The Maldives has recorded significant achievement in human development. The infant mortality rate which was 63 in 1986 is now 30 per 1 000 births (1996) and the overall mortality rate (crude death rate) which was 17 per five 1000 in 1971 is now five per live 1000. The crude birth rate, which stood at 49 per 1000 in 1985, has fallen to 26 per 1000 in 1996, showing a decline of about 40 percent. In 1995, the average life expectancy at birth had increased to 70.6 years. This meant about 20 years have been added to the life expectancy of a Maldivian at birth since 1980.

Notable achievements have also been made in the control of communicable diseases. There has been no indigenous case of malaria seen for the past ten years. At the end of 1995, incidence rate of leprosy was 0.1 and the prevalence rate was 0.3 per thousand. Thus, the Maldives is very close to achieve zero transmission status, with respect to leprosy. Tuberculosis, which had a prevalence of 35 cases per thousand in 1974, had declined in 1995 to about 0.66 per 1000. Childhood TB (under 5 years) is almost nil for the past three years due to the high rate of BCG vaccination. By the end of 1996, a total of 57 TB cases were under treatment.

The progress recorded in the field of health is thus quite significant. In order to meet further health targets and provide better health services, the Ministry of Health held discussions in December 1996 to formulate a ten-year health master plan.

General Health Services

Health services in the Maldives are organised and promoted through the Primary health care approach, which emphasises the overall health needs of the community. These services are Provided through a countrywide referral network of Family Health Workers at least one in each inhabited island, 27 Atoll Health Centres, four Regional Hospitals and a central level hospital in Male'.

In effect, there is one doctor for every 1400 Population, 1.1 Family Health Workers for every 1 000 Population, 0.2 Community Health Workers for every 4000 Population. All the inhabited islands also have resident midwives.

Tertiary level medicine services are focally located in Male' at the Indira Gandhi Memorial Hospital (IGMH). The 200-bed hospital, which was inaugurated in 1994, is a well-equipped medical service facility providing a wide range of secondary and tertiary need of the total population of the Maldives. There are about 15 specialists in IGMH. In 1996 there were 32 specialists and 39 general duty doctors, along with 113 staff nurses and 69 general nurses employed at IGMH.

Besides the Indira Gandhi Memorial Hospital in Male' there is a 40-bed private hospital which provides a wide range of preventive, curative, surgical and other specialized services. In addition to the hospitals in Male', there are four regional hospitals located in the north, south and the central regions of the country. These hospitals play a major role in extending the quality of health services in to the rural population. The four regional hospitals are in Addu Atoll Hithadhoo (southern atolls), Haa Dhaalu Kulhuduffushi, Raa Atoll Ungoofaaru (northern atolls) and Meemu Atoll Muli (central atolls). The regional hospitals provide secondary health services as well as some specialist care. By the end of 1996, the four hospitals had a total bed capacity of 125 and have 34 doctors and 107 nurses.

In addition to the existing regional hospitals, the government has begun constructing a fifth regional hospital to be located in Gaafu Dhaalu Atoll. The foundation stone for this hospital was laid on Thinadhoo on 13 November 1996, The hospital is expected to be completed shortly.

At the general level, Atoll Health Centres provide health services in the 19 atolls where physicians and paramedical personnel are stationed. At the island, level the very basic essential preventive and the Family Health Workers meet primitive needs of the community especially in the areas of family health and childcare.

Specific preventive services include immunisation given to children, pregnant women and women of child-bearing age, promotion of family planning, control of communicable diseases such as tuberculosis, malaria, filariasis, dengue and diarrhoea, and health education to the masses on the preventive and promotive aspects of health. A combination of strategies is implemented in a combined manner to tackle these problems at the community level. Emphasis is placed on providing holistic care with the community and Government health delivery system working in close co-operation.

The vaccination programmes for mothers and children particularly immunisation for children have been completed throughout the archipelago in one year, earning the commendation of both UNICEF and WHO. As part of a regular programme, vaccination is carried out twice a week on rotation at the Indhira Gandhi Memorial Hospital and Male' Health Centre. This is a year-round programme. Mobile teams also cover the atolls in regular intervals in order to maintain the national vaccine coverage above 95 percent.

Water Supply and Sewerage

In The Maldives the main source of fresh water is the aquifer that floats on saline water about two metres below ground level. The soil being generally porous and most of the islands being small, the available ground water supply in the island aquifer is particularly susceptible to pollution mainly due to the absence often environmentally-sound sewerage disposal systems.

Therefore water-borne disease, a major cause of illness and death in The Maldives, had sometimes reached epidemic proportions in the overcrowded islands. This was especially true in Male', the capital which houses a quarter of the country's population. However, since Male' received a sound sewerage disposal system in 1988, this was no longer a serious problem.

Under the Male' Water Supply and Sanitation Project which was completed on August 1988 ' a total of 46,387 metres of sewer pipes were laid and nine pumping stations were constructed in Male', by 1997, a total of over 50,000 meters of sewer pipes have been laid in Male'.

As a major step to provide the people of Male' safe drinking water and a hygienic sewerage disposal system, the Male' Water Supply and Sanitation Project was initiated in July 1985. The West German Government and the European Economic Union funded the project. In addition, the government also obtained a loan from Saudi Fund.

Under Danish Government aid, work was also begun to install desalination plants in Male', The first operated through reverse osmosis process had a capacity of 200 cubic metres per day. Two more plants were installed under the Danish aid. A fourth plant was installed under the French assistance.

In order to manage the Male' water and sewerage works in a cost effective manner, in April 1995, the government established the Male' Water and Sewerage Company Ltd. (MWSC). MWSC a joint venture of the Maldivian government and a Dutch company has now installed desalination plants that have a capacity to produce 2000 tonnes of water per day. Under a separate project to provide safe drinking water which commenced on 20" October 1996, the new company has enabled the people of Male' to have fresh water piped to their homes.

The Maldives Water and Sanitation Authority (MWSA) is also undertaking a nation-wide project to provide safe and environmentally sound sewerage systems to the atolls. The project covers 40 islands selected on the size and density of the population. So far three islands namely Vaavu Atoll Rakeedhoo, Raa Atoll Kandhothudhoo, and Lhaviyani Atoll Hinnavaru have been provided with sewerage systems. MWSA is already laying down pipes in three other islands namely Baa Atoll Thulhaadhoo, Shaviyani Atoll Komandoo and Gaafu Dhaaiu Atoll Thinadhoo.

Under the programmes implemented to improve the sanitation in the atolls, now more than 86% of the population in the outer atolls have access to safe drinking water.

Health Services Training

The Institute of Health Sciences (IHS) trains the required para-professional health personnel for all the inhabited islands including Male'. IHS conducts a three-year diploma course in nursing and midwifery. The first course commenced in September 1991. The Institute has so far trained 32 people under its Diploma Programme. By mid 1997, IHS has trained 524 Family Health Workers, 112 Community Health Workers, 276 Nurse Aides, 586 Traditional Birth Attendants, 34 Auxiliary Nurses Midwives, 90 Pharmacy Assistants and 348 First Aides. On 7 July 1996, the IHS has started a new three-year diploma course in primary health care.