Marshall Islands Five Year Health Plan, Final Draft

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Everywhere in the world there is a trend of increasing cost for all services. This i~ true for health care services, too. In the United States, the Congress passed pllblicLaw 93-641 in 1975 in an effort to deal with the problem of rising medical costs and equal availability and accessibility of quality of medical care to all segments of the population. This Law requires all States of the Union to develop comprehensive - health plans which must be approved by appointed authorities in the States in order for each State to be eligible to receive funds from the Department of Health, Education and Melfare, Under this Law, a State Health Coordinating Council has the legal mandate to revise and approve the State Health Plans. The Law also designated the Trust Territory of the Pacific Islarldsas a “State” under the same requirements. The responsibility of the development of the Territorial Health Plan was entrusted by the High Commissioner to the Department of Health Services, which in turn desigt)atecithe Office of Health Plan)lingwithin the Department to be responsible for the development of the Health Plan. In the effort to nmke the Territorial Plan more responsive to the needs of the different Districts, the Office of Health Planning decidccl”to first develop a’Health Plan for each District and then to use each District Plan as a basis for the development of tJlcTerritorial Plan. Under this L,lw,the Micronesia Health Coordinating Council, with members from each District, was formed to be the legal authority responsible for the revision and approval of the Plan. Marshallese nlei~lbersof the Council

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d re: Dr. Ezra Riklon, Mr. Jibs Kabua, and Mr. Caleb Rantak. 11. NETHODS AND APPROACH: Development of the [l~rshalls District Health Plan was started in August, .> 1977. A team of planners from Saipan came to Majuro and Ebeye to gather information and material that would be used in the development of the Plan. The District Director of Health Services and his staff provided all needed help and manpower for n this process by providing needed material, equipment, the various tasks. Members of the Marshall District ng Council also actively participated in the formulation of questionnaires used in a Consumer Survey as well as participating in conducting the Survey itself. Input data and information came from three main sources: 1. The Health Service System Itself: The planners gathered data and.— information from the hospital and dispensaries that would help them describe and assess the present situation of the health system’s facilities, services, and manpower. Assessment of the system included assessment of the Administration, Medical Care Delivery, Nursing Care [)elivery, Dispensary Operations, operation of all support services at the hospital, and all other health services programs now existing within the health ser’~ices system. Input for thiS segment of the t]ealthplan came from the Departments of Education, Public Safety, Public Affairs, and Vocational Rehabilitation,

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as well as the Office of District Planning and the Budget office within @ the District Administration. Selected Community Leaders also gave input in this Section. The health planners interviewed respective Departwnt heads to get their ideas about the existing situations in health services ~ and also their to improve the ideas about how the system might be improved in order health status of the population of the MarshalIs. A survey of consumer attitudes of the delivery of health care in the klarshalls was administered during the first field visit. The total number of respondents was 33. All respondents were women and had no vocational relationships with the Marshalls Department of Health A questionnaire was developed by the field team and translated into the e Marshallese language. The questionnaire was composed of eight questions and identification of the respondent was not required. The respondents resided in four villages on Majuro and Ebeye, The Saipan team of health planners were in the Plarshallsfor this data gathering phase for a total of three weeks, All of the information and d~t~ gathered during this phase were analyzed in Saipan and formed the basis of the Marshalls Health Plan which was written November; 1977. Analysis of health information gathered in the assessment of the health system in the }Iarshalls District revealed the following prevalent

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a) The Marshalls has an extremely high birth rate in comparison to the Trust Territory. The population will increase 50% every four b) It would appear the major ciiusesof rrnrbidity (illness} in the Marshall District are skin, respiratory and gastrointestinal related conditions. This holds true for Majuro, Ebeye, and the Outer Islands - c) It would appear the major chronic illness in the Marshall District are asthma, diabetes, and hypertension. d) Causes of death closely pa rallel those of the United States with the long term, non-communicable diseases of the heart and cerebravascular systems and cancer being responsible for 40% of the deaths from a 1974 to 1976. At the sanw time however, prematurity and conditions associated with delivery are significant causes of death. e) Neonatal deaths would appear to be a far more significant problem in the urban center-sof the District than in the Outer Islands while infant and child death rates are approximately equal across all geographic f) Prematurity (the second leading cause of death 1974-1976) is MUch higher in Ebeye than in either Majuro or the Outer Islands although the rate in Majuro greater than in the at 53.9 incidence per 1,000 live births) is far

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for hyperemesis and prolonged labor) are far lower than in the other fore there is a large population at risk in case of communicable disease In general, providers and the general public consider the providers of medical care to be well trained and capable of delivering quality health care. The exception to this is that practically all dispensary users were dissatisfied with the present level of skills of the Health Assistants. Most consumers of health care expressed dissatisfaction with the use of e Medex in the delivery of health care at the hospital. The majority of problems expressed by the consumers of health care regarding the health system have to do with the administration: Lack of availability of physicians at the hosp Lack of controls to assure delivery of quality the performing of physical examinations before tal during weekends, medical care, such as Other problems of health care have to do with pub]ic expectations of the level of professionalism and diligence from the health providers. The consu~rs often complained about the unfriendliness and lack of courtesy of certain nurses; physicians taking time for coffee bre~ks while

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patients wait, etc. Consumers of health care also complained about the inadequacy of activities or controls directed in assuring the cleanliness of the environment (increased number of junked cars, rodents, litter in the environment, as well as the infrequency of 3. Consumers of Health: Certain problems-— the consumers of health care: Foremost is a lack of understanding on sanitation team visits, etc. ). were also identified with health related issues. There is also a certain level of expectations of services that are not aligned with economic realities, such as expectation of services at no cost or minimal cost, expectation of physician care at all Iv. GOALS AND OBJECTIVES: Certain goals and objectives have been developed based on the problems identified with respect to the health status of the population and the administration of the health services system as well as the level of consumers’ understanding and participation in the improvement of the health status of the total population of the Mar-shahs. l-hesummary of these goals and objectives follows: Goal #l: To increase support of and to concert efforts on the activities.——— and services that are directed towards the prevention of diseases. This goal Lummrizes the goals and objectives for Public Health, Environmental

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Health, Health Education, Nutrition Serv. @ of the Department of Health Services, as ces, and blentalHealth Divisions well as the goals and objectives for the Departments of Public Affairs, Public VJorks, Public Safety, and Goal i12: To improve the administration and supervision of health services to the extent that more effective and efficient medical care services could be delivered by the health system. This goal summarizes the goals and objectives set for Health S@rvices Administration (including the Medical Staff) , Nursing and Dental Health Divisions, as well as the Division of Public Health as it relates to the dispensary Goal {13: To raise the level of awareness and understanding of the e public regarding health-related issues, to the extent that more individuals would involve tl]emselves actively in improvement efforts of their own for their health and the health status of the community. Part of this goal is also directed towards raising the public awareness and understanding of the responsibility that the public has in affecting health policies. This would be done through proper channels such as the Municipal and District Government offices, the District Legislature and the Marshall Health Coordinating Council. This goal summarizes the goals and objectives set up for the Departn~nts of Education and Public Affairs and the Divisions of Health Education, Nutrition, Nlentall{ealth,and Administration within the Health Services Departmnt--as well as the goals and objectives for the Community leaders.

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v. PHILOSOPHY IN DEVELOPMENT OF GOALS AND OBJECTIVES AND PRIORITY SETTING: In the development of goals and objectives and in the setting of @ priorities for the Marshall District Five-Year Comprehensive Health plan, the underlying two-fold philosophy adhered to was: o To change the eml~hasis of health services from the curative to the preventive and to emphasize the goals and objectives which require minimal additional resources, including the use of expatriate The purpose of this philosophy is to involve the general population to a much greater extent than before in the responsibility for their own health and to utilize local resources to the fullest extent. It is hoped that the use of available local resources would stimulate national pride and self respect. It is also an effort to minimize the drainage of monetary !-esourcesspent on outside consultants, many of whom-- judging from past performance--have been largely ineffective.

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MARSHALL ISLANDS DISTRIC1 COMPREHENSIVE FIVE-YEAR HEALTH PLAN TABLES AND APPENDICES STATE ADMINISTRATIVE PROGRAM (self-contained) GEOGRAPHIC AND DEMOGRAPHIC DESCRIPTIONS (self-contained) HEALTH STATUS (Tables 1-23; Figure 1) GOALS AND OBJECTIVES (self-contained) 1. PROPOSED PLAN FOR FACILITIES AND STAFF P’ODIFICATIONS FOR FY 1979 AND THEREAFTER; PRESENT HOSPITAL STAFFING; PLANS FOR FACILITIES RENOVATION. 2. TRUST TERRITORY FEE SCHEDULE

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Tables and Figures Table X Population By Age, 1973 p23 Tbble II ,Population BY Geographical Distribution, 1973 p23 Table 111 Geographical Distribution Of High-Risk Age Group, 1973 p23 ~’ Table IV District Center Population Growth/Majuro Copulation as Percent of Entire District, 1967-1982 p23 Figure 1 Crude Eirth Rates: District Compared To TTPI, 1955-1975 Population, Birth, Infant Deaths, Deaths, And Natural Increase TTPI Marshall Islands, 19.55-197’5 Population, Birth, Infant Deaths, Deaths, And Natural Complications of Pregnancy, 1974 Complications of Pregnancy, 1975 Complications of Pregnancy, 1976 Complications of Pregnancy Sllmmary, 1.974, 1975, 1976 Fetal, Neonatal ; Infant And child Deaths, 1974-1976 Infant Flortality Rare for All District, 1976 Neonatal, Infant And Child Deaths, 1974-1.976 Continuation of Above Causes of Mortality, 1974, 1’975, 1976 Ten Leading Causes of Death: United States, 1973 Deaths Reported in Trust Territory of the I’acific Iolands in Calendar Year 1974, 1975, and 1976 (Listed in Rank Order)

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Tables and Figures Cases of Notifiable Diseases Reported in Trust Territ”;ry Districts, January - December 1976 Cases of Notifiable Diseases Reperked in61acahaT&srIQ&~ds Ten Leading Causes of Outpatient Visits in Marshalls Ten Leading Causes of Outpatient Visits in Ebeye District Di.epensary Utilization By Condition For Which Care Was Ten Leading Causes of Dispensary Utilization, 1976-1977 Ten Leading Causes of Inpatient Visits in Ebeye SubHospital Number of Hospital DischargesFor Twenty-Five Diseases and For Child Birth Related llealth Care, 1974, 1975, 1976 Number of Hospital Discharges For Twenty.Fi.ve Diseases And for Child Birth related Health Care, 1974, 1975 1976 , Immunization Levels, Marshall. Discri.ct Summary of Immunization Assessment 8irth Groups: 1969-1.974 Health Services Budget, 1.977, 1978, 1979 Listings Of District I{ospita].Personnel, TiEle, Pay Level Summary of Ill-Patient Services, Kbeye District

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Tables and Figures Data on operations, tiarshall Health Services, 1976 -19~7 Summary of T,T, Referrala By Services, January-August 1977 Referrals From District Center To Location9 To Outside Referrals From District Center To Locations Outside Outlays, T.T,Nide Fledical Referrals Dispensary Facilities Inventory, Marshalls District, JUIY 1977 Health Manpower Inventory Percent of Extractions, Fillings, And Other Services for All Patients Treated in District Clinic By Dental Officers And Dental Nurses, 1976 Percent of Extractions, Filling6, And Other Services for All Patients Treated in District Clinic By Dental Officers And Dental Nurses, 1976 Same as above Extractions Vs Permanent Fillings for 17 year olds and Cervical Cancer Detection: Comparative Figures fol- Disrrict Vocational Rehabilitation, Majuro (lLYTreatments) Communication And Transportation Services to Outer Islands Ag of November 1977

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Total All Complications Outer Islands Kwajalei; *Oc fined as gestation perfod less than 40 weeks. Source: UP I birth certificates: TT Oepartmnt of Health Services Oivis!on of

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CO)WLICATIONS OF PREGNANCY - MARSHALL DISTRICT (TTPI Citizens only) 1975 aKwajaJein Majuro Total District Total All Complications **Drfineclas 40 weeks or longer gestation period but birth weight less than 51bs. 8 OZS. Source: J“TPI birth certificates: TT Department of I!calthServices Division of

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*D~finecl as gest~tion period less than 40 weeks, **Defined as 40 weeks or longer qestation period but birth weight less than 51bs. 8 OZS. Sotirce: TTPI birth certificates: TT Department of tlealthServices Division of

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Total All Complications *Defined as gestation period less than 40 weeks, **Defined as 40 weeks ’or longer yestation period but birth weight less than 51bs. 8 OZS. Source: TTP1 birth certificates: TT Department of Health Services Division of

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COMPLICATIONS OF PREGNANCY - 1974 OTHER COMPLICATIONS OF DELIVERY Outer Islands Kwajalein OTHER CCIMPLICATIONS OF PREGNANCY CONGENITAL DEFECTS OF CHILD Cord around neck

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OTHER COMPLICATIONS OF DELIVERY Outer Islands Kawajalein Majuro -o- Difficult delivery 1 Low lying placenta 1 OTHER COMPLICATIONS OF PREGNANCY - Preeclampsia 1 -o- Uterine bleeding 2 CONGENITAL DEFECTS OF CHILD Cleft Palate 1 Achondroplasia 1 Super nurrrnery

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COMPLICATIONS OF PREGNANCY - 1976 Outer Islands Kwajalein OTHER COMPLICATIONS OF PREGr4ANCY CONGENITAL DEFECTS OF CHILD

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SELECTED INTERNATIONAL INFANT MORTALITY RATES FOR 1974 (with biarshalls District and TTPI included) o Location: Infant Mortality Rate: Outer Is. - Marshall District 13.2

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... LEADING CAUSES OF DEATH: MARSHALL DISTRICT 1974- 1976 @ DISEASE NUMBER OF CASES 9. Chronic lung conditions 10. Nonmaterial conditions associated * Hasting of the body due to lack of food. Condition is generally listed in official statistics as relating to senility. In all cases in the Marshall District this condition occurred in individuals over the age

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RA}IKORCIERSELECTED CAUSES OF DEATH - YEARS O THROUGH 4, 1974-1976 Deaths by: Prematurity Congenital defect & birth

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Other Conditions 1974 are: Cirrhosis of liver Spinobulbur muscular atrophy Other Conditions 1975 are: Viral respiratory tract infection 1 Uterine gangrene infection 1 Other Conditions 1976 are: Central nervous system disorder Infection above knee amputation

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TEN LEADING CAUSES OF DEATH - UNITED STATES - 1973 Ischaemic Heart Disease trachea, bronchus & lung. Diseases of arteries, Motor vehicle accidents Malignant neoplasms of Malignant neoplasms of TEN LEADING CAUSES OF DEATH …