Annual Health Data Report 2009

MINISTRY OF HEALTH REPUBLIC OF THE MARSHALL ISLANDS “KUMITI EJMUUR"

ANNUAL REPORT FY 2009

A Joint Message from the Minister and Secretary of Health

We are pleased to present the Annual Report for the Ministry of Health Fiscal Year 2009. Based on the MOH vital statistics, there were 1,603 registered births in FY2009. Out of these registered births, 232 births were born to mothers under 20 years of age showing teenage pregnancy rate of 14%. There were 43 babies with low birth weight born to teenage mothers, and 18 premature teenage pregnancies during the fiscal year. Although there is improvement in submitting the vital statistics reports, 106 of the birth registration forms did specify age of mothers during births, which may explain the decrease in the percentage of teen pregnancy rate during the fiscal year. The need to improve completion of vital statistics forms submitted from health centers is a continuing barrier for the Ministry.

Mortality and morbidity statistics indicated 339 deaths during the fiscal year with 38 infant deaths and four (4) maternal deaths, the highest number of maternal deaths since 1988. Infant mortality rate is calculated at 24/1,000 live births during the fiscal year. Leading cause of infant death is prematurity. Diabetes related diseases remain the number one cause of death followed by all types of cancer during the fiscal year.

In reproductive health services, the percent of pregnant mothers who visit prenatal clinics during the first trimester of their pregnancy remains low at 18%. Although the Ministry encourages pregnant mothers to attend prenatal care during the first three months of pregnancy, most pregnant mothers seek prenatal care during the second trimester, and this accounts for 33% of the first prenatal care visits during the fiscal year.

Additionally, the contraceptive commonly used by women who visited the family planning clinic was the three‐month hormonal injection followed by oral contraceptives. The family planning clinic recorded 2,305 female clients during the fiscal year, and out of this number 204 women visited the clinic because they wanted to get pregnant. Most women in the 20‐34 age are the regular users of the family planning program. Condom distribution is carried out not only in the family planning clinics but to other designated areas such as the Youth to Youth in Health clinic, STI program, outer islands health centers, businesses sites on Majuro, 177 HCP and Kwajalein Atoll Health Care services. Similar to previous two fiscal years, the number of male clients that visited family planning services was very low at 199 and only one case of vasectomy.

One of the challenges that MOH faces during the past two years is the discrepancy of the immunization coverage rates for the RMI. The definition of immunization coverage rate is based upon having a child age 19‐35 months completing 1‐4‐3‐3‐3‐2 (BCG‐DTaP‐OPV‐HepB‐HIB‐ MMR) immunization protocol. Three vaccines have been included during the fiscal year into the immunization program against pneumonia, diarrheal diseases and meningitis. The vaccination schedule has been modified based on needs and new vaccines added to the program and still in compliance with recommended schedule by WHO and CDC.

Since the immunization program was introduced in 1980’s, the denominator used for calculation of coverage rate is the number of MOH registered children 19‐35 months that have completed their required vaccination. This formula was developed for the RMI based on the distance and isolation of population in the RMI. The Immunization Program attempts every year to reach 95% immunization coverage rate. However, unexpected circumstances such as transportation to reach all the children in the outer islands are a constant challenge. During the fiscal year the program managed to reach 21 atolls. Based on the definition and formula used by MOH, the immunization coverage rate for RMI is 89% for FY2008. All babies born in the two hospitals continue to receive the first dose of Hepatitis B during the first 24 hours after delivery and the BCG shot against TB. Because of the distance and the lack of necessary equipment to keep cold chain of vaccines intact, not all children born in the outer islands receive Hepatitis B and BCG during the first 24 hours. However, they are vaccinated at a later date with visiting teams.

Diabetes Mellitus remains the highest health challenge during the fiscal year. The changes in lifestyles which include eating habit and lack of exercise have contributed to the high prevalence rates of diabetes, disabilities due to diabetes related causes and number one causes of death in the country. The prevalence rate of diabetes continues to be very high at 368 per 10,000 populations. The number of surgeries for amputation remains high at 57 for the fiscal year and cases presented with gangrene complications was 92. Diabetes is a disease that can be controlled, and individuals need to take charge of their own health to live a healthy life regardless of diabetes. Although the Ministry can provide educational information for promoting healthy choices and lifestyles, taking charge is one’s responsibility. We encourage every individual in the country to take charge of their own health and change their lifestyles. Like diabetes, cancer of all types is the second leading cause of death in the RMI.

Prevalence of Tuberculosis (TB) remains high with number of new cases found due to aggressive screening and contact tracing. With funding from the Global Fund, the Ministry was able to hire more staff for the TB program for contact tracing and strengthening of the DOT program in the community. However, there are still patients who refuse treatment, and there are still those who defaulted from treatment because they relocate to outer islands or to the states without informing the program staff. The ministry alone cannot be successful if the patients themselves do not take the initiatives to comply with treatment. Even though the course of treatment for TB is extensive, but it is an illness that is curable if the patients comply with treatment. We need the support of our stakeholders and partners to encourage individuals to complete treatment and/or refer patients for treatment if necessary. 6

Last but not least, although the Ministry conducted a nationwide leprosy screening in 1997, the prevalence rate of leprosy has continued to increase during the last fiscal year. Increase in the prevalence rate from 8/10,000 population in FY2006 to 21/10,000 is a grave concern. The increase in prevalence rate indicates transmission of the disease is on‐going within various communities. The Ministry has already identified atolls with high prevalence rate to target for aggressive screening, treatment and follow‐up.

Detailed information and tables for other program areas and services is inclusive in this report, and we do hope that this report is useful. For the next fiscal year, the Ministry will be going into the first phase of reorganizing its structure to strengthen areas in public health and preventive services.

Thank you.

TABLE OF CONTENTS

I. Geography and Demography 11

II. Financial Support 15

III. Workforce 19

IV. Statistics 23

V. Maternal and Child Health 29

VI. Immunization 35

VII. Oral Health 45

VIII. Mental Health 47

IX. Non‐Communicable Disease 51

X. Communicable Disease 55

XI. Medical Referral 61

XII. Hospital Services 67

XIII. Organizational Chart 75

XIV. Acknowledgement 76

GEOGRAPHY AND DEMOGRAPHICS

The Marshall Islands consists of 29 atolls and five major islands, which form two parallel groups‐ the

“Ratak (sunrise) chain and the “Ralik” (sunset) chain. The Marshallese is of Micronesian origin. The matrilineal Marshallese culture revolves around a complex system of clans and lineages tied to land ownership.

The Marshall Islands has an area of 1826 square kilometers and is composed of two coral atoll chains in the Central Pacific. The Marshall Islands is a parliamentary democracy, constitutionally in free association with the United States of America. It has a developing agrarian and service‐oriented economy.

Table 1: RMI Population Developments, 1999, 2006‐2010 Year Total Male Female 2010 54,305 27,843 26,462 2009 54,065 27,741 26,324 2008 53,889 27,643 26,246 2007 52,701 27,022 25,679 2006 52,163 26,746 25,417 1999 50,840 26,026 24,814 Table 2: RMI Projected Population by Age Age Group 2008 2009 0 ‐ 4 7,949 8,011 5‐9 7,471 7.371 10‐14 6.949 7,200 15 ‐ 19 6,351 6,152 20 ‐ 24 6,384 6,370 25 ‐ 29 4,275 4,491 Table 1 indicates the RMI Population Estimate of April 2009. EPPSO released 30 ‐ 34 2,626 2,639 a new population estimate different 35 ‐ 39 2,304 2,212 from the Projected Population done in 40 ‐ 44 2,180 2,103 July 2007. MOH updated the table 45 ‐ 46 2,068 2,043 based on the recent release. As per 50 ‐ 54 1,790 1,784 2007 and 2008 data, it was calculated 55 ‐ 59 1,479 1,525 on the population released on July 60 ‐ 64 897 971 2007. 65 ‐ 69 473 498 70 ‐ 74 331 333 75+ 361 363 Total 53,889 54,065 Source: EPPSO RMI Population Estimate April 2009

GEOGRAPHY AND DEMOGRAPHICS

Table 3: Health Care System by Main Islands Table 4: Number of Beds in Two Major Hospitals Majuro Number Leroij Atama Zedkeia Medical Center Hospital of beds Laura Health Center Leroij Atama Zedkeia Medical Center 101 Rongrong Health Center Leroij Kitlang Kabua Memorial Hospital 45 Ebeye, Kwajalein Leroij Kitlang Kabua Memorial Hospital Santo Health Center Outer Islands Ratak Chain Ralik Chain Table 5: Specialized Program Milli Ebon Clinics Location Nallu Toka Majuro 177 Clinic Majuro Enejit Namdrik Ejit Clinic Ejit, Majuro Lukonwor Jabwor Kili Health Center Kili Tokewa Jaluit Enewetak Health Center Enewetak Ailuk Jabnoden Utrik Health Center Utrik Tinak Mejrirok Mejatto Health Center Kwajalein Kilange Narmij DOE Clinic Majuro Ine Imiroj Diabetes Wellness Center Majuro Aerok Maleolap Imiej Taiwan Health Center Majuro Ulien Aerok Ailinglaplap Bikarej Bwoj Tutu Woja Aur Katiej Tobal Jeh Table 6: Private Clinics Aerok Jabot Clinic Name Location Tarawa Loen Medical Clinic Jang Mae Majuro Clinic Delap, Majuro Ollet Majkin Dental Clinic Kaven namu Capital Dentistry Uliga, Majuro Wotje Lib Optometry Clinic Wodmej Lae Eyesight, Professional Delap, Majuro Likiep Ujae Opticare Delap, Majuro Jebal Wotho Mejit Enejelar

GEOGRAPHY AND DEMOGRAPHICS

Table 3 indicates the hospital and health centers under the Ministry of Health. Leroij Atama Zedkeia Medical Center commonly known as Majuro Hospital and Leroij Kitlang Kabua Memorial Hospital commonly known as Ebeye Hospital are serving inpatient, outpatient, public health clinics and ancillary services. Each health centers are managed by health assistants. Medical and public health staff conduct outreach to the health centers in the outer islands and within the community as well.

The 177 Health Care Program Clinics are providing primary health care services to the four atolls affected by the nuclear testing. A primary health care physician manages the 177 Clinics. DOE Clinic is providing medical services to the nuclear patients under the Department of Energy. Diabetes Wellness Center which is managed by Canvasback Missions, in collaboration with MOH, to show that natural foods and an active lifestyle could reduce or replace the need for diabetic medications and provide a higher quality of life for the participants. Taiwan Health Center concentrates on developing health education materials and training programs mostly in Non Communicable Diseases (NCDs) like diabetes and also helps our outreach activities.

Table 5 indicates the private clinics in Majuro. All of the doctors practicing in the private clinics are licensed under the MOH’s Medical Examining and Licensing Board to practice in the RMI.

FINANCIAL SUPPORT

Table 7: MOH Budget Allocation from All Sources, FY 2007‐2009 Funds FY 2007 FY 2008 FY 2009 Compact Fund 5,815,108 $ 6,512,349 $7,079,620 General Fund 3,130,042 $ 3,130,042 $3,059,851 Health Fund 5,125,000 $ 5,600,000 $7,040,000 Ebeye Special Needs 1,531,984 $ 1,570,406 $1,743,289 US Federal & Other Grants 2,697,080 $ 3,802,607 $3,973,989 Other Revenues 615,921 $ 450,720 $643,655 Total $ 18,915,135 $ 21,066,124 $23,540,404

Table 7 indicates the allocated budget of the Ministry of Health for all its services. There was an increase of 5.3% of funding in 2009.

Table 8: Basic Health Fund Expenditures by Location Location FY 2007 FY 2008 FY 2009 Philippines Referrals $1,720,151 $1,747,404 $2,713,760 Honolulu Referrals $356,189 $215,180 $171,995 Inter Island Referrals and PHC $167,444 $175,347 $196,508 Administration ‐ Majuro, Ebeye, Honolulu & Philippines $1,061,924 $734,837 $398,303 Total $3,305,708 $2,872,768 $3,480,566

Table 9: Health Care Revenue Fund Expenditures by Location Location FY 2007 FY 2008 FY 2009 Majuro $1,488,750 $2,212,000 $2,360,491 Ebeye $517,500 $816,000 $623,136 Outer Islands $300,000 $429,000 $185,989 Total $2,306,250 $3,457,000 $3,169,616

Health Care Revenue Fund is used to purchase pharmaceuticals and medical supplies for on island care. The Basic Health Fund Revenue comes from the RMI taxes collected as stipulated under the Health Fund Act.

FINANCIAL SUPPORT

Table 10: Grant Agency Grant Amount Granting Agency/Grant Name 2007 2008 2009 CDC RMI National Comprehensive Cancer Control Program $203,782 $199,996 Comprehensive STD Prevention System $136,934 $136,934 $136,934 Tuberculosis Elimination & Laboratory $127,376 $114,638 $114,138 Preventive Health Services $0 $6,569 $6,016 HIV/AIDS Surveillance Program $17,673 $17,673 $13,532 Immunization & Vaccines for Children Grants $793,254 $995,171 $702,996 Sexual Violence Prevention & Education $11,765 $11,765 $8,638 HIV Prevention Project for the Pacific Islands $122,518 $122,518 $30,630 Systems/base Diabetes Prevention Control Program (DPCPS) $86,301 $86,301 $86,301 Tobacco $100,000 Public Health Preparedness & Response for Bioterrorism $560,134 $560,134 $559,469 Total $1,855,955 $2,255,485 $1,958,650

HRSA Pacific Basin Initiative $500,137 $571,677 $962,699 Children's Oral Healthcare Access Program $67,256 $160,000 $160,000 Maternal & Child Health Services (MCH) $235,878 $235,920 $241,149 HIV Care Grants (Ryan White Grant) $52,968 $52,968 $13,000 Bioterrorism ‐ Hospital Preparedness Programs $469,986 $333,477 $318,384 UOW Xylitol Dental Program $23,367 $0 $0 Total $1,349,592 1,354,042 $1,695,232

PHS/OPHS Continue delivery of Family Planning Services to the People of Marshall Islands $190,494 $153,792 $201,115

SAMHSA New Freedom State Coalitions to Promote Community Base Care $10,000 $10,000 10,000 State Mental Health Data Infrastructure for Quality Improvement Grants/DIG $51,012 $50,000 39,600

Block Grants for Community Mental Health Services $79,586 $70,636 69,392 Total $140,598 $130,636 $118,992

TOTAL US FEDERAL GRANTS $3,536,639 $3,893,955 $3,973,989

OTHER GRANTS USAPIN ‐ Pacific Regional Central Cancer registry $27,240 $27,240 $27,240 WHO/SPC Grants $33,975 $32,814 $27,845 CEED Program $20,000 ROC Grants $0 $17,930 0 Japan Government's Grants $166,454 $67,315 $83,950 Australian Grants (Disaster Fund Hospital) $83,270 $0 $484,620

Total 310,939 145,299 643,655

Grand Total $3,847,578 $4,039,254 $4,617,644 Source: Finance Department, OAPF‐MOH

WORKFORCE

The Ministry of Health’s Administration is consists of the Office of the Secretary and three administrative offices namely, Office of Health Planning and Statistics (OHPS), Office of Administration, Personnel, and Finance (OAPF), and Office of Medical Referral Program (OMRP). OAPF is responsible for the daily management of all MOH funding, centralized point of procurement and supply, and overseeing the administrative, personnel, and financial functions of the Ministry. OHPS is responsible for recording, collecting, and monitoring of health indicators and birth/death certificates, preparations of MOH’s Annual Report and other reports, and responsible for the MOH’s network and Ministry of Health Integrated Information System which includes Hospital Information System, Public Health Information System, and Management Information System. OMRP is responsible for the management of the Health Fund, Basic Referral Program, and Supplemental Health Program

Table 11: Medical Providers by Position Position BMAHCS BKAHCS BOIHCS Total Family Practitioner 9 2 1 12 General Practitioner 0 0 1 1 Pediatrician 2 1 0 3 OB‐Gynecologist 2 2 0 4 Ophthalmologist 1 0 0 1 Psychiatrist 1 0 0 1 Radiologist 1 0 0 1 Pathologist 1 0 0 1 Orthopedic Surgeon 1 1 0 2 Internist 1 1 0 2 General Surgeon 1 2 0 3 Anesthesiologist 1 2 0 3 Urologist 0 1 0 1 Medical Assistant 3 0 0 3 Health Assistant 5 0 56 61 Dentists 5 2 0 7 Total 34 14 58 106

WORKFORCE

Table 12: Nurses by Position FY2009 Position BMAHCS/BOIHCS BKAHCS Total Graduate Nurse Public Health 26 8 34 Clinical 72 22 94 Practical Nurse Public Health 12 10 22 Clinical 18 0 18 Nurse Aide Public Health 4 0 4 Clinical 23 0 23 Total 155 40 168

Table 13: Ancillary Services, FY2009 Services BMAHCS BKAHCS Pharmacy Services 4 2 Laboratory Services 16 5 Radiology Services 6 2 Dietary Services 8 1 Biomedical Services 2 2 Rehabilitation Services 4 0 Infection Control Unit 1 0 Quality Assurance Unit 0 0 Dental Services 19 3 Sterilization/Central supply 1 0 Total 61 15

W ORKFORCE

Table 14: Staff by Bureaus and Offices

Bureaus/Offices FY2008 FY2009 Secretary's Office & Office of Administration, Personnel and Finance 14 19 Bureau of Majuro Atoll Health Care Services 290 289 Bureau of Kwajalein Atoll Health Care Services 125 135 Bureau of Outer Islands Health Care Services 78 65 Office of Health Planning and Statistics 4 5 Office of Medical Referral Program 13 11 Total 532 524

The direct health care services are provided by the three (3) Bureaus namely, • Bureau of Majuro Atoll Health Care Services, • Bureau of Kwajalein Atoll Health Care Services, and • Bureau of Outer Islands Health Care Services.

These direct health care services include, but not limited to : a) clinical services in the hospitals and health center facilities and outreach activities; b) primary health care or preventive services in the hospital and health center settings, school and community compounds, house‐to‐house outreach; c) health promotions and educational activities, special projects with community groups; d) collection of data for the Health Information System to monitor health indicators , how the health services is provided and assessment of health care system in the RMI.

STATISTICS

Table 15: Summary of Birth Information Description FY 2007 FY 2008 FY 2009 Registered Birth 1,591 1,526 1,603 *1 Crude Birth Rate 30 29 30 LBW 206 210 202

VLBW 12 18 20 Premature 159 106 121 Teen Pregnancy 278 253 232 Source: Vital Statistics, MOH

Crude Birth Rate: (Number of resident live births / Number of total population) x 1,000

Total Resident Live Births X 1,000 Total Population

Very Low Birth Weight (VLBW): Liveborn infants that weigh less than 1,500 grams or less than 3 lbs and 4 ozs. Low Birth Weight (LBW): Liveborn infants that weigh less than 2,500 grams or less than 5 lbs and 8 ozs. Premature Birth: commonly used as a synonym for preterm birth, refers to the birth of a baby before its organs mature enough to allow normal postnatal survival, and growth and development as a child. Preterm birth refers to the birth of a baby of less than 37 weeks gestational age Teen pregnancy: Pregnancy occurring in young women less than 20 years old.

Table 16: Teen Pregnancy (Mother’s Age is less than 20 years old) Description FY 2007 FY 2008 FY 2009 Teen Pregnancy 278 253 232 VLBW for Teen Pregnancy 2 5 2 LBW for Teen Pregnancy 61 53 43 Premature Teen Pregnancy 39 31 18 % of Teen Pregnancy from All Birth 17% 17% 14% Source: Vital Statistics, MOH

1 Per 1,000 live birth 24

STATISTICS

Table 17: Births by Main Islands Fiscal Year Majuro Ebeye Outer Islands Total 2007 1,000 375 216 1,591 2008 1,015 345 166 1,526 2009 1,030 383 190 1,603 Source: Vital Statistics, MOH

Table 18: Births by Gender and Main Islands FY 2009 Age Majuro Kwajalein Outer Islands Total Male 485 198 104 787 Female 545 185 86 816 Total 1,030 383 190 1,603 Source: Vital Statistics, MOH

Table 19: Births by Gender Table 20: Birth by Type of Birth Age FY 2007 FY 2008 FY 2009 Type FY 2007 FY 2008 FY 2009 Male 796 798 787 Single 1,563 1,510 1,590 Female 795 728 816 Twin 28 16 13 Total 1,591 1,526 1,603 Triplet 0 0 0 Source: Vital Statistics, MOH Total 1,591 1,526 1,603 Source: Vital Statistics, MOH

Table 21: Birth by Attendant FY 2009 Attendant Majuro Kwajalein Outer Islands Total Not Stated 1 30 0 31 Graduate Nurse 91 0 0 91 Health Assistant 2 9 175 186 Medical Assistant 10 0 0 10 Doctor 135 138 7 280 Nurse Midwife 771 119 5 895 Other 10 0 0 10 Registered Nurse 1 87 0 88 Practical Nurse 0 0 1 1 Traditional Birth Attendant (TBA) 9 0 2 11 Total 1,030 383 190 1,603 Source: Vital Statistics, MOH

STATISTICS

Table 22: Birth by Mother's Age

Age FY 2007 FY 2008 FY 2009 Not Stated 5 7 106**

10 – 14 5 4 5 15 – 17 92 79 54 18 – 19 181 170 173

20 – 24 548 523 504 25 – 29 411 409 411

30 – 34 197 217 223 35 – 39 115 94 97

40 – 44 37 20 24 45 – 49 0 3 6

Total 1,591 1,526 1,603 Source: Registered Births Vital Statistics, MOH

** Challenge/Barrier: This number referenced to the number of incomplete birth registration forms that were submitted to the Statistics Office without the age of the mothers, which continues to be a barrier for vital statistics.

The Vital Statistics under of Office of Health Planning and Statistics is responsible in registering birth and death events occurring in the hospitals, health centers, at home, and anywhere within the Marshall Islands. There is one year registration period for birth. More than one year is considered late registration. For the late registration, Ministry of Internal Affairs handles the registration.

RMI’s teen pregnancy is still high and 19% of the teen births have low birth weight babies. Some of the reasons that may contribute to the LBW in teenage mothers are immaturity, lack of knowledge, and high risk of premature labor, anemia, and high blood pressure. This fiscal year, the teenage pregnancy rate is 14%. However, due the submission of incomplete registries for mother’s age, the rate may still be high at 19%.

Plans to address high teenage pregnancy rates and recording: • Aggressive health promotion and community awareness targeting women, youths, students and school drop‐outs. Community participation in health promotion and education is very essential to reduce teen pregnancy rates. • More outreach clinics to increase accessibility to reproductive and family planning services • Discussions on vital statistics recording/reporting for health assistants

STATISTICS

Table 23: Summary of Death Data Description FY 2007 FY 2008 FY 2009 Registered Death 276 299 339

Infant Death 51 47 38 Fetal Death (Still Birth) 21 13 19 Early Neonatal Death 15 15 15

Neonatal Death 18 20 19 Post Neonatal Death 33 27 19

Perinatal Death 36 28 34 Child Death (Under 5 years old) 63 56 52 Maternal Death 0 0 4 Rate/Ratio Crude Death*1 5 6 6 Infant Mortality Rate*1 32 31 24 Fetal Mortality Rate*1 13 8 12 Neonatal Mortality Rate*1 11 13 12 Perinatal Mortality Rate*1 23 18 21 Child Mortality Rate*1 40 37 32 Maternal Mortality Ratio*2 0 0 250 Source: Vital Statistics, MOH The number of registered deaths among infants (below one year of age) per 1000 live births in a given year or period of time Fetal Mortality Rate is the number of fetal deaths divided by the number of live births plus fetal deaths (for a specified time period, usually a calendar year) and multiplied by 1,000. Child Mortality Rate or Under‐5 mortality rate is the number of children who die before the age of five, per thousand live births. This is also one of the Millennium Development Goals. Maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Maternal Mortality Ratio is calculated by the number of maternal deaths to the number of live births per 100,000. Neonatal deaths: Deaths among live births during the first 28 completed days of life. It may be subdivided into early neonatal deaths, occurring during the first 7 days of life, and late neonatal deaths, occurring after the 7th day but before the 28th completed day of life. Number of deaths during the first 28 completed days of life per 1,000 live births in a given year or period. Post‐neonatal Mortality Rate is the number of deaths of infants between 28 days and <1 year divided by the number of live births Perinatal Mortality Rate is number of stillbirths or fetal death and deaths in the first week of life per 1,000 live births 27 2 Per 100,000 live births STATISTICS

In FY 2009, we have 4 maternal deaths. Preeclampsia, post partum hemorrhage, obstructive labor and gestational hypertension are the causes of these 4 maternal deaths.

Plans for addressing maternal deaths:

The Ministry of Health will be reviewing and developing steps to address WHO key working areas listed.

• Strengthening health systems and promoting interventions focusing on policies and strategies that work, are pro‐poor and cost‐effective. • Monitoring and evaluating the burden of maternal and newborn ill‐health and its impact on societies and their socio‐economic development. • Building effective partnerships in order to make best use of scarce resources and minimize duplication in efforts to improve maternal and newborn health. • Advocating for investment in maternal and newborn health by highlighting the social and economic benefits and by emphasizing maternal mortality as human rights and equity issue. • Coordinating research, with wide‐scale application, that focuses on improving maternal health in pregnancy and during and after childbirth.

Maternal death can be prevented by skilled care and emergency care.

Table 24: 5 Leading Cause of Infant Death, FY 2009 Table 25 : 5 Leading Cause of Diagnosis Number Mortality, FY 2009 Premature 8 Diagnosis Number Asphyxia 5 Diabetes Related Disease 64 Septicemia 4 Cancer (All Types) 36 Congenital Heart Septicemia 31 Disease/Sepsis/Pneumonia/ Hypertension 28 Meningococcemia 2 Suicide 14 Dehydration/ Meningitis/ Source: Vital Statistics, MOH Pertussis/ Drowning 1 Source: Vital Statistics, MOH

Table 26: Number of Registered Deaths by Main Islands Fiscal Outer Ship/ Registered Year Majuro Ebeye Islands Ocean Total 2007 190 46 40 276 2008 204 46 49 299 2009 223 48 62 6 339 Source: Vital Statistics, MOH

MATERNAL AND CHILD HEALTH

Reproductive Health Services

The services under RH are prenatal care, women’s health screening, and family planning counseling and services on RH related issues.

Screening for CSHCN/child finding continues in collaboration with MOE, Special Education Programs/sharing information and providing services for both clients and families. In 2008, RH Clinic expanded its clinic twice a week after normal working hours to Youth to Youth in Health (YYTIH) and Laura

Clinic every Saturdays. The YYTIH clinics provide services for STI screening, family planning, contraceptive distribution based on choice, and physical exam for all gender. Funding sources for RH services are Title X/Family Planning, Title V/Maternal and Child Health Block Grants, and UNFPA.

Table 27: Summary of Prenatal Visits

Type FY FY FY 2007 2008 2009 Total Visits All Trimesters 3,383 3,100 4,895

st Number of 1 Visits 1,152 1,215 1,537 1st Trimester (18%) 1,248 961 879 nd 2 Trimester (33%) 1,102 1,081 1,615 rd 3 Trimester (49%) 1,033 1,058 2,401 Source: RH program, Majuro, Ebeye, & Outer Islands

Table 208 : Prenatal Visit by Center FY 2009

Type Outer RMI Majuro Ebeye Islands Total Total Visits All Trimesters 3,935 378 582 4,895

st Number of 1 Visits 1,098 378 61 1,537 st 1 Trimester 571 198 110 879 nd 2 Trimester 1,237 130 248 1,615 rd 3 Trimester 2,127 50 224 2,401 Prenatal Care

Some of the health centers and the two main hospitals provide prenatal care services for pregnancy management, STI/HIV screening, Pap smear screening, oral health, and immunization.

In FY 2009, there was an increase of 27% of number of pregnant mothers that attended the Prenatal Clinic, particularly for pregnant mothers to attend prenatal clinic during the first trimester. However, Table 27 shows that 49% of pregnant women starts prenatal care during the third trimester.

The number of 1st visits consists of First Visits in 1st, 2nd, and 3rd Trimester. This calculates the number of pregnant women that attended the clinic. The MCH Program encourages pregnant women to visit prenatal clinic on their 1st trimester to capture abnormalities as earliest as possible.

MATERNAL AND CHILD HEALTH

Cervical Cancer is one of the leading types of cancer among women in the RMI. Early detection of Table 29: Pap Smear Test, FY 2009 abnormalities in the cervix through Pap smear is the # of first stage in handling cervical cancer. Pap smear tests Table : Pap Smear Test, FY2009 Tests are available in all the MCH Clinics in Majuro, Majuro 1,948 Kwajalein, and Outer Islands. The Ministry of Health is Kwajalein 78 advocating early detection of cancer. All pregnant Outer Islands 598 mothers that visit the hospitals for their prenatal care undergo pap smear test. Total 2,624

Table 30: Unduplicated Number of Female Family Planning Users by Primary Method and Age 2007 2008 2009 Female Sterilization 127 147 57 Hormonal Implant 150 159 308 3 Month Hormonal Injection 599 907 933 Oral Contraceptive 280 438 395 Female Condom 16 22 13 Fertility Awareness Method(FAM) 2 0 3 Abstinence 0 0 0 Other Method 9 10 31 Method Unknown 0 27 3 No Method Pregnant/Seeking Pregnancy 5 143 204 Other Reason 177 257 300 Relay on male method Vasectomy 0 0 1 Male Condom 36 39 57 Total Female Users 1,401 2,149 2,305 Family Planning

There are several methods available for family control. The two most popular and used method are the 3 months hormonal injection and oral contraceptive. Family Planning Services is not only concentrating on control methods for planning of pregnancy, but also on parents planning for a pregnancy.

With the promotion for family planning and safe sex, condoms are distributed in places accessible to the people in the community. The statistics for family planning indicates very, very low number of male clients accessing the services. More than 90% of the clients who access family planning services are female clients.

MATERNAL AND CHILD HEALTH

Table 31: FP Methods for Unduplicated Male Users Method FY 2007 FY 2008 FY 2009 Condom 112 54 124 Vasectomy 6 4 2 Fertility Awareness Method(FAM) 0 1 0 Other Method 0 0 1 Method Unknown 0 0 1 Partner pregnant or seeking pregnancy 0 2 0 Other Reason 0 31 70 Rely on Female Method 7 0 1 Total 125 72 199 Source: RH program, Majuro, Ebeye, & Outer Islands

Table 32: Unduplicated Number of Family Planning by Age and Gender Age Group Female Users Male Users Total Users Under 15 29 13 42 15‐17 86 38 124 18‐19 168 41 209 20‐24 640 62 702 25‐29 598 25 623 30‐34 396 6 402 35‐39 231 7 238 40‐44 107 0 107 Over 44 50 7 57 Total Users 2,305 199 2,504 Source: RH program, Majuro, Ebeye, & Outer Islands

MATERNAL AND CHILD HEALTH

Table 33: Condom Distribution Per Sites Clinic Sites Number of Gross (1cs=50gross) Total pieces (1 gross=144 pcs.) RH Clinics (FP/Male Clinic/Prenatal/Women’s 44 gross Male Condoms 6,396 clinics) 60 pcs Female Condoms Youth to Youth 196 gross 28,224 STI Program 2cs +26 gross 18,144 Outer Islands 34 gross + 230pcs 5,126 Majuro Hospital 72 gross 10,368 Kwajalein Atoll Health Care Services 14 gross 2,016 177 Health Care Plan 11 gross 1,584 Laundry/Restaurant/Stores/Bars/Hotels/Apts. 19 gross 2,736 Laura/Zones 3 gross 432 Total 56,882 condoms Source: RH program, Majuro, Ebeye, & Outer Islands

Table 34: Children with Special Health Care Needs Diagnosis FY 2007 FY 2008 FY 2009 Joint/Bone Deformity or Fracture 52 83 87 Hearing Problems 7 0 0 Burns (any kind) 6 0 5 Cleft Palate 3 14 5 C/foot 2 0 0 Cong. Deformed 0 3 0 Eye Problem 0 0 0 Cardiac 7 1 2 Others ‐ Extra Fingers 14 0 5 Others ‐ Arthritis 2 0 0 Others ‐ Paralyze 2 0 0 Others ‐ Seizure 2 0 0 Developmental Delay 1 0 0 Total 98 101 104 Source: CSHCN Registration, MCH – Majuro Office

Children with Special Health Care Needs (CSHCN)

The Maternal and Child Health (MCH) Program in Majuro handles the screening, medical examination, evaluation, tracking, and referral of CSHCN for RMI. CSHCN are referred mainly to Shriners’ Hospital in Honolulu for further treatment. Children ages 0–21 years old are accepted under this program. The MCH Block Grant is utilized for bringing in children from Outer Islands for follow up with visiting specialists and to Honolulu if necessary. 33

IMMUNIZATION

Child Immunization

Immunization Coverage Rate for 19 to 35 months is completing the 1‐4‐3‐3‐3‐2 (BCG‐DTaP‐OPV‐HepB‐HIB‐ MMR) vaccination protocol. Immunization program needs to achieve its >95% immunization coverage rate. It is imperative to note that immunization program in KAHCS achieved a 98% complete coverage. Kwajalein Atoll Health Care Services is consistent in achieving their goal to increase immunization.

As a nation, there were a lot of challenges in reconciliation of data due to duplicate registration of children, multiple names given to a child, movement of children with families from one zone to another or from one island/atoll to another, and availability of transportation from the urban centers to outer islands.

Outer Islands Health Care Services’ Immunization Program’s major constraints are the unavailability of transportation and lack of solar refrigerator to store the vaccines. For Wotho and Jabat Island, the constraint is occasional flight to these islands. Outer Islands Health Care Services addressed these constraints by renting private boats to reach the population which is very costly to the program. Despite the transportation problems, Immunization Program managed to reach 21 atolls and increased Outer Islands’ Immunization Coverage for 19‐35 months old to 71% in FY 2009. Immunization rate for Majuro has increased by 2% in FY2009. There has been no outbreak of preventable diseases since 2003.

For the two hospitals in Majuro and Ebeye, 100% of babies received the 1st dose of Hepatitis B within 24 hours after birth. 100% of new born babies receive BCG before discharged from the hospital. The babies born in the outer islands are not able to receive the initial doses similar to the hospitals due to lack mechanism to keep the vaccines in cold storage in the health centers.

Table 35: RMI Immunization Coverage Rate Islands FY 2007 FY 2008 FY 2009 Majuro 95% 92% 94% Kwajalein 92% 96% 98% Outer Islands 51% 60% 71% RMI 79% 83% 89%

Table 36: FY 2009 Complete Immunization Coverage for 19 to 35 months Old Children Islands No # of Completed Coverage Population Immunization Rate Majuro 946 892 94% Kwajalein 388 382 98% Outer Islands 487 347 71% RMI Total 1,821 1,621 89%

IMMUNIZATION

Note: RMI Immunization Program don’t have Varicella and Hepatitis A vaccines

IMMUNIZATION

Table 37: New Vaccines Administered In FY2009, Ebeye Immunization Program received their Vaccine FY2008 FY2009 first HPV vaccines. HPV vaccines were given to 864

Prevnar 682 2,643 female students from 6 Grade to 12 Grades from all Rotavirus 502 1,355 school in Ebeye on this fiscal year. For Majuro, 144 HPV 152 1,464 women were vaccinated with the HPV. While for Outer Source: Immunization Program Islands, 456 HPV vaccines were given. The increase of HPV vaccination is because of the availability of supplies to Outer Islands and Ebeye.

Adult Immunization

Tetanus Toxoid (TT) is included in all prenatal visits. TT was also given to ER patients for protection and to pregnant mothers against tetanus virus during delivery.

Flu shot is a once a year vaccine. There was big increase in flu shot administration in FY2009 due to the fact that H1N1 virus existence around the world. During FY2009, the H1N1 vaccine was not available.

Table 38 : Vaccine Administration Fiscal Flu Shot Year Tetanus Toxoid 2009 1,060 5,685 2008 1,501 1,948 2007 1,152 1,829

Table 39: Tetanus Toxoid Schedule on Pregnancy Expected duration Dose When to give of protection 1 At first contact or as early as possible in pregnancy None 2 At least 4 weeks after first dose TT or Td 1‐3 years At least 6 months after second dose of TT or Td or during 3 At least 5 years subsequent pregnancy At least 1 year after third dose of TT or Td or during 4 At least 10 years subsequent pregnancy For all childbearing At least 1 year after fourth dose of TT or Td or during 5 years and possibly subsequent pregnancy longer

IMMUNIZATION

Table 40: Majuro Atoll Immunization Fall Assessment Report Data by School 2009‐10 Grade Preschool Report

Name of School School Total # Total # Medical Needs Students Needing Additional Doses Total Up‐To‐ Type of Up‐To‐ Exemptio Follow Check Date Students Date n Up Polio DTP HepB MMR MMR HIB (1+2+3) Rate 1 2 Rairok Elem. Public 57 48 0 12 6 17 6 1 2 0 57 84% School Majuro Baptist 66% Sch. Private 65 43 0 21 11 15 0 1 3 0 65 D.E.S Public 39 35 0 2 0 0 0 0 0 0 39 90% Delap SDA Private 33 29 0 6 1 6 2 1 2 0 33 89% Laura SDA Private 6 5 0 2 2 2 0 1 0 0 7 83% Coop Sch. Private 23 19 0 11 0 9 0 0 0 0 23 83% Ajeltake Sch. Public 49 49 0 0 0 0 0 0 0 0 45 100% Assumption Sch. Private 39 30 0 8 1 8 2 1 1 3 39 77% Woja Elem Sch. Public 14 14 0 0 0 0 0 0 0 0 14 100% Laura Elem Sch. Public 64 64 0 0 0 0 0 0 0 0 64 100% Total 389 336 0 62 21 57 10 5 8 3 389 86%

IMMUNIZATION

Table 41: Majuro Atoll Immunization Fall Assessment Report Data by School 2009‐10 – 1st Grade Report

Name of School Total # Total # Medical Needs Students Needing Additional Doses Total Up‐To‐ School Type of Up‐To‐ Exemptio Follow Check Date Students Date n Up Polio DTP HepB MMR MMR HIB (1+2+3) Rate 1 2 Rairok Elem. School Public 79 79 0 0 0 0 0 0 0 0 79 100% Majuro 93% Baptist Sch. Private 25 23 0 2 1 2 1 0 0 0 25 Uliga Elem Sch. Public 57 53 0 4 0 3 1 0 0 0 57 93% D.E.S Public 83 80 0 1 0 0 0 0 0 0 83 96% Delap SDA Private 30 28 0 2 1 2 0 0 1 0 30 93% Laura SDA Private 11 9 0 2 2 1 0 0 0 0 11 81% Coop Sch. Private 23 21 0 4 0 3 0 0 0 0 23 91% Ajeltake Sch. Public 31 31 0 0 0 0 0 0 0 0 31 100% Assumption Sch. Private 50 29 0 28 18 27 18 15 20 0 50 44% Woja Elem Public 23 19 0 2 0 2 0 0 0 0 23 90% Sch. Laura Elem Sch. Public 65 65 0 0 0 0 0 0 0 0 65 100% Total 477 437 0 43 15 42 14 14 5 6 477 92%

IMMUNIZATION

Table 42: Majuro Atoll Immunization Fall Assessment Report Data by School 2009‐10 – 7th Grade School

Name of School Total # Total # Medical Needs Students Needing Additional Doses Total Up‐To‐ School Type of Up‐To‐ Exemption Follow Check Date Students Date Up Polio DTP HepB MMR MMR HIB (1+2+3) Rate 1 2 Majuro Baptist 89% Sch. Private 28 25 0 3 0 2 2 1 1 0 28 Laura SDA Private 8 7 0 1 0 0 1 0 1 0 5 80% Delap SDA Private 19 18 0 0 0 0 0 0 0 0 19 100% Woja Elem.School Public 21 19 0 1 0 0 0 0 1 0 21 94% Coop Sch. Private 26 23 0 1 0 1 0 1 0 0 26 96% Ajeltake Sch. Public 24 24 0 0 0 0 0 0 0 0 24 100% Majuro Middle Sch. Public 289 279 0 10 9 8 9 3 10 0 289 96% Assumption Elem. Sch. Private 37 18 0 18 2 3 3 2 13 0 34 49% Laura Elem Sch. Public 39 39 0 0 0 0 0 0 0 0 39 100% Total 491 452 0 34 11 14 15 7 26 0 491 92%

IMMUNIZATION

Table 43: Majuro Atoll Annual Immunization Fall Assessment Report Data by School 2009‐10 – Grade 9 Report

Name of School School Total # Total # Medical Needs Students Needing Additional Doses Total Up‐To‐ Type of Up‐To‐ Exemptio Follow Check Date Stude Date n Up Polio DTP HepB MMR MMR 2 (1+2+3) Rate nts 1 Marshall Is. High Sch. Public 290 260 0 34 15 20 11 0 8 294 89% Delap SDA Private 24 23 0 1 1 1 1 1 1 24 96% Assumption High Sch. Private 48 31 0 15 10 10 10 10 5 48 65% Laura High Sch. Public 275 256 0 4 4 0 4 4 4 275 96% Total 637 570 0 54 30 31 26 15 18 637 89%

IMMUNIZATION

Table 44: Ebeye School Immunization Coverage Description FY2008 FY2009 No. of % No. of % Students Students Complete immunization 2,891 96% 2,826 95% (complete record) Incomplete records but 50 2% 136 5% were up‐to‐date No immunization record 55 2% ‐0‐ in the school Total Students Enrolled 2,996 100% 2,962

Table 45: FY2009 Immunization Coverage by School (Kwajalein Atoll) NAME OF SCHOOL TOTAL COMPLETE/ INCOMPLETE PERCENT ENROLLEES UP‐TO‐DATE COVERAGE COMPLETE COVERAGE COVERAGE 1. Head Start 169 162 7 96% 2. Ebeye Public Elementary School 1021 1008 13 99% 3. Jabro Private School 202 187 15 93% 4. Queen of Peace High School 70 66 4 94% 5. Ebeye Christian School 105 100 5 95% 6. KA Public High School (KAPHS) 272 220 52 81% 7. Queen of Peace Elementary 226 226 0 100% 8. Ebeye SDA School 284 276 8 97% 9. Ebeye Calvary School 159 149 10 94% 10. Ebeye Gem Christian School 117 117 0 100% 11. Ebadon Public School 34 30 4 88% 12. Mejatto Public School 117 114 3 97% 13. Carlos Public School 17 14 3 82% 14. Ennibur Public School 169 157 12 93% TOTAL 2962 2826 136 % Incomplete Coverage 5% % Complete Coverage 95% Note: data at the beginning of the school year; year‐end figures actually showed 97% coverage. IMMUNIZATION

Out of the 14 schools on Kwajalein Atoll, two (2) schools, Queen of Peace Elementary School

(QOPES) and & GEMCS had 100% immunization record and coverage. Around 9 schools reached above 93% and only three schools had below 90% immunization record/coverage. Only one child had permanent medical exemption from immunization. Furthermore, the School Immunization Assessment Survey that was done in November 2008 revealed that majority of the schools is taking steps in ensuring immunization coverage to the students. It appears that almost all schools now understand their role in updating their student’s immunization records.

ORAL HEALTH

Table 46 : Dental Clinical Services Main Atolls FY 2007 FY 2008 FY 2009 Majuro 10,825 11,365 12,673 Ebeye 4,528 4,912 3,560 Total 15,353 16,277 16,233 Source: Dental Department ‐ Majuro, Ebeye & Outer Islands

Clinical Services

Services provided in this area included tooth extractions, fillings, dental hygiene, fluoride treatment, and regular check‐ups for Diabetes Program, Cancer Program and Prenatal. Ebeye Dentali Clinical Services has decreased by 38% because shortage of staff. Their dentist and dental hygienist position are vacant. Majuro Dental Program increased by 12% from FY2008.

Preventive Services

This section deals with effective means to prevent tooth decay and further tertiary services in dental services. Dental staffs visit the schools every year to provide sealant to students in Head Start and grade 1, 2, 6, & 7. A weekly clinic is held for children who are six months to 4 years old for fluoride treatment and educating their mothers on proper cleaning of teeth. All the children in the Fluoride Varnish Program received tooth brushes and toothpaste every visit.

Table 47: MCH Oral Health Services FY 2009 Majuro/Outer Ebeye Islands Total Number of Dental Encounters 12,763 3,560

Target: Infants and Children Number of infants or children who received 1,534 284 fluoride varnishing Number of children who were given 1,525 356 dental/fissure sealants Number of schoolchildren who received annual 1,252 474 dental examination Number of schoolchildren who receive health 1,252 755 talks on oral hygiene

Target: Youth and Adults Number of restorative procedures done annually 2,822 1,054 Number of prenatal clinic users with annual 480 118 dental/oral examination

HUMAN SERVICES & MENTAL HEALTH

Many people underestimate the impact mental health conditions can have on individuals, society and the economy as a whole. Possible reasons could be: 1. People prioritize physical health more than mental health, 2. Lack of awareness of the repercussion of mental illness, and 3. Compared to other health programs mental health seemingly receives the least priority.

The total cost to the Marshall Islands regarding mental health conditions is not known at this time. However, the cost to an individual can be a lot greater; left untreated, mental health conditions can result in unemployment, homelessness, the break‐up of families and suicide.

There were 55 new cases of mental disorder in FY2009. The top 3 main diagnosis for the mental health cases are Schizoprenia, suicide, and Major Depressive Disorder.

It is worth knowing that all suicides related with alcohol were done at the height of intoxication. Family members should be very sensitive in identifying any sign of depression and detection of an early signs of suicide attempt with other members. Hanging is the most common method of suicide. It is also alarming that a 13 year old committed suicide in the height of alcohol intoxication.

Table 48 : Mental Health Cases Table 49: Suicide Cases Fiscal Fiscal Year Majuro Ebeye Outer Islands RMI Year Attempted Completed Total 2009 338 20 11 369 2007 16 6 22 2008 283 20 11 314 2008 16 10 26 2007 214 20 6 240 2009 14 14 28 Source: Mental Health Program, Majuro & Ebeye Source: Mental Health Program, Majuro & Ebeye

HUMAN SERVICES & MENTAL HEALTH (HSMH)

The program in Ebeye conducted health talks to 769 students and one major survey on Substance Abuse and Sexual Risk Behaviors was also conducted this year – which revealed concerning information on this health‐related social issue.

Table 50: Survey on Substance Abuse and Sexual Risk Behaviors, Ebeye FY 2009 Out of 321 High‐School Respondents Questionnaire on Alcohol and Substance Abuse, and Sexual Risk Behaviors 122 (38%) Have tried drinking alcohol/ yeast in the past 98 (30.5%) Smoke cigarettes 68(21.1%) Chew betel nut 19 (5.9%) Have tried smoking Marijuana 56(17.4%) Use Copenhagen 14 yrs old( both male & female) Age of start drinking alcohol/yeast 68(21.1%) Ideation of suicide 30 females (9.3%) Ideation of suicide ‐10 unreported attempted suicides 38 males (11.8%) Ideation of suicide ‐15 unreported attempted suicides 16yrs (female) Age of first sexual intercourse 14yrs(male) Age of first sexual intercourse 47 female (%) Has been forced sex (incest) 24 males ( Has been forced sex(incest) Reason of drinking For fun; for anger

Table 51: Survey on Substance Abuse and Sexual Risk Behaviors, Ebeye FY 2008 Out of 192 High‐School Questionnaire on Alcohol and Substance Abuse, and Respondents Sexual Risk Behaviors 110 (57%) Have tried drinking alcohol in the past 78 (41%) Are still drinking alcohol for the past 3 months 65 (34%) Smoke cigarettes, chew betel nut, and/or use Copenhagen 5 (2.6%) Have tried smoking Marijuana 0 (0.0%) Have used drugs or cocaine 76 (39.6%) Have expressed desire to quit drinking Alcohol 56 (29%) Expressed intention to cut down on use of Alcohol 89 (46.5%) Already had sexual intercourse 46 (24%) Has been forced or coerced to have sex and most are family members

Issues and challenges related to mental health, alcohol and social problems have not been properly addressed in the RMI. Alcohol related behavior can have a direct negative impact on family lives. Alcoholic behavior creates social problems among our youths today, increase in sexually transmitted diseases, suicide, domestic violence within the family setting to name a few. These social and behavioral problems are sensitive issues that ignored today. Unless the society empower itself to address these issues with the Ministry of Health, negative and high risk behavior will continue to have a negative impact on family lives in the RMI.

NInON COMMUNICABLE DISEASE

NONCOMMUNICABLE DISEASE

Diabetes

Diabetes is the leading cause of mortality and morbidity in RMI. In FY 2009, 20% of registered deaths are due to diabetes related diseases such as the End Stage Renal Failure, Uremia, and Septicemia. Diabetes is a life style disease that can be prevented by following healthy lifestyle. The Ministry of Health has been advocating healthy lifestyle through physical activities and healthy eating habits. Kumiti Diabetes Wellness Center is one example for promotion of healthy lifestyles. Health promotion through posters, presentations, and meetings are ways to communicate to the community about the effect of diabetes and how to prevent it.

In FY2009, MOH celebrated the World Diabetes Day with the community. A well organized event was held at ECC. NGOs, private sectors, and government agencies combined their efforts to celebrate the day in a healthy way. Physical exercises, foot care clinic, diabetic clinic, screening tests booth, health promotional materials, and healthy food were available for the community to participate. Ebeye Diabetes Program held outreach activities with the Ebeye community and churches and disseminate educational materials and information on prevention of Diabetes and Hypertension.

Table 52: RMI Registered Diabetes Cases Description FY FY FY 2007 2008 2009 Population 52,701 53,236 54,065 Registered Diabetes Cases 1,097 1,727 1,979 Diabetes Prevalence Rate 208 324 368 Per Per Per 10,000 10,000 10,000 Source: Diabetes Program, Majuro, OI, & Ebeye

The registered cases are those patients who come to attend clinics and are admitted. There are many patients who have not registered and don’t attend clinic but know that they have the disease.

Table 53: Diabetes Activities FY FY Type 2008 2009 Diabetes Encounters 9,661 9,053 Diabetes Admission 728 341 Amputation Due to Diabetes 78 57 Gangrene Encounters 72 92

NONCOMMUNICABLE DISEASE

National Comprehensive Cancer Program (NCCP)

Cancer is the 2nd leading cause of death in RMI. Breast cancer, cervical cancer, liver cancer and lung cancer are the most common type of cancer.

The NCCP Cancer Registry was developed to link with the Medical Records, Laboratory, and Vital Statistics for confirmed cases and possible cases of cancer. RMI Cancer Coalition is an organization with membership from the community and private sectors in partnership with the Ministry of Health that promotes awareness on cancer prevention. Cancer survivors have organized themselves as well to promote awareness and provide support needed to individual survivors. The NCCP coordinates with various programs in the Ministry, other Ministries, community, and NGOs for activities that will help the community in fighting cancer. Health promotional materials were developed for distribution to the community.

Table 54: Death Due for Cancer by Site FY 2009 Cancer Site Male Female Total Lung Cancer 6 2 8 Breast 5 5 Cervical Cancer 3 3 Colon 2 2 Liver 2 1 3 Ovarian 3 3 Eye 1 1 2 Nasopharyngeal 2 2 Thyroid 1 1 Rectal 1 1 Oral Cancer 1 1 Unknown 1 1 Kidney 1 1 Pancreatic 1 1 Leukemia 1 1 Testicular 1 1 Lymphoma 1 1 Laryngeal 1 1 Total 19 19 38 Source: MOH Vital Statistics Death database.

NONCOMMUNICABLE DISEASE

Table 55: Cancer Registry Cases 2009 New Cases Total Cases Cancer Site FY2006‐2008 Male Female RMI Total FY2009 Breast 11 0 5 5 16 Cervical 16 0 14 14 30 Thyroid 10 0 1 1 11 Colorectal 7 2 0 2 9 Lung 12 6 0 6 18 Nasopharyngeal 6 0 1 1 7 Stomach 5 0 0 0 5 Bone 2 0 0 0 2 Lymphoma 5 2 0 2 7 Laryngeal 2 0 0 0 2 Ovary 6 0 1 1 7 Uterine 2 0 2 2 4 Salivary gland 1 0 0 0 1 Vulva 2 0 0 0 2 Oral 4 0 0 0 4 Kidney 2 2 0 2 4 Leukemia 7 0 2 2 9 Liver 7 2 1 3 10 Pancreas 3 1 0 1 4 Prostate 4 0 0 0 4 Para Nasal 1 1 0 1 2 Bladder 0 0 0 0 0 Esophagus 1 0 0 0 1 Rectal 3 1 0 1 4 Brain 2 0 0 0 2 Eye 2 0 0 0 2 Testicular 2 1 0 1 3 Skin 7 2 0 2 9 Mouth 1 0 0 0 1 Ankle 1 1 0 1 2 Retroperitioneal Sarcoma 1 0 0 0 1 Choriocarcinoma 1 0 0 0 1 Iliac Fossa ® 0 0 1 1 1 RetroBladder Sarcoma 0 1 0 1 1 Unknown origin 4 0 2 2 6 Total 140 22 30 52 192

COMMUNICABLE DISEASE

Tuberculosis

Tuberculosis is still a major health problem in the Republic of the Marshall Islands. RMI is one of the four countries with the highest burden of TB among the US‐affiliated countries and in the Western Pacific Region, as well. The National Tuberculosis Program leans more toward following WHO guidelines which are endorsed by CDC as being more appropriate and relevant to the local situation.

The services provided under the TB/Leprosy Program can best be lumped into four main areas‐ the Clinical Aspect, Prevention and DOT, Laboratory Services and Leprosy Services.

RMI National TB Program (NTP) has received support and assistance from international organizations. In FY2009, the RMI NTP hired 4 DOT (Direct Observation Therapy) workers under the Global Fund Program. 3 DOT workers were assigned in Majuro and 2 DOT workers in Ebeye. The program also purchased 3 vehicles for the DOT activities; 1 for Ebeye and 2 for Majuro.

In FY2009, a team of experts from CDC and WHO assisted the National TB program on the MDR TB tracing. Since 2004 up to now, there are 10 MDR‐TB cases (7 active cases and 3 deaths). All ten patients had been born in the RMI. No epidemiologic links were found between cases in Majuro and cases in Ebeye. The investigation identified about 300 persons in the RMI who were close contacts of patients with confirmed or probable MDR TB. Evaluations are ongoing, but to date, no additional cases of MDR TB have been identified among these contacts.

MDR TB is resistant to at least isoniazid and rifampin, the two most effective anti‐TB medications. MDR TB is a public health concern because the case‐fatality rate is greater for MDR TB than for susceptible TB, the treatment duration is longer and more costly, and adverse effects are more common during treatment.

Table 56: TB Registered Cases FY FY FY FY Registered Cases 2006 2007 2008 2009 New Pulmonary Smear Positive 43 30 30 37 Pulmonary Smear Negative 47 82 74 45 Extra Pulmonary TB 41 43 28 34 Relapse 9 13 6 1 Treatment after Default 0 3 4 5 Treatment after Failure 0 0 0 0 Transfer in 1 2 1 1 Other 1 0 1 2 Total 142 173 144 125 Prevalence Rate Per 10,000 27 33 27 23

COMMUNICABLE DISEASE

Leprosy

Leprosy is an infectious disease that has been known since biblical times. It is characterized by disfiguring skin sores, nerve damage, and progressive debilitation.

Symptoms include: • Skin lesions that are lighter than your normal skin color o Lesions have decreased sensation to touch, heat, or pain o Lesions do not heal after several weeks to months • Numbness or absent sensation in the hands, arms, feet, and legs • Muscle weakness

Leprosy causes nerve damage in the arms and legs, which causes sensory loss in the skin and muscle weakness. People with long‐term leprosy may lose the use of their hands or feet due to repeated injury resulting from lack of sensation. It is common in countries that have temperate, tropical, and subtropical climates.

WHO target to eliminate leprosy in 2001 was 1/10,000. RMI did not meet the target prevalence rate. The program continues to see new cases of leprosy. WHO extended the target to 2010.

Table 57: Leprosy Registered Cases FY FY FY FY Registered Cases 2006 2007 2008 2009 PB 15 24 17 MB 29 40 30 Total 44 64 47 112 Prevalence Rate per 10,000 8 12 9 21

COMMUNICABLE DISEASE

Sexually Transmitted Illness / HIV

Sexually Transmitted Illnesses still rank as one of the greatest health burden in the community particularly among the youth who is at the greatest risk because of poor sexual behavioral practices. The social stigma attached to STIs is a barrier to treatment and to prevention of spread because infected individuals (both asymptomatic and symptomatic) are unlikely to seek diagnostic services.

Syphilis remained as the most common STI in the population. Most patients were asymptomatic at the time of diagnosis. The program started to re‐emphasize the importance of staging of syphilis and re‐ testing after treatment completion. The data are based on cases referred to STI/HIV Program from Prenatal, OPD, wards, TB clients, and outreach activities in the Outer Islands. All thirteen (13) cases were diagnosed by clinical examination and the maternal serology without RPR tests done from the infants. All neonatal cases completed ten days course of Procaine Penicillin daily injection.

Out of the 253 cases of Chlamydia in 2009, 184 are pregnant women who are routinely screen at the Prenatal Clinic. If left untreated, babies from infected mothers can have conjunctivitis, blindness, and neonatal pneumonia.

Adult Hepatitis B infection remains as one of the major health concerns in our population. Hepatitis B is endemic in the Marshalls. The advent of childhood immunization only started several decades ago. For children born in the hospitals, we vaccinate them with HepB within 12 hours from birth. We have 100% HepB vaccine with children born in the hospitals.

Although, RMI is classified as a low prevalence country for HIV disease, but still at greater risk of acquiring HIV due to high incidence and prevalence of STI, low condom usage and lack of safe sex practice. We need to be more proactive and work alongside actively with our community partners. Out of the 4 positive cases, 1 died with severe malnutrition and pneumonia. All the 3 remaining positive cases are under ARV (Antiretroviral agents). The STI/HIV Program conducted regular awareness activities to schools, Youth to Youth in Health, seafarers, and the community.

COMMUNICABLE DISEASE

Table 58 : STI/HIV Cases STI FY 2007 FY 2008 FY 2009 Positive Prevalence Positive Prevalence Positive Prevalence Case Rate Case Rate Case Rate Syphilis 289 548 302 567 486 904 Gonorrhea 36 68 27 51 107 199 Chlamydia 27 51 67 126 393 731 Hepatitis B 104 195 77 143 HIV 2 4 4 8 10 18 Source: STI/HIV Program, Majuro & Ebeye Prevalence rate is per 100,000

Table 59 : Status of Syphilis with Positive RPR, FY 2008 Status Majuro Ebeye Outer Total Islands New Case 149 32 52 233 Re‐infection/Old Infection 46 21 1 68 Neonatal Syphilis 1 0 0 1 Total of Positive RPR 196 53 53 302

Table 60 : Status of Syphilis with Positive RPR, FY 2009 Status Majuro Ebeye Outer Total Islands New Case 119 69 88 276 Re‐infection/Old Infection 35 0 162 197 Neonatal Syphilis 13 0 0 13 Total of Positive RPR 167 69 250 486

COMMUNICABLE DISEASE

H1N1

H1N1 sometimes called “Swine Flu” is a new influenza virus that causing illness in people. This new virus was first detected in the US in April 2009. The virus is spreading from person to person worldwide, in the same way that regular seasonal influenza viruses spread.

RMI Epi‐Net Team immediately takes action on this new disease and immediately started the surveillance in all ports (airport, docks). WHO, CDC, PIHOA, and SPC supported WHO on this event. The public was regularly updated by the Ministry. Health promotional materials, health talks, and media announcements were made to inform the public on good hygiene and healthy lifestyle to avoid the disease.

The Ministry utilizes the selected laboratories outside the RMI to send lab specimens for confirmation. We have 115 laboratory confirmed H1N1 cases. The first H1N1 positive patient was detected on July 2009. Surveillance on H1N1 is on‐going until today.

Table 61 : H1N1 Cases Age Distribution 0‐4 5‐14 15‐64 65+ Cumulative Infants Children Adults Elderly Unknown Total Cases 17 23 71 2 2 115 Deaths 0 0 1 0 0 1 Note: 1 Fatal case ‐ H1N1 with co‐morbid condition, TB

MEDICAL REFERRAL SERVICES

Basic Referral

Having to utilize Philippines hospitals more than Honolulu hospitals alleviate financial burden on the referral budget when it was already been reduced of its share to 35% from 45% of the Health fund tax. To that effect, at a lower cost for medical bills but high quality health care services in Philippines relieved the program when the financial status is unsteady.

Both the Tripler Army Medical Center and Shriner’s Children Hospital provide health care services with no cost to the RMI. The MOH is very fortunate to have the opportunity to send patients to these hospitals in Honolulu. Besides, the Shriner’s Children Hospital in Honolulu was able to send one of our patients to their specialized hospitals in California.

Basic referrals are approved by the Medical Referral Committee, consists of three (3) members appointed by the Minister and approved by the Cabinet as stipulated in the Health Fund Act.

Table 62: Top Ten Diagnosis for Off‐Island Referral FY 2007 FY 2008 FY 2009 Ortho 24 Cancer 24 Orthopedic 30 Cancer 24 Ophthalmology 23 Cancer 23 Congenital 14 Orthopedic 19 Congenital 23 Ophthalmology 14 Congenital 18 Ophthalmology 14 Surgery 12 Cardio 13 Cardiovascular 14 Cardio 8 Surgery 8 Neurology 12 Neurology 6 Neurology 7 Internal Medicine 9 Urology 5 Urology 7 Urology 6 ENT 5 OBGYN 6 Surgical 4 Internal Medicine 5 ENT 6 ENT 3

MEDICAL REFERRAL SERVICES

Table 63: Basic Referral Activity Referral Centers FY 2007 FY 2008 FY 2009 Honolulu & USAKA 9 3 7 Philippines 80 109 103 Total Basic Referrals 89 112 109

Trippler Hospital (PIHCP) 22 16 22 Shriners’ Hospital 13 11 15 Total Referrals 124 139 147

Table 64: Direct Referral Expenses/Referrals Fiscal Direct Referrals Average Year Referral (Expense/Referrals) Expenses 2007 $2,146,192.00 124 $17,308.00 2008 $2,027,364.00 139 $14,585.35 2009 $2,512,235.01 147 $17,090.00

Table 65: Basic Health Plan Financial Report‐ Revenues and Expenditures 2007 2008 2009 Revenues: Audited Unaudited Unaudited Health Fund Tax 3,377,399.00 $3,649,224.00 $2,677,172.82 RepMar Subsidy 0 0 $140,000.00 Others 1,838.00 $16,552.00 $593,318.59 Total Revenues $3,379,237.00 $3,665,776.00 $3,410,491.41 Expenses: Off‐Island Care $1,618,760.00 $1,485,385.00 $1,925,732.02 Travel/Stipends: Patients/Escorts $527,404.00 $541,979.00 $586,502.99 3rd Party Administration Fees $110,000.00 $128,750.00 $279,000.00 Contractual Services THI/JMI $0.00 $35,279.00 $140,000 Majuro Administration $277,355.00 $191,574.00 $277,775.41 Honolulu Office Operations $277,786.00 $280,336.00 $122,688.66 Subsidy to Inter‐Island Referral $164,917.00 $209,465.00 $194,506.15 Total Expenditures $2,976,222.00 $2,872,768.00 $3,622,664.48 Net Revenue (Loss) $403,015.00 $793,008.00 ($212,173.07) *Note: FY08 revenues based on 35% of Health Fund collection for off island referral, 55% remitted to Health Care Revenue Fund & 10% to PHC/Prevention and Domestic Referrals.

MEDICAL REFERRAL SERVICES

Supplemental Referral

The Supplemental Health Plan thus far proved to be a self‐sustaining plan. The Plan’s improved performance resulted from increased collections of premiums and the reduction of health services expenses as members utilizing Philippines for medical care and check‐ups. Enrollees in the Supplemental Health Plan have expressed their satisfaction for receiving health services in the Philippines

Table 66: Supplemental Health Plan Users for FY 2009 Location 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr Total Philippines 18 20 28 13 79 Honolulu 47 40 37 51 175 Total 65 60 65 64 254

Table 67: Supplemental Health Plan Enrollee Description FY 2007 FY 2008 FY 2009 Resident Members 766 822 938 Non‐ Resident Members 67 40 46 Total Members at Beginning of year 833 862 984 New Members 136 191 155 Terminated Members 107 69 93 Total Active Members End of Year 862 984 1,046

Table 68: Supplemental Health Plan Financial Report – Revenues and Expenditures 2007 2008 2009 Revenues Audited Unaudited Unaudited Supplemental Health Plan Collection $541,054.00 $575,814 $629,036.00 Other income $0.00 $0 $0.00 Total Revenues $541,054.00 $575,814 $629,036.00 Expenses Direct Expenses $527,014.00 $405,753 $212,508.37 Administration ‐ Majuro & Honolulu $9,787.00 $9,787 $ 48,029.23 Total Expenses $536,801.00 $415,540 $260,537.60

Net Revenue (Loss) $4,253.00 $160,274 $368,498.40

Beginning Net Asset $135,262.18 $241,901 $237,648.00

Ending Net Assets $305,731.64 $402,175 $241,901.00

MEDICAL REFERRAL SERVICES

Basic and Supplemental Health Plans Claims

The main objective for the claims section has always been to process claims for payment as quickly and accuratelyTable as 7.10 possible. Claims The Processed targeted for turnaroundFY2004‐2009 time to process claims always within 30 days time frame.

However, the target objective was not met during the whole year of FY2009. This was due to the new system of encoding all claims and medical bills from Philippines into the Claims System. Processing claims from Philippines is completely different than the processing claims from Honolulu and US in terms of adjudicating HCFA versus encoding detailed financial statements from Philippines.

Table 69: Average Claims Turnaround (Days) Year 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr FY 2004 48 days 44.5 days 49.6 days 25.4 days FY 2005 19.5 days 61days 47 days 38 days FY 2006 39 days 47 days 59 days 33 days FY 2007 35 days 35 days 37 days 28 days FY 2008 32 days 45 days 32 days 30 days FY2009 32 days 60 days 39 days 59 days

Table 70: Claims Processed for FY2004‐2009 Year Number of Claims Number of Line Items 2004 2,033 5,739 2005 1,310 4,012 2006 1,332 3,902 2007 1,057 2,979 2008 1,043 3,240 2009 1,149 2,654

MEDICAL REFERRAL SERVICES

Honolulu Referral Office

Great improvements were accomplished in Honolulu Office with regards to maintaining and fixing the buildings where it became clean and safe for the patients to reside. Along with the improvements and accomplishments, new housekeeper/driver was hired: 1. Newly installed metal‐screen doors in every room to provide sense of security and privacy to the patients. 2. Installed slippery‐resistance mats on the stairs in all the two buildings stairs to prevent injury. 3. New appliances including rice cookers, coffee pots and toasters and cooking utensils are assigned to replace the old ones. 4. Check‐in/out forms of patients are now monitored to keep track of all appliances and items. This is also needed for inventory purposes. 5. Weekly inspection of the units is routinely taking place; this is needed to fix and report damages. 6. The ground and landscape are regularly maintained. 7. The apartment occupancy report is consistently submitted on a weekly basis.

Operation and Management of Philippines Referral

New TPA was hired in January 1, 2009 to handle all the logistic portion parts of the referral program in Philippines where it provides more convenient and services to the RMI patients. Since the inception of the new TPA methods to improve the referral operation and patients services was in place but at the same cost control for the program was being exercised.

Several factors contribute to the accomplishments in the new method of improving patients’ services yet controlling the referral costs: • Both TPA and RMI coordinator are working together as team to provide patient services and provide weekly patient services report to Majuro office. • RMIMOH officials met with new TPA and Providers to get them familiarize with all the medical and clinical aspect of RMI referral program. Subsequently both RMIMOH and new TPA continue to maintain the open communication. • RMIMOH worked closely with new TPA to find ways to expand the dollars yet patient services not being interrupted. To that affect several alternatives were being utilized: Monitor inpatients stays, utilizing outpatient services more than to put up the patients in the hospital where it is more costly, rent monthly rooms instead of daily rooms for patients staying outside the hospitals.

Maintaining Referral Program

To provide the best continuity of care for RMI patients, several ways were expedited by both RMIMOH and new TPA: • Patients are no longer waited in the waiting room but are admitted directly for the Pre‐admission forms are being submitted in advance. • Once the patient is discharged to return home, therapy regime is with the patient for continuity of care in Majuro. • New TPA volunteers to provide durable medical equipments such as, walkers, wheelchairs and crutches for outpatients’ services. 66

HOSPITAL SERVICES

Table 71: Summary of Hospital Services FY 2008 FY 2009 Services Majuro Ebeye Total Majuro Ebeye Total Admitted Encounters 3,851 1,791 5,642 4,033 1,533 5,566 Outpatient Encounters (includes 43,340 26,777 70,177 47,370 30,545 77,915 Public Health, Dental, RH, Refills) ER 6,375 3,388 9,763 7,964 3,227 11,191 Radiology Services 12,000 2,317 14,317 11,260 3,109 14,369 Laboratory Services 214,933 35,235 250,168 61,867 *1 Pharmacy Services 129,682 No 129,682 *2 Data Rehabilitation Services 7,130 1,610 8,740 7,717 2,604 10,321 Dietary Services 88,164 31,432 119,596 27,375 Surgical Services 1,229 334 1,563 923 282 1,205 *1. No statistical data available in Ebeye Hospital due to pathologist unmet performance. 2. Ebeye Hospital has a new Inventory with Pharmacy system but lack of IT personnel hinders them to fully implement the system

Table 72: Majuro Hospital’s Top 10 ER Diagnosis FY2009 Rank Diagnosis Total 1 465.9 ‐ Acute URI NOS 1,701 2 558.9 ‐ Non Infectious Gastroenteritis 559 3 491.9 ‐ Unspecified Chronic Bronchitis 472 4 250.0 ‐ Diabetes Mellitus 429 5 789.0 ‐ Abdominal Pain 320 6 401.9 ‐ Unspecified Hypertension 287 7 276.5 ‐ Volume depletion 244 8 599.0 ‐ Urinary Tract Infection 236 9 535.00 ‐ Acute Gastritis 215 10 079.99 ‐ Unspecified Viral Infection 207

HOSPITAL SERVICES

Table 73: Ebeye Hospital’s Top 10 ER Diagnosis FY 2009 Rank Diagnosis Total

1 Bronchial asthma 1,350 2 Bronchiiolotis 340 3 Acute gastroenteritis 228

4 CAD/CVD/ASHD 90 5 AURI 86 6 Abscess/Cellulitis 77

7 Bronchitis 74 8 Dental emergency service 72 9 Hypoglycemia 61

10 Burns 45

Table 74: Majuro Hospital’s Outpatient Encounters (Excluding ER Visits) FY 2009 Rank Diagnosis Number 1 465.9 ‐ Acute URI NOS 5,205 2 V70.0 ‐ Routine General Medical Examination at a Health Care Facility 5,131 3 250.0 ‐ Diabetes Mellitus 3,056 4 401.9 ‐ Unspecified Hypertension 1,525 5 491.9 ‐ Unspecified Chronic Bronchitis 1,185 6 558.9 ‐ Non Infectious Gastroenteritis 1,128 7 382.9 ‐ Unspecified Otitis Media 689 9 366.9 – Cataract 677 8 599.0 ‐ Urinary Tract Infection 606 10 789.0 ‐ Abdominal Pain 599

Table 75: Ebeye Hospital’s Top 10 Outpatient Encounters FY 2009 Rank Diagnosis Total 1 AURI 2,454 2 Dental examination 1,788 3 Dental extraction 1,444 4 Acute gastroenteritis 744 5 Medical examination 404 6 Hypertension 301 7 Hypoglycemia 279 8 Abscess / Cellulitis 255 9 Error of refraction 255 10 Arthritis 247

HOSPITAL SERVICES

Table 76: Majuro Hospital’s Top 10 Admission Diagnosis FY 2009 Rank Diagnosis No 1 V27.0 ‐ Single liveborn (Outcome of delivery) 1,013 V30.00 single liveborn, born in hospital delivered without mention of 2 cesarean delivery 869 3 650 ‐ Delivery in a complete normal case 866 4 786 ‐ Pneumonia, organism unspecified 236 5 Diabetes Mellitus without mention of complication 208 6 485 ‐ Broncho Pneumonia, organism unspecified 188 7 616.10 ‐ Vaginitis, unspecified 130 8 493.9 – Asthma 123 9 599.0 ‐ Urinary Tract Infection 112 10 669.7 ‐ Cesarean delivery 111

Table 77: Ebeye Hospital’s Top 10 Admission Diagnosis FY 2009 Rank Diagnosis Total 1 Birth delivery 241 2 Bronchopneumonia 140 3 Acute gastroenteritis 124 4 Diabetes mellitus 76 5 Pneumonia 55 6 UTI 51 7 AURI 38 8 Hypertension 32 9 Prematurity 29 10 Dehydration 20

Table 78: Majuro Hospital's Operating Room Activity FY2009 Activity 1Q 2Q 3Q 4Q Total

General Surgery 157 119 89 91 456 OB GYN 85 43 51 52 231 Orthopedic 14 15 36 6 71

Urology 4 9 16 14 43 Eye 35 5 54 28 122 ENT 0 0 0 0 0

Total 295 191 246 191 923

HOSPITAL SERVICES

Table 79: Ebeye Hospital's Operating Room Activity FY2009

Activity 1Q 2Q 3Q 4Q Total General Surgery 26 41 27 10 104 OB GYN 32 14 33 36 115 Orthopedic 7 7 Urology Eye 3 13 16 ENT Total 58 62 63 59 242

Table 80: Majuro Hospital’s Outpatient Encounter by Type of Visit FY2009 Type of Visit No. of Encounters OPD 20246 Dental 7420 Public Health 13044 Family Planning 6327 ER 7969 177 7 Refill 321 Not Stated 4 Total 55,338

Table 81: Ebeye Hospital’s Outpatient Encounter by Type of Visit FY 2009 Type of Visit No. of Encounters OPD 12,790 Dental 3,439 Public Health 7,348 Family Planning 1,225 School Based Health Program 1,890 ER 3,227 177 48 Outreach program 578 Total 30,545

H OSPITAL SERVICES

Table 82: Majuro Hospital’s Admission Table 83: Ebeye Hospital’s Admission Encounter by Service Ward FY 2009 Encounter by Service Ward FY 2009 Ward No. of Encounters Ward No. of Encounters Dental 1 Dental 3 TB 2 TB 4 ICU 10 ICU Medical 684 Medical 334 Maternity 2,206 Maternity 102 Pediatrics 604 Pediatrics 663 Surgical 529 Surgical 106 Obstetrics 1 Obstetrics 321 Total 4,037 Total 1,533

Table 84: Rehabilitation Department's Referral information FY 2009 Activity 1st Q 2nd Q 3rd Q 4th Q Total New Referrals 141 141 131 89 502 Average # of Treatments Per day 30.4 33 35 27 31 Completed Prostheses 1 2 2 3 8 Total Treatments Per Quarter 1,871 1,987 2,184 1,675 7,717

Patient Encounter in Majuro Hospital's Rehabilitation Department

FY2009 7,717

FY2008 7,130

FY2007 7,281

6,800 7,000 7,200 7,400 7,600 7,800

OSPITAL ERVICES H S

Table 85 : Ebeye Hospital’s Rehabilitation Department Referral information FY 2009 Activity 1st Q 2nd Q 3rd Q 4th Q Total New Referrals 34 45 47 41 167 Average # of Treatments Per day 9 10 12 10 10 Completed Prostheses 0 0 0 0 0 Total Treatments 625 625 778 651 2,679

Table 86: Majuro Hospital’s Radiology Examinations Examinations FY 2009 X‐Ray 8,509 Ultrasound 1,260 EKG 1,160 CT Scan 320 Mammography 11 Total 11,260

Table 87:Ebeye Hospital’s Radiology Examinations Examinations FY 2009 X‐Ray 2,052 Ultrasound 987 EKG 70 CT Scan All referred to Majuro Total 3,109

HOSPITAL SERVICES

Table 88: Overall Laboratory Activities and Workload in Terms of Phlebotomies and specimens, Majuro Hospital Activities/ Load of work Hospital PHC Total Phlebotomies 8110 7958 16,068 CBC 6404 2474 8,878 Prothrombin Time 150 4 154 Chemistry 4130 505 4,635 HbA1C 171 73 244 Urines 2356 6052 8,408 Stools 1013 4996 6,009 Sputa 848 Body fluid 45 0 45 Blood cultures 11 0 11 CT & GC 44 1456 1,500 Swabs for culture and sensitivity 186 1 187 Serology 701 7280 7,981 Donor screenings 1795 0 1,795 Crossmatches 1244 0 1,244 Units drawn 950 0 950 Pap‐gynec 0 2229 2,229 Pap‐surgical 120 0 120 Surgical tissues 264 0 264 Off‐island 153 84 238 Shipping (IATA 650 & 602) 60 0 60 Total 27907 33112 61,867

O RGANIZATIONAL CHART

MINISTRY OF HEALTH REPUBLIC OF THE MARSHALL ISLANDS

Minister of Health

Health Services Board Secretary of Health

Assistant Secretary Office of Medical Referral Services Assistant Secretary Office of Administration, Personnel & Finance

Executive Secretary Assistant Secretary Office of Health Planning and Statistics

Assistant Secretary Assistant Secretary Assistant Secretary Bureau of Kwajalein Atoll Health Care Bureau of Outer Islands Health Care Services Bureau of Majuro Atoll Health Care Services Services

A CKNOWLEDGEMENT

The Ministry of Health acknowledges the continued support from our colleagues and partners, Air Marshall Islands Asian Development Bank (ADB) Bank of Guam (BOG) Bank of the Marshall Islands (BOMI) Business Sector Center for Disease Control and Prevention (CDC) College of the Marshall Islands (CMI) Continental Airlines Councilwoman Deborah Kramer‐Shoeniber Economic Policy, Planning, and Statistics Office (EPPSO) Government of Australia Government of Japan Government of the Marshall Islands Ministry of Education Ministry of Internal Affairs Ministry of Foreign Affairs Ministry of Resources and Development Ministry of Transportation and Communication Ministry of Finance Ministry of Public Works Honolulu Jepta Iroij and Leroij Ro (Traditional Leaders) Iroij Anjua Loeak Jepta Jarin Rarik Dron Johndell M Ilao (JMI) KIJLE Kora In Okrane (KIO) Kramer Family Kumiti Cancer Coalition Kumiti NCD Coalition Majuro Atoll Local Government Majuro English Assembly Marshall Islands Journal Marshall Islands Medical Society (MIMS) Marshall Islands Nursing Association (MINA) Marshallese Lejmanjuri Organization (MaLO)

MediSource Pacific MedPharm Minister Amenta Matthew Mission Pacific Office of Environmental Planning Policy Coordinator Pacific Health Research Initiative Pacific Islands Health Officers Association (PIHOA) Republic of China, Taiwan Rita Elementary School RMI Environmental Protection Authority Secretariat of the Pacific Community (SPC) Shriners' Hospital for Children The Church of Jesus Christ of Latter‐Day Saints The Salvation Army Church Tony Muller Trinity Health International (THI) Tripler Hospital UNICEF United Nations Development Programs United Nations Fund for Program Activities (UNFPA) United States Government University of Hawaii (UH) University of South Pacific (USP) USDA Rural Development WAC World Health Organization (WHO) WUTMI Youth to Youth in Health (YTYIH)