Summary of Needs Assessment Process

In 2020, a comprehensive review of MCH population needs, program/workforce capacity, and partnerships that are critical components of the state system to provide care to MCH populations was undertaken. The assessment data collection process helped to identify the strengths and weaknesses, and other factors affecting MCH Services in RMI. State Priority Needs, objectives, and linking of National Performance Measures and Evidence-based/Informed Strategy Measures were derived from the needs assessment stakeholder engagement addressing of the gaps and interventions.

The process involved various departments and programs within the Ministry and other partners and stakeholders including community members to identify health priority needs and at the same time assess the capacity within the State to address these needs. This is a continuous and on-going process throughout the year as the needs may change depending on the situation(s) that may arise.

The design of the Needs Assessment, including the diversity of perspectives for input, was based on a collaborative approach that:

1. incorporated input from key stakeholders with different perspectives, not only public health professionals;
2. ensured geographical representation across the RMI; and,
3. built partnerships among stakeholders through participation in the Needs Assessment process.

Logic Model

The MCH Logic Model depicts the process used, which involves continuously analyzing performance and reassessing strategies as time progressed. This logic model served as a model for the strategic meetings as input was synthesized and defined over time and as the RMI continued to work in partnership to improve the MCH Block Grant.

Figure 5 Title V MCH Block Grant Needs Assessment Framework Logic Model

Recognizing the complexity of the Needs Assessment, RMI MCH organized a Needs Assessment team that worked with stakeholders to ensure that all domains were adequately addressed and that priorities, objectives and strategies made sense within and across population domains. The MCH 2020 Needs Assessment Coordinating team, was led by MCH Director Caroline Johnny, IT Director Edlen Anzures and Lead consultant Marshall Islands Epidemiology & Prevention Initiatives (MIEPI).

RMI’s MCH 2020 was a short 1-year to the process, promoting and practicing collaboration with MCH 2020 Stakeholders and keeping the door open for public input. Key activities included:

• Host and facilitate MCH meetings
• Attend, facilitate, or present at three MCH strategic planning meetings with various stakeholders
• Conduct Focus Groups with pregnant mothers, women without children, women with children and women who gave birth in the outer islands.
• Gather input through the MCH Public Input survey.

A key difference from MCH 2015, which also engaged stakeholders and implemented solid action plans, was intentionality during MCH 2020 to build partnerships and initiate collaboration at the state and local levels including hosting stakeholder meetings with the World Bank Early Childhood Development Program and working alongside NGO partners to administer qualitative surveys.

The outcomes of this intentionality included new partnerships, cross connections between counties, and presentations that provided education about KDHE MCH services so that the state was well represented and participants were informed and valued through in-person interaction.

Table 10. RMI MCH 2020 Stakeholders

MoHHS Guiding Framework

Throughout the process, the focus was on the MoHHS’ Mission Statement: “To provide high quality, effective, affordable, and efficient health services to all people of the Marshall Islands, through a primary care program to improve the health statistics and build the capacity of each community, family and the individual to care for their own health.” To the maximum extent possible, the MOH pursues these goals using the national facilities, staff and resources of the RMI.

Methods for Assessing MCH Populations

Selection factors that was included during the process:

1. Availability of resources and services within the islands
2. Challenges and success of meeting the targets
3. Strategies and activities for each state priorities
4. Mapping of information, data and sources
5. Commitment of Ministry of Health, Community, and stakeholders.

Data Sources

Both qualitative and quantitative data were implemented in the Needs Assessment process for MCH 2020. Qualitative data consisted of focus group surveys, prioritization ranking survey and stakeholder, partner, and community input and feedback at stakeholder meetings.

Quantitative indicators were compiled and presented at meetings to stakeholders and partners and much of the discussion toward determining the status of MCH and specific needs for each MCH domain came from sharing this data. Limitations were noted as data were disseminated.

Data sources included, but not limited to:

Population level

EPPSO Population Data

RMI MoHHS Annual Report 2018 (Vital Statistics)

RMI MOHHS Key Performance Indicator Dashboard, 2016-2019

MCH/RH administrative data

UNFPA reports

UNICEF ICHNS Survey 2017

Public School System Annual Report 2018

Qualitative data were used to assign meaning to the quantitative data that were reviewed. Data driven decision-making was a key factor in the Needs Assessment process and balanced the degree of data collected through meetings and surveys. This combination of proactive input provided rich and varied data.

Status of MCH in the RMI

Projected MCH Population

Current projected population was derived from the review of RMI 2011 Census conducted by EPPSO.  It is estimated that over 40% of the RMI population is under the age of 17 years.

Source: EPPSO RMI Projected Population, 2020-2025, RMI Household Census 2011

Demographic Indicators

A review of Key Performance Indicators Annual Scorecard from 2016 and 2019 show no change in the Infant Mortality Rate in 2019 (16) from 2016 (15). An improving trend was reported for Early child (<5 years) mortality and Maternal mortality ratio. Early child mortality rate decreased by nearly 50% (17 from 32) and below the Sustainable Development Goal (SDG) target of 25.

Figure 6. MCH Indicators, KPI Scorecard 2019

   Source: Key Performance Indicators Annual Scorecard 2019, RMI MoHHS

Prenatal Visits

It is not uncommon for women in the RMI to visit the hospital for their first Prenatal visit late in their 2nd or 3rd trimester. The Reproductive Health clinics observe that over 20% of mothers visit the hospital for their first prenatal booking in the 3rd trimester, with some coming into the hospital just in time for delivery.

Table 12. First prenatal visit by trimester, for women (≥20 years) and teens (≤19 years), 2010-2019, RMI

Source:  Administrative log books, Reproductive Health Clinic, MoHHS, 2019

Family Planning Users

In the RMI, the large majority of family planning users recorded at the Reproductive Health Clinics are females.

Table 13.Unduplicated Family Planning users, 2010-2019, RMI

Source:  Administrative log books, Reproductive Health Clinic, MoHHS, 2019

In 2017, only 16% of women 15-44 years who used any form of contraception. The most common form of Family planning method was female sterilization, followed by 3-month hormonal implant. Less than 13% of women 15-44 used oral contraceptives.

Table 14: Contraceptive Rate 2011-2017 and Unduplicated users by preferred Family planning method 2017, RMI

Source: RMI Ministry of Health and Human Services Annual Report FY17

Infant birth weight

Table 15. Summary of Birth Information, RMI 2010-2017

Source: RMI Ministry of Health and Human Services Annual Report FY17

Infant Mortality Rate

Figure 7. Infant Mortality Rate, RMI 2009-2017

Source: RMI Ministry of Health and Human Services Annual Report FY17

Table 16. Infant Causes of Death, RMI 2017

Source: RMI Ministry of Health and Human Services Annual Report FY17

Dental Services

In 2020, the Dental Clinics saw over 7,042 patients, with nearly half of these were extraction cases.

Table 17. Patients seen at Dental Clinics by Dental Service received, RMI 2020

In 2020, the Dental Clinics observe on average 200-300 patients in the RMI were elementary age children (1-14 years). With over 80% of these cases were children seen are due to pain, often resulting in tooth extractions.

Dengue Outbreak in RMI June 2019 – September 6, 2020

Cases: After the initial cases in Ebeye in May 2019 transmission soon occurred to Majuro.  A travel ban to the Outer Islands kept them without cases until it was lifted in November 2019. Atolls affected include Utrik, Aur, Maloelap, Mili, Ailinglaplap, Wotje, Arno, Namu, Enewetak and Jaluit. Currently only Majuro has new cases, continuing the lower-level transmission.  To date there have been 3,591 dengue like illness of which 1,719 have been lab confirmed. Two deaths (Majuro and Arno) and one severe dengue patient evacuated out-of-country to date.

Organization of Response:

• EpiNet teams activated on July 16, 2019 and now with declining cases meet 1x/week.
• Presidential Declaration of Health Emergency and activation of multi-ministry and NGO National Emergency Operations Center on August 6, 2019 and RMI Dengue Response Plan finalized
• Conference calls with technical assistance partners held as needed. 

Case Definitions (based on PPHSN):

Probable case: Acute fever > 2 days with two or more of the following: anorexia and nausea; aches and pains; rash; low white blood cell count; tourniquet test positive; warning signs (abdominal pain or tenderness; persistent vomiting; mucosal bleeding; liver enlargement; lethargy, restlessness; increase in hematocrit with decrease in platelets).

Confirmed case: Suspected case with lab confirmation (+Rapid test (for NS1 or IgM) or +PCR test)

Current Response Goals: 

1) Slow spread in affected atolls; prevent spread to other outer atolls, 2) Assure excellent clinical care to minimize deaths, 3) Stop transmission entirely

Surveillance:  Daily Active surveillance continues Majuro, Ebeye, and Outer islands with some communication challenges.

Vector Surveillance and Control:  1) fumigation of houses of new cases in Majuro continues, 2) Ongoing Fumigation on vessels.  Mosquito trapping is continuing and specimens will be sent to CDC for identification and virus testing.

Outer Islands:  An Outer Islands Protocol was implemented to include training of OI Health Assistants to perform Dengue Rapid Test; Patient Care Management; One new case identified in Mili Atoll signifying reintroduction to that Atoll.  Public Health & Environmental team is going for investigation and mosquito eradication.

Majuro:  Cases continue to be in double digits (18) in the last week; the high-density villages of Rita (3) and Delap (5) and Woja (3) are the hotspots at this time. Of the 18 new cases, 8 (44%) were hospitalized; 1 discharged with the average length of stay at 5 days; 7 remain hospitalized (2 pediatric, 5 adults)

Travel Advisory:  There is no current travel restriction from outer atolls/islands to/from Majuro and or Ebeye by sea and/or air

Health Education: Ongoing radio awareness in V7AB, 103.5 and new radio station 90.7 discuss the ongoing dengue activities and data; Dengue Fever SitRep in MIJ Newspaper updated weekly; MOHHS Facebook posting of updated situation reports, health alerts and other related activities.  More Community Participation is being encouraged to stop the outbreak.  WASH cluster is resuming meetings to work with MalGov  and MAWC for community cleanup.

Republic of the Marshall Islands, Ministry of Health and Human Services, Organization Chart 2020

Agency Capacity

The MCH/CSHCN Program coordinator is a member of the Ministry of Health and Human Services Core Committee which coordinates all community awareness activities. The MCH program is also a member of the RMI Interagency Council under a Memorandum of Understanding as well as parent representatives. The Interagency Council meets regularly to ensure continuous services are provided to all CSHCN, both in school and those who are not.

The program capacity includes delivery systems, workforce, policies, and support systems (e.g., training, research, technical assistance, and information system) and other infrastructure needed to maintain service delivery and policy making activities. Program capacity results measure the strength of the human and aerial resources necessary to meet public health obligation. As program capacity sets the stage for other activities, program capacity results are closely related to the results for process, health outcomes, and risk factors.

The State Program Collaborate with other States Agencies and Private Organization. State establish and maintain ongoing interagency collaborative processes for the assessment of needs with respect to the development of community-based systems of services for CSHCN. State programs collaborate with other agencies and organizations in the formulation of coordinated policies, standards, data collection and analysis, financing of services, and program monitoring to assure comprehensive, coordinated services for CSHCN and their families.

The State support for communities. State programs emphasize the development of community-based programs by establishing and maintaining a process for facilitating community systems building through mechanisms such as technical assistance and consultation, education and training, common data protocols, and financial resources for communities engaged in systems development to assure that the unique needs of CSHCN are met.

The services that are the base of the MCH pyramid of health services and form its foundation are activities directed at improvement and maintaining the health status of all women and children by providing support for development and maintenance of comprehensive health services systems including development and maintenance of health services standard/guidelines, training, data and planning systems. Examples include needs assessment, monitoring, training, applied research, information systems and systems of care. In the development of system of care it should be assured that the systems are centered, community based and culturally competent.

Workforce development/Capacity building
Health Organization: National MCH/RH Program is under the Bureau of Primary Health Care Services. As the national program, MCH Director work closely with Majuro, Ebeye, Outer Islands and 177 Health Care Program on MCH program and activities.
Secretary of Health and Human Services - Mr. Jack Niedenthal. Secretary Niedenthal advocates the work plan and activities of the MCH Block Grant.
Deputy Secretary of Health and Human Services: Mailynn Konelios-Langinlur. She provides advice and support to the program alongside with Public Health Medical Director. MCH Director reports directly to the Deputy on administrative functions of the program.
Public Medical Director: Acting / Dr. Frank Underwood. Dr. Underwood provides over all clinical advise to the MCH Program alongside the OBGYNs and Pediatricians.

Staff funded under MCH Block Grant
MCH Director: Caroline Johnny-Jibas. Caroline graduated from the College of the Marshall Islands in 1995 with an AS Degree. She started working in 1996 as a Public Health Zone Nurse before she was promoted to be the Hansen’s disease program coordinator in 2011. She was transferred to MCH program as the director in April of 2016. She manages and coordinates all the activities between all clinics, health centers and stakeholders. Funded under the Compact funds.
CSHCN Coordinator: Caroline Johnny-Jibas. Currently, Caroline is the coordinator until a new one is hired. Position will be open in the next budget period. As the CSHCN Coordinator, she works closely with Pediatricians, Pediatric Ward Head Nurse, MCH nurses, EHDI (Early Hearing Detection Initiative) Program, Medical Referral Services, Public School systems and Shriner’s Hospital. She is also member of the committee leading the World Bank Project: RMI Early Childhood Development Program.
Staff Nurse: Maypol Briand, Carlwin Aisea, Eomra Lokejak and Johanna Rilang. The three staff nurses graduated with AS Nurse degree in College of the Marshall Islands. They are responsible for Women’s Health Clinic, Prenatal and Post-Natal Clinic, Youth to Youth Clinic and leads MCH related outreach mobile visits. Funded under MCH Block Grant.
Dental Assistant: Kim Laidren. She overlooks pregnant women referred to the dental clinic and refer patients when further evaluation and treatment is needed. Funded under MCH Block Grant.
Staff working with MCH Program funded under different grants
Family Planning Services Staff: Tauki Korean, Jacqueline Mojilong, Whynonna Wonne and Komi Mea. These staff are paid under Title X – Family Planning Grant. Aside from their family planning activities, they are also working with the Women’s Health, Prenatal and Post-Natal clinics, Youth to Youth in Health Clinic and outreach activities
Ebeye MCH Coordinator: Ana Valotu. She handles Women’s Health, Prenatal and Post-Natal Clinic, and Family Planning Services in Ebeye Hospital along with 1 nurse.
OBGYNE: Dr. Meeankshi Prathak, Dr. Ivy Claire Lapidez, Dr. Corazon Rivera, Dr. Andrea Abello. There are 3 OBGYNs on Majuro and 2 on Ebeye.
Pediatrician: Dr. Mary Jane Gancio, Dr. Menasa Baleinamau, Dr. Venus Jopia, Dr. Paz Estoesta. There are 3 Pediatricians in Majuro and 1 in Ebeye
SSDI Coordinator: Edlen J. Anzures. She graduated from Adamson University with a degree of B.S. Computer Engineering and recently finished DDM (Data for Decision Making) course under Fiji School of Medicine. She works closely with MCH Director on the activities supported by SSDI. She is also the Health Informatics Director of the Ministry of Health and Human Services.

SSDI Data Encoder/Administrative Staff: She is funded under SSDI grant. She works closely with MCH Director, assist in the administrative needs of the program and enters encounter forms for MCH/RH program.
Deputy Secretary of Health and Human Services: Francyne Wase-Jacklick. She graduated in Hawaii Pacific University with a degree of B.S. Biology and A.S. Biology in Mt. St. Mary College. She provides support in the monitoring and evaluation of the work plan of the MCH Program. Mrs. Wase-Jacklick was recently promoted to Deputy Secretary.

Nurse Practitioners: There are 10 Nurse Practitioners that rotate duty in the MCH, RH, Immunization and other Public Health programs. They were trained to handle prenatal, family planning, cancer screening, ncd screening and management, immunization services and other PH activities.

Medical Interns: There are 6 medical interns that are rotating in MCH clinics and activities as part of their training.

National MCH Program under the Bureau of Primary Health Care Services aims to keep the goal of the bureau: Preventative and public health services will be efficiently maximized through a healthy islands lifestyle concept and with essential medical and administrative functions to ensure that the health and life span of various individuals, families and communities are enhanced.

The Bureau of Preventative and Public Health includes the following departments:

         Outer Island Health Services

         Communicable Diseases

       STD/HIV

       Leprosy

       Tuberculosis

         Non-Communicable Diseases

       Diabetes

       Hypertension

       Cancer Control Program

         Maternal and Child Health

         Immunization

         Behavioral Health

         Health Promotions

         Zone Health/Community Outreach

         Administration

There is streamlining of program activities and coordination and reduction of silos to avoid duplication of efforts and over-all improvement of services for MCH population.
Improvement Plan on Workforce and Capacity Building
1. Create and implement a MCH 101 training module for new and old employees.
2. Monthly meetings on quality improvement of MCH State Action Plan
3. Continue the MCH Workshop

Partnerships and collaborations

The MCH program collaborates with all the programs in Public Health and other partners, local and international in providing quality and essential services to the target population on Majuro, Ebeye and the outer islands.  Such services include oral health hygiene, STI/HIV services, Non communicable diseases, non-communicable diseases, mental health and human services, Cancer Program, TB and Leprosy program, EHDI, Outer Islands Health Centers, wellness and 177 Health Care program.

The MCH program also partners and collaborates with international programs such as UNICEF, UNFPA and WHO.  UNICEF, in collaboration with MCH, MOHHS conducted the Nutritional Survey in 2017 and other activities for the immunization program. UNFPA, in collaboration with MCH, MOHHS in 2018 conducted the Health Facility Readiness Service Availability (HFRSA), with the results and findings releasing October 2020 and other activities targeting women’s health and reproductive health.  A workplan for RMI has been created to with activities to implement.  UNFPA also provided capacity building to the staff to improve counselling services and Gender Based Violence.  The program also collaborates with World Bank on the activities for the Early childhood program for the MOHHS component.  Workplan has been created with activities to implement.  WHO provides assistance in training of midwives and other fields related to MCH.

MCH partners and collaborates with local NGOs like WUTMI, YTYIH, MIEPI and government agencies like Ministry of Culture and Internal Affairs and Public-School System for MCH activities.

 Identifying Priority Needs and Linking to Performance Measures