Geographical dispersion poses unique challenges to healthcare delivery in archipelagic states. Discuss, citing the Maldives' hub-and-spoke health system.

In archipelagic states, small populations live scattered across large stretches of sea, so healthcare cannot reach people the way roads allow on a mainland. A 1970s report on the Maldives counted only 192 inhabited islands out of about 2,000, on just 115 sq miles of land, served by one 52-bed hospital in Malé [1]. The country's hub-and-spoke system is a response to this dispersion, but it also shows where that response falls short.

Challenges posed by geographical dispersion

• Access and emergency transfer: There are no roads between islands. WHO names the "geographical remoteness" of islands and "vast oceanic distances" as the core hurdles for emergency care [3].
• Diseconomies of scale: Tiny island populations cannot support specialists or advanced equipment on every island. Advanced cardiac care and advanced imaging are still unavailable in the atolls [2].
• Workforce dependence: In the 1970s, the first ENT specialist ever to reach Malé came from Madras on a short WHO assignment [1].
• Livelihood-linked disease: Fishing, diving, a vitamin-poor fish-and-rice diet and harsh weather drove chronic tonsillitis and mastoiditis [1].

The Maldives' hub-and-spoke model

• Hub: Indira Gandhi Memorial Hospital (IGMH), Malé, is the largest facility and the sole public tertiary-care provider [2].
• Spokes: Six atoll hospitals are designated regional hospitals and refer complex cases upward to IGMH [2].
• Strength: concentrated excellence. Pooling scarce expertise works. IGMH was the national reference hospital and laboratory when the Maldives became the world's first country to achieve triple elimination of mother-to-child transmission of HIV, syphilis and hepatitis B (2025) [4].
• Strain: congestion at the hub. Weak primary care pushes patients to Malé. WHO's Regional Director said that low PHC investment "directly increased tertiary care costs and congestion", with only about 1% of health spending going to prevention [5].
• Strain: equity gap. Outer-atoll residents depend on referrals to Malé, while specialist care stays concentrated in the capital [2].

Dispersion turns every gap in island-level care into a costly sea crossing. The hub-and-spoke model manages this problem but cannot remove it. The way forward is to strengthen the spokes:

• scale up primary care, as the Faafu Atoll PHC demonstration site is testing [5];
• use the 2025 EMS and Mass Casualty Management Guidelines developed with WHO and ADB [3];
• expand telemedicine;
• train local staff and keep them in service.

Such reforms would move the Maldives towards SDG 3.8 (universal health coverage) and offer lessons for India's own Lakshadweep and Andaman & Nicobar islands.