The Public’s Mistrust in Healthcare

Trust is a fundamental element in interpersonal relationships and the importance of trust within healthcare cannot be stressed upon enough. Patients present themselves to healthcare providers at their most vulnerable time and must be able to trust both the institution and the individuals involved in their care. They must be able to trust that these individuals and organizations are competent and have their best interests at heart. At present this is far from true in this country. Most patients do not trust the institutions nor the individuals providing the care. They are weary and suspicious of any medical encounter. Numerous accounts of mismanagement, maltreatment and neglect by doctors are exchanged daily in the queues at IGMH or ADK. People would rather go abroad for the simplest ailment than get a consultation here at home.

Several factors have contributed to the buildup of this mistrust.

Firstly, as the face of healthcare, some doctors do not bother or are not trained in creating a healthy doctor-patient relationship that is crucial to the success of any treatment. Most Maldivian doctors are trained in South Asia, either in India, Nepal, Pakistan or Bangladesh, where a paternalistic approach to patient care is acceptable, practiced and used in training. The doctors know what is best and the patient should do whatever the doctors order, no questions asked. Procedures can be done on patients even without consent. There is no room for the patient to refuse treatment. On daily rounds it is common to see doctors scolding patients for not complying with treatment. The rights of the patient and proper ethical conduct are hardly an issue. Thus it is not surprising that such incidents are all too common in our hospitals where the doctors are either trained in or are from such countries. The possibility of trust in such an environment is impossible, especially when Maldivian patients in general ask more questions and are somewhat more aware of their rights (hence the popular belief among doctors that Maldivian patients are 'troublesome' and ʻdifficultʼ).

Secondly, healthcare institutions and individuals do not protect the patients' rights of confidentiality and treat their medical information as coffee-time gossip. It is all too common to hear doctors discussing personal details of their patients for their amusement, or lab technicians discussing a patient's paternity test. Healthcare professionals owe a duty not to disclose information against the patient's wishes as medical confidentiality is an important feature of the doctor-patient relationship.

Thirdly, healthcare institutions are all too keen to cover up medical mistakes and no framework exists to deal with such mistakes. Hardly any incident is thoroughly investigated and proper actions taken, and those wronged are not compensated. There are no professionals trained in legal medicine and those sitting on the ethics committee lack any training in the area.

Fourthly, there is no institution to regulate and standardize healthcare. The recruitment of expatriate doctors, who make up majority of doctors especially in the atolls, should be more stringent and registration at the Maldivian Medical Council should be followed by a licensing exam. Many are familiar with the account of a cook who used to work in one of the islands as a doctor for several years. There is a lack of standardized management protocols for common conditions, and adherence to those existing protocols is limited and not enforceable. There is no code of ethics or a code of professional conduct for doctors, which is a necessary tool for the regulation of the profession. Policy makers should consult healthcare professionals in making decisions that affect the health of the population in general. The recent changes to the appointment system at IGMH (which has fortunately been reversed), seriously violated a patient's basic right to choose his/her healthcare provider, and only intensified the public's mistrust.

In such a setting, where healthcare is not standardized or regulated, and where the healthcare providers are not bound by any obligations, legal, professional or otherwise, the public's mistrust towards healthcare is not surprising. It has increased the number of second opinions being sought and requests for referral abroad. Failure to comply with treatment is commonplace. It has also increased the number of people turning towards other sources of treatment.

Having said all this, I know of no doctor who wishes harm on his patient. Perhaps it is the combination of several factors rather than a single one that has led to this mistrust. Trust is a potentially powerful variable affecting healthcare decisions. And as such, both healthcare institutions and individuals should work to regain and reestablish this trust, by building a relationship in which the values and goals of both parties are clearer to each other, one of shared decision making, and one which promises to increase patient satisfaction and lead to greater understanding of treatment and illness.

[Contributed by Dr. Faisal Saeed]

Free Healthcare – a context!

By Ahmed Afaal

Is there any such thing as free health care? Or is it just an attractive jargon that pleases people? Health care is a basic right for every citizen of every country and Governments are supposed to provide appropriate access to services, a statement well understood by everyone! In the recent past there has been a lot of talk about health care reform in almost all corners of the world. Health care reform becomes a major talking point of each political election. In the 1990's economists in their quest to find better and efficient ways to finance collapsing health care systems started the health care reform jargon. With advancement and sophistication in health care interventions, escalating costs left governments and the public struggling to afford health care and hence more and more people did not have access to health care, even in the developed world.

If we look at the most advanced health systems of the world for example, the United Kingdom is one that boasts "free" health care. But the National Health System (NHS) of the UK has in the recent years struggled to cope with the costs and slowly is moving towards a more market based system. Free health care is mainly seen in economies with high taxation. However even with this, there is division for example in the UK Labour Party whether to introduce a new health tax to supplement the already expensive NHS budget which stood at a staggering 53 billion pounds in 2001 (The Guardian, November 30, 2001) and keeps increasing. Who pays? The people with a tax burden of over 40% of there earnings! Do we call this 'free' health care? Most related literature state that the UK health system is on one extreme of the financing spectrum, not a very good one.

On the other extreme in the US where health care financing is based mainly on private insurance. This system has left millions without access to health care. This year the estimated number of people without insurance in the US has reached over 43 million. Why? People can't afford healthcare. No wonder, health care becomes a major campaign slogan of every American election. In the recent presidential campaign in the US, Barrack Obama proposed government subsidies on the current expensive market based system (Times, September 29, 2008) in an attempt to relieve the burden paying insurance. Also recent experience such as the bail out of insurance giants AIG shows the vulnerability of such a market. Again most literature on the subject if you read indicate that the US has one of the most regressive health care financing systems in the world.

Countries like France have made their health systems more responsive by innovation. Social Health Insurance schemes with co-payments and capitations have improved the sustenance of their systems. However, still there are questions about such systems. For example in the last election campaign of the previous Premier of Australia, John Howard in his campaign promised 'free" healthcare for all Australians. But just 3 months into his term, he raised the health care tax rate – his answer to the public? If the government implemented free health care Australia will go bankrupt and he said something along the following lines "I'm sure Australians will forgive me since my financial advisors were wrong at that time. I cannot make Australia go bankrupt just because I made an election promise" Perhaps one of the reasons his government did not last too long this time.

Coming to the context of the Maldives which is what we need to get worried about, we have a system that is extremely regressive. Out of pocket payments have made people beg for health care. Many families have gone into unrecoverable debt since they had to borrow for health care. Just like all other parts of the world, health care costs will keep on escalating. The more sophisticated the more expensive it becomes. Good financing schemes are the only solution to this phenomenon of escalating costs. Government has failed to implement a proper scheme to finance the Maldivian health system, at least in the past and so far we have to wait and see what will come up with the new Administration. One fact though is that the current political environment has made health care financing one of the major talking points.

On a positive note, slowly the concepts of insurance are creping into the country. A good sign, but how sustainable is it? We saw the first Government Employees Insurance Scheme collapse before it was really even born. A bitter experience! Now the new scheme "Madhana" is claiming that it is a more promising scheme. We have to wait and see.

Note: A first version of this article was published in Mr. Afaal's blog, http://afaal.blogspot.com. This edited version is provided to this blog for the readers of this blog.