Overview of the State – Republic of the Marshall Islands

 

As a grantee of the Maternal and Child Health Services Title V Block Grant Program, the Republic of the Marshall Islands (RMI) is required to do a statewide maternal and child health (MCH) needs assessment every five years. The needs assessment process outcome is the identification of priority needs for the maternal and child population groups.

The RMI Ministry of Health and Human Services’ (MOHHS – formerly known as Ministry of Health) MCH Program is responsible to facilitate the needs assessment process and administers MCH grant funds.  The mission statement of the Ministry is "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 MOHHS pursues these goals using the national facilities, staff and resources of the RMI.

 

Geography

The Marshall Islands are located in the Central Pacific Ocean, approximately 2,000 miles southwest of Hawaii and 1,300 miles southeast of Guam. They are comprised of 29 scattered chains of remote atolls, the Eastern Ratak (Sunrise) and Western Ralik (Sunset). The total land area is 181 square kilometers and has some 370 km of coastline (less than 0.01 percent of the total surface area). The Marshall Islands face great challenges in the delivery of basic health services. Transportation and communications are limited by the isolated nature of many of the islands and atolls. Two-thirds of the population lives on the two major urban atolls, Majuro and Kwajalein (including Ebeye Island). Population densities in some of the urban settlements exceed 28, 000 people/km2. More than half of the RMI total population lives in Majuro.
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.  

 Figure 1Map of the Republic of the Marshall Islands



The Marshall Islands is a parliamentary democracy, constitutionally in free association with the United States of America.  It has a developing fisheries and service-oriented economy.  It is mainly a Christian nation with the majority of the population being protestant followed by Catholic and other religions.  The two main urban centers (Majuro and Ebeye-Kwajelein atoll) have paved roads and with piped water and a sewer system.  The island of Ebeye is considered to be one of the most densely populated places in the world, only second to Bangladesh/Dakka.  While the majority of the RMI population is concentrated on the two main urban centers, it is important to note that a great portion is dispersed around the many islands/atolls.  This makes the provision of comprehensive health services to the entire population a challenge.  However, the development of fundamental services such as health care and education has, over many decades, developed and improved in the remote islands.  Health services capacity is further enhanced through provision of on-site health visits and follow-up care from the urban centers through field trips including availability of case evacuation and referrals to the central hospital.   This established system is under RMI constitutional mandate, a responsibility of the Government.

Population

The total population count of the 2011 census is 53,158; which increased only by 2,300 people since the last census in 1999. The slow growth of the population in the country is primarily caused by the emigration of the Marshallese to the United States and elsewhere. (UNFPA, 2014) The population for 2017 is 55,396. The Marshall Islands has a young population. 66% of RMI Population is less than 30 years old.

 

In FY2017, the MCH Program has served the following population:
1. Pregnant Women : 1,257

2. Infant <1 year old : 989
3. Children from 1 to 22 years old: 8,707
4. CSHCN : 156
5 Female Population 15-44 yrs old:1,984

 

Percentage of Populations Served by Title V

Pregnant Women Notes:

Number of pregnant women: 1,453

Population (Form 5b reference data): 1816

% served: 80%

 

Infant <1 year old

Number of <1 yr old with encounters for Immunization and Well baby clinic: 1,515

% served: 85%

 

Children 1 through 21 Years of Age

Number of children served : 11,363

Population (RMI Projected population): 34,434

% served: 33%

 

Children with Special Health Care Needs

Number of children served : 156

Population (registered CSHCN): 156

% served: 100%

 

Others

Number of population served: 1,984

Population of 22 and above (RMI Projected population): 38,323

% served: 8%

Projected Population, 2011 – 2015, EPPSO

Projected Population, 2016-2018, EPPSO
 

Age Group	2016		2017		2018		2019
	Male	Female	Male	Female	Male	Female	Male	Female
0-4	3814	3595	3693	3480	3579	3373	3594	3387
5-9	3911	3594	3926	3618	3898	3606	3914	3621
10-14	3563	3337	3624	3393	3705	3457	3720	3471
15-19	3219	2932	3315	3025	3356	3077	3370	3090
20-24	2049	1926	2125	1975	2288	2095	2297	2104
25-29	2176	2026	2061	1900	1905	1750	1912	1757
30-34	1781	1869	1793	1846	1824	1824	1831	1831
35-39	1593	1645	1577	1650	1552	1646	1558	1653
40-44	1381	1362	1381	1377	1385	1397	1391	1403
45-49	1267	1236	1266	1237	1257	1232	1262	1237
50-54	1064	1060	1080	1083	1099	1102	1103	1107
55-59	907	840	917	862	924	890	927	894
60-64	712	697	731	719	748	732	751	735
65-69	482	411	510	455	534	501	536	503
70-74	208	194	238	220	272	248	273	249
75+	127	182	132	187	140	196	140	196
Total	28,254	26,906	28,370	27,026	28,465	27,126	28581	27237

Source: EPPSO: Economic Planning, Policy and Statistics Office

 

 

  Female, age 15-44 years old Population by Reproductive Age

Age Group	2011 Census	2012	2013	2014	2015	2016	2017	2018	2019
15-19	2,314	2,349	2,469	2,632	2,796	2,932	3,025	3,077	3,090
20-24	2,480	2,357	2,206	2,061	1,958	1,926	1,975	2,095	2,104
25-29	2,245	2,231	2,208	2,174	2,117	2,026	1,900	1,750	1,757
30-34	1,913	1,926	1,922	1,910	1,892	1,869	1,846	1,824	1,831
35-39	1,549	1,566	1,587	1,610	1,631	1,645	1,650	1,646	1,653
40-44	1,366	1,370	1,365	1,359	1,357	1,362	1,377	1,397	1,403
Total	11,867	11,799	11,757	11,746	11,751	11,761	11,773	11,790	11,838
Source: EPPSO RMI Projected Population, 2011 RMI Household Census

Educational Attainment

The level of educational attainment is an important indicator of the degree of development and quality of life standards achieved by countries, as reflected in many demonstrated inter-relationships between education and demographic, economic and social development. For example, educated mothers tend to have fewer and healthier children. Higher levels of education also contribute to a better qualified workforce, and better educated people also have improved chances to find employment, both domestically and overseas. It is for such reasons that education is an important development goal for Pacific island countries and their development partners.

 

According to the RMI 2011 Census, 42.9% of people aged 25 and over have completed high school or pursued further studies and training; an additional 47.8 % had completed primary education (19.2%) or completed some years of High school (28.6%). While this picture represents a small improvement over the situation prevailing in the late 1990s, as reflected in comparative figures of 40.1% and 45.6% respectively, the fact that (1) 28.6% of people aged 25 or older had started but not completed high school, and that (2) this proportion actually increased since the late 1990s (21.6%), could be seen as two major policy challenges.
 

The vast majority of Marshallese attends school, although many do not complete primary school and very few go on to complete secondary or higher education. Starting at age 14, attendance rates decline noticeably for all children.

 Educational Attainment in the RMI, 1999 and 2011 comparison

Educational Attainment	1999		2011
	Number	Percent	Number	Percent
No Schooling	554	3.1%	296	1.3%
Some Elementary	2003	11.2%	1747	7.9%
Elementary completed	4284	24.0%	4247	19.2%
Some high school	3858	21.6%	6317	28.6%
High School completed	4450	24.9%	5478	24.8%
Some college or higher	1419	7.9%	2008	9.1%
College or higher completed	1303	7.3%	1987	9.0%
Total	17871	100.0	22080	100.0%
Source: RMI Household Census 2011

 

Enrollment Status

School enrollment has increased slightly for children aged 5-9 years to 80.1% in 2011 from 74.2% in the late 1990s, and increased to 91.9% from 86.6% aged 10-14 over the same period. While showing a positive development in recent years, building on these achievements in the context of achieving education for all children, especially those that drop out due to adolescent pregnancy and reversing the recent decline in enrollment represent an important policy challenge

Enrollment Ratios by Age Group, 5-24, 1999 and 2011

Age Enrolled	Number Enrolled		Total Persons		Enrollment Ratio
	1999	2011	1999	2011	1999	2011
5 - 9	4,929	5,611	6,640	7,009	74.2%	80.1%
10 - 14	6,518	5,943	7,513	6,464	86.8%	91.9%
15 - 24	4,719	3,601	10,861	9,473	43.4%	38.0%

 

Nuptiality

 Figure 2: Population 12 years old and over by marital status, RMI: 2011

Figure 2 shows the distribution of household population 12 years old and over by marital status. More than half of this population (55.4%) was married, with 29.5 percent legally married and 25.8 percent living in a common-law union or live-in status. Almost two-fifths were never married and some 3 percent were widowed and 1.8 percent were either divorced or separated. Over three-quarters of widowed persons were women; this is attributed to the difference in the age of spouses at the time of marriage (women tended to be younger than their spouses) and a higher life expectancy at birth for women compared to men. The percentage of widowed women increased with age as they tended to remarry less frequently upon divorce or the death of a spouse.

 

In every age group, a higher percentage of males were never married than females, supporting the general observation that men marry later than women. In the 15–19 age group, over 95 percent of males and 88.9 percent of females in the Marshall Islands were never married. The percentage of the never married population declined significantly with age. In the 40–44 age group, less than 10 percent of males and females were never married.
 

RMI Health Care Service System

The Marshall Islands has a well-developed/organized primary/preventive and public health system.  There are two main hospitals located in the two urbanized islands in the Kwajalein (Ebeye Hospital) and Majuro (Majuro Hospital) Atolls.  Including the two main hospitals, there are 60 health centers/health clinics located in the various islands that make up the Marshall Islands.  The two main hospitals serve the urban areas including the surrounding islands through referrals and medical evacuation.  The two hospitals provide primary/secondary and some tertiary care.  However, most tertiary care patients are referred off-islands to hospitals in the Philippines and Hawaii (Tripler Army Medical Center).  The health clinics in the Outer-Islands are staffed by Health Assistants who are locally trained and assigned to these clinics as primary care providers.  The Marshall Islands MCH Title V program is one of the key programs in the Division of Public Health and provides the mandated services for the MCH population.

 

The 177 Health Care Program (Victims of Nuclear Fallout of Bikini, Rongelap, Enewetak, and Utrik) Clinics provide primary health care services to the four atolls affected by the nuclear testing.  A primary health care physician manages the 177 Clinics. The Department of Energy has a DOE Clinic which provides medical services to the nuclear patients.  The Diabetes Wellness Center which is managed by Canvasback Missions, in collaboration with MOH, demonstrates that natural foods and an active lifestyle can reduce or replace the need for diabetic medications and provides a higher quality of life for the participants.  Taiwan Health Center concentrates on developing health education materials and training programs primarily used in Non-Communicable Diseases (NCDs) like diabetes and also helps with outreach activities.

 

These health care services include, but are not limited to : a) clinical services in the hospitals and health center facilities and outreach activities; b) primary health care or preventive services in the hospital and health center settings, school and community compounds, house-to-house outreach; c) health promotions and educational activities, special projects with community groups; d) collection of data for the Health Information System to monitor health indicators, including monitoring and evaluation of health services and the health care systems.

 

In addition to the above-mentioned government sponsored health care services, there is one private health clinic and one private optometry practices in Majuro. All of the doctors practicing in the government and private clinics are licensed under the MOHHS’ Medical Examining and Licensing Board to practice in the RMI.

 

Medical Referral is handled by the Medical Referral Office. MCH program coordinated the CSHCN referral with Medical Referral Office. RMI has a national health insurance offering basic and supplemental health insurance. For Basic insurance, patient pays a) $5 for full outpatient visit which includes laboratory, diagnostics and pharmacy b) $17 for Emergency visit and c) $10 for admission. For patient with no insurance, patient pays a) $20 for full outpatient visit which includes laboratory, diagnostics and pharmacy b) $35 for Emergency visit and c) $110 for admission. To be able to receive basic referral where patients are referred to tertiary hospitals in Hawaii, Manila, and Taiwan, patients’ needs to be enrolled in Basic Insurance. All Marshallese citizen are automatically under the Basic Insurance. For foreigners living, they need be an active member of Marshall Islands Social Security Administration with regular payment for 1 year and existing legal immigration papers.

 

Taiwan Health Center is services provide by the Republic of China, Taiwan. THC coordinate and manage the Taiwan Health Missions in RMI. Missions ranges from ophthalmology, orthopedic, ENT, Urology and other medical needs that the Ministry request the center. There are 3-4 missions a year provided in Majuro and Ebeye. THC is also bringing experts in diabetes, tuberculosis, parasitic and other specialists to provide training and expertise.

 

Wellness Center is managed by Canvasback mission with funding from the RMI Government. Wellness Center sells healthy vegetarian breakfast and lunch for an affordable price. Center also works closely with NCD Program and Community Lifestyle Program for diabetes management and education. Canvasback Mission provided two medical missions in 2018. Orthopedic and OBGYNE missions were conducted in Majuro Hospital in 2018.

 

Communication
Marshall Islands National Telecommunication Authority (MINTA) is the sole provider for voice and data communication. MOHHS contracted MINTA to purchase and install DAMA (Demand Assigned Multiple Access) Systems in the Outer Islands. 8 Health Centers in the Outer Islands were installed with the DAMA system from 2014 to 2015. There is a plan to install the next 10 health centers as soon as funding is approved. The DAMA sites will be used for voice and data. In 2016 and 2017, we will roll out the data collection and telehealth in the health centers with DAMA. The main challenge for communication is the high cost. Internet connection fee is very expensive in RMI. For Majuro Hospital, we pay $10,000 per month for 20mbps of connection. $600 per month in Laura Health Center and $600 for Woja Health Center to connect for internet dsl. For Ebeye Hospital, we pay $3,600 for the internet connection per month. A total of $14,800 per month for all our internet connection. International calls are $1.25 per minute. National Calls are $0.50 per minute. But overall, we have better communication system compared to 5 years ago. Radio VHF connection is still our main communication in the Outer Islands. To collect information like weekly disease syndromic surveillance, birth and death occurrence and any unusual event, the Outer Islands main office in Majuro calls all 56 working health centers managed by the program in a weekly basis which is scheduled every Monday and Tuesday.

 

Transportation

 

Mode of transportation:

 

a.       Majuro: Public transportation is shared taxi with minimum fee of $1.00 to maximum of $5.00. Speed boats are used to go to the small islands, 20-30 minutes ride to the nearest small islands inside Majuro.

b.       Ebeye: Public transportation is shared taxi with minimum fee of $1.00. Speed boats are used to go to the small islands, 1 hr. ride to go to the farthest health center in Ebeye. Ebeye Hospital staff use the military plane to go to one of the islets in Ebeye to provide health care. Military base also provide military ship to bring people from Ebeye to the US Military base where Kwajalein airport is located. Marshallese working in the base is also using the ship to go to work daily.

c.        Outer Islands: RMI has government own ship that brings people, food, and other supplies to the Outer Islands. Within the outer islands, there are speed boats, bicycle and trucks to bigger atolls. Air Marshall Islands has two planes that service the whole RMI. But it’s not reliable.

 

Food Security
 

The Marshall Islands faces multiple challenges. It has few natural resources, and imports by far exceed exports. Agricultural production is relatively small but important to the livelihood of people and the economy.

 

The Republic of Marshall Islands (RMI) has been severely affected by rising food and fuel costs coupled with natural disasters. The dependency on imported fuel and food has led to high inflation rates. According to the RMI Food Security Policy (FAO, 2013), the food import in RMI goes up to 80-90% depending upon Islands. The population has seen rapidly increasing levels of food and nutrition related non communicable diseases, which impact negatively on health system, families and national economy.

 

The major constraints to food security in RMI are:

•    Limited technical expertise in agriculture production with the Ministry of Resources and Development (MRD)
•    Lack of improved agriculture and livestock production skills among growers
•    Limited disease and pest control and surveillance capacity and practices in Agriculture production system
•    Lack of food preservation/processing facilities, technologies and skills
•    Limited awareness and knowledge on nutrition 
•    High vulnerability to natural disasters