Country Health Information Profile for
The Republic of the Marshall Islands 1997

by World Health Organization


THE MARSHALL ISLANDS, THE REPUBLIC OF

COUNTRY SITUATION AND TRENDS
HEALTH STATUS
NATIONAL HEALTH PRIORITIES
HEALTH RESOURCES
WHO COLLABORATIVE PROGRAMMES
SOCIOECONOMIC AND HEALTH INDICATORS: Part 1
SOCIOECONOMIC AND HEALTH INDICATORS: Part 2



COUNTRY HEALTH INFORMATION PROFILE

THE MARSHALL ISLANDS, THE REPUBLIC OF

COUNTRY SITUATION AND TRENDS

Geography

Demographic Statistics

HEALTH STATUS

Morbidity

Mortality

Major health problems

 

COUNTRY SITUATION AND TRENDS

The Republic of the Marshall Islands is made up of two nearly parallel chains of islands comprising
29 coral atolls, each made up of many islets, and 15 islands located in the North Pacific Ocean. Scattered over 2 million sq. km. of the Pacific Ocean, the total land area is only 179 sq. km., 20% of which is uninhabitable because it was previously used as a nuclear testing site or because it is now used for United States military purposes. Approximately half of the population live in Majuro, which is only 3.75 square miles and about
20% of the population live in Ebeye, located on the southwest corner of Kwajalein Atoll, the site of the U.S. Army's Kwajalein Missile Range. Majuro and Eveye represent some of the world's highest population densities. The land mass is distributed over 1 225 atolls, islands and islets, with a mean height of only 7 feet above sea level. These low elevations make the atolls vulnerable to damage from storms and high waves.


As of (Year)


As of (Year)

POPULATION [Total]

[0-14 years]

[65+ years]

56 219 (1995)

28 615 (50.9%)

1 639 (2.9%)

LIFE EXPECTANCY AT BIRTH (years) [Both]

[Male]

[Female]

62.8 (1994)

59.9 (1994)

63.6 (1994)





CRUDE BIRTH RATE

23.93 (1993)

TOTAL FERTILITY RATE

3.3 (1993)

(per 1 000 population)


(per woman 15-49 yrs.)


CRUDE DEATH RATE

(per 1 000 population)

4.00 (1993)

% OF POPULATION SERVED [Total]
WITH SAFE WATER [Urban]

76.5 (1990)

100.0



[Rural]

33.0

INFANT MORTALITY RATE

(per 1 000 live births)

26.42 (1994) *

% OF POPULATION WITH ADEQUATE [Total]
SANITARY FACILITIES [Urban]

36.5 (1988)

...

MATERNAL MORTALITY RATIO

(per 100 000 live births)

None **

[Rural]

...

* Infant mortality rate was reported as 63.0 in 1988 census; in 1994-95 was reported to be about 30.0 (Ministry of Health data)

** There are no cases of maternal deaths as a result of child birth.

The Republic of the Marshall Islands has one of the world's highest rates of population growth, 3% to 4% (based on 1988 census data and UNFPA reports) and fully half of the population is below 15 years of age. Even though more recent statistical analyses indicate that the rate of population growth may be decreasing in some areas, the population is still expected to double in less than 20 years. The population has outpaced the facilities for the provision of safe water and sanitation.

 

HEALTH STATUS

In 1993 the leading causes of morbidity were:


MORBIDITY


Children (0-4)

Children/Teenagers (5-18)

Adults

Respiratory diseases

Infectious and parasitic diseases

Diabetes

Infectious and parasitic diseases

Nutritional diseases

Injury due to accidents and fish
poisoning

Hypertension

Coronary artery disease

Skin diseases

Respiratory diseases

Arthritis

Gastrointestinal diseases

Skin diseases



Endocrine and nutritional diseases


* Republic of the Marshall Islands Health and Vital Statistics Abstract 1993, Ministry of Health, as reported in the 1996/Draft
UNFPA Situation Analysis of the Republic of the Marshall Islands.

In 1993 the mortality patterns for all age groups were:

MORTALITY (per 100 000 population)

Males

Females

Pneumonia

79.0

59.0

Sepsis

45.0

74.0

Cancer, all types

44.0

49.0

Myocardial infarction

36.0

8.0

Cerebrovascular disease

22.0

35.0

Suicide

35.0

8.0

* Republic of the Marshall Islands Health and Vital Statistics Abstract 1993, Ministry of Health as reported in the 1996 Draft/
UNFPA Situation Analysis of the Republic of the Marshall Islands.

Diseases not listed in the preceding tables which cause significant morbidity, but which are not reflected in mortality data, include sexually transmitted diseases (syphilis and gonorrhoea), tuberculosis and leprosy. There has been one death from AIDS in a non-resident Marshallese person and there is now one confirmed HIV positive case in the Marshall Islands.

Deaths are severely underreported in the Marshall Islands; in 1986, it was estimated that 57% of adult deaths were not reported. In 1993, of the 240 reported deaths, 18% were of persons aged 75 and older, while infant deaths accounted for 14% of the total. The main causes of infant deaths in 1993 were prematurity (33%), and pneumonia (21%). Childhood malnutrition is a very significant health problem of children below five years of age, accounting for approximately 17% of all deaths in that age group.

In the context of decreasing financial resources, high population growth and overcrowding in urban areas, the people of the Republic of the Marshall Islands continue to suffer from the infectious diseases usually associated with rapidly growing, low income countries, while at the same time they are increasingly being affected by the negative effects of a modern lifestyle. Leprosy and tuberculosis coexist with increasing rates of diabetes, hypertension, cerebrovascular accidents and heart disease. Immunization coverage in 1994 was reported as 96% for BCG while the coverage for measles, the basic series of OPV and DPT averaged only 63% in the same time period.

The consumption of imported foods high in sugar and fat has led to adult obesity and a rise in noncommunicable diseases. Teenage pregnancy, suicide, and alcoholism are at unacceptable levels. The use of tobacco under conditions of overcrowding contributes to increasing numbers of patients with asthma and bronchitis.

 

NATIONAL HEALTH PRIORITIES

The national health priorities are to:

develop and strengthen the capabilities of indigenous personnel;
institutionalize primary health care strategies, decentralize health care, promote community-based health care
and take steps to make community-based health care systems as self-reliant as possible;
strengthen and develop the health information system;
secure a sustainable financial base from the government, community and private sector for health care delivery;
reduce transmission of sexually transmitted diseases and develop HIV/AIDS/STD prevention programmes;
reduce population growth and urban densities;
address and manage causes and effects of malnutrition;
address, prevent and manage rising cases of diabetes and their health and social impact;
coordinate and strengthen the provision of health education; and
coordinate all aspects of the health care delivery system through the National Health Services Board of the Ministry of Health.

 

HEALTH RESOURCES

Training of indigenous personnel is considered a government priority as the lack of a well-trained indigenous workforce remains one of the main impediments to progress in health development. An inordinate proportion of the health budget is spent on the salaries of expatriate doctors, dentists and nurses due to the lack of a well-trained national health workforce.

Total recurrent health expenditures in the Marshall Islands previously amounted to over 15% of the GDP; since 1988 expenditures have amounted to 12% to 13% of the GDP. As a share of total recurrent government expenditures however, this level has amounted to over 20% since 1988. The overall per capita recurrent budget was US$78.00 in 1992, as compared to US$143.00 in 1988.

A significant proportion of health services are funded under external aid or grant programmes including US Federal Health Grants and grants under the Compact of Free Association between the Marshall Islands and the USA; the 177 Health Care Plan for populations affected by nuclear testing, and bilateral donor grants for developmental programmes sponsored by WHO, UNDP, UNICEF, and UNFPA.

Since 1992, the Asian Development Bank has lent the Marshalls more than US$40 million for projects or technical assistance.

Internally generated funds include recurrent budget appropriations, a Basic Health Plan (Social Security Health Fund), and a smaller Supplemental Health Plan established in 1992. Over 32% of the health fund has been budgeted for health services outside the Marshalls, services which benefit only a very small percentage of the population. The US funded share of health care financing has amounted to over 45% of the budget. Economic reforms have been planned, including government budget cuts, as financial crises are imminent given that the Compact of Free Association aid monies to the Marshalls will end in 2001. The implementation of programmes to address many of the main health problems would be greatly facilitated if there were adequate numbers and types of Marshallese health workers who could provide appropriate services.

 

WHO COLLABORATIVE PROGRAMMES

WHO's regular budget activities focus primarily on developing human resources for health, on further supporting the reorganization of the public health nursing services, including institution of the zone nursing project, and on providing technical support for the control of certain communicable diseases.

Other priority areas include health promotion and health education, particularly in regard to noncommunicable diseases, nutrition, substance abuse and reproductive health. However, these activities are the focus of the US$12 million Health and Population Project now being implemented with funding and technical support from the Asian Development Bank. WHO was represented on the ADB fact-finding mission and continues to stay abreast of activities being implemented through the project.

Major areas of country activities (1996-1997)

Strengthening primary health care services through the training of local health workers;
expanding and updating the knowledge and skills of clinical nurses;
improving the quality of patient care, thus decreasing complications and the need for in-patient services;
establishing and implementing a practical training programme at Ebeye Hospital for recent high school graduates;
further strengthening the training of nurses in public health and midwifery to prepare them to provide
community-based services in the restructured primary health care delivery system;
continuing support for the training of a dietitian/nutritionist for Ebeye Health Services;
assessing the effectiveness of current tuberculosis and leprosy surveillance and control programmes; and
increasing the capacity of health staff to identify, treat and follow up persons with tuberculosis and leprosy.

Projections for 1998-2001

The 1998 to 1999 priority areas of collaboration will continue to focus on strengthening the indigenous health workforce. There still remains a critical shortage of national doctors, nurses and paramedical health workers, resulting in an inordinately high percentage of the health budget being spent on the salaries of expatriate health workers and on off-island medical referrals.

A major problem for health services that needs to be addressed is the training of a local workforce of adequate size. The number of Marshallese students entering the College of the Marshall Islands health training programmes is decreasing and there are few Marshallese young people enrolled in pre-nursing courses.

Therefore, priority areas of collaboration for the 2000-2001 biennium are expected to focus on the recruitment of young people into the health professions and related training and continuing education activities.

 

SOCIOECONOMIC AND HEALTH INDICATORS: Part 1


Indicator(s) for: REPUBLIC OF THE MARSHALL ISLANDS

Year

Data

Source of Data






1.

Area (in 1 000 sq.km.)

1995

0.179

12/96

2.

Estimated population ('000)

1995

56.22

12/96

3.

Annual population growth rate (%)

1995

3.76

12/96

4.

Percentage of population - below 15 years of age

1993

50.90

12/96


- 65+ years


2.90


5.

Urban population (%)

1994

65.00

14/94

6.

Rate of natural increase of population (% per annum)

1990

6.10

13/91

7.

Crude birth rate (per 1 000 population)

1993

23.93

12/96

8.

Crude death rate (per 1 000 population)

1993

4.00

12/96

9.

Life expectancy at birth - Total (years)

1994

62.80

12/96.1


- Male (years)

 

59.90

 
 

- Female (years)

 

63.60


10.

Infant mortality rate (per 1 000 live births)

1994

26.42

12/96.1

11.

Total fertility rate (women 15-49 years)

1993

3.30

12/96

12.

Socioeconomic indicators for the year 2000





- Estimated population ('000)

2000

63.00

14/95


- Life expectancy at birth - Total (years)


...



- - Male (years)

...



- - Female (years)

...



- Annual population growth rate (%)

1995-2000

3.42

14/93


- Crude birth rate (per 1 000 population)


...



- Crude death rate (per 1 000 population)


...



- Rate of natural increase (% per annum)


...


13.

Per capita Gross National Product at market prices (US$)

April 1995

1850.00

12/96.1

14.

Rate of growth of per capita GNP (%)

1984

9.90

06/86

15.

Percentage Gross Domestic Product (GDP) derived from manufacturing at constant factor cost (%)

1990

60.58

12/96.1

16.

Economically active population in primary sector

1988

11488.00

12/96.1


- Number in agriculture ('000)

 

3044.00



- Percent in agriculture (%)


46.10


17.

Daily per capita calorie supply (calories)


...


18.

Daily per capita protein supply (grams)


...


19.

Adult literacy rate - Total

1988

90.70

13/91


- Male


...



- Female


...


20.

Health expenditure





- Amount (US$)

1995

4733397.00

12/96.1


- Per capita

1995

85.00



- As % of total budget

1995

13.00


 

Sources of Data:


13/91:

Government's Report on Evaluating the Strategies for Health For All By the Year 2000, Common Framework: Second Evaluation (CFE/2), 4 May 1991 and 12 June 1991.

06/86:

1985 Trust Territory of the Pacific Islands, 38th Annual Report, October 1, 1984 to September 30, 1985, Department of State, United States of America.

06/91:

Government's Reply to Cumulative Totals of Cases and Deaths from 18 Selected Diseases for the Year 1991.

12/96:

Country Health Information Profile revised by Government, August 1996.

12/96.1:

Country Health Information Profile cleared and revised by Government, December 1996.

14/93:

Expanded Programme on Immunization Information System, Summary for the WHO Western Pacific Region, WHO/EPI/CEIS/93.1 WP, April 1993.

14/94:

Pacific Island Populations, Report prepared by the South Pacific Commission for the International Conference on Population and Development, 5-13 September 1994, Cairo.

14/95:

Expanded Programme on Immunization Information System, Summary for the WHO Western Pacific Region, WHO/EPI/CEIS/95.2 WP, September 1995.

 

SOCIOECONOMIC AND HEALTH INDICATORS: Part 2


Indicator(s) for: REPUBLIC OF THE MARSHALL ISLANDS

Year

Data

Source of Data

21.

Health manpower a/


No. of Persons

Rate per

10 000



- Physicians

1991

20

4.30

13/91


- Medical assistants


...

 



- Professional nursing/midwifery personnel

1991

134

29.00


22.

Leading causes of adult morbidity


No. of Cases

Rate per

100 000



- Diabetes

1993

108

414.00

12/96.1


- Hypertension

1991-93

878

2493.00



- Coronary artery diseases

1993

...




- Arthritis

1993

...



23.

Leading causes of death for all age groups

 

No. of Deaths

Rate per

100 000



- Pneumonia

1993

36

...

12/96.1


- Sepsis

1993

31

...



- Cancer, all types

1993

...

...



- Myocardial infarction

1993

...

...



- Cerebrovascular disease

1993

15

...



- Suicide (hanging)

1993

9

...


24.

Cases & deaths for six diseases under the WHO-EPI

 

Cases

Deaths



- Diphtheria

1994

0

 

14/95


- Pertussis

1994

0

 



- Tetanus

1994

0

 



- Neonatal tetanus

1994

0

 



- Poliomyelitis

1994

0

 



- Tuberculosis

1994

- 61 b/

...



- Measles

1994

0

 


25.

Cases & deaths for diseases under the WHO Annual CD Bulletin

 

Cases

Deaths



- Gonorrhoea

1991

87

...

06/91


- Hepatitis viral - Type A

1991

1

...



- -Type B

1991

28

...



- - Unspecified

1991

5

...



- Syphilis

1991

175

...



- Trachoma

1991

783

...



- Yaws

1991

-

-


26.

Cases & deaths for six diseases under the WHO Monthly CD Notes

Cases

Deaths



- Cholera

1991

-

-

06/91


- Dengue/DHF

1991

-

-



- Encephalitis

1991

-

-



- Influenza (Haemophilus, type b infection)

1991

1317




- Meningitis

1991

...

...



- Plague

1991

...

...


27.

Percentage of infants below 1 year of age who have been fully immunized against tuberculosis, diphtheria, polio and measles and pregnant women immunized against tetanus

 





- BCG

1994

93.8


12/96.1


- DPT III

1994

79.0




- OPV III

1994

82.5




- Measles

1994

24.0




- Tetanus II

1994

89.0



28.

Percentage of population served with safe water

1995

T-82.0; U- 82.0; R- ...

12/96.1

29.

Percentage of population with adequate sanitary facilities

1993

T- ...; U- 88.0; R- 57.14

12/96.1

30.

Percentage of low birth weights (below 2 499 grams)

1994

14.4


12/96.1

31.

Maternal mortality ratio (per 100 000 live births)

 

None c/


12/96.1

a/ Public sector only

b/ Cases for 1993

c/ There are no cases of maternal deaths as a result of child birth.




Originally published by WHO Western Pacific Region as part of the Country Health Information Profile .



 




(c) WHO Western Pacific Region 1997
Reproduced with permission