First published in ITIJ 123, April 2011
Mark Twain once famously wrote: “Mauritius came first, and then came heaven.”
As a role model for emergent multi-cultural societies rapidly elevating themselves from Third World status, the idyllic Indian Ocean Island of Mauritius has been extremely resilient, with highly religious Christians, Muslims, Hindus, Buddhists and Jews not only managing to co-exist successfully, but also interweaving their indivudual cultures.
There was civil strife for independence back in 1968 and again, less seriously, a few years back. But those sad events are now seen as hiccups – albeit large ones – on the otherwise smooth road to status as one of the African region’s most integrated, stable, democratic and prosperous nations.
In the four decades since the end of British rule, Mauritius has seen average annual growth figures of between five and six per cent – transforming itself from a poor, essentially single-crop, agricultural economy into a diversified middle-income economy with growing textile manufacturing, fish and seafood processing and financial sectors and a thriving tourism industry. Sugarcane fields can still be found across the island – accounting for a whopping 90 per cent of all agricultural land – but they now compete for space with new-build luxury hotel properties.
To attract tourists and stimulate the economy, Mauritius is aiming to achieve duty-free status within the next five years
Pharmaceuticals are another fast-growing sector of the economy. Such products as gelatine capsules, bulk drugs, medicaments, disposable syringes, perfusers and diffusers are now being produced on the island for the export market – especially within the COMESA (Common Market for Eastern & Southern Africa) region.
Per capita gross domestic product, measured at purchasing power parity, stands at US$12,356 – the region’s sixth highest, behind the Seychelles, Equatorial Guinea, Gabon, Libya and Botswana. Mauritius is one of only three African countries to achieve a high UN Human Development Index rating.
Increased life expectancy – currently standing at 75 – lowered infant mortality rates, and a vastly enhanced infrastructure have been among the many benefits of sustained growth. Mauritius is currently ranked at 65 out of the 177 nations listed in the Human Development Index and at 63 in the gender-related Development Index. Population of the island currently stands at 1.23 million.
The government’s ongoing development strategy centres on foreign investment. Mauritius has attracted more than 9,000 offshore business entities over the past decade, with many targeting commerce with South Africa and India and a growing number in the medical sector. Inward business investment has reached more than US$1-billion.
To attract tourists and stimulate the economy, Mauritius is aiming to achieve duty-free status within the next five years. Already, tax has been reduced or eliminated altogether on more than 1,850 products, including food, clothing and audio-video and photo equipment, while corporation tax has been lowered to 15 per cent to encourage non-resident companies to trade or invest through a permanent establishment on the island or otherwise.
A major weakness of the Mauritian health system lies in its primary care provision, generally the first point of patient entry into the system
Underpinning the new society are comprehensive state-provided education and healthcare systems, the latter coping well with not only the locals but the needs of the hordes of visiting tourists.
Healthcare in Mauritius is viewed as a human rights issue. As a consequence, public healthcare services are free and fully tax funded. Current annual public health spending is running at some US$222 per capita, accounting for 9.8 per cent of total central government expenditure. However, in a World Health Organization (WHO) compiled report on the overall efficiency of health service provision, Mauritius ranked just 84th of the 191 countries rated – behind some countries with a per capita GDP of less than half its own.
In the recent book The Idea of Justice, Amartya Sen voices the opinion: “Individuals sometimes do not realise how bad their health systems are. Someone raised in a community with many prevalent diseases and poor facilities may be inclined to view symptoms as being normal when they are actually clinically preventable.” A major weakness of the Mauritian health system lies in its primary care provision, generally the first point of patient entry into the system. Most GPs, outside the hospitals, are in private practice with a vested interest in seeing that their patients, who are generally poorly informed, stay within the private system. All GPs working outside the hospitals are in private practice and charge for their services.
Serious steps are now being taken to develop participatory approaches to health service planning and delivery. There has been recent heavy government investment in new technology, such as telemedicine. The long-term aim is to both decentralise and modernise the healthcare system.
Over recent decades, there has been an epidemiological transition as the main causes of morbidity and mortality have shifted from infections to chronic and degenerative diseases. Comments Dr Romesh Munbodt, the WHO Liaison Officer for Mauritius: “Though malaria has been eliminated, Mauritius is prone to outbreaks of viral fever. Traveller’s diarrhoea is the most common disease and vaccination is required for yellow fever, rubella, cholera, rabies, hepatitis A, measles, polio and mumps. Non-communicable diseases now represent 74 per cent of the total burden of disease in men and 76 per cent in women.”
Improved water quality has been a major health issue. The EC has been a key player in assisting the Mauritian government to implement a modern wastewater treatment infrastructure, which has dramatically improved the situation.
The public health system is open to all citizens and funded entirely from the government’s tax revenues, with no compulsory health insurance scheme being in operation at present. The country has no reciprocal healthcare agreements with other nations. However, when a patient – be they a local or a foreigner with a work permit or resident permit – enters a government health facility, all services are provided completely free of charge. This inclusive free healthcare approach runs from doctor consultation and initial treatment through to the most complex operations and includes the cost of medications, though the range offered by hospital dispensaries is sometimes limited and can include low-quality imported medications from India. A nominal charge, though, may be made for visitors on a tourist visa.
Trauma centres are to be found in the big regional public hospitals in Candos, in the capital city of Port Louis and in the north. Free ground ambulance coverage is provided island-wide by the state health service run by SAMU (Service Aide Medicale Urgence) but that organisation’s air ambulance service is overdue for improvement.
A private ground ambulance service is operated by MediCare, while private air ambulance services based on Reunion Island and in East and South Africa provide emergency evacuation from the island. Mauritius has a well-established EMS system, with a single 999 ambulance dispatch system covering the whole island.
Private air ambulance services based on Reunion Island and in East and South Africa provide emergency evacuation from the island
The oldest but – thanks to a recent 275-million Mauritius Rupees (£5.9-million) investment – also the most modern private health clinic on Mauritius is the Fortis Clinique Darné, in Floréal. It was established in 1953 by Dr François Darné, with a handful of beds and just one operating theatre. The brand new, much-expanded clinic now offers 110 operational in-patient beds, with installed capacity for up to 120 beds and a wide range of general and specialised services. The five-storey building has been carefully configured to provide for an efficient flow of patients between departments.
Other prominent private clinics include Clinique du Bon Pasteur, in Rose Hill, and City Clinic, in Port Louis, while the islands’ principal public hospitals are Queen Elizabeth Hospital on Rodrigues Island (Mauritius is a Commonwealth member state); Flacq Hospital, in Flacq; Dr AG Jeetoo Hospital, in Port Louis; and Jawaharkal Nehru Hospital, also in Port Louis.
The public primary care service currently has a network of two mediclinics, 23 area health centres and 103 community health centres. Fully 100 per cent of the population enjoys a first point of contact with the health service within just three miles of their homes.
Secondary level healthcare is provided by two district hospitals and five regional hospitals, which provide primary inpatient and outpatient services, including A&E, general medicine, general and specialised surgery, gynaecology and obstetrics, orthopaedics, traumatology, paediatrics and intensive care, as well as supervising the emergency services and satellite area health centres and community health centres. The tertiary level is the highest referral level, comprising four specialised hospitals with a 980-bed capacity. A 53-bed cardiac centre offers specialised services in cardiac surgery, invasive cardiology and neurosurgery.
Outside the state system, private healthcare has evolved in two forms – fee-paying private medical and dental care practices and 13 clinics that provide private beds and facilities for consultation, examination and diagnostic procedures, mainly in the spheres of radiology and clinical pathology.
The public/private healthcare debate is ongoing and things are heating up with the arrival of Indian group Apollo, which has just opened its first hospital in Mauritius in a joint venture with a politically influential local group.
To quote a recent Expatblog posting: “A local friend recently had to undergo surgery and consulted with a private clinic, quickly concluded that he could not afford it, and thus turned to a public hospital. Much to his surprise the surgeon in the public hospital was the very same surgeon that also worked in the private clinic!” The blogger added: “Now, I'm aware that it's not all about the surgeon/doctor but also about equipment, expertise, consultation, language, patient care and the general management of the hospital etc but I still keep asking myself: are we paying through the roof for medical insurance that we don't actually need?”
The public / private healthcare debate is ongoing and things are heating up with the arrival of Indian group Apollo
Founded in 1991 in partnership with International SOS Assistance of Geneva, Medic Assistance International became wholly owned and independent three years later. Today it has five full-time employees and a part-time staff of 12 and is the only locally based medical assistance company. It operates across the Indian Ocean, covering cases in the Seychelles and Madagascar, as well as Mauritius, using US, UK and European Union (EU)-trained doctors.
Chief executive officer and medical director Dr Siddick Maudarbocus trained in Dublin then worked as an emergency physician for a US oil drilling company in West and Central Africa before settling in Mauritius and working closely with the local tourism industry, delivering healthcare to visitors through a network of well-trained doctors and specialists. Over the past decade, the company has developed close working relationships with such major international assistance groups as MAPFRE (Spain), Mercury (Germany), Touring Club (Belgium), First Assist and Worldwide Assist (UK), MRI and International SOS Assistance (South Africa), AEA and SOS Assistance (Singapore) and World Care (Australia). Services provided by the company include air ambulance evacuation, medically supervised repatriation, legal, compliance and regional regulation advice and consultation and cost containment services.
Dr Maudarbocus sees quality control as the biggest challenge facing the public health sector
Dr Maudarbocus sees quality control as the biggest challenge facing the public health sector: “Graduates working in the system have qualified all over the world – they have trained in the UK, the EU, North Africa, Russia, the Ukraine, India, Pakistan and, most recently, at the Chinese universities – and sometimes quality of care varies more than one would wish. In our dealings with the medical profession and with overseas insurance and assistance companies, there are sometimes communication problems, despite our being a multi-lingual organisation.” He went on to say: “I have seen many poorly worded medical reports and we consequently get many requests from our overseas’ partners for more detailed and updated medical reports. [Conversely], we are often kept waiting overly long for guarantee of payment letters from partner assistance companies. This is most often due to long delays in getting GPs to present their medical history reports. In some cases, such as acute gastroenteritis, such reports are not even relevant, yet we still suffer these delays”
Medic Assistance claims a solid advantage in having a multilingual workforce. The company’s doctors have been trained in many countries so that, for example, a French tourist can be placed in the care of a Parisian-trained local doctor while a Russian visitor can have access to a Mauritian doctor who speaks fluent Russian and qualified in Russia.
Cost containment of medical expenses, though, has become a major issue for international travel insurers. Given the island’s isolation, overseas insurance and assistance companies find it hard to assess local hospital pricing structures efficiently and many bills are hyper-inflated. Comments DR Fontana, of Italian-based ACI Global: "We have frequently dealt with two repatriation cases from Mauritius and in one of them found the hospital charges to be what was felt were excessively high."
Observes Dr Maudarbocus: “We are regularly being asked to renegotiate clinic bills and have now appointed specialist full-time staff to deal with such matters.
“Mauritius has aims to develop itself as a medical tourism destination, but cost containment will be a critical factor in winning such business.”