Role of Volunteering in Health in Maldives

M. Zuhair, Society for Health Education, IYV 2001 National Committee Maldives

Country Setting

Maldives presents a host of unique geo-physical and socio-economic characteristics that influence development, and guide volunteerism. Among geo-physical characteristics, the composition of small coral island and their dispersion over a large surface area, innumerable number of reefs and lagoons that inhibit sea travel, and fragile environment, have to be recognised as factors that had moulded the voluntary traditions in Maldives for ages. At present, small size of the communities and their dispersion, migration of rural population to urbanising capital, increasing congestion in the capital and few other islands, and consequential over stretching of capacity factors like land, water and surrounding lagoons invariably determine developmental strategies and norms of community participation. Despite the narrow economic base dominated by tourism and fisheries, Maldives had shown significant improvements in socio-economic parameters such as economic growth, per capita income, infant mortality, life expectancy, and school enrolment, among others. This progress, however, had not minimised the influence of barriers that had inhibited development for decades. For example the challenge of over coming negative consequences of inherent dis-economies of scale, per capita return on investment in social infrastructure, and ever increasing dependence on imports and expatriates, continue to influence most development initiatives. Maldives’ recent entry into the modern development era compels the country to sustain its traditional development tools such as mobilisation of community volunteers in the area of education and health. Meanwhile Government is also compelled to meet the increasing inspiration of communities that expect the public sector to provide all services on each individual inhabited island, irrespective of physical and population size.

Characteristics of the Health Sector

The needs and demands of the health sector directly emanate from the above-summarized country setting. For example, service accessibility is being hampered by the wide dispersion of the communities. Further, the average population size of the communities–currently estimated at around 800–leads excessive unit cost of investments. These factors, along with the financial limitation of the public sector, had delayed the introduction of modern health services to the country until the late 1950s. Services were initially confined to the capital Male’, and despite consistent efforts it took another three decades before modern health facilities became effectively accessible to the rural sector, or the Atoll Region. At present, the health system comprises a network of five levels of establishment. At the grassroots level, each community is supported by a health unit served by a Family Health Worker. At the second tier, or the Atoll-level, Atoll Health Centres and Atoll Hospitals extend health services to the island communities in the neighborhood. The third level is characterized by the five Regional Hospitals serving a selected group of Atolls. The highest level comprises the modern health facilities established in the capital, Male’.

The established services, still, remain inaccessible to a significant number of the communities due to distance and travel constraints. Accordingly the health system needs to expand to meet the expectations of the individual communities. Further, the nature of services provided at the lower levels of the system also cannot provide the services demanded by communities. Consequently, the current policy supports establishing an adequate size facility within a distance of two hours of travelling time.

In the Maldives context, sustainability of established services remains a much greater challenge than the introduction of them. The health establishments face considerable difficulty in recruiting health professionals. Majority of doctors and nurses are expatriates. Even expatriates are often required to provide routine support services, including maintenance and janitorial functions. Excessive demand for expatriates is partly caused by the indifference of the locals to join the health profession. In the meantime, considerable amount of resources is being transferred abroad by those seeking medical treatment outside the country.

Certain social factors too reinforce the need for volunteering. Population pressure in terms of growth, spread, concentration, and composition create entry points for voluntary support. For example, some of the problems associated with the high proportion of youth (around 45 %) could effectively be addressed by volunteers and non-governmental organisations. Such demands for voluntary support are also bing generated by the prevailing high fertility rate and associated parity levels. As in most cultures, sensitivities associated with the promotion of small families and contraception, could best be addressed by the non-governmental sector. Other factors that support involvement of volunteers include the high prevalence of some genetic disorders like thalassaemia, potential risks of HIV/AIDS pandemic, unabated increase in substance abuse. In addition, failure in improving nutritional situation, despite improvements in many social indicators, demands a paradigm shift that could be supported by direct involvement of volunteers.

Role of Volunteers

The above highlights on Maldives, delineate a wide range of avenues for national volunteers. In fact, community volunteers had been supporting many crucial functions of community life for centuries. Their contributions remain prominent in providing services relating to education, health, religious functions, welfare, transport and travel, and disaster mitigation. The community volunteers, who taught the basic skills for reciting the Holy Koran, partly contributed to the high literacy levels enjoyed by Maldivians for decades. In additions to helping the pupils to recite the Holy Koran, they taught the basic skills of writing, reading and arithmetic. Similarly, the local practitioner of traditional medicine (Hakim) provided preventive and curative care for common ailments, voluntarily, for the members of his own community and its neighbors. He is often supported by the traditional "faith-healers" who attend to physiological and psychological problems. They receive considerable respect and admiration from the communities they serve.

Inter and intra-atoll travels were not common, until mechanized transportation became the norm in the 1980s. Until then communities mainly kept routine contact with the capital, Male’, for supplying necessities. Services for such travel and occasional intra-atoll visits were traditionally provided by the private sector, on a voluntary basis.

Maldives is often cited as a country without absolute poverty. Even if the prevalence of poverty could be detected by applying refined analytical tools, the common poverty features exhibited by other developing countries had never prevailed in Maldives. This achievement is partly credited to community norms that had promoted solidarity, kinship, and voluntary support in times of hardship, natural disasters and food shortages. Further, prevailing extended family norms and community spirit had provided an effective safety net for centuries. These positive features in voluntarism gained formal recognition in the late 1970s, and major contributors had been receiving national awards, annually, since 1979.

Volunteerism, in Maldives, entered a new phase with the increasing involvement of NGOs in development. At present, the number of registered NGOs exceeds 400. Almost every island community, numbering 200- has at least one NGO. Although most of them may lack the capacity to provide substantial support to development programmes, their potential strength cannot be ignored. Recently, NGOs that provide direct support to development initiatives had increased significantly. Areas in which the involvement of local NGOs remain prominent include sports, recreation and entertainment, education (pre-school in particular), health promotion, electrification of small communities, environment, and welfare services.

Volunteers Contributions to the Health Sector

A wide range of support services are being extended by volunteers and NGOs working in the health sector, and their involvement mainly falls into the following six categories.

At present the NGO sector has yet to mature into an effective lobbying platform for policy changes in the area socio-economic development. Nonetheless, its success in advocating for appropriate policy reforms in the health sector has been noteworthy. For example the efforts of NGOs had resulted in incorporating gender dimensions in health service delivery. They have also contributed to endorsing more flexible policies towards expansion of health infrastructure in the Atoll-region, as well as posting doctors in Atoll Health Centres. Popular acceptance of the genetic blood disorder, thalassaemia, remains an outcome of efforts taken by a local NGO. Despite the high prevalence (18.1%), thalassaemia was not recognised as a critical concern of public health till the 1990s. Concerted efforts of a national NGO that educated the public about the seriousness of this issue in terms of its potential consequences and costly treatment led to the Government’s formal recognition of the problem in the 1990s. Thalassaemia majors require monthly blood transfusion and associated treatment to survive. The only permanent cure available is the costly bone marrow transplantation. Formal recognition of this problem, by the Government, led to the launching of a preventive programme and the establishment of the National Thalassaemia Centre in 1994. Recently the Government’s policy also has supported the acceptance of prenatal diagnoses and medical termination of pregnancy as options that could benefit reduction in number of thalassaemia majors.

NGOs also had played a crucial role in reforming policies in the area of family planning. Their programmes partly contributed to the desensitisation of contraception and popularisation of condoms. These efforts helped the Government to introduce policies that are more favourable to the expansion of family planning services through out the country.

Volunteers and the NGO sector are directly involved in health promotion activities. For this a wide range of print materials are being produced by the NGOs involved in the sector, and disseminated through health establishments and schools. These materials focus on preventive measures and addresses crucial topics such as HIV/AIDS, substance abuse, and nutrition. Sometimes the materials are presented to student in secondary schools and discussed in public forums specifically convened for that purpose. They are also being used in peer group training programmes. Occasionally, print materials focussing on health awareness are displayed in Health Exhibitions conducted in selected island. NGOs also support the health promotion activities of the Government by producing radio and TV spots. A weakly radio programme has been broadcast by one national NGO in collaboration with the government radio station. Beside using the media, NGOs very often use interactive approaches in delivering health messages by organising discussion forums for the public, parents and students. Under a regular programme, one NGO visits all the secondary schools in the capital to conduct discussion forums for student in grades 9 and 10. In addition, counselling services established by some NGOs also support health promotion activities.

Only few NGOs, has supported infrastructure development. A major contribution in this area is the construction of health posts in the Atoll-region. So far three island health posts had been constructed and handed over to the respective communities for management. In addition one Atoll-level health post had also been established to support health promotion and care within the atoll. Two facilities are currently under construction in the capital to provide treatment and rehabilitation support.

Many national NGOs are involved in programmes that support prevention of health problems, such as HIV/AIDS, thalassaemia, diabetes, cancer, and hypertension. On of the costliest prevention programme is the prevention of thalssaemia in Maldives. Under this programme one national NGOs spends US $13.5 per person, on average, for the screening of the target population of 15 - 35 years. Except for four communities, all localities have already being visited under this programme, thereby facilitating the screening of more than 60,000 people, representing around one fifth of the total population. Along with their involvement in prevention activities volunteers and NGOs are engaged in providing treatment services. Provision of free treatment, in fact, had remained the most significant contribution of traditional volunteers. For ages, the local practitioner of traditional medicine (hakim) had been providing free treatment. Very often he had been the only person who could provide any treatment support, and thus remain on call day in day out. With the expansion of the medical facilities the significant of this service had diminished in recent times, but is yet to be fully replaced. Currently voluntary share is being dominated by the cash and in-kind support provided by the more affluent people for costly treatment abroad. This assistance had benefited those receiving treatments for kidney and bone marrow transplanting, cancer, and major operations. For example, bone transplantation that remains the only cure for thalassaemia majors, costs more than US $30,000. And at present there are more than 450 children who eagerly waits for such a chance. For those few children who are lucky to secure funds and a matching sibling, success in bone transplantation is like getting a fresh start in life. Until they meet such a success thalassaemia majors have to depend on monthly blood transfusion and associated costly treatment for survival. NGOs are also supporting these children by donating relevant items such filters required for blood transfusions, Desferal injection, and injecting pumps used for iron chelation. In the meantime volunteer blood donors remain a strong ally of this treatment. Meanwhile NGO sector is also becoming more active in providing rehabilitation support for disabled people. This service is directly supported by volunteer medical doctors and relevant paramedics.

As highlighted above free consultation had been a key input of the volunteers for ages. Till the introduction of modern facilities, free consultation has been provided by the practitioner of traditional medicine who visit the patients at home, some times spending days on travel. At present some doctors volunteer to provide free consultation through programmes organised by NGOs. A new dimension of the involvement of volunteers in supporting consultation is their assistance in guiding patients who visit doctors working in country-based establishment as well as those located abroad.

NGOs role in the providing counselling services to different clientele had been quite significant. In fact, counselling as an option for treatment became popular as a result of the involvement of NGOs. Those organisation involved in counselling provide subject specific as well as general counselling services. Issues mainly addressed by counselling programmes include thalassaemia, substance abuse, marriage, and HIV/AIDS. Most often telephone help-lines are utilised by clients, due to privacy concerns. But visits to counsellors are slowly gaining popularity. Under the counselling programme, play therapy techniques are also be used for children who are need of such support.

Contribution of IYV 2001 and Future Prospects

National activities of IYV 2001, although has not dominated the events of 2001, they were able to highlight the potential of volunteering. In particular, the occasion helped to initiate a paradigm shift that is more accommodative to volunteering in Maldives. Above all, the commemoration provided an opportunity to assess the country situation more objectively. Consequently, the authorities are now more serious in studying the problems and benefits of the voluntary sector. On-going reviews and discussions on constraints faced by Maldivian NGOs, for example, could benefit in enhancing their role and status in national development in the near future.

Though the IYV2001 has yet to produce any meaningful networking mechanism, the concept and benefit of this instrument has already be accepted by the authorities as well as by the volunteers themselves. Future development in this area could become one of the main achievements of IYV2001.

Commemorations of IYV2001 have definitely promoted volunteering in Maldives. And the involvement of the media and the positive attitude demonstrated by them remain major successes of the occasion. This achievement has significantly brightened the future of volunteerism in Maldives.

Follow-up activities of IYV2001 focus on strengthening legal recognition of voluntary organisation and the establishment of co-ordination mechanisms. The authorities are now conscious of the urgent need to improve the situation in these two areas. And a viable platform that could lead to tangible results is the formalisation of the National Co-ordination Committee of IYV2001, as a permanent body that is entrusted to facilitate the development of volunteering in Maldives.

For more information:

Abstracts:
en Role of Volunteering in Health in Maldives
M. Zuhair

Presentations:
enppt Role of Volunteering in Health in Maldives (100K)
M. Zuhair