A look into Aasandha, as it evolved over the years.
In January 2011, the Maldives took a significant step towards universal healthcare with the launch of Madhana, a comprehensive insurance scheme initially targeting civil service officials and senior citizens. Over the years, this scheme has evolved in both scope and scale, reflecting the country's ongoing quest to provide accessible and affordable healthcare for its citizens. This journey, however, has not been without challenges, raising critical questions about the scheme's sustainability.
When Madhana was first introduced, it quickly became evident that a broader coverage was necessary which led to the creation of Madhana Plus with expanded benefits to include overseas care, albeit at a higher cost. Simultaneously, Madhana Basic offered a lower-scale option for individual subscriptions, providing similar benefit packages but with lower monetary caps.
Beneficiaries under Madhana could access outpatient and inpatient treatment at any empaneled facility on a cashless basis, subject to specific sub-limits and cost-sharing provisions. The standard cover was capped at MVR 100,000 per annum per beneficiary. By 2012, recognizing the need for even broader coverage, the scheme was rebranded as Aasandha. This iteration aimed to enhance affordability and accessibility, extending benefits to all Maldivians with the same annual cap but introducing a specific cap for outpatient services.
In 2014, the introduction of 'Husnuvaa Aasandha' [Limitless Aasandha] marked a significant change by removing the MVR 100,000 cap and further expanding coverage. This change was driven by the ambition to provide more comprehensive healthcare without the constraints of a fixed annual limit.
By 2019, the scheme extended its reach beyond the Maldives, with Merana providing financial assistance for healthcare to Maldivians residing in Sri Lanka, India, and Malaysia.
January 2024 saw the latest reform under the President's pledge to implement biannual medical check-ups for every citizen.
Despite these advancements in scope and coverage, the sustainability of Aasandha scheme remains a pressing concern. Over the past five years, Aasandha has consistently exceeded its budget absorption by 20 percent. With a total budget of MVR 1.9 billion (USD 123.2 million) allocated for 2024, the first quarter alone saw expenditures rise by nearly 5 percent compared to the previous year. Between January and March 2024, MVR 838 million (USD 54.34 million) was spent, reflecting a 4.8 percent increase from the same period in the prior year.
At the end of 2023, Aminath Zeeniya, the Managing Director of Aasandha Company, highlighted a staggering 56 percent of the budget being spent on pharmaceuticals. This high expenditure prompted discussions around cost-cutting measures, with initiatives such as bulk procurement and setting price ceilings for medications kicked off sometime back, but yet to materialize. The World Bank’s Public Expenditure Review (2022) also showed that spending on Aasandha scheme grew at 18 percent annually, on average between 2014 and 2019, and the average drug prices under Aasandha Scheme were 15 to 75 times higher than international benchmarks.
“Another significant issue is the procedural expenses of private hospitals”, Zeeniya noted that while initial procedural costs might seem affordable, the final invoiced bills often reflect substantial increases, sometimes even higher than the cost of treatment abroad.
This discrepancy is attributed to a lack of control and co-payment agreements with the Ministry of Health for private hospital procedures. It has also been observed that private providers including clinics charges a hefty amount for consultation and diagnostics. A senior citizen from Male’, Fathimath Ibrahim, expressed her concern: “While I’m grateful for the coverage, the costs at private hospitals and clinics continues to rise, and the out-of-pocket expenses have become more than what is being covered under Aasandha, which worries me”.
While Universal Health Care Insurance is widely utilized, there exists other insurance schemes underused, resulting in some individuals having double coverage under state funds.
“It is unacceptable that despite the many benefits provided by the Aasandha Scheme, there are other schemes offering broader coverage to some. I believe health insurance coverage should be uniform, and any additional coverage should be paid out of pocket.”- A middle-aged man expressed concern over lack of uniformity in insurance coverage.
The Maldives allocates a significant portion of its budget to healthcare, with an expenditure of MVR 7,459.4 million (USD 483.76 million) in 2024, comprising MVR 3,709.1 million (USD 240.75 million) for hospital services and MVR 2,190.8 million (USD 142.01 million) for medical support.
This investment represents approximately 7.24 percentage of the country’s GDP, comparatively higher than many other South Asian nations. Despite this considerable expenditure, the healthcare outcomes remain suboptimal.
The Aasandha Company has revealed that in the first quarter of this year, a total of 1,691 individuals were sent abroad for treatment and 1,599 evacuations were carried out to transfer patients locally from one island to another for emergency medical treatments.
Expressing concerns over the scheme's sustainability, during the parliamentary session in 2023, Zeeniya advocated for transitioning Aasandha into a service that includes co-payment or an annual fee from the public. The World Bank has also recommended several measures to improve the scheme's efficiency. These include bulk procurement of essential and generic drugs, negotiating closed-ended rates with overseas providers, and improving case management for chronic illnesses at the primary care level. The most recent IMF Country Report has also called to implement bulk procurement to generate cost savings and impose revised coverage prices for sustainability of the scheme.
While Maldives continues to refine its healthcare insurance system, the journey from Madhana to Aasandha reflects both progress and ongoing challenges. Ensuring the sustainability of this essential service requires not only financial prudence but also innovative approaches to healthcare delivery and management, as highlighted by the recent studies.
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