Clinical nurses’ experiencing occupational burnout within the health care setting
Posted on November 6, 2011
This article was contributed by Ms. Niyaza Abdul Rahman to the ADK Hospital Newsletter “TeamTalk” Issue 2o, November 2011. With her permission I share this article on my blog.
This is a systemic review based on selected ten research papers out of 100 papers for which the aim was to find out answer for the question of :
How do clinical nurses perceive their experiences in living with burnout within the clinical area setting?
This review was my dissertation for the course which I would like to share the result of it with you all, since it is very much related to our working field and might benefit our nurses in the long run.
The term “Burnout” which appeared around (1975) in scientific literature, is referred as a low job satisfaction in many cases (Lauderdale,1982,p35). There is no specific definition for burnout in terms of medical condition, but it is well recognised and defined as a psychological condition. As a matter of fact burnout is said to be the final stage of stress when everything else fails (IMCARES), 2008
- Nurses assisting in surgery
Comparatively health care professionals are at higher risk of getting burnout than any other profession, because of the nature of their work (Erikson & Grove 2008) and as well as the life and death decisions they take (Potter 2005). The main reason why nurses move out of the industry is because they experience stress,sadness, powerlessness, exhaustion, and frustration as their daily routine (Erikson & Grove 2008). From a health care commission report on Maidstone and Tunbridge wells NHS (National Health Service) revealed that staff shortage, ill health and heavy work load are contributory factors for failure of effective dealing with the patients. In addition staffs are also unaware of their own wellbeing for the safety of the patients (Bence 2008, p28). This shows that there is a link between nurses’ burnout and patient satisfaction.
A Nursing Times survey, conducted on 2000 nurses revealed that seven out of ten suffered from work related stress, where sick leaves were increased by 30 or more sick days for the previous years as a result of job threats, increased workload and staff shortage (Jones 2007).
Burnout in nursing effects not only the organisation but also to the patients as well as the nurses’ well being. As a result of burnout, nurses’ job turnover has been increasing day by day
All these things consequently leads to a low morale, high absenteeism, high job turn over and other personnel conflicts and thereby reducing the job satisfaction causing low performance in work ( Carson & Fagin 1996, Cited in Fothergill & Hannigan 2000).
The emerged themes from all ten papers were, Unsupportive management, Physiological and psychological aspects of burnout, Inadequate availability of resources, Experience of work place alienation, Excessive and heavy work load, Strategies for coping mechanism
For the theme of unsupportive management a vast negative perceptions were given by nurses. This theme was supported by nurses’ perceptions and experiences of negativism towards their work, lack of recognition, encouragement, support, poor supervision, high expectation from nursing management and unsupportive administrations.
All we want from management is some recognition for our hard work. Just a ‘Thank you, you’re doing a good job!’ will go a long way to motivate us. – Smit (2005, p26, col 2, lines 27 -29)
Physiological and psychological aspects of burnout were apparent from 9 out of 10 papers. Most frequently expressed psychological consequences from all of the papers were frustration, hopelessness, powerlessness, helplessness and emotional exhaustion.
But I still think in a way, I’ve complained several times but it’s not taken seriously. It’s swept under the rug. So then it really feels, what you say, it’s not worth much. In the long run I don’t think this is good for people. You need to feel involved and that you can change things. - Olofsson and Bengstsson and Brink (2003, p355 col 2 lines 16-21)
For the theme of inadequate availability of resources, mainly highlighted within the studies were, inadequacy of staff, time, high responsibilities with limited resources, skilled staff and basic resources for preventive measures.
Experience of work alienation was highlighted as unfamiliar work environment and equipments, inexperience and incompetency in work and lack of knowledge.
Difficulty in handling the advance equipments and operating the new machines were time consuming for them as they do not have the proper guidance and exposure to it.
Most leading issue from all ten papers were experiencing excessive and heavy workload.
This was highlighted in papers as multitasks with frequent interruptions within a limited time or performing multiple interventions at a limited time which further causes staff fatigue and exhaustion.
You never get any peace; never get done with anything, always interrupted by ringing telephones. During all this an assistant nurse comes and some patient is ill and you have to run. Then run from that to talk on the phone with a relative who’s calling and worried. Then rounds have to be done. These constant interruptions. While I’m supposed to do these things I want to get out and see the patients, what am I sitting here and documenting? How is the patient? How is he or she really feeling? - Olofsson and Bengstsson and Brink (2003, p354 col 2, lines 39-52)
As for the final theme, strategies for coping mechanism, they have provided perceptions and experiences of how they relived and coped with the stressors faced within the care setting. Apparent strategies were; attempting to reduce stress by remaining calm and quite during the stressful situations, relieving by individual interests, using support and assistance from peers and family members, communicating with co workers, getting involved in something else ignoring the situation and reflecting back the situation and communicating with a colleague.
Findings suggest that nurses’ working under heavy workload pressure experiencing high level of burnout affecting them mentally and physically, which is a serious issue to consider. Consequently this leads them to move out of the industry or with a low performance in their work. Thus health care managements should be more cautious about staff satisfaction and their wellbeing in order to restrain nurses. Additionally it is vital for the supervisors and nurse managers to conduct supervisory sessions and meetings to consider nurses’ problem and to assess their workload. Within the light of this review nurses’ should be able to identify and recognise their stressors early in order to prevent them from burnout or post traumatic stress. Moreover nurses should focus on their own health and well being, caring for themselves which would consequently decrease the level of burnout and promote a quality care.
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Hospital Observation Services
Posted on November 4, 2011
In hospitals, observation services are mainly referred to as
The use of a bed and periodic monitoring and/or short term treatment by a hospital’s nursing or other staff (BCBSNC)
Observation is a reasonable and necessary process to evaluate a patient’s condition to determine whether there is a need for the patient to be admitted hence is recognized as an alternative method of evaluation and treatment to inpatient hospitalization. It can even be classified as an outpatient service rather than a hospitalization.
The allocated length of stay at observation services may not be the same in different institutions. Ideally, the earlier a patient is discharged from an observation service, the better. The time allowed at an observation service may vary from few hours to a maximum of about 48 hours. Observations services, in some hospitals may even be developed separately with separate policies for different conditions, while in others common policies with common observations services are also provided. In the Maldives, it is mainly the latter that is practiced.
Different categories of patients can be put under observation for the reasons specified below.
- Patients who arrive in the hospital in an unstable medical condition would be placed for observation till a definitive care plan can be determined.
- Patients who develop unusual reactions to procedures and or medicines after minor outpatient surgical procedures are also placed for observation for further assessment and treatment.
- Diagnostic testing that require a specific preparation or an invasive procedure maybe placed at observation before and after the intervention.
- Some patients are also placed in observation for planed routine therapeutic services that require the patient to be observed after the treatment.
Given the above categories, patients who utilize the observation services should mainly be discharged after observation. Hospitalization an inpatient should be very low from the observation room.
Utilization statistics of ADK Hospital observation services, Jul-Oct, 2011
At ADK Hospital, the observation services are utilized heavily. As a result the demand for increased observation beds have been almost consistent. In august 2011, the hospital expanded its observation services from 3 beds to 6 beds, a 100% expansion. However, expansion alone is not enough. It is important to assess the utilization of these services. In this regard, an analysis of observation service utilization was assessed.
From July to October, observation service utilization has increased by almost 58% with 184 patients in July to 320 in October. This obviously is a sign of the expansion in beds and hence more patients have benefited from this intervention.
Also, it can be said that the observation service has been managed efficiently. On average, 95% of the patients utilizing observation services were discharged home and only about 5% required an admission. This is a clear sign of proper determination by the clinical staff on who actually requires observation services. The graph shows the utilization of the observation services at ADK Hospital.
In order to keep this service further efficient, a lot needs to be done. Some actions that can be implemented in the near future could be as follows.
- Improve the current observation service policy by reviewing and strengthening it.
- Attempt to provide slightly more complex services at observation so that more people can be treated without full hospitalization.
- Start to take statistics on return rates to observation services or for hospitalization after being released from observation services.
Continuous monitoring and assessment of the service would still be crucial to continuous maintenance of quality of service provided in observation.
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Clinical Audit
Posted on November 1, 2011
This article was contributed by Dr. Nitin Srinivasan to the ADK Hospital Newsletter “TeamTalk” Issue 2o, November 2011. With his permission I share this article on my blog.
OPD consultations follow an established process
Audit is well recognized as a fundamental and compulsory part of clinical practice for quality assurance to attain international standards. To achieve this there must be a well defined and smooth protocol in place comprising of on-going treatment starting from patient attending the hospital for the first time to discharge and further follow up. A multidisciplinary input and monitoring of outcome for all variables which could potentially affect the patient care should also be included. Important areas of assessment within this framework also include patient outcomes (treatment results), appropriateness of care, institutional performance, resource management and patient/health care provider satisfaction. The objectives of Audit can be summarized as
- To serve as a basis for continuous and sustainable improvement in patient outcomes. A systematic review of untoward results will allow s clinicians to monitor the clinical outcomes and to bring about improvement in service.
- To support research and development of clinical policies.
- To provide insight and feedback to clinician’s performance.
- To serve as a tool of accountability on clinical outcomes and use of resources.
History of Audit
Florence Nightingale was the first to initiate systematic audit during Crimean War of 1853-1855 with her team of 38 nurses. The results were excellent with her input resulting in mortality rates dropping down to 2% from an earlier of 40%.Ernest Codman (1869 – 1940) was the pioneer of modern Surgical Audit. His work anticipated contemporary approaches to quality monitoring and assurance, establishing accountability, and allocating and managing resources efficiently.
Staging of Audit Process-
Stage 1: Identification of problem or issue
This stage involves the selection of a topic or issue to be audited, and is likely to involve measuring adherence to surgical practices that have been shown to produce best outcomes for patients. Selection of an audit topic is important in:
- Where national standards and guidelines exist; where there is conclusive evidence about effective surgical practice (i.e. evidence based medicine).
- Areas where problems have been encountered in practice.
- Patient and public recommendations to be considered.
- Looking for improvement in service delivery.
- Improvement is needed in areas of high volume, high risk or high cost.
Stage 2: Defining criteria & standards
- Audit Criteria- Decisions regarding the overall purpose of the audit, either as what should happen as a result of the audit, or what question you want the audit to answer, should be written as a series of statements or tasks that the audit will focus on. Collectively, these form the audit criteria. These criteria are explicit statements that define what is being measured and represent elements of care that can be measured objectively. A criterion is a measurable outcome of care, aspect of practice or capacity.
- Audit Standards- The standards define the aspect of care to be measured, and should always be based on the best available evidence. A standard is the threshold of the expected compliance for each criterion (these are usually expressed as a percentage).
Stage 3: Data compilation
To ensure that the data collected are precise, and that only essential information is collected, certain details of what is to be audited must be established from the outset. These include:
- The user group to be included, with any exceptions noted.
- The healthcare professionals involved in the users’ care.
- The period over which the criteria apply.
Stage 4: Comparison of performance
This is the analysis stage, whereby the results of the data collection are compared with criteria and standards. The end stage of analysis is concluding how well the standards were met and, if applicable, identifying reasons why the standards weren’t met in all cases. These reasons might be agreed to be acceptable, i.e. could be added to the exception criteria for the standard in future, or will suggest a focus for improvement measures.
Stage 5: Implementation of change
Once the results of the audit have been published and discussed, an agreement must be reached about the recommendations for change. Using an action plan to record these recommendations is good practice; this should include who has agreed to do what and by when. Each point needs to be well defined, with an individual named as responsible for it, and an agreed timescale for its completion.
Action plan development may involve refinement of the audit tool particularly if measures used are found to be inappropriate or incorrectly assessed. In other instances new process or outcome measures may be needed or involve linkages to other departments or individuals. Too often audit results in criticism of other organisations, departments or individuals without their knowledge or involvement.
Re-audit: Sustaining Improvements
After a set period, the audit should be repeated. The same strategies for identifying the sample, methods and data analysis should be used to ensure comparability with the original audit. The re-audit should demonstrate that the changes have been implemented and that improvements have been made.
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The doctor-patient relationship!
Posted on October 29, 2011
This article is contributed by Dr. Jayashankar to the ADK Hospital Newsletter, “TeamTalk” Issues 11 and 12. With his permission I share this on my Blog.
“You are feeling better today,” announced the Doctor, as he sat down by patient’s hospital bed.
Patient: “Really? What’s better?”
“Well,” doctor sputtered, his face flushing, “in my professional opinion, you are better!”
Patient sighed, “ I don’t think so , I still feel the same, and tired “
Doctor: “Your lymphocytes are better and you should feel better.”
Patient stops reacting, unhappiness visible on his face.
Can you hear the tension in this encounter? Why are doctors and patients so often at odds? Why are both expressing more frustration and less satisfaction? To answer these questions, more and more researchers are putting the doctor-patient relationship under the microscope. What they are finding is fascinating!
The tug-of-war is because, doctors and patients are on different ends of the rope.
- To the doctor, illness is a disease process that can be measured and understood through laboratory tests and clinical observations. To the patient, illness is a disrupted life.
- The doctor’s focus is more on keeping up with the rapid advances in medical science than on trying to understand the patient’s feelings and concerns. Yet patient satisfaction comes primarily from a sense of being heard and understood.
- Many doctors do not see the role of physician as listener, but instead view their function more as a human car mechanic: Find it and fix it. Yet patients often feel devalued when their illness is reduced to mechanical process.
- Doctors feel frustrated, even betrayed, when patients withhold pertinent information. Yet patients who use alternative medicine, for example, may not tell their doctors for fear of ridicule or being labeled as Silly or uneducated.
Changes in our culture and in the practice of medicine have also added tension to the doctor-patient relationship. In some ways we have become more doctor dependent, because we see doctors sooner than people did 50 years ago, yet we are less dependent on the doctor for information and decision making.
All these changes are unsettling for both doctors and patients. Then there’s the blame factor. Doctors often blame patients when communication breaks down. But researchers have found that many doctors have shaky interviewing skills. For example,
- Doctors do more talking than listening. A new study published this year in Journal of the American Medical Association (JAMA) found that 72% of the doctors interrupted the patient’s opening statement after an average of 23 seconds. Patients who were allowed to state their concerns without interruption used only an average of 6 more seconds.
- Doctors often ignore the patient’s emotional health.
- Doctors underestimate the amount of information patients want and overestimate how much they actually give. In one study of 20-minute office visits, doctors spent about 1 minute per visit informing patients but believed they were spending 9 minutes per visit doing so.
Patients aren’t perfect either. In one survey doctors rated 15% of their patients as “difficult”. Disagreements involve everything from expecting an instant cure to demanding prescriptions. While one doctor’s difficult patient may be another doctor’s favorite, researchers have identified common characteristics of patients that everyone agrees are hard to manage.
Here are characteristics of patients described as “frustrating” by doctors
- Do not trust or agree with the doctor.
- Present too many problems for one visit.
- Do not follow instructions.
- Are demanding or controlling.
Patients who use the doctor as a scapegoat for their anger at the illness are less likely to get good care. “Doctors are profoundly influenced by the demeanor, comments, and attitudes of their patients.” A patient who is consistently rude and irritable will almost certainly not receive the same medical care as a patient who conveys more positive attitudes.
In spite of all these problems, there is reason for hope. Yes, doctors and patients will always be on opposite ends of the healthcare system, but that doesn’t mean they can’t pull in the same direction.
So what can the doctors do?
Cultivate a patient-centered partnership. “The patient desires to be known as a human being, not merely to be recognized as the outer wrappings for a disease”.
In a video-taped study of 171 office visits, doctors who encouraged patients to talk about psychosocial issues such as family and job had more satisfied patients and the visits were only an average of two minutes longer. Incidentally, doctors also benefit from the patient-centered approach, researchers note, because they feel more job satisfaction and are less likely to burn out.
- To improve patient compliance, work on mutual trust. Research confirms that the health of the doctor-patient relationship is the best predictor of whether the patient will follow the doctor’s instructions and advice.
- Respect patients as experts in the experience of illness. Patient-centered relationship that accepts the patient’s unique knowledge as just as important to outcome as the doctor’s scientific knowledge.
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Why are we protesting?
Posted on October 26, 2011
It looks as if someone told them to enjoy a day out without work! Everyone’s, smiling, jolly and shouting. Yes! I am talking about the recent “protest” held by the administrative staff of the Maldivian National University.
Photo - courtesy Haveeru Daily
As a member of the University Council, I believe that the employees were misled into having this protest. From the faces, it is seen that some of them are lost, some are enjoying and some were there just because someone asked them to do so. So what actually did happen?
Well, I started sitting in the University Council this year when a new Council was elected, appointed and or selected as per the provisions of the University Law. Since the very inception, staff salary was high on the agenda. Apparently, this was a process that started since 2004 and the previous College Council was also not able to do anything about. Then came the Civil Service Commission. The argument apparently by that Commission at the time was that the University will become independent by Law and then they can amend the salaries as they please.
Alas! The University was formed. It is “independent”. All earnings from the University go into the national treasury and the Government allocates a budget. In terms of spending the money, there is a contradiction between the legal provisions of the University Law, which give the University Council the discretion and authority to spend its earnings, but the National Treasury Laws put the Finance Minister responsible for all government earnings, a complex legal problem that need to be addressed.
At first, when the University Staff salary structure was brought to the present Council, it was thrown out! The justification was that it required more information and a methodology on how these salaries were arrived at. Being the National University, an expectation for proper research on the subject was required. The Council appointed a smaller sub committee to do the work and present their proposal. Extensive research led to a scientific methodology of relating the academic staff salaries to be related to the GDP Per Capita income of the country. A gold standard used by many established universities around the world.
Although the Council approved this, the members were also insisting on a structure for the administrative staff. Again, a similar process was followed and the Council agreed to set the administrative staff salaries not at an ideal increase but a reasonable increase, given the justification of the economic and financial situation of the country. Now one may ask why there was a compromise for administrative staff while the academic staff got an ideal thumbs up. Simple! There is a need to retain and attract the best academia to the National University given the emerging competition.
Rightly as been quoted on the reports after the administrative staff protest, the University Council endorsed a 20% increase as an allowance. From the moment, the Council formed sub committees to meet the Minister of Finance and eventually even the President, to get this increment to the staff. However, despite the efforts of the Council, the Council also had to settle for a compromise. A compromise where the academic staff got a pay rise but the administrative staff did not.
So the protest! I believe that the staff has not been provided adequate information on what actually happened. The slogans and headlines were that Council did not endorse a pay rise to the administrative staff! It is actually quite the contrary. The Council’s decision on the compromise was also to work additionally with more efforts to try and get an increment to the administrative staff as well and this is where the staff is misled.
The next day’s headline was that the staff assumed work with conditions. Ironically, the conditions quoted were exactly the same decision that the Council made on their meeting the day before the protest. Again reason to believe that the staff were not given proper information on the matter or perhaps deliberately misled? May be this is just part of the conditions and the full picture is not shown to the media? Perhaps the next Council meeting will be very interesting! Heated? Emotional?
There is a further issue too! The academic staff who got a pay rise after seven years! Or did they really get it? What next? A protest by the academic staff? That would be damaging!
I believe that the Maldives National University should undergo a major change. A Change in thinking! Looking at it in a critical manner within. I strongly believe there is great potential in the University for it to be an Institute of Excellence nationally and even perhaps internationally.
Universal Healthcare …
Posted on October 16, 2011
Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.
Article 25(a) of the United Nations Universal Declaration on Human Rights (UN, 1948)
Appendicectomies are currently covered under MADHANA
Recently President Nasheed announced that starting January 2012, all Maldivians will be covered under the National Health Scheme, MADHANA. An ambition and policy that all Maldivians would like to have happen. This probably is the first step the Maldives have taken towards universal healthcare. The notion of universal healthcare refers to an organized healthcare system built around the principle of universal coverage for all members of society, combining mechanisms for health financing and service provision (WHO).
Just like most countries, the Maldives’ health system has been evolving continuously. In the past we had had a very regressive system where all expenses were out of pocket and hence costly. Many people had to beg, borrow or steel to make healthcare affordable. I know instances where families went bankrupt when a member fell sick with a major non-communicable disease. However, in the latter part of the provisos government, health insurance or health cover become a priority. In a previous article of mine, I wrote about the initial stages of this scheme.
Even at present, we have some fundamental issues that needed to be addressed. Six years back, I wrote a concept paper for the government in which I proposed the following.
- A solid legal framework – especially one that looks at consumer protection and simultaneously protecting the providers from heavy financial losses.
- A vigorous campaign to educate the public on health insurance. I believe that we are really not aware of the benefits, exclusions and possible consequences and of course the fine print.
- There should be a national scheme administered by a government authority but shall not attempt to cover every citizen of the country. The national scheme should cover the civil service, the poor (we do not have a proper poverty line and a mechanism to identify the real poor) and the unemployed (again a grey area) and the retired. Employers should also have a responsibility for health care of their employees. The current Employment Act failed badly on this provision (one of the failures of the Act amongst many).
- The scheme should invest generated capital and continuously enhance the system from the profits. Should have 100% transparency and independent audit reports published nationally.
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E-suggestions! A mechanism for customer feedback …
Posted on October 14, 2011
Long before I joined ADK Hospital, I used to wonder about a certain “Suggestion Box” that was kept in the lobby. Since this box is no longer there, the current clients will not see it. Some who may have been regular at the Hospital may note this difference.
During those days, when I come to the hospital for a service I sometimes ask myself whether people really use it? What would they write about? Will they get any feedback? And even whether anyone in the hospital would read it and or take an action on what people suggest?
There was a form that was designed for people to comment on and drop into the box. I read this form more than once but never filled it to drop into the box.
When I took up my employment at ADK Hospital, one of the first things that I did was to take the pile of suggestions that people had put into the box. Out of curiosity perhaps, but more than that I thought that there could be some suggestions that are really constructive and if some changes can be brought based on those suggestions, customers would really see a difference. I believe that our customers would know quite a lot of things that could be improved.
I personally read the suggestions for three months. However, I wasn’t too impressed with what I read. There were hardly any suggestions that are constructive. Most of the comments were made on the reception girls. For example, many people answered the question, why did you choose ADK Hospital? The answers were something like “because of the girls in the reception” and so forth.
A couple of good suggestions struck me though.
One was to make it easy to get appointments for gynecological patients for their regular ANC visits. I thought a lot about this comment and studied that pattern of appointments of these patients and their waiting queue. Over 96% of these patients visit the hospital regularly for the whole nine months and after that too. For a start, then we decided to give all follow up appointments to these patients. Hence we started a process of making an appointment when a pregnant lady sees her doctor for the first time and continue it for the whole nine months and also for the post natal appointment. A reminder also was given by phone and sometimes appointments rescheduled for their convenience. Eventually all the departments of the Hospital now follow this as a standard procedure. Thanks to the person who send in the suggestion.
The second significant comment was about privacy in the private rooms. A patient suggested that a curtain be put up near the beds in private rooms. Although the room is private, the patient’s view was that for ladies, and for gents that matter, a curtain will provide even better privacy for doctors’ examinations, breast feeding and so forth. It was implemented immediately and now is the standard for all private rooms.
The regular collection of suggestions lead to an empty suggestion box for a few months and I decided that we will look for alternative mechanisms to get patient feedback. I did have some brainstorming among the staff. One staff member suggested having an electronic suggestion system. It seemed a good idea for many of us and we implemented the e-suggestions mechanism where users can send in suggestions through an email. It has been implemented now for over an year and I have to say that some very good suggestions have come to us. Apart from comments, grievances and complaints have also been sent via this mechanism.
We have made it a point to reply all the e-suggestions that come in and in some instances we have had made dialogue with patients to relive their problems. Some of the good suggestions that we have received are being worked on and will be implemented. We keep an open mind and accept customer feedback positively. This is one culture that I wish to develop further in the Hospital in order to make our customers happier. Customers obviously are our biggest assets. Send in your suggestions to suggestions@adkenterprises.com.
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The CHAMPIONS of tobacco control …
Posted on October 10, 2011
It is obvious that many steps need to be taken to control the tobacco menace. In past articles I have written about many aspects of tobacco control and the challenges faced by the advocates for tobacco control.
Well in this article, I will present to you real champions. People of the community who have taken drastic actions to ensure that they play a role in controlling tobacco. They made these decisions on their free will and for good reason.
One of the very famous shops in Male’ is Luxury Shopping Centre situated at a prime location on Majeedhee Magu. This shop is known as
Violet Shop on Rhadhebaimagu do not sell cigarettes
a place where people can get a variety of goods and a place of foreign exchange. In the not too distant past, they also were a mayo seller of tobacco. Cartons of tobacco were displayed and a particular window to the road is where these packs and cartons traded hands and on a regular manner. About two years back, Luxury stopped selling cigarettes. Why? Well they declared that they were selling a product harmful to the people. Rewards and awards should be given to such champions, but Luxury humbly declined any awards saying that they did it for the public good. What a luxury to have the thought! Luxury has not dropped its sales and the shop still operates at full swing day and night and it is hard to get in.
Apart from Luxury and Violet Shop shown in the picture, the following shops have also stopped selling tobacco.
Evening Mart, Anees Shop, Thanbee Shop, Approach, Huan Mart, Puree and Daily Link 1 in Male’. Kaaky mart and Check Mate in Vilimale’. I would call them real champions. Monetary gain foregone for the public good.
Well those are the shops. Can we ban smoking in hotels (kada). The notion of this makes some people raise eyebrows and open their eyes wide. For many this would be an impossible task. An action if taken will cause public outcry. Or will it really?
There is one kada, namely Naasthaa Hotel who has declared themselves tobacco free. They do not sell tobacco nor do the allow people to smoke. This also used to be like a normal kada with lots of noise and lots of smoke. A brave decision. And the kada is not deserted at all. Just like before there still is a lot of noise but without the smoke. Sounds really cool! More kada’s should follow suit.
Now comes the modern coffee culture. For many people, entertainment is a coffee with a smoke. It is a common sight in most of the middle to higher range coffee shops around. It is more of a norm. Unfortunately, the smoke is causing a problem for the shop owner. Why? Sales are down! Really? Yes. Many coffee shops are now opting not to sell loose sticks available, the coffee goers are spending more time at the table fuming hence reducing turn over of clients. Also, a number of customers who do not smoke turn away. Unfortunately these coffee shops are designed to smoke.
Coffee without smoke
Now look at this! Would there be someone bold enough for a challenge? Change the coffee culture smokeless? Yes a new champion has emerged. Recently an exclusive coffee shop has been designed and opened smoke free. Cafe’ Ier, Home of the Italian Coffee is full of customers and a new coffee culture emerged. Well one that is smoke free. Three cheers to Cafe’ Ier.
The notion that smoking bans in cafe’s and restaurants will cause a down turn business is a false. Research elsewhere in the world shows that there has been no impact on the sales with smoking bans. The pubs, cafes and restaurants in Ireland, Australia and New Zealand has gone smoke free and even in countries like Sri Lanka, roads are becoming smoke free and all of these with legislation. If we have a will, here in the Maldives we can do better.
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Economics of tobacco control – the Maldives
Posted on October 7, 2011
In the year 2003, myself and Dr. Ibrahim Riaz Shareef did a study on the economics of tobacco control in the Maldives. This paper was done for the World Health Organization and presented at a meeting on the Economics of Tobacco Control in the South East Asia Region held in Jakarta from December 3 – 4, 2003. This study was later published by the WHO-SEARO and World Bank and is also available at the e-scholarship database as well.
Economics of Tobacco Control - The Maldives full report
When I look back at that study and the recommendations that we made in 2003, nothing much has changed. In fact things look much worse that at that time.
For example, there has been n o gradual increase in the taxation of tobacco products up until this year when the rate of taxation per stick has been raised to 90 Laari. However, the incidence of tax on tobacco is still the lowest in the South East Asia Region and needs to be implemented. The current proposed draft regulations under the Law has many provisions for such incidences of taxation.
The prevalence of smoking has gone up and the female smoking rate has increased rapidly. The prevalence of non-communicable diseases have gone up and the leading cause of death in the country is now cardiac diseases. There is no proper cancer registry still and the direct impact of tobacco on health in the Maldives remain to be assessed.
The Law although an achievement is weak and the regulations are pending with a claim that gold standards in tobacco control regulation does not suit the Maldivian way of life and social structure. Something needs to be done to save Maldivians from the tobacco menace.
Following is the summary of the report. Click the image to read the full report.
Country Situation
The Maldives, an archipelago of about 1190 islands, lies in the middle of the Indian Ocean. The population was 269 010 in 2000. Per capita GDP was estimated at US$ 1279 in 1998, twice as high as the regional average, and has a growth at an average of 9% for the past 25 years.
The Maldives’ social welfare indicators are good compared to most countries with comparable income levels. Adult literacy rate is close to 1005. Infant mortality hd fallen to 35 per 1000 by 1995, and the crude death rate to 0.5%. Life expectancy at birth was 72 years in 1998. Cardiovascular and respiratory diseases and cancers are the 3 leading cause of death; they are all linked to tobacco use.
Curative and preventive health services are organized into a four-tier system comprising of central, regional, atoll and island levels. Services are provided through both public and private sectors.
Tobacco imports and tobacco control
Most tobacco products are imported, imported volumes are increasing. Cigarettes account for 97% of all tobacco products by quantity. There will be little local tobacco productions – just a small amount of bidi and tobacco for hukkah – in the Maldives. Tobacco smuggling is believed to be negligible. There are no specialist tobacco importers or retail outlets in the country. Thus no jobs would be lost if tobacco sales were to fall.
Maldivian tobacco control goes back to a 1942 law which banned tobacco product imports for some years. A 1947 bill that was enforced for a period of time banned smoking by all students and Maldivians under the age of 17, and prohibited smoking in public. In 1984, advertising was banned in government media, and in 1994 a total ban on all forms of advertisement and promotion was imposed. Smoking was banned in all health care facilities in 1993, and in all government buildings and educational institutions in 1994. Islands declaring themselves tobacco-free may qualify for trophies and cash prizes. In 2000, a large-scale school anti-tobacco programme was initiated by education sector for the whole country. One tobacco-free island, Madifushi, runs a quit smoking programme that provides accommodation and food for people who come to the island to quit smoking. This island received a WHO tobacco-free award in 2000.
Prevalence and consumption
A survey conducted in 1997 showed that 57% of males and 29% females consumed some form of tobacco, and the smoking prevalence stood at 41%. Prevalence is higher in the outlying islands. Per capita consumption is highest in the 15 – 49 age groups, and averages 14 cigarettes a day for men and 10 a day for women.
Prices, taxes and government revenue
Prices of cigarettes were relatively stable (in nominal and real terms) from 1997 to 2000. In 2000, prices rose steeply but then fell to 40% above the earlier price. Until May 2000, duty on all imported tobacco products was 50% of CHF value. In 2000 the levy for cigarettes only was changed to 30 laari per cigarette (100 laari = 1 rufiyaa) to reduce cigarette price differentials and eliminate trade in cheap cigarettes. The overall effect was positive for revenue and public health: imports dropped and import duty revenue rose by over 50%. Tobacco duty revenues have fallen as a share of all import revenues from around 4% to below 2%.
Policy recommendations
There should be an annual increase in tobacco prices. The World Health Organization recommends an annual 5% increase in the real price of tobacco products. Tax increases should apply to all tobacco products. The Maldives should consider introducing an ad valorem excise tax to sustain increase tobacco prices.
Tobacco control measures should be consolidated and a comprehensive tobacco control law formulated as a foundation for ratification of the Framework Convention on Tobacco Control. The National Tobacco Control Committee needs to be revamped to play a more active role in tobacco control. Surveillance and enforcement need to be enhanced. An assessment of smoking prevalence in the Maldives should be done every five years, as part of the existing regular household surveys.
The government should implement a smoking cessation programme.
Information, education and communication programmes need further innovation and strengthening.
The government should also improve routinely gathered data such as the cancer registry and lifestyle-related disease statistics so that the smoking-attributed burden of disease can be better understood. The government should also consider revising death certificates to include smoking status in order to enhance future research.
» Filed Under Tobacco Control | 9 Comments
Cigarette imports, an alarming statistic …
Posted on October 7, 2011
I wonder just how much tobacco is consumed in the Maldives!
One of the best indicators of this would be import figures. Lets for argument sake take just two brands and see the magnitude of the issue from a different angle. Take for example Marlboro and Camel import figures for 2010 (Customs).
In 2010 alone the following numbers of cigarette sticks were imported
Marlboro sticks: 26,485,000 corresponding to 1,324,250 packs.
Camel sticks: 205,350,000 corresponding to 10,267,500 packs.
Note that these are the import figures for only two brands. There are many other brands, but in less amounts imported.
Now who consumes this? When I quote the import figures, most people argue on the counter saying that its not for locals. The tourists consume them. Lets look at it more closely.
Ironically, the majority of tourists come from developed european countries where the consumption is much lower comparatively and keeps going down. Perhaps the increased Chinese and Russian market may have a higher consumption.
For the purposes of this argument, I take the following population.
Locals: 310,000
Expats: 85,000
Tourists: 700,000
That totals to 1,095,000
That would be a reasonable estimate of the total population of the country in a given year. Probably less.
Now if we correspond that to the import figures, about 24 sticks for Marlboro are imported per person (slightly more than 1 pack)
And for Camel, it comes to about 188 sticks per person (more than 9 packs)
On average this means over 10 packs are imported per person per year for these two brands alone to the country.
This means that the tobacco importers are earning huge profits at the expense of the health and well being of the people of this country. The motive of these companies would be perhaps to increase and sustain the addiction!!
What about the implications of this on the public expenditure on health. With the government implementing a universal health care financing scheme for the Maldivians, the big picture is that, tobacco will be the main menace to the sustenance of the costs governments will have to spend on healthcare. Wonder who thinks of this picture?
» Filed Under Tobacco Control | 1 Comment