MINISTRY OF HEALTH REPUBLIC OF THE MARSHALL ISLANDS “KUMITI EJMUUR" ANNUAL REPORT FY 2009 2 3 4 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. 7 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 9 10 GEOGRAPHY AND DEMOGRAPHICS 11 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 12 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