WHO MIND Mental Mental Health Health in in Development Development
WHO proMIND: Profiles on Mental Health in Development
REPUBLIC OF NAURU Mental Health Policy and Service Development
Department of Mental Health and Substance Abuse World Health Organization
WHO Library Cataloguing-in-Publication Data WHO proMIND: profiles on mental health in development: Republic of Nauru. 1.Mental health. 2.Mental health services. 3.Health policy. 4.Nauru. I.World Health Organization. II.Republic of Nauru. ISBN 978 92 4 150416 4 (NLM classification: WM 140)
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Suggested Citation: Tangitau A, Funk M, Soakai S, Skeen S, Hughes F, Thoma, K, Sinclair J, Shields L. WHO Profile on mental health in development (WHO proMIND): Republic of Nauru. Geneva, World Health Organization, 2012.
This and other profiles on mental health in development can be sourced from: http://www.who.int/mental_health/policy/country/countrysummary/en/index.html For feedback or suggestions for the improvement of this publication, please email Dr Michelle Funk (funkm@who.int)
REPUBLIC OF NAURU
"For all people in Nauru to be appreciative of, and to enjoy, mental well-being" Acknowledgements This publication has been produced as part of the World Health Organization's (WHO) profiles on mental health in development (WHO proMIND), and has been written and edited by: Dr Alani Tangitau, Director of Medical Services, Government of the Republic of Nauru Dr Michelle Funk, Coordinator, Mental Health Policy and Service Development, Department of Mental Health and Substance Abuse, WHO, Geneva Mr Sunia Soaki, Secretary for Health and Medical Services, Government of the Republic of Nauru Ms Sarah Skeen, Technical Officer, Mental Health Policy and Service Development, Department of Mental Health and Substance Abuse, WHO, Geneva Dr Frances Hughes, Former WHO PIMHnet Facilitator, Wellington, New Zealand Dr Kiki Thoma, Medical Officer in Charge of Mental Health, Republic of Nauru Hospital Ms Jessica Sinclair, Mental Health Policy and Service Development, Department of Mental Health and Substance Abuse, WHO, Geneva Ms Laura Shields, Mental Health Policy and Service Development, Department of Mental Health and Substance Abuse, WHO, Geneva The preparation of this profile would not have been possible without the support of the following staff from the Republic of Nauru and WHO: Ms Virginia Abraham, Mental Health Nurse and PIMHnet Focal Point, Republic of Nauru Hospital Dr Dong Il Ahn, The WHO Representative in the South Pacific, Suva, Fiji Dr Temo K. Waqanivalu, Coordinator, Office of the WHO Representative in the South Pacific, Suva, Fiji Dr Xiangdong Wang, Regional Adviser for Mental Health, WHO Regional Office for the Western Pacific, Manila, Philippines.
(WHO proMIND): Republic of Nauru Potential partners interested in finding out more about mental health in the Republic of Nauru should also contact project partners based in-country (contact details on page 7):
WHO proMIND Potential partners and donors interested in supporting or funding WHO proMIND projects should contact Dr Michelle Funk (funkm@who.int), Coordinator, MHP, Department of Mental Health and Substance Abuse, WHO, Geneva, Switzerland.
More information about WHO MIND and WHO proMIND projects is available on the website: http://www.who.int/mental_health/policy/en/
The WHO Pacific Islands Mental Health Network (PIMHnet)
The idea to establish the Pacific Islands Mental Health Network (WHO PIMHnet) came about at a meeting of Ministers of Health for the Pacific Island Countries (Samoa, 2005) during which the idea of a Pacific network as a means of overcoming geographical and resource constraints in the field of mental health was discussed. There was unanimous support among countries of the Pacific Region to establish the network, and with the support of New Zealand’s Ministry of Health, the World Health Organization initiated process to establish PIMHnet. The network was officially launched during the Pacific Island Meeting of Health Ministers in Vanuatu in 2007. PIMHnet currently counts 19 member countries, each with an officially appointed focal point: American Samoa, Australia, Commonwealth of the Northern Mariana Islands, Cook Islands, Federated States of Micronesia, Fiji, Guam, Kiribati, Marshall Islands, Nauru, New Zealand, Niue, Palau, Papua New Guinea, Samoa, Solomon Islands, Tokelau, Tonga and Vanuatu. The key aim of the Pacific Island Mental Health Network is to enable Island countries to work together and draw on their collective experience, knowledge and resources in order to establish mental health systems that can provide effective treatment and care. In consultation with countries, PIMHnet has identified a number of priority areas of work, including advocacy; human resources and training; mental health policy, planning, legislation and service development; and access to psychotropic drugs; and research and information. Network countries meet on an annual basis to develop workplans outlining major areas for action to address these priorities, to be officially endorsed by their ministers of health. PIMHnet has also been successful in forging strategic partnerships with NGOs and other agencies working in the Pacific Region in order to reduce the existing fragmentation of mental health activities and to build more coordinated and effective strategies to address the treatment gap, to improve mental health care and put an end to stigma, discrimination and human rights violations against people with mental disorders. Funding to support PIMHnet is provided to WHO by the New Zealand Agency for International Aid (NZAID).
THE PROJECT "For all people in Nauru to be appreciative of, and to enjoy, mental well-being"
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KEY ACHIEVEMENTS FOR MENTAL HEALTH IN NAURU
Development of a draft mental health policy Completion of a human resource and training plan for mental health in Nauru Participation in the WHO Pacific Islands Mental Health Network Placements of mental health nurses in Tonga and Australia to build skills and competencies Launching of the 24 hours Mental Health Toll-Free Help Line (donated by Digicel Nauru) and the Promotion Video Clip “Depression”
NEXT STEPS FOR NAURU
Consultation on draft mental health policy Implementation of human resource and training plan to build the capacity of nurses in mental health Development of improved system for the provision of home and community support
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OVERVIEW While there is limited epidemiological data available on mental health in Nauru, evidence suggests an overall increase in mental illness and substance abuse. Access to mental health services is extremely limited and there are no specialist services. Mental health services are provided by a single outpatient clinic located at the Republic of Nauru Hospital. Individuals requiring emergent in-patient treatment may be admitted to the 2-bed isolation ward at the hospital. However, people with mental disorders who are thought to be a danger to themselves or others are often detained in police cells until psychiatric care can be arranged. Up until the program’s end in 2007, Australian psychiatrists funded by AUSAID would spend 1 week per month in Nauru to provide medical treatment and support. Today, a single psychiatrist, funded by AUSAID, visits from Tonga to provide clinical supervision of mental health treatment and care. A mental health policy was drafted in 1993, however there was no consultation or finalization of this process. Key objectives and areas for action that were outlined in the policy include: Strengthening the existing community based mental health programme; Providing evidence-based and cost-effective treatment to all people who need mental health care; Promoting the human rights of people with mental disorders; Strengthening the families ability to provide care and support to people with mental disorders; Integrating mental health into general health care; Promoting mental health through sectoral and inter-sectoral initiatives; Protecting, promoting and restoring the physical and mental wellbeing of all residents in Nauru; Developing a mental health board for sustained leadership and direction.
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HISTORY AND MILESTONES
2005 A Situational Analysis on mental health needs and resources in Pacific Island countries was completed as part of a Pacific-wide review of mental health care and services by the World Health Organization and Auckland University, New Zealand. 2005 AUSAID Mental Health Program commenced in Nauru, through which Australian psychiatrists visited Nauru for one week of the month to provide treatment and support (1). 2006 Nauru joined the WHO Pacific Island Mental Health Network, providing the country with an opportunity to access much needed information and resources to develop its mental health policy and build capacity in its mental health workforce. 2007 In January, Nauru developed a draft mental health policy. 2007 In June, the Inaugural PIMHnet General Meeting and Policy and Planning Workshop was held in Apia, Samoa. Nauru participated in this meeting, which included a two-day mental health policy and planning workshop. 2008 The Second PIMHnet Annual General Meeting was held in September in Nadi, Fiji. Nauru attended and participated in a workshop focused on developing human resource and training plans. 2009 Nauru completed its human resources and training plan for mental health in September, which identified existing human resources and training needs in mental health and sets out strategies. 2009 In October, a Mental Health Awareness Programme was conducted at the Nauru Market by the Mental Health Team together with the Public Health Promotion Team in celebration of World Mental Health Day. 2010 A psychiatrist from Tonga (Dr. Mapa Puloka) was engaged to perform support visits, including reviewing assessment and treatment of people registered as having mental health problems. Funding for this was made available through AUSAID and supports three visits per year.
2011 General health checks conducted for service users diagnosed with mental illness Pamphlets on mental health, side effects of psychotropic medicines produced in Naoero language Funds made available for basic office equipment in the mental health unit of the RON hospital The first Clinical Attachment of Mental Health Nurse to Tonga completed.
2012 Two additional attachments to mental health services (1 mental health nurse for 4 weeks at Vaiola WHOproMIND: Nauru | 4
Hospital Mental Health Unit in Tonga; 2nd nurse for 6 week attachment at the Schizophrenia Unit at Rockhampton Hospital, Queensland Australia) Launching of the 24 hours Mental Health Toll-Free Help Line (donated by Digicel Nauru) and the Promotion Video Clip “Depression”
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Figure 1: Timeline 2012 Launching of the 24 hours Mental Health Toll-Free Help Line
2005 Commencement of AusAid Mental Health Program in Nauru 2006 Nauru joins the WHO Pacific Island Mental Health Network
2007 Inaugural PIMHnet General Meeting and Policy and Planning Workshop 2008 Second PIMHnet Annual General Meeting
2009 Mental Health Awareness Program conducted for World Mental Health Day
2005 Situational Analysis on mental health needs and resources in Pacific Island countries
2011 General health checks conducted for service users diagnosed with mental illness
2007 Development of draft Mental Health Policy
2009 Completion of human resources and training plan for mental health
2011 The first Clinical Attachment of Mental Health Nurse to Tonga completed 2012 2 additional attachments of 2 nurses to mental health facilities (Tonga and Australia
2010 Engagement of Tongan psychiatrist for mental health support visits
timeline 2005 2006 2007 2008 2009 2010 2011 2012
OFFICIAL DOCUMENTS
DEVELOPMENT AND POVERTY REDUCTION POLICIES, STRATEGIES AND PROGRAMMES Republic of Nauru. 2009. National Sustainable Development Strategy 2009 Version. http://www.naurugov.nr/pages/NSDS.html Republic of Nauru. 2004. National Sustainable Development Strategy 2005-2025. http://www.sprep.org/att/IRC/eCOPIES/Countries/Nauru/2a.pdf The Republic of Nauru and the Secretariat of the Pacific Community. 2007. Joint Country Strategy 2008-2010.
HEALTH AND MENTAL HEALTH POLICIES, PLANS AND PROGRAMMES Department of Health, Republic of Nauru. January 2007. Mental Health Policy: Final Draft. Ministry of Health, Republic of Nauru. 2006. Nauru Non Communicable Disease Action Plan 2007-2012.
LEGISLATION The Mental Health Ordinance. 1963. At present there is a draft legislation which was completed in 2007 but which has not been passed.
SITUATIONAL ANALYSES Asian Development Bank. 2007. Nauru Country Economic Report. http://www.adb.org/Documents/CERs/NAU/CER-NAU-2007.pdf WHO, 2005. Situational analysis of mental health needs and resources in Pacific Island countries. Centre for Mental Health Research, Policy and Service Development.
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MAIN PARTNERS
NATIONAL LEADING PARTNERS Mr Sunia Soakai, Secretary for Health and Medical Services, Government of the Republic of Nauru Email: sunia.soakai@naurugov.nr Dr Alani Tangitau, Director of Medical Services, Government of the Republic of Nauru Email: alani.tangitau@nauru.gov.nr Dr Kiki Thoma, Medical Officer in Charge of Mental Health, Republic of Nauru Hospital Email: kiki.thoma@nauru.gov.nr Ms Virginia Abraham, Mental Health Nurse and PIMHnet Focal Point, Republic of Nauru Hospital Email: virginia.abraham@nauru.gov.nr
WHO COUNTRY OFFICE Dr Dong Il Ahn, The WHO Representative in the South Pacific, Suva, Fiji Email: who.sp@wpro.who.int Dr Temo K. Waqanivalu, Coordinator, Office of the WHO Representative in the South Pacific, Suva, Fiji Email: waqanivalut@wpro.who.int
WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC (WPRO) Dr Xiangdong Wang, Regional Adviser in Mental Health and Control of Substance Abuse, WHO Regional Office for the Western Pacific, Manila, Philippines Email: wangx@wpro.who.int
WHO HEADQUARTERS Dr Michelle Funk, Coordinator, Mental Health Policy and Service Development, MSD Email: funkm@who.int Ms Natalie Drew, Technical Officer, Mental Health Policy and Service Development, MSD Email: drewn@who.int Dr Kanna Sugiura, Technical Officer, Mental Health Policy and Service Development, MSD Email: sugiuraka@who.int Dr Shekhar Saxena, Director, Department of Mental Health and Substance Abuse (MSD) Email: saxenas@who.int
OTHER Dr Frances Hughes, WHO PIMHnet Facilitator, Email: frances@wellpro.col: frances@wellpro.co
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THE CONTEXT
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1. COUNTRY DEMOGRAPHIC AND SOCIOECONOMIC PROFILE
Figure 2. Map of Nauru
Source: reference (2)
GEOGRAPHY AND CLIMATE Nauru is a small island with an area of 21km located 41 kilometres south of the equator. Extensive mining of the island’s central plateau has left the region uninhabitable. Nauru is exposed to extreme weather patterns that may range from wet storm surges to prolonged drought periods. DEMOGRAPHICS The population of Nauru is 14,540 (3). Approximately 34.6% of the population is less than 15 years of age (3). The broad population base pattern, illustrated in the population pyramid in Figure 3, indicates that the population is growing rapidly and this trend will continue when those currently aged younger than 15 years enter their reproductive years (4). Less than 5% of the population is currently older than 60, which is indicative of the low life expectancy and relatively high mortality rates (3). 2.
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Figure 3. Age structure diagram illustrating Nauru's high growth population, with high proportion of under 30s and relatively few elderly reflecting high mortality rates
Source: reference (5)
Figure 4. Age structure diagram showing Nauru's population stabilizing by 2050, as numbers in the older and younger cohorts begin to equalize and life expectancy increases.
Source: reference (5)
MIGRATION Emigration options for Nauruans are very limited and education standards need to improve radically if significant numbers of Nauruans are to qualify under relevant emigration and work schemes in the Pacific region and beyond (6).
CULTURE According to the latest (2002) national census, 70% of the island’s population was Nauruan, 12% Pacific Islanders and a minority from China, Kiribati, Tuvalu and other parts of Asia. Most of the population is Christian (7). Nauruan is the official language, although English is also widely used, especially for most government and commercial activities.
GOVERNMENT AND ADMINISTRATION Nauru is divided into 14 small districts of various sizes and varying numbers of inhabitants (7). The country is governed by a unicameral Parliament consisting of 18 elected members. Parliament elects the president, who is both chief of state and head of government, from among its members. The president appoints a cabinet from among members of Parliament. There is a small police force under civilian control. There are no armed forces (8).
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DEVELOPMENT INDICATORS There is no data on Nauru's current or past relative standing on the Human Development Index (HDI). However, Table 1 presents some key data for individual development indicators reflecting Nauru's high birth and mortality rates, low literacy levels, and low life expectancy.
Table 1 Individual indicators of human development for Nauru Indicator Life expectancy at birth Under-5 mortality per 100,000 Death rate (crude), per 1,000 population Birth rate (crude), per 1,000 population % births with skilled attendants Infant mortality per 1,000 live births Maternal mortality ratio per 100,000 live births % illiterate >15 years old Gross enrolment ratio in education (both sexes) (%) GDP per capita (USD) Source: references (4, 9-11)
Nauru Male 52.5 45 7.8 31.2 97.4 38 300 23.0 55.0 $2,671 45.5 Female 58.2
Year of Data 2002 2008 2002 2002 2007 2007 2002 2007 2010 2005-6
Nauru faces a number of developmental challenges. In the past Nauru has been economically selfreliant, taking high revenues from exports of phosphate which, at the height of phosphate mining, put its GDP among the highest in the Pacific and its living standards at levels comparable to high income countries. More recently however, phosphate reserves have been severely depleted and are soon expected to be exhausted, resulting in a drastic decline in revenue followed by a decrease in disposable income, and increased dependence on foreign aid. The rehabilitation of mined land and the replacement of income from phosphate are serious long-term challenges. In anticipation from this transition out of a phosphate economy, the Government has been cutting costs resulting in wage freezes and a reduction of overstaffed public service departments. Both food and water are, for the most part, imported from Australia and there are frequent disruptions of food, fuel, and equipment and materials supplies. Nauru is also particularly vulnerable because of its isolation with only one aircraft serving the country. The lack of a safe harbour for berthing of ships hinders marine transportation links beyond container freight and phosphate carriers (3). There is insufficient statistical information to fully assess Nauru’s progress on Millennium Development Goals (MDGs). However, the country's National Sustainable Development Strategy is in line with the aims of the MDGs and has reported qualitative and quantitative data on some key indicators. The Nauruan government estimates that, as a result of the close kinship system wherein income is transferred among extended family members, the low, biweekly general wage of $140 is often spread among multiple families making it likely that some Nauruans are living on income of less than $1 per day. Education is, compulsory and free up to 15 years and nine months of age. Primary school attendance is between 60 to 70 percent, although an enrolment in all levels of education is only between 23 to 45% - see Table 1 above (6).
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2 CONTEXTUAL FACTORS INFLUENCING MENTAL HEALTH NEEDS AND SERVICES
ECONOMIC AND ENVIRONMENTAL CONTEXT Nauru's current economic state has led to a number of factors that influence the mental health of its people. Previously, Nauru relied heavily on phosphate mining and residents had the secondhighest per-capita GNP in the world during the 1970s and 1980s. However, the subsequent depletion of this resource and poor investment of revenues has led to a decrease of disposable income and subsequent government bankruptcy and dependency on foreign aid, especially from Australia and Taiwan (China) (2). The economic challenges are compounded by environmental and cultural factors. Nauru is physically isolated. Strip-mining of phosphates has left the country environmentally devastated and successful rehabilitation of the land is thought to be either very difficult or impossible. Nauru imports 90% of its food supplies and other necessities, and has faced interruption of air service in the past due to bankruptcy of its airline. Much of Nauru's cultural heritage and traditional diet has been lost and this has now contributed to high rates of unemployment and obesity. These factors, along with high rates of drinking and tobacco, have resulted in critical socioeconomic challenges to Nauruan health and their health care system (2).
HEALTH STATUS There is a high rate of diabetes, obesity, and cardiovascular disease in Nauru (12). The traditional practices of fishing and gardening for food are no longer practiced; diets now consist largely of imported Westernised food. There is also limited physical activity (2). As a result, Nauruans have the highest rates of obesity in the Pacific with 72% of men and 77% of women classified as obese (13). Nauruans also have the highest incidence of diabetes in the world, with up to 30% diagnosed with Type II diabetes. There is anecdotal evidence that compliance with treatment for diabetes is poor. Treatment of advanced cases is expensive, sometimes requiring transfer of patients to the Fiji Islands or Australia (2). Use of alcohol and tobacco also present significant health and economic concerns. Approximately half of the adult population engages in binge drinking. Reports of heavy drinking increasing with rising unemployment rates have been associated with larger proportions of household income being spent on purchasing alcohol. In spite of the fact that it is banned, consumption of homedistilled alcohol has also increased and is associated with reports of deaths from poisoning (2). Approximately half of the adult population smokes tobacco daily, with higher rates of use among women (56%) than men (50%) (3). However, improvements in other areas of health have been noted. According to a survey conducted by the Nauruan Demographic and Health Survey in 2007, 95% of pregnant women saw a doctor, nurse, midwife or auxiliary midwife at least once during their most recent pregnancy in the five-year period prior to the study. Almost all deliveries in the sample took place in a health facility (4). Immunization coverage for standard vaccine-preventable diseases (such as tetanus, tuberculosis, polio, and hepatitis B) is estimated to be 100% and the entire population has access to good quality drinking water and sanitation facilities. HIV prevalence in adolescents and adults is estimated at less than 0.1% (3).
POLITICAL AND ECONOMIC FACTORS From 2001 to 2008, the Nauruan government hosted the Australian Offshore Processing Centre, which housed more than 1200 persons seeking entry to Australia. Although the centre brought in revenue in the form of a multimillion dollar aid package from Australia, the physical and mental health needs of asylum-seekers added to the burden on the Nauruan health system (3). Nauru received financial support from the Australian government for the health system costs related to operation of the centre, but this support ended when the facility closed in 2008. The closing of the processing centre led to the loss of 100 jobs, which was estimated to have affected 1000 Nauruans WHOproMIND: Nauru | 13
(nearly 10% of the population). This further increased Nauru's dependence on aid from foreign sources.
INTERPERSONAL VIOLENCE There is anecdotal evidence that suggests that there are high rates of domestic and sexual violence, including rape. Child and adolescent sexual and physical abuse that have been perpetuated by family members or family friends have been reported to the Mental Health Service. Domestic violence is associated with alcohol abuse, acute stress related disorders and with chronic anxiety disorders among those who are the victims of violence.
Figure 5 Contextual factors influencing health, mental health and development in Nauru (since the 1970s).
National workforce shifted to one sector
Economic focus on phosphate mining
Bad investment and overspending
Loss of 'traditional' skills (e.g. agriculture)
↘local production (e.g. agriculture and fishing) exports
Economic diversity Depletion of natural resources
Dramatic variations in GDP
Government bankruptcy ↘Economic resilience dependence on external trade +/aid Environmental devastation
Employment
Poverty Change diet, physical activity, alcohol and tobacco consumption
Dramatic changes in lifestyles
Social and economic deconstruction
Negative impact on health including mental health
Difficulty to maintain public services
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MENTAL HEALTH PROBLEMS AND TREATMENT IN NAURU
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3. BURDEN OF DISEASE AND TREATMENT GAP
PREVALENCE AND BURDEN OF DISEASE IN COUNTRY Studies to assess the prevalence of mental disorders in Nauru have not been conducted. However, the burden of neuropsychiatric conditions in Nauru according to WHO 2004 age-standardized DALY rates was 2,745 DALYs per 100,000 population, representing about 9.6% of the country’s all-cause disease burden (14). There are anecdotal accounts that suggest that both self harm and suicide are increasing. There is a high prevalence of mental disorders among people who abuse substances. Alcohol abuse is common in both men and women and anecdotal evidence suggests that the use of illicit drugs (predominantly marijuana) in Nauru is increasing.
TREATMENT AND SERVICE UTILIZATION DATA In 2006, a total of 48 people were assessed or received brief interventions for mental health problems and 24 patients diagnosed with schizophrenia or other psychotic disorders received regular visits by the mental health team. The majority of patients being treated by the service are aged between 20 and 45 years.
TREATMENT GAP Given that there is no national level data for population-based prevalence rates of mental illness in Nauru, the treatment gap has been estimated using the global rate of 13% prevalence (3% severe and 10% mild to moderate)(15), together with the limited service utilization reported above (72 people treated in 2006). Based on global prevalence rates, we can estimate that about 1,236 people in Nauru (13% of the 9,510 adult population) have had a mental disorder in the previous year, and about 285 (3% of the adult population) have had a severe form. If it is assumed that most of the people in Nauru who were treated had a severe mental disorder the treatment gap for severe mental disorders is 74.7%. If we base calculations on the total number of people with any form of mental disorder (mild to severe) then the treatment gap becomes larger at 94.2%. The estimated treatment gap is illustrated in Figure 6.
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Figure 6 The estimated treatment gap for mental disorders in Nauru
1400 1200 1000 800 600 400 200 0 Estimated prevalence in Nauru Treatment provided in Nauru in 2006
Moderate to Mild Mental Disorders 951 people Severe Mental Disorders 285 people
Total prevalence MD = 1,236 people
5.8% of people with any form of a mental disorder received treatment
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MENTAL HEALTH WITHIN THE GENERAL HEALTH SYSTEM
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4. MENTAL HEALTH WITHIN THE GENERAL HEALTH SYSTEM
The Republic of Nauru Health Service is divided into 2 sectors – acute health and public health. The services in each of these sectors, as well as how these are coordinated between the Ministry of Health and other bodies, are shown in Figure 7 opposite. The acute health service is located at the Republic of Nauru Hospital, consisting of a 55 bed hospital, 1 theatre operating suite, 4 bed emergency department and an outpatient department. There are 5 outpatient clinics and a renal dialysis department attached to the acute health service. There are 5 specialists and 5 medical officers working at the hospital. The 38 nurses and 21 nurse aids are a combination of expatriate and local staff. o Mental health services are only available at this hospital. People who are admitted for psychiatric reasons are admitted to a 2 bed isolation ward. Outpatient mental health services are also available from this facility. There is one doctor and one nurse aid who deal with all mental health clients.
The public health service provides public health and primary health care services from the Nauru Public Health Centre. There are 2 doctors, both expatriates, working in primary health (PH) and a range of other support staff. Services that are run from this centre include Well Baby Clinic, Health Promotion, Diabetic Clinic, and Environmental Health. The majority of staff in these sections are nurse aides. Community programmes are mainly organized and implemented by the Health Promotion Section and the District Primary Health Care Workers. They are the health representatives in their own communities and they follow up cases to ensure that they attend their clinics at the hospital or the Diabetic Clinic. They also assist with tracing mental health patients in collaboration with the current mental health nurse.
An Overseas Referral Committee chaired by the Director of Medical Services prioritizes cases recommended for overseas treatment guided by an overseas referral policy. The majority of cases referred overseas are referred to Australia. However, on some occasions, patients are referred to Suva Private Hospital in Fiji. In addition to referring patients overseas, Nauru has hosted several Visiting Specialist Teams including renovascular, ENT, eye, cardiology and gastroenterology teams which are funded by AUSAID. Furthermore, ICDF (International Cooperation and Development Fund) Taiwan Medical Mission visits twice annually and the specialist team depends on the request submitted by the Ministry of Health. At present, a psychiatrist from Tonga is engaged as a visiting consultant for mental health in Nauru with financial support from Australia. Since 2006, AUSAID has enabled the secretary of health and allied services and the director of nursing to improve health sector planning and management, develop a pharmaceuticals procurement system and physical health infrastructure that includes a new laboratory, pharmacy and dental clinic (16).
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Figure 7. The Health System in Nauru
OVERSEAS REFERRAL COMMITTEE Prioritize cases recommended for overseas treatment in Australia/Fiji
Ministry of Health Director of Medical Services
External support for mental health Support visits from medical officer from Tonga, approx. 3 times per year.
REPUBLIC OF NAURU HOSPITAL (2nd/3rd level) (Clinical services) 5 specialists 5 medical officers, of which 1 works in mental health 38 registered nurses 21 nurse aides (of which 1 works in mental health)
Referrals Overseas
NAURU PUBLIC HEALTH CLINIC (Public Health and primary health Services) 2 doctors 4 registered nurses 18 nurse aides Health promotion staff Other public health staff
Referrals
PRIMARY CARE CLINICS (1st level) Well Baby Clinic Health Promotion Diabetic Clinic Environmental Health
Referrals
COORDINATION The Nauru Mental Health Service was established by the Government of Nauru in partnership with the Australian government in early 2006 and continues to be coordinated by the Government of Nauru. The Mental Health Service is located at the outpatient clinic at the Republic of Nauru Hospital. Figure 8 below shows how mental health services are coordinated in Nauru. Figure 8. Coordination of mental health services in Nauru
MINSTRY OF HEALTH REPUBLIC OF NAURU HOSPITAL Outpatient clinic Mental Health Service 1 doctor (Senior medical officer) 1 nurse aide Visits to prison
Home visits for follow-up
LEGAL FRAMEWORK The Mentally Disordered Persons Ordinance was enacted in 1963. It focuses on involuntary treatment, but not patient and family rights and responsibilities. It is not consistent with international standards regarding mental health and human rights and is generally not referred to except in extreme circumstances. In 2007, the legal advisor to the Government of Nauru drafted a new mental health legislation that will act as a foundation for future legislation in Nauru. However, this is still in draft form and has not yet been passed.
MENTAL HEALTH POLICY AND PLAN The Nauru National Sustainable Development Strategy 2005-2025 (NNSDS) includes healthspecific goals for preventive health services in order to reduce diseases related to lifestyle. Because Nauru has the poorest health indicators in the region for non-communicable diseases (NCDs), the Ministry of Health has developed the Nauru NCD Action Plan. This plan details specific interventions, for example to reduce alcohol abuse in the community (6). While a national mental health policy was formulated in 2007, it has not yet been implemented. The plan focuses on reducing the burden of mental disorders by developing an up-to-date mental health legislation, promoting consistent and ongoing leadership within mental health, providing training to improve the capacity of the workforce, expanding specialist services, creating better links with the various informal mental health services, developing substance abuse services, providing infrastructure support for a community, and initiating advocacy and health promotion campaigns. There is no national substance abuse policy. There are no suicide prevention strategies in place.
HUMAN RIGHTS AND EQUITY Mental illness is not considered a disability within the Nauruan legal and health system, and the country does not provide disability benefits to persons with mental illness. Stigma and discrimination of people with mental disorders is highly prevalent within communities and even families. There are a range of negative cultural beliefs about mental illness, including the belief that that mental disorders are due to black magic or a curse on a family (17). There is a great deal of stigma and shame surrounding mental disorders and it is very difficult to get people to come to the health facility for treatment (17). WHOproMIND: Nauru | 22
4. MENTAL HEALTH WITHIN THE GENERAL HEALTH SYSTEM
FINANCING Health care services are provided for free. However, private services rely on out-of-pocket payments as private prepaid plans are not available. Nauru does not have an urban-rural split, as this small country is considered to be entirely urban (17). However, many health indicators (see Table 2) are negative and represent significant challenges for Nauruan health and their health system, especially given the current economic, political, and environmental factors, which are described below (17). There is no government budget specific to mental health or substance abuse services (including suicide prevention). The mental health service was established in February 2006 with funding from the Australian Department of Immigration and Multicultural Affairs. Initially, this funding paid for an expatriate mental health nurse (who has now left) and a visiting psychiatrist. Currently, AUSAID funds a visiting psychiatrist from Tonga to visit Nauru 3 times a year to provide support for mental health services.
Table 2 Health expenditure indicators, 2006 data Health expenditure Government Allocation to Health Per capita total expenditure on health Government spending on health per capita Total expenditure on health as a % of GDP General government expenditure on health as % of total expenditure on health Private expenditure on health as % of total expenditure on health General government expenditure on health as % of total government expenditure Source: reference (18)
Indicator US$ 18.4 million US$798 US$706 12.3 88.5
11.5
8.8
HUMAN RESOURCES The number of doctors and nurses working in Nauru can vary as there are several expatriate health workers who come to Nauru for consultancies and short-term contracts. Figure 9 shows 2004 WHO data for human resources in Nauru, at which time there were 10 doctors in Nauru.
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Figure 9 Human Resources for General Health in Nauru 70
60 60
50
40
30
20
10 10
10 3
1 0 Nurses Dentistry personnel Pharmacists
Midwifery personnel
Physicians
Source: reference (19)
No staff are dedicated to mental health in Nauru. As mentioned above, one doctor and a locally trained nurse assistant have gained some mental health experience, and provide some services (17). They are supported by the psychiatrist from Tonga who visits 3 times a year. Table 3 and Table 4 below show the distribution of staff at the Republic of Nauru Hospital and the Nauru Public Health Clinic, respectively, according to 2010 data.
Table 3 Republic of Nauru Hospital staff (2010 data) Position title Anesthetist Physician Surgeon Obstetrician / Gynaecologist Paediatrician Senior Medical Officer General Medical Officer Unit Manager Nurse Supervisor Staff Nurse Graduate Nurse Nurse Aide Number of posts
1 1 1 1 1 1 4 6 11 10 11 21
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Table 4 Nauru Public Health clinic staff Position title Director of Public Health Specialist Public Health Healthy Island Coordinator Health Promotion Educator Health Promotion Graphic Artist District Health Workers (Nurse Aide) Diabetic Care Manager Diabetes Care Officer Diabetes Foot Care Officer Diabetes Nurse Aide Primary Health Care Manager Primary Health Care Nurse Supervisor Primary Health Care Staff Nurse Primary Health Care Nurse Aide Dietetician Nutrition Officer Environmental Officer Food Inspector Sanitary Assistant Number of posts
1 1 1 1 1 14 1 2 1 1 1 2 2 3 1 1 1 1 5
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TRAINING As of 2007, 50% of the professional healthcare staff in Nauru were expatriates on contract. However, the government is also engaged in a programme to provide training to Nauruan nationals. Approximately 30 nationals were enrolled in healthcare training programs in the Western Pacific, including about a dozen in the Nauru campus of the University of the South Pacific. As of 2007, four students were training to be physicians, one was enrolled in a radiology program, and about a dozen were in nursing programs. The remainder were enrolled in pre-professional programs (3). No ongoing training is currently provided to staff working in mental health (see Table 5 below).
The
first Clinical Attachment of Mental Health Nurse to Tonga was completed in 2011. Table 5 Human resources and training for general and mental health in Nauru Training available in Nauru Human Resources Degree courses Mental Health continued professional development
Currently working in Nauru Number Density per 1000 population Number currently working in Mental Health
Mental Health Professionals Psychiatrists Psychologists Psychiatric Nurses Neurologists Occupational therapists Social workers in mental health No No No No No No No No No No No No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
General Health Professionals (20) Physicians Nurses Nurse's aides Social workers Dentists Pharmacists Midwives No No No No No No No No No On the job training
10 60 21 0 1 10 3
0.71 4.2 1.50 0 0.07 0.71 0.2
1 0 1 0 0 0 0
No No No No
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MEDICATIONS An essential drugs list was formulated in 1997 (12). There is anecdotal evidence to suggest that the availability of essential medicines for mental disorders is limited, and supply is often erratic. Only doctors can prescribe medication. Currently, medicines included in the list of essential drugs and used by the Mental Health Service are: Chlorpromazine Haloperidol Amitriptyline Cogentin Fluphenazine decanoate (the only long acting injectable antipsychotic available) Sodium valproate (for elevated mood) Table 6 below shows how this list of essential psychotropic medicines in Nauru compares to the WHO Essential Psychotherapeutic Medicines list of 2009. Medications are prescribed by the mental health service and administered by the patients themselves or by the person’s family. Inadequate laboratory services make monitoring and follow up difficult. Table 6 Comparison of recommended psychotropic medications and official policy in Nauru (see Appendix for more detail on WHO EPM List).
Drug
WHO Essential Psychotherapeutic Medicines 2009 (21)
Nauru National Essential Medicines List (12)
Chlorpromazine Haloperidol Fluphenazine Amitriptyline Fluoxetine Diazepam Clomipramine Carbamazepine Sodium Valproate Lithium Carbonate Methadone Nicotine replacement therapy
X
X X X
INFORMATION SYSTEMS Clinic records are held in the mental health unit, and are not readily available to Accident and Emergency or other hospital departments. The decision to maintain separate records was made due to a history of repeated breaches of confidentiality (22). There is no system for collecting and reporting aggregated mental health data. WHOproMIND: Nauru | 27
Figure 10. Mapping Health Care Services in Nauru Source: reference (23)
FACILITIES AND SERVICES There are very few mental health services in Nauru (Figure 10), and virtually no services for children and adolescents. 1. Longstay facilities and specialist services Severe episodes tend to be managed in the prison setting where they are visited by the Mental Health Service (MHS) when requested to do so by the Nauru Police Force (3). Prison officials have not received any training in mental health (3). Some severe cases are referred to the Overseas Referral Committee who coordinates referrals to Australia or Fiji. Psychiatric services within general hospitals Inpatient services In emergencies, people with mental disorders can be admitted to the 2-bed isolation ward at the Republic of Nauru Hospital. People with a mental disorder who are considered a risk to themselves or others are detained in police cells until psychiatric care is arranged. Where possible, the person receives treatment as a day patient and is returned home to their family. If their behaviour is very disturbed, they may remain in custody until their symptoms stabilize and the risk of harm is reduced (3). Outpatient services Outpatient services are provided to people with mental disorders by the Mental Health Service located at the outpatient clinic at the Republic of Nauru Hospital, which is staffed by one doctor and one nurse aide. During 2006, 48 people with mental disorders were assessed or received brief interventions (3). Most patients treated by the Mental Health Service were diagnosed with schizophrenia or other psychoses. There is no access to psychological treatments or rehabilitation through the mental health service. This is related to the lack of trained staff (3). 3. Formal community mental health services There are no planned community support services, although it was reported that as of December 2006, 24 patients with schizophrenia or other psychotic disorder received regular visits by the Mental Health Team (24). A 24 hours Mental Health Toll-Free Help Line was launched in 2012. Mental health services through primary health care Mental health has not been integrated into primary care services (Figures 11a and 11b). Informal community care Historically, people with mental illness in Nauru do not present for admission to hospital (3). Instead, they are cared for by their families or are placed in prison. Religious organizations and traditional healers also play a role in providing informal mental health services. Traditional healers Traditional healers are active in Nauru and treat most health issues. There is no formal linkage between traditional healers and the health system and it is not known how many traditional healers there are in Nauru. Non-government organizations (NGOs) There are no NGOs in Nauru that provide informal mental health services in Nauru. Faith-based organizations Faith based organizations, i.e. churches are part of the community resources that delivers limited crisis intervention and counselling services (3). Mental health services users or family associations There are currently no mental health consumer or family associations in Nauru.
2.
4.
5.
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Figure 11. The WHO Pyramid of Care and the reality in Nauru Source: reference (25)
PRISONS
PSYCHIATRIC SERVICES IN GENERAL HOSPITALS
Figure 11(a) The ideal structure for mental health care in any given country
Figure 11(b) The reality of mental health care in Nauru The levels of care that are non-existent, poorly developed or inappropriate have been removed from the pyramid of care.
BIBLIOGRAPHY
INTERNET RESOURCES Mental health and development: Targeting people with mental health conditions as a vulnerable group http://www.who.int/mental_health/policy/mhtargeting/en/index.html Improving health systems and services for mental health http://www.who.int/mental_health/policy/services/mhsystems/en/index.html WHO/Wonca joint report: Integrating mental health into primary care - a global perspective http://www.who.int/mental_health/policy/Integratingmhintoprimarycare2008_lastversion.pdf WHO Resource Book on mental health, human rights and legislation http://www.who.int/mental_health/policy/legislation/Resource%20Book_Eng2_WEB_07%20%282% 29.pdf The WHO Mental Health Policy and Service Guidance Package http://www.who.int/mental_health/policy/essentialpackage1/en/index.html The mental health context Mental health policy, plans and programmes - update Organization of services Planning and budgeting to deliver services for mental health Mental health financing Mental health legislation & human rights Advocacy for mental health Quality improvement for mental health Human resources and training in mental health Improving access and use of psychotropic medicines Child and adolescent mental health policies and plans Mental Health Information Systems Mental health policies and programmes in the workplace Monitoring and evaluation of mental health policies and plans
World Health Report 2001: New Understanding, New Hope http://www.who.int/whr/2001/en/index.html
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APPENDIX Essential psychotherapeutic medicines (WHO Model List of Essential Medicines, 16th list, March 2009) Where the [c] symbol is placed next to the complementary list it signifies that the medicine(s) require(s) specialist diagnostic or monitoring facilities, and/or specialist medical care, and/or specialist training for their use in children. Psychotic disorders Chlorpromazine Injection 25 mg (hydrochloride)/ml in 2ml ampoule Oral liquid 25 mg (hydrochloride)/5 ml Tablet 100 mg (hydrochloride) Injection 25 mg (decanoate or enantate) in 1ml ampoule Injection 5 mg in 1ml ampoule Tablet 2 mg; 5 mg
Fluphenazine Haloperidol Complementary list [c] Chlorpromazine
Injection: 25 mg (hydrochloride)/ml in 2‐ml ampoule Oral liquid: 25 mg (hydrochloride)/5 ml. Tablet: 10 mg; 25 mg; 50 mg; 100 mg (hydrochloride) Injection: 5 mg in 1‐ml ampoule Oral liquid: 2 mg/ml Solid oral dosage form: 0.5 mg; 2 mg; 5 mg
Haloperidol
Depressive disorders Amitriptyline Fluoxetine Complementary list [c] Fluoxetine Tablet 25 mg (hydrochloride) Capsule or tablet 20 mg (present as hydrochloride)
Solid oral dosage form: 20 mg (present as hydrochloride) a >8 years
Bipolar disorders Carbamazepine Lithium carbonate Valproic acid Tablet (scored) 100 mg; 200 mg Solid oral dosage form: 300 mg Tablet (enteric coated): 200 mg; 500 mg (sodium valproate).
Generalized anxiety and sleep disorders Diazepam Tablet (scored): 2 mg; 5 mg
Obsessive-compulsive disorders and panic attacks Clomipramine Capsule 10 mg; 25 mg (hydrochloride)
Medicines used in substance dependence programmes Nicotine replacement therapy Complementary list [c] Methadone* Chewing gum: 2mg, 4mg Transdermal patch: 5mg to 30mg/16 hrs; 7mg to 21mg/24 hrs
Concentrate for oral liquid 5 mg/ml; 10 mg/ml Oral liquid 5 mg/5 ml; 10 mg/5 ml *The square box is added to include buprenorphine. The medicines should only be used within an established support programme.
Source: reference (21)
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