Country  Emergency Situational Profiles

Maldives

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Context and Hazards

The Republic of Maldives is a chain of nearly 1,200 tiny coral islands in the Indian Ocean, of which only 999 are inhabited. The Maldives Archipelago contains 26 geographic Atolls that together form a chain 820 kilometers in length and 120 kilometers at the widest point. The 26 geographic atolls are grouped into 20 administrative regions. All islands of the Maldives are very low lying, and none exceeds an elevation of three meters. More than 80 percent of the land area is less than 1 meter above mean sea level.

The total population of the Maldives in 2004 is 290 000 with a growth rate 1.96%. The population pyramids of 1995 and 2000 show that there are possibilities for a baby boom in the near future. 

According to the vulnerability and poverty assessment report in 2004 less than one percent of the population had less than one dollar a day. (MDG report 2005) During the period 1997 to 2000 the GDP grew at an average annual rate of 6.8 percent which is significantly higher compared to the South Asian average of 5.9% and that of least developed countries (LDC) which stood at 4.5% during the same period1.

The Maldives is regularly exposed to multiple natural hazards such as storms, droughts, and heavy rains in the South Indian Ocean. In addition the country is susceptible to oil spills and aviation related hazards.  The country is also at particular risk from sea level rise due to climate change, given the fact that the Maldives is a nation of islands no more than two meters above sea level. Since the country is dependent on fisheries and tourism sector economies this enhances the social and economic vulnerability factors related to hazards of the sea.  The northern atolls are at greater hazard from cyclonic winds and storms than the southern atolls. The distribution and size of the human settlements in the Maldives poses threats to the population. In islands where the population is high the densities are high as well. In islands where the population size is small it lacks critical infrastructure such as health, education and communication. The island populations were categorized as being vulnerable due to factors enhancing pressure on food security. In the case of islands where presence of agriculture and horticulture as alternate food supply channels were present made these islands more self sufficient for a short period of time following major disasters.      

The Maldives Economy is faced with the challenge of a narrow economic base with a limited amount of human resources that is insufficient to sustain a dynamic, knowledge-based economy and the domestic market forces are too small to stimulate economic growth. These weaknesses are further aggravated by the fact that the country is dependent heavily on two major industries – tourism and fisheries. Furthermore, the smallness and the scattered nature of settlements pose considerable diseconomies of scale. Thus a decline in any of the two industries will have serious implications on the provision of public services, employment, development activities and the overall standard of living.

Other then Socio-economic factors, the Maldives being a small island state, the entire population is vulnerable to the adverse health effects of climate change and natural disasters. The main affecting human vulnerability is:

     the geographical situation of being a small island sate

     Environmental degradation

     Climatic disposition to natural disasters

     Increased population growth and rapid urbanization

     Little diversity of economy.

Deaths and Affected Families due to Natural Hazards

The Maldives do not have a history of major natural disasters. In the Tsunami of December 2004, 82 persons lost their lives.

Nutrition and Food Security

Nutritional indicators and causes of malnutrition: Abject poverty is no longer prevalent in the Maldives. However, considerable disparities in incomes prevail between atolls, islands and households. The difference in incomes between households has implications in the degree of accessibility to food and to the level of adequacy in the nutrient intake by the members in the household.

Although severe hunger in Maldives is not seen, moderate and mild forms of malnutrition are widespread and adversely affect a considerable proportion of the women and children. All available information suggest that malnutrition results from differences with respect to priorities, personal hygiene, habits of child rearing and dietary practices, rather than lack of food. Malnutrition rates among the children have decreased from 1995 to 2001 but remains high with 24.8% of children under five years of age with stunted growth, 13.2% wasted and 30.4% underweight the Multiple Indicator Cluster Survey (MICS 2001) by the WHO and the UNICEF.

Food demand and sources of supply: the domestic production of food at present meets only around 10%of the country’s requirements, and balance is imported from outside sources. The staple food in the Maldives is rice, but all the rice requirements are imported, as there is no rice growing in the Maldives. The other major food items imported to the country include wheat flour, sugar, dairy products, meat and eggs, and beverages.

In 1988 – 1990, the imported to domestic supply ratio remained high at 0.68. the share of crops in food production, imports, exports, and domestic food supply have declined between 1979-1981 and 1988-1990, while fishery products has increased in all these categories during the same period. The imported to domestic supply remains at similar high ratio even at present times, and with increased food imports in a stagnant domestic food supply, this ratio has even tended to deterioration. In 1995 the total food import bill according to the Maldives Customs Services was MRF.620.2 million. In 1996 the food import bill increased to Rf.759.7 million despite an uncharged the parity rate with the US dollar during this period.  

Water and Sanitation

Access to safe drinking water: The Multiple Indicator Cluster Survey conducted in 2001 shows that 76.5% of the households in the country have access to safe drinking water including rain water. Safe drinking water has been provided to 100% of households in Male’ and Villingili with desalinated water. Large variations are seen in the accessibility of safe water in the different regions with the lowest in the Northern region. The use of well water for drinking fell from 19% in 1995 to 16% in 2001. Well water is unsuitable for drinking in most parts of the country due to increased salinity and unhealthy state of ground water.

To provide rain water storage facility in the islands, government built ferrous cement community tanks. However, due to difficulties of maintenance these were later phased out and replaced by HDPE tanks. In a project which began in the 1994, HDPE tanks are provided to the island community both as community tanks.To date the HDPE tanks provided to the atolls give a total storage capacity of over 18.5 million liters.

Sanitary means of excreta disposal: The MICS II survey found out that 80.5% households have access to sanitary means of excreta disposal. The use of pit latrines or Gifili as a mean of excreta disposal has declined from 18% in 1995 to 3.2% in 2001 (MICS I, 1995; MICS II 2001). The pit latrines had been hazardous as they are often close to household wells and contaminate the water with fecal matter. According to MICS II, a large proportion of households in the country today use toilets that flush to pit, which is also a risk to the ground water. Only 22% of households in the country use toilets which flush to sewage system or septic tank. In the atolls this proportion ranges from 3.3% to 11.4% while in Male the facility is available for over 99% of households. Use of beach as a toilet facility is seen to have declined from 24% in 1995 to 18% in 2001.

Epidemiological Profile

The Maldives saw the introduction of modem medicine in the 1960s. Since then, a service delivery system has been established for both curative and preventative health and continually upgraded based on the primary health care concept.

Communicable Diseases

Due to a well functioning national surveillance system, the majority of endemic infectious diseases are under control. As the result, the Maldives has been recognized a malaria-free country since 1984. Leprosy and tuberculosis have drastically decreased since world war two, when these diseases were a serious problem for the Maldives. However, dengue fever, measles and infectious parotitis are still of public health concern. Furthermore, acute respiratory infections, diarrhea diseases and conjunctivitis have been reported among the ten most common causes of consultations for communicable diseases during January – August 2005. HIV/AIDS and STIs: The AIDS situation in the Maldives remains as a low prevalence country. The cumulative total of positive cases since the beginning of the screening program in 1991, stood at 13 at the end of 2003. On the other hand, due to a very active screening program, a cumulative total of 156 positive cases have been found among immigrant workers in the country.

However, the global come back of many communicable diseases, and more recently, emerging pandemics, such as SARS and avian influenza, require increased attention to protect the country from these diseases being imported. The risk is considerable though, as tourism and employment of foreign workers cause a situation comparable to “migration” situations. Also, according to the Ministry of Fisheries, 90% of food is imported in Maldives. This requires high levels of food safety control for preventing the introduction of diseases. 

Basic National Health Indicators

Non Communicable diseases

Like elsewhere, in Maldives, non-communicable diseases are increasingly becoming the major public health concern. As presented at the Regional Meeting of the South East Asia Network for NCD, Prevention and Control, 7-10th November 2005, the mortality from cardiovascular diseases increased from 38% in 2001 to 45% in 2003. The mortality from cancer is 15% and from diabetes 14%. Thallasaemia is a public health priority; injuries are increasing.

The following graph illustrates the context of NCD in Maldives 

The Health Care System

The health system in the Maldives has an inclination towards a totally integrated system where most of the financing, provision and stewardship is the responsibility of the government. However, the public integrated system is supplemented by a mosaic of private clinics ranging from single doctor consultations to polyclinics with laboratory services and some with inpatient capacity. The system is further complemented by different NGO’s participating in public health functions, a competitive pharmaceuticals market, traditional medicine to some extent and a major private tertiary hospital. The pharmaceutical industry falls into the category of a full market system.

Administrative Division and Structure of the Health System

Central institutions functioning under the Ministry include the Department of Public Health (DPH), the Indira Gandhi Memorial Hospital (IGMH), the National Thalassemia Centre (NTC) and the Maldives Water and Sanitation Authority (MWSA). Their services embody the fifth or highest referral level. Though not central in character, Male' Health Centre and Villingili Health Centre also function directly under the Ministry, providing primary and secondary level health care to the twin-island capital.

Ministry of Health is responsible for formulating overall health policy and health development plans and for monitoring and evaluating the health situation. Department of Public Health is responsible for delivering preventive health programmes for the prevention and control of communicable diseases and for the promotion of health and well being of mothers and children. It is also responsible for delivering basic health care (preventive, promotive, curative and rehabilitative) to the islands and atolls. IGMH, with a capacity of 236 beds, delivers tertiary curative care, serving as the central referral hospital for the whole country. MWSA is responsible for regulating and setting standards for water and sanitation services throughout the country.

In the periphery, there are 6 Regional hospitals and 10 Atoll hospitals with a total capacity of 357 beds. Furthermore, there are 68 health centres, 55 health posts and 57 family health service units.

The following figure illustrates the taxonomy of the health tiers in the Health system of Maldives according to geographical zoning.

Capacity of the Health System

Human resources for health:

The Maldives has seen a rapid increase in medical personnel in the last 10 years. The establishment of IGMH in 1995, expansion of regional hospitals and the recruitment of doctors to health centers saw an influx of medical personnel rising by almost 56% between 1994 and 1999. In 2003 there were 315 doctors including specialists of whom 87.9% are employed by the government and 79.4% are expatriates. This represents a patient to doctor ratio of 858. In year 2003 alone 30 people were sent abroad for training in different areas of health. A large percentage of the training is in the area of medicine to which a lot of emphasis is given. In year 2002 and 2003, 31 MBBS doctors returned to the country after graduation and 16 new students were sent for medical training. During this same period, 12 specialist doctors also returned from training and joined the workforce. It is now felt that the area of health management should be given more attention in future.

Expenditure and Revenue Trends:

Although the government policy on health services has remained steady for the past decade, the expenditure as a percentage of the national budget declined from 11.26 to 9.44 from 1996 to 2002 respectively. Despite this decline, the amount allocated (in monetary terms) for health expenditure has increased considerably. The health expenditure increased by Rf 124.1 million, from 1996 to 2002 respectively. Although the per capita health expenditure as of national budget dropped by Rf 34.4 from 2000 to 2001, it increased by Rf 34.2 from 2001 to 2002 respectively. In 2003, approximately 10.6 percent of the national budget was allocated to the health sector. The total health expenditure in 2003 stood at approximately Rf 315.10 million. About 85% of this was spent on recurrent expenditure and 15% as capital expenditure. In an attempt to classify the expenditure into health functions, the following rough breakdown is derived. These figures should be interpreted with caution since some of the support services and public health expenditure may still be classified into curative and vice versa. It is seen that a large percentage of expenditure is on curative services, contributing 57% of the total health expenditure. About 21% was spent on support services and 22% on preventative health.

Health Sector Emergency Planning and Coordination

No emergency preparedness and response (EPR) plans existed in the Maldives before the Tsunami hit, except for the emergency airport contingency plan. This plan, among others, includes protocols for the Indira Gandhi Memorial Hospital (IGMH) in the capital Male.

Since July 2005, the Ministry of Health has started developing a comprehensive health sector EPR plan, supported by WHO. A disaster health working group was set up to work on the plan. A health sector Tsunami lessons learnt workshop was conducted in September 2005. The health sector EPR will be part of the Health Master Plan as well as of the National Disaster Management plan.

The disaster health working group

This technical CU was established post-tsunami and is responsible for developing the health sector EPR plan, as well as implementing, monitoring and evaluating the EPR programme. The team is composed of representatives from different departments across the health sector.

The health relief team

The health relief team was created immediately after the Tsunami and its structure has so far proven to be functional

Figure: The organisational structure of the Health relief Team

Future vision:

A permanent EPR unit will be established in the Ministry of Health in the medium term.

This unit will be in charge of all aspects of the implementation of the EPR programme:

Coordination across agencies and sectors: The Ministry of Health, through the EPR unit, will be the lead health authority in an emergency response and will ensure coordination between all national and international health organisations with national and local health services.

     Coordinated allocation of responsibilities will ensure that health sector gaps are met and that duplications are avoided as much as possible. Specific responsibilities of different health agencies must be documented in consultation with the Ministry of Health (Memorandum of understanding "MOU" etc.)

     Regular health sector coordination meetings will be held for local and external partners at both central and field levels. The frequency and the priorities of these meetings will depend on the state of alert.

UN Maldives Emergency Preparedness

There is presently no plan. First steps have been done to draft one.

General Emergency Coordination

Coordination Mechanisms: The following coordination units (CU) ensure a concerted effort at all levels of the disaster management programme.

The National Disaster Management Centre (NDMC) Following the tsunami, the Government set up a Ministerial Committee and a Task Force. A National Disaster Management Centre was established to facilitate the response and coordination. The Ministry of Defense and National Security, Ministry of Finance and Ministry of Planning and National Development lead the emergency response and relief effort in collaboration with other departments, UN agencies and other development partners. This centre is focal point for response, relief and recovery activities. But the function of NDMC for longer term reconstruction and rehabilitation process is to be yet decided. Figure... illustrates the current organisational set up of the NDMC.

The National Disaster Steering Committee: This is the CU that coordinates all response agencies – at intrasectoral, intersectoral and international levels.  

Useful Contacts