despite all the criticisms of the health services, for the amount of financing that it receives (about 4% of GDP; Europe: 10%) its performance is commendable
It is only when we lose something that we possess that we realize its value and how much we miss it. The most prized possession of all is health: we may have all the possessions in the world, but if we do not have health they are worth nothing, absolutely nothing. Rightly, therefore, is it said that health is our true wealth.
This truism awakes us to the realization that the health of nations should be the finality of all development – for which wealth (money) is required. But to create that wealth every society needs a healthy population – in other words, human beings who are both physically and mentally fit so as to work, produce and develop whatever is required not only to keep them in good shape but also to enjoy their life, the fruits of their labour. Thus, there are determinants of health, that is, factors that are essential in order to have a healthy population. They are, broadly, medical (effective treatments available), economic (the cost of health care), political (organization of access to health care), and social (ability of patients to access health services and to comply with medical treatment).
As important as were the political advances that led to independence and the politics that have followed since with their impact on the overall socio-economic development of the country, certainly of no lesser interest – in light of the introductory remarks – is the evolution of our health services during that period. What follows is a very limited overview which tries to capture a few dimensions of our health system, in which I have been a ‘player’ since 1972. I started off as a non-specialist junior doctor in the Ministry of Health and then worked as a specialist (Orthopaedics and Plastic Surgery) until I was appointed as WHO representative in 1999/2000, and then Chief Medical Officer/Director General Health Services (2006-2013). I have also practised as a specialist in the private sector.
This summary of my positions in the MOH is meant only to indicate that I gained experience not only in the clinical field (treating patients) but also in the administrative domain, with exposure at national, regional and global levels. Together, they have constituted a vantage point from which I could assess our health situation in a holistic manner, and not from a narrow clinical perspective.
This, unfortunately, is an inevitable ‘déformation professionnelle’ especially when one is a specialist – for specialists are notoriously narrowly focused. I would just like to add that I also took an active part in union activities, including a go-slow (probably1981) that resulted in the loss of two days of pay from my Registrar Specialist salary which was then a princely Rs 3750/month.
Shift in pattern of diseases
Before we consider other aspects it is necessary to understand that the epidemiology or pattern of diseases in these 50 years has undergone an initially gradual then an accelerated shift, from what are called communicable (infectious) diseases to non-communicable diseases, which are known today as NCDs. Poor hygiene and sanitation facilities, along with lack of potable water, were in the main responsible for the former, whereas rapid industrialization and globalization have driven the rise of the NCDs which are now a worldwide scourge in all countries. In the poorer countries the NCDs are a ‘double burden’ as they add to the existing, large load of communicable diseases. We are not in that category.
Our health infrastructure, the range of services offered and the human resources required have therefore developed to meet the challenges brought about by this transition.
Brand new SSRN Hospital and infrastructure
That’s where I joined in July 1972. It was the third general hospital, later to be renamed Regional Hospital, that was built in the country, the other two being first, the oldest one in the island – Civil Hospital as it was then known –, and next Victoria Hospital which then harboured the only Orthopaedic Unit in the country. The Health Services (HS) then comprised these three general hospitals, the specialized Eye and ENT Hospitals and Brown Sequard Hospital, four small hospitals in Montagne Longue, Souillac, Flacq and Mahebourg, the Chest Hospital at Poudre d’Or, and a small network of dispensaries across the island. In the private sector there were a few clinics (5) along with the sugar estate dispensaries.
Today we have five Regional Hospitals, and the district hospitals in Mahebourg, Souillac and Montagne have been considerably upgraded. The Chest Hospital has been closed down. The dispensaries have been replaced by a network of over 140 Area and Community Health Centres in line with the focus on Primary Health care enshrined in the first Declaration on PHC at Alma Ata in 1979, supplemented by several Mediclinics. In the private sector there are now about 15 clinics.
Services offered: expansion and specialization
The most fundamental element that characterizes the HS is our immunization (vaccination) coverage rate that is almost 100%. This, along with the availability of potable water to the whole population and the major improvements in sanitation facilities (from bucket and pit latrines to the sewerage system), is what helped to combat infectious diseases. The School Health Services established in the 1950s made sure that children received their vaccinations, and the spread of education resulted in a population that became increasingly health-aware.
Other public health measures beefed up the improvements above, notable ones being the elimination of malaria as far back as the early 1970s (we are the only county with this status in the Sub Saharan region); the eradication of bilharziasis, a disease in which the bladder is infected by a parasite present in rivers, and which was endemic in the ‘Riviere Citron’ area; treatment of diseases caused by other parasites such as intestinal worms and scabies (‘la galle’) among others.
Occupational Medicine services developed to cope with the conditions associated with occupations, for example the ones related to the agricultural industry and factory work (pesticide use, noise levels that can lead to hearing loss), surveillance of risks associated with other chemicals and radiation, etc.
The clinical side saw the expansion of the major specialities in all the Regional Hospitals, and subsequently the addition of sub-specialities such as cardiac surgery, neurosurgery, renal transplantation, neonatology, cardiology, nephrology, and diabetology. Local expertise has been increasingly supported through collaboration with overseas centres such as the University Hospital Geneva, Cardiac/Neurosurgical/Ophthalmological Centers in India and elsewhere.
Dental services, besides being present in the Regional Hospitals, are offered at the Health Centers, which also cater to pregnant women, as well as provide advice on sexual and reproductive health.
All the above are robustly supported by the Central Health Laboratory at Victoria Hospital, and the National Blood Transfusion Service is also located there. These two departments are ably led by extremely competent staff, and undergo continuous major technical upgrades.
It goes without saying that a variety of human resources was needed to run these services. As far as doctors are concerned, traditionally Mauritians used to go to England and France, and a few to India. The opening of access to the USSR and other ‘iron curtain’ countries at the beginning of the 1960s gave the opportunity to many citizens to pursue medical studies there, and when India became a republic it also offered scholarships in medicine, while other students could avail of self-financing schemes; similarly with Pakistan. Over the past couple of decades, China has also become a good destination especially in terms of cost of studies.
The Mauritius Institute of Health (MIH) collaborated with Bordeaux University to train doctors as specialists as from the later 1980s, and SAMU staff also were prepared through a similar scheme. The University of Mauritius was also running a preliminary bachelor medical course of three years, following which the students went to the UK (now no longer) and to Bordeaux for completion. Now there is collaboration with the University of Geneva as well. In 2000 the SSR Medical College at Belle Rive was set up as a private institution, and there is also now the Anna Medical College.
As far as nursing is concerned, training continues to be imparted at the Central Nursing School at Victoria and its branch in Pamplemousses adjoining MIH. The latter has also trained other paramedical staff such as physical therapists and speech therapists, and has also run courses in sexual and reproductive health for the Africa region. Laboratory staff were also trained at the Central Laboratory and sat for their exams set by a recognized UK body, with those keen to do more specialized and degree courses proceeding overseas, mainly to the UK.
Doctors and dentists used to register at the Supreme Court before the advent of the Medical and Dental Councils in 1990, and a Nursing Council followed suit. A Pharmacy Council has seen the light of day recently, and a Health Professionals Council to regulate all other allied health professions is in the offing.
Briefly stated, from even before Independence services were offered ‘free at the point of delivery’, that is, the user did not have to pay for public health care. It was funded through indirect taxation. This is the model of the NHS in the UK, on which our HS is based, and has continued to date, and Mauritius therefore has universal health cover age according to WHO norms. However, there is also a significant private sector which is expanding, and despite the fact that it caters to only about 20% of the medical workload, private health expenditure has been shown to have exceeded public health expenditure in our National Health Accounts.
This incomplete account can only give a glimpse of the evolution of our HS and the progress made in the past 50 years, and each item or topic can be vastly elaborated upon. What I can say is that despite all the criticisms of the HS, the public sector in particular, for the amount of financing that it receives (about 4% of GDP – compare this to Europe’s 10% plus average and America’s approaching 20% soon) its performance is commendable, even in relation to advanced countries. We manage to treat almost the totality of medical conditions that we encounter, with only a relatively small number having to go overseas, and that number too is reducing.
My experience is that at 50 years of Independence, we can be proud of our HS. There are many issues, lacunae and challenges, but it is the same for all HS across the world. It is always a work in progress because of continuing advances in medical science and technology, and we will continue to have to keep pace and definitely make further improvements in the future
* Published in print edition on 2 March 2018