Country Health Information Profile for The Republic of the Marshall Islands 2000 by World Health Organization

COUNTRY SITUATION AND TRENDS

Geography, Demographic Statistics

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.

* 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

Morbidity,Mortality and Major health problems

In 1993 the leading causes of morbidity were:

*** 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

Human, financial, resource requirements

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

Major areas of country activities (1996-1997), Projections for 1998-2001

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.

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


(c) WHO Western Pacific Region 2000
Reproduced with permission