MINISTRY OF HEALTH
ACRONYMS
IAEA International Atomic Energy Agency PACS Picture Archiving & Communication System NP Nurse Practitioner DLS Diagnostic Laboratory Services PIHOA Pacific Islands Health Officers Association PCSI Program Collaboration Service Integration Conference APNLC American Pacific Nursing Leaders Conference VIA Visual Inspection with Acetic Acid NCCCP National Comprehensive Cancer Control Program OIHCS Outer Islands Health Care Services CHC Community Health Center UDS Uniform Data System OHPPS Office of Heath Planning, Policy and Statistics
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I. MESSAGE FROM THE MINISTER AND SECRETARY OF HEALTH
We are pleased to present the Annual Report for the Ministry of Health for Fiscal Year 2016. Although there is so much data and statistics collected for every single program and services in the Ministry, this report is presented for a better understanding of the type of resources allocated for the Ministry such as human and financial resources, and the utilizations of its resources or expenditures incurred during the fiscal year. Section on data and vital statistics presents the health status of RMI in terms of morbidity and mortality just for that fiscal year. Non‐ communicable Diseases (NCDs) or lifestyles diseases, tuberculosis and leprosy remain the three prioritized areas, and update on activities and data are included in this report. The last section is the Cost Analysis and Expenditures for the fiscal year in selected areas or services. It is important to note that actual costs of services provided by the Ministry are not charged accordingly. If the Ministry was to charge patients according to the costs of services, high revenues will be generated every fiscal year.
Because of the high rates of lifestyles diseases or chronic diseases and identified communicable diseases, the Ministry continues to shift its focus on preventive or primary health care’s services in compliance with the Declaration of Primary Health Care by World Health Organization (WHO) on September 12, 1978 in Alma Ata. The Declaration called for urgent action by all governments, all health and development entities and the world community to protect and promote quality health practices for all peoples.
Health is a shared responsibility between the RMI Government, communities, non‐ governmental organizations, churches, women’s groups, business communities, civil society,
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families and individuals. We are all responsible for our own health because we can make choices to take care of our own health through eating the right kind of food for better health, increase physical activities/exercise, stop smoking, and drink less alcohol. The risk factors related to lifestyles diseases such as tobacco use, alcohol consumption, lack of physical activities and poor diet contribute in high prevalence and incidence rates of NCDs in our nation.
RMI fully supports the NCD Declaration by the Pacific Islands Health Officers Association (PIHOA) because NCDs are affecting lives of so many people in our region and around the world including the RMI.
We are all Marshallese who live the “kumit” lifestyle, which shows supporting one another in every effort to improve health, education, lifestyles for Marshallese people for now and in the years to come. Improving lives, health and education is a shared responsibility and a healthy kumiti lifestyle for all.
There are still challenges in lifestyles that the Ministry encountered during the fiscal year. One of the highlighted challenges was the Zika outbreak that occurred towards the end of the fiscal year, which imposed the Ministry to shift resources to focus on the outbreak. The Ministry was able to respond quickly to combat the outbreak with support from the RMI Government, local and regional partners and international partners and agencies. We are indebted for supports received during the outbreak.
We extend our sincere appreciation to our local partners and stake holders in the RMI, our regional and international partners and to the RMI Government for your continued support to the Ministry of Health.
Komol Tata!
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Table of Contents
I. MESSAGE FROM THE MINISTER AND SECRETARY OF HEALTH ...... 2 II. MINISTRY OF HEALTH’S FY2016 HIGHLIGHTS ...... 5 III. MINISTRY OF HEALTH’S PROFILE ...... 17 KEY OUTCOME AREA 1: BUREAU OF PRIMARY HEALTH CARE SERVICES ...... 19 KEY OUTCOME AREA 2: MAJURO HOSPITAL SERVICES ...... 19 KEY OUTCOME AREA 3: BUREAU OF KWAJALEIN HEALTH CARE SERVICES ...... 19 KEY OUTCOME AREA 4: BUREAU OF ADMINISTRATION ...... 20 KEY OUTCOME AREA 5: OFFICE OF HEALTH PLANNING, POLICY & STATISTICS ...... 20 IV. HEALTH INDICATORS REPORT FY2016 ...... 32 V. FINANCIAL INFORMATION ...... 59
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II. MINISTRY OF HEALTH’S FY2016 HIGHLIGHTS
Bureau of Majuro Hospital Services The Assistant Secretary for Majuro Hospital Services is responsible for management and overall operation of Majuro Hospital Leroij Atama Zedkeia Medical Center commonly known as Majuro Hospital serving inpatient, outpatient, public health clinics and ancillary services. In addition to this core role there are other areas that fall under the Hospital Services jurisdiction, • Pharmaceutical Services • Biomedical Services • Laboratory Services • Radiology Services • Dental Services • Medical Records • Clinical Services Network • Nursing Services • Medical Services • Blood and Ambulance Services • Specialist Visiting Teams
Achievements 1. Policy and Planning: a. Revised Hospital Service Hour Policy.
2. System Development a. Picture Archiving & Communication System (PACS) installed at Radiology Department and workstations of Outpatient clinics, Public Health clinics, and Inpatient wards. b. Tracking system implemented for Morgue’s Embalming cases and payment c. Installed new oxygen generator for the hospital which is capable of 50 tanks a day. d. Installation of all non‐working fluorescent lamp with new LED light. Repair all clogged drainage P‐Trap in all wards and X‐Ray Department e. Established Kitchen inventory control f. Establishment of the dental school program within the Public School System working closely with grades K‐4th g. Bidding and Awarding of New CT Scan
3. Workforce Development: a. Training and Maintenance of Hyperbaric Chamber b. IAEA upgrading skills with the Laboratory and Radiology staff. c. 6 additional staff attending medical school in Shuang Ho Medical School d. 10 staffs attending Nurse Practitioner (NP) training in Majuro e. Completion of Midwifery Refresher Course in Fiji National University
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f. Kitchen staff given basic training for food handling g. Completed TB Laboratory Molecular Quality Assurance Program in molecular diagnosis (2016 GeneXpert Panel), established by the PATLAB and provided through DLS and PIHOA h. Completed ICD‐10 Training through WHO Support
4. Infrastructure Development: a. Renovated ER Doctors' and Telemedicine room b. Renovated Maternity Ward, Pediatric Ward, Medical Ward c. Converted a bathroom for screening room d. Constructed Radiology room to house the new CT‐Scan e. Upgraded New kitchen f. Implementation of Hospital Redevelopment Project.
5. Medical Missions: a. Canvasback Missions b. Taiwan Medical Missions c. First Humanitarian Mission d. Starky Hearing Mission
6. Donations: a. Donation of Local Food from Protestant Church b. Donation of Cleaning Supplies Assembly of God c. Donation of Cleaning Supplies and help with hospital monthly cleaning event Latter Day Saint Church (LDS) d. Donation of hygiene kits from the Chinese community
Water Drill Emergency Response Bureau of Primary Health Care Services
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The Assistant Secretary of Primary Health Care & Public Health Medical Director are responsible for formulation of strategic public, primary health policies and oversees the implementation of public health programs as legislated under the Marshall Islands Public Health Welfare Act 1966. There are 56 Health Centers in RMI. Aside from the 177 Health Centers, Health Assistants are the health care provider in the health centers. 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 with the Health Assistant manages the 177 Clinics. DOE Clinic is providing medical services to the nuclear patients under the Department of Energy. Kumiti Wellness Center which is managed by Canvasback Mission, in collaboration with MOH, shows right diet and exercise 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. Achievements 1. Policy and Planning: a. Endorsement of RMI Reproductive Health (RH) Policy b. Endorsement of Family Planning Program Administrative Policy Manual c. Completion of NCD Community Action Strategic Plan 2017‐2019 d. Completion of National Wellness Policy e. Completion of RMI Cancer Survivorship Plan f. Completion of Zika Protocol for Pregnant Mothers g. Completion of Human Services National Policy h. Completed Policy System and Environment (PSE) scan in Government worksites and Churches that have signed the pledge i. Four (4) Ministries signed the pledge to enforce the smoke‐ free law at their respective government worksites j. Eleven (11) Pastors signed the pledge to promote water and coconut water at their churches: Pledge signed by United Church of Christ Rev. Enja Enos, Assembly of God Rev. Erakrik Samuel, Congregational Church Reform Rev. Russell Edward, Salvation Army Rev. Hetai Silk, Bukot non Jesus Rev. Paul Hensene, New Apostolic Rev. Bartin Naisher, Latter Day Saint Zedkeia Zedkeia, Meram in Jesus Rev. Brandy Clanry Seventh Day Adventist Pastor Tommy Kilma Assumption Parish Father Ray T. Sabio and Ahmadiyya Muslim Community Imam Matiullah Joyia k. Public hearings held for “Import Duties Funding Supplement Amendment Act 2016” (on Tobacco, Alcohol, and Sweetened Beverages) and Betelnut Prohibition Amendment Act, two of the Bills the team worked on with key stakeholders in the government system (Attorney General, Legal Counsel,
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Ministry of Finance, etc.)
2. System Development a. Family Planning Information, Education, Communication (IEC) Committee established b. Launch of Healthy Workplace Screening for the Ministry c. RMI Cancer data Infograph d. Counseling Services to Teen pregnancy mothers provided by Human Services counsellor. e. Outer Islands Office established SOP to improve data collection and analysis f. Food Safety Inspection is an ongoing process every Tuesdays and Thursdays with health education staff along with EPA, Mal. gov’t together, we have been to restaurants, school vendors, and other food vendor areas
3. Workforce Development: a. HRSA Program Management Training for Family Planning Program b. WHO Pocketbook Training of Healthcare Providers c. Completion of Visual Inspection with Acetic Acid (VIA) Training d. RMI hosts Program Collaboration Service Integration Conference 2016 e. RMI hosts American Pacific Nursing Leaders Conference 2016 f. WHO Strategic Planning Training g. Completion of Outer Island Health Assistant Refresher Course h. TB Sputum Collection Training for the nurses from the wards and TB Clinics i. TB‐Diabetes Screening Protocol re‐introduced to all clinicians j. Staff from NCD Program and Health Promotion attended the Learning Collaborative Meeting by Pacific Chronic Diseases Coalition. k. Staff from National Immunization Program attended meetings and trainings on American Immunization Registry Association, Clinical Vaccinology, and WebIZ User Training.
4. Infrastructure Development a. New Cold Chain Equipment for National Immunization Program b. Renovation for OIHCS office, medical store‐room and pharmaceutical warehouse c. The 8 DAMA units installed in the health centers are still in service. (Toka ebon, Loen namu, Aerok ailinglaplap, Lukwonwod mili, Enejit mili, Imroj Jaluit, kaben maloelap and Jabat Island) d. New TB Contact Tracing Vehicle e. Completion of Outer Island Equipment Replacement & Maintenance Plan
5. Community Engagement: a. NCD Coalition Launches Community Lifestyle Outreach b. Completion of Wa Kuk Wa Jimor Pilot Project to Mili, Arno & Aur c. Cancer Program Church to Church Screening Evaluation Completed d. Launching of Wellness Center School Health Program e. World Cancer Day‐ February 4, 2016‐ March/Parade was carried out by MOH
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NCCCP, Cancer Support Group, and community stakeholders f. Launching of Co‐Op School Capstone Project g. Hepatitis B Sero Survey for all 1st graders.
RH Policy Endorsement and Training Bureau of Kwajalein Atoll Health Services The Assistant Secretary for Kwajalein Health Services is responsible for management and overall operation of Leroij Kitlang Kabua Memorial Hospital commonly known as Ebeye Hospital serving inpatient, outpatient, public health clinics and ancillary services. Medical and public health staff conduct outreach to the health centers in the outer islands and within the community as well. Achievements 1. Systems Development: a. Finalization of all clinical performance measurements for FY 2015 has been finalized, in synchronization with the Community Health Center (CHC) Performance measures, Healthy People 2020 Goals and SMG. These will be trended for programmatic evaluation of progress towards stated goals in FY 2017 Budget Portfolio and CHC UDS Reporting System b. Completion of Leprosy Case finding project via WHO Support. Through this project, program was able to identify five (5) new cases of leprosy, all from the Kwajalein Outer Islands (2 from Ebadon and 3 from Santo). Other than helping to get a better understanding of the true prevalence of Leprosy in the Kwajalein Atoll Community, the study also confirms huge disparity in the level of care
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being provided to the remote outer islands of Kwajalein as compared to the main island of Ebeye, among other things c. Patient Registration for the Mass TB and NCD Screening in Ebeye
2. Workforce Development a. Additional 10 medical staffs recruited b. Completed ICD‐10 Training through WHO Support c. Completion of Ebeye Physiotherapy training to improve the Foot Care Program, expand the Foot Care Team and also to reduce the number of diabetic complications and amputations within our region. The training was held at the conference room in Leroij Kitlang Memorial Health Center. The training was based on the Pathology of the Diabetic foot, the foot deformities that are presented with the disease, the mechanics of the diabetic foot, the injuries that diabetic foot is prone to and management of the diabetic foot. The training also emphasized on training/educating the patients and community for early intervention to prevent amputation d. IAEA upgrading skills with the Laboratory and Radiology staff. e. Staff from NCD Program attended the Learning Collaborative Meeting by Pacific Chronic Diseases Coalition. f. IT Staff and Immunization Coordinator attended meetings and trainings on Association of Immunization Manager’s Meeting, and American Immunization Registry Association and WebIZ User Training.
3. Infrastructure Development: a. Major diagnostic equipment including the Digital X‐Ray Carestream Directview and PAC SYSTEM and AU 400 Chemistry Analyzer are now operationalized. Installation and training of new equipment acquired are done. Improvement in diagnostic capability will ultimately have a positive effect on patient outcome onward b. Energy audit through CMI in June revealed that the MOH Ebeye can save up to $200,000.00/year, if the central cooling Unit is replaced by energy efficient split type air‐conditioner Units. Ebeye is seriously considering this recommendation, as a plan forward
4. Community Engagement: a. School Immunization Coverage rate is 96%. Although it’s above our target, we still need to do “catch up” vaccination in schools
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WHO sponsored ICD‐10 Training in Ebeye Hospital
Bureau of Administration The Ministry of Health’s Office Administration consists of Accounting, Personnel, and Finance (OAPF), Procurement & Supply, & Office of Medical Referral Services (OMRS). 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. OMRP is responsible for the management of the Health Fund, Basic Referral Program, and Supplemental Health Program.
Achievements 1. Policy and Planning: a. Re‐structure of the HR department, establishing of a HR network drive, HR policies, processes and flowcharts, HR introduction booklet and HR intranet page b. In collaboration with OHPPS, 3year rolling strategic plan and annual budget portfolio FY2017 are completed
2. System development: a. Addressed out of date organizational chart and job descriptions. HR Office worked with supervisors and directors on recommendations of A more functional hierarchy structure Job design (resulting in establishing/updating job descriptions and job titles) Career structure and opportunities Training opportunities b. Procurement Office initiated 3months bulk purchase for Majuro and Ebeye
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Hospital Pharmaceutical and Medical Supplies.
MOH participated in May Day Celebration
Office of Health Planning, Policy & Statistics Office of Health Planning, Policy & Statistics is responsible for collecting, analysis, and monitoring of health indicators, processing of birth and 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, Management Information System, Performance Management, Epidemiology, Health Preparedness Program & Performance Management.
Achievements 1. Policy and Planning: a. Revision of MOH Organizational Chart approved by the Minister of Health and Interim Secretary of Health b. Formation of Senior Leadership Team (SLT) c. Endorsement of Public Health Emergency Operations Plan (EOP), Hospital Emergency Preparedness EOP d. Drafted RMI Outbreak Surveillance Guide and Protocol e. Medical Countermeasure Operational Readiness Review grades arrived RMI considered B+ overall
2. System Development: a. Received and tested Video Teleconferencing equipment from: 2 VTC equipment were donated
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Vidyo software training Vidyo accounts for RMI were created. Zoom Video Teleconference Set up and training
b. Revised syndromic surveillance system based on the system assessment. Outer Islands Weekly Syndromic Surveillance System and Specific disease surveillance on Zika, Drought related diseases, and Mumps Majuro and Ebeye Weekly Syndromic Surveillance c. Completion of Birth and Death Certificates submission to Ministry of Internal Affairs – 1 year of certificates d. Establishment of VPN Connection to Ebeye Immunization Program e. Support, upgrade and maintenance of MOH Health Information Systems • Medical Records Database • Family Planning Database • MCH Database • Uniweb PACS • Timekeeping System • Medical Referral System • MIWebIZ – Upgrade from version 14.11 to 16.4 • Upgrade of Abila – MIP Accounting System (server and clients) • Microix Set up and Administration Training – Inventory System • STI/HIV Epianywhere, STD Databases • TB Epianywhere • Chronic Disease Electronic Management Systems • Vital Records Information System
f. MSuppy Pharmacy System
3. Workforce Development: a. Training and re‐certifying health staffs in preparedness related activities (ACLS, PALS, BLS, ICS, HAZMAT) b. Incident Command System Training c. Zika Surveillance Training d. Drought Surveillance Training e. International Health Regulations & Early Warning Surveillance Workshop through WHO Support f. ICD‐10 Training for Vital Statistics Department and IT Department through WHO Funding g. Health Strategic Planning Workshop with WHO
4. Infrastructure Development: a. Health Emergency Operation Command Center (EOC) Established b. Purchase of Preparedness equipment’s (Decontamination equipment, communication
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equipment, First responder equipment, etc.)
Blessing of the Uniweb PACS •
CRVS Meeting with Vital Statistics Director and Asst. Secretary, Health Strategic Planning Workshop with WHO OHPPS
Zika Outbreak Response
The first known case was an Australian tourist diagnosed in Australia in December 2015 after spending 3 weeks in the RMI. In February 2016 routine syndromic surveillance for AFR (acute fever and rash) detected possible cases of Zika virus infection. The case definition was purposely broad and non‐specific to ensure capture of all potential Zika cases.
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A Health Emergency declaration was signed by the Secretary of Health and the EpiNet team was called to action by the Chair, Dr. Aina Garstang. The MOH coordinated with the RMI Government, the World Health Organization (WHO), the Pacific Island Health Officers’ Association (PIHOA), the Centers for Disease Control and Prevention (CDC) and other domestic partners including traditional leaders, landowners, mayors and local governments. The response focused on multiple critical areas: disease epidemiology, syndromic surveillance, building laboratory database and personnel capacity, specimen obtainment and transfer, health communications and social mobilization, and travelers’ health. The US Department of Defense (DoD) provided entomological training. RMI staff from the Ministry of Health and the EPA were trained in vector surveillance: mosquito trapping and identification. They were also equipped and trained for household spraying of insecticide and larvicidal treatment of mosquito breeding sites. Outreach activities were initiated with non‐governmental organizations (NGOs), schools and religious organizations to provide community health information via posters in the international airport, pamphlets (in both English and Marshallese), announcements in the local newspaper and radio and SMS texts to mobile devices. The Sanitation Cluster organization members engaged in major cleanup activities to remove trash, tires, old cars and other equipment, remove and spread sand on illegal dump sites, cover ponding water. They also initiated covering of water catchment cisterns with mesh to alleviate breeding sites. Over the course of the next 6 months (through July 2016) MOH Public Health teams were active in case investigations, identifying any pregnant women in areas surrounding a possible Zika case patient. These women have been carefully followed by the OB/GYN and MCH staff through delivery and well‐child visits. Surveillance and laboratory staff continued to assess the possible cases with blood and urine testing and report the results in Situation Reports (SitReps). There were 49 suspected cases tested; 14 of these could only be reported as infected with an “unspecified flavivirus” due to cross reactivity with other arboviruses (Dengue, Chikungunya). Only 2 cases were confirmed positive by PCR and/or PRNT. One was a male, the other a pregnant woman whose child was born with normal characteristics. No other neurological manifestations of Zika infection in the child have been seen.
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Figure 1: Zika Possible Cases in RMI by Date of Onset
Figure 2: Zika Possible Cases in RMI by Age Group
Red Cross Volunteers packs Zika Kits for Zika Technical Assistance Conference call with CDC Distribution
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III. MINISTRY OF HEALTH’S PROFILE
MOH Vision: To reaffirm the commitment to facilitate the concept of healthy islands and health promotion and protection where Children are nurtured in body and mind; Environments invite learning and leisure; People work and age with dignity; Ecological balance is a source of pride; and The ocean is protected to sustain our needs
MOH Mission: To strengthen the commitment on healthy islands concept in implementing health promotion to protect and promote healthy lifestyles to improve the lives of the people through primary health, and to build the capacity of Ministry of Health, communities, families and partners to actively participate and coordinate preventive services programs and activities as the core resources in primary health care services.
Marshall Islands Medical Society Marshall Islands Nursing Association
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Figure 3. Ministry of Health Organizational Structure
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KEY OUTCOME AREA 1: BUREAU OF PRIMARY HEALTH CARE SERVICES Goal: Preventative and public health services will be efficiently maximized through a healthy islands lifestyle concept and with essential medical and administrative functions to ensure that the health and life span of various individuals, families and communities are enhanced. The Bureau of Preventative and Public Health includes the following departments: . Outer Island Health Services . Communicable Diseases STD/HIV Leprosy Tuberculosis . Non‐Communicable Diseases Diabetes Hypertension Cancer Control Program . Maternal Child Health . Immunization . Behavioral Health . Health Promotions . Zone Health/Community Outreach . Administration
KEY OUTCOME AREA 2: MAJURO HOSPITAL SERVICES Goal: To improve and the level of health care, the health status and a sustainable livelihood of the people living in the outlying islands/atolls in the Marshall Islands The Majuro Hospital Service includes the following departments: . Medical Services . Nursing Program . Clinical Support Services . Non‐Clinical Support Services . Administration
KEY OUTCOME AREA 3: BUREAU OF KWAJALEIN HEALTH CARE SERVICES Goal: To improve health outcome for the people of Kwajalein Atoll within constraints of limited resources. The Bureau of Kwajalein Health Care Service’s includes the following departments: . Hospital Nursing Services . Medical Services . Clinical Support Services . Non‐Clinical Support Services . Administration . Primary Health Care Services
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KEY OUTCOME AREA 4: BUREAU OF ADMINISTRATION Goal: Effective management and administration of Human and Financial resources in the Ministry of Health The Bureau of Administration includes the following departments: . Accounting & Finance . Human Resources . Procurement & Supply . Medical Referral Services
KEY OUTCOME AREA 5: OFFICE OF HEALTH PLANNING, POLICY & STATISTICS Goal: Provide cross‐cutting policy perspectives that bridges MOH Bureaus, public and private sector activities, and the research community, in order to develop, analyze, coordinate and provide leadership on health policy issues The Office of Health Planning, Policy & Statistics includes the following departments: . Information & Technology (IT) . Epidemiology & Vital Statistics . Emergency Preparedness Program . Performance Management . Environmental Health
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Table 1 indicates the hospital and health centers under the Ministry of Health. Leroij Atama Zedkeia Medical Center commonly known as Majuro Hospital and Leroij Kitlang Memorial Health Center commonly known as Ebeye Hospital are serving inpatient, outpatient, public health clinics and ancillary services. There are 56 Health Centers in RMI (Table 2). Aside from the 177 Health Centers, Health Assistants are the health care provider in the health centers. Medical and public health staff conduct outreach to the health centers in the outer islands and within the community as well. Table 1: OVERALL HEALTH CARE SYSTEM
MAJURO ATOLL Leroij Atama Zedkeia Medical Center Laura Health Center Rongrong Health Center KWAJALEIN ATOLL Leroij Kitlang Memorial Health Center Santo Dispensary Ebadon Dispensary Gugeegue Dispensary OUTERISLANDS Ratak Chain Ralik Chain 1. Aerok 1. Aerok 12. Loen 2. Maleolap 15. Lukonwor Ailinglaplap 13. Mae 3. Ailuk 16. Mejit 2. Bwoj 14. Majkin 4. Arno 17. Milli 3. Ebon 15. Mejrirok 5. Aur 18. Nallu 4. Imiej 16. Namdrik 6. Bikarej 19. Ollet 5. Imiroj 17. namu 7. Enejelar 20. Tarawa 6. Jabnoden 18. Narmij 8. Enejit 21. Tinak 7. Jabot 19. Toka 9. Ine 22. Tobal 8. Jabwor 20. Ujae 10. Jang 23. Tokewa 9. Jaluit 21. Woja 11. Jebal 24. Tutu 10. Lae 22. Wotho 12. Kaven 25. Ulien 11. Lib 13. Kilange 26. Wodmej 14. Likiep 27. Wotje
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Table 2: No. of Beds in Two Main Hospitals Hospital No. of beds Leroij Atama Zedkeia Medical Center (Majuro 101 Hospital)
Leroij Kitlang Memorial Health Center (Ebeye 54 Hospital)
Table 3: Private Clinics
Clinic Name Location Majuro Clinic Delap, Majuro Capital Dentistry Uliga, Majuro Eyesight, Professional Delap, Majuro
Table 3 indicates there are three licensed private clinics providing limited clinical services for the residents in Majuro. Such clinics are licensed under the MOH’s Medical Examining and Licensing Board to practice in the RMI.
Table 4: Specialized Program
Clinics Location Majuro 177 Clinic Majuro Ejit Clinic Ejit, Majuro Kili Health Center Kili Enewetak Health Center Enewetak Utrik Health Center Utrik Mejatto Health Center Kwajalein DOE Clinic Majuro Kumiti Wellness Center Majuro Taiwan Health Center Majuro
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Human Services Program deals with current social health issues such as mental health, suicide, alcohol and substance abuse, sexual assault, seizures, and domestic violence.
Majuro Human Services program
Mental Health Policy endorsed by the Minister of Health and Interim Secretary of Health Established working alliance with Attorney General’s Office and Majuro Atoll Local Government (MALGOV) Police Force. o Attorney General’s Office: Lawyers are available to provide services for domestic violence and rape cases. o MALGOV Police Force: 48 Policemen attended the suicide first aid training. Suicide Awareness Activities conducted at: 533 students ages 15 to 21 years old were reached o Marshall Islands High School: 216 (91 males, 118 females) o Rongrong High School: 144 students o College of the Marshall Islands‐Arrak Campus: 129 (66 males, 63 females) o General Education Development (GED): 8 (3 males, 5 females) o Life Skills Academy: 36 (14 males, 22 females) Coop Mentoring CAPSTONE Project COOP senior students are required to complete a CAPSTONE project before graduation. There are 3 students who are working on the following topics: 1. Alcohol & Substance Abuse 2. The effect of Alcohol in society 3. Human Trafficking Radio Program: Human Services Radio program is back on the air every Saturday at 3:30 – 4:00. It is a 30 minutes program that talks about mental wellbeing and metal health related issues.
Ebeye Human Services Program
Awareness and counseling services on Health effects of Alcohol, Substance abuse, Tobacco and Betel Nut consumption o Health Talk on Tobacco and Betel nut consumption o Elementary School in Ebeye : 20 Students (11 females and 9 males) o 1 high school: 370 High school students (140 males and 230 females) o Tobacco intervention counselling services to 30 males and 18 females o Counseling services to 77 males and 12 females for alcohol consumption and 1 client found out to be gasoline sniffer.
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o Visited 2 high schools to provide health career talk on healthy mind, body and spirit: 62 senior students (32 females and 30 males) Depression Screening is provided to Diabetes Clinic. 38 Diabetes patients undergo Depression Screening. Mental Health Screening to 297 Middle School students at Public Middle School
Outer Islands
Majuro Human Services Program provided outreach mobile visits to Enewetak.
National Comprehensive Cancer Control Program works closely on the cancer control and prevention activities including support Cancer Survivor Group and Cancer Support Group.
Major Accomplishments: Increased staff, coalition members and partners’ capacity to implement and evaluate the Policy, System and Environment (PSE) component of the Comprehensive Cancer Control Plan Increased the RMI Cancer Coalition’s infrastructure capacity Increased the dissemination of the Cancer Surveillance Report from 2 to 6 (goal was 4). Increased the percentage of clinical staff’s awareness of the new RMI National Screening Guidelines from 1 to nearly 80% (Goal was 75%) Public hearings were held for “Import Duties Funding Supplement Amendment Act 2016” (on Tobacco, Alcohol, and Sweetened Beverages) and Betelnut Prohibition Amendment Act. The team worked on these two Bills with key stakeholders in the government system (Attorney General, Legal Counsel, Ministry of Finance, etc.). Continued work with the cancer coalitions in Majuro and Ebeye for the church‐to‐ clinic cancer screening campaign
Reproductive Health Program provides Prenatal and Post‐Partum Services, Family Planning Services and Women’s Health Services.
Family Planning Services
Conduct in‐service training for all the RH/Family Planning staff, including clinical and management staff o 11 participants attended the VIA (Vinegar Inspection Acid), Cryotherapy and Family Planning Workshop held in Majuro.
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IEC (Inform, Educate, and Counsel) review committee was established
Continue providing educational awareness events with updated family planning IEC (Inform, Educate, and Counsel) materials o Family Planning Program participated in the Women United Marshall Islands (WUTMI) Annual Conference where the program presented educational awareness on the different methods and services available in the FP Clinics. 72 participated in this event o Post‐partum mothers were counseled on the available FP methods and services. 148 counselling services, 135 availed services, Ebeye: 92 o Male Clinics o Women’s Clinics o Home visits o Marshall Islands 9th graders High School students : 168 students (135 males and 133 females) o Kwajalein Atoll 10th graders High School students : 48 students
Family Planning Data
o More postpartum mothers are coming for their postpartum appointment and receiving methods. o More spouses are coming with their wife to the family planning clinic or come and get their wife’s family planning supply.
Prenatal and Post‐Partum Services
Tuesday is the 1st booking day. All booking mothers are provided with counseling on Family Planning and health class on these the topics of 1. HIV/STIs 2. Gestational Diabetes 3. Nutrition 4. Personal hygiene 5. Recognizing signs of danger and come to hospital ASAP
These Return Visits are done on: 1. Morning – Teen Pregnancy 2. Wednesday Afternoon – Normal Pregnancy 3. Thursday Morning – High Risk Pregnancy 4. Friday Morning – Normal Pregnancy
There were a total of 3 school outreaches during this quarter: a. All male workshops at CMI focusing on Reproductive Health and Sexually Transmitted Infections.
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b. All female workshop at CMI c. Presentation with MIHS 11th grade girls on the effects of Teenage Pregnancy There was 1 school tour/mini workshop with the Co‐op 10th graders focusing on Adolescent Reproductive Health and Sexually Transmitted Infections. Protocols and guidelines for Pregnant Mothers and ZIKA are in place. ZIKA kits put together and disseminated to 241 pregnant mothers in the RH clinic alone during this quarter starting from February 19, 2016. The ZIKA kits include 1 brochure, 1 mosquito net, 1 mosquito repellent and 9 pcs of male condoms. The RH team is working closely with the PH nurses to reach the pregnant mothers in the communities and outer islands. Increase number of women who received their FLU and Tdap compare to last quarter. Pap smear and GC testing have increased. VIA screening has been included in the RHC services. Regular RH health class and exercise two time a week by RH nurse and the Japanese volunteer.
Immunization Program 1. Vaccine Storage and handling a. Continued vaccine temperature monitoring of MCH Clinic, Laura Health Center and Ebeye Immunization Clinic by using the data loggers. Regular update of the loggers collected and monitored by Vaccine Management. b. Main activities: Receiving vaccines ordered from CDC, shipping vaccines to Ebeye, Monthly vaccine inventory, daily monitoring of vaccine temperature using the data loggers.
2. Continue to provide routine immunization to the whole RMI population a. Monthly spend plan, inventory, and vaccine order. b. Clinical base immunization – Immunization services are available in MCH Clinic, Maternity and Labor Ward, Prenatal Clinic, NCD Clinic, TB Clinic, STI/HIV Clinic c. Perinatal hepatitis B vaccination and activities d. HPV Vaccination Campaign
3. Immunization Outreach Activities: a. Continue the Majuro Zone Immunization Activities b. Outer Islands Immunization Outreach trips c. Ebeye Outreach Mobile visit d. Flu Vaccination Campaign e. HPV Vaccination Campaign
RMI Ministry of Health FY2016 Annual Report 26 | Page
4. Trainings and Meetings attended: AIRA Regional Training and WEBIZ Immunization Registry Training in Honolulu American Immunization Registry Association Conference in Seattle, Washington Immunization Information System Manager’s Meeting in Guam National Immunization Conference, Atlanta Clinical Vaccinology in Bethesda, Washington DC. 9th Immunization Program Meeting in Fiji CDC Immunization Awardee Meeting
5. MIWebIZ Activities : New version 16.4 of WebIZ has been implemented in Majuro and Ebeye Trained Majuro and Ebeye Immunization staff in MIWebIZ Use of MIWebIZ data on data reporting and analysis
6. Hep B Sero‐Survey on 1st Graders Training and assistance provided by CDC to conduct the survey Survey covers Majuro, Ebeye and Outer Islands for all 1st graders
Early Hearing Detection and Intervention (EHDI) Program
The EHDI Program has three major components: Newborn Hearing Screening, Audiological Diagnostic Evaluations and Early Intervention. Due to the geographical composition of the RMI the program is only providing services on the two main hospitals, Majuro and Ebeye. However, plans are underway to expand services to the outer islands.
Screenings
The program implements a two‐stage screening protocol where initial screenings are done 12‐24 hours after birth, preferably before discharge. Newborns who fail the hearing test are scheduled to have an outpatient re‐screen by two weeks old. A newborn failing the hearing screening for the second time or at two weeks old will then be put on a list to be seen by the audiologist who visits on a quarterly basis. Both inpatient and outpatient screenings are done by local nurses.
The following graph gives a visual representation of the steady improvement/progress made over the course of three consecutive years.
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Figure 3: New Born Hearing Screening from 2014 ‐ 2016
105.00%
100.00%
95.00% 90.00% 85.00% 80.00% Percentages 75.00% 2016 2015 2014 Not Screened 0.40% 0.81% 2.97%
Referred 4.75% 10.03% 13.19% Passed 95.05% 89.97% 88.07%
Table 5: New Born Hearing Statistics, 2014‐2016 Screening Data 2016 2015 2014 Births 1007 983 1045 Screened 988 967 1031 Passed 940 870 908 Referred 47 97 136 Not Screened 4 8 31
Diagnostics
Audiological diagnostic evaluations are done on a quarterly basis by a visiting/itinerant Audiologist. Over the years the number infants referred for diagnostics has been declining. This is due to the major improvement in the screening process. Infants and toddlers that have been diagnosed and identified with a permanent hearing loss (as well as other special health needs) are referred and enrolled in early intervention program. Infants/toddlers with a conductive hearing loss are referred to the ENT who visits twice a year to both Majuro and Ebeye. Below is a table summarizing all the team visits for the reporting period:
Table 6: Audiological Evaluations and Surgeries Age Group Audiology ENT Surgeries Total by age 0 to 3 163 46 30 239 3 to 6 38 20 15 73 6 to 18 105 86 21 212 18+ 43 76 33 152 Total by type 349 228 99
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n=4 n=9 n=102 100% 5 9% 24% 39% 80% 38% 17% 60% 36% 40% 50% 33%
20% 14% 20% 9% 12% 0% 2016 2015 2014 Normal Hearing Hearing Loss Not Evaluated In Process
Early Intervention
The early intervention is a ‘family‐centered’ program which provides services and support for those identified with hearing loss (and other special needs) to reach their full potential. This year a total of ten infants/toddlers were enrolled. Most of the services provided occur in the home setting where members of the families can learn strategies together to help their child. There are also group sessions, infant group (0‐18 months) and toddler group (18mo to 4y) which occurs once a week for each group. The caseload consist of many special needs ranging from hearing loss, Down syndrome, cerebral palsy, deaf blind, delayed speech, and cleft lip and palette. EI is provided by the EI teacher who is also the Coordinator.
Table 7: Cases under Early Interventions New cases 10 Old cases 8 Total 18
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Challenges
• Planning and scheduling of AuD/ENT visits has been a challenge. Once a visit coincided with another mission which made it difficult to share resources such as OR, OPD rooms, and local staff. • Lost (delayed for) to Follow‐Up of babies who need hearing screening and diagnostics. – Wrong contact info – Moved back to Outer Is. after delivery • Lack of Resources – No full time EI teacher‐Majuro • Coordinator is also .50 FTE EI teacher – No organized family support group – No EI teacher in Ebeye – No screening for babies born in the outer islands – No EI services for infants and toddler in the outer islands • Delayed language acquisition – Families are not signing enough
Successes
• After almost three years without a champion, this year the Secretary appointed Dr. Mary Jane Gancio as the EHDI Champion for the Marshall Islands • Consistent AuD/ENT visits – added value for the community not just babies • Onsite refresher training for screeners and Pediatrician on the use of screening equipment • Donations ‐ Ebeye – 15 large boxes medical and surgical supplies
RMI Ministry of Health FY2016 Annual Report 30 | Page
– Arranged/secured by Dr. Wagner and received by Ebeye Hospital Administration and Minister. • Audiology suite completed/operational in Ebeye • Early Intervention room/class room completed in Majuro • Video Otoscopy capability • Adopted CDC’s Zika Audiological Protocol for those exposed in utero • Tele‐Early Intervention via skype with a deaf three year old in Ebeye
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IV. HEALTH INDICATORS REPORT FY2016
RMI Ministry of Health Key Performance Indicators Annual Scorecard‐ 2016
Code for trend:u = Improving = Getting Worse = No change = Need more data =Target reached Type Key Performance Indicator Target 2015 result 2016 Result Trend (or earlier if noted) 1 Life expectancy at birtha NT 71.9 years (due in 2020) 2 Infant mortality rate,b,h 12t 13 15 c 3 Early child (<5 years) mortality ratea,b,h 25j 31 32
Indicators a,b,i j
Demographi 4 Maternal mortality ratio 70 87 121 5 Top 10 causes of deatha 6 Top 10 outpatient diagnoses 7 Top 10 hospital admission diagnoses NA (See Tables 1‐5) NA 8 Top 5 reasons for within‐RMI referrals 9 Top 5 diagnoses for out‐of‐RMI referrals Case Mix Indicators
10 Youth 30 day tobacco smoking prevalencea,b,k NT 32% (in 2011)d 31% 11 Youth 30 day alcohol use prevalencek NT 40.8%d Ø 12 Youth overweight + obesity prevalencek NT Ø 26.5% 13 Adult mortality rate, cancerb,l 122.3e 163 (in 2014) 130 14 Mortality rate, cardiovascular disease b,l 155.0e 207 (in 2014) 237 b,l e
NCD Core (in 2014)
Indicators 15 Mortality rate, diabetes 360.3 480 429 16 Mortality rate, chronic lung disease b,l 19.7e 26 (in 2014) 11 17 Suicide mortality rateb,m 11.4f 16 (in 2014) 16 18 Child immunization completeness14 90% 59% 47% 19 Coverage with Family Planning Services a,b,o NT 16% 16% 20 Teen birth rate a,b,p NT 58 49 21 Births attended by skilled personnel (%) a,b 95% 99% 99% MCH 22 Prevalence of underweight in children (age 5 years) a,b <5%v Ø XXX 23 Prevalence of overweight in children (age 5 years) a NT Ø XXX 24 Tuberculosis incidencea,b,q ≤ 1 22 30 25 TB one‐year on‐time Rx completion rate 95%g 87% 87% 26 Leprosy incidenceb,q < 1 10 16 27 Leprosy on‐time Rx completion rate 95%g 60% 36% 28 Incidence HIV in people age 18‐44 yearsr 0 5 5 (& # all ages living with HIV in RMI)b (3 new/7 living with HIV) 29 Pregnant ♀‐ Syphilis prevalence (%) NT Ø 1%
Indicators 30 Pregnant ♀‐ Gonorrhea prevalence (%) NT Ø Ø Ø Ø TB, Leprosy, STI 31 Pregnant ♀‐ Chlamydia prevalence (%) NT 32 Pregnant ♀‐ Hepatitis B infection (%) NT Ø 3% 33 Girls protected by HPV vaccine (%)s 90% 29% 32%
RMI Ministry of Health FY2016 Annual Report 32 | Page
RMI Ministry of Health Key Performance Indicators Annual Scorecard‐ 2016
Key Performance Indicator Target 2015 result 2016 Result Trend (or earlier if noted) 34 # of people for each physician and # of people for each NT 1663:1 (doctors) XXX nursea,b 368:1 (nurses) 35 Per capita health expenditures per yeara NT $436 XXX
36 Within‐RMI Referrals‐ Average cost per case NT $3787 XXX (total cost & # cases) ($200K/56 cases) 37 Out‐of‐RMI Referrals‐ Average cost per case NT $22,270 XXX (total cost & # cases) ($3.5M/161 cases)
38 Budget and end‐of‐year utilization % (“burn rates”): a) 90% a) XXX a) XXX Resource Indicators Compact & General Fund, b) Health Care Fund & Health b) XXX b) XXX Care Revenue Fund, c) Other Grantsa,b c) XXX c) XXX 39 Inventory: % meds on essential list in stockb 90% Ø XXX
40 Staff attendance: % workrate 90% 36% XXX
Admin 41 Vendor payment, contract, personnel action processing <60 Ø XXX
Indicators times days
NA= not applicable; NT= no target set yet; Ø= data not available; ?= uncertain; MCH= maternal & child health; NCD= non- communicable diseases a Healthy Islands indicator (see text below) b Sustainable Development Goals indicator (see text) c Baseline is average for previous 5 years (eg. Baseline for 2015 is average for years 2011, 12, 13, 14 and 15) d Baseline is from 2011 Youth Risk Behavior Survey in RMI high schools e Targets for NCD mortality indicators from WHO NCD Monitoring Framework, calling for a decrease in NCD cause‐specific mortality rates of 25% by year 2025 from 2010 baseline. Since we have no 2010 baseline for RMI we are using 2014 rates for baseline. f Target for suicides is average global rate. Ref: WHO: World Health Statistics, 2016. http://who.int/entity/gho/publications/world_health_statistics/2016/en/index.html g Target for TB and Leprosy On‐Time Treatment Completion Rates based on CDC TB Program national targets. h Rate is per 1000 live births i Ratio is per 100,000 live births j SDG Global Target k High School youth l Deaths among adults, 30‐69 years of age per 100,000 adults 30‐69 years of age m Suicide deaths, any age, per 100,000 population n Children age 19‐35 months of age complete for 4‐DTaP, 4‐Polio, 3‐HepB, 3‐HIB, 1‐MMR o Women, age 15‐44 years p Rate is per 1000 females age 15‐19 years q Per 10,000 population per year r Per 1000 people 18‐44 years of age per year s Girls, age 13 years tTarget from RMI MCH 5 year Needs Assessment, 2016‐2020 uChange in indicator from previous year must be at least 10% to count as a “significant” vUNICEF Global Target
RMI Ministry of Health FY2016 Annual Report 33 | Page
Life expectancy at birth
2016 Value = 71.9 years Benchmark Value = 71.4 years (no Target Value established)
Figure 4 Life Expectancy at Birth, RMI Life Expectancy at Birth, RMI, Since 1988
74 71.9 72 70 67.5 68 66 64 61 62 Age in Years 60 58 56 54 1988 1999 2011 Year of Measurement
Brief Definition: The average number of years that a newborn could expect to live, if he or she were to pass through life subject to the age‐specific death rates of a given period.
Relevance: Life expectancy at birth is a summary indicator of mortality conditions and, by proxy, of health conditions. It summarizes mortality risks and trends across all age groups, including older people. Measurement of life expectancy at birth also allows reporting of life expectancy at other ages to track health improvements for specific age groups in populations. Life expectancy is included as a basic indicator of health and social development in, among others, the Minimum National Social Data Set endorsed by the United Nations Statistical Commission and the OECD/DAC core indicators
Data Source(s): 1988 and 1999 values from RMI MOH Statistical Abstract 1999‐ 2001 (original data source unclear). 2011 value from 2011 RMI Household Census. Future values due in 2020.
Data Notes: Obtain the published RMI census every 10 years. Do not need to calculate at MOH.
RMI Ministry of Health FY2016 Annual Report 34 | Page
2015 Result: None. New estimate due with 2020 census.
Reliability: Good
Baseline: 61 years in1988
Benchmark: Global average= 71.4 years (range 50.1-83.7 in 2015)1
Infant mortality rate per 1,000 live births
2016 Value = 14.7 infant deaths per 1,000 live births Target Value = TBD
Figure 5: Infant Mortality Rate, RMI, 2009‐2016
Infant Mortality Rate (IMR), RMI, 2009‐2016
35 29.7 30 26.3 25.3 23.3 25 22
20 16 14.7 15 13 10 \
IMR per 1,000 live births 5 0 2009 2010 2011 2012 2013 2014 2015 2016 Year of Measurement 3 year running average up to and including reporting year
Brief Definition: Number of babies who died before their first birthday for every 1,000 live births.
Relevance: One of the most important worldwide indicators of health of the mothers and babies. Reflects quality of mother and newborn’s nutrition, breastfeeding, household sanitation, vaccination protection and quality of medical care.
Data Source(s): Vital Statistics Database
1 http://www.who.int/gho/mortality_burden_disease/life_tables/situation_trends/en/
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Data Notes: Data back to 2010 are thought by Vital Stats and IT staff to be reasonably reliable. The quality of birth and death records depends on coding by physicians of birth and death certificates (improving but still often inaccurate or non-specific) and by reports made by health assistants of births and deaths in the outer islands (incomplete and inaccurate, partly because it is often difficult to assign cause of death in absence of diagnostic tests and XRays). A review by the demographics division of SPC of the RMI 2010 to 2014 vital stats estimates that, even now, only about 78% of births and deaths that actually occur in the RMI are recorded. Starting in 2016, weekly death reporting and a verbal autopsy procedure was introduced for Outer Islands Deaths which should improve completeness and cause of death determination.
Reliability: Fair
Baseline: 29.7 (average IMR between 2007-2009)
Benchmark: Worldwide, reported country infant mortality rates range from 5.8 to 160 in 2015.
Under 5 years old mortality ratio per 1,000 live births
2016 Value = 31.7 deaths per 1,000 live births Target Value = 25 deaths per 1,000 live births in 2030
Figure 6: Under 5 years old Mortality Ratio, RMI, 2011‐ 2016
Under 5 years old Mortality Ratio, RMI 2011‐2016 35 30 31.3 32.3 31 31.7 25 27.7 26 20 15 10 5 0 2011 2012 2013 2014 2015 2016 # of deaths per 1,000 live births Years of Measurement 3 year running average up to and including reporting year
Brief Definition: Number of babies who died before their first birthday for every 1,000 live births.
RMI Ministry of Health FY2016 Annual Report 36 | Page
Relevance: This is the most commonly used indicator for child survival and is one of the recommended Sustainable Development Goals health indicators. Under five mortality is influenced by poverty, education (especially of mothers) by environmental risks including access to safe water and sanitation, by nutrition and by quality of health services. One of the most important worldwide indicators of health of the mothers and babies.
Data Source(s): MOH “VRIS” Vital Statistics database
Reliability: Good
Baseline: 31.3 deaths per 1000 live births in 2011 (i.e. average for 2009, 2010, and 2011)
Benchmark: 25 deaths per 1,000 live births in 20302
Maternal mortality ratio per 100,000 live births
2016 Value = 121.1 deaths per 100,000 live births Target Value = 70 deaths per 100,000 live births (2030)
Figure 7: Maternal Mortality Ration, RMI, 2009‐ 2016
Maternal Mortality Ratio, RMI, 2009‐2016 200.0 175.8 180.0 160.0 130.9 140.0 121.1 120.0 92.6 100.0 83.2 70.3 80.0 53.3 53.3 60.0 40.0 20.0 # of deaths per 1,000 live births 0.0 2009 2010 2011 2012 2013 2014 2015 2016 Years of Measurement 3 year running average up to and including reporting year
Brief Definition: # of maternal deaths in current year for every 100,000 live births
2 http://www.who.int/gho/child_health/mortality/mortality_under_five_text/en/
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Relevance: This is the most commonly used indicator for safety of childbirth and is one of the recommended Sustainable Development Goals health indicators. The most common causes of deaths related to pregnancy and childbirth such as bleeding and obstructed labor are almost entirely preventable through delivery of high‐quality family planning services and modern medical care.
Data Source(s): MOH VRIS/Vital Stats database
Data Notes: See data notes for Infant Mortality Rates above
Reliability: Good
Baseline: 83.2 in 2009 (average for 2007, 2008 and 2009)
Benchmark: Global average to 2015 is 216.0/100,000 live births (range 3.0 ‐1,360 in 2015)
Table 8: Top 10 Leading Causes of Mortality, FY2016 Rank Underlying Cause of Death Number 1 Diabetes 83 2 Cardiovascular Diseases 57 3 Cancer 32 4 Hepatitis B 26 5 Injury/Accident/Drowning ‐ All 20 together 6 Suicide 11 7 Pneumonia 10 8 Septicemia 8 Gastroenteritis 8 9 Gastrointestinal Bleeding 5 J40‐J47 Chronic Lung Disease 5 10 Tuberculosis of the Lungs 4 Source: Vital Records Information System, OHPPS‐MOH
Table 9: Top 10 Diagnosis for Outpatient Visits, FY2016 Rank Diagnosis Number 1 Diabetes 6977 2 Acute Upper Respiratory Infection 5644 3 Hypertension 2831 4 Dental carries 1585 5 Gastroenteritis 1574 6 Cellulitis and Abscess 1212
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7 Urinary Tract Infection 1120 8 Chronic Bronchitis 1070 9 Otitis Media 978 10 Cataract 558 Source: Majuro Hospital and Ebeye Hospital
Table 10: Majuro Hospital and Ebeye Hospital Top 10 Admission Diagnosis, FY2016 Rank ICD 9 Diagnosis No. 1 V30.x Single Born in Hospital 794 2 650 Normal Delivery 725 3 V27.x Single Liveborn, (Outcome of Delivery) 614 4 250.x Diabetes Mellitus 337 5 682.9 Abscess, NOS Cellulitis NOS 147 6 486 Pneumonia, Organism Unspecified 114 7 485 Broncho Pneumonia, organism unspecified 113 7 669.7 Cesarean delivery, w/o mention of indication 113 8 401 Hypertension, Unspecified 96 9 11.9 Pulmonary Tuberculosis, unspecified 78 10 280 Iron Deficiency Anemia 58 Source: Majuro Hospital and Ebeye Hospital Brief Definitions: a. Top 10 causes of death: Most common underlying causes of death b. Top 10 diagnoses, hospitalized patients: Most common primary causes for hospitalization c. Top 10 diagnoses, outpatient visits: Most common primary causes for outpatient care
Relevance: RMI like most countries in the Pacific has experience epidemiological transition over the past 20 years with increasing illness and deaths due to non- communicable diseases but with continuing burden of infectious and maternal and infant diseases. List of Top 10 deaths, hospitalization and outpatient visits gives a picture of the progress of this transition.
Data Source(s): a. Top 10 causes of death: MOH “VRIS” Vital Stats data base b. Top 10 diagnoses, hospitalized patients: Patient encounter database c. Top 10 diagnoses, outpatient visits: Patient encounter database
Data Notes: Data quality depends upon the completeness of reporting/data entry and the accuracy of diagnoses for cause of death, hospitalization, and outpatient care. There are minor to moderate problems for all three of these indicators.
Reliability: Good
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Baseline, Benchmark: NA
Table 11: Top Five Diagnosis for Off‐island Referral, RMI FY2012‐FY2016
FY 2012 FY2013 FY 2014 FY2015 FY2016
Orthopedic 30 Orthopedic 26 Cancer 35 Cardiovascular 34 Cancer 34 Cancer 16 Cancer 25 Orthopedic 22 Cancer 32 Cardiovascular/Orthopedic 29 Ophthalmology 14 Cardiovascular 20 Cardiovascular 21 Orthopedic 25 Ophthalmology 12
Congenital 14 Ophthalmology 19 Congenital 13 Ophthalmology 17 Pulmonology 7
Cardio 12 Congenital 13 Urology 12 Congenital 8 Surgical 5 Pediatric
Youth Risks ‐ Tobacco, Alcohol, Overweight/Obesity Youth NCD Risk Factors (30 day tobacco smoking and alcohol use prevalence, and overweight + obesity prevalence)
2016 Values: Tobacco Smoking = 30.7% 3 Target Value = Not Yet Determined
Alcohol Drinking = (40.8% in 2011, most recent year measured) 4 Target Value = Not Yet Determined
Overweight/Obesity = 26.5%5 Target Value = Not Yet Determined
3 RMI Global Youth Tobacco Survey, 2016 4 RMI Youth Risk Behavior Survey, 2011 5 Add on RMI Global Youth Tobacco Survey, 2016
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Figure 8: Youth Smoking, Alcohol Drinking and Overweight/Obesity Prevalence, RMI, 2003‐2016
Youth Smoking, Alcohol Drinking and Overweight/Obesity Prevalence, RMI, 2003‐2016 50%
40%
30%
20% Percent
10%
0% 2003 2005 2007 2009 2011 2013 2016
Years of Measurement Tobacco Smoking Alcohol Ingestion Overweight/Obesity
Brief Definition: Proportion of High School children with any tobacco smoking, alcohol ingestion in the past 30 days or overweight/obesity for age and gender.
Relevance: Onset of these important NCD Risk factors commonly occurs in the teenage years. Youth Risk give the earliest signal for the nation’s NCD situation that will develop in coming years.
Data Source(s): Rapid High School Survey (every 2 years per RMI NCD Monitoring & Surveillance Plan). In past results for some youth indicators were obtained from Youth Risk Behaviour Survey and Global Youth Tobacco Survey.
Data Notes: School surveys do not count behaviour of drop outs so may not be completely representative of the youth in RMI.
Reliability: Good
Baseline: Tobacco = 37.5%, 2003 Alcohol = 45.7%, 2003 Overweight/Obesity = 26.5%, 2016 (first year measured)
Benchmark: Not established yet
RMI Ministry of Health FY2016 Annual Report 41 | Page
Mortality rate, (adults, 30‐69 years of age) for 4 major NCDs (cardiovascular disease, cancer, diabetes, chronic lung disease)
Figure 9: Diabetes Mortality Rate for 30‐69 yrs old, RMI, 2014‐2016
Diabetes Mortality Rate for 30‐69 yrs old, RMI, 2014‐2016 500
480 480.4
460
440 429.4 420
400 402
380
360 2014 2015 2016
Mortality rate, diabetes (adults, 30‐69 years of age/100,000)
Brief Definitions: a. Diabetes Mortality Rate Per 100,000 Population, 30‐69 yrs old b. Cancer Mortality Rate Per 100,000 Population, 30‐69 yrs old c. Cardiovascular Mortality Rate Per 100,000 Population, 30‐69 yrs old d. Chronic Lung Disease Mortality Rate Per 100,000 Population, 30‐69 yrs old
Numerator: Average number of deaths for each of the four causes above in adults, age 30‐69 years over the past 5 completed calendar years. (X 100,000)
Denominator: Number of adults 30‐69 years in the RMI
Data Source(s): MOH Vital Statistics database
Data Notes: See data notes for infant mortality above. ICD‐10 Codes for NCD causes of death: Cardiovascular Disease: I00‐I99; Cancer: C00‐D48; Diabetes: E10‐E14; Chronic Lung Disease: J40=J47. Get average annual number for each cause by taking the total # of deaths over 5 years and divide by 5. (i.e. for 2015 add # deaths for 2011‐2015 then divide by five. For population of RMI 30‐69 years use the projected population from the most recent census for the mid‐year of the 5‐year span (i.e. for 2015 use the projected 2012 population). Age‐adjust to the WHO standard year 2000‐2025 population (this indicator was taken from the RMI NCD Monitoring and
RMI Ministry of Health FY2016 Annual Report 42 | Page
Surveillance Plan which is based on the USAPI NCD Monitoring & Surveillance Framework. Framework and Excel template for calculation of 5‐year age‐adjusted mortality rates can be found at www.pihoa.org ).
2015 Result: Not yet available. 2014 baselines: Cardiovascular Mortality: 207.1 per 100,000 per year Cancer Mortality: 163.1 per 100,000 per year Diabetes Mortality: 480.4 Chronic Lung Disease Mortality: 26.2 per 100,000 per year
Reliability: Fair
Baseline: 2014 mortality rates
Benchmark: Target 25% decrease from 2010 baseline, by year 2025 (as recommended by WHO). Since this is not available for RMI use 2014 baseline then 25% decrease: Cardiovascular to 155, Cancer to 122.3, Diabetes to 360.3, Chronic Lung Disease to 19.7.
Suicide mortality rate/100,000/year
2016 Values: 15.6 per 100,000 population
Figure 10: Complete Suicide, RMI, 2011‐2016
Completed Suicide*, RMI, 2011‐2016 25.0 19.2 19.4 20.0 17.7 16.1 16.0 15.6
15.0
10.0
Cases Per 100,000 5.0
0.0 2011 2012 2013 2014 2015 2016 Years of Measurement *5 year running average, Prior to 2016, data is reported for fiscal year.
RMI Ministry of Health FY2016 Annual Report 43 | Page
Table 12: Suicide Cases, RMI, FY2012‐FY2016
FY2012 FY2013 FY2014 FY2015 FY2016 Types of Suicide Majuro Ebeye Outer Islands Total Majuro Ebeye Outer Islands Total Majuro Ebeye Outer Islands Total Majuro Ebeye Outer Islands Total Majuro Ebeye Outer Islands Total Completed 5 1 1 7 2 3 1 6 10 1 0 10 7 1 0 8 102012 Attempted 6 6 0 12 8 7 0 15 5 5 0 7 3 4 1 8 8 4 2 14 Total 11 7 1 19 10 10 1 21 15 6 0 17 10 5 1 16 18 6 2 26
Figure 11: Suicide Cases, RMI, FY2007‐FY2016, Per year Case
Suicide Cases, RMI, FY2007‐2016 35 33 30 25 25 20 16 16 15 14 15 13 12 12 10 10 10 9 8 7 7 8 5 6 6 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Attempted Completed
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Table 13: Registered Mental Health Patients, Mental Health Clinics, RMI, 2008‐2016 Number of registered mental health patients per year
Islands 2008 2009 2010 2011 2012 2013 2014 2015 2016
Majuro 283 338 366 90 89 137 144 181 190
Kwajalein 20 20 20 23 22 14 14 9 9 (Ebeye) Outer Islands 11 11 11 7 8 10 8 8 24
RMI (Total) 314 369 397 120 119 161 166 198 223 Source: Human Services Program
Table 14: Summary of Birth Indicators, RMI, FY2010‐FY2016 Description FY FY FY FY FY FY FY 2010 2011 2012 2013 2014 2015 2016 Registered Birth 1,396 1,487 1,316 1,308 1,199 1116 1089 Crude Birth Rate Per 1,000 Live 26 28 24 24 22 20 20 births Total Fertility Rate 3.18 3.38 3.05 3.03 2.71 2.74 2.69 Rate of Natural Increase 2.04% 2.12% 2.12% 1.83% 1.72% 1.34% 1.33% LBW 186 181 167 180 156 196 120 VLBW 26 10 17 9 6 14 6 Premature 74 90 50 36 78 66 91 Teen Pregnancy (15 to 19 yrs. Old) 201 222 176 177 192 162 144 % of Teen Pregnancy from All 14% 15% 13% 14% 16% 15% 13% Birth Teen Pregnancy Rate Per 1,000 67 96 75 72 73 58 49 Population Source: Vital Statistics Office Table 15: Birth by Location, RMI FY2010‐FY2016
Fiscal Year Majuro Kwajalein Outer Islands Total 2010 944 311 141 1,396 2011 1,017 344 126 1,487 2012 906 305 105 1,316
2013 877 300 131 1,308
2014 829 232 122 1,173 2015 744 261 111 1,116
2016 725 277 87 1,089 Source: Vital Statistics, MOH
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Table 16: Births Attended by Skilled Health Personnel, FY2011‐FY2016 Description FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 No. of Birth by Skilled 1,374 1,263 1,290 1,160 1,109 1,069 Attendant No. of Birth 1,487 1,316 1,308 1,199 1,116 1,072 Percent 98% 99% 99% 97% 99% 99% Source: Vital Statistics, MOH
Table 17: Birth by Attendant and Location, FY2016 Attendant FY 2016 Majuro Kwajalein Outer Islands Total Nurse or Midwife 605 180 10 795 Health Assistant 0 61 11 72 Medical Assistant 0 0 0 0 Doctor 105 83 1 189 Others 1 0 0 1 Traditional Birth Attendant (TBA) 3 0 0 3 Not Stated 9 0 3 12 Total 723 324 25 1,072 Source: Vital Statistics, MOH
Table 18: Summary of Death Indicators, FY2010‐FY2016 Description FY FY FY FY FY FY FY 2010 2011 2012 2013 2014 2015 2016 Registered Death 286 361 332 335 280 384 353 Infant Death 31 41 26 23 12 12 25 Fetal Death (Still Birth) 15 21 15 14 18 6 10 Early Neonatal Death 16 16 8 16 5 7 9 Neonatal Death 22 25 13 18 6 7 12 Post Neonatal Death 9 16 13 6 6 5 13 Perinatal Death 31 37 19 30 23 13 19 Under 5 years old Death 36 31 25 39 40 60 34 Maternal Death 2 2 0 1 1 0 3 Rate/Ratio Crude Death Rate*2 5 7 6 6 5 7 6 Infant Mortality Rate*1 22 28 20 18 10 11 23
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Fetal Mortality Rate*1 11 14 11 11 15 5 9 Neonatal Mortality Rate*1 16 17 10 14 5 5 9 Perinatal Mortality Rate*1 22 25 17 23 19 1 2 Child Mortality Rate (under 5 28 34 25 24 29 40 26 years old) Maternal Mortality Rate*3 143 134 0 76 83 0 280 *1 ‐ Per 1,000 live births, *2 ‐ Per 1,000 Population *3 ‐ Per 100,000 Population, Source: Vital Statistics, MOH
Diabetes Table 19: Prevalence and Mortality rate of Diabetes, RMI, FY2011‐FY2016
Description FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 No. of Registered 1,980 1,794 1,804 2,166 2,384 2,737 Diabetes Patients No. of Death related 84 120 103 109 98 83 to Diabetes Population 53,158 53,727 54,166 54,550 54,880 55,161 Mortality Rate Per 15.8 22.3 19.0 20.0 17.9 15.0 10,000 Population Prevalence of Diabetes Per 10,000 356.7 311.6 314.0 377.1 416.5 481.1 Population
Table 20: Majuro Key outcome Measures for Diabetes, FY2011 – FY2016
Outcome Measures By By By By By By 9/30/11 9/30/12 9/30/13 9/30/14 9/30/15 9/30/16 No. of Registered Diabetic 589 925 1236 1535 1799 2108 Patients No. of Pts w/ 1+ visits 515 580 664 691 697 815 At least 90% of DM Patients 39.2% 33.4% 55 33.6% 28.0% 40.9% have annual Flu vaccination At least 70% of DM Patients 13.4% 28.4% 21.5 20.7% 17.9% 31.0% have annual Retinal exam Nutrition education 34.2% 30.3% 38.4 21.7% 18.7% 19.8% At least 90% of DM Patients 43.3% 45.0% 47.6 27.2% 13.3% 21.5% have annual foot exam At least 70% of DM Patients 36.1% 5.2% 10.8 17.8% 12.1% 32.3% have annual Dental exam DM education 34.3% 30.0% 38.3 20.8% 18.1% 12.4%
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At least 70% of DM Patients 0.0% 0.0% 23.9 23.6% 21.5% 12.4% have Self‐Management Goal setting At least 70% of DM Patients 7.6% 6.2% 8.9% 6.1% 5.6% 2.9% have 2 A1c within 90 days A1c <7% 3.9% 2.9% 4.7% 2.9% 3.4% 4.0% Creatinine check 48.7% 73.8% 62.7% 48.0% 61.0% 39.0% At least 40% of DM patients 72.9% 72.4% 69.4% 68.2% 77.6% 70.7% have BP of <140/90 mmHg annually At least 75% of patients (55 15.1% 17.8% 22.6% 24.7% 24.1% 25.4% years and older) have current prescriptions for ACE inhibitors annually Atleast 60% of patients are 13.8% 25.3% 46.2% 40.2% 45.8% 48.30% on Statins Source: CDEMS ‐ Majuro Table 21: Ebeye Key outcome Measures for Diabetes, FY2011 – FY2016 Outcome Measure By By By By By By 9/30/11 9/30/12 9/30/13 9/30/14 9/30/15 9/30/16 PECS DATA REGISTRY 413 476 596 544 882 629 SIZE 1. Average HbA1c of < 10.90% 11.30% 15% 10.20% 9.8 9.60% 7.0% 2. At least 90% of 2.10% 39.60% 3.90% 9.90% patients have at least 2 HbA1c/year 3. At least 70% of 12% 15% 4% 24.20% 2% 14% patients have SMG sessions 4. At least 40% of 29% 37.40% 40.10% 33.10% 28 29.80% patients have BP <130/80 mmHg 5. At least 75% of 69.60% 66.9 53.60% 59.00% 65.20% 86.40% patients (55 years and older) have current prescriptions for ACE Inhibitors 6. At least 60% of 26.40% 23.7 23.10% 25.30% 31% 29.40% patients (40 years and older) have current prescriptions for Statins
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7. At least 70% of NR NR NR 44% NA 96.10% patients have dilated eye exam for the past year 8. At least 70% of NR 10.90% 6.50% 24.20% NA 7.40% patients have comprehensive foot exam for the past year 9. At least 70% of 51% 43.60% 45% 38.50% 10% 15.60% patients have dental examination for the past year 10. At least 90% of 99% 99% 99% 90% 99% 98.90% patients have Influenza vaccination for the past year 11. At least 70% of NR NR NR NR NR NR patients have LDL determination below 100 mg/dl Source: PECS‐Ebeye
Cancer Table 22: Incidence and Prevalence of Cancers in RMI, FY2009‐FY2016
Description FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 No. of New Cancer 52 82 67 40 52 59 48 57 Patients Incidence Rate Per 10 15 13 7 10 11 9 10.3 10,000 Population No. of death related to 36 26 27 33 43 22 20 31 cancer Mortality Rate Per 7 5 5 6 8 4 4 6 10,000 Population No. of Old and New 192 238 341 376 476 513 541 567 Cancer Patients Prevalence Rate Per 36 50 64 70 88 94 99 102.8 10,000
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Figure 13: Incidence Rates of Female Cancer Sites, FY2016, Per 100,000
Incidence Rates of Female Cancer Sites, FY2016
100 89 90 80
70 60 50 40 30 15 X 100,000 POPULATION 20 11 11 10 44444 0
Cervical cancer is the most common type of cancer for female population. The Ministry of Health is addressing the increase of cervical cancer cases by emphasizing on the strength of prevention and early detection. The National Comprehensive Cancer Control Program (NCCCP) works together with Faith Based Organization in encouraging and providing assistance to women who wants to undergo papsmear or VIA. Reproductive Health Services and Canvasback Mission were ready to test the ladies who voluntarily screened for cervical cancer. In FY2017, the Ministry is implementing a population based mass screening of women for cervical cancer.
Table 23: Contraceptive Prevalence Rate, RMI, FY2011‐FY2016 Description FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 No. of Women 15‐44 yrs old that 1,234 1,373 1,721 1,917 1,836 1,826 used at least one method of contraception No. of 15‐44 yrs old women 11,867 11,799 11,757 11,746 11,751 11,761 Contraceptive Rate 10% 12% 15% 16% 16% 16% Source: Family Planning Clinics
Table 24: Female Unduplicated Users in Family Planning Clinics, RMI, FY2016 Description <15 15‐17 18‐19 20‐24 25‐29 30‐34 35‐39 40‐44 >44 Total Primary Method Female 0 0 0 1 193 200 129 45 17 585 Sterilization Hormonal 2 14 20 65 56 42 14 12 5 230 Implant
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3‐Month 0 35 65 150 147 113 84 34 20 648 hormonal injection Oral 1 7 16 54 62 56 33 16 10 255 Contraceptive Female 0 10 25 11 10 8 8 11 1 84 Condom Fertility 0 1 1 20 24 13 12 3 1 75 Awareness Method (FAM) Abstinence 0 0 1 0 0 0 0 0 0 1 Other Method 0 1 1 0 1 0 1 1 1 6 Unknown 0 0 0 0 0 0 0 0 0 0 Method Total 3 68 129 301 493 432 281 122 55 1,884 No Method Pregnancy or 5 31 79 245 226 163 92 19 6 866 Seeking Pregnancy Other Reason 0 20 40 101 138 100 79 39 55 572 (STI Testing, PapSmear VIA, Counselling) Total 5 51 119 346 364 263 171 58 61 1438 Rely on Method Vasectomy 0 0 0 0 2 0 0 0 0 2 Male Condom 0 0 3 7 9 7 4 4 2 36 Total 0 0 3 7 11 7 4 4 2 38 Total Female 8 119 251 654 868 702 456 184 118 3,360 Users of Family Planning Clinic Source: Family Planning Clinics
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Table 25: Male Unduplicated Users in Family Planning Clinics, RMI, FY2016 Primary Method <15 15‐17 18‐19 20‐24 25‐29 30‐34 35‐39 40‐44 >44 Total Vasectomy 0 0 0 0 0 0 0 0 0 0 Male Condom 0 0 6 12 5 1 1 0 1 26 Other Reason 0 0 0 1 2 0 0 0 1 4 Total Male Users 0 0 6 13 7 1 1 0 2 30 of Family Planning clinic Source: Family Planning Clinics
Table 26: Prenatal Care Coverage, FY2011‐FY2016 Description FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 No. of Pregnant Women 1,374 1,263 1,237 1,183 1,065 1,035 with Prenatal Care No. of Birth 1,487 1,316 1,308 1,199 1,116 1,089 Percent 92 % 95% 95% 98% 95% 95% Source: Prenatal Clinics
Table 27: Immunization Coverage Rate, 19‐35 months, FY2016 Vaccine Majuro Ebeye Outer Islands RMI Percent DTAP4 486 308 84 878 49% HepB3 769 316 213 1,298 73% HIB1 1011 319 387 1,717 96% IPV3 737 315 164 1,216 68% MMR1 684 314 297 1,295 73% No of fully immunized 458 306 80 844 No. of 19‐35 months old 1,110 321 354 1,785 Percentage 41% 95% 23% 47% Source: National Immunization Program
Table 28: Immunization Coverage Rate, 19‐35 months, Per Atoll, FY2016 ATOLLS/ISLANDS Target Complete # of incomplete % Population Immunization immunization Complete (4DTAP, 3HEPB, Coverage 1HIB, 3OPV, 1MMR) Ailinglaplap 42 3 39 7 Arno 76 18 58 24 Aur 14 1 13 7
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Ailuk 7 0 7 0 Ebon 23 1 22 4 Enewetak 36 18 18 50 Jabat 0 0 0 0 Jaluit 66 21 45 32 Kili 31 3 28 10 Kwajalein (Ebeye) 338 326 12 96 Lib 0 0 0 0 Lae 13 4 9 31 Likiep 13 1 12 8 Namu 14 1 13 7 Maleolap 23 3 20 13 Majuro 1,102 459 643 42 Mejit 7 2 5 29 Mili 25 0 25 0 Namdrik 15 1 14 7 Ujae 8 1 7 13 Utrik 13 2 11 15 Wotho 1 0 1 0 Wotje 14 3 11 21 Total 1,881 868 1,013 46
Table 29: FY2016 Immunization Dosage Report Per Age and Vaccines Vaccines Age in years <1 1 2 3‐5 6 7‐10 11‐ 13‐ 19‐ 25‐ 45‐ 65+ Total 12 18 24 44 64 BCG 931 21 3 4 0 0 0 0 0 0 0 959 HepB1 1,796 168 38 19 3 0 2 7 0 0 0 0 2,033 HepB2 678 94 39 27 3 1 1 4 1 0 0 0 848 HepB3 28 23 13 12 1 2 3 23 1 0 0 0 106 DTaP1 1,778 722 126 399 23 5 1 2 0 0 0 0 3,056 DTaP2 580 163 112 404 12 0 0 0 0 0 0 0 1,271 DTaP3 6 34 27 126 13 1 0 0 0 0 0 0 207 DTaP4 0 6 5 34 7 1 0 0 0 0 0 0 53 DTaP5 0 0 0 12 14 0 0 0 0 0 0 0 26 IPV1 1,766 237 66 726 44 45 15 12 44 7 0 0 2,962
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IPV2 580 99 41 86 12 5 0 0 4 0 0 0 827 IPV3 6 16 9 26 0 2 0 3 0 0 0 0 62 Rota1 843 2 0 1 1 0 0 0 0 0 0 0 847 Rota2 628 2 1 1 0 0 0 0 0 0 0 0 632 Rota3 488 0 0 1 0 0 0 0 0 0 0 0 489 Prevnar1 947 84 12 11 2 6 6 2 0 0 0 0 1,070 Prevnar2 758 132 46 39 4 3 0 0 0 0 0 0 982 Prevnar3 615 174 79 70 3 1 0 0 0 0 0 0 942 Prevnar4 2 468 82 147 4 0 0 0 0 0 0 0 703 Hib1 1,222 586 56 24 2 0 0 0 0 0 0 0 1,890 Hib2 479 219 60 24 0 0 0 0 0 0 0 0 782 Hib3 4 52 42 30 2 0 0 0 0 0 0 0 130 MMR1 0 805 103 46 2 5 1 13 6 32 10 2 1,025 MMR2 0 460 168 144 11 16 4 47 27 49 15 2 943 Td1 0 0 0 0 0 70 35 272 41 17 6 1 442 Td2 0 0 0 0 0 3 0 9 4 1 0 0 17 Td3 0 0 0 0 0 0 0 1 1 0 0 0 2 Tdap 0 0 0 0 1 7 6 281 261 311 41 4 912 HPV1 0 0 0 0 0 24 297 214 27 14 0 0 576 HPV2 0 0 0 0 0 3 135 157 22 9 0 0 326 HPV3 0 0 0 0 0 0 49 78 9 3 0 0 139 Flu 663 426 247 988 373 1,473 689 1432 906 2,477 1,367 261 11,302 PPV23 0 0 0 0 0 0 0 6 5 70 202 36 319 MCV4 0 0 0 0 0 3 11 326 205 87 13 1 646
HPV Coverage Rate Cervical cancer has been the leading cause of death in the RMI over the past 10 years; the incidence and death rates from cervical cancer are among the highest in the Pacific in RMI. HPV is the cause of most cases of cervical cancer. Effective delivery of HPV vaccine to girls before the onset of sexual activity can protect the next generation of RMI women from this terrible disease. For the past 3 years, the trend of HPV vaccination is increasing due to the Immunization Program’s campaign and activities in the school.
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HPV vaccine coverage of girls age 13 years, RMI, 2014‐2016*
100 90 80 70 60
Percent 50 40 29 32 30 22 20 10 0 2014 2015 2016 Year *2 Doses of HPV vaccine Source: Majuro and Outer Islands – MIWebIZ, Kwajalein – Filemaker pro
Tuberculosis
Table 30: Incidence and Prevalence of Tuberculosis in RMI, FY2010‐FY2016 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 New TB Cases 155 136 96 119 137 125 160 Incidence Rate Per 28 26 18 22 26 23 29.0 10,000 Population Old and New Cases 166 156 101 123 154 137 180 # of smear‐positive 50 33 36 61 65 89 * cases cured or completed treatment Prevalence Rate Per 30 29 19 23 29 25 32.6 10,000 Population New Cases of MDR TB 2 0 2 2 0 1 0 Source: National TB Program * Cure rate will be reported in 2017.
Leprosy incidence per 10,000 per year
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2016 result: 16.4 Per 10,000
Figure 14: Leprosy Incidence, RMI, 2014‐2016
Leprosy Incidence*, RMI, 2014‐2016 25.0
20.1 20.0 18.5 16.4
15.0
10.0 Cases Per 10,000
5.0
0.0 2014 2015 2016 Years of Measurement *5 year running average
Table 31: Incidence and Prevalence Rate, RMI, FY2010‐FY2016
Registered Cases FY FY FY FY FY FY FY 2010 2011 2012 2013 2014 2015 2016 New Cases 98 120 155 93 83 56 66 Incidence Rate Per 10,000/year 18 23 29 18 16 10 12 Number of Leprosy Cases 67 107 113 137 102 95 53 Cured/Completed Treatment Number of Leprosy Cases in the 162 245 266 236 196 158 146 year Cure Rate 41% 44% 43% 58% 52% 60% 36%
Table 32: STD/HIV Prevalence, RMI, FY2011‐FY2016
STI FY 2011 FY2012 FY2013 FY2014 FY2015 FY2016 + Rate + Rate + Rate + Rate + Rate + Rate Case Case Case Case Case Case
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Source: STD/HIV Syphilis 165 31 129 24 126 23 130 24 44 8 67 Program, Note: * Gonorrhea 96 18 25 5 4 1 16 3 35 6 43 no Chlamydia test Chlamydia 152 29 120 23 121 23 171 32 * * done in the HIV 8 2 8 2 8 2 8 2 7 1 7 reporting year. Prevalence rate is per 10,000 Population
HOSPITAL SERVICES Table 33: Majuro Hospital Outpatient and Inpatient Encounters, FY2014‐FY2016 Encounters FY2014 FY2015 FY2016 Outpatient 25,613 23685 22,361 ER 8,049 10303 9,583 Surgical 563 573 580 Pediatric 455 485 488 Medical Unit 590 731 721 Medical ICU 86 108 121 Medical TB Isol. 62 58 74 Maternity 839 750 733 Operating Room 1,194 1075 1095
Table 34: Majuro Hospital Rehabilitation Department Services, FY2013 to FY2016 Description FY2013 FY2014 FY2015 FY2016 New Referrals 579 500 303 420 Total treatments 8,032 7,291 5,849 4,809 Diagnosis/Reason for Referral Back pain 115 95 64 76 DJD (degenerative joint disease causing 8 8 3 35 pain) MSD problems (shoulder, hip, knee pain) 147 127 72 95 Arthritis (RA, septic) 6 14 6 11 Total Knee Replacement (TKR) 3 9 3 3 DM/DM foot comp/minor amp/major amp.) 138 80 81 95 Stroke 44 53 33 37 Fracture 31 33 15 10 Other 100 59 63 58
Total 592 478 340 420
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Diabetic Foot Care New Patient 174 129 45 96 Follow Up Patient 170 108 67 59 Poor Senstation in the feet 31 32 15 74 Referred Ulcer 72 25 13 68 Foot Care Treatment*1 41 56 33 99 Healed Ulcer 14 13 24 Amputated Patient 5 3 2 Foot Care Education 138 112 155
Type of Amputation AKA 3 5 7 2
BKA 23 19 18 8 Toe Amputation 30 37 34 12 TMA 11 6 4 3 UL amputation 1 1 1 0 Total 68 68 64 25
Prosthetics Completed Prostheses 9 5 10 7 Prosthesis under construction/ 2nd 7 11 7 measurement Patient who had 1st measurement 4 12 8 Prosthetic modification/adjustments made 11 3 7 Prosthetic re‐paint 0 2 0 Shoe Modification (per pair) 4 14 5
Table 35: Majuro Hospital Radiology Department Services, FY2015 to FY2016 FY2015 FY2016 CR Study CT Study Total CR Study CT Study Ultrasound Total Oct 480 82 562 576 0 0 576 Nov 544 37 581 474 0 0 474 Dec 349 30 379 433 0 16 449 Jan 365 21 386 507 0 4 511 Feb 662 3 665 561 0 42 603 Mar 428 0 428 620 0 139 759 Apr 328 0 328 666 0 117 783 May 153 0 153 486 0 0 486
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Jun 253 0 253 565 0 0 565 Jul 556 0 556 409 0 3 412 Aug 556 0 556 656 0 7 663 Sep 531 0 531 540 0 6 546 Total 5,205 173 5,378 6,493 0 334 6,827 Source: UNIWEV PACS. CTScan was down for replacement since February 2015 Table 36: Majuro Hospital Pharmacy Department Services, FY2015 to FY2016 Outpatient FY2015 FY2016 Inpatient FY2015 FY2016 Total no. of Script 57,891 52,578 Total no. of orders 3,153 3,142 Total no. days 363 366 Total no. of days 363 366 Total no. of Script/ 159 144 Average no. of 9 9 day Order/ Day Total no. of items 143,157 159,499 Total number items 22,133 19,175 dispensed dispensed Average no. of items 2 3 Average no. of items 7 6 per Prescription order Source: MSupply – Pharmacy System
Table 37: Majuro Hospital Laboratory department Services, FY2015 to FY2016 FY2015 FY2016 Customers 26,692 28,291 Specimens 43,393 49,576 Tests 127,610 89 Shipments 56 89
V. FINANCIAL INFORMATION
Table 38: MOH Budget Allocation from Top 5 Sources, FY2013 – 2016, RMI Fund FY2013 FY2014 FY2015 FY2016 Compact Fund 6,693,787 6,251,691 7,327,425 7,230,142 Compact Fund‐Ebeye 1,757,635 1,957,635 1,957,635 1,957,635 Special Needs
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General Fund 3,443,523 4,170,636 3,890,533 4,293,186 Health Fund 6,785,000 6,785,000 7,485,000 7,485,000 US Federal & Other Grants 4,307,444 4,938,497 7,643,497 7,319,528 Total 22,987,389 24,103,459 28,304,090 28,285,491 *based of FY16 report (end date 09/30/16)
Table 39: Financial: Budget, Actual and Balance FY2016, RMI Funding Source Adjusted Actual Balance Budget Available General Fund 6,171,435 5,750,338 421,097 Compact Funds – Base 7,230,142 6,237,369 992,773
Compact Funds – ESN 1,957,635 1,757,888 199,747 US Federal Grants ‐ FG cost 7,319,528 5,199,959 2,119,569 centers Total 22,678,740 18,945,554 3,733,186 *based of FY16 report (end date 09/30/16)
Table 40: Federal Grants, RMI, FY2013‐FY2016
Grants FY2013 FY2014 FY2015 FY2016 RMI National Comprehensive Cancer 200,000 198,000 260,481 196,614 Control Program Comprehensive STD Prevention System 127,827 187,504 136,660 140,474 Tuberculosis Elimination & Laboratory 326,487 447,030 282,588 137,066 Preventive Health Services ‐ ‐ 40,508 39,813 HIV/AIDS Surveillance Program 17,141 20,035 17,070 3,236 Immunization & Vaccines for Children 1,034,754 1,051,282 1,130,648 988,455 Grant Sexual Violence Prevention & Education 8,181 ‐ 0 0 HIV Prevention Project for the Pacific 176,595 211,323 175,872 33,192 Islands Hepatitis Program 8,145 5,834 11,650 11,650 Systems/base Diabetes Prevention & 86,301 196,523 196,523 192,673 Control Program (DPCPS) Tobacco Program 100,000 ‐ 0 0 National Public Health Improvement 250,000 250,000 0 0 Initiative
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Epidemiology and Laboratory Capacity 27,053 23,650 85,170 0 Grant Public Health Preparedness & Response 379,640 379,640 380,091 267,111 for Bioterrorism PPHF Chronic Disease and Health ‐ ‐ 0 0 Promotion Sub‐total CDC Grants 2,706,926 2,941,337 2,620,411 2,010,284 Pacific Basin Initiative (Ebeye CHC) 788,196 1,050,675 931,466 1,122,035 Maternal & Child Health Services (MCH) 161,233 207,043 113,286 0 EMSC Partnership Grants 40,000 118,600 13,000 105,000 HIV Care Grants (Ryan White Grant) ‐ 50,079 41,049 50,796 Bioterrorism ‐ Hospital Preparedness 317,821 313,637 380,091 380,652 Program State Systems Development Initiative 66,392 37,418 80,816 95,374 sub‐total HRSA Grants 1,373,642 1,777,452 1,559,708 1,753,857 Continue Delivery of Family Planning 134,000 125,960 0 Services to the People of the Marshall 105,000 Islands Block Grants for Community Mental 92,931 93,748 107,574 110,039 Health Services (CMHS) Single State Agency Grants 0 0 2,077,368 1,721,696 177 Health Care Plan Program 0 0 1,253,714 1,298,206 Ebola Grant/Zika Outbreak 0 0 25,000 114,468 HPP‐Ebola Response 0 205,978 sub‐total Other US Grants 226,931 219,708 3,463,656 3,555,387 TOTAL US FEDERAL GRANTS 4,307,499 4,938,497 7,643,805 7,319,528
Table 41: Marshall Islands Health Fund Statements of Revenues, Expenditures and Changes in Fund Balances Years Ended September 30, 2016, 2015, 2014 and 2013 2016 2015 2014 2013 Revenues: 7,758,175 8,084,035 7,348,605 7,497,097 Expenditures: Off‐island care 4,008,389 3,404,456 2,420,513 2,925,975 Off‐island travel 843,396 694,550 752,455 635,500 Professional and consulting fees 142,520 136,288 197,760 185,010 Other medical charges 231,456 212,126 152,070 62,519 On‐island care 143,583 136,454 124,064 ‐ Administrative: Salaries and wages 237,000 243,549 311,799 291,907 Collection fees 200,000 200,000 200,000 200,000 Travel 24,769 64,517 56,125 56,286 Utilities 54,897 51,121 45,597 34,546 POL 7,726 22,587 20,927 29,703
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Repairs 19,385 20,725 19,861 23,687 Rentals 2,400 ‐ 16,848 15,300 Supplies & materials 7,905 13,744 15,488 37,334 Training 10,905 5,564 14,385 16,719 Insurance 25,279 15,125 12,287 12,423 Communications 15,001 12,827 9,757 14,982 Capital outlays 3,632 9,234 9,164 24,732 Professional fees ‐ ‐ ‐ 11,000 Other admin charges 41,845 23,352 18,835 47,559 Total expenditures 6,020,088 5,266,219 4,397,895 4,625,182 Excess of revenues over expenditures 1,738,087 2,817,816 2,950,710 2,871,912
Other financing sources ( uses) Contributions to RMI Health Care Revenue (3,479,589) (3,533,494) (3,517,500) (3,187,649) Fund Contributions to RMI General Fund ‐ ‐ (24,426) ‐ Net change in fund balance (1,741,502) (715,678) (591,216) (315,737) Fund balance at beginning year 184,162 899,840 1,491,056 1,806,793 Fund balance at end of year (1,557,340) 184,162 899,840 1,491,056
Table 42: Health Care Revenue Fund Statements of Revenues, Expenditures and Changes in Fund Balances, RMI, FY2013‐FY2016 2016 2015 2014 2013 REVENUES: Hospital charges 392,237 396,763 351,818 333,361 Grants 367,600 371,498 285,637 692,968 Other 21,353 13,562 21,333 54,798 Total revenues 781,191 781,823 658,788 1,081,127
Expenditures; Pharmaceuticals 1,779,516 1,680,053 1,122,144 1,986,868 Medical supplies 1,447,057 1,437,035 636,944 1,507,668 Hospital equipment 153,803 252,981 122,634 297,882 Grants & subsidies 52,640 44,051 62,287 40,144 Professional & consulting fees 10,214 42,316 54,795 128,754 Freight & delivery 19,265 6,150 7,635 7,779 Administrative: Salaries & wages 186,651 177,008 220,676 227,438 Travel 86,406 63,975 95,022 42,199 Training 67,059 56,932 72,841 92,541 Bad debt ‐ 27,676 0 Supplies 2,697 6,845 15,433 13,971 Office equipment 4,862 14,664 12,647 5,908 Communications 2,845 2,966 600 2,578 Professional fees ‐ ‐ ‐ 21,500 Other admin costs 91,595 53,760 55,346 13,898
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Total expenditures 3,904,610 3,838,736 2,506,680 4,389,128 Deficiency of revenues under (3,123,419) (3,056,913) (1,847,892) ‐3,308,001 expenditures
Other financing sources (uses) Contributions from RMI Health Fund 3,450,506 3,504,142 3,517,500 3,187,649 Contributions to RMI General Fund ‐ ‐ (29,854) 0 Total other financing sources (uses) 3,450,506 3,504,142 3,487,646 3,187,649 Net change in fund balance 327,087 447,229 1,639,754 ‐120,352 Fund balance at beginning of year 5,547,984 5,100,755 3,461,001 3,581 353 Fund balance at end of year 5,875,071 5,547,984 5,100,755 3,461,001 NOTE: FY2016 HF and HCRF figures are unaudited as shown.
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