductive health remains the main focus, objectives now include efforts to control population growth.

Health policy including health promotion and protection

The Government is committed to the goals of Health For All, and the goals of the World Summit for Children, the Earth Summit, the Social Summit, the International Conference on Population and Development, the International Conference on Women and Development and the World Food Summit. It also recognises that the Primary Health Care approach is the most appropriate path to the attainment of these goals.

The Government of Maldives considers that the enjoyment of the highest attainable level of health is a basic right of every citizen. Thus the health policy of the Government aims to improve the health, well being and quality of life of present and future generations by reducing disease, suffering and disability, and to increase life expectancy further by reducing preventable deaths.

In order to continue the improvements in the health status achieved through disease prevention and health promotion, the Government has, in consultation with all partners in health development, identified priority areas that would need focused attention. These areas are tuberculosis, AIDS, reproductive health, heart disease, respiratory diseases, thalassaemia, hypertension, drug abuse, cerebro-vascular disease, kidney disease and cancer. In addition the promotion of healthy lifestyles has begun, focusing to reduce the burden of diseases in the community, and enabling early detection of preventable diseases, health problems and their complications. The initiatives that have been undertaken to discourage smoking are a good example. At the same time, attainment of the highest possible level of self-sufficiency in tertiary medical care will be a priority.

At a time when the country is developing rapidly in a changing world, the Maldives is faced with new challenges such as social stress, drug abuse, environmental health problems, age related problems and emerging and re-emerging diseases. The Government recognises that appropriate legal measures are needed to protect and promote health and will take adequate measures and legal support to ensure consumer protection and the welfare of all health care providers.

Health resources

Human resource development for health care has been given top priority. Local training of health personnel was initiated during the late 1950s and has culminated in the establishment of the Institute of Health Sciences (IHS). The ability of IHS to meet the health personnel needs of the country is greatly hindered by the acute shortage of qualified teachers, teaching aids and books, and practical training opportunities.

Meeting the human resource needs of the country is further hindered by the limited availability of trainable personnel. Although the number of students completing secondary school has been increasing over the last few years, the health sector faces stiff competition from other more attractive sectors.

A large part of the training requirements of the Maldives health sector has to be met in overseas institutions. The number of Maldivians undergoing medical training abroad has been increasing, especially so since 1994. Employment in both the public and private health sectors has risen. Training requirements abroad are substantial.

The physical health infrastructure has expanded considerably. The 200-bed Indira Gandhi Memorial Hospital (IGMH) has been built, a 50-bed private hospital opened, regional hospitals have been modernised, and a number of atoll health centres up-graded. Two more regional hospitals, a public health laboratory, a rehabilitation centre and more atoll health centres will be constructed. In addition to these, IGMH and IHS will be upgraded.

The Government will use available resources efficiently with the aim of developing a sustainable health care system based on appropriate technology. The Government has introduced alternative methods of health care financing, such as user fees at the Indira Gandhi Memorial Hospital and the regional hospitals and in the context of privatising water supply in the capital Male’ (from 1996) through the joint venture Male’ Water and Sewerage Company. Other methods of health finance and cost sharing will be explored. The Government would seek further partnerships with the private sector and NGOs and in this respect facilitate these development and regulation. From 1990, the importation of pharmaceuticals was privatised, leading to a very significant change in import pattern. Regulation of imports, monitoring and supervision of supplies (from approved suppliers) will be strengthened.

Continuing the steps taken in this direction, policies will focus on cost recovery through user charges and improving efficient use of available funds and facilities through decentralisation of health programme management. Increased participation and commitment by the communities in shouldering appropriate responsibilities and cost sharing would contribute to this strategy.

Social, economic and political environment, including technology

The economy of the Maldives has been doing well over a prolonged period, enjoying stability and growth. While earlier economic (GDP) growth rates amounted to about 10% or more annually, growth has slowed to a more sustainable annual rate of approximately 6%. However, the Maldivian economy has a narrow base, with tourism and fisheries forming the main pillars of the economy as the major sources of foreign exchange and government revenue. Furthermore, the Maldivian economy is sensitive to external stocks. While tourism in the Maldives has enjoyed several record years in succession, a potential downturn in either tourism, or fish catch/prices, would have sudden and far-reaching effects on the economy.

The Maldivian Rufiyaa, pegged to the US dollar, has been relatively stable. Per 1 US $, it depreciated from 9.195 in 1990 to 11.77 in 1995. Between 1990 and 1995, GDP grew by a remarkable 39% in real terms. Per capita GDP increased from Rf 4,551 to Rf 5,453.7 during the same period. While GDP growth has been maintained, the recent efforts to contain government borrowing helped to reduce excess demand pressures. The annual rate of inflation declined from over 20% in 1993 to 5.3 % in 1995 and is estimated at 6.2% in 1996.

The widely dispersed geography of this atoll country, with the population scattered across 200 inhabited islands and vast areas of sea, generates enormous diseconomies of scale, which make social, as well as industrial, development difficult and expensive. Despite problems in public finance, health expenditure as a percentage of the national budget increased from 6.8% in 1989 to 9.6% in 1995. This demonstrates the high priority attached by the Government to health development.

Taking advantage of the rapid advances in medical technology, hospital services have been improved to enable them to cater to public demand. Medical and diagnostic equipment available at central and regional level has been up-graded considerably. For example, CT scanning, echocardiography, EEG and endoscopy are (or will soon be) operational at Indira Gandhi Memorial Hospital. In addition, regional hospitals have been provided with X-ray, ultrasound and laboratory services. These advances are changing the image of medical services in the country. Quality assurance, however, is still in its infancy. During the Master Plan period, emphasis will be given to improve medical technology in the atoll level.

International partnership for health

The external aid received by the country, as well as the number of donors, have been in a downward trend in recent years. The amount of external aid received as a percentage of total health expenditure has also declined. The Government's continued commitment resulted in an increase in the health budget as a percentage of the national budget from 6.8% to 9.6%. From the point of view of macroeconomics, the Government had launched an ambitious programme of adjustment. The programme focused on addressing fiscal imbalances to help create an environment favouring domestic resource mobilisation, measures to reform public enterprises, rationalise public expenditure and increase private sector participation. Restoration of macroeconomic balance is felt necessary for sustainability, equitable growth and prosperity.

Development of health system and health services

Health for All, access to health care (for individual health), prevention & control programmes (for public health) and training (for capacity building in health) are critically important to the country. The former three-tier health system (island, atoll, central) has already evolved into a four-tier health system (island, atoll, regional, central) and all levels have been strengthened. At the central level, the tertiary level Indira Gandhi Memorial Hospital and the ADK hospital have been built. At the regional level, hospitals provide secondary level curative services; limited speciality services have been established to deal with obstetric and other surgical emergencies and their operating facilities have expanded considerably. Even at present these units carry out preventive health services. At the atoll level, since 1994, most atoll health centres have been staffed by doctors and community health workers (CHWs), and an up-grading programme to provide in-patient and labour room facilities continues. At the island level, basic health post services are provided by the family health workers (FHWs) and the foolhumaas or traditional birth attendants. The Government therefore lays emphasis on accessibility and affordability of health care services and the health of women and other vulnerable groups in the society.

Maternal mortality rates have remained high as a result of geographical constraints in service delivery, as well as human resource constraints. There is a continuing objective to reduce maternal mortality. Non-communicable diseases appear to show an increasing trend, perhaps due to the increasing life expectancy and changing life styles. This trend is likely to increase. This in turn may create pressure on health expenditure if expensive technologies are acquired to combat these diseases.

The Government will work to improve efficiency and quality of the health system by appropriate management reforms, to provide timely, effective and friendly services to the population. The health infrastructure is projected to develop further. Human resource constraints have hampered the development of health services. Therefore, the development of human resources for health will continue to command priority attention. There has been a ‘take-off’, since 1994, in the number of Maldivians undergoing medical and nursing training overseas. Simultaneously, in-country training has been expanded at the IHS, with a diploma-level course in nursing and midwifery introduced in 1991. The Diploma in PHC was introduced in 1996. The intake for this course has since been expanded. Alternative finances will be explored for external training including suitable allotments from the Government budget.

Intersectoral collaboration

Although health is usually the mandate of the Ministry of Health, health cannot be achieved by the health sector alone. Health has implications for other sectors and vice versa, especially in areas such as housing, water and sanitation which relate to the environment. Thus it is essential for the Ministry of Health to work closely with other sectors, in order to attain health objectives. There are many areas where a close link has been established between health and other sectors to achieve a common goal, and where future intersectoral collaboration is advised. In process and formulation, the Health Master Plan is a good example of this. Drug abuse, environmental health and nutrition are areas where such intersectoral collaboration is important.

FUTURE VISION

2.1 Vision statement

During the development of the Health Master Plan 1996-2005 the following vision statement has been proposed: All Maldivians will have the knowledge and skills required to protect themselves from ill health, and have access to effective and affordable health care that enhances their quality of life, and enables them to lead a healthy productive life.

2.1 Essential public health functions

The following essential public health functions are proposed. These are part of future vision, the product of considering together the country’s health objectives, strategies and guiding principles to meet health needs. In the Maldivian context public health means the following:

Equitable distribution of quality health services that are needed to prevent ill health and disabilities and cure diseases.

Prevention of epidemics and communicable diseases.

Protection of the population against environmental health hazards.

Prevention of disabilities.

Promotion of healthy lifestyles.

Disaster management and relief.

In order to meet the above mentioned public health needs, the Government will provide the following public health services.

Develop human resources that are required to provide equitable distribution of health services throughout the country.

Monitor health status to identify the health needs of the country.

Monitor health care coverage and utilisation to ensure quality of health care delivered.

Evaluate the effectiveness, accessibility, and quality of health services delivered by the private and public sector.

Carry out disease surveillance and epidemic management.

Assess environmental health hazards, develop and set standards for ensuring health and safety of the population.

Information, education and communication to empower people to lead healthy lifestyles.

Mobilise partnerships with private and non-government as well as government sectors to identify and solve health problems.

Develop and enforce laws and regulations that would protect and promote health and well being.

Develop research capacity.

Mobilise national, private and international resources for health.

Develop health policies and plans that address the needs of the present and future generations.

Deliver essential services needed for the prevention of ill health and disabilities, and for the promotion of health of all segments of the population, including emergency medical care.

PROPOSED STRATEGIES

Strengthening the health sector and specific health programmes

As explained, the process of formulating the Health Master Plan attempted to obtain intersectoral participation, co-operation and commitment at all levels including the grassroot level. The current long term planning process undertaken involves extensive consultation with the community and the various branches of the health sector.

There are a number of improvements in health resources and in the development of the health system, which are likely to impact positively on the health system. These include policy reforms, health resource development and administrative reforms. Examples concern the areas of health education and promotion, family and reproductive health, expanded programme of immunisation, disease prevention and control.

The health education and promotion programmes, focusing on behavioural changes, are likely to yield good dividends. A major function of future health education programmes has to be advocacy aimed at policy changes at different levels of the health care delivery system and health related sectors.

Family and reproductive health will be a key area. This could take the form of a package of good quality comprehensive maternal and child health services such as family planning, antenatal care, postnatal care, clean and safe delivery, timely referral for high risk cases, access to STD services and essential obstetric care including neonatal care. The programme would ensure strengthening of services and the availability of suitable methods of family planning at all levels. Further strengthening of the expanded programme of immunisation (EPI) is intended. The thrust of the programme would be to eliminate polio and neonatal tetanus, and to control measles as well as other immunisable diseases including viral hepatitis B.

The newly established public health units at the country’s regional hospitals will be strengthened, and coverage of immunisations maintained at above 90% for all vaccines, including tetanus toxoid for females in the reproductive age group, by conducting routine immunisation as well as national and supplemental immunisation days. The quality of vaccination will be monitored and maintained by the Ministry of Health through the national EPI programme. Monitoring and surveillance of EPI target diseases will be carried out. Effective clinical and virological surveillance of acute flaccid paralysis will be developed and implemented. Immunisation will be extended to include additional antigens.

In the area of disease control, attention will be focused on tuberculosis, AIDS and acute respiratory diseases. Intensified case detection and case management of TB cases using standard guidelines are essential along with introduction and expansion of directly observed treatment short course (DOTS) to each and every diagnosed case. Development of close co-ordination and co-operation with the private sector and other organisations for prevention and control of TB is also essential. Leprosy can be eliminated from the Maldives by further effective implementation of zero transmission survey activities, including effective surveillance at each level of the PHC system and early identification and management of leprosy cases. In order to maintain the country free from malaria, epidemiological and entomological surveillance needs to be continued and intensified. It is intended to develop a mechanism to strengthen intersectoral collaboration in prevention and control of vector-borne diseases to ensure that mosquito control activities are incorporated in all development activities. Selective and cost-effective vector control measures will be adopted.

Non-communicable diseases will be addressed through IEC aimed at promoting healthy lifestyles, such as family health motivation and regular health monitoring, adopting healthy behaviours including balanced and healthy diet, regular exercise, healthy environment, reduce smoking, stress management and other factors that reduce the incidence of such diseases. Renal diseases will be dealt through improvement in the treatment and management facilities for kidney diseases and research. Better diagnostic and treatment facilities will be made available.

The focus of the cardiovascular disease control programme will be that of early recognition of hypertension and diabetes, and well-balanced management of these conditions. The diabetes control programme will focus on the early detection of diabetes and the proper management of the condition. The key strategy will be promotion of healthy lifestyles. Reducing smoking, encouraging good dietary habits, managing of stress and physical exercise will be the main emphasis of the programme. The central level will have facilities for tertiary level care including stress testing and echocardiography. At the regional level, facilities will be provided for the early recognition of cardiovascular diseases and the atoll and island levels will be able to manage uncomplicated cases of cardiovascular diseases.

The strategy for cancer is aimed at providing the knowledge and the skills necessary to prevent common cancers such as oral, lung, breast and cervical cancers by adopting healthy behaviours. The strategy will educate people to utilise the cancer screening services that are available and create awareness on the need for early detection of cancers.

In the area of thalassaemia, all aspects of curative and preventive measures will be ensured through early diagnosis, counselling and treatment. Screening for thalassaemia will be expanded to cover the age group of 12 - 15 years, throughout the whole country. This will be done by strengthening the facilities at the regional level and by providing outreach services in the form of visiting mobile teams, at the island level. Counselling services will be expanded to cover the whole country. However, the main emphasis will be to cover the outer atolls where medical services are still difficult to reach and greater awareness needs to be created. The expansion will be achieved through the training of family health workers and community health workers, as well as through the involvement of community groups and non-governmental organisations. The blood bank facilities in the atolls will be initiated by the organisation of a voluntary blood donation system.

Mental health services will be made available at the central level. At the regional level, services will be provided by visiting psychiatrists. At the atoll and island levels, trained community health workers and nurses will provide basic psychiatric services. Home based care of psychiatric cases will be given priority over institutional treatment. Emphasis will also be given to the prevention of mental illness and the promotion of mental health and well being through awareness programmes. Physical disabilities will be ensured through early detection and strengthening and management of disabilities.

Substance abuse will be dealt with through a two pronged approach, namely demand reduction through awareness campaigns and drug rehabilitation, and supply reduction through strict enforcement of law. The Government will also encourage and motivate the participation of NGOs to play a complementary role to the Government in implementing these strategies.

Better treatment of common diseases and injuries will be ensured through up-grading of diagnostic and therapeutic facilities. Quality assurance needs to be practised at all levels of the health system. Strengthening management is required to ensure efficiency. Access to essential drugs should be provided at all levels. Specialist outreach services need to be provided to improve access.

In the area of health services, emphasis would be on sustaining existing health infrastructure, including facilities and manpower. This points to the future also, in strengthening existing referral centres, posting of specialists or general practitioners at central, regional and atoll health centres, strengthening of regional, atoll and island level health management. Laboratories will be established in the health centres. Additional infrastructure needs to be developed in under-served areas. Quality improvements are equally important. Further, there is also a need to formulate clear and objective policies with respect to enhancement of the role of the community, the private sector and NGOs and their participation in the area of health.

Development of human resources to improve managerial capability and capacity to manage specific health programmes and activities at atoll and island level should also be built into the health strategies. Considerable efforts in capacity building have already taken place. Policies are advised to improve the efficient use of personnel through regulation and management. The development of training programmes is emphasised to improve the quality of the community and family health workers serving in the outer atolls. During the Master Plan period CHWs will be introduced at the island level.

The following policy areas and broad strategies will be stressed during the Master Plan period:

Health manpower development directed towards meeting community needs.

Re-orientation of existing government regulations on decentralisation.

Development of operational working groups.

Analysis of structural and functional jobs within MOH and its institutions.

Establishment of the necessary institutional mechanisms to ensure that health goals are an integral part of the socio-economic development.

Increasing of awareness among all sectors that health is an important element in increasing the quality of life.

Development of self-reliance in health through an educational approach and the application of Atoll Team Problem Solving (ATPS).

Motivating of community participation and involvement.

Development of effective and efficient referral systems.

Promotion of Health and Environment.

Protection of the community against health and medical malpractice, environmental hazards and unwholesome food.

Provision of private and NGO sector participation.

Supervision and guidance in the production and use of effective traditional medicine accepted by the community while increasing the accessibility to ingredients needed for traditional treatments.

Improvement of the status of community health and nutrition and enhancing of the standard of living. Identification of key interventions (such as de-worming, school health, etc).

Intensification of efforts in communicable and non-communicable disease control.

Advocacy on environmental health and promoting healthy island concept.

Provision of clean water, environmental sanitation facilities and maternal and child health services, including family planning.

Equitable distribution of health services and facilities.

Increasing of community health financing through health insurance schemes and other alternative mechanisms.

Encouraging of the development of medically effective traditional medicine.

Promotion of rational use of drugs and essential drugs.

Increased collaboration of the private sector, including NGOs, in the health sector.

Strengthening of medical and laboratory services throughout the country.

Upgrading of the health care workers at the island level.

Promoting equity, education and appropriate technology for health

To date, the focus of health education has been the increase of knowledge. Future strategies would emphasise behavioural change. This means a health promotion approach needs to be taken which takes into consideration all the factors that influence health. Patient health education, so far addressed minimally, is also required. Health care providers should be taught modern techniques of health education and communication, as well as gender sensitivity. This would support the emphasis on behavioural change (and not only increase in knowledge). Future health education programmes should emphasise advocacy for policy change, changes that would create an environment conducive to behaviour change and maintenance of healthy lifestyles.

Strategies for the protection and promotion of maternal health will be stressed. These will focus on a package of comprehensive maternal and child health services, such as family planning, antenatal and postnatal care, nutrition, access to essential obstetric care, care of the new-born encompassing exclusive breast-feeding. Safe motherhood initiatives focus on creating awareness on the risks to mothers and infants associated with too early, too late, too closely spaced or too frequent pregnancies. All pregnant mothers would receive a minimum of three antenatal check-ups and postnatal care, with deliveries conducted by trained health personnel. Training of personnel in this area is part of the strategy. Quality of care will be supported by the development of midwifery guidelines to be used by health personnel in all facilities.

The Home-Based Maternal Record Card (HBMRC) strategy will be further expanded, and utilised as a quality control tool for delivery of maternal and child health services. At regional level, maternity-waiting homes will be secured in collaboration with Atoll Development Committees (ADCs), to assist patients referred from atoll health centres or health posts. Supervision of activities related to safe motherhood will be strengthened by the Department of Public Health. Procedures are furthermore planned to investigate maternal and infant deaths. Target-oriented awareness programmes will focus on the prevention of sexually transmitted diseases, reproductive tract infections, cancer, high-risk pregnancies and thalassaemia. These are envisaged for implementation at atoll and island levels with participation of community groups and atoll offices.

Partnerships for health

Establishment of an intersectoral committee for planning and monitoring of health projects: The presence of such a committee will ensure that all health programmes will be planned with the involvement of other sectors and ensure a sense of ownership of the health plans.

Advocacy and promotion of health as a condition for development: Within this strategy, the health sector will ensure that other sectors are involved in the planning of health programmes and that information exchange takes place. The relationship between women, health and development is particularly important. Also, educational activities on health issues, including women’s health, and seminars on specific issues, will be conducted to sensitise policy makers and other key officials of related sectors. Such seminars will also focus on the economic benefits that other sectors will enjoy if health is made their focus.

Monitoring of health status in relation to environmental health conditions and specific measures such as those for occupational health, chemical hazards, solid waste and disposal, urban health and related indications: A mechanism will be developed for regular monitoring of the impact of environmental conditions on health.

Continuing international partnerships for health by strengthening valued links with existing development partners and seeking fresh links with new contributors: This includes continuing efforts in aid co-ordination, in holding consultations and follow-up meetings with international partners and strengthening monitoring and evaluation of national and collaborative programmes.