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*Population in 2020、GNI and life expectancy are updated based on UN's 2019 data. *Medical information is based on WHO's 2017 report Mental Health Atlas-country profile. |
I. Overview |
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Negara Brunei Darussalam, referred to as Brunei, is a small absolute monarchy with an area of approximately 5,765 square kilometers, it is located on the northern shore of Borneo, the largest island in Asia (the third largest in the world, second only to Greenland and New Guinea). In 2020, the total population is about 437,000, two-thirds of which are Malays, and Chinese account for about 11%, and some other minorities including Indigenous people 3.4% and Indian Brunei 2.3%. Brunei’s population is quite young, with one third of it under 15 years old, and less than 3.5% over 65. According to WHO, the average life expectancy is 74.3 years. The official language is Malay, English and Hokkien are also used. Islam is the official religion, and about two-thirds of the population are Muslims. The average national income is US$32,230, which is a high-income country in the world. Among the ASEAN countries, the Human Development Index (HDI) is 0.845 and only next to Singapore, and has reached the WHO's Millennium Health Development Plan goals, the prevalence of HIV and AIDS is very low. The main disease burden is non-communicable diseases (NCDs). In 2014, 80% of deaths were caused by cardiovascular disease, cancer and diabetes. Brunei is an unitary country, and the Central Government has the supreme power. Bandar Seri Begawan, which is an important harbor at the north tip of its territory, is also the capital. Daerah (known as county) is the main administrative division of Brunei. The country consists of four counties, namely Mora, Malaya, Dudong, and Tamburong. There has a Jabatan Daerah which is the administrative unit at each of the county, and the Pegawai Daerah is appointed by the Ministry of the Interior (MoI, Central government) as the county chief officer. There are the subunits-Mukims (known as township), of which there are several Kampung (known as village) under its jurisdiction. Each Mukims (township) and Kampung (village) are under the control of the Jabatan Daerah (county) office. The central health authority is the Ministry of Health (hereinafter called MoH), whose mission is to provide and improve a high-quality, comprehensive health care system and well-being for all the people in Brunei Darussalam. |
II. Mental health policy and system |
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The government issued the Mental Health Order on November 1, 2014, which would aim to address the care, treatment, welfare and protection of patients with mental disorders. Ensure equality and reduce discrimination against people with mental disorders, and integrate patient-centered care and treatment, follow-up rehabilitation and reintegration into social issues At the same time, the management of involuntary admissions has been improved, the human rights of patients have been improved, and mental health and well-being have been greatly enhanced. But the mental health legislation to deal with criminals with mental disorders is not yet complete. The 1951 Criminal Procedure Code were targeted to "people with unsound minds", but did not include a definition of such persons. The MoH provides free medical and health care, covering four general hospitals and 16 primary health care centers and clinic networks, and it also contains maternal and child outpatient clinics; for the areas with inconvenient transportation, the medical services can be supplied through the air transport. In addition, two private hospitals accommodate services which are not provided by the general hospitals. For medical treatment or surgery which can not be conducted by Brunei government's hospitals, they will be sent overseas for further medical treatment under the government's payment. Primary health care centers provide general health care, pregnant women and postpartum care, as well as mental health and ophthalmology services. Medical care for citizens and permanent residents is free, and foreign citizens can pay in cash or through the insurance. Brunei began to promote electronic medical records in 2011, starting from the general hospitals in stages, and then to extend it to the primary care. It includes the basic population information, diagnosis, etc., and the follow-ups are to collect health data on a large scale. The psychiatric medical department has been actively promoting the integration of mental health into primary medical care and community services, and often organizes various special training courses. Psychiatric outpatient clinics are conducted in the primary medical units every week or every other week. At present, some medicines can also be obtained from the primary medical units to promote mutual cooperation. Brunei's NGOs are currently not involved in mental health care services, and only few groups are taking care of the children with autism and learning disabilities. There so far have no private day care or rehabilitation resources, no emergency line, no caregivers or professional organizations. Because of the stigmatization of the disease, patients and their families do not take the initiative to seek medical treatment. Community rehabilitation services encourage patients and caregivers to support each other through psychological health education groups and activities. It is hoped that patients and their families can achieve a process of active participation. The people of Brunei believe that various physical and mental illnesses are caused by supernatural phenomena and will give priority to traditional treatment. Many patients and their families will first consult the Islamic healing system. These traditional therapists have their own methods to deal with physical and mental health problems caused by supernatural causes, and their dialogue with modern psychiatric medicine is limited. At present, the MoH in Brunei does not have a policy on this phenomenon, and there is no relevant research either. |
III. Human Resources |
WHO’s 2017 Mental Health Atlas pointed out that the number of health professionals engaged in mental health work per 100,000 people in the country, i.e., 1.2 psychiatrists, 15.09 nurses, 50.03 psychologists, 0.24 social workers and 0.48 functional therapists, respectively.
The sustainability of human resources and services is a major challenge. The number of professionals working in the health service sectors is listed in Table 1 below. There are 6 full-time consultants or specialist psychiatrists, of which 2 were newly recruited by the end of 2013. There are 8 full-time "medical staff" or "senior medical staff" in the psychiatric department. These are medical graduates who have received some training in psychiatry. Most medical staff are foreigners and they have signed a three-year service contract.
The PAPRSB (Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah) Institute of Health Sciences of the Universiti Brunei Darussalam is the only medical education institution in the country. It provides pre-clinical undergraduate courses, and the graduates are sent to overseas cooperative institutions to complete clinical training. In recent years, they have applied the British system and set up a two-year basic training program for the returning medical graduates, which developed a vocational training plan for primary care doctors. The promising local doctors will have the chance to receive further overseas training, which is funded by the government. The psychiatric department of RIPAS Hospital (Raja Isteri Pengiran Anak Saleha) in the capital Bandar Seri Begawan is developing opportunities for scholarships or exchange programs with foreign psychiatry institutions, which plans to carry out and to cultivate the higher-level mental health manpower for the country. It is also the main referral hospital with a capacity of 1,260 beds and 257 doctors. The hospital is funded by the government and managed by MoH. It is also a teaching hospital and affiliated to the Universiti of Brunei Darussalam.
Nurse training is carried out by the MoH, and cooperated with Pantai Jerudong Specialist Centre (PJSC) and the Institute of Brunei Technical Education (IBTE). MoH recruits nurses with basic general nursing qualifications, after working in the psychiatric department of RIPAS hospital or Suri Seri Begawan hospital (SSB, located at Kuala Belait town of Malaya Daerah), they can apply for a mental health nursing diploma. Some people have the opportunity to be sent to overseas or local university for further studies. Nurses are replaced by mental health workers, nursing assistants and service personnel. There is no formal training program for clinical psychologists, occupational therapists or social workers, but most of them can have the occasions to receive advanced training abroad.
IV. Mental health system and promotion |
The funding for mental health services comes from the hospital budget and is not calculated separately. The cost of individual project comes from the MoH, and the medical services are fully funded by the government. Citizens and permanent residents only need to pay US$1 for medical treatment including prescription fees, while foreigners require to pay US$3.5 for medical treatment, hospitalization, examination and medication costs. It is completely free for children under 12 years old.
According to the 2008 National Mental Health Report, the country's mental health services are all operated by the government, mainly located in the psychiatry department of RIPAS Hospital and SSB Hospital. At that time, there were 36 psychiatric acute beds (20 beds in RIPAS hospital and 16 beds in SSB hospital), but the wards of RIPAS hospital were often full. There is no specialized inpatient ward, so patients who need to be hospitalized are admitted to the same general ward.
In terms of community mental health care: a community mental health team includes two to four psychiatric nurses and few consulting doctors. Services are provided in four regional hospitals. The focus of diagnosis and treatment is on the medicine treatment, mental state monitoring, and involving patients with their family members together in treatment. It is very common for multiple generations' participation. A community mental health team for children and adolescents has also been established, and it normally is composed of a child/ adolescent psychiatrist with three nurses. Each district has day hospital facilities with nurses, usually it shares with community team services. The capital Bandar Seri Begawan has a fairly complete community rehabilitation center.
There are no psychiatric hospitals in Brunei, and general hospitals in each district provide psychiatric services. But only two district hospitals provide inpatient services, while the other two districts hospitals have outpatient clinics, day care and community services. There are currently no private hospitals that provide mental health services. Various service organizations and the number of beds are shown in Table 2.
Table 2. Brunei Psychiatric Service Institutions and Number of Beds
Source: ASEAN mental health system report, page 7.
The inpatient service provided by the Psychiatric Department of RIPAS Hospital has 20 acute beds, covering an area with a total population of 320,000. More than 60% of patients are admitted to the hospital involuntarily. It also provides outpatient services, the community rehabilitation center and day ward in the residential area near the hospital. Another hospital (SSB) provides 16-bed inpatient services, day wards, community rehabilitation and community mental health services.
In recent years, the demand for psychiatric inpatient beds has increased significantly, with a bed-occupancy rate of 80% to 130%. However, due to the lack of referral community services or chronic inpatient beds, chronic patients may occupy acute wards for quite a long time. Before 2012, 40% of acute beds were improperly occupied by the chronic patients. The situation was improved because of the setting-up of the community rehabilitation center for female chronic patients after 2012. For the male psychiatric patients, the same rehabilitation long-term care center was established on 2014.
It also provides notes for general non-psychiatric inpatients and surgical patients' mental medical service needs, and it is to take care of them by the original team. Psychiatric services for children and adolescents are jointly provided by a team of specialists and nurses, including outpatient clinic once a month in the hospital or service in the community child development center once every two weeks. Since 2011, it had provided judicial psychiatric medical care for the patients in prison or in the national abstinence rehabilitation centers.
The types of atypical antipsychotics in Brunei are very limited, which include only Olanzapine, Risperidone, Quetiapine and Clozapine. A long-acting injection, like Depot paliperidone, is only available to certain patients. The SSRI antidepressants have limited use of Fluoxetine, Fluvoxamine and Sertraline. Mirtazepine and Venlafaxine are not stably supplied. Because most medications can only be prescribed by senior physicians in the psychiatric department, the medicines can't be obtained in time in the outpatient clinics of primary medical care unit, resulting in limited community services in the psychiatric department.
The Health Promotion Centre (HPC) under the MoH will carry out some mental health promotion activities for all ethnic groups. For example, they will conduct mental health promotion lectures and one-day mental health awareness lectures throughout the year for target groups, such as students, teachers, community leaders, village chiefs, etc., and to handle mental health seminars or study visits for the enhancement of the public’s awareness in mental health. Electronic media, print media and exhibitions are used to disseminate information about mental disorders and available resources to the public, and it is hoped to enable early detection and early treatment for patients with mental illness. The general acceptance of "mental illness can be treatable and cured" will help reduce the associated stigma, and it will have direct benefits for patients and their families to be accepted by the community.
V. Major issues, challenge, and opportunities |
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People have long recognized the need to increase the number of psychiatrists. The number of local psychiatrists is particularly needy, because foreign experts and doctors who cannot communicate directly with patients and their families in Malay local language, which are usually at a significant disadvantage in terms of patient assessment and psychotherapy management. Psychiatry training for nurses and full-time mental health professionals are to enhance for the need of further development. The integration of mental health services and primary medical care, and the expansion of community services are the main issues. Brunei has no documental study on the prevalence of mental disorders, but common diseases familiar to psychiatrists are evaluated and treated by mental health services, and they will face many tasks. The priority is to increase awareness and understanding of psychiatry, and to conduct epidemiological research. Since psychiatry is still an unpopular career choice for such a small number of medical graduates in the country, most mental health services are actually provided by foreign workers. There is a hidden crisis for the country's health experts that they worry about the possible impact of the country's depletion of crude oil reserves, which may cause many foreign medical staff to leave the country. It will lead to a blow to the mental health service department because mental health medical staff are composed entirely of foreigners. Most of them are trained in the UK, where they usually have a few weeks of contact to psychiatry as undergraduates. A small number of junior doctors in Brunei are currently receiving psychiatric training in nearby countries. |
VI. Potential exchange issues |
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It urgently needs to increase psychiatric acute beds and professional manpower as mentioned. The lack of local mental health research, such as inadequate data on the prevalence of mental illness and substance abuse, are still the problems so far. Therefore, the local research on the field of mental health are required and to build up some useful data on the prevalence of mental disorders among drug abusers anyhow. Partnerships with academic and research institutions in the region can be a practical way to encourage such research. The topics of future exchanges are the training of psychiatric personnel and the establishment of research partnerships. |