ORIGINAL PAPER

Primary Health Care: Hope and Challenges for Public Healthin Maldives

Asma I. Sulaiman • Sithi H. Abu Bakar •

Haris A. Wahab

� Springer Science+Business Media New York 2014

Abstract The government of Maldives considers that the

enjoyment of the highest attainable level of health is a

basic right of every citizen. Thus it lays emphasis on the

accessibility and affordability of health care services. In

order to achieve these objectives, it is very important to

expand curative services as well as preventive services in

the country. The major hurdles faced by the country are

result of the inherent structural problem faced by the

county which leads to sever diseconomies of scale in the

provision of healthcare services. Community and individ-

ual involvement and self-reliance are very important to

achieve Health for All by the Year 200 AD. Community

participation is one of the domains of community capacity

building in a small island country. It is one of the mech-

anisms to empower people to take part in community

development. In this paper, the nature, the dimensions of

community participation, and its role and scope in imple-

mentation of different components of primary health care

have been described. The health services in public and

curative care have been briefed. Some of the achievements

in health sector have also been briefly presented.

Keywords Community participation � Primary health

care � Health services � Community development

Introduction

Health promotion was defined in 1986 at the first interna-

tional health promotion conference in the Ottawa Charter as

the process of enabling people to increase control over, and

to improve their health and its determinants [14]. Any indi-

vidual must be able to identify and to realize their targets, to

satisfy needs, and to change or cope with the environment to

reach a state of complete physical, mental and social well-

being [15]. Community and individual involvement and self-

reliance are very important to achieve health for all [15].

Community participation is one of the domains of commu-

nity capacity building. It is one of the mechanisms to

empower people to take part in community development.

The journey of Maldives towards health and the truly

amazing set of achievements illustrate how Maldives has

successfully pursued the social goal of ‘‘Health for All’’

with primary health care as the key strategy to build the

comprehensive health system. While highlighting the sta-

tistics and background information to illustrate the success,

it also includes few human interesting stories behind these

achievements.

Therefore, this paper is an attempt to highlight the

remarkable achievement in the arena of health develop-

ment over the past 30 years in health development in the

Maldives. Since, the world embraces ‘‘Health for All’’ goal

and the Alma Ata declaration for Primary Health Care

Resolution. By focus on PHC era and analysis the whole

health system and key achievements. Furthermore, the

historical milieu to success of the main achievements is

elaborated.

A. I. Sulaiman (&) � S. H. Abu Bakar � H. A. Wahab

Department of Social Administration and Justice, Faculty of Arts

and Social Sciences, University of Malaya, Kuala Lumpur,

Malaysia

e-mail: asma3494@hotmail.com

S. H. Abu Bakar

e-mail: shajar@um.edu.my

H. A. Wahab

e-mail: haris@um.edu.my

123

J Community Health

DOI 10.1007/s10900-013-9809-3

Community Participation

Definition of Community Participation

Participation has a variety of meanings, focused on sharing in

activities by entitlement or right, which derive from basic

contrasts of democratic theory [10]. Even though popular

participation and community participation may be distin-

guished, they are clearly interlinked. Both concepts are

inspired by similar ideals and imply similar processes. Com-

munity participation has been considered to be major impor-

tance in health programs in the developing country [8, 11].

Community participation is an educational and

empowering process in which the people, in part-

nership with those who are able to assist them,

identify the problems and the needs and increasingly

assumes responsibilities themselves to plan, manage,

control and assess the collective actions that are

proved necessary p. 166. [12].

Ideally, true or active participation means that the peo-

ple should acknowledgeable about their own health prob-

lems and they should identify the needs for their solution or

reduction, draw out targets of actions based on the avail-

able resources. However, to consolidate the theory of

community involvement into health promotion leads to

positive outcomes such as empowerment for health action

and healthy public policies. Initially, the involvement may

be passive, and this can gradually increased by more active

participation.

Role and Scope of Community Participation in Primary

Health Care

The Government of the Maldives recognizes health as a

human right and is committed to ensure access to primary

health care to all citizens in an equitable manner at an

affordable price [5]. The provision of health services shall

ensure there is no discrimination on account of the person’s

gender or socio economic status. The concepts of people

participation in health development have been practicing

long back in Maldives; since the world embraced Primary

Health Care as the key strategy to achieve health for all by

year 2000. Community development program relies’

mainly on one’s community member’s participation. The

present health policy embraces community participation in

Maldives [5]. For community-based health promotion to

become a mainstream mode of dealing with public health, a

major reorientation of attitudes in government and medical

circles will have to occur. Moreover, the political realities

of social change needed to occur with community devel-

opment in order to pursue a more equitable system do not

sit well with many health professionals [3].

Maldives formulated its PHC plans in the early eighties in

an electric manner where the widespread commitment to the

principles of Primary Health Care was launched by an equal

commitment to delivery in the way in which those principles

are applied. Maldives firmly underlined that primary health

care was a vital means through which not only many pre-

ventive, diagnostic, treatment, rehabilitation and support

services are provided for individuals, but importantly the

means through which many public health services and

interventions are provided for local communities.

The facts concerning the early system of medicine and

health care in Maldives reveals that the earliest health care

was mostly based on traditional and herbal medicine, rela-

tively strong but not specifically on prevention but more

focused on the treatment. According to Fulhu [2] the ‘‘Ha-

keemee Beys’’ was established in the mid twelfth century

after Maldives embraced Islam. That was the predominant

treatment available for centuries and nearly all the medi-

cines, except some of the leaves and herbs ate brought from

abroad. Before opening the hospital few doctors have

practiced traditional medicine in the country. The first doctor

to Maldives was Dr. P. Armanaagm, who practiced tradi-

tional medicine on 25th June 1931. In the late 1940s a

hospital (‘‘Doctarugeh’’) was opened in Male’, with a doctor

called Dr. Gunaratnam and his assistance. The government

opened a well equipped hospital in 1967 at H. Violetfehi in

the current ADK hospital compound, with doctors and nurse

who had a regular training in medicine and nursing [2].

Modern allopathic medicine got established in the

1950s, although there were certain initial overtures in this

direction since the 1930s with the opening of the very first

dispensary by the government of Maldives.

Ibnu Bathutha who visited Maldives 800 years ago was

quoted as, ‘‘anybody who visits Maldives would have to get

fever’’ [2]. Among the neighboring countries this fever was

addressed as ‘‘Maldivian Fever’’, which was actually

malaria. In early 1960s a survey conducted by WHO con-

sultant, Dr. Unmaru Hayath, revealed that 60 % of children

under 10 years had spleen enlargement due to malaria.

Health Services: Public Health and Curative Services

Country Context

The Republic of Maldives is a nation of 1,190 small coral

islands, which form a chain that is 829 km in length and

130 km as its width, which of 99 % of its area compost of

the sea. The Republic is divided into 20 administrative

units, also called Atolls. Only 194 islands are inhabited

now and most with less than 1 km2 and are low lying, with

an average elevation of 1.6 m above mean sea level.

The population of the Maldives is estimated to be

298,968 [6] and consist of 151,459 (50.7 %) male and

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147,509 (49.3 %) female. In addition to this, there are

about 70,259 foreign workers and their dependents (male

64,739 and female 5,520). About 26 % of the population

lives in the capital island of Male’. The population density

of Maldives is 800 person per km2 compared with 30,000

persons per km2 in Male’, indicating a very high and

increasing pressure on land in the capital city.

In 2008 a new president was elected and the government

took over its executive functions in November 2008 with

the mission to deliver five key pledges; which are (1)

establishing a nationwide transport system, (2) ensuring

affordable living costs, (3) provision of affordable housing,

(4) provision of quality health care for all and (5) pre-

vention of narcotics abuse and trafficking [7]. The gov-

ernment initiated a local governance system which was

stipulated in the law no 7/2010 on decentralized gover-

nance providing the elected atoll and island councils the

power of local administration in that particular atoll and

island. Regionalization and decentralization would ensure

accessibility of services to the people and the realization of

human rights and the principles of good governance.

The government has grouped the atolls into seven

provinces in order to achieve more effective and efficient

service delivery at the local level. The rationale for clus-

tering two or more atolls to form a province is to achieve

effective and efficient planning, coordination and man-

agement as a means to facilitate effective administration

decentralization and accelerate local development. Health

facilities have been corporatized with the reform, espe-

cially changes brought to important public health programs

like immunization, child growth monitoring and family

planning. The government aims to increase community

participation in development programs and empower

young generations through an inclusive approach.

Important Health Indicators

The health status of Maldivian population has improved

notably in the last decade. All the indicators shown a

steady improvement, but still remain more to be done and

to be achieved (Table 1). Focusing on prevention and

public health aspects of health services needs to be

strengthening by mobilizing local community. Recent data

from Maldives Demographic and Health Survey shows that

the situation of under nutrition is improving with preva-

lence of underweight children below 5 years decreasing to

17 %, stunting to 19 % and wasting to 11 % in 2009.

Immunization coverage continues to be high with 93 % of

children having all the recommended immunizations. Less

than 1 % of children had severe symptoms of acute

respiratory infection (ARI), 4 % of children had diarrhea

and 84 % of these children had access to a health facility or

provider [4, 13].

The health status of the children has been improved but

nearly one-fourth are underweight. Worm infestation is

high in the country and 50–75 % children below 5 years of

age are estimated to be affected. WHO estimates that 36 %

of all years of life lost in Maldives in 2002 were due to

non-communicable diseases (NCD). NCDs are the most

leading cause of death in the country. The top three leading

causes of death are due to cardiovascular disease, respira-

tory disease and neoplasm (Table 2). Thalassaemia is also

a major health problem which is very common to the

Maldivian population (Nearly 694 cases of Thalassaemia

are registered by 2008) [1]. Disability prevalence in the

country ranges from 9 to 11 % (MoHF and Handicap

International [9]. Communicable diseases such as dengue

fever, chickungunya and scrub typhus have reemerged and

are now endemic. HIV and tuberculosis though under

control, is expected to increase unless urgent measures are

not taken to address the congested living conditions,

expatriate workers in urbanizing settings and increasing

trend of substance abuse and unsafe sexual practices

among high risk population groups [7].

All major positive achievements in health indicators

over the last 30 years had been accomplished with unlim-

ited support from the community to the health sector. In

Table 1 Comparison of health indicators in 1999 and 2008

Health indicators 1999 2008

Infant mortality (1,000 live births) 20 11

Under five mortality (1,000 live births) 28 14

Crude birth rate (1,000 pop) 19 22

Crude death rate (1,000 pop) 4 3

Maternal mortality (100,000 live birth) 6 4

Life expectancy in years (female) 73.2 74.1

Life expectancy in years (male) 72.1 72.5

Thalassaemia registered cases (per 100,000

population)

387 669

Other diseases

Tuberculosis incidence (per 100,000 population) 73 60

Leprosy incidence (per 100,000 population) 23 5

Conjunctivitis—reported cases (per 100,000

population)

HIV incidence (per 100,000 population)-total

population

19 15

Comprehensive indices

Expectation of healthy years lost (years) n.a 2002

Male 7.5

Female 9.0

As % of expected life at birth (ELB) lost n.a 2002

Male 11.3

Female 13.8

Source Center for Community Health & Disease Control 2009

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123

fact all of the islands in the earlier years it was the com-

munity that donated or built the health facilities and pro-

vided a considerable amount of volunteer work in running

them. The island atoll chiefs played very significant roles

in this work.

Building partnerships in health services is another policy

goal in the current ‘‘Master Plan’’ which addresses the

importance of expanding and improving service delivery.

Government has committed to;

• Establish partnerships with NGOs and private sector

through joint planning for implementing public health

services.

• Develop partnership/networks with community groups/

clubs/committees for social mobilization of health.

• Promote local and foreign investment in health care

delivery with adequate safe guards.

• Establishment of networks of institutions and NGO’s

and community based organizations.

• Developing a ‘‘community participation policy’’

• And sustained in the next phase of health system

development.

Current Challenges and the Way Forward

The government of Maldives is committed to further

improving the health status of its population, with equity,

accessibility and affordability as the cornerstones of the

policies. It has been proven that primary health care

approach played a major role in improving the health status

of Maldivian people over the last 30 years. Primary health

care has evolved during the last 30 years to incorporate

additional elements which are of importance with

Table 2 Ten leading causes of death’s in maldives. 2009

The Maldives health statistics 2011, Ministry of Health and Family

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123

demographic and epidemiological changes that are occur-

ring within the countries. Similarly, tackling issues and

changing health trends due to globalization is another

factor that each country needs to be taken into consider-

ation during health planning.

The previous Health Plans in 1980–1983 and

1996–2005 (Health Master Plan) mainly addressed ele-

ments of PHC. The Health Master Plan 2006–2015

addresses sustaining what the country has achieved

during the last decade, issues related to current health

trends both nationally and internationally and some of

the foreseeable future health trends. Improving the

quality, accessibility and affordability of health that is

being provided to the public is the major concern

addressed in this master plan. Additionally, developing

public confidence in the system is also another area that

the health sector needs to work on.

Being a small developing nation composed of islands,

Maldives faces certain special challenges such as climate

change and consequent rise in the sea levels, beach erosion,

high dependency on imports, especially oil, oil pollution of

marine life and a relative over-dependence on tourism for

economic growth. These too will need to be addressed in

the policy framework that is developed.

References

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