28 June 2013
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Rebecca de Boer
Social Policy Section
Framework for the provision of health care
Nauru and Manus Island health care systems
Nauru health care system
PNG health care system
IHMS contract provisions
Establishment of HSM Network (clause 5)
Critical Incidents (clause 8)
Health management (clause 9)
Information and health care records management (clause 10)
Financial management (clause 11)
Quality management (clause 13)
Complaints and Feedback (clause 14)
Part 2: Health care delivery
Health care records and information and Health Discharge Assessment (clauses 19 and 20)
Continuing health care and mental health care (clauses 21 and 22)
Mental health care
Health care arrangements (clause 24)
Exclusions (clause 17)
Adequacy of performance measures
Seeking health care
With the recent return to processing of asylum seekers in Regional Processing Centres (RPCs) on Nauru and Manus Island, a major concern for refugee advocates and human rights groups is the mental health status of asylum seekers being accommodated in these facilities. This concern stems from the perceived lack of specialist mental health resources available and the indefinite nature of detention. Previous experience has shown that offshore processing of asylum seekers can have serious consequences for both physical and mental health.
Amnesty International raised concerns about the physical health of asylum seekers in its November 2012 review of the Nauru Offshore Processing Facility, as conditions in the processing centres, such as heat, lack of shade and inadequate accommodation, were considered to be contributing to poor physical health. More recently, the ABC program Four Corners highlighted the conditions in the Nauru and Manus Island processing centres, and the concerns of former staff about access to health care and the health status of asylum seekers in this context.
As at 27 May 2013, there were 430 asylum seekers on Nauru and 302 on Manus Island. The combined total capacity of the facilities on Nauru and Manus Island is expected to reach around 2,100 by the end of 2013 (600 on Manus Island and 1,500 on Nauru). Current capacity is 500 on Manus Island and 528 on Nauru. 
The provision of health care to asylum seekers on Nauru and Manus Island is governed by the ‘Heads of Agreement’ between the Commonwealth of Australia (represented by the Department of Immigration and Citizenship (DIAC)) and International Health and Medical Services (IHMS) (the contract). The contract was tabled in the Senate on 21 September 2012, with the payment schedule and financial details redacted. Despite this, some financial details are known, such as that IHMS will be paid $22 million for the provision of health care for six months from 14 December 2012. The contract was not published online and is only available from the Senate Table Office. In the absence of an online document, this background note will set out the key clauses of the contract and examine their adequacy in providing for the mental and physical health needs of asylum seekers being detained in RPCs.
IHMS has provided health care services in immigration detention facilities in Australia since 2006. As at March 2012, the value of the two contracts with IHMS (one for a six year period covering services for Christmas Island and one for a five year period covering the mainland) was estimated to be $769.3 million. In 2010–11 more than 100,000 individual health services were delivered in immigration detention facilities. The number of IHMS community-based health service providers increased by 40 per cent to more than 700 in 2010‑11. These providers deliver services to the community detention network on behalf of IHMS. There is no provision in the contract to penalise the organisation for underperformance.
In May 2013, the Government announced that families who arrive by boat would be considered for bridging visas in the community, but would be subject to the same ‘no advantage’ principle as those held on Nauru and Manus Island. It is likely that these asylum seekers will not have the same access to health care services as those on Nauru and Manus Island, as they will not have access to Medicare and it does not appear that DIAC has a specific contract for the provision of health care services to this group in Australia. Exploration of this issue is outside the scope of this paper.
Framework for the provision of health care
The main objectives of the contract between DIAC and IHMS are to provide health care services to asylum seekers on Nauru and Manus Island that are:
- ‘open, accountable and transparent’ and
- to a ‘standard and range of health care that is the best available in the circumstances, and utilising facilities and personnel on Nauru and Manus Island’ and ‘that as far as possible (but recognising any unavoidable limitations deriving from the circumstances of Manus Island and Nauru) are broadly comparable with health services available within the Australian community’.
The ‘Statement of Work’ outlined at Schedule 1 of the contract elaborates further on this. The ‘overarching philosophy’ underpinning health care to be provided on Nauru and Manus Island largely reflects the objectives of the contract. It acknowledges the potentially complex health needs of asylum seekers and notes:
Health Care must be coordinated, high quality, safe and prioritised on the basis of clinical need. It should also be delivered without any form of discrimination, and with appropriate dignity, humanity, cultural and gender sensitivity, and respect for privacy and confidentiality.
The role of IHMS is to provide ‘primary level health care’ to asylum seekers. Primary care usually refers to the first point of contact within the health care system for the management of health conditions, and includes activities such as screening, episodic or acute services, health promotion services and services for the chronically ill. In this context, IHMS will provide onsite medical care for 12 hours per day, seven days a week, with emergency coverage to be provided after hours. The health services to be provided by IHMS include:
- registered nurse clinics
- nurse immunisation and vaccination services
- health promotion services
- radiography-trained nursing services
- General Practitioner (GP) clinics
- preventative health services
- emergency observation and treatment of critically ill Transferees
- minor surgical procedures and
- mental health clinics, comprising counselling, clinical psychology, mental health nursing, and psychiatry.
To enable IHMS to provide a range of health care services to asylum seekers, a network of health providers (referred to as ‘Network Providers’) must be established on Nauru and Manus Island. This network must have sufficient numbers of ‘appropriately qualified and experienced nurses (including mental health nurses), GPs, psychologists, psychiatrists and other medical specialists, pharmacists, dentists, optometrists, paramedics, pathologists and other appropriate allied health professionals’. Public hospitals and public health care providers funded by the Government are also Network Providers. IHMS must enter into ‘Network Provider Agreements’. These agreements outline the range of health care that is to be provided and specify the associated fee or rate. They also set out the expectations for Network Providers, such as confidentiality. An agreement is not required when there is no other provider of general practitioner services in the area or immediate region.
For clinically necessary health care that cannot be provided onsite, IHMS must organise a referral to an approved Network Provider. For emergency care that cannot be provided onsite, asylum seekers will be transferred to local hospitals.
IHMS works with local health care providers to provide emergency and acute care. There is limited publicly available information about the capacity of the health care systems of Nauru and Papua New Guinea (PNG). The Senate Inquiry into the Migration Amendment (Health Care for Asylum Seekers) Bill 2012 received evidence about public health concerns for PNG and the lack of adequately trained staff at the Nauru public hospital. Representatives from the medical community noted the high risk of multi-drug resistant tuberculosis, malaria, typhoid and hepatitis A in PNG and the implications this has for children. This was of particular concern as family groups with children have been transferred to PNG. They also noted that staff working in the Nauru hospital did not have sufficient qualifications to be registered in Australia. In addition, there have been recent reports of financial mismanagement of PNG hospitals, with the suspension of managers at two hospitals and investigations underway at the hospital on Manus Island. The CEO of the Manus Lorengau Hospital has publicly stated that the hospital services on Manus Island are in need of improvement.
There is no information about the Nauruan health care system on the Republic of Nauru Government website. The arrangements between Nauru and Australia about the treatment of persons on Nauru state that there are hospital facilities on Nauru including x-ray, pharmacy, pathology and dental services. There is provision in the contract for IHMS to enter into provider agreements with Government funded health care services.
The entry for Nauru in the Central Intelligence Agency’s World Factbook does not contain any information about the health care system apart from health expenditure as a percentage of GDP (11.2 per cent) and limited statistics about life expectancy and infant mortality. The Department of Foreign Affairs and Trade’s country brief on Nauru is also silent on the Nauruan health care system, but notes that the Australian Government helps pay for pharmaceuticals and medical supplies for the hospitals. The Australian Government also provides assistance with repairing and maintaining Nauru’s hospitals as well as electricity generation and water desalination equipment. Access to clean drinking water is an important pre-condition for health. The lack of a consistent supply of clean water, and associated health consequences on Nauru, have previously been highlighted, and it is likely that the increase in population due to asylum seekers will further compound this.
Australia and Nauru agreed on a partnership for development in 2009. This is to facilitate the achievement of the United Nations Millennium Development Goals and improve services for the Nauruan community in education, health and utilities (power and water). With respect to health, the results to 30 June 2012 show that there have been improvements in infant mortality (40/1,000 live births in 2002 to 24/1,000 in 2011) and a vaccination rate of 95 per cent for children for tuberculosis, measles, hepatitis B, polio, diphtheria and tetanus. The commitments for 2012-13 note that funding will continue for drugs, medical equipment, hospital maintenance and staff training, and that skilled Australian personnel will fill key management and medical positions.
Although not comprehensive, the information presented would suggest that the capacity of the Nauruan health care system is limited. It may also struggle with the influx of around 1,500 asylum seekers, given that the most recent estimate for Nauru’s population is 9,434. The need for ongoing support from the Australian Government for the provision of pharmaceuticals, medical equipment, training and staff further supports this. It is likely that IHMS will need to seek medical services from elsewhere or fly staff in to provide services that are not available on Nauru. It is not clear if there is adequate expertise within Nauru to treat complex mental health issues, although the contract between IHMS and DIAC specifies that mental health clinics comprising counselling, clinical psychology, mental health nursing and psychiatry must be provided. The limits of the Nauruan health care system are further highlighted by the fact that as of December 2012 four asylum seekers had been transferred to Australia for urgent medical treatment. The type of treatment required was not specified.
Under the PNG health system, primary health care is the responsibility of provincial governments and care is delivered through health centres, sub-centres and aid posts. Hospitals are statutory corporations governed by boards under the Public Hospitals Act. Churches and government providers are the dominant service providers, with churches (through the Church Partnership Program) providing care in approximately 46 per cent of all health facilities in PNG. In rural areas this figure is around 60 per cent. The Church Partnership Program also trains nurses and community health workers through structured training schools and programs. Despite the significant involvement of churches in the delivery of health care in PNG, the health care system is considered ‘fragmented’ with a disconnect between government, churches and other non-state providers. Health care in PNG is largely publicly funded, although churches and governments charge fees for service in some instances. Church organisations receive grants from the National Department of Health for the operation of health facilities.
One of the priority outcomes of the Partnership for Development agreed at the PNG-Australia Ministerial Forum in 2012 was to:
Pursue progress towards achieving an efficient health care system which can deliver an internationally acceptable standard of health service; and a healthy population free of sexually transmitted infections and HIV and AIDS (emphasis added).
This would suggest that the capacity of the PNG health care system is limited and that there is little scope for IHMS to rely on local health care services for the provision of health care to asylum seekers. Nurses in PNG have previously highlighted the shortcomings of the health care system, arguing that it is ‘understaffed and under-equipped’ and can no longer ‘effectively meet the need of the people’. There also have been claims of financial mismanagement of hospitals and misuse of funds.
Under the Partnership for Development, the Australian Government will make a number of contributions to the PNG health care system. This will include the rehabilitation and/or re-building of health and midwifery services, the rebuilding of one priority regional hospital and improved integration and linkages between STI/HIV and tuberculosis testing and treatment with maternal and child health services.
Health indicators show that PNG suffers from poor health outcomes across a range of areas:
- the World Health Organization (WHO) has identified PNG as having the lowest health status in the Pacific region
- life expectancy is low—estimated to be 55 for women and 54 for men
- the incidence and prevalence of HIV is a growing concern, with a national prevalence rate of 0.9 per cent. Co-infection rates with tuberculosis are also high.
- the PNG government spends the lowest proportion of revenue on health of all Pacific nations. Further, a misdistribution of health funding exists, with a short-fall in rural areas. 
Some of the goals agreed for health and HIV/AIDS as part of the Partnership for Development include increasing the rates of childhood immunisation and increasing the availability of medical supplies, including drugs and testing equipment for HIV, tuberculosis and malaria.
The risk of malaria in PNG is high. The 2012 WHO World Malaria Report estimates that 94% of the PNG population is at high risk of transmission of malaria. Many of the provinces of PNG have confirmed malaria cases of around 100 per cent. Manus Island has the highest rate of probable and confirmed malaria in PNG. Health authorities on Manus Island consider it to be endemic and a ‘way of life’. The most common form of malaria in PNG is plasmodium falciparum which requires treatment within 24 hours, and if left untreated can result in death in children and pregnant women.
Within the scope of the provision of primary health care services, the contract sets out the responsibilities of IHMS and relevant performance measures. This section is based on the Statement of Work (Schedule 1) of the contract and highlights provisions and clauses of note. References are made to the clauses and page numbers of the Schedule. For ease, the headings in this section reflect those in the Schedule. With respect to terminology, this paper does not adopt the terminology of the contract, and refers to detainees on Nauru and Manus Island as ‘asylum seekers’ rather than ‘transferees’ or ‘recipients’.
As noted previously, IHMS must establish a network (known as the HSM network) of health care providers and professionals to provide the health care services specified in the contract. IHMS ‘must ensure’ that the network has the ‘capacity, gender mix and specialist diversity’ to meet the complex health needs (including mental health) of a culturally diverse group. The Health Services Manager (HSM) is ultimately responsible for ensuring that the Network Providers are credentialed, receive appropriate training and support, maintain comprehensive health care records and have appropriate work permits (including police checks). They are also responsible for ensuring that DIAC receives value for money from the Network Providers, and for the scrutiny of invoices.
Of note, providers of general practitioner services have responsibility for referral and coordination of clinically necessary health care within the HSM network. This also includes services for which a referral is not usually required (for example dental, optometry and allied health).
The HSM is responsible for the regular monitoring and review of the network. This extends to performance and composition as well as ensuring the appropriate mix of services. Network Providers that are responsible for ‘frequent or serious’ service failures must be ‘promptly removed’, but no timeframe is specified for this. The outcomes of these regular reviews must be reported to DIAC.
As a general rule, Network Providers must enter into a ‘Network Provider Agreement’ with IHMS. This agreement sets out the services to the provided, fees and charges and the obligations of both parties. The exception to this is where:
There is no other provider of general practitioner services in the area or immediate region in which that type of Health Care service for Transferees and Recipients is required that:
(A) meets the minimum requirements and standards concerning the provision of the relevant specified Health Care to Transferees and Recipients; and
(B) Is willing to provide the specified Health Care to Transferees and Recipients and to enter a Network Provider Agreement.
As part of this agreement, Network Providers must agree that they will not make any public statements, assist the media or ‘publish, distribute or otherwise make available information to third parties’. All inquiries must be directed to DIAC.
‘Critical and Other Incidents’ are defined at Annexure A of Schedule 1. Examples of ‘Critical Incidents’ include death, refusal of (health) treatment, serious risk to health or life, outbreak of a confirmed public health risk (such as tuberculosis) or ‘sentinel events’. Occurrence of self-harm resulting in injury, attempted self-harm, voluntary starvation (over 48 hours), acute psychiatric hospital admission and serious accident/injury resulting in hospitalisation are classified as ‘Other Incidents’. These are selected examples - a full list is provided at Annexure A.
It is the responsibility of the HSM to develop and implement a Critical and Other Incident Management system for each facility. The purpose of the system is the timely notification and reporting of these incidents to DIAC. This system must be incorporated into the ‘Policy and Procedures Manual’, which governs the administration of the contract, and must be submitted to DIAC by IHMS as part of its contractual obligations. Further, IHMS must immediately inform DIAC (within one hour) of any Critical Incidents and provide a written report within four hours of such notification. For Other Incidents, IHMS must inform DIAC by a written report within 24 hours of becoming aware of the event. This report must provide background information, details as to participants, and the sequence of events. It must also describe all action taken by IHMS and service providers in response. In addition, a summary report of all Critical and Other Incidents must be provided by IHMS to DIAC within ten business days of the end of the month. After consideration of these reports by DIAC, the contract notes that IHMS must take ‘corrective or review action’ as agreed with DIAC.
The HSM has two main responsibilities under this clause. The first is to ensure that asylum seekers receive the care to which they are entitled under the contract and that no asylum seeker is denied or fails to receive care (except by their choice or if it is outside the scope of the care provided). The second is to ensure that asylum seekers take (shared) responsibility for their health care, while remaining alert and responsive to those who are unable to do so. Another responsibility defined in the contract is the provision of continuity of care. The HSM must use its ‘best endeavours’ to ensure consistency of health care providers during each episode of care and during their time on Nauru or Manus Island.
It is a condition of the contract that specialist, hospital and allied health services cannot be accessed without a referral from a GP or nurse. This is not dissimilar to how the Australian health care system works. If the care recommended is outside of the scope of the services provided under the contract, the HSM must seek approval from DIAC.
In addition, the HSM must ensure that any referrals are acted upon within a clinically appropriate timeframe. To that end, the HSM must maintain an electronic register for both facilities that includes details about referrals, appointments and consultations. The register is to be monitored to ensure that the appropriate care is provided and that referral patterns and practices are consistent with the contract Any suspected variations must be investigated by the HSM and notified to DIAC. The register must be made available to DIAC upon request.
Consent must be sought for the release of health information to other health care providers, as part of the referral process. Asylum seekers can refuse consent and the HSM must ensure that clinically necessary health care is not refused as a result. Further to this, consent must be sought before the delivery of any health care, and interpreters must be available to facilitate this.
Asylum seekers are able to make requests in relation to their health care. This includes being able to request access to their medical records and/or a second medical opinion (although this will only be granted if clinically recommended). The HSM must ensure that all requests are ‘acknowledged, responded to and actioned (as appropriate)’ in a ‘timely and reasonable manner’.
IHMS must develop and maintain comprehensive health care records for asylum seekers. Records must be stored on a secure electronic network and allow access by multiple providers. All Network Providers that provide health care to asylum seekers are required to maintain records on this network. The other notable feature of the medical record network is that a ‘holistic medical record’ should be available for each person at any given time. The HSM must audit the records on a regular basis to ensure compliance with these requirements. A copy of the audit, together with any findings and relevant action, must be provided to DIAC within ten days of the audit being completed. These audits must be conducted at intervals agreed with DIAC, but no less than quarterly.
The costs associated with the delivery of health care to asylum seekers (including any costs associated with investigations, treatments or procedures) must be itemised and able to be extracted and downloaded. This information must be reported to DIAC. In addition, the financial management system will support the cashless payment to Network Providers for the provision of health care.
The HSM must develop a quality management system with the objective of ‘continuous improvement of service delivery’ to ‘maximise value for money and achievement of the Department’s Agreement objectives’. The system must be able to identify and analyse service delivery and performance issues or failures across Nauru and Manus Island. It also must outline the process for responding to these issues or failures.
The HSM must develop and implement a complaint feedback system for asylum seekers and Network Providers. The emphasis of this system is to be the resolution of feedback or complaints in a ‘responsive, fair, open and timely manner’. The process for managing complaints must be provided to DIAC, and DIAC must be informed of all complaints received from asylum seekers or health care providers.
The intention of the feedback system to be used by Health Care Providers is that it will enable them to raise concerns ‘in confidence and without prejudice to their position or fear of negative repercussions, concerns over any aspect of Health Service delivery, or Health Care delivered to a Transferee’. If requested by DIAC, the HSM must work cooperatively with the Health Care Provider and DIAC to address these concerns. DIAC must also be informed of any complaints referred (either by asylum seekers or Health Care Providers) for external investigation. The policy governing Health Care Provider feedback must be included in the Policy and Procedures Manual developed by IHMS as part of administration of the contract.
This section of the contract outlines the performance standards (clause 17) of the contract. It reiterates the overarching objectives of the contract (as outlined above) and outlines additional requirements and/or services such as:
- ‘Health Discharge Assessment’ (clause 20)
- Continuing Health Care, including health management and periodic mental health screening and assessment (clause 21 and 22)
- medical escort service (Clause 23)
- at Nauru and Manus Island, the services described in clause 24.1 (outlined in a separate section below)
- an after hours service (clause 25)
Consistent with other parts of this paper, this section only notes clauses of significance. References are made to the clauses and page numbers of the Schedule. For ease, the headings in this section reflect those in the Schedule.
Upon arrival on Nauru or Manus Island, the HSM must provide asylum seekers with information about the health care services available, in writing and in a manner which can be understood. This information must be provided within 72 hours of arrival. It is also the responsibility of the HSM to ensure that asylum seekers are notified of any changes to the provision of health care.
As noted above, a health care record for each asylum seeker must be established and regularly maintained. The initial record reflects the ‘Health Induction Assessment’ undertaken by all asylum seekers at the time of arrival. One of the purposes of this assessment is to identify any follow-up action or ‘special requirements pertaining to the care and management of the person’.
The HSM must also develop and implement a Health Discharge Assessment process. The purpose of this assessment is to facilitate continuity of care once the asylum seeker leaves Nauru or Manus Island. It must also include clinical history, treatment received on Nauru or Manus Island, ongoing treatment regime and any health ‘Critical Incidents’. For asylum seekers returning to their country of origin, this assessment must be translated. Asylum seekers must also be provided with a 14-day supply of medication. Where required, the HSM must organise a clinical handover as well as any referrals for continuing treatment.
These provisions are likely to be of benefit to asylum seekers and for provision of their future health care needs. DIAC has in the past been criticised for not providing sufficient information to asylum seekers and/or their health care professionals upon discharge into the community.
All asylum seekers with an ongoing or underlying health condition must have a treatment plan and it is the responsibility of the HSM to ensure that this is initiated and coordinated by the asylum seeker’s GP. It is also the responsibility of the HSM to ensure that asylum seekers who have not visited a GP for 12 months are given the opportunity to do so. Medications must also be regularly reviewed and monitored.
The mental health needs of asylum seekers must be ‘adequately and appropriately identified, monitored and treated at all times’ by the HSM. The contract specifies how this is to be achieved (clause 22), for example:
- For those identified as ‘at risk’ or as having a mental health concern at the Health Induction Assessment or any other time, a ‘targeted mental health management plan’ must be developed for that person, using the expertise of the multidisciplinary teams of specialist mental health care providers.
- When in-patient mental health treatment is required, this must be arranged by the HSM. Care will be provided by either public or private hospitals that are Network Providers. As a general rule, the person will be referred to the nearest public hospital. Specialist private hospital care may be provided but prior written notice must be given to DIAC.
- In instances where asylum seekers require involuntary assessment and treatment under mental health legislation, the HSM must notify DIAC. The assessment and treatment must be done by an appropriately qualified person, in consultation with the ‘Medical Director’ and in accordance with the relevant laws.
IHMS must also develop and implement policies that monitor and assess the mental health of asylum seekers on Nauru and Manus Island. The policy framework must take into account the diversity of population groups and respond to any changes in mental health status. It must also be and developed in consultation with, DIAC. Mental health care (including screening and assessment) is to be delivered in accordance with the policies. Asylum seekers are also to be screened for any signs of torture and trauma, and referred for treatment as appropriate.
Clause 24 sets out the range of health care services to be provided to asylum seekers on Nauru and Manus Island. This is to be read in conjunction with Schedule 1, Annexure B, which outlines the clinic hours to be delivered on a weekly basis and staffing levels. Asylum seekers with serious or complex health needs that cannot be treated onsite must be referred by a GP to a clinically appropriate specialist. DIAC must be notified if this will result in a transfer to a hospital. In the case of a medical emergency, the asylum seeker may be taken directly to hospital.
The services provided under contract have been outlined in an earlier section of this paper (see ‘Framework for the provision of health care’). IHMS must provide health care services seven days a week on Nauru and Manus Island. Care will be provided for 12 hours, with 12 hour emergency coverage after hours. The contact does not specify in which hours the care must be provided.
A number of clinics, with a specific range of services, must be established on each site:
– services include triage and referral to GP clinic, coordination and follow-up services, health protection services such as infection control and immunisation and primary-care-level first aid and emergency response
– services include assessment (including for visa applications), treatment and monitoring, coordination, management and referral to other health care providers and primary care mental health services
– services include provision of advice to DIAC on placement and behavioural management issues for asylum seekers, general counselling services, psychological services, specialist psychiatric services and behavioural management advice services
– note that access to this clinic must be via referral from the Mental Health Team Leader or the onsite GP clinic and
– note that this is subject to the availability of ‘appropriate clinical infrastructure’.
A range of services must also be provided:
- radiography services (dependent on the acquisition of a x-ray machines on Nauru and Manus Island)
- after hours services
- optometry services, including the provision of glasses and
- preventive health services including health education, awareness and promotion (for example nutrition, diet, sexual and reproductive health) and preventive mental health education, awareness and promotion.
Staffing levels are specified in Annexure B. The number of medical staff appears to be calibrated to the number of asylum seekers. For Nauru, a Medical Director is only required onsite once the asylum seeker population is over 150. A psychiatrist is only required to be 0.25 full-time equivalent (FTE), which equates to approximately 10 hours per week (assuming a 40 hour week). This increases to 0.5 when the population increases to more than 1000. This is a visiting position. Although two psychologists are expected to be onsite, they are unable to prescribe medication and are not medically trained. In addition, two mental health nurses and two mental health team leaders are to be onsite, increasing to four of each when the asylum seeker population goes beyond 500. Counselling services on Nauru and Manus Island will be provided by telemedicine through the Sydney Assistance Centre.
There are similar requirements for Manus Island, although the overall staffing numbers are lower and the staffing mix is different. It would appear that nurses will be providing the majority of care on Manus Island. Three primary care nurses are required when the population is up to 150, rising to five when the population reaches 500-600. This is more than is required on Nauru for the same number of asylum seekers. In contrast, the overall number of GPs required on Nauru is higher (up to two for Manus Island and up to four for Nauru, dependent on the number of asylum seekers). A Medical Director is only required on Manus Island when the asylum seeker population is over 500. For mental health, there appears to be a greater focus on mental health nurses at Manus Island, rather than psychologists or mental health team leaders. This difference may be addressed by the slightly higher FTE requirements for on-site psychiatrists (0.3 FTE for Manus Island compared with 0.25 on Nauru for a population of up to 150 asylum seekers).
Access to services such as dental, pathology, optometry, radiography, clinical psychological and psychiatric services is by referral from a GP or a nurse. This is consistent with the primary care framework in Australia, whereby GPs act as the gateway to other parts of the health care system (with the exception of allied health and dental). Asylum seekers must be able to access services from the registered nurse clinic within 72 hours of making a request for consultation. A system must be developed by the HSM to collect requests on a daily basis.
The provision of services after hours is governed by clause 25. In short, the HSM must operate and manage an after-hours service on both Nauru and Manus Island which includes health triage and initial health advice to asylum seekers. This must be available at all times when the GP clinic is not open, and available to all asylum seekers. An after-hours GP service must also be available.
In the event of a ‘personnel shortfall’ or an ‘infrastructure failure’ (to the extent to which it contributes to the failure to deliver services), the HSM is not responsible for the failure to deliver services outlined in clause 24.
Part 2, clause 17 and Schedule 5 outline the performance measures for the provision of health care to asylum seekers. The performance measures are in addition to the reporting requirements outlined in the contract, such as Critical Incident reporting.
The standard of health care to be provided to asylum seekers must be ‘sufficient to maintain optimal health’, the ‘best available in the circumstances’ and ‘broadly comparable with health services available in the Australian community’. The health care to be provided must be culturally sensitive, with an understanding of the needs and concerns of asylum seekers, without discrimination and with respect to patient rights. Importantly, health care is to be based on the best available evidence and prioritised according to clinical need. As part of the contract, asylum seekers have access to health care throughout their time on Manus Island and Nauru and must be able to access health care within 72 hours of requesting a medical consultation. As previously noted, the majority of health care is to be provided onsite, although there is scope in the contract for the care to be delivered offsite subject to DIAC approval.
Schedule 5 notes that the performance measures have been designed to give DIAC a ‘level of assurance’ that the services provided by the HSM are in accordance with the Statement of Work in Schedule 1. There are four performance measures, each with performance thresholds and measurements:
- vaccination commencement (90 per cent)
– 90 per cent of asylum seekers who agree to receive vaccinations will be placed on an appropriate vaccination plan with 48 hours of arrival
- diabetes management (90 per cent)
– all asylum seekers to be tested for diabetes within 48 hours of arrival, or within 48 hours of possible diagnosis. Of those identified with diabetes, 90 per cent to be placed on an appropriate care plan with 48 hours of diagnosis or arrival (for a pre-existing condition)
- maintenance of records for clinicians (95 per cent)
– at a minimum, particular information for 95 per cent of clinicians deployed to Nauru or Manus Island, including personal contact details, details of next of kin/contact in case of emergency, date of expiry for professional registration and date of expiry for police checks and
- timely conduct of mental health screenings (90 per cent)
– mental health examinations conducted at the following intervals for 90 per cent of asylum seekers:
(i) 10–30 days after being detained in Australia, provided the period has not expired prior to their arrival on Nauru or Manus Island
(ii) 5–6 months after being detained in Australia
(iii) 11–12 months after being detained in Australia
(iv) 17–18 months after being detained in Australia and
(v) quarterly, in the second month of each quarter after the person has been detained for 18 months.
Monthly reports detailing performance against each measure are to be submitted within 10 business days of the last business day of each month. Reasons must be provided if performance measures are not met. In the event that performance measures are not met, the HSM must provide a remedial action plan and details of any preventative action, as well as demonstrate that the strategy has been implemented. In the event that performance reports are not supplied within the specified timeframe, DIAC can withhold payment.
There is scope in Schedule 5 to renegotiate the performance measures to better reflect the scope of services provided under the Contract.
There appear to be some discrepancies between the performance standards outlined at clause 17 and the performance measures in Schedule 5. For example, under clause 17, the health care provided must be of a sufficient standard to maintain optimal health. Yet there are no performance measures which attempt to assess this. Information about the timely conduct of mental health screening is an important measure of access to services, but there is no additional information about the type of treatment received or any assessment of its effectiveness. Similarly, health care is to be based on ‘best available evidence’, but there is no clinical auditing tool in the performance measures or standards to determine this. Furthermore, clinical referrals for more specialist care must be within ‘clinically appropriate timeframes’, yet the contract is silent on how this is determined and by whom this will be assessed. This raises questions about the extent to which DIAC (and the Government more broadly) can make an assessment about the adequacy and appropriateness of the health care provided by IHMS under this contract.
IHMS has a number of responsibilities under clauses 9 (health management) and 10 (information and health care records management) of the contract. The intent of these clauses is to define the scope of the care that is to be provided by IHMS and the manner in which it is provided. For example, communication with asylum seekers is to be in a manner that can be understood (including access to interpreters and provisions for those who are illiterate in their native language), seeking of informed consent, ensuring that asylum seekers are aware that they are able to request health services and coordination of these requests, and the development of detailed records. Although there are reporting requirements associated with some of these matters, they are not currently reflected in the performance measures of the contract.
The performance measures are silent on the adequacy and type of health care services being provided by IHMS. There are no reporting requirements associated with the exclusion clause (clause 17). It has been suggested that the medical facilities on Manus Island are ‘quite inadequate’ and, at times, suffer from an ‘appalling lack of supplies’. This has been disputed by IHMS. Another example is the availability of medical evacuation. Under the contract, medical evacuation must be available 24 hours per day, seven days a week. However it has been claimed that there is a 24-hour delay between calling a plane (for medical evacuation purposes) and its arrival on Manus Island. Irrespective of the claims and counter-claims, there are currently no provisions in the contract for DIAC to make an assessment of the appropriateness, timeliness and standard of care that is being provided.
It is the responsibility of the HSM to ensure that asylum seekers take a ‘shared responsibility’ for their health. They also must remain alert to those who are unable to achieve this. In addition, the contract appears to be focussed on the obligations of IHMS once asylum seekers request medical treatment (for example, the provision of general health services within 72 hours of request) rather than active engagement with asylum seekers about the most appropriate health care for their needs. The poor morale and limited facilities of Nauru and Manus Island have been well documented, and questions could be asked about the extent to which asylum seekers in this environment are likely to engage in health seeking behaviour. Although there is provision in the contract for asylum seekers to request a second opinion, questions could also be asked about the extent to which asylum seekers are likely to do this, especially if this is not common in the health care system in their country of origin and/or if they are suffering from major mental health trauma.
In its submission to the Parliamentary Committee on Public Works, DIAC acknowledged the health and wellbeing risks associated with the conditions on Manus Island. The Australian Human Rights Commission echoed these concerns, noting the harsh climate and serious risk of malaria as well as the limited infrastructure and services available. Journalists have also highlighted the harsh conditions on Nauru and Manus Island and the significant mental health needs of asylum seekers in these environments.
The contract governing the provision of health care on Nauru and Manus Island is intended to ensure IHMS provides a level of care that is sufficient to maintain optimal health, broadly comparable to what is available in Australia and the best available in the circumstances. Yet apart from journalist reports, there is limited publicly available information on which to base an assessment of whether these objectives are being achieved. Services provided under the contract also rely on linkages with local health care services for the provision of health care, but evidence would suggest that such services are quite limited. This may further limit the extent to which the objectives of the contract can be achieved.
The lack of rigorous reporting and accountability measures in the contract also make it difficult to assess performance. Although separate to the contract, oversight of offshore processing on Nauru is provided by an interim Joint Advisory Committee, which was established to ‘play an initial oversight role for the Nauru centre, as well as provide advice to both governments on the make-up of an independent permanent oversight committee’. Two members of the Committee (Professor Nicholas Procter and Dr Maryanne Loughry) have a background in health and mental health. It is not clear if a similar committee has been established for Manus Island or if the same committee also has responsibility for Manus Island. It remains to be seen whether the deliberations of the Joint Advisory Committee will be publicly available or if individual members are able to speak freely about their observations or concerns.
The Minister for Immigration has acknowledged the toll on people’s mental health and wellbeing as a result of being in detention. While this contract outlines the health care to be provided in offshore processing countries it will be difficult to overcome the underlying causes of ill health for asylum seekers on Nauru and Manus Island. As noted by the Joint Select Committee on Australia’s Immigration Detention Network (JSCAIDN), the length of time spent in an ‘information vacuum’ in detention is the primary problem and contributor to stress. The JSCAIDN also highlighted that remoteness affects the quality of psychiatric care received by asylum seekers. Mares and Jureidini have also documented the challenges of providing mental health services to asylum seekers in immigration detention, as the nature of the detention environment means that ‘recommendations aimed at improving detainees’ psychological and social circumstances cannot be implemented’. The challenge for DIAC and IHMS will be how best to fulfil their duty of care in this difficult environment.
. See J Phillips, The Pacific Solution revisited: a statistical guide to the asylum seeker caseloads on Nauru and Manus Island, Background note, Parliamentary Library, Canberra, 4 September 2012, accessed 6 June 2013, and J Phillips and H Spinks, Immigration detention in Australia, Background note, Parliamentary Library, Canberra, updated 20 March 2013, accessed 6 June 2013.
. D Whitmont and J Cohen, ‘No advantage’, Four Corners, transcript, Australian Broadcasting Corporation (ABC), 29 April 2013, accessed 12 May 2013.
. Ibid., pp. 30 and 110–1.
. Joint Select Committee on Australia’s Immigration Detention Network (JSCAIDN), Final report, Canberra, March 2012, p. 82, accessed 18 June 2013.
. Department of Immigration and Citizenship (DIAC), Annual Report 2010–11, DIAC, Canberra, 2011, p. 183, accessed 9 October 2012.
. JSCAIDN, op. cit., p. 81.
. Commonwealth of Australia represented by the Department of Immigration and Citizenship and International Health and Medical Services Pty Ltd, Heads of Agreement relating to the provision of health services on Nauru and Manus Island, clauses 5.1.1 (a) and (b), p. 9. Note: The contract uses the terms ‘transferees’ and ‘recipients’. For ease, this paper uses the term asylum seekers.
. S Duckett and S Willcox, The Australian Health Care System, 4th edition, Oxford University Press, South Melbourne, 2011, p. 160.
. Heads of Agreement, op. cit., Schedule 1, clause 24.1, pp. 43–44.
. Ibid., clause 5.1 (a), p. 9.
. Ibid., clause 5.4 (b) (i) (A), p. 10.
. Ibid., clause 5.4 (a), pp. 11–12.
. Ibid., clause 5.4 (b), (i), (B), p. 11.
. Ibid., clause 24.1 (a), (iii), p. 43.
. Whitmont and Cohen, op. cit., p. 12.
. Travel websites note that medical care on Nauru is ‘extremely limited’, but ‘adequate’ for routine medical problems. For example, see ‘Nauru’, MDtravelhealth.com website, accessed 26 September 2012.
. Commonwealth of Australia, Instrument of Designation of the Republic of Nauru as a regional processing country under subsection 198AB(1) of the Migration Act, Attachment B Statement about arrangements that are in place, or are to be put in place, in Nauru for the treatment of persons taken to Nauru, paragraph 13, Commonwealth of Australia, 10 September 2012.
. Heads of Agreement, op. cit., clause 5.4, pp. 10‑11. It has been assumed that ‘Government funded’ refers to health care services funded by the Australian, Nauru or PNG Government. The Glossary to the Agreement is silent on the meaning of ‘Government funded health care service’.
. Central Intelligence Agency (CIA), ‘Nauru’, The World Factbook, updated 11 June 2013, accessed 24 June 2013.
. Department of Foreign Affairs and Trade (DFAT), ‘Nauru country brief’, DFAT website, updated September 2012, accessed 24 September 2012.
. Australian Agency for International Development (AusAID), ‘Nauru’, AusAID website, 29 August 2012, accessed 24 September 2012.
. Ibid. Funding of $31.6 million was provided by the Australian Government in 2012–13.
. For population estimates see CIA, op. cit.
. Heads of Agreement, op. cit., clause 24.1(b), p. 43.
. J Ashcroft, R Sweeney, M Samei, I Semis and C Morgan, Strengthening church and government partnerships for primary health care delivery in Papua New Guinea: Lessons from the international experience, Health Policy and Health Finance Knowledge Hub – Working Paper Series Number 16, December 2011, The Nossal Institute for Global Health, University of Melbourne, p. 2, accessed 8 January 2013.
. PNG Church Partnership Program, Country information, PNG Church Partnership Program website, accessed 8 January 2013.
. J Ashcroft, R Sweeney, M Samei, I Semis and C Morgan, op. cit., p. 5.
. PNG-Australia Ministerial Forum, op. cit., p. 10. A complete list of Australian Government commitments is provided.
. Ibid., refer to map on page 161.
. Heads of Agreement, op. cit., Schedule 1, clauses 5.1 and 5.2, pp. 9–10.
. Ibid., clause 5.2 (b) (i), p. 10.
. Ibid., clause 5.3 p. 10.
. Ibid., clause 5.4 p. 10-13.
. Ibid., clause 5.4 (b), p. 11.
. Ibid., clause 5.4 (b), (a), (xiii), p. 12.
. ‘Sentinel event’ is defined as ‘any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, and not related to the natural course of the patient’s illness’. Ibid., Annexure A, paragraph 2 (f).
. Ibid., Annexure A, Incidents, paragraphs 2 and 3.
. Ibid., clause 8.2 (a), (ii), p. 19.
. Ibid., clause 8.2 (b), p. 19.
. Ibid., clause 8.2 (c), p. 19.
. Ibid., clause 8.3 p. 19.
. Ibid., clause 9.1 (a) (ii), p. 20.
. Ibid., clause 9.1 (a) (iii), p. 20.
. Ibid., clause 9.1 (c), p. 20.
. Ibid., clause 9.2 p. 21.
. Ibid., clause 9.2 (a), p. 2.1
. Ibid., clause 9.2 (b), (ii), p. 21.
. Ibid., clause 9.3 (a), p. 21.
. Ibid., clause 9.3 (a), (v), p. 21
. Ibid., clause 9.3 (b), p. 21.
. Ibid., clause 9.3 (b), (iii), p. 21.
. Ibid., clause 9.4. p. 22-3.
. Ibid., clause 9.4 (e), p. 23.
. Ibid., clause 9.6 p. 24.
. Ibid., clause 9.7 p. 24.
. Ibid., clause 9.7 (b), p. 24.
. Ibid., clause 9.7 (c), p. 25.
. Ibid., clause 10.1 p. 25-26. What must be included in each record is specified at clause 10.1 (b).
. Ibid., clause 10.1 (a), p. 25.
. Ibid., clause 10.1 (d), p. 26.
. Ibid., clause 10.1 (d), p. 26.
. Ibid., clause 11 (a) (d), p. 27.
. Ibid., clause 11 (b) (c), p. 27.
. Ibid., clause 13.1 (a), p. 29.
. Ibid., clause 13.1 (a), p. 29.
. Ibid., clause 14.1 (a), p. 29.
. Ibid., clause 14.1. (b) (c) and clause 14.2, p. 29.
. Ibid., clause 14.1 (c), p. 29.
. Ibid., clause 14.1 (a), p. 29.
. Ibid., clause 14.1 (c), p. 29.
. Ibid., clause 18, p. 35.
. For example, the use of the appropriate language or if illiterate, alternative communication methods. Ibid., clause 19.2 (b), p. 36.
. Ibid., clause 19.2 (c), p. 36.
. Ibid., clause 19.1, p. 35.
. Ibid., clause 19.1, p. 35.
. Ibid., clause 20, p. 36–8.
. Ibid., clause 20.1, p. 36–7
. Ibid., clause 20.1 (c), p. 37.
. Ibid., clause 20.1 (c), p. 37.
. Ibid., clause 20.1 (c), p. 37.
. Ibid., clause 20.1 (c), p. 38.
. Heads of Agreement, op. cit., clause 21.1 (a) and (b), p. 39.
. Ibid., clause 21.1 (c), p. 39.
. Ibid., clause 21.1 (d), p. 39.
. Ibid., clause 22.1 (a), p. 39.
. Ibid., clause 22.1 (b), p. 40.
. Ibid., clause 22.1 (c), p. 40.
. Ibid., clause 22.1 (d), p. 40.
. Ibid., clause 22.2 (a), p. 40.
. Ibid., clause 22.2 (a) and clause 22.2 (d), p. 40–1.
. Ibid., clause 22.2 (c), p. 41.
. Ibid., clause 24.1 (a), p. 43.
. Ibid., clause 21.1 (a ), p. 43.
. Ibid., Schedule 1, Annexure B and Tabled Document 5, Nauru staffing arrangements, Senate Legal and Constitutional Affairs Legislation Committee, Supplementary Budget Estimates 2012, 15 October 2012, accessed 18 June 2013.
. For a full list of services see Heads of Agreement, op. cit., clause 24.1 (c), (d), (e) and (f), p. 45–7.
. Ibid., clause 24.1 (e), p. 46.
. Ibid., clause 24.1 (f), (i), p. 47.
. Ibid., clause 24.1 (g), p. 48.
. Ibid., clause 24.1 (h), p. 48.
. Ibid., clause 24.1 (i), p. 48.
. Ibid., clause 24.1 (j) (i) A & B, p. 48.
. Australian Psychological Society (APS), ‘About psychologists’, APS website, accessed 9 February 2013. The Four Corners report (see footnote 3) broadcast on 29 April 2013 highlighted the significant mental health needs of some of the asylum seekers on Manus Island and Nauru. Critical mental health incidents, such as those described on the program, are likely to require psychiatric treatment.
. Heads of Agreement, op. cit., Schedule 1, Annexure B and Tabled Document 5, Nauru staffing arrangements, op. cit.
. Ibid. Note that Tabled Document 5 referred to above does not include any statement about how the counselling services are to be provided. However, Schedule 1, Annexure B (Manus Island staffing arrangements), states that counselling services will be provided through telemedicine via Sydney.
. Heads of Agreement, op. cit., clause 24.1 (b) (viii), p. 44.
. Ibid., clause 24.1 (b) (ix), p. 44.
. Ibid., clause 25.1 (a), p. 49.
. Ibid., clause 25.1 (b) (i) (ii), p. 49.
. Ibid., clause 25.2, p. 49.
. Ibid., clause 24.2 (a) and (b), p. 48–9.
. There are also performance measures for the provisions of health care to ‘recipients’ (these are persons nominated by DIAC from time to time, as defined in Schedule 3, Glossary). Part 3, clause 27, outlines the performance standards that govern the provision of health care to recipients.
. Heads of Agreement, op. cit., clause 17.1 (a), p. 34.
. Ibid., clause 17.1 (b), (i) and (ii), p. 34.
. Ibid., clause 17.1 (b), (iii), p. 34.
. Ibid., clause 17.1 (c) and (d), p. 34.
. Ibid., clause 17.1 (e), p. 34.
. Ibid., Schedule 5, paragraph 1.1.
. For further detail about the measurement of performance measures see Schedule 5, paragraph 1.3 (a) to (d).
. Ibid., Schedule 5, paragraph 2 (a) to (d).
. Ibid., Schedule 5, paragraph 3.
. Whitmont and Cohen, op. cit., p. 7.
. Heads of Agreement, op. cit., clause 23.2, p. 42.
. Whitmont and Cohen, op. cit., p. 8.
. Heads of Agreement, op. cit., clause 9.1 (iii).
. Ibid., clause 9.1 (iii).
. B Hall, op. cit. and Whitmont and Cohen, op. cit.
. JSCAIDN, op. cit., p. 114.
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