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Universal health insurance would undoubtedly be the single best thing the current government has done, which directly affected the lives of ‘every’ Maldivian. This had been the dream of many Maldivians but something beyond the comprehensibility of some that didn’t believe this would be possible.

The launching of Aasandha have challenged the two hospitals in Male’, pushing them to their limits with frenzied ‘patients’ (or should I call customers?) flooding and packing the hospitals. At ADK Hospital, we have seen about 50% increase in specialist consultation and over 100% increase in some of the services that are being offered. The hospitals got overwhelmed with literally no space for people even to move about. In the absence of an ongoing epidemic, statistically and epidemiologically speaking, it is unlikely that so many people would be sick needing healthcare simultaneously! The first 14 days record shows that over 41,000 individuals (note that the number of consultations or visits may be higher) have sought healthcare spending millions, raising serious concerns over its sustainability!

Aasandha is a very ambitious project, which I believe is intended for the good of the people with very noble intention. However, the intended benefits of it will not last long unless everyone takes the responsibility of making it successful and sustainable.

Aasandha has enable getting much-needed healthcare to a lot people that cannot afford it. However, the experience of the first two weeks also show that we got much to learn in terms of being responsible, saving for tomorrow and working for the greater good rather than individual desires.

With Aasandha it has become even more difficult getting appointments for doctors, especially specialists that is being filled by many who really don’t need a specialist consultation, denying access to those who need it. Advance appointments become full to its maximum duration. Queues for GP consultations and other services are getting longer everyday, causing delay in getting the services and tremendously increasing the time spent on getting healthcare.

Another emerging trend noticed is an unusually high number of people who takes appointment, make service memo but don’t turn up for the consultation or service. This is a huge injustice to those who are in real need of that time slot and desperately seeking it.

There also may be some element of provider-induced demand on diagnostic investigations, at least by some doctors! What is more evident and frequent is the number or request, pressure and times demand from patients and their family on doing medically unadvised or unnecessary investigation. Perhaps they don’t realize that this practice drains ‘their’ valuable money or funds in the insurance system to which they would have to rely to get critical service when ‘needed’!

In addition to the low awareness, poor understanding and gross irresponsibility of some of the citizens, there are several gaps and serious issues in Aasandha that is paving way for a lot of these and future problems. Some, but not all are:

• Lack of incentive for clients to be cost conscious or disincentive to prevent unnecessary spending. Clients do not share part of the cost, and the services are absolutely cashless with no direct payment for any service.
• Fee for service model of payment in an insurance system is prone for service provider-induced demand. This cannot be (significantly) avoided unless there is an effective and efficient regulatory system with full cooperation of the hospital management and responsible doctors. We all know that we don’t have that ‘ideal’ scenario in the Maldives.
• The coverage and inclusions in Aasandha is too generous for a basic health insurance package. Its like a private health insurance benefits with a premium of ‘peanuts’!
• There is lack of clarity on policy directions and plans. Government keeps on changing policies, which causes difficulty in managing and uncertainty on the future.