health service in mauritius essay

Health Care in Mauritius

5 Facts About Health Care in Mauritius

• Free Public Health Care. Public health care in Mauritius is free for its residents. In 2017, public health institutions provided for around 73% of the health requirements of the population while private institutions addressed 27% of these needs. The number of physicians per 1,000 people has also increased from 1.2 in 2010 to 2.5 in 2018. Additionally, as of 2021, Mauritius’ health care infrastructure consists of “five major regional public hospitals, four specialized public hospitals, two public district hospitals, two cardiac centers, 19 private clinics and hospitals and 30 medical laboratories.”
• The Health Care System Shifts to Develop High-Value Activities. Mauritius is promoting an increase in medical tourism, seeking to reign in more profit for its health industry. In fact, “in 2017, Mauritius attracted more than 11,500 foreign patients for treatment” in cosmetic surgery, orthopedics, fertility treatment and other specialized areas. As more investment pours into the sector, advancements in infrastructure can potentially attract more foreign patients.
• Health Care is One of the Government’s Main Priorities. Health care in Mauritius is Prime Minister Pravind Kumar Jugnauth’s main priority as he looks to improve the health care system by further addressing non-communicable diseases. Mauritius’ minister of finance, Renganaden Padayachy, whose role is to manage economic activities, is also prioritizing health care in Mauritius by expanding the public health care budget. In 2019-2020, 9.5% of the total budget went to the public health sector, marking a 7.4% increase from the previous year.
• Government Commitment in Addressing Health Care Challenges. One of the main challenges health care in Mauritius faces is ineffective distribution and mix of human resources in terms of numbers and skillsets of health workers. In response, the government recruited 538 medical and non-medical personnel in 2020 to receive training on primary health care services, such as immunization programs. Another challenge is Mauritius’ reliance on a paper-based administration form that proved to be inefficient. In January 2021, Mauritius launched an e-health project “to modernize the actual health care system and to make a transition to a technologically-based medical service.”
• Advancements in Medical Equipment. Mauritius is promoting the development of high-tech medical tools in the industry. In 2020, Mauritius imported around $30.5 million worth of medical equipment and exported $32 million of medical equipment. In 2021, Mauritius had six medical device manufacturers providing job opportunities to about 600 people.

Looking Ahead

At the onset of the pandemic, the World Health Organization (WHO) placed Mauritius among the African nations at significant “risk of a public health disaster” due to its dense population, a high proportion of elderly citizens and high rate of chronic illnesses. However, Mauritius’ progress and commitment to protecting the health and wellness of its citizens proved to be key in combating COVID-19 as Mauritius emerged as one of the few coronavirus-free places on Earth. Mauritius avoided WHO’s prediction by immediately implementing public health safety measures such as lockdowns, mass testing and contact tracing.

With continued progress in the health care arena, Mauritius stands as a beacon of hope and inspiration to post-colonial countries that progress is possible.

– Samyukta Gaddam Photo: Wikimedia Commons

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Willingness to pay to improve quality of public healthcare services in mauritius.

1. Introduction

2. literature review and conceptual framework, 2.1. theoretical framework contingency valuation and willingness-to-pay, 2.2. empirical literature, 2.3. conceptual framework and hypotheses development, 2.4. altruistic behaviour, 2.4.1. general warm glow, 2.4.2. subjective obligation to pay, 2.5. health risk attitude, 2.6. perceived response efficacy, 2.7. perceived quality, 2.8. theory of public goods, 2.8.1. dilemma concern, 2.8.2. trust in other people’s cooperation, 2.9. norm-activation model, 2.10. theory of planned behaviour, 2.11. control variables, 2.12. data gathering, 2.12.1. survey design and implementation, 2.12.2. bias control, 2.12.3. sampling, 2.12.4. design of the questionnaire, 2.12.5. the hypothetical scenario, 2.12.6. the method of payment, 2.12.7. eliciting monetary values, 2.12.8. altruistic behaviour, 2.12.9. health risk attitude, 2.12.10. perceived response efficacy, 2.12.11. perceived quality, 2.12.12. public goods theory, 2.12.13. norm-activation, 2.12.14. planned behaviour, 2.13. contingent valuation method and double dichotomous choice model, 2.14. hierarchical model, 3. data analysis, 3.1. quality attributes of public health care services, 3.2. empirical results, 3.2.1. estimated wtp, 3.2.2. demographic and socioeconomic characteristics, 3.2.3. altruistic behaviour, 3.2.4. health risk attitude, 3.2.5. perceived response efficacy (pre), 3.2.6. perceived quality, 3.2.7. public good theory, 3.2.8. norm activation, 3.2.9. theory of planned behaviour, 4. discussion, 5. strength and limitations, 6. conclusions, author contributions, data availability statement, conflicts of interest.

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Jeetoo, J.; Jaunky, V.C. Willingness to Pay to Improve Quality of Public Healthcare Services in Mauritius. Healthcare 2022 , 10 , 43. https://doi.org/10.3390/healthcare10010043

Jeetoo J, Jaunky VC. Willingness to Pay to Improve Quality of Public Healthcare Services in Mauritius. Healthcare . 2022; 10(1):43. https://doi.org/10.3390/healthcare10010043

Jeetoo, Jamiil, and Vishal Chandr Jaunky. 2022. "Willingness to Pay to Improve Quality of Public Healthcare Services in Mauritius" Healthcare 10, no. 1: 43. https://doi.org/10.3390/healthcare10010043

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• Expat guide
• Health care
• The health system in Mauritius

Healthcare in Mauritius

Health is a major issue when moving abroad. Are expats eligible for the Mauritian health system ? What are the conditions to be met? Do expats need health insurance coverage in Mauritius ? Below are the answers to the questions you might have.

Overview of the health system in Mauritius

Mauritius has regional hospitals , specialized hospitals and private clinics . This is supported by a network of regional and community health centers evenly distributed throughout the island. This is complemented by a network of pharmacies whose services extend to rural areas.

Public hospitals are freely accessible to both residents and expats. However, while care is free for residents, it is not free for non-residents.

In addition, it takes a lot of patience to get an appointment . The process is well-defined but long: in order to get an appointment, you must first go to the hospital and consult a general practitioner (GP) , and then a file will be put together for the appointment. Between each step, there is triage, waiting, and additional tests if necessary (weight, height, blood pressure, temperature, blood test, X-ray, etc.).

Although the public health system is capable of treating most health problems, expats show a clear preference for the private system, which is faster and often better equipped. With several clinics, the private sector has allowed Mauritius to become a destination of choice for medical tourism .

Two pieces of information to keep in mind:

• Getting treatment in a clinic in Mauritius is often very expensive;
• Mauritians who wish to benefit from advanced treatments unavailable in the country very often turn to Reunion Island, India and South Africa. This is something to consider if you require specific treatments. Moreover, for maximum protection, most expats in Mauritius choose to take out international health insurance .

Read also Traveling to Mauritius

Hospitals, health centers and clinics in Mauritius

Mauritius has a well-developed healthcare system governed by the Ministry of Health and Wellness. Healthcare is provided by both the public and private sectors. There are 5 major public hospitals, 6 specialized public hospitals, local health centers and clinics. There are also 18 private clinics and 11 specialized fee-for-service centers.

These structures are staffed by a large majority of foreign-trained doctors , as well as by doctors who are themselves expats. In Mauritius, the medical profession is regulated by the Medical Council of Mauritius. This ensures that medical practices conform to the highest international standards of quality and practice.

Good to know:

The government of Mauritius is committed to modernizing its healthcare system and incorporating the latest technological advances to enhance services for its citizens. In the presentation of the 2024–2025 budget, the Minister of Finance announced an allocation of Rs 17.2 billion for this pivotal sector.

The 5 public hospitals of Mauritius

The Victoria Hospital - PMOC complex, located in Candos in the PlaineWilhems district

The Victoria Hospital provides the following services: General Medicine - General Surgery - Orthopaedic Surgery - Plastic Surgery - Gynaecology and Obstetrics - Paediatrics - Nursery - Neonatal Intensive Care - Cardiology - Radiology - Oncology - Burns Unit - Psychiatry - Lithotripsy - Pathology - Dentistry - Haemodialysis - Accidents and Emergencies - Medical and Surgical Intensive Care - OPD Chest Diseases - OPD Dermatology.

Paramedical Services: Central Laboratory - Blood Bank - School of Nursing - Physiotherapy Department - Medical Social Service - Virology Department - Speech Therapy (at the ENT Center) - Occupational Therapy (at the ENT Center) - X-ray - C A T Scan - Dietician.

The area is also served by 20 community health centers and 5 regional health centers.

The regional hospital, Dr. A. Gaffoor Jeetoo, located in the district of Port-Louis, the capital

The Dr. A. Gaffoor Jeetoo Hospital provides the following services: General Medicine - General Surgery - Orthopedics - Pediatrics - Nursery - Gynecology and Obstetrics - Physical Medicine - Chest Diseases - NCD (Communicable Disease Clinic) - Skin Diseases OPD - ENT Clinic OPD - Oncology OPD - Ophthalmology OPD - Accident and Emergency Department - Medical and Surgical Intensive Care - Dental Facilities - Hemodialysis.

Auxiliary Departments: Medical Laboratory Services - X-Ray - Physical Therapy - Occupational Therapy - Speech Language Pathologist - Dietician - Social Worker - Medical Records Department.

The area is also served by 25 community health centers and 6 regional health centers.

Sir Seewoosagur Ramgoolam National Hospital, located in Pamplemousses

The Sir Seewoosagur Ramgoolam National Hospital provides the following services: General Medicine - General Surgery - Orthopedics - Surgery - Gynecology and Obstetrics - Pediatrics - Nursery - Neonatal Intensive Care - Cardiology - Cardiac Surgery - Radiology - Oncology OPD - Psychiatry - Lithotripsy - Pathology - Dental - Hemodialysis - Accidents and Emergencies - Medical and Surgical Intensive Care - Chest Diseases OPD - Dermatology OPD - Ophthalmology OPD.

Paramedical services: Magnetic Resonance Imaging Laboratory (MRI) - School of Nursing - Physiotherapy Department - Medical and Social Services - Speech Therapy - Occupational Therapy - X-Ray - C A T Scan - Dietician.

The area is also served by 23 community health centers and 4 regional health centers

Jawaharlal Nehru Hospital, located in Rose Belle

The Jawaharlal Nehru Hospital provides the following services: General Medicine - General Surgery - Renal Surgery - Orthopedics - Pediatrics - Nursery - Gynecology and Obstetrics - Physical Medicine - Chest Diseases - NCDs (Non-Communicable Diseases) - Skin Diseases - ENT - Oncology - Ophthalmology - Accident and Emergency - Medical and Surgical Intensive Care - Dental Facilities - Hemodialysis.

Auxiliary Departments: Medical Laboratory Services - X-ray - Nuclear Medicine - C A T Scan - Physiotherapy - Occupational Therapy - Speech Therapy - Dietician - Social Worker - Centralized Medical Records Department.

The area is also served by 17 community health centers and 5 regional health centers.

Dr. Bruno Cheong Hospital (formerly Flacq Hospital), located in Flacq

The Dr. Bruno Cheong Hospital provides the following services: General medicine - General surgery - Orthopedics - Pediatrics - Neonatal nursery - Gynecology and obstetrics - Psychiatry - Endocrinology - EMS services (emergency medical unit) - Physical medicine - Chest diseases - Outpatient clinic - NCD Secretariat - NCD Services - Skin Diseases - ENT Clinic - Ophthalmology - Accident and Emergency Department - Dental Facilities - Hemodialysis Unit - Ayurvedic Outpatient Clinic - Speech Therapy Unit - Nutrition Unit - Medical Social Worker.

Auxiliary Departments: Medical Laboratory Services - Blood Bank - X-Ray - Physiotherapy - Occupational Therapy - Centralized Medical Records Department - Centralized Sterile Supplies Department - Laundry Unit - Food Service Unit - Supply Unit - Energy Services Unit.

The area is also served by 24 community health centers, 4 regional health centers and 1 medical clinic.

District hospitals, community centers, and medi-clinics

The 2 district hospitals in Mauritius are the Souillac Hospital and the Mahébourg Hospital .

Community health centers and dispensaries will offer basic health services, family planning/maternal and child health services, dental care and immunization.

Medi-clinics offer basic health services, family planning/maternal and child health services, dental care, immunization, health education, public health services, laboratory services, X-ray and ultrasound.

Regional Health Centers (RHC) offer basic health services, family planning/maternal and child health services, dental care, immunization, health education and public health services.

Community Health Centers (CHC) offer basic health services, family planning/maternal and child health services, immunization and health education with community participation.

Family Health Centers (FHC) offer family planning, maternal and child health services and health education. Family Planning Clinics (FPC) offer family planning and health education services.

Useful links:

Health centres

The 4 specialized hospitals

Ear, Nose and Throat (ENT) Hospital : After functioning as a COVID quarantine center since March 2020, the New ENT Hospital has returned to its primary role as a specialized facility for ear, nose, and throat services. It is set to resume providing specialized care for issues related to the ear, nose, and throat, featuring a dedicated unit for pediatric surgery catering to children up to the age of 16. The 110-bed facility, equipped with digitized operating theaters and state-of-the-art equipment, will be operational 24/7, supported by a team of approximately 100 employees;

Brown Sequard Psychiatric Hospital in Beau-Bassin;

Subrahmanyam Bharati Eye Hospital in Moka;

Chest Hospital in Poudre d'Or .

Private clinics

In addition to hospitals, Mauritius is home to numerous private clinics offering a wide array of medical services . These services encompass general consultations, specialized services, dental care, diagnostic procedures, and mental health services.

Specialized services: Private clinics in Mauritius commonly provide specialized services in fields such as plastic surgery, cosmetic surgery, cardiology, ophthalmology, urology, and various other areas of specialized care.

Cost of care: The cost of healthcare in the private sector can vary based on the type of service, the clinic, and the extent of insurance coverage. Private healthcare can be relatively expensive, emphasizing the importance of having insurance coverage. A consultation with a general practitioner typically ranges from Rs 1,000 to Rs 3,000, depending on the clinic and tests conducted, while consultations with specialists can range from Rs 2,000 to Rs 6,000.

Travel for specialized treatment: For conditions requiring treatment beyond the island, patients can seek care at health centers in La Réunion, including the CHU Félix Guyon in Saint-Denis and its southern sites in Saint-Pierre, Saint-Joseph, and Cilaos.

You can find a list of all the private hospitals in Mauritius here .

For pathologies requiring travel outside the island, patients can go to the health centers of Reunion Island. In particular, the Félix Guyon University Hospital in Saint-Denis and its southern sites in Saint-Pierre, Saint-Joseph and Cilaos have high-performance technical facilities.

Read also Health insurance in Mauritius

Private doctors in Mauritius

Mauritius presents a plethora of healthcare options, boasting a multitude of medical practices scattered throughout the country. Finding a healthcare professional tailored to your needs is a straightforward process – simply conduct a quick search on an online search engine. These searches often yield listings of various medical specialties , ranging from general practitioners to highly qualified specialists , facilitating the discovery of the right practitioner for specific healthcare requirements.

It's noteworthy that most doctor listings are typically organized by geographical area, simplifying the process of locating healthcare professionals in proximity to your residence. If the desired practitioner is not immediately found in your current region, consider expanding your search by adjusting the specified region on your search engine. This flexibility allows for the exploration of a broader spectrum of healthcare professionals across the island.

Additionally, apart from online research, personal recommendations from family, friends, or colleagues serve as an excellent resource for discovering trustworthy doctors. Feedback from individuals who have previously consulted a practitioner can offer valuable insights into the quality of care and the doctor's approach to patients.

Whether seeking general consultations, specialized care, or mental health services, the diverse array of healthcare professionals in Mauritius ensures that residents and visitors have a comprehensive range of options to address their specific medical needs.

You will find a list of private doctors in Mauritius here .

Useful link:

Ministry of Health and Wellness

Settling down in Mauritius if you suffer from a chronic disease

If you suffer from a chronic disease and are taking medication , take the time to find out about the availability of your prescriptions before your departure.

If possible, plan to have sufficient stock to maintain your treatment during the first months after your arrival in Mauritius.

All treatments must be supported by a prescription . Make sure to have this document at hand to present to customs upon arrival.

Read also Health risks in Mauritius

Moving to Mauritius with a disability

To counter the effects of the crisis that followed the COVID-19 pandemic, Mauritius is also banking on social inclusion as an economic lever. As a result, the government plans to approach organizations to make services, communities and workplaces more accessible to people with disabilities , such as training public agents in sign language, news bulletins in sign language twice a week, installation of equipment on certain beaches to allow people in wheelchairs to access the sea, installation of 40 floating beach wheelchairs, etc. While these measures are mostly available to the most disadvantaged Mauritians, they testify to the will of Mauritius to finally adapt to people with disabilities.

As for parents, here is an official list of the many NGOs that work tirelessly for the development of children with disabilities in Mauritius.

Pharmacy and medication in Mauritius

Foreigners traveling to Mauritius are allowed to bring common medicines for their personal use, provided that they carry a copy of the prescription at all times and that the medication has been dispensed in a pharmacy.

Tranquilizers, hypnotics, narcotics and other strong analgesics require prior authorization from the Ministry of Health.

When you are there, don't hesitate to ask your pharmacist if they can order the medication you need but have run out of. Always present a valid prescription.

Read also Customs in Mauritius

Some medicines are not available in Mauritius, according to expats living on the island. These discussions on the English and French forums of the website have been created in order to list medications that may not be available. Do not hesitate to ask our members for advice.

Social security in Mauritius

There is a social security system in Mauritius . However, it does not cover the whole health sector.

Indeed, the "Mauritian Social Security" covers old age pensions, severe disabilities, eyeglasses, disability pensions, social assistance, rice and flour allowances, some funeral expenses (under conditions), redundancy, single mothers, children whose fathers are in prison, hearing aids, wheelchairs, elderly welfare and some loans (under conditions).

You are advised to check with the authorities in your country beforehand to see if there are any agreements between your local social security system and that of Mauritius.

It is also recommended to take out private health insurance before departure.

List of certified private clinics in Mauritius

Anne-Lise studied Psychology for 4 years in the UK before finding her way back to Mauritius and being a journalist for 3 years and heading Expat.com's editorial department for 5. She loves politics, books, tea, running, swimming, hiking...

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• Research article
• Open access
• Published: 06 March 2020

Assessing health system challenges and opportunities for better noncommunicable disease outcomes: the case of Mauritius

• Laurent Musango   ORCID: orcid.org/0000-0003-4016-5718 1 ,
• Maryam Timol 2 ,
• Premduth Burhoo 3 ,
• Faisal Shaikh 1 ,
• Philippe Donnen 4 &
• Joses Muthuri Kirigia 5  

BMC Health Services Research volume  20 , Article number:  184 ( 2020 ) Cite this article

18k Accesses

8 Citations

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Metrics details

The objectives of the study reported in this paper were: (a) to score the coverage of core NCD population-based interventions and individual services in Mauritius; (b) to analyse and score the presence of 15 common health system challenges that impede delivery of core NCD interventions and services in Mauritius; and (c) to provide policy recommendations for Mauritius to address health system barriers to delivery of NCD interventions and services.

The Mauritius country assessment applied the guidelines developed by the World Health Organization Regional Office for Europe for systematically scoring coverage of NCD interventions and assessing health system challenges for improving NCD outcomes. The assessment used qualitative research design approach.

Of the 24 core population-based interventions for addressing key NCD risk factors, 16.7% were rated extensive, 37.5% moderate and 45.8% limited. Three (20%), 8 (53%) and 4 (27%) of the 15 individual/personal CVD, diabetes and cancer services were rated extensive, moderate and limited respectively. The top five health system challenges hampering scale-up of coverage of population-based NCD interventions in Mauritius were inadequate interagency cooperation; limited application of explicit priority setting approaches; inadequate change management; sub-optimal distribution and mix human resources; insufficient population empowerment; and insufficient political commitment. The top five challenges had average scores of between 3.1 (interagency cooperation) and 2.4 (distribution and mix of human resources).

The top five health system challenges constraining expansion in coverage of individual NCD services were limited integration of evidence into practice; limited use of explicit priority-setting approaches; inadequate application of information and technology solutions; insufficient population empowerment; and sub-optimal distribution and mix of human resources. The top five challenges for individual interventions had mean scores varying between 2.6 (integration of evidence into practice) and 1.7 (distribution and mix of human resources).

Conclusions

Mauritius needs to increase its domestic general government investments into the national health system and requisite multi-sectoral action to address the priority health system challenges with a view of bridging the existing gaps in coverage of NCD population-based interventions and individual services.

Peer Review reports

Mauritius is an island state in the Indian Ocean located within the continent of Africa; and had an estimated population of 1.274 million in 2018 [ 1 ]. In the same year, the country had a gross domestic product (GDP) of US$ 13.297 billion and a per capita GDP of US$ 10,437 [ 1 ]. Mauritius is an upper-middle-income economy.

Noncommunicable diseases (NCD) are the leading cause of premature mortality and disability in Mauritius. In 2016, the country lost 413,536 disability-adjusted life-years (DALY), of which 340,551 (82%) were from NCD; 43,977 (11%) from communicable, maternal, perinatal and nutritional conditions; and 29,008 (7%) from intentional and unintentional injuries [ 2 ]. Malignant neoplasms, diabetes mellitus, mental and substance use disorders, cardiovascular diseases and respiratory diseases accounted for 70.7% of NCD-related DALY loss in 2016.

According to the World Health Organization (WHO) [ 3 ], majority of NCDs emanate from four specific behaviours (harmful use of alcohol, tobacco use, physical inactivity, and unhealthy diet) that lead to four key metabolic/physiological changes (raised cholesterol, raised blood pressure, overweight/obesity and raised blood glucose). In Mauritius total pure alcohol consumption per person aged 15 years and older was 3.6 l in 2016 [ 4 ]. Age-standardized prevalence of current tobacco smoking among persons aged 15 years and older in 2015 was 21.2% [ 5 ]. The age-standardized mean population salt intake among Mauritians aged 18 years and older was 14 g per day in 2010 [ 6 ]; which was almost three times the WHO recommended daily salt intake of 5 g per person [ 3 ]. In 2016, 29.8% of adults aged 18 years and above were insufficiently physically active [ 7 ]. Modification of those behavioural risk factors requires a strong multi-sectoral action under leadership of the health sector.

The Mauritius health system infrastructure consists of 124 public health-care facilities. Of these, 88.7% are health posts, 1.61% health centres, 1.61% district hospitals, 4.03% provincial hospitals and 4.03% regional hospitals. The health post density is 8.840 per 100,000 population; 0.161 health centres per 100,000 population; 0.161 district hospitals per 100,000 population; 0.402 provincial hospitals per 100,000 population; and 0.402 regional hospitals per 100,000 population [ 8 ]. The Mauritius radiotherapy unit’s density of 2.411 per million population is higher than the average of 1.2 per million population for upper-middle-income countries but lower than the WHO European Region average of 3.9 per million population [ 9 ].

As shown in Table  1 , the Mauritius health system is run by 2550 physicians, 4261 nursing and midwifery personnel, 380 dentistry personnel, 497 pharmaceutical personnel, 324 laboratory health workers, 238 environment and public health workers, 236 community and traditional health workers, 145 other health workers, and 2027 health management and support workers [ 10 ]. The Mauritius densities of health workers are lower than global averages for upper-middle-income countries [ 11 ].

In 2016, per capita total current health expenditure on health (CHE) in Mauritius was US$ 553 (Int$) [ 12 ]. About US$ 244 per capita came from domestic general government health expenditure; US$ 308 per capita from domestic private health expenditure; and US$ 1 per capita from external health expenditure. Mauritius CHE was within the range of US$ 297 (minimum) and US$ 984 (maximum) per person per year health systems investment recommended for achieving health sustainable development goal (SDG) 3 [ 13 ]. However, it is of concern that out-of-pocket spending (OOPS) of US$ 266 per capita, which is equivalent to 86% of private health expenditure and 48% of the total CHE, might be reducing effective financial access to health services for some people. According to the WHO World Health Report 2010 [ 14 ], when direct payments (OOPS) are above 15–20% of CHE, incidence of financial catastrophe and impoverishment increases substantially. Therefore, the OOPS in Mauritius are far much higher than the WHO threshold.

Treatment of NCDs exerts a significant burden on Mauritius health system and economy. According to Mauritius National Health Accounts 2017, of the Rupees (Rs) 25.3 billion spent on health care in 2016, Rs 16.50 billion (65.2%) was spent on treatment of NCDs. Of the total spending on NCDs, Rs 3.6 billion (21.8%) was on cardiovascular diseases, Rs 2 billion (12.1%) on respiratory diseases, Rs 1.7 billion (10.3%) on diseases of the genitourinary system, Rs 1.2 billion (7.3%) on diabetes, Rs 1.2 billion (7.3%) on mental and behavioural disorders (and neurological conditions) [ 15 ]. In addition to health system cost of managing NCDs, productivity losses associated with NCDs are significant. Stuckler, Basu and McKee [ 16 ] estimated that for every 10% increase in NCD mortality, economic growth is reduced by 0.5%. Kirigia et al. [ 17 ] estimated that NCD deaths that occurred in Mauritius in 2012 would be expected to have reduced future GDP by Int$ 1.144 billion.

The NCD-associated health and economic losses could be attributed to lack of comprehensive multi-sectoral action and suboptimal health services coverage to reduce the NCD burden. For instance, the UHC service coverage index – which encompasses population access to reproductive, maternal, new-born and child health, infectious diseases, and NCD services – was 64% [ 11 ]. This implies a service coverage gap of 36%. Prior to the assessment reported in this paper, no study had attempted to comprehensively score coverage of NCD interventions and appraise health system challenges that hamper efforts to scale-up effective coverage of NCD services in Mauritius.

The research questions of the assessment were: (a) What is the extent of implementation of the core NCD population-based interventions and individual services in Mauritius? (b) What are the common health system challenges that impede the delivery of core NCD services/interventions in Mauritius? (c) What can Mauritius do to tackle the identified health system challenges (barriers) to effective delivery of NCD interventions and services?

The objectives of the study reported in this paper were: (a) to score the coverage of core NCD population-based interventions and individual services that are essential for achievement of good NCD outcomes in Mauritius; (b) to analyse the presence of 15 common health system challenges that impede delivery of core NCD interventions and services in Mauritius; and (c) to provide policy recommendations for Mauritius to address health system barriers to delivery of NCD interventions and services.

The current study used guidelines developed by the WHO Regional Office for Europe (EURO) to systematically assess health system challenges and opportunities for improving NCD outcomes [ 18 ]. Following the guidelines, the Mauritius country assessment team (MCAT) started with a thorough analysis of 15 years’ trends in key NCD outcome indicators derived from the WHO NCD global monitoring framework [ 19 ], details of which can be found in the detailed country assessment report [ 20 ]. The country assessment project was conducted under the overall coordination of the Acting Director General of Health Services (ADG) in the Ministry of Health and Quality of Life (MOHQL); and the WHO Country Representative (WR).

The country assessment used qualitative research design. MCAT, working groups and key informants analysed and rated (a) coverage of NCD population-based interventions and individual services; and (b) the degree of perceived hindrance that 15 common health system challenges create for interventions scale-up efforts. All the discussions were closely guided by the questions contained in the WHO assessment guide entitled “Better NCD outcomes: challenges and opportunities for health systems: Assessment Guide” [ 18 ].

We explain below the steps followed in Mauritius to achieve the three objectives of the study.

Objective 1: scoring of the coverage of core NCD population-based interventions and individual services

Steps for scoring coverage of core ncd population-based interventions.

The following five steps were followed to rate NCD population-based interventions used:

Step 1: Constitution of the MCAT.

The MCAT consisted of Ag Director General of Health Services, Permanent Secretary, and Director of Health Services in the Ministry of Health and Quality of Life (MOHQL); Regional Public Health Superintendent (RPHS) in Victoria Hospital; and the WHO National Consultant (team leader), Country Office Operations Officer, National Professional Officer for health promotion and NCDs, and Technical Officer for health systems. The MCAT was purposively constituted by the MOHQL.

Step 2: Review of relevance of the core population-based NCD interventions aimed at preventing tobacco consumption, preventing harmful use of alcohol, and improving diet and physical activity. Table  2 contain the 24 core population-based interventions from the WHO Global Action Plan for the prevention and control of NCD [ 21 ] that the MCAT reviewed and deemed relevant for Mauritius.

Step 3: MCAT review of the three category criteria developed in the WHO [ 18 ] guide for scoring coverage of population interventions. Additional File  1 contains criteria, obtained from the WHO assessment guide [ 18 ], used for scoring coverage of population interventions.

Step 4: MCAT review of pertinent national and international literature to garner evidence of implementation of the interventions in Table 2 . The key documents consulted included policy papers [ 22 , 23 ], legislation [ 24 , 25 ], strategic frameworks/plans [ 26 , 27 , 28 ], health statistics [ 29 , 30 , 31 ], annual reports [ 32 , 33 , 34 , 35 , 36 , 37 , 38 ], monitoring and evaluation reports [ 39 , 40 , 41 ], World Bank website [ 42 ], WHO NCD-related publications [ 21 , 43 , 44 , 45 ], WHO website [ 46 ], WHO Global Health Observatory [ 47 ], research studies and survey reports [ 48 , 49 , 50 ], national health accounts (NHA) reports [ 15 , 51 ], and peer-reviewed articles [ 52 , 53 ].

Step 6: The MCAT plus 12 purposively selected key informants had a workshop where they rated each core population-based intervention in Table 2 on a three-point scale as limited, moderate or extensive. As explained in the WHO assessment guide, a rating of:

Limited: implies limited activities, limited commitment to real change, unimplemented initiatives, and dearth of evidence of population behaviour change for key NCD risk factors (p.12) [ 18 ].

Moderate: means that strategies, programmes or interventions exists, reflecting commitment, but either their design is not in line with international best practice or their implementation has been hindered, leading to limited health behaviour change (p.12) [ 18 ].

Extensive: implies evidence of extensive commitment demonstrated through strategies, programmes and interventions in line with international best practice, good implementation track record, and evidence of desired behaviour change and outcome improvement (p. 12) [ 18 ].

Among the key informants were the MOHQL senior officials, government officials from other ministries, heads of units/sections, service providers, representatives from the private sector, nongovernmental organizations, health training institutions and professional organizations.

Steps for scoring coverage of core NCD individual services

Table  3 contains the core individual NCD service and relevant global targets.

The rating of NCD individual services in Table 3 was done by the MCAT in four steps:

Step 1: Review of the core individual services for preventing, detecting, management and follow-up of cardiovascular disease, diabetes and cancer cases. Those services were extracted from the WHO Global Action Plan for the prevention and control of NCD [ 21 ].

Step 3: Review of the three category criteria developed in the WHO [ 18 ] assessment guide for scoring coverage of individual NCD services. The detailed criteria used by the MCAT in scoring coverage of individual services is contained in the Additional File  2 .

Step 4: The MCAT plus 12 key informants had a workshop where, through discussion moderated by the team leader, they rated each core individual services in Table 3 on a three-point scale as limited, moderate or extensive.

The MCAT and key informants referred to various national reports and WHO global reports to confirm their ratings of the coverage of both core NCD population-based interventions and individual services.

Objective 2: analyse the presence of 15 common health system challenges that impede delivery of core NCD interventions and services in Mauritius

Step 1: Constitution of five working groups (WG) by the MOHQL. Each WG had a chairperson and a report writer. Combined the working groups had 37 core members; 15 government officers co-opted from relevant government ministries when required; and representatives from five non-governmental organizations (Etoile d’Esperance, MACOSS/Mauritius Heart Foundation, APSA International, TiDiams and Link to Life). The 58 key informants, were purposively selected by overall project coordinators (i.e. ADG and WR), based on their perceived expertise in the relevant health system challenge area. The composition of the five groups (without names of individuals for confidentiality) is contained in Additional File  3 .

Step 2: Review of the 15 common health system challenges contained in Table  4 by the five WGs in plenary sessions.

The health system challenges reviewed were extracted from the.

Step 3: Assigning of the 15 common health system challenges to the five WGs as follows:

WG1: Political commitment to NCDs, explicit priority-setting approaches, and interagency cooperation;

WG2: Effective model of service delivery, coordination across providers, and effective management;

WG3: Regionalization, integration of evidence into practice, and access to quality medicines;

WG4: Distribution and mix of human resources, adequate information solutions, incentive systems, and managing change; and

WG5: Population empowerment; and ensuring access and financial protection.

Step 4: WGs review and adaptation of the WHO guide for assessing health system challenges and opportunities in tackling NCDs [ 18 ].

Step 5: WGs appraisal and scoring of the 15 common health system challenges hindering delivery of core NCD population and individual interventions and services that had moderate or limited coverage. The salience of the health system challenges was assessed using the following scale obtained from the WHO guide [ 18 ]:

“1 = Minor: This challenge does not prevent delivery of core interventions and services or has been fully addressed. 2 = Moderate: This challenge has moderate impact on the delivery of core interventions and services. Mauritius has already found ways to address it, or has solid plans to do so. 3 = Major: This challenge has a large negative impact on the delivery of core interventions and services. Mauritius has been struggling to find the right solutions to address it, or the chosen paths have not worked. 4 = Major persistent: This is a systemic problem that is persistently on the health system reform agenda and the country has not found a sustainable implementable solution or has failed numerous times to implement it” (p.30).

The WGs were guided by the respective set of questions and matrices in the WHO assessment guide when reviewing and evaluating available information related to NCD outcomes, interventions and services for assigned features to determine how they affect the performance of health systems in delivering primary prevention, secondary prevention and disease management, and treatment of acute events.

Each WG led by an expert group chair and under the guidance of the MCAT had at least eight working sessions (characterized by debate, dialogue and deliberation), each lasting two to three hours.

Step 6: For each challenge the scores were summed up in the last row of each matrix to tease out the most important barriers undermining delivery of core interventions and services.

Step 7: Preparation of individual WG reports: Each WG prepared a short report summarizing main findings, highlighting the key challenges, and making some initial recommendations for addressing the identified challenges.

Step 8: Peer review of WG reports: First, WG chairpersons presented their reports at a one-day stakeholder workshop held on 16 November 2017, and subsequently revised their reports incorporating suggestions and filling any information gaps. Second, the WGs made final presentations of their findings and recommendations to a high-level panel of the MOHQL and development partners which was chaired by the Acting Director-General of Health Services.

Step 9: Integration and synthesis of WGs findings: After the high-level panel, WG findings were integrated and synthesized across 15 features by a WHO national consultant, and then reviewed by the MCAT. The latter also reviewed WG rating of coverage of core interventions and individual services; reviewed scoring of health system challenges; analysed the linkages between coverage evaluation and health system challenges assessment; prioritized health system challenges that most significantly undermine coverage of core NCD interventions; consolidated the policy recommendations from WGs; and prepared the draft assessment report.

Coverage of core population and individual NCD interventions and services in Mauritius

Table  5 summarizes the assessment team’s evaluation (on a three-point scale, extensive, moderate or limited as per criteria given in the WHO assessment guide) of 24 core population-based interventions geared towards tackling the four main risk factors for NCDs, that is tobacco smoking, harmful alcohol use, unhealthy diet and physical inactivity.

The coverage of 4 (16.7%) of the interventions was rated extensive, 9 (37.5%) moderate and 11 (45.8%) limited. Out of the six anti-smoking interventions, two were rated extensive and four moderate. Out of the six interventions to prevent harmful alcohol use, one was rated extensive, one moderate and four limited. Of the six interventions to improve diet, one was rated extensive, two moderate and three limited. Of the six interventions to promote physical activity, none was rated extensive, two were rated moderate and four were rated limited. According to the assessment team’s rating, Mauritius still needs to invest more in scaling up the coverage of population NCD control interventions to the extensive level.

Table  6 encapsulates the assessment team’s evaluation (on a three-point scale, as extensive, moderate or limited based on criteria given in the WHO Assessment guide) of the 15 core individual services for controlling cardiovascular diseases (CVD), diabetes and cancer.

Three (20%), eight (53%) and four (27%) of the 15 individual NCD services were rated extensive, moderate and limited respectively. With regard to CVD, effective primary prevention in high-risk groups and secondary prevention after AMI were rated extensive; effective detection and management of hypertension, and rapid response and secondary care after AMI and stroke were rated moderate; and risk stratification in primary health care was rated limited. All the individual services for diabetes (detection and general follow-up, patient education, hypertension management and prevention of complications) were rated moderate. In the case of cancer first line services, prevention of liver cancer through hepatitis B immunization was rated extensive, and screening for cervical cancer and treatment of precancerous lesions were rated moderate. Of the four cancer second line services, only vaccination against human papilloma virus was rated extensive; with the early case-finding for breast cancer and timely treatment of all stages, population-based colorectal cancer screening, and oral cancer screening coverage rated limited.

Health system challenges hindering scale up of core NCD interventions and services

In relation to each intervention/service, the evaluation team assessed each challenge as either 1 = minor, 2 = moderate, 3 = major, or 4 = major persistent challenge. Table  7 summarizes the average scores and ranking of the top five health system challenges (interagency cooperation, explicit priority setting approaches, managing change, distribution and mix human resources, population empowerment, and political commitment) hampering scale-up of coverage of population-based NCD interventions in Mauritius.

The top five challenges had average scores of between 3.1 (interagency cooperation) and 2.4 (distribution and mix of human resources). Additional Files  4 details the scores pertaining to degree of challenge for NCD population-based interventions.

Table  8 presents the average scores and raking of the top five health system challenges (integration of evidence into practice, explicit priority-setting approaches, adequate information solutions, population empowerment and distribution and mix of human resources) hindering optimal expansion in coverage of individual NCD services.

The top five challenges for individual interventions had mean scores varying between 2.6 (integration of evidence into practice) and 1.7 (distribution and mix of human resources). Additional Files  5 portrays the scores pertaining to degree of challenge for individual NCD services.

The remaining part of this subsection present an analysis and scores of the 15 health system features contained in Table 4 .

Political commitment to NCDs

The Mauritius Government’s political commitment to continually improve the level and distribution of health is expressed in Mauritius Vision 2030 [ 22 ], Government Programme 2015–2019 [ 59 ], MOHQL vision and mission statement [ 60 ] and health sector strategy 2017–2021 [ 26 ]. The MOHQL mission is to create a modern high-performing quality health system that is patient centred, accessible, equitable, efficient (uses available human, financial and physical resources without waste) and innovative (using the full potential of information and communications technology) [ 26 ]. In relation to NCDs and health promotion, Mauritius strategic objective is to reduce the burden of premature morbidity, mortality and disability associated with NCDs and their risk factors [ 26 ]. At the time the assessment was conducted, efforts were underway to update the expired action plans on tobacco control [55, nutrition [ 28 ], physical activity [ 27 ] and cancer control [ 57 ].

The Government has enacted various public health legislations targeting various NCD risk factors. For instance, the 2008 public health regulations which prohibit advertisement, sponsorship and sale and consumption of alcoholic drinks in public places [ 55 ]. Another set of public health regulations that came into force in March 2009 imposed restrictions on tobacco products; and was reinforced by the June 2018 Mauritius accession to the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products [ 61 ]. The Minister of Health and Quality of Life published the Government Gazette of Mauritius No. Seventy-four of 15 August 2009 entitled “Food (Sale of Food on Premises of Educational Institutions) Regulations 2009”, which specifies the types of food which may be sold on the premises of educational institutions (pre-school, primary school, secondary school or pre-vocational school) [ 56 ].

Political commitment to NCDs was rated either major or major persistent challenge for 12 population interventions and for 2 individual services. The average score for population interventions was 2.5 and 1.6 for individual services. Sustaining high-level political commitment through effective budgetary and legislative support and improved coordination of NCD activities across government agencies remains an ongoing challenge.

Explicit priority-setting approaches

The strategic long term direction for development plans priorities has been spelt out in the Mauritius Vision 2030. The Ministry of Finance and Economic Development (MOFED) strategic plan provides a medium term strategic direction and targets. MOFED three-year strategic budget plan establishes indicative expenditure ceilings for the ministries. The MOHQL proposed annual budget estimates, which are established on historical basis, alongside those of other ministries, are reviewed by the Budget Estimates Committee meeting chaired by the MOFED.

The current budget allocation to the MOHQL is divided into five major subheads: general, curative services, primary health care and public health, treatment and prevention of HIV and AIDS, and prevention of noncommunicable diseases and promotion of quality of life (see Table  9 ).

Between 2016/17 and 2019/20 total government expenditure increased from Rupees (Rs) 10.9 to 12.3 billion, representing a 13% increase. During the same period expenditure on prevention of NCDs and promotion of quality of life grew from Rs 106.8 million to Rs 137.3 million, accounting for a 29% increase [ 15 , 51 ].

Application of explicit priority-setting approaches was rated either major or major persistent challenge for 17 population interventions and for 3 individual services. The average score for population interventions was 2.8 and 2.1 for individual services.

The use of national health accounts (NHA) to link the process of national health policy development to allocation and reallocation of resources is still in the nascent stage. Moreover, the use of cost effectiveness analysis evidence in allocation of resources has not been institutionalized. Therefore, there is no explicit mechanism for prioritizing health services and public health spending. In addition, there is absence of prioritization of the health budget with regard to burden of disease, cost-effectiveness and equity considerations.

Interagency cooperation

The MOHQL recognizes that multi-sectoral action and partnerships are crucial for core interventions and services to have the greatest impact on NCD outcomes; the MOHQL is forming close partnerships with other sectoral ministries and national institutions; and with UN agencies, diplomatic missions, and civil society organizations including NGOs, the media and other relevant stakeholders [ 26 ]. For example, the Ministry of Education and Human Resources, Tertiary Education and Scientific Research has been an important partner in the prevention strategies which include health education, screenings and referrals, sale of healthy food items in school canteens, human papilloma virus (HPV) vaccination, etc.; the Ministry of Social Security, National Solidarity and Environment and Sustainable Development has been a partner particularly in providing preventive, promotive, curative and rehabilitative services to older people and people with disabilities; the Ministry of Agro Industry and Food Security is also collaborating with the MOHQL to ensure food security and safety and to encourage consumers to change their eating habits; the Ministry of Youth and Sports is promoting physical activities by providing incentives for purchase of sports equipment, increasing accessibility of sports infrastructure to the general public and allocation of grants to sports clubs; the Ministry of Gender Equality, Child Development and Family Welfare is organizing regular talks and sensitization campaigns on healthy eating habits, physical activities and cancer through the network of women centres in the island. The NGOs active in the health sector expressed to the assessment team strong desire to have closer cooperation, better communication and more exchange with the MOHQL.

Interagency cooperation was rated either major or major persistent challenge for 20 population interventions. The average score for population interventions was 3.1. The assessment team deemed interagency cooperation not application for individual services in Mauritius.

The main challenges include lack of functional interagency cooperation mechanism; and dearth of synergy through joint government/NGO efforts for combatting NCDs.

Population empowerment

The MOHQL has developed infrastructure for planning and implementation of policies, programmes, services and activities aimed at raising health literacy among the population. Some of that infrastructure includes the Health Information Education Counselling Unit; the NCD and Health Promotion Unit; and the Primary Health Care Programme. A Health Literacy Framework was developed by MOHQL in 2013; it incorporated the strengthening of the health literacy components of the different national action plans being implemented to reduce risk factors and premature mortality as well as a strategy to guide actions to improve health literacy across the life course [ 62 ].

In addition, health promotion efforts care buttressed by pertinent health awareness raising activities of the Ministry of Social Security, National Solidarity and Environment and Sustainable Development; Ministry of Gender Equality, Child Development and Family Welfare; Ministry of Education and Human Resources, Tertiary Education and Scientific Research; Ministry of Youth and Sports; and Ministry of Agro Industry and Food Security. Four NGOs also contribute to population empowerment and protection of patient rights, including the Link to Life (focusing on breast cancer), TiDiam (focussing on diabetes), APSA (focusing on diabetic foot care) and VISA (targets tobacco use).

Population empowerment was rated either major or major persistent challenge for 12 population interventions and for one individual service. The average score for population interventions was 2.5 and 1.8 for individual services.

Despite the various strategies implemented for population empowerment, there is high prevalence of NCD risk behaviours and poor adherence to treatment plans, attributed to inadequate empowerment of population to change behaviour towards taking responsibility for their own health; lack of active engagement in decision-making processes around policy issues as well as individual treatment options/plans; lack of structured peer to peer patient support groups; high-risk population groups not adequately targeted for more tailored health promotion; and lack of explicit health literacy approach for the elderly.

Effective models of services delivery

Mauritius has a strong primary health care system that provides health promotion (health education, empowerment and health talks), disease prevention (health check-ups and opportunistic screening), curative services (NCD clinics and diabetologist clinics) and rehabilitation [ 20 ]. The primary health care centres are manned by community physicians, nutritionists, nurses and health care assistants, among others. In principle, patients visit a primary health care provider at a community health centre/area health centre for non-emergency needs, and if necessary, the service provider issues a referral memorandum to an hospital for specialist care.

Even though the assessment team did not rate impact of effective model of services delivery on population interventions and individual services, the assessment identified factors that undermine referral system, including patients bypassing the PHC providers and going directly to secondary or tertiary hospitals for non-complicated NCD care; lack of patient identifier leading to duplication of care and dysfunctional transition of care; many PHC centres do not have optimum physician consultation time; and dearth of diagnostic and preventive services for a significant segment of the population in prediabetes stage.

Coordination across providers

The coordination across providers at the different levels of care in Mauritius such as home care, PHC, and emergency care, regional and specialized hospitals is patient-focused with a referral system addressing the needs of NCD patients [ 20 ]. Multidisciplinary cooperation is effective at facility level, and patients attending PHC centres are seen by a multidisciplinary team of health professionals.

Even though the assessment team did not rate impact of coordination across providers on population interventions and individual services, the working groups identified key challenges for coordination across providers to be lack of effective interoperable patient clinical data transfer system; and inefficient functioning of PHC as a hub for general coordination of care and referral to specialists.

Regionalization

The overall public health-care system is well structured with three distinct levels of care, namely primary, secondary and tertiary. Effective regionalization of care has been achieved with a regional hospital and an extensive PHC network in each of the five health regions with a defined catchment population [ 63 ]. All five regional hospitals have a fully equipped cardiac unit for treatment of AMI. There are no wide variations in availability and quality of services within regions. Tertiary care hospitals are accessible within reasonable driving distance. There is also a 24-h free public emergency ambulance service manned by doctors and nurses with specialized training in emergency medicine [ 20 ].

Regionalization was rated as a major challenge for scale-up of coverage of one individual NCD service, i.e. the early case-finding for breast cancer and timely treatment of all stages one individual service. The average score for individual services was 1.4. The key issues surrounding regionalization challenge included lack of clarity in the definition of roles and responsibilities for management of NCD conditions at the different health service delivery levels; and implementation of stroke unit care.

Incentive systems

The public health professionals receive their salaries and allowances based on recommendations of the Pay Research Bureau (institution responsible for reviewing the pay and grading structures and conditions of service in the public sector) and these are linked to position levels, years of service and responsibilities assigned [ 64 ]. Continuing professional development (CPD) is mandatory for doctors [ 65 ] and dentists [ 66 ]. Creation of the Mauritius Institute of Health (MIH) has availed opportunities for continuing education for other health workforce cadres to develop new competencies and skills, which makes them eligible for internal promotions and career advancement [ 67 ].

Inspite of the fact that the impact of incentive systems on population interventions and individual services was not rated, the working groups assessment revealed that absence of monetary incentives linked to outstanding provision of quality NCD care at individual and institutional levels. Also, since the public health service delivery system provides free access to all core NCD population-based interventions and individual services, there are no incentives for healthy behavior change in population, better self-management for patients with chronic conditions, and adherence with the referral system.

Access to quality medicines

Concerning access to quality of medicines, based on the WHO concept of Essential Drugs [ 68 ], the MOHQL has developed its own medicine list covering all pharmacological classes including specialized items [ 69 ]. The list is reviewed every two to 3 years by the Drug Formulary Committee to assess its adequacy and the list approved serves as a guide for medical officers at public health facilities for prescription of medicines using their generic names and for drugs that are not on the essential list on a case-by-case basis. The Hospital Drugs Committee set up at regional level evaluates such requests and advises on the purchase of drugs needed for specific cases. In addition, monitoring of prices of pharmaceutical products is carried out by relevant authorities. So far, no cases of malpractices have been found in this respect and a National Pharmacovigilance Committee (NPC) has been set up under the aegis of MOHQL to collect and analyze data on any adverse drug reactions in relation to the prescription and use of drugs in the treatment and control of disease and reporting of suspected quality issues [ 59 ]. Public procurement of medicines is highly efficient in terms of procuring medicine at competitive prices through pooled Small Developing Island Project for procurement of priority medicines.

Access to quality medicines was rated either major or major persistent challenge for none of the population interventions and for one individual service, i.e. effective detection and general follow-up of diabetes cases. The average score for population interventions was one; and 1.1 for individual services.

The WGs identified factors accounting for sub-optimal access to quality medicines to include cumbersome administrative formalities in procurement of drugs sometimes cause delays in supply; lack of dedicated quality control laboratory to monitor the quality of drugs in the local market; NPC is not very effective; and existing inventory management sometimes is the cause of stock outs at central warehouses and health facilities.

Integration of evidence into practice and adequate information solutions

Research [ 53 ], surveys [ 49 , 50 ] and other databases on NCDs have been useful in providing local evidence for identifying more effective actions for combating NCDs. For example, the vaccination strategy against cervical cancer for young girls which started in 2016 was finalized after studies on HPV subtype prevalence done by the Central Health Laboratory and the Mauritius National Cancer Registry (MNCR) [ 58 , 70 ]. The Virtual Health Library (VHL) in Mauritius which was set up in 2015 by the MIH provides all public health professionals electronic access to scientific knowledge on health [ 62 ].

Research is complemented by other information systems solutions, for instance, the civil registration systems. Morbidity conditions and mortality causes are coded according to the 10th Revision of the WHO International Classification of Diseases [ 71 ]. The Health Statistics Report published annually also contains information on population and vital statistics, infrastructure and personnel, morbidity, mortality and the activities of almost all health services pertaining to the Republic of Mauritius. Most importantly, NCD Surveys that have been regularly carried out during the last 30 years provide trends in the prevalence of NCDs and their risk factors and measure impact of actions taken previously [ 29 , 30 , 31 ]. Other surveys conducted periodically or on an ad hoc basis such as surveys on nutrition [ 72 ], salt intake [ 73 ], tobacco control [ 74 , 75 ], household out-of-pocket expenditure [ 48 , 52 ], risky behaviours in children [ 76 ] and adolescents [ 77 , 78 , 79 ] also provide key information that cannot be obtained from routine sources. Annual and four-year reports are published regularly from the National Cancer Registry [ 58 ]. Since 2015, Mauritius has been conducting NHA and it has since been institutionalized [ 15 , 51 ].

Integration of evidence into practice was not rated as a challenge for NCD population interventions in Mauritius. However, it was rated either as a major or major persistent challenge for nine individual NCD services. The average score for individual services was 2.6.

Adequate information solutions were rated either major or major persistent challenge for seven population interventions and for none of individual services. The average score for population interventions was 2.1 and 2 for individual services. The assessment revealed that optimal integration of evidence into practice was constrained by a number of factors, including lack of a structured process for coordinated development, reviewing (for quality assurance), updating and monitoring of the NCD disease management guidelines and protocols; absence of an action research framework for prevention and control of NCDs; and structures and mechanisms for national NCD registries have not yet been institutionalized.

Distribution and mix of human resources

Out of the total number of human resources for health (HRH) in Mauritius, 23.9% are physicians, 40% nursing and midwifery personnel, 4.7% pharmaceutical personnel, 3.6% dentistry personnel, 3% laboratory health workers, 2.2% environment and public health workers, 2.2% community and traditional health workers, 1.4% other health workers, and 19% management and support workers [ 8 ]. In terms of health workforce distribution by services, 2.9% are in general services, 82.3% hospital and specialized services, 13.7% primary health care and public health, 0.3% treatment and prevention of HIV and AIDS, and 0.8% prevention of NCDs and promotion of quality of health. Approximately 73% of the MOHQL budget goes into remuneration of human resources for health [ 15 ]. All medical specialists are allowed private practice 2 years after their registration with the Medical Council of Mauritius.

Distribution and mix of human resources was rated either major or major persistent challenge for 13 NCD population interventions and for one individual service. The average score for population interventions was 2.4 and 1.7 for individual services. The main HRH weaknesses relate to absence of written HRH policy and needs assessment which can provide evidence to optimize health workforce performance; and limited up-to-date in-service training for service providers with regard to CVD, diabetes prevention and NCD surveillance capacity.

Effective health system management

Figure  1 shows organograms pertaining to top management positions at primary, secondary and tertiary levels of the public health system.

Management structure in public health system

Regional Health Directors (RHD) are doctors with postgraduate training, appointed by the Public Service Commission (PSC) through a procedure of open competition, based on the candidates’ educational qualifications, experience and merit [ 20 ]. The authority and responsibility of managers at various levels is to ensure smooth running of concerned institutions. Directors of regional health facilities do not have decision-making power pertaining to financial resource allocation (reallocation), staffing levels, dismissal of non-performing staff, types of services to be provided, etc. Such decision is centralized at the MOHQL headquarters. Community Physicians/Senior Community Physicians and senior doctors running hospital services have all undergone management training sessions.

Despite that the impact of effective health system management on coverage of NCD population interventions and individual services was not rated, the working groups assessment revealed that existing management system of health facilities cannot effectively be used as a tool for improving quality and outcomes due to lack of standardized set of NCD clinical protocols and guidelines against which audits can be done. In addition, even though facilities have boxes for receiving patient complaints, system for receiving and analyzing patient feedback to improve patient care and outcomes is inadequate.

Change management

In principle entails making positive changes to attitudes, policies, systems and laws in the health sector. Mauritius has over the years introduced reforms at PHC and hospital levels with a view to improving the health services delivery, e.g.:

the regionalization of NCD services with the creation of the posts of Community Physicians and NCD Coordinators to better manage the NCD services in the PHC system;

the extension of opening hours of area health centres and mediclinics;

early opening of health centres for taking of blood specimens from patients;

introduction of staggered appointment system;

sorting out exercises (triage) for patients attending the Accident and Emergency Departments at the regional hospitals;

introduction of diabetologist and some other specialized clinics in PHC; and

introduction of shift system in hospitals for medical health officers/senior medical health officers [ 20 ].

Change management was rated either major or major persistent challenge for 13 population interventions and for none of the individual services. The average score for population interventions was 2.5 and 1.2 for individual services.

The challenge of bringing about effective change in NCD prevention and control programme persists due to:

top down approach in identifying the changes required for better health outcomes without the involvement of the health personnel and/or recipients directly concerned with the changes;

lack of clarity of the change process, expected costs and benefits to health care providers, patients and the population;

weak inter-sectoral collaboration mechanism;

non-accompaniment of change by appropriate capacity building; and

absence of regular monitoring of the change process.

Financial access and risk protection

In relation to access to health services and financial protection, all government health services (including diagnostic tests, medicines and follow-up) are fully tax-funded, and thus, provided for free to all users [ 52 ]. Specialized services at regional hospitals are accessible in less than 1 hour’s drive from patient’s residence. A range of free domiciliary health services are also provided to the elderly and the disabled. Furthermore, free transport facilities are provided to eligible patients upon request; and Mauritius offers free public transport to the disabled and citizens aged 60 and above. Therefore, financial burden does not currently constitute a barrier to scale-up of core NCD population interventions and individual services within the public health system.

Approximately, 73% of the population attends public health care institutions whereas 27% seek care and treatment from the private health sector on a user-fee basis [ 51 ]. OOP expenditure varied across income groups. Households earning monthly income of less than Rs20,000 spent between 7 and 12% on health compared to only 4% health spending among households earning above Rs20,000 per month [48. In 2015, 3.7% of households experienced catastrophic expenditure on health [ 51 ].

However, according to the WHO World Health Statistics 2018, Mauritius has a universal coverage index of 64%, implying that there are other factors at play that account for suboptimal coverage of essential health services (including reproductive, maternal, newborn and child health, infectious diseases, and NCD health services) [ 11 ].

Financial access and risk protection was rated either major or major persistent challenge for none of the NCD population interventions and for none of the individual services. The average score for population interventions was 1.3 and 1.7 for individual services. The main issues identified by the WGs for financial access and risk protection include: high out-of-pocket expenditure as a percentage of total health expenditure (48% of CHE); significant differences in market prices of medicines; and low health insurance coverage in the population.

Key findings

The study rated coverage of core NCD population interventions and individual services; analysed the presence of 15 common health system challenges that impede delivery of core NCD interventions and services; and summarizes policy recommendations for Mauritius to address health system barriers to delivery of NCD interventions and services.

Only four (16.7%) out of the 24 core population NCD interventions and three of the 15 individual NCD services coverage was rated extensive in Mauritius. Therefore, there still remains substantial gaps in coverage of interventions aimed at reducing tobacco use, harmful alcohol use, consumption of unhealthy diet, and physical inactivity. Likewise, the individual NCD services coverage was found to be sub-optimal in the country.

Inadequate interagency cooperation and limited use of explicit priority-setting approaches were rated as major challenges to optimal expansion in coverage of population-based NCD interventions. Whereas, managing change, human resources for health, population empowerment and political commitment were other important challenges for population interventions.

Integration of evidence into practice was rated a major challenge for individual NCD services. Whereas, other health system challenges in order of priority, included use of explicit priority-setting approaches, adequate information solutions, population empowerment, distribution and mix of human resources for health, and ensuring access and financial risk protection.

Coverage of core population NCD interventions and individual services: a comparison between Mauritius and European region countries scores

We chose to compare Mauritius and European region countries core NCD interventions coverage scores due to close epidemiological similarities. For example, 82 and 82.8% of the DALYs lost in Mauritius and the European region were from NCDs, respectively. In addition, the Mauritius life expectancy of 74.8 years was generally comparable to that of the European region of 77.5 years [ 2 ].

Additional File  6 provides a comparison of Mauritius scorecards for core population-based interventions with those of 10 European region countries, namely Belarus [ 80 ], Croatia [ 81 ], Estonia [ 82 ], Hungary [ 83 ], Kyrgyzstan [ 84 ], The former Yugoslav Republic of Macedonia [ 85 ], Moldova [ 86 ], Tajikistan [ 87 ], Turkey [ 88 ] and Serbia [ 89 ]. The European country assessments did not contain ratings for interventions to promote physical activity. Thus, comparisons are for ratings of six antismoking interventions, six interventions to prevent harmful alcohol use, and six interventions to improve diet.

Antismoking interventions

(a) Mauritius’s efforts to raise tobacco taxes were rated moderate; Belarus, Croatia, Macedonia, and Serbia obtained similar ratings. Only Estonia and Turkey had an extensive rating. (b) Mauritius’s efforts to combat smoking through provision of smoke-free environments were rated moderate as in Croatia, Macedonia and Tajikistan. Only Turkey had an extensive rating. (c) Issuance of warnings on the dangers of tobacco and tobacco smoke was rated extensive in Mauritius, Macedonia, Turkey, and the remaining countries had lower ratings. (d) Banning of tobacco advertising, promotion and sponsorship was rated extensive in Mauritius, Macedonia and Turkey. (e) Provision of service for tobacco cessation to all those who want to quit (nicotine replacement therapy) was assessed to be moderate in Mauritius and Estonia, and extensive in Turkey. It was only in Turkey where five of the antismoking interventions were rated extensive. There is need for WHO to undertake detailed study in Turkey with a view to documenting best practice aspects that other countries, like Mauritius, can potentially emulate to improve implementation of antismoking interventions related to raising tobacco taxes, provision of smoke-free environments, and provision of service for tobacco cessation to all those who want to quit, that is nicotine replacement therapy.

Interventions to prevent harmful alcohol use

(a) Use pricing policies on alcohol including taxes on alcohol was rated moderate in Kyrgyzstan and Macedonia. (b) Restriction or banning of alcohol advertising and promotion was rated extensive in Mauritius, Tajikistan and Turkey. (c) Restriction of availability of alcohol in the retail sector was rated extensive in Croatia and Turkey; and moderate in Kyrgyzstan, Macedonia and Moldova compared to limited rating in Mauritius. (d) Enactment and enforcement of minimum alcohol purchase age regulation was rated extensive in Macedonia and Turkey compared to limited rating in Mauritius. (e). Implementation of a blood alcohol limit for driving was rated extensive in Estonia and Tajikistan compared to limited rating in Mauritius.

Interventions to improve diet

(a) Reduction of salt intake and the salt content of foods was rated moderate/extensive only in Turkey and limited in Mauritius and all other European countries in Additional File 6 . (b) Replacement of trans fats with unsaturated fats was rated moderate only in Hungary and Turkey compared to limited in Mauritius and all other European countries. (c) Reduction of free sugar intake was rated extensive in Hungary compared to moderate in Mauritius and limited in all other European countries. (d) Increased consumption of fruit and vegetables was rated limited in Mauritius compared to moderate in Belarus, Hungary, Tajikistan and Turkey. (e) Moderate rating of reduction in marketing pressure of food and non-alcoholic beverages to children in Mauritius was similar to that of Moldova and Turkey. The intervention was rated limited in other European region countries. (f) Awareness raising on diet was rated extensive in Mauritius compared to moderate in Belarus, Macedonia, Tajikistan, Turkey and Serbia.

Interventions to promote physical activity

(a) Implementation of communitywide public education and awareness campaigns for physical activity was similarly rated moderate in Mauritius as in Belarus, Macedonia, Tajikistan, Turkey and Serbia. (b) Provision of physical activity counselling and referral as part of routine primary health-care services through the use of a brief intervention was rated limited in Mauritius compared to moderate in Belarus. Comparison of ratings for the other interventions for promoting physical activity was not possible since information was missing for European region countries.

Coverage of individual NCD services: a comparison between Mauritius and European region countries scores

Additional File  7 compares Mauritius scoring for coverage of individual NCD services with those of ten European region countries. The scoring information on individual cancer interventions for majority of European region countries is missing in their reports. Thus, comparisons are made only for cardiovascular diseases and diabetes individual interventions.

Cardiovascular diseases (CVD) interventions

Risk stratification in primary health care.

CVD risk stratification in primary health care was rated limited in Mauritius compared to moderate rating in Croatia, Kyrgyzstan, Moldova, Turkey and Serbia.

Effective detection and management of hypertension

Effective detection and management of hypertension was similarly rated moderate in Mauritius, Turkey and Serbia.

Effective primary prevention in high-risk groups

Effective CVD primary prevention in high-risk groups was rated extensive in Mauritius compared to limited/moderate in European region countries.

Effective secondary prevention after acute myocardial infarction (AMI) including acetylsalicylic acid

Effective secondary prevention after AMI (including acetylsalicylic acid) was similarly rated extensive in Mauritius, Macedonia, Tajikistan, Turkey and Serbia.

Rapid response and secondary care after AMI and stroke

Rapid response and secondary care after AMI and stroke was rated moderate in Mauritius compared to extensive in Macedonia.

Effective detection and general follow-up

Effective detection and general follow-up for diabetes was rated moderate in Mauritius, Macedonia and Serbia.

Patient education on nutrition, physical activity and glucose management

Patient education on nutrition, physical activity and glucose management was rated moderate in Mauritius, Macedonia, Moldova and Serbia.

Hypertension management among diabetic patients

Hypertension management among people with diabetes was rated moderate in Mauritius compared to limited in Hungary, Macedonia and Serbia.

Prevention of complications (such as eye and foot examinations)

Prevention of diabetes complications (such as eye and foot examinations) was similarly rated moderate in Mauritius, Hungary and Serbia.

Policy recommendations

The following recommendations are made for further development of policies, programmes and interventions to reduce exposure to NCD risk factors, improve diagnosis and treatment of NCDs, strengthen the health system and aim towards UHC in Mauritius. They can also be used as a basis for policy dialogue between the different stakeholders in the development of the Health Sector Strategic Plan and an integrated NCD action plan.

Based on the assessment of features as well as the challenges identified and discussions with key stakeholders, a number of policy recommendations emerged.

First, it was noted that current interagency cooperation is not fully functional despite a new mechanism for more effective coordination and a little synergy through joint government/NGO efforts [ 20 ]. In order to keep all stakeholders engaged in health systems strengthening for NCD outcomes, a proposal was made to establish a high-level committee (consisting of relevant ministries, the private sector, academia, NGOs and the civil society) chaired at the highest level of government that oversees and coordinates the implementation of multi-sectoral activities to better address the social determinants of health and enhance a coherent approach to Health-in-All Policies (HiAP). In addition, recommendation was made to specify mandates of each sector explicitly linked with outcomes and resources to ensure accountability; build institutional capacity; and expand health workforce competencies to address inter-sectoral agenda of NCDs and to implement core population-based interventions through whole-of-government approaches.

Second, the population (especially older people) is not adequately empowered to change behaviour towards taking responsibility for their own health and engage actively in decision-making processes both around policy issues as well as individual treatment options/plans [ 20 ]. Recommendation was made to invest in community empowerment, through health promotion approaches, to strengthen community mobilization and participation to promote health literacy for behavioural and lifestyle change; to develop incentives for disease prevention, early detection and treatment; to engage and support NGOs and patients’ groups working actively on NCDs; and to set up structured peer-to-peer support groups within different stakeholders.

Third, primary health care (PHC) in the country is inefficient contributing to weaknesses in provision of preventive services, early diagnosis and treatment for those living with NCDs [ 20 ]. In order to address this issue, it will require improving quality of health care with people-centred health services. It will entail review, update and dissemination of treatment guidelines and standards, and monitoring of compliance; shift from an acute care model to a chronic care model; auditing of clinical services at all levels of care with explicit criteria for evaluating process and outcomes ; introduction of incentives for health workers to boost requisite capabilities for controlling NCDs; consolidating National Pharmacovigilance Committee. Furthermore, proposal was made to consolidate and scale up the role of primary health care as the centre of care for NCDs to respond to the ageing population and increasing rates of multi-morbidity. This will require strengthening PHC gatekeeping function and reducing duplication of services at PHC and hospital levels, as well as, reinforcement of the role of PHC in improving coordination between primary, secondary and tertiary care levels, implementing a more systematic screening and management of chronic conditions in PHC including improving links with NCD mobile clinics and risk stratification of patients with assessment of CVD risk factors using CVD risk scores.

Fourth, the assessment revealed issues of inadequate access, sharing and analysis of data generated by the health system, unavailability of modern information and technology solutions, and non-institutionalization of national NCD registries [ 20 ]. Recommendation was made to implement strong integrated health management information system. It will entail introducing e-health, whereby, all health information systems are integrated into an effective interoperable patient data transfer system, considering the use of a smart health card concerning all personal health information as well as setting up strong monitoring and evaluation systems.

Fifth, the assessment identified lack of explicit processes for prioritizing public health expenditures, leading to very low primary health care budgetary allocations [ 15 ]. Recommendation was made to develop and implement rational priority-setting mechanism for use in allocation of public health budget; appropriate budgeting and financing for addressing NCDs; increase substantially the allocation of funds for preventive and primary health care; earmark a fair share of the annual sin taxes collected on alcohol, tobacco and sugar for scaling up cost-effective population interventions for tackling NCD risk factors, for instance smoking, alcohol and substance abuse, unhealthy diets and low physical activity [ 20 ].

Finally, the assessment uncovered weaknesses in human resources for health (HRH) management such as the dearth of HRH planning and assessment, and inadequate NCD-related in-service training for service providers [ 20 ]. In order to improve the distribution and mix of human resources, recommendation was made to formulate a comprehensive policy and plan for HRH; improving training of HRH, especially in controlling NCDs; improving recruitment; efficient allocation of HRH; optimizing the performance of current workers via establishing clear-cut responsibilities for all grades of staff, competitive remunerations, capacity-building, performance contracts, and performance assessment; and reduction in attrition of HRH [ 20 , 90 ].

Limitations

The study had some limitations. First, as mentioned earlier, the MCAT and the WGs members were purposively chosen by the MOHQL. The key informants were also purposively selected by overall project coordinators (i.e. ADG and WR). Critiques might argue that, ideally, the MCAT, WGs and key informants should have been chosen using a statistical sampling methodology to avoid selection bias.

Second, the rating of coverage of both population-based NCD interventions and individual services was based on subjective judgements of fact by the MCAT and key informants. Thus, the ratings were dependent on the national reports and WHO reports referred to (see Tables  5 and 6 ), and the extent of knowledge and experience of the MCAT and key informants.

Three, the scoring of health system challenges was also based on subjective judgements of fact by the WGs and collaborated with pertinent national reports (as cited). Concerning the latter two potential limitations, like NG [ 91 ], we would argue that health scientists are more qualified than many others for making subjective judgements of fact closely related to their field study. According to NG [ 91 ], “a factual statement describes a fact as it is, and hence must be either true or false. In principle, it can be verified or falsified under ideal conditions (p.1014)”.

The coverage of majority (83%) of population-based interventions aimed at combatting main NCD risk factors (tobacco smoking, harmful alcohol use, unhealthy diet and physical inactivity) was rated as either moderate or limited. The sub-optimal coverage of population-based interventions has been attributed to largely to inadequate interagency cooperation, explicit use of priority-setting approaches, change management, distribution and mix of human resources for health, population empowerment, and political commitment.

About 86.7% of the individual NCD services coverage was rated moderate or limited. The sub-optimal coverage of individual NCD services has been ascribed to insufficient integration of evidence into practice, use of explicit priority-setting approaches, use of information and technology solutions, population empowerment, and distribution and mix of human resources for health. Thus, persistent health system challenges related to explicit priority-setting approaches, population empowerment and human resource for health hinder both the optimal coverage of both population-based interventions and individual services for NCD.

Therefore, Mauritius needs to increase its domestic general government investments into the national health system and requisite multi-sectoral action to address the priority health system challenges with a view of bridging the existing gaps in coverage of NCD population-based interventions and individual services.

Availability of data and materials

The NCD morbidity and mortality datasets used and/or analysed during the current study are available in the publicly accessible WHO Global Health Observatory [ https://www.who.int/gho/en ], the MOHQL website [ http://health.govmu.org/ ], and MOHQL published and grey literature included in references. The data on ratings on NCD interventions and services coverage; and scores of health system challenges are included in this paper.

Abbreviations

Acute myocardial infarction

Body mass index

Current health expenditure

Cardiovascular diseases

Disability-adjusted life-year

Diastolic blood pressure

WHO Framework convention for Tobacco Control

Gross domestic product

Health-in-all policies

Human resources for health

International monetary fund

International dollar or purchasing power parity

Mauritius country assessment team

Mauritius Institute of health

Ministry of health and quality of life

Non-communicable diseases

Nongovernmental organization

National health accounts

Out-of-pocket spending

Primary health care

Pay research bureau

Public service commission

Regional health director

Mauritius rupees

systolic blood pressure

UN sustainable development goals

United nations

United states dollar

Virtual health library

working group

World health organization

WHO regional office for Europe

WHO country representative

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Acknowledgements

We wish to thank members of the Mauritius Country Assessment Team who participated in scoring of the coverage of NCD interventions. We are also indebted to members of the five working groups that appraised the pertinence, presence and magnitude the common health system challenges to Mauritius. Contributions of the key informants is also greatly appreciated. This article is dedicated to all health workers in Mauritius who continue to relentlessly wage the fight against NCDs.

The Mauritius country assessment was funded by the MOHQL, WHO and EU/Lux/UHC Project. The staff of MOHQL (MT and PB) and staff of WHO (LM and FS) participated in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

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Contributions

LM, MT, PB, FS and JMK contributed equally in the design of the study, literature review, collecting and analysis of the data/information and writing of the manuscript. PD provided technical advice and quality control during the entire study process and reviewed the manuscript. All authors read and approved the final manuscript.

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Ethics approval and consent to participate.

The Republic of Mauritius Ministry of Health and Quality of Life (MOHQL) in a memorandum reference number MHO/WHONAHS approved the “National Assessment of Health Systems Challenges and Opportunities for better non communicable disease outcomes” on 8th September 2017. The MOHQL approval letter also covered the composition and names of project coordinator, assessment team, and multi-sectoral members of the five working groups. Therefore, the assessment did not require further formal ethical approval since its work undertaken by the MOHQL. The MOHQL in a memorandum reference number MHO/WHO/NAHS/V3 also gave approval on 27 February 2019 for publication.

The key informants were members of the multi-sectoral working groups constituted by the MOHQL (Reference No. MHO/WHONAHS). In the process of constituting the working groups the MOHQL checked their availability and obtained their verbal consent to participate in the entire assessment according to according to national procedures. Thus, being a MOHQL activity, it was deemed unnecessary to obtain formal written consent.

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Supplementary information

Additional file 1..

Criteria used for scoring coverage of NCD population-based interventions.

Additional File 2.

Criteria used for scoring coverage of NCD individual services.

Additional File 3.

Composition of the five working groups members that appraised, scored and ranked common health system challenges.

Additional File 4.

Scores pertaining to degree of health system challenge for NCD population-based interventions.

Additional File 5.

Scores pertaining to degree of health system challenge for NCD individual services.

Additional File 6.

Comparison of Mauritius scorecards for core population-based interventions with those of 10 European region countries.

Additional File 7.

Comparison of Mauritius scorecards for individual NCD services with those of 10 European region countries.

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Musango, L., Timol, M., Burhoo, P. et al. Assessing health system challenges and opportunities for better noncommunicable disease outcomes: the case of Mauritius. BMC Health Serv Res 20 , 184 (2020). https://doi.org/10.1186/s12913-020-5039-4

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Key success factors of Mauritius in the fight against COVID-19

Laurent musango.

1 World Health Organization Country Office for Mauritius, Port-Louis, Mauritius

Lovena Veerapa-Mangroo

2 Ministry of Health and Wellness, Port-Louis, Mauritius

Zouber Joomaye

3 Senior Adviser to the Prime Minister in Mauritius, Port-Louis, Mauritius

Adarshini Ghurbhurrun

4 Independent Consultant, Port-Louis, Mauritius

Vinoda Vythelingam

Elisabeth paul.

5 Department of Health Policies and Systems - International Heath, School of Public Health, Université Libre de Bruxelles, Brussels, Belgium

Summary box

• The COVID-19 response in Mauritius, which is viewed as a success story, benefited from strong leadership, highest political engagement, and strong involvement of the WHO, the private sector and other key stakeholders.
• Another key success factor lies in clear, transparent and consistent communication, including feedback mechanisms to understand public perception, the result of which is good adherence by the population.
• Public health measures (quarantine, contact tracing, case investigation and isolation of contacts, mass testing) have also contributed to the success of the country in the fight against COVID-19.
• The Mauritian success story can be inspiring for other countries, especially regarding the importance of adapting measures to evolving knowledge and developing a clear and consistent communication policy so as to buy the adherence of the population.
• However, contextual factors (an island has a limited number of entry points) have also facilitated the implementation and success of these measures.
• Not all countries can expect similar results by copy-pasting the Mauritian response strategy and should probably adopt a comprehensive policy acting on various factors to fight the pandemic.

Introduction

Mauritius is an island state in the Indian Ocean located within the continent of Africa, categorised as an upper-middle-income economy. It has an estimated population of 1.27 million inhabitants, a gross domestic product (GDP) of US$12.2 billion and a per capita GDP of US$ 9630 in 2021. 1

Following the declaration of the COVID-19 outbreak as a public health emergency of international concern on 30 January 2020, the WHO requested member states to develop a National Strategic Plan for Preparedness and Response to the Outbreak with nine strategic pillars. 2 Mauritius was identified as the country with the highest risk of exposure in the African Region, and South Africa, Cameroon and Algeria were the only large countries among the top 10 highest risk of exposure. 3 Using a mathematical model, stratified by age, to predict the evolution of COVID-19 epidemics, some authors predicted a median symptomatic attack rate of as much as 42% in Mauritius over the first 12 months, if the epidemics was unmitigated. 4

The first three COVID-19 cases (all imported) were detected in Mauritius on 18 March 2020. On 19 March, the borders were closed. With the escalation of cases, a curfew was imposed on 20 March, and eventually a complete lockdown was implemented on 24 March. 5 According to the national surveillance system, the outbreak quickly evolved from sporadic cases to clusters and then to local transmission and was contained on 26 April 2020, after 39 days, with no locally transmitted cases until November 2020. Then, two new community cases were reported, and since 26 November, only imported cases have been reported in the island. The measures adopted by Mauritius have highly been praised by international organisations. 6

Countries around the world have experienced very different epidemic profiles, with contextual factors, including social and environmental factors, playing an important role in shaping the outcomes 7 —hence the importance of shaping response policies to local contexts 8 and of adapting policies and interventions in light of emerging knowledge (evidence-based policy-making), engaging in transparent dialogues with stakeholders and developing appropriate communication strategies that build public trust and support. 9 The purpose of this article is to analyse the success factors of Mauritius that could inspire other countries—if properly adapted to their context—in future outbreaks.

This article adopts a reflexive analytical approach to comprehend the key success factors of Mauritius in fighting the COVID-19 pandemic. Reflexivity can indeed be defined ‘as an intentional intellectual activity in which individuals explore or examine a situation, an issue or a particular object on the basis of their past experiences to develop new understandings that will ultimately influence their actions’. 10 Data were collected through participative observation of key stakeholders involved in the fight against the COVID-19 pandemic in Mauritius (WHO, Ministry of Health and Wellness) complemented by a targeted documentary and literature review. After presenting an overview of the evolution of the pandemic in Mauritius, we present a number of key factors that have emerged from our reflexive analysis as major contributors to explaining the success of Mauritius in the fight against COVID-19.

Overview of the evolution of the pandemic in Mauritius

As shown in figure 1 , as of 17 January 2021, the cumulative number of confirmed COVID-19 cases was 556, of which 518 cases had successfully recovered, representing a recovery rate of 93.2%. Among the 556 confirmed cases, 341 (61.3%) were imported cases and 215 (38.7%) emanated from local transmission. There were 10 deaths in total; the incidence was 4.4 per 10 000 inhabitants and the case fatality rate was 1.8%. 11

Cumulative cases and cumulated deaths, Mauritius, 18 March 2020 to 20 January 2021 (WHO COVID-19 Weekly Situation Report 11 ).

Table 1 compares the situation of Mauritius with selected countries of the Indian Ocean Island in terms of COVID-19 confirmed cases and deaths reported in the last 7 days by countries, territories and areas, as of 17 January 2021. It shows that Mauritius is the country/territory that fares best in the Indian Ocean in terms of almost all indicators.

Comparison of Mauritius with neighbouring countries, selected COVID-19 indicators

COVID-19 Weekly Epidemiological Update. 11

The key success factors identified are presented below.

Strong governance and leadership

First, the COVID-19 response in Mauritius benefitted from strong leadership and highest political engagement. A High-Level COVID-19 Committee, chaired by the Prime Minister, was instituted on 31 January 2020 to monitor the local and international epidemiological situations and to rapidly share key information among the different ministries. The committee was composed of ministers in charge of Health and Wellness; Foreign Affairs, Regional Integration and International Trade; Finance, Economics, Planning and Development; Tourism; as well as the WHO Representative, the Secretary to Cabinet and Head of Civil Service, medical technical advisors and other key stakeholders. This whole-of-government approach enabled a timely and informed decision-making for a coordinated and scaled-up national response. In addition to this, an intersectoral committee was established at the level of Ministry of Health and Wellness (MoHW), which monitored the evolution of the epidemiological situation as well as the daily activities related to the operational plan. It also elaborated guidelines and standard operating procedures when needed. Numerous protocols were devised for the different processes of case management, including transfer to intensive care unit, oxygenation, ventilation, discharge of recovered patients and taking charge of patients’ family members. Some of the protocols were the WHO protocols, whereas others were adapted to the local context, taking into consideration the capacities of the Mauritian healthcare system. Many of them were modified several times to adapt to the changes in resources and epidemiological context and integrate the lessons learnt.

The COVID-19 response also benefited from a strong involvement of the private sector. Business Mauritius, which represents over 1200 local businesses, and the Mauritius Chamber of Commerce coordinated actions with the Government. For instance, the Mauritius Chamber of Commerce facilitated the making of food packs distributed by the Ministry of Social Security to families on the Social Registrar of Mauritius, ensured food supply chain continuity and contributed to devising the Work Access Permit and the alphabetical order strategy for shopping during the lockdown.

It is also important to mention the pivotal support provided by the WHO Country Office since the discovery of the virus. This comprised the sharing and regular updating of key information and guidelines, and technical assistance to assess preparedness and strengthen the capacities of country’s response to a health emergency, including the elaboration of the National Action Plan for Preparedness and Response. The WHO Country Office sustained its support, as the country prepared to start its vaccination campaign in January 2021. The purpose of ‘national vaccine table top exercises’ was to support country to plan, develop and update the national deployment and vaccination plan for COVID-19 vaccines, including testing and enhancing its planning assumptions. 12 Moreover, the WHO Country Office provided technical advice as member of the High-Level Committee on COVID-19.

Clear, transparent and consistent communication

Another key success factor in the fight against the pandemic of COVID-19 lies in clear, transparent and consistent communication. Mauritius started with an early intense sensitisation campaign on COVID-19. As of 23 January 2020, the MoHW started a national sensitisation campaign through different media (radio, television and written press) and visuals (posters, pamphlets, banners and billboards), explaining the occurrence of the novel coronavirus, its mode of transmission, signs and symptoms, and preventive measures to be taken to avoid the infection. During total lockdown, the National Communication Committee held press briefings in camera to avoid contact and answered questions from independent journalists sent on a live platform put in place by the National Broadcaster. These early messages placed emphasis on physical distancing, use of face masks, hand hygiene and cough etiquette, and encouraged the public to call the hotline for further information or to signal suspected cases. Pamphlets were distributed at the port and airport; in educational institutions, community halls and centres at the level of town municipalities; in village and district councils; and in all health facilities.

Clear and consistent communication was facilitated by the creation of the National Communication Committee on COVID-19 as a unique, central communication mechanism. It is entitled to transmit decisions taken by the High-Level Committee on COVID-19 to the Mauritian population and to address the key issues during daily press briefings. In addition, members of the National Communication Committee on COVID-19 also participated in special live television programmes on COVID-19 on the national television and radio channels. These enable to provide more details on the different response measures and to answer questions raised by the general public. It has proven to be a very effective strategy to ensure an accurate, transparent and trustworthy stream of communication directly from the decision-makers to the general public and to reassure the population. To expand the dissemination of information on COVID-19 and to achieve a maximum reach, several media platforms were created: a website, http://www.COVID-19.mu ; a Facebook page ‘Coronavirus Moris ’ dedicated to COVID-19 in Mauritius; and a mobile application, ‘beSafeMoris’.

Communication goes both ways, and henceforth, several feedback mechanisms to understand public perception on COVID-19 were established—namely, a hotline dedicated to COVID-19, the monitoring of social media platforms and live radio shows, and regular feedback from the Mauritius Police Force and MoHW. These mechanisms helped to monitor the populations’ behaviours with respect to the different measures implemented as well as their beliefs, fears and concerns which were consequently addressed during the regular press conference. As the outbreak progressed in Mauritius, the National Communication Committee on COVID-19 indeed observed that the population was more adherent to precautionary measures such as physical distancing and wearing masks while shopping and more respectful of the sanitary curfew in general. 13

The National Communication Committee on COVID-19 also addressed rumours, misinformation and fake news with clear and correct clarifications with a view of halting their propagation. The committee condemned the spreading of fake news on social media—notably about the prevalence of COVID-19 cases in Mauritius, the number of deaths, the reliability of tests and treatments, and the reclosure of supermarkets—characterised such behaviour as antipatriotic and highlighted their negative impact such as installing a climate of fear or panic.

Last but not least, the government was also engaged to reassure the population that the country is COVID-safe since 26 April 2020. The people were encouraged to remain alert and maintain recommended sanitary measures as the prevalence of COVID-19 is on the rise in foreign countries. This regular and transparent communication has proven to be highly effective. A considerable decrease in rumours and fake news was observed among the population and on social media. The population also reacted in a responsible and disciplined way when a cluster of two locally transmitted cases of COVID-19 were identified in November 2020. According to the reports from the COVID-19 testing centres, the Mauritius Police Force, media and social media, the population showed no behaviours expressing panic on the announcement of local cases. ‘The population is now better prepared and when there is a local transmission they understand that the authorities took the needful measures did the contact tracing … there was no panic, the population reacted responsibly and in discipline’—said Dr Joomaye Zouber, Senior Adviser to the Prime Minister in Mauritius, during his interview at the WHO Inter-Action Review exercise on 18 December 2020. There was also no indication of other behaviours such as panic buying and people not wanting to go to their workplace or sending their children to school.

Population adherence to physical distancing measures

During the COVID-19 community transmission phase in March to May 2020, high-level governmental commitment and good communication resulted in strong adherence of the population to physical distancing measures in place. These include, for example, the fact that while supermarkets opened 6 days a week, Mauritians were only allowed to shop twice a week in alphabetical order using family names: A to F on Mondays and Thursdays, G to N on Tuesdays and Fridays, and O to Z on Wednesdays and Saturdays. One person per household was allowed to shop for 30 min, and the wearing of protective masks was compulsory. Customers had to bring an identification document that was verified at the entrance of the supermarkets. The elderly, being more vulnerable, were dissuaded from shopping, whereas younger adults of the family were encouraged to do so. However, a special morning slot from 9:00 to 10:00 was created for elderly persons who had to shop for themselves. These measures were very well respected.

Strong public health measures

Capitalising on decades of experience in successfully fighting communicable diseases, Mauritius’ public health measures have also contributed to the success of the country in the fight against COVID-19. Contact tracing, case investigation and isolation of contacts were established under the supervision of the Communicable Diseases Control Unit. Once a positive COVID-19 case was notified by the Central Health Laboratory, the Communicable Diseases Control Unit contacted every person tested positive for case investigation following their transfer to the COVID-19 treatment centres. Key information about how long they had been sick, the people they stayed with, the people they had been in contact with and whether their contacts were sick, and the places they visited is collected. A list of all of the patient’s contacts is elaborated, and each of them is contacted, asked for symptoms and instructed to self-isolate while waiting to be visited by the contact tracing team.

On 27 April 2020, a mass rapid testing campaign for COVID-19 targeting frontliners was initiated by the MoHW. By 7 July 2020, 160 315 rapid tests were carried out among health personnel from both public and private institutions, including members of the police force, prison detainees, expatriates living in dormitories, pharmacies’ personnel, scavenging and cleaning services, supermarkets personnel, personnel working for port and airport authorities, private sector staff, staff from various ministries, members of religious and sociocultural organisations, public transport workers and athletes, among others. This campaign was designed to ensure that there was no case of COVID-19 in Mauritius in preparation for the phased ease of lockdown. No positive case was subsequently found, and the testing campaign was stopped.

Laboratory testing has also been a priority from the start of the pandemic. The total number of tests conducted as of 17 January 2021 was 319 242, comprising 158 927 PCR tests and 160 315 rapid antigen tests. A 14-day quarantine is mandatory for those entering Mauritius, with entrance conditioned on the presentation of a negative PCR test 7 days before travel to Mauritius and three tests during the quarantine on day 1, day 7 and day 14. All positive cases are treated in dedicated treatment centres until they get two consecutive negative tests at an interval of 24–48 hours. Mauritius is now elaborating the COVID-19 National Deployment and Vaccination Plan with a goal of re-opening borders.

On 19 January 2021, the High-Level Committee chaired by the Prime Minister met for the 101st time. It took note that while the number of cumulative cases compare with other African countries, the situation changed drastically because Mauritius, which was one of the most heavily hit African countries in April 2020, was the lowest affected country in the African region in January 2021. 11

Like many other countries, Mauritius faced an unprecedented situation because it had never experienced a pandemic of that scale and responded promptly by actions initially taken on an ad hoc basis. However, the government learnt throughout the national response and improved its management of the pandemic accordingly. Overall, it is estimated that measures implemented to prevent widespread community transmission of COVID-19 may have saved the country 837 human lives worth international US$258 080 991. This evidence, conjointly with human rights arguments, calls for increased investments to bridge the existing gaps for achieving universal health coverage by 2030. 14

We have identified governance and leadership, and communication, coupled with proactive contact tracing and test-and-treat measures as key factors contributing to the success of Mauritius. Other authors have also pinpointed the rapid response by the Mauritian Government, and appropriate and strong support and compliance from the public as key factors towards the control of the pandemic. 5 A retrospective study using inferential statistical methods identified a number of factors that have contributed significantly in controlling the propagation of the novel coronavirus in Mauritius; in particular, the sanitary curfew/lockdown, sanitisation and sensitisation campaigns, and safe shopping guidelines have helped to curb down, by a large extent, the number of COVID-19 cases. Hence, such preventive and proactive measures, with the main focus on sanitisation measures at grocery stores and in busy public places, should be maintained even after lifting lockdown orders. Quarantine centres for all incoming passengers have also significantly helped in timely containment of the novel coronavirus, eliminating to a great extent the risk of spreading in the local community. 6

The Mauritian success story can be inspiring for other countries. However, it should be noted that contextual factors have also facilitated the implementation and success of these measures. The fact that Mauritius is an island, with a limited number of entry points, has obviously facilitated the identification of arriving persons and the follow-up of their quarantine. The fact that Mauritius is a close-knit society has also perhaps facilitated social control and adherence to governmental measures. Therefore, not all countries can expect similar results by copy-pasting the Mauritian response strategy—and most countries should probably adopt a comprehensive policy acting on complementary social, economic, physical and environmental factors to improve the health stock of the population and to curb the COVID-19 mortality. 7 Nevertheless, Mauritius illustrates well the importance of adapting measures to evolving knowledge and developing a clear, transparent and consistent communication policy so as to buy the adherence of the population.

Handling editor: Seye Abimbola

Contributors: After analysis with all authors, LM wrote the first draft of this manuscript. EP contributed to framing the analysis and literature review. All authors contributed to revising the manuscript and approved the final version.

Competing interests: Some authors are WHO staff or have received consultancy fees from WHO, and EP has conducted consultations for various international and donor agencies, but this article has been written in total independence from any funder.

Patient consent for publication: Not required.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement: Data are available in a public, open access repository.

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Right to health in the welfare state of Mauritius: Is the State doing enough or is constitutional protection of right to health still required?

This chapter examines the notion 1of right to health in Mauritius. It provides an overview of the health situation and major health challenges in the country. Health services provided as part of the welfare system of governance in Mauritius is analysed especially in terms of acts of Parliaments that provide for those facilities. It then argues that right to health in Mauritius is not a right per se as it does not form part of the Constitution nor is it defined and granted as a right in any law of the land. The drawbacks of not having the right to health as a constitutionally protected right are then discussed. In so doing, an array of case law from the Supreme Court of Mauritius is considered to show that they are merely based on medical negligence and not cases that can influence policy-making. The application of international human rights law and more precisely the right to health as enshrined in international legal instruments by the Supreme Court is considered. The constraints that exist towards litigating the right to health are also noted. Finally, recommendations are made not only to have the right to health as a Constitutional right but also to amend the framework of application of international law as well as litigation possibilities for the right to health.

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Hospital Services

Curative services of Public Health Institutions are provided by 5 Regional Hospitals (Dr. Abdool Gaffoor. Jeetoo Hospital, Sir Seewoosagur Ramgoolam National Hospital, Dr. Bruno Cheong Hospital, Jawaharlal Nehru Hospital and Victoria Hospital), and 2 District Hospitals. They are supported by 7 specialised hospitals, namely, one psychiatric hospital, one for chest diseases, one for eye diseases, one for ear, nose and throat (E.N.T.) diseases, 2 Cardiac Centres and a new Cancer Hospital.

Services include emergency cases which are handled by the SAMU service and the Accident and Emergency departments of hospitals while chronic cases are seen at the Unsorted OPD of hospitals and primary health care centres. Specialised services are available on appointment provided by more than 23 specialties.

8,773,393 visits took place at the essential public health service points from 01 July 2021 to 30 June 2022 meaning that 23,971 cases were handled on average per day.

Accident and Emergency Departments of hospitals have catered for some 2,553 patients per day amounting to 931,910 visits for the whole financial year. Sorted outpatients on appointment arose to 915,338 visits followed by 818,547 unsorted visits without appointment. Hospitals have thus catered for 7,303 outpatient cases per day.

Overall attendances at dental services were 223,150 including 200,039 visits encountered at General Dental Services, 7,120 at Oral Surgery, 8,715 at Orthodontics and 7,276 at endodontics.

Ayurvedic Service was carried out at six service points and 44,257 attendances were recorded at these clinics. A wide range of Support Services provided professional back-up to doctors which included Audiology and Speech Therapy, Clinical Psychology, Hydrotherapy, Hyperbar, Medical Social Service, Diet and Nutrition, Occupational Therapy, Physiotherapy, Podiatry and Foot Care, Occupational Health Service, Orthopaedics Workshop, Retinal Screening and Smoking Cessation Clinics among others. They have catered for some 320,600 cases.

171 wards were available in public hospitals as at June 2022 with 3,620 available beds including 54 intensive care beds for adults and 29 for neonates. 153,823 admissions were registered in the FY. Overall bed occupancy has gone up to 69.7% with the highest of 79.9%, 79.7% and 74.2% at Dr A G Jeetoo Hospital, Brown Sequard Mental Health Care Centre and Victoria Hospital respectively.

Regional Hospitals, Souillac Hospital, S. Bharati Eye Hospital, ENT Centre and the Cardiac Centre have carried out 45,681surgeries. These included 895 open heart surgeries, 7,051 cataract surgeries, 860 lithotripsy and 319arterio-venous fistula cases. Additionally, 4,758 cardiac angiopraphies/angioplastries were carried out.

The Laboratory Service has reported on 14 million tests for the period 01 July 2021 to 30 June 2022.The Radiology Department has carried out 683,130 X-ray examinations including34,135 CT-Scans and 5,132 MRIs in 2021.

The Ministry of Health and Wellness is providing two new services at the Sir Seewoosagur Ramgoolam (SSR) National Hospital, namely the Fertility Clinic and an Epidural Service for women in labour since 14 February 2022. The Fertility Clinic provides a holistic approach to those couples who are facing difficulties to conceive based on the assessment, diagnosis and treatment modalities. Existing advanced reproduction technique such as artificial insemination is available to couples requiring the service.

The Pharmacy Department of the Ministry overlooks the Pharmacy Services of both the Public and the Private sector. The main duties and responsibilities are to ensure that

• the population at large have access to drugs which are of required Quality, safety and efficacy.
• the Practice of Pharmacy is in line with the Pharmacy Act 1983, Dangerous Drugs Act 2000 and the Pharmacy Council Act 2015.

The Pharmacy Department of the Ministry is supported by 37 Government Pharmacists and 97 Pharmacy Technicians posted at different points of Service throughout the Island.  Pharmacists are posted at the Ministry of Health and Wellness, Central Supplies Division, Main and Specialised Hospital Pharmacies whereas the Pharmacy Technicians ensure the dispensing activities at Hospital Pharmacies, Area Health Centres, CHCS, and Mediclinics.

The Medicines list of the Ministry incorporates the Essential Medicines recommended by the World Health Organization and is continuously updated by the pool of technical experts. The Pharmacovigilance Department of the Ministry is being upgraded and shall henceforth ensure that medications in use in the country are closely monitored for safety.

The Pharmacy Board is responsible for the exercise of control over the manufacture, importation, distribution and sale of medications in the country. Moreover, the Board is also responsible for the grant of licence for the operation of retail and wholesale pharmacies. Presently there are 380 Community Pharmacies operating throughout the Island and 45 Wholesale Pharmacies. The Pharmacy Council regulate and control the profession of Pharmacists and also promote the advancement in the field of Pharmacy. Among others, the Pharmacy Council register Pharmacists and Pre-registered trainees, exercise and maintain discipline in the profession of pharmacists.  As at date, there are 555 Pharmacists registered with the Pharmacy Council of Mauritius.

The policy in Oral Health Care is to improve access, quality and delivery of Dental Services by,  inter-alia,  reducing waiting time, putting emphasis on customer care and using latest medical technologies.

As at date, the total number of Dental Clinics was 55 (including in Rodrigues and Agalega) at Hospital and Primary Health Care level providing routine dental care and 13 Specialised Dental Clinics (Oral Surgery, Orthodontics and Endodontics) in 4 Regional Hospitals. At Dr. Bruno Cheong Hospital, these Specialised Services are covered by Specialists from SSRN Hospital for the time being.

A National Plan of Action for Oral Health for the next 5 years has been finalised and launched on 01 June 2022. The main objectives of the Action Plan are:

• Oral Health Promotion mainly to improve Oral Health literacy;
• Integration of Oral Health into National Health Policy;
• Oral Health preventive strategies as opposed to approaches that emphasise treatment of existing disease with a view to strengthening prevention and early intervention programmes;
• Consideration of workforce models that maximise efficiency;
• Infrastructural development and facilities;
• Development of accurate surveillance systems to define the oral disease burden which will improve population data on Oral Health status and enhance Oral Health promotion research;
• Evaluating and monitoring the concentration of fluoride for caries control;
• Phasing down the use of mercury in dental amalgam;
• Oral Health rehabilitation strategies; and
• Oral Health research approaches.

The primary role of the Service d’Aide Médicale Urgente (SAMU) services is to provide on-site pre-hospital medical treatment and stabilize critical and vital emergencies during transport, thus keeping in pace with the concept of the golden hour. The SAMU also perform secondary inter hospital transfers of severely ill patients for CT scans, MRI, Primary and Rescue Percutaneous Coronary Intervention (PCI), etc. as well as aero medical transfers.

The SAMU Control Room 114 which is functional on a 24-hour basis all year round is situated at Victoria hospital. Around 1,000 calls are attended daily and based on an efficient triage system, logistics and a recording system with specially trained staff, the SAMU attends to pre-hospital emergencies. Some 366,587 calls were received on 114 during the FY 2021-2022.

With the specialisation in Emergency Medicine by the Emergency physicians in 2019, a Resuscitation Unit has been added to the Accident and Emergency unit in each of the 5 Regional Hospitals to cater for all vital emergencies including patients with myocardial infarction.

In addition, SAMU staff participates in simulation exercises with other stakeholders and plays a leading role in situations where there are mass casualties during natural or man-made disasters.

It is envisaged to have a better and more appropriate collaboration with the Fire and Rescue services so that the two Departments can work in unison to attend to pre-hospital emergencies more effectively.

Dialysis treatment is provided free of charge to all patients attending Public Health Institutions. Some of the extra number of patients who cannot be accommodated in the Government Hospitals are referred to the Private clinics with whom this Ministry has entered into agreement to provide the service against payment. The Private Clinics are provided with the dialysis consumables kit for each dialysis session. Presently, such treatment is available in seven Government Hospitals and in six Private Clinics.

The number of haemodialysis in public hospitals has steadily increased from 157,948 in 2018 to 182,287 in 2021 while for the same period, in private hospitals, the number of haemodialysis performed decreased from 51,827 to 42,394. At the end of 2021, there were 1,208 patients on dialysis in the 5 regional hospitals, Long Mountain Hospital and Souillac Hospital; another 250 government hospital patients were on dialysis in private centres, making a total of 1,458 patients as compared to 1,403 and 1,532 as at the end of 2019 and 2020 respectively.

In Mauritius, mental health care is accessible to each and every one through decentralization. Psychiatric services are dispensed at Brown Sequard Mental Health Care Centre (BSMHCC) as well as in the five regional hospitals and some Area Health Centres/Community Health Centres. The services at BSMHCC consist of a 250 bedded facility for the treatment of acute cases and it can cater for around 500 patients in long stay wards.

Mauritius is one of the rare countries outside India where the practice of Ayurvedic medicines is legalised and governed by a law – the ‘Ayurveda and other Traditional Medicine Act-1989’. Under this Act the practice of Ayurveda, Homeopathy and Chinese system of Medicine are recognized and regulated in Mauritius. At present, six Ayurvedic Clinics are providing the following Ayurvedic services to the population:

• Free Consultation and Diagnosis;
• Ayurvedic Panchkarma Therapy on prescription;
• Advising therapeutic yoga in all required and appropriate cases;
• Advising and counselling of patient as per Ayurvedic principles;
• Free distribution of Ayurvedic Medicine; and
• Regular follow-up of all cases depending on its acute or chronic condition

Ayurvedic health services are provided at the outpatient level which is open 6/7 days. Mauritians attend these Ayurvedic clinics for various ailments ranging from hairfall, chronic joint disorders, skin problems like psoriasis, digestive problems, obesity, NCDS and even with complications like cardiovascular diseases, renal diseases, cancer etc.

The Diabetes and Vascular Health Centre (DVHC), situated at New Souillac Hospital, was set up in 2010 in response to the high prevalence of Diabetes in Mauritius as evoked in the National Service Framework for Diabetes (NSFD). The Centre provides holistic care to patients with diabetes and early detection and management of complications of diabetes. DVHC provides a multidisciplinary approach to the management of diabetes under one roof. This one-stop shop approach allows for better patients’ compliance. The following services are provided:

• Specialised care to patients with diabetes by Diabetologists;
• Podiatry Care;
• Foot Ulcer Management;
• Diabetic Retinopathy Screening Service (Provided in all 5 Regions);
• Counselling by Nutritionist;
• Empowerment programmes for patients with diabetes – Nurse-Led Clinic;
• Smoking Cessation Clinic; and
• In-patient management of diabetes and related complications.

The Diabetic Retinopathy Screening Service (DRSS) is important as it helps Diabetic patients to detect and manage early Diabetes complications. Each Retinal unit is well equipped with one retinal camera, one grading station and also trained staffs.  A well-defined protocol is established for channelling patients in all these units. All Diabetic Patients are referred at least once a year to the Retinal Units. Pamphlets also used to educate patients on Diabetic Retinopathy.

The Overseas Treatment Unit of the Ministry provides financial assistance and all necessary support to patients who have been recommended for treatment abroad by a Medical Board set up in the Regional Hospitals. These patients also have to meet the income eligibility criteria for households as set by the Ministry. Arrangements are made for the patients to be admitted in health institutions in India with which the MOHW has signed a Memorandum of Understanding.

The Overseas Treatment Scheme also provides the possibility for patients to opt for any medical institutions of their choice in other countries. Patients proceeding to hospital of their choices benefit financial assistance based on the lowest quotation received from the above-mentioned health institutions. They are however granted the equivalent of funds for a ticket equivalent to India airfare. In some severe cases, upon recommendation of the treating doctor, a stretcher is also provided.

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Public Health Delivery In Mauritius

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A New Approach to Quality Health Care

The quality and model of health care must be reengineered and benchmarked on best practices prevailing in the world so as to provide quality health care services to the people and to play a premier role in helping mauritius become a competitive centre of excellence of high tech medicine.

By Mrinal Roy

A sum of Rs 12.2 billion was earmarked in the Budget 2018-2019 for the Ministry of Health and Quality of life in order to ‘enhance the health care system and make of Mauritius a medical centre of excellence.’ What is the real situation in the health sector?

Mauritius benefits from a large health care infrastructure comprising general and specialized hospitals and health centres spread across the country manned by some 5,000 medical and paramedical personnel, which offer a broad spectrum of free health services to the people. Costly medical treatment such as cardiac surgery, dialysis, angioplasty and stent placement, neurosurgery, etc., or investigations such as MRI or CT scans,  etc., which all cost enormously in private clinics as well as the diverse consumables required for treatment are borne by public funds.

Yet, criticisms are intermittently levelled against the quality of public health care. Despite the wide range of facilities, the public health care service is perceived as being subpar to the costly medical services provided by private clinics despite the fact that very often the specialists in various fields practise in both the public and private health care sectors. Isn’t it time to reappraise the whole system of public health care to ensure that it is aligned on the highest benchmarks prevailing in the world?

It must also be underlined that apart from the quality of medical care provided, medical insurance cover is the key factor which determines the choice of treatment of patients in private clinics. The insurance cover is benchmarked on the costs of appropriate treatment available worldwide. It has had a potent cost-push effect on the cost of medical treatment locally. The upshot is that the medical insurance cover schemes guarantee to a large extent the revenues of private clinics.

Unequal choice

The choice of people for competent treatment and cure cannot depend on whether they benefit from private medical insurance cover or have the means to pay for the costly bills of treatment in private clinics. With such a substantial budget outlay invested in health care facilities, the public health service must be able to offer an equally competent treatment, health care and cure especially for the multitude who neither have medical insurance cover or the means for treatment in private clinics. The people cannot be short changed.

The medical landscape in the country is grim and the challenges daunting. The population is ageing. Health can be very fragile. In a country where some 200,000 persons are aged above 60 years old, it is vital that the health services of the country provide a quality health care to them and to people generally. They need to be treated with dignity and their ailment cured competently. For those suffering from life-limiting illnesses, every effort must be made to allay their suffering through palliative care and to comfort them. It is disconcerting that the vital project of a geriatric hospital has disappeared from the government screen. The quality of the medical and paramedical personnel must also be continuously upgraded so as to enable them to provide a constantly improved health care to patients.

All things being equal, more people will seek, owing to the ageing population, health treatment for a variety of ailments associated with old age. Furthermore, senior citizens cannot, owing to their age, obtain health insurance cover. They are compelled to be their own health insurers and whenever necessary foot the bill of the excessively high cost of health care and surgery if necessary, in private clinics. However, it is only a minority of elderly patients who can afford these costly treatments. Most of them depend on the public health service for treatment.

The public health services must therefore be fully prepared to treat a larger number of elderly patients who would require treatment for diverse ailments and more importantly would need a much higher quality of health care from the medical and paramedical personnel.

Life threatening

Medical statistics also show that diabetes, heart diseases, cancer & tumors, chronic respiratory diseases and cerebrovascular diseases are in that order the principal causes of death in the country. Are the national health services geared and equipped to competently deal with such a daunting list of life threatening diseases? Would it not therefore be more judicious and sensible to build the important state of the art cancer hospital from scratch on state lands in a location which is easily accessible by public transport instead of transforming the derelict MedPoint premises?

It should be noted in this context that the 2018 Nobel Prize winners in Medicine was awarded jointly to James P. Allison and Tasuku Honjo “for their discovery of cancer therapy by inhibition of negative immune regulation.” Thus, immunotherapy brings hope as it is now successfully used abroad to boost the body’s defense against cancer cells in the case of skin, bladder or lung cancer.

Is it not equally high time to start as is the case for the National Health Service in the United Kingdom a preventive medicine campaign based on an early tracking of diseases likely to affect people after a certain age, through appropriate tests carried out on all persons at risk? This should inter alia include mammography and pap smear test for women and psa to detect prostate cancer. Colonoscopy as from a certain age to detect colorectal cancer and chest X-Ray to detect lung cancer should also be included in the tracking procedures in place, for both men and women.

Proper communication with the patient and the next of kin is also a key element of treatment and cure. Whenever you come across somebody you know whose family member has been admitted to hospital, you seldom have precise information on the exact ailment the patient is suffering from, the treatment he is receiving, the name of the doctor who is treating the patient or on the prognosis, etc. In line with the best practices prevailing in the world, hand in hand with providing quality treatment to patients, it is equally important that the patient and his next of kin are regularly apprised of his/her state of health and the timeline and outcome of his/her treatment through regular communication. Is there not a well codified protocol to deal with hospital patients? Do the doctors in charge of their treatment regularly inform the patient and their next of kin on his/her state of health and the treatment envisaged?

Oath of duty

It does not cost anything for the medical and paramedical personnel to communicate regularly with patients and their next of kin to explain, reassure and comfort in line with the oath of duty of doctors towards their patients. The quality of health care would have been so much better. It would also lead to confidence building in public health services and establish a trustworthy connect between doctors and nurses and their patients.

High tech medicine has been earmarked to be another robust pillar of the economy. It should however be underlined that the well known foreign partners of private clinics who helped (with their pool of highly qualified specialists skilled in diverse cutting edge treatments)  build the reputation of Mauritius as a reputable centre for high tech medicine have left the country. Mauritius can only build this sector into a major pillar of the economy if the sector is geared to provide high tech medical services and offer the most pointed and state of the art medical procedures and treatment to foreign patients in a wide range of medical fields including cardiology, ophthalmology, nephrology, dentistry, cosmetic & plastic surgery, etc., at competitive prices.

Premier role

Should we not envisage as is the case in government hospitals in the United Kingdom and France specially designed private wings in state hospitals offering diverse medical treatments to foreign patients at competitive rates? These could be tied up with renowned specialists in different fields from across the world to offer more pointed and high tech medical treatment to both local and foreign patients. Such a development would not only help train local specialists, doctors and nurses into more pointed medical procedures but also be a significant source of financing to invest in better medical facilities and equipment. It would also bring healthy competition and benchmark medical costs in the country.

The status quo is therefore untenable. The quality and model of health care must therefore be reengineered and benchmarked on best practices prevailing in the world so as to provide quality health care services to the people and to play a premier role in helping Mauritius become a competitive centre of excellence of high tech medicine for the benefit of the country.

* Published in print edition on 16 November 2018

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Launching of mauritius national health sector strategic plan by prime minister.

Hon. Prime Minister of the Republic of Mauritius, Pravind Kumar Jugnauth launched the National Health Sector Strategic Plan (HSSP) 2020-2024 on 12 August 2020 at the Hennessy Park Hotel, Ebene, Mauritius in the presence of eminent personalities including Deputy Prime Minister, Hon. S. Obeegadoo, Dr Hon. Kailash Kumar Jagutpal, Minister of Health and Wellness, Dr Hon A. Husnoo, Minister of Local Government and Disaster Risk Management, Hon. N. Bodha, Minister of Foreign Affairs and other Private Parliament Secretary members. Dr Laurent Musango, WHO Representative in Mauritius, Mrs Christine Umotoni, UN Resident Coordinator and representative of European Union also attended the launching ceremony.

During his key note address, Hon. P. K. Jugnauth, Prime Minister of the Republic of Mauritius acknowledged the ‘able guidance of WHO’ in developing this first five year national health sector strategic plan which will enable the Government of Mauritius “to turn into reality its vision of a healthy nation”.

“This national HSSP has been aligned with the Mauritius Vision 2030 and the Government Programme 2020-2024 to give a clear direction to the health care sector”, said Hon. P. K. Jugnauth who also added that the HSSP will guide the Government to address new emerging health care challenges; which will require investment in health care delivery and acts as a driver for sustainable development.

The Prime Minister highlighted that past investment in health care is now bringing rewarding dividend as confirmed by three indicators, namely increase in life expectancy at birth, decrease in infant mortality and maternal death. He recalled that the Government of Mauritius is investing significantly to improve the health of its population before underlining the important health projects in the pipeline including the New Cancer Hospital, New Eye Hospital and the New Training Centre at the Flacq Hospital and decentralization of the health care services.

“Mauritius deployed all possible means to fight COVID-19, the lethal-multi organs disease which is affecting all countries around the world”, pointed out Hon P.K. Jugnauth. He stressed that the country registered less than 400 COVID-19 cases in all and managed bring down local transmission to zero five weeks after the first three COVID-19 cases were registered. He further underlined the need for a ‘rethink approach to pandemic preparedness”. According to the Prime Minister, NCDs which accounts for 80% of the burden of diseases remains one of the priority of the Government of Mauritius. The Prime Minister said that the increase in birth control and life expectancy have resulted in an increase in ageing population, a challenge that the country needs to address.

“The expectations of the patients in terms of quality of health care, clinical rights and rights for prevention, information and screening should be managed adequately to increase the patient’s satisfaction level and improve health outcomes”, said Hon P.K. Jugnauth.

Dr Hon. K. K. Jagutpal, Minister of Health and Wellness, during his address, highlighted “the extensive participatory approach adopted during the development of the HSSP”. He stated that, “the views and opinions of the private and public sectors, health care service providers as well the patients have been considered through societal dialogue, an innovative means of good governance recommended by WHO.

“This realistic document has been developed with the active participation of nine working groups which reported to the steering committee”, stated the Health Minister who added that the Government of Mauritius “fully understand the country men and country women expectations for a free health care system”. The strengths and weaknesses of the present system have been assessed as well as good practices before developing the plan further added Dr Hon. K.K. Jagutpal.

Dr Laurent Musango, WHO Representative in Mauritius during his address, expressed his solidarity with the Government of Mauritius and the people of the country afflicted by the national disaster related to the wreckage of MV Wakoshio off the coast of Pointe D’Esny.

“World Health Organization stands by the side of the Government of Mauritius and its people to provide the required response and ensure a prompt recovery”, said Dr L. Musango before congratulating the Government of Mauritius and the Ministry of Health and Wellness towards undertaking this important activity of developing the Health Sector Strategy Plan.

“This plan builds on the achievements made by the Republic of Mauritius in improving the health of its population as well as on the achievement of Goal no.3 of Sustainable Development Goals”, said Dr Musango who also pointed out that the global health environment is becoming increasingly complex. He mentioned social, demographic and epidemiological transformations fed by globalization, urbanization and ageing populations as challenges of a magnitude that was not anticipated three decades ago.

Dr Musango stated his appreciation that Mauritius is continually strengthening health systems and improving health security through robust, realistic, comprehensive, coherent and well-balanced health policies, strategies and plans. He underlined the strong leadership and commitment of the Prime Minister in stepping up and working intensely with the population.

“The development of this HSSP started with a National assessment of Health Systems Challenges and Opportunities for better Non-Communicable Diseases Outcomes (NCDs) recommending key policy actions, followed up by initiating the process of Societal Dialogue and technical assessment on Primary Health care”, stressed Dr Musango.

WHO Representative acknowledged the participatory approach adopted during the whole process of developing the HSSP. He mentioned the important participation of a broad range of stakeholders ranging from collaborating ministries, bilateral and multilaterals agencies, including EU, UNAIDS, UNFPA, WHO, among others, nongovernmental organizations and civil society, to allow for a comprehensive in-depth analysis using stakeholders’ expertise and views to jointly assess the available evidence and jointly feed into policy directions set in the five year HSSP.

Dr Musango concluded by recalling that “the scope of the HSSP extends much beyond the delivery of health care and covers broad public health agenda that includes social determinants, integrated and multisectoral action, health in all policies, health emergencies with rapidly detection and response including COVID-19 response and recovery, international health regulation, (IHR), health innovation and new technologies, school health, food safety, research, medical hub and others”. He advocated for a collaborative and coordinated effort by setting up a committee to implement, monitor and evaluate the HSSP.

For Additional Information or to Request Interviews, Please contact:

PITCHAMOOTOO Vinoda NPO (NCDs/HP) Email: [email protected]

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Health System in Mauritius

Mauritius, a beautiful island nation located in the Indian Ocean, boasts not only stunning beaches and vibrant culture but also a well-developed health system. The health system in Mauritius is known for its accessibility, quality care, and comprehensive coverage. In this essay, we will explore the key features of the health system in Mauritius and why it is considered exemplary.

One of the fundamental aspects of the health system in Mauritius is its universal coverage. The government of Mauritius has implemented a system that ensures all citizens have access to healthcare services, regardless of their socio-economic status. This commitment to universal healthcare has resulted in a high level of health equity and has contributed to the overall well-being of the population.

The health system in Mauritius is built on a strong foundation of primary healthcare. Primary healthcare centers are spread across the country, providing essential services such as preventive care, health education, and early detection of diseases. These centers play a crucial role in promoting community health and reducing the burden on secondary and tertiary healthcare facilities.

In addition to primary healthcare, Mauritius also boasts well-equipped hospitals and specialized healthcare facilities. These facilities offer a wide range of medical services, including specialized surgeries, advanced diagnostic procedures, and specialized treatments. The healthcare professionals in Mauritius are highly trained and skilled, ensuring that patients receive the best possible care.

Another notable feature of the health system in Mauritius is its emphasis on preventive care. The government has implemented various initiatives to promote healthy lifestyles and prevent diseases. These initiatives include public health campaigns, vaccination programs, and regular health screenings. By focusing on prevention, the health system in Mauritius aims to reduce the incidence of diseases and improve the overall health of the population.

Furthermore, the health system in Mauritius is supported by a robust health information system. This system enables the collection, analysis, and dissemination of health data, which aids in evidence-based decision making and policy formulation. The availability of accurate and timely health information allows healthcare providers to identify health trends, allocate resources effectively, and develop targeted interventions.

In conclusion, the health system in Mauritius is a well-organized and comprehensive system that prioritizes accessibility, quality care, and preventive measures. With its commitment to universal coverage, emphasis on primary healthcare, focus on preventive care, and robust health information system, Mauritius sets an example for other countries striving to achieve an efficient and effective health system. The success of the health system in Mauritius can be attributed to the government's dedication to the well-being of its citizens and its continuous efforts to improve the healthcare infrastructure.

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This review assesses the climate for domestic and foreign investment in Mauritius. It discusses the challenges and opportunities faced by the government in its reform efforts. Capitalising on the OECD Policy Framework for Investment and the OECD Foreign Direct Investment Qualities Policy Toolkit, this review explores trends and qualities in foreign investment, development successes and productivity challenges, investment policy, investment promotion and facilitation, and investment incentives. The review highlights potential reform priorities to help Mauritius fulfil its development ambitions that align with its commitment to comply with the principles of openness, transparency and non discrimination. This report also helps Mauritius, as a new Adherent to the OECD Declaration on International Investment and Multinational Enterprises, to promote greater investment policy transparency, as well as responsible business conduct.

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