“Aasandha is not what it was meant to be,” says an exasperated Fathimath Alia*.

With two young children and an aging mother, Alia has had multiple run-ins with Aasandha – the Maldives’ universal health care system.

Aasandha went live at the stroke of midnight on January 1 2012: a public-private partnership established with Allied Insurance to provide healthcare services to any Maldivian with a valid identity card.

The scheme gives Maldivians annual heath coverage of up to MVR100,000 (US$6,394) from health centres, clinics and hospitals in the country, as well as hospital stays in India and Sri Lanka for emergencies and treatments not available locally.

The Maldives Independent contacted Aasandha to talk about issues raised in this article, but there was no response to calls or emails.

– Hard choices –

Access to medical care has been precarious for Maldivians. For decades there was only one hospital, located in Malé, with few outer islands getting hospitals in early 2000. Most islands only have health centres to this day.

In 2007, following a new parliamentary law, the state started providing children with free school textbooks. The development had an impact on access to healthcare because, until that point, many had had to choose between healthcare or buying textbooks.

“My mum is in such bad shape, because she had to constantly work hard to make ends meet and educate me and feed me, healthcare was the last of her priorities. Even in old age her access to it is better but nowhere near as good it should be,” says Alia.

But healthcare remained remained expensive, especially for people living outside the capital who needed to factor in transport and accommodation during any hospital visit to Malé.

Aasandha was supposed to alleviate these problems.

“Maldivians were spending so much on healthcare, we wanted to ensure they didn’t have to go begging for it any longer. We believed it should be the State’s responsibility to provide healthcare for its citizens regardless of age, income or class,” says Aminath Jameel, the former health minister who rolled out the programme.

She says provisions were made so that “people with chronic diseases also didn’t have to go around begging for their treatment.”

Aasandha is not all bad, though.

Five years since its inception, it can work seamlessly for some patients, especially those being treated in the Maldives or who travel abroad with pre-approved cases.

“My father-in-law was diagnosed with cancer some years back, we submitted the papers and have been in the system since then. The first surgery was also covered by Aasandha,” says Bushry Latheef*.

Latheef recently returned from a medical trip to Cochin with his father-in-law. “It was to test if cancer had spread, we went to a pre-approved hospital in Cochin, which treated us like royalty.”

Aasandha allocates a specific amount and if the treatment exceeds it the patient can pay, or the treating hospital can write to Aasandha to try and have it covered.

“We exceeded by 20 dollars so we paid that ourselves,” says Latheef, who praised how well Aasandha worked.

Latheef wonders how much money could be saved if quality healthcare was available in the Maldives.

“The test we did was routine, but it’s not available locally despite the number of cancer patients here. From the Indian hospital set up you could see they considered the Maldives as an important market.

“Now imagine if the money spent on air tickets and accommodation was instead spent on improving healthcare in the Maldives.”

Tree Top, the recently opened private hospital with state of the art facilities and specialist consultants, will go some way towards alleviating the need for Maldivians to travel abroad for medical treatment.

Latheef is grateful for Aasandha. “It’s so much easier now. When I was small, I can remember a grandparent had cancer and they had to go knocking on different businessmen’s doors to collect enough money for their treatment.”

– Feudal or procedural –

Alia refers to the same system as Latheef. “In the olden days our parents and grandparents went begging to the presidential Theemuge Fund, or to businessmen, to collect a hundred here, a hundred there to pay for treatment. Aasandha centralized it. Now all we have to do is find one ‘bodumeeha’ and beg from him.”

Bodumeeha literally means ‘big person’. It is said that throughout the ages Maldivians survived by being under the protection of some powerful person, a feudal system where you aligned with a big hitter in society and lived off his largesse.

When Alia’s mother fell ill, she went and stayed in Sri Lanka with relatives. She consulted doctors at hospital ‘A’* and was told to do some heart tests.

“But the tests were only available in hospital ‘B’. We contacted Aasandha, they said get a document from the doctor, next day it was get a document from the hospital,” says Alia, adding that these tests were unavailable in the Maldives.

Alia spent four days collecting different documents only to have the case rejected. “They said get the tests done in hospital A, even though all of them weren’t available, I proposed getting the billing done via them, they rejected it.”

On the fifth day a call was placed to a cabinet minister who was a family friend. “The call took place at 8pm, by 12pm everything was arranged at Aasandha and they asked us to get the billing done at hospital A.”

Alia’s mum was then ferried by ambulance from hospital A to hospital B, where the tests were performed, then returned by ambulance to hospital A where the billing was done. “Not only do they make us beg from some person, in the end the cost is double for them.”

There are clear rules and procedures that govern the health system, but they don’t appear to be uniformly enforced.

“The Aasandha committee that decides on individual cases has ever-changing opinions,” says Alia. “We pulled strings and got it done, but imagine the people who can’t. Even worse, Maldivians have come to accept that the way to get coverage is to pull strings.”

 – Gaming the system –

Aminath Maisha has a similar story. Her daughter was admitted to a Colombo hospital with dengue. Aasandha refused her case, saying treatment was available in Malé. Maisha pointed out that she lives in Colombo.

“They said lot of Maldivians try and rook the system in cahoots with doctors.”

It was Maisha’s first time dealing with Aasandha. Again, a call had to be placed to a well-connected bodumeeha and Aasandha fell into place.

“I know it was wrong, I waited until the last moment, but when I saw nothing was moving, I did it.”

Later on a family member needed emergency surgery, but Aasandha rejected the case until a call was placed to a bodumeeha.

“By the time Aasandha came through, the patient had stayed an extra night in the hospital. This was a waste of money by the state as that extra night was expensive,” she says.

Are people overriding the system by pulling strings or is the set-up of the system wrong?

There are cases of the affluent and well-connected flying abroad for treatment that is locally available.

“Two Maldivians had operations to remove breast lumps, scheduled on the same day, in a Sri Lanka hospital.

“One got coverage by Aasandha, the other was rejected,” says Alia. “The one who got coverage is wealthy, with property in Malé, the other was from a normal middle class family, who had scraped together enough money for the operation. Is this just?”

When it was pointed out that lump removal operation is available in the Maldives, Alia said “then make it a fair system, reject both. Money, connections and political affiliations should not buy you coverage.”

There is anecdotal evidence that the privileged often fly to neighbouring countries for treatment and operations like orthopaedic surgeries, even though they are available in the Maldives.

They don’t fly out with the pre-approved documents from Aasandha, but once in the country of choice they manage to get coverage approved.

“The system is inherently unfair, that is why I feel sometimes Aasandha is just a state-sanctioned begging system,” says Alia.

*Names have been changed, and treatment names withheld, to protect the identity of interviewees.