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) 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.

 
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.   RMI has an area of 1826 square kilometers and is composed of two coral atoll chains in the Central Pacific.  
 

RMI 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-Kwajalein atoll) have paved roads and with piped water and a sewer system.  The island of Ebeye is 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 have, 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

 

In FY2022, the MCH Program has served the following population:
1. Pregnant Women: 1,309

2. Infant <1 year old : 1021
3. Children from 1 to 22 years old: 3,132

4. CSHCN : 78
5  Others: 3,923
 

Population Demographics

 

In September 2021, a national census of population and housing was conducted in RMI. The RMI Census of Population and Dwellings is conducted by the country’s statistics agency, the Economic, Planning, Policy and Statistics Office (EPPSO). It provides an official count of people, along with demographic and socioeconomic information at the atoll/island and community level. It is the 12th census of population to be undertaken after the first census enumeration was undertaken in the RMI in 1920.

 

There is 20% decrease in the total population count from the 2011 census. In 2011, there was 53,158 population while in 2021 census population is down to 42,418. Decrease in population is attributed to migration of Marshallese mostly to the USA because of job opportunities, health care and education. The Marshall Islands has a young population.

 

Table 1: Key Indicators, RMI 2021 Census Report

Indicator	Total	Males	Females
Total enumerated population (2021)	42,418	21,728	20,690
Annual rate of population change (%), 2011 to 2021	-2.23%
Population density (people per sq. miles) - national level	605
Kwajalein	1,546
Majuro	6,175
Proportion of population living in urban area (%)	78%
Proportion of population aged under 15 years of age	34%	34%	34%
Proportion of population aged 15 to 24 years (youth aged group)	20%	20%	20%
Proportion of population aged 15 to 59 years (working age population)	60%	59%	60%
Proportion of population aged 60 years and older	6%	6%	6%
Age dependency ratio	61
Median age (years)	22	21	22
Households
Number of private HHs	7,123
Average household size	5.85
Proportion of private HHs receiving a remittance in last 12 months	11%
Number of institutions (non-private HHs)	78
Number of people in institutions	843
Proportion of private HHs with piped water supply	44%
Proportion of private HHs with access to a flush toilet	88%
Proportion of private HHs using electricity as the main source of lighting	75%
Proportion of private HHs with access to the internet	43%
Proportion of private HHs with access to a mobile phone	89%
Births and fertility
Estimated births	704
Crude birth rate (CBR), per 1,000 population	16.6
Total fertility rate (TFR), per woman	3.4
Teenage fertility rate, per 1,000 (SDG 3.7.2)	47
Mean age at childbearing	27.6
Mean age at first birth	21.6
Average age at first marriage	25.6	26.5	24.8
Health and mortality
Disability prevalence (population aged 5 years and over)	3.1%	3.3%	2.9%
Net migration
Population who lived in a different location 1 year ago	1,088
Elsewhere in RMI	912
Outside the country	176
Population who lived in a different location 5 years ago	2,456
Elsewhere in RMI	1,700

 

 

 

Indicator	Total	Males	Females
Outside the country	756
Population who lived in a different location 1 year ago (%)	2.7
Elsewhere in RMI (%)	2.2
Outside the country (%)	0.4
Population who lived in a different location 5 years ago (%)	6.7
Elsewhere in RMI (%)	4.6
Outside the country (%)	2.1
Education
School enrolment rate of 6-14 year old (% of population of same age)	93%	93%	94%
Proportion of population aged 15 years and over (%) with:
Secondary education	62%	60%	63%
Secondary qualification (as highest grade completed)	61%	60%	62%
Tertiary education	5%	5%	4%
Tertiary qualification (as highest level completed)	5%	5%	4%
Gender parity index, Primary (GPI)	0.9
Gender parity index, Secondary (GPI)	1.0
Labour force (population 15+ years)
Employed population (number)	12,297	7,774	4,523
Paid workers (number)	11,574	7,500	4,074
Subsistence workers (number)	325	295	30
Not in the labour force (number)	13,529	5,243	8,286
Labour force participation rate	50.3	62.0	38.1
Employment to population ratio	45.2	56.3	33.8
Unemployed (number) - looking for, available and willing to start work	1,371	784	587
Unemployment rate (%) - looking for, available and willing to start work	10.0	9.2	11.5
Unemployed - available and willing to start work (number)	373	172	201
Unemployed - all unemployed + subsistence workers (number)	2,008	1,162	846

Source: Economic Policy, Planning and Statistics Office, 2021

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 2 RMI Population by Age Group, 2021

The 3 bottom bars show the population's younger dependents (0-14 years old). In RMI this is approx. 62% of the population. This means they have a YOUTHFUL population. Only 7% are over 65 years old.

 

Table 2: RMI Population by Age, 2021-2025

 

Source: Economic Policy, Planning and Statistics Office, 2021

 

Table 3. Population by Urban/Rural and atoll by sex – RMI Census 2021

 

Source: Economic Policy, Planning and Statistics Office, 2021

 

Educational Attainment

 

With the 2021 census, there are no new information on the education on enrollment to learning institutions.

 

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 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.

 

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.

 

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 is 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 provides 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. 

 

Public health staff conduct comprehensive outreach missions to provide preventive services to the hard-to-reach population in the Neighboring Islands (NI formerly knows as Outer Islands).  Services include Family planning, cervical cancer screening, Oral health, Immunization, Leprosy screening and treatment, TB screening and treatment, NCD and STI services. 

 

Most of the NI Health centers do not have electricity, making it a challenge for Health centers to have a cold chain storage and provide immunizations to the communities.  Such services are rendered only if there are comprehensive team travel to the atolls. In 2022, we have received the requested solar freezers for the cold chain storage of vaccines. These solar freezers are donated by the Japan Government through the assistance of UNICEF.  22 out of 24 UNICEF solar freezers were distributed during the COVID-19 NI vaccination. We are still waiting for 20 solar freezers purchased by World Bank funds. Majuro Public Health Team leads will provide continuing training and plans to fully implement immunization services in NI next year, 2023.

 

Our health centers in the are not equipped with dental equipment, supplies and manpower. Health Assistants have limited educational background and experience to provide oral health services. Since majority of the Health Assistants are male, it’s hard for women to seek care and services like family planning, cervical cancer screening and prenatal care services.

 

In 2022, the MOHHS received two boats from UNICEF and Government of Japan. We are still waiting for one more boat coming from World Bank which is included in the COVID-19 list of requested needs. The Public Health started using the medical boat in late 2022 to provide vaccinations, bringing in medical supplies like COVID-19 test kits, IPC supplies and other services.

 

Title V funds supported the time of staff, travel, fuel, and supplies. PIHOA’s support to train more midwives to be dispatched to the NI.  ECD support with training of Female Health Aides to support Sexual and Reproductive Health Services (SRH) in the NI without Female Health Assistants.  UNFPA supports a toolkit for assessing and inventory of essential medicine and SRH, and Gender based Violence (GBV) There is a major need to strengthen awareness on the importance of good oral hygiene and annual dental check.

 

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

 

 

 

 

 

 

 

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

 

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, MOHHS and Marshall Islands National Telecommunication Authority (MINTA) partnered through a grant to install VSAT in all the health centers in the NI. 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.

 

In 2022, 47 of the health centers have VSAT but only 8 were activated. Majority of the health centers need to install new solar power panel system to power on the IT equipment that will be installed. Through World Bank, WHO, CDC, and USAID COVID-19 funds, we purchased laptops and UPS, solar batteries, and panels that will be assigned and installed in the health centers. There are challenges in the procurement of the solar panel system which also cause delays in the implementation in NI. During the TB Mass Screening in Wotje, the TB physician and staff were able to access MHIS, update encounters and transfer images to the radiology system. The TB Mass Screening team was able to conduct hotwash calls with Majuro team to present cases and provide updates on the activities. We also encounter challenge in the VSAT connection and have to wait for NTA to assist in the troubleshooting.

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 and CDC Immunization 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 $1.50 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 NI. Within the NI, there are speed boats, bicycle and trucks to bigger atolls. Air Marshall Islands (AMI) has two planes that service the whole RMI. But it’s not reliable.

 

For the MCH program, we usually travel by AMI. 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 small boats to go to the small islands or islets in the NI. 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 NI. Recently with the donated medical boat from UNICEF, LiWatoon-Mour was able to service the NI outreach mobile trips.

 

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.

 

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
• High price

 

Early Childhood Development Program Update:

 

In 2019, the World Bank (WB) launched the Multisectoral Early Childhood Development (ECD) Program with the MOHHS, Ministry of Education, Sports, and Training, Ministry of Culture and Internal Affairs, and the MOFBPS. Results from the ICHN Survey conducted by UNICEF in 2017 portrayed an alarming rate of stunting in RMI. 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 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 2 years 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. 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 NI 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 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 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 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 the activities, 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 NI.

 

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:

 

• 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 NI Health Centers 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 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 NI Health Centers. Additional equipment/commodity/supply requirements may be identified in in the strategic mapping and the component can finance costs of upgrading NI Health Centers 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. Due to COVID-19 competing activities and community transmission in August 2022, the milestone passbook was not implemented in 2022.

 

NPM13: Preventative Dental Visit

 

The project has initiated discussion with partners from both MOHHS and Public School System (PSS) to roll out the dental school checkup and outreach. Early 2021, discussion took place to assist with revamping the annual school dental checkups 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.

 

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 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. MOHHS 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.

 

State of Emergency – COVID-19

 

In March 2020, RMI closed its borders because of SARSCOV-2. From then on, RMI started its preparedness efforts as a country. A National Disaster Committee was created and MOHHS leads the health sector. Each government agencies (Local and National) build up its capacity to respond to COVID-19.

 

MOHHS strengthens its surveillance, testing capability, risk communication and community engagement, prevention, and treatment against COVID-19.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• COVID-19 vaccinations increase due to:
  • Established a risk communication and community engagement working group.
    • Increased awareness to the communities on COVID-19 symptoms, and its preventative methods.
    • Use of media platforms for COVID-19 vaccinations awareness, social media, radio talk shows, local newspaper
  • Established a vaccine taskforce.
  • Feedback portal to enable questions and answers on COVID-19 vaccinations.
  • Administration of COVID-19 vaccinations within the clinics and after hours, as well as through the communities from house-to-house campaigns.
  • A COVID-19 vaccination raffle activity was rolled with cash prizes to those individuals that had their first dose of vaccination and another raffle for those who have had their second dose of vaccinations.
• Personal Protective Equipment (PPE) training
  • The nurses within the MCH clinics were trained in PPE donning and doffing (refresher training). They were also trained in proper mask wearing as well as hand hygiene.
• Collaboration with another Government Ministry - PSS
  • The MOHHS established a COVID-19 K-12 Screening (K12CST) testing taskforce with PSS.
  • They were able implement the K12CST program within the schools which was to conduct COVID-19 screening testing through the schools for any persons on the school premises that would show signs and symptoms.
  • Before implementation, members of the K12CST would have to present to the Parents and Teachers association for awareness and questions. As well as consent for swabbing from the parents.
  • Through this program, the faculty staff are trained in PPE donning and doffing, as well as swabbing for COVID-19 symptoms on site and testing on-site

 

By August 8, 2022, 1st COVID-19 community transmission was confirmed. The COVID-19 response plan rolled out. We close the hospital for non-emergency services like Outpatient and public health clinics were closed. Below are highlighted activities:

 

Response to COVID-19

• The COVID-19 test-to-treat (T2T) sites were installed at several schools at Majuro Atoll and the gymnasium on Ebeye Island.
• These COVID-19 T2T sites allowed for those who wanted to get vaccinated for COVID-19 first dose, second dose or booster. Availability of staff trained, laptops, and access to internet allowed for record checking for the COVID-19 vaccinations and data entry of COVID-19 administered doses.
• PSS faculty were able to aid at the COVID-19 T2T sites.
• Mobile clinics implemented to visit those individuals within the communities that were immobile and were not able to visit the COVID-19 T2T sites.
• We received assistance from CDC, WHO, and UNICEF subject matter experts to respond to community cases of COVID-19.

 

The above RMI COVID-19 situation report on the left bottom illustrates the number of COVID-19 cases reported from August 8, 2022 to December 28, 2022. The stacked bar chart compares the COVID-19 cases reported and tested from the 3 main atolls Majuro, Kwajalein (Ebeye), and the NI’s. As depicted in the stacked bar, there is an increase in number of COVID-19 cases reported and tested (rapid antigen test) in the first 2 weeks from Majuro atoll (blue color) of community transmission, then by the third week there was a decline in COVID-19 cases reported from Majuro atoll whilst testing continued. Similar pattern, also be seen with Kwajalein, whereby first case identified in the first week, and an increase in number of COVID-19 cases reported and tested shown in the second week with a decline in numbers reported by the third week. As for the NI’s, the COVID-19 cases were identified in the second week of the outbreak, and this was largely due to transporting COVID-19 test kits to the NI’s. Therefore, COVID-19 cases were identified and reported in the second week and by the third week onwards there was a decline in COVID-19 cases reported. On August 28th, 2022, the RNZ Pacific Correspondent (1) reported that “Johns Hopkins University, which tracks covid cases globally, reported that the Marshall Islands set a seven-day all-time record for the rate of positive cases of Covid. "But what the data also shows is a jurisdiction that is able to test, treat and provide access to healthcare," said Brostrom”. Dr Brostrom continued to mention in the report that RMI had given that accessibility to the communities through the alternate care sites (later renamed to test to treat sites) that allowed to treat and manage thousands of people in the communities within a short period of time.

 

Key Achievements

• RMI had the highest COVID-19 vaccination coverage rate during a COVID-19 outbreak;
• Multi-sectoral approach and collaboration played an integral part during the response phase;
• Team leads and their members in respective clusters were very supportive and operational;
• Fasting procurement processing; AND
• Coordination and team-work.

 

TB-NCD-Leprosy Mass Screening

 

In 2022, the TB program was able to conduct 1 successful TB Mass Screening amidst the demands of COVID-19 preparedness activities. 3% (n=20) of 699 screened were diagnosed with Active TB. Of the 20 Active TB cases, 2 are 0-5 yrs. old, 8 cases are 6-15 yrs. old, and 10 cases are 16 yrs. old and above. There are 165 Latent TB Infection (LTBI). There were 354 18 yrs. old and above screened for NCD. 41 are pre-diabetic, 9 newly diagnosed diabetic, 67 pre-hypertension and 9 newly diagnosed hypertension. 1 newly diagnosed Leprosy (Hansen’s Disease). Health Assistant in Wotje continued the TB Direct Observe Therapy (DOT) services on LTBI and Active cases.

 

 

 

 

 

 

Neighboring Islands Health Care Summit 2022

 

 

The 3-day summit to focus on reviewing current NI Health Center’s current status, operations, local partnership, and to establish a possible vision based on standards for NI health services. First Day will be an internal review (Pre-Summit) followed by a 2-day session that will include Marshall Islands Mayors Association (MIMA).

 

Meeting objectives:

• Review the status of NI health services through review of recent assessments and reports from Mayors association and MOHHS officials.

• Develop a set of appropriate standards for use in the RMI, with reference to a core domains framework for primary care services in outlying areas.
• Identify ways forward to meet standards
• Establish a strong partnership between MOHHS and NI Mayors.

 

 

RMI National Climate Change in Health Policy and Revised Action Plan

 

On December 8, 2022, the launching of the National Climate Change and Health Policy Revise Plan(2) took place. Importance of this policy is to address the impacts of climate change on people’s health in the Marshall Islands.  A number of key health issues – food and water safety and security, respiratory and vector-borne diseases, mental health, and extreme weather-related impacts – were identified as priorities. In addition, barriers to implementation of the plan, such as insufficient funding and human resources, apathy, and stigma, were highlighted. Stakeholders suggested responsible RMI agencies, strategies to manage these risks and timeframes. The strategies include increased resource allocation, educational campaigns, and continuing communication and engagement, particularly with traditional leaders, landowners, and community and faith-based groups.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reference