The Republic of Mauritius is a group of islands in the south-west of the Indian Ocean, consisting of the main island of Mauritius, Rodrigues and several outer islands, situated 900 km to the east of Madagascar. It has a total land area of 2040 km2 and a population of around 1.2 million. Mauritius has a multiracial population whose origins can be traced mainly to Asia, Africa and Europe. English is the official language but French remains the most widely spoken, along with the local dialect, Creole, which is derived from French. Mauritius is classified as an upper middle income country in sub-Saharan Africa by the World Bank. It has a per capita gross domestic product (GDP) of US$13 200.
Health resources and statistics
Mauritius spends 2.8% of its GDP on health, 1.9% in the public sector and 0.9% in the private sector.
In 2005, the crude birth rate was 15.2 births per 1000 per year, the death rate was 6.8 per 1000 per year and the infant mortality rate was 14.14 deaths per 1000 live births (Central Statistics Office, Mauritius).
Mauritius provides state health services throughout the country free at the point of use to all its 1.2 million people. It also has a well established private sector. The state health services employ over 650 doctors and the private sector employs over 400 doctors.
Mental health services
Initially, mental health services were centred at the main psychiatric hospital, named after the renowned Mauritius-born neurologist Charles-Édouard Brown-Séquard. It was renamed the Brown Sequard Mental Health Care Centre (BSMHCC) in 1998. Psychiatric services were decentralised in 1997. Essentially, decentralisation meant opening psychiatric units in each regional hospital, combined with the provision of outpatient services and liaison psychiatry. One or two psychiatrists were attached to each unit, along with medical officers and health officers who had work experience in this field.
There are now 15 psychiatrists nationally, 12 in the public sector. In-patient care was started initially in three hospitals to treat patients with alcohol-related problems, but it had to be discontinued in two centres owing to management problems. Out-patient clinics are also held at a few area health centres. Community care is mostly provided by social workers attached to these hospitals and community rehabilitation workers.
In 2005, a new 250-bed psychiatric hospital was built next to the old hospital. Daily out-patient clinics are held and inpatient care is provided for acutely ill psychiatric patients from all over Mauritius. In addition, a secure unit in the premises caters for patients from courts. Another ward opened in 2006 for in-patient detoxification of intravenous drug users.
The BSMHCC is staffed by six psychiatrists, six medical and health officers, a medical superintendent, three social workers, a psychologist and about 40 psychiatric nurses, general nurses, healthcare assistants, welfare assistants (who are mostly in the old hospital) and other ancillary staff.
Many of the 471 long-stay patients still cared for in the old hospital are institutionalised, having spent over 20 years in the hospital. Vigorous efforts are being made to get alternative care for those who can be relocated.
Patients are treated at the regional hospitals or area health centres as out-patients, but if they need admission or electroconvulsive therapy they are referred to the BSMHCC. After recovery they are referred back to the regions for follow-up. This arrangement will have to continue until the regional units are fully functional. Most psychotropic drugs are available in all centres.
Mental health statistics
The total number of out-patient attendances (new cases and follow-up cases) at the BSMHCC rose from 1998 to 2003 but thereafter decreased to 2005 (Fig. 1a). At the outstations the numbers increased from 1998 to 2005. These statistics indicate that the total number of patients seeking psychiatric help considerably increased over the period. It is interesting to note that the attendance at the main hospital is still high, despite decentralisation, probably because of the lack of inpatient facilities in the regional units. Many of the patients at the main centre suffer from serious mental illnesses.
Fig. 1. (a) Total number of out-patient attendances and (b) numbers of new cases at the Brown-Sequard Mental Health Care Centre (BSMHCC) and regional hospital outstations, 1998–2005.
However, the number of new cases at the outstations are gradually increasing (Fig. 1b). Attending the main psychiatric hospital is still a taboo. Often people do not come forward to seek help because of the stigma attached to mental illness. The rising number of cases in the outstations is the true indicator of psychiatric morbidity in the island.
The number of in-patients increased slightly from 1998 to 2003 followed by a decline to 2005. In 2004 about 35% of admissions at the BSMHCC were for schizophrenia and other psychotic states. About 51% were due to alcohol-related problems.
Suicide rates
Suicide was on the rise until it reached a peak in 1999 and later declined to 8.1 per 100 000 in 2004.
Substance misuse
Overall, 41.5% of substances misused were alcohol and 52.9% ‘brown sugar’ (an adulterated form of heroin).
The National Agency for the Treatment and Rehabilitation of Substance Abusers (NATReSA) is responsible for all demand reduction activities in Mauritius. The National Drug Control Master Plan was formulated in the year 2004 and the Mauritius Epidemiology Network on Drug Use (MENDU) was set up in 2001.
Legislation and policy
The Mental Health Act was proclaimed in 1998. It deals mainly with involuntary in-patients, although it did make provision for voluntary admission for patients with mental illness. The Act is being amended at present to involve all mental healthcare users and to make provision for community care.
In 2005, a National Strategic Plan for Mental Health was developed and submitted; implementation is awaited. This Plan was developed following a government white paper on health sector development and reform, of December 2002, and in keeping with guidelines from the World Health Organization (WHO). The white paper proposed a National Plan for Mental Health, which was developed in consultation with local specialists and other groups with advice from WHO experts. The National Strategic Plan for Mental Health includes the setting up of fully fledged regional hospitals, community care, rehabilitation services, specialised units (e.g. a child and adolescent unit) and mental health promotion, among other things.
Health promotion
Health promotion activities have been carried out widely to create awareness regarding mental health in the population, following the National Plan for Mental Health through WHO-funded programmes. A ‘focal person’ for mental health was appointed who acted as a coordinator for all mental health activities, including health promotion at all levels.
Training
Training is carried out at different levels:
Postgraduate training in psychiatry is being given to six doctors with the collaboration of the University of Bordeaux, France. The programme comprises 3 years in Mauritius with regular teaching by visiting French professors and clinical supervision by local psychiatrists followed by 1 year in Bordeaux. After regular assessments and examinations a degree will be awarded. Another batch of six may be trained at a later stage.
Community physicians and senior medical officers and health officers in the public sector are being given a crash course in psychiatry (under a WHO programme) in order to provide psychiatric services at the primary care level.
Courses for a diploma in psychiatric nursing are being carried out by the school of nursing.
House officers are posted for 4 weeks in psychiatric units so as to acquire experience and to try to kindle their interest in this branch of medicine.
Medical students from the local private medical college are posted for 2 weeks in the psychiatric hospital.
Community-based rehabilitation workers are given training in psychiatry with the collaboration of the Mauritius Institute of Health.
A module on psychiatry has been introduced in the training scheme of Non-Communicable Disease (NCD) Staff and Community Nurses, with the ultimate aim of incorporating community psychiatric services in the well established NCD network.
Occupational therapists and social workers are being trained by the University of Mauritius with psychiatrists also as resource persons.
Research
Epidemiological study
An epidemiological study was carried out in the year 2000 by l’Association Septentrionale d’Epidémiologie Psychiatrique (ASEP), the Département d’Information Médicale (DIRM) and l’EPSM Lille Métropole et le Centre Collaborateur de l’Organisation Mondiale de la Santé pour la recherche et la formation en santé mentale de Paris (CCOMS). The Mauritius Institute of Health and the Ministry of Health and Quality of Life were responsible for carrying out the study locally. The following statistics were presented:
22.2% of people interviewed in the study had a mental disorder
15% had signs of depression and related disorders
10% had signs of neurotic disorders
3% had alcohol-related problems
3.4% had psychotic states.
Study on disabilities
A cross-sectional study to detect the number of children with disabilities was carried out in 2003. Of the 2834 children with disability examined, 63.8% had intellectual impairment.
Joint Child Health Project
A longitudinal study has been carried out in Mauritius from 1972 onwards. Initially it was designed to identify people at risk for schizophrenia and to take preventive measures. Several papers have been published (e.g. Raine et al, 2003).
Study on suicide
In a study on suicide carried out in 1995, the annual suicide rate was reported to be 8 per 100 000 population in the 12-to 20-year age group, 10 per 100 000 for all age groups and 14 per 100 000 in the elderly age group.
Private sector
Psychiatric services in the private sector are provided by the government psychiatrists on a part-time basis and by three full-time private psychiatrists. There is no provision for involuntary admission in the private sector.
Non-governmental organisations
There are non-governmental organisations (NGOs) active in the private sector. For example, the only rehabilitation centre for people with serious mental illness is run by an NGO. There are few centres run for people with intellectual disabilities. ‘Befrienders’ are active and give support to people in distress.
The way ahead
Psychiatric services have seen tremendous changes in the past 8 years. The Lunacy Act of 1906 was repealed and replaced by the Mental Health Act 1998, which introduced voluntary care for psychiatric patients. With the implementation of the proposed amendments to the law and the dynamic National Strategic Plan for Mental Health, clear targets have been set. Encouraging public–private partnership is an area to be explored, mainly for rehabilitation and the relocation of long-stay patients. Recruiting the services of relatives as carers with financial incentives is another promising aspect to be looked at, as it will be cost-effective, the state having to spend more to keep the patient in the hospital than in the community. With increased personnel we hope to establish adequate community care and provide comprehensive psychiatric services to the population.
Sources and references
- Raine, A., Mellinghan, K., Lui, J., et al. (2003) Effects of environmental enrichment on schizotypal personality and antisocial behaviour. American Journal of Psychiatry, 160, 1627–1635. [DOI] [PubMed] [Google Scholar]
- Republic of Mauritius web portal, http://www.gov.mu (last accessed 19 April 2007).
- US Central Intelligence Agency World Factbook, https://www.cia.gov/cia/publications/factbook/geos/mp.html (last accessed 19 April 2007).