Changes in access to and costs of overseas treatment after the introduction of universal health coverage in the Maldives: Findings from surveys and the analysis of claims data

Abstract

Background

Shortages in resources for health and health service delivery in small island states make it inevitable for islanders to seek medical treatment out of the country. This study aimed to assess the changes in access to treatment overseas and its disparities before and after universal health care was introduced in 2012 in the island state of Maldives.

Methods

Using primary and secondary data, two analyses were performed: 1. Analysis of beneficiary data on public subsidy for medical treatment overseas 2010–2013; 2. A comparative analysis of two independent cross-sectional surveys conducted in 2010 and 2013. Public subsidy, financial protection, usage, and costs of medical treatment overseas were analyzed using descriptive statistics and the concentration curve and index.

Results

Number of beneficiaries subsidized for treatment overseas has increased by 199% and the average expenditure per beneficiary has increased by 49.7% during 2010–2013. Average number of visits abroad in a year has slightly decreased from 1.6 in 2009 to 1.4 visits in 2013, but among travelers who made more than one trip abroad, average visits remained at 2.7 per year. Median medical costs have increased by 26.9% and the proportion of household spending on overseas treatment in annual household spending has remained around 20% over the years. The proportion of travelers belonging to average households (household spending below $650) has increased by 107%, and the concentration index decreased from 0.08 in 2009 to 0.04 in 2013 indicating a change towards a more uniform distribution of MTO use.

Conclusions

Despite the fact that the objectives of the two surveys differed which may have led to differences in measurements, it can be concluded that UHC has narrowed the gap between the rich and poor in utilizing medical treatment overseas. However, median out of pocket spending on MTO has increased over the years indicating the need to broaden the benefit package of the UHC program. Further research is needed on the most deprived populations who have not accessed care abroad despite the change in the health financing system in the country.

Keywords

health equity Maldives medical treatment overseas universal health care

Introduction

Access to health services, especially tertiary care is a problem for dispersed populations living in remote areas. The Republic of Maldives, situated in the Indian Ocean presents this unique geographic setting that poses critical challenges to accessing tertiary health care. A population of 336,224¹ lives on 198 extremely small islands which ranges from 0.1 to 5 km in size.² Delivery of health care is a daunting job in the Maldives because of the extensive dispersion of the population, with limited public transport and a large expatriate health workforce with high turnover. In 2011, per capita household expenditure on MTO in the Maldives was $133³ while in 2013, an estimated $70 million was spent on accessing health services from other countries.⁴

The Maldivian government has been committed to facilitate access to health care both locally and from abroad. Per capita public expenditure on health care at average exchange rate has increased from $93 in 2000 to $233 in 2011.⁵ The benefit package of the UHC program “Aasandha” covers medical treatment overseas for services that are not available in country. Estimates of 2009 showed both geographic and economic inequities in health service utilization and mortality in the Maldives.^6–8 Although social disparities in utilization of health services has been analyzed using secondary data, either changes in access to overseas treatment nor the disparities associated with use of MTO has neither been assessed.

While out of the country medical treatment is unavoidable for many islanders, study on the accessibility to overseas medical treatment can provide important policy directions. This study aims to assess the changes in the utilization of treatment overseas and its disparities before and after universal health care was introduced.

Methods

Study setting: The study was conducted in the Republic of Maldives. The health system of Maldives is designed to cater to the unique geography of the Maldives, with one health facility located on each inhabited island. However, like many other small island states, access to tertiary care is a challenge due to its lack of manufacturing capacity (in pharmaceuticals), production capacity (doctors, paramedics, etc.), and absence of opportunities for economies of scale. Due to these shortages in the health system, public subsidy for overseas treatment is an invaluable source for making overseas treatment accessible. Three international airports strategically located in the North, South and Center serves as the main exit points for medical travel abroad. Both surveys covered the three airport islands.

Study design: Three sets of data has been used namely; the claims data among medical travelers (2010–2013), a subset of households that experienced medical travel from the household income and expenditure survey data (2009) and a survey of medical travelers in 2013. Figure 1 shows the three sets of data and how it contributes to the analysis. This study consists of

An analysis of claims data among subsidized medical travel from 2010 to 2013. The dataset is maintained by the National Social Protection Agency of the government of the Maldives. Demographic data of the patient, service use abroad and data on subsidy for each patient was analyzed.

Data set from a survey conducted among medical travelers during June–December 2013 (MTO survey) was compared with data on medical travel from a national household income and expenditure survey of 2009–2010 (HIES). These two cross-sectional surveys were conducted over a 5-month period. Although the 2009 survey was a study of households and 2013 survey was among travelers, the unit of analysis for both surveys is the household. As universal health care was introduced in 2012, HIES is used to represent the period before UC and the MTO survey in 2013 is used to represent the period after UC. The methodology details used in the two surveys are compared in Table 1.

Table 1.

Summary of methodology used in the two surveys.

	Household Income and expenditure survey (HIES) 2009–2010	Survey of medical travelers (MTO) 2013
Study design	Cross-sectional study of households.(only the subset of households that experienced medical travel abroad was used)	Cross-sectional study of inbound travelers who sought treatment overseas.
Study setting	Maldives, 20 Atolls and capital city of Male’	Same
Study period	5 months: September 2009 – January 2010	5 months: August to December 2013
Study sample	A random sample of 39 islands, from all the 20 atolls and the capital city Malé.	A consecutive sample of inbound privately funded passengers and a random sample of subsidized travelers taken from the national database at NSPA.
Sample size	2060 households (648 households experienced medical travel)	815 medical travelers
Inclusion/exclusion criteria	Islands with a population of >2000 were included. Households with expenditures <7MRF per person per day were removed from the sample.	Restricted to Maldivians, who traveled abroad for medical treatment during the study period.
Sampling method	Atolls were first stratified by population size and region. Malé city was stratified by wards. 20 households were randomly selected from each selected island and 15 households were selected from each block from Malé city.	Atolls were purposefully selected by the presence of an international airport. Haadhaalu atoll, Kaafu atoll, and Seenu atoll was chosen.
Data source	Household members	3 International Airports, 3 Regional level health facilities in the selected 3 atolls and government database on subsidized patients who traveled abroad during the study period.
Data collection technique	Face to face interviews and an expenditure diary kept for a one month period in the household.	Face to face interviews in the airport survey.Telephone interviews among subsidized patients.
Incentives	Gift vouchers were awarded for participating households.	No incentives were given for participants.
Recall period	12 months	12 months
Available variables	Expenditure and income data on the household and all individuals from the household.	Demographic data of the traveler and the household of the traveler, disease profile, productivity loss, utilization and expenditures for the treatment episode segregated by government contribution and out of pocket expense.
Variables not available	Demographic data of the traveler, productivity loss due to MTO	Data on private insurance for MTO

Figure 1.

Dataset used and the analysis purposes.

Participants: Claim data of all subsidized travelers were used. Out of the 2060 households interviewed in the household income and expenditure survey (HIES) 2009–2010, 648 households have experienced medical travel. Hence, the subset of these 648 households which was available by their use of financial protection for travel was used. The MTO survey of 2013 consisted of two strata of medical travelers; the subsidized travelers and the privately funded travelers.

Variables: Variables from the claims data include patient id, age, gender, region, diagnosis, treatment, country of treatment, hospital of treatment and subsidy amount. Between the two surveys, variables common to HIES and MTO survey were selected for analysis. Quantitative variables include costs, number of visits abroad and monthly household spending. Costs were segregated by type, such as food, lodging, medical treatment, travel, and other costs in both surveys. All costs were expressed in US dollar at the rate of 15.42Mrf per dollar. This is because, until 2011, the Maldivian rufiyaa was pegged to the US dollar at the rate of 12.85MRF, but in 2011 it was allowed to fluctuate within a 20% band of this amount, which was in the range of Rf10.28 and Rf15.42.⁹ Monthly household expenditures were used as a living standard measure. Household expenditure data refers to the consumption expenditures, where non-consumption expenditures such as loan repayments, taxes are excluded. Derived variables include; annual cost of treatment, annual household spending, and proportion of household spending. Annual cost of treatment was calculated as a product of total cost per episode and the number of visits in a year. Annual household expenditure was the product of monthly household expenditure and 12 months. The proportion of costs for MTO of household spending was calculated by dividing annual cost of MTO by annual household spending.

Data management: For the HEIS data set, monthly per capita household spending was cut into 3 categories using the $2 per day (international poverty line) and average of monthly spending of the (HEIS) sample households. All monetary values in 2009 were inflated to 2013 current price by dividing the value by the consumer price index (CPI) for December 2009 and multiplying with the CPI of December 2013. Other grouped variables include household size and region of residence. Residential atolls were grouped into the seven provinces and further grouped to North, Central and South region. Annual household spending on MTO was calculated by excluding government subsidies.

Statistical methods: HIES data was available in 13 separate tables on Microsoft Access. Tables with data on household, individuals, expenditures and travel were read into R software and merged before analysis. Frequencies, mean (standard deviation), and median (IQR) were used to describe the data. The level of significance was set at p < 0.05. The concentration curve and the concentration index were used to analyze the utilization of medical treatment overseas and financial protection for overseas treatment. The concentration curve displays the share of a health variable accounted for by cumulative proportions of individuals in the population ranked from poorest to richest. The concentration index is defined as twice the area between the concentration curve and the line of equality (the 45-degree line). A negative (positive) index indicates disproportionate concentration of the variable among the poor (rich).¹⁰ Data analysis was conducted using the open source R software, version 3.1.0.¹¹

Results

Results from the analysis of claims data on MTO 2010–2013

Public subsidy for medical treatment overseas

Table 2 and 3 shows the distribution of public funds during the period 2010 to 2013. Number of beneficiaries subsidized for treatment overseas has increased by 199% and the average expenditure per beneficiary has increased by 49.7% during 2010 to 2013. By 2013, public funds have extended its reach to cover 84.7% of the inhabited islands (details not displayed).

Table 2.

Distribution of government subsidy for medical treatment overseas 2010–2013.

	Social health insurance			Universal health care			Expenditure on health as a % of GDP^b
	N ^a	Mean (sd) expenditure ($)	Median (IQR) expenditure ($)	N ^a	Mean (sd) expenditure ($)	Median (IQR) expenditure ($)	Expenditure on health as a % of GDP^b
2010	1155	921.073 (973.85)	605.357	–	–	–	3.4
2011	1396	745.128 (852.36)	419.781	–	–	–	3.2
2012	–	–	–	3521	1261.29 (1584.56)	581.4 (154.5,1689.3)	3.2
2013	–	–	–	3456	1379.15 (1690.33)	739.8 (150,1801.8)	2.8

Values are inflated to 2013 current prices.

Number of subsidized medical visits abroad.

DNP 2014.

Table 3.

Distribution of government subsidy for medical treatment overseas by beneficiary groups 2010–2013.

	SHI* 2010		SHI 2011		UHC* 2012		UHC 2013
	N	Median (IQR)	N	Median (IQR)	N	Median (IQR)	N	Median (IQR)
Total	1155	605.4 (124.6, 1433.3)	1396	419.8 (106.6, 1225)	3521	581.4 (154.5, 1689.3)	3546	739.8 (150, 1801.8)
Region of residence
Central	421	567.2 (134.6, 1433.3)	479	602.9 (137.3, 1225)	1362	477.3 (154.5, 1528.1)	1429	645.4 (150, 1909)
North	322	611 (121.3, 1433.3)	490	351.1 (75.9, 1225)	1021	718.6 (154.5, 1961.5)	1045	818.7 (173.9, 1801.8)
South	412	610.5 (111.2, 1433.3)	427	323.6 (88.6, 1225)	1138	590.9 (154.5, 1655.5)	1072	668.3 (150, 1627.5)
p-Value		0.465		< 0.001		0.009		0.137
Sex
Female	535	574.9 (127.2, 1433.3)	660	482.6 (111.7, 1225)	1592	555.8 (154.5, 1436.8)	1620	753.9 (153.1, 1479.2)
Male	620	620.6 (120.3, 1433.3)	736	389.8 (103.6, 1225)	1929	599.6 (154.5, 1929.3)	1926	717.6 (150, 2128.5)
p-Value		0.405		0.625		0.038		0.061
Age groups
Children <9 yrs	131	574.9 (79.3, 1433.3)	98	430 (107.4, 1225)	559	268 (76.6, 1110.1)	589	379 (150, 1175.9)
Adolescents 10–19 yrs	61	488.5 (92.7, 1433.3)	73	340.6 (82.3, 1225)	204	219.7 (81, 931.2)	216	378.1 (150, 1145.2)
Youth 20–29 yrs	80	471.5 (115.6, 1433.3)	103	615.2 (169.9, 1019.2)	336	360.6 (154.5, 1344.4)	372	435.8 (150, 1565.6)
Adult 30–59 yrs	472	654.5 (130.8, 1433.3)	681	399.3 (82.8, 1225)	1441	676.2 (154.5, 1847.2)	1469	800.4 (173.1, 1830.1)
Elderly >60 yrs	411	594.9 (126.9, 1433.3)	441	418.7 (124.3, 1225)	981	928.2 (297.6, 2280.2)	900	900.9 (305.6, 2624)
p-Value		0.251		0.236		< 0.001		< 0.001

SHI = Social Health Insurance. UHC = Universal Health Coverage.

Throughout the period of study, dispersal of public money for overseas medical treatment among the recipients was generally equitable across regions, gender and age of beneficiaries (Table 3). Exceptions were found in 2011 and 2012 where geographical differences were observed (p < 0.001). This difference was insignificant in 2013. In 2012 and 2013, demographic disparities were detected (p < 0.001). However these can be attributed to need based differences and to higher estimate in these population groups.

Results from the comparison of two surveys 2009 and 2013

Use of medical treatment overseas

Table 4, derived from the two survey datasets, shows the distribution of the medical travelers during 2009 and 2013. Similar household features observed among most medical travelers from both years include living in small households (57.7% and 58.7%), having ownership of their homes (76.1% and 74.2%) and being located in the central region of the country (52.5% and 44.9%). Exclusively privately funded travelers have decreased from 65.1% in 2009 to 57.8% in 2013. Average number of visits abroad among all travelers has slightly decreased from 1.6 in 2009 to 1.4 visits in 2013, which may indicate more people making a single visit overseas. Among travelers who made more than one trip abroad, average visits remained at 2.7 per year. Over the 4 years, there was a 75% increase in medical travelers from the North region. None of the travelers in both surveys lived under the poverty line of $2 per day. The proportion of travelers who belonged to average households (household spending below $650) has increased by 107%. Correspondingly, the concentration curve in Figure 2 shows that in both years, the concentration index were positive or the rich had slightly more chance of utilizing treatment overseas. The value decreased from 0.08 in 2009 to 0.04 in 2013 indicating a change towards a more uniform distribution of MTO use.

Table 4.

Distribution of medical travelers by household characteristics (2009 and 2013).

	HIES 2009–2010	MTO survey 2013	Change
	N (%)	N (%)	%
Total	648	815	26
Household size
Small (<5 people)	374 (57.7)	478 (58.7)	28
Medium (6–10 people)	193 (29.8)	249 (30.6)	29
Large (>10 people)	81 (12.5)	88 (10.8)	9
Type of tenure
Owner occupied	493 (76.1)	605 (74.2)	22
Rent free	34 (5.2)	63 (7.7)	85
Rented	121 (18.7)	147 (18)	21
Region of residence
Central	340 (52.5)	366 (44.9)	8
North	140 (21.6)	245 (30.1)	75
South	168 (25.9)	204 (25)	21
Financial protection
Subsidized	226 (34.9)	344 (42.2)	52
Privately funded	422 (65.1)	471 (57.8)	12
Number of medical visits abroad
Mean (SD)	1.6 (1.2)	1.4 (1)	–13
Monthly household expenditures
$61–$649 (average households)	266 (41.0)	551(67.6)	107
>$650 (rich households)	382 (59)	264 (32.4)	–30

Financial protection for medical treatment overseas

As shown in Table 5, access to financial protection among the travelers has increased from 34.9% in 2009 to 42.2% in 2013. The characteristics of travelers who sought financial assistance have remained similar over the 5 years. Majority of the travelers who acquired financial assistance for medical travel in both 2009 and 2013 belonged to smaller households, with average household spending and lived in own homes, located in the central region. After universal coverage was introduced, the proportion of average households accessing financial protection has increased. Figure 3 shows the concentration curve of financial protection for MTO among medical travelers who used financial assistance from different sources in 2009 and financial protection through government subsidy in 2013. Financial cover for medical travel was slightly on the poor in both years with negative concentration indexes of −0.159 in 2009 to −0.0005 in 2013 indicating pro poor conditions.

Table 5.

Proportion of financially protected medical travelers by household characteristics (2009 and 2013).

	HIES 2009–2010	MTO Survey 2013
	%	%
Total	226/648 (34.9)	344/815 (42.2%)
Household size
Small (<5 people)	139/226 (61.5)	201/344 (58.4%)
Medium (6–10 people)	63/226 (27.9)	100/344 (29.1%)
Large (>10 people)	24/226 (10.6)	43/344 (12.5%)
Type of tenure
Own home	173/226 (76.5)	244/344 (70.9%)
Rent free	17/226 (7.5)	29/344 (8.4%)
Rented	36/226 (15.9)	71/344 (20.6%)
Region of residence
Central	104/226 (46)	190/344 (55.2%)
North	53/226 (23.5)	86/344 (25%)
South	69/226 (30.5)	68/344 (19.8%)
Number of medical visits abroad
Mean (SD)	1.6 (1)	1.4 (1%)
Monthly household expenditures
$61–$649 (average households)	124/226 (54.9)	225/344 (65%)
>$650 (rich households)	102/226 (45.1)	119/344 (35%)

Figure 2.

Concentration of financial protection for medical treatment overseas (2009 and 2013).

Costs of medical treatment overseas

Table 6 shows the costs of medical treatment overseas observed from the sample of travelers in 2009 and 2013. Median medical costs have increased by 26.9% and the annual household spending on MTO has also increased (47.1%). The proportion of household spending on overseas treatment in annual household spending has slightly increased from 20% in 2009 to24% in 2013. Travelers who had financial assistance incurred significantly lower total costs in both years. However, medical costs in 2013 were higher among subsidized travelers (p < 0.001). Geographical differences were observed in 2013 (p < 0.001) while in 2009, costs did not differ among travelers by their location of residence (p-values: 0.262 and 0.07). The travelers belonging to the upper economic group spent nearly 2 times more than the lower economic group on medical treatment overseas in 2009 (p < 0.001). This difference became non-significant in 2013 when both groups have increased their spending.

Table 6.

Expenditures of medical treatment overseas 2009 and 2013.

	HIES 2009–2010^a				MTO Survey 2013
		Medical costs $	Total household spending per MTO visit $^b	Proportion of annual household spending		Medical costs $	Total household spending per MTO visit $^b	Proportion of annual household spending
	Total	Median (IQR)	Median (IQR)	Median (IQR)	Total	Median (IQR)	Median (IQR)	Median (IQR)
Total	648	392.8 (200.3, 706.7)	1453.1 (778.1, 2499.2)	0.2 (0.1, 0.3)	815	500 (181.5, 1150) (26.9%)	2138 (1347, 3387.5)	0.24 (0.1, 0.4)
Financial coverage
Subsidized	226	293.3 (100.4, 538.4)	1054.9 (398, 1952.5)	0.1 (0, 0.3)	344	825 (300, 2085)	1797 (1137.5, 3092.2)	0.2 (0.1, 0.4)
Privately funded	422	471.1 (235.7, 841.3)	1669.1 (973.2, 2744.9)	0.2 (0.1, 0.3)	471	300 (147.5, 720.5)	2355 (1564, 3520.5)	0.2 (0.2, 0.4)
Ranksum test p-value		< 0.001	< 0.001	< 0.001		< 0.001	< 0.001	0.001
Region of residence
North	140	504.8 (220.8, 785.6)	1667.2 (928.1, 2802.8)	0.2 (0.1, 0.4)	245	500 (217, 1000)	2254 (1522, 3534)	0.3 (0.2, 0.5)
Central	340	336.5 (168.3, 673)	1315.5 (674.8, 2452)	0.1 (0.1, 0.2)	366	350 (138, 1068.2)	1760 (1042, 3124.2)	0.2 (0.1, 0.3)
South	168	336.5 (194, 715.1)	1527.1 (943.5, 2359.9)	0.2 (0.1, 0.3)	204	661 (219.2, 1412.5)	2609.5 (1819.5, 3619.8)	0.3 (0.2, 0.4)
Kruskal–Wallis test, p-value		0.262	0.07	< 0.001		< 0.001	< 0.001	< 0.001
Monthly household expenditures
$61–$649	266	269.2 (168.3, 523.7)	1146.6 (611.4, 1859.3)	0.3 (0.1, 0.4)	551	467 (184, 1000)	2166 (1363.5, 3445.5)	0.3 (0.2, 0.4)
>$650	382	504.8 (261.9, 939.4)	1687.9 (935.9, 2889)	0.1 (0.1, 0.2)	264	500 (173.8, 1341)	2098 (1330.8, 3223.8)	0.1 (0.1, 0.2)
Ranksum test p-value		< 0.001	< 0.001	< 0.001		0.362	0.688	< 0.001

Test statistic: Ranksum test and Kruskal–Wallis test compares the median values of the subgroups under comparison.

Values inflated to 2013 current prices.

Total cost per visit.

Figure 3.

Concentration of financial protection by various sources for MTO travelers in 2009 and 2013.

Discussion

Analysis of public subsidy suggests that universal health care has increased the number of beneficiaries and the expenditure of government subsidy for MTO. Comparison of the two surveys showed that considering the number of visits abroad made during the past year, the study travelers in the 2013 survey had less experience of MTO use compared to those in the 2009 survey. Despite the introduction of universal health care, medical costs for MTO and the annual household spending on MTO have risen. While access to financial protection among medical travelers has also increased, the least privileged group of the population has not accessed MTO before or after UHC was introduced.

Discussion on accessibility

After the introduction of universal health care, the number of people benefiting from public subsidy for overseas medical treatment has increased, and the distribution of public subsidy was found to be generally equitable across regions, genders and age groups throughout all the years under study. It is evident from countries which have achieved UHC and from countries on the pathway to achieving UHC that public subsidy facilitates access to health services and equity in utilization to have improved.^12–14 The fact that the disbursement of public funds across a socioeconomic indicator was not assessed in the study (due to data unavailability) is a limitation, as there has been evidence that SES-related inequities existed even in a universal health care setting.¹⁵

Our findings on the average annual number of visits abroad showed a slight decrease, but among travelers who made more than one visit in a year, the average number of visits remained the same over the years. This was consistent with survey findings from the Central Bank of Maldives, which showed that the proportion of medical travelers seeking treatment abroad has decreased from 63% in 2011 to 47% in 2013.¹⁶ This is, however, inconsistent with the general estimations of the growth of medical travel in the world.¹⁷ Development in the local health system, such as increased number of physicians and medical technologies which have been proven to be vital determinants for the improvement of a health care system¹⁸ may have contributed to this decline.

Access to financial protection among medical travelers has increased and the gap in utilizing financial protection across the socioeconomic indicator has also narrowed. Unlike the social health insurance program which covered only one-fifth of the population, the whole population was eligible for the universal coverage program¹⁹ which may have contributed to this increase. Other studies assessing the universal health care program “Aasandha” in the Maldives showed that 19% of the total expenditure of the program was claimed by overseas health facilities.²⁰

By the end of the 5-year period medical costs for overseas treatment and the household spending on overseas treatment have increased. Estimates of medical travel over the same period have shown to have increased from $4.4 billion in 2009 to $27.6billion in 2013.²¹ This represents a 145% increase in costs over the 5 years. The proportion of out of pocket household spending on MTO has not declined despite UHC. OOP financing has been found to be negatively correlated with the level of development of the country and positively with the degree of financial hardship arising from health payments.²²

Discussion on disparities

After universal health care was introduced the gap between the rich and poor in accessing and spending on medical treatment overseas has narrowed. Contrary to this, researchers have noted that in low income countries where shortages in drugs, equipment and human resources for health are severe, public subsidies tend to benefit the rich more than the poor.^23–25 The narrowed gap may also indicate a causal relationship between public subsidy for MTO and utilization where tax based financing has been argued for and against being pro poor at different levels of economic maturity.

Although economic disparity in spending for MTO has been overcome by 2013, the spending pattern has widened by the location of residence of the traveler especially in the North region. A noticeable increase was found among patients from the North, where the domestic airport was upgraded to international airport in February 2012 which may have contributed to the rise in utilization and spending on MTO. Incongruent to this, literature follows that service provided by tax financed systems are biased towards urban services.^23,26

Possible disparities that were observed from this study include the fact that none of the medical travelers, who traveled abroad before or after UHC was introduced, lived below the poverty line. According to the HIES 2010, 24% of the Maldivian population lived below the international poverty line of $2 per day.²⁷ This indicates that almost a quarter of the population has not accessed MTO and the introduction of universal health care did not have any positive impact on accessibility for the underprivileged population. However, the medical needs of this population should also be assessed and taken into account.

Limitations/Strengths

The fact that the objectives of the two surveys differ leads to differences in the measurements as well. Demographic data of the traveler was missing in the HIES as the questions on travel was asked at household level not at individual level. In addition, the costs for medical travel given by a household may be for more than one person. To measure public subsidies we have used the main source of subsidies, hence other minor sources may have been omitted. As this study was limited to users of medical treatment overseas only, the unmet need of MTO has not been assessed. The fact that both studies were conducted during the high season for medical travel, recall bias is expected to be low for medical travel costs. In order to make the two data sets comparable, the following data management was done:

-Subset of households with medical travel was used for analysis

-Inflated the prices to 2013 current prices

Conclusion

After the introduction of UHC in the Maldives, coverage of financial protection for MTO has increased and the gap between the rich and poor in the utilization of overseas medical treatment has narrowed. Medical costs for overseas treatment have risen during the four year period followed by an increase in the household spending on overseas treatment. This indicates the need to broaden the benefit package of the UHC program to make locally unavailable health services affordable and accessible. Study findings suggested possible disparities such as, none of the medical travelers who traveled abroad before or after UHC was introduced, lived below the international poverty line of $2. Further research is needed on the medical needs of the economically deprived populations who have not accessed care abroad despite the change in the health financing system in the country.

Footnotes

Author’s contribution

MS developed the study protocol, conducted the study and synthesized the first draft of the manuscript under direct supervision and feedback from VC. VC has contributed in revising and finalizing the manuscript from the first to its final draft.

Acknowledgments

We thank the managements of the three airports and health facilities for facilitating the access to inbound travelers. We appreciate the facilitation of the secondary data provided by the Ministry of Health and the Statistical Bureau of Maldives. Financial support for the study was provided by the Anne Mills Fellowship Program.

Ethical approval

The research was undertaken as a partial fulfillment of the PhD in epidemiology program of the Prince of Songkla University (PSU). Hence, ethical approval was obtained from the Ethics Committee of PSU and the Research Ethics Committee of the Ministry of Health of Maldives. Administrative approval was sought from the Ministry of Transport and Communications to conduct the airport survey in the three regional airports. The translated version of the questionnaire was validated in written format by the Ministry of Education of Maldives.

Declaration of conflicting interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial support for the study was provided by the Anne Mills fellowship program.

References

Department of National Planning M. Statistical year book of the Maldives, 2013. Republic of Maldives, 2013.

Naseer A. Pre-and post-tsunami coastal planning and land-use policies and issues in the Maldives. In: Proceedings of the workshop on coastal area planning and management in Asian tsunami-affected countries, 2006.

National Health Accounts 2009–2011. Maldives: Ministry of Health, 2013.

Ahmed F. Maldivians spent MVR3 bn abroad last year, survey says. Haveeru Online, 10 July 2014, Sect. Business.

Organization WH. Maldives: Health profile. Health Statistics of Maldives. http://www.who.int/gho/countries/mdv.pdf?ua=1 (accessed 2 November 2014).

Madhana NS. The Maldives national health insurance scheme. http://documents.worldbank.org/curated/en/2011/09/16814852/madhana-maldives-national-health-insurance-scheme (2011, accessed 2 November 2014).

Madhana NS and Forgia GL. Transition to a universal health insurance scheme in Maldives. Maldives Health Policy Notes, 2011.

Organization WH. Social disparities in Health in the Maldives. http://www.searo.who.int/maldives/documents/Maldives_Social_Disparities_in_Health.pdf (2010, accessed 2 November 2014).

Authority MM. Press release: The new exchange rate regime introduced on 11 April 2011. Republic of Maldives, 2011.

10.

O'Donnell

Wagstaff

. Analyzing health equity using household survey data: A guide to techniques and their implementation, Washington DC: World Bank Publications, 2008.

11.

Team RC. R: A language and environment for statistical computing. 2012.

12.

Barreto

Rasella

Machado

. Monitoring and evaluating progress towards universal health coverage in Brazil. PLoS Med 201411): e1001692–e1001692.

13.

Tangcharoensathien

Limwattananon

Patcharanarumol

. Monitoring and evaluating progress towards universal health coverage in Thailand. PLoS Med 201411): e1001726–e1001726.

14.

Lai

Habicht

Jesse

. Monitoring and evaluating progress towards universal health coverage in Estonia. PLoS Med 201411): e1001677–e1001677.

15.

Glorioso

Subramanian

. Equity in access to health care services in Italy. Health Serv Res 201449): 950–970.

16.

Hussain I and Amdhan M. An analysis of outbound travel of Maldivians. MMA Research Papers. 2014, p. 147.

17.

Ehrbeck T, Guevara C and Mango PD. Mapping the market for medical travel. The McKinsey Quarterly 2008; 11.

18.

Wang

Jamison

. International differences in the impact of doctors on health: A multilevel analysis of OECD countries. J Health Econ 200524): 531–560.

19.

Redaelli SNaS. Health expenditure, equity and evolution of Aasandha. 2013. http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2013/09/26/000333037_20130926111127/Rendered/PDF/812480BRI0P12100Box037933B00PUBLIC0.pdf.

20.

Nagpal SR and Redaelli S. Utilization trends and cost containment options for Aasandha. http://documents.worldbank.org/curated/en/2013/03/18304510/utilization-trends-cost-containment-options-aasandha (2013, accessed 2 November 2014).

21.

Keckley

Underwood

. Medical tourism: Consumers in search of value, Washington DC: Deloitte Center for Health Solutions, 2008.

22.

Van Doorslaer

O'Donnell

Rannan-Eliya

. Paying out-of-pocket for health care in Asia: Catastrophic and poverty impact. Proyecto Equitap: Documento de trabajo 20052): 1–51.

23.

Bennett S and Gilson L. Health financing: Designing and implementing pro-poor policies. DFID Health Systems Resource Centre, 2001.

24.

Victora

Wagstaff

Schellenberg

. Applying an equity lens to child health and mortality: More of the same is not enough. Lancet 2003362): 233–241.

25.

Preker

Carrin

. Health financing for poor people: Resource mobilization and risk sharing, Washington DC: World Bank Publications, 2004.

26.

Van de Walle

Nead

. Public spending and the poor: Theory and evidence, Washington DC: World Bank Publications, 1995.

27.

Household income and expenditure survey 2009–2010. Republic of Maldives: Ministry of Finance and Treasury, 2012.