Will Maldives health insurance scheme succeed?

Maldives yesterday launched its second social health insurance scheme in as many years. Will the scheme be second time lucky and succeed? Success of course depends entirely on how one defines success. If by success one means that those who are lucky enough to get enrolled into the scheme get the limited package of benefits that it promises, without bankrupting the scheme, there is a fair chance of success. However if by success one means that all citizens will get access to effective health care by paying an affordable premium, the story may be different.

Maldives is certainly not the first country to attempt "universal coverage" of social health insurance. So it is worthwhile to learn from the experiences of other countries. Fortunately for us such experience has been summarized by Guy Carrin in a brilliant meta-analytic article ("Guy Carrin, Social health insurance in developing countries: a continuing challenge, International Social Security Review, p57-69, Vol.55, 2/2002".)

According to Carrin some of the difficulties faced by countries include the following:

1. Inadequate or ineffective health care provided to the insured members: This implies that the general or special health care services provided to insured members are part of the basic benefit package that may already exist or be created by the SHI schemes. If the existing health care system is not able to provide the essential health care package, it makes little sense to start a SHI scheme. It is painfully obvious that the Maldives health system is far short of providing even a semblance of adequate health care. Just look at the thousands of Maldivians travelling abroad for treatment.
   
2. Lack of managerial or administrative capacity to organize a nation-wide SHI scheme, that make inadequate collection or reimbursements, inefficient management of revenues and assets collected, or lack of monitoring the necessary health and financial information: With little experience in handling any sort of insurance, let alone health insurance, Maldives is far from meeting the managerial criteria for organizing an effective health insurance scheme.
   
3. Poor political stability usually linked with economic insecurity and also lack of policy debates among high-level policy makers and beneficiaries: The Maldivian economy currently faces a crisis. Further, no open debate has ever been conducted among the stakeholders.
   

 

The ingredients of successful social health insurance have also been identified by the author. They include:

1. Level of income: Once general population has better income, they tend to make higher health insurance contributions. No country (with the exception of Haiti) with per capita GDP below $ 3000 has succeeded in implementing social health insurance. While the Maldives GDP approaches this figure, income inequalities are likely to hamper insurance.
   
2. Relative size of informal and formal sectors: The larger the informal sector, the more difficult it is to manage the setting and collection of contributions and even reimbursement. In the Maldives fishermen and a wide range of other workers are in the informal sector. This will make the situation extremely complicated.
   
3. Time implications: Experience indicates that a few decades are needed to reach universal coverage. Appropriate strategic development plans are required; it is likely that Maldives will take at least several decades to achieve universal coverage.
   

Which way will the election shift?

In Presidential Election 2008, so far eight candidates are in the fray. Among them only three rate as serious contenders on current strength: Gayoom, Gasim, and Anni, in that order. Like a seasonal sand dune, this scene could shift dramatically between now and October 10. But for now, let us speculate how each of these candidates could manipulate the situation to their advantage.

1. Gayoom
   

   His strength is that he is the most marketed product in the Maldives, with brand recognition far ahead of Nespray and Marlboro, his nearest rivals. But this advantage could melt away like ice sculpture, if rival candidates get the time and opportunity to conduct a cohesive campaign. So his strategy should be to hold the election without delay and to put as many administrative barriers as possible to thwart rival campaigns. If he fails to do this, he risks losing his top position.
   

   
   

2. Gasim
   

   His top strength is his image as a philanthropist, with beneficiaries all over the Maldives. He also has personal wealth and a bunch of businessmen to finance his campaign. His main weakness is lack of party infrastructure at island level to conduct an effective campaign. His strategy should therefore be to establish party branches as soon as possible. He would benefit from postponing the election, as it would give him more time to organize at island level.
   

   
   

3. Anni
   

   Anni's main strength is MDP, which has grassroots organization all over Maldives. His main weakness is his image, which is that of an activist rather than a statesman. The other weakness is that his manifesto has not been well marketed. Anni's main strategy should be to team up with a credible running mate and to market a positive manifesto, leaving aside the temptation of picking on Gayoom. MDP stands to lose from any postponement of the election, as it will give their rivals time to build grassroots organization.
   

   
   
   Readers may be wondering why Yaameen did not figure in the top three. Well, he has only to blame himself for squandering his pre-eminent position as Gayoom's leading rival within the span of less than a year. This process of self destruction will be complete if and when Yaameen joins Gayoom's cabinet. As for Mohammed Waheed Hassan Manik, the best he can hope for is for the election to be over before the expiry of his return ticket back to the US.

Who is the real Gasim?

"If I were to ask for anyone's help other than Allah's, I swear I'd ask for yours," Gasim Ibrahim wrote to Gayoom from his Dhoonidhoo cell, while imprisoned there following the August 12-13 incident of 2004.

"The Maldivian people know who fights for their rights and who doesn't," Gasim Ibrahim thundered to his supporters during his party's congress on 22 August 2008.

Was it the same Gasim who made these two statements, and if not which is the real Gasim? Fortune does not change men; it unmasks them. But sometimes people carry to such perfection the mask they have assumed that in due course they actually become the person they seem. So, has Gasim become the mask he wore?

Gasim's privately owned Villa Foundation awards about 150 scholarships to young Maldivians to pursue higher studies each year. Scholars are selected to the scheme on purely objective criteria, with no influence whosoever exercised by the Chairman. More than a 1000 students have benefited from this scheme so far. Gasim's welfare scheme has funded medical treatment abroad for 1000s of poor Maldivians. Most of them have never met Gasim. Was this a truly 'free lunch"?

These two philanthropic schemes rival, or perhaps even exceed, the corresponding Government schemes. Thus Gasim stands out as the philanthropist par excellence. Is this the real Gasim?

With his sponsorship of the 2001 petition signed by 40 intellectuals, Gasim is widely credited for the birth of the party system in the Maldives. He is rumored to be funding most opposition parties in the Maldives including MDP, IDP and Adaalath. On the other hand, he is also rumored to have funded the defection of prominent opposition MPs to DRP. Which of these roles, if any, did the real Gasim play? It's said that for some people there is more to life than just having everything. Is this true for Gasim?

Gasim is also widely credited to have led the constitutional amendment process to a successful conclusion. However, it is also alleged that the finally passed draft had many inconsistencies that Gasim could not prevent. In the process of removing these inconsistencies, it is also alleged he colluded with Ibra and AG Azima to introduce into the draft phrases and clauses never passed by the Majlis. What is the truth here?

As finance minister from mid 2005 to mid 2008, Gasim presided over the biggest budget fiasco in the history of Maldives, which diverted the country's fiscal course irreversibly towards bankruptcy. Did the budget fail because the trade minister and others failed to materialize the mega projects on which the budget depended, as Gasim alleges? Or did it fail because Gasim set rashly impractical targets and gambled with the country's economy?

Gasim's Villa Group currently owns about 15 % of all tourist beds in the country. The figure could even double when resorts currently under development are opened. With massive investments at Keekimini and Maandhoo, Gasim has a controlling interest in the fisheries industry. He also has similar controlling interests in the petroleum and LPG distribution industries. With investments in nearly all types of enterprises in the Maldives, Gasim is the capitalist par excellence. Is this the real face of Gasim?

In Senate confirmation hearings for constitutional posts in the United States, candidates are asked questions designed to bring out their attitudes and ideologies. The underlying belief is that people continue to hold and practice their old beliefs and ideologies in their new jobs, like the proverbial leopard, which does not change its spots. From Gasim's past actions can we predict what sort of president he would become?

Will he be a business friendly capitalist, or a pro-poor socialist with enough courage to introduce heavy taxation to fund social services? In other words, can he run with the hares while hunting with the hounds? Will he become the Lee Kuan Yu of Maldives running a clean administration or will he become the King Fahd of Maldives running a regime of favoritism? Will he become the selfless Mandela of Maldives or the monopolist Stanley Ho (the business tycoon who practically owns Macao) of Maldives? There are telltale clues in Gasim's track record to answer these questions with reasonable accuracy.

For 30 years Maldivians depended on the noblesse of a holy man to build their security. History tells us the outcome. For the next 10 years can they depend on the magnanimity of a philanthropist to build their security? Maldivians can choose their leader; destiny will choose the consequences.

["Destiny is a name often given in retrospect to choices that had dramatic consequences," – J. K. Rowling in Harry Potter and the Sorcerer's Stone ]