The archipelago of Maldives consists of 1,192 islands distributed across the Indian Ocean with a total population of over 540,000. Among these, only 188 islands are inhabited while the others are used for either agricultural and tourism purposes. I live in Malé, the capital of our nation, which is geographically situated near the middle of the archipelago.
It is shockingly beautiful here. There are blue waters as far as the eye can see from nearly everywhere in Malé. But within the beauty lies a huge healthcare challenge. The constitution of Maldives validates the right to access good and quality healthcare for every citizen, identifying health as a human right and its universality, but our geography makes it nearly impossible to bridge the inequitable healthcare services gap that exists in the Maldives.
For example, one of the remotest parts of the Maldives is the island of Thuraakunu in Haa Alif Atoll, which is located at the northern tip of the geographically dispersed nation. In order to reach Malé, people from Thuraakunu have to travel to the island of Kulhudhuffushi first, which costs approximately MVR 200 per head (US $13) for a boat ride across rough seas with three to four stops along the way up until 20 November 2020. On this day, the domestic Hoarafushi Airport was inaugurated. However, the national airline has not stated an airfare and does not have a flight schedule yet. Sea transport is cheaper than air transport anyway—and many people will continue to opt for it—but that means at least 15 hours of travel over rough seas.
Finding an affordable place to stay in the capital city is yet another throbbing issue for these travelers. During school holidays, landlords of rental services increase the daily rates, costing travelers to spend a significant amount of money for shelter and food.
If you’d ask me to estimate a total, I’d say in this example it would cost approximately MVR 10,000 to MVR 15,000 per person (US $648-$972) on a trip to the capital city. Arguably, there has never been a more crucial time for our nation to implement ways of easy access and equitable care for people living on all our islands.
Yes, of course, telemedicine is the first solution that comes to mind. It has been successfully implemented in many countries across the world, like Australia, to provide healthcare services to people living in remote areas. Telemedicine has increased access to care, improved the quality of care, and decreased costs and disruptions in services. Consumers are able to become more proactive and responsible for their own health by carefully planning their care effectively. This paradigm shift has significant potential to transform the general health of the population, if not the world.
Unfortunately, we’ve tried it. But for numerous reasons, we haven’t been able to make it work.
Since 2002, our telemedicine initiatives have held various names and have been funded by different global organizations like the World Health Organization and World Bank. Throughout the years, the objectives have remained the same: monitor health indicators, establish an efficient emergency or disaster management system, and improve the quality and affordability of healthcare with a focus on access for all.
Year over year, it felt like we took one step forward and then two steps back. There hasn’t been much research done to identify the failures of such a critical project, but a qualitative exploratory study done in 2011 by Mariyam Nazviya and Subrahmanyam Kodukula identifies a number of critical success factors for telemedicine implementation in Maldives, including:
- Standardized project management practice adoption
- Support from government
- Increased public awareness and acceptance
- Availability of technological infrastructure
- Availability of sustainable financial support
- Clearly defined legislation
- Defined referral mechanism
- Adequately trained personnel
- Proper communication between stakeholders
However, I think certain factors play a more crucial role in making such a project successful in the local context. For example, for any project to be successful, it is crucial that its consumers understand the benefit of the project on them. This is vital when the project is related to health, as health is valued above all in every society across the world. Literature reviews have identified the better people understand the benefit a particular project has for them, the greater their involvement is. Nevertheless, it is evident that there has been little focus on the human factor of this service in the planning and implementation phase of the project. Much of the work has focused on the technological aspect.
There is also a lack of legal framework governing telemedicine. Political influences, dysfunctional steering committee, non-translation of political will into concrete action, lack of consideration of telemedicine as a political priority, and lack of national telemedicine strategy are also considered contributing factors for the failure of implementing telemedicine in the Maldives.
Looking at it on paper feels unsurmountable, but I have hope. I look at my students, my colleagues, and my network of healthcare professionals and see a solution. Our people deserve a more efficient allocation of healthcare resources with better care at a lower cost.
There cannot be a better time than this.
Mariyam Huda, MBA, RN, is a lecturer at Villa College in Malé, Maldives. She’s a member of Sigma's Rho Delta Chapter.