Dr Niyaf's Online Clinic

Accepting the strike but not the method?

Dr Abdulla Niyaf — Tue, 03 Mar 2009 12:13:00 GMT

Lessons not learned?

Maldives has seen 4 major industrial strikes in recent years. The Taxi drivers strike, teachers strike, the tourism workers strike and now a "strike" by doctors at IGMH. All four have, in my personal opinion, not gone down well with the majority of the public. At the very least, that is the impression one gets from the publics' response. The fact that the state-controlled media aggressively portrayed the striking fraction as inhumane and selfish, in all four cases, didn't help either.

It is my understanding and belief, that calling for and going on strike is not the problem. It is the method of the strike and the way the strikers and the media "sell" the cause and effect of the strike. Most strikes that disrupt services, no matter how small the impact, would face resistance and hence has the potential to be disliked by the public. Perhaps, this was one of the reasons for the apparent poor acceptance of the doctors Sick-Leave-Strike!

Could a different method be more acceptable?

I wrote earlier, at another forum, on how I'd prefer to "strike", at least during the initial phase. Industrial action is within our rights too. I think in Maldives, at this stage of realization of our rights, we'd do better, in terms of results, with a more visual strike than industrial action. That is my opinion. I had discussed using the "lunch break" for demonstrating. It shouldn't halt services at IGMH because people taking part would be on their official break! The striking staff could stand along the sea wall just to the west of IGMH with banners and posters. These could display reasons for demonstrating and their demands. Perhaps slogans could be used too. Media could be invited to cover the daily Lunch-Break Strikes. The protest for the day must be wrapped-up before the lunch break ends to allow staff to return to work. A form of visual demonstration could be continued beyond the lunch-break using arm bands or badges. If these strike fail to achieve results or at least a constructive dialog then further steps could be considered. Then, for the greater good of the profession and ultimately that of the health of the people too, an industrial action would be necessary.

The medical service providers, including those of us at IGMH, have had unnecessary and unacceptable stress and inconveniences added to the frustrations of a grossly inadequate and under-resourced medical care provision system for years and years. Any time something good happens and the expectations and hopes for a better health care system gives us hope for the future, someone comes along to kill those dreams. The frustrations build and finally the last straw breaks the camels back!

Why strike? Is pay the only issue?

I can understand, one may say because I am an "insider", why the doctors at IGMH went on the Sick-Leave-Strike. There are several reasons for a strike or a show of disapproval and displeasure. Salary is an issue, an important one too, but it is certainly not the sole one, as some politicians and Commissions would like the public to believe. That was just bad politics adding insult to injury.

Pay is an issue because, in addition to our work being one which is in itself humanitarian, it is work and a means of earning a living too. There will be people who disagree with me, and that is perfectly fine with me, but it is not wrong to ask for a pay increment when your official work hour has increased by 2 hours per day too! Fine, we are faced with financial and fiscal challenges and one may need to revise pay scales to suit the financial capacity of the government. But then, why would the authorities call the changes to pay; a "pay increment"? Just for the technical truth in it? How is it that they then justify the political elite being allowed to continue to draw salaries that truly burden the national budget even during this same financial hardship? How dare the MPs attempt to discredit us on national TV when they have voted for themselves a pay rise? Then again, is there any reason why we should expect anything less from them?

Questioning a doctors humanity.

A doctors work should be professional, capable, caring and humane. Drawing a salary or getting paid for providing a service does not make it any less humane! I'd be happy if doctors participate in Free-Medical care. Many of us do that too in our own capacity. Go on, make health care free for the people. We'd be happy too. It is disgusting and hurting to think that people look at us as money hungry and inhumane. That is so far from the truth.

Perhaps ensuring alternative striking methods wouldn't have caused these false accusations. Again, I wonder if it is fair to expect anything different from those opportunistic politicians either way. Nonetheless, industrial action that results in service disruptions could have allowed for bad politics taking advantage of the situation.

What is the real pay change?

Just for the record, I have been told, that my take-home pay has not decreased during this pay scale revision. It is exactly the same Rufiyaa for Rufiyaa as it was before. All my allowances were canceled, according to my employers, but my basic salary was increased to adjust for that. So despite the significant increase in official work hours (lets not even talk about the actual time some of us spend at the hospital) we would have to be content that our salary is not going to be reduced. To think that it could have been worse, I am just about content.

Unfortunately though, I am told, some of my colleagues didn't fare as well. They will actually be taking home a significantly less salary than earlier. Some of them having to be "thankful" for a reduction of only a few thousand! That too when the purchasing power of the Rufiyaa is falling due to various reasons. It would put a different perspective to the situation if one accepts that the changes in economic condition would affect everyone, doctors included, and not just the government.

I'd like to add here that it is not only doctors or nurses who are affected by these pay changes. There are probably others in other fields of work too. My thoughts are with them as well. It is not fair for them either. I'd encourage them to make their voices heard too.

Giving more time to mismanagement.

During the recent presidential election campaign, while campaigning for DRP, we heard the then Health minister, Ilyas Ibrahim, say that it was a failure of the administration at IGMH that was the primary cause for the institutions failures. Many of us had literally gone blue in the face saying the same thing, repeatedly, to the authorities without them heeding a word of it. The only action they were ready to take was to try to silence the very people who tried to convey the truth.

Members of the current ruling party, MDP, both before and after the election continue to say that the administration at IGMH is a failure. Is it then not surprising that the very elements that they have so openly labeled as utter failures are now either in the same posts (may I mention with a better pay) or at similar or higher posts within the ministry. All that, when the public continue to suffer the inadequacies and failures of the health system and its institutions.

We anxiously wait to see what the 3 month deadline for an A-Z change at IGMH would actually bring about! I wonder too, what is the rationale for allowing the decay to continue for another 3 months while we wait for that all-fixing change?

Is the publics mistrust of the health sector justified?

Truth be told, the attitude and lack of professionalism among the service providers including doctors has not helped either. There is no smoke without fire and there must be reasons why the public mistrust health care workers! We hear again and again of few doctors speaking rudely to patients, doctors who fail to see patients under their care (even when patient is in ICU), doctors failing to provide reasonable explanations and information to their patients, etc. These are some of the reasons for the mistrust but there will be many other that one could list, should one attempt to make an all inclusive record. Having said that, it is also true that there are several doctors who are truly professional, caring and capable in their work. The few bad apples certainly are spoiling the whole basket. It would take much effort to bring out the kind, caring and professional face of this profession to the forefront. That is a challenge we must meet.

But meeting that challenge is increasingly being made impossible both by the actions of the politicians and Commissions who continue to attempt to undermine the profession and the health sector as a whole. Inciting the public, to further mistrust the service providers, on state media is likely to make the gaps even wider. Their short-sightedness may make them popular for a while, but it threatens to suffocate the health sector even further. Why would they care? They could easily afford, especially with the benefit of their healthier pay, to travel abroad for medical care. We suffer. Our patients suffer!

Do we have appropriate infrastructure?

It is no secret that quality medical services require certain infrastructure, including human infrastructure. Medical equipment at IGMH and many other health institutions are at best; basic and historically poorly maintained. Once in a while the media highlights non-functioning of certain essential equipment and brings it to the publics notice. CT scans, ultrasound scan machines, Xray machines and ECHO machines: out of order, blood culture services discontinued for months and ventilators waiting for spares happens far too frequently. The lack of back-up systems has on several occasions compromised the institutions ability to provide even essential care! Quality of care is an even bigger challenge in this situation. The brunt of all this is usually borne by the clinical workers. Add to that the lack of several important drugs despite repeated requests at various forums. Even with those that are supposed to be available, supply is a major concern. We have had instances when Male' ran out of Paracetamol, Augmentin, Penicillin and ceftazidime, just to name a few!

Personnel development and training opportunities has over the years been on the decline. Seats for MBBS and specialization supported by government funds (or donor aid) has decreased. Cheaper opportunities are invariably preferred over quality. It is an expensive field, we accept. A bit of investment to quality is nonetheless essential. Private funding has tried to fill that gap in past few years. Thankfully such arrangements have helped and we are very thankful to the parties who have sponsored many of us. It is not only about training doctors though. Providing health care requires a team: doctors, nurses, lab technicians and several others. Training opportunities for the support services too, is far from adequate. For instance, medical equipment need maintenance to keep them in proper working order. The lack of appropriately trained Biotechnicians at IGMH is one reason for the poor maintenance of vital medical equipment. Add to that the lack of support and spare parts and the system could literally grind to a halt.

So there are reasons for unhappiness. That list isn't an all inclusive list either. Perhaps some of us should sit together and make that all inclusive list soon.

What about next time?

I'd like to hope that there will be no need for a next time. It is not something we'd hope to see in a democracy that functions along the lines of fairness, equity and transparency. We are happier working than staying away from it. Whether one believes or not, we take great pride in the work we do, at the same time being humble in accepting our human limitations.

Strikes don't always work. They sometimes make things even worse than they were before. Perhaps, if forced with the necessity, a re-think of the method, a more thought-out, better planned and less disruptive strike could be more effective and acceptable with the public. Or would any strike be acceptable? Ever? Certainly not for the party in power. The public, though, maybe more receptive if they could be engaged and better informed.

Here is wishing that there'd be no need for any of it.

Joining the SICK-LEAVE !!!

Dr Abdulla Niyaf — Tue, 24 Feb 2009 08:47:00 GMT

Displaying solidarity with my colleagues back home!

Running into the Maldivian Health Minister at a food court in Delhi.

Dr Abdulla Niyaf — Tue, 24 Feb 2009 07:26:35 GMT

Yesterday was a half day at work for us, WHO Fellows at AIIMS, and we took the opportunity of an afternoon off to go to Delhi's favourite hangout: Select City Mall at Sarket. It is a nice place with a young Delhi crowd hanging around and having fun. After checking out the few electronic shops (my favourite part of any Mall) I ended up at the food court.

I was just near the end of my Shredded Lamb Sizzler when out of the corner of my eyes I noticed, to my surprise, familiar faces at the table just next to mine. There sitting and having Kebab were Minister Aminath Jameel and her team from the health ministry of Maldives. A small world, huh? I went over, and over pleasantries found out that they were in Delhi to meet the Indian health minister. I impulsively asked Dr Yasir, a member of that team, if it was regarding IGMH. What I gathered from the conversation was that IGMH-foreign-management wasn't a done deal yet and that their visit was related to a number of issues.

It was good to hear that they were trying to improve the health sector in the Maldives. They were trying to do what they believed was the right thing to do. I do not agree that giving IGMH to foreign management is the only solution though. But right now, I'd be willing to consider that option as an alternative to the utter mismanagement at IGMH! It is too painful to see our people suffering the effects of an inadequate and grossly mismanaged health care institutions. Certainly, a well performing health institution is far better than one that doesn't. It hurts to think that by bringing in a foreign management we are proclaiming our incapacity to manage such institutions ourselves. I would like to think that we do have people who could truly manage an institution of this size and importance among our own people! Then again; the handful of individuals who, over the years, were given the opportunity and responsibility of managing IGMH did not do anything worth much praise. Perhaps, one would argue, there are others who are more capable.

One way or the other, IGMH, and possibly other health institutions in Maldives, must change to meet the medical care needs of our people. Years of neglect and failure must now be addressed. It most certainly won't be easy. Difficult decisions may need to me made. I, as a practicing clinician and a Maldivian citizen hope that the changes happen quickly and more importantly deliver results that meet our peoples needs.

Planning to move the Question box to a different URL

Dr Abdulla Niyaf — Sun, 15 Feb 2009 16:50:00 GMT

I am planning to move the CBox (Question Box) to another URL. I have activated subdomain ask.niyaf.com for this purpose. That site will be used to host the CBox and a blog. It is already up and running. Please visit that site.

I will also keep the CBox on this blog for now. Let me know what you think.

Letter to Haveeru

Dr Abdulla Niyaf — Thu, 12 Feb 2009 14:40:00 GMT

Dear Editor,

I would be very grateful if you could share this bit of information with the author of the article on complementary feeding that appeared on Haveeru Online. I would also appreciate it much if a correction could be published as well. This is requested to prevent spread of misinformation and to prevent inappropriate feeding practices.

In the article the author mentions the age to start complementary foods (solids or weaning foods) to a child as 4-6 months. While I agree that some internet sources still mention 4 months, erroneously I must add, as an appropriate age to start complementary foods the current best practice advise is to initiate complementary foods at 6 months of age.

Exclusive breastfeeding is recommended from birth to 6 months of age. This is our national policy as well. It is the policy of WHO and UNICEF on infant feeding and nutrition.

Dr Abdulla Niyaf

References:

The WHO infant feeding recommendation

UNICEF key messages on infant and young child feeding.

I would like to thank Azhad for bringing this to my notice.
This post is made using content I sent to Haveeru via email.

Got reply to Email.

Dr Abdulla Niyaf — Wed, 04 Feb 2009 15:02:00 GMT

I got a reply from IGMH today regarding my query earlier about change in working hours, OPD timings and the new salary. I guess much of the work regarding all these things is still only just happening. I wouldn't be surprised if this is the case at many of the other institutions.

Anyway, my working hours would be, on a regular working day, from 8AM to 4PM with an hour break from 12PM to 1PM. The hospital OPD timings, I understood from the brief email, would be from 8AM to 12PM for morning and 1PM to 4PM for afternoon. It isn't yet clear to me, if, on my OPD duty days, I'd be doing OPD from 8AM to 12PM and also 1PM to 4PM. I have requested for clarification.

The salary is as much a mystery to them as it is for me. Apparently, the Civil Service Commission has not communicated the final decisions on the salary to my employers.

Request for information from my employers.

Dr Abdulla Niyaf — Tue, 03 Feb 2009 07:35:00 GMT

This was an email I had sent to IGMH a few days earlier. I guess they have been busy with other things and could not find time to reply. I was hoping that perhaps doing this might help move things a bit faster.

I would like to request for information on the changes to the work timing (for me as an SR in pediatrics), off days per week, change to salary and other new information that I, as an employee of IGMH, is required to be given.
I would be very grateful if you could provide me this information as soon as it is possible for you. As you might be aware, I am away from the country on a short training program and am unable to get the required information.

Could I also be bold enough to give a suggestion? I would like to suggest that IGMH administration use the internal email addresses (like dr.niyaf@igmh.gov.mv) that have been provided for its staff, to communicate important information, notices and memos. Every employee could then obtain such information as emails sent by the admin. I see this as one important reason to have this email address given to the staff.

Thank you,
Dr Abdulla Niyaf
SR (Pediatrics)
Hosp ID no: 19808

I wouldn't mind someone else replying with the information either.

Why I believe the new appointment system at IGMH is not in the patients best interest.

Dr Abdulla Niyaf — Sun, 01 Feb 2009 15:07:00 GMT

This is my personal opinion and it is independent of any official IGMH position.

I read a news article on Haveeru Online. It presented an interview with an official from IGMH regarding a change to the OPD appointment system starting from 1st February 2009. The change, apparently made after discussions with relevant staff (I was, sadly, considered irrelevant), was to stop doctor specific appointments. That is; you would no longer be able to get an appointment for a specific doctor by name. Instead patients will be provided the next available appointment slot for the related department dealing with the kind of illness. It could be for any doctor of that department.

I certainly would have voiced my concern had I been included in the group of relevant staff. Perhaps the fact that I am away from IGMH, on official leave, was the reason my opinion was not sought.

I believe the new system is not in the best interest of the patients. It is likely to force many patients to turn to private clinics to be able to consult the doctor of their choice. It is no wonder that many common people are speculating this as the intended reason for the change.

Why do I believe that not allowing doctor specific appointments is against the best interest of the patient?

Diagnosis may not be possible in a single consultation.

I agree that a large number of patients who present to hospital suffer from relatively minor ailments that are relatively easy to diagnose. Perhaps some of them could be diagnosed in a single OPD visit and treatment advised. In some of those cases a follow-up may not be needed.

However, a significant number of patients have illnesses that require more than a single visit for diagnosis and institution of the required treatment. Some of them may need to have investigations done to help establish diagnosis. Others may need follow-up after a few days of instituting therapy to assess the response so that therapy could be modified where response is not as desired.

In these situations having to see a different doctor at each visit could be frustrating for the patients. Each doctor may need to start from the very beginning, repeating many of the things already done by the other doctor at the previous visit; like repeat of history.

Having the opportunity to consult the same doctor with the reports or after initiation of therapy is therefore better for the patient and the doctor.

Continuity of care for Chronic illnesses.

Some illnesses have a long course, even with treatment. Some may have recurrent episodes of illnesses while others maybe lifelong. In these situations continuity of care is absolutely vital for proper care.
The system being proposed prevents this kind of continuity of care. It opens up the possibility of unnecessary alterations to treatment and therefore prolonging the ailment.

Not all doctors within a department have the same capacity.

Some doctors within a department may be better dealing with certain specific types of illnesses than others. This is recognized among doctors within a department as well. It sometimes happens that we refer patients between each other because of this reason.
Some doctors may have had extra training in specific areas, in addition to the specialty training of the department. We have some specialists who have acquired extra skills and knowledge specific to a sub-specialty field. For instance a physician may have extra skills in treating Diabetes or Kidney diseases. In such cases, being able to refer patients or guide them to one of these people, where the need exists is likely to be more rewarding to the patient. This wouldn't be possible with the new system at IGMH.

In addition to these, there are various other reasons why a patient may choose to or prefer to consult a specific doctor; like past experiences with a doctor could prompt a patient to either prefer a specific doctor or not.

I believe that the system needs to change to allow for an opportunity to allow patients to seek consultation with a doctor of their choice. I would support having some OPDs where patients are able to get appointment by a walk-in system. Such OPDs as OAPC (Open Appointment Pediatric Clinic) and Walk-In OPD at the internal medicine department were doing this even before. Perhaps they need to be managed better to improve its value to the public.

I urge the IGMH administration to reconsider the changes and come up with a system that indeed is in the patients best interest.

Out of country until 1st week of April 2009

Dr Abdulla Niyaf — Fri, 23 Jan 2009 09:22:00 GMT

This is for the kind information of visitors to this blog and the parents of my regular patients. I apologise for any inconvenience my absence from the country is causing them.

I am currently out of country on an official appointment. This time I will be away until 1st week of April 2009. I was selected by WHO for a short Fellowship program. I am currently in New Delhi, India; undergoing Fellowship training in Neonatology at All India Institue of Medical Sciences (AIIMS).

I intend to learn as much as possible during this program to further improve neonatal services at NICU at IGMH and across the country.

Out of town for 2 weeks

Dr Abdulla Niyaf — Tue, 18 Nov 2008 18:19:00 GMT

Dear readers

I am scheduled to be out of Male' for 2 weeks beginning 21st November 2008. I will be traveling to Chiang Mai, Thailand to join a Fellowship program on Infant and Young Child Nutrition.

It is likely that I may take much longer than usual to answer the questions posted on this blog during this time.

I hope to be back in Male' on the 7th of December 2008.