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Universal Health Coverage and Quality of Care in the Maldives

February 1, 2012 Leave a comment

By: Dr Jamsheed, COO

Unarguably Maldives’ health system has made tremendous improvements and has had commendable achievements over the past 2-3 decades. Despite this, the health sector and healthcare providers have been struggling to gain patient’s confidence and maintain a good rapport and a positive image. There are many valid reasons for the ‘bad’ image that are quite directly related to the quality of care provided. Similarly, it should also be acknowledged that there are several health professionals trying their best to provide an optimum, quality care amid all the shortcomings and difficulties we have.

Universal health coverage by the new National insurance scheme Aasandha is a welcoming necessity for the large majority of the Maldivians who have been facing the challenge of increasing healthcare cost. However, due to its design, it is also like a double-edged sword. The Fee-For-Service (FFS) financing model fueled by the weak (practically none-existing) regulatory mechanism poses a great threat to further deterioration of the quality of service that is provided!

Private healthcare providers across the world have different incentive models to retain health professionals by increasing their remuneration based on the services they provide. Any responsible service provider would also try to balance the revenue they generate and quality of service they provide. However, the challenge is that FFS model in an insurance system is an extremely powerful incentive to develop a culture of ‘more’ neglecting the quality of care provided. At times this supplier-induced demand may reach fraudulent proportions with unethical and gross professional misconduct, ‘cashing in’ on the increased ‘affordability’. The FFS model not only offers the opportunity for unreasonable and unacceptable incentives to service providers but offers no incentive for patients to be ‘cost sensitive’ and avoid unnecessary consultations, investigations, procedures or treatments. This is further inflated due to the moral hazard created, as patients directly bear no part of the cost at the point of service.

Neither Aasandha nor any National regulatory authorities have a reporting requirement on the performance in terms of quality of care! What Aasandha requires is an invoice for the services provided, which they will use to verify if those services are covered under the scheme or not. This facilitates a culture of rewarding doctors for ‘bad’ medicine they practice in terms of unnecessary investigations and procedures.

Under these facts and realities, hospital administrators and management should get more vigilant on the performance of the doctors and other professionals. The number of consultations made by an individual over a day, the investigations requested by individual practitioners, indications for a specific test or procedure, length of stay in the hospital should all be more closely monitored and scrutinized. Post surgical complications requiring corrective surgeries or leading to handicap, disfigurement and irreversible damages would need to be looked thoroughly and seriously. Problems that arise from medical errors, poor care or negligence would need to be better distinguished and acted upon. Any professional who attempts to abuse the system with ‘more’ on mind need to be identified and stopped. This would make some of the professionals unhappy but it is a vital necessity; because we want to ensure that patients who get services are always getting the right care; because we want to ensure that the taxpayers get their money’s worth for the limit given to them under the scheme; because we value our customers and we strive to do better every time; because we take our service and our reputation seriously. It is also important because we want to set a new benchmark of healthcare in the Maldives.

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Categories: Issue 23: Feb 12

Creating the perfect smile …

February 1, 2012 Leave a comment

By: Dr. Sumathi, Prosthodontist

Prosthodontics is the branch of dentistry that deals with the replacement of missing teeth and related mouth or jaw structures by bridges, dentures, or other artificial devices.

Earlier Prosthodontics was considered to be a branch of dentistry which replaces only missing tooth structures. With modern skill and technology the Prosthodontist replaces the missing structures of oral cavity, face, head and rest of the body with Prosthesis. It is different from plastic surgery where skin grafts or original body tissues are used to replace the loss.

Following are some of the selected cases done by me including preparation of prosthesis at Sri Ramachandra Dental College in Chennai during my Post Graduation period under supervision of Head of Department, Dr. T.V.Padmanabhan*.

MAGNET RETAINED REMOVABLE BRIDGE

Pre-operative picture shows drifted lower teeth with receding gums and no upper teeth. Teeth with poor prognosis were extracted. Root canal treatment and tooth preparation were done

Metal copings cemented on the prepared teeth

Magnets were fixed to the inner surface of the bridge with resin cement

Complete Post operative picture

IMPLANT SUPPORTED COMPLETE DENTURE

Implant supported prosthesis looks and functions like a natural tooth and replaces the missing tooth without sacrificing neighbouring teeth.

Implant supported Over Denture has many practical advantages than conventional Complete Denture. These include reduced bone resorption, increased function, phonetics, patient’s psychological outlook and quality of life.

Earlier 4-6 implants were used for Over Denture but recent studies have proved that single implant supported Over Denture provides satisfactory retention and stability. Single implant placement reduces the surgical procedure, pain and is also economical to the patient.

MAXILLO FACIAL PROSTHESIS

Maxillofacial prosthetics is a branch of Prosthodontics that deals with restoration of congenital or acquired defects, both intra oral and extra oral.

MAXILLARY OBTURATOR: An Obturator is a prosthesis used to close defects of the hard/soft palate that may affect speech production or cause nasal regurgitation during feeding.

The defect was created due to removal of a tumour in Hard Palate.

VELOPHARYNGEAL OBTURATOR: A patient reported with complaint of regurgitation and nasal speech after excision of pharyngeal tumour. Velopharnygeal obturator was planned to cover the defect.

A cast partial framework was done first and pick up impression made with rubber base impression material. Acrylic extension was done to cover the defect.

EYE PROSTHESIS

Impression was made with rubber base material. Stock eye shell was selected comparing with the other eye and wax pattern was fabricated.                        

Ocular Prosthesis was made with RTV Silicone and artificial hairs were attached to the prosthesis for eyelashes.

Picture shows ocular defect due to Enucleation (Removal of Eyeball) due to a Tumour.

Categories: Issue 23: Feb 12

Let’s Relax!

February 1, 2012 Leave a comment

By: Dr Saravanan, Pediatritian

How do you feel when someone comes rushing  towards you and says, “You are in deep trouble. And it’s serious”.  Now you know the feeling.  Instantly your heart starts pounding, your muscles tense, your breathing gets faster, you feel weak and your mind becomes instantly alert. Welcome to the world of stress reactions.

But then something unexpected happens. The person starts to laugh out loud suddenly and tells you it was just a prank, just for fun. With a great sense of relief, you notice the stress reaction melt away over the next minute or two, and you slowly return to the relaxed state you were in before.

The experience of our body go to a temporary state of “high alert” is the stress reaction. We probably inherited the stress reaction from our caveman ancestors and because of it’s protective nature, it was passed down genetically through the millennia. Think of a caveman confronting a lion and you understand why the stress reaction was so vital to survival. In an instant, our forebear had to mobilize enough energy to either fight or run away from the threat to his physical safety. This is the classic “fight or flight response”, mediated by adrenaline, cortisol and other stress hormones in the body, which allowed our predecessor to either defend himself or flee.

We experience the same reaction today and while it’s crucial in a real crisis, it is inappropriate in our day-to-day lives. Not only are most of our stressors not life threatening, but fighting and running away are not exactly acceptable responses to most stressors. If someone is chasing you down a dark alley, the stress reaction can be lifesaving. But when, the stress comes from an angry customer or a long line at the bank, it might be frowned upon to hit someone or run down the street at high speed.

Dr.Hans Selye, one of the fathers of stress theory defined stress as” the non specific response of the body to any demand made upon it” The demand can be a threat, a challenge or any change that requires the body to adapt. Stress is good when it protects us in times of danger or helps us to adapt to change. It is inevitable and necessary to survival. But it serves us in other ways too, helping us study for exams or work towards a deadline. It motivates and stimulates us in work, allowing us to be productive and creative.

Stress becomes a problem when there’s too much, when it lasts too long or when it comes too often. Different people respond differently to the same stimulus that provokes the stress reaction and what is comfortable to one person can be terrifying to another.  In every case of stimulus, the main assessment we make is “Am I in danger or not? If it’s yes, our bodies react with a stress reaction. If we judge that we’re not in harm’s way we usually relax.

Some times stress can result from internal source when there is high ideals and expectation from oneself leading to burnout. If the stress reaction goes on for too long or recurs frequently,  it can cause damage to the body and can lead  to many illnesses. Many of the symptoms of sleep deprivation are also symptoms of stress.

Stress is one of the leading causes of ill health in our society. But, as if that’s not bad enough, many of our coping strategies, are in themselves unhealthy. The solution for chronic stress is quite simple.  Healthy life style choices such as physical exercises,  relaxing techniques including prayer and meditation, practicing good nutrition, taking time-outs and being assertive are better strategies for stress relief which also promotes good health. These may not seem very thrilling or exciting – but they sure have a big payoff.

Categories: Issue 23: Feb 12

Clinical Waste Management

February 1, 2012 Leave a comment

By: Afaal, MD

In a hospital, most of the time, everyone is occupied with the services that is being provided and how good they are delivered to the service seeker. Well this would be true for any service for that matter. Often, one important aspect of service delivery that does not get enough attention, but equally important, the processes that go behind the scene, the Back Room.

Clinical waste collection bin at ADK Hospital

A number of activities are carried out behind the scenes. Waste management, laundry services, maintenance, power, IT and many more are kept intact by the efforts of many staff throughout the 24 hour operations.

Waste management is a serious activity for any hospital. Apart from just waste, hospitals generate hazardous waste. Hazardous waste are also further categorized and can be desegregated and treated and/or disposed off differently. Hazardous waste includes sharps, anatomical waste, clinical waste, contaminated waste, infectious waste, human tissue, cytotoxic, pharmaceutical waste, laboratory waste, chemical waste and radioactive waste.

In order to ensure that accidental exposure to such hazardous waste, for both staff and patients, hospitals have to ensure a proper process of managing such waste, including collection, handling and disposal. In the Maldives, clinical waste disposal is one aspect of health care that needs immense improvement. Lots of effort is required to ensure that hazardous waste is disposed safely.

At present, none of the health facilities in the Maldives have an exceptionally good waste management system. In many institutes, the collection and desegregation is present but at disposal all the waste get mixed up again. This means that there is no establishment that would collect the disposed waste on a desegregated manner and destroy them properly.

It is thus important that, health facilities take an initiative to ensure that such mechanisms are put in place. Also, regulatory authorities should develop and implement guidelines to the effect.

In its endeavors to set standards in health related matters, ADK Hospital has initiated a new policy of improving its waste management. The main strength of the Hospital is that it has onsite incineration facilities. Though this may not be the best solution, it is a standard which is recognized adequate. Furthermore, in the Hospital waste is collected in a desegregated manner. Clinical waste is collected separately and incinerated on site. Similarly sharps are collected separately in sharp bins and incinerated too. Only general waste is what gets disposed of to the mainstream.

Hazardous waste shredded and sterilized ready for disposal

In the modern world, incineration has now been replaced by shredding and sterilizing hazardous waste so that it can easily be disposed off to the mainstream. Some of degrades by itself while others can be recycled. Perhaps thats what new investments in waste management should be headed towards.

Categories: Issue 23: Feb 12