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 FY2019, the MCH Program has served the following population:
1. Pregnant Women : 1,198

2. Infant <1 year old : 980
3. Children from 1 to 22 years old: 5,376
4. CSHCN : 89
5 Female Population 15-44 yrs old:1,984

 

Percentage of Populations Served by Title V

Pregnant Women Notes:

Number of pregnant women: 1,198

Population (Form 5b reference data): 1816

% served: 80%

 

Infant <1 year old - 980

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 1 through 21 years of age served by the MCH Block Grant and Program includes patients that come to Dental, Children with Special Health Care Needs, MCH Clinic, and Family Planning program. MCH Block grant provided training on breastfeeding, integrated children nutrition survey training, Vitamin A and Deworming training and clinic and office supplies. In dental services, one FTE is funded under the MCH Block Grant. MCH Block Grant supported the travel to the Outer Islands for outreach mobile visits.

512 - Family Planning Services

MCH Clinic - 3950

Dental Services - 529

Prenatal/Women's Health: 296

CSHCN: 89

 

Others:2.668

Number reflects the patients that come to the Women's Clinic with services but not limited to cervical cancer screening, OB-GYNE cases, women missions wherein MCH Block Grant supports the staff, clinic supplies, office supplies, laboratory testings and training (on-island and off-island).

 

2230: Dental Services, RH Prenatal and Women's Health

438: Family Planning Services

 

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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Source: United Nations Fund for Population Activities, 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 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.
 

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.

 

Ministry of Health and Human Services (MoHHS) works in conjunction with the Community Health Councils (CHC) in the Outer Islands. The system requires community participation in health care and ensures that the community beyond the urban centers are involved and included in the provision of health care services.

 

The health care system is comprised of two hospitals, one in Majuro and one in Ebeye and fifty-six

(56) 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 or the Philippines.

 

Health centers in the outer islands are the focus for preventative, promotive and essential clinical care services. All health care centers are permanently staffed by full time Health Assistants who provide health services and work with the Community Health Councils to promote and foster the concept of shared responsibility for health.

 

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. Aside from the 177 Health Centers, Health Assistants are the health care providers in the health centers. Medical and public health staff conduct outreach to the health centers in the outer islands and within the community as well. Health centers in the Outer Islands provides preventative, promotive and essential clinical care services. All health care centers are permanently staffed by full time Health Assistants who provide health services and work with the Community Health Councils to promote and foster the concept of shared responsibility for health.

 

 

Table 5: Health Care Locations
MAJURO ATOLL
Leroij Atama Zedkeia Medical Center (Majuro Hospital) Laura Health Center Rongrong 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
Capital Dentistry	Uliga, Majuro
Eyesight, Professional	Delap, Majuro
Medisource Pacific Pharmacy	Majuro and Ebeye

 

 

 

 

 

 

 

 

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
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