Maldives National Health Accounts 2011
Health Economic Unit, Policy Planning Division Ministry of Health, Maldives January 2013
HSD-MAV-1 Distribution: General
Maldives National Health Accounts 2011 Health Economic Unit, Policy Planning Division Ministry of Health, Maldives January 2013
© World Health Organization 2014 All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from SEARO Library, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: searolibrary@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. This publication does not necessarily represent the decisions or policies of the World Health Organization. Printed in India
Contents List of tables..................................................................................................................................v List of figures................................................................................................................................vi Abbreviations..............................................................................................................................vii Foreword...................................................................................................................................viii Acknowledgements......................................................................................................................ix 1. Introduction........................................................................................................................... 1 1.1 Background................................................................................................................... 1 1.2 Maldives health sector................................................................................................... 1 1.3 Socioeconomic background........................................................................................... 2 1.4 Demographic and health status indicators in Maldives.................................................... 6 1.5 The national health care system..................................................................................... 6 1.6 Profile of the health system in Maldives........................................................................ 11 2. National Health Accounts activity in Maldives...................................................................... 16 2.1 Overview..................................................................................................................... 16 2.2 Methodology............................................................................................................... 16 2.3 Study limitations.......................................................................................................... 18 2.4 National Health Accounts main findings in 2011 financial year.................................... 19 2.5 Health care financing in Maldives................................................................................ 20 3. Sectoral analysis: 2011......................................................................................................... 35 3.1 Ministry of Health and Family...................................................................................... 35 3.2 Insurance market in Maldives....................................................................................... 39 3.3 Health Service Cooperations........................................................................................ 43 3.4 General private practitioners........................................................................................ 44 3.5 Pharmaceutical sector analysis..................................................................................... 44 3.6 Household expenditures on health.............................................................................. 45 3.7 Traditional healers........................................................................................................ 47 3.8 Cross-country comparative analysis.............................................................................. 48 4. Conclusions and recommendations...................................................................................... 49 4.1 Notes on health-care financing.................................................................................... 49 Annex 1: Piloting the System of Health Accounts 2011 in Maldives............................................ 51 Annex 2: National Health Accounts 2011 summary tables......................................................... 56
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List of tables Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Table 10 Table 11 Table 12 Table 13 Table 14 Table 15 Table 16 Table 17 Table 18 Table 19 Table 20 Table 21 Table 22 Table 23 Table 24 Table 25 Table 26 Table 27 Table 28 Table 29 Table 30 Table 31 Table 32 Population distribution of Maldives for the years 1995, 2000 and 2006 Projected population distribution of Maldives for the year 2011 Projected distribution of households by gender, household size and region of residence in 2011 Household Income and Expenditure Survey, 2009−2010 Population and hospital bed utilization in Maldives, 2011 Hospital utilization in Maldives, 2011 Hospital utilization in Maldives, 2009−2011 Health indicators in Maldives Leading reportable communicable diseases in Maldives, 2011 Leading causes of mortality in Maldives, 2009 Profile of the health system in Maldives Summary of National Health Accounts findings, 2011 Sources of funds for health budget in Maldivian Rufiyaa, 2011 Source and distribution of funds to providers, 2011 Source and distribution of funds per function, 2011 Source of funds, 2011 Share of health-care services by financing agent Total health-care expenditure by type of facility Functional distribution of total health expenditure Aggregated functional distribution of total health expenditure Ministry of Health and Government expenditures and Gross Domestic Product evolution, 1995−2011 Source of Ministry of Health and Family funds, 2011 Use of Ministry of Health and Family funds Ministry of Health and Family budget line items Ministry of Health and Family expenditures based on NHA classification Sources of NSPA/Madhana funds, 2011 NSPA expenditure by type of health provider, 2011 Functional distribution of NSPA funds Sources of private insurance funds, 2011 Use of private insurance funds by provider, 2011 Use of private insurance funds by function, 2011 Health Service Corporations expenditures by provider type, 2011
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Table 33 Table 34 Table 35 Table 36
Functional distribution of NSPA funds Out-of-pocket expenditures by function, 2011 Household spending on traditional healers, 2011 Comparison of health expenditures as a percentage of gross domestic product in the South-East Asia Region
List of figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Population distribution in Maldives, 1995–2000 Population distribution in Maldives, 2011 Sources of health funds, 2011 Managing the health funds, 2011 Providers of health services, 2011 Ministry of Health and Family expenditures as a percentage of Government budget, 1995−2011 Ministry of Health and Family expenditures, 1995−2011(in million MVR) Ministry of Health and Family, Government and GDP evolution, Index 1996−2005 Sources of Ministry of Health and Family funds, 2011 Out-of-pocket spending by function, 2011 Comparison of public share and private share of total health expenditure in South-East Asia countries
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Abbreviations GDP HIES HSC IGMH MoFT MoHF MVR NCD NGO NHA NSPA OECD PHI SHA gross domestic product Household Income and Expenditure Survey Health Service Corporation Indira Gandhi Memorial Hospital Ministry of Finance and Treasury Ministry of Health and Family Maldivian Rufiyaa noncommunicable disease nongovernmental organization National Health Accounts National Social Protection Agency Organisation for Economic Co-operation and Development private health insurance System of Health Accounts
TB tuberculosis THE WHO total health expenditures World Health Organization
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Foreword Maldives is witnessing a demographic and epidemiological transition that has put the health system under serious constraints to support financially the burden of disease and to adjust the supply of services and manpower to emerging needs. The global financial downturn has affected health financing across countries, and Maldives is no exception. With limited financial resources, providing universal access to health services remains a major concern for the Government of Maldives. This concern was the driving force behind the key reform policies of the Ministry of Health and the Government for public sector development, and behind modernization to improve the efficiency and effectiveness of the health system and service delivery. Given the complexity of issues to address, in order to ensure the optimal road for health sector development, the Ministry of Health had to find answers to basic questions such as: •• •• •• what policy can ensure equal access to services for all those in need? at what price? at what burden on households?
The National Health Accounts team gives a comprehensive description of resource flows in a health-care system, showing where resources come from and how they are used. Although previous health-care expenditure studies have been carried out in Maldives, none have used the integrated framework of National Health Accounts to organize and compile data. This study will certainly have a great impact in shaping the health financing reform. Most importantly, it constitutes an essential benchmark for assessing the health system performance and evaluating health policies in the future.
Dr Ahmed Jamsheed Mohamed Minister of Health
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Maldives National Health Accounts 2011
Acknowledgements The 2011 National Health Accounts Survey was undertaken to provide information and evidence for health policy decisions and resource distribution to improve the quality of health service delivery in the Republic of Maldives. The survey is a result of the cooperation between the Ministry of Health (MOH) and the World Health Organization (WHO) and relentless efforts of the technical teams at all levels. Leadership for this important work was consistently provided by Dr Aminath Jameel (Minister of Health, 2008–2012) in conceptualizing the survey, and by Dr Ahmed Jamsheed Mohamed (Minister of Health, 2012–2013) in guiding data collection, analysis and dissemination. Dr Akjemal Magtymova, WHO Representative to the Republic of Maldives, led WHO coordination efforts and technical guidance throughout. In addition, implementation of the study would not have been possible without the contribution of the many individuals mentioned below. The National Health Accounts Team of the MOH with technical and financial support from WHO conducted the survey data collection and analysis. The current publication was drafted by Ms Aminath Nafha, Senior Administrative Officer, MOH, and Dr Osmat Azzam, Technical Officer of the WHO Country Office Maldives. The team of peer and technical reviewers include the following key officials of the Ministry of Health of the Republic of Maldives: Ms Geela Ali, Permanent Secretary; Dr Sheeza Ali, Director General of Health Services; Ms Aishath Samiya; Director, Policy and Planning Division; and Ms Mariyam Shafeeq, Chief Executive Officer, National Social Protection Agency. Technical review and comments were provided by Dr Alaka Singh, Regional Adviser, WHO Regional Office for SouthEast Asia, New Delhi, India. In addition to the above principal reviewers, the draft National Health Accounts report was also reviewed by Ms Mariyam Niyaf, Department of National Planning; Ms Mariyam Shazna, Maldives Food and Drug Authority; Ms Fathimath Aroosha, Maldivian Blood Services; Ms Mariyam Ali, National Drug Agency, and several concerned governmental and nongovernmental stakeholders. Input and support from many Government officials at various stages of the survey are also gratefully acknowledged, including from Mr Thoriq Ali Luthufi, State Minister, MOH, and many others. Administrative support and valuable guidance were provided by the staff of the Ministry of Health and the WHO Country Office Maldives.
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1. Introduction 1.1 Background The Republic of Maldives is an archipelago in the Indian Ocean comprising 1190 islands spread over 820 km long and 120 km wide, with an area of 90 000 km2. Only 198 islands are inhabited, 84 of which are used as resorts, and 14 serve industrial purposes. The inhabited islands are very small: only 33 have an area larger than 1 km2. The capital city of Malé with an area of almost 2 km2 accommodates a third of the country’s population of 320 000. The country’s land area is estimated to be 300 km2. For administrative purposes, the 26 natural atolls of Maldives are classified into 20 groups, each of which is referred to as an administrative atoll. The geographic characteristics of Maldives present a tremendous challenge for resource allocation and health facility distribution. There has been some recognition that the quality of available health-care services available is poor. While Maldives achieved significant reduction in child mortality up until 2011,its overall health performance has been, and remains poor compared with countries with the same income level. Maldives’ gross domestic product (GDP) has grown at an annual rate of 6–8%, driven by investment in tourism and a low level of inflation. Significant progress has also been achieved in human and social development over the last two decades, lifting Maldives from its status as one of the 20 poorest countries in the 1970s to one that shares characteristics of a lower-middle income country today with a GDP of Maldivian Rufiyaa (MVR) 29 936 million (US$ 1941 million) and a per capita GDP of US$ 6067. The Government is currently faced with an alarming burden of escalating health-care costs. This, along with the population profile and disease patterns, led the Government to consider the financial effects on the health system and the most pressing issues for health reform, which resulted in the creation of the National Health Insurance Scheme in 2012.
1.2 Maldives health sector The Maldives health sector is undergoing significant changes. The Government is revising its main policy document on health priorities, and at the same time moving to a system of national health insurance that will cover the whole population. The Ministry of Health and Family (MoHF) coordinates and manage health sector reforms with significant support from its major development partners such as the World Health Organization (WHO) and other donors like the World Bank and United Nations agencies, to implement government reforms and address key health sector systemic and operational issues. The MoH developed a health financing reform plan based on its priorities, and the National Health Accounts (NHA) was one of the priorities, to be developed in 2012. Four key health policy reform approaches needed to be introduced: (1) Improve the health status of the people (2) Improve access to services
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(3) Improve the quality of services delivered (4) Make more effective use of resources. To undertake the above health financing policy reforms, comprehensive and reliable health system information was required about the composition of the health system, the key actors in the system, their relationship with each other, and the key financing sources, agents and users of national health funds in Maldives. NHA is a widely accepted tool that is promoted by WHO and the World Bank to allow policymakers to understand and manage their health systems, and to improve system performance. It is a framework for measuring total – public, private, and donor – national health expenditure. Formatted in a standard set of tables, NHA methodology organizes, tabulates, and presents information on health spending in a user-friendly format. This format can be easily interpreted by policy-makers, including those without a background in economics. NHA essentially measures the “financial pulse” of a national health system by answering questions like: •• •• •• Who in the country is financing health services? How much do they spend and on what types of services? Who benefits from these health expenditures?
Thus, NHA is designed to give a comprehensive description of resource flows in a health-care system, showing where resources come from, and how they are used. As a macroeconomic policy tool, NHA can assist the Government of Maldives in obtaining “the big picture” of the size, structure, and relative efficiency of the health-care sector. It allows the Government: •• •• •• •• to estimate the proportion of GDP spent on health care; to identify areas within the health system that may be operating less efficiently; to assess the alignment of the health-care system with national health policies; and to assist in evaluating the impact of national and health sector policies over a period of time.
1.3 Socioeconomic background 1.3.1 Population This chapter provides the demographic and socioeconomic characteristics of the Maldives for 2011 and a descriptive assessment of the health characteristics and environment in which populations live. Information on age and gender distribution is presented, as it could serve as useful input for social and economic development planning and help understand the results presented in the following sections. The first data for Maldives, recorded in 1911, showed a population of only 72 237. This figure nearly doubled over the next 60 years (Census 2006 Analytical Report), and the population has grown since the 1960s at an average 3% per year. The annual growth rate then decreased significantly from 3.43% in 1985–1999 to 1.69% in 2000–2006. The 2006 population census put the total population at 298 968, of which about 49% were women.
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Maldives National Health Accounts 2011
Maldives has recorded significant achievements in human development. The infant mortality rate declined from 63 in 1986 to 4 deaths per 1000 births in 2010 (Maldives Health Statistics, 2011). The crude death rate declined from 17 in 1971 to 4 deaths per 1000 population in 2010. Effective immunization programmes and access to better health care throughout the country have played a major role in the fall of death rates. The crude birth rate, which was 49 per 1000 population in 1985, declined to 23 births in 2010. In the same year, life expectancy at birth was 72.8 years for men and 74.8 years for women (Maldives Health Statistics, 2011).
1.3.2 Age and composition of the population Table 1 presents the distribution of households by gender and individual age groups according to the last three censuses conducted in Maldives in 1995, 2000 and 2006. The age distribution of the population differs slightly to the results presented in this report, as the latter includes more recent data. Table 1: Population distribution of Maldives for the years 1995, 2000 and 2006 1995 Census Age group Under 4 5 to 14 15 to 39 40 to 59 60+ Age not stated Total Source: Census 2006.
2000 Census Female 17 859 37 503 47 130 12 276 5 272 152 120 192 Both sexes 30 912 70 016 110 730 31 826 16 341 1276 270 101 Male 15 699 40 233 54 733 16 431 9 289 815 137 200 Female 15 213 38 783 55 997 15 395 7 052 461 132 901 Both sexes 26 171 66 866 138 103 43 235 19 510 5 083 298 968
2006 Census Male 13 362 34 463 67 805 21 893 10 642 3 294 151 459 Female 12 809 32 403 70 298 21 342 8 868 1 789 147 509
Both sexes 36 972 76 629 92 113 25 715 12 842 543 244 814
Male 19 113 39 126 44 983 13 439 7 570 391 124 622
From the trends over the past 10 years and according to the most recent census in 2006, it can be seen that the population growth stabilized, mostly due to a decline in birth and death rates. However, it has to be noted that a rise in the population growth rate is envisaged: an increase in birth rates is predicted in the years to come when the dominating young people in the age structure of the population reach reproductive age. The information on age and gender distribution was used to construct population pyramids for both urban and rural areas, and for Maldives as a whole, which is represented in Figure 1. These pyramids have a wide base indicating a large concentration of population under the age of 15 years. The 2011 population, projected by the Department of National Planning and the MOH, is 320 000, distributed by broad age groups as indicated in Table 2 and Figure 2.
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Figure 1: Population distribution in Maldives, 1995–2000 75+ 70–74 65–69 60–64 55–59 50–54 45–49 40–44 35–39 30–34 25–29 20–24 15–19 10–14 5–9 0–4
Femal
Male
75+ 70–74 65–69 60–64 55–59 50–54 45–49 40–44 35–39 30–34 25–29 20–24 15–19 10–14 5–9 0–4
Femal
Male
25 000
15 000
5 000
5 000
15 000
25 000
25 000
15 000
5 000
5 000
15 000
25 000
Source: Census 2006.
Table 2: Projected population distribution of Maldives for the year 2011 Age group Under 4 5 to 14 15 to 39 40 to 59 60+ Age not stated Total Number Both sexes 28 012 71 570 147 818 46 277 20 883 5 441 320 000 Male 14 302 36 887 72 575 23 433 11 391 3 526 162 114 Female 13 710 34 683 75 243 22 843 9 492 1 915 157 886 Both sexes 8.8% 22.4% 46.2% 14.5% 6.5% 1.7% 100% Percentage Male 8.8% 22.8% 44.8% 14.5% 7.0% 2.2% 100% Female 8.7% 22.0% 47.7% 14.5% 6.0% 1.2% 100%
Figure 2: Population Distribution in Maldives, 2011
Using the 2006 census data, the following table presents a projected distribution of gender, household size and annual population growth according to the region of residence.
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Table 3: Projected distribution of households by gender, household size and region of residence in 2011 Population by island Region Malé Malé Malé (excluding other areas) Other areas Atolls North North Thiladhunmathi (Haa AlifAtoll) South Thiladhunmathi (Haa Dhaalu Atoll) North Miladhunmadulu (Shaviyani Atoll) North Central South Miladhunmadulu (Noonu Atoll) North Maalhosmadulu (Raa Atoll) South Maalhosmadulu (Baa Atoll) Faadhippolhu (LhaviyaniAtoll) Central Malé Atoll (Kaafu Atoll) North Ari Atoll (Alif Alif Atoll) South Ari Atoll (Alif Dhaal Atoll) Felidhu Atoll (Vaavu Atoll) South Central Mulakatholhu (Meemu Atoll) North Nilandhe Atoll (Faafu Atoll) South Nilandhe Atoll (Dhaalu Atoll) Kolhumadulu (Thaa Atoll) Hadhdhunmathi (Laamu Atoll) South Region North Huvadhu Atoll (Gaafu Alif Atoll) South Huvadhu Atoll (Gaafu Dhaalu Atoll) Fuvahmulah (Gnaviyani Atoll) Addu Atoll (Seenu Atoll) Source: 2006 Census data. Maldives National Health Accounts 2011
Locality
Both sexes 110 988 109 579 1 409 209 012 14 444 17 379 12 780 10 720 15 794 10 252 9 837 16 527 6 182 8 968 1 719 5 041 4 030 5 316 9 090 12 833 8 843 11 788 8 173 19 294
Male 55 650 54 251 1 399 106 464 6 755 8 031 6 038 4 912 7 638 5 323 5 065 11 663 3 566 5 053 944 2 589 1 957 2 758 4 513 6 607 4 479 5 775 3 807 8 992
Female 55 338 55 328 10 102 548 7 689 9 348 6 742 5 808 8 156 4 929 4 772 4 865 2 616 3 915 775 2 452 2 073 2 558 4 578 6 226 4 364 6 013 4 366 10 302
Number of households 15 099 14 804 295 34 344 2 596 3 198 2 247 1 938 2 717 1 661 1 551 1 633 828 1 135 278 849 607 822 1 556 2 109 1 576 2 296 1 426 3 322
Average household size 7.9 7.5 5.4 6.5 6.0 5.8 6.1 5.9 6.2 6.6 6.7 10.8 8.0 8.5 6.6 6.3 7.1 7.0 6.2 6.5 6.0 5.5 6.1 6.2
Annual population growth rate (expn) 6.0 6.2 (6.0) (0.1) (0.9) (0.7) 0.9 (0.7) 0.3 (0.1) (0.3) 2.5 0.9 1.3 (1.6) (1.4) (0.3) (0.3) (1.6) 0.6 0.01 (1.4) 0.2 (0.4)
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1.4 Demographic and health status indicators in Maldives The last Household Income and Expenditure Survey (HIES) was carried out in 2009−2010, covering 4.5% of the population (2060 households) and representing all Maldivians. The estimated average household size is 6.2 people (7 in Malé and 5.9 in the atolls). The estimated population in 2009 was 307 000. Around 35% of households live in Malé, while 65% live in the atolls. Table 4: Household Income and Expenditure Survey, 2009−2010 Indicator Sample size (as a % of households) Number of islands surveyed Number of blocks surveyed Sample size (households) Total population Total number of households Average household size Source: Household Income and Expenditure Survey 2009−2010.
Republic 4.5% 40 113 2 060 306 730 49 321 6.2
Malé 4.3% 1 40 600 109 494 15 637 7
Atolls 4.6% 39 73 1 460 197 236 33 684 5.9
Limited data available from this Household Survey show that spending on health services in the atolls is almost double compared to Malé. Outpatient services account for 30% of household expenditure on health in Malé, while in the atolls these account for 35%. Of the total household expenditure on health, pharmaceuticals account for 26% in Malé and only 16% in the atolls. This may be due to the fact that items that households purchase (medicines, for instance) are harder to obtain and more expensive in the atolls.
1.4.1 Health services in Maldives The last few years in Maldives have seen the beginnings of wide-ranging reforms in the health-care system. Reforms cover the scope, financing, costing, organization and management of health-care services and insurance cover. The estimated 8% of health-sector spending in GDP for 2009 (WHO) remains unusually high for a low- to middle-income country, while access to health care remains highly uneven. The high spending is in part due to challenges of geographical distribution of the islands. By the end of 2011, the Government had engaged in major health-system reforms, transferring the responsibility of hospitals and health centres to eight health service corporations (HSC). The health sector governmental structures within each HSC differed markedly. Under the Decentralization Act, primary health care functions that were not institution based were moved to island councils. However, in May 2012 the Government decided to discontinue the operations of HSCs and essentially reintegrate service delivery facilities within the structures of the Ministry of Health.
1.5 The national health care system One of the goals of the Maldives Government is to improve the health status of all citizens via a health system that assures universal coverage for all Maldivians. This will be accomplished by improving the basic coverage package of the health system based on the principles of equity, efficiency, quality, affordability, sustainability and client satisfaction.
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Health services in Maldives are provided through a network of two tertiary referral hospitals − one public hospital (Indira Gandhi Memorial Hospital) and one private hospital (ADK) − six regional public hospitals, thirteen atoll hospitals, 132 health centres, 108 private and polyclinics and 290 dispensing pharmacies. Some major tertiary services are not available in Maldives and are referred for treatment overseas, mainly in India. Most of the health services provided in 2011 were funded through the Ministry of Finance and Treasury (MoFT), allocated to the MoH , the National Social Protection Agency (NSPA) and HSC. Significant out-of-pocket expenses include private doctor visits and charges at private pharmacies and the ADK hospital. All health services are heavily subsidized at government health facilities. The availability of various specialized health services in Malé means that the urban population has better access compared to the atolls. The health system is also constrained in relation to the availability of qualified human resources at all levels.
1.5.1 Health infrastructure distribution As noted above, there is one tertiary public hospital in Malé and secondary level public hospitals are located in each atoll. In addition, one tertiary level private hospital exists in Malé and private clinics are concentrated mostly in urban regions. Maldives has 2.5 hospital beds per 1000 population, which is a high ratio compared with neighbouring countries. However, the beds are not uniformly distributed among the islands. For example, South Central Region (Thaa and Laamu atoll hospitals) has 135 hospital beds for 36 312 population (3.7 per 1000), while the Central Region excluding Kaafu Atoll (Alif Alif, Alif Dhaaland Vaavu atoll hospitals) has 39 hospital beds for 33 397 population (1.2 per 1000). The beds to population figures are relatively low in the Central Region as it is in close proximity to Malé. Table 5 shows the distribution of population, beds and utilization rates as per the Maldives Health Statistics 2011. Tables 6 and 7 summarize the distribution of providers and hospital beds from 2006 to 2010 as per the Maldives Health Statistics 2011.
Table 5: Population and hospital bed utilization in Maldives, 2011 Region Malé North North Central Central South Central South All regions Total population 110 988 44 602 46 602 33 396 36 310 48 098 320 000 No. of hospitals 3 3 4 3 5 4 22 No. of beds 335 68 80 39 135 143 800 Beds/1000 population 3.02 1.52 1.72 1.17 3.72 2.97 2.50 Hospital admissions 15 473 4 566 3 780 922 4 550 9 093 38 384 OPD visits 333 115 81 462 90 057 29 030 85 645 143 028 762 337 OPD visits/1000 population 3 001 1 826 1 932 869 2 359 2 974 2 382
OPD: outpatient department. Source: Maldives Health Statistics 2011.
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8 Table 6: Hospital utilization in Maldives, 2011 Total population OPD visits 333 115 22 677 48 357 10 428 12 476 34 017 17 613 25 951 91 63 103 6 735 18 340 3 955 411 456 615 765 3.97 2.04 4.24 33 42 22 800 4.04 2.18 2.50 2 303 698 2 649 2 174 3 572 38 384 12 752 10 110 14 851 16 024 31 908 19 961 37 430 33 851 51 786 762 337 36 66 63 82 113 116 84 179 79 225 266 185 120 63 43 167 2 782 816 1 164 2 154 1 718 2 638 1 089 2 045 2 301 2 529 2 509 2 793 1 763 2 486 2 257 3 175 4 142 2 684 2 382 10% 20% 5% 6% 23% 11% 17% 26% 11% 41% 35% 74% 77 1 570 139 3 001 110 988 14 444 17 379 12 780 10 720 15 794 10 252 9 837 16 527 6 182 8 968 1 719 5 041 4 030 5 316 9 090 12 833 8 843 11 788 8 173 19 294 320 000 1 1 1 50 1 18 1 51 1 24 2.64 1 15 2.82 1 15 3.72 1 30 5.95 1 6 3.49 109 1 16 1.78 592 1 17 2.75 221 0 1 19 1.93 1 014 1 18 1.76 648 1 26 1.65 1 444 1 17 1.59 674 1 17 1.33 547 1 33 1.90 2 911 1 18 1.25 1 108 3 335 3.02 15 473 83% 9% 67% 33% 22% 60% 29% 41% No. of hospitals No. of beds Beds per 1000 pop Hospital admissions Admissions per 1000 OPD visits per 1000 Occupancy rate
Region
Locality
Malé
Malé (excluding other areas)
North
North Thiladhunmathi (HA)
South Thiladhunmathi (HDh)
North Miladhunmadulu (Sh)
Maldives National Health Accounts 2011
North Central
South Miladhunmadulu (N)
North Maalhosmadulu (R)
South Maalhosmadulu (B)
Faadhippolhu (Lh)
Central
Malé Atoll (K)
North Ari Atoll (AA)
South Ari Atoll (ADh)
Felidhu Atoll (V)
South Central
Mulakatholhu (M)
North Nilandhe Atoll (F)
South Nilandhe Atoll (Dh)
Kolhumadulu (Th)
Hadhdhunmathi (L)
South
North Huvadhu Atoll (GA)
South Huvadhu Atoll (GDh)
Fuvahmulah (Gn)
Addu Atoll (S)
Country
OPD: outpatient department; pop: population.
Table 7: Hospital utilization in Maldives, 2009−2011 Total inpatient admissions 2009 2 461 1 018 523 1 672 1 887 … 816 67 505 762 895 367 712 126 410 633 642 879 1 701 … 2 516 1 859 796 698 2 174 1 368 664 765 567 615 15 445 14 849 18 876 26 740 … 525 456 9 751 195 109 4 112 710 592 14 610 16 165 5 098 10 144 11 942 15 002 20 688 31 129 21 861 249 221 8 064 9 153 873 1 014 25 907 23 481 23 481 9 153 16 165 5 098 10 144 11 942 15 002 20 688 31 129 21 861 630 648 15 419 16 509 16 509 341 674 12 179 12 491 12 491 2 3 3 3 2 1 3 3 2 2 2 … 238 547 1 831 10 787 10 787 5 1 204 1 108 20 755 22 828 22 828 3 2 2 … 3 4 2 2 1 2 0 3 2 2 3 3 209 3 572 … 45 405 45 405 3 3 2 395 2 649 24 790 34 334 34 334 3 3 3 3 3 … 2 3 3 2 2 1 3 3 2 2 2 4 1 481 2 303 25 306 29 093 29 093 3 3 3 396 411 13 242 12 814 12 814 3 1 1 15 40 32 NA 12 17 16 33 32 26 31 10 18 12 17 16 44 … 1 317 1 444 22 889 23 413 23 413 3 4 4 39 2 620 2 911 45 833 48 605 48 357 3 3 3 53 53 61 … 32 33 68 16 … … … 39 12 28 … 20 … 19 12 44 18 2010 2011 2009 2010 2011 2009 2010 2011 2009 2010 Total outpatient visits Average length of stay days Bed occupancy rate 2011 67 60 6 26 41 74 9 33 22 29 41 10 20 5 23 11 17 11 35 24
Hospital
Kulhudhufushi Regional Hospital
Ungoofaaru Regional Hospital
Muli Regional Hospital
Gan Regional Hospital
Thinadhoo Regional Hospital
Hithadhoo Regional Hospital
Haa Alif Atoll Hospital
Shaviyani Atoll Hospital
Noonu Atoll Hospital
Baa Atoll Hospital
Lhaviyani Atoll Hospital
Alif Alif Atoll Hospital
Alif Dhaalu Atoll Hospital
Vaavu Atoll Hospital
Faafu Atoll Hospital
Dhaalu Atoll Hospital
Thaa Atoll Hospital
Gaaf Alif Atoll Hospital
Gnaviyani Atoll Hospital
Maldives National Health Accounts 2011
Hulhumale' Hospital
Source: The Maldives Health Statistics 2011 … - data not available
9
1.5.2 Health indicators The prevalence and incidence rates of tuberculosis (TB) have generally declined in the past few years. However, appropriate interventions and public health promotion activities need to be undertaken to maintain these low rates. The HIV/AIDS status in Maldives shows that since 2008, only one Maldivian has tested positive, although several HIV-positive cases are found each year during expatriate medical examinations, and these workers are deported. In addition, there are alarming risk factors in Maldives such as the increased number of injecting drug users. Appropriate monitoring of high-risk groups and other measures are needed to maintain the low HIV status in the country. Vector-borne diseases such as dengue and chikungunya are prevalent throughout the year. Data show that dengue fever was most prevalent from June to August in both 2009 and 2010; measures therefore need to be taken to eliminate mosquito breeding grounds, along with special precautions during the peak seasons to reduce the number of dengue cases. On the morbidity side, proper data collection mechanisms need to be established for noncommunicable diseases (NCDs) as these are becoming a higher burden in the country than communicable diseases. A basic health services network for handling communicable diseases had been established in the outer atolls, but facilities for diagnosis and treatment of NCDs were not available. Moreover, the extensive use of foreign health personnel and their high turnover made it difficult to ensure standardized treatment. Tables 8, 9 and 10 show the key health indicators as per the Maldives Health Statistics 2011. Table 8: Health indicators in Maldives Indicators Estimated population* Crude Birth Rate/1000 persons Crude death rate/1000 persons Maternal mortality rate/1000 live births Infant mortality rate/1000 live births Total fertility rate Median age of the population/years *Government estimation based on Census 2006. Source: Maldives Health Statistics 2011.
2011 320 000 22 4 112 11 2.15 19.4
10
Maldives National Health Accounts 2011
Table 9: Leading reportable communicable diseases in Maldives, 2011 Rank 1 2 3 4 5 6 7 8 9 10 Cause Acute respiratory infections Viral fever Diarrhoea Dengue fever Conjunctivitis Chickenpox Scrub typhus Hand, foot and mouth disease Mumps Chikungunya Total Source: Vital Statistics System, Ministry of Health, 2011.
Number of cases 113 834 70 608 18 979 2 909 2 878 1 186 91 71 69 39 210 664
% of total cases 54.04 33.52 9.01 1.38 1.37 0.56 0.04 0.03 0.03 0.02 100
Table 10: Leading causes of mortality in Maldives, 2009 Rank 1 2 3 4 5 6 7 8 9 10 11 Cause (in brackets ICD-10 codes) Diseases of the circulatory system (100−199) Diseases of the respiratory system (J00−J99) Neoplasm (C00−D48) Certain conditions originating in the perinatal period (P00-P96) External causes of morbidity and mortality (V01−Y99) Endocrine, nutritional and metabolic diseases Diseases of the nervous system (G00−G99) Certain infectious and parasitic diseases (A00−B99) Diseases of the digestive system (K00−K93) Diseases of Genitourinary System (N00−N99) Symptoms, signs, and abnormal findings not classified elsewhere (R00−R99) Cases 458 142 81 55 50 42 41 35 32 26 158 % of total cases 39.55% 12.26% 6.99% 4.75% 4.32% 3.63% 3.54% 3.02 2.76% 2.25% 13.64%
Source: Vital Statistics System, Ministry of Health, 2011.
1.6 Profile of the health system in Maldives The following table summarizes the key components and players in the Maldives health system, in terms of health-service coverage, source of financing, prevailing provider−payer relationships, and the size of each health-care subsystem.
Maldives National Health Accounts 2011
11
12 Table 11: Profile of the health system in Maldives Principal financing sourcesc Provider–payer relationshipd Size of operationf Population covered or eligiblee •• Ministry of Finance and Treasury (general revenues). All Maldives citizens are eligible. •• Household spending (out-ofpocket). Primary and secondary services treatment as well as tertiary treatment provided by the MoH – financed through budget derived from general revenue. Health facilities are owned by the MoH including 363 licensed health facilities,80 of which are located in Malé. The MoH operates all public health facilities: •• Primary care: 132 health care centres and 108 polyclinics (81 medical clinics, 8 eye clinics, 16 dental, 1 skin clinic and 2 ENT clinics). •• Secondary care: 6 Regional Public General Hospitals and 13 Atoll Hospitals. •• Tertiary care: one General Hospital (IGMH) and one private referral hospital (ADK) and overseas treatment. Ministry of Finance and Treasury (general revenues). Primary and secondary service treatment provided by health centres. Tertiary treatment provided by Atoll Hospitals, financed through budget derived from general revenue. All resident Atoll citizens are eligible. Health facilities are owned by the Government that operates: •• Primary care: 132 health care centres, 108 polyclinics, community health workers and family health workers. •• Secondary care: 6 Regional Public General Hospitals and 13 Atoll Hospitals. •• Tertiary care: 2 referral general hospitals: one public (IGMH) and one private hospital (ADK), both located at Malé.
Benefits by health subsystema
Coverage/ special categoriesb
I. Government sector
Ministry of Health and Family
Maldives National Health Accounts 2011
Provides comprehensive public health care services − primary, preventive and curative −through its facilities in addition to partial funding of overseas treatment including round trip tickets, per diem and part of the medical bill.
All citizens of Maldives.
Health Service Corporations (8)
Provides comprehensive primary, preventive and curative care services through its facilities on each inhabited island and atoll.
All citizens residing in each island.
Benefits by health subsystema Principal financing sourcesc Size of operationf
Coverage/ special categoriesb
Provider–payer relationshipd
Population covered or eligiblee
Two city councils (Malé and Addu City) •• Ministry of Finance and Treasury (general revenues). •• Local Government Authority reports to the Ministry of Home Affairs. Primary and curative health services financed by the Ministry of Finance and Treasury and managed by the Local Government Authority. All citizens residing in each city and all referrals from the atolls. City councils operate one primary health care centre in Malé and polyclinics.
Provides comprehensive primary and curative health services financed by the Ministry of Finance and Treasury and managed by the Local Government Authority.
All citizens residing in each city and all referrals from the atolls.
The National Social Protection Agency (through a social insurance scheme named ‘Madhana’) Contracted providers include MoHF and private providers. Contracted providers include MoH and private providers. Serves all individuals covered.
Coverage is all-inclusive.
Eligible groups:
•• Maldives locals Insurance contributions are collected by the NSPA. Premium set for Madhana was MVR 2000 for basic package and additional 1500 for Madhana Plus (services abroad) per person. Self-employed contribution is based on number of dependents.
NSPA is a separate body accountable to the Government. It designs policy and standards on the national health insurance scheme and monitors and regulates the scheme. Medical benefits and healthrelated social assistance budgets are consolidated and managed by the NSPA which is under the control of the MoHF.
•• Citizens of other countries contributing to the scheme.
Principally funded through a system of premiums paid by the Government and other contributors. Contribution rates are set per capita rather than health risks.
•• Expatriates contributing to the scheme.
Universal health insurance is managed by Allied Insurance Company through a scheme called Madhana.
A cap of MVR 100 000 per year.
11.67% of the population of Maldives (35 000/ 300 000) were registered for coverage on 27 August 2008. A third of the population was covered by 2011.
Maldives National Health Accounts 2011
It covers Maldives nationals and nonnationals contributing to the scheme.
13
14 Principal financing sourcesc Provider–payer relationshipd Size of operationf Population covered or eligiblee Principally funded through a system of premiums. Contribution rates are set according to benefit package and health risks. Contracted providers may be from the public or private sector. Serves covered groups. Contracted private providers operate within: •• public facilities •• private practices •• private pharmacies •• private dental clinics. Mainly household out-of-pocket spending. Sale of outpatient care, dental care, medicines and drugs. Providers operate: 99 private medical clinics 290 dispensing pharmacies 13 dental centres 2 ENT clinics 10 eye clinics. All citizens can choose to access these services provided they can afford to meet the costs. Mainly in-kind payment by households living in rural areas. Services are provided against in-kind payment. In this category, there are: 8 registered traditional healers 11 alternative medical clinics. All citizens can choose to access these services. Mainly from their disposable income. Payments for primary, secondary and tertiary care. All citizens. Analysed by number of visits/ admissions per capita.
Benefits by health subsystema
Coverage/ special categoriesb
II. PRIVATE SECTOR
Private Health Insurance Scheme (PHI)
Maldives National Health Accounts 2011
PHI aims to offer a broad range of health services, to control administrative costs and ensure equity.
The scheme covers different scenarios of benefit packages and may top up the NHI coverage affecting the premium price. Eligible groups: Maldive nationals and non-nationals contributing to the scheme.
Private providers (clinics, dental surgeries and pharmacies) not included within PHI scheme above
These are pharmacies, private clinics and any health provider owned by individuals operating in the private sector.
All citizens are eligible to use services. Costs are high compared with the public sector.
Traditional healers and traditional birth attendants
These traditional healers operate in the private sector, mainly in rural areas.
All citizens are eligible to use services.
Household (out-of-pocket)
This is spending by individuals on health services offered by health providers.
All citizens.
Benefits by health subsystema Principal financing sourcesc Provider–payer relationshipd Size of operationf
Coverage/ special categoriesb
Population covered or eligiblee
III. OTHER SOURCES
Nongovernmental organizations (NGOs) Mainly from international NGOs, donors and donations from large local employers, corporations and companies, as well as fund raising organized by NGOs. Implementation of village interventions for prevention and awareness programmes. Delivery of primary health care-related activities and first-aid kits mainly through grants and donations from international NGOs. The population covered is not defined. The number of NGOs has recently increased in Maldives and are mostly working closely with Government ministries and religious groups to deliver their messages to the community.
NGOs mostly provide health-related programmes to raise public awareness and improve sanitation and the environment; in some cases they provide primary health care medicines and first-aid kits to village-based organizations.
All citizens subject to an application being lodged through a recognized (often religious) organization, providing proof that they are able to carry out the activity.
Donors Mainly from external governments and organizations. Providing funds for primary health service programmes and secondary health services. All citizens are eligible. The most prominent donors and international organizations are the European Union, Japanese International Cooperation Agency (JICA), United Nations Children’s Fund (UNICEF), United Nations Development Programme (UNDP), United Nations Educational, Scientific and Cultural Organization (UNESCO), United Nations Population Fund (UNFPA), World Bank, and the World Health Organization.
These are external governments and organizations that donate both cash (in the form of grants and short-term loans) and in-kind items for the health sector,mainly through the Government but occasionally through NGOs.
Everyone is covered through these funded programmes.
a
Maldives National Health Accounts 2011
Type of services and benefits available. Coverage and eligibility criteria, and special programmes for specific population groups. c Main sources of financing. d Relationship between financing and service delivery functions. e Number of people covered or eligible by health system nationwide. f As indicated by staff, beds, or number of facilities. ENT: ear, nose and throat; NGO: nongovernmental organization; NSPA: National Social Protection Agency; PHI: private health insurance.
b
15
2. National Health Accounts activity in Maldives 2.1 Overview This NHA report details the overall national health expenditure for Maldives, the main sources of health funds, the main users and utilization of health funds for the year 2011. It is intended to present the key findings on how much Maldives is spending on health, who is paying what, and what on. The report attempts to highlight broad policy issues arising from the findings. Up until now, information on health resources, expenditure and its distribution in Maldives has been limited to the public health sector. Health expenditure information previously reported thus reflected mainly the Government’s expenditure on health. This NHA report includes health financing information for Maldives including the formal private health sector, donors, NGOs and other major players in the health sector. The 2011 National Health Accounts Report is the result of collaborative efforts of many individuals, teams, organizations and institutions. The diligent work of the NHA team, the Ministry of Health staff, the NSPA and the WHO Country Office is appreciated. The NHA team posed several key questions related to the health financing issues faced by the country, such as: •• •• •• Is Maldives spending an appropriate amount on health? Is the health budget appropriately distributed among islands, between urban and rural areas, different population groups, and across different socioeconomic categories? Is the amount spent on health being used efficiently and effectively and is there a balance between expenditure on hospital-based services, outpatient care, and preventive and public health services? Is the pattern of expenditures aligned with the desire of the Government that individuals take greater responsibility for their health status?
••
2.2 Methodology The Maldives NHA study followed the methodology recommended in the Guide to Producing National Health Accounts (2003) prepared by WHO in collaboration with the World Bank and the United States Agency for International Development (USAID). The methodology is based on information matrices that allow four levels of analysis: (i) sources of health funds, (ii) financing agents handling funds, (iii) providers of services, and (iv) health functions. Needed adjustments were made to the classification schemes to bring them in line with the Maldives national specifications as well as preparing the team to use the new System of Health Accounts (SHA II). Several criteria were used to adapt the classifications. The transactions were grouped so that they each represent an important, policy-relevant dimension. Partitioned transactions are mutually exclusive and exhaustive, so each transaction of interest is placed in one– and only one –category.
16
Maldives National Health Accounts 2011
Efforts were made, to the extent possible, to consider existing international standards and conventions when placing certain transactions into groups to assure international comparability of Maldives data. While preparing preliminary 2011 NHA tables, the NHA team relied on existing data sources but, when essential, additional efforts were made to compile the information. The following is a list of the key components of the information matrices and levels of analysis: (1) Sources of health funds –– –– –– –– –– –– –– –– –– –– –– –– –– –– –– –– –– –– Ministry of Finance and Treasury Private sector (employers and households) Donors and other sources. Public health sector (MOH, HSC, NSPA and other ministries, and public firms) Private health sector (household out-of-pocket, private insurance companies, NGOs, employer benefit schemes, etc.) Donors. Government facilities (hospitals and health centres) Private facilities (hospitals and doctors) Private pharmacies Health administration providers Other providers Providers of other health-related functions. Inpatient care services Outpatient care services Medical goods and pharmaceuticals Preventive and public health services Health administration Other health-related functions.
(2) Financing agents
(3) Health providers
(4) Functional classification of health
The compilation of National Health Accounts 2011 for Maldives commenced in January 2012 with extensive meetings between WHO, MoH officials, NSPA, key stakeholders, and the NHA team. The aim of this round was to support and guide the Government and MoH officials in reforming the health sector, highlighting the key health funds and actors, as well as assessing national health expenditures (public and private). Reforming the health sector will have an impact on the provision, financing and regulation of health services, and access to these services in Maldives. Thus the MOH with the help of WHO undertook research and studies to understand better the composition of the health-care system. This round of NHA 2011 provides the total health expenditures (THE) and traces the flow of health spending and resource allocation within the entire health sector.
Maldives National Health Accounts 2011
17
The NHA working team was led by the MOH Accounts Division. Secondary data sources were identified and analysed, data gaps were identified, and survey and data collection instruments developed. Surveys on NGOs, donors, private insurers, employers and providers were completed. Data on government spending from the MoFT as well as data from the Maldives Statistics Reports contributed to the finalization of the NHA report. The following sources informed the report: •• •• •• •• •• •• •• •• •• •• •• •• •• •• Ministerial accounts using the MoH Annual Report (Maldives Health Statistics 2011) Provider and facility-based surveys (time-use surveys, equipment and supplies surveys, and utilization surveys) Health Facility Registry (as at 13 November 2012) Annual Communicable Disease Report 2011 Donor/lender records from the Donor Survey and “donations missions consultancies updates” NGO Survey Household Income and Expenditure Survey, Findings 2009−2010 (Department of National Planning, Ministry of Finance and Treasury, 22 May 2012) Census 2006 Insurance Records Survey (public and private insurers) Traditional Healers Survey (NHA team 2013) Poverty Reduction in the Maldives (Asian Development Bank, January 2002) Interviews or expert opinions Health management information systems (Demographic and Health Survey 2009 (October 2010 publication) Central purchasing and essential drugs programmes.
2.3 Study limitations The preliminary NHA report revealed several strengths as well as shortcomings in the existing systems and data in the Maldives. The main challenges faced were: •• •• Household-level expenditure captured by the HIES 2009−2010 was insufficient for NHA purposes. Significant variations from the Government classification and the NHA Producers Guide classification led to shared concerns on the quality of the data, and preliminary plans for future data quality improvement were identified. Disaggregating spending by medical schemes of different ministries, other than the MoH, proved difficult, although special efforts were made by the NHA team to collect as much data as possible.
••
18
Maldives National Health Accounts 2011
••
Data from private insurance companies and private hospitals were sometimes either inadequate or unavailable. Further analyses were therefore used to extrapolate data from NSPA and other available research and studies. NGO expenditure data were of poor quality and those available were aggregated rather than by function or provider. Household expenditure data were available from the HIES by broad categories; special efforts were made to disaggregate the data according to specific types of provider and/or function. The Provider Survey was used to extrapolate household spending by function and provider to eliminate any significant limitation on the presented analysis. The quality of household-level data has been given particular attention because this will help to improve NHA estimates, and contribute to better private health spending and thus better health-care financing policy development. Thus, the presented data should be treated as best possible estimates. Data on the private pharmaceuticals market were derived mainly from the Provider Survey as well as data from the 2012 Pharmacy List of the MoH.
•• ••
••
••
In addition, actual volumes of health expenditure described in this first ever NHA report in Maldives are reflected in the required format without adjustments, if not stated otherwise. These are the first NHA estimates and attempt to achieve a compromise between timeliness and detail on the one hand and data quality on the other. As with any such estimation, revisions will be necessary to the methodology and numbers as new data sources become available, and as improved estimation procedures are developed. Routine revisions will therefore be necessary in future years in order to maintain, improve and update the quality and usefulness of the NHA. The NHA estimates reported are based on primary and secondary data collection. The NHA team was not able to run a Household Utilization and Expenditure on Health Survey for 2011 and used the NHA surveys to validate main data on household spending detailed in the HIES Findings 2009−2010. The figures were treated as best possible estimates before initiation of the primary data collection.
2.4 National Health Accounts main findings in 2011 financial year The main findings inferred from the NHA matrices are summarized in Tables 12. More detailed explanations of the summary findings are presented in Tables 13, 14 and 15. Table 12 above shows that the total national health expenditures in Maldives amounted to MVR2 766 million (US$ 179 million) in 2011 fiscal year, with per capita health spending of MVR8 646 (US$ 561). Health spending as a share of GDP came to 9.2%. This represents a high range for lowand middle-income countries. The NHA 2011 results show that almost 44% of the total funds originate from public sources, whereas 53% are apportioned by private funds and the remaining 3% are contributed by international donors. Household out-of-pocket spending represented 49% of total health expenditure. A breakdown of total health expenditures by function (Table 15) indicates that over 23% is spent on inpatient curative services, 24% on inpatient treatment abroad,19% on outpatient basic services, 2% on prevention and public health services, 17% on medicines, 12% on health administration
Maldives National Health Accounts 2011
19
and the remaining 2% on health-related functions such as education and research. Expenditure on drugs in Maldives is thought to be higher than most neighbouring countries with similar income levels. It is important to remember that this is the first ever estimation of functional classification at the national level in Maldives. Table 12: Summary of National Health Accounts findings, 2011 Total Government budget Government budget on health Total health expenditure Government budget on health as a % of its total budget Government budget on health as a % of total health expenditure GDP estimate for Maldives GDP per capita Total health expenditure as a % of GDP Public sector expenditure on health as % of GDP Private sector expenditure on health as % of GDP MoH budget as a % of Government budget Household out-of-pocket expenditure as a % of total health expenditure Drugs as a % of total health expenditure Maldives population: 320 000; Exchange Rate: MVR 15.42 for US$ 1.0.
MVR 12 824 579 283 1 217 423 491 2 766 573 290 9.5% 44% MVR 29 936 000 000 93 550 9.2% 4.4% 4.8% 3.1% 49.0% 17.0%
2.5 Health care financing in Maldives The past several years in Maldives have seen the beginnings of wide-ranging reforms in health-care financing. Reforms cover the scope, financing, costing, organization and management of healthcare services and insurance schemes. The share of health-sector spending in GDP (9% for 2011) remains unusually high for a country of low-to mid-level income, while access to health care remains highly uneven. High spending relative to GDP is accompanied by prevailing weaknesses in the efficiency, equity and quality of health services and marked fragmentation in service delivery and financing. Deeper reforms are necessary if the financial sustainability of the health-care system is to be maintained and the population provided with adequate access to quality health care. Among the key challenges to be addressed over the coming years is the centralization of the country’s health-care system to allow for better exploitation of economies of scale in delivery, financing and administration of health care. In 2011, the Government engaged in major health system reforms, transferring hospitals and public health centres to seven HSCs and a State Trade Organization. The health sector governmental structures within each HSC differed markedly. Federal law stipulates that the authority over health sector operations resides with the local authorities, including service delivery, revenue/insurance collections, expenditures, policy and planning. Yet in May 2012, the Government decided to discontinue the operations of HSCs and essentially reintegrate service delivery facilities within the MoH structures.
20
Maldives National Health Accounts 2011
Table 13: Sources of funds for health budget in Maldivian Rufiyaa, 2011 FS.1 Public Funds FS.2 Private Funds FS.3 Rest of the world Employers’ funds (FS.2.4) ROW international gov’t (FS.3) TOTAL MVR
Ministry of Finance & Treasury (FS.1.1) Other public funds (FS.1.2) Household funds (FS.2.2)
Nongovernmental organizations (FS.2.3)
HF.1.1
National Government
HF.1.1.1 181 108 426 22 165 836
Central Government 17 125 657 220 399 919 – 811 660 976 811 660 976 – – –
HF1.1.1.1
MOHF
HF1.1.1.2
MOD
HF1.1.1.3
Health service cooperations
HF1.1.1.4
Ministry of Labor and Social welfare
HF1.1.1.5
Ministry of Public Security
HF1.1.1.6
Other ministries and public agents
HF.1.1.2
Local Government
–
HF.1.2 216 453 532
Social health protection agencies 34 361 685 250 815 216 –
HF.1.2.1
NSPA (Madhana)
Maldives National Health Accounts 2011
HF.1.2.5
Other health protection agents
21
22 FS.1 Public Funds TOTAL MVR FS.2 Private Funds FS.3 Rest of the world Employers’ funds (FS.2.4) ROW international gov’t (FS.3) Ministry of Finance & Treasury (FS.1.1) Other public funds (FS.1.2) Household funds (FS.2.2) Nongovernmental organizations (FS.2.3) 8 200 557 1 245 290 196 4 910 654 68 111 166 63 554 904 19 853 903 91 609 364 1 245 290 196 4 910 654 68 111 166 73 775 797 73 775 797 – 1 209 222 934 8 200 557 1 365 372 621 4 910 654 87 965 070 90 901 454 2 766 573 290
HF.2
Non-public sector
HF.2.2
Private insurances
Maldives National Health Accounts 2011
HF.2.3
Private households’ out of pocket
HF.2.4
Local non-governmental organizations
HF.2.5
Private firms and employers
HF.3
Rest of the world
HF.3.1
Donors agencies
HF.3.2
International NGOs
TOTAL (THE)
Table 14: Source and distribution of funds to providers, 2011 HF.1 National Government Central Government MOD HSC MOPS NSPA (Madhana) Other health protection agents Private insurances Private households’ out of pocket Donors agencies International NGOs Local nongovernmental organizations Private firms and employers Social health protection agencies HF.2 Non public sector HF.3 Rest of the world MVR
MOHF
Total
HP.1
Hospitals
HP.1.1 217 038 981 184 492714 179 764 536 3 395 085 151 550 6 019 379 968 623 44 534 498 8 624 689 43 281 270 10 108 520 279 780 4 206 901 111 562 9 831 472 3 914 169 57 476 768
General hospitals 292 579 853 291 041 691 190 578 953 -
HP.1.1.1
MOHF regional hospitals
Indhira Gandhi Memorial Hospital
HP.1.1.2
MOHF atolls hospital
HP.1.1.3
Private sector general hospitals
HP.1.1.9
Other ministries & departments general hospitals
HP.1.2
Rehabilitation hospitals
HP.1.3
Specialized hospitals
HP.1.3.1
MOHF specialized hospitals
HP.1.3.2
Private specialized hospitals
HP.3 6 965 121
Other providers of health 40 545 572 256 180 420 8 450 000 8 072 736 303 691 114 8 450 000 8 072 736 197 855 298 32 509 447 2 294 040 7 184 284 28 793 27 862 207 361 484 32 538 240
HP.3.1
Clinics and physicians
HP.3.2
Dentists clinics
HP.3.3
Traditional healers and other health practitioners
HP.3.4
Primary health care centres
HP.3.4.1
Health centres
Maldives National Health Accounts 2011
HP.3.4.2
Health posts
23
24 HF.1 National Government Central Government MOD HSC MOPS NSPA (Madhana) Other health protection agents Private insurances Private households’ out of pocket Donors agencies International NGOs Local nongovernmental organizations Private firms and employers Social health protection agencies HF.2 Non public sector HF.3 Rest of the world MVR Total 10 785 384 181 459 639 27 221 399 250 065 925 246 098 458 993 061 10 595 663 47 294 555 7 282 682 14 954 593 677 250 656 175 917 63 180 135 141 525 823 14 954 593 102 529 886 656 175 917 811 660 976 250 815 216 91 609 365 1 245 290 196.18 4 910 654 68 111 166 73 775 797 2 766 573 290
MOHF
HP.3.5
Medical and diagnostic laboratories
HP.3.9
Emergency and transport
Maldives National Health Accounts 2011
HP.4
Retail sale and other providers of medical goods
HP.4.1
Public pharmacies
10 785 384
HP.4.2
Private pharmacies
HP.4.3
Providers of medical equipments and supplies
HP.4.4
Pharmaceutical factories
HP.5
Providers and administration of public health programmes
36 698 893
HP.6
General administration of health and insurance
HP.6.1
Government administration
134 243 141
HP.6.2
Private administration
HP.8
Institution providing health related services
38 672 501
HP.9
Rest of the world providers
HP.N.S.K
Provider not specified by kind
TOTAL (THE)
220 399 919
Table 15: Source and distribution of funds per function, 2011 HF.1 National Government Central Government MOD HSC MOPS NSPA (Madhana) Other health protection agents Private insurances Private households’ out of pocket Private firms and employers Donors agencies International NGOs Local nongovernmental organizations Social health protection agencies HF.2 Non public sector HF.3 Rest of the World MVR
MOHF
Total
HC.1 448 148 388 656 175 917 52 136 484 8 887 801 59132 121 4 882 792 67 865 068
Services of curative care 641 052 654 656 175 917 220 797 724 155 102 8 072 736 39 927 8 450 000 9 259 161 40 545 572 263 393 497 27 862 534 023 817 8 605 102 8 072 736 39 927
HC.1.1
In-patient curative care
HC.1.2
In-patient treatment Abroad
HC.1.3
Out-patient curative care
HC.1.3.1
Out-patient curative care (Without Dental)
HC.1.3.2
Out-patient dental care
HC.1.3.3
All other specialized health care (TH Curative Care)
HC.1.9.9
Emergency services within hospitals
HC.2
Services of rehabilitative care -
HC.2.1
In-patient rehabilitation care
HC.2.3
Out-patient rehabilitative care
HC.4 2 189 930 115 925 684 164
Ancillary services to health care 2 189 930 115 925 684 164
HC.4.1
Clinical laboratory
HC.4.2
Diagnostic imaging
Maldives National Health Accounts 2011
HC.4.3
Patient transport and emergency rescue
25
26 HF.1 National Government Central Government MOD HSC MOPS NSPA (Madhana) Other health protection agents Private insurances Private households’ out of pocket Private firms and employers Donors agencies International NGOs Local nongovernmental organizations Social health protection agencies HF.2 Non public sector HF.3 Rest of the World MVR Total 29 020 458 851 79 657 142 321 181 459 639 27 221 399 250 065 925 246 098 469 807 465 458 851 79 657 142 321 13 174 414 37 500 536 236 507 348 29 812 574 544 13 174 414 37 500 33 343 754 4 398 723 29 812 574 544 138 819 968 7 282 682 14 954 593 273 063 109 7 282 682 14 954 593
MOHF
HC.5
Medical goods dispensed to out-patients
HC.5.1
Medicines
10 785 384
HC.5.2
Medical supplies non-durable
Maldives National Health Accounts 2011
HC.5.3
Medical supplies durable
HC.5.4
Medical equipment
HC.6
Prevention and public health services
HC.6.1
Maternal & child health, family planning and counselling
HC.6.2
School health services
HC.6.3
Prevention of communicable diseases
32 807 518
HC.6.4
Prevention of noncommunicable diseases
3 891 375
HC.6.5
Occupational health
HC.6.9
All other miscellaneous public health service
HC.7
Health administration and health insurance
HC.7.1
Genera government administration of health
HC.7.1.1
Government administration of health (except social security)
134 243 141
HC.7.1.2
Administration, operation and activities of social security
HC.7.2
Private health administration and health insurance
HF.1 National Government Central Government MOD HSC MOPS NSPA (Madhana) Other health protection agents Private insurances Private firms and employers Donors agencies International NGOs Private households’ out of pocket Local nongovernmental organizations Social health protection agencies
HF.2 Non public sector
HF.3 Rest of the World
MVR
MOHF
Total
HC.R 677 250 3 427 280 54 931 958 339 068 176 896 40 740
Health related functions 35 012 182 62 696 808 339 068 176 896 40 740 811 660 976 250 815 216 91 609 365 1 245 290 196 4 910 654 68 111 166 73 775 797 2 766 573 290
HC.R.1
Capital formation of health care provider institutions
30 907 652
HC.R.2
Education and training of health personnel
7 764 849
HC.R.3
Research and development in health
HC.R.4
Food, hygiene and drinking water control program
HC.R.5
Environmental health
HC.R.nsk
HC.R expenditure not specified by kind
TOTAL (THE)
220 399 919
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The main government source of health-care financing is the MoFT, which derives its resource base from wage taxes, an unclear flow of funds between various extra budgetary social insurance funds, and limited Government contributions to compensate for cases that are exempt from obligatory contributions. The financing of health care scores poorly on equity and efficiency grounds. The extreme fragmentation of financing and delivery systems makes the use of health insurance revenues highly inefficient across the country. Insurance revenues fall significantly short of covering legislated entitlements due to a combination of expensive service delivery and weak revenue collection. To help increase the efficiency of service delivery and sectoral resource use, the authorities aim to introduce a revised system of provider payments that would create incentives for cost containment and improve provider performance. The MoH plans on switching from a system with different provider mechanisms to a prospective payment system, with some form of capitation payments for primary care and possibly outpatient secondary care. Prospective payment (possibly with feefor-service) would also be considered for hospital care and for established package services. The Ministry now wishes to take this work a step further and develop and test a new, integrated system of payment mechanisms that provides incentives for more rational resource use and quality care. The Minister of Health has sought assistance for this task from WHO, and terms of reference have been submitted for this technical assistance. Preparatory work has been carried out to prepare the primary health care payment pilots and to start costing a potential basic package of health-care services to be provided through health insurance. A detailed study is needed to get data on demographics, epidemiology, and health service utilization, and particularly costs and use of funds.
2.5.1 Sources of finance There are three principal sources of finance for the health sector in the Maldives: public, private, and external. Public sources (or Ministry of Finance and Treasury). Public sources include government financing for health care distributed to all HSCs in the atolls as well as the MoH and the NSPA. Private sources (household and employer funds). Private sources are payments made directly to a wide range of providers, including public hospitals, private practitioners and private pharmacies. User fees, whether for government or privately provided health services, are out-of-pocket payments and therefore considered here as health financed from a private source. Other indirect payments for health-care services are made by major companies and employers. Private sources of health financing also include NGOs and charities. Donors (rest of the world). Donors are an alternative mechanism of raising finance at the community level. These include United Nations agencies like WHO, the World Bank and foreign government funds. Some of these are linked to service use and programme funds, while others are directly community-based. External sources consist mainly of multilateral and bilateral aid donors. A summary of the sources of funds for the year 2011 is provided in Table 16.
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Table 16: Source of funds, 2011 Source of health funds Ministry of Finance and Treasury Other public sources Household funds NGOs and community health funds Employer funds Donors Total Amount in MVR 1 209 222 934 8200557 1 365 372 621 4 910 654 87 965 070 90 901 454 2 766 573 290 Percentage 43.7% 0.3% 49.4% 0.2% 3.2% 3.3% 100% Amount in US$ 78 419 127 531 813 88 545 566 318 460 5 704 609 5 895 036 179.414.610 Per capita in US$ 245 2 277 1 18 18 561
Figure 3: Sources of health funds, 2011 NGOs and community health funds. 0.2% Employer funds. 3.2%
Donors. 3.3%
Ministry of Finance and Treasury. 43.7% Household funds. 49.4%
Other public sources. 0.3%
As shown in Table 16 and Figure 3, the major source of health funds is the people of Maldives (49.4%). The second main source of finance is the Government (43.7%). External sources, such as multilateral and bilateral donations and grants for aid, contributed 3.3%, and employers contributed 3.2% to cover their employees for health insurance.
2.5.2 Financing agents Financing agents in the Maldives receive health funds from the three main sources. The involvement of the HSC at the atoll level, and the MoH and NSPA as main Government agencies merits clarification of their roles in the share of financial risks, in regulating and managing providers through incentive schemes, and in controls and utilization reviews. HSC administers 29% of the health funds market. Financing agents are divided into several categories, as listed in Table 11.
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2.5.3 Expenditure by financing agents As shown in Table 17, direct out-of-pocket expenditures are high. Overall, more than 49% of total health expenditure is managed and spent directly by the household, 45% by public financing agents and 3% by donors and NGOs. HSC manages most of the public financing resources (29% of THE) and includes public health issues in its mandate; however most of these resources have been diverted to curative care services at the atoll level. Private insurance sources manage a growing amount of health funds in Maldives and represent almost 4% of THE. Donors transfer most of their funds to the MoHF and then to their own donor-run health service facilities and other aid groups and NGOs. Table 17: Share of health-care services by financing agent Financing agent MoH Health Service Corporations NSPA (Madhana) Private insurances Private households’ out-of-pocket Local NGOs Private firms and employers Donors agencies Total Amount in MVR 220 399 919 811 660 976 250 815 216 91 609 364 1 245 290 196 4 910 654 68 111 166 73 775 797 2 766 573 290 Percentage 8.0% 29.3% 9.1% 3.3% 45.0% 0.2% 2.5% 2.7% 100% Amount in US$ 14 293 121 52 636 899 16 265 578 5 940 945 80 758 119 318 460 4 417 067 4 784 423 179 414 610 Per capita in US$ 45 164 51 19 252 1 14 15 561
Figure 4: Managing the health funds, 2011 Private firms and employers, 2.5% Local NGOs, 0.2% Donors agencies, 2.7% MoHF, 8.0%
Private households ’ out-of-pocket , 45.0%
Health Service Corporations, 29.3%
Private insurances, 3.3%
NSPA (Madhana), 9.1%
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2.5.4 Providers of health services Public providers are the major recipients of national health funds, and receive more than 38% of total health expenditures. Public providers consist of MoH facilities, including regional Government hospitals, atoll hospitals, outpatient health-care centres and health posts. Public hospitals receive more than 30% of THE , public outpatient health centres 7.5%, and health posts receive the remaining 1%. Private providers account for just 28% of THE. The major private actors are private physicians, dentists and pharmacists. The external providers account for 23%,mainly overseas treatments and paid mostly by the people of Maldives. Table 18: Total health care expenditure by type of facility Type of facility Indira Gandhi Memorial Hospital Hulhumale Hospital MoHF Regional Hospitals MoHF atoll hospitals Clinics and physicians Dental clinics Traditional healers and other health practitioners Health centres Health posts Public pharmacies Private pharmacies Providers and administration of public health programmes Government administration Private administration Institutions providing health-related services External (rest of the world) providers Total Amount in MVR 291 908 358 22 162 080 269 551 106 190 578 953 303 691 114 8 450 000 8 072 736 207 361 484 32 538 240 10 785 384 458 993 061 47 294 555 141 525 823 14 954 593 102 529 886 656 175 917 2 766 573 290 % 10.6% 0.8% 9.7% 6.9% 11.0% 0.3% 0.3% 7.5% 1.2% 0.4% 16.6% 1.7% 5.1% 0.5% 3.7% 23.7% 100% Amount in US$ 18 930 503 1 437 230 17 480 616 12 359 206 19 694 625 547 990 523 524 13 447 567 2 110 132 699 441 29 766 087 3 067 092 9 178 069 969 818 6 649 150 42 553 561 179 414 610 Per capita in US$ 59 4 55 39 62 2 2 42 7 2 93 10 29 3 21 133 561
2.5.5 Functional breakdown of health expenditures This section presents estimates of the distribution of health expenditures by function. Health expenditures are disaggregated into spending categories as defined in the NHA Producers Guide framework. Using available data and making certain assumptions, the distribution of both public and private health expenditures across the country was estimated. The estimation of health expenditures by function requires a wider definition of health than is historically reported in government budgetary estimates in two respects. First, a wider range of health categories is proposed. Second, for comparison purposes, health expenditure needs to be
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Figure 5: Providers of health services, 2011 Indira Gandhi Memorial Hospital, 10.6% Hulhumale Hospital, 0.8% MoHF Regional Hospitals, 9.7%
External (rest of the world) providers, 23.7%
Institutions providing health-related services, 3.7% Private administration, 0.5%
MoHF atoll hospitals, 6.9%
Government administration, 5.1% Providers and administration of public health programmes, 1.7% Private pharmacies, 16.6%
Clinics and physicians, 11.0%
Dental clinics, 0.3% Traditional healers and other health practitioners, 0.3% Public pharmacies, 0.4% Health centres, 7.5% Health posts, 1.2%
aggregated as per the international classification for health accounts. Thus, for the purpose of the NHA estimates, health expenditures in Maldives were defined to include the following components: •• •• •• •• •• •• curative health prevention drugs public health programmes health administration capital investment and other health-related functions.
As is evident, the pattern in use of public and private expenditures is different. The aggregated categories ultimately used in this report are based on the classification of the NHA Producers Guide. The most significant difficulty in producing this round of NHA was the lack of a functional classification, due to the use of Government line items classification. Therefore the NHA team in Maldives used a special methodology for estimating the functional classification. Most of the Government statistical reports, MoH and donor reports contributed to the NHA analysis. The National Accounts of Maldives and the household survey data were also used to extrapolate the functional classification and outof-pocket expenses. The NHA results show that Maldives health funds are primarily spent on curative, rather than preventive care. The majority of total health expenditure in Maldives (66.8%) is spent on inpatient and outpatient curative care, with almost 11% spent on administration, 5.5% on prevention, and 17% on drugs.
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Table 19: Functional distribution of total health expenditure Function Services of curative care Ancillary services to health care Medical goods dispensed to outpatients Prevention and public health services Health administration and health insurance Health-related functions Total Amount in MVR 1 847 970 152 2 990 018 470 488 294 51 558 748 295 300 385 98 265 693 2 766 573 290 Percentage 66.8% 0.1% 17.0% 1.9% 10.7% 3.6% 100% Amount in US$ 119 842 422 193 905 30 511 562 3 343 628 19 150 479 6 372 613 179 414 610 Per capita in US$ 375 1 95 10 60 20 561
A summary of the functional breakdown in Table 20 shows that nationwide, Maldives spent US$ 130 per capita on inpatient curative services and the same amount on inpatient treatment abroad. Only US$ 11 per capita was spent on public health programmes. The Pharmaceutical Survey revealed that US$ 95 per capita was spent on drugs in 2011. This high spending is a great concern for the Government and further attention has been given to the Pharmaceuticals and Drugs Policy in terms of consumption and control of import−export operations. Administration accounts for 10% of THE, and 3%was spent on health-related functions, new investments and technology for health, mostly paid by donors.
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Table 20: Aggregated functional distribution of total health expenditure Function Inpatient curative care Inpatient treatment abroad Outpatient curative care (without dentistry) Outpatient dental care All other specialized care (total curative care) Emergency services within hospitals Clinical laboratory Diagnostic imaging Patient transport and emergency rescue Medical goods dispensed to outpatients Maternal and child health, family planning and counselling School health services Prevention of communicable diseases Prevention of noncommunicable diseases Occupational health All other miscellaneous public health services Government administration of health (except social security) Administration, operation and activities of social security Private health administration and health insurance Capital formation of health care providing institutions Education and training of health personnel Research and development in health Food, hygiene and drinking water control programme Environmental health Total Amount in MVR 641 052 654 656 175 917 534 023 817 8 605 102 8 072 736 39 927 2 189 930 115 925 684 164 470 488 294 13 174 414 37 500 33 343 754 4 398 723 29 812 574 544 273 063 109 7 282 682 14 954 593 35 012 182 62 696 808 339 068 176 896 40 740 2 766 573 291 % 23.2% 23.7% 19.3% 0.3% 0.3% 0.0% 0.1% 0.0% 0.0% 17.0% 0.5% 0.0% 1.2% 0.2% 0.0% 0.0% 9.9% 0.3% 0.5% 1.3% 2.3% 0.0% 0.0% 0.0% 100% Amount in US$ 41 572 805 42 553 561 34 631 895 558 048 523 524 2 589 142 019 7 518 44 369 30 511 562 854 372 2 432 2 162 371 285 261 1 933 37 260 17 708 373 472 288 969 818 2 270 570 4 065 941 21 989 11 472 2 642 179 411 970 Per capita in US$ 130.0 133.0 108.0 2.0 1.6 0.0 0.4 0.0 0.1 95.0 3.0 0.0 7.0 1.0 0.0 0.1 55.0 1.0 3.0 7.0 13.0 0.1 0.0 0.0 560
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3. Sectoral analysis: 2011 3.1 Ministry of Health and Family The MoHF provides comprehensive public health services − primary, preventive and curative care −through its facilities. It highly subsidizes health-care services for the entire population. These are funded by general tax revenues and donations. In the year 2011, health facilities were under HSC and Councils management and provided comprehensive health services at each inhabited island and atoll. NHA results found that almost 90% of inpatient and 70% of outpatient services were provided by these facilities in 2011 (Provider Survey). All Maldives citizens were eligible. This coverage is independent of the income and asset status of the individual. In addition the MoHF, with the help of its donor partners, also covers the cost of all preventive services and immunization. In term of national policy and planning, a major role of the MoH was to formulate policy, health planning regulation and monitor health service functions, facilities and health professionals. In term of providers of health services, the HSCs operate a total of 363 licensed health facilities, 80 of which are located in Malé. MoHF providers and facilities included: •• •• •• •• •• 1 main central referral general public hospital 6 regional public general hospitals 13 atoll hospitals 132 health-care centres 108 health aid posts.
3.1.1 Ministry of Health and Family budget evolution The MoH health expenditure grew from MVR 157 million in 1995 to MVR 546 million in 2011. Total Government expenditure grew from MVR 1709 billion to MVR 12 160 billion during the same period, as seen in Table 21. As per Figures 6, 7 and 8, the MoH budget accounted for more than 9% of the total Government budget in 1995, dropping to 4.5% in 2011. Yet from 1995 to 2007, MoH expenditures grew much faster than the Government budget and the GDP evolution. After 2008, the Government budget evolution surpassed MoH expenditures, which could have been due to a shift in Government priorities or a change in the policy and distribution of the budget. In retrospect, there were two reasons: the first was a change in Government policy and leadership, and the second was the privatization of health-service providers. By 2011, MoH expenditures accounted for around MVR 220 million (not including NSPA), almost 2% of the Government budget.
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Table 21: Ministry of Health and Government expenditures and Gross Domestic Product evolution, 1995−2011 MoHF expenditures Financial year In million MVR 157 191 212 224 259 305 301 317 327 400 551 668 712 1 019 1 073 761 546 21.7% 11.0% 5.7% 15.6% 17.8% -1.3% 5.3% 3.2% 22.3% 37.8% 21.2% 6.6% 43.1% 5.3% -29.0% -28.3% Annual increase (%) Government expenditures In million MVR 1 709 1 702 1 906 2 053 2 506 2 694 2 886 3 117 3 388 3 583 5 658 6 948 8 201 10 176 10 953 10 815 12 160 -0.4% 12.0% 7.7% 22.1% 7.5% 7.1% 8.0% 8.7% 5.7% 57.9% 22.8% 18.0% 24.1% 7.6% -1.3% 12.4% Annual increase (%) Gross Domestic Product In million MVR 4 696 5 301 5 982 6 357 6 935 7 348 9 650 10 425 11 931 13 552 12 704 16 683 19 737 24 213 24 858 26 566 29 936 12.9% 12.8% 6.3% 9.1% 6.0% 31.3% 8.0% 14.4% 13.6% -6.3% 31.3% 18.3% 22.7% 2.7% 6.9% 12.7% Annual increase (%) MoH budget index 100 122 135 143 165 194 192 202 208 255 351 425 454 649 683 485 348 Yearly evolution Government budget index 100 100 112 120 147 158 169 182 198 210 331 407 480 596 641 633 712 GDP budget index 100 113 127 135 148 156 205 222 254 289 271 355 420 516 529 566 637
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Figure 6: Ministry of Health and expenditures, 1995−2011 (in million MVR) 1200 1000 800 600 400 200 0
2001
2003
1995
2002
2005
1999
2004
1996
2006
1998
1997
2007
2008
2009
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Maldives National Health Accounts 2011
2000
2010
2011
Figure 7: Ministry of Health and expenditures as a percentage of Government budget, 1995−2011 12% 10% 8% 6% 4% 2% 0% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Figure 8: Ministry of Health and Family, Government and GDP evolution (in US$), Index, 1996−2005
3.1.2 Source of Ministry of Health funds The main source of MoH funds, as shown in Table 22, is the Government budget, which amounts to over 82% of its total expenditure. Donors contributed 7.8% of the MoH budget, mainly to public programmes that they finance through the Government channel. The other source of funding is household out-of-pocket income, which constituted 10% of the budget, based on registration and licensing fees paid to MoH headquarters in Malé.
3.1.3 Total Ministry of Health expenditures by function The MoH budget uses the system of national accounts of the Ministry of Finance and Treasury based on chapter classification (or line items). One of the most significant challenges was to distribute the chapter classification into the NHA functional classifications. The accounts system used by the MoH, as at other public agencies, is summarized by: •• •• •• Item 1: Expenditures at MoH management Item 2: Centre for Community Health and Disease Control Item 3: All the atoll health services budgets.
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Table 22: Source of Ministry of Health and Family funds (in MVR), 2011 Source Ministry of Finance and Treasury Households Foreign capital Total Funds 181 108 426 22 165 836 17 125 657 220 399 919 Percentage 82.2% 10.0% 7.8% 100%
Figure 9: Sources of Ministry of Health and Family funds, 2011 Households, 10.0% Foreign capital, 7.8%
Ministry of Finance and Treasury, 82.2%
Table 23 below describes the sub-classification used by the MoH as total expenditure (current and capital). Expenditures are itemized into departments and sections. It should be noted that the atolls expenditures are those spent by atoll providers before the responsibilities were moved to HSC in February 2011. Table 23: Use of Ministry of Health and Family funds User of funds Ministry of Health and Family Centre for Community Health and Disease Control Department of Gender and Family Protection Services Family and Children Services Centre National Blood Transfusion Service Home for People with Special Needs Maldives Food and Drugs Authority Children’s Home Department of Drugs Prevention and Rehabilitation Services Atolls Health Services (before HSC) Total From Government 66 077 469 30 570 933 2 882 023 9 871 169 838 338 8 816 449 7 930 406 2 284 904 11 956 455 62 046 114 203 274 262 From donors 14 889 072 2 236 585 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 17 125 657 Total 80 966 541 32 807 518 2 882 023 9 871 169 838 338 8 816 449 7 930 406 2 284 904 11 956 455 62 046 114 220 399 919 Percentage 36.7% 14.9% 1.3% 4.5% 0.4% 4.0% 3.6% 1.0% 5.4% 28.2% 100%
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As classified by the MoH, the budget funds allocated to personnel is over 62% versus 40% for goods and services (Table 24).In the health industry, this can be unclear if it is not related to a health account functional classification. However, the NHA classification shows that the MoH spent 61% of its budget on personnel including doctors and nurses, 17% on prevention, 14% on capital investments, 3% on education and training and 5% on pharmaceuticals. Table 24: Ministry of Health and Family budget line items Code 210 213 221 222 223 224 225 226 228 281 421 Salary and allowances Pension Travelling expenses Administrative supplies Administrative services Operational consumables Training expenses Repairs and maintenance Grants, contributions and subsidies Losses from private parties Capital expenditures Total budget Budget line MVR 40 924 817 1 417 355 649 979 1 755 556 9 489 438 6 904 162 3 721 459 618 381 223 922 305 650 66 750 66 077 469
Table 25: Ministry of Health and expenditures based on NHA classification Allocation of funds HC.5 HC.6 HC.7 HC.R.1 HC.R.2 HC: health care.
Amount 10 785 384 36 698 893 134 243 141 30 907 652 7 764 849 220 399 919
Percentage 4.9% 16.7% 60.9% 14.0% 3.5% 100.0%
Medical goods dispensed to outpatients Prevention and public health services Administration and salaries Capital formation of health-care provider institutions Education and training of health personnel Total
3.2 Insurance market in Maldives The insurance sector started playing a major role in financing the Maldives health system in 2011. The main insurance company was Madhana, a social public insurance. Three other private insurance companies offer health insurance to the private sector. Premiums are for one year and paid in advance. An NHA survey completed by the NHA team shows that the health insurance market in Maldives was estimated at around 161 612 persons in 2011, representing more than 50% of the total population and covered by the three private and one social health insurance entity. The survey
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objective was to highlight deductibles, co-payments, basic and additional benefits and geographical coverage. Most insurers provide comprehensive health plans covering inpatients, outpatients and drugs, with some offering additional benefits (treatment overseas, evacuation, etc.). The rating methodology is an essential tool to fix a premium payment scheme. There are two major rating methodologies for insurance companies: experience rating and community rating. Under experience rating, health insurers collect information regarding the health status and the claims history of the insured group to determine the premium rate to be charged to the group. Under community rating, premiums are based on average costs of the whole population. Currently, while premiums charged by insurance companies in Maldives are based on neither of the two methodologies, they are more in line with experience rating. This is influenced by three parameters. Firstly, insurance companies may go through an underwriting process that screens for previous medical conditions. Secondly, as mentioned above, they price their products based on experience rating and the premiums are likely to increase if the utilization rate of services increases more than expected. Finally, insurance companies may have lower premiums since the privately insured often use publicly financed health services even when the same services are covered by private health insurance.
3.2.1 Social health insurance scheme (NSPA/Madhana Scheme in 2011) The 2011 model introduced a social health insurance scheme to which both employees and employers contributed, and with the Government supposedly subsidizing the rest of the population for health services. In order to ensure the quality and affordability of benefits received under the scheme, the Government defined the content of the benefit package and put a cap of MVR 100 000 per person (applied in 2012). If a higher level of benefit package is required by employees, they have the choice to contribute to any private insurance policy in Maldives or pay out-of-pocket. Key characteristics of the NSPA/Madhana Based on information collected by the NHA team, the main characteristics of the NSPA are as follows: •• •• •• •• It is compulsory for individuals working in the civil service. The Government subsidizes the elderly, minors, the vulnerable, and the unemployed. The Government will continue to finance the provision of public health services, preventive care, and the management and regulation of the health system. The scheme covers a basic benefit package that includes outpatient curative care, drugs, local inpatient curative care and an allocation paid to cover health insurance for treatment abroad, provided this takes place in selected hospitals in India. The scheme is financed through employer/employee contributions and Government subsidies. Beneficiaries are restricted to the use of local health-care facilities and the selected hospitals abroad, if insured. Private insurance can cover services not in the basic benefits package or provide for higher level of care. Off-site referral (treatment abroad) is not covered under Madhana, but under Madhana Plus described in Table 11. The NSPA/Madhana is administered by the NSPA Administration separately from the MoH.
•• •• •• •• ••
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Maldives National Health Accounts 2011
NSPA sources of funds The main source of NSPA funds in 2011 (Table 26) was the Government budget, which amounted to 86.3% of total expenditure. Households and individuals contributed the remaining 13.7% in the form of premiums and deductibles. Table 26: Sources of NSPA/Madhana funds, 2011 Source Individual contributions/premiums Government grants Total Amount 34 361 685 216 453 532 250 815 217 Percentage 13.7% 86.3% 100%
Use of NSPA funds by providers Private pharmacies are the major recipients of NSPA funds, which amounted to MVR 181 million over 72% of total NSPA funds in 2011. Public providers, consisting of IGMH Hospital, other Government regional hospitals, atoll health centres, receive 22% of funds. NSPA salaries and administration costs account for the remaining 6% use of the funds, which is considered low compared with other agencies in the country. Table 27: NSPA expenditure by type of health provider in MVR, 2011 Health-care provider MoH regional hospitals Indira Gandhi Memorial Hospital MoH atoll hospitals Clinics and physicians Health centres Private pharmacies Government administration Institutions providing health-related services Total Amount 4 206 901 44 534 498 3 395 085 6 965 121 2 294 040 181 459 639 7 282 682 677 250 250 815 216 Percentage 1.7% 17.8% 1.4% 2.8% 0.9% 72.3% 2.9% 0.3% 100%
Functional distribution of NSPA funds The NHA surveys found that NSPA funds were primarily spent on medicines (MVR 181.5 million, over 72%). Inpatient curative care absorbed MVR 52 million and accounted for nearly 21%; basic outpatient care for a further 4%, with the remaining 3% spent on administration (Table 28).
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Table 28: Functional distribution of NSPA funds Function Inpatient curative care Outpatient curative care (without dentistry) Medicines Administration, operations and activities of social security Capital formation of health-care provider institutions Total Amount 52 136 484 9 259 161 181 459 639 7 282 682 677 250 250 815 216 Percentage 20.8% 3.7% 72.3% 2.9% 0.3% 100%
3.2.2 Private insurance in Maldives As part of the NHA study, various efforts were made to collect more accurate information on the private insurance sector. The NHA team used two methods to do this: collecting data through insurance companies; and approaching all providers in Maldives. According to the insurance companies, the monthly premium in Maldives varies between US$ 50–70 per individual and US$ 200 per family. Based on the survey, the total private insurance for the health market was estimated at MVR 91.6 million (US$ 6 million) in 2011. Of this market, 69.4% was contributed by individuals, 21.6% by employers and 9% came as grants from the Government (Table 29). Table 29: Sources of private insurance funds, 2011 Source Employer contributions/premiums Group contributions/premiums Individual contributions/premiums Grants from Government Total Amount 19 120 485 733 418 63 554 904 8 200 557 91 609 364 Percentage 20.9% 0.8% 69.4% 9.0% 100%
In term of providers, most funds from the private insurance companies were used in private clinics and private chemists (44% and 30% respectively), 10% at the hospital level (mainly IGMH) and almost 16% was on administration and return on operations. Table 30: Use of private insurance funds by provider, 2011 Provider MoH regional hospitals Indira Gandhi Memorial Hospital MoH atoll hospitals Clinics and physicians Medicines Administrative expenditures Total Amount 111 562 8 624 689 151 550 40 545 572 27 221 399 14 954 593 91 609 365 Percentage 0.1% 9.4% 0.2% 44.3% 29.7% 16.3% 100%
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In term of functions, and as described in Table 31, private insurance funds are mainly spent on outpatient care and drugs. Table 31: Use of private insurance funds by function, 2011 Function Inpatient curative care Outpatient curative care (without dentistry) Medicines Administrative expenditures Total Amount 8 887 801 40 545 572 27 221 399 14 954 593 91 609 365 Percentage 9.7% 44.3% 29.7% 16.3% 100%
3.3 Health Service Cooperations HSCs absorbed 29% of total health expenditures and almost 65% of the total Government budget for health in 2011. The HSC plays the primary role in managing and distributing funds to all public facilities at the three levels of care, i.e. primary, secondary and tertiary. HSC sources of funds. The sole source of HSC funds in 2011 was the Government budget, which derives its resource base from taxes. The HSC budget in 2011 amounted to MVR 812 million (US$ 53 million). Use of HSC funds by providers. Table 32 shows the distribution of HSC funds by type of provider. Hospitals are the major recipients of HSC funds, and received almost MVR 600 million or 72% of this budget in 2011. IGMH alone absorbed 23% of the HSC budget as it is a major provider of health services in the country. Health centres and health posts received the remaining 28%. Table 32: Health Service Corporations expenditures by provider type, 2011 Provider of health services MoH regional hospitals Indira Gandhi Memorial Hospital MoH atoll hospitals Health centres Health posts Total Amount 217 038 981 184 492 714 179 764 536 197 855 298 32 509 447 811 660 976 Percentage 27% 23% 22% 24% 4% 100%
Use of HSC funds by function. As shown in Table 33, the NHA surveys showed that HSC funds are primarily spent on inpatient curative care. The second highest was outpatient care, and administration of HSCs cost the Government 17% of the funds allocated to HSC.
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Table 33: Functional distribution of NSPA funds Category Inpatient curative care Outpatient curative care (without dentistry) Outpatient dental care Emergency services within hospitals Clinical laboratory Diagnostic imaging Patient transport and emergency rescue Medicines Medical supplies non-durable Medical supplies durable Medical equipment Administration Total Amount 448 148 388 220 797 724 155 102 39 927 2 189 930 115 925 684 164 29 020 458 851 79 657 142 321 138 819 968 811 660 977 Percentage 55% 27% 0.02% 0.00% 0.27% 0.01% 0.08% 0.00% 0.06% 0.01% 0.02% 17% 100%
3.4 General private practitioners In 2011, the NHA team surveyed 16 clinics and 67 pharmacies. Data in this section are related to the private sector providers market as perceived and reported by general practitioners through personal visits, mostly in the capital cities in Maldives.
3.4.1 Data on clinic visits According to the Private Physicians Survey, the number of people who visited a health professional for an illness was 66 334 in 2011, which was higher than expected and reported in previous reports. The cost per private visit ranged between US$ 31 for a first visit to US$ 15 for a follow up. This is valid regardless of whether an individual lives in an urban or rural area.
3.4.2 Sources of general practitioner funding Total provision of ambulatory care visits to private clinics and physicians amounted to MVR 31 million (US$ 2 million) in 2011 and absorbed almost 1.5% of THE. Of this total, 84% was paid by household out-of-pocket funds and the remaining reimbursed by private and public health insurance.
3.5 Pharmaceutical sector analysis The MoH bulk medicines budget in 2011 amounted to MVR 10.8 million (US$ 700 000),less than 5% of the total MoH budget. The Ministry supplies essential drugs and chronic drugs through its central warehouse and health-care dispensaries to the public. A minor user fee is in place which covers less than 10% of the cost per prescription.
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In addition, there is a growing private sector in Maldives. Private importers are now significant in the city of Mali and even sell pharmaceuticals to Government agencies and facilities. The number of private pharmacies in Maldives has increased in the last few years due to liberalized practice, and now consists of 290 main pharmacies selling drugs on prescription and over the counter. This has had a direct impact on the availability of drugs, but not necessarily on accessibility and affordability. Maldives is expected to have many non-registered drugs on the market. For a long time, the public has been able to buy a large number of prescription drugs over the counter and this might contribute to escalating drug costs.
3.5.1 Estimating the size of the pharmaceutical private sector Pharmaceutical expenditures accounted for over 17% of THE in 2011. Considerable uncertainty exists about the size and composition of the pharmaceutical sector in Maldives. All pharmaceuticals are imported as there is no local manufacture. Thus, Maldives has not only high per capita expenditure on pharmaceuticals (US$ 95) but almost all of the drugs are trade name products. As per the NHA Provider Survey, private spending on pharmaceuticals or household outof-pocket expenditures amounted to US$ 16 million, which accounts for 53% of spending on pharmaceuticals at an average US$ 13 per sale unit. Public spending on pharmaceuticals is the second largest category at US$ 14 million. It is clear that at 17%of total health expenditures, pharmaceuticals is a major area of the health sector that needs to be managed and regulated if health-care costs are to be held in check. The rapid growth in the pharmaceutical sector, and the near complete reliance on imported brand name drugs to meet demand, make rationalizing expenditure on pharmaceuticals a key area for policy intervention.
3.6 Household expenditures on health Data on household expenditures from the HIES 2009–2010 and the Census 2006 were used, along with data from additional NHA surveys of the major providers in Maldives, to extrapolate total out-of-pocket spending. Thus, the estimated household expenditure is based on different private provider surveys conducted by the team in 2012. The draft estimates for out-of-pocket spending were cross-validated with HIES 2009–2010 numbers. Household out-of-pocket expenditures account for almost 49% of total health expenditure in Maldives. The percentage of household contributions to health expenditures highlighted in this NHA report was above expectations. This high percentage is due to a variety of reasons including a higher estimate for the cost of pharmaceuticals and for treatment abroad, derived from HIES 2009–2010. A more systematic approach was used to estimate household expenditures taking into account the market size, including the private sector and user fees at different provider levels.
3.6.1 Estimating the total household expenditure on health A variety of data sources were used to calculate household expenditures as follows: •• The HIES 2009–2010 estimated total out-of-pocket health expenditures and treatment abroad (MVR 656 million). It is assumed that most of these expenditures are reflected in the provider data, and that adding the out-of-pocket expenditures to the total would result in significant over-reporting. The General Practitioner and Private Pharmacy Surveys were used to estimate out-ofpocket expenditure at private providers.
••
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45
•• •• •• ••
The Private and Social Insurance Survey was used to estimate the total premium paid by households. The Traditional Healer Survey was used to derive out-of-pocket costs on traditional healers. Total household spending at public facilities is also included. However, household spending on patient transport could not be estimated.
In summary, the total household expenditure on health in 2011 amounted to MVR 1.3 billion (US$ 88.5 million) or 49% of total health expenditure in Maldives. The amount of US$ 277 out-ofpocket spending per capita on health is extremely high compared with most countries in the region. Almost 53% of household expenditure was spent on public providers and 47% in the private sector. Table 34 and Figure 10 below show the distribution of out-of-pocket expenses per function. Table 34: Out-of-pocket expenditures by function, 2011 Function Inpatient curative care Inpatient treatment abroad Outpatient curative care (without dentistry) Outpatient dental care All other specialized health care (traditional healer curative care) Medicines Out-of-pocket registration fees to MoH Premium paid to health insurance Total Amount in MVR 59 132 121 656 175 917 263 393 497 8 450 000 8 072 736 250 065 925 22 165 836 97 916 589 1 365 372 621 Percentage 4.3% 48.1% 19.3% 0.6% 0.6% 18.3% 1.6% 7.2% 100% Amount in US$ 3 834 768 42 553 561 17 081 290 547 990 523 524 16 216 986 1 437 473 6 349 973 88 545 565 Per capita in US$ 12 133 53 2 2 51 4 20 277
Figure 10: Out-of-pocket spending by function, 2011 Out-of-pocket registration fees to MoH, 1.6% Premium paid to health insurance, 7.2% Inpatient curative care, 4.3%
All other specialized health care, 0.6%
Medicines, 18.3%
Outpatient dental care, 0.6%
Outpatient curative care (without dentistry), 19.3%
Inpatient treatment abroad, 48.1%
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Maldives National Health Accounts 2011
3.7 Traditional healers Traditional healers are defined as people with knowledge of healing using indigenous plant and animal remedies. These practitioners acquire their trade through the passing of skills from healers as an apprentice or receiving skills and knowledge through dreams and communication with the supernatural or ancestors (Rogers, 2001 ).Traditional healers are an integral part of the informal sector of health care in Maldives; it is estimated that more than 200 traditional healers exist with an average of two in every village. The 50 registered traditional healers are located in the capital city of Malé.
3.7.1 Estimating the magnitude of traditional healers The MOH carried out a mini-survey by interviewing 6 out of the 50 registered traditional healers. The main purpose of the survey was to find out how much Maldivians spent on traditional healers and how often they use their services. Although the exact number of traditional healers and traditional birth attendants is still uncertain, their number is estimated at almost 200.
3.7.2 Survey findings In the four weeks preceding the survey, it was reported that the six main traditional healers in Maldives treated a total of 754 patients. This round of NHA presents a more conservative number of traditional healers and people treated, based on the number patients and costs derived from the survey (Table 35). Table 35: Household spending on traditional healers, 2011 TH TH1 TH2 TH3 TH4 TH5 TH6 Total Ave LOS days 8 13 10 12 12 22 13 Ave cost per patient (in MVR) 308 1 600 1 620 998 214 1 180 1 019 Ave MVR per visit 39 121 159 85 18 53 79 No. of patients (over one month) 313 141 98 170 16 16 754 Total HH spending at TH per month 96 404 225 600 158 760 169 660 3 424 18 880 672 728 Total HH spending at surveyed TH per year 1 156 848 2 707 200 1 905 120 2 035 920 41 088 226 560 8 072 736
Ave: average; HH: household; LOS: length of stay; TH: traditional healer.
In summary, the NHA reports that Maldives spent around MVR 8 million (US$ 524 000) on traditional healers per year based on an estimated 754 visits per month.
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3.8 Cross-country comparative analysis As seen in Figure 11, the public share of health expenditures in Maldives is reasonably high at 47%. Figure 11: Comparison of public and private share of total health expenditure in South-East Asia countries Bhutan Thailand Timor-Leste OECD DPR Korea Indonesia Maldives Sri Lanka Nepal Bangladesh India Myanmar 0% 20% 40% Public shares 60% Private shares 80% 100%
OECD: Organisation for Economic Co-operation and Development; DPR: Democratic People’s Republic (of). Source: World health statistics 2010.
As reported in Table 36, a comparison of total health expenditures with neighbouring countries shows that Maldives spends more and is in line with high-income countries and countries of the Organisation for Economic Co-operation and Development. Table 36: Comparison of health expenditures as a percentage of gross domestic product in the South-East Asia Region Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste OECD Year 2009 2009 2009 2009 2009 2011 2009 2009 2009 2009 2009 2009 Per capita GDP (US$) 559 2 882 32 588 1 324 1 618 6 067 353 735 2 471 4 941 2 147 24 930 Health expenditure per capita (US$) 19 98 1 108 45 55 561 12 25 84 168 73 2 470 Health expenditure as a % of GDP Total 3.4 5.5 6.5 4.2 2.4 9.2 2.0 5.8 4.0 4.3 12.3 9.9 Public 1.1 4.5 3.5 1.4 1.2 4.4 0.2 2.0 1.8 3.3 8.7 6.0 Private 2.3 1.0 3.0 2.8 1.2 4.8 1.8 3.8 2.2 1.0 3.6 3.9
DPR: Democratic People’s Republic (of); GDP: gross domestic product; OECD: Organisation for Economic Co-operation and Development. Source: World health statistics 2010.
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4. Conclusions and recommendations At this stage of the health sector reform, this first NHA report focuses on identifying total health expenditures, to allow the Government of Maldives to make active policy decisions based on the results. Key policy issues that arise from the NHA findings are broad and numerous, and include: •• •• •• •• •• •• •• How much should Maldives spend on health services? How much should the Ministry of Health spend? How much can the people of Maldives afford to spend? How can the Government recover some of its health budget? How might the Government realign its budget process on health and how can the NHA findings be used to formulate an equitable and sustainable health insurance scheme? How should the Government shape health sector financing to control any under/or overuse of curative versus preventive services? What should be the role of donors, and the public and private sector in Maldives?
4.1 Notes on health-care financing Several key issues in health-care financing are identified in the paper. •• •• There is little coordination among multiple public delivery systems or among public and private systems. The way the health sector is managed changed in 2012, when the national health insurance scheme started. Two things need to be kept in mind: (1) Actuarial studies are of critical importance at this stage in order to calculate risks and premiums; and (2) the methods used to pay providers of care can influence access, efficiency, and quality. Expenditures in relation to GDP are high and in line with OECD countries averages (9.2%). Almost half of Maldives’ health expenditures derive from out-of-pocket payments of the population (inclusive of the premium for health insurance deducted from their salaries). This is high and precarious, and begs the question of what impact this will have on poverty and vulnerability: can the Government cover this amount or reduce the gap? Can the Government afford to sustain contributing 44% of the health budgeting the future? Very little (3%) is paid for prevention and mostly funded by donors. Prevention is stated to be one of the health-care priorities of the nation – health promotion, prevention, and primary health care – what action is the Government taking towards preventing diseases? Why does donor support to health in Maldives not exceed 3% of total health expenditures? Private expenditures represent 53%of sector-wide expenditures – 6 times the MoH expenditures. There is only one private hospital in the capital city of Malé and the Government is the only provider of inpatient care in the atolls. Pharmaceuticals accounted for over 17% of total health expenditure. The majority of pharmaceuticals sold in Maldives are brand e names, and only very few are generics.
•• ••
•• ••
•• •• •• ••
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4.2
Notes on the insurance market
A major issue for the health insurance market in Maldives is that the insurance companies make no enquiries on the insured’s medical condition, income, business or profession, place of work, etc. To be insured at any private insurer, it is sufficient to pay the premium in advance. The average premium is low as people are not encouraged to have a private policy. The private insurance industry is hoping to develop products that will be attractive to the emerging middle- and upper-income groups. It also intends to capture the people currently going abroad for treatment. There is limited capacity to regulate the private insurance industry. Although the Government, through its agency the NSPA, launched a national health insurance scheme, the public sector still lacks the expertise to operate a such a scheme. The lack of actuaries to calculate risks and premiums is currently a major constraint for the development of any public health insurance. There is a need to train actuaries for the development of health insurance products, and for the NSPA to run an assessment in the near future for the national health insurance scheme. This assessment should: (1) evaluate the sustainability of the national health insurance scheme and the long-term potential to provide equity, coverage and financial protection; (2) test different scenarios of “provision/payment” to inform stakeholders on how the NSPA can be fiscally sustainable and how Maldives’ other health financing objectives can be met; (3) address current national attention on the health insurance plan preparation, which necessarily brings into sharp focus the question of how to assure adequate, communitywide, health-care financing in Maldives; (4) build basic knowledge of the national health insurance plan model and different scenarios and options that can be applied based on the proposed Bill started in January 2012; (5) study the Basic Benefit Package on coverage and services caps; (6) study the provider payment mechanism; (7) analyse the different contribution/collection mechanisms and Government disbursement; (8) recommend appropriate contribution rates subject to the anticipated effectiveness of the Government funds and the employers/employees market; and (9) propose an appropriate Government contribution rate for the identified disadvantaged groups in the context of principles of risk pooling and solidarity; and study specifically an impact analysis focusing on: –– –– –– –– the impact on public finances and on total health spending; possible effects on equity, access, coverage and health-seeking behaviours; potential for financial protection against catastrophic spending including that related to overseas treatment; and possible effects on the current level and quality of health-care services.
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Annex 1: Piloting the System of Health Accounts 2011 in Maldives
The key concepts for describing the structure of health financing under the System of Health Accounts (SHA) 2011 are based on measuring: •• •• the expenditure of health care financing schemes, under which good sand services are purchased directly from health care providers, and the types of revenues of health-care financing schemes (such as Government domestic revenues, social insurance contributions, and voluntary prepayments).
Health-care financing schemes are perceived in SHA 2011 as the main building blocks of the structure of a country’s health financing system: they are the main types of financing arrangements through which people can access health care, for example government schemes, social insurance and voluntary insurance.
Classifying financing schemes in Maldives As described in SHA 2011, health-care financing schemes are structural components of health-care systems. They are the main types of financing arrangements through which people obtain health services. Health financing schemes include direct payments by households for services and goods and third-party financing arrangements. Third-party financing schemes are a distinct body of rules that govern the mode of participation in the scheme, the basis for entitlement to health services and the rules on raising and then pooling the revenues of the given scheme. Financing agents are perceived under SHA 2011 as the institutional units that operate the financing schemes in practice. There is not necessarily a one-to-one correspondence between financing schemes and financing agents. Table A1.1 shows the flow of funds under each financial scheme by type of agent.
Financing schemes by type of provider Knowing how much health providers spend under each financial scheme was not easy to identify during this round of NHA, as the data collected were not disaggregated by scheme but by type of agent. The NHA team in Maldives tried to map these data in order to know how much health providers spent on the inputs to produce health-care services under each scheme. In this light, the total distribution of expenditures under each scheme is expected to equal the disaggregation by provider type. Table A1.2 shows the flow of funds under each financial scheme by type of provider.
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52 Table A1.1: Financing schemes by type of agent, in MVR, 2011 Financing agent FA1 FA2 FA3 FA4 FA5 FA6 General Govt. Households Insurance Corp. Corporations (other than Insurance Corp) Rest of the world Non-profit institutions serving households All financing schemes 181 108 426 811 660 976 216 453 532 8 200 557 87 965 070 4 910 654 34 361 685 63 554 904 1 245 290 196 73 775 797 1 000 969 959 216 453 532 87 965 070 4 910 654 1 365 372 621 90 901 454 22 165 836 17 125 657 220 399 919 811 660 976 250 815 217 164 631 185 1 245 290 196 73 775 797 2 766 573 290
New financing agent code
Financing scheme
Maldives National Health Accounts 2011
HF1
Governmental and compulsory health insurance
HF1.1
Ministry of Health and Family
HF1.2
Health Service Corporation
HF1.3
Compulsory health insurance (NSPA)
HF2
Voluntary health care payments
HF3
Household out-of-pocket payments
HF4
Rest of the world financing schemes (non-resident)
Total
All financing schemes
HH: household.
Table A1.2: Providers of health services by financing scheme, 2011 Financing scheme Governmental schemes and compulsory health insurance Individual and private schemes Ministry of Health and Family Health Service Corporation HF1.2 581 296 231 52 136 484 81 635 661 59 132 121 HF1.3 HF2 HF3 HF4 774 200 497 – 230 364 745 9 259 161 40 573 434 279 916 233 560 113 574 – 10 785 384 36 698 893 134 243 141 7 282 682 14 954 593 181 459 639 27 467 497 250 065 925 10 595 663 469 778 445 47 294 555 156 480 416 – 38 672 501 677 250 656 175 917 220 399 919 811 660 976 250 815 216 164 631 185 1 245 290 196 73 775 797 63 180 135 102 529 886 656 175 917 2 766 573 290 HF1.1 Compulsory health insurance (NSPA) Voluntary health-care payment Household out-of-pocket payment Rest of the world financing schemes (non resident)
$ Providers
Total providers
HP.1
Hospitals
HP.2
Residential long-term care providers
HP.3
Providers of ambulatory health care
HP.4
Providers of ancillary services
HP.5
Retailers and other providers of medical goods
HP.6
Providers of preventive care
HP.7
Providers of health administration and financing
HP.8
Other health-care providers
HP.9
Health care related providers: rest of economy
HP.10
Rest of the world
Maldives National Health Accounts 2011
All health providers
53
Financing schemes by expenditures type in the Maldives To be able to classify expenditures by health-care function, the team first linked the function with the provider type and then attributed the function to a financing scheme. Thus, all factors were considered in this classification. As mentioned above, it was difficult to determine a clear classification that includes cash in-kind contributions, and describes the factors of health-care provision that can account for the total value of the resources. The report aims to classify the amount paid to providers by the financing schemes for health-care goods and services consumed during the accounting period. Spending on health-care related functions is still included given the difficulty to separate those funds from total spending. As mentioned before, this pilot study was a first attempt by the NHA team to address information on health financing schemes and distribution of expenditures by provider and expense type. Health expenditure information previously reported ,not only in Maldives but around the globe, was mainly from the National Health Accounts. This SHA includes all NHA available data as at 2011, while accepting that, as with all new initiatives to establish baseline information on a national scale, there are inherent delays and limitations in the completeness and validity of these data.
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Table A1.3: Health services by financing scheme, 2011 Governmental schemes and compulsory health insurance Voluntary health-care payment schemes Household out-of-pocket payments HF3 995 224 271 250 065 925 164 631 185 1 245 290 196 HF4 14 859 855 58 915 942 73 775 797 1 847 970 152 – – 2 990 018 470 488 294 51 558 748 295 300 385 – 98 265 693 2 766 573 290 HF2 122 209 095 27 467 497 14 954 593 Rest of the world financing schemes (non resident)
Financing schemes Ministry of Health and Family Scheme HF1.1 10 785 384 36 698 893 134 243 141 38 672 501 220 399 919 811 660 976 250 815 216 677 250 138 819 968 7 282 682 709 849 181 459 639 2 990 018 669 141 141 61 395 645 HF1.2 HF1.3 Health Service Corporation Scheme Compulsory health insurance (NSPA Scheme)
Health-care function
Total providers
HC.1
Curative care
HC.2
Rehabilitative care
HC.3
Long-term health care
HC.4
Ancillary services not specified by function
HC.5
Consumption of medical goods
HC.6
Preventive care
HC.7
Governance: management and health administration
HC.8
Other health-care functions
HC.9
Health-care related functions: rest of economy
All health-care functions
Maldives National Health Accounts 2011
HC: health care.
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Annex 2: National Health Accounts 2011 summary tables Table A2.1: Source of funds Sources of health funds Ministry of finance & treasury Other public Household funds NGOs and community health Employers’ funds Donors Total Amount MVR 1 209 222 934 8 200 557 1 365 372 621 4 910 654 87 965 070 90 901 454 2 766 573 290 Percentage 43.7% 0.3% 49.4% 0.2% 3.2% 3.3% 100% Amount US$ 78 419 127 531 813 88 545 566 318 460 5 704 609 5 895 036 179 414 610 Per capita US$ 245 2 277 1 18 18 561
Table A2.2: Share of total health-care expenditures by financing agent Financing Agents MoH Health service corporations NSPA (Madhana) Private Insurances Private households' out of pocket Local nongovernmental organizations Private firms and employers Donors agencies Total Amount MVR 220 399 919 811 660 976 250 815 216 91 609 364 1 245 290 196 4 910 654 68 111 166 73 775 797 2 766 573 290 Percentage 8.0% 29.3% 9.1% 3.3% 45.0% 0.2% 2.5% 2.7% 100% Amount US$ 14 293 121 52 636 899 16 265 578 5 940 945 80 758 119 318 460 4 417 067 4 784 423 179 414 610 Per capita US$ 45 164 51 19 252 1 14 15 561
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Table A2.3: Distribution of health-care expenditures by provider Expenditures by Providers Indhira Gandhi Memorial Hospital Hulhumale Hospital MoHF Regional Hospitals MoHF Atolls Hospitals Clinics and physicians Dentists clinics Traditional healers and other health practitioners Health centres Health posts Public pharmacies Private pharmacies Providers and administration of public health programmes Government administration Private administration Institution providing health related services Rest of the world providers Total Amount MVR 291 908 358 22 162 080 269 551 106 190 578 953 303 691 114 8 450 000 8 072 736 207 361 484 32 538 240 10 785 384 458 993 061 47 294 555 141 525 823 14 954 593 102 529 886 656 175 917 2 766 573 290 Percentage 10.6% 0.8% 9.7% 6.9% 11.0% 0.3% 0.3% 7.5% 1.2% 0.4% 16.6% 1.7% 5.1% 0.5% 3.7% 23.7% 100% Amount US$ 18 930 503 1 437 230 17 480 616 12 359 206 19 694 625 547 990 523 524 13 447 567 2 110 132 699 441 29 766 087 3 067 092 9 178 069 969 818 6 649 150 42 553 561 179 414 610 Per capita US$ 59 4 55 39 62 2 2 42 7 2 93 10 29 3 21 133 561
Table A2.4: Use of total health funds – functional classification Expenditures by functions Services of curative care Ancillary services to health care Medical goods dispensed to outpatients Prevention and public health services Health administration and health insurance Health related functions Total Amount MVR 1 847 970 152 2 990 018 470 488 294 51 558 748 295 300 385 98 265 693 2 766 573 290 % 66.8% 0.1% 17.0% 1.9% 10.7% 3.6% 100% Amount US$ 119 842 422 193 905 30 511 562 3 343 628 19 150 479 6 372 613 179 414 610 Per capita US$ 375 1 95 10 60 20 561
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Table A2.5: Out-of-pocket distribution by function HH OOP expenditures by functions In-patient curative care In-patient treatment abroad Out-patient curative care (without dental) Out-patient dental care All other specialized health care (TH curative care) Medicines Out-of-pocket registration fees to MoHF Premium paid to health insurance Total Amount MVR 59 132 121 656 175 917 263 393 497 8 450 000 8 072 736 250 065 925 22 165 836 97 916 589 1 365 372 621 Percentage 4.3% 48.1% 19.3% 0.6% 0.6% 18.3% 1.6% 7.2% 100% Amount US$ 3 834 768 42 553 561 17 081 290 547 990 523 524 16 216 986 1 437 473 6 349 973 88 545 566 Per capita US$ 12 133 53 2 2 51 4 20 277
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The aim of this publication is to present an analysis of health financing system of the Republic of Maldives and to provide information and evidence for health policy decisions and resource distribution to improve the quality of health service delivery across the country. The study presents a descriptive analysis of resource flows in the health system, showing where resources come from and how they are used. Presented data constitutes an essential benchmark for assessing the system performance and evaluating health policies and interventions in the future. Maldives NHA report followed the methodology recommended in the Guide to Producing National Health Accounts (2003) prepared by WHO in collaboration with the World Bank and USAID.
HSD-MAV-1