Maldives Women Health Information
Reported, January 2, 2012
Health is a basic right of every Maldivian. This is the fundamental principle guiding the countrys strategies for health. In his Vision 2020 statement, His Excellency President Maumoon Abdul Gayoom states: that The people will have greater awareness of and commitment to healthy lifestyles. All citizens will benefit from good quality medical care in the area in which they live, with easy access to an affordable health insurance scheme enabling them to meet their medical expenses.
In line with the above, and as stated in the Sixth National Development Plan 2001-2005, the key objectives of the health sector are:
Reducing the burden of disease, suffering and disability in order to improve the quality of life;
Increasing the healthy life expectancy of all Maldivians by reducing preventable deaths; and
Improving the health of present and future generations.
A number of challenges exist in achieving these objectives. These include the delivery of basic medical services in an affordable and equitable manner considering the unique geography of the country, human resource constraints, and the ever-increasing cost of health care delivery. New problems such as emerging and re-emerging diseases, environmental health problems and problems related to drug abuse are adding to these challenges.
The overall strategy for overcoming these challenges has been the expansion of medical services to the atolls as well as extensive health education and health promotion. During the Sixth National Development Plan period, the focus is on nutrition and health promotion, outreach care, legislative mechanisms for health and capacity building for managerial and administrative support. In addition, continuous training is to be provided for medical professionals and nurses as well as peripheral health workers, enabling strengthening and easy access to health care services throughout the country.
Maldives has made a firm commitment to achieve the HFA goals with PHC as the key approach. To provide tools to address equity concerns as well as specific health problems, integrating the health and human development concerns into public policies, the Government developed a Health Master Plan(HMP) for 1996-2005. HMP envisages that by 2005 all Maldivians will have the knowledge and skills required to protect themselves from ill-health and will have access to effective, affordable health care that enhances their quality of life and enable them to lead healthy, productive lives. Emphasis is placed on preventive health and promotion of healthy lifestyles; reducing the burden of diseases in the community; early detection of preventive diseases, health problems and complications; equitable access and affordability of health care services; and health of women and other vulnerable groups. Attainment of the highest possible level of self-sufficiency in tertiary medical care within the available resources is also a high priority.
Disease Trends
Remarkable progress has been made in the control of communicable diseases. Malaria has been eliminated from the country service the last 15 years and other diseases such as leprosy and filaria are now at the stage of zero transmission. Since the early 1990s, tuberculosis prevalence has declined from 1.23 per 1000 population in 1991 to less than 0.2 in 1994, and the case-fatality rate has been zero since 1996. Furthermore, high coverage of BCG vaccination has resulted in negligible records of TB incidence among children. Case prevalence in HIV/AIDS has declined, and by the end of 2001, there were a total of 5 HIV cases in the country. HIV/AIDS surveillance has improved throughout the country, and a high degree of awareness among the local population on the causes and preventive measures of HIV/AIDS have resulted in the low prevalence. Trends in STDs, however, have not been properly determined yet, and surveillance needs to be undertaken.
With achievements in universal immunization, most childhood infectious diseases have been eradicated. No indigenous cases of, polio and diphtheria and whooping cough have been reported since 1978. However, measles continues to prevail in varying degrees. An outbreak of measles was reported in 1995, with 3070 cases, and in 2001, a total of 51 cases were reported.
Although there have been fluctuating trends, endemicity of diarrhoeal diseases has started declining since 1995. The incidence of diarrhoea stood at 30 per 1000 population in 2001. Surveillance has now been strengthened and diarrhoeal deaths declined steadily, with case-fatality rates below 1 since 1992. Intestinal parasitic diseases are still common. However, there has been a decreasing trend in death rates from such infections.
Acute Respiratory Infections (ARI) are one of the most common causes of morbidity. The number of ARI cases reported has increased sharply during the last few years. The number of reported cases increased by 48% during 1996-2000. A total of 19349 cases were reported throughout the country in 2001, and it is the second major cause of death in the hospital. There is also a striking difference in the number of ARI cases reported from Male as compared to the atolls. This suggests that ARI is associated with congested urban living conditions, as well as with environmental factors, such as pollution from increased construction activity.
The incidence of viral fever is the second highest cause of morbidity, with 11510 cases reported throughout 2001. There has been no major outbreak of dengue haemorrhagic fever since 1998. However, sporadic cases have been reported in the past 2-3 years. During 2001, 55 cases of dengue fever and 19 cases of dengue haemorrhagic fever were reported.
Although significant achievements have been made in the control of communicable diseases, non communicable diseases, particularly lifestyle-related diseases, pose a major challenge for the health services. A large percentage of patients admitted to hospitals for non communicable diseases suffered from ischaemic heart diseases, cerebrovascular diseases and hypertensive diseases. In 2001, 26% of the deaths that occurred in Indira Gandhi Memorial Hospital(IGMH) were from diseases of the circulatory system.
Patients seeking medical assistance from cancer have also been increasing significantly.The majority of cancers were found to be cervical and breast cancer in women. Oral cancer is also high. In 2001, 14% of deaths in IGMH resulted from various neoplasms or cancers.
In addition incidences of renal diseases, diabetes, gastro-intestinal diseases and diseases of the nervous system and mental disorders on the increase, with increasing deaths reported from such diseases.
The high prevalence of thalassaemia continues to be a major challenge for the country. Approximately one sixth of the population is affected by the condition, which is one of the highest incidences of the disease in the world. The number of children under treatment has increased from 55 in 1988 to 469 in 2001, with an average of 40 new cases detected every year. Intensive awareness campaigns, rigorous screening and improved treatment have increased the life expectancy of thalassaemics.
Nutritional disorders are common. Malnutrition among children below 5 years of age is extremely high. In 2001, 30% of children were found to be underweight, 25% stunted, 13% wasted and 9% severely undernourished. The prevalence of malnutrition is found to be more prominent in children at age 6-11 months. Micronutrient deficiencies such as vitamin A and iodine are also common. More than 5% of children under 5 years of age suffered from vitamin A deficiency in 2001, and according to the 1995 IDD survey, moderate goitre was prevalent among 25% of children between the ages of 6 and 12 years. The prevalence of anaemia, especially among women of reproductive age, is another major health problem. In 2001, 50% of women in the reproductive age group and 56% of pregnant women were found to be anaemic. It is one of the major factors contributing to serious complications in pregnancy and maternal deaths.
Health Service Delivery
By the end of 2001, health services in the country were reorganized from a 4-tier to a 5-tier system. The health service delivery system now comprises the central level (IndiraGandhiMemorialHospital – IGMH), regional level (regional hospitals), atoll level (atoll hospitals), sub atoll level (atoll health centres) and island level (health posts and family health sections). These five tiers of the health system are structured into a referral system, with the hierarchy ascending from the family health workers at the island level to specialist medical practitioners at IGMH.
The Ministry of Health (MoH) is the apex institution having overall responsibility for the delivery of health services in the country. MoH formulates the overall health policy and the health development objectives. The central level also encompasses the Department of Public Health (DPH), Indira Gandhi Memorial Hospital (IGMH), National Thalassaemia Centre (NTC) and the Maldives Water and Sanitation Authority (MWSA).
DPH is responsible for prevention and control of communicable diseases, delivery of health care to the atolls and islands and overall health promotion. Male Health Centre and Villingili Health Centre provide primary health care services to the population of Male and Villingili respectively. The public health laboratory ensures the quality of food and water through laboratory testing.
IGMH provides general and specialty services to the general public, and serves as the tertiary referral hospital for the entire country.
NTC provides blood transfusion, diagnostic and treatment facilities for thalassaemic children.
MWSA plans and regulates water and sanitation services throughout the country.
The six regional hospitals are situated at strategic locations, namely Haa Dhaal Kulhuduffushi, Raa Ugoofaaru, Meemu Muli, Laamu Gan, Gaaf Dhaal Thinadhoo and Seenu Hithadhoo. These hospitals provide secondary-level curative services and preventive health services to the atolls that fall under each region. They also have the responsibility to supervise atoll level health service providers, including atoll hospitals.
At the atoll level, 8 atoll health centres have been upgraded to atoll hospitals. These hospitals are situated in Shaviyani Funadhoo, Noonu Manadhoo, Alif Dhaal Mahibadhoo, Baa Eydhafushi, Lhaviyani Naifaru, Dhaal Kudahuvadhoo, Gaaf Alif Villingili and Gnaviyani Fua Mulaku. They provide laboratory and operating facilities, with gynaecological and obstetric services.
At the sub-atoll level, both doctors and community health workers (CHWs) serve their respective communities through the atoll health centres. Each atoll has at least one atoll health centre that provides basic health care and improved amenities in maternal health services.
Island health posts and family health sections at island offices provide health services at the island level. These facilities are at the bottom of the health service hierarchy. Family health workers and foolhumaas (traditional birth attendants) provide health care at these outlets.
In addition to the above government health care facilities, a significant number of private health care facilities provide services to the general public, especially in Male and in the developing regions of the country.
Private hospitals such as ADKHospital provide tertiary level health care in Male, while private medical clinics provide outpatient medical care, including minor operations and laboratory facilities in Male and in some atolls.
Human Resources for Health
The number of health professionals is increasing at a rapid pace due to the new and upgraded health facilities and increased speciality services. More atoll health centres are being built and some upgraded to atoll hospitals, while some atoll hospitals are becoming regional hospitals. These facilities demand increased contemporary surgical, obstetric and laboratory facilities, which in turn demand human resource competencies in these areas. During 1999-2001, the largest increase in health personnel occurred among laboratory technicians and other paramedical health workers. The number of foolhumaas and health workers decreased at the atoll level due to improvement and upgrading of service delivery at this level, while the numbers of general practitioners, specialists, staff nurses and nurse aides increased.
In both the government and the private sector, the gap between emerging requirements and the availability of skilled manpower was filled by recruiting expatriate health professionals since the training of locals to fill these positions takes sometime. In 2001, out of a total of 203 doctors in the government sector, 83% were expatriates. Likewise, 58% of nurses, 29% of laboratory technicians and 3% of other paramedics were expatriates. In the privates sector, out of the total of 60 doctors, 98% were expatriates. Similarly, 88% of nurses, 96% of laboratory technicians and 63% of other paramedics were expatriates. These trends indicate that there is an increasing need for training and development of human resources for the health sector.
Greater emphasis is given to the development of human resources through both in-country and overseas training. During the 1990s, a large number of trainees sent abroad comprised medical doctors and diploma-level nurses. A diploma-level nursing course started at the Faculty of Health Sciences of the Maldives College of Higher Education in 1990 now obviates the need to send this category of trainees abroad. In medicine, a greater emphasis is now given to training speciality doctors. Lower-level paramedical health workers are trained in-country at the Faculty of Health Sciences. In 2001, 46 FHWs, 31 nurse aides, 14 auxiliary nurse midwives, 12 pharmacy assistants and 9 diploma nurses were trained.
Key Issues in Health
The major health problems and key issues facing the health sector in Maldives are a result of the inherent structural problems faced by the country. The geographical severity of the country, coupled with the scattered population, leads to severe diseconomies of scale in the provision of health care services. Compounding these issues are the relatively high population growth rates and increasing life expectancy rates. Furthermore, the acute scarcity of skilled health personnel is a major constraint in the sustainable development of the health sector.
Malnutrition among children below 5 years of age, with a high degree of stunting, wasting and under-nourishment requires that emphasis is placed on effective management of national nutrition, food security and food safety programmes. Furthermore, increasing cases of anaemia and maternal nutrition deficiencies has made nutrition one of the major priorities of the health sector.
The burden of diseases, including vector-borne diseases influenced by the environment, emphasizes the need for improved environmental health, including access to safe drinking water and proper sanitation, especially at the island level. Furthermore, the burden of emerging, re-emerging, preventable, communicable and non communicable diseases stresses the need for improving the operational efficiency of ongoing intervention programmes. Interventions aimed at improving healthy behaviour and inculcating healthy lifestyles need to be strengthened by the enhancement of community awareness through effective IEC strategies. Advocacy for disease prevention, environmental health and inter sectoral coordination need to be addressed adequately.
The high population growth rate and maternal and perinatal disorders emphasize the need to ensure an effective reproductive health programme throughout the country. These programmes need to be focused on specially targeted and vulnerable populations.
A serious constraint for the health sector is the lack of adequately-trained personnel. Shortages in professionally and technically skilled national health manpower in almost all areas and levels of the health sector has led to the hiring of expatriates, resulting in a high financial burden for the government. This emphasizes the need for appropriate development and management of human resources for health. In addition, in-country training facilities also need to be improved.
Focus is now required to develop health facilities on islands selected under the Population and Development Consolidation Programme. The needs of other islands could be met through greater investments in accessibility mechanisms such as ferry systems and emergency transportation services. The infrastructure and facilities for using tele-medicine to reach outlying populations also need to be explored.
Increased participation of the private sector and NGOs in health activities calls for effective regulatory mechanisms to be put in place. Standards for management of health facilities and care delivery need to be established.
Shortages and non-availability of essential drugs, especially in the atolls and islands, emphasizes the need to increase the availability and access to quality affordable drugs.
The large amounts of data collected by the current health information system need to be managed, processed and analysed for effective, evidence-based management and decision-making. Adequate capacity for data collection, data storage and retrieval as well as capacity to analyse and report information needs to be strengthened. Appropriate technology and networking could also be used to strengthen the flow system of the information.
More information and credits at:
http://www.who.org.mv/EN/Section6.htm