The population of Nauru was estimated at for 2007, about 34.6% below 15 years of age and around 5% 65 years and above.

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1 1. CONTEXT 1.1 Demographics The population of Nauru was estimated at for 2007, about 34.6% below 15 years of age and around 5% 65 years and above. 1.2 Political situation The 18-member Parliament is elected every three years. The Parliament elects a President from among its members, who appoints a Cabinet of five to six people. The President is both head of state and head of government. On 18 April 2008, President Stephen declared a state of emergency and dissolved Parliament. This action was prompted by a stalemate in Parliament over the Speaker s introduction of a Bill to ban Members of Parliament holding dual citizenship. The last election was held on 26 April 2008 and President Stephen was re-elected. 1.3 Socioeconomic situation Until recently, Nauru was a self-reliant country. Traditionally, revenues of this tiny island have come from exports of phosphate. At the height of phosphate mining activities, the country s gross domestic product (GDP) was one of the highest in the Pacific and living standards were comparable with those of high income countries. However, phosphate reserves are expected to be exhausted soon, and the drastic decline in phosphate revenue has been followed first by a decrease in disposable income, and then by aid-dependence. The rehabilitation of mined land and the replacement of income from phosphate are serious long-term challenges. In anticipation of the exhaustion of Nauru s phosphate deposits, substantial amounts of phosphate income were invested in trust funds to help cushion the transition and provide for the country s economic future. As a result of heavy spending from the trust funds, however, the Government is facing bankruptcy. To cut costs, the Government has frozen wages and reduced overstaffed public service departments. There are few resources other than phosphate. The central plateau has limited agricultural value, but some hectares, mainly around the costal belt, are available for cultivation. Coconut, banana and papaya are the main fruit crops and small quantities of vegetables are also grown. However, cultivated crops are for home consumption only and, apart from fish, most food is imported from Australia, including water. There are frequent disruptions of supplies of food, fuel, equipment and materials. In 2001, a group of Afghani refugees rescued at sea was transferred to a camp on Nauru in exchange for a multimillion dollar aid package from Australia. Use of Nauru s isolated location and its Offshore Processing Centre was discontinued in February 2008 following a change in Australia s policy of holding asylum seekers on Nauru. Already heavily dependent on foreign support, mainly from Australia and Taiwan (China), Nauru has expressed a need for extra support now that Australia s Offshore Processing Centre has been closed. 1.4 Vulnerabilities and hazards Nauru is particularly vulnerable due to its isolation, with overdependence on the national air carrier and its single aircraft. The lack of a safe harbour for berthing of ships hinders marine transportation links beyond container freight and phosphate carriers. COUNTRY HEALTH INFORMATION PROFILES 259

2 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition As a result of an effective public health programme focused on water and sanitation, there have been no recent infectious disease outbreaks. Noncommunicable diseases, such as diabetes, hypertension, heart disease and cancer, have become leading causes of morbidity and mortality. Rates of obesity are very high. The recent STEPS survey reports diabetes prevalence among the age group is 16.3%. Diabetes increases in prevalence with age and was found to be 24.1% in the age group, 37.4 % among year-olds and 45 % in the age group. 2.2 Outbreaks of communicable diseases See Section Leading causes of mortality and morbidity See Section Maternal, child and infant diseases According to the preliminary report of the 2007 Nauru Demographic and Health Survey (NDHS), almost all pregnant women (94.5%) reported having consulted with a health professional doctor, nurse or midwife at least once for prenatal care for the most recent birth in the five-year period before the survey. Ninety-seven per cent of births are delivered by a health professional. The 2006 estimated infant mortality rate (IMR) for Nauru was 25.0 per 1000 live births. The most common causes of childhood mortality are acute respiratory illness and dehydration caused by severe diarrhoea. According to the NDHS, only 5% of Nauruan children are underweight (2007). Boys are slightly more likely to be underweight than girls. Almost a quarter (24%) of Nauruan children are stunted and 1% are wasted. 2.5 Burden of disease No available information. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives Mission statement for the health system: To cater for the health needs of Nauru and to enhance the quality of life of the People of Nauru through appropriate and effective health care; and to reform and improve the health infrastructure through a well structured, co-ordinated long term policy of: recruitment; capacity building; purchasing and maintenance of equipment and facilities. Mission statement for curative services: With a clear understanding of the health needs of the people and a full appreciation of the Nauruan culture, we shall provide an appropriate, accessible and affective health service that applies judicious use of all available resources to ensure the health of all patients on Nauru is enhanced; and provide a range of improved and efficient health services through a combination of: 260 COUNTRY HEALTH INFORMATION PROFILES

3 educational programs; screening procedures; registrations of disease establishing emergency protocols and the provision of service to meet the needs of all Nauruans. Mission statement for public health services: Values: We shall implement and sustain a range of public health policies and programmes that will enhance the quality of life for the people of Nauru by targeted risk factors reduction and promoting a healthy island lifestyle, and set in place a developed and legislated Healthy National Policy which promotes community awareness and participation to induce healthy choices, early, easy, exciting and everywhere. Customer focus: We aim to provide quality health care, respecting the dignity of all people. Equity: We strive to be fair in all our dealings: irrespective of ethnicity, religion, political affiliation, disability, gender and age. Quality: We seek a high quality outcome in all facets of our activities. Integrity: We are committed to the achievement of the highest ethical standards in all that we do. 3.2 Organization of health services and delivery systems Nauru General Hospital (NGH) and the National Phosphate Corporation (NPC) Hospital amalgamated in July 1999 to become the Republic of Nauru Hospital. The Hospital has five doctors and employs a complement of nursing and clinical support staff. 3.3 Health policy, planning and regulatory framework The Ministry of Health Operational Plan 2007 aims to complement the major goal of the Nauru National Sustainable Development Strategy (NNSDS): A future where individual, community, business and government partnerships contribute to a sustainable quality of life for all Nauruans. Specific goals of the NNSDS include: stable, trustworthy, fiscally responsible government; provision of enhanced social, infrastructure and utilities services; development of an economy based on multiple sources of revenue; rehabilitation of mined-out lands for livelihood sustainability; and development of domestic food production. Health-specific goals of the NNSDS include the provision of effective preventative health services to reduce lifestyle-related illness. The recent Nauru NCD Risk Factors STEPS Report further highlighted that Nauru has the poorest health indicators for NCDs (cardiovascular disease, diabetes, cancer and respiratory diseases) in the region. The Ministry of Health has responded by developing the Nauru NCD Action Plan, which details specific activities to reverse the declining health of the population and implement strategies that are known to be effective and have relevance and acceptability to the people of Nauru. Of significant interest to health under other categories in the NNSDS are: Infrastructure : provide a reliable supply of clean water. COUNTRY HEALTH INFORMATION PROFILES 261

4 Cross-cutting: governance, policy and institutional reforms; improve human resource development, including strategic management capacity; bring about an attitudinal change in the work ethic; and strengthen partnerships between government, civil society, the private sector and the donor community. Further, page 19 of the NNSDS states: Decreasing financial resources has led to a sharp drop in the provision of basic health services. Policies, programs and projects are inadequate and regulations are largely ineffective. Limited programs to prevent malnutrition exist and implementation is weak. There are limited standards and epidemiological information available. Limited funding is available for preventative and curative services. Public resources do not achieve intended goals, especially community education. Limited policies for HIV/AIDS and TB are in place but awareness is inadequate. A growing proportion of the population cannot afford the financial burdens of illnesses including the care of women and children. The Ministry of Health intends to focus attention on the major issues outlined above during Like many developing countries, Nauru has committed to a range of Millennium Development Goals (MDGs). As a signatory to UN Conventions and Treaties, the Government of Nauru has obligations to meet the requirement of these, which encompass the principles espoused in conventions such as the WHO Constitution, the Framework Convention on Tobacco Control, the International Convention on Population Development, Women Plan of Action and the Convention on Rights of the Child. Specific MDGs included in the NNSDS are: Reduce child mortality: Reduce by two thirds the under five mortality rate between 1990 and Improve maternal health: Reduce by three quarters the maternal mortality ratio between 1990 and Combat HIV/AIDS, malaria, and other diseases: Have halted by 2015 and begun to reverse the spread of HIV/AIDS. Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases. Ensure environmental sustainability: Halve by 2015 the proportion of people without sustainable access to safe drinking water. Develop a global partnership for development: In cooperation with pharmaceutical companies provide access to affordable essential drugs in developing countries. These MDGs have been included as high-level outcomes in the Ministry of Health s Operational Plan. It is a priority for the Ministry of Health to improve the reliability of the current health information system (HIM). In the absence of a robust HIM, the development of this plan has relied on the resources of the Nauru Bureau of Statistics, the data contained in the Nauru NCD Risk Factors Steps Report and information contained in the Health Status and Health System Report The primary health care approach to acute respiratory infections and diarrhoeal diseases will be strengthened and the Expanded Programme of Immunization will expand its coverage of target diseases. 262 COUNTRY HEALTH INFORMATION PROFILES

5 3.4 Health care financing Over the last two financial years, the Ministry of Health has embarked on a greatly improved system of budget development. The health budget is prepared by senior staff in accordance with the NSDS guidelines by early May, refined and then presented to the Finance Department. Subsequently, the Secretary for Health is required to attend Cabinet to speak to the budget and answer any relevant questions that may arise. As part of the financial management reform process, departmental heads now receive a monthly financial statement detailing current expenditure and projected year-end results against allocated budgets. In 2006, total health expenditure was estimated at US$ 6.0 million or 10.8% of GDP. Government expenditure on health was US$ 3.8 million or 55.3% of total health expenditure. 3.5 Human resources for health The Government plans to make available a balanced supply of health care providers, including physicians, nurses and other specialized staff and community health workers. Currently 50% of professional staff are expatriates on contract, and investment in training of Nauruan nationals is well underway. Course Number Country Status Medicine Pre Med Cuba x 2 Fiji Nauru USP campus 1 st 3 rd Science/English Radiology 1 Fiji 2 nd Pre Pharmacy 3 Nauru USP campus Science/English Pre Physiotherapy 1 Nauru USP campus Science/English Pre Laboratory 1 Nauru USP campus Science/English Pre Dentistry 1 Nauru USP campus Science/English Nursing Pre Nursing Fiji Fiji Fiji Kiribati Kiribati Nauru USP campus Final 2 nd 1 st 2 nd 1 st Science/English 3.6 Partnerships The Ministry of Health has partnerships with WHO, the Secretariat of the Pacific Community (SPC), the United Nations Children s Fund (UNICEF), the University of the South Pacific, the Global Fund and the Australian Agency for International Development (AusAID). Visiting medical specialists have included a team from the AusAID-funded PIPS programme, a mobile medical team from Taiwan (China), and Cuban and Israeli specialists. 3.7 Challenges to health system strengthening The Nauru Ministry of Health endorses the statement in the preamble to the constitution of the World Health Organization that: The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition. In support of this, the Ministry acknowledges that it is the right of every citizen of the Republic of Nauru, irrespective of race, sex, colour, creed or socio economic status, to have access to a national health system that provides a quality, affordable health service, the principle function of which is to promote and maintain the health and well-being of the citizens of Nauru to the maximum extent possible within available resources. The Ministry of Health also acknowledges that peoples lifestyles and the conditions in which they live, work and play strongly influence their health. Recognized social determinants of health include: COUNTRY HEALTH INFORMATION PROFILES 263

6 the need for policies that prevent people from falling into long-term disability and disadvantage; the impact of the social, psychological and physical environment on health; the importance of ensuring a good environment in early childhood and adolescent; the impact of work on health; the problems of unemployment and job insecurity; the role of family, friendship and social cohesion; the dangers of social exclusion; the effects of tobacco, alcohol and other drugs; the need to ensure access to supplies of healthy food choices for everyone; the need for effective transport systems. All of the above social determinants are experienced differently for men and women, and these gender-based differences need to be recognised as the Ministry of Health seeks to increase the health status of the population. A comprehensive integrated approach to addressing social determinants of good health for men and women requires the mainstreaming of gender concerns into the day-to-day operations of the Ministry of Health. This will ensure that the basic right of every citizen, irrespective of sex, to have access to a national health system that provides a high quality of care appropriate to their needs is respected. Whilst the Ministry of Health cannot address all of these issues alone, it recognizes the need to develop health outcomes and health improvements that are measured through improved health status of the population. The value of both health protection and promotion are now recognized as essential components when developing health outcome measures with the move away from evaluating services based on activity alone. The Ministry s commitment to the principles and philosophy of primary health care is based on the belief that success in achieving and maintaining health is not the responsibility of hospitals and the medical and/or curative model of care alone, but will come from a health-system-wide approach working with all government departments, the nongovernmental sector and civil society. 4. LISTING OF MAJOR INFORMATION SOURCES AND BASES Title 1 : Nauru Bureau of Statistics Web address : Title 2 : Nauru Demographic and Health Survey 2007 (Preliminary report) Operator : Bureau of Statistics Nauru, Secretariat of the Pacific Community, Macro International Inc. Title 3 : Republic of Nauru hospital data 5. ADDRESSES MINISTRY OF HEALTH Office Address : Government Offices, Yaren District, Nauru Official Address : secretary.health@naurugov.nr Telephone : Ext 261/262 WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4, Provident Plaza 1, Downtown Boulevard, 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Address : who@sp.wpro.who.int Telephone : (679) / / Fax : (679) COUNTRY HEALTH INFORMATION PROFILES

7 COUNTRY HEALTH INFORMATION PROFILE NAURU WESTERN PACIFIC REGION HEALTH BANK, 2008 Revision INDICATORS Demographics 1 Area (1 000 km 2 ) Estimated population ('000s) est 2 3 Annual population growth rate (%) Percentage of population years years - 65 years and above est est est 2 5 Urban population (%) est 3 6 Crude birth rate (per 1000 population) Crude death rate (per 1000 population) Rate of natural increase of population (% per annum) 2.34 a Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age est fertility rate (women aged years) Socioeconomic indicators 11 Adult literacy rate (%) 12 Per capita GDP at current market prices (US$) Rate of growth of per capita GDP (%) 14 Human development index Environmental indicators Urban Rural 15 Proportion of vehicles using unleaded gasoline (%) 16 Health care waste generation (metric tons per year) Communicable and noncommunicable diseases Number of new cases Number of deaths 17 Selected communicable diseases Hepatitis viral - Type A - Type B - Type C - Type E - Unspecified Cholera Dengue/DHF Encephalitis Gonorrhoea Leprosy Malaria Plague Syphilis Typhoid fever COUNTRY HEALTH INFORMATION PROFILES 265

8 INDICATORS Communicable and noncommunicable diseases Number of new cases Number of deaths 18 Acute respiratory infections Diarrhoeal diseases Tuberculosis - All forms - New pulmonary tuberculosis (smear-positive) Cancers All cancers (malignant neoplasms only) - Breast - Colon and rectum Cervix - Oesophagus - Leukaemia - Lip, oral cavity and pharynx - Liver - Stomach - Trachea, bronchus, and lung Circulatory All circulatory system diseases - Acute myocardial infarction - Cerebrovascular diseases - Hypertension - Ischaemic heart disease - Rheumatic fever and rheumatic heart diseases Diabetes mellitus Mental disorders Injuries All types - Homicide and violence - Motor and other vehicular accidents - Occupational injuries - Suicide Leading causes of mortality and morbidity Number of cases Rate per population 26 Leading causes of morbidity (inpatient care) 1. Pregnancy, childbirth and the pueperium 2. Endocrine, nutritional and metabolic diseases 3. Diseases of the respiratory system 4. Disease of the skin and subcutaneous tissue 5. Symptons, signs and abnormal clinical and laboratory findings not elsewhere specifiied 6. Infectious and parasitic diseases 7. Diseases of the genitourinary system 8. Diseases of the digestive system 9. Diseases of the cirulatory system 10. Diseases of the musculosketal system and connective tissue COUNTRY HEALTH INFORMATION PROFILES

9 INDICATORS Number of deaths Rate per population 27 Leading causes of mortality 1. Endocrine, nutritional and metabolic diseases 2. Diseases of the cicrulatory system 3. Pregnancy, chidlbirth and the puerperium 4. Injury, poisoning ad certain other consequences of external causes 5. Neoplasm 6. Diseases of the digestive system 7. Diseases of the respiratort system 8. Diseases of the nervous system 9. Diseases of the genitourinary system Maternal, child and infant diseases 28 Percentage of women in the reproductive age group using modern contraceptive methods 29 Percentage of pregnant women immunized with tetanus toxoid (TT2) 30 Percentage of pregnant women with anaemia 31 Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth 33 Immunization coverage for infants (%) - BCG - DTP3 - POL3 - Hepatitis B III Number of cases Number of deaths 34 Maternal causes - Abortion - Eclampsia - Haemorrhage - Obstructed labour - Sepsis Selected diseases under the WHO-EPI - Congenital rubella syndrome - Diphtheria - Hib meningitis - Measles - Mumps - Neonatal tetanus - Pertussis (whooping cough) - Poliomyelitis - Rubella - Tetanus COUNTRY HEALTH INFORMATION PROFILES 267

10 INDICATORS Health facilities Number Number of beds 36 Facilities with HIV testing and counseling services 37 Health infrastructure Public health facilities - General hospitals Specialized hospitals - District/first-level referral hospitals - Primary health care centres Private health facilities - Hospitals - Outpatient clinics Health care financing 38 health expenditure - amount (in million US$) - total expenditure on health as % of GDP - per capita total expenditure on health (in US$) Government expenditure on health - amount (in million US$) - general government expenditure on health as % of total expenditure on health - general government expenditure on health as % of total general government expenditure External source of government health expenditure - external resources for health as % of general government expenditure on health p p p p p p p 12 Private health expenditure - private expenditure on health as % of total expenditure on health Exchange rate in US$ of local currency is: 1 US$ = p p Health insurance coverage as % of total population INDICATOR 40 Human resources for health Urban Rural Public Private Physicians - Number Rate per 1000 population Dentists - Number Rate per 1000 population Pharmacists - Number 4 b 0 4 b Rate per 1000 population Nurses - Number Rate per 1000 population Midwives - Number Rate per 1000 population Paramedical staff - Number - Rate per 1000 population Community health workers - Number 41 Annual number of graduates - Rate per 1000 population Physicians Dentists 268 COUNTRY HEALTH INFORMATION PROFILES

11 INDICATORS Urban Rural Public Private 41 Annual number of graduates Pharmacists Nurses Midwives Paramedical staff 42 Workforce losses/ Attrition Community health workers Physicians Dentists Pharmacists Nurses Midwives Paramedical staff Community health workers INDICATORS Health-related Millennium Development Goals (MDGs) 43 Prevalence of underweight children under five years of age 44 Infant mortality rate (per 1000 live births) est 5 45 Under-five mortality rate (per 1000 live births) est 5 46 Proportion of 1 year-old children immunised against measles Maternal mortality ratio (per live births) Proportion of births attended by skilled health personnel Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Percentage of deliveries in health facilities (as % of total deliveries) Contraceptive prevalence rate 50 Adolescent birth rate 51 Antenatal care coverage - At least one visit At least four visits 52 Unmet need for family planning 53 HIV prevalence among population aged years 54 Estimated HIV prevalence in adults a 55 Percentage of people with advanced HIV infection receiving ART 56 Malaria incidence rate per population 57 Malaria death rate per population 58 Proportion of population in malaria-risk areas using effective malaria prevention measures 59 Proportion of population in malaria-risk areas using effective malaria treatment measures 60 Tuberculosis prevalence rate per population Tuberculosis death rate per population Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) 63 Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) 64 Proportion of population using an improved drinking water source NR Proportion of population using an improved sanitation facility NR Proportion of population with access to affordable essential drugs on a sustainable basis Urban Rural COUNTRY HEALTH INFORMATION PROFILES 269

12 Notes: Data not available p Provisional est Estimate NR Not relevant a Computed by Health Information and Evidence for Policy Unit of WHO Regional Office for the Western Pacific. b Figure refers to dispensers only c Not included in the official list of MDG indicators s: 1 Pacific island populations- estimates and projections , Secretariat of the Pacific Community, Noumea, [ 2 Demographic Tables for the Western Pacific Manila, World Health Organization Regional Office for the Western Pacific, United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population Wallchart (United Nations publication, Sales No. E.08.XIII.3). 4 Birth and death documents from Director of Public Health World Health Statistics Geneva, World Health Organization, World health report Changing history. Geneva, World Health Organization, Nauru Demographic and Health Survey 2007 (Preliminary report). Bureau of Statistics Nauru, Secretariat for the Pacific Community, Noumea, New Caledonia, Macro International Inc. Calverton, Maryland, U.S.A., April Nauru Bureau of Statistics. [ 9 WHO Regional Office for the Western Pacific, data received from technical units 10 RON Hospital inpatient record study up to March 24 (data from Health Planning Officer) 11 Republic of Nauru (RON) Hospital data (data from Health Planning Officer) 12 World Health Organization - National health accounts series [ 13 Nauru population profile. A guide for planners and policy makers. Noumea, Secretariat of the Pacific Community. 270 COUNTRY HEALTH INFORMATION PROFILES