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位于南太平洋的世界上最小的独立共和国瑙鲁，它是世界上肥胖率最高的国家之一。大约71.1%的成年人被认为是肥胖。由于世卫组织将肥胖被定义为“异常或过度的脂肪堆积可能损害健康”。最重要的直接结果或副现象是心血管疾病（如中风），其中提到的是2012年死亡的主要原因。其他疾病包括糖尿病、肌肉骨骼疾病（如骨关节炎）、某种癌症和精神障碍。
如今，瑙鲁的肥胖可能是由于缺乏健康的环境，尤其是缺乏新鲜健康的食物和缺乏体力活动造成的。除此之外，还必须讨论前一时期的其他原因，这也可能是目前局势的原因。
1968独立后，瑙鲁曾经是世界上最富有的国家之一，由于其丰富的磷酸盐矿床，人均国内生产总值的比率很高。由于治理不善，例如资金管理不善，缺乏结构、经济和环境政策，瑙鲁最终破产了。今天，该国是一个低收入国家，其特点如下：
Table of content
1 Obesity as the major health risk for the population of the Republic of Nauru –Causes and Impact ………………………………………………………………. 3
2 Possibilities and constraints of health protection policies in Nauru …………….. 4
2.1 Assessment of the requirements of adequate health policies in Nauru ……... 4
2.2 Discussion of Financing Options of Social Health Protection in the Case of
Nauru ………………………………………………………………………… 6
3 Conclusions and Recommendation ……………………………………………… 8
1 Obesity as the major health risk for the population of the Republic of Nauru –
Causes and Impact
The world’s smallest independent Republic Nauru, which is located in the South Pacific Ocean, set a distressing record of being one of the countries with the highest obesity rates. About 71.1 % adult of the population are considered to be obese (CIA 2014). Due to the WHO (2014), obesity is defined as “abnormal or excessive fat accumulation that may impair health”. The most important direct results or epiphenomena are cardiovascular diseases (e.g. stroke), which are mentioned by the WHO as the leading cause of death in 2012. Other ailments are diabetes, musculoskeletal disorders (e.g. osteoarthritis) some sort of cancer as well as mental disorders (WHO 2014).
Nowadays, obesity at Nauru may result from the lack of access to a healthy environment, especially lack of access to fresh and healthy food and lack of physical activity. Besides that, other reasons from previous periods have to be discussed shortly, which may also be responsible for the present situation.
After independence in 1968, Nauru used to be one of the richest countries in the world with high rates of GDP per capita due to its rich phosphate deposits. Due to bad governance, for instance the mismanagement of funds, lack of structural, economic and environmental policies, Nauru went bankrupt finally. Today, the republic is a low-income country and can be characterized by the following attributes:
Lack of established industries
Deteriorating capital plants
High unemployment rate of 90% due to estimations by the CIA of 2005 (CIA 2014)
Destroyed landscape (90% of the land are deteriorated due to intensive phosphate mining) (CIA 2014)
High dependency on imports of almost all goods (food and other consumer goods)
High dependency from aid, especially from the donor Australia
In spite of all these health problems, Nauru lacks a good health care system and it cannot afford to create one because of its weak economic and social state. Now, Nauru lacks the capacities to deal with the most important health risk obesity on the one hand, which affects the majority of the country. On the other hand it can be estimated, that Nauru will not be able to create an environment for the community to prevent further progress of overweight and obesity within the next years. For that reason it can be stated, that the country will not be able to deal with the problem in a proper way in the short and in the intermediate term.
In the light of this, the paper would examine the present situations of Nauru healthcare and why the standard financing options won´t work while also falsifying already tested hypotheses about the effectiveness of standard financing options.
2 Possibilities and constraints of health protection policies in Nauru
2.1 Assessment of the requirements of adequate health policies in Nauru
What are the requirements for an adequate health policy, and how might the situation in Nauru look like, in detail? In the following, this chapter is going to answer the stated questions. Therefore, it uses six basic indicators of good health policies; the focus on lifestyle and needs of population, consideration of other sectors relevant for health, participation of the population, use of locally available resources, integration and coordination of preventive, promotional, curative and rehabilitative measures, and decentralization of services.
With this, the subject of the following chapter is to create an understanding of Nauru´s situation today, while simultaneously trying to present the major problems.
Focus on lifestyle and needs of population
Beginning with lifestyle, we address directly one of the major problems. Before the country became rich, due to phosphate exportation, the population provided themselves through farming, fishing and hunting (20min 2011). The natural food and the gently cooking preparation, through boiling, supported the inhabitants with healthy, organic and substantial food. But with the growing income the eating habits changed towards imported, fat and durable food from the West, especially, meat and chips found their way in the supermarkets and so into stomachs of the population. Together with a low amount of working people, Nauruan grew fatter and unhealthier.
Another problem is that only processed or canned food finds its way on the island, until today, because the transportation of vegetables or fruits would take too long and would be too expensive. Even with an active government, the imported goods are still a problem (20min 2011).
The lifestyle of the population changed over the last decades. Today´s government focuses on the problem and is trying to support the population. Information on measures and programs are discussed in several media but are not published via official channels. Therefore it remains questionable, if the government´s efforts are sufficient and suitable to address the problems.
Use of locally available resources – considering their scarcity
The considerations of the government lead to daily walks of the president, anti-obesity campaigns, with signs and banners, and a support campaign for natural and healthy foods, which seemed to have some success. Especially the small trend towards more healthy food, developed with the growing poverty. Imported food is often more expensive than rural food. Therefore, the people do not have much of a choice and it is hardly to count as a success.
Participation of the population in search for solutions
The participation of the population seems rather small. Even though the average lifespan of a male Nauruan dropped under the age of 50, the support of the population is limited (WHO Nauru 2012). A few people profit from the working benefits, only the youngest go to school or college. The problem, the 95% obese people, are whether neither young nor working. Most of them are out of school and not working. Therefore, they do not see the necessity for change (Nauru Government 2014). Due to this, they are hard to motivate and engage. Participation of the population is critical for the success of all measures to reduce the health risks. It can be stated, that participation is rather low. It should be a major concern of the government to focus on that issue.
Consideration of other sectors relevant for health
With the acceptance and notion of the problem obesity, the government tried to support the population through single activities; additional focus on sport activities in the education system, free aerobic classes, the creation of sport tournaments, the provision of more sport areas and the support of those areas with the needed equipment and a guaranteed time for employees to do fitness. Naturally, because only a few people work, only a few benefit from the walking regulation, which does not support a change efficiently. Additionally, they started an anti-diabetes campaign and inform children in schools about the difficulties coming from an unhealthy lifestyle early on. As a result of this, the president walks every day, visible for everyone, on the landing zone of the airport, to motivate the population (20min 2011).#p#分页标题#e#
Integration and coordination of preventive, promotional, curative and rehabilitative measures
The government of Nauru agreed that they could only support the older population through high medicine standards, sufficient medication in case of diabetes, free athletic classes, obesity warnings and specialized medicine treatments (20min 2011). The young generation gets additional education about unhealthy living styles, is supported with more opportunities and motivation to do sports and. The focus of the government therefore lays on trying to change the development of the future generations and alleviation of the present problems for the older generations. Extravagant measures, like the daily walk of the president are one of the things, which were implemented to raise awareness.
Decentralization of services
The decentralization is not relevant because of the very small size of the country.
2.2 Discussion of Financing Options of Social Health Protection in the Case of
Nauru
There are various ways that a social health insurance could be financed. This section of the paper will be explaining the various financing options, the various features of each of the options, how they work and then assess its feasibility in financing social health insurance policies in Nauru.
The various financing options the paper would examine are as follows: User fees, Prepayment scheme, Government budget and Private insurance. Besides that Social insurance and Micro-insurance are further options of financing, which will not be focused in the following discussion.
User Fees
This involves an “out-of-pocket” financing of health services. In other words, the people would have to pay out of their pocket and it is usually on an immediate basis. It has been argued overtime whether this form of financing is effective or not, and also whether it promotes the use of social health insurance. While some argued that it provides a measure to check over utilization of health services, some argued that it doesn’t encourage the poor (who are the most vulnerable to health risks) to use health services as it is usually too expensive for them to manage. Also, it doesn’t really protect people from risks as there is no insurance element.
With all the above mentioned, it is quite clear why this form of financing cannot be used in Nauru. In a country with 90% unemployment according to CIA fact book and with its citizens having no source of income, it will be impossible for them to pay for health services out of their pockets much less immediately.
Prepayment Scheme
Prepayment scheme as the name implies is the payment for a service in advance. This involves a payment of premium before the occurrence of the hazard. It has same features like the user fees except that it has an insurance element in that the users pay ahead of the occurrence of the hazard.
This also cannot work for the citizens of Nauru as most of them are unemployed so there is no way of making payments in installments. Also, most of the employed are working in the informal sector, which makes it even more difficult for pooling of funds.
Government Budget (Taxes)
The government can also get to finance health care policies. This is usually done by allocating a percentage of government budget to the health care sector. Also, it could be done through payment of tax by citizens to government but usually with subsidies. This form of financing acts as a balance between the rich getting health coverage and the poor getting coverage as well. This is so because it is cheaper, provides universal access with low administration costs and most importantly, more coverage at little or no costs.
The Nauru government has an annual budget of $AUD 35.6 million as reported by the UNICEF in 2002, as well as a total expenditure of $AUD 79 million, which brings its deficit to $AUD 49 million. With this huge deficit and 90% of her revenue coming from aid, the health sector remains under funded still even though a higher percentage of her budget goes to providing health services. Making it also almost impossible to singlehandedly provide good health services based on government funding.
Private Insurance
Private health insurance is a form of voluntary insurance taken out by users themselves for various reasons. It has been argued that private health insurance helps cater to needs of the rich which allows the government to focus on catering better to the needs of the poor with limited resources. Also, it helps to provide more choices to the consumers and acts as a catalyst to reforms and efficiency in public health insurance. Despite all of these advantages, it is still really expensive and even widens gap between the rich and poor. Moreover, it is a bit difficult to administrate.
Presently, there is no form of private health insurance in Nauru. This is no surprise as private health insurers usually invest where the profits are higher and also insure people with lowest vulnerability to risks. In Nauru, most of its people suffer from obesity and diabetes; thus, if there were to be any coverage by insurance, these two diseases have to be a main focus but private insurers won’t want to insure them as the probability of the risk occurring is really high.
3 Conclusions and Recommendation
The paper focused mainly on two pillars, which are assessment of the requirements of adequate health policies and financing options. Within the chapters 2.1 and 2.2., we could give evidence for a number of problems, of which inhabitants of Nauru suffers today. Those can be summarized by the following characteristics:
1. Country specific obstacles like the small size, small number of inhabitants, high number of unemployed people, as well as the high number of diseased people and mismanagement in the past.
2. Lack of self-responsibility
3. High dependency burdens
4. Budget constraints
These problems affect the health conditions of the country to large extend and worsen the situation of people who suffer from obesity but also support a large number of obesity incidence.
We must come to the conclusion that for the same reasons / problems, Nauru will not be able to deal with the problem in a proper way in the short and in the intermediate term. Also, it can be estimated, that Nauru will not be able to formulate adequate policies and strategies to address the needs of those people who already suffer from obesity as well as those who are in danger to come down with obesity.
Furthermore it is critical to find sufficient and sustainable sources how to finance the budget and especially a budget for health policies.
Even if the authorities are aware of the problem and have been implementing single strategies to fight against obesity, it lacks of a broad and sustainable implementation of concrete measures to address the problem.
Due to the requirements of adequate health policies, it can be stated, that Nauru is not able to improve the situation remarkably. At the moment, the awareness concerning a responsibility and especially self-responsibility of the Nauruan authorities to address the needs of a healthy population is not obvious. The major argument here is, that there is no transparency because of lack of adequate information.
In terms of financing options, Nauru has to look for other, maybe unconventional financing options e.g. selling the right for an arts project (film, book) because of the countries unique past or Nauru could initiate a crowd funding campaign, which offers adventure vacation for money. Besides that, Nauru should focus on financing options, which makes the country independent from single donor states like Australia, e.g. credit at the World Bank.
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