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.  

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 2019 is . The Marshall Islands has a young population. 66% of RMI Population is less than 30 years old.

 

In FY2020, the MCH Program has served the following population:
1. Pregnant Women : 1,631

2. Infant <1 year old : 1,028
3. Children from 1 to 22 years old: 3,588

4. CSHCN : 89
5 Others: 2,668
 

Population Demographics

 

The population of the RMI is 53,158 persons (2011 Census), with Majuro and Kwajalein (largely Ebeye) currently accounting for three-quarters of the country’s population (Table 1). The RMI population growth rate was a mere 0.4% over the past twelve years. However, the United Nations Development Programme (UNDP) estimates RMI’s true population growth rate as 2.2%, one of the highest in the Pacific region. Furthermore, the average annual growth rate in the outer atolls and islands -1%, depicting a rural to urban migration, with overseas destinations assuming greater importance as well.

Table 1. RMI Population Size, Growth Rate and Density for Majuro, Kwajalein and Outer islands

Atoll /Island	Population				Average Annual Growth Rate			Land area sq./ miles	Population Density
	1980	1989	1999	2011	1980-1988	1988-1999	1999-2011		1988	1999	2011
TOTAL (RMI)	30,873	43,380	50,840	53,158	4.2	1.5	0.4	70.1	619	726	759
Majuro	11,791	19,664	23,676	27,797	6.3	1.8	1.4	3.8	5,244	6,314	7,413
Kwajalein	6,624	9,311	10,902	11,408	4.2	1.5	0.4	6.3	1471	1,722	1,802
Other outer atolls & islands*	12,458	14,405	16,262	13,953	2	1	-1	55.3	395	419	337
*the remaining 32 outer atolls and islands and EPPSO-classified as ‘Rural RMI’ Source: RMI Census on Population and Housing 2011, EPPSO

 

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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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. The last RMI Census was in 2011 with the next census planned for in 2021. The projected population growth predicts a slow but steady rise for the RMI, with more rural (outer islands) to urban (Majuro/Kwajalein) migration.

 

Table 2. Projected RMI Population by Atoll, 2020-2025
Atoll	RMI Census 2011	Projected Population
		2020	2021	2022	2023	2024	2025
Total	53,931	54,897	55,090	55,283	55,476	55,669	55,862
Ailinglaplap	1,652	1,557	1,537	1,518	1,499	1,480	1,461
Ailuk	281	209	194	180	165	151	136
Arno	1,702	1,588	1,565	1,542	1,519	1,496	1,473
Aur	486	471	467	464	461	458	455
Bikini	8	6	6	5	5	5	4
Ebon	641	559	543	526	510	494	477
Enewetak	601	522	507	491	475	459	444
Jabat	80	76	75	74	73	72	71
Jaluit	1,828	1,877	1,887	1,897	1,907	1,917	1,927
Kili	473	379	360	341	322	303	284
Kwajalein	11,577	11,788	11,830	11,872	11,914	11,956	11,998
Lae	355	366	368	370	372	374	376
Lib	158	161	162	162	163	164	164
Likiep	359	307	296	286	275	265	254
Majuro	29,171	30,888	31,231	31,575	31,918	32,261	32,605
Maloelap	624	552	537	523	508	494	479
Mejit	325	297	291	286	280	274	269
Mili	640	518	493	469	444	420	395
Namdrik	420	310	288	266	244	222	200
Namu	739	688	678	667	657	647	637
Rongelap	99	124	129	134	139	144	149
Ujae	339	307	301	294	288	282	275
Ujelang	0	0	0	0	0	0	0
Utirik	436	437	437	437	437	437	437
Wotho	81	61	57	53	49	45	41
Wotje	857	854	853	853	852	851	851

  Source: Economic Policy, Planning and Statistics Office, 2020

 

 

Table 3. Projected RMI Male Population by Age, 2020-2025

	RMI Census 2011	Projected Male Population
		2020	2021	2022	2023	2024	2025
Male	27243	28,134	28,233	28,332	28,431	28,530	28,629
0 - 4 years	4031	4,163	4,177	4,192	4,207	4,221	4,236
5 - 9 years	3622	3,740	3,754	3,767	3,780	3,793	3,806
10 - 14 years	3385	3,496	3,508	3,520	3,533	3,545	3,557
15 - 19 years	2417	2,496	2,505	2,514	2,522	2,531	2,540
20 - 24 years	2614	2,699	2,709	2,718	2,728	2,737	2,747
25 - 29 years	2159	2,230	2,237	2,245	2,253	2,261	2,269
30 - 34 years	1876	1,937	1,944	1,951	1,958	1,965	1,971
35 - 39 years	1587	1,639	1,645	1,650	1,656	1,662	1,668
40 - 44 years	1419	1,465	1,471	1,476	1,481	1,486	1,491
45 - 49 years	1189	1,228	1,232	1,237	1,241	1,245	1,249
50 - 54 years	1016	1,049	1,053	1,057	1,060	1,064	1,068
55 - 59 years	815	842	845	848	851	854	856
60 - 64 years	583	602	604	606	608	611	613
65+ years	346	547	549	551	553	555	557

 

Table 4. Projected RMI Female Population by Age, 2020-2025

	RMI Census 2011	Projected Female Population
		2020	2021	2022	2023	2024	2025
Female	25915	26,763	26,857	26,951	27,045	27,139	27,233
0 - 4 years	3712	3,833	3,847	3,860	3,874	3,887	3,901
5 - 9 years	3395	3,506	3,518	3,531	3,543	3,555	3,568
10 - 14 years	3108	3,210	3,221	3,232	3,244	3,255	3,266
15 - 19 years	2314	2,390	2,398	2,406	2,415	2,423	2,432
20 - 24 years	2480	2,561	2,570	2,579	2,588	2,597	2,606
25 - 29 years	2245	2,318	2,327	2,335	2,343	2,351	2,359
30 - 34 years	1913	1,976	1,983	1,989	1,996	2,003	2,010
35 - 39 years	1549	1,600	1,605	1,611	1,617	1,622	1,628
40 - 44 years	1366	1,411	1,416	1,421	1,426	1,431	1,435
45 - 49 years	1155	1,193	1,197	1,201	1,205	1,210	1,214
50 - 54 years	914	944	947	951	954	957	960
55 - 59 years	761	786	789	791	794	797	800
60 - 64 years	469	484	486	488	489	491	493
65+ years	534	551	553	555	557	559	561

 

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 3 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.

 

Health care in the RMI

 

 

In 1986 the RMI Government adopted the concept of Primary Health Care declared by the WHO in 1978. The Bureau of Primary Health Care was established to target the strengthening of preventive programs/services at the community level. The bureau is renamed the Bureau of Primary Health Care Services.

 

The health care system comprises two hospitals, one in Majuro and one in Ebeye and fifty-six (56) active health care centers in the outer atolls and islands. Both hospitals provide primary and secondary care, but limited tertiary care. Patients who need tertiary care are referred to Honolulu, ROC-Taiwan, or the Philippines.

 

Health centers in the outer islands focus on the preventative, promotive and essential clinical care services. All health care centers are permanently staffed by full time Health Assistants who provide health services. Currently, there are 16 Health Assistant Interns on training provided by our Marshallese Doctor. They are following a curriculum designed by Fiji National University and PIHOA. They will replace the retired Health Assistants.

 

Table 4 indicates the hospital and health centers under the MOHSS. Leroij Atama Zedkeia Medical Center commonly known as Majuro Hospital and Leroij Kitlang Memorial Health Center commonly known as Ebeye Hospital are serving inpatient, outpatient, public health clinics and ancillary services. There are 56 Health Centers in RMI. 177 Health Care Program funded by US grant can hire 1 doctor and 1 health assistant in their 4 Outer Islands Clinics namely Utrik, Enewetak, Kili and Mejatto. 177 Health Care Program provide services to the people that were affected by the nuclear testing. Aside from the 177 Health Centers, Health Assistants are the health care providers in the health centers. Medical and public health staff conduct outreach services to the health centers in the outer islands. Health centers in the Outer Islands provides preventative, promotive and essential clinical care services. If the services in the Outer Islands are not enough, the patients are referred to the 2 main hospitals via regular referral or medical evacuation.

 

 

 

Table 5: Health Care Locations
MAJURO ATOLL
Leroij Atama Zedkeia Medical Center (Majuro Hospital) Laura Health Center Rongrong Health Center Woja Health Center
KWAJALEIN ATOLL
Leroij Kitlang Memorial Health Center (Ebeye Hospital) Santo Dispensary Ebadon Dispensary Gugeegue Dispensary
OUTER ISLANDS HEALTH CENTERS
Ratak Chain Aerok Maleolap Ailuk Arno Aur Bikarej Enejelar Enejit Ine Jang Jebal Kaven Kilange Likiep	Lukonwor Mejit Milli Nallu Ollet Tarawa Tinak Tobal Tokewa Tutu Ulien Wodmej Wotje	Ralik Chain Aerok Ailinglaplap Bwoj Ebon Imiej Imiroj Jabnoden Jabot Jabwor Jaluit Lae Lib	Loen Mae Majkin Mejrirok Namdrik namu Narmij Toka Ujae Woja Wotho
177 HCP Program	Department of Energy Clinic	Kumit Wellness Center	Taiwan Health Center
Majuro Clinic Ejit Clinic Kili Heakth Center Enewetak Health Center Utrik Health Center Mejatto Health Center

 

 

 

Table 6: No. of Beds in the two Main Hospitals
Hospital	No. of beds
Leroij Atama Zedkeia Medical Center (Majuro Hospital)	101
Leroij Kitlang Memorial Health Center (Ebeye Hospital)	54

 

Table 7: Private Clinics and Pharmacy
Clinic Name	Location
Majuro Clinic	Delap, Majuro
Eyesight, Professional	Delap, Majuro
Medisource Pacific Pharmacy	Majuro and Ebeye

 

 

 

 

 

 

 

 

Top 10 Causes of Death- RMI, 2020

FY2020
Rank	Underlying Cause of Death	Count
1	Cardiovascular Diseases	95
2	Diabetes Related	53
3	Pneumonia	41
4	Cancer	36
5	Sepsis	15
6	Suicide	12
7	Drowning	10
8	Perinatal Conditions	9
9	Gastroenteritis	6
10	Chronic obstructive pulmonary disease/ Gastrointestinal bleeding	5

 

 

Top FY2020 Majuro Hospital Outpatient Diagnosis
1	Z23	Encounter for immunization	3482
2	Z34	Encounter for supervision of normal pregnancy	2655
3	J00-J06	Acute Upper Respiratory Infections	1177
4	J20	Acute bronchitis	662
5	E10-E14	Diabetes mellitus	591
6	N39.0	Urinary tract infection, site not specified	513
7	O34.21	Maternal care for scar from previous cesarean delivery	369
8	I10	Essential (primary) hypertension	344
9	M54.5	Low back pain	297
10	O09.893	Supervision of other high risk pregnancies, third trimester	225

 

 

Government health funding and human resources

 

In a 2015 WHO study of 11 selected Pacific Island countries, the RMI had the highest government health expenditure in the last six years of period reviewed (Figure 3) . The study found RMI government funding amounted to only 40% of the necessary health expenditure for the entire population. A considerable proportion of the remaining health budget is sourced from external aid, comprising mainly of US Compact of Free Association (COFA) payments and other US federal assistance.

Source: World Health Organization (WHO) Global expenditure database, 2015

 

Furthermore, limited human resources in the RMI cause substantial strain on the health system. Although the RMI meets the WHO minimum threshold for the health workforce (Figure 3-9), the majority of physicians are expatriate contract-workers (WHO, 2015). According to the MOH Annual Report 2015, 43 physicians were employed with the majority posted at the Majuro Hospital. To support the health system, over 66 health assistants were hired and generally serve in rural health clinics.

 

Figure 4 Health workforce (doctors, nurses and midwives) per 1,000 population in selected Pacific Island countries, 2015

Source: The first 20 years of the journey towards the vision of Healthy Islands in the Pacific, World Health Organization (WHO) (2015)

 

Communication
 

In 2020, Ministry of Health and Human Services and Marshall Islands National Telecommunication Authority (MINTA) partnered through a grant to install VSAT in all the health centers in the Outer Islands. This will replace the DAMA (Demand Assigned Multiple Access) Systems which have high subscription fee and expensive maintenance. The VSAT will provide voice and data. Our plan is to be able to use the VSAT services for better communication, telehealth, access to the MHIS (Marshall Health Information System) and can provide remote training. The improvement in communication will also decrease medical evacuation that can costs from 10,000 to 15,000 per case. Specialists from Majuro and Ebeye can do an assessment first based on the information that will be submitted through email and video calls.

 

Through World Bank COVID-19 funds, we are purchasing laptops, UPS, solar batteries, and panels that will be assigned and installed in the health centers. These laptops will complement the VSAT connection. Once this whole system is set, MCH program will conduct its telehealth for the Children with Special Health Care Needs, High risk pregnancy and follow up of cases. Weekly reporting of syndromic surveillance, birth and death occurrence will improve.

 

With the Health Informatics Department’s communication plan, MOHHS purchased new HF radios to replace the old/nonfunctional radios. Satellite phones were also purchased for redundant communication. Funding was provided under CDC Crisis funds – COVID-19. CDC Epidemiology and Laboratory Capacity - COVID-19 supplemental funds support the communication fees to ensure communication in all the health centers are hospitals are uninterrupted. 

 

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 connections. International calls are $1.25 per minute. National Calls are $0.50 per minute. To use VSAT, there will be an additional cost $200/site/month for MOHHS to incur.

 

 

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 a shared taxi with a 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 provides 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 a government-owned 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.

 

For the MCH program, we usually travel by Air Marshall Islands. One way airfare can range from $70 on the nearest island to $400 on the farthest island. There are instances that public health outreach team including MCH staff get stranded for a day or a month if the planes are not working. We also use boats to go to the Outer Islands. The trip to Enewetak is 4-5 days via boat, which is the farthest island. Enewetak is near Pohnpei. When the weather is bad or the ocean is too rough, we can’t provide outreach visits to the Outer Islands.

 

Food Security
 

The Marshall Islands face 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 the 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

 

Early Childhood Development Program Update:

 

In 2019, the World Bank launched the Multisectoral Early Childhood Development (ECD) Program with the Ministry of Health and Human Services, Ministry of Education, Sports, and Training, Ministry of Culture and Internal Affairs, and the Ministry of Finance, Banking, and Postal Services. Results from the ICHN Survey conducted by UNICEF in 2017 portrayed an alarming rate of stunting in the Marshall Islands. The ECD program is taking on the initiative to assist with the most vulnerable, pregnant mothers, and children 0-5 years of age. It is important to highlight the much-needed action within the first 1,000 days of a child’s life for intervention.

 

 

Component 1 (MOHHS) aims to improve the availability and coverage of an evidence-based package of essential RMNCHN and stimulation services for the first 1,000 days (pregnant and lactating women and children up to age 2).

 

Adolescent girls, women of reproductive age and children aged 2-5 years will be secondary target groups, with interventions for these populations incorporated in an opportunistic manner and/or in later stages of Project implementation. The component seeks to both strengthen the package of services provided and alleviate supply- and demand- side barriers to the use of this package of services.

The first two years of the Project will focus on alleviating key pressure points to ensure adequate coverage of a revised and evidence-based package of RMNCH-N services in the Majuro/Ebeye Hospitals. Project financing will focus on strengthening hospital and clinic-based service delivery in Majuro and Ebeye and filling short-term gaps in supply-side readiness in OI clinics. This immediate term measure is considered vital for preventing further deterioration of key health and nutrition outcomes. The component will also support a suite of TA activities to identify strategic shifts in service delivery in order to inform further scale-up beyond the initial phase.

 

The component has two sub-components; one aimed at strengthening stewardship and management of health administration and the other at directly strengthening service delivery. Each sub-component will have four dimensions: (a) RMNCH-N service package; (b) human resources; (c) equipment and supplies; and (d) data and information.

 

Implementation of SBCC activities will be financed under component 1 (MOHHS) and other components (MOCIA, MOEST, MOFBPS). While component 1 will support MOHHS in the delivery of early years-focused SBCC activities in combination with other RMNCH-N interventions, a comprehensive, cross- sectoral SBCC strategy and campaign will be developed under component 4. Sub-component 1.1 will support the development and roll-out of training, capacity building, and coaching packages required for MOHHS to effectively deliver SBCC, whereas sub-component 1.2 will finance the production of materials, roll-out and delivery of the campaign through MOHHS channels.

 

5. Sub-component 1.1: Strengthening MOHHS management and stewardship capacity to deliver essential RMNCHN services. The objective of this sub-component is to strengthen the management and stewardship capacity of MOHHS to scale up access to a package of essential RMNCH-N services. Activities/inputs to be financed include:

 

• Essential RMNCH-N Service Package: The Project will finance a suite of TA activities to define an essential RMNCH-N package, assess supply-side readiness to deliver the package and recommend strategic shifts in service delivery needed to improve coverage and utilization. While many RMNCH-N interventions are underway, there is a need for MOHHS define and deliver a basic essential package of services, strengthening areas such as: maternal nutrition counselling during ANC; infant and young child feeding promotion; routine monitoring and promotion of optimal child growth and development; identification of disability and developmental delay, birth registration, etc. The component will support an assessment to define the essential RMNCH-N package and an expanded package of activities as well as accompanying operational guidelines for the essential package. A supply-side readiness assessment, will be undertaken to identify frontline needs and gaps. A service delivery study will be undertaken and complemented by a Health Financing Systems Assessment to develop recommendations for sustainable, cost-effective delivery models and modalities in Majuro/Ebeye and the OI.

 

Human Resources: The Project will finance: a human resources mapping and needs assessment to develop a HR strategic plan focusing on the delivery of the essential RMNCH-N package; TA to develop a performance management system; the development of training and coaching packages as identified in the needs assessment. Two ECD Coordinators (national and international) will be placed within the MOHHS, who will not only be responsible for managing activities under the Ministry’s mandates (as discussed under component 4), but in doing so will provide specific guidance to staff in the ministry and other implementing agencies to build capacity to work on their mandate in the future. It is expected that the national ECD coordinator will be absorbed into the MOHHS payroll during the life of the project (approximately year 4).

 

• Equipment, commodities, and supplies: The Project will finance TA on forecasting, purchasing, procurement, and commodity management, as needed.

 

• Data and information: The Project will undertake a rapid assessment of the data needs of the MCH and RH programs to monitor RMNCH-N service utilization and outcomes as well as the existing HMIS. The assessment will be used to identify gaps in the existing HMIS that already benefit from support from Taiwan, China.

 

6. Sub-component 1.2: Enhancing delivery of essential RMNCH-N services. The objective of this sub-component is to scale up access to and coverage of a package of essential RMNCH-N services. This sub-component will support the following:

 

Essential RMNCH-N Service Package: The Project will finance support MOHHS in delivering the newly defined package (See sub-component 1.1). This includes: the production of materials, job aides, etc.; routine operational costs of service delivery, including SBCC activities, in accordance with operational guidelines. In the first 12-24 months of the Project, the focus will be on enhancing RMNCH-N delivery in Majuro/Ebeye Hospitals and Laura Clinic. Special attention will be paid to enhancing the availability of evidence-based nutrition specific interventions, which have fallen through the cracks in primary health care. Service delivery will be scaled up to other areas based on the service delivery TA produced during Year 1 (see also subcomponent 1.1).

 

• Human Resources: The Project will finance contracted service delivery providers (e.g. doctors, nurses, midwives) to support MOHHS to achieve a more optimal number, distribution, skills/skills mix, and performance of health care professionals required to effectively deliver the RMNCH-N service package. This includes: (a) surge support to Majuro/Ebeye Hospitals to fill critical human resource gaps for RMNCH-N provision; (b) additional health providers to complement and assist the Health Assistants in the OI Dispensaries in delivering RMNCH-N services; (c) a third-party provider to deliver training and coaching to boost provider skills and adherence to guidelines; and (d) design and roll-out of a transparent performance management system, including the associated management, supervision, and mentoring costs. Direct hire or contracting arrangements identified as appropriate by the service delivery TA will be used for (a) and (b). It is expected that contract providers will be absorbed into the MOHHS payroll during the life of the project. Therefore, the number and type of additional contract staff will be included in the annual work plan and budget, and jointly agreed between the Government of RMI and the WB. Counterpart financing is one option that may be considered.

 

Equipment, commodities and supplies: The Project will finance the procurement of small equipment (including anthropometric measurement equipment), materials, pharmaceuticals/commodities, in order to meet standards of readiness to deliver the basic essential RMNCH-N package. In the first phase, procurement will be limited to filling equipment, commodity, and supplies requirements for the Majuro/Ebeye Hospitals, Laura Clinic, and OI Dispensaries. Additional equipment/commodity/supply requirements may be identified in in the strategic mapping and the component can finance costs of upgrading OI dispensaries and/or equipping zone nurses, health outreach workers, mobile clinics, etc. to deliver the RMNCH-N service package. Investments in the immunization cold chain will be complementary to those financed under the Asian Development Bank’s regional immunization TA.

 

• Data and Information Technology: The Project will finance gaps in the IT system infrastructure (hardware, software, and training) to monitor RMNCH-N patient records and service utilization, manage stock, and assess performance. Enhancing the availability, quality, and use of data for decision-making will be necessary in order to translate the supply- and demand-side investments to improved health and nutrition outcomes. With support from Taiwan, China, efforts are underway to upgrade and modernize the HMIS. Development of innovative IT solutions to strengthen community outreach and service delivery may be considered at the midterm review. The Project will further support the development of a database and digital dashboards to make the information for decision-making readily available.

 

Table 1: Key Project Data

 

 

NP1: Well-women visit

 

ECD has been involved with minor works within the Majuro and Ebeye Hospital. One project specifically applies to the MCH One Stop Shop. With guidance from the team, the ECD project has met with program managers and hospital staff to discuss the structure and floor plan of this works. Documentation has been sent over to the World Bank for approval from the safeguard and financial management team. We hope to start renovating by October 2021.

 

NPM3:  Risk Appropriate Care

 

The Milestone Passbook or newborn baby passports, is set to launch in November 2021 and is currently in its final stages of approval. Translation and consultations with stakeholders have taken place to ensure consensus. Various programs such as MCH, EHDI, RH, ECD, etc. have led this project and hope to pilot this for the next 2 years to capture the much needed data and to determine next steps.

 

NPM13: Preventative Dental Visit

 

 The project has initiated discussion with partners from both MOHSS and PSS to roll out the dental school check up and outreach. Early 2021, discussion took place to assist with revamping the annual school dental check ups done by the MOHHS dental team. With the support from Taiwan Health Center (THC), PSS, and MOHHS, this initiative will launch in September 2021. THC was able to give a generous donation of dental kits and ECD will assist with financial support regarding travel to Ebeye for outreach at the school’s there. The main challenge is lack of funding and staff for the dental program. It is important this program can continue and reach the outer islands as a required health check up to improve overall dental health in the RMI.

 

Challenges:

 

The main challenge for the ECD project is lack of staffing and financial constraints caused by the COVID-19 pandemic. With only the National Coordinator on board, it has been a challenge hiring and keeping staff in order to implement and roll out this project. Due to the COVID-19 project, the borders have been closed and have made it harder to bring in consultants, trainers, staff, and so forth. The Ministry of Health and Human Services has been in a constant State of Emergency since August 2019, in part due to the dengue outbreak. The MOHHS has been exhausted and working tirelessly to make sure the RMI is safe and COVID-free.