Performance Evaluation Report

PPE: RMI 26322

Health and Population Project (Loan 1316-RMI[SF]) in the Marshall Islands

December 2005

Operations Evaluation Department

Asian Development Bank

ABBREVIATIONS ADB BPHC CHC DHSHP DMC DPH EA HA HC HMIS LA MCH MDG MMR MOH NGO OED OEM OIHCS PAM PAT PCR PHC PIU PSC RMI STD TA TB TBA TOR UNDP UNFPA US WUTMI YTYIH Asian Development Bank Bureau of Primary Health Care community health council Division of Human Services and Health Promotion developing member country Division of Public Health Executing Agency health assistant health center health management information system Loan Agreement maternal and child health care Millennium Development Goal measles, mumps, and rubella Ministry of Health nongovernment organization Operations Evaluation Department Operations Evaluation Mission Outer Island Health Care System Project Administration Manual Policy Advisory Team for Economic Management Project Completion Report primary health care Project Implementation Unit Public Service Commission Republic of the Marshall Islands sexually transmitted disease technical assistance tuberculosis traditional birth attendant terms of reference United Nations Development Programme United Nations Fund for Population Activities United States Women United Together Marshall Islands Youth to Youth in Health

NOTE In this report, "$" refers to US dollars.

Director General Director Team Leader Team Member B. Murray, Operations Evaluation Department (OED) R. K. Leonard, Operations Evaluation Division 1, OED J. Tubadeza, Senior Evaluation Officer, Office of the Director General, OED C. J. Mongcopa, Senior Operations Evaluation Assistant Operations Evaluation Division 1, OED Operations Evaluation Department, PE-676

CONTENTS Page
BASIC DATA EXECUTIVE SUMMARY MAP I. INTRODUCTION A. B. II. Evaluation Purpose and Process Project Objectives ii iii v 1 1 2 2 2 3 4 5 5 6 9 10 11 11 11 17 20 20 21 22

DESIGN AND IMPLEMENTATION A. B. C. D. E. F. G. H. I. Formulation Rationale Cost, Financing, and Executing Arrangements Procurement, Scheduling, and Construction Design Changes Outputs Consultants Loan Covenants Policy Setting

III.

PERFORMANCE ASSESSMENT A. B. Overall Assessment Other Assessments

IV.

ISSUES, LESSONS, AND FOLLOW-UP ACTIONS A. B. C. Issues Lessons Follow-Up Actions

APPENDIXES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Project Results/Achievements as per Project Completion Report Primary Health Care Issues in the Republic of the Marshall Islands Appraisal and Actual Costs Results of a Survey of Special Provisions to Support Primary Health Care in the Outer Islands Outer Islands Health Centers Built Under the Project Assessment of Project Overall Performance Vision 2018 Health Targets Health Indicators Pre- and Post- Project, 1993 and 2004 Utilization of Outer Islands Health Centers Built Under the Project Accomplished Outer Island Trips 24 30 39 40 42 50 52 53 58 59

The guidelines formally adopted by the Operations Evaluation Department (OED) on avoiding conflict of interest in its independent evaluations were observed in the preparation of this report. Penelope Schoeffel (health and population specialist) and Ellia Sablan-Zebedy (social development specialist) were the consultants collaborating with the OED evaluation team. To the knowledge of the management of OED, there were no conflicts of interest of the persons preparing, reviewing, or approving this report.

BASIC DATA Health and Population Project (Loan 1316-RMI[SF]) PROJECT PREPARATION/INSTITUTION BUILDING PersonMonths 10.0 15.0 Amount ($) 250,000 465,000a Approval Date 31 Dec 1992 22 Sep 1994

TA No. 1833 2164

TA Name Preparation of Health and Population Project Health Management Information System and Health Planning

Type PPTA ADTA

KEY PROJECT DATA ($ million) Total Project Cost ADB Loan Amount/Utilizationb ADB Loan Amount/Cancellation KEY DATES Fact-Finding Appraisal Loan Negotiations Board Approval Loan Signing Loan Effectiveness First Disbursement Project Completion Loan Closing Months (Effectiveness to Completion) BORROWER EXECUTING AGENCY

As per ADB Loan Documents $7.12 $5.70 $0.00 Expected

Actual $5.90 $5.23 $0.07

25 May 1995 30 Nov 1999 31 May 2000 54.2

Actual 217 Dec 1993 21 Apr13 May 1994 831 Aug 1994 22 Sep 1994 24 Feb 1995 14 Mar 1995 4 May 1995 31 Oct 2001 30 Jul 2002 79.7

Republic of the Marshall Islands Ministry of Health and Environment

MISSION DATA Type of Mission Fact-Finding Appraisal Project Administration Inception Review Country Program Special Project Administration Project Completion Operations Evaluation

No. of Missions 1 1 1 8 4 2 1 1

No. of Person-Days 60 92 11 131 74 18 28 42

= not available, ADTA = advisory and operational technical assistance, PPTA = project preparatory technical assistance, SDR = special drawing rights. a Including supplementary technical assistance amounting to $65,000, approved on 23 July 1997. b The original loan amount of SDR3.911 million ($5.7 million) was equivalent to $5.23 million as at loan closing date.

EXECUTIVE SUMMARY This report details the findings of an evaluation of the Health and Population Project in the Republic of the Marshall Islands (RMI). This was the first Asian Development Bank (ADB) support for the health sector in the RMI. The RMI comprises 31 atolls dispersed over a vast span of ocean, with a total land area of just under 110 square kilometers. It has a population of 50,840 of whom 70% live in two crowded urban locations (Majuro and Ebeye) and 30% live on small, scattered outer islands. The Marshall Islands was formerly part of the United States (US) Trust Territory of the Pacific Islands (19451986), under a United Nations trusteeship agreement. In 1986, the RMI entered into a Compact of Free Association with the US, which expired in 2001. A new 20-year Compact was subsequently negotiated, effective from October 2003. Dependence of the RMI on aid is unusually high among ADBs Pacific developing member countries (DMCs). The rationale for the project was the poor development results of the high per-capita expenditure on health in the RMI, by Pacific DMC standards ($100 in 1991), despite which the country ranked comparatively low on health indicators. Epidemiological evidence showed that the RMI had a high prevalence of both infectious and chronic diseases. At the time of project formulation (19921994), the health and population sector was confronted by four major problems: quality of health services, equity of access to health services, sustainability of health services, and rapid population growth. There was a need to shift the emphasis of health service provision from expensive curative services to preventive services based on a primary health care (PHC) approach. The Project aimed to develop a PHC approach and more effective PHC services in the Ministry of Health (MOH, formerly the Ministry of Health and Environment). This was to be achieved by providing (i) technical support for establishing PHC models and for improving the institutional capacity of MOH; (ii) physical infrastructure for new outer island health centers and specialized health centers on Majuro, plus equipment; and (iii) support for project implementation. Associated technical assistance (TA) was provided to establish a health management information system (HMIS) and to support health planning. The objectives were grounded in the Governments health and population policies; ADBs policies for the health and population sector, and its country strategy for the RMI; and the results of the project preparatory TA, which included a health sector study. In formulating the Project, there was insufficient recognition of the likely barriers to success posed by staff shortages in MOH. It was known that the Public Service Commission might not approve the appointment of essential counterpart staff, but it was assumed, incorrectly, that this obstacle could be overcome by attaching covenants to the loan requiring cooperation among government agencies. An overlapping ADB TA and program loan for public sector reform provided policy advice to the Government to reduce public service employment, advice that was not coordinated with the implementation needs of the Project. The project design was based on an overoptimistic assessment of what might realistically be achieved, given the magnitude of the challenges. There were too many objectives and components for the size of the loan, the scope of consulting services, the duration of the project, and local institutional capacity. The Project lacked adequate leadership, and there were weaknesses in implementation. The performance of the consultants was variable, and the contracted consulting companies

iv

performed below expectation. The attached TA for the HMIS was unsuccessful. The physical infrastructure and equipment components were successfully implemented, although maintenance provisions were unsuccessful. The project provided 26 new outer island health centers and 4 specialized health centers on Majuro, which have improved access to PHC services. The technical support components and provisions for health promotion and population awareness activities achieved few of the expected outcomes and impacts. Although trends in population growth, life expectancy, and infant mortality rates improved in the intercensus period 19881999, it is unlikely that these were due to the Project, as most of its components were not completed until 19981999 or later. Although public health education and outreach programs encouraged by the Project are being implemented with continuing support from US programs and other funding agencies, the results of many of these efforts continue to be disappointing. Health statistics show little improvement since the Project was formulated. The Project is assessed as relevant, less effective, less efficient, and less likely to be sustainable. The OEMs overall assessment of the Project is partly successful. ADBs performance was considered only partly satisfactory due to perfunctory project supervision and to issues related to country programming. The objectives and conditionalities of the program loan and TA for public sector reform conflicted with the implementation needs of the Project. However, ADB showed sound judgment in extending the loan closure date until 2002 to allow the allocation for equipment for the new Ebeye Hospital to be spent. The Governments performance was satisfactory, although its efforts to resolve implementation obstacles related to staffing policies through a high-level coordination committee did not succeed until close to the time of project completion. A lesson identified is the need for executing agency participation in formulating strategies to ensure sustained support for project objectives. This is necessary to increase the probability that development results will be achieved. There was insufficient attention to the need to inspire a sense of ownership of the proposed innovations among MOHs managers. It is possible that greater consultation would have led to changes in some of the proposed innovations, and alternative strategies might have been proposed to reflect local ideas, cultural understanding, and more in-depth knowledge of the issues. The RMIs health problems have deep structural roots in the limitations of an atoll environment, urban overcrowding, cultural breakdown in urban areas, poor water and sanitation, external dependency, low levels of education among the population, poverty, lack of available and affordable nutritious food, and cultural beliefs about health. These problems suggest that health should be approached as a cross-cutting issue, integrated into nonhealth sectors including education, water and sanitation, waste management, housing, and renewable energy.

Bruce Murray Director General Operations Evaluation Department

I. A. Evaluation Purpose and Process

INTRODUCTION

1. The Health and Population Project (the Project) in the Republic of the Marshall Islands (RMI) was selected as part of the annual random sample of completed projects to be evaluated by the Operations Evaluation Department (OED) of the Asian Development Bank (ADB). The Operations Evaluation Mission (OEM)1 visited the RMI from 22 October to 4 November 2005, approximately 4 years after the Project had been completed on 31 October 2001. The original closing date of 31 May 2000 was extended to 31 July 2002 to allow for completion of physical infrastructure and utilization of funds allocated for equipment for the new Ebeye Hospital, which was rebuilt under a separate loan. 2. The evaluation draws on a review of project documents and other relevant studies, and on discussions with ADB staff, senior officials and staff of the Ministry of Health (MOH, formerly the Ministry of Health and Environment, the Executing Agency [EA])2 as well as other relevant government agencies; personnel of nongovernment organizations (NGOs); and community representatives on Majuro, Arno Atoll (Arno Island and Bikarej Island), and Ebeye on Kwajalein Atoll. A copy of the draft evaluation report was circulated among the concerned ADB departments and those of the borrower, and their comments have been incorporated and acknowledged where relevant. 3. In 2002, the Project Completion Report (PCR)3 rated the project as successful, taking account of basic health data showing improvements such as decreased infant mortality, increased life expectancy, and wider immunization coverage. It restructured the project framework to provide a clearer hierarchy of objectives. 4. The economic and social development objectives of the Project were assessed by the PCR as highly relevant, and the outputs and inputs as efficacious, despite the facts that many targets relating to population and family planning had not been achieved, that the experience with the contracted consulting firms had been unsatisfactory, and that the objective of rationalizing the health service delivery system in the outer islands had been only partly achieved.4 The assessment took account of the major improvements made by the Project in providing health infrastructure for the outer islands. The PCR noted that no economic and financial analysis had been done during the Projects preparation and therefore no assessment could be made of the efficiency of the investment. It considered that the Project was likely to be sustainable because there had been significant policy developments toward its close. These included a government decision in 1999 to allow MOH to make medical and associated professional appointments, thus removing a major obstacle to Project implementation, namely the appointment of essential counterpart staff.

2 3

The mission comprised J. Tubadeza, senior evaluation officer/mission leader, P. Schoeffel, primary health care specialist/staff consultant, and E. Sablan-Zebedy, social specialist/staff consultant. The Ministry of Health and Environment was redesignated the Ministry of Health in 2004. ADB. 2002. Project Completion Report on the Health and Population Project (Loan 1316-RMI[SF]) in the Marshall Islands. Manila. The Project Completion Review was undertaken on 1627 September 2002. Rationalizing the health service delivery system in the outer islands was also a recommendation for the health sector made by the Policy Advisory Team for Economic Management under TA 2295-RMI. ADB. 2000. Technical Assistance Completion Report on the Policy Advisory Team for Economic Management in the Republic of Marshall Islands. Manila.

2 5. The PCR noted that some targets were too ambitious, and that the failure of the TA to establish a health management information system (HMIS) negatively affected performance monitoring and evaluation. It pointed out the following lessons: (i) the unsatisfactory experience with the consulting firms indicated the need for strong monitoring to detect poor performance and for termination of contracts to be built into the contracting procedures and the Projects management; (ii) a 5-year implementation period was too short to achieve the performance targets; 68 years would have been more realistic; (iii) the amount of training planned was unrealistic, given the staffing constraints in the EA; (iv) the time budgeted for consultants for the health financing and accountability segment was insufficient; and (iv) accounting weakness in the Project Implementation Unit (PIU) led to underspending on some of the planned primary health care (PHC) outputs. B. Project Objectives

6. The Project was classified as a human resource development project, with a secondary objective of women in development. Its goals were (i) to improve the health status of the population and develop a healthy lifestyle, and (ii) to support the national population policy and reduce the population growth to a level that would enable harmonious social and economic development of the country. The objectives were to (i) improve the quality of health and family planning services, and (ii) strengthen the Governments PHC services and organize a health services delivery system that would be appropriate for the country and sustainable. 7. The project framework set unrealistic targets for assessing the achievement of specific project objectives, which were not commensurate with its inputs. The targets for population awareness, family planning utilization, healthy lifestyle, and increased local resources for health and health personnel for PHC were particularly unrealistic. Many of the monitoring mechanisms relied on an HMIS that was to have been established under the attached TA5 but that did not deliver the expected information. The PCR made considerable revisions to the project framework to try to show results and achievements. The OEMs commentary on the project framework is provided in Appendix 1. II. A. Formulation DESIGN AND IMPLEMENTATION

8. The Projects dual strategy to shift emphasis from hospital-based services towards a PHC approach and to strengthen capacity in MOH was based on a health sector review in 1993 under a project preparatory TA.6 This made comprehensive and well-founded recommendations on sectoral and intersectoral planning and policy issues. However, its proposals for health education, public awareness and community mobilization and participation relied heavily on assumptions that the behavioral changes required to improve public health could be achieved by public education (Appendix 2).7 9. The project contained special features for community participation, womens participation, and environmental dimensions. Funds were to be provided for information,
5

TA 2164-RMI associated with Loan 1316. ADB. 1994. Report and Recommendation of the President to the Board of Directors on a Proposed Loan and a Technical Assistance Grant to the Republic of the Marshall Islands for the Health and Population Project. Manila. ADB. 1993. Technical Assistance to the Republic of the Marshall Islands for Preparation of a Health and Population Project (TA 1833-MAR). Manila. Coffey MPW Pty Ltd. 1993. Project Priorities Proposals. Australia.

3 education, and communication activities; training; civil works and equipment; consulting services; project implementation; and part of the incremental recurrent costs on a declining basis. 10. The proposed training activities were extensive, and the training costs were to be covered largely by local contributions. The design overestimated the capacity of MOH to support these activities and took insufficient account of its human resource constraints. 11. More consultation was needed in formulating the proposed PHC innovations, such as increased participation of women and communities, to ensure ownership of these ideas in MOH. A more consultative and participatory approach was also needed during project formulation to ensure that the management of MOH owned the proposed family health promotion activities, and that the EA considered that proposed assistance was appropriately targeted, necessary, and feasible. For example, the Assistant Secretary for the Department of PHC during project formulation and implementation was Marshallese and an experienced health educator, so it is difficult to see why international consultant services were required to evaluate the strength and weaknesses of existing health education programs, in particular their relevance to the Marshallese culture; to advise on strategies that were culturally appropriate and acceptable to Marshallese; and other similar outputs specified in the terms of reference (TOR).8 The issues and topics for health promotion were well known in MOH. What MOH required was practical advice and training to increase the capacity of health education staff to do their work more effectively. 12. A further weakness in project formulation was insufficient policy dialogue (noted in the PCR). MOH was not authorized to appoint medical and associated technical staff. Despite the loan covenant (Section 4.04) requiring interagency cooperation in support of the Project, between 1995 and 1999 the Public Service Commission (PSC) refused the appointments of seven essential counterpart staff,9 which created insuperable obstacles to skill and knowledge transfer during project implementation. 13. In formulating the Project10 ADB followed standard approaches to implementation arrangements, consulting services, and procurement, and these were all clearly specified in the Project Administration Manual (PAM). B. Rationale

14. The RMI comprises 31 atolls11 dispersed over a vast span of ocean, with a total land area of just under 110 square kilometers (km).12 Seventy percent of the total population live in two crowded urban locations, and 30% live widely dispersed on small, scattered outer islands.
8 9

Project Administration Manual, May 1995, Appendix 11:56. Positions in MOH never approved by PSC for counterpart staff to work with the consultants were (i) a training coordinator, (ii) a replacement for the family health coordinator on leave, (iii) four technicians to be trained in maintenance, and (iv) the PIU post for a procurement officer. 10 The Loan Fact-Finding Mission visited RMI from 217 December 1993. The appraisal mission was fielded 21 April to 13 May 1994. The appraisal Mission was assisted by a consultant specialist in Pacific Island demography, who endorsed the main elements of the project design. 11 An atoll comprises a number of small inhabited and uninhabited coral islets, most of which are scattered around large lagoons partly enclosed from the ocean by coral reefs. Five atolls in the RMI consist of a single set of islands with no central lagoon. 12 The Marshall Islands was formerly part of the US Trust Territory of the Pacific Islands (19451986) under a United Nations trusteeship agreement. In 1986, RMI entered into a Compact of Free Association with the US, which expired in 2001. A new 20-year Compact was subsequently negotiated, effective from October 2003.

4 At the time of project formulation (19921994), the health and population sector was characterized by major problems. The population growth rate was 4.5% and the fertility rate was 7.2% (1988 census), which was high by developing country standards, and of particular concern, given the RMIs limited economic and land resources. Overseas migration was insignificant. Access to health services was inequitable, and their quality was generally poor, as were health indicators. There was financially unsustainable dependence on overseas medical referrals. Health expenditure per capita ($100 in 1991) was high in comparison with ADBs other Pacific developing member countries (DMCs), yet there was high and rising prevalence of infectious, parasitic, and chronic diseases; teenage pregnancy; and infant and child malnutrition. There was low acceptance of family planning, and rapid population growth; life expectancy was low by Pacific DMC standards, and infant mortality rates were relatively high.13 15. There was a strong rationale for ADB to provide support for reorientation of health and population services in the RMI toward a PHC model. ADBs operational strategy for the country focused on four areas of intervention, one of which was the development of human resources through education, human resource training, health, and family planning. The health sector review under the project preparatory TA indicated problems with management and capacity, the quality and effectiveness of services, and economic analysis highlighting the high and increasing costs of curative and overseas treatment at a time when the RMI faced an uncertain future with regard to its US Compact funding and other US federally funded health and healthrelated welfare programs. C. Cost, Financing, and Executing Arrangements

16. The details of the appraisal and actual costs are provided in Appendix 3. The total cost of the Project at appraisal was estimated at $7.12 million, of which ADB was to finance (from its Special Funds resources) the foreign exchange cost of $4.950 million including service charge during construction (69.5% of the total project cost), plus about $0.750 million (10.5% of the total project cost) of the local currency cost. The Government was to put in the equivalent of $1.420 million for the local currency cost, representing 20% of the total project cost. At loan closing, the overall actual project cost amounted to $5.903 million. Of this, ADB had financed a total of $5.228 million, comprising about $4.950 million in foreign currency (83.9%) and about $0.278 million in local currency (4.7%) costs. The Government contributed about $0.675 million (11.4%).14 More funds were spent on civil works (26% higher than appraised) due to construction of additional facilities (paras. 2023), while funds for training and health promotion activities were considerably underspent. This was the result of lack of staff in MOH to implement the intended activities (paras. 2728), as well as lack of leadership in the management of the Project and lack of accounting capacity in the PIU (para. 37). The unutilized loan balance of about $0.070 million was cancelled when the loan account was closed on 30 July 2002. 17. As the EA for the Project, MOH was responsible for project planning, organization, and implementation. The PIU was set up within MOH for day-to-day implementation of project activities. A Project Steering Committee, chaired by the minister of MOH, was to provide higher level policy guidance. Its members comprised representatives from the ministries of Finance, Internal Affairs, Education, and Social Services; the Office of Planning and Statistics; the Marshall Islands Social Security Agency; and other concerned agencies. The Ministry of Works was
13

Population growth was 4.2% in 1988, among the highest in the world. Life expectancy was 60 for men, 62 for women. The infant mortality rate was 63 per 1,000 live births. 14 As noted in the PCR, the under reporting of the Governments contribution was mainly the result of serious weaknesses in accounting. Much expenditure was not properly recorded under the government share.

5 responsible for design and construction of all civil works specified in the Loan Agreement (LA), but in 1996 this ministry was abolished and its responsibilities under the Project were transferred to the new Ministry of Resources and Development under an agreement with ADB signed on 1 February 1996. Subsequently, responsibility for implementation of civil works for the Project was transferred to a designated government contractor. D. Procurement, Scheduling, and Construction

18. Procurement was carried out in accordance with ADB procedures as specified in the PAM by the PIU, although with some delays due to staffing lacunae in the PIU and to the scheduling of project inputs. 19. At appraisal, it was envisaged that the Project would be implemented over 5 years commencing in November 1994 and be completed by 30 November 1999. Retroactive financing of up to $230,000 (4% of the loan amount) was provided for under the loan to finance eligible expenditures incurred by the Government from 15 June 1994 for the preparation of surveys, initial procurement of equipment for the new hospital at Ebeye, and consulting services for the PIU. The actual amount of retroactive financing was $230,000. The Loan Agreement was signed on 24 February 1995, and the loan became effective on 14 March 1995. As the Government does not own land, the community health councils (CHCs) established under the Project were made contractually responsible for identifying and providing sites to build the new health centers (HCs). The process caused some delays in the implementation schedule. Overall, actual project completion was delayed by 2 yearsuntil October 2001. The delay was due mainly to stoppage of work at Ebeye Hospital for lack of funds.15 E. Design Changes

20. Civil Works. The project design made provision for construction of 21 outer island HCs. During implementation, the number of HCs provided under the Project was increased to 26 at the Governments request and with ADB approval. 21. The PAM specified that the HCs were to be designed with optimal features for an atoll environment and of a size relevant to the population to be served, including cross-ventilation and solar-powered ceiling fans. Three types of buildings were proposed having different sizes related to the population to be served: nine treatment centers with three rooms; four centers with four rooms, including a small inpatient facility; and eight centers with a four-bed ward. Apparently for reasons of cost containment, MOH decided that a single uniform design of HCs would be constructed in all the designated locations. The standard design selected was a fourroom model (waiting room, treatment room, and two small single-bed wards) with a separate washroom and toilet at the rear of the building. The design features specified in the PAM for cross-ventilation, louver windows, and solar-powered fans were omitted. 22. Each HC was to be provided with a water catchment tank, but the budget allowed for materials only, as it was envisaged that the beneficiary communities would build the tanks. It was found that the communities lacked the skills and equipment to construct the water tanks, and the cost of water tanks and toilets was incorporated into the building contract for the HCs. The contribution of the communities was amended to the provision of labor during construction of the HCs.
15

Procurement of equipment under the Project started only after substantial progress was made under a subsequent ADB loan (Loan 1694-RMI [SF]: Ebeye Infrastructure Project, approved on 12 August 1999 for $9.4 million).

23. The Project provided for the construction of four new HCs in Majuro to relieve the pressure of providing PHC services at the Majuro Hospital outpatient facility. There was provision for two urban HCs and two specialized centers, one catering to youth and a center for human services (mental health and health education outreach services). Instead of the two urban HCs, ADB agreed to MOHs request to build a larger HC at Laura, located 48 km from the urban area of Majuro, utilizing funds allocated for the second HC planned for the urban area. At the time MOH expected (but did not obtain) funding from another source to build the proposed urban HC. MOH also obtained ADB consent to build an additional facility at the hospital to provide family planning services. The Project cofunded the youth HC with an NGO, Youth to Youth in Health (YTYIH), providing approximately 75% of the funds. 24. Technical Support. During financial negotiations with the first-ranked consulting firm to provide technical support for implementation, it was found that the cost of services was considerably higher than the budget allocated under the loan. With ADBs concurrence, the number of person-months was reduced from 53 to 44. However, only 37 person-months were actually utilized. F. Outputs 1. Support for Primary Health Care

25. Organizational Management and Technical Support for PHC. An analysis of the organizational arrangements for PHC in MOH, with recommendations for improvements, was produced in November 1996.16 Two national seminars were held, in 1997 and 1999, to promote the PHC objectives of the Project among decision makers. A household survey followed by a survey on family planning and population awareness was completed in 1995. A thyroid study required by MOH in relation to compensation provisions under Clause 177 of the Compact was also completed. A review of health education containing detailed recommendations for family health promotion was produced in August 199617 as well as a draft family health book intended for distribution to all households, and a draft family health calendar. A quarterly PHC newsletter (still being produced) was established in 1996. In 19981999, training was provided for health educators using practical approaches and mechanisms to help them do their work more systematically and effectively. 26. CHCs were established on 51 outer islands with HCs. Most of the CHCs established had about 50% female membership. The CHCs signed agreements to promote PHC, and, in locations with health centers built by the Project, the agreements with CHCs included a requirement to provide land for the HCs. A community trainers handbook was produced, and 10 MOH staff were trained as trainers in short courses in 1996. The trainers went to five outer islands in 1996 to provide short courses for the communities. MOH conducted national level training programs attended by three members each of the 51 CHCs in 1997. 27. Training of Health Personnel in PHC Services. Twenty-eight women were enrolled in a course to train women as health assistants (HAs), and 24 completed the training. Apparently, 18 graduates were initially appointed to outer island posts. At evaluation, nine were still serving in outer island HCs, and four were employed on Majuro. Others had emigrated or had taken other employment in the health sector.
16 17

K. Harmon. Implementation of Primary Health Care. Interim Report, 13 February30 November 1996. L. Shaw. Report on Family Health Promotion, August 1996 and May 1997.

28. The project provision for retraining of 51 HAs and 14 public health nurses in PHC approaches, as specified in the PAM, does not appear to have been implemented. Training measures to improve the health of women and children in the outer islands did not achieve the expected outcome. The project provisions for training of 60 traditional birth attendants (TBAs) and 30 wives of male HAs as specified in the PAM were only very partly achieved according to an OEM survey in October 2005 (Appendix 4). MOH mobile public health teams provided training to few of the wives of the HAs. The United Nations Fund for Population Activities (UNFPA), not the Project, provided training for TBAs in reproductive health and family planning. The project budgetary allocation for training was underspent by $0.45 million. If the proposed training had been implemented, the outcomes of the Project might have been more effective. However, there were insufficient available personnel to conduct the training, and MOH was unable to appoint more staff. At the very same time, ADB, through its Public Sector Reform Program and associated TA,18 was encouraging to the Government to reduce expenditure on staff, which probably contributed to the less effective outcome of the component for training. 29. Physical Infrastructure. All project infrastructure was provided, along with the specified equipment and materials, comprising 26 outer island HCs, an HC at Laura in Majuro atoll, a family planning center, a human services center, and a youth HC. Two outer island HCs were not fully completed until 2005. 30. The design of the outer island HCs could have been more user friendly. The specifications in the PAM for appropriate design for islands without electricity (cross-ventilation, louver widows, solar-powered fans) were not applied, the HCs are hot, and sometimes inpatients cannot be comfortably accommodated in them. The maintenance schedule specified in the PAM has not been implemented, and the current arrangements for maintenance of the HCs are only partly satisfactory; a program for repainting was observed by the OEM to have been scheduled, but repairs to plumbing, gutters, water supply, and washroom/toilet facilities had not been systematically done. An inventory of the HCs is provided in Appendix 5. Most have no source of electricity. Some HCs lack necessary radio communication equipment to enable the HAs to receive guidance from the Division of Outer Island Health Care System (OIHCS) when they need it. In some locations, a four-room facility appears excessive for the size of the population being served. 31. The Laura Community Health Center is well maintained and provides a well-patronized service staffed by a doctor (Medex19 graduate) and three female HAs. MOH is considering using it as an in-service training center for HAs, the present limitation on this plan being the shortage of staff accommodation. 32. The human services center and family planning/reproductive health clinic centers are part of a building complex at the Majuro hospital. They appeared in reasonable condition. The human services center needs some interior maintenance. The facility serves as a suite of offices for health promotion and mental health personnel, who conduct health education and outreach programs. MOH intends to convert the section of the building now housing the human services center to a dedicated mental health service facility when the new Majuro Hospital is completed and the health promotion staff are relocated to the new building.
18

TA-2295-RMI: Policy Advisory Team (PAT) for Economic Management, approved on 31 January 1995 for $2.5 million. The identification, need, and design of the public sector reform program (Loan 1513-RMI [SF], approved on 30 January 1997 for $12.0 million) were largely developed from the work of the PAT team. 19 A Medex is a medical officer with five-year training course offered through a program formerly provided in the Federated States of Micronesia.

33. The youth HC managed by YTYIH does not conform to the youth-friendly specifications envisaged in the project design and PAM. It comprises a substantial two-story building of offices and counseling and treatment rooms located next to the courthouse. The interior of the building is currently in poor condition, although termite proofing and some repairs have been conducted by YTYIH. Few if any health services are currently being provided there. The NGO has financial and personnel problems. Substantial financial support ended in 2002 when funding from a major donor was not renewed. YTYIH has a well-qualified and committed board of advisors. Further external assistance is now being sought. The Japan International Cooperation Agency recently funded a hall located behind the Project facility (costing approximately $80,000) for use by YTYIH, which has been almost completed. YTYIH recently signed a memorandum of understanding with MOH for mutual cooperation and assistance. 34. Repair and Maintenance for Ebeye and Majuro Hospitals and Outer Island HCs. A facility maintenance plan (July 1997) and a facility maintenance manual (August 1997) were produced, but the output was not acceptable to MOH. No training of maintenance personnel was done under the project as specified in the PAM, apparently because the new positions for maintenance personnel to staff the proposed maintenance unit were not approved by PSC. Maintenance is contracted to the private sector with mixed results. Arrangements at the Ebeye Hospital appeared satisfactory, while in Majuro new arrangements will be made following the completion of the new hospital. The Laura Community Health Center is well maintained. The maintenance schedule specified in the PAM for outer island HCs was not implemented and the current arrangements for maintenance of the HCs appear only partly satisfactory. 35. Equipment for Ebeye Hospital. Equipment was provided for the Ebeye Hospital according to budget in 2002. Equipment procured under the Project includes general and medical surgical equipment; cardiology, clinical laboratory, dental, imaging, neonatal care, ophthalmic, and refrigeration equipment; beds and furnishings; receptacles; stretchers; and surgical instruments. This equipment is appropriate, operational, and being maintained. 2. Institutional Strengthening

36. The expected outputs for capacity building and in-service training under this component were only partly achieved. By the completion of the Project, only 5 months of consulting services for finance had been provided (para. 40), which included some training in health service finance (November 1997). The planned three workshops for senior administrators on management, administration, and health care financing, and two management seminars were not held because the services of a management specialist were cancelled due to the expected imminent closure of the loan in 1999.20 An administration manual for MOH was produced in January 2000 using an additional 3 months of consulting services. The Project provided assistance for preparation of the MOH Fifteen-Year Plan (2002). 3. Project Implementation

37. Project Implementation Unit. The PIU was established with the required local staff except for a procurement officer (because the post was not authorized by PSC). The PIU was assisted by 19.5 months of services by an individual consultant project management specialist. An individual consultant hospital equipment specialist was recruited by the PIU for 1 month to prepare a master list and technical specifications for equipment for the Ebeye Hospital, but his
20

The Project was in fact extended to 2001 to allow the funds for equipment for the Ebeye Hospital to be utilized.

9 second input for procurement was cancelled due to the delay in completing the hospital. After the position of finance officer in the PIU became vacant and the director of the PIU became ill and passed away, three individual consultants to the PIU provided successive short-term financial and administrative assistance. Training of PIU counterpart staff in project administration was conducted by individual consultants. 38. Technical Assistance. An associated TA (footnote 5)21 was provided to develop, install, and test a user-friendly computerized HMIS with an HMIS manual; and to produce modules for medical records, public health and epidemiology, medical referrals abroad, health finance, personnel management, and benefit monitoring and evaluation. The TA was also to develop performance indicators for monitoring and evaluation and to conduct workshops and training for health personnel on interpretation of health statistical reports. 39. Outputs from the TA included a draft report and the design of forms to collect health information. One of the consultants gave inputs for the preliminary MOH Five-Year Plan (revised in December 1996), which provided an overview of issues, goals, and objectives for 19972001 for secondary and PHC services, as well as a program budget allocation analysis (see para. 91). G. Consultants

40. According to its proposal, the winning consulting firm from Australia was to have provided a health finance and management specialist/team leader (Table 1). The present and former Secretaries of MOH informed the OEM that this firm was preferred by MOH because of the expertise of this consultant. However, after negotiations between the firm and ADB were completed, the consulting firm was unable to field this consultant or to identify an alternative specialist acceptable to MOH. A management and administration specialist was contracted in 1999, but due to the impending loan closure the services of the person were not utilized. Accordingly, no management support services could be provided, and only 5 months of consulting services were provided for finance and managementby two finance and accounting specialists, who commenced work in November 1998. One of these specialists provided a further 3 months of services to produce the administration manual. Table 1: Services Proposed, Contracted, and Provided by the Consulting Firm
Specialist 1. Health Services, Financing, Administration, and Management (Team Leader) 2. Finance and Accountability (1) 3. Finance and Accountability (2) 4. Management and Administration 5. Administration Manual 6. Primary Health Care, First Team Leader 7. Primary Health Care, Second Team Leader 8. Family Health Promotion 9. Training and Coordination 10. Repair and Maintenance (1) 11. Repair and Maintenance (2) Total
Source: RMI PCR on the Health and Population Project.
21

Person-Months Firms Proposal Contracted 15 0 0 0 0 0 17 0 4 5 3 0 44 4 2 6 3 17 7 4 5 0 3 51

Provided 0 3 2 0 3 12 6 4 4 0 3 37

A supplementary TA amounting to $65,000 was approved on 23 July 1997.

10 41. The PHC specialist fielded in 1995 became the substitute team leader and provided 12 months of services of her 17-month contract. The services of this consultant for institutional support of PHC did not achieve the expected results, largely due to the absence from the consultant team of the health finance and management consultant, along with additional impediments such as staff shortages and other institutional weaknesses. A second PHC specialist/team leader was fielded in late 1998 and provided 6 months of services in three successive inputs.22 42. The consultant training coordinator (who provided 4 months of services in two inputs commencing in December 1996 and in June 1997, and without a local counterpart) experienced difficulties in completing his TOR due to conflicting recommendations concerning the restructuring of MOH, its training needs, and training plans. The Project overlapped with the ADB Public Sector Reform Program (footnote 18), which commenced in January 1997 with the aim of achieving operational restructuring of the public service and reduction in public sector expenditures. The TA Policy Advisory Team for Economic Management (PAT) included a health care and management consultancy, which was not coordinated with the Project and produced policy recommendations that conflicted with some of the project outputs on institutional strengthening. 43. A consultant family health promotion specialist provided 4 months of service in mid1996, also without a local counterpart. The TOR noted the need for cultural awareness, a lack of which seems to have been the main difficulty experienced by the consultant, although she evidently made sincere efforts to fulfill her TOR. Her extensive recommendations on health education approaches and staffing were reportedly not shared with the health education staff, nor utilized.23 44. The repair and maintenance specialist designated in the firms proposal could also not be fielded, and was replaced by an alternate specialist. 45. The consulting services to the PIU appear to have been of value, but they failed to ensure that the design of the HCs followed the specifications in the PAM, or to overcome accounting weaknesses, resulting in misallocation of expenditure, which appears to have contributed to underspending on some of the planned PHC activities. H. Loan Covenants

46. The Government complied with the standard loan covenants. The most serious breach of special covenants was LA Schedule 6:14, which required that the borrower shall ensure that an agreement is entered into between MOH and the PSC in order to facilitate MOHs management and control of its health personnel. Noncompliance created some serious implementation problems due to lack of counterpart staff for the consultants providing technical support. Covenant LA 6:5 required the appointment of a family health coordinator but was also not followed due to noncompliance with LA 6:14. However, as the PCR notes, there was an obvious contradiction between pressure from ADB to decrease the public service employment
22

MOH informed the OEM that the work of the first PHC consultant did not succeed in building a sense of ownership of PHC innovations. The contribution of the second PHC consultant was particularly appreciated. 23 Noted by the Secretary of MOH in discussions with the OEM and recorded in the Progress Report, June 1999, for in-country visits from 6 February to 19 March 1999, and 17 April31 May 1999 by the second primary health care consultant/team leader. It is likely that the consultant did not share her recommendations with the staff because of her comments on weak staff capacity and key recommendations for the appointment of an expatriate health educator.

11 and the request to create additional positions. More coordination was required within ADB to resolve these issues. 47. There was only partial compliance with the covenant for the maintenance of project facilities in the outer islands (LA 3:10). The covenant (LA 6:8) that required HCs to be designed and constructed with due consideration given to the environment and natural resources was weakly complied with (para. 21). The covenant requiring the Borrower in consultation with the Bank to raise import duties on alcohol, tobacco and food with high sugar and high fat content and low nutritional value to improve the nutritional status of the population (LA 6:9) was only partly complied with. The tax on beer and tobacco was raised but remained low on spirits, while all foods, nutritious or not, are subject to the same duty.24 The covenant requiring that a plan be made for CHCs to retain fees collected (LA 6:11) was found to be impracticable, and the covenant requiring MOH to retain hospital user fees (LA 6:12) was not complied with until authorized in 2002. No covenant was modified, suspended, or waived. I. Policy Setting

48. The Government was to have established a national health council and a national population council to provide policy advice, to be chaired by the Minister for Health or representative. However, these entities were apparently not active during project implementation, or subsequently. 49. In hindsight, the Project was premature in relation to policy development in the RMI. Better outcomes would likely have been achieved after the Government had worked out the terms of the second Compact and its new national plan, Vision 2018 (2000). The plan contains clear goals for the social sectors and the public sector in general, and provides a stronger policy mandate for prioritizing PHC.25 III. A. Overall Assessment PERFORMANCE ASSESSMENT

50. The overall rating of the Project is partly successful (Table 2). The objectives were well founded on national social and economic needs, the Governments population policy, and ADBs health policy and country strategy for the RMI. Although ADB made a sincere effort to address health and population issues in the RMI, given the magnitude of the challenges, the design was based on an overoptimistic assessment of what might realistically be achieved. There were too many objectives and components, given the size of the loan, the scope of consulting services, the duration of the Project, and the capacity of the Government. 51. During implementation, the performance of the consultants was mixed, and the contracted consulting companies performed below expectation. This undermined the objective of building institutional capacity in MOH. During the design phase there was inadequate appreciation of the cultural, environmental, and capacity constraints to achieving the major goals and objectives of the Project, particularly provisions for community and womens participation and health education aimed at producing population awareness and behavior
24

All foods are subject to an import tax, cost in freight, of 5%, beer is taxed at $0.60 per can, spirits at $12.0 per gallon, wine at $3.75 per gallon, and tobacco at $1.00 per packet. In addition, sales taxes totaling 7% are levied. 25 Although the Project may have contributed to the formulation of this policy position, there were serious policy road blocks to implementation in 19951999.

12 change. An analysis of why the educational and social mobilization measures to promote PHC in the Project were not successful is given in Appendix 2. Table 2: Assessment of Project Performance Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight 20% 30% 30% 20% Assessment Relevant Less Effective Less Efficient Less Likely Partly Successful Rating Value 2 1 1 1 not applicable Weighted Rating 0.4 0.3 0.3 0.2 1.2

Source: Operations Evaluation Mission assessment.

52. Although the project design highlights a participatory approach, greater efforts should have been made during project preparation to ensure the participation of key PHC personnel in MOH in the formulation of the project design and innovations to ensure ownership and sustained support by MOH of the project strategies. 53. Separate assessments of components and subcomponents are given in Appendix 6. Component A for support of PHC had five subcomponents. Separate assessments of each individual component are made because of their variable performance; they are rated as follows: (i) organization and technical support, unsuccessful; (ii) training of health personnel, partly successful; (iii) physical infrastructure, successful; (iv) repair and maintenance, unsuccessful; and (v) equipment for the Ebeye Hospital, successful. Component B for institutional strengthening and Component C for support for the PIU are both rated partly successful. 1. Relevance

54. The Project is assessed as relevant. The component for PHC promotion was consistent with national health and population needs, problems demonstrated by comprehensive statistical indicators for health (1993), and the poor returns on high health per-capita expenditure by Pacific DMC standards. In 1986, the Government adopted the policy to promote a PHC model of preventive health services. The MOH Mission Statement26 is based on the Alma-Ata Declaration on Primary Health Care (1978).27 In the Second Five-Year National Development Plan, 1991/921995/96, the main objectives of the Government for the health sector were to (i) improve the overall standard of health of the population, (ii) enhance the degree of selfreliance in the delivery of health services to the population, and (iii) overcome special health problems. The PHC approach received further endorsement in the 1990 RMI National Population Policy, which called for a participatory health-oriented approach to population awareness.
26

To provide high quality, effective, affordable, and efficient health services to all people of the Marshall Islands, through a primary health care program to improve health status and build the capacity of each community, family and individual to care for their own health. To the maximum extent possible, MOH pursues these goals using the national facilities, staff and resources of the Republic of the Marshall Islands. 27 Alma-Ata Declaration.1978. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978: Essential health care based on practical, scientifically sound and social acceptable methods and technology made universally accessible to individuals and families through their full participation and at a cost that the community can afford and maintain at every stage of their development in the spirit of self reliance and self determination.

13

55. The project component was consistent with the ADB operational strategy for the Marshall Islands at appraisal, which noted the social and economic problems of high population growth rates, and the need for policy reforms and more cost-effective services. It also reflected ADB policy for the health sector, which emphasized the importance of a PHC approach and encouraged DMCs to allocate sectoral resources more equitably and efficiently. The project strategies reflect the ADB Population Policy,28 which encourages more effective integration of health and population activities. 56. The main weakness affecting the relevance of the Project arose from insufficient attention during formulation to the need to inspire a sense of ownership of the proposed innovations for PHC among MOHs managers and staff. The proposed innovations were culturally sensitive, so there was a particular need to draw on the ideas, knowledge, and experience of local health professionals in formulating strategies to address womens health needs, encourage community participation, communicate health information, and encourage behavior change. The design assumed that a sense of ownership of key ideas could be promoted post-facto through counterpart arrangements and national seminars during implementation, but it is now evident that a more participatory process during project formulation was needed. Further, in formulating the Project there was insufficient recognition of the likely barriers to success posed by staff shortages and lack of capacity at lower levels. There was also an unanticipated problem in getting the new staff positions that were required approved, and conflict in this regard with policy advice to the Government provided by the PAT (footnote 18). 57. The Project remains relevant. MOH continues to affirm PHC as its priority, and its Vision 2018 health targets (Appendix 7) reflect PHC-related Millennium Development Goals (MDG). The ADB Assessment of Hardship and Poverty29 notes the low rank of the RMI on the United Nations Development Programme (UNDP) Pacific Indices for Human Development and Human Poverty, rankings that reflect the serious health challenges in the RMI and their link to poverty and disadvantage. The ADB Country Strategy and Program Update (20052006)30 for the health sector continues to emphasize the importance of the PHC approach and the need to decrease the financial burden on social services. It emphasizes the need to focus on greater community participation in development processes to raise ownership and the demand for social and economic progress. 2. Effectiveness

58. The Project is rated less effective. Its first expected outcome was improved access to PHC services. This has been partly achieved by the provision of the outer islands HCs and specialized centers on Majuro. However, most of the outer islands HCs are still delivering curative rather than PHC and preventive services. The loss of trained female HAs has reduced the effectiveness of the Project in prioritizing the health needs of women. The provision of maternal and child health care (MCH) and other key PHC services to the outer islands still depends on the overstrained capacity of mobile public health teams sent from Majuro. 59. The second expected outcome of the Project is improved public health. On the basis of statistical trends in health there has been little change since the Project was formulated
28 29

ADB. 1994. Population Policy Paper: Framework for Bank Assistance. Manila. ADB. 2002. Assessment of Hardship and Poverty. Manila. 30 ADB. 2004. Country Strategy and Program Update (20052006): Marshall Islands. Manila.

14 (Appendix 8). There were some improvements in basic health indicators in 19881999for example, life expectancy rose, and infant and child mortality and fertility rates fell. These trends were claimed as indicators of achievement in the revised project framework in the PCR. However, the OEM does not consider that these changes can be attributed to project interventions, as most significant project outputs did not occur until 19981999 or later. The RMIs health and social indicators remain at the lower end of the spectrum of Pacific DMCs and the incidence and prevalence of infectious and chronic diseases remain problematic. A recent World Bank study (2004)31 warns of statistical trends suggesting that the improvements in infant and child mortality rates noted in 2000 are leveling off; it cites recent studies demonstrating the rising prevalence of child malnutrition, teenage pregnancy, low birth weights, and suicide rates (suicide being among the leading causes of death in 2004). 60. Organizational and technical support for PHC was ineffective. The inputs and outputs intended to achieve improvements in the organization of PHC services and to raise public awareness were not achieved. The recommendations made by the first PHC consultant have not been adopted by MOH, nor were the activities commenced under the Project sustained (national seminars on PHC, outer island CHC training, and use of the training manual, for example.) Similarly, the outputs for family health promotion were not utilized by MOH, being considered inappropriate. The training of health personnel was less effective, as the orientation of health services is still towards secondary and tertiary service. 61. The institutional strengthening component was less effective. Although the management of MOH and the quality of its diagnostic and clinical services have improved considerably since 1995, few of these improvements can be attributed to the Project. The Projects intended outcome for improved financial management and administration of health services and control of personnel that would support greater emphasis on, and resource allocation to, PHC was not realized. The contracted consulting company was unable to supply the required health management and finance expert for implementation, and the Project succeeded only in providing very limited support for financial management. 62. The Project partly achieved the expected outcome of developing a long-term strategy for the health sector. The associated TA to develop an HMIS and build health planning capacity failed to make the expected contribution. However, the work of the short-term PHC and finance specialists contributed to the development of the MOH Fifteen-Year Plan (2002), making some contribution to the development of MOHs capacity in health planning in the process. 3. Efficiency

63. The Project is assessed as less efficient. The physical infrastructure and equipment components, which accounted for 60% of the total project cost, have generally been cost effective, providing a reasonable quality of and access to basic health services to the remote island population. However, the support inputs and outputs (40%) were only partly cost effective. 64. The physical infrastructure and equipment components are assessed as efficient. At the time of formulation, the existing facilities were in poor condition, and the provision of new facilities provided a base for PHC activities as well as supporting the traditional function of the
31

World Bank. 2004. Opportunities that Change Peoples Lives: Human Development Review of the Pacific Islands. Country Case Study: Republic of the Marshall Islands (Draft). Washington, DC and Sydney Australia: Human Development Department and Pacific Islands Country Department, East Asia and the Pacific Region.

15 centers in dispensing medicine and first aid. Given the geography of the atolls, which are scattered over 181.3 million hectares of ocean, the increased access to health services has resulted in cost savings stemming from reduced transport costs and a decline in referral cases to the Majuro Hospital. In addition, the construction of the new HCs has encouraged the communities to use the basic health services provided despite cultural barriers. Comparative figures on number of outpatient visits before and after the construction of the HCs show increased utilization of health services by the communities. Based on the survey conducted by MOH, the utilization rate of the HCs ranged from 90% to 100% of the catchment population, and the rate of satisfied clients, also from 90% to 100% (Appendix 9). The equipment provision for the Ebeye hospital was cost effective although its contribution to the project goals and objectives, being mainly for secondary services, is minimal. While the OEM was able to identify some of the economic benefits of the project investments, the economic internal rate of return was not calculated due to difficulty in the valuation of benefits.32 65. Organizational support for PHC was inefficient. The campaigns, seminars, and workshops; surveys; and PHC and family health promotion consultants did not deliver the expected outcomes (para. 60). Training of health personnel was only partly achieved, and the services of the training coordination consultant were not effectively utilized due to conflicting objectives of the Project and the TA for Public Sector Reform (footnote 18). Furthermore, the allocations for repair workshops and for a repair and maintenance consultant produced no useful results. 66. The institutional strengthening component is assessed as less efficient. Although it was a major element in the expected impact of the Project, it accounted for only 3.2% of total expenditure, being for consultant services. It was not cost effective due to weak implementation. 4. Sustainability

67. The sustainability of the Project is assessed as less likely. The participatory, community-based model of PHC, which the Project sought to promote, is still not a significant or effective part of the RMI national health services. Improving the quality and coverage of PHC services remains a challenge, and there are still major issues to be addressed in changing public attitudes to health. 68. Community participation has been weakly sustained. The results of the OEM survey (Appendix 4) of the beneficiary communities where the 26 new HCs were built under the Project show that only 13 (50%) of the CHCs were still in existence. These all said that they provided occasional help to the HAs with cleaning the HCs and surrounding areas, and seven mentioned that they promoted PHC messages in the community and helped visiting teams during their visits. The beneficiary communities appear to lack the resources and capacity to maintain and repair their HCs. The reasons for lack of sustainability of the CHCs include (i) migration of CHC leaders, and (ii) lack of understanding of what the role of the CHC should be after the HC was built. 69. Although population growth declined from 4.2% to 1.5% and fertility rates from 7.2 to 5.7 between 1988 and 1999, the change is considered to have been mainly the result of outmigration by people of reproductive age, and the Project appears to have had a limited impact on demographics.

32

No economic and financial analysis was done during project preparation and completion.

16 70. Health education, awareness, and outreach programs encouraged by the Project are being implemented, with continuing support from US federal programs and other external agencies. Standard recommended practices, protocols, and approaches advocated by international agencies such as the World Health Organization, UNFPA, the United Nations Program for AIDS, and the South Pacific Community are being applied to the management of public health problems. However, the results of these commendable efforts continue to be disappointing, judging by statistical trends in health, which show little change since the Project was formulated (Appendix 8). 71. Training is less likely to be sustainable. Retraining of HAs and public health nurses was not provided under the Project. The number of women HAs, TBAs, and wives of HAs trained who are in positions to provide a woman-to-woman service is too small to sustain the expected impact of the Project. The limited success of this innovation is due to the lack of more careful planning and supportive measures and has created prejudices against the appointment of women HAs. The Director of OIHCS considers the appointment of women to outer islands HCs an unsuccessful experiment33 and does not intend to train any more. The most recent OIHCS program trained 14 young male high school graduates for vacant HA positions. 72. The physical infrastructure component is likely to be sustainable. Although the sustainability of the civil works under the Project is currently affected by the lack of adequate maintenance provisions, a program of repainting and minor renovations is now being carried out. The water catchments and plumbing in many HCs are not being adequately maintained. However, an inventory of assets has been completed by consultants to the Government, and plans and budgets are in preparation to ensure the maintenance of and sustainability of the investments. Equipment for the Ebeye hospital is likely to be sustainable, as it was procured and is in use. A private contractor has been engaged to maintain both the equipment and the hospital. 73. The institutional strengthening component is assessed as less likely to be sustainable. MOH has yet to achieve the institutional arrangements to effectively support PHC. However, MOH still has not committed resources commensurate with its policy on PHC. PHC services are still subsidiary to clinical services. The MOH goal of four visits to each atoll per year by a team comprising a full complement of staff specialists in the PHC program is not being achieved (Appendix 10). An analysis of PHC service delivery issues34 shows that most HAs are not actively promoting the PHC approach in the communities. Most still see themselves as doctors dispensing medicine and first aid to sick people. 74. The PCR considered that policy development, particularly the Governments decision to allow MOH to make its own appointments of medical and allied staff, was an indicator of sustainability. While acknowledging this progress and its advocacy by the Project, the OEM notes that health expenditures in the RMI continue to account for about 15% of gross domestic product, and are significantly higher per capita than in other Pacific DMCs, while the RMIs health indicators are among the lowest. The pattern of disease is still dominated by childhood communicable diseases, indicating the need to give higher priority to PHC services for immunization, growth monitoring, and family planning. However, the allocation of resources for health continues to be inefficient, and a disproportionate share of MOH financial resources is spent on tertiary services (the management of chronic diseases, mainly those associated with
33

He argued that women are reluctant to attend emergencies at night; are culturally debarred from using canoes to go to other islands; and are likely to take frequent maternity leave, so their posts would be left unattended. 34 MOH. 2005. Primary Health Care Assessment. Majuro.

17 diabetes). The allocations for PHC declined from 25% to 15% of the health budget in 2004 2005, although a number of public health programs are supported by separate US federal grants. 75. Although the Project cannot claim credit, it is relevant that the Ebeye Hospital is attempting, with apparent success, to maximize the investment in its new facilities (including equipment provided under the Project) and medical personnel by requiring its specialists to provide service to all its clients. The identification of the clients needs or diagnosis of the clients health problem is followed by referral to specialized clinics, including the PHC clinics for immunization, family planning, and reproductive health. Ebeye Hospital also operates a schoolbased program targeting the most disadvantaged children, and a number of targeted community-based outreach programs on reproductive health and sexually transmitted infections. The hospital appears to have successfully integrated PHC and clinical services. This model is to be adopted on Majuro following completion of the new hospital, and the Government also plans to improve the integration of OIHCS into the health service centers in Majuro and Ebeye. B. Other Assessments 1. Impact on the Achievement of Millennium Development Goals by the RMI

76. The Project has not made a major contribution to the RMIs progress towards achievement of the MDGs. The MDG indicators for health focus on MCH, and high achievements demonstrate a successful PHC service. Although the RMI is doing fairly well on a worldwide scale, compared with other Pacific DMCs the under-5 mortality rate is higher and is the fourth highest of 12 Pacific Island countries.35 Although intercensus comparisons (1988 1999) show that the mortality rate of children under 5 per 1,000 decreased from 93 to 48, and infant mortality decreased from 63 to 29, it is unlikely that the Project can claim credit, as its relevant outputs were not delivered until 19981999 or later. Some indicators of health problems that are dealt with under primary services show deterioration; the prevalence of underweight children under the age of 5 years rose from 19% in 1991 to 27% in 1999, and immunization coverage is acknowledged to be low for most vaccines. The MDG indicator for measles immunization is high (90% of children aged 1 year) only because an emergency measles vaccination program was undertaken during a measles epidemic in 2003. 2. Impact on Women and Children

77. Lack of sustained efforts to train and appoint women as PHC service providers has weakened the intended impact of the Project in prioritizing the health needs of women and children. Of 51 HAs serving in the outer islands as the sole service provider, 42 are men and 9 are women. Accordingly, due to cultural barriers, most outer islands women do not have access to family planning and reproductive health services. The Project tried to overcome this obstacle by (i) training women HAs, and (ii) providing for the training of TBAs and the spouses of male HAs. However, the first of these initiatives has not been sustained by MOH, while the second does not appear to have been widely or effectively implemented. 78. The project strategy to train TBAs and the wives of male HAs was a well-founded idea. However, there is an issue of incentives, as a number of leaders of the national womens NGO,
35

UNDP and the Secretariat of the South Pacific Community. 2004. Pacific Islands Regional Millennium Development Goals Report. Noumea.

18 Women United Together Marshall Islands (WUTMI), pointed out to the OEM. HAs are paid and have the prestige of doctors, but only some TBAs are paid (by local governments). Further, many are growing old and have no younger women to take over from them. The (very few) wives of HAs who have been trained to provide advice on family planning and reproductive health care by MOH are expected to work free of charge. 79. Most Marshallese women do not like to consult men on female health issues, and culture prohibits reference to sexual or reproductive matters between related persons. In the outer islands the HAs are usually from the local community and related to many people there. There are still very few providers of woman-to-woman health services in the outer islands and not enough on Majuro or Ebeye. An assessment by MOH (footnote 34) notes that, although it is in their duty statements, most HAs do not provide MCH services such as perinatal checkups and infant and child growth monitoring, or advice on contraception and reproductive health. Immunization and MCH services are provided by mobile public health teams as well as by urban zone public health nurses in Majuro. Most women from poor and disadvantaged households on Majuro live quite far from the hospital, and there is still no urban health center to serve their needs, although this was included in the original project design. 80. Training and appointing women as HAs was a sound strategy. PHC providers in most Pacific DMCs are female public health nurses with training in midwifery, particularly in the countries with the highest health and human development indexes. However, in the RMI the obstacles to appointing women HAs were insufficiently recognized in project formulation, and no measures were devised to ensure the sustainability of the innovation. People in the outer islands are accustomed to HAs being male. Prejudice against women was likely, because the positions of HAs are comparatively well paid and prestigious and therefore considered to be appropriate for men, despite the obstacle to men serving womens reproductive health needs. Further, there were other social issues and obstacles: the women HAs were mainly young, and many were single. These difficulties should have been recognized in project preparation. Measures should have been included to provide support and guidance. The fact that half of those posted have resigned or were transferred elsewhere suggest this was not provided. 81. Outer island delegates of WUTMI informed the OEM that they did not consider gender to be a factor in the performance of HAs; some did a good job and others did not, irrespective of their gender. However, the delegates confirmed the need for woman-to-woman MCH services. Noting the difficulties that some women HAs had, they suggested that both male and female service providers, ideally married couples,36 should be trained as HAs with different service responsibilities. This suggestion is worthy of further consideration, particularly if MOH pursues its objective to rationalize outer island health services by providing a central HC on each atoll to provide support and additional services to the smaller community HCs. 3. Environmental Impact

82. The project has had no negative environmental impacts. The staffs of new HCs were instructed in the disposal of waste by burying or burning it, and have followed these instructions. The OEM notes that most of the HCs generate negligible amounts of biomedical waste due the fact that very few medical procedures are performed in them.37
36

Sexual jealousy is pronounced in Marshallese culture. Single male and female HAs are regarded with suspicion by married men or women, as the case may be, in outer island communities. 37 As far as the OEM could ascertain, there are no national regulations pertaining to biomedical waste disposal in the outer islands HCs; however there are regulations covering the two national hospitals.

19

4.

ADB Performance

83. ADBs performance is rated less satisfactory.38 At appraisal there was insufficient participation by the EA to ensure that the project design was feasible and the strategy was owned by MOH. There was a need for more detailed consultations and discussions with other concerned government agencies, so that obstacles to implementation were recognized and provision was made to overcome them in the project design. 84. Most of the ADB missions during implementation were supervising several projects in the RMI concurrently, leaving them little time to identify and address implementation problems in any given project. As noted in the PCR, ADB did not become aware of the failure of the consulting firm contracted for the associated TA in 19961997 to establish an HMIS, or take action on the problem, until 1999. The Project was the fifth loan to the RMI and the first to the health sector. Government officials were not fully familiar with ADB modalities or with handling consultants. Although the OEM notes that ADB responded to the requests of the EA promptly, there was a need for the supervisory missions to provide more advice to MOH on how to resolve implementation problems and on its rights in dealing with consultants and consulting firms. 85. ADB failed to adequately coordinate its country program, with the result that under different projects, conflicting or uncoordinated policy recommendations were made to MOH and to the Government on reforms for the health sector. This was a significant deficiency. 86. ADB took a rather lenient attitude to enforcing compliance with covenants and related assurances. Although some were unrealistic or incorrectly conceived (land acquisition, for example), these should have been discussed with the Borrower and revised, to indicate that ADB takes loan obligations seriously. Reviewing compliance with covenants at an appropriate time during implementation would have provided ADB with an opportunity to discuss and possibly rectify some of the major impediments to progress. 87. ADB showed sound judgment in extending the loan closure date due to the delay in rebuilding the Ebeye Hospital (para. 1), in order to allow the utilization of funds allocated for equipment for the hospital. 5. Borrower Performance

88. The Borrowers performance is rated satisfactory. The Technical Committee established by the Government to guide the Project was effective. It comprised the four assistant secretaries for health, the national health planner, the director of the Office of Planning and Statistics, and selected medical personnel. 89. The Government established a Project Steering Committee comprising high-level representatives of relevant ministries and agencies to provide policy guidance. Under the Loan Agreement this Committee was expected to meet quarterly, but the measure was not effective, as the Committee seldom met; there was a high turnover of members, and few were familiar with the objectives and implementation of the Project. No guidance or assistance was provided by the Committee to resolve the issue of delegation of authority to MOH for control of its

38

The PCR rated ADB performance as satisfactory.

20 personnel or for making appointments prescribed in the Loan Agreement. In 1997, the Committee was rationalized as a National Steering Committee to deal with all ADB projects. 90. Positive developments towards the end of the Project were (i) the greater autonomy given to MOH to manage its approved health budget, and (ii) a financial cap on health funds for medical referrals and safeguards for the budget earmarked for medical supplies. In 2002, MOH was authorized to retain hospital user fees. 6. Technical Assistance

91. The TA completion report39 rated the associated TA unsuccessful, an assessment endorsed by the OEM. The consulting services were provided by an American university, but no usable HMIS was produced. An experimental model was attempted that was incompatible with systems familiar to staff in MOH. ADB provided a small TA in 2000 when the consultant insisted it had completed its TOR and refused to provide further services. The supplementary TA was intended to help MOH utilize what had been done but was also unsuccessful due to the inadequacy of the HMIS. IV. A. Issues ISSUES, LESSONS, AND FOLLOW-UP ACTIONS

92. Despite the Governments policy commitment to a PHC philosophy, it is acknowledged by senior officials that, while the Government is concerned about public health issues and wants to improve PHC services, its major health sector objective is to strengthen national capacity to deliver diagnostic and curative or early intervention services to reduce the cost of referring patients overseas for treatment. 93. The Government is also concerned about the heavy dependence on overseas contract personnel: 78% of physicians and 23% of nurses are expatriates, recruited mainly from other developing countries. The expatriate nurses account for more than half of the fully trained nurses. The sole qualified pharmacist and all the dentists are expatriates. Although some degree of dependence on expatriate expertise in the health sector is normal in very small Pacific DMCs, there are regional training programs for islander health professionals in Fiji and Guam that have enabled a far higher degree of self-sufficiency in health personnel in other Pacific DMCs than is the case in the RMI. This situation reflects the poor performance of the education sector in the RMI, with few high school graduates qualifying for training in the health professions. Further, nursing is perceived as a financially unrewarding career option for high school graduates, although the RMI offers salaries that have attracted nurses from other Pacific DMCs. This reflects the comparatively high wage and salary structure in the RMI public sector. 94. A World Bank study (footnote 31) argues that the continuing bias towards tertiary services is driven both by supply issues within the health financing structure and its incentives [referring to recurrent US federal grants and sectoral grants, and other external contributions] and by demand factors from Marshallese themselves, who make little effort to avoid succumbing to chronic and eventually fatal diseases. Although the OEM agrees with this conclusion, the RMI is not alone in this problem; worldwide, preventive measures to maintain good health are most likely to be accepted and practiced by people of higher educational and
39

ADB.2002. Technical Assistance Completion Report on Health Management Information System and Health Planning in the Republic of Marshall Islands. Manila.

21 socioeconomic status.40 The sustainability of interventions to rationalize health expenditures and improve services will depend on an integrated approach to improving social services, notably the efficiency of education services in the RMI, particularly among the poor and disadvantaged. B. Lessons

95. Project Strategies. As the PCR comments, the Projects problems demonstrate how donors can press governments to agree on policy positions consistent with their own views and priorities, allowing too little time for the necessary political process. Greater efforts should have made during project preparation to ensure the ownership of key PHC personnel and the sustained support of MOH for the project strategies. 96. The participatory, community-based model of PHC, which the Project sought to promote, may have been unrealistic in view of the realities of Marshallese culture and the countrys social and environmental problems. The RMIs health problems have deep structural roots in the limitations of an atoll environment, urban overcrowding, cultural breakdown in urban areas, poor water and sanitation, external dependency, low levels of education among the population, poverty, lack of available and affordable nutritious food, and cultural beliefs about health. Further, the service needs of the 70% of the population living in urban settlements and the 30% scattered on remote islands are different, although equally challenging. 97. The Project demonstrates the need, in such problematic circumstances, for strategies based on more modest goals, with clearly defined objectives and achievable targets. Because the Project was so broadly conceived and ambitious in its scope, it failed to adequately address a central problem in the RMIs PHC, namely the lack of effective MCH service delivery. The proposed solutions to this problem became submerged in efforts to deliver the multiplicity of other outputs within a short time frame. 98. The Project design laid excessive emphasis on public education and behavior change, which was overoptimistic in view of the environmental health problems in the RMI. The health sector study conducted by the project preparatory TA highlighted the need for an integrated PHC strategy to provide safe water, sanitation, waste disposal, food security, and improved housing, as well as improving the delivery of the basic elements of PHC services, especially MCH. However this recommendation was not reflected in the design of the Project. The RMI has no shortage of recurrent funding for health programs, but it lacks the resources for major investments in physical infrastructure to improve living standards and environmental health. In this regard, the recommendation made by OEDs Special Evaluation Study on ADBs Policy for the Health Sector41 is of relevance to the health development needs of the RMI. It notes that health should be considered a cross-cutting issue and recommends that ADB look for ways to integrate health considerations into the nonhealth sector, which, in the case of the RMI, would include water, sanitation, and renewable energy. 99. Coherence in Country Programming. ADBs lack of coordination in its country program resulted in the policy recommendations made by the PAT team to MOH and to the Government on reforms in the health sector conflicting with some of the project outputs. For example, the Project required the Government, under a loan covenant, to increase taxes and tariffs levied on snack food, candy, and soda, as well as liquor and tobacco. The aim was to improve public health by increasing price incentives to supply and consume nutritious foods
40 41

World Health Organization. 2005. Preventing Chronic Diseases: A Vital Investment. Geneva. ADB. 2005. Special Evaluation Study of Policy for the Health Sector. Manila: OED.

22 (meat, fish, vegetables, canned foods, rice, and other staples). However this policy objective was not addressed by the PAT team. If considered at all, it was evidently made subservient to goals for the simplification of procedures, and was not implemented. 100. Further, the Projects training objectives, a major component of the outputs, were not achieved, partly due to the inability of MOH to recruit new staff. The staffing freeze and retrenchments in MOH were supported by the recommendations of the PAT team. Similarly, the advice and recommended strategies provided by the consultants who conducted the project preparatory TA on organization and institutional strengthening, as well as subsequent advisory services provided by the consultants to MOH during implementation of the Project, were contradicted by the advice and recommendations by the PAT team. The project experience demonstrates the need for different parts of ADBs country program to be coherent. 101. Maintenance of Assets. The failure of Project provisions for maintenance of the assets was due to their inadequacy, as well as to the institutional changes in the provision of public works (also arising from the public sector program [footnote 18]). Maintaining physical infrastructure is expensive and difficult in the RMI due to the atoll environment, the remoteness of the country, and the distances between atolls and islands. In preparation for the new Compact an inventory of public infrastructure and maintenance needs and costs was undertaken. The Government is concerned about the cost implications resulting from the survey data. In future projects with infrastructure components, ADB should explore the possibility of including a sinking fund for repair and maintenance, with the Government matching in the assistance package. C. 102. Follow-Up Actions The following time-bound actions are recommended. Responsibility Time Frame 20062010

Actions

1. If ADB remains active in the health ADB Pacific Department sector in the RMI, formulation of the next project should focus on the improvement of maternal and child health (MCH) services in urban areas and the outer islands. In particular, the assistance should aim to (i) overcome gender issues that prevent women from receiving a full range of health services; (ii) establish urban neighborhood MCH clinics; and (iii) rationalize and improve outer island MCH health services, so that each atoll has one fully equipped health center with electricity, staffed with male and female health workers, who are provided with accommodation, communication technology, and transportation to provide services to all the inhabited islands comprising each atoll.

23

Actions 2

Responsibility

Time Frame 20062010

ADB Pacific Department ADB should look for ways to improve public health in the RMI by providing assistance in the water, sanitation, housing, and renewable energy sectors.

ADB = Asian Development Bank.

24

PROJECT RESULTS/ACHIEVEMENTS AS PER PROJECT COMPLETION REPORT

Targets to be Achieved Objectively Verifiable During Implementation of the Results/Achievements Indicators Project Project Completion 2002
- Annual population growth rate - Total fertility rate - Office of Planning and Statistics (OPS) lowest projections - OPS lowest projections - Declined from 4.2% in 1988 to 1.5% in 1999 - Declined from 7.2 in 1988 to 5.7 in 1999

Appendix 1

Hierarchy of Objectives
Goal 1 Reduce population growth rate

Comments Based on 2005 Evaluation

The trends are related to the unprecedented rate of emigration in the mid-1990s of adults of reproductive age. As Project outputs and inputs were not provided until 19981999 or later, these trends are unlikely to be project achievements. Confirmed, indicating lack of achievement of these project objectives.

Objectives 1. Awareness of population issues 2. Training of family planning (FP) personnel 3. Provision of facilities and contraceptives 4. Utilization of FP services Outputs 1. Physical access to FP services 2. Social access to FP

- Ideal family size - Number of teenage pregnancies - Interval between births - Pregnancies after age 35

- Reduction of 20% - Reduction of 20% - Reduction of 20% - Reduction of 20%

- No data available - Increased from 18.6% of live births to 19.5% - Achieved - Increased by 39%

- Number of centers providing FP services - Female FP personnel - Contraceptive prevalence rate - Youth contraceptive prevalence

- All health centers providing choices of methods - Female personnel in all centers - Increase by 25% - Increase by 25%

- Yes (but barriers to access mainly cultural) - No - Achieved (+40%) - No data available

Weak achievements of the Project in training and appointing women as service providers. Family planning coverage is variously estimated at between 10% and 25% of women of fertile age. Family planning training was provided by UNFPA, not by the Project. Confirmed.

Inputs 1. Awareness of population issues

2. Provision of trained personnel, facilities, and contraceptives

- Availability of public information - Budget for FP services - Staff trained in FP - Population growth rate

- Workshops on all atolls and in Majuro and Ebeye

- Done

- Reduction of 20% in population growth rate

- Achieved (mainly because of emigration to the United States)

Hierarchy of Objectives
Goal 2 Improve the health status of the population

Targets to be Achieved Objectively Verifiable During Implementation of the Results/Achievements Indicators Project Project Completion 2002
- Infant mortality rate - Under 5 mortality rate - Low birth weight in hospitals - Reduce by 15% - Reduce by 30% - Reduce by 15% - Achieved (-65%) - Achieved (-51%) - No, decreased by 4.2%

Comments Based on 2005 Evaluation

Confirmed, but as project outputs and inputs were not provided until 19981999 or later, these trends are unlikely to have been affected by the Project. Confirmed. Allocation for PHC declined from 25% to 15% of the health budget for 20042005.

Objectives 1. Establish a primary health care (PHC) model

- Government budget for health sector - Government recurrent funding for PHC as percentage of the government budget for the health sector - PHC services directed to women and children

- Government expenditures for PHC (recurrent funding) must increase from 2.6% (1994 budget) to 20% of the government budget.

2. Prioritize health needs of women and children

Female health assistants in the health centers

- Share of PHC increased to 25% in 2001 from 21.5% in 1993, but decreased in real terms since 1996 (highest figure at $1.723 million to $1.607 million in 2001). The highest share was achieved in 1999, with 37%. 20 new female health assistants were trained and recruited

3. Healthy lifestyle

- Cigarette consumption

- Reduction of 25%

- Main issue is youth as regards alcohol and cigarette consumption

- Beer consumption

- Reduction of 10%

- Sport activities

- Membership in sport clubs

- Achieved

- Availability of island food

- Increase 25%

- Island food available

28 women were trained, 24 graduated, 18 were initially appointed, and current 9 women are serving as health assistants in outer islands and three at Laura on Majuro. - Cigarette consumption cannot be accurately measured by imports or sales figures, as smuggling is common. No survey has been conducted. - Beer consumption has been reduced by increased taxation, and consumption of cheap spirits has increased. - There are few if any sports facilities for the majority of the population. - Island food is expensive and in limited supply in the urban areas, where 70% of the population live.

Appendix 1

25

26

Hierarchy of Objectives
4. Participation of communities and women in delivery of health programs

Targets to be Achieved Objectively Verifiable During Implementation of the Results/Achievements Indicators Project Project Completion 2002
- Active health committees - Women in health committees - 10 meetings per year - At least 25% of members are women. - More than 50% of health council members are women, and the majority of councils are very active - No

Comments Based on 2005 Evaluation

Appendix 1 Sample survey shows 50% of health councils exist and less that 25% are active. Those that still exist have at least 25% of women members because their function is perceived to be cleaning the health center.

- Female health assistants Outputs 1. Access to PHC - Travel time to health centers - Utilization of centers - Number of health personnel trained - Medical competence of health personnel on selected PHC activities - Services available - Appropriate technology

- At least 20 female health assistants - Within 1 hour - Increased by 25% - 90% of trained personnel - At least 75% of health personnel answer correctly at the end of the Project - All secondary services - All equipment in use

- Yes - Utilization rate unchanged - Done - Survey not conducted

- Confirmed. - Increased utilization by the communities - Training of health personnel were only partly achieved - Confirmed

2. Trained health personnel for PHC

3. Enhanced PHC services offered

4. Improved management of Ministry of Health (MOH) health personnel and services

5. Efficient implementation of the Project

- Level of health care services to be provided by hospitals - MOH to exercise effective control of its personnel - Internal rules and regulations - Job description - Baseline data - Indicators for benefit monitoring and evaluation - Project implementation

- Support of PHC activities

- Improved - Most done (some limit as regards medical skills, new recruitments under way) - Done

Confirmed

- MOH to exercise effective control of its personnel - Internal regulations in use - Job descriptions available - Health management information system (HMIS) - List of indicators

- Yes

Confirmed

- Yes

- New HMIS not operational at the end of the project, but indicators developed

Indicators but no data as yet.

- No implementation delay. No cost overrun.

- Some delays, but out of the control of the Executing Agency. No cost overrun.

Hierarchy of Objectives
Inputs 1. Awareness of PHC and healthy life style

Targets to be Achieved Objectively Verifiable During Implementation of the Results/Achievements Indicators Project Project Completion 2002
- Public information - National seminar - Media campaign - Two national workshops - Done

Comments Based on 2005 Evaluation

Confirmed. Not done by Project, but supported by other agencies. Only 5 could be confirmed under the project.

2. Community mobilization 3. Training activities

- Community workshops - Female health assistants - Existing health assistants

- Community workshops in outer islands - 20 new health assistants (female) - All health assistants retrained

- Done - Done - Done

24 females trained and 12 are currently employed as health assistants. Not done Not confirmed

- Traditional birth attendants - Spouses of health assistants

- All practicing birth attendants retrained - All interested spouses trained - All health personnel updated on PHC

- Approximately 50% retrained - Approximately 20% trained - Done

4. Physical facilities a. Outer islands health centers b. Urban health centers c. Human services center

- Other health personnel - Location and completion of health centers

- 23 centers completed and operational - Youth clinic within youth center - Human service center operational - Equipment installed and operational - All personnel trained

- 26 built and in operation - Built and in operation - Done

Confirmed.

5. Ebeye Hospital

- Provision of hospital equipment - On-the-job training

- Done

Confirmed.

6. Capacity strengthening of MOH

- Some training done in health financing and health planning - Done

Confirmed but with limited achievement. Appendix 1

- Workshops and seminars

- At least four seminars - Documents available; training

Not confirmed.

27

28

Hierarchy of Objectives
7. Support of Project Implementation Unit Goal 3 Improve self-sufficiency in delivery of health services

Targets to be Achieved Objectively Verifiable During Implementation of the Results/Achievements Indicators Project Project Completion 2002
- Project implementation

Comments Based on 2005 Evaluation

Appendix 1 Weaknesses in PIU performance.

- Local resources for health - Approved 5-year development plan

- Government funds to cover at least 75% of annual health budget

- Government funds 84% of annual health budget

Confirmed.

Objectives Reforms in management and administration of health services & control of personnel Development of long-term strategies Containment of operating costs

MOH to have effective control of its personnel and budget utilization

- Approval of legal requirements for policy reforms - Staff vacancies reduced to 5%

- Public Service Commission delegated to MOH the responsibility for clinical staff - Staff vacancies less than 1% - Long-term strategic plan done by MOH - Social Security Agency delegated to MOH the collection of user fees, and collection now increasing (ten-fold in 2002). - HMIS not operational and no staff trained - Health planner appointed - Achieved (4.1% of the budget) - Budget for health education increased by 60% ($75,000) - All centers have a health council

Confirmed.

Approval of 5-year development plan for MOH User fees collected Reduction of overseas referrals

- Development plan

- Increase of 100% in user fees - Staff trained in the use and maintenance of HMIS - HMIS operational - Appointment of trained health planner - Maintenance expenditure at least 4% of health budget - At least four meetings every year - Regular activities; budget increase by 30% - All 23 project health centers - At least 10%

Development of HMIS Development of MOHs capacity in health planning Increase local resources for health Outputs 1. Health education

Operation of HMIS Appointment of trained health planner Increase in operational budget - Planning/coordination of activities - Health education activities - Number of health committees - Number of health committees not included under the Project

Confirmed.

At least 50% are inactive.

2. Health councils

Hierarchy of Objectives
3. Repair and maintenance of health facilities 4. HMIS system

Targets to be Achieved Objectively Verifiable During Implementation of the Results/Achievements Indicators Project Project Completion 2002

Comments Based on 2005 Evaluation

Limited repair and maintenance activities

- Technical assistance was unsuccessful, but MOHE is progressing well with additional assistance - Done

Confirmed.

5. 5-year development plan Inputs 1. Repair and maintenance

15-year health plan assisted by project. Confirmed. No technician trained. Confirmed, but maintenance of health centers is inadequate especially water catchments and plumbing.

- Guidelines on maintenance - Training of maintenance staff - Workshop equipment

- Availability of maintenance guidelines - At least four technicians trained - Maintenance equipment available

- Not done

2. Consulting services for development of HMIS and 5-year development plan 3. MOH capacity strengthening

- Reports of consultants - HMIS documentation

- Full implementation of HMIS - Training of staff in HMIS operation

- Technical assistance was unsuccessful, but MOH is progressing well with additional assistance

Not achieved. Not completed.

Limited achievement.

Appendix 1

29

30

Appendix 2

PRIMARY HEALTH CARE ISSUES IN THE REPUBLIC OF THE MARSHALL ISLANDS A. Introduction

1. Primary health care (PHC) is understood in different ways. The Alma-Ata Declaration1 (1978) defines PHC as an approach or philosophy of health care: Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families through their full participation and at a cost that the community can afford and maintain at every stage of their development in the spirit of self reliance and self determination. 2. A more basic definition of PHC is that it is the first level of health careactivities aimed at preventing health problems and diseases from starting. The established core practice of PHC provided by the health departments of most of the Asian Development Banks Pacific developing member countries (DMCs) is maternal and child health care (MCH) services (perinatal care, advocacy of birth spacing and family planning, and provision of contraceptives based on a choice of methods, vaccination of infants and children, monitoring of the growth of infants and children under 5 and interventions where needed, and provision of advice on hygiene and nutrition). It may also include other health education programs (on diabetes and STD [sexually transmitted disease]/HIV, for example), and MCH service providers may also be trained in surveillance for diseases such as tuberculosis (TB). 3. For at least the past 50 years in most Pacific DMCs, MCH has been a woman-to-woman service provided at central clinics, although in some countries such as Samoa the service is village based. Where MCH services are well established and accepted, and well organized and accessible to most women and children, the results are remarkably cost effective and account for the very good basic health indicators typical of countries such as Cook Islands, Tonga, Fiji, and Samoa. 4. Since the 1950s, and in many Pacific DMCs long before, PHC was supported by colonial administrations that enforced public health regulations to control disease vectors by removal of breeding places for mosquitoes, flies, and parasites; protect water sources or improve the supply; specify areas for burial of the dead and the location of houses in some countries; and enforce construction and use of latrines and pig pens. In many Pacific DMCs fines or even harsher penalties were used to ensure compliance. In the postindependence era, some Pacific DMCs abandoned some of the more unpopular public health regulations, but in those Pacific island countries with higher social and health indicators, many hygienic practices have become well established in the local way of life, while various public health regulations are still enforced by local authorities. In countries with the lowest social and health indicators, enforcement of public health measures is weak or has been abandoned altogether. 5. This analysis aims to explain why the objectives of the Health and Population Project in the Republic of the Marshall Islands (RMI) did not successfully achieve goals and objectives for promoting behavior change for healthy lifestyles.

Alma-Ata Declaration.1978. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978

Appendix 2

31

B.

Background 1. Historical Factors

6. The RMI is different from the other Pacific DMCs in the extent of its external dependence. The islands were administered by Germany from the late 19th century until 1914. After World War I, the islands passed to Japan, which governed under a League of Nations Mandate until 1945. The islands were a major theater in World War II, which caused devastation of a number of populated islands. After the defeat of Japan, the Marshall Islands became part of the United States (US) Trust Territory of the Pacific (under a United Nations trusteeship). In 1986, the RMI entered into a Compact of Free Association with the US, which expired in 2001. A new 20-year Compact was subsequently negotiated, effective from October 2003. 7. After 1945, the US Army rented most of Kwajalein atoll for its nuclear testing program and subsequently for its missile testing program; the military base provides an important source of private sector employment as well as substantial rents to landowners. Between 1946 and 1958, the US tested 67 nuclear weapons there. Approximately 2,000 Marshallese are currently receiving compensation benefits because they incurred diseases attributable to exposure to radiation. Also, under Article 177 of the Compact, the populations of affected atolls receive special compensatory health and social service packages from the US. 8. A further cause of high import and aid dependency, and one that contributes to health nutritional problems, is associated with the period from 1965, when most of the population of the Marshall Islands (along with other island groups in the Trust Territory) became entitled to receive a range of US federally funded programs for poverty alleviation (designed to help the US inner-city poor). They included school-based feeding programs, food stamps, and a lunch program for seniors. 9. The food programs were maintained after the RMI became independent but were eventually discontinued in the mid-1990s due to budgetary constraints. The food provided was imported and contributed to the prevailing preference for imported rather than local staple foods, as well as reducing incentives to grow and market local crops. 10. This dependency was accelerated over time as the population of the RMI became concentrated in two densely settled urban locations on Majuro and on Ebeye Island in Kwajalein Atoll. Initially, these populations grew when people were resettled from islands occupied by the US Army or affected by US Army test programs. The numbers continued to grow as outer islanders moved to urban areas to join relatives, and to seek wage employment and better services. Currently, 70% of the population live in the two crowded urban locations, and most lack land to enable self-sufficiency in food. 2. Government Primary Health Care Services

11. The Ministry of Health (MOH, formerly, the Ministry of Health and Environment) is organized into six bureaus: primary health care; referral services; administration, personnel, and finance; Majuro Hospital services; health planning and statistics; and Kwajalein Atoll health care services. Each bureau is headed by an assistant secretary reporting to the Secretary of MOH, who chairs the health services board and reports to the Minister for Health. PHC services are organized differently in the Majuro and Kwajalein population centers.

32

Appendix 2

12. In Majuro, the Bureau of Primary Health Care (BPHC) is operationally and organizationally separate from the Bureau of Majuro Hospital Services. BPHC has four divisions. 13. The Division of Human Services and Health Promotion (DHSHP) has three major but overlapping programs:
(i)

(ii)

(iii)

The nutrition and diabetes prevention program has separate but interactive subprograms for diabetes prevention and nutrition. It has a cross-cutting role with the diabetes program in the Division of Public Health (DPH). The health promotion program is responsible for health education and therefore has a cross-cutting role with DHSHP programs and other divisions and programs in BPHC. The human services program has subprograms for mental health, social work, substance abuse prevention, and vocational rehabilitation. The program also has a cross-cutting role with other public health programs.

14.

DPH has six programs:

(i) (ii) (iii)

(iv) (v) (vi)

The chronic diseases program operates clinics for diabetes and hypertension. The STD/HIV/AIDs program provides surveillance, treatment, and referral services. The immunization program operates through a well-baby clinic and a school outreach program. Its work is cross-cutting with the reproductive health services program The reproductive health services program provides an interrelated MCH (perinatal) care subprogram and a family planning program. The TB and leprosy program does surveillance, treatment, and referral work and runs the TB Directly Observed Therapy subprogram. The clinical services program provides officially required physical examinations.

15. The Division of Dental Services has three programs: clinical service, a dentures service, and preventive services, which has subprograms for school fluoride sealant services, early childhood services, and community outreach. 16. The Division of Outer Island Health Care System (OIHCS) is responsible for the Rongrong Community Health Center and the Laura Community Health Center, which are both on Majuro Atoll, and for 51 outer island health centers (HCs) on other atolls. OIHCS coordinates the training of health assistants (HAs), who are mainly male, and provides management and clinical advice, general supervision, and supplies to the HCs. 17. Each HC is staffed by one or more HAs who have the following responsibilities overlapping with the other divisions and programs of BPHC, although the linkage is weak: (i) disease screening; (ii) management of chronic and infectious diseases; (iii) prenatal, diabetic and hypertension, and family planning clinics, and also attending births; (iv) child health surveillance; (v) in-patient observation; (vi) management and referral to hospital of acute cases; (vii) health education during clinics;

Appendix 2

33

(viii) (ix)

health education in schools; and working with the community health council.

18. BPHC provides multiprogram teams of health specialists who visit the outer islands to hold clinics addressing various health problems. The program is coordinated by an officer responsible to the assistant secretary for PHC, not to OIHCS. BPHC receives a considerable portion of its operational funding from special program grants provided from US federal funds, other aid agencies, and specialized regional and international agencies. This tends to reinforce the often artificial division between programs. 19. The Bureau of Kwajalein Atoll Health Care Services provides a more effective model of service delivery from the Ebeye Hospital than Majuro, because the services are more closely integrated. It has four divisions: support services, PHC, hospital services, and information and planning. The division of PHC administers outpatient services at Ebeye Hospital, which is integrated with the hospitals medical and clinical support services. Its public health program has fairly well-integrated subprograms in health education, family planning, human services, dental services, STD and communicable diseases, MCH, well baby, immunization, hypertension, diabetes, and youth health. It also has a school health program and a community outreach program, and a small outer islands program for the dispensaries on Ebadon and Santo, which are part of Kwajalein atoll. 20. At the Ebeye Hospital, physicians, regardless of their clinical specializations, are always on duty at the outpatient clinic. Therefore, clients with several health problems can be more effectively served. Consideration is being given by MOH to adopting the Ebeye Hospital service model on Majuro when the new hospital is completed. 3. PHC Issues Identified by MOH

21. The Ministry of Health Primary Health Care Assessment2 (2005) found that the PHC policy is not being practiced well in the national health system. It found that there are problems in the delivery of outer island health services at the HC level. More than 80% of HAs do not see themselves as health educators and health promoters, but as doctors, dispensing medicine and treatments. Key PHC practices were not being done, such as weighing babies weekly to monitor growth, while few pregnant women would allow themselves to be examined or delivered by a male HA, or seek family planning advice from him, especially if he is related to them. Most HAs are members of the local community and related to many people. The HAs were not keeping records properly; 35% had no functioning radio communication with OIHCS to receive guidance and supervision, but used the local government council radiooften on another quite distant islandin emergencies. HAs cannot vaccinate children, because there is no electricity on most outer islands and no refrigeration for the vaccines; therefore, this must be attempted by visiting health teams from Majuro or in some cases from Ebeye, who face both staffing and transportation constraints, and who do not know the communities as well as the HAs. 22. The MOH assessment of PHC notes that the number of staff working in BPHC is small compared with the number employed in curative services. These staff are mainly local. They have many responsibilities both on Majuro and to provide service to the outer islands. Their coverage is inadequate in both urban and rural areas. Community involvement in primary and preventive health efforts is weak, and people still believe that MOH is responsible for health, not individuals. This makes it difficult for staff to persuade people to change their lifestyles or adopt
2

MOH. 2005. Primary Health Care Assessment. Majuro.

34

Appendix 2

healthy practices. Further, the assessment notes that few people seek preventive services such as physical or dental checkups. Finally, the assessment notes that the environment in the RMI is not conducive to healthy choicesthere are few places to exercise, and stores do not stock a variety of affordable healthy foods. C. Key Social and Environmental Issues

23. Community Participation. The Health and Population Project laid great emphasis on community participation as a key strategy to encourage ownership of the outer island HCs. Community health councils (CHCs) were established and trained in 51 outer islands. They were intended to inspire the communities using the HCs with a sense of ownership of the HCs so they would repair and maintain them, and also to promote the PHC philosophy. 24. In outer island communities, effective ties between people are based on kinship, which is the primary base of mutual loyalty and cooperation. Other cross-cutting affiliations are church memberships. In small communities there can also be deep rivalries and ill-feeling between groups of people, who live with these divisions by being circumspect in their dealings with one another. It is difficult for communities to manage a communal asset harmoniously unless there is effective authority exercised on the basis of accepted traditional rank and leadership rights. It is likely that the people who would feel the greatest ownership of the HC are those on whose land the center is built, since all the HCs were built on private land, after discussions among local leaders. It is also difficult for members of an outer island community to discuss with others, let alone instruct others, what food they should plant, what they should eat, how they should manage their water supply, or how they should maintain their health. These are regarded as sensitive, private matters. 25. The MOH Primary Health Care Assessment (footnote 2) found that CHCs were not helping maintain the HCs. A sample survey of 26 outer island CHCs by the Operations and Evaluation Department (OED) in October 2005 showed that fewer than half were still in existence after being established in 19961999, and of these, only five appeared to understand the roles assigned to them by the Project to promote health by encouraging the production of local food, better nutrition, and clean water. Only one understood that its role was to make repairs to the health center. The respondents did not know why the CHCs failed, other than that the members stopped meeting. Apparently in some cases the CHC leaders migrated overseas. However, the reasons for failure are likely to be more complex. Some indication of the inherent difficulty in establishing CHCs is evident from the weakness of many outer island local governments in achieving practical local development; most tend to be politicized by local rivalries between clans, which become reflected in contentious political affiliations. 26. Culture and Health Education. The Health and Population Project also laid great emphasis on community participation and public awareness as a key strategy to reduce the fertility rate and teen pregnancies, increase birth intervals, and encourage a healthy lifestyle and consumption of island foods. It gave insufficient recognition to the significant cultural and environmental obstacles to be overcome in order to successfully implement an effective program of community-based disease prevention and health promotion. 27. A Community Health Assessment3 targeting Marshallese teenage parents and teachers showed that medical services are associated in peoples minds with treating sickness,
3

Evensen, Sonja, Hilda C. Heine, and Julian Heinz. 2004. Results of a Community Health Assessment in the Republic of the Marshall Islands. Pacific Resources for Education and Learning (PREL).

Appendix 2

35

especially very severe sickness, not with maintaining good health. There is also a continuing tendency for people to prefer traditional medicine over medicines and services provided at health centers and hospitals. Health workers interviewed by OED confirmed that there is a hierarchy of resorts in which a person feeling unwell decides how his or her symptoms should be dealt with. In most cases, people choose traditional remedies, self-administered or provided by a family member or someone else in the community with a reputation as a healer. An intermediate strategy before seeking medical help may be prayer, or consultation with a religious leader. Symptoms of disease are often thought to be of supernatural origin. For example, illness may be regard as the result of a curse or witchcraft. Many chronic conditions are simply endured by Marshallese people. Only when sickness persists or causes unendurable pain or discomfort are they likely to go to a clinic for treatment. In many cases, intervention is sought when the disease is difficult or impossible to treat, reinforcing public mistrust of medical services. 28. Contraceptive Acceptance. The family planning and population survey demonstrated that there is a significant gap between knowledge, attitudes, and practice concerning population issues and contraceptive acceptance. Of 1,463 women and men surveyed, 37% said that they practiced family planning, a larger proportion than found in earlier surveys, but also a much higher proportion than family planning service providers currently acknowledge. While most respondents indicated that an ideal family size for themselves and for the Marshall Islands is two to four children, most women bear five to seven children.4 The study found a widespread fear of side effects of using contraception. Examples of such fears are that contraceptive drugs might cause cancer, or that cessation of menstruation as a result of using hormone-based contraceptives causes bad blood to be retained in the body. Condoms are thought to reduce sexual pleasure.5 29. Recent annual reports of MOH do not provide proportional data on contraceptive acceptance, but the latest report6 (2004) records a total of 908 family planning encounters, with 146 new females and 28 new male clients. 30. The latest figures for Ebeye (2004) show a coverage rate of 25%, which means that approximately 370 people of fertile age use contraception, while about 1,690 do not. The figures do not show how many continue to use contraceptives or for how long. Of those using contraceptives, fewer than 1% are male. The most popular methods are those that women can keep secretDepo-Provera injections, Norplant, and sterilization. Other methods have minimal use rates. As the MOH assessment notes, very few women in the outer islands use contraceptives because, although they are available, women will not ask a male HA to provide them due to cultural sensitivities. Those women who use contraceptives obtain them from an HAs wife (if she is not a relative) or public health nurses visiting with outer island health teams, who provide occasional family planning clinics, usually only one or two a year, if any. 31. Food and Nutrition. Most Marshallese do not understand causes of disease in scientific terms, but have cultural understandings that might be quite contrary to scientific knowledge about the cause of disease. Therefore, health education, even when well presented in the local language, may not be effective, because it contains premises that are contrary to what people believe. Further, the actions to protect or preserve health prescribed by health education
4

5 6

Total fertility rates vary from year to year, e.g., 5.6 in 1990, 7.1 in 1994, 5.9 in 1999, 3.9 (estimate) in 2005. ADB. 2004. Key Indicators 2004. Manila. Balachandra, H.K. Report of a visit to Namu Atoll, September 2002. MOH. 2004. Annual Report 2004. Majuro.

36

Appendix 2

messages may be beyond the individuals control because of his or her environment or social situation. 32. The connection between diet and health is an example. Marshallese often do not believe that one food is superior to another for maintaining good health in adults or children. Food is evaluated by other criteria such as taste and price. Overweight or obesity is rarely seen as a problem, and symptoms of poor nutrition are typically considered to have other causes than an inadequate diet. Malnutrition is very common in the Marshallese population. A recent survey shows, for example, that nearly 60% of children aged 15 were diagnosed with Vitamin A deficiency, 25% with iron deficiency, and one third of children in the RMI have both deficiencies.7 One outer island survey showed that of a sample of women, 37% were obese and 34% were overweight (footnote 5). Diabetes (related to obesity, poor diet, and childhood malnutrition) was a contributing cause of disease in 75% of hospital admissions in 2004. 33. Prescriptions to eat healthy food, even if the message is believed, may be beyond the resources or capacity of most people. This is because most people live in large, often overcrowded households; depend on money for food; do not have enough money to make a lot of choices about food; and share food in the household with others who may not have heard the same messages about health and diet, who do not accept the messages, or who cannot afford to practice them. Food may not be a priority for spending money in the households; more money may be spent on cigarettes, alcohol, canned soda, non-nutritious snack foods, and candy than on food. In the majority of households, most individual members do not make the choices or decisions about how available money is spent. 34. On a per kilojoule/calorie basis, local food is generally more expensive than imported food and usually much scarcer, being dependent on the season and weather conditions. Table A2.1 shows the typical unit price of commonly consumed foods in the RMI. Rice is a staple food, and most people eat rice at least once a day. There is a wide variation in household incomes in urban areas; and people with low income seldom eat much meat, fish, chicken, or vegetables but eat a lot of rice flavored with soy sauce, ramen, bread, and fried pancakes. Table A2.1: Commonly Consumed Imported and Local Food By Unit and Price, November 2005 Local and Imported Foods Imported Rice Imported Flour Imported Instant Noodles Imported Soy Sauce Imported Sugar Local Coconut Local Fresh Breadfruit Local Cooked Breadfruit Local Pumpkin
Source: OEM Survey.
7

Typical Unit (US weight) 20-pound bag 25-pound bag 3.5-ounce pack 20-fluid ounce bottle 4.4-pound pack piece piece piece pound

Price ($) 7.25 9.95 0.480.55 2.892.49 1.651.49 0.50 1.00 2.00 0.80

Cited in World Bank. 2004. Opportunities that Change Peoples Lives: Human Development Review of the Pacific Islands. Country Case Study: Republic of the Marshall Islands. Human Development Department and Pacific Islands Country Department, East Asia and the Pacific Region, Draft. Washington DC, USA and Sydney, Australia. pp. 2526.

Appendix 2

37

35. Imported tinned meat is more expensive than local or imported fish, but is a very popular food. Canned and fresh fish are comparably priced, but fresh fish is often harder to obtain than the kind that comes in cans (Table A2.2). Canned fish is popular with big families, as it can be stretched to feed a lot of people when mixed with ramen or rice. Fresh fish is harder to serve in small portions and so is more expensive to serve to a big family than canned fish. Table A2.2: Comparative Price per Pound of Imported and Local Meat and Fish Meat and Fish Imported Corned Beef Imported Canned Luncheon Meat Imported Canned Mackerel Imported Sardines Imported Tuna Local Fresh Wahoo, Yellowfin Tuna, Mahimahi Local Fresh Skipjack, Marlin Local Fresh Snapper, Grouper Fresh Sturgeon, Parrot Fish
Source: OEM Survey.

Price Per Pound (US weight) 4.11 2.393.23 0.951.31 0.912.02 2.00 2.50 1.50 2.00 2.50

36. On Kwajalein, where few people can produce any of their own food by fishing or growing it, the average household income is about $14,000, while in the outer islands, where people can produce some of their own food, the average household income is about $4,000 (footnote 7). It is estimated that about 20% of households in the RMI fall below the poverty benchmark of $1 per day (purchasing power parity). Although the RMI is ranked 9th out of 14 Pacific DMCs on the United Nations Development Programme human development and human poverty index,8 reflecting health education and poverty indicators, it had the second highest per capita income of seven Pacific DMCs.9 37. Masculine Roles, Mental Health, and Family Violence. Suicide was the fifth leading causes of death in 2004. Suicide or attempted suicide is most common among young men. The MOH annual report notes that most suicides are linked to alcohol consumption, but the cause of suicide is not alcohol; it is more likely to be the lack of a meaningful male role. In Marshallese culture, a woman fulfils cultural expectations by bearing and taking care of children, whether she lives in a rural or urban environment. But many young men have no defined social role to play; traditional male activities of canoe building, sailing and navigating, fishing, and climbing coconut trees to cut toddy are now practiced only in some of the outer islands. There are few alternative roles for young men; unemployment is very high and there are few sporting and recreational facilities for positive masculine activities. Masculine roles too easily become negatively defined among young men as drinking, gang membership and lack of respect for women. Drunkenness is a factor in the prevalence of family violence in the RMI, which contributes to many physical and mental health problems among women.

8 9

ADB. 2004. Country Strategy and Program Update (20052006): Marshall Islands. Manila. RMI. 2005. Statistical Yearbook 2004. Majuro.

38

Appendix 2

D.

Conclusion

38. This discussion is not intended to produce answers to the issues and problems described or to make recommendations about actions needed. Rather, it reflects on why the educational and social mobilization measures to promote PHC in the Project were unsuccessful. The RMIs problems are deeply embedded in its historical experience, urbanization, cultural breakdown, poverty, low levels of education, and external dependence. The problems are made worse by the limitations of an atoll environment, poor housing, the water and sanitation situation, and waste disposal. The answers to these problems lie in the arena of public policy.

APPRAISAL AND ACTUAL COSTS($) Appraisal Estimates Foreign Local Total 1,472,000 900,000 150,000 63,000 275,000 47,000 1,435,000 1,206,000 132,000 44,000 104,000 104,000 0 0 270,000 183,000 4,950,000 164,000 0 0 0 0 0 0 0 263,000 499,000 26,000 636,000 440,000 0 142,000 0 2,170,000 1,636,000 900,000 150,000 63,000 275,000 47,000 1,435,000 1,206,000 395,000 543,000 130,000 740,000 440,000 0 412,000 183,000 7,120,000 Actual Costs Local 208,710.59 0 29,547.55 0 0 0 29,547.55 8,355.00 74,277.27 51,524.41 16,780.00 526,845.08 37,064.00 0 0 0 953,103.90

Component A. B. Civil Works Equipment and Materials 1. Ebeye Hospital 2. Project Health Centers 3. Project Implementation Unit 4. Repair Workshops 5. Manuals/Handouts Subtotal Consulting Services/Personnel Campaigns, Seminars, and Workshops Training Surveys Project Management Costs Incremental Recurrent Costs Taxes and Duties Contingencies Service Charge Total

Foreign 1,855,912.41 990,292.45 358,972.17 110,975.88 161,104.20 0 1,621,344.70 1,185,570.11 13,469.95 7,353.63 66,861.57 59,251.92 0 0 0 140,498.38 4,950,262.67

Total 2,064,623.00 990,292.45 388,519.72 110,975.88 161,104.20 0 1,650,892.25 1,193,925.11 87,747.22 58,878.04 83,641.57 586,097.00 37,064.00 0 0 140,498.38 5,903,366.57
Appendix 3

C. D. E. F. G. H. I. J. K.

39

40

Appendix 4

RESULTS OF A SURVEY OF SPECIAL PROVISIONS TO SUPPORT PRIMARY HEALTH CARE IN THE OUTER ISLANDS 1. The survey was carried out by questionnaires and by interviews using VHF radio direct to members or former members of community health councils (CHCs). There are 51 islands with health centers (HCs). The survey was based on a sample of the 26 islands (in 15 atolls) where new HCs were built by the Project. It aimed to ascertain how many CHCs were active, their gender composition, and their role in supporting the primary health care (PHC) objectives of the Project, including awareness of population issues and disease prevention. The survey also aimed to find out whether there were female health assistants (HAs) appointed and if any traditional birth attendants (TBAs) and wives of HAs had been trained under the Project. 2. CHCs were active in less that half of the beneficiary communities, and of those, most had between 5 and 10 members, all but 1 had women members, and 5 had more than 3 women members. The TBAs were more likely to have been trained through a United Nations Fund for Population Activities program rather than through the Project; 10 of 16 TBAs had received some training on reproductive health and family planning (Table A4.1). Table A4.1: Health Assistants, Community Health Councils, and Primary Health Care Supporters Item Health Centers Female Health Assistants Male Health Assistants Community Health Councils (CHCs) Established CHCs Active CHCs with Less Than 5 Members CHCs with 5 to 10 Members Active CHCs with No Women Members Active CHCs with 1 or 2 Women Members Active CHCs with 3 to 6 Women Members Communities with Traditional Birth Attendants (TBAs) TBAs Trained by the Ministry of Health Wives of Health Assistants Trained by the Ministry of Health Wives of Health Assistants Currently Assisting at a Health Center Health Centers That Dispose of Waste Without Effect on the Environment
Source: OED Survey, October 2005.

Number 26 2 24 26 11 1 10 1 5 5 16 10 7 9 26

3. Since the respondents were not the seven wives of health assistants who were trained by the Ministry of Health, the results show only what they were perceived to have learned. Most respondents thought they had learned skills in clinical assessment of sick people. Only two were thought to have learned how to advise other women on health, or about family planning, which was the objective of the training (Table A4.2).

Appendix 4

41

Table A4.2: Perception of the Skills Learned by Wives of Health Assistants Skill Learned Clinical Assessment (Blood Pressure, Temperature, etc.) Sharing Health Information with Women in the Community Family Planning
Source: OED Survey, October 2005.

Number of Responses 5 1 1

4. Few respondents could say why the CHCs had ceased to be active: 11 respondents said that the members had stopped meeting (possibly because they did not understand what their role was to be) once the HC was built; while the remainder did not know. It is believed that in several cases, leaders of the CHCs had migrated overseas. In the active CHCs, most respondents believed that the role of the CHC is to keep the HC and surrounding area clean (Table A4.3). Only one thought repairing the HC was their duty. Only five mentioned the main role intended by the Projectpromoting PHC practices in the community such as food production, good nutrition, and clean water supply. Table A4.3: Perceived Role of Active Community Health Councils Role Clean the Health Center and Surrounding Area Make Repairs to the Health Center Promote Primary Health Care such as Growing Food, Good Nutrition, and Clean Water Assess Need of the Dispensary and Help the Health Assistant, Help Visiting Health Teams
Source: OED Survey, October 2005.

Number of Responses 11 1 5 4

5. Most respondents thought no maintenance was needed by the HC (Table A4.4); however, the Operations Evaluation Mission visited one of the HCs where there was an active CHC and where it was thought that no maintenance was needed (Arno, Bikarej), finding that the toilet and guttering were broken, the large cement tank was leaking and contained no water, the additional plastic tank was not functioning well, and there was no water supply for the HC. Therefore these responses should be regarded with some skepticism. Table A4.4: Community Assessment of Condition of Health Centers Condition of Health Center No Maintenance Needed So Far Maintenance Has Been Done Effectively When Needed Some But Not Enough Maintenance Has Been Done Maintenance Is Needed, But Not Done Yet
Source: OED Survey, October 2005.

Number 12 7 3 4

OUTER ISLANDS HEATH CENTERS BUILT UNDER THE PROJECT

Health Atoll Center 1 Ailinglaplap Airok General Description of Condition Access air, sea, road roof and walls are in good sound condition; interior surfaces are in good condition General Description of Performance lighting and power not functioning in the building; no downpipe to the fiberglass water catchment; concrete catchment cracked and leaking so no water evident in dispensary average condition, but incomplete very poor; health center not operating (completed in 2005 and is now operating) good performance average

42

Zone Central

Site Features raised concrete path with exposed aggregate finish; one china WC; one fiberglass water tank; one concrete water catchment; concrete septic tank

Appendix 5

Buoj

Central

sea, track

concrete path to toilet block; toilets not installed; concrete water catchment; septic tank being constructed concrete path; toilet block; concrete septic tank concrete path; toilet block; concrete and fiberglass water catchments; concrete septic tank toilet block at rear; fiberglass catchment, plus concrete catchment china WC; concrete and fiberglass water tanks; concrete septic tank concrete path; china WC; plastic and concrete water tanks; concrete septic tank path to toilet block; china WC ; concrete and fiberglass catchment; concrete septic tank concrete path between building and toilet block; china toilet; single layer water taps/tanks; concrete septic tank

3 4 Arno

Woja Arno

Central Southeastern

air, sea, track good condition poor to average

5 6 Aur 7

Bikarej Aur Tobal

Southeastern Northern Northern

sea, track sea, track

average to good condition good to very good average to good

good good average

8 Ebon

Ebon

Southern

sea, track

poor to average

average

9 Jabat

Jabat

sea, track

very good

very good

10 Jaluit

Iniej

Southern

sea, track

average to good

good

toilet; concrete and fiberglass catchments; septic tank

11

Imroj

Southern

sea, track

average to good

good

toilet block at rear; concrete and fiberglass catchment; concrete septic tank

Outer Islands Health Centers Built Under the Projectcontinued

Health Atoll Center 1 Ailinglaplap Airok Water Drainage Power outlets installed but not functioning Lighting fixtures installed but tubes missing No. of People Communication Using Asset Assessor's Comments HF radio 300400 Government leases land from local landowner; 1 doctor; village has water supply shortage; water catchments empty at time of inspection

Buoj

none

none

none

none

none

not used

building deteriorating because it has not been completed, e.g., plywood doors not painted; broken windows because building left unattended

3 4 Arno

Woja Arno

12-volt battery

12-volt radio batterysola

5 6 Aur 7

Bikarej Aur Tobal 12-volt battery

HF radio

15 people per week (300400 population); 20 per week 150 (12 patients unattendeddoctor away; toilets and shower per month) locked; not assessed

HF radio

8 Ebon

Ebon

9 Jabat

Jabat

12-volt solar system

12-volt battery system fluorescent from 12-volt battery

3050 per week ceramic floor tiles lifting and cracking; wooden (200 population) framed security screens falling off building; pipe from water catchments to building blocked 10 per week dispensary used a temporary accommodation for visitors to the island when doctor not on duty 56 patients per building recently constructed by APC contractors; week (116 concrete water catchment has never held water, people on island) right from new; type of exterior doors used in building inappropriate for exposed positions and are rotting; building yet to be dedicated population no radio; concrete water catchment leaking; wellapproximately kept garden 100 (1012 per week) (population of people travel to Imroj at Christmas and Easter; 100) 1015 putting bigger demand on services at these times patients per of the year; people from Mejatto and Ajeejen also week use dispensary; radio broken and away for repair; large battery bank in battery box runs freezer/refrigerator

10 Jaluit

Iniej

11

Imroj

12-volt battery system, but not wired to 12-volt battery lighting system

Appendix 5

radio aerial, but no radio

43

Outer Islands Health Centers Built under the Projectcontinued

Atoll 12 Health Center Narmij Zone Southern Access General Description of Condition average General Description of Performance average Site Features path joining health center and toilet block; toilet block; concrete and fiberglass catchment; concrete septic tank concrete path between building and toilet block; china toilet; concrete and fiberglass catchments; concrete septic tank concrete path between building and toilet block; toilet block; concrete and fiberglass catchments; concrete septic tank good flushing vitreous china WC; leaking plastered concrete block catchment; septic tank adjacent to toilet block vitreous china WC in separate building; concrete block water catchment; no fiberglass catchment; stone edging to perimeter of site concrete path between building and toilet block; china toilet; concrete septic tank

44
Appendix 5

13 Kwajalein

Ebadon

Central

sea, road

average to good

good

14 Lae

Lae

Western

sea, road

average to good

average to good

15 Lib

Lib

Central

sea

materials in good, sound condition; surface finishes are generally poor

16 Likiep

Jebal

Northern

sea

overall in good condition

17 Maloelap

Airok

Northern

sea, track

good to average

building functions well apart from lighting; no electricity to run the lighting; water catchment leaks and water pressure low no power to run any lighting or electrical equipment; otherwise, performance good overall good

18

Kaben

Northern

sea, track

none

none

concrete path between building and toilet block; china toilet; water catchments; concrete septic tank

19 Mili

Mili

Southeastern

air

good condition apart from paint finishes

good

concrete path between building and toilet block; toilet; water catchment

Outer Islands Health Centers Built Under the Projectcontinued

Atoll 12 Health Center Narmij Water Drainage Power Lighting Communication radio No. of People Using Asset Assessor's Comments

13 Kwajalein

Ebadon

4-kilowatt generator

fluorescent and incandescent

10 patients per week

14 Lae

Lae

15 Lib

Lib

from catchment

waste drains to septic tank

12-volt solar panel/ battery system none

334

family living in dispensary; dispensary uses only the consultation room; wall and ceiling marked with soot from kerosene lamp; venetian blinds broken 1 doctor; size of dispensary adequate for the community; built in 2001; concrete water catchment leaks; sink in doctors consultation room not yet completed built in 1999; catchment not holding water; water pressure weak; security screens over the windows easy to pull out; not very secure

fixtures present but no power to run them HF radio

100+

16 Likiep

Jebal

from catchment

to septic tank

none

180

built in 2001; water comes through front (south) door

17 Maloelap

Airok

no radio

10 patients per week, 200 population

18

Kaben

12 patients per week, local people (population: 100) catchments drainage to none septic tanks fluorescent and incandescent lights wired in but no power to the building 600

water pipe from fiberglass catchment broken and plugged; doctor and family live in health center because MOH does not provide accommodation; no solar panels or lighting; no refrigeration; doctor runs own generator to power own washing machine problem with water flow from catchment; 12-volt DC water pump to improve water flow provided as part of the solar panel freezer package Appendix 5

19 Mili

Mili

5 years old; materials from Japan; 1 doctor; acting mayor believes the building works well for the community

45

46

Outer Islands Health Centers Built under the Projectcontinued

Health Center Enijet General Description of Condition good condition General Description of Site Features Performance poor lighting at night; doctor toilet; water catchments; septic tank has provided his own solar powered light

Appendix 5

Atoll 20

Zone Southeastern

Access air, sea

21 Namdrik

Namdrik

Southern

sea, track

good to average

good; large population for one dispensary

path to toilet block; toilet block; concrete and fiberglass catchment; concrete septic tank

22 Namu

Loen

Central

sea, track

good to very good

good

23

Majkin

Central

air, sea, track very good

very good

concrete path between building and toilet block; china toilet; concrete and fiberglass water catchments; concrete septic tank concrete path between building and toilet block; separate toilet/shower block; concrete and fiberglass water catchments; concrete septic tank

24

Namu

Central

sea, track

average to good

good

concrete path between building and toilet block; separate toilet block; concrete and fiberglass water catchments; concrete septic tank

Outer Islands Health Centers Built Under the Projectcontinued

Health Center Enijet No. of People Lighting Communication Using Asset doctors own; no radio 167200 fluorescent lights wired in but no power

Atoll 20

Water catchment leaksno water

Drainage Power to septic none tank

Assessor's Comments patients also come from Mili when there is no medicine at Mili; built in 1999 but some work remains unfinished, i.e., some tiling to the shower, plumbing and faucets for the wash hand basin; waste pipe in the sink bench unit leaks; doctor has wired up one single light to a solar panel

21 Namdrik

Namdrik

12-volt battery system

Alinco HF radio

22 Namu

Loen

adequate water catchments good water catchment supply

radio located in adjacent house

23

Majkin

24

Namu

doctor needs radio for communication; dispensary well used

up to 10 patients concrete water catchment leaking; windows and per day; 800 security screens broken; no refrigerator to keep population medicine coolneed refrigerator and power supply; no mains power to run AC system; exterior door rotten and needs replacing; door unsuitable; need heavier security screen on windows. current mesh too light; present batteries and solar panel inadequate to provide enough lighting time population none greater than 100; 6 patients per week 400 population; health center in good condition and very clean; approximately 15 doctor lives in private house adjacent; water patients per catchments provide good water supply; solar week panels charge large batteries to run freezer; no radio; antenna to doctors house, but no radio provided; although the concrete catchment new, it has significant leaks; exterior power outlet on building; not wired to mains supply population 270; back door of dispensary facing into prevailing 10 per week wind, causing door rotting at bottom; doctor needs HF radio for communication; dispensary well used; water pipes between catchment and toilet leaking; vontractor heated pipes and pushed them together instead of using solvent cement; some graffiti on building doors

Appendix 5 47

48

Outer Islands Health Centers Built under the Projectcontinued

Health Center Wodmej General Description of Condition generally in very good condition apart from the exterior walls which, show signs of cracking General Description of Performance building functions very well; no electricity to run any of the electrical fixtures

Appendix 5

Atoll 25 Wotje

Zone Northern

Access sea, track

Site Features vitreous china WC in separate building; leaking concrete block catchment; fibreglass catchment; septic tank

26

Wotje

Northern

air, sea

building generally in very good condition; only interior painted surfaces showing wear

no power or water supply to fixtures

vitreous china WC, requires bucket of water to flush; concrete block water catchment; concrete septic tank

27 Majuro

Laura

Majuro

road

building in sound condition apart from an area of the ceiling in the dispensary badly water damaged by water leaking from airconditioning ducting in ceiling

dispensary performing well; has adequate space and comfortable accommodation in the same building

china toilets in good working condition; polyethylene catchment in good condition; concrete catchment leaking through a number of cracks; concrete septic tank; asphalt concrete area for car parking (not marked)

Outer Islands Health Centers Built Under the Projectcontinued

Health Center Wodmej No. of People Using Asset

Atoll 25 Wotje

Water Drainage rainwater sewer to collected in septic tank catchment

Power

Lighting

Communication

26

Wotje

from catchment

to septic tank

~ 800

concrete local mains on the computer and 10 people and water building only phone observed using catchment dispensary fed from between 1 pm building and roofwater 4 pm system AC = alternating current, DC = direct current, MOH= Ministry of Health, HF=high frequency, WC = water closet Source: Health Sector Report prepared by Beca International Consultants, October 2003.

27 Majuro

Laura

Assessor's Comments Doctor was away in Majuro at the time of survey; the dispensary was locked and blinds were drawn on all but two windows; assessment of the building interior estimated based on what was visible through the window and the general condition of the entire building not enough working space; during immunization programs, 6070 families line up outside in the sun; larger shaded porch would be sufficient; no water pump to bring water from the catchment into the building; treatment room too small for consultations police at adjacent police station said that dispensary well used and doctor has very good reputation; people from town travel out to dispensary for treatment

Appendix 5 49

50

Appendix 6

ASSESSMENT OF PROJECT OVERALL PERFORMANCE PART A: Support for PHC (78.5%) A1. Organizational and Technical Support for PHC (11.3%) Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight Assessment 20% 30% 30% 20% Relevant Ineffective Inefficient Unlikely Unsuccessful Rating Value Weighted Rating 2 0 0 0 N/A 0.4 0 0 0 0.4

A2. Training of Health Personnel (2.6%) Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight Assessment 20% 30% 30% 20% Highly Relevant Less Effective Less Efficient Less Likely Partly Successful Rating Value Weighted Rating 3 1 1 1 N/A 0.6 0.3 0.3 0.2 1.4

A3. Physical Infrastructure at the Health Center Level in Support of PHC (42.8%) Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight Assessment 20% 30% 30% 20% Relevant Effective Efficient Likely Successful Rating Value Weighted Rating 2 2 2 2 N/A 0.4 0.6 0.6 0.4 2

A4. Repair and Maintenance Activities and Programs (4.4%) Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight Assessment 20% 30% 30% 20% Relevant Ineffective Inefficient Unlikely Unsuccessful Rating Value Weighted Rating 2 0 0 0 N/A 0.4 0 0 0 0.4

A5. Equipment for the Ebeye Hospital (17.3%) Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight Assessment 20% 30% 30% 20% Relevant Effective Efficient Likely Successful Rating Value Weighted Rating 2 2 2 2 N/A 0.4 0.6 0.6 0.4 2

Appendix 6

51

ASSESSMENT OF PROJECT OVERALL PERFORMANCE PART B: Institutional Strengthening (3.2%) Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight Assessment 20% 30% 30% 20% Highly Relevant Less Effective Less Efficient Less Likely Partly Successful Rating Value Weighted Rating 3 1 1 1 N/A 0.6 0.3 0.3 0.2 1.4

PART C: Project Implementation Unit (18.3%) Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight Assessment 30% 40% 30% Relevant Less Effective Less Efficient Not Applicable Partly Successful Rating Value Weighted Rating 2 1 1 N/A 0.6 0.4 0.3 0 1.3

OVERALL ASSESSMENT Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight Assessment 20% 30% 30% 20% Relevant Less Effective Less Efficient Less Likely Partly Successful Rating Value Weighted Rating 2 1 1 1 N/A 0.4 0.3 0.3 0.2 1.2

52

Appendix 7

VISION 2018 HEALTH TARGETS Program Infant Mortality Child Mortality, < 5 years Immunization Coverage (%) Diabetes Prevalence People in Control of Their Own Fertility Malnutrition, < 5 years
Source: Vision 2018 of the Republic of Marshall Islands.

Baseline 1998 25.0 10.0 64.0 40.0 10.0 24.5

Target 2018 12.0 5.0 90.0 10.0 50.0 0.0

Appendix 8

53

HEALTH INDICATORS PRE- AND POST- PROJECT, 1993 AND 2004 A. Sources of Data

1. The method of presenting health statistics when the Project was being formulated was different from the current method of presentation, which presents some problems of comparability. However, overall, the data suggest little improvement, and for diabetes, tuberculosis (TB), leprosy, and sexually transmitted diseases (STDs), a deterioration in the health status of the population, despite the reduction in infant mortality and child mortality rates, from 1989 to 1999. It is difficult to assess changes in primary health care (PHC) services, as no recent data are available. 2. Statistics for 1993 are derived from Vital and Health Statistics Abstract 19891993 by the Ministry of Health and Environments Bureau of Health Planning and Statistics. The health statistics are based on more or less complete sets of data collected by the ministry from its hospitals and health centers (HCs), organized into sets relating to morbidity (disease) and mortality (deaths) and to use of health services (maternal and child health, family planning, youth, leprosy and TB, STDs, mental health, alcohol prevention, social work, and outer island dispensaries). Prevalence rates for morbidity focus on notifiable diseases according to standard international classifications of the time, which focus on infectious diseases. Immediate and main causes of death are also provided. 3. The 2004 statistics are provided by the annual Statistical Yearbook 2004 compiled by the Economic Policy Planning and Statistics Office in the Office of the President. The statistics are based on incomplete sets of data provided by the Ministry of Health (MOH) from the Majuro Hospital (inpatient and outpatient data) and Ebeye Hospital (outpatient data). The statistics are organized accordingly in the Yearbook. MOHs assessment of PHC (2005) notes that there are data problems relating to the outer island HCs. Most health assistants (HAs) staffing the outer islands HCs do not keep and file individual patient records, just lists relating to the number and type of encounters (use of HC services), but usually provide verbal reports monthly, by radio. 4. This situation illustrates the failure of the technical assistance (TA) to develop a health management and information system. Health statistics are now less complete than they were in 1993, and the project preparatory TA reports for the Republic of the Marshall Islands (RMI) Health and Population Project noted that there were data collection problems then. However, MOH produces informative annual reports based on what data it has, and those for 20022004 were consulted, as well as the two other sources noted, by the Operations Evaluation Mission (OEM) when making its assessment of the evidence for changes in the health status of the population. 5. In the following analyses it is important to recognize that in a small population annual variability can affect rates, making variations look more significant than they are. B. Mortality

6. There has been little change in the leading causes of death (Table A8.1), but a few significant differences in the mortality rates (increased for sepsis, reduced for pneumonia) are evident. Child mortality rates are significantly lower, but the reduction in infant mortality is not very significant due to annual variation (Table A8.2).

54

Appendix 8

Table A8.1: Leading Causes of Death, 19932004 Ten Leading Causes of Death, 1993a Rate per Cause Number 100,000 Pneumonia Sepsis Cancers Heart Attack Stroke Renal Disease Heart Failured Prematurity Suicide Head Injury Dehydration Tuberculosis
a b

Ten Leading Causes of Death, 2004b Number Rate per Cause 100,000 Sepsis Cancers Heart Attack Pneumonia Suicide Cerebrovascular and Renal Diseasec Drowning Prematurity Trauma Heart Failure and Hepatitis Be 46 23 15 14 13 12 10 8 6 5 90.48 45.24 29.50 27.54 25.57 23.60 19.67 15.74 11.80 9.83

36 31 23 19 15 15 12 11 9 7 7 6

68.97 59.39 44.07 36.40 28.74 28.74 22.99 21.07 17.24 13.41 13.41 11.50

Republic of the Marshall Islands. Vital and Health Statistics Abstract, 19981993. Ministry of Health. 2004. Annual Report 2004. c This aggregate does not make it clear whether the figure refers to the combined total of the two causes of death, or to 12 cases of each cause. d Classified as cerebrovascular incident. e This aggregate does not make it clear whether the figure refers to the combined total of the two causes of death, or to 5 cases of each cause. Sources: Vital and Health Statistics Abstract 19891993; MOH Annual Report 2004.

Table A8.2: Child and Infant Mortality Mortality Infant Mortality Child Deaths Number 33 40 1993 Rate per 1,000 26.42 4.38 Number 27a 11 2004 Rate per 1,000 23.02b n.d

n.d. = no data. a Of these deaths 20 were on Majuro, 6 on Ebeye and 1 on outer atolls. b Infants less than one year of age. In 2003 the rate was 30, and in 2002 it was 29. Main causes of infant death were prematurity, malnutrition, pneumonia, congenital abnormality, sepsis, and respirator distress. c Child between 14 years of age. In 2003 there were 14 child deaths, and in 2002, 11 deaths. Causes were severe malnutrition, drowning and car accident. Sources: Vital and Health Statistics Abstract 19891993; MOH Annual Report 2004.

C.

Morbidity

7. The 1993 and 2004 morbidly data, being presented in different ways, are only somewhat comparable for gastrointestinal and respiratory infections. The 1993 data may refer to the number of cases; however, the 2004 data (Table A8.3) refers to the number of patient encounters. Therefore, the comparison rate cannot be calculated. Even on this basis, the prevalence of these two groups of disease may be considered to have risen.

Appendix 8

55

Table A8.3: Leading Causes of Morbidity

Leading Causes of Hospital Admission and Outpatient Diagnosis, 2004b Majuro Majuro Ebeye Ebeye Hospital Hospital Hospital Hospital Admissions Outpatients Admissions Outpatients (Number) (Number) (Number) (Number) 244 (5.8%) 367 (7.5%)e n.d. 1,770 (3.6%) 9,010 (17.2%)f 1,293 (2.6%)h n.d. n.d. n.d. 1,348 (6.4) 5,400 (25.8) n.d.

Causes Gastrointestinalc Respiratory Infections VaccinePreventable Disease Conjunctivitis Periodontal Disease, Dental Caries Diabetesi Hypertension

Leading Causes of Morbidity, 1993a Rate per 100,000 Number 5,233 1,501d 35g 10,023.94 2,984.00 67.85

n.d. n.d.

n.d. n.d.

n.d. n.d.

937 (1.9%) 5,794 (11.7%)

n.d. n.d.

n.d. n.d.

n.a. n.d.

n.a. n.d.

109 (2.6%) n.d.

2,934 (5.9%) 1,277 (2.6%)

n.d. n.d.

1,861 (n.d.) n.d.

n.a. = not available, n.d. = no data. a Ministry of Health Planning and Statistics. Vital and Health Statistics Abstract, 19891993. b Republic of the Marshall Islands. Statistical yearbook, 2004. Economic Policy, Planning and Statistics Office. c Classification comprises gastroenteritis, infantile diarrhea, adult diarrhea, typhoid and paratyphoid, amoebiasis. hepatitis A, and hepatitis B. d Influenza. e 6.8 pneumonia, 1.7 asthma. f Upper respiratory infection 11.3, acute bronchitis 3.7, bronchitis 2.7. g Whooping cough, measles, mumps. h Viral hepatitis. i 2857 patients were hospitalized (Majuro & Ebeye) with diabetes-related morbidity. Sources: Vital and Health Statistics Abstract, 19891993. Ministry of Health Planning and Statistics Statistical yearbook, 2004. Economic Policy, Planning and Statistics Office.

8. Vaccine-preventable diseases in 1991 referred to whooping cough, measles, and mumps. In 2004, the only vaccine-preventable leading cause of morbidity referred to was viral hepatitis, which accounted for a very high 2.6% of outpatient encounters at Majuro Hospital (Table A8.3). 9. Health statistics for 2004 provide more detailed information on chronic diseases, particularly diabetes, than was the case in 1993, when morbidity and mortality from diabetes mellitus was hidden among the statistics on the various diseases that result from diabetes (for example, renal disease, sepsis, ophthalmic disease). Majuro and Ebeye hospitals recorded 4,795 patient encounters (not cases, as these could refer to several or many encounters with the same patient) of diabetes (Table A8.3). The number of encounters indicates the scale of the problem in the RMI. According to the 2004 Statistical Yearbook, diabetes encounters had increased by 52% since 2001. Officials of MOH informed the OEM that 75% of all non-obstetric hospital admissions are diabetes-related. 10. The rate of a number of serious Infectious disease rates can be compared (Table A8.4). These data show increased prevalence since 1993 of TB, leprosy, and STDs gonorrhea and

56

Appendix 8

syphilis. The STD chlamydia rose from zero to 15% in 20022004. The rate of STD is a serious concern, as high STD rates increase vulnerability to infection with human immunodeficiency virus. TB is an associated health concern, and there was a 125% increase in TB cases, from 43 in 2001 to 97 in 2004. Table A8.4: Prevalence Rate of Selected Infectious Diseases Diseasea Pulmonary Tuberculosis Other Tuberculosis Leprosy Scabies Chlamydia Gonorrhoea Syphilis HIV 1993 Number 67 13 19 1,051 n.d. 110 77 n.d. Rate per 100,000 128.39 49.91 36.40 2,013.60d n.d. 210.75 300.45 n.d. Numberb 97c 93 n.d. 161e 30 335 6 2004 Rate per 100,000 190.79 182.93 n.d. 316.68 59.01 658.93 11.80

n.d. = no data, HIV = human immunodeficiency virus. a The 1993 classification other important infectious diseases (total 2462, rate 4,741.92) has been disaggregated for purposes of comparison. b Active cases at the end of 2004. c There were 43 cases in 2001. d This was the highest rate recorded in 19891993. e Chlamydia cases increased from 0% in 2002 to 15%. Statistical Yearbook 2004. Sources: Vital and Health Statistics Abstract, 19891993. Ministry of Health Planning and Statistics Statistical Yearbook 2004. Economic Policy, Planning and Statistics Office.

D.

Primary Health Care Services

11. Antenatal Care. In 1993, 669 women received prenatal checkups (first visit), and 235 made postnatal visits. There are no data for 2004. 12. Growth Monitoring. In 1993, 555 visits were made for growth monitoring of infants and young children. There are no data for 2004. 13. Immunization. In 1993, 18,668 doses of all types of vaccines were administered. Coverage levels could not be assessed. In 2004, 19,942 doses were administered, which is not a very significant increase. Coverage levels could also not be assessed. There is no refrigeration in most outer islands, and so HAs cannot store vaccines. Services to the 30% rural population depend on infrequent visits by mobile public health teams. According to staff of MOH there are problems of coverage are associated with follow-up vaccinations, and many children are incompletely vaccinated. The situation with measles vaccination illustrates this point. Three doses of measles, mumps, rubella (MMR) vaccine within a certain period of time are needed to give an infant immunity. Immunization against measles is an achievement indicator for reducing child mortality in the Millennium Development Goals (MDGs). The Governments report on progress towards the achievement of the MDG (2004) refers to a review of MMR immunization rates on Majuro, which showed that only 1% of infants were completely immunized. Demonstrating the serious issues with followup, the report comments that despite improvements in MMR vaccinations to infants one year and under for all three doses, the

Appendix 8

57

pattern of low numbers of infants receiving MMR in comparison to the total number of infants born, and the steeply declining proportion of first dose recipients receiving the second and final dose, has been the same since 2001. 14. Family Planning. Family planning acceptance between 1993 and 2004 increased by about one third (Table A8.5). However, in 2004, about twice as many women were choosing injections of Depo Provera and sterilization than in 2003. Coverage is still very low. The official coverage rate is 25% of couples of fertile age. However, family planning providers say the rate is much lower due to discontinuance. Table A8.5: Number of Family Planning Acceptors, 1993 and 2004
1993 Number of % of Acceptors Acceptors 242 -1 241 32 484 7 96 14 -134 1,116 1,251 21.7 21.6 2.9 43.4 0.6 8.6 1.2 Acceptors at Ebeye Hospital 189 0 20 524 0 733 2004 Acceptors at Majuro Hospital 343 4 224 586 198 0 48 1,403 % of Total Acceptors for Both Hospitals 24.9 0.2 11.4 52.0 9.3 2.2

Method Pill Intrauterine Device Condom Cream/Foam Injection Depo Provera Rhythm Female Sterilization Male Sterilization Norplant Total Acceptors Total Acceptors and Defaulters

= not available. Note: A minus sign (-) indicates default on the method. Sources: Vital and Health Statistics Abstract 19891993; MOH Annual Report 2004.

E.

Overseas Referrals

15. In 1993, on average, seven patients per month were referred abroad and required about 10% of the health budget. In 2001, overseas referrals declined from 147 in 2000 to 120 (at a cost of $6,552,766), but rose from 70 cases in 2003 to 95 cases in 2004. However, there was only a minor increase in cost ($2,459,388 in 2003 to $2,469,118 in 2004). Nevertheless, overseas referrals continue to consume a substantial proportion of the health expenditure (14%).

58

UTILIZATION OF OUTER ISLANDS HEALTH CENTERS BUILT UNDER THE PROJECT 1993 Construction Year of Estimated Number of Cost ($) Completion Population Outpatients 800 62,000 1999 428 236 60,500 2005 330 720 62,000 1999 470 720 55,750 1999 383 n.a. 55,750 1999 76 n.a. 56,000 2000 254 n.a. 53,000 2000 252 118 55,500 1999 218 118 54,800 2003 130 79 56,000 2000 183 118 55,000 1999 162 118 55,000 1999 108 n.a. 56,000 2000 57 236 54,800 1999 343 n.a. 69,000 1999 133 118 56,000 2000 86 n.a. 50,950 1999 225 n.a. 50,950 1999 285 n.a. 55,000 1999 451 n.a. 56,000 2000 178 1,360 55,500 1999 942 n.a. 236 56,000 1999 n.a. 236 56,000 2000 n.a. 236 56,000 1999 n.a. n.a. 55,000 1999 n.a. 120,000 2000 417 79,000 1999 1,823 Estimated Population 403 287 527 293 198 311 271 210 103 180 141 87 101 329 159 53 186 288 429 165 836 167 360 279 150 732 2,442 2003/2004 Number of Encounters 1,320 240 780 nd 264 n.a. 600 520 300 520 79 240 520 231 n.a. 300 520 624 n.a. 397 2,000 312 700 520 n.a. 1,000 11,398 Rate of Rate of Satisfied Clients Users 90% 90% n.a. n.a. 99% 99% 100% 100% 100% 100% n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 100% 100% 100% 100% n.a. n.a. 100% 100% n.a. n.a. 100% 90% 100% 100% 99% 99% n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 99% 99% n.a. n.a. 100% 100% 100% 100%

Appendix 9

Atoll Health Center Ailinglaplap Airok Buoj Woja Arno Arno Bikarej Aur Aur Tobal Ebon Ebon (Jittoen) Jabat Jabat Jaluit Iniej Imroj Narmij Kwajalein Ebadon Lae Lae Lib Lib Likiep Jebal Maloelap Airok Kaben Mili Mili Enijet Namdrik Namdrik Namu Loen Majkin Namu Wotje Wodmej Wotje Majuro Laura
n.a. = not available.

Source: 1993 Vital health Statistics Abstract; 2005 Outer Islands Health Care System: 2005 Primary Health Care Asessment Health Sector Report prepared by Beca International Consultants, October 2003.

ACCOMPLISHED OUTER ISLAND TRIPS

Atoll Ailinglaplap Ailuk Arno Aur Ebon Jabat Jaluit Number of HCs Operating 5 2 7 2 2 1 7 Public Health Mar Feb, Aug Jul Jul Jan, Apr, Jun, Aug, Sep Nov Aug Apr, Aug Aug Apr, Aug Jun Sep Nov Aug, Nov Feb, Jul 24 13 Oct Oct Oct 2003 Reproductive Health Dental Oct May Oct Jan Jun Total No. 2 0 3 2 2 0 6 2004 Public Reproductive Health Health Dental Apr Mar Sep Nov Jan, Sep Feb Oct Apr Feb Jan Total No. 2 2 3 1 1 1 1 2005 (up to October only) Public Reproductive Total Health Health Dental No. Apr Oct 2 Mar 1 May 1 Feb, May Mar 3 Jan, Aug May 3 Sep 1 Jan, Jun Apr 3

Kwajalein (Ebeye) Lae Lib Likiep Maloelap Mejit Mili

2 1 1 2 5 1 5

0 1 0 2 3 2 2 Oct 3 1 1 3 3 36 15

Sep Jan, Apr

Feb Jan

Sep Sep Apr, Jun, Nov May Apr

2 3 0 0 1 2 4 0 1 1 0 3 28 15

Aug, Oct Apr Feb Feb Jan, Sep Mar Feb, Sep Apr, Jul Mar May 21 15 7 4

Jul, Oct

Jun Sep Jan Jul Feb Jul 11 11

2 1 0 1 1 5 2 5 4 1 1 2 39 18

1 Namorik/Namdrik 4 Namu 1 Ujae 1 Wotho 2 Wotje Total Number of HCs 52 Total Number of Outer Island Trips Number of Outer Islands Visited

Oct

Jul Aug Feb 14 10 Dec 5 5 Mar 9 9

Jul, Aug May

Jun Dec 10 10 2 2

HC = health center. Note: Health promotion is being conducted by teams in all outer island trips. Source: Ministry of Health.

Apppendix 10

59