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National Health Workforce

Strategic Plan

2014–2018

Ministry of Health and Gender

Republic of Maldives

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Contents

Abbreviations ....................................................................................... 6

Executive summary ............................................................................... 7

Background ....................................................................................... 7

Main HRH issues ................................................................................ 7

Conclusion ........................................................................................ 8

Section A: Introduction ............................................................................ 9

Background ......................................................................................... 9

Methodology ...................................................................................... 10

Review of records, reports and literature ............................................. 10

Interviews, group discussions and consultation ..................................... 11

Site visits and discussions with representatives .................................... 11

Section B: HRH situation analysis ............................................................ 12

Framework for situation analysis ........................................................... 12

External factors influencing HRH ........................................................... 13

Geographic factors ........................................................................... 13

Demographic factors ......................................................................... 15

Epidemiological factors...................................................................... 19

Sociocultural factors ......................................................................... 22

Political factors ................................................................................ 23

Economic factors .............................................................................. 24

Internal factors affecting HRH ................................................................. 25

Health care delivery system ............................................................... 25

HRH situation and trends ..................................................................... 30

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Availability ...................................................................................... 31

Distribution ..................................................................................... 32

Recruitment and retention ................................................................. 34

Skill mix and competencies ................................................................ 36

HRH policy ......................................................................................... 36

HRH education ................................................................................... 37

Pre-service training of health professionals .......................................... 37

Postgraduate training of health professionals ....................................... 45

Continuous professional development ................................................. 47

HRH management systems .................................................................. 48

Recruitment and bonding .................................................................. 48

Remuneration .................................................................................. 51

Non-financial incentives/working conditions ......................................... 53

Performance management ................................................................. 55

Quality assurance ............................................................................. 56

HRH information and evidence for decision-making ............................... 57

HRH leadership ................................................................................... 59

Current HRH coordination mechanism and champions ........................... 59

HRH stewardship .............................................................................. 60

HRH partnerships ................................................................................ 61

HRH financing .................................................................................... 63

HRH requirements .............................................................................. 63

Scenario 1: Achieving staffing standards (Tables 18 and 19) .................. 64

Scenario 2: Reducing the expatriate health workforce (Tables 23 and 24) 68

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SECTION C: Health workforce strategic plan .............................................. 72

Vision ................................................................................................ 72

Mission .............................................................................................. 72

Guiding principles ............................................................................... 72

Strategies and interventions ................................................................. 75

Strategic line 1: Policy, leadership and management systems ................. 75

Strategic line 2: HRH education and training ........................................ 80

Strategic line 3: HRH Financing and partnerships .................................. 84

Section D: The way forward .................................................................... 86

Annexes ............................................................................................... 88

Annex 1. Technical working group ......................................................... 88

Annex 2. Stakeholders engaged in development and validation ................. 90

Annex 3. HRH positions approved by the CSC for health-care facilities under

the MOHG (staffing standards) ............................................................. 92

Annex 4. Distribution of expatriate/local HRH, standards and vacancy rates in

hospitals level 1–4 (regional/atoll) (Source: MOHG) ................................. 95

Annex 5. Distribution of expatriate/local HRH, standards and vacancy rates in

health centres level 1–4 (Source: MOHG) ............................................... 97

Annex 6. Distribution of HRH, standards and vacancy rates in all health

facilities under the MOHG (MOHG + institutions information missing) ......... 98

References .......................................................................................... 101

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List of tables

Table 1 Population distribution among atolls 18

Table 2 Concentration of population in islands 19

Table 3 Key health indicators for Maldives 20

Table 4 Incidence of selected communicable diseases 21

Table 5 Ten leading causes of mortality 21

Table 6 Utilization of regional hospitals, 2011 26

Table 7 Utilization of atoll hospitals, 2011 27

Table 8 Vacancy rates by cadre in hospitals, levels 1–4 31

Table 9 Vacancy rates by cadre in health centres, levels 1–4 32

Table 10 Ratio of population to health workers 33

Table 11 Number of local health workers employed in the atolls 33

Table 12 Pass rates at GCE O-Level examination 38

Table 13 Number of students sitting GCE A-Level examination 38

Table 14 Number of students enrolled and graduated in different courses

offered by FHS

42

Table 15 Expected year of return for postgraduate trainees (other than

medical) sent for training overseas by the MOHG (Source

MOHG)

45

Table 16 Postgraduate medical education enrolment supported by MOHG

and international partners, since 2000

46

Table 17 Postgraduate medical students graduated, since 2000 47

Table 18 Cost of training priority cadres to reach staffing standards 66

Table 19 Proposed calendar to achieve staffing standards for key cadres 67

Table 20 Cost of training medical doctors (general and specialists) to

replace all expatriates

69

Table 21 Cost of training other health professionals to replace expatriates

70

Table 22 Forward plan 86

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List of figures

Figure 1 The conceptual framework 13

Figure 2 Map of Maldives 15

Figure 3 Projected mid-year population, 2013–2018 16

Figure 4 Projected population pyramids for Maldives, 2014 and

2018

17

Figure 5 Trends in infant mortality rate, under-5 mortality rate

and maternal mortality ratio, 2001–2011

20

Figure 6 MMC registrations and requests for certificates of good

standing

35

Figure 7 Total number of medical graduates registered under MMC

(up to June 2013)

39

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Abbreviations

CHW community health worker

CPD continuous professional development

CSC Civil Services Commission

FHS Faculty of Health Sciences

GCE A-Level General Certificate of Education, Advanced Level

GCE O-Level General Certificate of Education, Ordinary Level

GHWA Global Health Workforce Alliance

HRDMC Human Resource Development and Management Committee

HRH Human Resources for Health

IGMH Indira Gandhi Memorial Hospital

IMF International Monetary Fund

MBBS Bachelor of Medicine, Bachelor of Surgery

MNDF Maldives National Defense Forces

MDG Millennium Development Goal

MIHIS Maldives Integrated Health Information System

MMC Maldives Medical Council

MOHG Ministry of Health and Gender

QAI Quality Assurance and Improvement

WHO World Health Organization

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Executive summary

Background

The Republic of Maldives has achieved remarkable health gains over the past

few decades. Being a small island nation, Maldives is highly vulnerable to the

effects of globalization as well as epidemiological, socioeconomic, cultural and

political changes. The Human Resources for Health (HRH) situation of the

country is determined by a complex interplay of these factors as well as internal

issues governing HRH such as health financing, policy, management and

training.

Main HRH issues

• Weak health workforce leadership and management at all levels

• Fragmented information management systems leading to limitations in

evidence-based decision making

• Difficulties in attracting and retaining health workers in atolls and islands

leading to high turnover and high vacancy rates

• Overdependence on expatriate health professionals

• Inequitable distribution of health workers between Male’ and atolls

• Lack of career and professional development opportunities

• Difficulties in legally binding staff to service/training bonds

• Variability in the quality of pre-service, postgraduate and professional

continuous education

• Underfunding and inefficient use of existing financial resources for HRH

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Strategic actions

1. Strengthening the systems and structures to effectively manage and support

HRH; improving policies, regulatory frameworks and institutions, and fostering

leadership capacities to adequately perform the essential HRH management and

monitoring functions.

2. Enhancing education and training outputs harmonized with national health

care needs.

3. Increasing financial inputs from public, private and international sources;

streamlining the multi-stakeholder coordination processes, and fostering

bilateral partnerships with organizations, entities, institutions and countries.

Conclusion

To address complex issues in HRH, a well thought out and holistic plan is

needed. A systematic approach to HRH policy, management, leadership,

education and training, and the promotion of partnerships as well as financial

components, should be used in combination to improve the HRH situation of the

country.

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Section A: Introduction

Background

HRH is a crucial component and pillar of a health system.1 In order to provide

the entire population with access to qualified and efficient services, HRH of an

adequate quantity and skill mix are required, which are equitably distributed,

well-supported and sufficiently motivated.

The World Health Report 2006 – Working together for health reveals an

estimated shortage of almost 4.3 million doctors, midwives, nurses and support

workers worldwide.2 Maldives is not among the 57 countries that face a serious

shortage of health workforce, which negatively influences health-related

Millennium Development Goals (MDGs). However, there are critical issues

regarding the sustainability of the health workforce and inequitable distribution

of HRH, as well as some concerns about quality. The First Global Forum on HRH,

convened by the Global Health Workforce Alliance (GHWA), agreed on the

Kampala Declaration and Agenda for Global Action to provide guidance to

countries through six interacting strategies focusing on all stages of health

workers' careers from entry to health training, from job recruitment through to

retirement.3

In recent years, challenges in HRH have prompted the Ministry of Health and

Gender (MOHG) in Maldives to put greater focus and emphasis on the health

workforce. By achieving better HRH management and development, the MOHG

expects to ensure that all Maldivians have equitable access to comprehensive

health services provided by a competent and professional health workforce.

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During the past decade, the MOHG made attempts to solve HRH issues by

implementing the National Human Resources for Health Plan (2001–2010).4 The

MOHG made significant progress in expanding and upgrading regional, atoll and

island level health facilities, and in increasing the number of local and expatriate

HRH as planned. However, important HRH issues persist.

Since challenges associated with HRH concern a wide range of stakeholders,

solving such complex issues requires a well thought out strategic plan resulting

from intense policy dialogue among all related actors, following the country

coordination and facilitation approach delineated by the GHWA.3,5 Thus, the

MOHG developed a structured approach to analyse the HRH situation and put

together the National Health Workforce Strategic Plan 2014–2018 based on the

findings of this analysis. The strategic plan will: a) guide MOHG action in

securing support for HRH development; b) provide a framework for making

consistent decisions for planning HRH and their capacity-building; c) help

monitor MOHG action on HRH development and management; d) identify gaps

in the system that need to be addressed; and e) help estimate the costs of

human resource training and deployment, and assess the sustainability of the

existing workforce by modelling different scenarios. In turn, the HRH strategic

plan will help secure better finances from the national budget by prioritizing

HRH as a critical area with documented evidence.

Methodology

In order to ensure current and accurate information to support evidence-based

recommendations, several approaches were used for data collection.

Review of records, reports and literature

An extensive study of available documents and databases from the MOHG,

WHO, Faculty of Health Sciences (FHS) and other sources was undertaken.

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These documents were analysed and discussed with the relevant authorities and

stakeholders.

Interviews, group discussions and consultation

A series of consultative meetings was conducted with representatives, key

stakeholders and/or decision-makers from several organizations including WHO,

MOHG, FHS, Maldives Medical Council (MMC), Maldives Nursing Council and

Maldivian Board of Health Services.

Site visits and discussions with representatives

Site visits and discussions with those engaged in HRH action have been carried

out, including the FHS, Indira Gandhi Memorial Hospital (IGMH), HulhuMale’

Hospital, ADK Hospital and health centres. A technical working group was

established comprising all concerned stakeholders, including the MOHG, FHS,

private sector, Civil Service Commission (CSC) and Ministry of Finance and

Treasury.

This HRH strategic plan was developed through a participatory and consultative

process, with the lead role taken by the technical working group (Annex 1) and

findings from two stakeholders’ consultations (Annex 2) representing various

government agencies, regulatory bodies and developmental partners.

The findings were presented in a multi-stakeholder meeting, for validation of

the situation analysis and dialogue on the proposed strategies. This process was

complemented by means of an online consultation with all stakeholders for

reviewing, revising and finalizing this strategic document. A full revision of the

NHWSP proposal was undertaken adjusting to new policies and plans of the new

government. The final version was presented at a national launching meeting in

April 2014.

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Section B: HRH situation analysis

Framework for situation analysis

The HRH situation is dynamic as it is affected by the interplay of complex

conditions at local, country and global levels. A country’s HRH situation is

affected by factors both external and internal to the health system. The various

transitions in global and regional contexts often influence HRH systems. At the

same time, changes in the sociodemographic profile and in epidemiological,

socioeconomic, political and cultural circumstances have both direct and indirect

effects on health systems and HRH. The HRH situation is determined by a

complex interplay of these external factors as well as internal factors governing

the health workforce.

The conceptual framework shown in Figure 1 is an adaptation of the HRH Action

Framework developed by the GHWA. It is designed to facilitate an

understanding of the current HRH situation in Maldives from a broad

perspective, taking into account factors both external and internal to the health

sector and the link between these driving forces and the different dimensions of

the health workforce.

This HRH situation analysis was guided by the conceptual framework.

Geographic, epidemiological, sociocultural, political and economic factors were

assessed. In order to assess the HRH system, the six dimensions of the HRH

Action Framework (HRH management, leadership, partnership, finance,

education and policy) were analysed. This situation analysis provides evidence-

based information for the development of HRH strategies (as detailed in Section

C).

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Figure 1. The conceptual framework

External factors influencing HRH

Geographic factors

The geography of the Maldives has a significant impact on health care service

delivery. Maldives is an archipelago consisting of about 1 190 coral islands

grouped in a double chain of 26 atolls, spread over approximately 90 000

square kilometres, making it one of the most dispersed countries in the world.

The distance from the capital Male’ to the extreme north and south of the

country is approximately 820 km in each direction. On average, each atoll

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includes 5–10 inhabited islands. The average land area of an island is only 1–2

square kilometres. These geographical characteristics, and the fact that the

population is extremely dispersed, have a significant impact on the delivery of

services at central, atoll and island levels.

Health facilities are scattered across the country. The geographically dispersed

layout and a weak transportation network often lead to disparities in access to

health services between different atolls. Patients travel from the islands to the

nearest atoll hospital; more complex patients are referred to Male’, where the

only tertiary health care facility (IGMH) is located. As a result of the high cost of

patient transportation, and other elements such as seasonal extreme weather

conditions, access to health care is becoming increasingly challenging.

This is further complicated by the lack of a structured national transportation

network between islands/atolls and Male’. Moreover, the transport network

that has evolved over the years is mostly oriented towards developing links

between the islands and their atoll capital, and between atolls and Male’. In

some situations, even links between the islands and the relevant atoll capital

are not well developed whenever the capital is deemed too far, and links have

preferentially been developed with Male’. Links between atolls are often weak;

therefore, it can be more convenient and cheaper to refer patients to the

tertiary hospital in Male’ rather than a regional hospital, even if the latter is

geographically closer to the island. This situation is generating huge pressure on

IGMH.

The following map of Maldives (Figure 2) illustrates the logistical challenges in

providing equitable health care, due to the unique geographical nature of the

country.

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Figure 2. Map of Maldives

Demographic factors

The Population and Housing Census of Maldives 2006 indicated that the

population was 298 968, with an annual average population growth rate of

1.6%. The estimated mid-year population for 2013 was 335 000. Figure 3

provides population projections from 2013 to 2018.6 The population growth rate

shows a trend towards stabilization, mostly due to a decline in birth and death

rates during the first years of the last decade. However, it should be noted that

birth rates have been slowly increasing in recent years and a discrete rise in

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population growth rate is envisaged when the predominant young population

reaches reproductive age.

Figure 3. Projected mid-year population, 2013–2018 (Data source:

Department of National Planning (DNP))

The general shape of the population pyramid indicates that the age and sex

composition of the population is similar to other developing countries, with a

relatively small proportion in the older age categories and a larger proportion in

the under-20 years of age categories. Women in the reproductive age group

(15–49 years) comprise 30% of the population; furthermore, 36% of the

population are aged 10–24 years. This demographic pattern is likely to remain

unchanged (Figure 4).

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Figure 4. Projected population pyramids for Maldives, 2014 and 2018

(Data source: DNP)

According to the Household Income and Expenditures Survey 2009–2010,

estimated average household size is 6.7 people per household (7 in Male’ and

5.9 in atolls). Around 35% of the population is based in Male’ and 65% in the

atolls. Rapid and unplanned urbanization of Male’ has seen one of the world’s

smallest capitals double its population within 16 years, from 55 000 inhabitants

in 1990 to 152 000 in 2006, making it by far the most densely populated island

in the country and one of the world’s most densely populated capitals. Much of

this is a result of inward migration from other atolls, due to the availability of

better education, social services and job opportunities in Male’.6 Table 1 details

the population distribution among atolls.6

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Table 1. Population distribution among atolls

Atoll Population

( Census 2006 )

North Thiladhunmathi (HA) 13 495

South Thiladhunmathi (HDh) 16 237

North Miladhunmadulu (Sh) 11 940

South Miladhunmadulu (N) 10 015

North Maalhosmadulu (R) 14 756

South Maalhosmadulu (B) 9 578

Faadhippolhu (Lh) 9 190

Male’ Atoll (K)* 119 134

North Ari Atoll (AA) 5 776

South Ari Atoll (ADh) 8 379

Felidhu Atoll (V) 1 606

Mulakatholhu (M) 4 710

North Nilandhe Atoll (F) 3 765

South Nilandhe Atoll (Dh) 4 967

Kolhumadulu (Th) 8 493

Hadhdhunmathi (L) 11 990

North Huvadhu Atoll (GA) 8 262

South Huvadhu Atoll (GDh) 11 013

Fuvahmulah (Gn) 7 636

Addu Atoll (S) 18 026

(Data source: DNP)

*Includes the population of Male’, the capital of Maldives

Out of 1190 islands in Maldives, only 194 are considered as administrative

islands with inhabitants. There is only one island (Male’) with a population over

25 000, whereas there are 72 islands with a population less than 500 (Table 2).

Due to economies of scale, providing equitable health services for this widely

dispersed population is challenging.

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Table 2. Concentration of population in islands

Population size range Number of islands

Administrative islands 194

<500 72

500–999 66

1 000–1 999 42

2 000–4 999 12

5 000–24 999 3

25 000 and over 1

Non-administrative islands*

100–399 111

(Data source: DNP)

*Non-administrative islands include tourist resorts (104), industrial islands and islands used

for other purposes.

Epidemiological factors

The health status of the Maldivian people has improved in the past few decades.

In 1977, life expectancy at birth was 46.5 years. In 2011, it was 73 years for

males and 75 years for females. In 1990, 34 babies per 1000 live births died

before reaching the age of one. In 2011, the comparative infant mortality rate

was 9 per 1000 live births, with a majority of the infant deaths occurring in the

neonatal period. The maternal mortality ratio declined from about 500 per

100 000 live births in 1990 to 56 per 100 000 live births in 2011, and the MDG

target of reducing maternal mortality ratio by half by 2015 has already been

achieved.7 Table 3 provides key health indicators for Maldives, while Figure 5

illustrates the trends in some of these indicators.

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Table 3. Key health indicators for Maldives, 2012

Indicator Maldives

South-

East Asia

average

Global

average

Life expectancy at birth (years)

77 67 70

Under-5 mortality rate (per 1 000 live births)

11 55 51

Maternal mortality ratio (per 100 000 live

births) 56 200 210

Prevalence of tuberculosis (per 100 000

population) 44 271 170

Prevalence of HIV (per 100 000 population)

8.4 189 499

(Data source: MOHG and WHO)

Figure 5. Trends in infant mortality rate, under-5 mortality rate

and maternal mortality ratio, 2001–2011 (Data source: MOHG)

Vector-borne diseases such as dengue and chikungunya are reported

throughout the year, with epidemic seasonal outbreaks. In 2011, there was a

dengue outbreak with a total of 2909 cases and the highest number of deaths

reported in a year to date. Table 4 shows the incidence of selected

communicable diseases in 2010 and 2011.7

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Table 4. Incidence of selected communicable diseases

Disease 2010 2011

Acute respiratory infections 92 553 113 834

Viral fever 54 718 70 608

Acute gastroenteritis/diarrhoea 18 509 18 979

Conjunctivitis 4 606 2 878

Dengue fever 920 2 909

Typhoid fever 137 61

Scrub typhus 61 91

Mumps 50 69

Leprosy 7 13

(Data source: MOHG)

In general, Maldives is in transition from the burden of communicable diseases

to a higher burden of noncommunicable diseases. In 2011, the leading cause of

death was other forms of heart disease (Table 5). 7

Table 5. Ten leading causes of mortality, 2011

Cause Number of deaths

Other forms of heart disease 130

Ill-defined and unknown causes 120

Ischaemic heart diseases 113

Cerebrovascular diseases 108

Chronic lower respiratory diseases 80

Hypertensive disease 79

Malignant neoplasms 78

Accidental injury 37

Diabetes mellitus 36

Renal failure 28

(Data source: MOHG)

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Sociocultural factors

Maldivian culture is extensive and varied. Cultural aspects influence both the

health system in general, and the health workforce specifically.

Among Maldivians, the level of attractiveness of health-related occupations

varies depending on the occupation. ”Low level” jobs are perceived as

unattractive by youth; health attendants and similar positions, for example, are

mainly held by expatriate workers. The explanations given include the low

remuneration and lack of social recognition and prestige for these jobs. Young

people prefer to remain unemployed rather than apply for these jobs, and their

families support this behaviour. Youth and their families expect an office job

(preferably within a tourist resort) or a Civil Service job after completion of

their ordinary or advanced-level qualifications, or a job in a shop at worst. A job

in a health facility where they would have to give hygiene-related care is not

considered as desirable.

The global predominance of female nurses is taken to the limit in Maldives,

where no male nurses are present among the entire workforce. Nursing being

considered a woman’s profession leads to young Maldivian men not applying for

nursing training. Despite a global tendency towards feminization of the medical

profession, in Maldives it remains being a predominantly male profession.6

However, there are some women among the predominantly male community

health workers (CHWs).

As in other Islamic countries, Maldivians are in general reluctant to accept

health care requiring the physical examination of a woman by a male

professional. Such cultural and religious factors pose additional challenges for

staffing, particularly in smaller health posts in remote areas.

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Expectations about access, availability and quality of health services are very

high among the Maldivian population. Even on the smaller islands (less than

500 inhabitants), there is a strong demand for a full-time medical doctor, as

well as a secondary grade school and full-time teacher. This aspect might have

been induced by politically-influenced decisions and promises made to the

population in the past.

Political factors

The Executive of the country is the President, who is both Chief of State and

Head of Government. The Cabinet of ministers is appointed by the President.

There are 16 ministries at present. The Legislative is a unicameral entity called

the People's Council or People's Majlis (77 seats; members are elected by direct

vote to serve 5-year terms). A new Government was elected in November 2013.

In Maldives, an ongoing decentralization process has devolved power to 20 atoll

councils, including some public health responsibilities, as stated in Chapter 4,

article 24 of the Decentralization of the Administrative Division of the Maldives

Act: “The island council shall provide the following municipal services to the

people of the island: … (f) In accordance with the Law of the Maldives, provide

primary health care and other basic health security services”. The atoll council

plays a coordinating, guiding and supportive role in managing the islands’

development and guiding stakeholders in planning development programmes.

The MOHG has kept its central role in the delivery of health care services and

has maintained a partnership with local councils to provide primary health care

services. However, the Decentralization Act does not provide a definition or

define the services comprised under the term ”primary health care”. The MOHG

felt the need for a strong network linking health centres with other levels of the

health care system, and has kept them under the MOHG umbrella to avoid

fragmentation of government-funded health services.

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Economic factors

Maldives ranks among the lower segment of the middle-income countries.

However, its gross domestic product (GDP) has grown at an annual rate of

6–8% over the past two decades, driven by investments in tourism and the low

level of inflation. Significant progress has also been achieved in human and

social development over the past two decades, lifting Maldives from its status

as one of the 20 poorest countries in the 1970s to one that shares the

characteristics of a lower-middle income country today, with a GDP of MVR

29 936 million (US$ 1 941 million) and a per capita GDP of US$ 6 067.8

However, Maldives is now facing an alarming escalation in health care costs,

which places a burden on the Government. The population profile and disease

patterns have caused the Government to greatly reconsider its financial

commitment to the health system. This has led to a blueprint for health reform

focusing on the most pressing issues, particularly the introduction of a

mandatory universal national health insurance scheme (Aasandha) at the

beginning of 2012. Furthermore, in recent years the country’s financial situation

has deteriorated. According to an assessment by the International Monetary

Fund (IMF) in 2012, the economy is slowing, inflation has risen, and the fiscal

position is in a critically vulnerable state. Overestimated revenues and

underestimated expenditures are creating a significant budgetary gap (11% of

GDP estimated for 2013) which will need to be financed, creating major

concerns about debt sustainability. This might have an impact on the health

care sector if two of the avenues proposed by the IMF – reducing Aasandha

coverage and reducing the public wage bill – were to be applied.9

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Internal factors affecting HRH

Health care delivery system

Public sector

The MOHG is the main health service provider in Maldives. The health system is

organized into a broad three-tier referral system, comprising the national

referral hospital, regional and atoll hospitals, and health centres. There are 20

hospitals (excepting IGMH) in the country. Hospitals are graded (level 1–4)

depending on capacity, population covered and workload.

With 275 beds, IGMH delivers tertiary-level curative care and serves as the

central referral hospital for the entire country. In 2011, 37% of hospital

inpatient care was provided by IGMH, with all other health facilities in the

country accounting for 63%.1 Similar proportions were observed with regards to

the provision of outpatient care. This over-utilization of the national referral

hospital highlights serious issues related to the implementation of the referral

system, the overall management of the national health system, and the health-

seeking behaviour of the population.6

There are six regional hospitals providing secondary-level curative services and,

through public health units, implementing preventive health programmes. The

regional hospitals provide inpatient and outpatient care, diagnostic services and

specialty care, as well as emergency care for patients referred from other

centres. Hulhumale Hospital near the capital is considered a level 1 hospital but

due to its close distance to IGMH doesn’t function as a regional hospital.

The utilization of regional hospitals is variable (Table 6). While the reasons

affecting utilization could be multifactorial, a statistically significant high

correlation (r=0.63) was found between the bed occupancy rate and the

26

distance to Male’ from each regional hospital. This suggests that population

living more near to the capital tend to use IGMH as their main hospital service.

Table 6. Utilization of regional hospitals, 2011

Regional hospital Outpatients Inpatients Bed occupancy rate

HDh. Kulhudhuffushi 48 357 2 911 67

R. Ugoofaaru 34 017 1 444 60

M. Muli 12 752 411 6

L. Gan 31 908 2 303 26

GDh. Thinadhoo 37 430 2 649 41

S. Hithadhoo 51 786 3 572 74

(Data source: DNP)

There is one atoll hospital in each atoll, except in those that have a regional

hospital (level 1). Services provided at atoll hospital level include maternal and

child health services, immunization services, nutrition, DOTS providers

(tuberculosis), primary emergency services, and laboratory and other diagnostic

services. In addition to these basic services, they are equipped to provide major

surgery under regional and general anaesthesia, comprehensive emergency

care, obstetric care (including caesarean sections and family planning services),

and radiology. Atoll hospitals also provide essential medicines through

partnerships with private pharmacies operating in the health facilities.

Atoll hospitals provide services to a population of 10 000–15 000, depending on

geographical access. Atoll hospital bed ratio for 2011 was 11.3 per 10 000

population, with a bed occupancy rate of less than 50% (Table 7).

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Table 7. Utilization of atoll hospitals, 2011

Hospital Inpatient Outpatient Bed occupancy

rate

HA. Dhiddhoo 22 677 1 108 9

Sh. Funadhoo 10 428 547 33

N. Manadhoo 12 476 674 22

B. Eydhafushi 17 613 648 29

Lh. Naifaru 25 951 1 014 41

AA. Rasdhoo 6 735 221 10

ADh. Mahibadhoo 18 340 592 20

V. Felidhoo 3 955 109 5

F. Nilandhoo 10 110 456 23

Dh. Kudahuvadhoo 14 851 615 11

Th. Veymandoo 16 024 765 17

Ga. Villigilli 19 961 698 30

Gn. Fuahmulah 33 851 2 174 35

Hulhumale Hospital 1 368 133 24

(Data source: DNP)

Regional hospitals, or atoll hospitals in atolls with no regional facility, coordinate

and supervise the work of health centres in the different islands of each atoll.

There are 121 health centres in Maldives, graded as level 1–4 depending on the

population covered, patient load, and average bed occupancy based on

inpatient bed capacity. Each atoll has between 3 to 13 health centres serving a

population ranging from 500–10 000, with an average of 1 health centre per

2300 population. Even the smallest island population is served through a public-

28

financed health-care facility. About 85% of health centres are staffed by at least

one medical officer (levels 1–3). The remaining 15% (level 4) are staffed by

trained health workers such as nurses, midwives and CHWs.

Health centres provide a comprehensive service in all areas of primary health

care, including maternal and child health services, immunization services,

communicable diseases, noncommunicable diseases, DOTS providers

(tuberculosis), primary emergency services and laboratory services. Some

health centres have provision for simple medical and surgical care, and basic

emergency obstetric care. However, space for inpatient care is limited.

Level 4 health centres were previously referred to as health posts. There is a

total of 27 level 4 health centres; each is primarily equipped with 1–2

observation beds, a consultation room and office space. Level 4 health centres

provide basic health care and preventative services. They are staffed by trained

CHWs, nurses, midwives and support staff. CHWs play an important role in

these settings in the absence of medical officers. They have clinical, managerial

and public health roles with a mandate to strengthen the link between the

community and the health system. A level 4 health centre serves a population

of less than 500.

The utilization of health centres is low. The reasons appear to be multifactorial,

with several management-related issues. Health centres and atoll hospitals lack

proper maintenance, and the 2013 costing survey indicated that these health

facilities frequently experience shortages in supplies, drugs and equipment.

There has been a continuing depletion of experienced professionals at all levels.

Human resources are inadequate in number to provide the basic package of

services. In addition, there is a high turnover of staff at all levels, which has a

negative impact on continuity of care. Expensive medical equipment is

29

sometimes dispatched to health centres with no adequate training provided to

health care workers.10

Another major issue is the absence of a gatekeeping referral system. The

population often seek specialist care without any referral from a general

practitioner or CHW, leading to important inefficiencies, overloaded tertiary-care

services and patients being at risk of receiving inappropriate care. This health-

care-seeking behaviour is nowadays extended to areas where traditionally mid-

level cadres were successfully delivering high-quality care at the primary health

care level; for example, maternal and neonatal care, including normal deliveries

provided by midwives. There is now a growing expectation that even

uncomplicated deliveries should be attended by an obstetrician and that a

paediatrician should attend to each and every newborn.

There is a small 21 beds military hospital (Sehahiya Hospital) in Male staffed

with around 57 workers including 22 specialist and 7 general doctors providing

services to all uniformed bodies (MNDF, police, customs, etc.) and their families’

Private sector

There are three private hospitals in Maldives: ADK and Medica hospitals located

in Male’, and the International Medical and Diagnostic Centre located in

Hithadhoo, Addu Atoll. There are 99 private medical clinics of small capacity: 10

eye clinics; 2 ear, nose and throat clinics; 13 dental centres; and 290

dispensing pharmacies. The majority of private clinics are located in Male’.

These private facilities incurred 11% of total health care expenditure in 2011.6

In terms of HRH, the private sector comprises of 357 employees of whom 33

are doctors, 54 are nurses and 244 are pharmacists. However, dual practice

(public/private) is common in Maldives.

30

Alternative medical system

The MOHG is attempting to register traditional healers in order to have a better

record of the overall health system in Maldives. It is estimated that there are

more than 200 traditional healers in the country, with an average of 2 per

island. However, only 50 of these practitioners have registered to date, all of

whom are located in Male’. There are traditional healers who charge fees for

their services, but there is no mechanism to get them registered. Practitioners

working informally or in shadow clinics are difficult to count, since there is no

tracking mechanism for them. However, the general opinion is that this

category is much larger than the 50 practitioners currently registered. The

category comprises native traditional practitioners and practitioners of Indian

and Chinese medicine.

HRH situation and trends

The Maldivian health service system has a high dependence on expatriate

health professionals, especially doctors and nurses. Although there has been a

gradual increase in the number of local health professionals, the expansion of

health services, high turnover of staff and limited capacity to locally produce

health professionals has led to reliance on international recruitment.

In 2010, there were 525 doctors in Maldives with a ratio of 1 doctor per 610

persons; however, 81% of these doctors were expatriates. The number of

registered nurses totalled 1868, of which 55% were expatriates. At the

community level, there were 805 paramedical workers in the public sector, 278

CHWs, 313 family health workers and 214 traditional birth attendants, all of

whom were local.6

31

The major HRH challenges that the Maldivian health system faces include

inequitable distribution, overall shortages of HRH, retention of staff in the

islands, and inadequate skill mix and competencies.

Availability

Although the size of the health workforce has gradually increased in Maldives,

the health service system is facing HRH shortages in island facilities, particularly

shortages of doctors and nurses. At the time of writing, there were no official

staffing standards approved in Maldives. The number of positions approved by

the CSC is used as a proxy for planning purposes. Overall vacancy rate is 43%,

with 40% in hospitals (excepting IGMH) and 55% in health centres (see Tables

8 and 9). IGMH is the best staffed health facility in the country with a 17.6%

vacancy rate. However, there are key specific cadres that are in low availability

such as anaesthesiologists (60% vacancy rate) or paediatricians (50%); see

Annexes 4, 5 and 6.

Table 8. Vacancy rates by cadre in hospitals, levels 1–4

Total posts

approved

Total occupied Total gap Vacancy rate

Specialist doctors 186 77 109 59%

General doctors 100 94 6 6%

Nurses 1 051 666 385 37%

CHWs (all categories) 70 5 65 93%

Regional/atoll

Manager 20 8 12 60%

(Data source: MOHG)

32

Table 9. Vacancy rates by cadre in health centres, levels 1–4

Total posts

approved

Total occupied Total gap Vacancy rate

General doctors 114 110 4 4%

Nurses 956 545 411 43%

Midwives 141 0 145 100%

CHWs (all categories) 182 26 156 86%

Laboratory technicians 114 68 46 40%

(Data source: MOHG)

Due to the absence of a medical school in Maldives and the limitations in

production capacity of other health professionals in local academic institutions,

the number of local health workers is limited. Therefore, there is a strong need

to rely on the foreign health workforce. This high dependence on expatriates

poses important challenges in regard to the management of the Maldives HRH

system.

Distribution

About 90% of health professionals were employed in the public sector in 2010,

an increase since 2005 (from 85%). The distribution of health staff by

geographical location in 2010 showed that 27% of medical and paramedical

staff (including nurses) were deployed in Male’, whereas 72% were deployed

in the atolls. The relation between population and HRH in Male’ and the atolls

is shown in Table 10. The ratio of population to doctors was 507:1 in Male’

compared to 683:1 in the atolls. However, the ratio for nurses was much more

equitable (168:1 in Male’ compared with 173:1 in atolls).6

It is worth noting that the HRH density in Maldives (as defined by number of

doctors, nurses and midwives per 1000 population) is 7.5 per 1000, which falls

well above the minimum recommended by WHO of 2.28 per 1000.

33

Table 10. Ratio of population to health workers

Profession

Maldives

(pop = 320 000)

Male’

(pop = 110 998)

Atolls

(pop = 209 012)

All doctors 609:1 507:1 683:1

General doctors 970:1 1 047:1 933:1

Specialists 1 641:1 982:1 2 549:1

Nurses 171:1 168:1 173:1

(Data source: DNP)

Table 11 illustrates the increasing preference of local health workers for working

in Male’ rather than the atolls. The proportion of local doctors working in the

atolls decreased from 7.3% in 2005 (14 out of 190) to 1.2% (4 out of 324) in

2012. The situation for nurses and other cadres, despite following a similar

trend, is not as acute: in 2005 the proportion of nurses working in the atolls

was 61.4% (312 out of 508), while in 2012 it was 48.8% (627 out of 1282).

Table 11. Number of local health workers employed in the atolls

Profession

2005 2009 2010 2012*

Expat Local Expat Local Expat Local Expat Local

All doctors 176 14 317 0 300 6 320 4

General

doctors 124 12 237 0 218 6 248 3

Specialists 52 2 80 0 82 0 72 1

Nurses 196 312 719 481 639 569 655 627

Laboratory

technicians 50 27 79 41 94 41 113 40

CHWs 0 186 0 228 0 276 0 N/A

Family

health

workers

0 340 0 283 0 313 0 N/A

Data sources: DNP (2007–2012), * MOHG (2012)

34

At present, the majority of local staff prefer a posting in Male’, and the

majority of expatriates are sent to rural areas (small islands). There is currently

no health sector specific policy on internal staff movement, other than that of

the CSC and MOHG. The MOHG is unable to accommodate staff transfer

requests from the islands to Male’, and from lower service levels to higher

levels due to the difficulty in filling the vacancies of technical positions.

Recruitment and retention

The number of new Maldivian doctors (MBBS) and specialists registered with the

Maldives Medical Council (MMC) has seen an exponential increase in the past

few years. However, there is only a marginal increase in the number of local

doctors working in the public sector, from 85 in 2005 to 98 in 2012. This

indicates that local doctors have been drained from public health services,

either to the private sector or to other countries. Looking to the number of

requests to the MMC for certificates of good standing – which is a mandatory

requirement for registration with medical councils in other countries and

therefore a proxy to intention to emigrate – there has been an increase from 3

in 208 to 20 in 2013 (Figure 6).

There is a high staff turnover in the islands, particularly among doctors and

nurses. The causes of low retention, given by professionals appointed in these

facilities, are (besides those derived from the remote and isolated environment)

derived from weaknesses of the health system, such as poorly equipped and

maintained facilities and shortages of drugs and medical materials.

35

Figure 6. MMC registrations and requests for certificates of good

standing (Source: MMC)

The lack of essential services such as schools, banks and other facilities is also

reported as a disincentive to accept appointments in remote islands. Some

expatriate professionals also report hostile relationships with local populations,

particularly when there are complications or fatal outcomes. A small population

generates a professionally unchallenging environment, particularly for younger

professionals. Most international staff use appointments in remote areas as a

stepping-stone, to acquire experience which helps them to move somewhere

else. Salaries in neighbouring countries have also increased in the last few

years, which make Maldivian wages less attractive for foreign professionals.

In the past, nurses trained at FHS were immediately recruited to island health

facilities due to the existence of service bonds. However, despite tuition fees

still being highly subsidised by the Government, there are currently no bonding

contracts and direct recruitment of nurses is not possible anymore. Therefore,

graduate nurses need to apply for posts advertised through the official

recruitment system. Compared to nurses, most positions for CHWs are based in

0

5

10

15

20

25

0

10

20

30

40

50

60

70

Go

od

Sta

nd

ing C

ert

ific

ate

s

Re

gis

tra

tio

ns

MMC registrations and Good Standing

Certificates

MBBS Specialists Good standing certificate

36

island health facilities with a limited number in Male’; hence, compared to

other cadres, their retention in remote settings is higher.6

Skill mix and competencies

Despite national health policy aiming at a primary health care orientation of the

health system, Maldivian curative services absorb a large proportion of the

health workforce. The demand for curative health services has been strongly

promoted among the population during the past decades. The health system

initially centred on primary health care during the 1950s to the 1990s, but then

shifted towards a more curative focus with the expansion of infrastructure and

the introduction of doctors in atolls and islands. The limited capacity of the HRH

system in producing technical cadres to provide curative services, and the

subsequent increasing reliance on international recruitment of professionals

from different countries and with different levels of education, together with

some weaknesses in quality assurance mechanisms, poses a challenge to the

quality of care provided.

HRH policy

The Health Master Plan 2006–2015 is the principal planning document of the

Government’s health sector.11 One of its national health goals revolves around

the health workforce including HRH production, recruitment, attraction and

retention, HRH development and provision of appropriate skills. However, due

to several constraints, the HRH component of the plan has not been fully rolled

out.

The national decentralization programme posed important challenges to the

country’s health system. During 2009 to 2012, the Government decided to

devolve health care provision by constituting public health facilities into public–

37

private entities. Health services corporations were established in eight regions,

and all responsibility for public hospitals and health centres was transferred to

these without specific regulatory frameworks. As a result, health services and

HRH were managed differently by each corporation. However, in 2012, the

decentralization was reversed and the assets and responsibilities for health

service delivery were returned to the MOHG. Health workforce management was

transferred back to the CSC and the Central Ministry of Health. These changes

have sometimes left health workers disoriented and unclear about their roles

and reporting channels. Several issues related to HRH derive from these radical

changes such as salary structure, incentive schemes, career advancement etc.,

and are currently being addressed.

HRH education

Pre-service training of health professionals

Pool of applicants for pre-service training programmes for health

professionals

In Maldives, school education for future potential trainees in the health

professions remains an area of concern. Only a small percentage of students

meet the English language, mathematics, science skills and knowledge

requirements to pursue health professions training programmes, with most

students from the atolls not having the opportunity to pursue these subjects in

their local schools. Thus, their background does not sufficiently prepare them to

access nursing, medical or paramedical education. Even some of those who do

have the opportunity to pursue science subjects up to the General Certificate of

Examination Ordinary Level (GCE O-Level) do not have the minimum

competencies required,4 often having to undertake foundation courses to bridge

the gap. The pass rates at GCE O-Level are poor, although improvements have

been achieved in recent years (Table 12). In 2011, only 55% of candidates

38

passed three or more subjects, which is the minimum entry requirement for

degree courses offered by the FHS.6

Table 12. Pass rates at GCE O-Level examinations

2009 2010 2011

Candidates Passed % Candidates Passed % Candidates Passed %

Total 7 137 2 282 32 6 920 2 404 35 6 432 3 538 55

Male’ 1 902 1 054 55 1 894 1 017 54 1 802 1 045 58

Atolls 5 235 1 228 23 5 026 1 387 28 4 630 1 379 30

(Data source: DNP)

There is a sharp fall in enrolment for higher secondary education (21%). The

main reason for this is that only 38 out of the 225 schools in the country offer

education at that level12 (see Table 13).

Table 13. Number of students sitting GCE A-Level examinations

2005 2006 2007 2008 2009 2010 2011

Total 833 1 006 1 024 1 325 1 194 1 338 1 515

Male’ 729 703 780 774 741 847 816

Atolls 104 303 244 551 453 491 699

(Data source: DNP)

Registration, accreditation and quality assurance of health professionals’

education

Doctors need to register with the MMC in order to practice. For expatriates,

approval for registration with MMC requires previous registration with the

medical council in their respective country.13,14 The MMC is currently planning to

implement licensing exams for all doctors wanting to practice in Maldives.

Registration of nurses is under the responsibility of the Maldives Nursing

Council, which defines and regulates the criteria to enter into the profession.

39

Registration of all other health professionals is under the responsibility of the

Maldives Board of Health Sciences.

Doctors registered by the MMC to date represent over 300 medical schools

worldwide, leading to a wide variation in the quality of training standards. The

MMC does not screen applicants according to the medical school from which

they graduated. The majority of doctors registered under the MMC to date are

graduates from India, followed by Pakistan and China (Figure 7). A total of 212

expatriate health professionals were recruited in 2012 and 222 in 2013

(excluding December).

Figure 7. Total number of medical graduates registered under MMC (up

to June 2013) (Data source: MMC)

40

In-country training of health professionals

The FHS is the only public institution for training of health professionals in the

country. It has its main campus in Male’, plus there are campuses in four other

locations around the country: GDh. Thinadhoo, HDh. Kulhudhuffushi, S.

Hithadhoo and Laamu. Peripheral campuses have great potential to improve the

attraction and retention of health professionals to atoll and island health

facilities. Theory-related training and the initial training on practical procedures

takes place within the premises of FHS. For clinical practice and fieldwork

students are sent to IGMH, regional hospitals and health centres.

The pre-service training programmes conducted by FHS are:

Advanced Certificate in Counselling (2 semesters)

Advanced Certificate in Nursing (2 semesters)

Advanced Certificate in Pharmacy (2 semesters)

Advanced Certificate in Primary Health Care (3 semesters)

Bachelor of Primary Health Care (8 semesters)

Bachelor of Nursing (8 semesters)

Diploma in Medical Laboratory Technology (4 semesters)

Diploma in Nursing (5 semesters)

Diploma in Pharmacy (4 semesters)

Diploma in Counselling (4 semesters)

Certificate in Social Services (1 semester)

41

Advanced Diploma in Critical Care Nursing (6 semesters)

Advance Diploma in Midwifery (6 semesters)

MSc in Nursing (4 semesters)

MSc in Public Health (4 semesters), starting from January 2014

New courses planned by the FHS include a BSc in Medical Laboratory

Technology as well as an Advanced Diploma in Physiotherapy. Table 14 shows

the number of students enrolled and graduated from the different courses

offered by FHS.

In the past decade, 4947 students have enrolled in training courses at FHS with

an output of 1836 health professionals graduated in the same period. Enrolment

and graduation capacity has gradually increased in key health professions, such

as nursing and laboratory technology. To carry out this considerable workload in

the training of health professionals for the country, FHS has several strengths

including purpose-built infrastructure, flexible articulation between training

programmes, availability of a well-equipped state-of-the-art clinical skills

laboratory and, most importantly, very dedicated staff working under

constraints.

Curricula for the courses offered are coordinated by the Curriculum Committee

at FHS and developed by FHS staff in consultation with professional bodies,

such as Maldives Nursing Council and the service sector. Draft curricula have to

be approved by the professional bodies and then submitted to the Academic

Board of the Maldives National University. The Committee comprises

representatives from the MOHG, IGMH, FHS, and private health sector.

42

Table 14. Number of students enrolled and graduated in different courses offered by FHS

(Source: FHS 2013)

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

TO

TA

L

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

TO

TA

L

Advanced Certificate in Counselling 2 semesters 17 23 24 19 22 11 22 19 22 179 11 11 10 16 8 11 - 11 9 87

Advanced Certificate in Family Health (disrupted in 2009) 2 semesters 21 14 21 42 17 1 - - - 116 0 14 23 15 - - - - 52

Advanced Certificate in Midwifery (disrupted in 2006)1 semester (full) or

2 semesters (part)18 16 - - - - - - 34 0 12 - - - - - - 12

Advanced Certificate in Nursing 2 semesters 83 58 41 38 93 151 77 123 68 72 804 83 48 41 34 - 66 64 59 25 47 467

Advanced Certificate in Pharmacy 2 semesters 19 15 23 10 16 10 28 31 76 228 19 13 23 15 7 4 - 9 9 32 131

Advanced Certificate in Primary Health Care 3 semesters 26 36 28 29 57 86 46 51 39 40 438 0 23 20 12 14 26 22 16 - 13 146

Advanced Certificate in Social Services Work (being adapted) 2 semesters 0 35 18 14 - - 67 0 27 - 15 - - 42

Advanced Certificate in Traditional and Complementary Medicine (disrupted) 2 semesters 15 11 - - - - - - 26 8 11 - - - - - - 19

Bachelor of Health Sciences in Health Services Management (disrupted) 4 semesters - 38 15 1 - - 54 - - 16 2 - - 18

Bachelor of Nursing - Conversion (phased out) 7 14 1 14 12 12 20 80 7 13 0 12 - - 32

Bachelor of Primary Health Care 8 semesters - - - - - 41 41 - - - - - - 0

Certificate III in Pharmacy (disrupted) - - 14 - - - 14 - - 12 13 - - 25

Certificate III in Social Services Work 1 semester 20 1 0 - - 22 43 16 0 - 4 - 14 34

Diploma in Critical Care Nursing (upgraded to Adv. Diploma) 10 - - - - - 10 - - - - - - 0

Diploma in Medical Laboratory Technology 4 semesters 6 31 29 49 48 50 54 71 65 73 476 0 19 14 7 11 12 12 7 9 16 107

Diploma in Midwifery (upgraded to Adv. diploma) 8 15 0 41 9 25 34 27 159 5 15 0 15 8 - 10 20 73

Diploma in Nursing 6 semesters 79 38 74 84 120 148 135 194 169 258 1299 0 0 24 15 22 23 55 23 42 67 271

Diploma in Nursing - Conversion (phased out) 23 19 7 29 13 32 62 37 110 332 0 16 7 10 11 2 26 1 14 87

Diploma in Pharmacy 4 semesters 12 0 17 5 - - 12 46 10 - - 5 - - - 15

Diploma in Primary Health Care 5 semesters 37 25 35 32 29 25 20 35 31 49 318 0 0 13 20 22 30 41 7 24 49 206

Diploma in Primary Health Care - Conversion I (phased out) 1 semester 6 4 9 11 16 4 9 8 27 94 6 4 - - - - - - 10

Diploma in Primary Health Care - Conversion III (phased out) 2 semesters 5 0 28 27 2 2 25 89 2 - - - - - - 2

MSc Nursing - - - - - - 0 - - - - - - 0

MSc Public Health - - - - - - 0 - - - - - - 0

COURSES Duration

Enrolled last 13 years Graduated last 13 years

43

Challenges faced by the FHS include the availability of clinical training facilities,

faculty development and infrastructure facilities. Currently, the FHS has to

depend on IGMH (275 beds) and regional hospitals (30–50 beds in 6 hospitals)

to provide clinical skills training. However, these facilities are inadequate to

cater for the training requirements of all the courses conducted at FHS. Already

the facilities are overloaded and cannot accommodate more than 5–6 students

in each ward during a shift. In addition, some of the procedures are not

available to students during their clinical rotation period, which is a matter of

particular concern in the area of midwifery. For this reason, internships are

often arranged overseas.

There are only 40 full-time academics available at FHS, resulting in a teacher to

student ratio of 1:20 with only three teachers in the senior lecturer category.

Part-time teachers and visiting lecturers share a considerable proportion of the

teaching load. There is a need for training of teachers in clinical supervision,

some specialty areas such as diagnosis and treatment, pharmacology, health

promotion, health service management, counselling skills and different areas of

medical laboratory techniques.

Currently, there is no regular staff development programme at FHS. However,

some faculty get upgraded by pursuing their own postgraduate education

through other means (currently there are three staff with postgraduate

qualifications in medical/health professions education)

Research activity is very limited at FHS, which has important connotations for

academic excellence and also on the availability of local evidence to support

decision-making in the health sector. It is expected that, with the recent launch

of new masters-level courses, research activity will increase considerably.

44

Collaboration between the FHS and MOHG is an important area for

improvement. Introduction of new courses at FHS needs to be linked with the

human resource requirements of the health sector. The link between production

of health professionals at FHS and the needs defined by the dynamics of the

health labour market requires strengthening.

Training for general medical doctors

All Maldivian doctors are trained abroad. Thirty four students have been sent for

training in the last 6 years, with support from the MOHG and international

partners (see Table 16). The Department of Higher Education provides soft

loans for students willing to pursue their MBBS abroad. In 2012, 95 applications

were accepted for funding. The places currently available are at medical schools

in Nepal and Bangladesh. The official figure for students who are self-funded is

not available, but it is estimated that over 100 self-funded medical students are

currently undergoing medical training overseas. Due to problems in enforcing

bonding mechanisms and the lack of information in this regard, it is difficult to

precisely calculate educational outputs. However, the number of registrations

with MMC, which is a good proxy with no great significance as an educational

indicator but useful for labour market analysis, shows a sharp increase in

medical education outputs. The number of Maldivian MBBS graduates registered

was 9 in 2011, 23 in 2012 and 46 in 2013.

Maldives National University and several international organizations have

expressed interest in establishing a medical school in Maldives. In 2013, WHO

supported the development of standards for medical education,16 proposing two

basic models that could be considered: either a government initiative linked to a

centre of excellence abroad, or through direct foreign investment. However,

there are several challenges to establishing a medical school, including the lack

of faculty (around 75 faculty staff would be required as per WHO assessment,

but currently there are no trained medical teachers in Maldives), lack of

45

infrastructure, issues regarding availability of clinical material and case mix

(IGMH: 275 beds) and an estimated cost of approximately US$ 12 million. A

medical school entirely owned, technically and financially operated and

supported by Maldives alone, is not viable at this time and hence will not be

considered further.

Postgraduate training of health professionals

The FHS is the main institution providing postgraduate and post-basic training

programmes for health professionals in the country. FHS offers postgraduate

education in midwifery, critical care, family health, pharmacy, social work and

traditional and complementary medicine. New courses planned by FHS include a

master’s degree programme in nursing and more recently, a master’s degree

programme in public health in collaboration with the University of Sydney,

Australia.

The MOHG provides scholarships for health professionals to obtain overseas

postgraduate qualifications. Table 15 shows the number and expected year of

return for postgraduate trainees (other than medical) sent for overseas training

by the MOHG.

Table 15. Expected year of return for postgraduate trainees (other than medical) sent for training overseas by the MOHG (Source MOHG)

Course Level 2013 2014 2015 2016 2017

Food Science Masters 1 - - - -

Human Science (Sociology) Degree 1 - - - -

Bachelor of Science Degree - 1 - - -

Psychology (Hons) Degree - 1 - - -

Biomedical Engineering Degree - - 2 2 -

Economics (Hons) Degree - - 1 - -

46

The number of registrations of new Maldivian specialists with the MMC (20, 18

and 14 in 2011, 2012 and 2013, respectively) exceeds the figures reported by

the MOHG (7, 2 and 6), probably due to self-funded students (Tables 16 and

17).

All Maldivian medical postgraduates are trained overseas. Currently there are

placements available in Nepal and Bangladesh. Memoranda of Understanding

are being finalized with Myanmar and Sri Lanka. Support is also provided by

multilateral stakeholders such as WHO through its scholarship programme.

Table 16. Postgraduate medical education enrolment supported by MOHG and international partners since 2000 (Source MOHG)

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 TOTAL

Medical doctors

Anaesthetists 3 yrs - - - 1 - - - - - - - - - - 1

Dermatologist 3 yrs - - - - - - - 1 1 1 - - - - 3

Dermatologist (Dip) 1 yr - - - - - - 1 - - - - - - - 1

Obstetrician/gynecologist 3 yrs - 2 1 1 1 1 1 - 1 - - 1 1 - 10

Ophthalmologist 3 yrs - - - - - - 1 - - - - - - - 1

ENT specialist 3 yrs 1 - 1 1 - - - - - - - - - - 3

Orthopaedician 4 yrs 1 - - 1 1 - - 1 - - - - - - 4

Pediatrician 3 yrs 2 1 1 1 1 - - 1 1 - - 2 - - 10

Physician (internal medicine) 3 yrs 2 2 1 4 - - - 1 1 - 2 - - - 13

Surgeon 3 yrs - - 1 2 - - - 1 - - - 1 - 1 6

Psychiatrist 3 yrs - - - - - - - - - - - 1 - - 1

Radiologist 4 yrs - - - - 1 - - 1 - - - - - - 2

Microbiologist 3 yrs 1 - 2 - - - - - 1 - - - - - 4

Pathologist 3 yrs - 1 - 1 1 - - - 1 - - - - - 4

Haematologist 4 yrs - - - - - - - - - - - - - - 0

Cardiologist 3 yrs - - - 2 - - - 1 - - - - - - 3

Endocrinologist 0

Neurologist 0

Urologist 0

Nephrologist 3 yrs - - - - - - - - - - 1 - - - 1

Neurosurgeon 0

Cardiothoracic surgeon 3 yrs - - - - - - - - - 1 - - - - 1

Gastroenterologist 0

Emergency medicine 4 yrs - - - - - - 1 - - - - - - - 1

Respiratory medicine 3 yrs - - - - - - - - - 1 - - - - 1

ProfessionalsYears of

training

enrolled last 13 years

47

Table 17. Postgraduate medical students graduated since 2000 (Source MOHG)

Continuous professional development

Continuous professional development (CPD) programmes are designed to

support workers to achieve the competencies required for optimal job

performance. A comprehensive approach towards CPD should be based on

country-specific health needs. The ultimate goals of the programme are to

reassure patients and the public that health professionals remain competent,

confident and compassionate throughout their career and to improve patients’

care, outcomes and satisfaction by setting standards for good practice.18 CPD

programmes also have important connotations for the motivation of health

workers.

TOTAL 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 TOTAL

Medical doctors

Anaesthetists 1 1 - - - - - - - 1

Dermatologist 3 - - - - 1 1 - 1 3

Dermatologist (Dip) 1 - - - - - - - - 0

Obstetrician/gynecologist 10 1 1 - 1 - - - 1 4

Ophthalmologist 1 - - - 1 - - - - 1

ENT specialist 3 - - - - - - - - 0

Orthopaedician 4 - 2 - - - 1 - - 3

Pediatrician 10 - - 1 3 1 - 1 - - - - 2 - - 8

Physician (internal medicine) 13 - - - 2 2 1 1 - - - 1 - - 2 9

Surgeon 6 - 1 1 - - 1 1 - - - 1 - - - 5

Psychiatrist 1 - 1 - - - - - - - - - - - - 1

Radiologist 2 - - - - - - - - 1 - - 1 - - 2

Microbiologist 4 - - - 1 - 2 - - 1 - - - 1 - 5

Pathologist 4 - - - - - - 1 1 - - - 1 - - 3

Haematologist 0 - 2 - - - - - - - - - - - - 2

Cardiologist 3 - - - - - - - - - - - 1 - 1 2

Endocrinologist 0 0

Neurologist 0 0

Urologist 0 0

Nephrologist 1 - - - - - - - - - - - - - - 0

Neurosurgeon 0 0

Cardiothoracic surgeon 1 - - - - - - - - - - - - 1 - 1

Gastroenterologist 0 0

Emergency medicine 1 - - - - - - - - - - 1 - - - 1

Respiratory medicine 1 - - - - - - - - - - - - - 1 1

Graduated last 13 years

Professionals

48

CPD in Maldives is neither systematic nor planned. Local workshops and

seminars are generally conducted within the MOHG and IGMH on an ad hoc

basis. The FHS also conducts in-service training workshops and seminars, and

invites nominations from the MOHG and IGMH. MOHG/IGMH personnel may be

funded by the MOHG or nominated for funding by other agencies, for

participation in short-term training-related activities out-of-country.

Opportunities for CPD are further limited due to the scattered nature of the

islands, together with the limited regular transport links between them. As a

result, in smaller hospitals and health centres on remote islands, health workers

remain professionally isolated and have less access for further study or career

advancement. Given this fact, distance and online learning could be considered

as a feasible option for delivery of CPD.19

HRH management systems

Recruitment and bonding

The MOHG is in charge of recruiting doctors, nurses and other cadres for each of

its facilities.

There are no official staffing standards defined at the moment. After the HRH

decentralization of 2009–2011, different corporations used different standards

to staff their health facilities. The CSC and MOHG are currently in the process of

addressing this issue. All staff records have been now transferred to the CSC

database. The next step should include a definition of staffing standards by the

MOHG and approval from the CSC.

49

For the purpose of defining HRH requirements in this strategy, positions

officially approved for each health facility by the CSC have been accepted as the

staffing norms (see Annex 3).

According to the bonding system currently in place, doctors or other

professionals who obtained financial support from the Government are bound to

return and work in the public sector for a minimum of 10 years. However,

implementation of this policy is ineffective. This problem is not restricted to the

health sector, but affects most areas of the Government where education

abroad is required.

The immediate consequence of this problem is human resource losses to the

system, with an increasing number of bonded health professionals – particularly

doctors – leaving the country, as indicated by the increasing number of requests

to the MMC for certificates of good standing. Professionals either repay the bond

or simply leave without paying, since there is no effective legal mechanism to

manage the breach of bonding contracts. Some cases have been sent to the

Prosecutor General’s Office but there has not been any prosecution engaged so

far.

Only a small number of doctors opt to work in the islands. In the absence of an

effective bonding system or other legal obligation, added to an ineffective

incentive system, the attraction of doctors to work in the islands even for a

short time period is very limited.

Bonding for nurses was implemented in the past through government

scholarships. Nurses with an island background were returning to work in their

home islands after graduation. However, since 2012 when the FHS became

independent from the MOHG, the students have had to pay 13% of the tuition

fees themselves with the Government still subsidising the rest (87%), but

50

bonding contracts were discontinued. As for doctors, most nurses choose to

work in Male’ instead of going to the islands.

Expatriates are recruited on a 1-year contract with a 3-month probation period.

After the first year, they have a performance assessment after which (if passed)

they are renewed on yearly basis. Performance assessment is undertaken by

medical managers at atoll facilities. If any problem is found during the

assessment, doctors are sent to the Health Service Division at MOHG central

level for further assessment. Problems identified are often not related to clinical

standards, but more to issues related to their adaptation to the new

environment. Sometimes problems are due to conflicting personal relations, in

which case redeployment to another location can often solve the issue. When

problems identified are related to the quality of care provided, cases are

referred to the MMC for further technical assessment and action.

There are some issues concerning recruitment and deployment of expatriate

professionals. These include financial and legal matters between private

recruitment agencies and the MOHG; issues related to immigration, such as

work permit cancellations; delayed payments; and, withholding of identification

papers of the recruited expatriate professionals. The MOHG is currently

changing its policy and discontinuing the use of recruitment agencies. Instead,

the department of international recruitment will get in touch with professionals

directly, either via word-of-mouth between colleagues or through other

institutions. Some of the agencies previously working for the MOHG are also

facilitating contact. International recruitment is done on a discretionary and

case-by-case basis. No batch recruitment is currently being undertaken.

Currently, there are no restrictions regarding from which medical school

applicants graduated or quality assurance mechanisms other than the

administrative requirements established by the MMC. The MMC plans to

51

introduce a licensing examination in 2014. At present, foreign applicants are

only requested to provide documentation, including proof of graduation and

completion of internship; testimonial from the dean of the medical school where

the professional graduated; postgraduate medical degree (for specialist

applications); certificate of good standing from their original medical council;

certificate of registration with any other licensing authority; English language

proficiency qualification (e.g. level 7 IELTS or TOEFL) and a letter of verification

of expertise from an employer (e.g. MOHG for applicants to public sector).

As mentioned above, retention of foreign doctors in the atolls and islands is

often poor, with 50% not staying beyond 1 or 2 years. Part of the problem is

unrealistic expectations of the applicants about the living conditions and health

service standards that they will find in Maldives. Poor information provided by

the employer prior to registration is probably the main reason behind this.

There are no induction programmes for new employees in place; however, the

MMC is currently developing guidelines and information packages to address

this problem. In the future, a better organized international recruitment process

will allow for more elaborated and interactive programmes to help professionals

manage their expectations in a more realistic way, adjust better to their new

environment and obtain a better general experience. This will most probably

have a positive impact on the retention of these professionals.

Remuneration

During decentralization, terms of employment with regard to work site, hours

and benefits (including remuneration) were different from one corporation to

another, even for the same categories of health professionals and for the same

jobs. This was especially the case for expatriate general medical doctors and

specialists.

52

With the full integration of the health workforce into the Civil Service, the basic

salary structure will be similar for all health care workers in the same

categories. Neighbouring countries have increased salaries for medical

professionals in the last few years, which has weakened the income differential

factor that was previously attracting professionals to Maldives. For doctors, a

cabinet decision was made that a new salary structure would be implemented

from January 2014. Nurses’ and other professionals’ salary scales will also be

revised soon. Given the great burden that the wage bill contributes to the

overall health budget (around 79%), the financial impact of relying so heavily

on an expatriate workforce will need to be evaluated and alternative options

may have to be found soon.

Currently, take-home pay is different between the local and expatriate health

workforce. Expatriates get a migration allowance, utility allowance, and food

allowance whereas local health workers do not, which may have a negative

impact in terms of job satisfaction for local professionals.

Although there is a small monetary allowance for doctors working in the islands,

it is not enough to constitute an effective incentive to attract these professionals

to work in peripheral facilities. There is a need to develop an effective incentive

policy, including both financial and non-financial rewards.

Income received in the public sector is slightly lower compared to the private

sector, but not significantly so. Since there are a limited number of private

services, income differential is unlikely to be the only factor draining doctors

and nurses from the public to the private sector. Other factors more related to

the work environment, health service management and leadership may also

contribute, such as equipment and medical supply availability, or consistent

supervision.

53

Non-financial incentives/working conditions

The health service system in the islands faces difficulties in balancing peoples’

expectations and the availability of health resources. While there are high

expectations regarding the quality of services provided, the availability of health

workforce, particularly paramedical and support staff, is often limited. Vacancy

rates among medical officers is relatively low (around 5%) compared to that for

nursing positions in hospitals (37%), or CHWs in health centres (86%). As

mentioned above, there are no effective non-monetary incentives in place to

attract and retain the health workforce in the islands.

Housing provision

Housing is provided at some regional hospitals for some health staff. In island

facilities, atoll hospitals or health centres, housing is not available. For those

who do not originate from the islands where they are working, an

accommodation allowance (MVR 1500) and a living allowance (MVR 1800) are

provided. However, these amounts do not cover the relatively high cost of life in

the islands.

Drugs and medical supply provision

During the decentralization period, procurement of drugs and medical

equipment was devolved to the corporations. Weak management capacity often

led to inefficiencies, with stock ruptures and weak supply occurring in some atoll

and island facilities. This affected patients’ care-seeking behaviour, increasing

self-referral to higher levels of the system, often to IGHM in Male’.

Furthermore, these problems have caused job dissatisfaction among the health

workforce on the islands.

Recently, the MOHG has decided to establish a central procurement unit which

is expected to contribute towards a more cost-effective, timely, and reliable

54

medical procurement system. This in turn should have an impact on access to,

and utilization of, health services by local populations and improve staff morale

and professional esteem.

Workplace environment

Health workers’ perceptions regarding working in the islands are mixed. It is

often reported that it is a relaxing experience with the benefits of good

teamwork. Some health workers have a good relationship with patients and

their families, and can provide a holistic approach to care. For those who are

interested in preventive care and health promotion, sometimes there are

opportunities to carry out research or specific projects (often funded by

international agencies) which help expand their professional experience.

However, working in the islands has several drawbacks. Isolation from family,

friends and professional groups are among the main issues. In some islands,

the population is small and most of the patients seen at health services suffer

from common diseases. This lack of exposure to challenging clinical conditions

can make working in the islands professionally unattractive. Cultural and

language barriers may also contribute to an uncomfortable working atmosphere.

Poor managerial support from central and regional levels and inadequate

orientation for new employees also add to the problems. Sometimes, the lack of

an effective grievance and complaints policy affects the safety of foreign

professionals, who are threatened by patients or their families when

expectations are not satisfied or unexpected outcomes occur.

Career development

Career advancement is better for professionals working in the secondary and

tertiary levels. After working for 3 years in hospitals, doctors are automatically

promoted to senior medical officer which, following specialization, can lead to

different grades of consultancy categories. Doctors working in primary health

55

care reach their professional ceiling after promotion to senior doctor, following 3

years of work.

Other health professionals, such as nurses and CHWs, have limited career

advancement possibilities. Despite nurses having had a well-structured career

path in the past, recent changes introduced with corporatization and then by

recentralization processes have created some regulatory loopholes that

currently do not support their professional advancement. Similarly, in the past,

CHWs’ career structure ranked from assistant CHW, CHW, to senior CHW (the

highest position). A new CSC policy defines career progression within each

subcategory, greatly limiting the professional career span and potential for

promotion. A committee has now been established at the CSC to revise career

structures for all cadres within the health services, which is expected to be

completed during 2014.

Family aspect

Family-related reasons often explain health workers’ unwillingness to work in

atoll and island health services. Job availability for spouses, education for

children and lack of services are reasons often given by health workers for not

taking up rural positions. Professionals with an island background are also often

attracted to live in Male’ and reject rural positions for similar reasons.

Migration from the islands to Male’ has greatly increased in the last decade.

Performance management

Performance appraisal was introduced by CSC in 2009 to improve the quality,

productivity and efficiency of health workers. Each individual sets their own

targets, and these are to be reviewed and assessed by supervisors annually.

However, the appraisal is not linked with any salary increase or career

promotion. The supervisors rarely use the appraisal results to score individuals

56

for the purpose of competition for a higher position. The general feeling is that

high and poor performers are treated equally.

Quality assurance

The quality assurance of health services is the responsibility of the Quality

Assurance and Improvement (QAI) section which is under the Health Service

Division. Its roles include development of standards and guidelines, health

facility inspections and service audits, management of service complaints,

services registration and quality improvement. Some clinical guidelines are

currently being developed to assist each health facility in quality improvement.

They are to be implemented at all health facilities when they have been

approved by the MOHG. Due to staff limitations within the QAI section, regular

inspections are mostly limited to private health facilities in Male’. For the same

reason, and due to transport limitations, there are no regular inspections of

island health facilities. A quality improvement plan for the islands was

developed during the decentralization period. The plan stated that all regional

hospitals should designate quality improvement officers to oversee, inspect and

ensure quality assurance for all health facilities in each region. However, the

plan was never rolled out.

As the majority of care providers are expatriates, trained from various medical/

nursing schools and exposed to health systems with different standards, the

quality of services is difficult to assure. At each hospital, the hospital manager

and a specialist doctor provide technical support to lower-level health facilities.

Four selected hospitals offer telemedicine consultations to lower-level health

facilities in 39 islands; however, the telemedicine programme has not yet been

fully implemented. Professional councils also play a role in assuring the

standards of practice of individual professionals. However, their role in

inspecting and auditing is limited, as there are shortages of staff in the councils.

57

Policies for referrals are in place. Health centres refer patients to atoll/regional

hospitals or IGMH depending on the severity of the case and the need for

specialised care. However, lack of gatekeeping at the lower levels of the system

has made these policies ineffective, leading to self-referral of patients (often to

IGMH in Male’) which greatly contributes to inefficiencies and misuse of

services.

The new Government is trying to address some of the quality assurance issues

presented above.

HRH information and evidence for decision-making

Timely and accurate HRH information is essential for planners, health-care

providers and managers to make decisions on HRH effectively. Despite data

about the health workforce being relatively available in Maldives, information is

not generated, managed and used appropriately. Fragmentation of the existing

Health Information and Research Section (HIRS) is partially a consequence of

the strong administrative orientation of the Human Resources Department (e.g.

data are generated exclusively for administrative purposes such as calculation

of overtime, payroll, etc. rather than for strategic workforce planning). Data are

often dispersed among different sections and institutions, and there is no

consolidated database that permits a comprehensive data analysis. The process

of decentralization had a strong negative impact on the HIRS, as much of the

information flow was disrupted when workforce management was devolved to

the corporations.

There is currently a new plan to develop a Maldives Integrated Health

Information System (MIHIS) by the HIRS, under the Policy and Planning

Division. The aim of the proposed MIHIS is to promote evidence-based decision-

making in the health sector to strengthen capacity on health information

58

production, use and management and to ensure an appropriate reporting

system. The MIHIS is a uniform information system which is intended to include

all individual, independent, public and private entities of the health sector, as

well as external authorities with service links to the health sector, through

developmental phases. The system is intended to serve both the operational

management of the health system as well as its strategic development. In a

first phase, the plan envisions to undertake a system requirements assessment,

to develop the required software for implementation in 21 hospitals between

July 2014 and December 2015. The cost of this first phase is around MVR 13

million; however, funding for the plan is not yet secured. Initially the system

will concentrate on individual information (e.g. health service activity,

morbidity, mortality, etc.) and it is not planned to include HRH information. In a

second phase, different specific modules including HIRS will be developed. In

order to bridge the existing gap in HRH information to allow for strategic

workforce decision-making, a transitory solution needs to be found.

Besides HRH data, health workforce evidence and knowledge are the main

contributors to appropriate decision-making. There is very limited health system

and services research undertaken in Maldives. Therefore, decisions are often

made ad hoc or based on anecdotal evidence.

The HIRS under the Policy and Planning Division has a mandate to support

research and production of evidence for policy-making. However, understaffing

and an unclear functional role of the Section in regard to research leave this

area relatively neglected. In 2013, a research agenda was developed through

an interactive process with all sections of the MOHG. However, there is no

research topic proposed for the area of HRH. The agenda is currently not being

implemented, mainly due to overall limited research capacity in the country and

lack of specific funding.

59

HRH leadership

Current HRH coordination mechanism and champions

The prime responsibility for the health workforce in Maldives lies with the

MOHG. However, coordination with other involved stakeholders such as the

CSC, Ministry of Education, professional councils and Ministry of Finance and

Treasury to address HRH issues at the national level is often weak. At the

MOHG, there is a Human Resource Development and Management Committee

(HRDMC) chaired by the Permanent Secretary and with representatives from all

departments and support divisions. The Secretariat, based in the Human

Resources Department, meets on weekly basis. Although the Committee is

mandated to carry on important functions, such as HRH policy development and

strategic planning or HRH management and development, the existing functions

are mostly limited to solving day-to-day issues. This adds to the problem

already identified at the Human Resources Department regarding the narrow

focus of their operations. The main constraints preventing the HRDMC from

being fully operational in the fields of HRH policy, planning and development are

the limited technical capacity of the Committee members, together with a lack

of technical assistance and lack of time.

Currently, a joint working committee from the MOHG and CSC has been

established to develop a new salary structure for the health workforce. This is

an ad hoc committee that has been set up by CSC to provide information to

define the salary structure. The committee comprises MOHG officials and

health-care providers from different cadres.

Coordination between the public health sector and training institutions was very

strong in the past when FHS was under the responsibility of the MOHG. Since

responsibility for the FHS was transferred to the Maldives National University,

interaction between both institutions has weakened with the MOHG being just a

60

member of the commission in charge of the student selection process. This

weak coordination has important connotations in terms of adjusting the

production of health workers to the needs of the public health system.

There are four professional councils under the MOHG: MMC, Maldives Nursing

Council, Maldives Board of Health Sciences and Maldives Board of Traditional

Medicines. The Secretariat of these councils lies in the Regulatory Boards and

Councils entity overseen by the Directorate General of Health Services. The

roles of each council are to regulate their respective health professionals

working in the country, regulate/approve new curriculum at the universities,

and register expatriates. Currently, only pharmacists are requested to sit a

licensing examination. However, all other professional councils plan to introduce

this measure soon. Although the roles of the professional councils are to

monitor and ensure the standard of practice of their respective health

professionals, currently they have some limitations in carrying out this task

mainly due to a lack of qualified staff and financial means.

HRH stewardship

All HRH management functions previously performed by the health service

corporations are now centrally coordinated by the MOHG. However, some of the

functions are still delegated to atoll level.

Excepting IGMH, all health managers in Maldives are non-clinical health

professionals. Most of them are from a public health background with long

experience of working in the health system. Most health managers are not

formally trained; they have learned management skills through their past

experience. Only a few of them have attended formal training courses. The

medical officers in charge are appointed to oversee and manage the clinical

work. The need to improve managerial skills in HRH is strongly perceived. It is

61

realized that effective management skills could contribute to improving

efficiency and quality within the health system.

A Bachelor of Health Sciences in Health Service Management used to be

provided by FHS, but it was discontinued after the introduction of the Maldives

National Qualifications Framework in 2009 and is currently being revised.

Although the Civil Service Training Institute provides courses in administration

and management, the curriculum is not specifically for health managers. There

are human resource management courses provided by private education

institutions, but none is specific to the health sector.

HRH partnerships

Maldives has a relatively long history of collaboration with international agencies

and foreign governments/entities in relation to HRH. The main HRH

collaborative issues are production and development. The lack of training

institutions for some key disciplines has forced Maldives to seek collaborations

with neighbouring countries. The need to recruit internationally has also

triggered some bilateral agreements. Multilateral international partners also

play a role in supporting HRH production and development, particularly for

postgraduate education and continuous professional development. Being a

middle-income country, Maldives is often not eligible for concessional loans.

However, the country is still receiving aid from various donors.

At country level, the main stakeholders within the health sector involved in HRH

(besides the MOHG) are FHS, MMC, Maldives Nursing Council, Maldives Board of

Health Sciences, and representatives of the private sector. The private sector

has expanded to play an important role in HRH. There are three private

hospitals, two of which are located in Male’, and some small clinics. The impact

of the private sector on the availability of HRH varies, depending on categories.

For specialists, the impact is more significant with 171 specialists in the public

62

sector and 24 in the private sector (14%), while the proportion of private-sector

general practitioners and nurses is low. Crucial stakeholders from other sectors

include the Ministry of Finance and Treasury, Ministry of Education, CSC and, to

some extent, local authorities.

Public and private partnership for HRH in Maldives is strong in the case of

pharmacists. Except for the pharmacy operated by the State Trading

Organization (a Government-shared private entity), all pharmacies in the

country are within the private sector. These private pharmacies have signed

Memoranda of Understanding to provide pharmacy services for a fixed number

of hours per day and to pay a rent for their premises. All 21 hospitals in the

country have similar organization for the delivery of pharmaceutical services.

Owing to the remote and small population in many islands, and the need to

ensure access to essential medicines and preventive health services, the

Government supports women’s or youth committees to establish community

pharmacies. However, the programme is implemented inconsistently.

There are some civil society-based initiatives contributing to service provision

for vulnerable populations most directly affected by shortage of HRH. For

example, the Aged Care Maldives (Manfaa Clinic) provides empowerment and

awareness programmes for the elderly and their caregivers, and the Care

Society conducts community-based programmes for persons with disabilities.

These partnerships, although having informal linkages with the MOHG, have

played an important role in increasing non-formal HRH to provide health

services in the remote or island areas, as well as enabling community

participation.

63

HRH financing

The health workforce absorbs a considerable share of the health budget, which

is generally consistent with the pattern of spending in developing countries. The

total spending on HRH was estimated at almost MVR 174 million in 2011

(National Health Accounts 2011). Total spending on the health workforce as a

percentage of the recurrent health budget is in the order of 79%, falling within

the normal 60–80% range for developing countries;10 however, it is relatively

higher than other countries in the region.

HRH financing in Maldives is resourced from tax revenues managed by the

Ministry of Finance and Treasury. Most staff salaries are paid centrally.

Nevertheless, financing recurrent health facility expenses, including payment of

salaries to some specific support cadres, is decentralized to the atolls and

sometimes to the islands.

HRH requirements

To provide services that are high quality, cost-effective and accessible to the

people, HRH availability needs to match with HRH requirements in terms of

numbers, skills and distribution.

The HRH requirement projections are calculated based on two scenarios.

Scenario 1: Achieving staffing standards.

Scenario 2: Reducing the number of expatriate health workers.

Given the high number of HRH required, the period planned for achieving these

scenarios goes beyond the period covered by this strategic plan. It greatly

depends, on the one hand, on the capacity of the Government to allocate

enough funds or to generate enough investment from the private sector and/or

64

international partners to support students to graduate in health

disciplines/educational programmes not available in the country; and, on the

other hand, on scaling up the existing capacity of the FHS to produce cadres

locally.

As previously stated, there are no official staffing standards approved in

Maldives at present. This analysis has used positions approved by the CSC for

each level of health service delivery as the standard (see Annex 4).

Lack of information about losses in each cadre (attrition) has made it impossible

to introduce this variable into the analysis. In order to balance this limitation,

rounding up of calculations has been applied.

Scenario 1: Achieving staffing standards (Tables 18 and 19)

This scenario aims at reducing vacancy rates and calculates the number of

health workers required to achieve current staffing standards in each specific

cadre. As mentioned above, vacancy rates are relatively high, particularly in

some key cadres. It is proposed that in order to fill vacancies, Maldivian

resources are produced either locally or abroad rather than recruiting

internationally, to reduce dependency on expatriates and increase workforce

sustainability in the long run.

In line with Government priorities for the orientation of the health system

towards primary health care, it is recommended to first concentrate on

producing those cadres that are most needed in peripheral facilities (island, atoll

and regional facilities) and to continue relying on expatriates for specialities that

are available only at the central level (IGMH). Maldivian doctors willing to go for

specialization should adjust their speciality choice to the needs of the country,

with financial support offered by the Government, moving exclusively to those

specialities that are most required. Priority should be given to internal medicine

65

specialists, surgeons, anaesthetists, obstetricians, paediatricians and

orthopaedic surgeons. Other priority cadres include nurses, midwives, CHWs,

laboratory technicians, radiographers and physiotherapists. Managers should

also be included as a top priority, as currently most senior and mid-level health

management positions are vacant with a potentially severe negative impact on

health service efficiency.

Due to a lack of information about cost and programmes for some of the

medical specialities, assumptions were made about the cost and duration of

training; however, for other cadres it was impossible to calculate costs.

The cost of achieving staffing standards (Table 18) for priority cadres by

training Maldivians is approximately MVR 350 million (US$ 22.5 million) and it

could be achieved in approximately 11 or 12 years (Table 19).

66

Table 18. Cost of training priority cadres to reach staffing standards (Source: MOHG)

#

Posts

NEEDS TO

REACH SS

TRAINING

LOCAL/

ABROAD

YEARS OF

TRAINING COST OF TRAINING (MVR)

TOTAL FUNDING REQUIRED

(MVR)

TOTAL FUNDING REQUIRED

Exchange Rate(US$) 15.42

4 Physician 15 A 3 799 877.19 11 998 157.82 778 090.65

5 Orthopaedic Surgeon 8 A 3 799 877.19 6 399 017.51 414 981.68

9 Radiology 1 A 3 799 877.19 799 877.19 51 872.71

14 Gynaecologist 21 A 3 799 877.19 16 797 420.95 1 089 326.91

15 Anaesthesiologist 18 A 3 799 877.19 14 397 789.39 933 708.78

16 Surgeon 15 A 3 799 877.19 11 998 157.82 778 090.65

17 Paediatrician 15 A 3 799 877.19 11 998 157.82 778 090.65

22 General Practitioner (Senior Medical

Officer/Medical Officer /Registrar) 32 A 6 1 630 541.64 52 177 332.48 3 383 744.00

23 Dentist 5 A 5 1 670 544.00 8 352 720.00 541 680.93

26 Radiographer 7 A 3 796 580.00 5 576 060.00 361 612.19

30 Physiotherapist 11 A 26 months 13 078.11 143 859.17 9 329.39

33 Laboratory Technician 45 A 26 months 13 337.55 600 189.80 38 922.81

37 Nurses 865 L 4 164 680.00 142 448 200.00 9 237 885.86

38 Nurse Midwife 141 L 3 146 226.33 20 617 913.00 1 337 089.04

41 Regional Health

Administrator/Director/Manager 19 L 4 25 876.00 491 644.00 31 883.53

42 Assistant Manager / Deputy Manager 13 L 3 16 006.00 208 078.00 13 494.03

44 Community Health Worker 221 L 4 198 382.67 43 842 569.33 2 843 227.58

TOTAL 348 847 144.28 22 623 031.40

67

Table 19. Proposed calendar to achieve staffing standards for key cadres

POST NEED

S

TIME

years

TRAINING RECRUITMENT

20

14

20

15

20

16

20

17

20

18

20

19

20

20

20

21

20

22

20

23

20

24

20

14

20

15

20

16

20

17

20

18

20

19

20

20

20

21

20

22

20

23

20

24

Physician 15 3 3 3 3 3 3

3 3 3 3 3

Orthopaedic

Surgeon 8 3 2 2 2 2

2 2 2 2

Radiology 1 3 1

1

Gynaecologist 21 3 3 3 3 3 3 3 3

3 3 3 3 3 3 3

Anaesthesiologist 18 3 3 3 3 3 3

3 3 3 3 3 3

Surgeon 15 3 3 3 3 3 3

3 3 3 3 3

Paediatrician 15 3 3 3 3 3 3

3 3 3 3 3

Medical Officer 32 6 8 8 8 8

8 8 8 8 8

Pharmacist 2 5 2

2

Radiographer 7 3 2 2 2 1

2 2 2 1

Physiotherapist 11 26 m 3 3 3 2

Laboratory

Technician 45 26 m 8 8 8 8 8 5

Nurses 865 4 110 110 110 110 110 110 110 110

110 110 110 110 110 110 110

Nurse Midwife 141 3 25 25 25 25 25 25

25 25 25 25 25 25 25

Senior Manager 19 4 5 5 5 4

5 5 5 4

Assistant Mgr. 13 3 5 5 3

5 5 3

CHW 221 4 35 35 35 35 35 35 21

35 35 35 35 35 35 21

Red cells: categories for which calculations could not be made due to lack of information.

68

Scenario 2: Reducing the expatriate health workforce (Tables 23 and 24)

Maldives, as most health systems in the world, needs to rely on expatriates to

complete its health workforce. However, current levels of international

recruitment are proving unaffordable. As described earlier, there are other

problems attached to international recruitment than just the financial element.

This scenario envisions a progressive reduction of the expatriate workforce and

their replacement with Maldivians. Emphasis should be put on those cadres for

which local education is available, such as nurses, midwives and laboratory

technicians, by scaling up their production. However, increasing production will

not solve the problem by itself. Other measures such as improvements in

attraction and retention, strengthening management and leadership, or

improving working environment will need to be in place to ensure that good

quality Maldivian health workers remain in the public health system working

productively and efficiently.

As mentioned in the previous scenario, in order to be consistent with the

primary health care orientation of the Maldivian public health system, cadres

working at the primary and secondary levels (e.g. health centres and

atoll/regional hospitals) should be given priority.

The total cost of training Maldivians to fully replace the existing expatriate

health workforce (health professionals only) would be around MVR 662 million

(Tables 20 and 21). The timing of replacement will largely depend on the

funding available for training local resources.

69

Table 20. Cost of training medical doctors (general and specialists) to replace all expatriates

HOSP HCs Th Cr IGMH TOTAL

MEDICAL DOCTORS 447,813,401.33 29,041,076.61

1 Cardiologist 0 A 3 - -

2 Urologist 0 A 3 - -

3 Pulmonologist 0 A 3 - -

4 Physician 7 7 A 3 799,877.19 5,599,140.32 363,108.97

5 Orthopaedic Surgeon 4 1 5 A 3 799,877.19 3,999,385.94 259,363.55

6 Gastroenterologist 1 1 A 3 799,877.19 799,877.19 51,872.71

7 Neurologist 0 A - -

8 Emergency Medicine 0 A - -

9 Radiology 1 1 A 3 799,877.19 799,877.19 51,872.71

10 Pathology 2 2 A 3 799,877.19 1,599,754.38 103,745.42

11 Maxillofacial Surgery 0 A - -

12 Orthodontics 0 A - -

13 Ophthalmologist 3 1 4 A 3 799,877.19 3,199,508.75 207,490.84

14 Gynaecologist 17 17 A 3 799,877.19 13,597,912.20 881,836.07

15 Anaesthesiologist 18 4 22 A 3 799,877.19 17,597,298.14 1,141,199.62

16 Surgeon 9 1 10 A 3 799,877.19 7,998,771.88 518,727.10

17 Paediatrician 15 1 16 A 3 799,877.19 12,798,035.01 829,963.36

18 Dermatologist 0 A - -

19 Cardio surgeon 0 A - -

20 ENT Surgeon 2 1 3 A 3 799,877.19 2,399,631.56 155,618.13

21 Psychiatrist /Clinical Physiologist 1 2 3 A 3 799,877.19 2,399,631.56 155,618.13

22 Medical Officer (MBBS) 90 110 2 28 230 A 6 1,630,541.64 375,024,577.20 24,320,660.00

#

COST OF

TRAINING

(MVR)

TOTAL FUNDING

REQUIRED (MVR)

TOTAL

FUNDING

REQUIRED

(USD) 15.42

EXPATRIATES

YEARS OF

TRAINING

TRAINING

LOCAL/ABROADPosts

70

Table 21. Cost of training other health professionals to replace expatriates (Red cells: information about cadres not available)

HOSP HCs Th Cr IGMH TOTAL

OTHER HEALTH PROFESSIONS (Includes health managers) 215,577,457.22 13,980,379.85

23 Dentist 5 3 8 A 5 1,670,544.00 13,364,352.00 866,689.49

24 Dental Hygienist /Dental Assistant 1 1 A 265,526.67 265,526.67 17,219.63

25 Pharmacist 0 A - -

26 Radiographer 25 11 36 A 3 796,580.00 28,676,880.00 1,859,719.84

27 Radiographer Assistant 0 A - -

28 Radiographer Trainee 0 A - -

29 Optometrist 0 A - -

30 Physiotherapist 6 7 13 A 26 months 201,664.40 2,621,637.23 170,015.38

31 Physiotherapist Assistant 0 A - -

32 Physiotherapist Trainee 0 A - -

33 Laboratory Technologist 53 60 1 12 126 A 26 months 205,665.04 25,913,794.99 1,680,531.45

34 Laboratory Assistant 0 L 2 100,456.33 - -

35 EEG/EMG Technician 0 A - -

36 Speech Therapist 0 A - -

37 Nurses 316 276 3 283 878 L 4 164,680.00 144,589,040.00 9,376,721.14

38 Nurse Midwife 1 1 L 3 146,226.33 146,226.33 9,482.90

39 Dietician 0 A - -

40 Counsellors 0 L - -

41 Health Manager (Director) 0 L - -

42 Assistant Manager / Deputy Manager 0 L - -

43 Administrative Officer 0 L - -

44 Community Health Worker 0 L - -

45 Family Health Officer 0 L - -

#

COST OF

TRAINING

(MVR)

TOTAL FUNDING

REQUIRED (MVR)

TOTAL

FUNDING

REQUIRED

(USD) 15.42

EXPATRIATES

YEARS OF

TRAINING

TRAINING

LOCAL/ABROADPosts

71

The HRH situation in Maldives is determined by a complex interplay of factors

including the effects of globalization and changes in the epidemiological,

socioeconomic, cultural and political situation, as well as internal factors

governing HRH such as health financing, policy, management and training. The

HRH challenges in relation to the shortage of local health professionals,

inequitable distribution, high turnover rate of health staff in the islands, and

inappropriate skill mix and competencies, need to be addressed. This situation

analysis found the following contributory factors.

1. Inadequacy of HRH management policies and support to provide equitable

distribution with an appropriate skill mix, or attract and retain HRH in the

islands.

2. Lack of policies and regulatory frameworks for quality assurance towards an

enhanced health workforce performance and productivity, and absence of

HRH database and evidence-based information to advocate policies.

3. Pre-service and in-service training outputs are not aligned with the needs of

the health service system in terms of number and quality.

4. Limitations of leadership capacities to adequately perform the essential HRH

management and monitoring functions.

5. Lack of a multi-stakeholder coordination mechanism for policy dialogue,

consultation, planning, implementation and monitoring of HRH outcomes.

6. Lack of national policy and plan to enhance the HRH resources from the

national budget as well as other resources.

72

SECTION C: Health workforce strategic plan

Vision

A competent and sustainable health workforce in the Maldives health system,

based on primary health care to deliver quality health services to the people.

Mission

To produce, deploy and retain a well-trained, competent, gender-balanced,

well-supported and motivated health workforce in sufficient quantity with the

appropriate skill mix. To gradually increase the number of local health

professionals to ensure delivery of equitable, cost-effective, efficient, good

quality, and ethically and culturally acceptable health services to all inhabitants

of Maldives.

In line with the national health policy recognizing the right of the population to

quality health care, provided by a pool of qualified and competent health

workers, with a right mix in accordance to the local health needs.

Prime attention is given to national health and development priorities, within

the regional and global health agenda.

Guiding principles

In developing the HRH Strategic Plan 2014–2018, due consideration has been

given to the following guiding principles.

Availability: Increasing opportunities and openings for needs-based pre-

service training for sufficient quality of skilled domestic health workforce with a

required skill mix.

73

Accessibility and equity: Ensuring access to health services for all, through

the equitable distribution of competent, supported and well-motivated HRH at

all levels of the health care system.

Acceptability and gender equality: Culturally-appropriate health services

promoting related strategies for ethics, respect for sociocultural values and

equal opportunities for both women and men.

Quality: Adequate quality standards in training and services to deliver

acceptable health care to the population, with high professional standards in

accordance with global health developments.

Feasibility: Interventions to be achievable within the expected resource

envelope and integrated within the overall health sector planning and

development framework, taking into account other external factors and support

processes.

Cost-effectiveness: The selected strategies and interventions should be the

best value for money.

Sustainability: Developing investment and interventions that ultimately lead

towards a sustainable and indigenous health workforce.

Health systems approach: Strategies and interventions to be mainstreamed

and integrated with other components of the health system, based on a primary

health care approach.

Responsive to current and projected health needs: Guided by the evidence

and through rigorous scientific situation analysis, strategies should respond to

current and projected health needs.

74

Accountability and transparency: Accountability and transparency to be

maintained throughout the implementation of the plan through the ownership

and leadership of the national Government.

National stewardship: National capacity, particularly the HRH Department of

the MOHG, should play a central role as a coordinating entity with enhanced

capacity for management and leadership.

Partnerships and collaboration: Promoting a policy dialogue and consultative

process for strong partnerships with developmental partners, the private sector,

professional associations and other related stakeholders to strengthen HRH

planning, financing, implementation and monitoring.

Public and private partnership: The potential of the private sector to be fully

mobilized towards health inputs, with a focus on HRH development.

75

Strategies and interventions

Strategic line 1: Policy, leadership and management systems

Strategic

objective 1

Strengthening the systems and structures to effectively

manage and support HRH; improving policies, regulatory

frameworks and institutions, and fostering leadership

capacities to adequately perform the essential HRH

management and monitoring functions.

Rationale

The main challenge for HRH in the Maldives health system is

the difficulty in attracting and retaining HRH in the islands,

particularly doctors, nurses and qualified health managers.

Strengthening the health workforce is recognized as a priority

in the Health Master Plan. Previous HRH policies and plans

were not fully implemented. Several policy issues related to

HRH urgently need to be addressed.

Leadership and managerial skills are deficient at all levels of

the system, either due to lack of appropriate staff or limitation

in capacity of existing managers.

Expected

outcome

The national health system efficiently managing and

supporting the health workforce through evidence-based

policies and practices, leading it towards the agreed vision.

76

Strategies Interventions

1.1

Establish HRH information

management system and

knowledge management towards

evidence-based planning and

policy development,

management decision-making

and promoting supportive

processes.

1.1.1

Develop HRH information system

using modern technologies

embedded in the MIHIS.

1.1.2

Promote and facilitate HRH

research in various thematic

areas of national interest.

1.2

Improve attraction/retention of

health workforce to/in

atolls/islands.

1.2.1

Establish mechanisms and

processes to increase rural

recruitment, local training and

placement of island-specific

candidates in medical/health

institutes.

1.2.2

Revise and develop incentives

system for health staff working in

islands.

1.2.3 Effectively implement and

77

enforce the bonding system to

ensure attraction and retention of

health workers in islands or at

facilities where the employee is

posted after MOHG training

(backed up with a sound financial

guarantee and aligned with

promotion and educational

benefits).

1.2.4

Improve working environment to

retain health workforce in islands

or at facility of job postings;

engaging the local councils to

provide support for health staff

safety, security, facilitation and

social recognition.

1.2.5

Recognize island health

workforce for dedicated service

and extraordinary performance.

1.2.6

Marketing health sector as an

attractive workplace and

fostering a work culture that will

motivate employees.

1.3

Carry out innovative measures

and initiatives to ensure

adequate health workforce in

1.3.1

Streamlining the CHWs

programme.

78

remote areas to cope with

emerging health needs.

1.4

Strengthening capacity of the

HRD at central and peripheral

levels.

1.4.1 Capacity-building at all levels.

1.5

Strengthen national capacity for

health system management and

leadership development at the

national level.

1.5.1

Develop and provide executive

managerial training courses for

health managers, including

MOHG to excel their

management skills and

leadership capacities, as well as

improve health service

management for all those

working as managers at facility

level.

1.5.2

Develop a competency-based

model for health management at

all levels of service, including

MOHG, to carry out periodic

results-based assessment of all

management staff linked to their

promotions.

1.5.3

Introduce a health service

performance appraisal system for

health facilities.

1.5.4

Strengthen capacity for local

planning at subnational level.

1.5.5 Introduce workload criteria using

79

Workload Indicators for Staffing

Needs (WISN) for HRH planning.

1.5.6 Improve international

recruitment.

1.6 Establish a licensing system for

health professionals. 1.6.1

Develop and implement a

licensing examination system for

medical doctors and other health

professionals.

80

Strategic line 2: HRH education and training

Strategic

objective 2

Enhancing education and training outputs harmonized to the

national health care needs.

Rationale

Issues related to training of Maldivian health professionals are:

paucity of students meeting the academic standard to enter

health professions training programmes; limited opportunity

for clinical training; lack of faculty and infrastructure in training

institutions; non-availability of institutions to train key health

professionals locally; and, inadequate local specialized

trainings on health and related areas.

There is a need for scaling-up and quality improvement of the

training of Maldivian HRH.

Expected

outcome

Qualified health workforce with an adequate skill mix and

quality training is available to provide services, with an

increasing share of local workforce. The trainings and skill mix

of medical, public health and administrative/managerial are

developed systematically.

Strategies Interventions

2.1 Strengthen pre-

service training of 2.1.1

Promote pre-medical education and ensure

the quality of students entering into health

81

health

professionals and

scale up training of

local health

professionals.

professions education, through adequate

marketing and policy support by Ministry of

Education.

2.1.2

Establish a mechanism for regular monitoring

and review of quality of health professions

training programmes through an

institutionalized process.

2.1.3

Expand clinical training opportunities through

innovative approaches.

2.1.4

Strengthening the capacity of FHS in training,

research and development. The training

conducted should cater for the needs of the

national health sector and trainees should be

bonded to the public health sector.

2.1.5

Increasing uptake of public services staff with

training bonds or subsidized rates at

government training institutions, including

FHS.

2.1.6

Establishing the foundations to develop a

medical school through public–private

partnership, initially inviting faculty from

outside on a term-by-term basis and

gradually developing national faculty.

2.2 Expand

opportunities for 2.2.1

Negotiate to increase the number of overseas

training slots for training of specialists and

82

specialized

postgraduate

training of health

professionals.

strengthen the bonding system.

2.2.2

Develop IGMH as an accredited training

centre affiliated to overseas degree-awarding

organization/s.

2.2.3

Bilateral arrangement with international

institutes for training in Maldives through

faculty exchange.

2.2.4

Identify and facilitate scholarships and loan

schemes for overseas training.

2.2.5

Expand or plan training opportunities in

administrative/managerial and technical areas

for medical, nursing and public health staff.

2.3

Institutionalize

quality assured

health

professionals’

education for all

cadres.

2.3.1

Establish quality assurance standards and

processes for health professionals’ education

and training.

3.3.2

Introduce an internship and residency

programme for doctors, with at least 20%

service in islands.

2.3.3

Develop an induction programme for new

recruits in all cadres, for orientation at the

time of joining service or a new position in

the health system.

83

2.4

Establish a

comprehensive

and structured

CPD programme

for health

professionals.

2.4.1

Develop and implement a national CPD

strategy for workers to achieve the

competencies required for optimal job

performance.

2.4.2

Provide telemedicine, distance and online

learning opportunities through developing

knowledge centres in hospitals and guidance

services under the CPD secretariat.

84

Strategic line 3: HRH Financing and partnerships

Strategic

objective 3

Improving financial inputs from public, private and

international sources; streamlining the multi-stakeholder

coordination processes, and fostering bilateral partnerships

with organizations, entities, institutions and countries.

Rationale

HRH absorbs a considerable share of the health budget. Total

spending on health workforce is approximately 79% of the

recurrent health budget, which is higher than other countries

in the region. However, Maldives currently faces an alarming

escalation in health care costs together with a vulnerable fiscal

position, which is a burden on the Government.

Appropriate opportunities and methods should be made

available to enable and empower all stakeholders, including

intersectoral partners, to participate in decision-making and

work in honest and open partnership.

Expected

outcomes

Increased financial input from the Government and other

stakeholders, with better accountability mechanisms and

synergic partnerships.

Strategies Interventions

3.1

Develop national

policy and plan for

enhancing the

HRH resources

from the national

budget as well as

3.1.1 Develop HRH resource mobilization

strategy.

3.1.2

Advocating for a greater share and

allocation of public sector financial

resources.

3.1.3 Allocate resources under each programme

85

other resources. for HRH development and align their use

with a harmonized and transparent process.

3.2

Establish a mutual

accountability

process for

effective use of

available

resources for HRH

with all partners.

3.2.1 Carry out financial mapping of partners’

resources for HRH.

3.2.2

Carry out mutual accountability exercise

annually and re-define roles with the

national HRH agenda.

3.3

Strengthen

partnership in

HRH. 3.3.1

Strengthening coordination and monitoring

in HRH.

3.4

Foster

partnerships with

the private sector

and foreign

entities to build

national capacity

in HRH.

3.4.1

Provide local and overseas training

opportunities, contracting and partnering

with the private sector (public–private

partnership) and international organizations.

3.4.2

Develop Memoranda of Understanding with

other countries for mutual collaboration on

HRH development.

3.4.3

Make arrangements with international

organizations to provide free access to

knowledge products and online development

courses to the health staff of Maldives.

86

Section D: The way forward Based on findings highlighted in this report and several stakeholder

consultations, the HRH strategic plan proposed in Section C addresses HRH

challenges in Maldives. The three strategic objectives will serve as guidelines to

implement plans to solve HRH problems. Detailed steps required to ensure

appropriate implementation of the strategic plan are provided in Table 25.

Table 22. Forward plan

Objectives Activities Sub-activities Process Roles

Developing a

detailed

operational

plan to

implement the

planned

strategies and

interventions.

Operational

plan

Development

of draft plan

Hire a consultant

to develop initial

draft based upon

the agreed

operational plan

WHO

Inputs from all

concerned and

revision

Consultation

with

stakeholders

through

individual and

group meetings

Consultant

Validation

Face to face/

online

consultation

Consultant

Approval Agreement WHO, MOHG

Estimating the

cost of the

planned

activities,

interventions

and strategies,

indicating each

partner’s share

and timeframe.

Costing

Costing draft

based upon

operational

plan

Hire a consultant

to make costing

the agreed

operational plan

(activity-wise,

intervention-

wise and

strategy-wise,

and then total)

WHO

Consultation

and revision

Review by

stakeholders Consultant

Validation

Face to face/

online

consultation

Consultant

Approval Agreement WHO, MOHG

87

Preparing a

monitoring and

evaluation plan

to ensure the

set objectives

are met.

Monitoring

and

evaluation

plan

Monitoring and

evaluation plan

draft

The consultant

hired for

operational

planning will

develop

monitoring and

evaluation plan,

along with the

indicators and

implementation

framework

Consultant

Validation

Face to face/

online

consultation

Consultant

Approval Agreement WHO, MOHG

Developing a

resource

mobilization

plan to guide

HRH financing

efforts.

Resource

mobilization

plan

Resource

mobilization

policy and plan

draft

The consultant

hired for costing

will develop the

resource

mobilization plan

Consultant

Validation

Face to face/

online

consultation

Consultant

Approval Agreement WHO, MOHG

88

Annexes

Annex 1. Technical working group

Name Designation Organization

Dr Sheeza Ali Director General of Health

Services Ministry of Health and Gender

Dr Akjemal

Magtymova WHO Representative WHO Country Office, Maldives

Dr Igor Pokanevych Medical Officer WHO Country Office, Maldives

Ms Asma Ibrahim Director Health Protection Agency, Ministry of

Health and Gender

Ms Aisath

Mohammed Director

Maldives Food and Drugs Agency,

Ministry of Health and Gender

Ms Sofeenaz

Hassan Director

Human Resource Division, Ministry of

Health and Gender

Ms Aminath Shaina Assistant Director Policy Planning Division, Ministry of

Health and Gender

Ms Aminath Nashia Assistant Director Ministry of Health and Gender

Mr Ahmed Shakir Director Health Service Division, Ministry of

Health and Gender

Dr Mohamed

Habeeb Chief Civil Servant Indira Gandhi Memorial Hospital

89

Ms Aishath

Shaheen Ismail Dean Faculty of Health Sciences

Dr Mohamed Solih Chairperson Maldives Medical Council

Ms Ashiya Rasheed Chairperson Maldives Nursing Council

Mr Ahmed Mirshan Senior Human Resource

Officer Civil Service Commission

Ms Aishath Sama Human Resource

Development Officer Civil Service Commission

90

Annex 2. Stakeholders engaged in development and validation

Name Designation Organization

Ms Geela Ali Permanent Secretary Ministry of Health and Gender

Dr Sheeza Ali Director General of Health Services

Ministry of Health and Gender

Dr Akjemal

Magtymova

WHO Representative to the

Republic of Maldives WHO

Ms Shareefa Adam Manik

Director General Maldives Food and Drugs Authority

Ms Asma Ibrahim Director Health Protection Agency, Ministry of Health and Gender

Ms Aishath Samiya Director Policy Planning Division, Ministry of

Health and Gender

Ms Sofeenaz Hassan

Director Human Resource Division, Ministry of Health and Gender

Ms Aminath Shaina Assistant Director Policy Planning Division, Ministry of Health and Gender

Ms Aminath Nashia Assistant Director Training Section, Ministry of Health and Gender

Mr. Ahmed Shakir Director Health Service Division, Ministry of Health and Gender

Dr Mohamed

Habeeb CEO Indira Gandhi Memorial Hospital

Mr Abdulla Shinah Chief Operating Officer ADK Hospital

Ms Aishath Shaheen Ismail

Dean Faculty of Health Sciences

Dr Mohamed Solih Chairperson Maldives Medical Council

Ms Ashiya Rasheed Chairperson Maldives Nursing Council

91

Ms Aishatt Mahfoosa

Chairperson Maldives Board of Health Sciences

Mr Yoosuf Naeem Assistant Director Ministry of Finance and Treasury

Mr Ahmed Mirshan Senior Human Resource Officer Civil Service Commission

Ms Aishath Sama Human Resource Development Officer

Civil Service Commission

Ms Zeba Tanvir Bukhari

UNICEF Representative to Maldives

UNICEF

Ms Azusa Kuboto Programme Operation Coordinator

UNDP

Mr Alejandro Ruiz-Acevedo

Project Centre Manager UNOPS

Ms Athifa Ibrahim Programme Analyst UNDP

Mr Murthada Sessay

Project Manager UNOPS

Ms Jeehan Saleem National Programme Officer UNFPA

Mr Mohamed Faisal Coordination Specialist Resident Coordinator’s Office, UN Maldives

Mr Mohamed

Hunaif Under Secretary President’s Office

92

Annex 3. HRH positions approved by the CSC for health-care facilities under the MOHG

(staffing standards)

Medical workforce

IGMH TH CTR

# Fclts. # Fclts. # Fclts. # Fclts. # Fclts. # Fclts. # Fclts. # Fclts.

5 5 7 3 20 41 33 27

1 Cardiologist 1 5 0 0 0 0 0 0 0 2 7

2 Urologist 1 5 0 0 0 0 0 0 0 1 6

3 Pulomonologist 0 0 0 0 0 0 0 0 2 2

4 Physician 2 10 1 5 1 7 0 0 0 0 0 11 33

5 Orthopaedic Surgeon 1 5 1 5 0 0 0 0 0 0 7 17

6 Gastroenterologist 0 0 0 0 0 0 0 0 1 1

7 Neurologist 0 0 0 0 0 0 0 0 3 3

8 Emergency Medicine 0 0 0 0 0 0 0 0 2 2

9 Radiology 0 0 0 0 0 0 0 0 5 5

10 Pathology 0 0 0 0 0 0 0 0 5 1 7

11 Maxillofacial Surgery 0 0 0 0 0 0 0 0 1 1

12 Orthodontics 0 0 0 0 0 0 0 0 1 1

13 Ophthalmologist 1 5 1 5 0 0 0 0 0 0 6 16

14 Gynaecologist 2 10 2 10 2 14 1 3 0 0 0 0 12 49

15 Anaesthesiologist 2 10 2 10 1 7 1 3 0 0 0 0 10 40

16 Surgeon 2 10 1 5 1 7 0 0 0 0 0 10 32

17 Paediatrician 2 10 1 5 1 7 1 3 0 0 0 0 10 35

18 Dermatologist 1 5 0 0 0 0 0 0 0 4 9

19 Cardio surgeon 0 0 0 0 0 0 0 0 1 1

20 ENT Surgeon 1 5 0 0 0 0 0 0 0 4 9

21 Psychiatrist /Clinical Physiologist 1 5 1 5 0 0 0 0 0 0 3 13

22General Practitioner (Senior Medical

Officer/Medical Officer /Registrar)7 35 5 25 4 28 4 12 2 40 1 41 1 33 0 91 3 308

TOTAL

STANDARDSS

HOSP 1 HOSP 2 HOSP 3 HOSP 4 HC 1 HC 2 HC 3 HC 4

SS SS SS SS SSSS SS SS SS# Posts

93

Paramedical workforce

IGMH TH CTR

# Fclts. # Fclts. # Fclts. # Fclts. # Fclts. # Fclts. # Fclts. # Fclts.

5 5 7 3 20 41 33 27

23 Dentist 1 5 1 5 0 0 0 0 0 0 8 18

24 Dental Hygienist /Dental Assistant 2 10 1 5 0 0 0 0 0 0 16 31

25 Pharmacist 0 0 0 0 0 0 0 0 2 2

26 Radiographer 2 10 2 10 1 7 1 3 0 0 0 0 14 44

27 Radiographer Assistant 0 0 0 0 0 0 0 0 6 6

28 Radiographer Trainee 1 5 1 5 1 7 1 3 0 0 0 0 20

29 Optometrist 0 0 0 0 0 0 0 0 1 1

30 Physiotherapist 2 10 1 5 0 0 0 0 0 0 12 27

31 Physiotherapist Assistant 0 0 0 0 0 0 0 0 10 10

32 Physiotherpaist Trainee 1 5 1 5 0 0 0 0 0 0 10

33 Labortaory Technologist 6 30 4 20 3 21 2 6 2 40 1 41 1 33 0 60 12 263

34 Labortatory Assistant 2 10 1 5 1 7 1 3 0 0 0 0 10 35

35 EEG/EMG Technician 0 0 0 0 0 0 0 0 2 2

36 Speech Therapist 0 0 0 0 0 0 0 0 1 1

37 Nurses 86 430 60 300 36 252 23 69 18 360 10 410 4 132 2 54 619 16 2642

38 Nurse Midwife 0 0 0 0 2 40 1 41 1 33 1 27 8 149

39 Dietician 0 0 0 0 0 0 0 0 1 1

40 Councellors 1 5 1 5 1 7 1 3 0 0 0 0 3 23

41Regional Health Administrator/ Director/

Manager1 5 1 5 1 7 1 3 0 0 0 0

14 2 36

42 Assistant Manager / Deputy Manager 2 10 1 5 1 7 1 3 0 0 0 0 13 38

43 Administrative Officer 0 0 0 0 0 0 0 0 67 11 77

44

Senior Health Cordinator / Community

Health Cordinator / Community Health

Supervisor/ Community Health Worker

4 20 4 20 3 21 3 9 2 40 2 82 1 33 1 27

1 253

45 Family Health Officer 0 0 0 0 1 20 1 41 1 33 1 27 121

TOTAL

STANDARDSS

HOSP 1 HOSP 2 HOSP 3 HOSP 4 HC 1 HC 2 HC 3 HC 4

SS SS SS SS SSSS SS SS SS# Posts

94

Support workforce

IGMH TH CTR

# Fclts. # Fclts. # Fclts. # Fclts. # Fclts. # Fclts. # Fclts. # Fclts.

5 5 7 3 20 41 33 27

46 Secretary 5 25 4 20 3 21 2 6 3 60 3 123 3 99 2 54 7 415

47 Budjet Officer 3 15 2 10 2 14 2 6 1 20 0 0 0 10 75

48 Maintenance Officer 2 10 1 5 1 7 1 3 0 0 0 0 25

49 Medical Record Officer 4 20 3 15 2 14 1 3 1 20 0 0 0 3 75

50 IT Officer 2 10 2 10 1 7 1 3 0 0 0 0 10 40

51 Cashier 8 40 6 30 5 35 4 12 2 40 1 41 1 33 0 34 265

52 Public Realation Officer 6 30 4 20 3 21 3 9 1 20 0 0 0 24 124

53 Clinical assistant 0 0 0 0 0 0 0 0 69 2 71

54 Translator 18 90 12 60 8 56 5 15 2 40 1 41 1 33 0 335

55 Reception Clark 8 40 6 30 6 42 5 15 3 60 3 123 3 99 0 6 415

56 Store Keeper 3 15 2 10 2 14 1 3 1 20 0 0 0 5 67

57 House Keeper 2 10 1 5 1 7 1 3 1 20 0 0 0 28 73

58 Sarudhaaru 1 5 0 0 0 0 0 0 0 5

59 Messenger 1 5 1 5 1 7 1 3 0 0 0 0 20

60 Masakkathu (Support Staffs) 4 20 2 10 2 14 2 6 4 80 3 123 3 99 1 27 9 388

61 Masakkathu (staff Accomodation) 4 20 4 20 3 21 3 9 0 0 0 0 70

62 Attendent / Health Auxiliary 16 80 12 60 10 70 8 24 9 180 7 287 4 132 2 54 9 5 901

63 Security Officer /Watcher 10 50 6 30 6 42 4 12 2 40 2 82 1 33 0 43 332

64 Mechanic 4 20 4 20 2 14 2 6 1 20 0 0 0 27 107

65 Electrician 2 10 1 5 1 7 1 3 1 20 0 0 0 12 57

66 Bio Medical Technician 1 5 1 5 1 7 1 3 0 0 0 0 3 23

67 Ambulance Driver / Attanedent 10 50 8 40 6 42 5 15 3 60 2 82 2 66 0 146 501

68 Dhonna (Laundry Assistants) 6 30 6 30 4 28 4 12 2 40 2 82 1 33 1 27 282

69 Nevi/Captain/Driver 2 10 2 10 1 7 1 3 0 0 0 0 22 52

70 Mechanic Driver 2 10 2 10 1 7 1 3 0 0 0 0 30

71 Falhuveri 4 20 4 20 2 14 2 6 0 0 0 0 60

263 1315 190 950 132 924 102 306 64 1280 40 1640 28 924 11 297 1526 53 9215

TOTAL

STANDARDSS

HOSP 1 HOSP 2 HOSP 3 HOSP 4 HC 1 HC 2 HC 3 HC 4

SS SS SS SS

Grand Total

SSSS SS SS SS# Posts

95

Annex 4. Distribution of expatriate/local HRH, standards and

vacancy rates in hospitals level 1–4 (regional/atoll) (Source:

MOHG)

Loca l Expa t Loca l Expa t Loca l Expa t Loca l Expa t

1 Cardiologis t 1 0 0 0 0 0 0 05

1 1 0 -480%

2 Urologis t 0 0 0 0 0 0 0 05

0 0 0 -5100%

3 Phys ician 0 4 0 3 0 0 0 022

7 0 7 -1568%

4 Orthopaedic Surgeon 0 3 0 1 0 0 0 010

4 0 4 -660%

5 Ophthalmologis t 0 3 0 0 0 0 0 010

3 0 3 -770%

6 Gynaecologis t 0 7 0 3 0 6 0 137

17 0 17 -2054%

7 Anaes thes iologis t 0 4 0 5 0 7 0 230

18 0 18 -1240%

8 Surgeon 0 5 0 3 0 1 0 022

9 0 9 -1359%

9 Paediatrician 0 5 0 3 0 5 0 225

15 0 15 -1040%

10 Dermatologis t 0 0 0 0 0 0 0 05

0 0 0 -5100%

11 ENT Surgeon 0 2 0 0 0 0 0 05

2 0 2 -360%

12 Ps ychiatris t /Clinical Phys iologis t 0 0 0 1 0 0 0 010

1 0 1 -990%

13 General P ractitioner (Senior Medical Officer/Medical Officer /Regis trar) 3 31 0 19 1 30 0 10 100 94 4 90 -6 6%

14 Dentis t 1 2 0 3 0 0 0 010

6 1 5 -440%

15 Radiographer 0 10 0 5 0 7 0 330

25 0 25 -517%

16 Phys iotherapis t 0 5 0 1 0 0 0 015

6 0 6 -960%

17 Laboratory Technologis t 11 21 10 9 4 17 0 677

78 25 53 1-1%

18 Dental Hygienis t /Dental As s is tant 0 0 0 0 0 0 0 015

0 0 0 -15100%

19 Radiographer Trainee 2 0 3 0 7 0 1 020

13 13 0 -735%

20 Phys iotherapis t Trainee 3 0 0 0 0 0 0 010

3 3 0 -770%

21 Laboratory As s is tant 2 0 2 0 2 0 0 025

6 6 0 -1976%

22 Nurs es 176 126 68 87 90 73 16 30 1051 666 350 316 -38537%

23 Couns ellors 0 0 0 0 0 0 0 020

0 0 0 -20100%

24 Regional Health Adminis trator/ Director/ Manager 2 0 1 0 3 0 2 0

208 8 0 -12

60%

25 As s is tant Manager / Deputy Manager 5 0 2 0 4 0 0 025

11 11 0 -1456%

26Senior Health Coordinator / Community Health Coordinator / Community Health Supervis or/ Community Health Worker

3 0 0 0 1 0 1 0 70 5 5 0 -6593%

Ga p Va ca ncy ra te

Tota l (sta nda rd) OCCUPIED EXPATLOCAL# POSTS

Hosp L1 Hosp L2 Hosp L3 Hosp L4

96

(Contd.)

Loca l Expa t Loca l Expa t Loca l Expa t Loca l Expa t

27 Secretary 31 5 20 2 28 0 5 072

91 84 7 19-26%

28 Budget Officer 9 0 12 2 15 0 3 045

41 39 2 -49%

29 Maintenance Officer 3 0 3 0 2 0 0 025

8 8 0 -1768%

30 Medical Record Officer 5 0 3 1 6 0 3 052

18 17 1 -3465%

31 IT Officer 2 0 2 0 3 0 0 030

7 7 0 -2377%

32 Cas hier 16 0 3 4 17 0 6 0117

46 42 4 -7161%

33 Public Relations Officer 17 0 8 1 15 0 5 080

46 45 1 -3443%

34 Trans lator 47 0 26 4 29 0 9 0221

115 111 4 -10648%

35 Reception Clark 28 0 15 4 25 0 7 0127

79 75 4 -4838%

36 S tore Keeper 3 0 3 1 8 0 2 042

17 16 1 -2560%

37 Hous e Keeper 6 0 4 0 4 0 3 025

17 17 0 -832%

38 Sarudhaaru 1 0 0 0 0 0 0 05

1 1 0 -480%

39 Mes s enger 2 0 0 0 2 0 2 020

6 6 0 -1470%

40 Mas akkathu 13 0 10 2 13 0 6 050

44 42 2 -612%

41 Mas akkathu (s taff Accommodation) 13 0 12 1 21 0 7 070

54 53 1 -1623%

42 Attendant / Health Auxiliary 50 0 24 7 45 0 13 0234

139 132 7 -9541%

43 Security Officer /Watcher 28 0 18 3 22 0 8 0134

79 76 3 -5541%

44 Mechanic 9 0 3 2 10 0 1 060

25 23 2 -3558%

45 Electrician 8 0 1 0 3 0 2 025

14 14 0 -1144%

46 Bio Medical Technician 0 1 1 0 0 0 0 020

2 1 1 -1890%

47 Ambulance Driver / Attendant 38 0 21 2 29 0 6 0147

96 94 2 -5135%

48 Dhonna 29 0 18 3 26 0 11 0100

87 84 3 -1313%

49 Nevi/Captain/Driver 3 0 4 1 7 0 3 030

18 17 1 -1240%

50 Mechanic Driver 3 0 3 1 8 0 1 030

16 15 1 -1447%

51 Falhuveri 9 0 5 2 14 0 6 060

36 34 2 -2440%

582 234 305 186 464 146 129 54 3495 2100 1480 620 -1395 40%TOTAL

Ga p Va ca ncy ra te

Tota l (sta nda rd) OCCUPIED EXPATLOCAL# POSTS

Hosp L1 Hosp L2 Hosp L3 Hosp L4

97

Annex 5. Distribution of expatriate/local HRH, standards and

vacancy rates in health centres level 1–4 (Source: MOHG)

loca l expat loca l expat loca l expat loca l expat

1 Community Health Worker 3 0 9 0 8 0 6 0182 26 26 0 -156 86%

7 Administrative Officer /Secretary 53 0 82 0 42 0 20 0 336 197 197 0 -139 41%

3 SMO/MO/Registrar 0 33 0 45 0 32 0 0114 110 0 110 -4 4%

4 Nurses 116 83 111 118 38 58 4 17956 545 269 276 -411 43%

5 Nurse Midwife 0 0 0 0 0 0 0 0141 0 0 0 -141 100%

6 Laboratory Technologist 5 22 3 33 0 5 0 0114 68 8 60 -46 40%

8 Budget Officer 0 0 0 0 0 0 0 020 0 0 0 -20 100%

9 Cashier 15 0 5 0 4 0 0 0114 24 24 0 -90 79%

10 Medical Record Officer 0 0 0 0 0 0 0 020 0 0 0 -20 100%

11 Translator 34 0 38 0 24 0 0 0114 96 96 0 -18 16%

12 Public Relation Officer 0 0 0 0 0 0 0 020 0 0 0 -20 100%

13 Reception Clark 28 0 20 0 10 0 0 0282 58 58 0 -224 79%

14 Store Keeper 0 0 0 0 0 0 0 020 0 0 0 -20 100%

15 Family Health Officer 0 0 0 0 0 0 0 0121 0 0 0 -121 100%

16 House Keeper 0 0 0 0 0 0 0 020 0 0 0 -20 100%

17 Masakkathu 43 0 86 0 42 0 21 0329 192 192 0 -137 42%

18 Attendant /Health Auxiliary 86 0 114 0 47 0 2 0653 249 249 0 -404 62%

20 Ambulance Driver /Attendant 42 0 67 0 37 0 0 0208 146 146 0 -62 30%

21 Mechanic 2 0 0 0 0 0 0 020 2 2 0 -18 90%

22 Electrician 0 0 0 0 0 0 0 020 0 0 0 -20 100%

23 Watcher 28 0 35 0 22 0 0 0155 85 85 0 -70 45%

24 Dhonna 14 0 23 0 17 0 0 0182 54 54 0 -128 70%

469 138 593 196 291 95 53 17 4141 1852 1406 446 -2289 55%TOTAL

HC L1 HC L2 HC L3 Va ca ncy ra tePOSTS#

HC L4OCCUPIED EXPATLOCALTota l

sta nda rd Ga p

98

Annex 6. Distribution of HRH, standards and vacancy rates in all

health facilities under the MOHG (MOHG + institutions information

missing)

1 Cardiologist 7 1 1 2 -5 71%

2 Urologist 6 1 1 -5 83%

3 Pulomonologist 2 0 -2 100%

4 Physician 33 7 11 18 -15 45%

5 Orthopaedic Surgeon 17 4 5 9 -8 47%

6 Gastroenterologist 1 1 1 0 0%

7 Neurologist 3 0 -3 100%

8 Emergency Medicine 2 2 2 0 0%

9 Radiology 5 4 4 -1 20%

10 Pathology 7 5 5 -2 29%

11 Maxillofacial Surgery 1 0 -1 100%

12 Orthodontics 1 1 1 0 0%

13 Ophthalmologist 16 3 2 5 -11 69%

14 Gynaecologist 49 17 11 28 -21 43%

15 Anaesthesiologist 40 18 4 22 -18 45%

16 Surgeon 32 9 8 17 -15 47%

17 Paediatrician 35 15 5 20 -15 43%

18 Dermatologist 9 4 4 -5 56%

19 Cardio surgeon 1 1 1 0 0%

20 ENT Surgeon 9 2 1 3 -6 67%

21 Psychiatrist /Clinical Physiologist 13 1 2 3 -10 77%

22General Practitioner (Senior Medical

Officer/Medical Officer /Registrar)308 94 110 69 3 276 -32 10%

GAPGrand

Total

Vacancy

Rate

TOTAL

STANDARD

Total

Existing

Hospital

Total

Existing

HCs

Total

Existing

IGMH

Total

Existing

Th Cntr

Total

Existing

MOH +

Institus.

# Posts

99

(Contd.)

100

(Contd.)

46 Secretary 415 91 4 95 -320 77%

47 Budjet Officer 75 41 9 50 -25 33%

48 Maintenance Officer 25 8 8 -17 68%

49 Medical Record Officer 75 18 3 21 -54 72%

50 IT Officer 40 7 7 14 -26 65%

51 Cashier 265 46 24 34 104 -161 61%

52 Public Realation Officer 124 46 21 67 -57 46%

53 Clinical assistant 71 30 2 32 -39 55%

54 Translator 335 115 96 211 -124 37%

55 Reception Clark 415 79 58 6 143 -272 66%

56 Store Keeper 67 17 3 20 -47 70%

57 House Keeper 73 17 27 44 -29 40%

58 Sarudhaaru 5 1 1 -4 80%

59 Messenger 20 6 6 -14 70%

60 Masakkathu (Support Staffs) 388 44 192 9 245 -143 37%

61 Masakkathu (staff Accomodation) 70 54 54 -16 23%

62 Attendent / Health Auxiliary 901 139 249 132 4 524 -377 42%

63 Security Officer /Watcher 332 79 85 30 194 -138 42%

64 Mechanic 107 25 2 33 60 -47 44%

65 Electrician 57 14 5 19 -38 67%

66 Bio Medical Technician 23 2 2 4 -19 83%

67 Ambulance Driver / Attanedent 501 96 146 242 -259 52%

68 Dhonna (Laundry Assistants) 282 87 54 141 -141 50%

69 Nevi/Captain/Driver 52 18 20 38 -14 27%

70 Mechanic Driver 30 16 16 -14 47%

71 Falhuveri 60 60 60 0 0%

9215 2124 1852 1276 45 5297 -3918 43%

GAPGrand

Total

Vacancy

Rate

TOTAL

STANDARD

Total

Existing

Hospital

Total

Existing

HCs

Total

Existing

IGMH

Total

Existing

Th Cntr

Total

Existing

MOH +

Institus.

Grand Total

# Posts

101

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