Annual Health Data Report 2011

Ministry of health Republic of the Marshall Islands “KUMITI EJMUUR"

ANNUAL REPORT Fy 2011

Joint Message from the Minister and Secretary of Health

We are pleased to present the Annual Report for the Ministry of Health for Fiscal Year 2011. 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, 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 dengue fever 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. A detailed report on the dengue fever outbreak will be presented in the Ministry’s Fiscal Year 2012 Annual Report.

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.

Kommool tata.

TABLE OF CONTENTS

A JOINT MESSAGE FROM THE MINISTER AND SECRETARY OF HEALTH ...... Error! Bookmark not defined. GEOGRAPHY AND DEMOGRAPHICS ...... 11 Table 1: RMI Population Developments ...... 12 Table 2: RMI Projected Population by Age ...... 12 Population Pyramid of RMI in 2011 ...... 13 Table 3: Health Care System ...... 14 Table 4: Number of Beds in Two Major Hospitals ...... 14 Table 5: Specialized Program ...... 15 Table 6: Private Clinics ...... 15 FINANCIAL RESOURCES AND EXPENDITURES ...... 17 Table 7: MOH Budget Allocation from All Sources, FY 2008-2011 ...... 17 Table 8: Basic Health Plan Financial Report- Revenues and Expenditures ...... 17 Table 9: Basic Health Fund Expenditures by Location ...... 18 Table 10: Supplemental Health Plan Financial Report – Revenues and Expenditures ...... 18 Table 11: Health Care Revenue Fund Expenditures by Location ...... 18 Table 12: Grants and Financial Resources ...... 19 Table 13: Capital Health Budget Allocation and Expenditure FY2011 ...... 20 HUMAN RESOURCES FOR HEALTH ...... 23 Table 14: Medical Providers by Position FY2011 ...... 23 Table 15: Nurses by Position FY2011 ...... 24 Table 16: Ancillary Services, FY2011 ...... 24 Table 17: Support Services, FY2011 ...... 25 DATA AND VITAL STATISTICS ...... 29 Table 19: Teen Pregnancy (Mother’s Age is less than 20 years old)...... 29 Table 18: Summary of Birth Information ...... 29 Table 20: Births by Main Islands ...... 30 Graph 1: Birth Trend from FY2007 to FY2011 ...... 30 Table 21: Births by Gender and Main Islands FY 2011 ...... 31 Table 22: Births by Gender ...... 31 Table 23: Birth by Attendant per Year ...... 31 Table 24: Birth by Attendant FY2011 ...... 31 Table 25: Birth by Mother's Age ...... 32 Table 26: Summary of Death Data ...... 33 Table 27: Number of Registered Deaths by Main Islands ...... 34

Graph 2: Maternal Mortality Trend ...... 34 Table 28: Infant Deaths by Main Islands ...... 35 Graph 3: RMI Infant Mortality Rate Trend ...... 35 Table 29: 5 Leading Cause of Infant Death ...... 36 Graph 4: Child Mortality Rate ...... 37 Table 30: 5 Leading Cause of Mortality ...... 38 MATERNAL AND CHILD HEALTH ...... 39 Table 31: RMI MCH Health Indicators ...... 39 Table 32: Summary of Prenatal Visits ...... 39 Table 33: No. of Pregnant Women who attended Prenatal on the 1st Trimester, FY 2011 ...... 40 Table 34: Prenatal Visit by Main Islands ...... 40 Graph 5: RMI Trend of Prenatal Care ...... 40 Table 35: Number of Pap Smear Test ...... 41 Table 36: RMI Unduplicated Number of Female Family Planning Users ...... 41 Table 37: RMI FP Methods for Unduplicated Male Users ...... 42 Table 38: RMI Unduplicated Number of Family Planning by Age and Gender ...... 42 Table 39: New Cases of Children with Special Health Care Needs ...... 43 Graph 6: Annual School Physical Exam Coverage Rate ...... 44 Table 40: Most Common Physical Exam Findings - Ebeye ...... 44 Table 41: Waterlow Classification for Under nutrition of School Children FY2011 ...... 45 Table 42: BMI Percentile Nutritional Assessment of School Children FY2011 ...... 45 Graph 7: Undernutrition Assessment - Stunting of 2,044 Students, FY2011 ...... 46 Graph 8: Undernutrition Assessment - Wasting of 2,044 Students, FY2011 ...... 46 IMMUNIZATION ...... 47 Table 43: RMI Immunization Coverage for Children 19-35 months, FY2011 ...... 47 Table 44: RMI Immunization Coverage Rate ...... 47 Graph 9: Immunization Trend in RMI ...... 48 Table 45: Immunization Outer Islands Outreach Mobile Visits, FY 2011...... 48 Table 46: New Vaccines Administered ...... 49 ORAL HEALTH ...... 51 Table 47: Key Outcome Measures for Dental Program ...... 51 Table 48: No. of Dental Encounters ...... 51 HUMAN SERVICES & MENTAL HEALTH ...... 53 Table 49: No. of Registered Cases in Mental Health Program ...... 53 Table 50: Data on Suicide Cases ...... 53 Graph 10: RMI Trend of Suicide Cases ...... 53 Table 51: Suicide Cases in RMI by Type and Location ...... 54

HEALTH PROMOTION AND DISEASE PREVENTION ...... 55 Table 52: Health Promotion Outer Islands Outreach Mobile Visits, FY 2011 ...... 56 Table 53: One on One Health Education Encounters in Ebeye FY2011 ...... 56 DIABETES ...... 59 Table 54: Prevalence Rate of Diabetes ...... 59 Table 55: RMI Diabetes Encounters ...... 59 Table 56: Diabetes Patients enrolled in the CDEMS FY 2011 ...... 60 Table 57: Diabetes Foot Care Encounter ...... 61 Table 58: Key Outcome Measures for Ebeye Diabetes Program FY2011 ...... 61 NATIONAL COMPREHENSIVE CANCER CONTROL PROGRAM ...... 63 Table 59 : Death Due to Cancer by Gender ...... 63 Table 60: Cancer Registry ...... 64 TUBERCULOSIS ...... 67 Table 61: TB Registered Cases ...... 68 Table 62: New TB Cases by Age Distribution, FY2011 ...... 68 Table 63: TB Treatment Outcome FY2011 ...... 69 Table 64: TB-HIV FY2011 ...... 69 Table 65: MDR-TB Cases 2009-2011 – On going ...... 69 LEPROSY ...... 71 Table 66: Leprosy Cases, FY 2011 ...... 71 Table 67: Registered New Cases by Type, Gender and Age, FY2011 ...... 72 Table 68: New Registered by Atoll, FY2011 ...... 72 Table 69: Treatment Outcome, FY2011 ...... 72 Table 70: New and Old Cases on Treatment at the End of the FY2011 ...... 72 Table 71: High Proportion of Children on Treatment ...... 73 SEXUALLY TRANSMITTED DISEASE ...... 75 Table 72: STI/HIV Cases ...... 75 Table 73: Syphilis Testing, FY2011 ...... 75 Table 74: Chlamydia Testing, 2011 ...... 76 Table 75: Gonorrhea Testing, FY2011 ...... 76 Table 76: Majuro HIV Testing, FY2011 ...... 77 Table 77: RMI Current HIV Cases ...... 77 MEDICAL REFERRAL SERVICES ...... 79 Table 78: Basic Referral Activity ...... 79 Table 79: Top Ten Diagnosis for Off-Island Referral ...... 80 Table 80: Supplemental Health Plan Enrollee ...... 80 Table 81: Supplemental Health Plan Users ...... 81

HOSPITAL SERVICES ...... 83 Graph 11: Ebeye Hospital’s Outpatient Encounters Trend ...... 83 Graph 12 : Majuro Hospital’s Outpatient Encounters Trend ...... 83 Table 82: Top Leading Causes of Out Patient Visits, 2011 ...... 84 Top 83: Leading Causes of Out Patient Visits-For Females, 2011 ...... 84 Table 84: Top 10 Leading Causes of Out Patient Visits-For Children < 5 years ...... 85 Table 85: Operating Room Activity ...... 85 Table 86: Admission Encounter by Service Ward FY 2009-2011 ...... 86 Table 87: Top 10 Leading Causes of Admissions...... 86 Table 88: Top 10 Leading Causes of Admissions, For Females, 2011 ...... 87 Table 89: Top 10 Leading Causes of Admissions, For Children <5 years, 2011...... 87 Table 90: Rehabilitation Department's Referral information ...... 89 Table 91: Diagnosis/Reason for Rehabilitation Services ...... 89 Table 92: Summary of Majuro Laboratory Activities, FY2011 ...... 91 MOH COST ANALYSIS OF HOSPITAL SERVICES ...... 93 Graph 14: Material Cost - Majuro Hospital Laboratory Services ...... 93 Graph 16: Majuro Hospital Trend Analysis of Laboratory Tests ...... 93 Graph 17: Majuro Hospital Surgical Material Costs ...... 94 Table 93: Majuro Hospital Eye Surgery Costing FY2011 ...... 95 Table 94: Majuro Hospital Urology Surgery Procedure Costs FY2011 ...... 95 Table 95: Procedure Costs of General Surgery ...... 96 Table 96: Majuro Hospital Reproductive Health Care Procedure Material FY2011 ...... 98 Table 97: Procedure Costs of General Surgery Patients in OR ...... 99 Table 98: Majuro Hospital Orthopedic Surgery OR Procedure Material Costs FY2011 ...... 102 Table 99: Cost Analysis of Majuro Hospital Pediatric Ward Patients FY2011 ...... 104 ORGANIZATIONAL CHART ...... 105 ACKNOWLEDGEMENT ...... 105

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 Year Total Male Female 2011 53,158 27,243 25,915

2010 54,439 27,938 26,501 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

Table 2: RMI Projected Population by Age Age 2008 2009 2010 2011

0 - 4 7,949 8,011 8,031 7,717 5 - 9 7,471 7.371 7,390 7,022 10 - 14 6.949 7,200 7,331 6,496

15 - 19 6,351 6,152 6,107 4,735 20 - 24 6,384 6,370 6,278 5,095 25 - 29 4,275 4,491 4,743 4,403

30 - 34 2,626 2,639 2,740 3,791 35 - 39 2,304 2,212 2,132 3,141 40 - 44 2,180 2,103 2,041 2,783

45 - 46 2,068 2,043 2,013 2,348 50 - 54 1,790 1,784 1,791 1,929 55 - 59 1,479 1,525 1,555 1,583

60 - 64 897 971 1,049 1,047

65 - 69 473 498 540 526 70 - 74 331 333 332 249 75+ 361 363 367 293 Total 53,889 54,065 54,439 53,158

EOGRAPHY AND EMOGRAPHICS G D

In 2011, RMI through Economic Planning, Policy and Statistics Office (EPPSO) conducted a National Census. The 2011 data reflected the recent census. The population for 2006 to 2010 was from the RMI Population Estimate of April 2009 released by EPPSO.

Population Pyramid of RMI in 2011

Population Pyramid of RMI in 2011 Male Female

75+ 70 - 74 65 - 69 60 - 64 55 - 59 50 - 54 45 - 49 40 - 44 35 - 39 30 - 34 25 - 29

20 - 24 15 - 19 10-14 5-9 0 - 4 5000 4000 3000 2000 1000 0 1000 2000 3000 4000 5000 Population

The population pyramid of RMI in 2011 indicates that it is an expansive population. This is supported by the high crude birth rate and high crude death rate of RMI. For FY 2011, RMI has a Crude Birth Rate is 28 per 1,000 live births and Crude Death Rate is 7 per 1,000 population. Based on FY2011 Total Fertility Rate, Marshallese woman will have 3 children in her lifetime. The rate of natural increase of population is 2.13%.

Geography and Demographics

Table 3: Health Care System Table 4: Number of Beds in Two Major Hospitals Majuro Hospital No. of beds Leroij Atama Zedkeia Medical Center Leroij Atama Zedkeia Medical Center 101 Laura Health Center Leroij Kitlang Kabua Memorial Hospital 45 Rongrong Health Center Ebeye, Kwajalein Leroij Kitlang Kabua Memorial Hospital Santo Health Center Ebadon Health Center Outer Islands Ratak Chain Ralik Chain Milli Ebon Nallu Toka Enejit Namdrik Lukonwor Jabwor Tokewa Jaluit Tinak Jabnoden Kilange Mejrirok Ine Narmij Tarawa Health Center Arno Imiroj Tarawa Health Center Ulien Imiej Bikarej Aerok Ailinglaplap Tutu Bwoj Aur Woja Tobal Jabot Aerok Maleolap Loen Tarawa Mae Jang Majkin Ollet namu Kaven Lib Wotje Lae Wodmej Ujae Likiep Wotho Jebal Mejit Enejelar Wodmej Health Center Ailuk

GEOGRAPHY AND DEMOGRAPHICS

Table 5: 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

Table 3 indicates the hospital and health centers under the Ministry of Health. Leroij Atama Zedkeia Medical Center commonly known as Majuro Hospital and Leroij Kitlang Kabua Memorial Hospital commonly known as Ebeye Hospital are serving inpatient, outpatient, public health clinics and ancillary services. 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. Table 6: Private Clinics

Clinic Name Location

Majuro Clinic Delap, Majuro

Capital Dentistry Uliga, Majuro

Eyesight, Professional Delap, Majuro Opticare Delap, Majuro

Table 6 indicates the private clinics in Majuro. Doctors practicing in the private clinics are licensed under the MOH’s Medical Examining and Licensing Board to practice in the RMI.

Utrik Health Center

FINANCIAL RESOURCES AND EXPENDITURES FINANCIAL RESOURCES AND EXPENDITURES

Table 7: MOH Budget Allocation from All Sources, FY 2008-2011 Funds FY 2008 FY 2009 FY 2010 FY 2011 Compact Fund $6,512,349 $7,079,620 $6,959,858 $6,834,858 General Fund $3,130,042 $3,059,851 $3,059,851 $3,053,466 Health Fund $5,600,000 $7,040,000 $6,477,000 $2,717,842 Ebeye Special Needs $1,570,406 $1,743,289 $1,690,353 $1,708,523 US Federal & Other Grants $3,802,607 $3,973,989 $5,963,038 $4,072,159 Other Revenues $450,720 $643,655 $628,156 $175,186 Total $21,066,124 $23,540,404 $24,778,256 $22,861,654

Table 7 indicates the allocated budget of the Ministry of Health for all its services. This table indicates a decrease in funding allocation for FY2010.

Table 8: Basic Health Plan Financial Report- Revenues and Expenditures Revenues: FY 2008 FY 2009 FY 2010 FY 2011 Unaudited Unaudited Audited Unaudited Health Fund Tax $3,649,224.00 $2,677,172.82 $2,766,969.00 $2,946,952.70 RepMar Subsidy $0.00 $140,000.00 $0.00 $0.00 Others $16,552.00 $593,318.59 $28,760.00 $22,251.53 Total Revenues $3,665,776.00 $3,410,491.41 $2,795,729.00 $2,969,204.23 Expenses: Off-Island Care $1,485,385.00 $1,925,732.02 $890,961.00 $1,360,834.60 Travel/Stipends: $541,979.00 $586,502.99 $456,469.00 $618,496.39 Patients/Escorts 3rd Party Administration $128,750.00 $279,000.00 $134,250.00 $179,000.00 Fees Contractual Services $35,279.00 $140,000.00 $200,000.00 $200,000.00 THI/JMI-Edison Majuro Administration $191,574.00 $277,775.41 $278,170.00 $254,907.32 Honolulu Office Operations $280,336.00 $122,688.66 $125,384.00 $143,292.90 Subsidy to Inter-Island $209,465.00 $194,506.15 $216,451.00 $192,740.56 Referral Total Expenditures $2,872,768.00 $3,622,664.48 $2,301,685.00 $2,949,271.77 Net Revenue (Loss) $793,008.00 ($212,173.07) $494,044.00 $19,932.46 *Note: FY08 revenues based on 35% of Health Fund collection for off island referral, 55% remitted to Health Care Revenue Fund & 10% to PHC/Prevention and Domestic Referrals.

FINANCIAL RESOURCES AND EXPENDITURES

Table 9: Basic Health Fund Expenditures by Location Location FY 2008 FY 2009 FY 2010 FY 2011 Philippines Referrals $1,747,404 $2,713,760 $1,731,200 $2,079,685 Honolulu Referrals $215,180 $171,995 $250,000 $230,806 Inter Island Referrals and PHC $175,347 $196,508 $226,800 $224,710 Administration - Majuro, Ebeye, Honolulu & Philippines $734,837 $398,303 $560,000 $633,524 SHF - Majuro Admin $1,000 0 SHF - HNL Admin $109,000 $53,831 SHF - HNL Referral $400,000 $386,354 SHF - PI Referral $50,000 $203,844 Total $2,872,768 $3,480,566 $3,328,000 $3,814,765

Table 9 indicates that in FY2011, the budget amount has increased in the amount of $3,814,765. Table 10: Supplemental Health Plan Financial Report – Revenues and Expenditures 2008 2009 2010 2011 Revenues Unaudited Unaudited Audited Unaudited Supplemental Health Plan Collection $575,814 $629,036.00 $663,402.00 $610,488.05 Other income $0.00 $0.00 $0.00 $0.00 Total Revenues $575,814 $629,036.00 $663,402.00 $610,488.05 Expenses Direct Expenses $405,753 $212,508.37 $625,124.00 $516,714.87 Administration - Majuro & Honolulu $9,787 $ 48,029.23 $76,689.00 $56,830.86 Total Expenses $415,540 $260,537.60 $701,813.00 $573,545.73 Net Revenue (Loss) $160,274 $368,498.40 $38,411.00 $36,942.32 Beginning Net Asset $241,901 $237,648.00 $241,901.00 $203,490.00 Ending Net Assets $402,175 $241,901.00 $203,490.00 $240,432.32

Table 11: Health Care Revenue Fund Expenditures by Location Location FY 2008 FY 2009 FY 2010 FY 2011 Majuro $2,212,000 $2,360,491 $2,031,105 $2088,301

Ebeye $816,000 $623,136 $740,015 $592,453

Outer Islands $429,000 $185,989 $377,880 $145,525

$3,457,000 $3,169,616 $3,149,000 $2,826,279 Total

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

FINANCIAL RESOURCES AND EXPENDITURES

Table 12: Grants and Financial Resources Grant Amount Granting Agency/Grant Name 2008 2009 2010 2011 CDC RMI National Comprehensive Cancer $203,782 $199,996 $273,712 $209,451 Control Program Comprehensive STD Prevention System $136,934 $136,934 $137,434 $136,600 Tuberculosis Elimination & Laboratory $114,638 $114,138 $153,243 $135,735 Preventive Health Services $6,569 $6,016 $25,477*1 0 HIV/AIDS Surveillance Program $17,673 $13,532 $13,532 $18,042 Immunization & Vaccines for Children $995,171 $702,996 $ 1,009,281 $1,086,766 Grants Sexual Violence Prevention & Education $11,765 $8,638 $8,549 0 HIV Prevention Project for the Pacific $122,518 $30,630 $122,518 $122,518 Islands Systems/base Diabetes Prevention $86,301 $86,301 $86,301 $86,301 Control Program (DPCPS) Tobacco 0 $100,000 $100,000 $100,000 National Public Health Improvement 0 0 0 $250,000 Initiative Public Health Preparedness & Response $560,134 $559,469 $1,115,400 $388,143 for Bioterrorism Total CDC $2,255,485 $1,958,650 $3,019,970 $2,533,556 HRSA Pacific Basin Initiative $ 571,677 $ 962,699 $ 549,299 $676,190 ARRA - Ebeye CIP FY10 $0 $0 $ 546,485 0 Children's Oral Healthcare Access $160,000 $160,000 $ 173,827 $160,000 Program Maternal & Child Health Services (MCH) $235,920 $241,149 $232,647 $232,609 HIV Care Grants (Ryan White Grant) $52,968 $ 13,000 $52,820 $25,479 Bioterrorism - Hospital Preparedness $333,477 $318,384 $946,039 $316,983 Programs New Born Hearing & Screening $0 $0 $ 150,000 $150,000 Total HRSA $1,354,042 $ 1,695,232 $2,651,117 $1,561,261 PHS/OPHS Continue delivery of Family Planning $153,792 $201,115 $159,092 $162,721 Services to the People of Marshall Islands

SAMHSA

FINANCIAL RESOURCES AND EXPENDITURES

New Freedom State Coalitions to $10,000 10,000 $20,000 0 Promote Community Base Care State Mental Health Data Infrastructure $50,000 39,600 $50,000 0 for Quality Improvement Grants/DIG Block Grants for Community Mental $79,586 $70,636 $76,391 $82,265 Health Services Total $140,598 $130,636 $146,391 $82,265.00 TOTAL US FEDERAL GRANTS $3,536,639 $3,893,955 $5,963,038 $4,155,803

OTHER GRANTS USAPIN - Pacific Regional Central Cancer $27,240 $27,240 $58,302 $27,240 registry WHO/SPC Grants $32,814 $27,845 $569,854 $0*2 CEED Program 0 $20,000 $0 0 ROC Grants $17,930 $0 $0 0 Japan Government's Grants $67,315 $83,950 $0 0 Australian Grants (Disaster Fund $0 $484,620 $0 0 Hospital)

Total $145,299 $643,655 $628,156 $172,240

Grand Total $4,039,254 $4,617,644 $6,859,496 $4,367,313 NB: 1. The Notice of Grant Award for the Preventive Health and Health Services Block Grant was not received properly because it was mistakenly addressed to Secretary of Health in CNMI by the grant agency. 2. WHO Funds is for 2 years. For 2010 and 2011, MOH was given 145,000

Table 13: Capital Health Budget Allocation and Expenditure FY2011 Atoll Health Budget Expenditure % of Population Per Capita Health Allocation Expenditure Expenditure Majuro 15,179,935 15,179,935 100% 27,797 $546 Ebeye 5,362,700 4,832,700 90.12% 11,408 $423.62 Outer Island 842,685 842,685 100% 13,953 $60.39 Total 21,385,320 20,855,320 97.52% 53,158 $392.34

FINANCIAL RESOURCES AND EXPENDITURES

Effective and Efficient Financial Management

 Utilization of regional and international assistance to improve performance  Development of a database to assist with planning effectively for the future  Strengthening of internal control  Utilize training opportunities to build capacity of staff  Continue identify cost trends and cost savings opportunities  Strengthen communication with the rest of the Bureaus and units on all cross cutting issues including budget balances, new polices and etc.  Continue to utilize meetings with staff to know workplace situation and what needs critical focus

Wotje Health Center

HHUMANUMAN RRESOURCESESOURCES FOR FOR HEALTH HEALTH

In March 2011, the Ministry of Health implemented a new organizational structure.

There are two Administrative Offices . Office of Administration, Personnel and Finance (OAPF) . Office of Health Planning, Policy and Statistics (OHPPS)

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. OHPPS 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, and Management Information System.

Table 14: Medical Providers by Position FY2011 Majuro Ebeye Public Health/ Total Position Hospital Hospital Outer Islands Family Practitioner 5 2 0 7

General Practitioner 0 2 4 6 Pediatrician 2 1 0 3 OB-Gynecologist 1 1 0 2

Ophthalmologist 1 0 0 1 Psychiatrist 0 0 0 0 Radiologist 0 0 0 0

Pathologist 1 0 0 1 Orthopedic Surgeon 1 1 0 2 Internist 1 2 0 3 General Surgeon 2 2 0 4 Anesthesiologist 0 1 0 1 Urologist 0 0 0 0 Medical Assistant 1 0 6 7 Health Assistant 2 2 55 59 Dentists 0 1 3 4 Total 17 15 68 100

Table 14 shows the total number of medical providers currently delivering medical services in Majuro, Ebeye, and the Outer islands for FY2011.

HUMAN RESOURCES FOR HEALTH

Table 15: Nurses by Position FY2011 Position Majuro Ebeye Total Graduate Nurses Public Health 20 6 26 Clinical 72 24 96 Practical Nurses Public Health 10 6 16 Clinical 18 6 24

Nurse Aides Public Health 2 0 2 Clinical 25 0 25 Total 147 42 189

Table 15 indicates the total of 189 nurses who are currently working both in Majuro and Ebeye. More than ½ of them are expatriates. Table 13 discloses a total of 72 ancillary personnel currently at both Majuro and Ebeye.

Table 16: Ancillary Services, FY2011 Services Majuro Ebeye Total Pharmacy Services 5 2 7 Laboratory Services 12 5 17 Radiology Services 8 2 10

Rehabilitation Services 5 2 7

Infection Control Unit 1 0 1 Quality Assurance Unit 1 0 1 Dental Services 24 3 27 Sterilization/Central supply 2 0 2 Total 58 14 72

HUMAN RESOURCES FOR HEALTH

Table 17: Support Services, FY2011 Services Majuro Ebeye Total Biomedical Services 2 2 4

Security 11 7 18

Housekeeping 8 7 15 Dietary Services 9 5 14 Maintenance 3 4 7 Morgue 2 0 2 Total 35 25 60

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

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

Ministry of Health (MOH) currently employed and administered a total of 534 workforces. Out of the 534 workforce, 21% (113) are expatriate, the administrative and support staffs are 37.5% (200), whereas the remaining 62.5% (334) are Medical providers. During the reporting period, a total of 35 staff members resigned, out of this 4 are medical doctors, 14 from the health force, 2 from laboratory and the remaining 15 are from administrative and support staffs. A total of 46 new employees also hired during the reporting period, and out of this 5 are doctors, 26 are nurses and the remaining 15 are administrative and support staffs.

Human Resources Challenges  High number of expatriate workers  Staff turnover, low salary scale  Lack of staff retention policy

The Ministry took the following strategy in order to improve the human resource efforts at MOH  Conducted human resources assessment with complete reports and recommendations.  Human Resources for Health issues are prioritized for possible interventions

HUMAN RESOURCES FOR HEALTH

MOH Human Resources Investment In 2008, the Ministry initiated the 18-month training for 20 health assistants from outer islands. In July 2010 the Health Assistant completed the training. The Ministry arranged with the USP Campus here in Majuro to have nine of these Health Assistants enroll at USP to take the Preliminary and Foundation courses in math and science as a preparatory program before MOH can assist to send these Health Assistants to Fiji School of Medicine to study medicine.

In July 2011, these nine Health Assistants started their courses at USP. Since then two HA have dropped out of the program at USP, and are currently employed at the MOH. The current seven Health Assistants are into their second year at the USP, and MOH keeps track of their studies with the School Principal. MOH pays for their annual registration which is $100 per student and all Health Assistant trainees are on contract with MOH as an incentive for transportation and other needs for them to continue study at USP. MOH will continue to assist these Health Assistants in seeking financial support to continue pursue their health career after completion of their studies at USP.

The seven HA trainees are: • Readney Horiuchi • Anten Alex • Asdan Timothy • Nixon Has • Jason Lalimo • Juonran Juonran • Weston Ejli

Keep up the good work boys. We are proud of you.

HUMAN RESOURCES FOR HEALTH

Readney Horiuchi Anten Alex

Nixon Hax Jason Lalimo Asdan Timothy Readney Horiuchi

Nixon Hax

D ATA AND VITAL STATISTICS

There were 1,487 births from October 2010 to September 2011 There was a 7.69% increase in crude birth rate for this fiscal year. Crude Birth Rate is calculated as the Number of live births divided by Number of total population) x 1,000. Very Low Birth Weight (VLBW) is calculated as live born infants that weigh less than 1,500 grams or less than 3 lbs and 4 ozs. Low Birth Weight (LBW) is calculated as live born infants that weigh less than 2,500 grams or less than 5 lbs and 8 ozs. Premature Birth is commonly used as a synonym for preterm birth, refers to the birth of a baby before its organs mature enough to allow normal postnatal survival, and growth and development as a child. Preterm birth refers to the birth of a baby of less than 37 weeks gestational age.

The Total Fertility Rate in FY2011 is 3.38. This means that a Marshallese woman will have 3 children in her lifetime.

Table 18: Summary of Birth Information Description FY 2007 FY 2008 FY 2009 FY 2010 FY2011 Registered Birth 1,591 1,526 1,603 1,396 1,487 Crude Birth Rate Per 1,000 Live births 30 29 30 26 28 Total Fertility Rate 3.86 3.58 3.58 3.18 3.38 Rate of Natural Increase 2.50% 2.28% 2.23% 2.04% 2.12% LBW 206 210 202 186 181 VLBW 12 18 20 26 10 Premature 159 106 121 74 90 Teen Pregnancy 278 253 232 198 222 % of Teen Pregnancy from All Birth 17% 17% 14% 14% 15% Teen Pregnancy Rate Per 1,000 Population 40 39 36 31 41 Source: Vital Statistics, MOH

Table 19: Teen Pregnancy (Mother’s Age is less than 20 years old) Description FY 2007 FY 2008 FY 2009 FY2010 FY2011 Teen Pregnancy 278 253 232 198 222 VLBW for Teen Pregnancy 2 5 2 3 4 LBW for Teen Pregnancy 61 53 43 37 40 Premature Teen Pregnancy 39 31 18 10 9 % of Teen Pregnancy from All Birth 17% 17% 14% 14% 15% Teen Pregnancy Rate Per 1,000 population 40 39 36 31 41 Source: Vital Statistics, MOH

D ATA AND VITAL STATISTICS

Teen pregnancy is the pregnancy occurring in young women under 20 years old. In FY 2011, there were 41 teen pregnancies per 1,000 population less than 20 years old. Teen Pregnancy remains a grave concern for the Ministry because of the complications that may incur during birth and challenges to the family, government, and the teenage mothers. Family Planning Clinics under the Maternal and Child Health Program and Youth to Youth in Health Clinic continue to offer contraceptives and counseling to teenagers.

Table 20: Births by Main Islands Fiscal Year Majuro Ebeye Outer Islands Total 2007 1,000 375 216 1,591 2008 1,015 345 166 1,526 2009 1,030 383 190 1,603

2010 944 311 141 1,396 2011 1,017 344 126 1,487 Source: Vital Statistics, MOH

Table 20 indicates a decrease in the total birth in the Marshall Islands from FY2009 to FY2011.

Graph 1: Birth Trend from FY2007 to FY2011

Birth Trend from FY2007 to FY2011 1,650 1,600 1,603 1,550 1,591

1,500 1,526 1,450 1,487 1,400 1,350 1,396 1,300 1,250 2007 2008 2009 2010 2011

D ATA AND VITAL STATISTICS

Table 21: Births by Gender and Main Islands FY 2011

Age Majuro Kwajalein Outer Islands Total Male 543 183 72 798 Female 474 161 54 689

Total 1017 344 126 1,487 Source: Vital Statistics, MOH Table 21 shows the gender distribution of FY2011 births on the 3 main islands.

Table 22: Births by Gender Age FY 2007 FY 2008 FY 2009 FY2010 FY2011 Male 796 798 787 761 798

Female 795 728 816 635 689 Total 1,591 1,526 1,603 1,396 1,487 Source: Vital Statistics, MOH

Table 23: Birth by Attendant per Year Attendant FY2009 FY 2010 FY 2011

Nurse 1076 1003 1063 Health Assistant 186 122 110 Medical Assistant 10 6 12 Doctor 310 254 277 Other 10 4 7 Traditional Birth Attendant (TBA) 11 7 18 Total 1,603 1,396 1,487

Table 24: Birth by Attendant FY2011 FY 2011 Attendant Majuro Kwajalein Outer Islands Total Nurse 841 210 12 1063 Health Assistant 7 5 98 110 Medical Assistant 8 0 4 12 Doctor 138 129 10 277 Others 6 0 1 7 Traditional Birth Attendant (TBA) 17 0 1 18 Total 1017 344 126 1,487 Source: Vital Statistics, MOH

DATA AND VITAL STATISTICS

Table 25: Birth by Mother's Age Age FY 2007 FY 2008 FY 2009 FY2010 FY2011 Not Stated 5 7 106** 52 17 10 – 14 5 4 5 2 0 15 – 17 92 79 54 60 85 18 – 19 181 170 173 141 137 20 – 24 548 523 504 452 496 25 – 29 411 409 411 375 400 30 – 34 197 217 223 215 219 35 – 39 115 94 97 63 108

40 – 44 37 20 24 33 25 45 – 49 0 3 6 3 0 Total 1,591 1,526 1,603 1,396 1,487 Source: Registered Births Vital Statistics, MOH ** Challenge/Barrier: This number referenced to the number of incomplete birth registration forms that were submitted to the Statistics Office without the age of the mothers, which continues to be a barrier for vital statistics.

The Vital Statistics under the Office of Health Planning, Policy, and Statistics is responsible to register birth and death occurring in the hospitals, health centers, and at home. Teen pregnancy is still high. 18.02% of the teen births have low birth weight. Some of the reasons that may contribute to the LBW in teenage pregnancies are immaturity, lack of knowledge, and high risk of premature labor, anemia, and high blood pressure. At any rate this year, the teenage pregnancy rate is at 15%.

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

DATA AND VITAL STATISTICS

Table 26: Summary of Death Data Description FY 2007 FY 2008 FY 2009 FY2010 FY2011 Registered Death 276 299 339 286 361 Infant Death 51 47 42 31 41 Fetal Death (Still Birth) 21 13 19 15 21 Early Neonatal Death 15 15 15 16 16 Neonatal Death 18 20 19 22 25 Post Neonatal Death 33 27 23 9 16 Perinatal Death 36 28 34 31 37 Child Death (Under 5 years old) 63 56 52 39 50 Child Death (1-4 years old) 12 9 10 8 9 Maternal Death 0 0 4 2 2 Rate/Ratio Crude Death*2 5 6 6 5 7 Infant Mortality Rate*1 32 31 26 22 28 Fetal Mortality Rate*1 13 8 12 11 14 Neonatal Mortality Rate*1 11 13 12 16 17 Perinatal Mortality Rate*1 23 18 21 22 25 Child Mortality Rate (under 5 years old) 40 37 32 28 34 Child Mortality Rate (1-4 years old) 8 6 6 6 6 Maternal Mortality Ratio*3 0 0 250 143 13 Source: Vital Statistics, MOH;

Formula in calculating the Death Indicators:

The number of registered deaths among infants (below one year of age) per 1000 live births in a given year or period of time

Fetal Mortality Rate is the number of fetal deaths divided by the number of live births plus fetal deaths (for a specified time period, usually a calendar year) and multiplied by 1,000.

Child Mortality Rate or Under-5 mortality rate is the number of children who died before the age of five, per thousand live births. This is also one of the Millennium Development Goals.

Maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

Maternal Mortality Ratio is calculated by the number of maternal deaths to the number of live births per 100,000.

1 Per 1,000 live births 2 Per 100,000 live births 33 3 Per 1,000 Population

DATA AND VITAL STATISTICS

Neonatal deaths: Deaths among live births during the first 28 completed days of life. It may be subdivided into early neonatal deaths, occurring during the first 7 days of life, and late neonatal deaths, occurring after the 7th day but before the 28th completed day of life.

Post-neonatal Mortality Rate is the number of deaths of infants between 28 days and <1 year divided by the number of live births

Perinatal Mortality Rate is number of stillbirths or fetal death and deaths in the first week of life per 1,000 live births

Table 27: Number of Registered Deaths by Main Islands Fiscal Year Majuro Ebeye Outer Islands Ship/Ocean Registered Total 2007 190 46 40 0 276 2008 204 46 49 0 299 2009 223 48 62 6 339 2010 188 47 47 4 286 2011 258 61 37 5 361 Source: Vital Statistics, MOH

Table 27 shows the number of death according the five years interval. The total number of death remains almost the same.

Graph 2: Maternal Mortality Trend

Maternal Mortality Rate Per 10,000 30 25 25 20

13 14 13 15 10

5 0 0 0 FY2006 FY2007 FY2008 FY2009 FY2010 FY2011

Maternal Mortality Rate Per 10,000

Graph 2 indicates that the maternal death had a higher rate in FY2009 of 25 per 10,000. There were 4 maternal deaths in FY2009.

DATA AND VITAL STATISTICS

In FY2011, there were 2 maternal deaths. The 1st case was a 34 years old that died because of disseminated intravascular coagulation and amniotic fluid embolism. Second is a 43 years old that died because of amniotic fluid embolism with term pregnancy.

In the last five years, the RMI has had maternal deaths which were preventable. Priority will be placed on improving the health care of pregnant women to avoid maternal death. Detection of high risk pregnancy will be increased.

MOH Objective: Improve Reproductive Health Issues Services

Objective 1: All Maternal and Child Health clinical staff will have been trained on high risk pregnancy management.

Objective 2: All high risk pregnant women will have been enrolled in the High Risk clinic and managed appropriately

Table 28: Infant Deaths by Main Islands Fiscal Year Majuro Ebeye Outer Islands Total IMR 2008 27 3 17 47 31 2009 25 5 12 42 26 2010 24 2 5 31 22 2011 24 10 7 41 28

Source: Vital Statistics, MOH

Graph 3: RMI Infant Mortality Rate Trend

Infant Mortality Rate Trend

35 32 31 28 30 26 24 25 22 20

10 5 0 FY2006 FY2007 FY2008 FY2009 FY2010 FY2011

Infant Mortality Rate Per 1000 live births

DATA AND VITAL STATISTICS

Table 29: 5 Leading Cause of Infant Death FY 2008 FY 2009 FY 2010 FY 2011 1 Premature - 9 Premature - 8 Premature - 7 Premature - 5 2 Pneumonia - 5 Asphyxia - 5 Malnutrition - 4 Pneumonia/ Birth Asphyxia/ Congenital Heart Disease/ Neonatal Sepsis - 3 3 Congenital Heart Septicemia - 4 Pneumonia - 3 Bronchopneumonia Disease/Sepsis - 3 -3 4 Sudden Death Congenital Heart Asphyxia/ Malnutrition/ Syndrome/Hypoxi Disease/Sepsis/Pneumo Sepsis - 2 Dehydration/ c Ischemic nia/ Meningococcemia - Anemia/ Encephalopathy/ 2 Hydrocephalus -1 Birth Trauma – 1 5 Dehydration/ Gastroenteritis/D Meningitis/ Pertussis/ rowning - 1 Drowning - 2

The Infant Mortality Rate (IMR) remains high for all years. The IMR increased by 18% in FY 2011. Mothers not attending prenatal care or seek prenatal care very late are contributing factors. Prematurity is one of the causes of infant mortality which is linked to the health of the mother.

Table 29 indicates that prematurity is attributable to the main cause of death for the infants during the FY2008-2011. One of the major objectives to be mindful of is reducing the Infant Mortality Rate by 10% each year. In FY2011, the Ministry has started the presumptive Chlamydia treatment for pregnant mothers attending prenatal care.

MOH Objective: To reduce the Infant Mortality Rate by 10% in FY2012

For the past four years, IMR has decreased by 18%.

Priority Activities for FY2012 is to reduce the Infant Mortality Rate by: (1) Continue to improve the immunization for children two years and under; (2) Continue to encourage breast feeding practices as the best infant food; (3) Continue to educate to improve nutrition practices and family hygiene; and (4) Continue presumptive treatment of Chlamydia for pregnant mothers.

DATA AND VITAL STATISTICS

Millennium Development Goal (MDG) 4: Reduce Child Mortality Rate

WHO Target: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate.

WHO promotes four main strategies which MOH adapted:  appropriate home care and timely treatment of complications for newborns;  integrated management of childhood illness for all children under five years old;  expanded program on immunization;  infant and young child feeding.

These child health strategies are complemented by interventions for maternal health, in particular, skilled care during pregnancy and childbirth. In FY2011, RMI Growth Monitoring and Infant and Young Child Feeding Training Course was conducted with participants from the hospital and women’s group. This training was funded by WHO and SPC. The training target improvement of care for newborn, infant, and children.

Graph 4: Child Mortality Rate

Child Mortality Rate Per 1,000 Live birth 8

7 8 6 6 6 5 6 6 4 3 2 1

0 FY2007 FY2008 FY2009 FY2010 FY2011

Child Mortality Rate Per 1,000 Live birth

Graph 4 demonstrates reduction in child mortality rate. The trend over the years shows a downward mobility.

DATA AND VITAL STATISTICS

Table 30: 5 Leading Cause of Mortality FY 2008 FY 2009 FY 2010 FY 2011 DM Related – 79 DM Related - 64 DM Related - 53 DM Related - 84 Pneumonia- 24 Cancer (All Types) - 36 Pneumonia - 29 Pneumonia - 36 Myocardial Septicemia - 31 Cancer (All Types) - 26 Cancer (All Types) - 27 Infarction - 23 Cancer (All Hypertension - 28 Malnutrition - 16 Myocardial Infarction - Types) - 22 17 CVA- 21 Suicide - 14 CVA - 14 Suicide - 10

It is worth noting that Diabetes Mellitus related diseases remain over the three years interval as the leading cause of death; though it is encouraging that it shows a downward mobility

MATERNAL AND CHILD HEALTH

MReproductiveATERNAL HealthAND C ServicesHILD H EALTH

Screening for Children with Special Health Care Needs (CSHCN) continues in collaboration with Ministry of Education (MOE), Special Education Programs/sharing information and providing services for both clients and families. In 2008, RH Clinic expanded its clinic twice a week after normal working hours to Youth to Youth in Health (YYTIH) and Laura Clinic every Saturday. The YYTIH clinics provide STI screening, family planning, contraceptive distribution based on choice, and physical exam for all gender. The RH services are funded by Title X/Family Planning, Title V/Maternal and Child Health Block Grants, and UNFPA.

Table 31: RMI MCH Health Indicators FY2007 FY2008 FY2009 FY2010 FY2011 Total Number of Pregnancies 1,591 1,526 1,603 1,396 1,487 Antenatal Care Achieved 1,152 1,215 1,537 1,373 1,374 Antenatal Coverage (%) 72 80 96 98 92 Number of First Trimester Booking 539 543 607 556 510 Rate of First Trimester Booking 34 36 38 40 34 Number of deliveries Attended by trained 1,575 1,510 1,582 1,385 1,,462 health personnel Number of Non pregnant women of 12,688 12,792 12,685 12,690 13,024 reproductive age (15-49) Number of unduplicated acceptors of family 1,499 2,236 2,504 2,565 1,679 planning Family Planning Coverage (%) 12 17 20 20 13

Prenatal Care

The two main hospitals provide the following prenatal care services for pregnancy management, STI/HIV screening, Pap smear screening, oral health, and immunization. Health centers in Outer Islands provide pregnancy management. . Outreach Mobile Team that visited the Outer Islands includes MCH services including prenatal care. MCH Staff coordinates with the Health Assistants for pregnancy management and update training with the Health Assistant.

Table 32: Summary of Prenatal Visits Type FY FY FY FY FY 2007 2008 2009 2010 2011 Total Visits All Trimesters 3,383 3,100 4,895 5,066 5,994 Number of Pregnant Women 1,152 1,215 1,537 1,373 1,374 st 1 Trimester Encounters 1,248 961 879 822 721 2nd Trimester Encounters 1,102 1,081 1,615 1,681 1,937 rd 3 Trimester Encounters 1,033 1,058 2,401 2,563 3,336 Source: RH program, Majuro, Ebeye, & Outer Islands

MATERNAL AND CHILD HEALTH

MATERNALTable 33: AND No. CofHILD Pregnant HEALTH Women who attended Prenatal on the 1st Trimester, FY 2011 FY2011 Majuro Ebeye OI Total No. of Pregnant Women who attended Prenatal during 1st 228 210 72 510 Trimester Total Pregnant Women who attended Prenatal Clinic 964 338 72 1,374 Percentage 24 62 100 37

Only 37 % of the pregnant women that attended Prenatal Clinic come to the clinic in their 1st Trimester. Table 34: Prenatal Visit by Main Islands FY2009 FY2010 FY2011 Type Majuro Ebeye OI RMI Majuro Ebeye OI RMI Majuro Ebeye OI RMI Total 3,935 378 582 4,895 4,247 360 720 5,066 5,366 338 290 5,994 Visits All Trimesters No. of 1,098 378 61 1,537 949 360 64 1,373 964 338 72 1,374 Pregnant Women 1st 571 198 110 879 500 205 117 822 417 210 94 721 Trimester 2nd 1237 130 248 1,615 1,431 98 152 1,681 1,744 73 120 1,937 Trimester 3rd 2,127 50 224 2,401 2,316 57 190 2,563 3,205 55 76 3,336 Trimester

It is important to note that the total encounters/visits for all trimesters have increased slightly. Table 28 confirms an increase in total prenatal encounters from 4,895 in FY2009 to 5,327 during FY2010. That shows more mothers recognize the importance of prenatal visits but not all mothers attended prenatal care.

Graph 5: RMI Trend of Prenatal Care

Trend of Prenatal Care

1,800 1,591 1,603 1,526 1,487 1,600 1,396 1,400 1,200 1,000 1,373 1,374 800 1,537 1,152 1,215 600 400 200 0 FY2007 FY2008 FY2009 FY2010 FY2011

Total Number of Pregnancies 40

No. of Pregnant Women who received Prenatal Care ATERNAL AND HILD EALTH M C H

MATERNAL AND CHILDTable HEALTH 35: Number of Pap Smear Test Pap Smear Test FY2009 FY2010 FY2011 Majuro Laboratory 1,948 1,983 1,453 Kwajalein Laboratory 78 408 354 Total 2,026 2,391 1,807

Cervical Cancer is one of the leading types of cancer among women in the RMI. Early detection of abnormalities in the cervix through Pap smear is the first stage in handling cervical cancer. Pap smear tests are available in the MCH Clinics in Majuro, and Kwajalein. For Outer Islands, the Mobile Team from Majuro and 177 Women’s Mission usually conducts the Pap smear testing. All pregnant mothers that visit the hospitals for their prenatal care undergo Pap smear test.

MCH Program continues to encourage pregnant women to be screened on schedule in order to detect abnormalities as early as possible and to promote cervical cancer prevention and awareness. High risk family planning users will be screened for cervical cancer during each clinic visit. However, the figures show that not all women want to have pap smear.

Family Planning There are several methods available for family planning services. The two most popular and used method are the 3 months hormonal injection and oral contraceptive. Family Planning Services also helps on parents planning for a pregnancy.

Table 36: RMI Unduplicated Number of Female Family Planning Users 2007 2008 2009 2010 2011 Female Sterilization 127 147 57 70 40 Hormonal Implant 150 159 308 286 261 3 Month Hormonal Injection 599 907 933 1,013 611 Oral Contraceptive 280 438 395 612 280 Female Condom 16 22 13 41 7 Fertility Awareness Method(FAM) 2 0 3 12 3 Abstinence 0 0 0 0 5 Withdrawal or Other Method 9 10 31 1 2 Method Unknown 0 27 3 2 0 No Method Pregnant/Seeking Pregnancy 5 143 204 158 19 Other Reason 177 257 300 333 366 Relay on male method Vasectomy 0 0 1 0 0 Male Condom 36 39 57 37 33 Total Female Users 1,401 2,149 2,305 2,565 1,627 41

MATERNAL AND CHILD HEALTH

MATERNAL ANDTable CHILD 37: R HMIEALTH FP Methods for Unduplicated Male Users FY FY FY FY FY Method 2007 2008 2009 2010 2011 Condom 112 54 124 188 34 Vasectomy 6 4 2 2 0 Fertility Awareness Method(FAM) 0 1 0 0 0 Other Method 0 0 1 0 0 Method Unknown 0 0 1 0 0 Partner pregnant or seeking pregnancy 0 2 0 0 0 Other Reason 0 31 70 10 14 Rely on Female Method 7 0 1 2 4 Total 125 72 199 202 52 Source: RH program, Majuro, Ebeye, & Outer Islands

Male and female condoms are available in the Family Planning Clinics, STD/HIV Clinics, Health Centers, Youth to Youth in Health, hotels and the bars for free.

One of the major attempts of the MCH program has to do with educating all expected mothers to visit the Family Planning Clinic further information and to receive family planning available services. The total number of female user for FY 2011 slightly dropped.

Table 38: RMI Unduplicated Number of Family Planning by Age and Gender FY2009 FY2010 FY2011 Age Group Female Male Total Female Male Total Female Male Total Under 15 29 13 42 14 3 17 10 0 10 15-17 86 38 124 67 19 86 73 4 77 18-19 168 41 209 181 52 233 115 4 119 20-24 640 62 702 700 67 767 400 25 425 25-29 598 25 623 712 34 746 419 11 430 30-34 396 6 402 493 15 508 285 5 290 35-39 231 7 238 238 8 246 160 1 161 40-44 107 0 107 104 0 104 90 1 91 Over 44 50 7 57 56 4 60 75 1 76 Total Users 2,305 199 2,504 2,565 202 2,767 1,627 52 1,679 Source: RH program, Majuro, Ebeye, & Outer Islands

MATERNAL AND CHILD HEALTH

MATERNAL AND CHILD HEALTH Children with Special Health Care Needs (CSHCN)

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

Shriners Hospital consulted conducted their yearly visit in September 2011. They screened new patients and follow up with patients that were referred. Orthopedic CSHCN cases were referred to Shriners in 2011.

Table 39: New Cases of Children with Special Health Care Needs Diagnosis FY2007 FY2008 FY2009 FY2010 FY2011 Joint/Bone Deformity or Fracture 52 83 87 18 26 Hearing Problems 7 0 0 0 0 Burns (any kind) 6 0 5 0 5 Cleft Palate 3 14 5 5 2 C/foot 2 0 0 0 0 Cong. Deformed 0 3 0 1 0 Eye Problem 0 0 0 0 0 Cardiac 7 1 2 3 3 Others - Extra Fingers 14 0 5 0 0

Others - Arthritis 2 0 0 0 0 Others - Paralyze 2 0 0 0 0 Others - Seizure 2 0 0 0 0 Developmental Delay 1 0 0 0 0 Total 98 101 104 27 36 Source: CSHCN Registration, MCH – Majuro Office

MATERNAL AND CHILD HEALTH

MATERNAL AND CHILD HEALTH Ebeye School Health Program We have done physical examination on 2,044 students out of the 2,064 total enrollees in Ebeye’s 7 major schools. This comprised 99.03% of the targeted students for fiscal year 2011.

Graph 6: Annual School Physical Exam Coverage Rate

TARGET

Five of the seven schools (SDA, QOPES, Calvary, ECES, and EGCES) have 100% coverage rate. Through the annual physicals, acute and chronic health problems of the students are better addressed. In FY2011, 20.10% of students examined have essentially normal Physical Exam (PE) findings compared to 16.60% from the previous year. The three most common abnormal PE findings for the past three years remained basically the same: dental caries, cervical lymphadenopathies, and skin infections. Those with dental caries were referred for dental consultation. Minor skin infections, conjunctivitis, oral sores, ear infections, common colds, and respiratory tract infections were prescribed medications. Foreign bodies in the ear were likewise removed by the school physician. On this fiscal year, hundreds of students with dermatologic and ENT problems were referred during the Canvasback Mission for care.

Table 40: Most Common Physical Exam Findings - Ebeye Number % Essentially Normal Findings 411 20.10% 1. Dental Caries 1,314 64.29% 2. Cervical Lymphadenopathies 291 14.24% 3. Pediculosis capitis 261 12.77% 4. Acute Rhinitis 181 8.86% 5. Acne Vulgaris 152 7.44% 6. Tinea 118 5.77% 7. Impacted Cerumen 112 5.48% 8. Verrucae vulgaris 96 4.07% 9. Perforated tympanic membrane 36 1.76% 10. Acanthosis Nigricans 29 1.42%

MATERNAL AND CHILD HEALTH

MATERNAL AND CHILD HEALTH Nutritional Health Status of Schoolchildren FY2011 Comprehensive nutritional assessments were done on the school children by the Pediatrician. Anthropometrics can be sensitive indicators of health, growth, and development in infants and children. Anthropometrics is the single most universally applicable, inexpensive method available to assess the size, proportion, and composition of the human body. Meanwhile, it has now been well-established that the Body Mass Index (BMI) is the most appropriate variable for nutritional status assessment among adolescents. All 2,044 students were assessed for undernutrition using the Waterlow Classification, while only 2,019 of the 2,044 were included in the BMI percentile assessment. Excluded in the BMI measurements were students above 20 years of age.

Table 41: Waterlow Classification for Under nutrition of School Children FY2011 SDA QOPES Calvary ECES EGCES JPS EPES EPMS Total STUNTING No Stunting 37.71% 39.79% 20% 16.33% 36.9% 26.11% 20.61% 20.41% 25.93% Mild Stunting 45.76% 49.74% 57.27% 54.08% 46.43% 49.44% 48.13% 38.17% 47.11% Moderate 15.68% 7.85% 19.09% 24.49% 1.19% 20.56% 24.20% 30.77% 21.28% Stunting Severe 0.85% 2.62% 3.64% 5.10% 3.57% 3.89% 7.05% 10.65% 5.68% Stunting 100% WASTING No Wasting 94.49% 96.86% 99.09% 94.9% 95.83% 98.89% 97.1% 98.82% 97.11% Mild Wasting 5.51% 3.14% 0.91% 5.10% 3.57% 1.11% 2.63% 1.18% 2.74% Moderate 0% 0% 0% 0% 0.60% 0% 0.14% 0% 0.10% Wasting Severe 0% 0% 0% 0% 0% 0% 0.14% 0% 0.05% Wasting 100%

Table 42: BMI Percentile Nutritional Assessment of School Children FY2011 Boys Girls Total Number of Children Assessed 1040 979 2,019 Underweight (< 5th Percentile) 5% 2% 4% Normal BMI (5th to 85th Percentile)/Healthy 86% 84% 85% Weight Overweight or Obese (> 85th Percentile) 9% 14% 11% Obese (> 95th Percentile) 2% 5% 2%

4% of the students are underweight using BMI percentile – that’s 81 undernourished students. On the other hand, around 11% of the students are overweight with 2% of them obese – that equates to 182 overweight and 40 obese children.

MATERNAL AND CHILD HEALTH

M ATERNAL AND CHILD HEALTH Graph 7: Undernutrition Assessment - Stunting of 2,044 Students, FY2011

Undernutrition Assessment (Stunting) of 2044 Students FY 2011

47.11% 50.00% 45.00% 40.00%

35.00%

30.00% 25.93% 25.00% 21.28%

20.00%

15.00%

10.00% 5.68% 5.00%

0.00% No Stunting Mild Stunting Moderate Stunting Severe Stunting

Graph 8: Undernutrition Assessment - Wasting of 2,044 Students, FY2011

Undernutrition Assessment (Wasting) of 2044 Students FY 2011 97.11% 100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 2.74% 1.00% 0.50% 0.00% No Wasting Mild Wasting Moderate Wasting Severe Wasting

IMMUNIZATION

IMMUNIZATION Table 43: RMI Immunization Coverage for Children 19-35 months, FY2011 Immunizations Majuro Ebeye Outer Total Islands Number of 19-35 months 981 355 377 1,713 BCG 923(34.1%) 355(100%) 349(97.2%) 1627(96%) DTAP4 663(67.6%) 354(99.7%) 219(61%) 1236(72.9%) MMR1 771(78.6%) 355(100%) 301(83.8%) 1427(84.2%) HepB3 756(77.1%) 355(100%) 190(52.9%) 1301(76.8%) Hib1 900(91.7%) 354(99.7%) 349(97.2%) 1603(94.6%) OPV3 796(81.1%) 355(100%) 210(58.5%) 1361(80.3%) No. of Children Fully Immunized 663 354 206 1,223 Full Immunization Coverage 68% 99.7% 55% 72%

Immunization Coverage Rate for 19 to 35 months is completing the 1-4-3-3-1-1 (BCG-DTaP- OPV-HepB-HIB-MMR) vaccination protocol. Immunization program needs to reach 95% immunization coverage rate. In FY2011, Immunization Program in Ebeye achieved 99.7% complete immunization coverage.

There were a lot of challenges in the manners of collection and analysis of data due to duplication of registration of children, multiple names given to a child, movement of children from one zone to another or from one island/atoll to another. One important factor to this dilemma is availability of transportation from the urban centers to outer islands. It is worth noting that during FY2011, the total coverage for Majuro tremendously dropped to 68% due to data entry in terms of lateness in entering and inability to keep track of children moving from one locality to another, which disrupted the manner of calculation.

Table 44: RMI Immunization Coverage Rate Islands FY 2007 FY 2008 FY 2009 FY2010 FY2011 Majuro 95% 92% 94% 93% 68% Kwajalein 92% 96% 98% 99% 99.7% Outer Islands 51% 60% 71% 56% 55%

RMI 79% 83% 89% 84% 72%

IMMUNIZATION

IMMUNIZATION Graph 9: Immunization Trend in RMI

RMI Immunization Rate 120%

100% 80%

60% 40%

20%

FY 2007 FY 2008 FY 2009 FY2010 FY2011 Majuro Kwajalein Outer Islands RMI

Table 45: Immunization Outer Islands Outreach Mobile Visits, FY 2011 Atoll Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept 2010 2010 2010 2011 2011 2011 2011 2011 2011 2011 2011 2011 Enewetak Ailuk Mejit Namu Aur Ujae Lae Wotho Lib Arno Wotje Aur Maloelap Ebon Namdrik Kili Utrik Likiep

IMMUNIZATION

IMMUNIZATION Table 46: New Vaccines Administered Vaccine FY2008 FY2009 FY2010 FY2011 Prevnar 682 2,643 2,398 2,758 Rotavirus 502 1,355 1,807 2,021 HPV 152 1,464 1,421 Source: Immunization Program

Atolls/Islands Target 19 to 35 months # of incomplete Complete Population who have children Coverage completed all required vaccination Ailinglaplap 44 9 35 20% Arno 53 26 27 49% Aur 4 0 4 0% Ailuk 16 5 11 31% Ebon 41 34 7 83% Enewetak 26 19 7 73% Jabat 3 1 2 33% Jaluit 16 13 3 81% Kili 12 5 7 42% Kwajalein (Ebeye) 355 354 1 99.7% Lib 7 5 2 71% Lae 10 9 1 90% Likiep 2 2 0 100% Namu 21 13 8 62% Maleolap 23 12 11 52% Majuro 981 663 318 68% Mejit 18 13 5 72% Mili 5 0 5 0% Namdrik 12 10 2 83% Ujae 17 8 9 47% Utrik 13 9 4 69% Wotho 7 5 2 71% Wotje 27 8 19 30% Total 1,713 1,223 490 72%

Highlights of Accomplishments  Declared polio free by the World Health Organization in October 29, 2000.  No report of vaccine preventable diseases since 2003.  Implementation of the School Rules and Regulations since 2004.  Revised the measles elimination plan that was developed in 2005.  Maintained 100% Hepatitis B birth dose in the two urban hospitals of Majuro and Ebeye since 2005.  Prevalence rate of 1.8% chronic hepatitis B virus (HBV) infection among children aged 4-9 years, born since the implementation of routine childhood hepatitis B vaccination.  Eligible for the certification of hepatitis B control goal in the World Health Organization Western Pacific Region.  Introduction of new vaccines in 2008 - 2010 (Pneumococcal, Rotavirus, HPV, H1N1, Td, Tdap, Meningococcal) and extended to the outer atoll communities.  Drafted a Perinatal Hepatitis B Program Protocol in collaboration with the Maternal and Child Health and STI Programs.  Revised the developed draft National Immunization Program Handbook for the Ministry’s endorsement.  Revised the developed draft yellow card to include new vaccines for children, adolescents and adults.  Trained all the Public Health nurses in implementing the WebIZ registry.  Ebeye Hospital has achieved 99% immunization coverage for the third straight year.

ORALORAL H HEALTHEALTH

ORAL HEALTH Table 47: Key Outcome Measures for Dental Program FY 2009 FY 2010 FY 2011 Majuro Ebeye OI Majuro Ebeye OI Majuro Ebeye OI Total Number of Dental 12,763 3,560 2,791 11,676 3,807 2,482 11,425 3,984 745 Encounters Target: Infants and Children Number of infants or children 1,534 284 2580 288 42 1,477 846 114 who received fluoride varnishing Number of schoolchildren 1,252 474 831 323 468 1,183 393 114 who received annual dental examination Number of schoolchildren 1,252 755 3813 1301 468 1,183 393 114 who receive health talks on oral hygiene Target: Youth and Adults Number of restorative 2,822 1,054 1556 1,050 19 2,724 1,261 6 procedures done annually Number of prenatal clinic 480 118 398 195 392 165 users with annual dental/oral examination

The dental routines provided in this area include tooth extractions, fillings, dental hygiene, fluoride treatment, and regular check-ups for Diabetes Program, Cancer Program and Prenatal. A total of 16,154 dental encounters were treated with 3,991 restorative procedures done in FY2011. There were 3 Outer Island trips. A total of 745 patients treated including 144 students, with 601 patients for extraction and 6 for fillings.

Table 48: No. of Dental Encounters

Main Atolls FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 Majuro 10,825 11,365 12,673 11,676 11,425 Ebeye 4,528 4,912 3,560 3,807 3,984 Outer Islands 1,910 1811 2,791 2,482 745 Total 17,263 18,088 19,024 17,965 16,154 Source: Dental Department - Majuro, Ebeye & Outer Islands

The total number of children who received fluoride varnish during FY2009 was 1,818, 3,336 in FY2010 and 3,986 in FY2011. They were also given tooth brushes and fluoride tooth paste, effective tooth brushing instruction sessions at every Fluoride Varnish application visit. The students attending Special Education program also received similar treatment.

O RAL HEALTH

ODentalRAL H staffEALTH visits the schools every year to provide sealant to students in Head Start and grade 1, 2, 6, & 7. Weekly clinics are held for children who are six months to 4 years old for fluoride treatment and educating their mothers on proper cleaning of teeth. All the children in the Fluoride Varnish Program received tooth brushes and toothpaste every visit.

Seventeen of the Dental Staff attended the one day workshop for Emergency Cardiopulmonary Resuscitation conducted by Dr. Robert Maddison.

Challenges: The Targeted Maternal and Child Oral Health System Services Grant (TOHSS) ended in August 2011. Ministry struggles to find funding sources to support the activities that were previously budgeted under the TOHSS grant.

Way Forward: 1. The program aims to reach 90% of all 6 year old children will receive three Topical Iodine and Fluoride Varnish annually. 2. Increase percentage of population who has regular dental check-ups. Expand Oral Health Workforce. 3. Increase the number of patients served. Increase the number of children who receive fluoride varnishing and dental sealants. Increase the number of school children seen for oral and dental examination. 4. Increase the number of children who receive health talks or education on dental hygiene. 5. Increase the number of restorative procedures annually. Increase the number or percentage of DM patients with annual dental examination. 6. Increase the number or percentage of prenatal care users with annual dental examination. 7. Increase the number of patients screened for Oropharyngeal Cancer

HHUMANUMAN SSERVICESERVICES && M MENTALENTAL H HEALTHEALTH

HTheUMAN top 3 S mainERVICES diagnosis & M forENTAL the mental HEALTH health (HSMH) cases are Schizophrenia, Suicide, and Major Depressive Disorder. Patients are referred by: 1.) Other medical subspecialties; in-patient or out-patient, 2.) Other government agencies, 3.) Family Members, and 4.) Walk-in patients who come in for psychiatric consultations, and counseling. These are patients whose symptoms are florid acute warranting prompt evaluation and management.

Table 49: No. of Registered Cases in Mental Health Program Fiscal Year Majuro Ebeye Outer Islands RMI

2007 214 20 6 240 2008 283 20 11 314 2009 338 20 11 369

2010 366 20 11 397 2011 54 53 0 107 Source: Mental Health Program, Majuro & Ebeye

Table 49 shows that there were 107 patients who received medications and mental health counseling

Table 50: Data on Suicide Cases Fiscal Year Attempted Completed Total 2007 16 6 22

2008 16 10 26

2009 14 14 28 2010 25 4 29 2011 33 13 46 Source: Mental Health Program, Majuro & Ebeye

Graph 10: RMI Trend of Suicide Cases

Trend of Suicide Cases

33 35 30 25 25 20 16 16 14 14 13 15 10 10 6 4 5 0 2007 2008 2009 2010 2011

Attempted Completed 53

HUMAN SERVICES & MENTAL HEALTH

It His worthUMAN knowing SERVICES that suicides & MENTAL related H withEALTH alcohol (HSMH) were done at the height of intoxication. Family members should be very sensitive in identifying any sign of depression and detection of an early signs of suicide attempt with other members. Hanging is the most common method of suicide. This fiscal year has the highest suicide cases. All attempted cases received mental health counseling from the Human Services Program.

Table 51: Suicide Cases in RMI by Type and Location 2011 2010 2009 Majuro/ Majuro/ Majuro/ Types of Outer Outer Outer Suicide Islands Ebeye Total Islands Ebeye Total Islands Ebeye Total Completed 12 1 13 4 4 8 8 4 12 Attempted 17 16 33 16 9 25 17 3 20

Rape Prevention & Education/Sexual Violence  There were two rape cases referred to the Social Work unit. One from Arno and one from Delap, Majuro. All these cases were referred to Human Services and counseled by the Social Work staff. The suspects are locked in jail.  Presentations were conducted on Sexual Violence to 135 senior students at the Northern High School in Wotja.

Outer Islands Visits The program staffs were able to reach the following Islands during the reporting Period: Arno, Jaluit, Wotja, Likiep, Aur, Maloelap, Ailinglaplap, Ailuk, and Utrik. During these trips the staffs were able to conduct mental health screenings, follow-up on patients, and meet with family members regarding the patients.

Way Forward: The program will strengthen public health awareness on the availability of services. Strengthen referral system of mental health cases. Finalize and endorsement of Mental Health Policy. Better intervention strategies will be instituted in the program including access to mental health services of a psychologist or psychiatrist. It is also important that the general population is knowledgeable in detecting the early signs of suicide in order to strengthen community collaboration for patient referral and counseling.

HEALTH PROMOTION AND DISEASE PREVENTION

ON OMMUNICABLE IS EDICAL EFERRAL ERVICES N During-C the reporting year,D theM program wasR able to coordinateS major initiatives and planned

activities for year 2011 plan of action. The CPPW basically is to supplement the diabetes & EASEtobacco collaborative performance agreement (CPA), and its main objectives are to promote policy & environmental change at community or national level.

Achievements:  The program received the 3rd Year budget period for Diabetes and Tobacco Grant. This year, we were awarded a supplemental funds that focus on Chronic Disease Plan  During the World Diabetes Month, World Food Day, and Father’s Day Initiative, the program conducted 13 Outreach activities in coordination with Taiwan Health Center and other partners.  Caregiver Support Train the Trainer Workshop was conducted in August 15-19, 2011. Participants for this training came from different stakeholders and partners: 5 church groups, 3 NGOs, and MOH staff. There were 40-50 participants that came daily during the duration of the workshop. This training was sponsored by the CDC Diabetes Grant.  HPDP with Ministry of Education conducted the Food Services and Sanitation Workshop for Northern High School, Jaluit High School, and Kindergarten school and staff. The workshop was held from July 4-8, and July 27-28.  A pilot project at Delap Elementary School for banning junk snacks and Tobacco Free School. The Principal is a key player in making this activity successful.  There were 24 healthy cooking class conducted to diabetes patients and caregivers that have gone through the diabetes foot care clinic.  Awareness and educational presentations were conducted on Smoke Free Schools Policy to 2 pilot schools (Delap Elementary School and Ajeltake Elementary School  RMI Growth Monitoring and Infant and Young Child Feeding Training Course was conducted with participants from the Majuro, Ebeye, and Outer Islands MOH Staff and women’s group. This training was funded by WHO and SPC.  Baby Friendly Hospital Initiative (BFHI) committee was established to create a Breastfeeding policy, manage the Community Support group training, and monitor all activities under the BFHI. The Community Support group is consisting of community partners that will be trained for proper breastfeeding and will support the breastfeeding mothers.  582 received Diabetes and Nutrition Education from Diabetes Clinic in Majuro. 70 patients received Self-Management Goal Settings Sessions and 40 received healthy lifestyle education in Ebeye.  Ebeye Health Promotion visited 5 of the 7 schools to educate the schoolchildren that were assessed to have nutritional problems by the School-Based Health Program. A total of 433 students received health talks about nutrition and physical activity.  Ebeye Cancer Outreach assisted in the cancer awareness outreach to the schools. Six of the 7 target schools were visited to give health talks among grades 6 to 12 students. A total of 447 students were educated.

HEALTH PROMOTION AND DISEASE PREVENTION

NON Ebeye-COMMUNICABLE Health Promotion D progISMramEDICAL continued REFERRAL to run health SERVICES education videos and movies in the outpatient waiting area every morning. The program also led the daily 9 AM exercises EASEin the hospital lobby every day. Most Primary Health Care Staff joins the daily exercises.  On this fiscal year, Ebeye Health Promotion program translated five (5) new health pamphlets were translated and produced (HIV, Family Planning, Physical Activity, and Hypertension). These health brochures are placed in the hospital lobby for easy reading for patients.  Continued capacity building - 2 staff attended the Non Communicable Disease Forum 2011 in Tonga. Main objectives strengthening the network between the jurisdictions in the Pacific and to push the declarations of NCD Emergency declaration. - Diabetes Coordinator from Majuro and Ebeye attended the Annual CDC DDT Conference - 3 staff attended the OSH Summer/Fall Institute in Atlanta GA.

Table 52: Health Promotion Outer Islands Outreach Mobile Visits, FY 2011 Atoll Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept 2010 2010 2010 2011 2011 2011 2011 2011 2011 2011 2011 2011 Ailuk Mejit Namu Ujae Lae Wotho Lib Wotje Aur Maloelap Ebon Namdrik

On this fiscal year, Ebeye Health Promotion Program had 169 encounters which are one-on-one health education to clients on various health topics such as healthy lifestyles, sexually- transmitted diseases, family planning, and healthy pregnancy.

Table 53: One on One Health Education Encounters in Ebeye FY2011 Encounters 1 Healthy Lifestyles (BMI determination/Obesity/Diet/Physical Activity) 44

Self-Management Goal-Setting Sessions (DM 2 70 Diet/Activity/Medications/Compliance) 3 Prenatal Care (Healthy Pregnancy/Diet/Exercise) 6 4 Postnatal Care (Breastfeeding/Immunization) 5 5 Family Planning (Contraceptives/Importance of Family Planning) 14

HEALTH PROMOTION AND DISEASE PREVENTION

N6ON -STI/HIVCOMMUNICABLE (Risk Behavior DReduction/CondomISMEDICAL REFERRAL Usage) SERVICES 10

7 Tuberculosis and Hansen’s Disease 20 EASE 169

Way Forward: 1. Strengthen the referral of diabetic patients from Outpatient, ER, and Admission Wards to the Public Health Diabetic Clinic for regular consultancy and management of their diabetes. 2. Recruit a Tobacco Coordinator to strengthen the tobacco activities. 3. Finalize the Regulations for RMI Framework Convention on Tobacco Control (FCTC) and Food Safety Policy. 4. Coordinate with other program areas and partners to strengthen health promotions activities in the outer islands 5. Collaborate with the Community Health Councils in developing or implementing and monitoring community health program 6. Continue to implement the NCD and Nutrition Strategic Plan (KUMIT Plan) 2008-2012. 7. Conduct RMI STEPwise approach to surveillance (STEPS). The last STEPS was done in 2002. 8. Create the NCD Kumit Plan for 2013-2017.

D IABETES

NON-COMMUNICABLE DISEASE Diabetes is the leading cause of mortality and morbidity in RMI. In FY 2010, 23% of registered deaths are due to diabetes related diseases such as the End Stage Renal Failure, Uremia, and Septicemia. Diabetes is a life style disease that can be prevented. The Ministry of Health has been advocating healthy lifestyle through physical activities and healthy eating habits. The Diabetes Wellness Center is one example to promote healthy lifestyles. Health promotion through posters, presentations, and meetings are ways to communicate to the community about the effect of diabetes and how to prevent it. The Health Promotion and Disease Prevention Unit is implementing the KUMIT NCD plan to address the Non Communicable Diseases.

In FY2011, MOH celebrated the World Diabetes Day with the community. As such, community health screening and health promotion activities were conducted during the World Diabetes Day,

Table 54: Prevalence Rate of Diabetes Description FY 2007 FY 2008 FY 2009 FY2010 FY2011 Population 52,701 53,236 54065 54439 53158 Majuro 1694 1570 1369 1385 1357 Ebeye 600 600 600 623 623 Majuro and Ebeye 2,294 2,170 1,969 2,008 1,980 Prevalence Rate* 435 408 364 369 372 Increase/Decrease 6.2% 10.8% 1.4% 0.81% * Per 10,000 Population

Table 55: RMI Diabetes Encounters Fiscal Year Outpatient/Public Health Admission 2011 3,672 411 2010 3,726 387 2009 3,673 328

Majuro Diabetes Program  Chronic Disease Electronic Management System (CDEMS) has been implemented. For FY2011, diabetes visits during the Diabetes Clinic were entered. CDEMS is a registry system not only for Diabetes but for all Chronic Diseases. For FY 2011, we concentrated on registration of Diabetes patients. CDEMS help the Physician manage the patient better because of availability of laboratory results, services given, medications that patients are taking, and record of their visits.

DIABETES

N ON-COMMUNICABLE DISEASE Table 56: Diabetes Patients enrolled in the CDEMS FY 2011 Age Gender Male Female Unknown Total Unknown 3 7 0 10 15-19 1 1 0 2 20-24 1 0 0 1 25-29 1 2 0 3 30-34 3 6 0 9 35-39 7 13 0 20 40-44 16 25 0 41 45-49 31 60 2 93 50-54 38 62 2 102 55-59 50 82 1 133 60-64 43 65 2 110 65-69 26 33 0 59 70-74 12 19 0 31 75-79 4 9 0 13 80+ 6 4 0 10 Total 242 388 7 637

The program started using CDEMS in October 2010 and has enrolled 637 diabetic patients in CDEMS. These patients are seen during the Diabetic Clinic in Public Health. A total of 1,357 old and new diabetes patients that were seen in Majuro Hospital and Majuro Public Health Clinic.  Diabetes One Stop Shop is still on going. The one stop shop consists of diabetes management in Public Health, Foot Care Clinic, Health Education, Dental services, Radiology Services, and Laboratory Services  Diabetes Task Force was established and met in 3 major meetings. In each meetings, the task force discussed the current activities in the Diabetic clinic, challenges, and improvements.

Majuro Diabetes Foot Care Clinic

Visits of diabetic patients to Diabetes Foot Care (DFC) Clinic have increased by 42%. In January 2010, Diabetes Foot Care Clinic at the Rehabilitation Department was opened for the 1st time. The clinic opens every Monday and Friday mornings in conjunction with the Diabetes Clinic. The primary goal of the new offered service is to perform the five LEAP components as follows: (1) Foot Screening (2) Management of Simple Foot Problem (3) Patient Education (4) Daily Self- Inspection and (5) Footwear selection. The clinic tends to reduce the prevalence of ulcer and amputation. Long term goal for the DFC Clinic is to decrease the number of amputation performed at the hospital.

DIABETES

NON-COMMUNICABLE DISEASE Table 57: Diabetes Foot Care Encounter Description FY 2010 FY 2011 New referrals 346 335 Follow-up 254 518 Total Encounter 600 853

In FY 2011, 335 diabetic cases were screened (foot sensory examination, foot care education / management; nutrition counseling) - 46 % have poor sensation and at risk for foot problems/complication. - 30% have foot ulcer/wound (104 patients were referred by the surgeons and OPD dressing to DFC for foot care management) - 74% of compliant patients had healed ulcer; 6% had amputation; 20% are still receiving foot care management. - 23% are non-compliant

Ebeye Diabetes Program

The program received a 5-Year CDC-AAPCHO (Association of Asian Pacific Community Health Organizations) project grant to eliminate Diabetes-related disparities in vulnerable populations. On Fiscal Year 2011 (Year 1 of the project) – the program was able to re-establish and strengthen the Kwajalein Diabetes Coalition and complete 4 major needs and assets assessment related to Diabetes.

There were 416 registered Diabetes Clinic users with 3,314 encounters made for the fiscal year. There were only 5 major diabetes-related lower extremity amputations this year. There are 34 new diabetes clinic users and 13 new hypertension clinic users. DM-related deaths still ranked as the most common cause of death among adults accounting for around 23% of all deaths recorded.

Table 58: Key Outcome Measures for Ebeye Diabetes Program FY2011 Outcome Measure By 9/30/11 PECS DATA REGISTRY SIZE 413 1. Average HbA1c of < 7.0% 10.9% 2. At least 90% of patients have at least 2 HbA1c/year 2.1% 3. At least 70% of patients have SMG sessions 12% 4. At least 40% of patients have BP <130/80 mmHg 29% 5. At least 75% of patients (55 years and older) have current prescriptions for 69.6% ACE Inhibitors 6. At least 60% of patients (40 years and older) have current prescriptions for 26.4% Statins 7. At least 70% of patients have dilated eye exam for the past year 11.14% 8. At least 70% of patients have comprehensive foot exam for the past year 8.78%

DIABETES

NON9. At-C leastOMMUNICABLE 70% of patients D haveISEASE dental examination for the past year 51% 10. At least 90% of patients have Influenza vaccination for the past year 99% 11. At least 70% of patients have LDL determination below 100 mg/dl NR

General Knowledge and Barriers to Control of Diabetes: A Survey of 100 Diabetic Patients in Kwajalein Atoll. The survey revealed a lot of important information about the challenges and preferences of diabetic patients in controlling their disease and preventing complications.

Assets Mapping Report: The assets mapping activity was completed by the Kwajalein Diabetes Coalition which enabled them to identify strengths of the community, potential resources, and possible partnerships to help address healthy lifestyle challenges for the community.

Community Assessment: A Focus Group Discussion of Marshallese Diabetic Patients. The FGDs revealed very important issues related to diabetes such as stigma, importance of community- based activities, and cultural factors.

Key Informant Interview: Multisectoral Community Leaders Take on Diabetes and Its Burden to the Community. The interviews revealed key findings about the need to develop systems and environmental change to improve the lives of diabetics.

Kwajalein Diabetes Coalition Campaign One of several Coalition Meetings

Some members of the Coalition One of many coalition training meetings

NATIONAL COMPREHENSIVE CANCER CONTROL PROGRAM

NONCancer-COMMUNICABLE is the 2nd leading cause DISEASE of death in RMI. It affects the female population more than the male. The death is attributed to breast cancer, cancer of the cervix, liver cancer, and of course, lung cancer.

The NCCCP Cancer Registry was developed to link with the Medical Records, Laboratory, and Vital Statistics for confirmed cases and possible cases of cancer.

Table 59 : Death Due to Cancer by Gender FY 2009 FY 2010 FY 2011 Cancer Site Male Female Total Male Female Total Male Female Total Lung Cancer 6 2 8 2 0 2 3 1 4 Breast 0 5 5 0 2 2 0 2 2 Cervical Cancer 0 3 3 0 8 8 0 4 4 Colon 2 0 2 0 0 0 0 1 1 Liver 2 1 3 2 0 2 6 0 6 Ovarian 0 3 3 0 0 0 0 0 0 Gastric 0 0 0 0 1 1 0 0 0 Eye 1 1 2 0 0 0 0 0 0 Nasopharyngeal 0 2 2 0 0 0 2 0 2 Thyroid 0 1 1 0 0 0 0 0 0 Rectal 1 0 1 0 0 0 0 0 0 Nose 0 0 0 1 0 1 0 0 0 Oral Cancer 1 0 1 0 0 0 0 0 0 Unknown 1 0 1 2 0 2 2 0 2 Kidney 1 0 1 0 0 0 1 0 1 Pancreatic 1 0 1 1 0 1 0 0 0 Leukemia 0 1 1 1 0 1 0 0 0 Testicular 1 0 1 0 0 0 0 0 0 Lymphoma 1 0 1 2 1 3 1 1 2 Multiple Myeloma 0 0 0 0 2 2 0 0 0 Bone 0 0 0 0 0 0 1 0 1 Bladder 0 0 0 0 0 0 1 0 1 Prostate 0 0 0 1 0 1 1 0 1 Laryngeal 1 0 1 0 0 0 0 0 0 Total 19 19 38 12 14 26 18 9 27 Source: MOH Vital Statistics Information System

NATIONAL COMPREHENSIVE CANCER CONTROL PROGRAM

NON-COMMUNICABLE DISEASETable 60: Cancer Registry Cases FY 2009 New Cases FY 2010 New Cases FY 2011 New Cases RMI FY2006- Male Female Total Male Female Total Male Female Total Total Cancer Site 2008 Cases Breast 11 0 5 5 0 10 10 0 3 3 29 Cervical 16 0 14 14 0 18 18 0 10 10 58 Thyroid 10 0 1 1 0 0 0 0 0 0 11 Colorectal 7 2 0 2 0 0 0 0 0 0 9 Colon 0 0 0 0 0 0 0 0 1 1 1 Lung 12 6 0 6 4 0 4 3 2 5 27 Nasopharyngeal 6 0 1 1 4 1 5 6 0 6 18 Stomach 5 0 0 0 0 2 2 0 0 0 7 Bone 2 0 0 0 1 3 4 1 0 1 7 Lymphoma 5 2 0 2 5 1 6 2 1 3 16 Laryngeal 2 0 0 0 1 0 1 1 0 1 4 Ovary 6 0 1 1 0 0 0 0 1 1 8 Uterine 2 0 2 2 0 2 2 0 6 6 12 Salivary gland 1 0 0 0 0 0 0 0 0 0 1 Vulva 2 0 0 0 0 0 0 0 0 0 2 Oral 4 0 0 0 1 0 1 0 0 0 5 Kidney 2 2 0 2 0 1 1 0 1 1 6 Leukemia 7 0 2 2 2 3 5 1 3 4 18 Lip (lower) 0 0 0 0 0 0 0 0 1 1 1 Liver 7 2 1 3 2 0 2 5 0 5 17 Pancreas 3 1 0 1 1 0 1 1 0 1 6 Prostate 4 0 0 0 2 0 2 3 0 3 9 Para Nasal 1 1 0 1 0 0 0 0 0 0 2 Bladder 0 0 0 0 0 0 0 2 0 2 2 Esophagus 1 0 0 0 0 1 1 0 0 0 2 Rectal 3 1 0 1 0 0 0 0 0 0 4 Brain 2 0 0 0 0 0 0 2 0 2 4 Eye 2 0 0 0 2 0 2 0 0 0 4 Testicular 2 1 0 1 8 1 9 0 0 0 12 Skin 7 2 0 2 0 0 0 5 1 6 15 Mouth 1 0 0 0 0 0 0 0 0 0 1 Ankle 1 1 0 1 0 0 0 0 0 0 2 Retroperitioneal 1 0 0 0 2 1 3 0 0 0 4 Sarcoma Chorio- 1 0 0 0 1 0 1 0 0 0 2 carcinoma

NATIONAL COMPREHENSIVE CANCER CONTROL PROGRAM NON-COMMUNICABLE DISEASE Iliac Fossa ® 0 0 1 1 1 0 1 0 0 0 2 RetroBladder 0 1 0 1 0 0 0 0 0 0 1 Sarcoma Unknown origin 4 0 2 2 1 0 1 2 0 2 9 Hard Plate 0 0 0 0 0 0 0 1 0 1 1 Head 0 0 0 0 0 0 0 1 0 1 1 Buttocks 0 0 0 0 0 0 0 1 0 1 1 Total 140 22 30 52 38 44 82 37 30 67 341

Accomplishments/Success

 Cabinet passed a resolution declaring February 1-7 as perpetual annual RMI National Cancer Awareness Week. During the National Cancer Awareness Week. The Program planned various activities for community awareness throughout the week in collaboration with the local partners and Coalition members.  NCCCP supported the Marshall Islands National Olympic Committee’s Marshall Islands Sport Education Program (MISEP) to train and certify community members as coaches and referees for community sporting events and leagues including information on healthy lifestyles (physical activity and nutrition), anti-doping (including tobacco cessation and the dangers of alcohol and other substance abuse), the importance of regular health checks, etc.  NCCCP regularly conduct public awareness addressing cancer through weekly advertisements in the local newspaper and multiple outreaches to schools, churches and different women’s groups. Approximately 2000 cancer education/awareness resources were distributed during outreaches and activities. Twenty-one cancer awareness articles/ads were published in the local newspaper.  Standardized screening guidelines for cervical cancer, breast, and colorectal cancer have been adopted by the Ministry of Health. Korain Eoeo im Kibed Non Ejmour (KIEKNE), RMI’s Cancer Survivors’ Support Group, spear heads RMI NCCCP’s efforts with on-going outreaches to cancer patients, survivors and their family members and support network. NCCCP Coalition is very active and plays a big role in reaching out to the community.  FY2011 is the second year for the Ebeye Cancer Control Program to significantly strengthen its Breast and Cervical Cancer (BCC) Prevention efforts for the women in the community. This fiscal year, the program in partnership with the Ruk Jen Leen Chapter completed a one- year Pacific CEED Legacy Project grant to mobilize women’s groups towards prevention and early detection of Breast and Cervical cancer. The project was successful as evidenced by:

1) Successful training of 48 women from 8 women’s groups, 2) Completion of 12 community-based activities including the formation of 4 women exercise groups, 3) Improved pap smear and comprehensive breast examination rates, and as evidenced by

NATIONAL COMPREHENSIVE CANCER CONTROL PROGRAM NON-COMMUNICABLE DISEASE 4) Comprehensive community based survey which clearly showed increased knowledge and awareness on BCC for the past two years. The first two projects clearly lead to improvements in Breast and Cervical cancer screening rates.

The Cancer Control and Prevention Program continue to work with the Ebeye Cancer Coalition in initiating community-based interventions against cancers and to implement the National Comprehensive Cancer Control and Prevention Plan.

Challenges: There are national and local laws and even community-specific guidelines about substance abuse. However, most perceive that laws governing the purchase of alcohol and tobacco are sporadically or rarely enforced. There has been increased public outcry regarding this lack of enforcement that is known to exacerbate the problem. The Ministry continues to face challenges in fixing the mammogram machine so screening for breast cancer screening campaign is was not carried out. The Program’s 5-year grant will end in June 2012. New competitive application will be submitted in March 2012.

Way Forward: 1. Collaborate with the traditional leaders play an active leadership role in substance abuse prevention. They can also provide enforcement in terms of defining what acceptable and unacceptable lifestyles in the community are. 2. Strengthen awareness and outreaches to the policy enforcers: police, justice system, business owners, educators, parents and other stakeholders. 3. NCCCP will conduct training in Visual Inspection of the Cervix with Acetic Acid (VIA) for cervical cancer screening especially to atolls where Pap smear kits are unavailable. Care Giver Training will be conducted in 2012. 4. NCCCP will continue the collaboration with stakeholders, assists and coordinate the Cancer Support Group, and continue community outreach and public awareness.

TUBERCULOSIS HOSPITAL SERVICES The Republic of the Marshall Islands is one of the three remaining countries in the Western ASEPacific that was not able to reach the threshold for TB elimination set by the WHO. The TB program does receive assistance in terms of grants and technical assistance from both WHO and CDC to combat the disease. Irrespective of both, the Tuberculosis continued to be in rampant.

The Marshall Islands NTP adopts the DOTS (Directly Observed Therapy Short Course) strategy to effectively ensure a high cure rate, the emergence of acquired drug resistance is prevented, and a high case detection rate is ultimately maintained to:  Reduce TB mortality, morbidity and disease transmission of the infection; and  Prevent the development of Multi Drug Resistance (MDR) TB  An effective TB program has a high cure rate, low level of acquired drug resistance, and ultimately a high case detection rate

Specific Targets  Achieve a success cure rate of 95% from detected new sputum smear-positive TB cases; and treatment  Detect 85% of existing sputum smear-positive TB cases

Strategies of the Program:  Sustained political commitment to increase human and financial resources and make TB control a nationwide priority integral to the national health system.  Access to quality-assured TB sputum microscopy for case detection among persons presenting with, or found through screening to have, symptoms of TB (most importantly prolonged cough). Special attention is necessary for case detection among HIV-infected people and other high-risk groups, such as household contacts of infectious cases and people in institutions.  Standardized short-course chemotherapy for all cases of TB under proper case management conditions, including direct observation of treatment. Proper case management conditions imply technically sound and socially supportive treatment services.  Uninterrupted supply of quality-assured drugs with reliable drug procurement and distribution systems.  Recording and reporting system enabling outcome assessment of all patients and assessment of overall program performance. This is the basis for systematic program monitoring and correction of identified problems.

DOTS plus Strategy – MDR/HIV  Reduce the transmission of MDR by strict isolation and compliance  HIV-TB co-infection, HIV test by TB patients, vice-versa  Maintenance of second line drugs and ARV drugs  Implement active HIV and MDR screening  HIV screening among TB cases  TB screening among HIV cases

TUBERCULOSIS

Table 61: TB Registered Cases FY FY FY FY FY Registered Cases 2007 2008 2009 2010 2011 New Pulmonary Smear Positive 30 30 37 48 44 Pulmonary Smear Negative 82 74 45 56 32

Extra Pulmonary TB 43 28 34 51 60

13 6 1 4 8 Relapse Treatment after Default 3 4 5 0 0 Treatment after Failure 0 0 0 1 0 Transfer in 2 1 1 1 2 Other 0 1 2 5 10 Total 173 144 125 166 156 Prevalence Rate Per 10,000 33 27 23 30 29

Table 62: New TB Cases by Age Distribution, FY2011 New Pulmonary Smear New Pulmonary Smear New Extra Pulmonary

Positive Negative Age Male Female Total Male Female Total Male Female Total 0-4 1 0 1 3 2 5 4 9 13 5-14 0 1 1 3 2 5 10 6 16 15-24 7 5 12 2 1 3 4 7 11 25-34 2 8 10 3 1 4 5 4 9 35-44 3 2 5 2 2 4 1 3 4 45-54 3 5 8 1 4 5 3 3 6 55-64 3 2 5 2 0 2 0 1 1 65+ 1 1 2 4 0 4 0 0 0 Total 20 24 44 20 12 32 27 33 60

TUBERCULOSIS

ASE Table 63: TB Treatment Outcome FY2011 Transferred Description Cured Completed Died Failed Defaulted out New Pulmonary Smear Positive 45 5 6 0 1 2 Pulmonary Smear Negative 0 48 11 0 3 0 Extra Pulmonary TB 0 60 1 0 2 2 Relapse 1 2 1 0 0 0 Treatment after Default 0 1 0 0 0 0 Treatment after Failure 0 0 0 0 0 0 Transfer in 0 0 0 0 0 0 Other 3 5 1 0 0 0

Table 64: TB-HIV FY2011

HIV testing of TB patients Number of TB patients tested for HIV 114 Number of TB patients who tested positive 1 Number of TB patients who tested negative 73 Number of TB patients whose test was indeterminate 0 Number of HIV infected TB patients receiving Anti-retroviral therapy 1 Co-trimoxazole preventive therapy 0

Table 65: MDR-TB Cases 2009-2011 – On going Case ID Complete No. of Contacts Contacts Contacts Default Treatment Contacts (-) TST (+) TST CT Case 1 Yes 69 23 46 35 11 Case 2 Yes 12* 7 5 1 4 Case 3 Aug 2012 52 14 38 30 8 Case 4 Jan 2013 ** Case 5 June 2013 35 30 5 0 0 Total 168 74 94 66 23

TUBERCULOSIS

COMMUNICABLE DISEASE Achievements National Advisory Council (NAC) for HIV and TB was established in 2011. Support the MOH review and monitor HIV, STI and TB program progress against the RMI MOH strategic plans and stated goals and objectives; Assist the MOH to plan, coordinate, strengthen and monitor local efforts to improve cross-sector collaboration and partnerships to address HIV, STIs and TB, including strengthening linkages and partnerships with the private sector and civil society in the response to HIV, STIs and TB; provide recommendations, provide advocacy support and liaison between community. MOH actively provide Direct Observation Therapy (DOT) to TB Patients. TB Isolation Ward in Majuro is operational. There is a clear need to intensify implementation of the USAPI Standards for the Management of Tuberculosis and Diabetes. The Ebeye TB program has intensified the TB testing for Diabetes patients. There were 27 positive TB patients out of 102 Diabetic patients that were tested. One of the positive cases is a MDR-TB case.

Challenges  The need to have a dedicated staff for the Ebeye TB Isolation Ward  Brining in TB contacts from outer islands for x-ray and work up is costly.  There is always the challenge for space, human resources and laboratory capacity when new program requirements are addressed  There is also co-infection of TB with HIV and Diabetes.  Because the TB patients are given daily medications at homes, vehicles need regular maintenance to ensure transportation is available for DOT. Public knowledge about TB is a barrier for cooperation from the communities and families to ensure compliance for treatment is successful. Funding sources is a continuous challenge knowing that Global Fund may end within the next year or so.

Way Forward 1. The National TB Program will intensify Diabetes screening for TB patients and DOT program to prevent increase in the number of MDR-TB. 2. Majuro NTP will start the TB screening for Diabetic patients. 3. The TB Program will conduct TB 101 training for Public Health Nurses as part of the MOH Human Resource Development 4. Finalization and implementation of the RMI National TB Manual. 5. Reduce the prevalence of TB by 90%, strengthen the early detection of TB cases, enhance the contact tracing of TB, strengthen public awareness through media campaign, increase the percentage of identified contacts of infectious cases 90%, increase the percentage of evaluations for identified contacts of infectious cases to 90%, increase the percentage of contacts of infectious cases who are eligible for treatment for LTBI and complete treatment in RMI to 60%. 6. With the closing of Global funds, MOH will advocate for additional financial assistance and identify the true and actual needs of the National TB Program. With the help of Health Promotion and Disease Prevention Unit, we will empower the general public with knowledge. Adopt the concept of volunteered Health Care Workers (HCW)

LEPROSY

CProgramOMMUNICABLE Goal DISEASE By 2015, the RMI will eliminate HD by reducing the prevalence rate to 1/10,000 or 6/60,000. Leprosy is curable with Multi Drug Therapy (MDT) which can also prevent disability and deformity. There are 2 classification type of Leprosy: Paucibacillary (PB) Leprosy – one to five skin lesions and Multibacillary (MB) Leprosy – 6 or more skin lesions

Burden of Disease for 2011 Prevalence rate: 45/10,000 New case detection rate: 26/10,000 Incubation period: 3-10mos

Program Objectives  Ensure patient treatment compliance  Treatment is available at all times, no stock outs  Contact tracing and household investigations are conducted  yearly for all index cases for five years  Change treatment guideline to DOT for DAYS 1-28

Treatment Monthly Multi Drug Therapy MDT (PB) – duration of 6-9mos Monthly Multi Drug Therapy MDT (MB) – duration of 12-18mos Monthly supervised treatment or DOT (DAY 1) – 3 drugs including rifampin Unsupervised Daily treatment (DAYS 2-28) – no rifampin

Table 66: Leprosy Cases, FY 2011 Description MB PB Total Number of Cases on Treatment at the Beginning of the Year 67 36 103 Number of New Adult Cases Detected 42 31 73 Number of New Cases 0-14 years detected 18 29 47 Number of Old Cases started treatment 13 9 22

Number of New Cases Detected with Grade 1-3 Disability 2 0 2

Number of Cases Classified as RFT, T/O, Defaulted 69 63 132

Number of Cases on Treatment at the End of the Year 71 42 113

There are 245 cases in 2011 where in 120 are new cases and 125 are old cases.

LEPROSY

COMMUNICABLETable 67 D: ISEASERegistered New Cases by Type, Gender and Age, FY2011 Age Female Male Total PB MB PB MB <15 10 10 19 8 47 15+ 17 20 14 22 73 Total 27 30 33 30 120

Table 68: New Registered by Atoll, FY2011 MBA MBC PBA PBC Total Ailinglaplap 3 1 2 0 6 Arno 3 3 0 3 9 Ebon 2 0 0 1 3 Ebeye 6 2 0 1 9 Enewetak 0 0 2 1 3 Jabat 0 0 1 0 1 Jaluit 2 4 4 4 18 Lib 0 0 3 2 5 Majuro 21 5 11 14 51 Namdrik 2 0 2 1 5 Namu 3 1 2 1 7 Ujae 0 2 3 1 7 Total 21 13 19 16 69

Table 69: Treatment Outcome, FY2011 Complete Defaulted Transfer Stopped Died Total Treatment Out D/C Treatment MB 53 11 1 4 0 69 PB 54 6 0 3 0 63 Total 107 17 1 7 0 132

Table 70: New and Old Cases on Treatment at the End of the FY2011 Place MBA MBC PBA PBC TOTAL Majuro 24 5 8 6 43 Ailinglaplap 4 1 2 0 7 (2 taking rx in (taking rx in Ebeye;2 in Jaluit) Jaluit) Arno 3 3 1 2 9 (All in Majuro) (2 taking rx in (1 taking rx in Majuro) Majuro) Ebeye 8 2 1 0 11 Ebon 2(1 taking rx in 0 0 0 2 Jaluit)

LEPROSY COMMUNICABLE DISEASE Enewetak 2(1 taking rx in 0 2 2 6 Majuro) Jaluit 4 4 1 1 10 Lib 0 0 3 2 5 Namdrik 2(1 taking rx in 0 2 0 4 Jaluit, 1 in Majuro) Namu 3(1 taking rx in 1 3 1 8 Majuro) Ujae 1(taking rx in 2(1 taking rx in 3 2 8 Ebeye) Ebeye) Total 53 18 26 16 113

 Number of cases registered in Majuro : 43(38%), Outer Islands : 53(47%), 177 Atolls : 6(5%), Ebeye : 11(10%)  Number of children registered: 34(30%)

The proportion of children on treatment is an indication of the level of ongoing transmission in the community.

Table 71: High Proportion of Children on Treatment Place No. Of Cases Zone 1 Majuro 4 Arno 5 Jaluit 5 Ujae 4

Achievements:  There are 4 new additional nurses (3 Graduate nurses, and 1 practical nurse) that were hired.  Leprosy Operational Manual was finalized and distributed.  There was a consistent contact screening for old and new cases which resulted to increase of case detection.  MOH received additional funding from WHO for contact tracing.  Two Leprosy consultants from WHO visited Ebeye in the fiscal year to train the program staff in case holding, case recording, and clinical management.  A CME on Leprosy Diagnosis was also given to healthcare providers. Additional training was provided for the program staff through the US National Hansen’s Disease Program in Louisiana, USA during this fiscal year.  The Ebeye Leprosy program also increased advocacy for Leprosy and against stigma and discrimination. They received support from the Mayor and they were able to distribute Leprosy fact sheets to the community including posters.

LEPROSY COMMUNICABLE DISEASE

Way Forward  In FY2012, Leprosy program will conduct a country wide leprosy screening to immediately capture and treat infected patients.  Additional Leprosy trainings will be conducted for health workforce.  The program will conduct public awareness through media campaign to increase public’s knowledge on Leprosy.  Strengthen health education activities the general public.  Finalize and implement the Leprosy Elimination Plan.  Conduct in service trainings for Health Assistants and School Teachers.

Outer Island Outreach Screening

SEXUALLY TRANSMITTED DISEASE

OMMUNICABLE ISEASE CSexually transmitted Dinfection poses as one of the greater risks among all ages, but more so for the youths. Syphilis and Chlamydia remain to be the two most common form of STI which threaten the livelihood out of the population. The Marshall Islands, although, it has been considered a low prevalence for HIV, RMI cannot live with a feeling of complacency. All the known and recommended measures have been postulated as our protection and control procedure.

Table 72: STI/HIV Cases STI FY 2008 FY 2009 FY 2010 FY 2011 Positive Prevalence Positive Prevalence Positive Prevalence Positive Prevalence Case Rate Case Rate Case Rate Case Rate Syphilis 302 57 486 90 342 63 165 31 Gonorrhea 27 5 107 20 116 21 96 18 Chlamydia 67 13 393 73 331 61 152 29 Hepatitis B 104 20 77 14 44 8 60 11 HIV 4 1 10 2 8 2 8 2 Source: STI/HIV Program, Majuro & Ebeye Prevalence rate is per 10,000

Table 73: Syphilis Testing, FY2011 Age Majuro Ebeye Group Male Female Total Male Female Total Age # Test + # Test + # Test + # Test + # Test + # Test + <15 51 1 79 3 130 4 7 0 12 1 19 1 15 - 19 283 3 501 3 784 6 21 1 77 3 98 4 20 - 24 342 2 660 17 1002 19 111 6 152 15 263 21 25 - 29 160 5 437 15 597 20 108 10 110 18 218 28 30 - 34 94 3 348 14 442 17 68 5 69 11 137 16 35 - 39 78 1 250 5 328 6 46 4 55 3 101 7 40 - 44 63 0 211 1 274 1 32 3 25 3 57 6 45 - 49 52 1 172 1 224 2 16 1 22 2 38 3 50 + 65 0 275 1 340 1 23 3 32 0 55 3 Total 1,188 16 2,933 60 4,121 76 432 33 554 56 986 89

SEXUALLY TRANSMITTED DISEASE

COMMUNICABLE DISEASE Table 74: Chlamydia Testing, 2011 Majuro Ebeye Age Male Female Total Male Female Total Group # Test + # Test + # Test + # Test + # Test + # Test + <15 0 0 5 4 5 4 0 0 0 0 0 0 15 - 19 17 6 54 18 71 24 3 0 17 3 17 3 20 - 24 57 22 103 26 160 48 0 0 30 5 33 5 25 - 29 28 12 77 16 105 28 0 0 25 10 25 10 30 - 34 12 3 34 10 46 13 0 0 11 1 11 1 35 - 39 4 3 16 7 20 10 0 0 7 0 7 0 40 - 44 7 2 3 2 10 4 0 0 1 0 1 0 45 - 49 2 1 0 0 2 1 0 0 0 0 0 0 50 + 1 0 2 0 3 0 3 0 0 0 0 0 Not 0 0 2 1 2 1 0 0 0 0 0 0 Stated Total 128 49 296 84 424 133 3 0 91 19 94 19

Table 75: Gonorrhea Testing, FY2011 Majuro Ebeye Male Female Total Male Female Total Age Group # Test + # Test + # Test + # Test + # Test + # Test + <15 0 0 5 1 5 1 0 0 0 0 0 0 15 - 19 17 5 54 5 71 10 0 0 17 1 17 1 20 - 24 57 26 102 12 159 38 3 0 30 0 30 0 25 - 29 28 17 77 7 105 24 0 0 24 2 24 2 30 - 34 11 4 34 3 62 7 0 0 11 0 11 0 35 - 39 4 3 16 4 27 7 0 0 7 0 7 0 40 - 44 7 2 3 0 7 2 0 0 1 0 1 0 45 - 49 2 2 0 0 7 2 0 0 0 0 0 0 50 + 1 0 2 0 4 0 0 0 0 0 0 0 Not Stated 0 0 2 2 3 2 0 0 0 0 0 0 Total 127 59 295 34 422 93 3 0 90 3 93 3

SEXUALLY TRANSMITTED DISEASE

COMMUNICABLE DISEASE Table 76: Majuro HIV Testing, FY2011 Majuro Ebeye Male Female Total Male Female Total # # # # # # Age Group Test + Test + Test + Test + Test + Test + <15 0 0 5 0 5 0 3 0 5 0 8 0 15 – 19 201 0 373 0 574 0 27 0 69 0 96 0 20 – 24 275 0 488 1 763 1 88 0 104 0 192 0 25 – 29 81 0 294 0 375 0 98 0 85 0 183 0 30 – 34 58 0 174 0 232 0 65 0 52 0 117 0 35 – 39 61 0 85 0 146 0 39 0 33 0 72 0 40 – 44 56 0 36 0 92 0 27 0 17 0 44 0 45 – 49 35 0 24 0 59 0 17 0 11 0 28 0 50 + 66 0 31 0 97 0 24 0 12 0 36 0 Not Stated 6 0 4 0 10 0 0 0 0 0 0 0 Total 839 0 1,514 1 2,353 1 388 0 388 0 776 0

Table 77: RMI Current HIV Cases Age Male Female Total <15 0 0 0 15 – 19 0 0 0 20 – 24 0 2 2 25 – 29 2 2 4 30 – 34 0 1 1 35 – 39 1 0 1 40 – 44 0 0 0 45 – 49 0 0 0 50 + 0 0 0 Total 3 5 8

In FY2011, a new case of HIV was first diagnosed as TB patient. There are currently eight (8) People Living with HIV/AIDS (PLWHA). 5 HIV cases are on ART medication, 2 refused to take medication and one (1) newly diagnosed case.

The STD Program continues to upgrade the skills of its staff by attending STD/HIV related trainings namely: HIV Clinical Training in Fiji, CTR and RT training in Guam, HIV Respect Training in Honolulu, AETC clinical tutorial train to trainer workshop in Honolulu, Hawaii.

SEXUALLY TRANSMITTED DISEASE

MajuroCOMMUNICABLE STD Program provided DISEASE the following health education to: YTYIH HIV and STD awareness workshop - 100 students attended the two hours lecture, HIV Case Presentation to medical health workers - Fifteen staff attended the one hour lecture, STD/HIV presentation to Child and Women Health in Pacific Conference where 20 participated.

Ebeye STD Program: A total of 807 pre-test counseling and 679 post-test counseling were done this year. This is a big improvement compared to previous years. The purpose of the counseling is to educate the patients about the test for STDs; to assess behavioral risk factors; and to impart preventive measures against transmission of STDs. There were a total of 50 clients or contacts followed-up for STD partner services. Of the 50 contacts – 9 cases of Syphilis were detected and were given appropriate treatment. Talks on HIV and Teenage Pregnancy were given to 5 schools this fiscal year. A total of 307 teenage students received the health talk. An additional 263 pamphlets on Chlamydia were produced and distributed in line with the campaign for presumptive treatment. Ebeye has started the Presumptive Chlamydia Treatment in FY2011.

Way Forward: 1. Review the current methods for surveillance, reporting, detection, and education to determine the reason for the steady increase in STDs. 2. Continue CTR activities (HIV/AIDS) to target high risk groups (young adolescents, STD clients, TB cases, pregnant mothers). 3. Continue to provide acute and long-term care for HIV/AIDS cases through various sources/grants (i.e. RYAN WHITE FOUNDATION). 4. Continue the surveillance program for detection, confirmation and monitoring programs through the Global Fund/SPC – detection, confirmation and monitoring and CDC grants. 5. Continue STD/HIV screening activities through contact tracing. 6. Continue health education – on STD/HIV prevention through mass media, schools, Youth-to-Youth NGO community gatherings. 7. Continue to improve data collection. 8. Continue to provide health care services utilizing the Youth to Youth in Health. 9. Strengthen health promotion and educational activities for community awareness.

MEDICAL REFERRAL SERVICES

EDICAL EFERRAL ERVICES MThe MedicalR Referral ServiceS has been given the responsibility of providing relevant treatment of the cases that would not be able to be treated locally in selected health care facilities in Honolulu, Philippines, and Taiwan.

In Honolulu, approved health care providers in Honolulu are as follows: 1.) Straub Clinic and Hospital, 2.) Kapiolani Medical Center, 3.) Wahiawa General Hospital, 4.) Honolulu Medical Group, 5.) Mililani Physician Center, and 6.) Pali Momi Medical Center

In the Philippines, the Third Party Administrator which is JMI oversees the operation in the Philippines in collaboration with a RMI Medical Liaison Officer. Following is a list of the approved health care providers in Philippines: 1.) Asian Hospital, 2.) Saint Luke’s Medical Center, and 3.) Medical City

In Taiwan, the Wan Fang Hospital and National Taipei Hospital are the approved health care providers.

Basic Referral

Table 78: Basic Referral Activity Referral Centers FY 2007 FY 2008 FY 2009 FY 2010 FY2011 Honolulu & USAKA 9 3 7 11 9 Philippines 80 109 103 43 84 Taipei Veteran 1 Total Basic Referrals 89 112 109 54 94

Trippler Hospital (PIHCP) 22 16 22 44 44 Shriners’ Hospital 13 11 15 11 8 Total 35 27 37 55 52

Total Referrals 124 139 147 109 146

MEDICAL REFERRAL SERVICES

MEDICAL REFERRAL SERVICES Table 79: Top Ten Diagnosis for Off-Island Referral FY 2008 FY 2009 FY 2010 FY 2011 Cancer 24 Orthopedic 30 Cancer 30 Cancer 34 Ophthalmolog 23 Cancer 23 Orthopedic 21 Cardio 17 y Orthopedic 19 Congenital 23 Cardiovascular 11 Orthopedic 15 Congenital 18 Ophthalmolog 14 Internal 11 Ophthalmology 15 y Medicine Cardio 13 Cardiovascula 14 Congenital 9 Congenital 11 r Surgery 8 Neurology 12 Urology 7 ENT 7 Neurology 7 Internal 9 Ophthalmolog 6 Neurology 5 Medicine y Urology 7 Urology 6 Neurology 5 OBGYN 4 OBGYN 6 Surgical 4 OBGYN 3 Urology 3 Internal 5 Plastic 3 Medicine

Supplemental Health Plan

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

Table 80: Supplemental Health Plan Enrollee Description FY2007 FY2008 FY2009 FY2010 FY2011 Resident Members 766 822 938 995 946 Non- Resident Members 67 40 46 48 151 Total Members at Beginning of year 833 862 984 1,043 1,097 New Members 136 191 155 143 93 Terminated Members 107 69 93 169 80 Total Active Members End of Year 862 984 1,046 1,017 1,110

MEDICAL REFERRAL SERVICES

MEDICAL REFERRAL SERVICES Table 81: Supplemental Health Plan Users

Referral Site FY 2008 FY 2009 FY 2010 FY 2011

Philippines 121 79 81 104 Honolulu 214 175 256 138 Taiwan 16 Total 335 254 337 258

Accomplishments: 1. RMI was rated as the top ranks on referral cases accepted by Tripler from all the Pacific Islands. 2. JMI-Edison awarded as the new Third Party Administrator for 2 years. 3. Medical Referral Services established new contract with Hawaii Pacific Health. 4. The number of supplemental enrollees for 2011 increased by 93 compare to 2010. The number of supplemental users in Honolulu decreased by 118 compare to 2010. 5. Successfully established the new contracted rates into the MERIS system for claims to be processed and paid accordingly. Re-fumigation of Honolulu Medical Referral Housing Compound was done carried out successfully. 6. One basic referral patient was sent to Taipei Veteran General Hospital

Challenge: 1. There is was an increase in the number of referrals to Manila because Tripler Army’s Medical Center Radio Oncology Department was understaffed which lead to higher usage of Basic Referral Funds. 2. We The program experienced problem in submitting payments for Honolulu billings because of modification of new contracted rated.

Way Forward: 1. Ensure claims are processed and paid within the turnaround time of 30 days. 2. Work closely with the local physicians, to maintain positive relationship with our outside Health Care Providers such as Tripler Army’s Medical Center and Shriner’s Hospital for Children. 3. Work closely with the Medical Referral Committee to find ways to help decrease the number of off island referrals. 4. Work closely with the patient coordinator in Philippines and Majuro to be more involved in patient care services and be attentive to the patients/referrals. 5. Smooth and Efficient running of the program. 6. Explore more healthcare possibilities in Asia. 7. Ensure proper coordination for supplemental referrals to Honolulu, Manila, or Taiwan. 8. Ensure that off island referrals do not exceed its budget.

HOSPITAL SERVICES

HOSPITALOut-Patient SERVICES Clinical Services

The Out-Patient Services (OPS) has continued to be the foremost mechanism in the delivery of primary and clinical care services. The OPS is a one-stop shop where patients can access various services with just one visit. Most primary health care clinics are held in the morning while specialty clinic (OPD) services are held in the afternoon.

Ebeye Hospital Graph 11: Ebeye Hospital’s Outpatient Encounters Trend

The Out-Patient Services also has the task to spearhead the various Special Medical Team missions in Ebeye. One Canvasback Mission took place at the end of the fiscal year for Ophthalmology, Dermatology, and Dental services resulting to an estimated $708,722.00 value of donated services.

Majuro Hospital

Graph 12 : Majuro Hospital’s Outpatient Encounters Trend

Majuro Outpatient Services Trend

57,025 57,244 55,496 60,000 52,533 52,933 49,714 47,195 50,000 41,986 39,609 40,000 30,635 30,000

20,000

10,000

HOSPITAL SERVICES

Table 82: Top Leading Causes of Out Patient Visits, 2011 Rank Diagnosis Cases % 1 465.9 - Acute URI NOS 9,441 25% 2 250.0 - Diabetes Mellitus without mention of complication 7,878 20% 3 V70.0 - Routine general medical examination at a health care facility 4873 13% 4 401.9 - Unspecified hypertension 4132 11% 5 Influenza 3777 10% 6 558.9 - Other and unspecified non-infectious gastroenteritis and colitis 2821 7% 7 Dental Caries, Eruption 2,079 5% 8 789.0 - Abdominal Pain 1491 4% 9 491.9 - Unspecified chronic bronchitis 1112 3% 10 599.0 - Urinary Tract Infection, site not specified 894 2% Total of leading Causes 38,498 50% Total of all Causes 76,636

Top 83: Leading Causes of Out Patient Visits-For Females, 2011 Rank Diagnosis Cases % 1 250.0 - Diabetes Mellitus without mention of complication 3,701 24% 2 465.9 - Acute URI NOS 3,696 24% 3 V70.0 - Routine general medical examination at a health care facility 3,043 20% 4 401.9 - Unspecified hypertension 2,074 13% 5 599.0 - Urinary Tract Infection, site not specified/ 558.9 - Other and unspecified non-infectious gastroenteritis and colitis 866 6% 6 491.9 - Unspecified chronic bronchitis 519 3% 7 789.0 - Abdominal Pain 473 3% 8 493.90 - Asthma, 389 3% 9 366.9 - Cataract 341 2% 10 010.9 - Primary tuberculous infection, unspecified 310 2% Total of leading Causes 15,412 62% Total of All Causes-For Females 25,020

HOSPITAL SERVICES

HOSPITAL SERVICES Table 84: Top 10 Leading Causes of Out Patient Visits-For Children < 5 years Rank Diagnosis Cases % 1 465.9 - Acute URI NOS 3,816 53% 2 491.9 - Unspecified chronic bronchitis 725 10% 3 558.9 - Other and unspecified non-infectious gastroenteritis and 872 12% colitis 4 684 - Impetigo 552 8% 5 382.9 - Unspecified Otitis Media 187 3% 6 692.9 - Contact dermatitis and other eczema, unspecified cause 288 4% 7 485 - Broncho Pneumonia, organism unspecified 218 3% 8 786.2 - Cough 215 3% 9 382.9 - Unspecified Otitis Media 187 3% 10 493.90 - Asthma, unspecified without mention of status 170 2% asthmaticus Total of leading Causes 7,230 69% Total of All Causes-For children < 5 years 10,430

Admission Services

Table 85: Operating Room Activity FY 2009 FY 2010 FY2011 Majuro Ebeye Majuro Ebeye Majuro Ebeye Activity Hospital Hospital Hospital Hospital Hospital Hospital

General Surgery 456 104 428 212 429 131 OB GYN 231 115 199 136 224 139 Orthopedic 71 7 29 13 108 Urology 43 0 47 0 8 0 Eye 122 16 213 190 153 2 ENT 0 0 19 0 0 0 Plastic 0 0 5 0 0 0 Total 923 242 940 551 922 272

HOSPITAL SERVICES

HOSPITAL SERVICES Table 86: Admission Encounter by Service Ward FY 2009-2011 FY 2009 FY 2010 FY2011 Majuro Ebeye Majuro Ebeye Majuro Ebeye Ward Hospital Hospital Hospital Hospital Hospital Hospital Dental 1 3 0 0 0 0 TB 2 4 0 0 1 0 ICU 10 0 10 0 18 16 Medical 684 334 713 363 633 171 Maternity 2,207 423 1,997 423 1,793 673 Pediatrics 604 663 499 552 500 577 Surgical 529 106 502 164 463 272 Total 4,037 1,533 3,721 1,502 3,408 1,709

Table 87: Top 10 Leading Causes of Admissions Rank Diagnosis Cases % 1 V30.00 - Single liveborn, born in hospital delivered without mention of caesarean delivery 1,029 27% 2 V27.0 - Single liveborn (Outcome of delivery) 1,007 27% 3 650 - Delivery in a complete normal case 727 19% 4 664.4 - Unspecified perineal laceration during delivery 244 7% 5 V30.01 - Single liveborn, born in hospital delivered by cesarean delivery 183 5% 6 485 - Broncho Pneumonia, organism unspecified 161 4% 7 486 - Pneumonia, organism unspecified 159 4% 8 493.90 - Asthma, unspecified without mention of status asthmaticus 102 3% 9 285.9 - Anemia, unspecified 85 2% 10 276.51 - Dehydration 52 1% Total of leading Causes of Admissions 3,749 48% Total of All Causes of Admissions 7,793

HOSPITAL SERVICES

HOSPITAL SERVICESTable 88: Top 10 Leading Causes of Admissions, For Females, 2011 Rank Diagnosis Cases % 1 V27.0 - Single liveborn (Outcome of delivery) 876 31% 2 650 - Delivery in a complete normal case 881 31% 3 V30.00 - Single liveborn, born in hospital delivered without mention of cesarean delivery 368 13% 4 664.4 - Unspecified perineal laceration during delivery 243 9% 5 250.0 - Diabetes Mellitus 195 7% 6 V30.01 - Single liveborn, born in hospital delivered by cesarean delivery 88 3% 7 669.7 - Cesarean Delivery 85 3% 8 285.9 - Anemia, unspecified 69 2% 9 599.0 - Urinary Tract Infection, site not specified 67 2% 10 644.2 - Early onset of delivery 58 2% Total of leading Causes of Admissions 2930 58% Total of All Causes Admissions-For Females 5,047

Table 89: Top 10 Leading Causes of Admissions, For Children <5 years, 2011 Rank Diagnosis Cases % 1 V30.00 - Single liveborn, born in hospital delivered without mention of cesarean delivery 1022 62% 2 V30.01 - Single liveborn, born in hospital delivered by cesarean delivery 182 11% 3 485 - Broncho Pneumonia, organism unspecified 112 7% 4 493.90 - Asthma, unspecified without mention of status asthmaticus 95 6% 5 263.9 -Unspecified protein-calorie malnutrition 51 3% 6 491.9 - Unspecified chronic bronchitis 45 3% 7 276.5 - Volume depletion 45 3% 8 558.9 - Other and unspecified non-infectious gastroenteritis and colitis 48 3% 9 486 - Pneumonia, organism unspecified 36 2% 10 280.9 - Iron deficiency anemia, unspecified 25 2% Total of leading Causes of Admission 1661 74% Total of All Causes of Admissions-For children < 5 years 2253

HOSPITAL SERVICES

HOSPITAL SERVICES Rehabilitation Services

Ebeye Hospital

The department is manned by two local physical therapy assistants. Patients requiring physical rehabilitative service are referred for management by this department. Most of the referrals are from the Inpatient wards and the Diabetes program. Total patient referred for the year was 439 with 1,120 total treatments.

Majuro Hospital

The average number of treatments per day during FY 2011 was 41. Nevertheless, the total treatment accounted for all of last year, FY 2011 was 8,862. It is about 23% increase compared to the previous year, FY 2010. In furtherance, the total amputation performed during FY2011 was 55. Majority of the cases being amputated were attributed to diabetes. As such, 46% had poor sensation and were at risk for foot complications; 30% were attributed to foot ulcers and 23% were due to non-compliant. The Rehabilitation Department also was involved in doing prosthetic services. The program has recorded a total of 21 cases were given prostheses below the knees.

Accomplishment: 1. Diabetes training was conducted for the staff of the Rehabilitation staff of the Ebeye Hospital. 2. Foot clinic has also been established for the community on Ebeye. Staff of the Rehabilitation Department has been able to extend such service to selected islands and atoll around the Marshall Islands. 3. A container of mobility aids (230 wheelchairs, 200 canes and 100 walkers) was donated by the Humanitarian Aid of Latter-Day Saints for the people of RMI. Throughout the FY2011, 198 wheelchairs were already distributed to patients including the 25 wheelchairs sent to Ebeye Hospital. 70 walkers and 38 canes were also given to needy individuals. 4. Humanitarian Aid of Latter-Day-Saints painted the rehabilitation department. They have also provided Dry Glass Bead Sterilizer which is used to sterilize scissors, scalpers and clippers for foot/wound care. 5. Lecture/training on Diabetes Foot Care Management: level was presented to the staff to for capacity building. Rehabilitation Department also has “Patients Day”. The department also provided lectures in Youth for Christ Convention and Family Care-giver Train the Trainer Workshop.

HOSPITAL SERVICES

H OSPITAL SERVICES Table 90: Rehabilitation Department's Referral information FY 2009 FY 2010 FY 2011 Majuro Ebeye Majuro Ebeye Majuro Ebeye Activity Hospital Hospital Hospital Hospital Hospital Hospital New Referrals 502 167 423 132 643 Average # of Treatments Per day 31 10 29 9 41 Completed Prostheses 8 0 13 0 16 Total Treatments Per Quarter 7,717 2,679 6,910 561 8,862

Table 91: Diagnosis/Reason for Rehabilitation Services

Reason FY2011 Back Pain 141 Degenerative Joint Disease 31 Musculoskeletal problem (shoulder pain, hip pain etc.) 173 Arthritis 10 DM Foot Complication (amputation, debridement) 116 Stroke 42 Fracture 29

Other 100 TOTAL 643

Ebeye Hospital Laboratory Services

Staffing: The department saw an increase of 4 staffs during the year which brought the total Lab staff to 6. The increase was due to successful recruitment to fill the vacated microbiologist post; returning Laboratory technician that was on educational leave for 2 years; and hiring of 2 additional technicians with funding from STD/HIV and TB grants. The remaining vacant post that has yet to be filled is that of a Pathologist. Recruitment process is on-going.

Equipment: A microbiology analyzer (Vitek II) was installed in April of 2011. Training was provided to the staff on usage of the machine and on daily maintenance tasks. Since the machine was put into use, more tests are now being done on-site and referrals to USAKA laboratory has drastically reduced. The department is need of a new Hematology to replace the old one. This has been budgeted in the next fiscal year.

Training: To upgrade their skills, the staffs have enrolled in various training programs. Currently four (4) have enrolled in the POLHN distance learning courses. Three of these staffs have also enrolled in the PPTC Medical Laboratory Diploma Program (a 2 year program).

Laboratory expansion: The Laboratory work space is limited and a planned expansion is scheduled to take place in 2nd quarter of FY2012 when the new Medical storage warehouse is

HOSPITAL SERVICES

HOSPITAL SERVICES completed. The lab will expand to the current medical supply office that is adjacent to the Lab. The medical supply department will then be relocated to the new Medical storage warehouse.

Majuro Hospital Laboratory Services

The entire year experienced a total of just 14 staff (pathologist: x1; Lab Manager: x1; Sub divisional Supervisors: x4; Subordinate Technical Staff: x7; Receptionist: x1). The laboratory conducted in 17,816 phlebotomies, processed 48,838 specimens through 249,285 tests and shipped 823 TB sputa, 364 immunochemistry and 3 tissue specimens.

Two new trainee staff was recruited. International visitors appraised laboratory in good standing. 8 staff continued to participate in Pacific Paramedical Training Center’s online advanced training programs especially in STI and biochemistry. Pacific Paramedical Training Center, NZ (PPTC) sponsored two laboratory staff for training in Blood cell morphology and Clinical biochemistry for 4 weeks duration.

Through Secretariat of Pacific Community (SPC), Laboratory Department was trained on CD4 cell counting method and algorithm of confirming and TB Sputa Management Course was conducted.

Microbiology supervisor and Housekeeping Division have consistently worked and made every effort to keep laboratory clean; disinfection of all the benches and regular bio waste disposal is observed. Hospital Infection Control: Laboratory participation in this activity has been regular and more concentrated in areas with high prevalence of MRSA (Methicillin resistant staphylococcus aureus).

Way Forward: 1. Localizing immunochemistry testing, 2. Overseas training of Marshallese staff, 3. Revising policy and planning of the laboratory’s goals and objectives, Implementing basic level training programs for junior staff, 4. Introducing new lab request forms, Altering the pattern/format of lab data collection and analysis to make the process simple to clearly segregate hospital from PHC work and costs, 5. Monitoring stock take on fortnightly basis resulting, Using Global Tb Fund allocations for 9th period (July-Dec 2012), 6. Training of Marshallese lab staff in screening of pap smears in diagnosis of cervico vaginal diseases including pre cancers and cancers, 7. Training of Marshallese staff (Majuro & Ebeye laboratory) in Tb sputa management, and Arranging retraining and shipping licenses to the staff.

Table 92: Summary of Majuro Laboratory Activities, FY2011

Activities/specimens Hospital services PHC services Total Microbiology 890 11689 12579 STI Immunology 2761 11227 13988 Non STI Immunology 43 0 43 Hematology 7276 1727 9003 Blood Bank 3854 0 3854 Biochemistry 5125 1317 6442 TB Sputa 0 823 823 TB Effusions 36 0 36 Histo & Cytopath 251 1455 1706 Specimen Referral 364 0 364 Total 20,600 28,238 48,838

This table provides overview of PHC work load that exceeded by almost 40% of hospital specimen volume.

MOH COST ANALYSIS OF HOSPITAL SERVICES

HOSPITAL SERVICES This section provides the actual costs of services for areas presented in the tables. If all the actual costs for services are added, it will clearly show that the Ministry of Health’s budget is not even sufficient to provide health care services. Cost analysis of services section is a new addition to the Ministry’s annual report to show the actual costs of services for only two areas in the Ministry: Operating Theatre/Room and Laboratory Services based on the number of patients and types of medical supplies needed.

Graph 14: Material Cost - Majuro Hospital Laboratory Services

Majuro Hospital Laboratory Services FY2011 Material Cost TB sputa , HistoCytology, $35,528.24 Haematology $14,179.67 , $27,112.07 Phlebotomies, STD detection, $21,380.00 $125,735.04

Overseas Referrals, $33,086.95 Biochemistry, $57,282.96 Blood Transfusion, $128,435.12 Microbiology, $44,469.76

Non STI Immunology, $890.26

Graph15: Material Costs Analysis FY2010-2011, Majuro Hospital Laboratory

Majuro Hospital Material Cost Analysis of Laboratory

$500,000.00 $450,000.00 $400,000.00 $350,000.00 $300,000.00 $250,000.00 $200,000.00 $150,000.00 $100,000.00 $50,000.00 $- Total STD Blood Micro Non Bioch Overs Phleb Haem Histo TB Mater detec Trans biolog STI emist eas otomi atolo Cytol sputa ial tion fusion y Immu ry Refer es gy ogy cost nolog ral y 2010 $435, $89,9 $90,2 $63,2 $573.3 $57,7 $24,5 $17,1 $40,3 $17,9 $28,9 93 2011 $457,4 $125,7 $128,4 $44,46 $890.2 $57,28 $33,08 $21,38 $27,11 $14,17 $35,52 MOH COST ANALYSIS OF HOSPITAL SERVICES HOSPITAL SERVICES Graph 16: Majuro Hospital Trend Analysis of Laboratory Tests

Majuro Hospital Trend Analysis of Laboratory Tests, FY2009- 2011

90000 80000 70000

60000 50000 40000 30000 20000 10000

0 Bio- Histo- Oversea Phlebot Haemat Blood Immun Micro- Cytolog Shippin chemist Patholo s omy ology bank olgy biology y g ry gy Referral

FY20009 16068 72159 17935 16222 40756 22850 2645 809 60 614 FY20010 17142 72528 23222 22546 52737 30266 3967 456 50 320 FY20011 17816 69574 14320 22361 60710 82325 1701 573 52 364

Graph 17: Majuro Hospital Surgical Material Costs

Majuro Hospital Surgical Material Costs

$1,800,000.00 $1,600,000.00 $1,400,000.00 $1,200,000.00 $1,000,000.00 $800,000.00 $600,000.00 $400,000.00 $200,000.00 $0.00

Surgery

General Orthopedic Urology Optholmology RHC Total Cost FY2010 $779,277.00 $59,806.00 $44,445.00 $246,478.00 $216,615.00 $1,346,621.00 FY2011 $918,433.17 $215,812.33 $23,206.14 $255,434.40 $257,141.65 $1,670,027.69

MOH COST ANALYSIS OF HOSPITAL SERVICES

HOSPITAL SERVICES Table 93: Majuro Hospital Eye Surgery Costing FY2011 Time Cost of Surgery types (minutes) 1 surgery No. Total cost Cataract ( ECCE)) 60 $1,146.85 101 $106,657.05 Pterygium Excision 30 $551.55 30 $11,031.00 Eviceration with sphere implant 60 $1,495.85 1 $1,495.85

Corneal perforation repair 60 $1,600.00 3 $4,800.00

Phaco &Pciol 60 $1,495.85 0 0

Phaco 60 $1,495.85 3 $4,487.55

Repair Ruptured Corena 60 $1,495.85 1 $1,495.85

Chalazion Eyelid 20 $551.50 0 0

Excision Biopsy 40 $551.50 4 $2,206.00 Excision cyst 40 $551.50 0 0 Enuceleation 60 $1,495.85 1 $1,495.85 Removal of cornea suture 20 $425.00 2 $850.00 Conjuntival Flap graft 40 $725.00 6 $4,350.00 Lens extraction 60 $1,146.85 2 $2,293.70 Eye exam under anesth 20 $425.00 1 $425.00 Laser surgeries Yag Capsulotomy $551.50 20 $11,030.00 Retinal laser $1,146.85 83 $95,188.55 Laser iridotomy $725.00 9 $6,525.00 Yag vitreolysis $551.50 2 $1,103.00 Total 269 $255,434.40

Table 94: Majuro Hospital Urology Surgery Procedure Costs FY2011 No. of Time in Ave Stay Cost Total cost surgeries minutes in Days per surgery Cystoscopy D J Stent insert/remove 2 45 10 or 5 $632.43 $1,264.86 Circumcision 0 20 1 $351.42 $0.00 Bil Vasectomy 0 30 1 $353.66 $0.00 Radical Orchidectomy 0 45 5 $3,366.58 $0.00 Scrotal Repair 0 45 7 $1,394.15 $0.00 Orchidopexy 0 45 7 $2,574.79 $0.00 Revision Turp 0 30 3 $1,635.30 $0.00 Meatul Dilation 0 20 3 $1,336.63 $0.00 Inguinal Herniotomy/Hrp 0 45 7 $2,668.77 $0.00 Cysto and Turf 3 90 7 $1,847.70 $11,086.20 Uritorolithotomy 1 60 10 $2,713.77 $2,713.77 Suprapubic Cystostomy 1 60 10 $2,713.77 $2,713.77

MOH COST ANALYSIS OF HOSPITAL SERVICES HOSPITAL SERVICES Pyelonephrolithotomy 1 60 10 $2,713.77 $2,713.77 Removal D J Stent 1 45 10 $2,713.77 $2,713.77 Total 9 $23,206.14

Table 95: Procedure Costs of General Surgery Treatment No. of Time Av cost per Surgery Types surgeries (min) stay(Days) surgery Total costs Appendectomy 22 60 4 $3,361.12 $73,944.64 Lap/ Appendectomy 1 90 4 $3,361.12 $3,361.12 Craniectomy 1 40 5 $3,773.64 $3,773.64 Colectomy 1 40 5 $3,773.64 $3,773.64 Hemicolectomy 2 40 5 $3,429.64 $6,859.28 Mastectomy 0 90 15 $4,070.00 $ Parotidectomy 1 90 15 $4,070.00 $4,070.00 Cholecystectomy 8 120 21 $4,486.88 $35,895.04 Lobectomy 0 90 6 $3,400.00 $ Bowel Resection 2 150 21 $5,486.88 $10,973.76 Release Contracture 1 45 6 $3,406.00 $3,406.00 Orchidopexy 1 60 7 $2,574.79 $2,574.79 Wound explore 4 60 7 $2,637.97 $10,551.88 Lip Construction 1 45 7 $2,637.97 $2,637.97 Excision Thyroid Nodule 1 50 5 $2,607.97 $2,607.97 Myringotomy 1 60 7 $2,637.97 $2,637.97 Repair Anal Laceration 1 30 5 $1,297.12 $1,297.12 Release Z Plasty 1 60 3 $2,525.15 $2,525.15 Fistulectomy 2 50 5 $2,607.97 $5,215.94 Below elbow amputation 1 60 20 $4,064.40 $4,064.40 Trans Metatarsal Amputation 6 45 20 $4,064.00 $24,384.00 Hermorrhoidectomy 1 50 14 $2,644.26 $2,644.26 Explore Laceration 1 40 14 $1,614.64 $1,614.64 Disarticulation 20 30 14 $2,201.00 $44,020.00 Cleft Lip Repair 1 60 14 $2,896.97 $2,896.97 Thorocentesis(local) 2 25 5 $902.36 $1,804.72 Fasciotomy (spinal/ga) 1 35 5 $1,632.84 $1,632.84 Explore Sinus 2 20 1 $348.42 $696.84 Debridement (spinal./IV) 69 40 21 $2,748.11 $189,619.59 Rpt Debridement 18 50 21 $2,748.11 $49,465.98

MOH COST ANALYSIS OF HOSPITAL SERVICES exploHOSPITAL lap illiostomy SERVICES 0 90 21 $4,165.99 $ Incisional herniorraphy 13 60 3 $3,612.82 $46,966.66 Incisional herniotomy 6 60 3 $3,613.36 $21,680.16 Amputation (AKA,BKA) 16 60 30 $4,959.76 $79,356.16 Colostomies 1 45 14 $3,912.26 $3,912.26 Exploratory Laprotomy 3 120 21 $4,486.88 $13,460.64 Sigmoid Colostomy 0 60 14 $4,563.18 $ Tracheostomy 0 45 30 $1,854.64 $ Colonoscopy 1 45 7 $1,355.64 $1,355.64 Iliostomy 0 45 5 $1,286.70 $ I&d/debridement 6 30 30 $3,431.46 $20,588.76 Incision & drainage 37 30 14 $2,262.00 $83,694.00 Gastrostomy 0 45 21 $3,939.34 $ Gastrotomy tube insert 2 45 21 $3,995.20 $7,990.40 Wound/Closure stump 0 30 14 $2,201.00 $ Full thick skin graft 6 60 21 $2,966.34 $17,798.04 Sequestrectomy 1 30 21 $902.67 $902.67 Thorocostomy 0 60 21 $956.78 $ Paracentesis 0 20 21 $756.02 $ Exc ganglion cyst 0 20 3 $406.70 $ Trucut breast bx 0 20 3 $408.62 $ Marsupiliasation 1 30 3 $1,068.13 $1,068.13 Circumcision 34 15 1 $348.42 $11,846.28 Cod 5 30 1 $801.26 $4,006.30 Remove Suture 1 25 1 $376.70 $376.70 Wide Excision Lesion 2 20 3 $859.70 $1,719.40 Excision Granuloma 2 10 1 $355.46 $710.92 Incisional bx/biopsy 8 20 2 $382.88 $3,063.04 Punch Biopsy 14 20 2 $382.88 $5,360.32 Lymphnode Biopsy 1 15 1 $351.74 $351.74 Cervical node Biopsy 1 20 3 $831.26 $831.26 Open biopsy 2 20 2 $835.88 $1,671.76 Excision Lipoma 11 20 2 $382.88 $4,211.68 Excision Keloid 3 20 2 $366.74 $1,100.22 Excision Papiloma 2 20 2 $382.88 $765.76 Excision mass 3 30 2 $382.88 $1,148.64 Excision Fibremo 3 30 2 $379.16 $1,137.48 Excision fibroadenoma 0 45 2 $379.16 $ Excision Hematoma 0 30 3 $384.74 0

MOH COST ANALYSIS OF HOSPITAL SERVICES

ExcisionHOSPITAL Polyp S ERVICES 3 15 $348.42 $1,045.26 Excision skin tag 2 10 $348.26 $696.52 Excision breast mass 1 45 14 $3,890.20 $3,890.20 Excision Ganglion 1 30 3 $406.70 $406.70 Excision Mole 7 10 1 $355.46 $2,488.22 Excision Papilloma 2 15 2 $382.88 $765.76 Vasectomy 1 25 2 $697.34 $697.34 Nail Avulsion 1 20 2 $348.26 $348.26 Revise scar 1 20 2 $348.26 $348.26 Breast Biopsy 3 15 2 $370.46 $1,131.38 Examination Under Anseth 7 15 2 $370.46 $2,593.22 Steroid Injection 1 10 0 $340.46 $340.66 Wide Excision Lesion 2 40 2 $823.46 $1,646.92 Excisional bx 14 30 2 $375.44 $5,256.16 Inguinal lymph bx 0 30 2 $1,292.44 0 Excision cyst/seb 37 30 2 $375.44 $13,891.28 Excision mole 7 10 1 $355.46 $2,488.22 Ngt insertion 0 10 1 $348.26 0 Cauterisation 5 15 3 $388.70 1943.5 Excision gouty deposits 0 30 2 $382.88 0 Proctosigmoidioscopy 0 20 2 $382.88 0 Nasopharynx Endoscopy 0 20 2 $382.88 0 Laceration Suturing 0 30 2 $387.08 0 Wound closing/cleaning 13 20 2 $1,418.88 $18,445.44 Revision of wound stump 0 40 5 $1,779.59 0 Castin Backslab 0 20 2 $1,219.44 0 Amputation finger/toes 9 20 5 $1,506.14 $13,555.26 Disarticulation finger/toe 0 20 5 $1,465.94 0 Removal foreign body/ 13 20 2 $802.28 $10,429.64 Total 488 $918,433.37

Table 96: Majuro Hospital Reproductive Health Care Procedure Material FY2011 Time in Ave Total No. Treatment Cost Surgery Types minutes Stay surgeries of 1 patient Total Cost Cesearian section 60 3 118 $1,000.83 $118,097.94 B T L 40 1 21 $1,334.88 $28,032.48 C/Section &BTL 60 3 28 $1,416.99 $39,675.72 Hysterectomy 60 3 2 $1,410.01 $2,820.02 Subtotal Hysterctomy 60 3 10 $1,419.49 $14,194.90 D&C 45 1 7 $903.59 $6,325.13

MOH COST ANALYSIS OF HOSPITAL SERVICES

Diagnostic D &C 15 1 8 $903.59 $7,228.72 CervicalHOSPITAL biopsy SERVICES 45 1 4 $1,027.61 $4,110.44 Leep 40 1 8 $1,027.61 $8,220.88 Salpingectomy 60 3 3 $1,035.13 $3,105.39 Cervical corniztion 40 1 0 $1,027.45 0 Cervical/ Polyectomy 30 1 0 $1,037.30 0 Ovarian Cystectomy 45 3 1 $1,075.18 $1,075.18 Oophorectomy 45 3 1 $1,075.10 $1,075.10 Bartholin Cystectomy 20 1 0 $695.46 0 Explolap (Ectopic pregenancy) 60 3 0 $1,075.18 0 Eua/staging cevical Bx 40 1 0 $344.20 0 TAHBSO 120 3 0 $1,834.62 0 ERPOC 40 1 16 $1,122.67 $17,962.72 Evacuation Hematoma 30 1 0 $1,034.45 Marsupalisation 30 1 1 $1,047.22 $1,047.22 Fractional Curretage 30 1 0 $1,043.54 Incision&Drainage 20 1 1 $1,101.02 $1,101.02 Manual Removal Placenta 20 1 1 $1,132.50 $1,132.50 Cervical Polypectomy 30 1 1 $1,032.70 $1,032.70 Fibroid Polypectomy 90 1 0 $1,035.86 Internal v/exam 20 1 0 $1,027.45 0 Bil Salpingoophorectomy 60 3 0 $1,051.09 0 Exam under Anesth (EUA) 20 1 1 $903.59 $903.59 Total 232 $257,141.65

Table 97: Procedure Costs of General Surgery Patients in OR Treatment No. of Time Ave stay cost of 1 Surgery Types Surgery (min) (Days) patient Total costs Appendectomy 22 60 4 $3,361.12 $73,944.64 Lap/ Appendectomy 1 90 4 $3,361.12 $3,361.12 Craniectomy 1 40 5 $3,773.64 $3,773.64 Colectomy 1 40 5 $3,773.64 $3,773.64 Hemicolectomy 2 40 5 $3,429.64 $6,859.28 Mastectomy 0 90 15 $4,070.00 $0 Parotidectomy 1 90 15 $4,070.00 $4,070.00 Cholecystectomy 8 120 21 $4,486.88 $35,895.04 Lobectomy 0 90 6 $3,400.00 $0 Bowel Resection 2 150 21 $5,486.88 $10,973.76 Release Contracture 1 45 6 $3,406.00 $3,406.00

MOH COST ANALYSIS OF HOSPITAL SERVICES

OrchidopexyHOSPITAL SERVICES 1 60 7 $2,574.79 $2,574.79 Wound explore 4 60 7 $2,637.97 $10,551.88 Lip Construction 1 45 7 $2,637.97 $2,637.97 Excision Thyroid Nodule 1 50 5 $2,607.97 $2,607.97 Myringotomy 1 60 7 $2,637.97 $2,637.97 Repair Anal Laceration 1 30 5 $1,297.12 $1,297.12 Release Z Plasty 1 60 3 $2,525.15 $2,525.15 Fistulectomy 2 50 5 $2,607.97 $5,215.94 Below elbow amputation 1 60 20 $4,064.40 $4,064.40 Trans Metatarsal Amputation 6 45 20 $4,064.40 $24,384.00 Hermorrhoidectomy 1 50 14 $2,644.26 $2,644.26 Explore Laceration 1 40 14 $1,614.64 $1,614.64 Disarticulation 20 30 14 $2,201.00 $44,020.00 Cleft Lip Repair 1 60 14 $2,896.97 $2,896.97 Thorocentesis(local) 2 25 5 $902.36 $1,804.72 Fasciotomy (spinal/ga) 1 35 5 $1,632.84 $1,632.84 Explore Sinus 2 20 1 $348.42 $696.84 Debridement (spinal./IV) 69 40 21 $2,748.11 $189,619.59 Rpt Debridement 18 50 21 $2,748.11 $49,465.98 explo lap illiostomy 0 90 21 $4,165.99 $0 Incisional herniorraphy 13 60 3 $3,612.82 $ 46,966.66 Incisional herniotomy 6 60 3 $3,613.36 $21,680.16 Amputation (AKA,BKA) 16 60 30 $4,959.76 $79,356.16 Colostomies 1 45 14 $3,912.26 $3,912.26 Exploratory Laprotomy 3 120 21 $4,486.88 $13,460.64 Sigmoid Colostomy 0 60 14 $4,563.18 $0 Tracheostomy 0 45 30 $1,854.64 $0 Colonoscopy 1 45 7 $1,355.64 $1,355.64 Iliostomy 0 45 5 $1,286.70 $0 I&d/debridement 6 30 30 $3,431.46 $20,588.76 Incision&drainage 37 30 14 $2,262.00 $83,694.00 Gastrostomy 0 45 21 $3,939.34 $0 Gastrotomy tube insert 2 45 21 $3,995.20 $7,990.40 Wound/Closure stump 0 30 14 $2,201.00 $0 Full thick skingraft 6 60 21 $2,966.34 $17,798.04 Sequestrectomy 1 30 21 $902.67 $902.67 Thorocostomy 0 60 21 $956.78 $0 Paracentesis 0 20 21 $756.02 $0 Exc ganglion cyst 0 20 3 $406.70 $0

100

MOH COST ANALYSIS OF HOSPITAL SERVICES

TrucutHOSPITAL breast bx S ERVICES 0 20 3 $408.62 $0 Marsupiliasation 1 30 3 $1,068.13 $1,068.13 Circumcision 34 15 1 $348.12 $11,846.28 Cod 5 30 1 $801.26 $4,006.30 Remove Suture 1 25 1 $376.70 $376.70 Wide Excision Lesion 2 20 3 $859.70 $1,719.40 Excision Granuloma 2 10 1 $355.46 $710.92 Incisional bx/biopsy 8 20 2 $382.88 $3,063.04 Punch Biopsy 14 20 2 $382.88 $5,360.32 Lymphnode Biopsy 1 15 1 $351.74 $351.74 Cervical node Biopsy 1 20 3 $831.26 $831.26 Open biopsy 2 20 2 $835.88 $1,671.76 Excision Lipoma 11 20 2 $382.88 $4,211.68 Excision Keloid 3 20 2 $366.74 $1,100.22 Excision Papiloma 2 20 2 $382.88 $765.76 Excision mass 3 30 2 $382.88 $1,148.64 Excision Fibromo 3 30 2 $379.16 $1,137.48 Excision fibroadenoma 0 45 2 $379.16 $0 Excision Hematoma 0 30 3 $384.74 $0 Excision Polyp 3 15 $348.42 $1,045.26 Excision skin tag 2 10 $348.26 $696.52 Excision breast mass 1 45 14 $3,890.20 $3,890.20 Excision Ganglion 1 30 3 $406.70 $406.70 Excision Mole 7 10 1 $355.46 $2,488.22 Excision Papilloma 2 15 2 $382.88 $765.76 Vasectomy 1 25 2 $697.34 $697.34 Nail Avulsion 1 20 2 $348.26 $348.26 Revise scar 1 20 2 $348.26 $348.26 Breast Biopsy 3 15 2 $370.46 $1,131.38 Examination Under Anseth 7 15 2 $370.46 $2,593.22 Steroid Injection 1 10 0 $340.46 $340.46 Wide Excision Lesion 2 40 2 $823.46 $1,646.92 Excisional bx 14 30 2 $375.44 $5,256.16 Inguinal lymph bx 0 30 2 $1,292.44 $0 Excision foriegnbody 0 20 2 $461.44 $0 Excision cyst/seb 37 30 2 $375.44 $13,891.28 Excision mole 7 10 1 $355.46 $2,488.22 Ngt insertion 0 10 1 $348.26 $0 Cauterisation 5 15 3 $388.70 $1,943.50

101

MOH COST ANALYSIS OF HOSPITAL SERVICES

ExcisionHOSPITAL gouty depositsSERVICES 0 30 2 $382.88 $0 Proctosigmoidioscopy 0 20 2 $382.88 $0 Nasopharynx Endoscopy 0 20 2 $382.88 $0 Laceration Suturing 0 30 2 $387.08 $0 Wound closing/cleaning 13 20 2 $1,418.88 $18,445.44 Revision of wound stump 0 40 5 $1,779.59 $0 Castin Backslab 0 20 2 $1,219.44 $0 Amputation finger/toes 9 20 5 $1,506.14 $13,555.26 Disarticulation finger/toe 0 20 5 $1,465.94 $0 Removal foriegnbody/ 13 20 2 $802.28 $10,429.64 488 $918,433.17

Table 98: Majuro Hospital Orthopedic Surgery OR Procedure Material Costs FY2011 Surgery types Time in Average OR Number Total costs minutes Stay cost/1patient Orif/plating (major) 90 21 days $2,827.08 2 $5,654.16 Orif/Supracondylart(major) 120 21 $2,932.08 0 $0 Orif/Nail femur(major) 60 30 $3,159.74 0 $0 Orif Pinning (Major) 60 21 $2,944.68 1 $2,944.68 Orif & k wire 60 21 $2,944.38 1 $2,944.38 Close Reduction 30 3 $1,370.07 10 $13,700.70 Removal Pin 20 3 $1,449.24 0 $0 Removal Foreign Body 20 2 $1,408.86 0 $0 Remove Implant 20 2 $1,399.26 0 $0 Removal screws 20 2 $1,399.26 0 $0 Rpt Debridemnt 30 14 $2,301.68 0 $0 Debridement 30 21 $2,763.48 32 $88,431.36 Oesteostomy & Debridement 30 30 $2,158.68 0 $0 Below Knee ampu 60 30 $3,763.84 15 $56,457.60 Above knee ampu 60 30 $3,687.34 0 $0 Amputation hand 40 30 $3,687.34 1 $3,687.34 Amputation digit 30 5 $1,444.26 1 $1,444.26 Trans Metatarsal amputaion 40 30 $3,687.34 1 $3,687.34 Metatarsal Amputation 45 21 $1,725.37 0 $0 Arthtotomy knee 30 14 $1,545.34 0 $0 Skeletol Traction 30 14 $1,612.12 1 $1,612.12 Cyst excision 20 5 $1,358.26 1 $1,358.26 Hip spica cast 30 30 $1,751.98 0 $0 Tru cut Biopsy 20 5 $1,354.27 0 $0 Disarticulation toes 20 5 $2,134.47 12 $25,613.64

102

MOH COST ANALYSIS OF HOSPITAL SERVICES

TendonHOSPITAL repair SERVICES 60 7 $1,593.39 0 $0 Excision extra digit 20 5 $1,490.49 1 $1,490.49 Incision and drainage 30 14 $2,262.00 3 $6,786.00 Total 82 $ 215,812.33

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Table 99: Cost Analysis of Majuro Hospital Pediatric Ward Patients FY2011 Average Ward Meals($13.00 Cost 1 Disease Types 2009 2010 2011 stay costs(medicines) /DY) patient Total costs Respiratory diseases Bronchiolitis/RAD 170 183 194 10Days $448.50 $130.00 $578.50 $112,229.00 Pneumonia 329 143 199 10days $67.20 $130.00 $197.20 $39,242.80 PNA/ RAD, respiratory acute 0 0 0 10days $284.76 $130.00 $414.76 Malnutrition types 38 26 72 $26,405.28 a)Marasums 10days $185.36 $180.00 $365.53 b)Kwashirkor 10days $186.74 $180.00 $366.74 Vitamin deficiency a)Stmattius 10days $150.90 $180.00 $330.90 b)Iron Deficiency/ Anemia 21 9 23 10days $65.10 $180.00 $245.10 $5,637.30 AGE/Dehydration/ Amoebiasis/Giardiasis 114 41 87 10 days $552.00 $130.00 $682.00 $59,334.00 Sepsis 22 12 21 10days $528.22 $130.00 $658.22 $13,822.62 CNS Infection 9 6 7 10days $76.58 $130.00 $206.58 $1,446.06 Meningitis 3 10 days $60.45 $130.00 $190.45 $571.35 b) Meningococcemia c) Cerebral Palsy / seizure Disorder 15 12 16 10 days $10.00 $130.00 $140.00 $2,240.00 Tuberculosis 7 11 14 a) Pulmonary T B 1 2 1 10dys $267.68 $130.00 $397.68 $397.68 120 days(10 b) T.B maintenance Phase 7 days) $124.00 $130.00 $254.00 $1,778.00 Cardiac Cases (stabalising) 23 9 20 10 days $49.30 $130.00 $179.30 $3,586.00 a) CHD(conginital heart disease) 10days $133.10 $130.00 $273.10

104

MOH COST ANALYSIS OF HOSPITAL SERVICES

OSPITAL ERVICES b) RVHD,RheumaticH S valve heart disease $255.50 $130.00 $385.50 Infections Otitis Media 2 8 6 10 days $213.20 $130.00 $343.20 $2,059.20 Measles 0 0 0 Pertussis 2 0 1 10days $62.00 $130.00 $192.00 $192.00 Typhoid Fever 8 21 12 15days $463.20 $195.00 $658.20 $7,898.40 MRSA (Methicillin Resistant Staph. Aureous) 2 0 5 10days $60.45 $130.00 $190.45 $571.35 b)Abscess skin disorder 16 0 0 10 days $187.32 $ 130.00 $317.32 Scabies/ Pyoderma/Abscess 66 41 75 10days $424.06 $130.00 $554.06 $41,554.50 Febrile Seizure a) Seizures, cerebral palsy 0 0 18 10 days $20.00 $130.00 $150.00 $2,700.00 b) seizure disorder 0 0 0 10 days $20.00 $130.00 $150.00 $0 Nephrotic Syndrome: (kidney) a) Nephratic hypertension 0 0 0 10 days $446.30 $130.00 $576.30 $0 b) Urinery Track Infection 4 1 2 10 days $207.20 $130.00 $337.20 $674.40 c)Acute Glmerulo Nephritis 10 13 4 10 days $60.90 $130.00 $190.90 $763.60 d)Pyelonepheitis 10 days $75.10 $130.00 $205.10 $0.00 Hepatitis 0 1 1 10 days $89.10 $130.00 $219.80 $219.80 $323,323. Total 859 539 788 34

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O RGANIZATIONAL CHART

ORGANIZATIONAL CHART MINISTRY OF HEALTH REPUBLIC OF THE MARSHALL ISLANDS

Minister of Health

Health Services Board Secretary of Health

Executive Secretary

Assistant Secretary Assistant Secretary Assistant Secretary Bureau of Kwajalein Atoll Health Care Bureau of Primary Health Care Services Bureau of Majuro Atoll Health Care Services Services

Assistant Secretary Health Planner Office of Administration, Personnel & Finance Office of Health Policy, Planning and Statistics

107

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ACKNOWLEDGEMENT

ACKNOWLEDGEMENT The Ministry of Health acknowledges the continued support from our colleagues and partners, Air Marshall Islands Asian Development Bank (ADB) Bank of Guam (BOG) Bank of the Marshall Islands (BOMI) Business Sector Center for Disease Control and Prevention (CDC) College of the Marshall Islands (CMI) Continental Airlines Councilwoman Deborah Kramer-Shoeniber Economic Policy, Planning, and Statistics Office (EPPSO) Government of Australia Government of Israel Government of Japan Government of the Marshall Islands  Ministry of Education  Ministry of Internal Affairs  Ministry of Foreign Affairs  Ministry of Resources and Development  Ministry of Transportation and Communication  Ministry of Finance  Ministry of Public Works Genesis Hospital, Pohnpei FSM Honolulu Jepta Iroij and Leroij Ro (Traditional Leaders) Iroij Anjua Loeak Jepta Jarin Rarik Dron (JRD) Johndell M Ilao (JMI) Kora in Jiban Lolorjake Ejmour (KIJLE) Kora In Okrane (KIO) Kramer Family Kumiti Cancer Coalition Kumiti Coalition Kumiti NCD Coalition Majuro Atoll Local Government Majuro English Assembly Marshall Islands Journal

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Marshall Islands Medical Society (MIMS) Marshall Islands Nursing Association (MINA) Marshallese Lejmanjuri Organization (MaLO) MediSource Pacific MedPharm Minister Amenta Matthew Mission Pacific National Hansen Disease Center, USA Office of Environmental Planning Policy Coordinator Pacific Health Research Initiative Pacific Islands Health Officers Association (PIHOA) Pacific Leprosy Foundation, New Zealand Public Service Commission Republic of China, Taiwan Rita Elementary School RMI Environmental Protection Authority Secretariat of the Pacific Community (SPC) Shriners' Hospital for Children The Church of Jesus Christ of Latter-Day Saints The Salvation Army Church Sen. Tony Muller Trinity Health International (THI) Tripler Hospital UNICEF United Nations Development Programs United Nations Fund for Program Activities (UNFPA) United States of America Government University of Hawaii (UH) University of South Pacific (USP) USDA Rural Development WAC World Health Organization (WHO) WUTMI Youth to Youth in Health (YTYIH)

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