2 TABLE OF CONTENTS

Topic Page No.

MAP OF THE REPUBLIC OF THE MARSHALL ISLANDS...... 7 1.0 INTRODUCTION ...... 9 MESSAGE FROM THE MINISTER OF HEALTH ...... 11 EXECUTIVE SUMMARY...... 13 SPECIAL APPRECIATION...... 15 2.0 BUREAU OF HEALTH PLANNING AND STATIS TICS ...... 19 2.1 BUDGET ALLOCATION FROM RMI...... 20 Table 2.1 Ministry of Health Budget Allocation ...... 20 Graph 2.1 Budget Allocation ...... 20 Table 2.2 General Fund Allocation for FY 2005 ...... 20 2.2 LIFE EXPECTANCY...... 21 Table 2.3 Life Expectancy ...... 21 2.3 POPULATION AND DEMOGRAPHY...... 21 Table 2.4 Projected Population...... 21 2.4 HEALTH INDICATORS ...... 21 Table 2.5 Compilation of Health Indicators...... 21 2.5 BIRTHS...... 24 Graph 2.2 Number of Registered Birth...... 25 Graph 2.3 Number of Registered Birth by Major Atolls ...... 25 Graph 2.4 Low Birth weight ...... 26 Table 2.6 Birth Complication by Mother’s Age < 20...... 26 Graph 2.5 Registered Teenage Pregnancy by Age FY 1995-2005 ...... 27 Graph 2.6 Registered Teenage Pregnancy FY 1995-2005...... 27 Graph 2.7 Breakdown of Registered Births by Mother’s Age...... 28 2.6 DEATHS...... 28 Graph 2.9 Registered Infant Death by Major Atolls...... 29 2.6.1 Infant Mortality rate ...... 29 Table 2.7 Infant Mortality Rate, 1999 – 2005...... 29 Table 2.8 Top 5 Main Cause of Infant Deaths From 1999-2005...... 30 2.6.2 Child Death...... 30 Graph 2.10 Registered Child Deaths...... 30 2.7 INFORMATION TECHNOLOGY...... 31 2.7.1 Video Teleconference...... 31 Graph 2.11 Video Teleconference Statistics for FY 2005...... 32 2.7.2 Network Project...... 32 3.0 BUREAU OF ADMINISTRATION, PERSONNEL AND FINANCE...... 35 3.1 PERSONNEL...... 36 Graph 3.1 Ministry of Health Personnel...... 37 3.2 FINANCE...... 37 Graph 3.2 Ministry of Health’s Funds ...... 37 Graph 3.3 Health Care Revenue Fund Expenditure by Location ...... 38 Graph 3.4 Basic Health Fund Expenditure by Location...... 39 Update on Audit of Health Care Revenue Fund (HCRF) and Health Fund (HF)...... 39 4.0 BUREAU OF KWAJALEIN ATOLL HEALTH CARE SERVICES ...... 41 4.1 DIVISION OF SUPPORT SERVICES...... 44 4.1.1 Appropriation...... 45 Table 4.1 Adjusted Appropriation for FY 2005...... 45 Table 4.2 Expenditures per Major Cost Categories (line item) ...... 45 Table 4.3 Expenditures by Department (Performance Budgeting) ...... 45

3 4.1.2 Patient Revenue Collection Services...... 46 4.1.3 Personnel Activities...... 46 4.1.4 Maintenance...... 46 4.2 PRIMARY HEALTH CARE SERVICES...... 47 4.2.1 Diabetes Program...... 49 Table 4.4 No. of patients attending Diabetes & Hypertension Clinic from FY 2003-2005 ...... 49 Graph 4.1 Distributions of DM / HTN Clients...... 49 4.2.2 STD/HIV-AIDS Program...... 49 Graph 4.2 Percent of STD/HIV Cases by Type 2005...... 50 Graph 4.3 Kwajalein Prevalence Rate per 1000 Population, 2005...... 50 Table 4.5 Summary of STD Testing FY 2005 ...... 51 Graph 4.4 Reasons for Syphilis Testing...... 51 4.2.3 School Health Program...... 51 4.2.4 TB / Henson (Leprosy) Program...... 52 4.2.4 Immunization and Family Planning...... 52 Table 4.6 Summary of Prenatal Users and Visits ...... 53 Graph 4.5 Prenatal Users and Visits...... 53 Graph 4.6 Teen Pregnancy in Ebeye Hospital...... 53 Graph 4.7 Prenatal Visits by Trimester FY 2005...... 54 Table 4.7 Number of Deliveries FY 2005...... 54 Graph 4.8 Diseases Encountered in SBHC FY 2005...... 55 4.2.5 Dental Services...... 55 Table 4.8 Dental Services, FY 2005 ...... 55 Graph 4.9 Percentages of Caries Among Students in Ebeye, FY 2005...... 56 Graph 4.10 Dental Problems Encountered Among School Children in Ebeye, FY 2005 ...... 56 4.2.5 Health Promotion...... 57 4.2.6 Demographic Data of Encounters...... 57 Graph 4.11 Age Distribution among Encounters for FY 2003-04...... 57 4.2.7 Referral Services ...... 58 Graph 4.12 Visual Defects among Eye Referral, FY 2005...... 58 Graph 4.13 Number of Student Referrals in FY 2005 ...... 58 4.3 DIVISION OF HOSPITAL SERVICES...... 59 4.3.1 Hospital Admissions & Discharges...... 59 Graph 4.14 Common Admission Diagnoses ...... 59 Staffing...... 60 Medical /Surgical Ward ...... 60 Pediatric Ward ...... 60 Maternity Ward ...... 60 ICU Ward ...... 60 Emergency Ward ...... 61 4.3.2 Surgical Department...... 61 4.3.3 Laboratory Department...... 61 Biochemistry...... 62 Hematology...... 62 Blood Banking...... 62 Serology...... 62 Bacteriology...... 62 Parasitology...... 62 4.3.4 Radiology Department...... 62 4.3.5 Pharmacy Department ...... 63 Graph 4.14 Pharmaceutical Purchases, FY 2005 ...... 63 Graph 4.15 Purchases by Vendors, FY 2005...... 64 5.0 BUREAU OF MAJURO HOSPITAL ...... 65 5. 1 PATIENT REGISTRATION AND RECORDS DEPARTMENT...... 67 5.1.1 In-patient Services...... 67 Table 5.1 Number of Patients Admitted by Quarter...... 68 Table 5.2 Number of Births ...... 68

4 Graph 5.1 Number of Births by Quarter...... 69 5.1.2 Outpatient Services...... 69 Table 5.3 Number of Outpatient Visits...... 69 Graph 5.2 Outpatient Visits...... 70 5.3 MEDICAL SERVICES...... 70 5.3.1 Surgeries...... 70 Table 5.4 Surgery ...... 70 Table 5.5 Number of Surgeries (2002 – 2005) ...... 71 Table 5.6 Total Number of Surgeries Performed...... 71 5.4 CAPITAL EQUIPMENT ...... 71 5.5 CLINICAL LABORATORY SERVICES ...... 72 Table 5.7 Number of Diagnostic Tests Performed in Clinical Laboratory...... 72 5.6 RADIOLOGY SERVICES...... 72 Table 5.8 Number of Diagnostic Tests Performed in Radiology ...... 72 Graph 5.3 Diagnostic Tests Performed in Radiology ...... 73 5.7 PHARMACY SERVICES ...... 73 Table 5.9 Number of Prescriptions Dispensed...... 73 Graph 5.4 Prescriptions Dispensed FY 2003-2005...... 73 5.7 REHABILITATION SERVICES ...... 74 Table 5.10 Number of Rehabilitative Treatments...... 74 Table 5.11 Number of Completed Prosthesis ...... 74 5.8 DIETARY SERVICES...... 74 Table 5.12 Number of Meals Served ...... 75 Graph 5.11 Meals served for FY2002-FY2004 ...... 75 5.9 NURSING SERVICES...... 75 Table 5.13 Training Sessions by Nursing Services...... 76 6.0 BUREAU OF PRIMARY HEALTH CARE ...... 85 6.1 STD/HIV-AIDS PROGRAM...... 88 Table 6.1 Syphilis (RPR Tests) FY 2005...... 88 Table 6.2 Gonorrhea (GC tests) FY 2005...... 88 Table 6.3 Chlamydia (CHL Tests) FY2005...... 89 Table 6.4 HIV/AIDS Tests FY 2005 ...... 89 6.2 TB & LEPROSY PROGRAM...... 90 Table 6.5 Tuberculosis FY 2005...... 90 Table 6.6 Leprosy FY 2005 ...... 90 6.3 DIVISION OF HEALTH PROMOTIONS AND HUMAN SERVICES...... 91 6.3.1 Nutrition and Diabetes Prevention...... 91 Table 6.7 Breastfeeding...... 91 Table 6.8 Continue Breastfeeding FY 2005...... 91 6.3.2 Pediatrics High Risk Program...... 92 Table 6.9 Number of children admitted into Pediatrics Unit, Majuro Hospital...... 92 6.3.3 Diabetes Prevention & Control Program...... 92 Table 6.10 Diabetic Treatment...... 93 Graph 6.1 Percentage of Diabetic Treatment FY 2005...... 93 Table 6.11 Fasting Blood Sugar (FBS) and Blood Pressure (BP) testing: Encounter forms...... 94 Graph 6.2 Percentages of FBS and BP Encounters in FY 2005 ...... 94 6.3.4 Community Outreach Program...... 95 Table 6.12 Number of people screened for early detection of Diabetes and Hypertension ...... 95 Graph 6.3 Percentage of Screening for Early Detection...... 95 6.3.5 Weight Loss Program: ...... 96 Table 6.13 Number of People Participated in Wight Loss and Control ...... 96 Graph 6.4 Percentage of People Who Participated in Weight Loss and Control Program...... 96 Table 6.14 Number of outreach conducted and coordinated ...... 97 Table 6.15 Obesity Screening Results...... 98 6.3.6 Human Services Activities...... 99 Table 6.16 Suicide Cases ...... 99 6.4 OUTER ISLANDS HEALTH CARE SYSTEM ...... 99 Table 6.17 Morbidity Report by Rank...... 99 Table 6.18 Types and number of other Complaints...... 99

5 Table 6.19 Number of Birth...... 100 Table 6.20 Number of Deaths...... 100 Table 6.21 Clinics Utilization...... 100 Table 6.22 Family Planning Activities for the Outer Islands Communities ...... 101 Table 6.23 Pregnancy Management in the Outer Islands Communities ...... 101 6.5 DIVISION OF DENTAL SERVICE...... 102 Table 6.24 Dental Clinic Details ...... 102 Table 6.25 Outer Islands Dental Services ...... 102 Table 6.26 School Sealant Program ...... 103 6.6 DIVISION OF REPRODUCTIVE HEALTH AND FAMILY PLANNING...... 103 Table 6.27 Prenatal Visits...... 103 Table 6.28 Prenatal Visits by Age ...... 103 Graph 6.5 Prenatal Visits 2005...... 104 Graph 6.6 Prenatal Visits by Age Group Distribution 2005...... 104 Graph 6.7 Prenatal Visits by Percentage of Past Pregnancy...... 105 Table 6.29 RH Clinic Female Users by Method 2005...... 107 Table 6.30 RH Clinic Male Users by Method 2005...... 107 6.7 IMMUNIZATION...... 108 Table 6.31 Doses Administered FY 2005...... 108 Graph 6.8 Majuro Kindergarten Immunizations and Vaccines Coverage ...... 109 Graph 6.9 Majuro 1st Grade Immunizations and Vaccines Coverage ...... 109 Graph 6.10 Majuro 7th Grade Immunizations and Vaccines Coverage ...... 110 Graph 6.11 Majuro 9th Grade Immunizations and Vaccines Coverage ...... 110 Graph 6.12 Majuro Immunizations and Vaccines Coverage for Children 2 Years of Age, December 2005...... 111 Graph 6.13 Outer Islands Immunizations and Vaccines Coverage for Children 2 Years of Age ...... 112 Table 6.32 Immunization Coverage Report for Outer Islands and Majuro for 2 Years Old ...... 112 Graph 6.14 Percentage of Fully Immunized Coverage Per Atoll, 2005 ...... 113 7.0 BUREAU OF MEDICAL REFERRAL SERVICES ...... 115 7.1 ADMINISTRATION...... 116 7.2 HEALTH SERVICES BOARD...... 116 7.3 FINANCIAL MANAGEMENT...... 117 Table 7.1 Basic Health Plan Revenue and Expenditure for FY 2000 – 2005...... 118 Graph 7.1 Direct Referral Expenses ...... 119 Table 7.2 Direct Referral Expenses and Referrals ...... 119 7.4 REFERRAL ACTIVITY ...... 120 Table 7.3 Referral Activity for FY 1999-2005...... 120 Table 7.4 Referral Activity for FY 2005 by Quarter...... 121 Graph 7.2 Referral Activities for FY 2003 - 2005...... 121 Graph 7.3 Approved Referrals for FY 2005 ...... 122 7.5 SUPPLEMENTAL HEALTH PLAN...... 122 Table 7.5 Statement of Revenues and Expenditures- Supplemental Health Plan...... 122 Table 7.6 Supplemental Health Plan Enrollee ...... 123 7.6 CLAIMS...... 123 Table 7.7 Claims Processed ...... 123 Table 7.8 Average Claims Turnaround days...... 123 7.8 CASE MANAGEMENT...... 124 7.9 TRAINING...... 125 7.10 PROVIDER NETWORK DEVELOPMENT ...... 125 7.11 MANAGEMENT INFORMATION SYSTEMS ...... 127 7.12 HONOLULU OPERATIONS ...... 127 7.12.1 Personnel...... 127 7.12.3 RMI Building Complex...... 127 7.14 PHILIPPINES OPERATIONS ...... 128 ACRONYMS & DEFINITIONS:...... 131

6 Map of the Republic of the Marshall Islands

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8

1.0 Introduction

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 with a developing agrarian and service-oriented economy.

The Ministry of Health is the main provider of all health care services to the entire nation. Under the constitution of the Republic of the Marshall Islands, the Ministry continues to face challenges in providing quality and affordable health care to the peoples of the Republic. However, with creative and collaborative thoughts, generally arrives at creative solutions to deliver its mandate.

During fiscal year 2005, Ministry of Health annual budget was $15,955,932. This is an equivalent of 13.68 percent of the nation’s global budget to keep in line with the Ministry’s mission statement;

“To provide high quality, effective, affordable, and efficient health services to all peoples of the Marshall Islands, through a primary health care program to improve health status and build the capacity of each community, family and the individual to care for their own health. To the maximum extent possible, the Ministry of Health pursues these goals using the national facilities, staff and resources of the Republic of the Marshall Islands.”

The Ministry continues to explore avenues to provide the best quality health care possible to the people despite its meager funding and limited human and capital resources. The current health indicators reveal a much improved health status and a steady progress with community participation in implementing this theme “Health is a Shared Responsibility.” However, there is still a need to reflect more on the changing lifestyles associated with epidemiological transition from infectious to non-communicable diseases.

This report represents a summary of the Health Ministry’s major activities and development and an assessment of the medical progress during the fiscal year 2005.

9 10 Message from the Minister of Health

First and foremost I would like to take this wonderful opportunity to highlight my sincere gratitude and thankfulness to the President of the Republic of the Marshall Islands, His Excellency President Kessai H. Note, Members of the Cabinet, Members of the Parliament, the Council of Chiefs, Members of the Diplomatic Corp and the International and Regional Partners for all the supports you generously rendered throughout Fiscal Year 2005. I am most certain that the same, or perhaps, even a stronger spirit of collaborations and partnership will take their places in 2006 and beyond.

I also would like to extend the same heartfelt recognition and appreciation to the Secretary of Health, the management, as well as the clinical and medical staff and everyone at the Ministry for all your commitment and sacrifices to ensure that precious lives are saved and that people receive the health services and care they deserve.

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On the same token, I must congratulate and thank the people of the Republic of the Marshall Islands for making the effort to take charge of their own health. There is no doubt that should you have not taken the right choices toward your health, regardless of how hard the Ministry strive to provide health care services, all efforts would be in vain.

Under this framework, the Ministry of Health, as mandated by our Constitution to provide best quality health care for the peoples of the Republic of the Marshall Islands, continues to devise inclusive national policies, calculated approaches and plans of action to address health issues in the country by providing comprehensive preventive, curative and rehabilitative services to the peoples of the Republic. This is evident by our Government becoming signatory to many international and regional declarations and regulations such as the International Health Regulations (2005) and many other conventions and instruments of similar importance for health promotion and care.

More importantly however, all governmental and non government sectors must unite forces to prevent diseases and their complications. Without this collaboration, it does not matter how clear and how logical the health policies we formulate and endorse, it will be difficult for us to live healthy and productive lives. Thus we will forever be burdened with health and other social issues which each individual could provide for oneself.

For that reason, as the Minister responsible for this mandate, I once again encourage and challenge each and every one of us to join our resources and efforts to improve the quality of health in the Republic, today and for many ages to come.

12 Executive Summary

I am pleased to submit, for review and reference, the Ministry of Health’s Annual Report for Fiscal Year 2005. The report summarizes the major accomplishments and challenges experienced by the Ministry of Health during the said period. The Ministry has six Bureaus which include the Bureau of Health Planning & Statistics, the Bureau of Administration, Personnel and Finance, the Bureau of Medical Referral Services, the Bureau of Hospital Services, the Bureau of Primary Health Care, and the Bureau of Kwajalein Atoll Health Care Center

The Ministry’s past and continuing achievements and endeavors were a result of the commitment, dedication and hard work of its personnel. As with all major Health Care Providers in other developing countries within the region and around the globe, the Ministry of Health continued to face numerous administrative, financial and medical challenges, as well as health threats. The challenges and threats, however, have been successfully kept at bay by the motivation, innovation and assertiveness of the skilled and trained personnel at the Ministry.

The Bureau of Health Planning & Statistics continues to collect, generate and disseminate vital health information that had made the Ministry’s decision making process effective and efficient. One of the many highlights of the year included the accomplishments procedures for the MOH’s network, which will be implemented in early 2006. The project will greatly enhance the Ministry’s communications capabilities, especially the availability and free flow of pertinent health data for decision making.

13 The Bureau of Administration, Personnel and Finance diligently made sure all financial and administrative needs of the Ministry were efficiently and economically met. In fact the Ministry was able to carry out its essential services despite of unexpected incidences.

The Ministry of Health, through a kind financial assistance from the Government and the people of Japan, was officially handed over the keys for the newly build annex of the Majuro Hospital. The Bureau of Hospital Services was able to achieve: 1) a four percent reduction in the number of admitted patients, 2) an increase of twenty-two percent in the number of life-saving ambulance services, 3) the implementation of more than one hundred and eighty continuing education seminars and training for the nurses, and 4) purchasing and acquisition of pertinent medical equipment for strengthening of diagnostic capabilities and delivery of hospital services.

Aside from continuing to provide preventive services, the Bureau of Primary Health Care established the first ever RMI Cancer Program to address increased the numbers of cancer in the country. The next fiscal year will be as challenging to establish concrete plan for the program. The Bureau’s efforts to increase the immunization coverage rate remain a priority. We are thankful for the collaboration the Ministry of Education in the initiatives.

The Bureau of Medical Referral Services reported a 27% increase in the number of medical referral cases from the previous year. Despite the increase in the referral cases, the cost has been maintained during the fiscal year. The increase in number of referral was a direct result of the increase use of providers in the Philippines and increase in number of patients accepted by Tripler Army Medical Center (TAMC). During the fiscal year, the Bureau sought other options for referral and capacity building with Republic of China (ROC).

The Bureau of Kwajalein Atoll Health Care Center as taken on a more community based approach involving the community and key stakeholders. The Play Therapy Room, which was designed for observing and counseling students at the Ebeye Public Elementary School, is fully operational. The RMI government finally signed the long awaited comprehensive maintenance contract on January 2005. The diabetic program has been revitalized and strengthened.

Finally, I wish to stress that throughout the years since the government endorsed the concept of Primary Health Care in 1986, the shift form curative services to preventive services has not been fully implemented. In fact, PHC concept still remains in its infancy. Funds allocated for the MOH indicates that 48.95% is allocated for curative services and 17.23% is for preventive services. The lack of concrete definition of preventive services on primary health care has inhibits the developments of a solid plan to implement or perhaps strengthen preventive services, PHC is a concept that required the collaboration efforts to take charge of our own health at all level of services: education, business sector, community, chambers, community groups, government together. That’s the reason why the Ministry’s theme is “Health is a Shared Responsibility” . The MOH aims high to continue to find ways to fully develop effective PHC programs and services that is acceptable, appropriate and affordable at all levels of care in the years to come.

14 Special Appreciation

In this report, the Ministry expresses its humble gratitude and appreciation to the donor agencies and partners such as the formerly Work Investment Act (WIA) which is now merged into the National Training Council (NTC), Trinity Health International (THI) and international organizations such as the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), UNFPA, JOCV/JICA, Government of Japan, Government of Israel, UNICEF, Republic of China (ROC), AusAID and the Secretariat of the Pacific Community (SPC) , Pacific Islands Health Officers Association (PIHOA), (HRSA), and friends, who have been so generous in their technical and financial contribution to the overall successful operations of the Ministry. We value your kind and unwavering support and commitment to the Ministry’s efforts and challenges to implement its numerous programs and services to the people of the Marshall Islands. To our local stakeholders such as Iroij, Alaps, business community, WUTMI, churches, local governments, MIMA, and government agencies, friends, thank you for your support.

The Ministry also wishes to extend the same heartfelt thankfulness and indebtedness to the following governments, organizations, agencies and companies for the generous and unconditional help during the Ministry’s relief efforts after the unfortunate fire that destroyed most of the Ministry’s pharmaceutical and medical supplies.

1. Abetement Tech. USA 2. ACE Hardware 3. Aloha Laboratory 4. Asia Pacific Airlines 5. Australian Government 6. AYUDA Foundation 7. Bank of Guam 8. Bank of Marshall Islands 9. BECA 10. Belau Medical Clinic 11. Bergen Brunswig Drug Co. 12. Center for Disease Control and Prevention (CDC) 13. Chief Secretary and RMI Disaster Committee 14. Church of Jesus Christ and Latter Day Saints 15. Commonwealth of the Northern Mariana Islands (CNMI) 16. Continental Airlines 17. Crazy Price 18. Department of Family Medicine and Community Health, University of Hawaii 19. Department of Energy Pacific Health Research Institute (DOE/PHRI) 20. The Elizabeth Livine Foundation, Inc. 21. Federated States of Micronesia (FSM) Department of Health 22. Federated States of Micronesia (FSM) Red Cross 23. Government of Federated States of Micronesia 24. Genesis Hospital (Pohnpei) 25. Guam Public Health Laboratory

15 26. Home Garden 27. Jane’s Corporation 28. JC Marketing 29. J&J Company 30. JMI Medical Systems 31. Kaiser Permanente 32. Kauakini Hospital 33. Kwajalein Health Care System 34. Majuro Atoll Local Government 35. Majuro Stevedore and Terminal Company 36. Majuro Chamber of Commerce 37. Majuro Community 38. Marshall Islands Resort 39. Medline 40. Medpharm 41. Ministry of Public Works 42. Ministry of Justice 43. Momotaro Corporation 44. New Zealand Government 45. Ocean Medical Foundation 46. Pacific Air Command 47. Pacific Basin 48. Pacific International Incorporated (PII) 49. Palau Ministry of Health 50. Payless Supermarket 51. Queen’s Medical Center 52. Rehab Hospital 53. Republic of China (ROC) 54. Republic of the Marshall Islands (RMI) Government 55. Robert Reimers Enterprises (RRE) 56. Salvation Army 57. Stitching IDA, USA 58. Tokai Kogyo Co. and Local workers 59. United Nation Fund Population Activity (UNFPA) 60. United States of America Kwajalein Atoll (USAKA) 61. United States Department of Health and Human Services 62. United States Embassy, Majuro 63. Women United Together Marshall Island (WUTMI) 64. World Health Organization (WHO)

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17 18 2.0 Bureau of Health Planning and Statistics

The Bureau of Health Planning and Statistics is responsible for the collection, compilation, and analysis of all health and health-related information for the Ministry of Health. These include but not limited to information on births, deaths, and program-specific data collected in the hospitals, outer islands health centers, and the public health clinics. The Bureau is also responsible for the maintenance of the health management information systems used by the Ministry.

19 2.1 Budget Allocation from RMI

Table 2.1 Ministry of Health Budget Allocation

% of Budget Projected Per FY Ministry of Health Global Budget Allocation Population Capita 2000 $13,876,211.00 $101,411,672.00 13.68% 53,064 $263.45 2001 $11,930,711.00 $98,258,712.00 12.14% 53,995 $218.60 2002 $12,207,274.00 $106,582,000.00 11.45% 55,147 $186.00 2003 $14,189,820.00 $98,550,200.00 14.40% 58,949 $241.12 2004 $15,756,334.00 $108,627,669.00 14.50% 61,218 $257.40 2005 $15,955,932.00 $116,646,945.00 13.68% 63,780 $251.00

Graph 2.1 Budget Allocation

Budget Allocation for the Ministry of Health

16.00% 14.40% 14.50% 13.68% 13.68% 14.00% 12.14% 12.00% 11.45% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% 2000 2001 2002 2003 2004 2005

Table 2.2 General Fund Allocation for FY 2005

Service Area FY 2005 % Allocated Preventive $ 393,077 17.23% Curative $ 1,116,440 48.95% Administration $ 627,172 27.50% Planning and Statistics $ 144,139 6.32% Total $ 2,280,828 100.00%

20 2.2 Life Expectancy

Table 2.3 Life Expectancy

Year Gender Male Female 2005 67.0 70.6 2004 67.0 70.6 2003 66.8 70.4 2002 66.5 70.2 2001 66.2 69.9 2000 66.0 69.7 1999 65.7 69.4 Source: Economic Policy, Planning and Statistics Office (EPPSO)

The table illustrates the life expectancy of Marshallese. Based on the information females, in general, live longer than males.

2.3 Population and Demography

Table 2.4 Projected Population

Year RMI Majuro Kwajalein Outer Islands 2000 52,671 24,605 9,833 18,233 2001 54,584 25,626 10,206 18,752 2002 56,639 26,770 10,593 19,276 2003 58,849 28,054 10,990 19,805 2004 61,215 29,488 11,396 20,331 2005 63,579 30,820 11,820 20,939 Source: EPPSO

The table outlines the projected population of the nation for the last six years including 2005. In FY 2005, Majuro (48%) and the outer islands (33%), in general, have a higher population growth rate compared to Kwajalein (19%).

2.4 Health Indicators

Table 2.5 Compilation of Health Indicators

FY 2004 FY 2005 1. Crude Birth Rate (Per 1000 Population) 24.5 25.6 - Total 1502 1625 - Male 786 820 - Female 714 803 - Not Stated 2 2 2. Crude Death Rate (Per 1000 Population) 4.5 4.4 - Total 275 279 - Male 168 158 - Female 107 121

21 3 Total Fertility Rate per 1000 Population (women 110 112 ages 15-44) 4 Neonatal Mortality Rate (Per 1000 Live Births) 13.72 14.33 - Both Sexes 22 23 - Male 16 15 - Female 6 8 5 Infant Mortality Rate (Per 1000 Live Births) 24.94 19.7 - Both Sexes 40 32 - Male 28 21 - Female 12 11 6 Maternal Mortality Rate (Per 1000 Live Births) 0 0

As indicated from the table, during the year there was a minimal increase in the number of birth, death, neonatal mortality and fertility rate from the previous year. For every 1000 women ages 15-44, there are 112 babies born for FY 2005. The trend indicates that a woman can have 3 children before she reaches the age of 30. More mothers are having children at a very young age instead of going to school. The high birth and fertility rates in the RMI, points out and strongly suggest that there has to be an aggressive and massive health education campaign promoting the use of contraceptives On a more positive note, the infant mortality rate has decreased from nearly 24.94 in 2004 to 19.7 in 2005.

7 Leading Causes of Morbidity FY 2004 FY 2005 Influenza 5170 Influenza 3384 Conjunctivitis 2632 Gastroenteritis 2153 Gastroenteritis 2041 Conjunctivitis 1532 Diarrhea, Infantile 1640 Scabies 637 Scabies 778 Amoebiasis 260 Chicken Pox 426 Chicken Pox 246 Amoebiasis 312 Diarrhea, Infantile 224 Fish Poisoning 251 Syphilis 154 Syphilis 172 Fish Poisoning 132

8 Leading Causes of Mortality FY 2004 FY 2005 Sepsis/Septicemia 46 Cardiorespiratory Arrest/Failure 43 Cancer (All Types) 23 Sepsis/Septicemia/Septic Shock 36 Myocardial Infraction 15 End Stage Renal Failure 16 Pneumonia 14 Cancer (All Types) 15 Suicide 13 Hepatic/Liver Failure 14 End Stage Renal Disease and 12 Pneumonia 9 Cerebrovascular Disease Drowning 10 Asphyxia 7 Prematurity 8 Cerebrovascular Accident 6 Trauma 6 Congestive Heart Failure 5 Congestive heart Failure and 5 Hepatitis B 5 Hepatitis B

22 Cardiorespiratory arrest/failure was the leading cause of mortality during the year, followed by Sepsis/Septicemia/Sepsis shock. Sepsis/Septicemia, however, continued to be a top five leading cause of mortality for two consecutive years, 2004 and 2005 respectively.

Cancer remains in the top five causes of deaths. The Ministry has taken the initiative to establish a Cancer Comprehensive Program which will develop the Cancer Registry and related work for cancer education and prevention through screening.

9. RMI Tube rculosis

New cases Detected

X X

TX at Died

year PSP # Lost to T Beginning Not a Case Migrated Out Cases at the # still on Complete T the end of Year # of # of PSN # of EPTB Total New Cases # FY 2004 40 61 18 29 108 12 2 2 0 56 76

FY 2005 76 37 16 33 86 4 1 4 8 88 57 PSP – Pulmonary Smear Positive; PSN – Pulmonary Smear Negative; EXTB – Extra -pulmonary TB; TX - Treatment

The table indicates that at the beginning of the Fiscal Year, there were 76 registered TB cases (an increase of 53% from FY 2004). It further indicates that there were a total of eighty-six new registered cases, making the total of 162 registered patients. At the end of the year, however, after the patients have completed their treatments, migrated out, died and/or did not completed their treatment, there were 57 cases remained on treatment.

10. RMI Leprosy

New # # Active # at the cases # lost to migrated # completed cases at the Year beginning detected TX out died TX end of year FY 2004 76 60 0 0 0 69 67 FY 2005 67 56 0 0 0 61 62

The table indicates that there were a total of 67 cases at the beginning of the year with 56 new cases making a total of 123 cases for 2005. A total of 61 patients completed their treatment, which resulted in 62 still on treatment. Compared to last year, there was a 10% reduction in the number of cases.

23 11. RMI Sexually Transmitted Disease

Sexually Transmitted FY 2004 FY 2005 Diseases (STD) Number of Rate Number of Rate Positive Case Positive Case Syphilis 341 1.14 280 1.0 Gonorrhea 24 0.1 30 0.1 Chlamydia 97 0.3 212 1.0

As indicated from the table, syphilis continues to be the most prevalent form of STD in RMI. Despite a twenty-two percent decline in the number of positive cases from 2004, the figure remains as alarming concern. The MOH continued to aggressively conduct outreach activities for STD screening, contact tracing and treatment.

Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 Male 0 0 0 0 1 0 0 0 0 0 Female 0 0 0 0 1 0 0 0 0 0 U/K 0 0 0 0 4 0 0 0 0 0 Total 0 0 0 0 6 0 0 0 0 0

Year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Male 0 0 0 0 1 0 1 0 0 0 Female 0 0 0 1 0 0 0 0 0 0 U/K 0 0 0 0 0 0 0 0 0 0 Total 0 0 0 1 1 0 1 0 0 0

Year 2000 2001 2002 2003 2004 2005 TOTAL Male 0 0 0 0 0 1 3 Female 1 0 0 0 0 1 3 U/K 0 0 0 0 0 0 4 Total 1 0 0 0 0 2 10

Based on the table, there were ten HIV positive cases in Marshall Islands. Four of these were diagnosed in 1984. The four confirmed cases were not Marshallese. Two died in 1984. During the same year, there was no available test on the island. The cumulative number of HIV registered in RMI is 12. There are 10 still alive and 3 of them are living in RMI.

2.5 Births

There were 1,625 officially registered live births in the Marshall Islands. This numbers includes the Majuro, Kwajalein and Outer Islands. Graph 3.2 presented the total births for each month form October 1, 2004 to September 30, 2005.

24 Graph 2.2 Number of Registered Birth

Registered Birth FY 04-05

180 160 140 120 100 80 60 40 20 0 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep FY 2004 147 130 145 130 103 121 100 126 112 97 132 159 FY 2005 154 127 149 138 138 138 124 114 114 140 154 133

Graph 2.3 lists the breakdown of the number of births by major atoll. A total of 1136 babies were born in Majuro, 360 in Ebeye, Kwajalein and 129 in the Outer Islands. The numbers of registered birth changes as unavoidable circumstance occur such as late registration.

Graph 2.3 Number of Registered Birth by Major Atolls

Registered Birth by Major Atoll FY 2005

Outer Islands 8% Kwajalein 22%

Majuro 70%

There were 101 babies with low birth weight (LBW) and 2% of them were categorized as very low birth weight (VLBW). However, it must be noted that there are late registration of births. Low birth weight is a factor most closely associated with neonatal mortality and LBW infants are more likely to experience long-term disability (such as developmental disorders) or die during the first year of life compared to infants of normal weight. Very Low Birth Weight infants have been increasing in recent years with a recorded high of 1.35% from the total number of registered live births in 2001. There were 94 premature births

25 Graph 2.4 Low Birth weight

Percent of LBW and VLBW for FY 1997-2005

25 23.5 20 19.7 15.79 15 14.82 14.2 11.6 11.9 12.39 10

5 6.22 1.35 1.19 1.19 0 0.33 0.25 0.14 1.01 0.17 0.12 1997 1998 1999 2000 2001 2002 2003 2004 Jan-Dec 2005

Percent of LBW babies Percent of very LBW babies

Table 2.6 Birth Complication by Mother’s Age < 20

Complication 2000 2001 2002 2003 2004 2005

Low Birth Weight (LBW) 37 39 56 52 44 25

Premature 30 38 28 36 20 26

There were a total of 299-registered teen pregnancies for this fiscal year. The teenage pregnancy rate is 18.4 % for FY 2005.

26 Graph 2.5 Registered Teenage Pregnancy by Age FY 1995-2005

Registered Teenage Pregnancy by Age FY 199-2005

140 12 Years Old 120 13 Years Old 100 14 Years Old 80 15 Years Old 60 16 Years Old 17 Years Old 40 18 Years Old 20 19 Years Old 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Graph 2.6 Registered Teenage Pregnancy FY 1995-2005

Registered Teenage Pregnancy FY 1995-2005

350 315 319 299 299 283 281 300 269 261 258 253 250 207 200

150

100

50

0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

The above graph indicates the number of teen pregnancies over the last ten years. There was a steady rise in the number of teen pregnancies since 2002. There was a 15% increase this year in the number of teen pregnancies from FY 2004. It is obvious from the data that the number of teen pregnancy continues to increase. The health, social and economic burdens directly associated with teen pregnancies, should be aggressively stressed and conveyed to assist in reversing the current trends.

27 Graph 2.7 Breakdown of Registered Births by Mother’s Age

Registered Birth by Mother's Age

40 to 44 Age 45 to 49 Age Group Group Not Stated 35 to 39 Age 1% 0% <15 Group 0% 0% 15 to 19 Age 6% Group 30 to 34 Age 18% Group 14%

25 to 29 Age 20 to 24 Age Group Group 23% 38%

The graph illustrates the number and percentage of registered births by the mother’s age. By far, women in the age group of 20-24 (38%) years old consists of most the registered births, followed by age group 25-29 (23%) and 15-19 (18%). Mothers between ages 15-24 constitute for 56% of the total birth for the year. What is disturbing about the data is that the 15-19 age group who are having babies and not in school at this age.

2.6 Deaths

There were 279 registered deaths in the Marshall Islands in FY 2005. Out of the total 222 were registered in Majuro, 21 in Kwajalein, 33 in the Outer Islands and 3 died in the ocean/ship.

Graph 2.8 Registered Death by Atolls

Registered Death by Atoll FY2005

Not Stated/ In Outer the Ocean, On Atolls/Islands - Ships 12% 1%

Kwajalein 8%

Majuro 79%

28

There were 32 infant deaths for this year. Refer to the graph below for the distribution with the major Atolls.

Graph 2.9 Registered Infant Death by Major Atolls

Registered Infant Death by Major Atolls FY 2005

30 26 25 20 15 10 4 5 2 0 Majuro Kwajalein Outer Island

2.6.1 Infant Mortality rate

Table 2.7 Infant Mortality Rate, 1999 – 2005

Year No. 1999 13 2000 33 2001 26 2002 29 2003 30 2004 23 2005 32 Note: No. of Infant Death per 1,000 live births. Infant: less than one year of age

The infant mortality rate (IMR) is used to measure the health status of children and that of women before and during pregnancy as well as the quality and accessibility of primary health care for pregnant women and their babies. Data may vary due to late registration.

29 Table 2.8 Top 5 Main Cause of Infant Deaths From 1999-2005

Rank 1999 2000 2001 2002 2003 2004 2005 Respiratory Distress Birth 1 Syndrome 4 Prematurity 15 Sepsis 11 Prematurity 11 Prematurity 16 Sepsis 6 Asphyxia 7 Pneumonia/ Hyaline Membrane Cardiorespira 2 Sepsis 4 Sepsis 9 Prematurity 6 Sepsis 8 Sepsis 8 Disease 4 tory Arrest 6

Multilpe Pneumonia/Bi Congenital rth Birth Congenital Birth Neonatal 3 Malformation 3 Complication 7 Pneumonia 5 Complication 5 Abnormality 7 Complication 3 Sepsis 3 Hyaline Membrane Malnutrition/C Disease / ongenital Multiple Meningitis Heart Congenital Congenital Severe Birth CNS Infection 4 Disease 2 Abnormality 4 Anomalies 4 Pneumonia 4 Asphyxia 6 Aspiration 2 / Bacterial 3 Congenital Heart Bronchopneu Congenital Cardiopulmo 5 Prematurity 2 Disease Pneumonia 3 Malnutrition 3 monia 2 Anomality 2 nary Arrest 2

2.6.2 Child Death

The major causes of child death during FY 2005 were severe malnutrition, drowning and vehicular accident.

Graph 2.10 Registered Child Deaths

Registered Child Death's Trend FY

16 14 14 14 12 12 12 11 11 10 8 8 6 4 2 0 1999 2000 2001 2002 2003 2004 2005

Child Death: Death from 1-4 years of age

30 2.7 Information Technology

2.7.1 Video Teleconference

The MOH staffs participate in video teleconferences (VTCs) with different health providers and educational institutions in the State of Hawaii. Aside from presentations on health topics, the MOH also established its Telehealth with Shriners Hospital with coordination from Shriners’ coordinator, Mother and Child Health Nurse Coordinator, Orthopedic Surgeon, and the MOH VTC Coordinator. Through the VTC, MOH can present from Majuro to Shriners’ Children Hospital in Honolulu, Hawaii. This helps in the decision making of the Shriners’ Physicians and Nurse Coordinator to make the arrangements for the patients from RMI for referrals.

Telehealth with Shriners Hospital Physician with MOH Staff

VTC Presentation: Nurses from the Majuro Hospital

31 Graph 2.11 Video Teleconference Statistics for FY 2005

Video Teleconference for FY 2005

16 16 15 14 12 12 11 11 10 10 10 8 8 7 6 6 4 2 0 0 0 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

MOH has been encountering problems with the leased line connecting the hospital and CMI. The leased line is being operated by National Telecommunication Authority (NTA). For the month of August and September,gg MOH had scheduled conferences with Hawaii. However all of the scheduled teleconferences were cancelled due to the leased line problems.

2.7.2 Network Project

The Ministry has embarked on a network project that will link all of the buildings and programs within the MOH in Majuro. The network is significant because it will greatly enhance the Ministry’s capacity for collection, dissemination and analysis of data from all programs within MOH. Better collection of data on a timely basis will be beneficial for better planning and efficient implementation of services and programs provided by the Ministry. Equipments for the project are being purchased and will be installed in February of 2006. The project is expected to be completed and operational in early March 2006.

32

Technical analysis of bid documents for the Network Project.

33

Vital Statistics Department and IT Department

34 3.0 Bureau of Administration, Personnel and Finance

The Bureau of Administration Personnel and Finance is responsible for all matters relating to personnel, administration, accounting, and budgeting and deals directly with all of the human and material requests and management of the Ministry of Health.

35 Fiscal Year 2005 brought a lot of challenges to the Bureau of Administration, Personnel and Finance as it is this bureau that must ensure that there is compliance throughout the whole Ministry in terms of financial resources received by the ministry; most especially, the requirements for the Health Sector Grant under Compact II. Although there were challenges in the past year, this bureau continued to carry out its functions as part of the team mandated under the Constitution to provide health care services to the people of the Republic of the Marshall Islands.

3.1 Personnel

The division of Personnel and Human Resources Development in the Ministry is responsible for the keeping and maintenance of all personnel files as well as ensuring that the necessary and relevant trainings are made available to all staff in the ministry. Therefore, the past year this division made capacity building a priority and hired the HRD coordinator during the beginning of the year. The major accomplishments of this division in the past year are:

? Hired HRD Coordinator ? Contracted a Training Firm to provide training for MOH staff ? Developed a Work Development Plan ? Commenced Dialogue with Firm to upgrade time management and keeping system ? Conducted a Personnel Audit

In addition to the above accomplishments, this division was also able to make available to all staff in the ministry a total of 39 trainings through the Pacific Open Learning Health Net Lab that is funded through the World Health Organization (WHO). This WHO project provides a computer lab where all staff in the ministry may gain access to enroll in courses offered by the Fiji School of Medicine, School of Public Health and the University of the South Pacific as well as some courses offered by PREL. In addition to the courses available online, the medical and nursing staff may also utilize the computer lab for continuing education sessions that are available on the internet.

The Personnel and HRD division is responsible for the safekeeping and maintenance of the more than 400 personnel files for all staff in the ministry. Below is a breakdown of the distribution of staff to posts:

36 Graph 3.1 Ministry of Health Personnel

Ministry of Health Personnel

160 138 140 120 100 71 80 63 59 60 48 40 39 43 40 13 20 0

Doctors Nurses Security

Administration Practical NursesPrimary Health Ancillary Services Health Assistants Support Services

3.2 Finance

This division in the bureau is responsible for the daily transactions that take place within the ministry. It is also this bureau that ensures all bureaus in the ministry comply with all regulations whether it be for the Federal grants or the Compact Funds. Below is a summary of all funds available for the ministry to carry out its mandate:

Graph 3.2 Ministry of Health’s Funds

Ministry of Health's Funds From All Sources FY 2005 ($20,107,254)

UN/WHO Grants Papa Ola Lokahi 1% 0% General Fund Basic Health 11% Fund 18%

Health Care Revenue Fund Compact Funds 15% 36%

Federal Grants 19%

37 The division of Finance had set goals and objectives at the beginning of FY 2005. This division was able to be current and up to date with all vendors regarding payments. Ministry’s goal is to be able to pay vendors on average of about 14 days after receipt of an invoice. Below is a brief summary of what was accomplished at the end of the year:

? Developed and Implemented new accounting rules and procedures ? Decreased turn around payment to vendors from average of 18 days upon receipt of invoice to 14 days.

Finance division is responsible for the administration and management of the Health Fund. The ministry was fortunate in the past year as it was able to accomplish a lot of its goals and objectives without many obstacles in the procurement of pharmaceuticals and medical supplies. Below is a breakdown of expenditures for the Health Care Revenue Fund as well as the Basic Health Fund:

Graph 3.3 Health Care Revenue Fund Expenditure by Location

Health Care Revenue Fund Expenditure by Location

$1,657,749 $2,000,000

$1,500,000

$1,000,000 $410,608 $407,178

$500,000

$0 Majuro Ebeye Outer Islands

38 Graph 3.4 Basic Health Fund Expenditure by Location

Basic Health Fund Expenditures by Location

$1,400,000.00 $1,211,218.10 $1,200,000.00 $1,000,000.00 $757,354.85 $800,000.00

$600,000.00$322,998.65 $400,000.00 $200,000.00 $61,232.65 $0.00

Honolulu Referrals Philippine Referrals Majuro Administration Inter Island Referrals

Update on Audit of Health Care Revenue Fund (HCRF) and Health Fund (HF)

The final audit reports for HCRF and HF for fiscal year 2003 were released on November 28, 2005. We are pleased with the result as we received an unqualified or “clean” opinion on the financial statements for both funds. Below is the opinion paragraph on the Independent Auditor’s Report from Deloitte & Touche:

‘In our opinion, such financial statements present fairly, in all material respects, the financial position of the Health Care Revenue Fund/Health Fund, special revenue fund of the Republic of Marshall Islands, as of September 30, 2003, and the results of that fund’s operations in the financial position for the years then ended in conformity with the accounting principles generally accepted in the United States of America.’

We also received a clean opinion on the internal controls for HF, to wit:

‘We noted no matters involving the internal control over financial reporting and its operation that we consider to be material weaknesses.’

Internal controls for HCRF was generally considered clean except for one reportable condition stated in the auditor’s report on internal control over financial reporting. Briefly described, the reportable condition was due to insufficient general ledger maintenance. Management addressed this issue and the corrective action plan was to hire a Chief Accountant and an accountant to help in the maintenance of accounting systems and records.

39 For the audit of fiscal year 2004, the audit fieldwork for both funds is done and management is now waiting for the release of the initial draft of the audit reports, which expectedly will come out early March 2006.

As for fiscal year 2005, the Ministry was able to comply with the deadline of submission of trial balance and financial statements to the auditors. Audit fieldworks for both funds are still in process as of this writing. According to Deloitte, both funds will be included in the FY2005 Consolidated RepMar financial statements, considering that we will provide all the necessary documents to facilitate the audit. Initial draft of the audit reports is expected to be available for review within March 2006.

Accounting Department

40 4.0 Bureau of Kwajalein Atoll Health Care Services

The Bureau of Kwajalein Atoll Health Care is responsible for providing hospital and public health care services to the population of Kwajalein Atoll. The bureau is comprised of three divisions: Administration, Hospital, and Primary Health Care. In addition to providing public health care services to Ebeye, the division also services neighboring islands that include North and South Loi, Guegeegu, Carlson Island, Santo Island, and Ebadon.

The Administration is responsible for the daily management of the bureau.

The Division of Primary Health care is responsible for all primary health care programs and preventive health services in Kwajalein Atoll and surrounding atolls. Health Assistants provide health services in the outer island dispensaries on a daily basis and are supported with quarterly site visits by a team of preventive health personnel. The Division is responsible for operating clinics at the Ebeye Hospital and for outreach programs within zones on Ebeye. The Division operates programs in Public Health, Maternal and Child Health, Family Planning, Communicable Disease, Human Services, Health Education, and Dental Services.

The Division of Ebeye Hospital Services is responsible for all curative services provided to the population of Kwajalein Atoll and neighboring outer islands.

Leroij Kitlang Memorial Health Center, Ebeye, Kwajalein

41 42 The Bureau of Kwajlaein Atoll Health Care Services continues to provide comprehensive and affordable healthcare services to the community on Ebeye, the other six communities within Kwajlaein Atoll, and serves as another referral facility for the Western atolls and Lib Island. During the Fiscal Year 2005 the Bureau had formed partnerships within the community in carrying out its mandate through community participation in planning and implementation of community outreach activities. For example, every Tuesdays, Wednesdays and Thursdays, members of community actively participated with the Bureau’s Diabetes and Hypertension programs. The more the community understands the importance of prevention the more active they have become in participating with health related activities.

The scope of the Bureau’s responsibility also includes providing emergency services, hospital and specialized care health services. The Bureau has four divisions: which include Support Services, Primary Health Care, Health Information and Hospital Services.

Highlights for the fiscal year 2005

During the fiscal year, these are the activities and events that the Bureau considers as highlights and worth mentioning:

1. Signing of the Operation and Maintenance Contract. The RMI government finally signed the long awaited comprehensive maintenance contract on January 2005. The AIC of Guam is now in charge of providing maintenance services at the Ebeye Community Health Center facility and all its equipments. 2. The opening of the Play Therapy Room. It is a counseling room established in the School Based Health Center for the sole purpose of observing and counseling students at the Public Elementary School. In counseling the children, play becomes the medium of exchange. Students visit this room after being seen by the Physician or when it has come to a point that teachers needed to refer their students to the Therapy Room. 3. International Women’s Day. This Day was held on March 8, 2005. A seminar for women was conducted. There were 30 women who participated, and the topics discussed were: Teen pregnancies, Importance of Cervical Cancer Check-up and Early Detection of Breast cancer by self breast examination. In each of the high schools in the islands, power point presentation on HIV/AIDS, Teen pregnancy and alcohol and substance abuse were given by t one of the health educators, one Ob/Gyn and a social worker. 4. World TB Day. This World TB Day was celebrated on the 24th of March by conducting a workshop both traditional leaders and heads of government offices on the island. Workshop was an opportunity for participants to ask questions about TB, HIV and preventive measures. 5. Vitamin A and De-worming. During March, the staff administered Vitamin A 100,000 IU to 243 children between the ages of 6 months to one year and 200,000 I.U. to those between the ages of 2 to 12. 6. Outreach Program: This year, the outreach program continued to increase health activities in the community on Ebeye and the other communities within Kwajalein Atoll. The outreach schedule has changed from four times a year to every Wednesdays and now every week from Monday – Thursday starting at 6P-9PM.

43 7. Introduction of Patient Electronic Care System (PECS). This program is used for collecting data on the diabetic collaborative program. 8. The Diabetes Program: To date, clinic days have increased from one day to three days a week to provide comprehensive healthcare services to the clients. The patients during the one to one sessions are introduced to the Self Management Program to learn how to manage their diabetes and also familiarized themselves with the medicine they are taking. 9. The Rotary Club of Hawaii sponsored a team of Dentist that visited the Ebeye community. The Dental services provided by the team were free and they visited all the schools on Ebeye and Enniburr. 10. The KAHC Board of Directors revised and adopted their bylaws and signed an affiliation agreement with the Ministry of Health. 11. Training for Health Educators. The PHC Medical Director started a training program for all our health educators. This program took placed once a week. 12. The PIPCA and HPCA conducted a Board Training on site for three days. 13. The PEACESAT program was finally approved and all the paper works were signed by MOH and PEACESAT. 14. Participation in Conferences. Staffs participated in the following conferences and trainings.

a. HRSA Health Disparities Collaborative (Diabetes) in Anaheim in February. b. 39th National Immunization Conference in Washington DC c. TB workshop in Majuro d. HIV/AIDS workshop in Majuro e. PAC RIM Conference on People with Disabilities in Hawaii f. Reproductive Health Training in Majuro g. NACHC 30th Annual Policy & Issue Forum in Washington DC. h. Attended the WHO Western Pacific meeting in New Caledonia.

15. Problems encountered during the fiscal year:

a. Shortage of medical and pharmaceutical supplies due to the following reasons: The process to prepare and make payments on the Bureau’s bills is very lengthy and cumbersome. b. The processing of contract usually takes more than six (6) months and sometimes due to the long waiting period, the potential candidates end up selecting jobs elsewhere. c. Staff housing is also a problem on Ebeye. d. The process of filling vacant post for local staffs is also very slow.

4.1 Division of Support Services

The Division of Support Services comprises of Finances and Revenue collection activities, Personnel activities, Housekeeping and Maintenances activities, and the Hospital Dietary program.

44 4.1.1 Appropriation

At the beginning of the fiscal year, the Bureau of Kwajalein Atoll Healthcare received a total overall appropriation of $3,353,352.00 to provide healthcare services to the Kwajalein Atoll, including three health centers on Ebadon, Enniburr and Guegeegue.

Table 4.1 Adjusted Appropriation for FY 2005

2001 2002 2003 2004 2005 General Funds $479,649 $895,926 $1,157,466 $0 $0 $2,339,835 $208,000 Compact Funds $611,124 $607,000 $600,209 $2,349,983 2,131,853 Federal Grants $469,010 $456,770 $595,509 $566,225 $519,652 Healthcare Revenue $800,000 $800,000 $678,000 $519,692 $493,865 $3,353,352.00 ($3,145,370.00 –Adjusted $2,359,783. $2,759,696.00 $3,031,184.00 $3,435,900.00 Revenue)

During the second quarter of FY 2005, a total of $208,000.00 was transferred from the Ebeye Hospital Operation Budget (Compact funds) back to Majuro Hospital’s operation budget. As a result of the transactions, the Bureau experienced significant budget constraints during the last two quarters. However, the Ministry reprogrammed a total of $197,000.00 to cover anticipated shortfalls in utility and pharmaceuticals/medical supplies. The table above illustrates year end budget compositions after consideration of various budget adjustments.

Table 4.2 Expenditures per Major Cost Categories (line item)

Personnel expenses $1,866,715.00 56% Supplies(all others)expense $507,753.00 15% Pharmaceutical & Medical $623,836.00 19% Supplies Facility & Maintenance. Expenses $355,966.00 10% Total Expenses $3,354,270.00 100%

Table 4.3 Expenditures by Department (Performance Budgeting)

Primary Health Care Services $1,157,323.00 34% Curative Services $1,268,976.00 38% Non-Clinical Support Services $ 928,852.00 28% Total $3,355,151.00 100%

45 The following illustrations can be observed from the above Tables:

1. Major portion of the funds allocated to the Bureau to fulfill its mission of providing healthcare derived from Compact money which constituted 68% of the total fund, Healthcare revenue came in second with 18%, and Federal Grants with 14%.

2. Analysis of line item budgeting revealed that Personnel Expenses accounted for 56% of the overall expenditure for the Fiscal Year, followed by Pharmaceutical/medical supplies 19%, other supplies and materials 15% and maintenance expenses 10%.

3. Financial update on performance indicators revealed that Hospital Services Operations accounted for 38% of the overall expenditure for the Fiscal Year while Primary Healthcare Services operations cost the Bureau 34% of its budget and non-clinical support 28%.

4.1.2 Patient Revenue Collection Services

The total collection for patient services’ at the end of fiscal year 2005 was $35,283.00. In FY 2004, the total collection was $33,160.00. There was an increase of 6% in the total collection for FY 2005.

4.1.3 Personnel Activities

At the end of the FY 2005, the Bureau had a total of 125 staff members. Personnel and human resources needs accounted for 56% of the Bureau’s total annual budget. Personnel issues continued to be a major challenge, which include the following: a. Lengthy hiring process due to unforeseen circumstances served as a major hindrance to the delivery of medical service and budgeting process. b. Housing needs for the medical staff continued to be a challenge during the year. c. Poor staff attendance continued to be another challenge, especially for the local staff. d. The apparent and current lack of a pool of qualified labor force for recruitment purposes is a factor that makes the Bureau to hire from other countries and not from within the Marshall Islands.

4.1.4 Maintenance

This particular area costs the Bureau an overall total of $453,310.00 to sustain during the Fiscal Year, excluding the Operations and Maintenance contract with the American International Corporation (AIC).

One of the challenges was to finalize the Operation and Maintenance, which was finally accomplished. At present, the department looks forward to incorporating the AIC contract with the existing maintenance crew already on board without causing any unwanted conflicts. A new Maintenance Engineer was recruited. The ultimate goal is to have its own maintenance staff

46 working under the direction of the Maintenance Engineer to oversee the Operation and Maintenance once the contract with AIC is completed.

4.2 Primary Health Care Services

The Division of Primary Healthcare Services is given the mandatory responsibility to find innovative ways to improve the health of the communities within Kwajalein Atoll. Throughout the Fiscal Year, the division carried out numerous community outreach activities including house to house visit seminars for young mothers and young men in the community, zone visits in the evenings (5:00 to 9:00 pm), health education activities in all the schools, radio program once a week, Direct Observation Therapy (DOT) and contact investigation for the TB patients.

During the 4th quarter of this past fiscal year the division started the evening outreach throughout Ebeye and all of the PHC program coordinators collaborated in the initiative. Each PHC Program Coordinator rotated each week based solely on the topic scheduled for the particular week. The initiative has proven to be very effective as the aim is to delay pregnancy especially among teenagers and students, by providing information about sexually transmitted diseases.

In addition to its regular activities, the division conducted special activities with the rest of the Ministry during the World Diabetes Day, World AIDS Day, International Women’s Day, World TB Day, World Health Day and Health Month, World Breastfeeding Day and National Health Month. With the assistance of its partners in Health - the Community Health Volunteers and the Youth to Youth in Health, the staff was able to successfully plan and implemented the health activities splendidly.

It is worth mentioning that the Bureau received a letter from one of the schools expressing its thoughts about the health presentations conducted at the school. The principal said, “it is with great pleasure and satisfaction that I commend the actions and efforts of members of your talented and brilliant team of health professionals. These individuals presented the school with a well-planned and executed presentation on issues surrounding Teenage Health related to Family Planning and Reproductive Health. They were well presented and well equipped to provide students with the reality of these health concerns.”

Other Highlights for the PHC Division include :

1. The establishment Play Therapy Room started by the Social Worker to observe the students’ behavior. The findings during these sessions, especially for the 8th graders, revealed that 67% expressed feeling of sadness and unhappiness, 32% stated that they used alcohol, 15% smoke, 10% sniffing gasoline and 17% use Copenhagen regularly.

2. A recent survey conducted among 14 -19 years old students showed similar result with males being the highest percentage of substance users. Peer group pressure is responsible for majority of students turning to alcohol, smoking and other substances.

47 3. The Human Services Program treated and counseled 30 mentally ill individuals, 31 alcohol and drug abusers, worked with 7 children with problems and conducted 218 counseling sessions with individuals referred to the program.

4. A total of 23 patients were identified with chronic mental illnesses and depression. 5. There were 8 attempted suicide and 4 complete suicides. The individuals were all males between the ages of 16-35. All these cases are alcohol related.

6. A Youth Clinic has been established but only a small percentage of youths are taking advantage of the clinic. The community outreach initiatives conducted by the Health Team has targeted youths and invited them to come and utilize the clinic.

7. The immunization coverage for this year was 76% compared to last year which was 65%, an increased of 14% in FY 2005. Hepatitis B vaccine was administered to all school age group. The coverage now is 90% as most of the school children have received their 3 doses of Hepatitis B this past school year.

8. There were 390 doses of Flu vaccine administered to the prescribed groups. Surveillance Report of Acute Flaccid Paralysis, Acute fever & Rash and Neonatal Tetanus was sent to World Health Organization, on a monthly basis, through the National Coordinator stationed in Majuro.

9. The division has now begun to utilize the Pacific Public Health Surveillance Network- Hospital Based Active Surveillance System Monthly report form. The system is being facilitated by the Secretariat of the Pacific Community to track and report infectious disease and/or outbreaks.

10. The Diabetes clinic has improved significantly since it joined the Health Disparity Collaborative Program. There is now a new emphasis on Patient Electronic Care System (PECS) that required the accurate recording on initial patient baseline data including laboratory tests and screening procedures. Attendance has improved significantly.

11. Self Management Goal (SGM) setting is being implemented where patients monitor their own health. The one-on-one sessions with the providers, and the group sessions where patients are trained to monitor their own health and learned from each other during the group session have proven to be an effective strategy. At present, when patients are asked what type of medication they are taking and/or how much they are taking each day, they are now willing and able to answer with confidence.

48 4.2.1 Diabetes Program

Table 4.4 No. of patients attending Diabetes & Hypertension Clinic from FY 2003-2005

FY Diabetes Hypertension Diabetes Hypertension Total new new clients encounters encounters Encounters clients 2003 45 16 1380 296 2160 2004 34 22 1389 267 2128 2005 75 20 1581 299 2471

Graph 4.1 Distributions of DM / HTN Clients

Distribution of DM / HTN Clients from FY 2003-2005

2500

2000

1500

1000

500

0

Total Encounters Diabetes new clients Diabetes encounters Hypertension new clients Hypertension encounters

2003 2004 2005

In FY 2005, there was an increase in the number of patients attending the Diabetes & Hypertension Clinic.

4.2.2 STD/HIV-AIDS Program

STD/HIV/AIDS

The STD/HIV/AIDS program reports one confirmed case of HIV on Ebeye and the staff is working closely with the youth population and/or the sexually active group to prevent the spread of HIV. Since majority of the youth population on Ebeye (55.7%) is under the age of 20, the staff on the STD/HIV Program continued to promote healthy behavior among this age-group. The theme “Healthy Mothers, Healthy Children” was chosen for the National Health Month (April).

49

The Health Educator team has been very dedicated in working closely with the outreach team, which includes staffs from the STI (Sexually Transmitted Infections) Program, the Counselors, the Social Worker and the School Health Program. Dissemination of health information in the community and the schools regarding prevention of sexually transmitted diseases is one of their activities

Graph 4.2 Percent of STD/HIV Cases by Type 2005

18% 20%

0% Gonorrhea Syphiis HIV Chlmydia

62%

Graph 4.3 Kwajalein Prevalence Rate per 1000 Population, 2005

Kwajalein STD Prevalance Rate per 1000 Population, 2005

1000

0.2 5 6 17

Syphillis Gonorrhea Chlamydia HIV Population

STI remained to be the main and leading cause of health problem among the young people. The prevalence rate of Syphilis is 17/1000 population, Gonorrhea is 6/1000, Chlamydia is 5/1000 and HIV is 0.2/1000 population (calculation is based on 1999 census).

50 Table 4.5 Summary of STD Testing FY 2005

Total STD Total Tests Positive Percent of Positive Tests Syphilis 1155 81 7.01% Gonorrhea 622 26 4.18% Chlamydia 176 24 13.64% Total 1953 131 6.71%

Graph 4.4 Reasons for Syphilis Testing

Reasons for Syphilis Testing, FY 2005

Other Reasons, 142 Walk-ins, 25 Prenatal, 319 TB Patients, 4

Students, 127 Pre- Employment, Blood Donors, 301 237

A total of 1155 people were screened for Syphilis this fiscal year. Graph 8.4, illustrates the reasons for syphilis testing. The other reasons comprises of Family Planning First Acceptors, referrals from OPD or Inpatients Ward. Prenatal clinic compulsory tests all expected mothers. 81 out of 1155 syphilis testing were found to be positive, with 57 (70.3%) comprised of females between the ages of 20 -24.

622 persons were screened for Gonorrhea with 26 positive cases. 454 (73%) of those tested positive were males between the ages of 20-24.

This year Chlamydia test was introduced. A total of 176 people were screened with 24 (14%) tested positive. 154 or (88%) of those tested positive were females between the ages of 15-19.

4.2.3 School Health Program

During the fiscal year, the division visited all of the schools on Ebeye, and the nearby islands within Kwajalein Atoll as well as all the wetos (land parcels) and government offices. During the visits staff members distributed condoms, education pamphlets, conducted group meetings, answered questions posed by the audience, provided individual counseling, conducted DOT for TB patients, traced the contacts, visited elderly who could not come to the clinic and provided treatment accordingly, and did follow up with children who did not show up for their

51 immunization appointments. Additionally, the staff conducted clinics during working hours and did outreach in the evening from 5-9PM from Monday to Thursday every week.

4.2.4 TB / Henson (Leprosy) Program

The TB/Henson Disease (HD) Program continued with its normal operations without encountering any major set backs during the year.

? DOT and follow up with the patients and did contact tracing in the community. ? Screening in all of the schools and in all the public health clinics. ? Distribution of health education materials to the community, schools and government offices. ? There were six (6) registered Henson Disease cases this year and they are on Multi- Bacillary (MB) treatment. Two (2) of the clients have completed their treatment, with four still receiving the MB treatment. ? There were 45 registered TB cases, including 39 pulmonary cases, with 6 newly discovered cases pulmonary cases. Among the pulmonary cases sputum positive were 16 new cases, 4 relapse cases and 19 children were sputum negative. ? At the end of the fiscal year there were 24 cases left and continued to be on DOT. There were 12 cured cases and 18 cases that have completed treatment. There are 2 Multi Drug Resistant TB cases but the culture results have turned out negative twice. Both patients continued to receive treatment. There is one INH resistant case. All contacts were screened for TB but none were found to be infected.

4.2.4 Immunization and Family Planning

A collaborative effort between the Immunization, Family Planning, STI, Outreach and Pre-natal program has been established. Together these programs visited schools and the community and conducted outreach/seminars in an effort to reduce health related problems such as teenage pregnancy, STI problem as well as to increase the number of first trimester visits for prenatal care.

These programs also conducted seminar for young mothers who attended the prenatal clinic on Fridays lecturing on hygiene, nutrition, breast feeding, taking care of one’s health during pregnancy, importance of early visit to the prenatal clinic for mothers-to-be, prevention of STI, healthy habits and consequences of drinking and smoking during pregnancy. As a result, attendance in the prenatal clinic has increased for Pap smear tests and counseling.

Teenage pregnancy is still a paramount problem. Male involvement in the family planning program is still unsatisfactory. The division has yet to keep up on its efforts to be more creative in finding effective methods of attracting more male participants to the program.

52 Table 4.6 Summary of Prenatal Users and Visits

1st Q 2nd Q 3rd Q 4th Q Total No. of Pregnant Mothers 106 78 100 110 394 No. of Visits 636 589 511 638 2374 Teenage User 28 24 15 23 90

Graph 4.5 Prenatal Users and Visits

Prenatal Users and Visits, FY 2005

700 636 638 589 600 511 500 400 300 200 106 78 100 110 100 0 1st Q 2nd Q 3rd Q 4th Q

No. of Pregnant Mothers No. of Visits

In FY 2005, there was a slight increase in the number teen pregnancy from FY 2004 by 22 %

Graph 4.6 Teen Pregnancy in Ebeye Hospital

Teen Pregnancy in Ebeye Hospital

111 120 90 100 70 80 60 40 20 0 FY 2003 FY 2004 FY 2005

53 There were 394 pregnant mothers this year and a total of 2374 visits encounters. There were 90 teenage pregnancies and 5 of them were under the age of 15. In FY 2004, there were 70 teen- pregnancies recorded. First trimester visits has increased this past year, with 161. The total number of live births is 368. There was 1 stillbirth, 2 intrauterine deaths and 12 neonatal deaths which include a twin and a triplet. The number of deliveries un-booked was 9.

Graph 4.7 Prenatal Visits by Trimester FY 2005

Prenatal Visits by Trimester FY 2005

3rd Trimester 20% 1st Trimester 41%

2nd Trimester 39%

In FY 2005, there was an increased seen in the 1st and 2nd trimester visits. The goal is to increase the 1st trimester booking by 5% every year.

Table 4.7 Number of Deliveries FY 2005

1st 2nd 3rd 4th Total Q Q Q Q No. of Deliveries with Prenatal Visit 94 103 80 82 359 No. of Deliveries without Prenatal Visit 2 2 2 3 9 Post Natal Attendance 60 79 82 22 243

The total number of Family Planning program encounters for the fiscal year was 523. There were 518 females and only 5 males. Of the total encounters, 37 were new female clients and 4 new males clients recorded. There were also 37 defaulters, all females, during the fiscal year. In a recently administered household survey, it was discovered that 76.5% of the reproductive age group never used the Family Planning services.

School Based Health Clinic (SBHC)

The SBHC opened and provided services to students throughout the year from 9AM – 3PM from Monday through Friday. It continued to provide services such as physical check up, screening for mental health problems and other emotional problems, immunization, dental services,

54 administration of vitamins and worm medication, emergency care on site and referral to the Community Health Center for further evaluation and treatment.

Graph 4.8 Diseases Encountered in SBHC FY 2005

Diseases Encountered in SBHC FY 2005

Skin Infection 5% 14% URI

Conjunctivitis 4% Gastritis and worm 7% infestation 56% Diarrhea 3% Aches and pains 11% Injuries

4.2.5 Dental Services

The Dental Services is part of the outreach team. It also provided services at the Community Health Center for the general public, at the SBHC and the Public School. The Dental Department performed the following tasks during the year:

Table 4.8 Dental Services, FY 2005

Procedure Total Dental Encounters 5,340 Dental Procedures 5,392 Extraction 2,664 Fillings 1,187 Prenatal Check up 205 Toothbrush Distributiom 183 Floruide Varnishing 21

During this past year oral health examinations were conducted for all school children and of the 1638 that were seen, 1310 or (80%) of them have caries or tooth decay. This was and is still one of the biggest problems encountered by the staff during the department’s outreach activities in the schools and with patients seen at the SBHC.

55 Graph 4.9 Percentages of Caries Among Students in Ebeye, FY 2005

Percentage of Caries Among Students in Ebeye, FY 2005

20%

80%

Tooth Decay Caries Free

Graph 4.10 Dental Problems Encountered Among School Children in Ebeye, FY 2005

Dental Problems Encountered Among School Children In Ebeye

5% 1%1%

93%

Decayed Primary Teeth Missing Teeth Decayed Permanent Teeth Filling Teeth

The above table reflects that more children seen had problems with the primary teeth (93%) as opposed to the primary teeth (1%). Children needing fillings was relatively low, compared with those who had missing teeth.

56

There were several visiting dental teams from Majuro Preventive Dental Program and the International Community that visited and worked with staff in providing dental services. Aside from the Majuro Dental Team, another team from Honolulu sponsored by the Rotary Club visited the schools and provided free dental services for three weeks. Another dental team that visited the Ebeye community was the Red Cross Society USA. They accompanied the outreach team and conducted oral health activities in the community.

The proposed plan for the next fiscal year (2006) is to put more emphasis on dental health promotion in all the schools, with the expectation of lowering the rate of carries by 20% by the end of next fiscal year.

4.2.5 Health Promotion

The Health Promotion Department continued to be involved in all of the PHC activities, especially with the youth population. The Youth to Youth in Health is under the guidance of the Health Educators. There are currently 20 members of the Youth to Youth in Health. The Outreach Program Coordinator worked closely with the Medical Director in providing training for the Youth Group, the Community Volunteers and the Health Educators.

4.2.6 Demographic Data of Encounters

During this fiscal year the number of patients has increased compared to the past two years (2003-04). The total patients seen during the year was 17,118. The total encounters for 2005 was 24,636. Those between the ages of 0-19 accounted for 33.6% of the total encounters. The data further revealed that more females utilized the services more often than male patients.

Graph 4.11 Age Distribution among Encounters for FY 2003-04

Age Distribution among Encounters for FY 2003-04

3% 12% 13%

17%

23%

13%

9% 10%

<1 Yr 1-4 Yrs 5-12 Yrs 13-19 Yrs 20-24 Yrs 25-44 Yrs 45-64 Yrs 65 Yrs +

57 The age group with the highest encounters was those between the ages of 25 – 44 years of age and more females than males.

4.2.7 Referral Services

There were 309 students referred to various Health Departments for further health treatment during the fiscal year. The Dental Department received the highest numbers of referrals followed by immunization and the eye clinic.

Graph 4.12 Visual Defects among Eye Referral, FY 2005

Visual Defects Among Eye Referral, FY 2005

7% 2% 7%

2%

82%

Normal Vision Nistigmus Squint Congenital Eye Defect Conjunctivitis

Graph 4.13 Number of Student Referrals in FY 2005

Referral of Students, FY 2005

160 136 140

120 98 100

80 57 60

40 14 20 7 4 1 0 TB Dental Leprosy Eye Immunization Malnutrition Hospital OPD/Emergency

58 4.3 Division of Hos pital Services

This division provides curative services to all the communities within Kwajalein Atoll and from time to time received referral cases from the Western Atolls, Lib Island and Namo Atoll. This fiscal year the hospital services division carried out these services:

4.3.1 Hospital Admissions & Discharges

There was a total of 1,474 hospital admission during the fiscal year 2005. Of these 1,468 were discharged home, 3 were referred to other health facilities and 2 were discharged against medical advice. The average monthly admission was 122 patients. The maximum number of inpatient admissions occurred in September with 143 patients. In the previous year, September also has the most admission with 165. There were 35 inpatient deaths, 17 less than the previous year’s total of 52. The most common cause of death this year were premature (new born) infants, followed by suicide by hanging, and hypertension with diabetes mellitus.

The primary causes of admission were child delivery, gastroenteritis, and bronchopneumonia. The age groups most affected were 0-4 yrs (44%) and 20-44 yrs (30%). Distribution of admission by gender shows females accounting for 65% and males 35%. Average hospitalization per patient was 3 days with a maximum of 29 days (a diabetic patient with leg amputation). There has been a constant downward trend in patient hospitalization for the last 3 years.

Graph 4.14 Common Admission Diagnoses

Common Admission Diagnosis 0 100 200 300 400 500 600

Birth delivery Gastroenteritis & infectious colitis Bronchopneumonia Urinary tract infection Pneumonia Cataract, Clarification of lens Diabetes mellitus Colic, Abdominal tenderness Essential hypertension, high blood Other Cellulitis & Abscess All Others

59 Staffing

Breakdown: 20 – Registered nurses (including Chief Nurse, DCN and 4 head nurses) 6 - Practical nurses 1 – ATO

New / Vacant Posts

There are 6 posts that are yet to be filled. The personnel were hired and are awaiting the processing of their contracts and personnel action. Once these posts are filled, all vacant post will be filled and inpatient services will be fully manned. Scheduling problem will finally be resolved.

Nurses who are on Educational leave: University of Guam - Kenye Mike and Bremity Lakjohn; CMI Nursing School (RMI) – Eomra Lokeijak, Harry Harry and Billy Bollong.

Medical /Surgical Ward

Average daily census per month was 13. Medical cases consisted mostly of diabetic related illnesses, pneumonia, Kock’s infection and cardiac problems. Surgical cases are diabetic wound or gangrene, which usually lead to amputation and prolong hospitalization. Other surgical cases are cataract extractions and eye inoculation and artificial eye implant. 9 cases of attempted suicide were encountered of which 4 recovered and sent home. These cases were referred to Human Services for further evaluations.

Pediatric Ward

The average daily patient census is 10. Cases commonly encountered are bronchopneumonia gastroenteritis, malnutrition mild dehydration, otitis media and cellulites.

Maternity Ward

Average patient census is 12. Often time census dropped after 24 hours due to discharged of post partum mother who have no complication. Cases encountered are pre-term in labor and gynecology cases such as CA of the reproductive system, bartholinitis, PID, vaginal bleeding and abortion, which resulted to dilation and curettage procedure.

ICU Ward

The ICU is operational although not fully utilized until needed equipment is in placed. There are 3 nurses manning the ward. The equipments were place on order during the latter part of the 4th quarter and expected to arrive during the 1st quarter of fiscal year 2006.

60 Emergency Ward

ER was not operational on a 24 hours basis for 9 months due to shortage of staff. The much needed staff have finally arrived during the beginning of 4th quarter. ER is now staffed by a registered nurse and a practical nurse during every shift. Nine cases of suicide by hanging were received with only 4 were revived and transferred to the medical ward.

4.3.2 Surgical Department

Total number of surgical procedures performed during the fiscal year was 362 a 65% increased from last year or an average of 30 per month. Of these, 280 were minor surgeries with 82, which were major surgeries. Third quarter had the most surgeries with 135 while fourth quarter had the least with 61.

Obstetrical / Gynecological procedures totaled 120. The most common procedures were same as previous year with Caesarian, D&C and Caesarian with BTL.

General surgeries totaled 221. The most common were eye surgeries (ECCE, IOL), debridimen and appendectomy. There were 8 amputations: 2 AKA, 4 BKA, 1 finger and 1 toe. A major increase from previous year’s total of 2 amputations. The increased number of surgeries was attributed to 3 diabetic patients referred from outer islands.

The OR is fully manned with 5 staffs. The anesthesiologist resigned at the end of the year due to personal problem and a replacement had been recruited and is expected to arrive during the 1st quarter of next year. A staff physician who is also an anesthetist has been reassigned temporarily to cover the vacant post.

4.3.3 Laboratory Department

Laboratory tests for the year totaled 19,420, an increase of 1,434 (8%) from the previous year. Microbiology accounted for 42% of all Lab tests followed by Biochemistry with 32%, Hematology 17% and Blood bank 9%. 4th quarter had the most tests with 6,011 while 3rd quarter had the least with 4,322.

The revamping of the PH diabetes, SDI and TB programs has increased number of tests over previous year. The Lab equipments purchased last year has enabled the Lab technician to cope with the increased demand.

Laboratory specimens referred to Off-island laboratories totaled 403 or 108% increase over previous year. Specimens to DLS lab in Honolulu for biopsies (cancer, pap smears, etc) accounted for 55%; TB specimens to CDC represented 40%; and 5% to USAKA lab for blood chemistry and culture & sensitivity. At present, Ebeye lab refers all culture and sensitivity tests to USAKA lab. Microbiology equipment has been purchased and a pathologist has also being hired. Improved capability is expected to take place during the 1st quarter of FY06.

61 Biochemistry

The five most common tests were Glucose which accounted for 60%; followed by BUN with 6%; Creatinine with 5%; Cholesterol, triglyceride and K + 4% each respectively; all other tests accounted for 13%. The top five tests are mostly requested by the diabetic clinic. For Glucose screening the diabetic clinic accounted for 85% while outpatient and inpatient combined accounted for the remaining 15%.

Hematology

There were 3,283 performed during the year. Two most common tests were Hb/HCT and CBC. Both accounted for 47% and 45% respectively or 92% combined. The number of patients screened total 1,008 with an average of 3.3 tests per patients. The lab averages 821 tests per quarter or 274 monthly.

Blood Banking

There were a total of 822 tests during the fiscal year. Blood typing were the most common test with 70% followed by Blood donor with 17% and X-matching 13%.

Serology

There were 3,232 test performed for FY05 with 203 positive results for an overall positive rate of .06%. RBR tests totaled 1,604 with .06% positive rate; Hiv/Aids tests totaled 683 with no positives results; Pregnancy tests totaled 303 with 20% positive rate; HBsAg totaled.623 with .06% positive rate and HBsAb tests totaled 17 with 12% positive rate.

Bacteriology

Total tests performed were 3,788, of these 97 were found positive for an overall positive rate of .03%. Protein/Glucose accounted for (50%) of all tests performed with 1,896 followed by Urinalysis with 909 (24%); Gram stain with 561 (15%); and TB with 422 (11%). Gram stain tested 561patients and found 13 with positive results; TB tested 422 and found 84 positive results. Gram stain and TB showed positive rates of .02% and 20% respectively.

Parasitology

There were 946 Fecalysis tests performed, of these 201 or 23% were positive. E. Histolytica accounted for 82% of all positive cases followed by G. Lamblia with 15% and T. Trichura with 3%. 4.3.4 Radiology Department

There were 2,846 radiology procedures performed during the fiscal year. Of these, Chest X-ray accounted for 1,979 or 70% of all procedures, followed by Pelvis with 348 (12%) abdomen with 171 (6%), extremities with 180 (6%), head and neck with 82 (3%) and EKG-78 (3%).

62 The month of June had the highest number of procedures with 286, while December had the least number with 140. The Radiology Department averaged 237 procedures monthly.

The Department has not been utilized to its’ full potential due to lack of functioning equipments. The x-ray equipments that were ordered were not fully installed by the supplier. Communication with the supplier has been ongoing for more than a year and has not produced any positive results.

Funding source has been identified to remedy the problem. The current proposal is to bypass the seller and deal directly with the manufacturer of the x-ray equipment for the installation. It is expected that the completion will take place during the 1st quarter of FY06.

4.3.5 Pharmacy Department

The total value of pharmaceuticals purchased for the year was $440,854 for an average of $36,738 per month. Of these, $309,826 or 70% was received. Medpharm accounted for 38% of all purchases followed by Bergen Brunswig with 30%; Multichem with 19%; JC Marketing with 9% and Opal 5%. Please refer to the tables below for a comprehensive breakdown of annual purchases.

Graph 4.14 Pharmaceutical Purchases, FY 2005

450,000 400,000 350,000 300,000 250,000 200,000 150,000 100,000 Received 50,000 Purchased 0 Medphar Multiche JC Bergen JMI Opal Total: m m Marketing

Purchased 131,562.38 - 166,311.98 83,677.31 21,263.18 38,039.65 $440,854.5 Received 108,818.53 - 109,852.74 69,886.86 21,268.18 - $309,826.3

63 Graph 4.15 Purchases by Vendors, FY 2005

Purchases by Vendors 180,000 160,000

140,000 120,000 4th 100,000 3rd

80,000 2nd 60,000 1st 40,000 20,000

0 Bergen JMI Medpharm Multichem Opal JC Markeing

Both Medpharm and Bergen delivered 35% of all supplies received during the year followed by Multichem with 23% and Opal with 7%. Delivery by JC Marketing was not reported since merchandise was received after the reporting period. The overall total of deliveries received was 70%.

64 5.0 Bureau of Majuro Hospital

The Bureau of Majuro Hospital is responsible for all hospital-based services. Being the largest health care facility in the Marshall Islands, Majuro Hospital provides both secondary and tertiary medical care and is the main referral hospital in the republic.

Leroij Atama Medical Center, Majuro

65 66 The Bureau of Majuro Hospital, consistent with its performance plans for Fiscal-Year 2005 endorsed by the Ministry of Health, continued to provide consistent services across all of its numerous medical, diagnostic, and support services. Building on the developments and successes of the previous years, Majuro Hospital focused again on improving its services through continuing developments of its human resources, purchase of necessary equipment, hiring of needed professionals, and maintaining proper utilization of resources. The following experiences highlight Fiscal-Year 2005:

? Admissions has slightly dropped compared to the three previous years with 4,097 admissions; ? Outpatient visits has also dropped by 26% (37,274 compared to 47,043 the previous year); ? Births have increased by 16% (1,229 compared to previous year of 1,033); ? 1,142 surgeries were performed; ? 25 prostheses were processed for citizens who eventually became productive citizens again; ? 121,703 prescriptions were dispensed compared to 132,285 dispensed in FY2004; ? 22% increase in lifesaving ambulance dispatches (889 compared to 689 in FY2004); ? 186,071 diagnostic tests (for radiology & laboratory combined) performed; ? Enhanced human resources developments through consistent on-island trainings with 188 continuing education training sessions conducted; ? Further improvement in services and thus lesser dependence on off-island services through continuing hiring of specialized medical professionals; ? Improvements in medical and diagnostic services with the purchase of new equipments; ? Continuing improvements in patient environment and comfort through continuing repair of facilities; ? Nearing completion of the New Majuro Hospital Annex

5. 1 Patient Registration and Records Department

Patient Registration and Records Department (formerly Medical Records), is traditionally charged with the safekeeping and maintenance of patient records within the hospital, reported the following patient activities for Fiscal-Year 2005:

5.1.1 In-patient Services

The tables and graphs below summarize, by months and quarters, the number of patients admitted to Majuro Hospital for Fiscal-Year 2005. Majuro Hospital admitted the most patients in October (428), November (391), July (360), and August (409), with May having the least with 274 admitted patients. Generally, most admissions occurred during the 1st and 4th quarter this year, and followed the general pattern of previous years.

67 Table 5.1 Number of Patients Admitted by Quarter

1st Q 2nd Q 3rd Q 4th Q TOTAL FY2005 1160 939 893 1105 4097 FY2004 1156 843 1096 1156 4251 FY2003 1175 876 1004 1183 4238 FY2002 1119 949 920 1155 4143

Births

Births played a significant factor in the admissions statistics for the hospital. Generally, following the general pattern to the overall admissions, most births occurred in the 1st and 4th quarter. Overall, compared to FY2004 however, there has been a 16% increase in the number of births. The level of services was handled by the same staff who continued to provide nursing care in the maternity, obstetrics, and neonatal care units.

The policy remains that much effort on capacity building is continued and maintained in order to accommodate the much needed and specialized care for obstetrics, maternity, and premature babies. More Marshallese staff nurses are continuing to be trained in the midwifery program in Fiji sponsored by the WHO to improve their capacities for obstetrics services. Two additional nurses have been sent for midwifery training and are expected to complete in May 2006. The continuing nursing challenges in this unit required the hospital to hire the most expatriate nursing midwife staff to this particular area of service. Neonatal care remains a challenge as well. A neonatal care nurse was requested through Government of Japan. Continuing development in neonatal services is a challenge for FY2006.

Table 5.2 Number of Births

1st Q 2nd Q 3rd Q 4th Q TOTAL FY2005 354 315 238 322 1229 FY2004 298 230 230 275 1033 FY2003 334 205 262 286 1087 FY2002 331 227 229 247 1034

Medical Records Staff

68 Graph 5.1 Number of Births by Quarter

Number of Births by Quarter

354 400 315 322 350 300 238 250 200 150 100 50 0 1st Q 2nd Q 3rd Q 4th Q

5.1.2 Outpatient Services

There was 26% reduction in outpatient visits this past year compared to FY2004. A total of 37,274 patients were seen and treated at the outpatient clinics, compared to 33,454 in FY2002 and 38,150 in FY2003, and 47,043 in FY2004. More visits were evident in the 1st and 4th quarter. Generally since 1999, when major concerns over the off-island referral expenses resulted in decisions to shift more resources to domestic services, there has been steady upward change in patient visits to the outpatient clinics. One reason contributing to this shift is the availability of more medical specialists, diagnostic services, and treatment options for patients.

Table 5.3 Number of Outpatient Visits

1st Q 2nd Q 3rd Q 4th Q TOTAL FY2005 9,620 8,279 8,872 10,503 37,274 FY2004 10,913 11,021 11,679 13,430 47,043 FY2003 8,343 7,836 9,947 12,024 38,150 FY2002 10,906 6,485 6,632 9,431 33,454

69 Graph 5.2 Outpatient Visits

13,430 4th Q 10,503

11,679 3rd Q 8,872

11,021 2nd Q 8,279

10,913 1st Q 9,620

0 2,000 4,000 6,000 8,000 10,000 12,000 14,000

FY2005 FY2004

5.3 Medical Services

Medical services available at Majuro Hospital include Family Practice, Pediatrics, Internal Medicine, Gynecology, Obstetrics, General Surgery, Urology, Ophthalmology, Orthopedics, Otorhinolaryncology (ENT), Anesthesiology, Radiology, Pathology, and Respiratory Care.

5.3.1 Surgeries

General surgeries and obstetrical surgeries continue to dominate the types of surgeries performed at Majuro Hospital. What is continually becoming evident, moreover, is the routine performance ENT, urological, and orthopedic surgeries in the Operating Theater. This year there were twelve (12) ENT surgeries, thirty-four (34) urology surgeries, and sixty-seven (67) orthopedic surgeries performed. These are significant numbers considering that these types of surgeries were never performed at the hospital and were never before part of routine services at the hospital.

Table 5.4 Surgery

FY2005 Total number of surgeries Percentage of overall surgeries performed General surgeries 673 59% Obstetrics/Gynecology 276 24% surgeries Orthopedic surgeries 67 6% Ophthalmology surgeries 80 7% Urology surgeries 34 3% Otorhinolaryncology (ENT) 12 1% surgeries

70 Table 5.5 Number of Surgeries (2002 – 2005)

FY2002 FY2003 FY2004 FY2005 % change compared to FY2002 General surgeries 713 739 677 673 -6% Obstetrics/Gynecology 271 252 294 276 2% surgeries Urology surgeries 0 60 43 34 34 Orthopedic surgeries 40 87 124 67 40% Ophthalmology 191 160 121 80 -139% surgeries Otorhinolaryncology 8 0 31 12 33% (ENT) surgeries

Table 5.6 Total Number of Surgeries Performed

1st Q 2nd Q 3rd Q 4th Q Total FY2005 292 267 263 320 1,142 FY2004 341 332 312 292 1,277 FY2003 403 353 290 296 1,342 FY2002 227 280 247 469 1,223

5.4 Capital equipment

To assist the Hospital with its services the following equipments were purchased in FY2005: Oxygen Generating System, ambulance, Orthopedic beds, Delivery Beds, Patient Beds and Cribs, Nurse Call System, Propane Ovens, IV Pumps, and Computers. The equipments improved delivery of care and efforts of the Ministry’s acute care services at Majuro Hospital.

CT Scan

71 5.5 Clinical Laboratory Services

Majuro Hospital Clinical Laboratory Services provides laboratory diagnostic services to both Majuro Hospital and the Bureau of Primary Health Care. The number of diagnostic tests performed by the Clinical Laboratory this past year has reduced by 41% to 178,485 compared to 254,889 in FY2004. There has been better accountability of its services, improve discipline among staff, and better management of services under the Pathologist. The following table and graph, which illustrates significant changes since FY2002, outline the activities of the department for Fiscal Year 2005:

Table 5.7 Number of Diagnostic Tests Performed in Clinical Laboratory

1st Q 2nd Q 3rd Q 4th Q Total FY2005 42,317 46,863 42,862 46,443 178,485 FY2004 68,928 69,568 69,634 46,759 254,889 FY2003 73,235 56,038 71,098 74,808 275,179 FY2002 15,322 25,629 35,770 50,718 127,439

Labotaroy Staff

5.6 Radiology Services

The following table summaries the activities of the Radiology Department for Fiscal Year 2005:

Table 5.8 Number of Diagnostic Tests Performed in Radiology

1st Q 2nd Q 3rd Q 4th Q TOTAL FY2005 2 ,075 2,103 1,868 1,540 7,586 FY2004 2,524 1,879 1,726 2,368 8,497 FY2003 11,938 7,260 1,484 1,559 22,241 FY2002 3,259 3,740 3,624 4,977 15,600

72 Graph 5.3 Diagnostic Tests Performed in Radiology

Diagnostic Tests Performed in Radiology

25,000 22,241

20,000 15,600 15,000

10,000 7,586 8,497

5,000

0 FY2005 FY2004 FY2003 FY2002

5.7 Pharmacy Services

A total of 121,703 prescriptions were dispensed this past year compared to 132,285 in Fiscal- Year 2004, approximately 9% less than the previous year. This averages to approximately three hundred thirty three (333) prescriptions a day.

Table 5.9 Number of Prescriptions Dispensed

1st Q 2nd Q 3rd Q 4h Q TOTAL

FY2005 30,857 27,713 30,296 32,837 121,703 FY2004 33,085 30,334 29,563 39,303 132,285 FY 2003 33,504 27,227 29,263 38,760 128,754

Graph 5.4 Prescriptions Dispensed FY 2003-2005

Prescriptions Dispensed FY 2003 - 2005

134,000 132,285 132,000 130,000 128,754 128,000 126,000 124,000 121,703 122,000 120,000 118,000 116,000 FY2005 FY2004 FY 2003

73

5.7 Rehabilitation Services

Since FY2003 there has been a continuing increase in the number of treatments applied at the Rehabilitation Unit. As illustrated in the table below, six thousand two hundred ninety eight (6,298) treatments were applied this past year compared to 5,933 the previous year. This is 6% increase from FY2004 and 23% increase from FY2003. The demand for rehabilitative services by the medical staff and patients continues to increase, especially with the increase in orthopedic surgical cases performed by the hospital. The table below summarized its performance for FY2005.

Table 5.10 Number of Rehabilitative Treatments

1st Q 2nd Q 3rd Q 4h Q TOTAL FY2005 1,487 1,670 1,638 1,503 6,298 FY2004 1,215 1,450 1,422 1,846 5,933 FY2003 957 1,177 1,266 1,438 4,838

This past year, twenty-five (25) prostheses were completed compared to thirty (30) the previous year. Overall since the reactivation of prosthetics services at Majuro Hospital, there has generally been increased demand for prosthesis, mostly due to amputations as a result of complications from diabetes. Regardless of the reasons, Majuro Hospital is certainly glad to have made a difference in providing opportunities for these patients to be productive again. The table below indicates that a total of 102 prostheses were processed since the service restarted.

Table 5.11 Number of Completed Prosthesis

1st Q 2nd Q 3rd Q 4h Q TOTAL FY2005 7 7 5 6 25 FY2004 14 6 3 7 30 FY2003 4 2 13 3 22 FY2002 1 8 7 9 25

5.8 Dietary Services

After hiring a Clinical Dietitian, the Dietary Services improved its management and worked on stabilizing its food preparation and presentation aspect of its services. Dietary Services Department provides meals for admitted patients. With a budget of $ 170,000, 88,676 meals were served this past year. This amounts to $ 1.92 per meal. Because of the need of patients to be consistent with clinical care, dietary services will be specializing services in FY 2006. The number of meals served to patients had increased steadily the last four years as illustrated in the table below:

74 Table 5.12 Number of Meals Served

1st Q 2nd Q 3rd Q 4h Q TOTAL FY2005 23,907 22,407 20,184 22,178 88,676 FY2004 21,218 20,800 20,393 22,676 85,087 FY2003 20,580 18,832 19,233 24,976 83,621 FY2002 22,644 18,853 16,338 22,558 80,393

Graph 5.11 Meals served for FY2002-FY2004

Meals Served FY 2002-FY2004

90,000 88,676 88,000 86,000 85,087 83,621 84,000

82,000 80,393 80,000 78,000 76,000 FY2005 FY2004 FY2003 FY2002

5.9 Nursing Services

Nursing care continues to be a challenge at the Majuro Hospital especially with regards to nurse shortage, management, and quality of care. With all head nurse and supervisor nurse posts filled in FY2005, except for the Outpatient Services, management has improved tremendously. Management of nursing care has also improved at its highest level of nursing administration with the hiring of an Assistant Chief Nurse for Patient Care. Continuing improvements in the quality of care as come in the form of improving capacity for nurses. Nurses were sent for training in Nurse Management, Midwifery, Quality Assurance, and Intensive Care Services. A request for a Neonatal Intensive Care Nurse through the JOCV program remains opened.

Nurse training and development has had major accomplishments this past year as was with the previous year. Realizing the need and importance to improve nursing care through continuing development of our nursing staff, the Bureau of Majuro Hospital made a policy decision in FY2004 to establish a Nursing Training and Development Office under the portfolio of an Assistant Chief Nurse for Nurse Training and Development. With the assistance of a Nurse Trainer employed through JOCV, one hundred eighty eight (188) continuing education and training sessions were conducted and are outlined as follows:

75 Table 5.13 Training Sessions by Nursing Services

Title of session Place # of Sponsors Participants 1. Hepatitis B (management & diagnosis) Majuro 30 PHRI 2. Early infant Care & Importance of Touch for Majuro 8 MOH Nurse Aides 3. Improve children’s health care quality (video Majuro 3 University of conf.) Hawaii (UOH) 4. Management of COPD (video conf.) Majuro 4 UOH 5. Problem solving technique Majuro 11 MOH 6. Health promotion & behavioral change Majuro 14 MOH 7. Advance Directive (video conf.) Majuro 4 UOH 8. Saving kids’ lives & medications and Majuro 13 MOH injection for kids (Video) 9. Hypertension (changing concepts in Majuro 10 UOH management of), video conf. 10. Spinal Anesthetic Failure Majuro 17 MOH 11. Nursing & Counseling Majuro 20 MOH 12. GHB poisoning/MDMA poisoning (VTC) Majuro 2 UOH 13. Smallpox preparedness (Video) Majuro 16 MOH 14. Acute Respiratory Failure & Breath sounds Majuro 11 MOH (Video) 15. Sleep disorders (VTC) Majuro 7 Ministry of Health 16. Smallpox (video) Majuro 5 MOH 17. The Nurse Theorists (video) Majuro 3 MOH 18. Hematology Majuro 11 MOH 19. CHF and Primary care provider (VTC) Majuro 1 UOH 20. Portraits of excellence Majuro 17 MOH 21. Chickenpox (video) Majuro 6 MOH 22. Echocardiography Majuro 14 MOH 23. TB management (update) Majuro 21 MOH 24. Hospital acquired pneumonia (VTC) Majuro 15 MOH 25. Guam RFK Library training Majuro 25 UOG 26. Echocardiography demonstration Majuro 6 MOH 27. OR lecture Majuro 44 MOH/JOCV 28. Manual Handling of patients Majuro 12 MOH 29. CPR & First Aid for Security officers Majuro 24 MOH 30. Examination of Foot & ankle (VTC) Majuro 6 UOH 31. Pneumothorax on a plane (video) Majuro 7 MOH 32. Vascular surgery (new advances), VTC Majuro 4 UOH 33. Bed baths Majuro 7 MOH 34. Physical assessment (video) Majuro 10 MOH 35. Portraits of excellence (video) Majuro 3 MOH 36. Hyperbaric treatment (VTC) Majuro 2 MOH 37. Cardiac Emergencies & Fluid and Electrolyte Majuro 4 MOH emergencies (video) 38 After Cataract surgery & diabetes (video) Majuro 7 MOH 39. Acute & chronic renal failure & chronic Majuro 13 MOH cough and chronic diarrhea (video) 40 Inpatient asthma/Quality Improvement Majuro 8 UOH

76 Initiatives (VTC) 41 HRT Update—findings from the women’s Majuro 4 UOH health initiative (VTC) 42. ACLS (video) Majuro 3 MOH 43. Reading EKG’s and Heart Failure and Majuro 3 MOH Pulmonary Edema (VCR) 44. Children Oncology (VTC) Majuro 3 UOH 45. Myocardial infarction and Heart Disease Majuro 5 MOH Prevention and Management (VCR) 46. Evaluation and management of common Majuro 4 UOH neurological problems. Office to the emergency (VTC) 47. Pain management (VTC) Majuro 3 UOH 48. Diabetes Mellitus and Coronary Artery Majuro 5 MOH Disease (VCR) 49. Arthritis in the elderly (VTC) Majuro 9 UOH 50. Management of Abnormal pap smear Majuro 32 PHRI 51. Improving Secondary Prevention of Majuro 10 UOH cardiovascular disease (VTC) 52. Abnormal Newborn Head Shapes (VTC) Majuro 11 UOH 53. The Gift of Life-organ donations (VTC) Majuro 16 UOH 54. Chronic Granulomatious Disease (VTC) Majuro 17 UOH

55. HIV Care (VTC) Majuro 12 UOH 56. Pain Management (VTC) Majuro 20 UOH 57. Diabetic Wound Care (VTC) Majuro 4 UOH 58. Nutrition Majuro 6 MOH 59. Refresher Course Majuro 168 MOH 60. BEAD (Breast Exam) Necklace Training Majuro 47 UOH 61. Futile Medical Care and End of Life Issues Majuro 9 UOH (VTC) 62. RMI National TB Program Workshop Majuro 98 CDC 63. A Heart to Heart Talk (VTC) Majuro 15 UOH 64. Nutrition Majuro 7 MOH 65. First Responder Course Majuro 81 MOH 66. CPR/AED Majuro 4 MOH 67. Introduction Equipments Majuro 51 MOH 68. Update on Cord Blood Banking and Majuro 5 UOH Transportation (VTC) 69. HIV Workshop Majuro 122 AETC 70. Miracle of Life Majuro 3 MOH 71. Reproductive Health Program Management Majuro 27 MOH Workshop 72. More Effective Approach to Emergency at Majuro 11 MOH Majuro Hospital 73. Myocardial Infarction & Heart Disease Majuro 10 MOH Prevention and Management 74. CPR & First Aid for Care Program Majuro 21 MOH 75. A 39 Years Old Palauan Man with Majuro 3 UOH Pancytopenia (VTC)

76. CPR & First Aid for MIMRA staff Majuro 16 MOH

77 77. Miracle of Life for Ms. Aid Majuro 3 MOH 78. Bone Density vs Bone Quality (VTC) Majuro 2 UOH 79. Damage Control in Chest Injuries Majuro 17 MOH 80. STI/HIV/AIDS Counseling PPD Test (Refresh Majuro 22 MOH Training) 81. AIDS Can I Get It? Majuro 6 MOH 82. Problem-Based Learning CME Workshop Majuro 33 PACT 83. Nursing Management of Acute Head Injuries Majuro 8 MOH How to Recognize and Classify and Epilepsy 84. BT-HEOP Health Emergency Operation Plan Majuro 5 MOH 85. Reading EKG’s Heart Failure and Pulmonary Majuro 9 MOH Edema 86. Management of Behavior Disturbance in Majuro 2 UOH Patients with Dementia (VTC) 87. Weapons of Mass Destruction for Injection Majuro 20 MOH 88. Calculations: Drug Dosages for Injection Majuro 10 MOH 89. Weapons of Mass Destruction Training Majuro 111 MOH 90. Cesarean Section Majuro 8 MOH 91. Diabetes Road Map Majuro 6 MOH 92. Contrast Nephropathy: An Update (VTC) Majuro 2 UOH 93. Assessing the Adult Head to Toe Majuro 7 MOH 94. Nursing Calculations: Dosage of Tablets and Majuro 1 MOH Mixtures 95. Nursing Calculation Infusion Majuro 1 MOH 96. Appendicitis Peritonitis Majuro 9 MOH 97. The Treatment of the Aged Majuro 3 MOH 98. New Treatment Options for Diabetes: Start Majuro 3 MOH Insulin Earlier 99. Infection Control: Nosocomial Infection Majuro 10 MOH

100. National PH Seminar on Prevention of Majuro 111 FSM Alcohol and Substance Abuse: HIV/AIDS and Suicide 101. CPR & First Aids Majuro 9 MOH 102. Hypertension Majuro 16 UOW 103. Diabetes Program Outcome Study: Update Majuro 5 UOH (VTC) 104. PMTCT Lecture Majuro 35 MOH 105. Parkinson’s Disease and Movement Majuro 8 UOH Disorders (VTC) 106. Blood Transfusion Majuro 12 MOH 107. Nosocomial Infections Majuro 17 MOH 108. Meconium Aspiration Syndrome Majuro 25 MOH 109. The Art of Chi Gong (VTC) Majuro 2 UOH 110. Wound Care & Outpatient Management of Majuro 4 MOH Burn Wounds 111. ACLS Majuro 29 MOH 112. Nursing Calculation: Intravenous Infusion Majuro 5 MOH 113. Basic Nutrition Majuro 5 MOH Hospital Food Survey 114. Breath Sounds Majuro 7 MOH 115. Challenges and Upcoming Trends in Majuro 9 MOH

78 Diabetes Care (VTC) 116. Hypertension Majuro 3 MOH 117. Fluid & Electrolyte Emergencies Acute and Majuro 4 MOH Chronic Renal Failure 118. Medication: Errors Medications Majuro 7 MOH Injections for Pediatric 119. Obesity Majuro 4 MOH 120. Infection Control Majuro 8 MOH 121. Nursing Calculations: Dosages of Tablets Majuro 3 MOH and Mixtures 122. The Gut as Potential Answer to The Majuro 11 UOH Treatment of Type2 Diabetes Patient (VTC) 123. Nursing Calculations: Intravenous Infusion Majuro 5 MOH 124. Legal and Ethical Issues in Nursing Majuro 14 MOH Documentation 125. Computer-Based Training Majuro 35 MOH 126. Nursing Management Majuro 8 MOH 127. Pediatric Ventricular Fibrillation and Updates Majuro 9 UOH on the Use of Automated External Defibrillators in Children (VTC) 128. Hemorrhagic Disorders Pregnancy Majuro 10 MOH Emergency and Complicated Delivers 129. Neonatal Resuscitation Training Majuro 29 MOH & Mormon Church 130. Nursing Management of Acute Head Injuries Majuro 7 MOH 131. New Paradigms in Asthma Majuro 10 MOH 132. Dosage of Tablets and Mixtures Majuro 2 MOH 133. A 18 years old boy with anemia, jaundice & Majuro 7 MOH acute liver 134. Administration of Dopamine Majuro 14 MOH 135. BT Workshop Majuro 44 MOH 136. Hypertension Majuro 5 MOH 137. STD’s Majuro 28 USS Boxer 138. Reading EKG’s & Heart Failure and Majuro 5 MOH Pulmonary Edema 139. IT Training Majuro 34 MOH 140. Leep & Colposcope Majuro 14 MOH 141. Japanese La nguage Majuro 9 MOH 142. Disposable Trash Majuro 6 MOH 143. Pneumonia Smoking Cessation Majuro 7 MOH 144. Diabetes Road Map; Living with Type2 Majuro 3 MOH 145. Oral Care Majuro 11 MOH 146. Take Control of Diabetes Blood Borne Majuro 4 MOH The Human Body 147. Advanced Training Course of Emergency Majuro MOH Nursing 148. IT Training Majuro 22 MOH 149. Nursing Research by internet Majuro 3 MOH 150. “Purple Egg, Yellow Babies, and Mad Kings” Majuro 10 UOH video conference 151. Rehabilitation (Back Care) Majuro 10 MOH

79

It is important to acknowledge the contribution of the Bureau’s Physicians, Nurses, Laboratory staff, Pharmacy staff, and visiting consultants in conducting these sessions.

Nursing Department

Opening of Anesthesia Training

Anesthesia Training

80 AUSTRALIAN VOLUNTEER INTERNATIONAL

The Australian Volunteer International (AVI) again assisted Majuro Hospital with its services with the hiring of an Occupational Therapist/Director of Rehabilitation Services and a Director of Material Management. Majuro Hospital cannot stress enough how important this program has been to its development and services. The program will be a great loss to the Country.

JAPAN OVERSEAS COOPERATION VOLUNTEERS

Majuro Hospital continued to utilize the Japan Overseas Cooperation Volunteers for the Ministry’s capacity building efforts. In addition to the training provided by the JOCV, it also provided the Majuro Hospital with a Scrub Nurse and a Nurse Trainer. The kind assistance offered to our Government from the Government of Japan continues to have its positive impact to services at Majuro Hospital.

REPUBLIC OF CHINA (TAIWAN) VOLUNTEERS

The Republic of China (Taiwan) generously allowed three volunteers from Taiwan to work at the Ministry of Health. One of which was deployed to Majuro Hospital as an Information Technology specialist. The Taiwan volunteer’s scope of engagement includes training of staff in basic computer use. This is a very welcoming from ROC, one that will further enhance services to our patients.

FIRE

At approximately 12:10pm on September 16, 2005, Majuro Hospital experienced a fire that destroyed its entire supply warehouse, its pharmaceutical supply room, half of Housekeeping/Laundry department, and part of an access corridor. Close to a million dollars worth of supplies, pharmaceuticals, equipment and facilities were destroyed. There were no fatalities or major injuries from the dramatic incidence. Within four weeks after the disaster, Majuro Hospital was able to stabilize the situation with the arrival of supplies and instant repairs of the damages. (As of the submission of this report, final touches were being made to the affected areas).

“PROJECT FOR IMPROVEMENT OF MAJURO HOSPITAL”

September 2004

81 After its ground breaking in April 2004, the New Majuro Hospital health facility construction work continued throughout FY2005 with scheduled completion in September 2005.

Phase I constituted construction of two building complexes to include:

? Emergency Department ? Radiology Department ? Laboratory Department ? Reproductive Health ? Outpatient Services ? Public Health ? Generator Room and Pump Room ? Purchase and installation of capital equipment including General X-ray, Fluoroscopy, Ultrasound, Adult Ventilator, Pediatric Ventilator, Operating Table, Patient Monitor, Operating Light, Electrosurgical Unit, Laboratory Center Table and Instrument Cabinet.

Phase II constitutes construction of a two-story building to include:

? Reception/Registration Services ? Medical Records ? Dentistry ? Pharmacy ? Health Promotion & Human Services ? Hospital Administration ? Primary Health Care Administration

82 ? Purchase and installation of capital equipment including Dental units, Dental Panoramic X-ray unit, Dental Intraoral X-ray Unit, Dental X-ray Processor, and a Treatment Cabinet.

By the end of FY2005 (September 2005), the project was 97% complete.

Tokai Kogyo Co. with Sandy Alfred and Francis Silk

83 84 6.0 Bureau of Primary Health Care

The Bureau of Primary Health Care, formerly Preventive Services, was renamed in 1997 to reflect the broad scope of the bureau’s mandate for community based health promotion and service delivery to both urban and rural populations. There are four divisions in the bureau: Dental Services, Health Promotion and Human Services, Outer Islands Health Care, and the Division of Public Health. Another division will be added in FY 2006 as reflected on the proposed organizational chart

The Division of Public Health is the largest division in the Bureau of Primary Health Care. The division is further divided into five programs: Reproductive Health Services, Immunization program, Sexually Transmitted Diseases (STD)/HIV program, Chronic disease control program, and the Tuberculosis and Leprosy program. All programs in the division are responsible for conducting regular clinic and outreach activities

85 86

The Primary Health Care (PHC) Bureau was established specifically to strengthen public health programs and to further support the concept of Primary Health Care endorsed by RMI government in 1987. Services are being implemented by means of health promotion activities, nutrition education, immunization, RH services, screening for communicable diseases, non- communicable diseases and health promotions. The primary goal of health promotion is to promote changes in lifestyles. Thus will enhance individuals to better take care and be more responsible for their health.

Changing people’s thinking to take charge of their own health remains the Bureau’s challenge. The Bureau’s attempts to actively involve the citizenry in its mission and grass root level programs and services did not fully materialize. The low level of interest among the citizenry to participate in the Bureau’s mission and programs could possibly be attributed to their lack and/or limited level of knowledge regarding health related issues. Having improved health services include strengthening Preventive Services at all levels, including better understanding of what primary health care is all about.

As such, the Bureau’s target group is the public at large with more focus on pulation as far as the preventive sense of the work is concerned. The Bureau’s preventive services have been strengthened quite tremendously. However, the Bureau has not been able to provide the necessary scheme of capacity building of its staff. Realizing the apparent weakness, the Ministry of Health has to create a comprehensive training for the staff on Primary Health Care.

The Bureau of PHC needs staff that is motivated and has the extra sense of creativity necessary to lure and educate people to take extra sense of responsibility for caring for their own health and well being. Motivation of key staff to work with Stakeholders towards a more comprehensive, community-based PHC program is the key.

The Bureau successfully recruited a new OB/GYN doctor to improve the Reproductive Health services which is one of the vital programs that describes the health status of the country. Teen pregnancy rate still is very high in the RMI.

Furthermore, the Cancer Comprehensive Program has been established as a part of the Bureau’s services. It is a program that has the connotation of dealing directly or indirectly with tobacco control and prevention screening efforts for cancer prevention and education program on cancer.

87 6.1 STD/HIV-AIDS Program

Table 6.1 Syphilis (RPR Tests) FY 2005

Syphilis Oct 2004-Sept 2005 Age M + F + Total test Total + % of + <15 106 2 140 4 246 6 2% 15-19 410 19 623 35 1033 54 5% 20-24 391 34 709 54 1100 88 8% 25-29 272 20 452 22 724 42 6% 30-34 177 7 339 4 516 11 2% 35-39 140 6 264 1 404 7 2% 40-44 121 1 210 1 331 2 1% 45-49 61 1 167 1 228 2 1% 59+ 109 3 202 1 311 4 1% Total 1787 93 3106 123 4893 216 28%

During the fiscal year 2005, 4,893 RPR tests were performed. Of the total, 216 tests were found to be positive tests for both males and females. Out of 216 positive RPR, 16 were considered close case because their RPR titer comes down fourfold from the previous one. Therefore at the end of the year, the actual total cases of syphilis are 200/4893 (4%) Out of the 200 cases of syphilis, 98 (49%) were traced and contacted. All new cases of syphilis and contact (200) were treated base on the stage of the disease. One of the reason for the low number of contacts is people are moving from village to village and/or island to island.

The positives cases and the contacts are currently being treated as illustrated above. It is worth noting that the age group that had the highest number of positive cases ranged from 20-24 followed by age group 25-29 years old with 130 or 60% of the total).

Table 6.2 Gonorrhea (GC tests) FY 2005

Gonorrhea Oct 2004-Sept 2005 Age M + F + Total test Total + % of + <15 0 0 15 0 15 0 0.00% 15-19 24 2 206 0 230 2 0.43% 20-24 35 3 375 0 410 3 0.49% 25-29 20 1 233 0 253 1 0.40% 30-34 5 0 116 0 121 0 0.00% 35-39 1 0 37 0 38 0 0.00% 40-44 2 0 11 0 13 0 0.00% 45-49 0 0 3 0 3 0 0.00% 59+ 2 1 0 3 0 0.00% Total 89 6 997 0 1086 6 0.37%

The table shows that there were 6 positives cases for gonorrhea during FY 2005. Out of the total of 1086 tests administered, only 6 positive cases of gonorrhea attributed to male. All 6 cases including their contact were treated at the clinic.

88 Table 6.3 Chlamydia (CHL Tests) FY2005

Chlamydia Oct 2004-Sept 2005 Age M + F + Total test Total + % of + <15 0 0 18 7 18 7 38.89% 15-19 30 2 242 40 272 42 15.44% 20-24 44 7 430 76 474 83 17.51% 25-29 30 3 272 40 302 43 14.24% 30-34 6 0 139 17 145 17 11.72% 35-39 4 0 42 9 46 9 19.57% 40-44 3 1 13 2 16 3 18.75% 45-49 0 0 1 0 1 0 0.00% 59+ 2 1 1 0 3 1 33.33% Total 119 14 1158 191 1277 205 22.49%

Table 6.3 indicates a total of 1277 tests were performed for Chlamydia, 205 (16%) of tests were positive cases. Attributed to female were 191 (93%) positive cases, while 14 (7%) attributed to the males who were tested.

Regarding contact, there were 89 contacts. 76 (85%) attributed to the male contact and 13 (15%) attributed to female contact. Overall, all the 205 cases and 89 contacts were treated with single dose of Azithromycin.

Table 6.4 HIV/AIDS Tests FY 2005

HIV Oct 2004-Sept 2005 Age M + F + Total test Total + % of + <15 112 0 131 0 243 0 0.00% 15-19 401 0 602 0 1003 0 0.00% 20-24 387 0 683 0 1070 0 0.00% 25-29 274 0 436 1 710 1 0.00% 30-34 200 0 327 0 527 0 0.00% 35-39 152 0 257 0 409 0 0.00% 40-44 133 1 213 0 346 1 0.00% 45-49 72 0 161 0 233 0 0.00% 59+ 120 0 201 0 321 0 0.00% Total 1851 1 3011 1 4862 2 0.00%

As indicated in the previous three tables, STD especially Chlamydia and Syphilis are still high therefore it place one at risk of acquiring HIV. Although, RMI is consider a HIV low prevalence countries worldwide, the high prevalence of STD might reverse this scenario to scary picture. For instance, for the past several years, there hasn’t been any reported case of HIV in RMI until 2001, 31 years old girl was reported to have HIV positive. And for FY 2005, Majuro Hospital reported two newly diagnosed cases of HIV. Division of Health Promotion and Health Education presented to the public numerous health information regarding HIV/AIDS/STD and other sexually transmitted disease. Given the finding of the new two cases, public awareness need to be strengthening and upgrade and second generation survey should be implemented at once to assess the level of the sexual behavior especially among youth who are account for high percentage of STD.

89

6.2 TB & Leprosy Program

Table 6.5 Tuberculosis FY 2005

New cases Detected

X X

TX at Died

year # Lost to T Beginning Not a Case Migrated Out Cases at the # still on Complete T the end of Year # of PSP # of PSN # of EPTB Total New Cases # FY 2004 40 22 18 29 69 12 2 2 0 56 37

FY 2005 37 31 16 33 80 4 1 4 8 58 42 PSP – Pulmonary Smear Positive; PSN – Pulmonary Smear Negative; EXTB – Extra -pulmonary TB; TX - Treatment

The table reflects that at the beginning of the year there were 37 cases with the addition of 80 new cases, which made the total of 117 for the year. At the end of the year, after migrating out, completion of treatment, lost to treatment and/or not a case, there were 42 patients still undergoing treatment. The table further illustrates that there was an increase of 12% in the number of TB cases from FY 2004.

Table 6.6 Leprosy FY 2005

New # # Active # at the cases # lost to migrated # completed cases at the Year beginning detected TX out died TX end of year FY 2004 76 58 0 0 0 68 66 FY 2005 66 50 0 0 0 59 57

There were 66 active leprosy cases by the end of FY 2004. These cases were carried at the beginning of FY 2005. 50 cases were detected as new cases this fiscal year. In total, we have 115 cases for FY 2005. By the end of FY 2005, we have 57 active cases and still undergoing treatment.

90 6.3 Division of Health Promotions and Human Services

6.3.1 Nutrition and Diabetes Prevention

Table 6.7 Breastfeeding

Month # of live # # # mix # bottle # birth breastfed Exclusively feeding only Artificial registered breastfed Milk Oct 04 105 105 104 1 0 0 Nov 04 91 91 89 2 0 0 Dec 04 103 103 100 3 0 0 Jan 05 97 97 95 2 0 0 Feb 05 92 92 89 2 0 1 Mar 05 84 84 82 2 0 0 Apr 05 83 81 81 0 2 0 May 05 68 68 66 2 0 0 Jun 05 70 66 66 4 0 0 Jul 05 102 102 99 3 0 0 Aug 05 112 112 109 3 0 0 Sept 05 92 92 88 4 0 0 Total 1099 1093 1068 28 2 1 Percentage 99.45 97.18 2.55 0.18 0.09 (Source: clinical data – Maternity Unit, Majuro Hospital) The table indicates that the total live birth during FY 2005 was 1,099. 99.45% of these babies were breastfed, which is excellent, while 96% were exclusively breastfeeding. It is worth noting that more mothers are convinced that breastfeeding does indeed plays a huge role in the prevention of diseases from occurring, especially to the new born child. The number of live registered birth may vary with the data given by the Bureau of Health Planning and Statistics because the data in this section is Majuro Hospital data only and late registered birth is not included. Table 6.8 Continue Breastfeeding FY 2005

Age # of Children # breastfed # # mix # bottle # food only Exclusively feeding only breastfed 2,163 1,593 0-6 months 2,334 (50%) (68%) 570 152 19 7-12 months 585 456 (78%) 69 (12%) 387 72 57 13-24 months 101 36 (36%) 0 36 1 64 >24 months 20 2 0 2 0 18 Total 3,040 2,657 1,662 995 225 158 Percentage 87% 55% 33% 7% 5% (Source: Well Baby Clinic worksheets)

91 The table indicates that a large portion of mothers favor breastfeeding over other feeding methods. For example, breastfeeding (87%) and exclusive breastfeeding (55%) came in as the first and second choices as opposed to bottle feeding (7%).

6.3.2 Pediatrics High Risk Program

Table 6.9 Number of children admitted into Pediatrics Unit, Majuro Hospital

Month 0-1 year 2-5 years >5years

Oct-04 15 4 1 Nov-04 10 1 0 Dec-04 2 0 0 Jan-05 3 0 0 Feb-05 7 2 0 Mar-05 3 1 0 Apr-05 4 2 1 May-05 3 0 0 Jun-05 5 1 1 Jul-05 9 3 3 Aug-05 1 0 0 Sep-05 8 1 0 TOTAL 70 15 6 (Source: Pediatric logbook)

During FY 2005, the Pediatrics High Risk Program referred 70 children, whose age ranged between zero to over than five, to the Pediatric Unit for further medical evaluation and check up. More than seventy percent (78%) on the children referred were under the zero to one year old, which was a startling discovery.

There were 23 malnourished children referred to Salvation Army’s Feeding Program in FY2005.

6.3.3 Diabetes Prevention & Control Program

The information gathered below was used to monitor progresses made towards objectives for recommenced foot exams, eye exams, flu vaccination and others services included in the performance measures guidelines in order to ensure that all diabetic patients attending the weekly diabetic clinic are receiving quality care.

92 Table 6.10 Diabetic Treatment

Month # Rec’d Rec’d Rec’d Rec’d Oral TX Diet / Other TX Encounter Routine Yearly Yearly Yearly Ex. Foot Dilated Dental Flu Only Exam Eye Care Vaccine Exam Oct-04 90 43 33 4 46 78 5 6 Nov-04 103 76 58 2 80 90 13 1 Dec-04 70 25 29 0 29 69 11 0 Jan-05 108 73 62 12 39 96 10 2 Feb-05 100 53 54 4 61 93 7 0 Mar-05 114 75 70 6 31 106 8 0 Apr-05 116 90 88 3 49 104 9 5 May-05 60 30 30 2 28 59 1 0 Jun-05 130 88 88 0 78 122 20 2 Jul-05 139 72 67 1 58 131 4 4 Aug-05 157 97 90 86 86 152 3 2 Sep-05 114 88 74 56 56 108 2 4 Total 1301 810 743 176 641 1208 93 26 (Source: NDPP Clinical data logbook)

Graph 6.1 Percentage of Diabetic Treatment FY 2005

Percentage of Diabetic Treatment FY 2005

Other Diet / Ex. Only, Treatment, 7.15% 2.00% Received Oral Treatment, Routine Foot 92.85% Exam, 62.26%

Received Yearly Received Yearly Dilated Eye Flu Vaccine, Received Yearly Exam, 57.11% 49.27% Dental Care, 13.53%

The above table lists the number of patients’ encounters at the Diabetic Clinic. Oral medications (92.85%), foot (62.26%) and eye examinations (57.11%) were the three most frequently used services by patients attending the diabetic clinic. An alarming low of 7.15 % were involved or attended the diet and exercise program. The information listed below was to monitor progress made towards objectives for wellness activities such as blood glucose and blood pressure control, participation in weight loss program, smoking cessation program and early detection, screening and prevention of diabetes and its complications.

93 Table 6.11 Fasting Blood Sugar (FBS) and Blood Pressure (BP) testing: Encounter forms

Month Total Total Total Total Total FBS Total FBS Total BP Total Encou Female male new 120-200 > 200 – BP- nter cases mg/dl mg/dl Systolic Diastolic report > 140 >90 Oct-04 90 66 24 3 37 32 37 42 Nov-04 103 66 37 1 35 47 35 20 Dec-04 70 45 25 0 29 37 31 14 Jan-05 108 58 50 14 52 27 41 25 Feb-05 100 55 45 5 46 53 45 42 Mar-05 114 83 31 3 48 54 39 33 Apr-05 116 73 73 1 51 51 57 31 May-05 60 34 26 2 26 27 25 14 Jun-05 130 85 45 8 48 67 53 27 Jul-05 139 87 52 6 61 55 59 33 Aug-05 157 108 49 6 73 61 86 57 Sep-05 114 85 29 2 29 47 56 29 Total 1,301 845 486 51 535 558 564 367 (FBS reading between 75-110 is considered normal; FBS starting at 126 or more is considered high). (Source: NDPP Clinical data logbook)

The total number of diabetic patients that participated in the program was less than expected. The Program was able to identify 51 new diabetic patients. The low number of participants, attributed to the large portion of the people in the community who continued to be in denial and/or have refused to accept the fact that they have acquired the illness.

Graph 6.2 Percentages of FBS and BP Encounters in FY 2005

Percentage of FBS and BP Encounters FY 2005 Total BP- Diastolic >90, Total Female, 28% 65% Total BP – Systolic > 140, 43% Total male, 37%

Total FBS > Total new Total FBS 120- 200 mg/dl, 43% cases report, 200 mg/dl, 41% 4%

Graph 6.2 illustrates that 41% of the participants have FBS of 120-200 mg/dl, while another 432% received a total of FBS greater than 200 mg/dl. The FBS figures are frightening because more than 80% of the participants are well above the normal FBS reading. Even more shocking is the fact that only a small portion (7.15%) of the patients is involved in the Diet and Exercise Program administered by the Diabetes Program.

94

The data leads to one conclusion, and that is the rising number of diabetic cases in the RMI is attributed to the citizenry’s poor lifestyle, diet and their apparent lack of knowledge of the serious complications associated to the illness.

6.3.4 Community Outreach Program

Table 6.12 Number of people screened for early detection of Diabetes and Hypertension

Month Total Total Total Total Total BP Total BP Total Total number BMI of BMI of BMI > Systolic Diastolic RBS > FBS > screened 20-24 25-29 30 > 140 > 90 200 126 mg/dl mg/dl Oct-04 199 15 31 191 32 17 15 32 Nov-04 21 2 7 12 0 0 0 2 Dec-04 0 0 0 0 0 0 0 0 Jan-05 10 0 4 6 2 0 2 2 Feb-05 70 14 20 7 3 5 2 0 Mar-05 168 24 59 78 40 40 2 47 Apr-05 24 2 5 8 7 7 4 6 May-05 61 5 20 39 23 21 3 0 Jun-05 44 3 9 32 0 0 1 4 Jul-05 105 24 27 54 22 16 5 21 Aug-05 59 5 33 28 7 6 2 7 Sep-05 136 17 47 72 49 52 18 22 Total 897 111 262 527 185 164 54 143 (Source: Community outreach logbook)

Graph 6.3 Percentage of Screening for Early Detection

Percentage of Screening for Early Detection FY 2005

Total FBS > 126 mg/dl, 16% Total BMI of 20- Total RBS > 24, 12% 200 mg/dl, 6% Total BMI of 25- 29, 29% Total BP Diastolic > 90, 18%

Total BP Systolic > 140 , Total BMI > 30 21% , 59%

The total number of people participated and screened in the wellness program during the year was 897. Out of the total participants, over 80% are either overweight (29%) or obese (59%). A mere 12% were in the healthy weight category. Furthermore, the table shows different diastolic and systolic counts for each participant. In this particular category, almost 40% were above the

95 border line, which means they have hypertension or high blood pressure. What may be concluded from the data is that the average Marshallese person is likely to be overweight and/or obese, which ultimately lead to more serious illnesses such as diabetes and hypertension. Body Mass Index (BMI) is a measure used for checking overweight. BMI is equal to weight in lbs divided by 2.2 kg divided by height in cm times 2.

Random Blood Sugar (RBS) is a blood sugar testing after meals.

6.3.5 Weight Loss Program:

Table 6.13 Number of People Participated in Wight Loss and Control

Month Total Normal Overweight Obese BMI number weight BMI BMI 25-29 >= 30 registered 20-24 Oct-04 8 2 2 4 Nov-04 13 0 7 6 Dec-04 8 1 3 4 Jan-05 50 2 12 36 Feb-05 40 0 8 32 Mar-05 20 0 8 12 Apr-05 28 3 4 21 May-05 10 0 0 10 Jun-05 14 0 4 10 Jul-05 17 1 3 13 Aug-05 37 5 14 18 Sep-05 29 2 11 16 Total 274 16 76 182 (Source: NDPP logbook)

Graph 6.4 Percentage of People Who Participated in Weight Loss and Control Program

Percent of People Who Participated in Weight Loss and Control Program FY 2005

Normal weight BMI 20-24, 6% Overweight BMI 25-29 , 28%

Obese BMI >= 30 , 66%

96 During FY 2005, a total of 276 participants participated in the weight loss and control program. 66% of the participants were obese, while 28% were overweight. The data reflected in the table further solidifies the fact that, and is a fair assessment and clear indication, most people in the RMI are overweight, worst yet obese.

Table 6.14 Number of outreach conducted and coordinated

Activity Number Number attended activity Conducted Total Females Males Diabetes & Foot Care Seminar 1 68 49 19 Workshop 1 21 20 1 Community Outreach 10 372 269 103 Outer island trip 2 73 49 24 Obesity Screening 24 822 200 622

Table 6.14 shows the number and types of health promotion activities performed during the year. Obesity screening (63%) and community outreach programs (26%) constituted for more than 90% of the health promotion activities conducted.

The table 6.15 indicates the locations where obesity screening and health promotion activities were conducted. There were a total of 24 offices, both government and private, visited by the staff of the Health Promotion and Human Services. As may be noted from the table, almost all of the participants that were checked for body fat and BMI turned out to be either overweight or obese. As for blood pressure and blood sugar, most participants had normal readings.

One of the posters used by Health Promotion for public awareness.

97 Community Outreach

Table 6.15 Obesity Screening Results.

BMI Body Fat Blood sugar Blood pressure Total Healthy Overweight Obese Normal Over Normal High Normal High Organization participants weight

Ministry of Health 76 11.8% 23.7% 52.6% 22.4% 69.7% 27.6% 3.9% - - Ministry of Foreign Affair 15 0% 40% 53.3% 13.3% 80% 93.3% 6.7% 60% 33.3% Ministry of Internal Affairs 21 9.5% 28.6% 61.9% 23.8% 76.2% 76.2% 23.8% 76.2% 23.8% Ministry of Justice (court 9 11.1% 11.1% 77.8% 0% 88.9% 66.7% 22.2% 77.8% 22.2% house) Public Safety 18 11.1% 16.7% 72.2% 0% 100% 88.9% 11.1% 22.2% 22.2% Ministry of Public Works 60 20% 40% 35% 33.3% 60% 90% 10% 76.7% 23.3% Ministry of Resources & 35 17.1% 42.9% 40% 45.7% 51.4% 82.8% 14.3% 77.1% 20% Development Ministry of Finance: 12 16.6% 16.6% 66.7% 25% 75% 66.7% 25% 41.7% 50% (Custom & Revenue) Ministry of Finance 38 7.9% 31.6% 60.5% 15.8% 84.2% 92.1% 7.9% 76.3% 23.7% (upstairs) Ministry of Transportation & 24 8.3% 25% 62.5% 25% 70.8% 91.7% 8.3% 79.2% 20.8% Comm. AMI , downtown 16 18.7% 37.5% 37.5% 25% 68.8% 81.3% 12.5% 75% 18.7% Bank of Guam 9 44.4% 11.1% 44.4% 66.7% 33.3% 88.9% 11.1% 66.7% 33.3% Ejit Island 42 7.1% 31% 59.5% 30.9% 64.3% 85.7% 9.5% 50% 50% JOCV Office 4 25% 0% 50% 0% 50% 75% 25% 75% 25% Laura Salvation Army 33 24.2% 27.3% 48.5% 39.4% 54.5% 81.8% 0% 69.7% 12.1% MALGOV 65 12.3% 36.9% 49.2% 23.1% 76.9% 83% 13.8% 72.3% 27.7% Lomor Office 15 20% 26.7% 53.3% 26.7% 73.3% 93.3% 6.7% 86.7% 13.3% Micronitor News & Printing 15 40% 40% 13.3% 60% 40% 93.3% 6.7% 93.3% 6.7% Moylan Insurance 6 33.3% 33.3% 33.3% 33.3% 66.7% 66.7% 16.7% 66.7% 16.7% MWSC 38 7.9% 28.9% 60.5% 18.4% 78.9% 97.4% 2.6% 78.9% 18.4% OIHCS office 15 20% 33.3% 46.7% 26.7% 66.6% - - - - Public Service Commission 12 16.7% 33.3% 50% 25% 75% 75% 25% 75% 25% Rongelap Atoll Local 16 18.8% 31.2% 50% 25% 75% 81.3% 18.7% 68.8% 31.2% Government Tobolar 28 14.3% 53.6% 32.1% 32.1% 67.9% 100% 0% 78.6% 21.4%

98 6.3.6 Human Services Activities

There were 9 attempted suicide incidences occurred during 2005. Two of the recorded incidences involved females, while the other seven involved young males. Unfortunately, two of the cases were registered as completed suicides.

One of the major priorities of the Division of Human Service is to recruit and hire a full time Psychiatrist. It is expected that once on board the individual could do more in working with the young people, who unfortunately, are prone to commit suicide. The Program continued to provide necessary mental health services to the clients and met with the families of those who committed suicides.

Table 6.16 Suicide Cases

Suicide Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Attempted 2 3 1 Completed 2 1

6.4 Outer Islands Health Care System

At present, there are 58 Community Health Centers in the Republic of the Marshall Islands providing health care services to people in the outer islands. The Primary Health Care Program continued to upgrade the level of care, which is relevant to the types of health problems found in the outer islands communities.

Table 6.17 Morbidity Report by Rank

Conditions Total Percent Influenza 3,413 42.7 % Diabetes 2,774 34.7 % Hypertension 670 8.4 % Scabies 523 6.7 % Tuberculosis 257 3.2 % Vitamin A complication 175 2.2 % Chicken Pox 90 1.1 % Sexually Transmitted Diseases 87 1.0 % Total 7,989 100 %

The table shows the types and number of medical conditions that were seen and treated in the outer islands during fiscal year 2005.

Table 6.18 Types and number of other Complaints

Conditions Total Percent Acute Respiratory Infection (ARI) 2,478 30.5 % Headache 1,676 20.6 % Non-Infectious diarrhea 1,556 19.0 % Abdominal pain (Acute) 682 8.4 %

99 Pneumonia 670 8.2 % Conjunctivitis 523 6.4 % Open would 445 5.5 % Burns 106 1.3 % Total 8,136 100 %

The table illustrates that Acute Respiratory Infection is most prevalent compared to the other diseases found in the outer islands. It consisted of 30.5% of total visits to the dispensaries in the outer islands.

Table 6.19 Number of Birth

Number of Birth Total Live Births 197 Male 112 Female 85 Still births 3 Total Births 197

The total number of births for the outer islands during the fiscal 2005 was 197. Of the total, there were more male children (57%) born as opposed to females (43%).

Table 6.20 Number of Deaths

Number of Deaths Total < 1 year old 16 1 – 4 years old 1 5 – 14 years old 4 15 - 49 years old 7 50 + 21 Total Deaths 49

The table indicates that there were a total of 49 deaths in the outer islands during the year. An astonishing discovery was that children whose age was less than one year old constituted for 33% of the total deaths.

Table 6.21 Clinics Utilization

Age Groups Total < 1 years old 2,365 1 – 5 years old 5,412 6 –14 years old 4,411 15-19 years old 8,808 50 + 4,558 Total visits 25,554

100 The total number of visits to the outer islands clinics was 25,554. Patients in the age group 15-19 (34%) frequently visited and sought medical attention at the clinics, followed by patients between ages 1-5 (21%).

Table 6.22 Family Planning Activities for the Outer Islands Communities

Services Total Counseling 160 Pills 129 Condoms 145 Foams 2 Depo provera 570 Total 1,006

As for family planning activities conducted in the outer islands, by far, Depo-provera is the most preferred birth control method accounting for 57% of all contraceptives used in the outer islands. Counseling (16%) and the use of condoms (14%) came in second and third respectively.

It is quite clear that family planning, in general, is presently not very acceptable. Due to the misconception of condom usage, most people do not prefer it as a proper method for family planning, population control and/or the controlling and prevention of sexually transmitted diseases.

Table 6.23 Pregnancy Management in the Outer Islands Communities

Services provided Total Total visits for prenatal 592 No of 1st visits 85 1st trimester visits 148 2nd trimester visits 236 3rd trimester visits 243 Postpartum exam/follow up 101 Well-baby examination 339 Others 1,571 Total 3,315

Table shows the number and types of prenatal services performed in the outer islands by the Health Assistants. The total visits for the prenatal clinics were 3,315. The total 1st trimester visits accounted for 148 (24%), the 2nd trimester accounted for 236 (38%) and the 3rd trimester accounted for 246 (39%). A total of 1,367 children in the outer islands received Vitamin A, while 1,492 children were given de-worming medications.

101 6.5 Division of Dental Service

Table 6.24 Dental Clinic Details

Procedure 0-4 years 15-24 years 25 + years Total Female Male Female Male Female Male All Patient Visits 1,594 1,584 1,542 1,075 3,546 2,188 11,529 Extraction 1,141 1,023 1,069 493 1,724 1,084 6,534 Fillings 477 263 571 242 973 436 2,962 Sealants 136 95 26 11 16 7 291 Root Canals 46 23 73 15 194 61 412 Scaling/cleaning 81 74 78 44 209 205 691 Dentures 11 4 6 13 345 254 633 Other procedure 67 192 167 83 360 303 1,172 Total Procedure 3,553 3,258 3,532 1,976 7,367 4,538 24,224

The table shows that a total of 24,224 dental procedures were administered in and out of the dental clinics. During FY 2005, the two leading dental procedures were extraction, with a total of 6,534 (27%), and fillings with 2,962 (12%) respectively. Preventive procedure such as scaling and cleaning was fairly low with 691 or (3%). Patients whose age ranged between 0-4 years old constituted for 33% of the total extraction cases. The statistic is quite alarming because the children are either losing their teeth or have some type of tooth problem at a very young age.

The total number of accumulative patient visits was 11,529. The data reflects that most patients do not consider or attempt to do preventive dental procedures to their teeth until it is too late. More emphasis will be directed towards educating the citizenry on the importance of oral prevention.

Table 6.25 Outer Islands Dental Services

Types of Care Total Percent Toothache 1,493 52.3 % Tooth Extraction 911 33.1 % Other dental service 348 12.6 % Total procedures 2,752 100 %

The outer islands dental care services are provided slightly different from the two urban centers (Majuro & Ebeye, Kwajlein). The sole reason for the difference is the inadequate dental equipments, which are unable to perform similar dental services being exerted in the urban centers. As such, toothache is often the chief problem encountered in the outer islands accounting for 52.3% of all the complaints. The most frequent procedure performed is tooth extraction with 33.1%.

The Division of Dental Services continued to provide dental care for the population in Laura village, as well as in the outer islands communities. Varnish and Fluoride continued to be disseminated to the children in the Republic of the Marshall Islands, through the former Head

102 Start Program, which has now been converted to the newly established Kindergarten Program that is currently being administered by the Ministry of Education.

Preventive dental service has become a vital service, which is always encouraged as part of the health promotion and dental hygiene initiatives. Other dental services for mothers and children are provided through MCH grant and program.

Table 6.26 School Sealant Program

FY2005 # of Schools Visited Head Starts # of Children # of Sealants applied 1st Q 2 0 447 256 permanent teeth 2nd Q 10 5 864 1467 permanent teeth 3rd Q 2 5 332 387 permanent teeth 4th Q 0 0 0 0 Total 14 10 1,643 2,110 permanent teeth

For the 4th quarter, no schools and Head Starts were visited because of summer vacation.

6.6 Division of Reproductive Health and Family Planning

The Division of Reproductive Health is comprised of Family Planning and Maternal and Child Health Care Service.

Table 6.27 Prenatal Visits

Type of Visit Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Total Visits 1st Visit 106 102 93 88 76 80 101 123 120 98 89 1,076 Return Visit 520 511 554 543 536 565 520 545 532 521 532 5,879 Total Encounters 626 613 647 631 612 645 621 668 652 619 621 6,955

Table 6.28 Prenatal Visits by Age

Age Group Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Total by Age 12-19 age group 26 15 24 15 24 15 15 21 17 17 17 206 20-24 age group 37 47 27 36 25 30 51 30 43 39 32 397 25 + age group 43 40 42 43 27 35 35 72 40 56 40 473 Total Encounters 106 102 93 94 76 80 101 123 100 112 89 1,076

103 Graph 6.5 Prenatal Visits 2005

Prenatal Visits Jan-Nov 2005

1st Visit 15%

Return Visit 85%

Graph 6.6 Prenatal Visits by Age Group Distribution 2005

Visit by Age Distribution Jan-Dec 2005

12-19 age group 19%

25 + age group 44%

20-24 age group 37%

The teen pregnancy situation in the RMI is still significantly high at 18%. The current figure puts RMI, among the other Pacific countries, with the highest rate of teen pregnancy. The youngest mother to have attended the clinic was 13 and the oldest was 43 years old. The average age for the pregnant teenage mother that attended the clinic was 15 and the oldest was 40 years old. Given the multiple medical conditions associated with multiple pregnancies and being pregnant at an older age, health education programs should be initiated to discourage the current trend from escalating any further.

104 Graph 6.7 Prenatal Visits by Percentage of Past Pregnancy

Prenatal Visits by Percentage of Past Pregnancy 2005

First Time Mothers 32%

Mother's with two or more children 68%

The average number of children per family ranged from a low of four to a high of nine. Graph 6.7 illustrates that 346 (32%) of the clients consists of first time mothers, while 729 (68%) consists of those who have two or more children. As far as young mother is concerned, the program continued to registered and provided services to more very young pregnant mothers. Some of young mothers were discovered to have been sexually abused and/or came from broken and violent families.

The average proportion of initial visits at 20 weeks continued to remain at 36% and was consistent through the year. The program has to be innovative in finding methods to insure that the figure is brought up to the recommended and acceptable level, which is 50%.

Over 50% of the total pregnant mothers for the year came from the adolescent group, whose age ranged between 13-24 years old. A frightening scenario about the data is the fact that this group consists of females that are and should to be in school. Another startling and perhaps a more disturbing fact about the situation is that most of the young pregnant mothers, after giving birth, too often do not return to complete their education or participate in some type of capacity building program.

The end result is devastating since most of young mothers will most likely end up without a job, thus heavily dependent on their parents and families for economic and social support, which in the long run, will become a huge burden on the mothers themselves, their families and the society as a whole. There is no doubt that creative measures are to be developed and aggressively employed to help reverse the current trend.

105

Safe Motherhood Training, Marshall Islands Resort, December 2004.

Reproductive Health Training with Salvation Army, Laura, Ausgut 2005

106 Table 6.29 RH Clinic Female Users by Method 2005

Age Female IUD Hormonal Hormonal Oral Abstinence Other Male Total Group Sterilization Implant(Norplant) Injection Contraceptive Method Condom (BTL) (DepoProvera) <15 0 0 0 0 0 20 0 0 20 15-17 1 0 5 54 65 32 3 254 414 18-19 0 0 58 89 220 32 5 324 728 20-24 21 4 54 804 226 22 4 422 1557 25-29 26 4 39 763 255 12 6 234 1339 30-34 43 2 13 432 247 7 0 312 1056 35-39 31 0 2 318 191 0 6 234 782 40-44 23 0 0 13 18 0 0 0 54 >44 0 0 0 7 8 0 0 0 15 Total 145 10 171 2480 1230 125 24 1780 5965

The BTL is only for 2005. There was an increase in female users due to data reported from outer islands and Ebeye.

Table 6.30 RH Clinic Male Users by Method 2005

Age Group Vasectomy Male Condom Abstinence Total

<15 0 0 12 12 15-17 0 34 15 49 18-19 0 231 9 240 20-24 0 654 16 670 25-29 0 436 0 436 30-34 1 543 0 544 35-39 0 675 0 675 40-44 0 564 0 564 >44 0 654 0 654 Total 1 3791 52 3844

107 6.7 Immunization

Table 6.31 Doses Administered FY 2005

# OF VACCINES DOSES DPT/DTaP 6,539 POLIO/OPV 5,235 HEP.B 5,225 MMR 1,659 HIB 3,065 BCG 1,358 DT 440 TT 1,567 FLU 1,082 TOTAL 26,170

The table indicates that there were a total of 26,170 immunization doses administered during the year. Of the total DPT/DTaP was the highest with 25%. The least was DT with 2%. The Ministry’s goal for all immunization coverage is 95% or higher. As may be noted from the above tables, the completion coverage rate for kindergarten for the year was at 71% completion rate; first graders was at 80%; seventh graders was 96%; ninth graders was at 51%; children in Majuro who were under 2 years old was at 70% and 52% for the outer islands.

The drop in High School coverage rate involved several factors such as missing personal records and school lack of resources. However, Immunization Program has planned to increase the coverage to 80 % by October 2006.

School Immunization Program has required several grade levels such as Kindergarten, 1st, 7th, and 9th grades to report annually as a means of monitoring school age group receive immunization to protect from preventable diseases. The challenge has been with some private school not incompliance with the school regulations.

The graphs below shows the complete rate of each grade level and percentage of vaccines administered

108 Graph 6.8 Majuro Kindergarten Immunizations and Vaccines Coverage

MAJURO KINDERGARTEN IMMUNIZATION AND VACCINES COVERAGE SCHOOL YEAR 2005-2006 (LES, AES, WES, RRES, COOP, LAURA AND DELAP SDA, BAPTIST, RES, DUD)

100% 95% 92% 92% 90% 90% 90% N=473 79% 80% 71% 70% Polio 60% DTP Hepatitis B 50% MMR 1 MMR 2 40% Hib COMPLETE RATE 30%

20%

10%

0% Polio DTP Hepatitis B MMR 1 MMR 2 Hib COMPLETE RATE

Graph6.8 shows complete rate for Majuro Kindergarten at age five. The percentage is based on 483 Kindergarten students immunized.

Graph 6.9 Majuro 1st Grade Immunizations and Vaccines Coverage

MAJURO 1ST GRADE IMMUNIZATION AND VACCINES COVERAGE SCHOOL YEAR 05-06 (LES, WES, AJELTAKE, RRES, RES, COOP, LAURA AND DELAP, UES, BAPTIST, DES) 99% 99% 100% N=600 90% 91% 90% 82% 80% 80%

70%

60% Polio DTP 50% Hepatitis B MMR 1 40% MMR 2 COMPLETE RATE 30%

20%

10%

0% Polio DTP Hepatitis B MMR 1 MMR 2 COMPLETE RATE

109 Graph 6.9 shows grade 1 of both public and private schools. Grade one mostly students at age 6 but there are students age 5. Polio has reach 100 % complete based on 483 students immunized.

Graph 6.10 Majuro 7th Grade Immunizations and Vaccines Coverage

MAJURO 7TH GRADES IMMUMNIZATION AND VACCINES COVERAGE SCHOOL YEAR 2005-2006 (LES, WES, AJELTAKE, COOP, LAURA SDA, DELAP SDA, MIDDLE SCHOOL)

99% 99% 100% 99% 100% 97% 96% N=344 90%

80%

70%

60% Polio DTP Hepatitis B 50% MMR 1 MMR 2 40% COMPLETE RATE

30%

20%

10%

0% Polio DTP Hepatitis B MMR 1 MMR 2 COMPLETE RATE

Graph 6.10 shows grade 7 with ages from 10 to 13 years old. Presently, the school reported has reach MMR1 at 100 % completed and 96% of all required vaccine complete based on 344 students immunized.

Graph 6.11 Majuro 9th Grade Immunizations and Vaccines Coverage

9TH GRADE IMMUNIZATION AND VACCINES COVERAGE SCHOOL YEAR 2005- 2006 (MIHS, NIHS, SDA, ASSUMPTION)

100% 98% N=401 90% 83%

80% 78% 77% 72% 70%

60% Polio DTP 51% Hepatitis B 50% MMR 1 MMR 2 40% COMPLETE RATE

30%

20%

10%

0% Polio DTP Hepatitis B MMR 1 MMR 2 COMPLETE RATE

110 Graph 6.11 shows High School students grade 9 mostly at the age of 13 and 14. The percentages calculation is based on 401 students. The record shows that the 98 % MMR1 and 83 % MMR2 completed from the measles campaign in 2003.

The Immunization Program continued to increase immunization sessions in the following areas; Majuro Public Health clinic, Majuro Zones, Laura clinic and Outer Islands. The challenge for FY 2005 has been with people migrating from one place to another and with availability of cold chain equipments especially for outer islands.

The tables below show the vaccines given and percentage of complete rate for children two years of age. The recommendation required as completer for 2 years of age as shown in the graphs are as follows DPT 4 doses, HEP B 3 does, HIB 3 doses, BCG 1 dose at birth, and MMR1 at one year and MMR2 after 4 weeks from the first one. At age four the child should be complete by taking the required dose of DPT #5 and Polio #5.

Graph 6.12 Majuro Immunizations and Vaccines Coverage for Children 2 Years of Age, December 2005

MAJURO IMMUNIZATION AND VACCINES COVERAGE FOR CHILDREN 2 YEARS OF AGE DECEMBER 2005

100% 92% 90% 90% 88% N=987 80% 78%

71% 70% 70% 68% DPT4 OPV3 60% HEP. B3 HIB3 50% 45% BCG MMR1 40% MMR2 FULLY IMMUNIZED 30%

20%

10%

0% DPT4 OPV3 HEP. B3 HIB3 BCG MMR1 MMR2 FULLY IMMUNIZED

Graph 6.12 shows the percentage of vaccine administered in Majuro and complete rate for children two years of age based ion 987 children immunized.

Graph 6.13 shows outer islands percentage of vaccine administered and complete arte based on 671 children two years of age immunized during the years. The records shows that BCG was mostly administered at Majuro Hospital during birth.

111 Graph 6.13 Outer Islands Immunizations and Vaccines Coverage for Children 2 Years of Age

OUTER ISLANDS IMMUNIZATION AND VACCINE COVERAGE FOR CHILDREN 2 YEARS OF AGE DECEMBER 2005 (All Atolls except Mejjato)

100%

90% 87% N=671 81% 82% 80% 74%

70% DPT4 OPV3 60% 56% HEP. B3 52% HIB3 50% 42% 42% BCG MMR1 40% MMR2 FULLY IMMUNIZED 30%

20%

10%

0% DPT4 OPV3 HEP. B3 HIB3 BCG MMR1 MMR2 FULLY IMMUNIZED

Table 6.32 Immunization Coverage Report for Outer Islands and Majuro for 2 Years Old

VACCINE COVERAGE RATE (2 Years Old) ATOLL/ # FULLY ISLAND CHILDREN IMMUNIZED DPT4 OPV3 HEPB3 HIB3 BCG MMR1 MMR2 AILUK 38 34% 54% 92% 82% 34% 82% 68% 50% ARNO 105 55% 57% 76% 76% 41% 82% 75% 33% AUR 33 33% 36% 79% 79% 30% 61% 76% 40% EBON 24 60% 63% 90% 99% 42% 88% 84% 58% KILI 15 45% 56% 67% 73% 13% 80% 93% 89% LAE 9 22% 22% 44% 55% 33% 88% 55% 0% LIB 1 0% 0% 100% 100% 0% 100% 0% 0% LIKIEP 42 62% 64% 88% 83% 40% 90% 76% 36% MALOLAP 42 57% 62% 71% 74% 31% 95% 76% 40% MEJIT 25 64% 68% 100% 95% 64% 92% 92% 56% MILI 52 57% 63% 78% 78% 40% 78% 75% 44% NAMDRIK 45 64% 66% 82% 73% 47% 96% 82% 4% NAMO 39 64% 65% 88% 92% 51% 77% 92% 41% UJAE 24 60% 63% 83% 88% 63% 83% 88% 60% UTRIK 22 68% 68% 95% 77% 64% 95% 91% 64% WOTHO 7 57% 57% 71% 100% 57% 100% 86% 55% WOTJE 56 63% 66% 82% 86% 52% 95% 80% 55% AILINLAPLAP 48 54% 56% 61% 68% 36% 78% 54% 36% JALUIT 38 61% 63% 88% 89% 54% 90% 73% 52% JABAT 6 68% 68% 78% 81% 38% 85% 72% 54% MAJURO 987 70% 71% 88% 89% 68% 92% 78% 45%

112 Graph 6.14 Percentage of Fully Immunized Coverage Per Atoll, 2005

Percentage of Fully Immunized Coverage Per Atoll

80% 68% 68% 70% 70% 62% 64% 64% 64% 63% 60% 60% 61% 57% 57% 57% 60% 55% 54%

50% 45%

40% 34% 33% 30% 22% 20% 10% 0% 0%

LIB KILI LAE AUR MILI UJAE EBON AILUK ARNO LIKIEP MEJIT NAMO UTRIK JABAT WOTJE JALUIT WOTHO MAJURO MALOLAP NAMDRIK

AILINLAPLAP

The table reflects the coverage rate for individual atolls and islands within the Republic. Missing from the table is Enewetak and Kwajlein, including the community on Mejatto.

113 Immunization Program with the Stakeholders

Public Health Awareness

114 7.0 Bureau of Medical Referral Services

The Bureau of Medical Referral Services is responsible for both the operations of Basic Health Plan and Supplemental Health Plan. The Basic Health Plan is the plan that handles patients who are approved by the Medical Referral Committee for an off island tertiary care, whereas, the Supplemental Health Plan handles self referral patients who are seeking medical treatment off island from an approved Medical Provider.

115 The Bureau of Medical Referral Services continued to develop during FY2005, following its reorganization into a distinct Bureau in June 2004. The challenge for FY2005 has been to continue the trends for ongoing improvement established in FY2003 and FY2004.

7.1 Administration

The Bureau of Medical Referral Services includes offices in different locations to better serve RMI. In FY2005, the bureau visited all locations to evaluate and make assessments to improve services for medical referral services.

Majuro Honolulu

Ebeye Philippines

7.2 Health Services Board

The Health Services Board was established under the Health Fund Act in 2002 and serve as the governing board for the Medical Referral Services.

Since its inception in 2003, the Board has contributed significantly in strengthening the financial and administrative functions of the Medical Referral Services. The Medical Referral Services is one of the most challenged and discussed program in the Ministry because it involves referrals of patients for off-island medical care. Because of this reason, the decisions of the Medical Referral Committee are the only factors used for medical decisions for referrals based on the Health Fund Act. Often times medical decisions are questioned because patients and families are not satisfied

116 with any medical decisions that will not allow for off-island medical care. Thus such questions and decisions often lead to anger and frustrations not only among patients and families but also among the medical staff, the Medical Referral committee, and political leaders.

Regardless whether the program is efficiently managed the Bureau of Medical Referral continued to be the most discussed and challenged every year. It should be noted that when the Health Fund was transferred to the Ministry of Health in 2003, the Ministry also inherited liabilities if the Health Fund including liabilities to the Retirement Fund at MISSA.

The Health Services Board made the decisions to pay liabilities owed to the Retirement Fund. Since that payment started in January 2004, as of FY 2005 the Health Fund paid 43 % of the total liability with $ 662,000 still outstanding. The total liability that the Health Fund owed to the Retirement Fund was $1,177,963.83.

7.3 Financial Management

Financial performance continued the trend set in FY2003 and FY2004 as we continue to develop cost-effective, high quality referral sites for the program. The outstanding debt accumulated prior to FY2003 has been retired and old claims over two years old are no longer accepted for payment or appeal. Requiring providers to present claims in a timely manner will further assist in maintaining better financial management.

Again in FY2005 the increased use of providers in the Philippines, where the MRS typically pay advance payments to providers, has helped to maintain a more current picture of our expenditures for off-island referrals.

Two factors had major influences on our improved performance this year.

? Tripler Army Hospital increased the number of referrals they accepted. This keeps the overall referral costs down but the long stays by patients being treated there resulted in increased per diem costs over FY 2004.

? Transitioning off-island referrals to the Philippines has had a strong positive effect on overall referral expenses and helped to compensate for the decision to open referrals to non-urgent cases

117

Table 7.1 Basic Health Plan Revenue and Expenditure for FY 2000 – 2005

Basic Health Plan Revenue and Expenditures for Fiscal Years 2000 - 2005

2005 2004 2003 2002 2001 2000 Revenues: (Unaudited) (Unaudited) Audited (MISSA) (MISSA) (MISSA) Health Fund Tax $2,815,369.27 $2,861,264.42 $3,027,471.16 $3,980,804.00 $3,714,087.00 $4,485,822.00 RepMar Subsidy $0.00 $0.00 $0.00 $1,700,000.00 $2,160,000.00 $3,100,000.00 Others 1,424.51 $230,633.61 $25,915.22 $260,228.00 $158,339.00 $91,562.00 Total Revenues 2,816,793.78 $3,091,898.03 $3,053,386.38 $5,941,032.00 $6,032,426.00 $7,677,384.00

Expenses: Off-Island Care 1,062,268.00 $1,355,103.92 $1,993,574.74 $3,298,105.00 $3,158,543.00 $4,027,717.00 Travel/Stipends: $506,117.93 $387,592.06 $201,105.52 $585,988.00 $718,988.00 $957,291.00 Patients/Escorts 3rd Party Administration $0.00 $0.00 $0.00 $389,613.00 $388,951.00 $550,732.00 Fees Contractual Services 313,554.14 $360,485.23 $0.00 $0.00 $0.00 $0.00 THI/MedPharm Administration $161,815.24 $236,085.03 $230,825.42 $303,927.00 $353,032.00 $150,065.00 $126,405.66 $129,851.88 $42,830.10 Honolulu Office Operations Subsidy to Inter-Island $61,648.65 $0.00 $0.00 $1,756,299.00 $1,933,252.00 $1,791,076.00 Referral Total Expenditures $2,231,809.52 $2,469,118.12 $2,468,335.78 $6,333,932.00 $6,552,766.00 $7,476,881.00

Net Revenue (Loss) $584,984.21 $622,779.91 $585,050.60 ($392,900.00) ($520,340.00) $200,503.00 *Note: FY2005 revenues based on 55% of Health Fund collection. 45% already remitted to Health Care.

118 During FY2005, the program increased the number of off-island referrals by 27 % and decreased the average cost per referral by 32 % by sending more patients to Tripler Army Medical Center and hospitals in the Philippines. Continued performance in reducing referral costs is illustrated in the graph below which isolates direct referral expenses from FY1999 through FY2005.

Graph 7.1 Direct Referral Expenses

Direct Referral Expenses

$6,000,000.00

$5,000,000.00

$4,000,000.00

$3,000,000.00 Expenses

$2,000,000.00

$1,000,000.00

$0.00 1999 2000 2001 2002 2003 2004 2005 Year

Table 7.2 Direct Referral Expenses and Referrals

Year 1999 2000 2001 2002 2003 2004 2005 Direct $ 3,359,567.00 $5,535,740.00 $4,266,482.00 $4,273,706.00 2,194,680.26 1,742,695.98 $1,507,610.22 Referral Expenses Referrals 147 147 120 87 75 95 121 Average (Expenses $22,854.20 $37,658.10 $35,554.02 $49,123.06 $29,262.40 $18,344.17 $12,459.59 / Referrals)

Improved financial management and performance is an ongoing project for the Bureau

Key areas to be targeted in FY2006 will include: ? Continue to tighten the monitoring of expenses and trends ? Closely monitor patient and escort stipend expenses, especially in relation to the TAMC and program for possible recommendations for program changes if necessary. ? Establish procedures to update the Medical Referral Committee on a budget status on a regular basis.

119 7.4 Referral Activity

FY2005 has been the busiest year for medical referrals since FY2003. The lifting of the restrictions from emergency cases only created a 27% increase in off-island referrals. The majority of the referrals in FY2005 were sent to the Philippines and to Tripler Army Medical Center (TAMC). The increased use of services in the Philippines and at TAMC reduced the direct average cost per referral but also increased the work required by the Bureau staff to coordinate logistics and care.

Referrals to the Philippines increased by 70%, with a total of 51 patients referred in FY2005. This increase in the number of patients referred to the Philippine has significantly reduced the average cost per referral. The increased number of patients has created a much heavier load of work for the patient coordinator in Manila and the staff of MedPharm. As the Bureau continues to expand the network of providers, close monitoring of will be necessary.

Table 7.3 Referral Activity for FY 1999-2005

Referral Centers Number of Patients 1999 2000 2001 2002 2003 2004 2005 Honolulu & USAKA 81 95 76 60 27 21 12 Philippines 46 30 15 0 6 30 51 Total Basic Referrals 127 125 91 60 33 51 63

Trippler Hospital (PIHCP) 20 22 29 27 37 35 55 Shriners 5 9 3

Total Referrals 147 147 120 87 75 95 121

120 Table 7.4 Referral Activity for FY 2005 by Quarter

Number of Patients 1st Q 2nd Q 3rd Q 4th Q Totals Honolulu & Other 8 0 2 1 11 Philippines 14 11 6 20 51 USAKA 0 1 0 0 1 Total Basic 22 12 8 21 63 Referrals

Tripler Hospital 11 14 14 16 55 (PIHCP) Shriners’ Children 0 1 1 1 3 Hospital

Total Referrals 33 27 23 38 121

The chart below illustrates the shift in our use of referral sites over the last three years.

Graph 7.2 Referral Activities for FY 2003 - 2005

60

50

40

Number of 30 Referrals

20

10

0 2003 2004 2005 Year

Honolulu & USAKA Phillippines Tripler (PIHCP) Shriners

121 Graph 7.3 Approved Referrals for FY 2005

Approved Referrals 2005

Honolulu & Shriners USAKA 2% 10%

Tripler (PIHCP) 46% Phillippines 42%

7.5 Supplemental Health Plan

Table 7.5 Statement of Revenues and Expenditures- Supplemental Health Plan

2005 2004 2003 Revenues Unaudited Unaudited Audit Supplemental Health Plan Collection $513,434.22 $492,359.15 $416,525.10 Other income $0.00 $0.00 $174.42 Total Revenues $513,434.22 $492,359.15 $416,699.52

Expenses Direct Expenses $302,727.13 $359,423.08 $633,292.43 Administration - Majuro & Honolulu $0.00 $0.00 $201.93 Total Expenses $302,727.13 $359,423.08 $633,494.36

Net Revenue (Loss) $210,707.09 $132,936.07 ($216,794.84)

Beginning Net Asset ($83,858.77) ($216,794.84)

Ending Net Assets $126,848.32 ($83,858.77) ($216,794.84)

The financial performance of the Supplemental Health Plan improved in FY2005 compared to previous years. By the end of FY2005 the Supplemental Health Plan had covered the deficits from previous years and ended with a positive net asset of $126,848.32. The Plan’s improved

122 performance resulted from increased collections of premiums and the reduction of health services expenses as members utilized contracted providers in Honolulu and Manila.

Table 7.6 Supplemental Health Plan Enrollee

2005 2004 2003 Resident Members 843 737 974 Non-Resident Members 27 61 65 Total Members at Beginning of Year 870 798 1039 New Members 122 168 NA Terminated Members 218 97 241 Total Active Members End of Year 774 870 1039

The number of Supplemental Plan enrollees increased in FY2005 by 122. The Bureau implemented new marketing programs early in FY2005 to attract new members. The marketing strategy included radio and newspaper announcements in Majuro and presentations to employer groups in Ebeye.

7.6 Claims

Claims processing has made great strides since it began in 2002, beginning by processing all of the claims manually to now entering and processing claims within the MRO Database program.

Claims processed since the transfer of services to the RMI:

Table 7.7 Claims Processed

Number of Number of Year Claims Line Items 2002 thru 2003 3,042 6,599 2004 2,033 5739 2005 1,310 4,012 Totals 6,385 16,350

The main objective for the claims section has always been to process claims for payment as quickly and accurately as possibly

Table 7.8 Average Claims Turnaround days

Year 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

FY 2003 49.0 days 49.0 days 34.0 days 49.5 days

FY 2004 48.0 days 44.5 days 49.6 days 25.4 days FY 2005 19.5 days 61 days 47 days 38 days

123 Claims turnaround time to pay medical bills is measured from the date the claim is received in the Honolulu Medical Referral Office until the claim is processed for payment in Majuro. The Honolulu Medical Referral Office stamps and logs all the claims that are received and forwards to the Majuro Medical Referral Office for payment. As noted on the above chart, claims turnaround time increased significantly in the second quarter of FY2005. This increase was due to delays in receipt of claims in the Majuro office. These delays occur when claims are held in Honolulu or the pouch form Honolulu is not delivered in a timely manner. In addition, there was a shortage of personnel due to absences for paid time off and training. By the end of the fiscal year the process was back on track but still needs major improvement.

The major objective for FY2006 will be to: 1. Develop consistency in processing. 2. Cross-train all Majuro and Honolulu staff to provide backup support 3. Complete procedures manual and system documentation.

7.8 Case Management

Trends

Demand for case management services in Honolulu gradually decreased in FY2005, mainly because of the increased number of referrals to the Philippines. Referrals sent to Honolulu were reduced to mainly complex emergency or urgent cases by the end of FY2005.

Due to a limited network of Providers in Honolulu, Case Managers encountered difficulty in obtaining appointments for patients needing services in OB/GYN, ophthalmology, urology, neurology, oncology, and orthopedics. The pediatric patients needing orthopedic/neurological trauma and oncology services were the ones who had the most difficult time in accessing services. The Medical Referral Office has expanded services in the Philippines to meet these service needs.

Several patients originally began receiving care under the Supplemental Health Plan and later requested retroactive approval of care through the Basic Health Plan. These services were for conditions covered under the Health Fund Act and were approved by the Medical Referral Committee. Some of these patients obtained care through providers who were not contracted and offered no discounted rates. This practice has created a loophole that usually results in additional expenses for the Ministry of Health. Developments of new policies for the Supplemental Health Plan are being drafted to help minimize the financial consequences of this loophole.

124 7.9 Training

Training of personnel was implemented in the following areas and is ongoing:

Cross Training

Claims Management: The new claims officer started employment in May 2004 and received training in claims management and adjudication throughout FY 2005. He also attended an extensive training program in ICD-10 coding in Sydney, Australia, along with other MOH staff.

Contracting: The Bureau staff continued to develop skills in provider network development by conducting meetings with providers in Manila and Taipei, along with THI consultants.

Case Management: The case manager in Honolulu continued on the job training in case management processes with the consultant from Trinity Health International. Formal training and certification are planned for FY2006.

Micro Information Product (MIP) training: The accountant in the Bureau received additional training on the MIP accounting systems and put it to good use with an on-site visit to audit and reconcile expenses for referrals in the Philippines.

Provider and Patient Services: The support staff in the Bureau had opportunities to expand their understanding of patient and provider services and processes through orientation visits to the referral offices in Honolulu and Manila during the year.

Specific training for personnel in the ancillary offices in Manila, Honolulu and Ebeye are goals for the Bureau in FY2006.

7.10 Provider Network Development

Representatives from Medical Referral Program conducted two very successful visits to expand our provider networks during FY2005. With the goal to expand the Bureau’s options for cost- effective and high quality care, staffs met with providers in Manila, Philippines and Taipei, Taiwan.

125 In Manila, staffs met with The Heart Center and Medical City. Both these medical facilities agreed to treat both Basic and Supplemental Plan members and coordinate services through the MedPharm staff. Negotiations of additional discounts at all these facilities are ongoing.

The Ministry of Foreign Affairs provided assistance to the Bureau of Medical Referral Program in arranging an investigative trip to Taipei. Ambassador from the RMI Embassy in Taipei kindly coordinated visits with the Ministry of Health in Taipei and four separate medical centers. The Ministry of Health and each of the staff of the centers that the team met with expressed a willingness to accept our basic referrals as well as a serious interest in working with our Ministry of Health to develop opportunities for training for our physicians and on-site visits for their staff to work here in the Marshall Islands. The hope was expressed that we can work jointly with the Ministry of Foreign Affairs to arrange a follow-up meeting her in Majuro and begin finalizing working arrangements by the 2nd quarter of FY2006.

126 7.11 Management Information Systems

The MRO database system continued to be improved throughout FY2005. Since this is a custom-designed system development is an ongoing work in progress as administrative processes change.

Examples of improvements made during FY2005 include: ? Completion of the authorization tracking system for both Honolulu and Majuro ? Conversion to electronic reporting for stipends and patient status reports ? Implementation of NRC module ? Training for the staff member in Honolulu and Manila.

7.12 Honolulu Operations

7.12.1 Personnel

The Honolulu office staff has made significant progress in respect to their areas of responsibilities. The patient coordinators and administrative support staff were trained and began using the database management system consistently in FY2005. This resulted in better efficiency in tracking and reporting for referrals, authorizations, and stipends. The staff also made suggestions for new controls to continue to improve stipend management and this has been planned for implementation in FY2006.

7.12.3 RMI Building Complex

In FY2005 the Honolulu housing complex was renovated because the facilities and furniture had deteriorated to the point that they posed safety hazards for the patients.

Arrangement was made with the Pagoda Hotel for all patients to stay there for the duration of the renovation process.

Before renovation

127

After renovation

The renovation of RMI Housing Complex took 14 days to be completed. The following work was done to the patients rooms: ? The entire building was fumigated for pests. ? The interior rooms were painted ? Furniture such as beds, couches, kitchen tables and chairs, and bathroom sink were replaced. ? All room curtains were mended and dry cleaned.

One staff from Majuro Medical Referral Office went to Honolulu to help during the process. Since the patients had to be relocated to the Pagoda Hotel, the staffs in the Honolulu Medical Referral Office (HMRO) were challenged by the difficulty of working in the HMRO office, in the other building complex, and having to drive patients to appointments from the Pagoda Hotel.

7.14 Philippines Operations

The major shift of referrals from Honolulu to the Philippines in Fiscal 2005 represented a major cost savings for the program but also increased the challenges to provide adequate case management and support services to our patients and their families.

The Bureau finalized a contract with Medpharm in Manila to provide claims and case management services. This contract has provided access to hospitals and physician groups at discounted rates.

In addition, discounted services were expanded to include Supplemental Plan members, including package prices for complete physical exams. Many Supplemental members have begun shifting their care from Honolulu to Manila resulting in significant cost savings for both the member and the program.

128 The need for patient service support was resolved in early FY2005 with the hiring, relocation and training of the Patient Services Coordinator. Staff continued to visit Philippines to provide assistance to patients and monitor the services provided.

129 130 Acronyms & Definitions:

1. BMI (Body Mass Index) - BMI is a measurement method used to determine if a person has the appropriate weight, is overweight or obese, based on height, weight and age. A normal BMI count ranges between 20-24. 25-29 is considered overweight and over 30 is obesity.

2. BP (Blood Pressure) - The normal blood pressure is 120/80; 140/90 is border line and anything above is considered bad.

3. FBS (Fasting Blood Sugar) - The term is referred to the level of glucose (sugar) in a person’s blood. It is often used for patients who are checking for or have already acquired diabetes. A FBS reading between 75-110 is considered normal; 120-200 is high and readings above 200 are considered extremely high.

4. Direct Observation Therapy (DOT) - This is the process in which TB patients are visited and directly observed by a Nurse to insure that they take all of the required medications.

5. Case Lost to Treatment – The term is referred to a TB patient who had failed to completed or defaulted on his/her treatment.

6. Fertility Rate – Refers to the number of live birth reported to women ages 15-44 divided by the number of women in the age group.

7. Crude Birth Rate – Is derived from dividing the total live births by the total population.

8. Infant - An individual that is less than one year of age.

9. Low Birth Weight - Birth weight wherein is equivalent to 2,500 grams or less (5lbs., 8 ozs) regardless of the period of gestation.

10. Very Low Birth Weight – The birth weight is less than 1,500 grams (approximately 3.3 pounds).

11. Mortality Rate - Number of deaths less than 365 days divided by the total number of registered live births.

12. Crude Death Rate – Is derived by dividing the total deaths by the total population.

13. Neonatal – Infants who are 28 to 364 days of age.

14. NTA – National Telecommunication Authority, Majuro, Marshall Islands.

131

15. Oral TX – A clinical option made available to patients attending the Majuro Diabetic Clinic, in which, they receive oral medications to control the level of glucose in their blood.

16. Patient Electronic Care System - An electronic software utilized by the Kwajalein - Division of Primary Health Care to collect, analyze and disseminate information on diabetic and hypertension patients.

17. Health Disparity Collaborative Program - A federally funded program that the Kwajalein - Division of Primary Health Care utilizes to administer its Chronic Disease Programs, starting with patients with diabetes.

18. Pacific Public Health Surveillance Network – An organization of the Pacific Island countries and territories, facilitated by the Secretariat of the Pacific Community, that is responsible for disease surveillance and other health related information within the region.

19. Pediatric High Risk Program – A joint collaboration between the Majuro Hospital Pediatric Ward and the Primary Health Care’s Nutrition Program established to accommodate and treat severely malnourished children.

20. SBHC – School Based Health Center located on Ebeye, Kwajlein.

21. School Act of 1981 – After the Measles outbreak in Majuro during the Summer of 2003, the RMI Cabinet approved the new rules and regulations on immunization in reference to the Marshall Islands School Act of 1981, Title 7 Health, Safety and Welfare Code, Chapter 4, Regulations 1-15, which required all private and public schools in the RMI to enforce the immunization requirements, to maintain immunization records of all enrolled children, and to submit annual reports to the Ministry of Health.

22. Self Management Goals – These are goals advised and jointly set by the doctor and diabetic patient to help control the patient’s glucose level. The goals include health information pertaining to nutrition, exercise and prescribed medications.

23. Supplement Vitamin A & Deworming Program – The program is rendered by the Nutrition and Diabetes Program, whereby Vitamin A and de-worming capsules are provided to children ages 6 months to 14 years old and postpartum mothers. The capsules are dispensed annually on March and September.

24. TAMC – Tripler Army Medical Center, Honolulu, Hawaii.

132