WESTERN PACIFIC Country Health Information Profiles 2005 REVISION World Health Organization Regional Office for the Western Pacific 2005 ii WHO Library Cataloguing in Publication Data Western Pacific country health information profiles : 2005 edition 1. Health status indicators 2. National health programs 3. Health priorities ISBN 92 9061 197 9 (NLM Classification: WA 900) © World Health Organization 2005 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. 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No. (632) 521-1036, email: publications@wpro.who.int iii Contents Page Introduction v Millennium Development Goals: Progress and challenges in the Western Pacific Region vii List of acronyms xiv American Samoa……………………………………………………………………………………………………….. 1 Australia…………………………………………………………………………………………………………………… 12 Brunei Darussalam…………………………………………………………………………………………………….. 25 Cambodia…………………………………………………………………………………………………………………. 36 China……………………………………………………………………………………………………………………….. 48 Cook Islands…………………………………………………………………………………………………………….. 58 Fiji…………………………………………………………………………………………………………………………… 69 French Polynesia……………………………………………………………………………………………………….. 80 Guam……………………………………………………………………………………………………………………….. 88 Hong Kong (China)……………………………………………………………………………………………………. 97 Japan……………………………………………………………………………………………………………………….. 108 Kiribati……………………………………………………………………………………………………………………… 118 Lao People’s Democratic Republic……………………………………………………………………………….. 128 Macao (China)………………………………………………………………………………………………………….. 140 Malaysia…………………………………………………………………………………………………………………… 149 Marshall Islands…….………………………………………………………………………………………………….. 159 Micronesia, Federated States of………………………………………………………………………………….. 170 Mongolia………………………………………………………………………………………………………………….. 179 Nauru………………………………………………………………………………………………………………………. 194 New Caledonia………………………………………………………………………………………………………….. 202 New Zealand…………………………………………………………………………………………………………….. 212 Niue…………………………………………………………………………………………………………………………. 223 Northern Mariana Islands, Commonwealth of the…………………………………………………………. 232 Palau………………………………………………………………………………………………………………………… 240 Papua New Guinea……………………………………………………………………………………………………. 249 Philippines……..…………………………………………………………………………………………………………. 260 Pitcairn Islands………………………………………………………………………………………………………….. 274 Republic of Korea………………………………………………………………………………………………………. 276 Samoa……………………………………………………………………………………………………………………… 288 Singapore…………………………………………………………………………………………………………………. 299 Solomon Islands………………………………………………………………………………………………………… 310 Tokelau……………………………………………………………………………………………………………………. 322 Tonga………………………………………………………………………………………………………………………. 330 Tuvalu……………………………………………………………………………………………………………………… 345 Vanuatu……………………………………………………………………………………………………………………. 355 Viet Nam…………………………………………………………………………………………………………………… 365 Wallis and Futuna……………………………………………………………………………………………………… 378 Statistical Tables……………………………………………………………………………………………………….. 385 Annex Charts……………………………………………………………………………………………………………. 411 Appendix. Glossary of Terms……………………………………………………………………………………… 423 v Introduction Country health information profiles (CHIPS) were first published in 1974 by the WHO Regional Office for the Western Pacific. The first CHIPS were primarily a reference for WHO staff responsible for briefing other staff, writing reports, drafting plans of action and verifying statistical data. CHIPS then became a resource tool used by other United Nations agencies, international organizations and government agencies. In response to ever-growing demands for current data and information, every effort is made to update the figures and analysis in CHIPS annually, if possible. Each profile contains data on the health and demographic conditions, health indicators and trends, and health care system (if available) of the countries and areas of the WHO Western Pacific Region. The data are either supplied by the respective health ministries or compiled from national databases and reference libraries. The revised format of the 2005 edition includes the following: • Millennium Development Goals (MDG) – Summarizes the progress achieved, key issues or challenges, and the promising approaches towards achieving the health-related goals. • Demographics, gender and poverty – Highlights the main demographic and socioeconomic determinants of health, the influence of gender and poverty as determinants of health risks, health care-seeking, access to health services and health outcomes. • Political situation – Outlines the political factors that may have an impact on health, such as political stability, major government initiatives, and recent and forthcoming political events, such as elections. • Economic situation – Explains and quantifies the economic determinants of health, such as levels of poverty and unemployment, economic growth rates, regional economic disparities, employment and working conditions and government spending on health • Health trends – Details the major communicable diseases (including outbreaks) in the country and their trends, rates of noncommunicable diseases and the health transition and leading causes of morbidity and mortality, and provides information about rates of maternal and infant mortality, childhood diseases, etc. • Health systems – Describes the organization and financing of the health sector, including the role of the private sector and any key problems/ limitations/ issues with funding, infrastructure, human resources, quality of services, or inequalities in access to and use of services. Highlights new innovative or ‘pro-poor’ approaches to health care financing, such as social safety nets and social health insurance, and their impact. Also includes a brief summary of MDG achievements and monitoring, such as recent activities and progress, important developments over the previous year, key issues or challenges and partnerships for MDG achievement. • National health plan and priorities – Outlines the government’s long-term objectives for the health sector, highlighting health plans, legislation recently passed or pending and health reform proposals. • List of major information sources vi • Health department organizational chart (if available) Annexed to each country profile is a summary table with information on sociodemographic conditions, as well as health indicators such as immunization coverage of infants, maternal health, health expenditure, health workforce, health infrastructure, leading causes of morbidity and mortality, and number of cases and deaths from selected diseases. A statistical annex is included at the end of the publication which contains nearly all information in the summary table of each country as well as indicators on selected diseases such as HIV prevalence rates, obesity and overweight prevalence rates among adults, mean BMI, underweight/stunting/wasting prevalence rates among children below 5 years of age, smoking prevalence among young people, major emergencies that occurred in the Region over the last two years, etc. Prior to publication, clearance by the respective governments was sought. However, it should be noted that data reliability and data coverage vary for each indicator and from country to country. Moreover, for indicators for which a country has no data availability, secondary sources were used to estimate these indicators. Individual country profiles and the CHIPS volume as a whole are accessible on the website of the WHO Regional Office for the Western Pacific (http://www.wpro.who.int/). Note on title. As in the 2004 revision, the year of publication has been used (rather than the year of most recent data). This brings CHIPS into line with other WHO publications, such as the World health report. However, it does mean that the series "jumps" from Country health information profiles 2002 revision (old naming convention) to Country health information profiles 2005 revision (new naming convention). vii MDG: PROGRESS & CHALLENGES IN THE WESTERN PACIFIC REGION 1. Background In 2000, the United Nations General Assembly unanimously adopted the Millennium Declaration which outlines a vision for the new century based on fundamental values of freedom, equality, solidarity, tolerance, health, respect for nature and shared responsibility. These core values inspired the formulation of the Millennium Development Goals (MDG). The MDG relate to the following: 1) poverty; 2) primary education; 3) gender equity; 4) child mortality; 5) maternal health; 6) HIV/AIDS, malaria and other diseases; 7) environmental sustainability; and 8) global partnerships for development. The MDG recognize the interdependence among many development challenges. They require the participation of all members of society; and place the responsibility both on the developed and developing nations. They are time bound. They are to be monitored using agreed upon indicators. Health and health-related indicators are subsumed under all the MDG, except for Goals 2 and 3. So far, eight countries and areas within the Western Pacific Region (WPR) have produced country MDG reports: Cambodia, China, The Lao People's Democratic Republic, Malaysia, Mongolia, Papua New Guinea, The Philippines and Vietnam. The MDG reports for Fiji and Solomon Islands are in draft form. The United Nations supported the preparation of these reports. Three regional reports have been written as well. In 2003, the Economic and Social Commission for Asia and the Pacific and the United Nations Development Programme jointly launched the report on Promoting the Millennium Development Goals in Asia and the Pacific. The Asian Development Bank and the Secretariat of the Pacific Community independently published the Millennium Development Goals in the Pacific: Relevant and Progress in 2003 and the Pacific Islands Regional Millennium Development Goals Report 2004, respectively. The WHO Western Pacific Regional Office (WPRO) established a technical working group on MDG composed of members from relevant technical units. The working group is tasked with supporting MDG implementation and monitoring in countries and areas, and liasing with WHO Headquarters and country offices. The Region intends to provide technical support in conducting advocacy and building awareness among Member States on the MDG; building national capacity for health monitoring and reporting, particularly tracking progress and measuring achievements; collaborating with other agencies to strengthen MDG monitoring and to promote its integration with national health system plans; and promoting pro-poor and equitable progress on the MDG. viii The objectives of this chapter are to provide a bird's eye view on the performance of the Region in accomplishing selected indicators and to briefly describe the challenges the Region faces in meeting the health MDG. 2. Progress by goals How has the WPR performed with respect to some of the health and health-related indicators? The succeeding analysis used information published in the Health-related Millennium Development Goals 2005 by the WHO South-East Asia and Western Pacific Regional Offices. The selection of countries and areas was primarily constrained by data availability, unless otherwise specified. By intent, the review focused on the Region; there was no attempt to compare progress with that of other regions or countries outside the Region. Progress was compared against targets set for each of the MDG. 2.1 Eradicate extreme poverty and hunger Figure 1. Halving the prevalence of underweight, 1990, 2001 & Target 2015 Source of data: World Health Organization South-East Asia and Western Pacific Regional Offices. Health-related Millennium Development Goals 2005. New Delhi and Manila, World Health Organization South-East Asia and Western Pacific Regional Offices, 2005. The health-related target for the poverty reduction goal is to get by one half the number of people who suffer from hunger. Underweight and undernourishment are both indicators. Figure 1 shows the prevalence of underweight among children who are under five years of age in 15 countries and areas in the Region. As of 2001, Malaysia (MAA), China (CHN) and Samoa (SMA) appear to have achieved the target, while Viet Nam (VTN) seems to be on track. On the contrary, almost one half of the countries and areas need to put special attention to eradicating malnutrition. The 2001 prevalence rates in Fiji (FIJ), Lao People's Democratic Republic (LAO) and Mongolia (MOG) essentially did not change compared to their 1990 level. Kiribati (KIR), Marshall Islands (MSI), Micronesia (MIC), and Tonga (TON) show a reverse trend. 2.2 Reduce child mortality The MDG target is to reduce by two thirds, between 1990 and 2015, the under-five mortality rate. Aside from the under-five mortality rate and the proportion of 1-year-old children immunized for measles, the infant mortality rate (IMR) is another relevant indicator. 0 10 20 30 40 50 60 CAM VTN LAO PHL PNG MAA SOL CHN MSI MIC MOG FIJ SMA KIR TON Pr e v a le n c e o f u n de rw e ig ht am o n g u n de r- fiv e ch ild re n 1990 2001 Target 2015 ix Figure 2. Reducing the infant mortality in WPR, 1990-2000 Trend and 1990-2015 Target Figure 2 shows the progress in reducing IMR. It plots the trend line from 1990 to 2000 and the average annual rates of reduction to achieve the target by 2015. A two thirds reduction in the mortality rate requires an average rate of 4.2%. From 1990 to 2000, the IMR following the trend line has been higher than the corresponding average rates. Put another way, the Region is missing its targets. Figure 3. Infant mortality rates in countries/areas, 1990, 2002 & Target 2015 The five countries and areas with the highest IMR in 1990 are, namely, Cambodia (CAM), Kiribati, Lao People's Democratic Republic, Papua New Guinea (PNG) and Solomon Islands (SOL) (Figure 3). There were four countries and areas in the Region with a 2002 IMR worse than the 1990 IMR: Cambodia, Fiji, Niue (NIU) and Tonga. Among these four, Cambodia needs special mention because its baseline level of 80 per 1000 live births was the 4th highest. At least 60% reduction in IMR was observed in the following: China, Cook Islands (COK), Japan (JPN), Malaysia, Mongolia, Marshall Islands, New Zealand (NEZ), Philippines (PHL), Samoa, Singapore (SGP), Tuvalu (TUV), Vanuatu (VAN), and Viet Nam (VTN). They appear to be on track in meeting the MDG target. 2.3 Improve maternal health To monitor the reduction of the maternal mortality ratio (MMR) by three quarters, the MDG indicators are the MMR and the proportion of births attended by skilled health personnel. Among the 37 countries and areas in the Region, 10 did not have 1990 data on MMR, while 18 did not have on the other indicator. 0 5 10 15 20 25 30 35 40 45 1990 1995 2000 2005 2010 2015 In fa n t m o rt al ity ra te , pe r 1, 00 0 liv e bi rt hs Trend line, 1990-2000 Target 2015 (4.2% average annual rate of reduction) 0 20 40 60 80 100 120 140 LA O SO L PN G CA M KIR MO G MS I PH L CH N VA N VT N TU V SM A MI C PL A CO K FIJ NIU NR U MA A BR U NE Z TO N KO R AU S SG P JP N In fa n t m o rt al ity ra te , pe r 1, 00 0 liv e bi rt hs 1990 2002 Target 2015 x Figure 4. Reducing the maternal mortality in WPR, 1990-2000 Trend and 1990-2015 Target An average annual rate of reduction of 5.4% is required to achieve the target of three quarters reduction in 25 years. Figure 4 shows that the overall MMR for the Region were not significantly different from the targeted MMR during the initial seven years in the 1990s. Afterwards, however, the trend line shifted direction. Information pertaining to the first five years of the 21st century needs to be collected. A review of seven priority countries revealed that the Cambodia and the Philippines seem to be on track in improving maternal health. Both have achieved at least 50% reduction in MMR. The per cent reductions in MMR between 1990 and 2002 were from 25%-50% in China and Mongolia. At midterm between the baseline and target years, Papua New Guinea and Viet Nam have reduced their MMR by less than one quarter. Figure 5. Maternal mortality ratios in 1990 and their per cent reduction between 1990 and 2002 in some countries and areas 2.4 Halting and reversing the spread of HIV/AIDS and incidence of malaria and other diseases Two of the indicators for the MDG 6 are the proportion of smear-positive pulmonary tuberculosis cases detected and put under directly observed treatment, short-course (DOTS), and proportion of smear-positive pulmonary tuberculosis cases detected and cured under DOTS. The target for the detection rate is 70% while for the cure rate is 85%. Of 25 countries and areas, only seven have achieved the target for detection and 10 for 0 20 40 60 80 100 120 140 1990 1995 2000 2005 2010 2015 M at er n al m o rt al ity ra tio , pe r 10 0, 00 0 liv e bi rt hs Trend line, 1990-2000 Target 2015 (5.4% average annual rate of reduction) 0 100 200 300 400 500 600 700 800 900 PHL CAM MOG CHN LAO VTN PNG M at er n al m o rt a lit y ra tio , pe r 10 0, 00 0 liv e bi rt hs 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 Re du ct io n in M M R, 19 90 & 20 02 , % 1990 Maternal mortaltiy ratio (MMR) Reduction in MMR, 1990 & 2002, % ON TRACK WARNING OFF TRACK xi cure (Figure 6). Macao (China), Micronesia and Vietnam have met both the detection and cure targets. Figure 6. Improving detection, treatment and cure of tuberculosis under directly observed treatment short course (DOTS) strategy in some countries/areas Among the countries in the Region with a high burden of tuberculosis, only Viet Nam has performed well in both detection (86%) and cure (92%). Although it exceeded the cure rate target, Cambodia (60%), China (43%) and the Philippines (68%) have yet to reach the target rates for case detection. 2.5 Ensure environmental sustainability How has the Region progressed in halving, between 1990 and 2015, the number of people without sustainable access to safe drinking water? Figure 7 was based on the per cent of rural population with access to improved water sources. Among other things, it illustrates two significant points - the problem related to the availability and quality of data to track progress in achieving the health MDG. Out of 37 countries and areas in the Region, 18 do not have the required information for 1990 and 2015, and so they were excluded from the graph. Further analysis of Figure 7 requires validation of information with other sources. 0 10 20 30 40 50 60 70 80 90 100 M IC P LA V TN TO N M A C N M I V A N M A A P H L M O G FR P FI J C A M H K G N E Z N R U S M A LA O S G P C H N JP N N E C K O R P N G A U S D et ec te d, tr ea te d & cu re d u n de r D O TS , % Detected & put under DOTS (2003) Cured (2002) Target cure rate =85% Target detection rate=70% D et ec te d, tr ea te d & cu re d u n de r D O TS , % xii Figure 7. Sustainable access to safe drinking water in some countries and areas, 1990, 2002 and Target 2015 2.6 Develop a global partnership for development Progress in access to essential medicines is the result of a combined effort by governments, strategic partners such as United Nations agencies, public-private partnerships, nongovernmental organizations and professional associations. For this reason, providing access to affordable, essential drugs in developing countries is classified as one of the targets under MDG 8. Lack of baseline data on the per cent of population with access to essential drugs in 1990 precluded an assessment of progress. Table 1 lists the 16 countries that have information for 1997. All high-income countries have very high access, whereas the low-income countries have very low to medium access. The range of access for middle-income countries is from low to high. Table 1. Access to essential medicines, 1997 Percentage of population with access to essential drugs Income Group Very low access (<50%) Low to medium access (50-80%) Medium to high access (81-95%) Very high access (>95%) Low income Cambodia Lao PDR Mongolia Papua New Guinea Viet Nam Middle income China Philippines Samoa Malaysia Marshall Islands High income Australia Brunei Darussalam Japan New Zealand Republic of Korea Singapore 0 10 20 30 40 50 60 70 80 MOG PNG KIR VTN VAN CHN PHL NEZ MIC COK SMA TUV TOK MSI PLA NMI AUS FRP JPNR u ra l p o pu la tio n w ith o u t a cc e s s to im pr o v ed w a te r s o u rc e , % 1990 2002 Target 2015 xiii 3. Challenges ahead in meeting the health MDG Regardless of their progress in attaining the health MDG, countries face a combination of challenges. Countries that are on track continue to be vigilant, but they acknowledge the many evolving challenges that may impact their successes. On the other hand, countries that are off track know that slow progress in MDG is not always because of a lack of technical knowledge. In fact, many of them have incorporated effective technical interventions in their national programmes. They know where they stand, they know what needs to be done, but they are constrained in many ways. Both the countries that are on and off track in meeting the MDG know well the many challenges they face: 1) changing the disease burden; 2) weak health systems; 3) limited cross-sectoral actions even if the multidimensional nature of health is well known; 4) insufficient and inefficient use of resources for health; and 5) inequality as a threat to progress. Many countries in the Region are saddled with a double challenge, or a double disease burden. Communicable diseases, reproductive health and malnutrition issues account for one half of the disease burden. The other one half is composed of noncommunicable disease groups, mainly cardiovascular diseases, injuries, neuro-psychological diseases and other conditions such as diabetes. This double challenge requires the health system to be doubly skilled and equipped in managing both types of health conditions. Furthermore, it challenges governments to include non-communicable conditions in their MDG agenda. Figure 8. Maternal mortality ratio and births attended by skilled attendants by countries, 2002 Deployment of skilled personnel who will attend births could make deliveries safer and contribute to lowering maternal deaths (Figure 8). The health workforce makes a health system run. Nonetheless, in many countries the health workforce is not viewed as an asset. Instead, it is seen as a recurrent cost. There are other challenges in related to the health workforce, which takes up 50%-75% of government health budget in many systems. In many countries, there are very difficult working conditions (e.g. poor facilities, low pay and shortages) that lead to low morale. The style of leaderships does not encourage problem solving at the local level. Shortages in the health workforce in several countries are partly due to a growing global labour market. Regarding monitoring and evaluation, one of the fundamental challenges is guaranteeing the availability of data. Other concerns include improving the reliability and timeliness of information. Often information is not disaggregated according to age, sex, subnational level, rural/urban and income/wealth. Thus, the assessment of the most vulnerable populations groups is hardly possible. There is a lack of capacity to analyse information and use it for policy. Cross-sectoral action is not something unique to health MDG. It is a necessity for all health programmes. It is not even a new strategy. In fact, it was one of the major strategies 0 100 200 300 400 500 600 0 10 20 30 40 50 60 70 80 90 100 110 Births attended by skilled attendants, % M at er n al m o rt al ity ra tio , pe r 10 0, 00 0 liv e bi rt hs , 20 02 xiv of primary health care in the 1970s and 1980s. In many countries, the government is no longer the sole provider and financier of health services and goods. When patients are affected with certain conditions, for example those that still carry a social stigma such as tuberculosis, HIV/AIDS and sexually transmitted infections, many patients prefer to avail of the services of the private sector. In these settings, partnerships with the private sector have become a necessity. The major challenge lies in developing institutional arrangements to ensure further cross-sectoral actions. How can governments provide conductive policy, regulatory and legislative environments? How can inter-ministerial and local level planning be further enhanced to secure budgets for health and health-related items? How can ownership be cultivated at all levels, among the stakeholders, including target populations? How can one generate inter-sectoral synergies on one hand, and avoid the harmful effects of cross-sectoral investments on the other hand? How can one assess the impact of cross-sectoral actions on health and vice versa? On securing the efficient use of resources, countries have funded a major part of their health expenditures through domestic resources. Most health spending comes from out-of-pocket private sources, which is regressive and therefore the least desirable source. Many countries need a substantial increase to meet the health MDG. For the poorest countries, progress is difficult without external financial resources. The quality of aid is as important as its quantity. In this respect, the challenges include alignment of donor strategies with the country priorities, better cooperation among development partners, and the promotion of inter-country cooperation within the Region. Another issue is the allocation and management of resources. Currently, the majority of the funding usually goes to urban areas, often supporting costly curative services. Despite the success stories in some countries, the overall picture in Western Pacific Region is that of a wide variation in progress, both within and between countries. Inequities within countries have widened in recent decades so much so that the poor and other vulnerable segments of the population are increasingly unable to access affordable health services and goods. In Viet Nam, for example, the MMR is two times higher in remote and mountainous areas than in other parts of the country. The country recognizes the importance of providing better reproductive services to redress this inequity. Cognizant of the need for stronger and more purposeful strides in overcoming the aforementioned challenges and to remain on track to meet the health MDG, the World Health Organization collaborated with the Government of Japan, The Asian Development Bank and The World Bank in organizing a High-Level Forum on Health MDG in Asia and the Pacific from 21 to 22 June 2005 in Tokyo. Both the forum report and background paper, entitled Turning Promises into Progress: Attaining the Health MDGs in Asia and the Pacific, can be accessed from the WPRO homepage http://www.wpro.who.int/sites/hin/meetings/mdg_japan.htm. xv List of Acronyms ADB Asian Development Bank AFP Acute flaccid paralysis AIDS Acquired immunodeficiency syndrome APEC Asian Pacific Economic Cooperation ARI Acute respiratory infection ASEAN Association of Southeast Asian Nations AusAID Australian Agency for International Development BBA Born before arrival BCG Bacille-calmette guérin BMI Body mass index CDD Control of diarrhoeal disease CEDAW Convention on the Elimination of all forms of Discrimination Against Women CFP Cour de Franc Pacifique CPR Contraceptive prevalence rate CROP Council of Regional Organisations of the Pacific CSR Congenital rubella syndrome DALY Disability-adjusted life years DDHS Division Directors of Health Services DEPD Department of Economic Planning and Development DHB District Health Boards DHF Dengue haemorrhagic fever DMF Decayed, missing or filled DOTS Directly observed treatment short-course DPHSS Department of Public Health and Social Services DTP Diphteria-tetanus-pertussis EEZ Exclusive Economic Zones ENT Ear, nose and throat EPI Expanded programme on immunization EU European Union FCTC Framework Convention on Tobacco Control FFA Forum Fisheries Agency FGP Family group practices FMIS Financial management information system GDP Gross domestic product GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GLC Government-linked companies GNI Gross national income GNP Gross national product GTZ Deutsche Gessellschaft für Technische Zusammenarbeit HACCP Hazard analysis critical control point HBV Hepatitis B vaccine HDI Human development index HIB Haemophilus influenzae type b HIES Household income and expenditure survey HIS Health information system HIV Human immunodeficiency virus HKSARG Hong Kong Special Administrative Region Government HPAI Highly pathogenic avian influenza HRD Human Resources Development HRDF Human Resources Development Fund HRIS Human resource information system ICD International classification of diseases ICT Immuno chromatographic test IDP Internally-displaced people xvi IEC Information, education and communication IMCI Integrated management of childhood illness IMF International Monetary Fund ITU International Telecommunications Unit JICA Japan International Cooperation Agency LDC Least developed countries MCH Maternal and child health MDA Mass drug administration MDG Millennium Development Goals MF Microfilaria MMR Measles-mumps-rubella NCD Noncommunicable disease NGO Non-governmental organization NGPES National Growth and Poverty Eradication Strategy NHIP National Health Insurance Program NHIS National Health Insurance Scheme NPS National Pension Scheme NZAID New Zealand Agency for International Development NZODA New Zealand Official Development Assistance OECD Organisation for Economic Cooperation and Development OPV Oral polio vaccine PCD Priority-chronic diseases PHC Primary health care PIC Pacific Island Countries PIDP Pacific Islands Development Program PIFS Pacific Islands Forum Secretariat PPP Purchasing power parity PRISM Pacific Regional Information System PRSP Poverty reduction strategy paper PSC Public Service Commission RCMS Rural Cooperative Medical System RDT Rapid diagnosis test RF/RHD Rheumatic fever/ rheumatic heart disease SAPHE Sanitation, Public Health and Environment SAR Special Administrative Region SARS Severe acute respiratory syndrome SOE State-owned enterprises SOPAC South Pacific Applied Geo-Science Commission SPBEA South Pacific Board for Educational Assessment SPC Secretariat of the Pacific Community SPREP South Pacific Regional Environment Programme SPTO South Pacific Tourism Organization STI Sexually transmitted infection TB Tuberculosis TCM Traditional and complementary medicine TT Tetanus toxoid UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Fund for Population Activities UNICEF United Nations Children’s Fund UNTAC UN Transitional Authority in Cambodia USAID United States Agency for International Development USP University of the South Pacific WB World Bank WHO World Health Organization WTO World Trade Organization COUNTRY HEALTH INFORMATION PROFILES | 1 AMERICAN SAMOA 1. DEMOGRAPHICS, GENDER AND POVERTY In 2004, American Samoa had an estimated population of 62 600, with around 40% of them below 15 years of age. Almost 4% were above 65 years of age. The average age was estimated at 21.3 years. About one-half of the population resides in urban areas. As of the latest census in 2000, life expectancy at birth for men is 69 years, while for women it is 76 years. Based on 2004 estimates, there are 104 males for every 100 females. Table 1. Core population and health data (2004 estimate) [Total] 62 600 [Both] ... [0-14 years] (38.95%) [Male] 69.0 (2000) Population [65+ years] (3.58%) Life expectancy at birth (years) [Female] 76.0 (2000) Crude birth rate (per 1000 population) 26.70 (2002) Total fertility rate 4.0 (2000) [Total] 99.00 [Urban] 99.00 Crude death rate (per 1000 population) 3.90 (2000) % of population served with safe water [Rural] 99.00 [Total] 99.00 [Urban] 99.00 Infant mortality rate (per 1000 live births) 8.50 (2001) % of population with adequate sanitary facilities [Rural] 99.00 Maternal mortality rate (per 100 000 live births) 123.00 (2002) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation American Samoa was defined by a treaty in 1899 between the United States of America, the United Kingdom of Great Britain and Northern Ireland, and Germany, which gave the United States of America control of all Samoan islands east of 171ºW. In 1978, the first popularly elected Samoan governor was inaugurated. There is a bicameral legislature (Fono), consisting of a senate (18 members chosen by county councils) and a house of representatives (20 members elected by popular vote, plus one nonvoting member from Swains Island, which is privately owned). There is also an independent judiciary. 2.2 Economic situation American Samoa is a small developing economy that depends on two main sources of income: the United States Government and tuna canning. Federal expenditures and the canning business together account for 93% of the economy. The remaining 7% results from a small tourism industry and service sector. Transfers from the United States Government add substantially to American Samoa’s economy. Annual budget revenues of US$ 121 million comprise grants from the United States of America (63%) and local revenue (37%). The United States is the main trading partner. Gross domestic product (GDP) per capita (purchasing power parity) was estimated at US$ 8000 in 2000. AMERICAN SAMOA 2 | COUNTRY HEALTH INFORMATION PROFILES 3. HEALTH SITUATION 3.1 Health trends The crude birth rate was 26.70 per 1000 population in 2002, and the crude death rate was 3.9 per 1000 population in 2000. The infant mortality rate is estimated at 8.50 per 1000 live births, and the under-five mortality rate at 4.90 per 1000 live births. The total fertility rate for women aged 15-49 years is 4.50, and the maternal mortality ratio was 123 per 100 000 live births in 2002. In 2000, 33% of women in the reproductive age group were using modern contraceptive methods. There has been considerable progress in primary health care in recent years. Water supplies and sanitation systems are well organized and maintained, and 99% of the population have access to safe water. Water is increasingly supplied from deep bores, with a smaller portion from reservoirs, and is chlorinated. Although 99% of the population have adequate excreta disposal facilities, solid waste disposal is still a problem. Waste collection systems have improved significantly, but adequate space for solid waste landfill operations is very limited. The morbidity pattern has shifted significantly over the past three decades from infectious diseases to a predominance of noncommunicable diseases related to modernization and lifestyle changes. Enumerated data on the leading causes of morbidity are currently unavailable. However, based on the observations and personal experiences of senior health officers, the following are assessed as the leading communicable diseases presently affecting the population: respiratory infectious diseases, filariasis, dengue, hepatitis, tuberculosis, leprosy and intestinal worm infestations. For noncommunicable diseases, obesity, diabetes and complications (including hypertension, heart disease and stroke), chronic disabling conditions (including asthma, gout, osteoarthritis and osteoporosis), tobacco-related obstructive pulmonary disease, cancer and oral health are the leading causes of morbidity. The most serious health issues are related to the increase in chronic diseases associated with lifestyle, with their roots in improper nutrition and physical inactivity. Significant increases in the prevalence of obesity, in both sexes and at increasingly younger ages, are associated with a number of these conditions. Hypertension, cardiovascular diseases, cerebrovascular diseases, Type II diabetes mellitus and its complications, arthritis, gout and some forms of cancer are among these important chronic diseases. American Samoa reported one positive case of HIV in 2001. The Government is taking the issue of HIV/AIDS seriously and has developed a national policy and prevention programme. Filariasis is a major endemic problem. The mass drug administration (MDA) campaign in 2001 reported coverage of 52% for the target population. The reported coverage represents a 50% improvement compared with the 1999 MDA, which only had 19% coverage. In 2003, MDA coverage among the total population was 70%. Blood survey results for filariasis were 2.6% (microfilaria) and 11.5% (immunochromatographic test) in 2001. 3.2 Health systems The Department of Health and the National Hospital continue to co-exist as two separate systems. The Department of Health is responsible for public health issues, communicable disease control (including tuberculosis and HIV/AIDS) and health dispensaries at district and community levels. The National Hospital in Pago Pago is under the management of the Hospital Board, designated by the Governor, and is subject to the federal rules and regulation of the United States of America (i.e. the hospital does not have to report to the Department of Health). Nevertheless, coordination between the Department of Health and the National Hospital is generally well conducted at the technical level. Most public health programmes continue to be funded by federal grants. The health infrastructure consists of one hospital (LBJ Tropical Medical Center) and five primary health centres. The 2003 health workforce included 49 physicians (American doctors, Fiji School COUNTRY HEALTH INFORMATION PROFILES | 3 of Medicine graduates and foreign doctors), 15 dentists, 2 pharmacists, 127 nurses, 1 midwife, 98 other nursing/auxiliary staff, 146 paramedical personnel, and 13 other health personnel. The LBJ Tropical Medical Center, a 128-bed general acute care hospital, is the only hospital in the territory. The Medical Center provides a reasonable scope of general inpatient and outpatient services covering: medicine; surgery; obstetrics and gynaecology; ear, nose and throat (ENT); eye; paediatrics; mental health; and renal dialysis. However, the absence of an available health workforce pool in a small island population, and chronic severe government financial difficulties, make long-range health workforce planning uncertain, and recruitment and retention problematic. Both the hospital and the Department of Health have inadequate resources for continuing education for their staff members. This leaves the Department of Health with a rapidly growing gap between evolving professional responsibilities and existing workforce competencies. The long-standing problem of health workforce deficiencies is one of the greatest challenges for health development. Therefore, human resource development for health has been identified as a priority area for national health development, particularly for WHO collaboration. Training of nurses takes place locally and through overseas education in the American system and, as recognition of qualifications requires certification and/or registration by American professional associations, much undergraduate and post-graduate training is undertaken in that system. Adequate numbers of licensed practical nurses are produced this way, but the supply of registered nurses is insufficient to meet the quality standards required for United States federal health care financing programmes. Specialized training courses and workshops sponsored by WHO and American sources are welcomed and add to the quality of services, particularly those related to public health. The newly acquired telecommunications capability at the LBJ Tropical Medical Center provides additional opportunities for distance learning through the telemedicine/telehealth system housed in that facility. Medical and dental officers are trained at the Fiji Schools of Medicine and Dentistry, and post- graduate training through short-term courses and attachments is being arranged in Australia and New Zealand. A number of medical students are also in medical schools in the United States of America, although this practice does not provide any assurance that these individuals will return to the island as doctors after their training. Financial management of public health programmes is mainly grant-driven rather than programme-driven. The hospital generates financial resources from user fees, local government appropriations, and federal health care financing through the Medicaid and Medicare programmes. The total government health budget amounts to 14% of the territory’s total budget and the bulk goes to curative care, with only about 10% going to public health. Total health expenditures are around US$ 32.3 million, which corresponds to a per capita health expenditure of US$ 500. The United States health care financing administration provides about US$ 3 million a year to the LBJ Tropical Medical Center (16% of its funding), most of which is used to purchase medicine and medical supplies used at the centre. Pharmaceuticals and vaccines are purchased from the United States of America. United States Federal Drug Administration regulations prevent the territory from purchasing pharmaceuticals from foreign sources. There are frequent shortages due to problems with ordering logistics and financial shortfalls. A planned project to build a new acute care hospital to replace the LBJ Tropical Medical Center has been deferred due to cost, and an alternative plan to renovate and expand the existing facility is being implemented. AMERICAN SAMOA 4 | COUNTRY HEALTH INFORMATION PROFILES 4. NATIONAL HEALTH PLAN AND PRIORITIES The territorial health priorities are as follows: (1) Increase the capacity of the health system to meet the health challenges of the 21st century through: - improving health policy development mechanisms, - developing the health workforce, - improving management processes at all levels, and - strengthening long-range health planning and programme planning. (2) Identify emerging and re-emerging diseases and implement effective interventions. (3) Implement effective interventions to decrease the burden of chronic diseases related to unhealthy lifestyles, especially cardiovascular disease, cancer and diabetes mellitus. (4) Actively implement the Healthy Islands concepts of health promotion, health protection and primary health care in priority settings, particularly through community health centres and school-linked programmes. (5) Increase the effectiveness of public investment in health through development of decision-oriented information systems, applied research, effective deployment of the health workforce, application of appropriate technology, and increased allocation of funding for health promotion, health protection and primary health care. 5. MAJOR INFORMATION SOURCES Department of Health Department of Commerce Pacific Island Populations 2004, Secretariat of the Pacific Community (http://www.spc.int) CIA World Factbook 2003 (http://www.cia.gov/cia/publications/factbook/) Demographic Tables for the Western Pacific Region 2000-2005. Manila, WHO Regional Office for the Western Pacific World Population 2002. United Nations Population Division, Department of Economic and Social Affairs 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Pago Pago, American Samoa 98799 Postal Address : Official Email Address : Telephone : (684) 633 4606 Fax : (684) 633 5379 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILES | 5 WHO REPRESENTATIVE IN SAMOA Office Address : Ioane Viliamu Building Beach Road, Apia, Western Samoa Postal Address : P.O. Box 77 Apia, Samoa Official Email Address : who@sma.wpro.who.int Telephone : (685) 23756 Fax : (685) 23765 Office Hours : AMERICAN SAMOA 6 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: DEPARTMENT OF HEALTH COUNTRY HEALTH INFORMATION PROFILE 7 AMERICAN SAMOA WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 0.20 2004 2 2 Estimated population ('000s) 62.60 … … 2004 est 2 3 Annual population growth rate (%) 2.00 … … 2000 1 4 Percentage of population - 0–14 years 38.95 39.27 38.62 2004 est 3 - 65+ years 3.58 3.31 3.87 2004 est 3 5 Urban population (%) 54.00 … … 2003 4 6 Crude birth rate (per 1000 population) 26.70 … … 2002 1 7 Crude death rate (per 1000 population) 3.90 … … 2000 1 8 Rate of natural increase of population (% per annum) 2.60 … … 2000 1 9 Health-adjusted life expectancy (HALE) (years) - at birth … 69.00 76.00 2000 2 - at age 60 … … … 10 Adult literacy rate (%) … … … 11 Neonatal mortality rate (per 1000 live births) 6.20 … … 2000 1 12 Infant mortality rate (per 1000 live births) 8.50 … … 2001 est 2 13 Under-five mortality rate (per 1000 live births) 4.90 … … 2002 1 14 Total fertility rate (women aged 15–49 years) 4.50 2000-2005 3 15 Maternal mortality ratio (per 100 000 live births) 123.00 2002 1 16 Percentage of newborn infants weighing at least 2500 g at birth 97.00 … … 2000 1 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 32.00 2002 1 19 Immunization coverage for infants (%) - BCG NR NR NR 2003 5 - DTP3 94.00 … … 2003 5 - OPV3 93.00 … … 2003 5 - Measles 89.00 … … 2003 5 - Tetanus II NR NR NR 2003 5 - Hepatitis B III 89.00 … … 2003 5 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 70.00 2002 1 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) 1.00 2002 1 - Percentage of deliveries in health facilities (as % of total deliveries) 99.00 2002 1 21 Percentage of women in the reproductive age group using modern contraceptive methods 33.00 2000 1 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … AMERICAN SAMOA 8 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 99.00 99.00 99.00 2004 1 26 Proportion of population with access to improved sanitation 99.00 99.00 99.00 2004 1 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index … … … 32 Per capita GDP at PPP (US$) 8000.00 a 2000 est 6 33 Rate of growth per capita GDP … … … 34 Health expenditure Total health expenditure - amount (in million US$) 32.30 2003 7 - total health expenditure on health as % of GDP … - per capita total expenditure on health (in US$) 500.00 2003 7 Government expenditure on health - amount (in million US$) 31.80 2003 7 - general government expenditure on health as % of total expenditure on health 98.00 2003 7 - general government expenditure on health as % of total general government expenditure 14.00 2003 7 External source of government health expenditure - external resources for health as % of general government expenditure on health 70.00 2003 7 Private health expenditure - private expenditure on health as % of total expenditure on health 2.00 2003 7 Exchange rate in US$ of local currency is: 1 US$ = 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 49 36 13 6.00 … … 2003 1 - dentists 15 8 7 2.50 … … 2003 1 - pharmacists 2 2 0 0.30 … … 2003 1 - nurses 127 4 123 21.00 … … 2003 1 - midwives 1 0 1 … … 0.30 2003 1 - other nursing/ auxiliary staff 98 8 90 16.00 … … 2003 1 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 146 63 83 24.00 … … 2003 1 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 13 13 0 2.50 … … 2003 1 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … COUNTRY HEALTH INFORMATION PROFILE 9 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity b Number Rate per 100 000 population 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Heart disease 55 … … 92.00 … … 2001 1 2. Neoplasms 36 … … 60.00 … … 2001 1 3. Diabetes 20 … … 33.00 … … 2001 1 4. Cerebrovascular disease 19 … … 32.00 … … 2001 1 5. Accidents 15 … … 25.00 … … 2001 1 6. Prenatal condition 10 … … 17.00 … … 2001 1 7. Nephritis / nephrosis 9 … … 15.00 … … 2001 1 8. Chronic obstructive pulmonary disease 8 … … 13.00 … … 2001 1 9. Septicaemia 4 … … 7.00 … … 2001 1 10. Pneumonia / influenza 4 … … 7.00 … … 2001 1 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 … … … … … 2003 5 - Pertussis (whooping cough) 0 … … … … … 2003 5 - Tetanus NR NR NR … … … 2003 5 - Neonatal tetanus NR NR NR … … … 2003 5 - Poliomyelitis 0 … … … … … 2003 5 - Hib meningitis 0 … … … … … 2003 5 - Measles 0 … … … … … 2003 5 - Mumps 0 … … … … … 2003 5 - Rubella 0 … … … … … 2003 5 - Congenital rubella syndrome 0 … … … … … 2003 5 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A < 5 … … 0 0 0 2003 1 - Type B < 5 … … 0 0 0 2003 1 - Type C < 5 … … 0 0 0 2003 1 - Unspecified 0 0 0 0 0 0 2003 1 Cholera 0 0 0 0 0 0 2003 1 Typhoid fever < 5 … … 0 0 0 2003 1 Encephalitis 0 0 0 0 0 0 2003 1 Plague 0 0 0 0 0 0 2003 1 Syphilis 3 1 2 0 0 0 2003 1 Gonorrhoea 41 30 11 0 0 0 2003 1 AMERICAN SAMOA 10 INDICATORS DATA Year Source 42 Cases and deaths for selected communicable diseases Total Male Female Total Male Female Number of Cases Number of Deaths Leprosy 2 … … … … … 2003 5 Malaria … … … … … … Dengue/DHF 1185 … … 0 0 0 2002 5 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of Cases Number of Deaths - All types 3 … … … … … 2003 5 - New pulmonary tuberculosis (smear-positive) 2 … … … … … 2003 5 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 54.00 … … 6.00 … … 2003 5 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 24.00 … … 100.00 (2002) … … 2003 5 Number of cases Number of deaths 45 Acute respiratory infections … … … 11 … … 2002 1 46 Diarrhoeal diseases … … … 0 0 0 2002 1 47 Cancers All cancers (malignant neoplasms only) 58 … … 37 … … 2002 1 - Trachea, bronchus, and lung 2 … … 7 … … 2002 1 - Stomach 7 … … 5 … … 2002 1 - Colon and rectum 7 … … 3 … … 2002 1 - Lip, oral cavity and pharynx 4 … … 0 … … 2002 1 - Liver 2 … … 6 … … 2002 1 - Cervix 7 … … 4 … … 2002 1 - Leukaemia 2 … … 2 … … 2002 1 48 Circulatory All circulatory system diseases … … … 88 ... … 2002 1 - Ischaemic heart disease … … … … … … - Acute myocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … 17 … … 2002 1 - Hypertension … … … 9 … … 2002 1 49 Maternal causes - Haemorrhage … … … … - Abortion … … … … - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … COUNTRY HEALTH INFORMATION PROFILE 11 INDICATORS DATA Year Source Total Male Female Total Male Female 50 Diabetes mellitus 2417 1119 1298 29 … … 2002 1 51 Mental disorders 135 … … 0 0 0 2003 1 52 Injuries - All types 1500 … … 26 … … 2002 1 - Motor and other vehicle accidents 101 … … 5 … … 2002 1 - Suicide 35 … … 4 … … 2002 1 - Homicide and violence 130 … … 10 … … 2002 1 - Occupational injuries … … … 1 … … 2002 1 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 128 2003 1 - Specialized hospitals … … - District/first-level referral hospitals … … - Primary health care centres 5 0 2003 1 Private hospitals … … Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate NR Not relevant a GDP is not specifically calculated for American Samoa b The leading indicators of morbidity in American Samoa for communicable infectious or parasitic diseases are: respiratory infectious diseases, filariasis, dengue, hepatitis, Hansen's disease, and intestinal worm infestations. For noncommunicable diseases, the morbidity patterns are: obesity, diabetes and complications (hypertension, heart disease and stroke), chronic disabling conditions (asthma, gout, osteoarthritis and osteoporosis), tobacco-related obstructive pulmonary diseases, cancer and oral health. c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Department of Health 2 Pacific Island Populations 2004. Secretariat of the Pacific Community <www.spc.int> 3 Demographic Tables for the Western Pacific Region 2000-2005. Manila, WHO Regional Office for the Western Pacific 4 World Population 2002. United Nations Population Division, Department of Economic and Social Affairs 5 WHO Regional Office for the Western Pacific, data received from technical units 6 CIA World Factbook <http://www.cia.gov/cia/publications/factbook/> 7 Department of Commerce 12 | COUNTRY HEALTH INFORMATION PROFILES AUSTRALIA 1. Demographics, Gender and Poverty Australia had a population of 20 111 297 in 2004, 77% Australian-born, 2.4% with indigenous status and 23% overseas-born. The average age of the population is 35 years with a life expectancy at birth of 77.8 years for men and 82.8 years for women. It is one of the world’s most urbanized countries, with about 70% of the population living in the 10 largest cities. Most of the population is concentrated along the eastern seaboard and the south-eastern corner of the continent. Table 1. Core population and health data (2004) [Total] 20 111 297 [Both] … [0-14 years] 3 908 951 (19.80%) [Male] 77.8 (2003) Population [65+ years] 2 604 885 (13.00%) Life expectancy at birth (years) [Female] 82.8 (2003) Crude birth rate (per 1000 population) 12.60 (2003) Total fertility rate 1.76 (2003) [Total] 100.00 (2002) [Urban] 100.00 (2002) Crude death rate (per 1000 population) 6.70 (2003) % of population served with safe water [Rural] 100.00 (2002) [Total] 100.00 (2002) [Urban] 100.00 (2002) Infant mortality rate (per 1000 live births) 4.80 (2003) % of population with adequate sanitary facilities [Rural] 100.00 (2002) Maternal mortality rate (per 100 000 live births) 8.20 (1997-1999) 2. Political and Socioeconomic Situation 2.1 Political Situation Australia was created in 1901 when former British colonies (now the six states) agreed to federate. The Government is based on a popularly elected parliament with two chambers, the House of Representatives and the Senate. Ministers appointed from these chambers conduct executive government. Policy decisions are made in meetings of the Cabinet. Ministers are bound by the principle of Cabinet solidarity. Although Australia is an independent nation, Queen Elizabeth II of the United Kingdom of Great Britain and Northern Ireland is also formally Queen of Australia. The Queen appoints a Governor-General (on the advice of the elected Australian Government) to represent her. The Governor-General has wide powers, but by convention acts only on the advice of ministers on virtually all matters. Australia’s system of government is based on the liberal democratic tradition, which includes religious tolerance and freedom of speech and association. Its institutions and practices reflect British and North American models, but are uniquely Australian. Australia has a written constitution that defines the responsibilities of the Federal Government, which include foreign relations and trade, defence and immigration. Governments of states and territories are responsible for all matters not assigned to the Commonwealth. State parliaments are subject to the national constitution as well as their state constitutions. A federal law overrides any state law not consistent with it. A national general election must be held within three years of the first meeting of a new federal parliament. The average life of parliaments is about two-and-a-half years. The Australian COUNTRY HEALTH INFORMATION PROFILES | 13 colonies inherited an electoral tradition from the United Kingdom that included limited franchise and public and plural voting. Abuses, such as bribery and intimidation of voters, stimulated electoral reform. Australia pioneered reforms that underpin the electoral practices of modern democracies. 2.2 Economic Situation Australia has had one of the strongest economies in the world over the past decade: more competitive, open and vibrant than ever before. Australia's high level of economic performance, resting on strong growth, low inflation and low interest rates, has been the result of effective economic management and ongoing structural reform, along with a competitive and dynamic private sector and a skilled, flexible workforce. With its abundant physical resources, Australia has enjoyed a high standard of living since the nineteenth century. It has made a comparatively large investment in social infrastructure, including education, training, health and transport. In recent decades, the shift from manufacturing to services has been rapid, with most new jobs created in the services sector. Service industries are now Australia’s biggest employers. By August 2002, according to the Australian Bureau of Statistics, service industry employees accounted for approximately 74.5% of the total employed workforce in Australia. The new economy is characterized in part by the increasing pace of technological and social change, with innovation leading to higher productivity, and the development of information and knowledge in all industries. Knowledge-based industries now contribute almost half of Australia’s gross domestic product (GDP). Information and communications technology, one of the fastest- growing sectors, is currently the key driver of economic growth. In addition, around 4.3% of GDP in 2000-2001 was generated by Internet-economy revenue. 3. Health Situation 3.1 Health Trends The twentieth century was a period of great social, economic and scientific development in Australia. In health, these developments brought better nutrition and living conditions from the start of the century, widespread immunization and improvements in medical treatment in the second half, and a growing awareness of the effects of lifestyle and socioeconomic factors on health in more recent times. Such advances have resulted in death rates that are now less than one-third of those in 1900, an improvement in life expectancy at birth of over 20 years, and a dramatic decline in perinatal mortality and deaths from infectious diseases. However, there has also been a greater prominence of chronic diseases (e.g. cardiovascular diseases and cancer) and the rise and partial fall of two epidemics, coronary heart disease and lung cancer. Although most Australians enjoy good health today, some groups in the population continue to suffer poor health, in particular Aboriginal and Torres Strait Islander peoples. The 2003 infant mortality rate was 4.8 deaths per 1000 live births, a 4% decrease from the previous year, and a decline from 6.1 in 1993 and 9.6 in 1983. In 2003, 42% of all infant deaths occurred within one day of birth. The current infant and child death rates are low by international standards. Although infant and child deaths form only a small proportion (less than 2%) of all deaths, they nevertheless have important public health policy significance. In the four years from 2000 to 2003, two major groups of causes accounted for 94% of neonatal deaths: conditions originating in the perinatal period (68%), and congenital malformations (26%). Conditions originating in the perinatal period include causes that relate to pregnancy, foetal growth, labour and delivery. Congenital malformations are conditions present at birth that are either hereditary or originating from pregnancy, including deformities and chromosomal abnormalities. Between 1987-1990 and 2000-2003, the neonatal death rate for congenital malformations halved, declining from 1.6 to 0.08 deaths per 1000 live births, partly due to AUSTRALIA 14 | COUNTRY HEALTH INFORMATION PROFILES improved screening methods to detect such conditions (including amniocentesis and ultrasound) and greater awareness of preventative measures during pregnancy. There has also been a dramatic decline in mortality rates for women during childbirth. Maternal death rates remained relatively high until a dramatic decline in 1937, when antibacterial drugs became available. Improved nutrition, better general health, the advent of medical interventions like antiseptic procedures, a decrease in pregnancies (due to contraception and family planning), use of blood transfusions and the professional training of those attending births have all contributed to a sustained decrease in deaths of women following childbirth. In the triennium 1997-1999, the maternal mortality ratio (MMR) was 8.2 deaths per 100 000 confinements. The risk of death was highest for women aged 40-44 years, who had an MMR of 23.2 deaths per 100 000 confinements, and lowest for women aged 20-24 years, who had an MMR of 4.0 deaths. The MMR for Aboriginal and Torres Strait Islander women continues to be higher than the rate for non-indigenous women, with an MMR of 23.5 deaths for 100 000 confinements, compared with 6.7 for non-indigenous women. There is justification for continuing concern about this disparity. In 2003, Australia's fertility rate was 1.76 live births per woman, slightly higher than in 2001 (1.73). Significant increases in life expectancy have occurred throughout the twentieth century, reductions in infant and child mortality being the most significant contributing factors. Life expectancy at birth continued to increase, reflecting the general decrease in death rates. A boy born in 2001-2003 could expect to live 77.8 years, while a girl could expect to live 82.8 years. Since 1983, life expectancy at birth has increased by six years for males and five years for females. In 2001-2003, life expectancy at birth for males and females varied across the regions of Australia by up to 11 years. Indigenous life expectancy at birth was about 20 years less than for the total population, at 59 years for indigenous males and 65 years for indigenous females (1996-2001). There were 132 292 deaths registered in 2003, consisting of 68 330 male and 63 962 female deaths, a decline of 1% on the corresponding figure for 2002 (133 707). There has been a corresponding decrease in the standardized death rate of 22%, from 828.7 deaths per 100 000 population in 1991 to 642.3 deaths per 100 000 population in 2003, which is consistent with continuing improvements in life expectancy. The leading underlying causes of death in 2003 were generally consistent with 2002 data with respect to standardized death rates and relative proportions. However, there have been some changes in these relative proportions since 1991. In 2003, malignant neoplasms (28%) and ischaemic heart diseases (19%) were responsible for 47% of all deaths, while in 1991 these two causes contributed almost equally (26% and 25%) and were responsible for 51% of all deaths. The most serious health issues are related to the increase in chronic diseases associated with lifestyle, with their roots in improper nutrition and lack of physical activity. Significant increases in the prevalence of obesity, in both sexes and at increasingly younger ages, are associated with a number of these conditions. Hypertension, cardiovascular diseases, cerebrovascular diseases, Type II diabetes mellitus and its complications, arthritis, gout and some forms of cancer are among these important chronic diseases. An estimated 13 630 people were living with HIV/AIDS in Australia in 2003. The annual number of new HIV diagnoses, adjusted for multiple reporting, declined from around 930 in 1994 to 690 in 1999, and then increased to around 780 in 2003. The rate of AIDS diagnosis among overseas-born and Australian-born people declined from 3.9 to 1.1 per 100 000 population from 1994-2003. The per capita rate of HIV and AIDS diagnosis among indigenous people was similar to that among non-indigenous people, but a higher proportion of HIV diagnoses in indigenous people were among women (33.7% compared with 10.1%). Transmission of HIV infection in Australia continues to be mainly through sexual contact between men, as reported in more than 85% of cases of newly acquired HIV infections diagnosed in 1999-2003. However, an almost equal proportion of diagnoses among indigenous COUNTRY HEALTH INFORMATION PROFILES | 15 people are attributed to male homosexual contact and heterosexual contact. Survival following AIDS in Australia increased from 16.8 months for cases diagnosed prior to 1995 to 32 months for cases diagnosed in 2000. The Australian Government’s domestic response to HIV/AIDS is guided by the principles and priorities outlined in the fourth National HIV/AIDS Strategy 1999-2000 to 2003-2004. Australia’s achievements in relation to HIV/AIDS have been largely attributed to the cooperative partnership between all levels of government; community organizations; the medical, health care and scientific communities; and people living with or affected by HIV/AIDS. The Government is planning to release the fifth National HIV/AIDS Strategy in the first part of 2005. The new Strategy is expected to consider the changing treatment and care needs of people living with HIV/AIDS, new prevention education approaches, maintenance of quality Australian HIV/AIDS and related research, and a review of Australia’s HIV testing policy. 3.2 Health Systems In 2002-2003, there were 1297 hospitals in Australia, 748 of them public hospitals and 549 private. The number of beds per 1000 population in health care institutions is a useful indicator of the comparative supply of health care services between public and private beds across the states and territories. In 2002-2003, there were 2.64 available hospital beds per 1000 population in public hospitals, and 1.37 available beds per 1000 population in private hospitals, providing a total of 4.01 beds per 1000 population. In 2003, approximately 423 285 people were employed in health occupations, comprising 4% of the total number of employed persons in Australia. The health care workforce grew by an average of 2.6% from 1998, similar to the rate of growth for total employment (2%). Registered nurses and registered midwives increased in number between 1998 and 2003, while the number of enrolled nurses declined, reflecting the structural changes in nursing occupations. More than one-third (38%) of the health workforce are employed on a part-time basis, compared with 27% for the total Australian workforce. In 2001-2002, health expenditure was US$ 33 753 million, an average of US$ 1739 per person. Health expenditure represented an estimated 9.1% of GDP for the same period, approximately double the percentage in 1960-1961 (4.3%). Primary health care is developing and there has been considerable progress in recent years. Decentralization of services is gaining momentum with the construction of new community health centres. Water supply and sanitation systems are well organized and maintained, and safe water is available to the entire population. The proper disposal of solid waste remains a problem. Waste collection systems have improved significantly, but adequate space for solid waste landfill operations is limited. 4. National Health Plan and Priorities In view of the importance, high cost and complexity of maintaining health, it is necessary to coordinate activities, set priorities and monitor the performance of the health system. Performance indicators exist for Aboriginal and Torres Strait Islander health, the seven National Health Priority Areas (asthma, cancer control, cardiovascular health, diabetes mellitus, injury prevention and control, mental health and arthritis and musculoskeletal conditions) and hospital services. The National Public Health Partnership and the new National Health Performance Committee, established by health ministers in 1999, are coordinating the development of frameworks for public health and for monitoring the performance of the overall health system. The type of evidence and information required to support informed priority setting in health depends on the societal goals for health. Improving the overall health of the population is a major goal of all societies. However, priority-setting based on the potential for health gain is not the only goal that Australians might value. Others might be: AUSTRALIA 16 | COUNTRY HEALTH INFORMATION PROFILES • to give priority to those most disadvantaged, so that inequalities in health are reduced; • to attach greater priority to large benefits than to the sum of many small ones, with lifesaving counting the most of all; • to attach greater importance to giving everyone some benefits as opposed to larger benefits for a few; and • to attach less importance to life extension past a normal lifespan, thus attaching greater moral weight to the quality of life. There are a number of issues that are currently influencing decisions on health priorities to some extent and are likely to take on greater significance in coming years. These include: demographic changes, such as population ageing; changes in service delivery models, including a move to greater emphasis on community care; and coordinated care. 5. Major Information Sources Australian Bureau of Statistics (ABS). Australian demographic statistics, June Quarter 2004 (Cat. No. 3101.0). ABS. Australian social trends 2004 (Cat. No. 4102.0). ABS. Births Australia 2003 (Cat. No. 3301.0). ABS. Causes of death, Australia 2003 (Cat. No. 3303.0). ABS. Deaths Australia 2003 (Cat. No. 3302.0.) ABS. Labour force survey, Nov 2004 (Cat. No. 6291.0.55.001). ABS. Motor vehicle census, Australia, 2003 (Cat. No. 9309.0). ABS. National health survey Australia 2001 (Cat. No. 4364.0). ABS. National income, expenditure and product, June quarter 2004 (Cat. No. 5206.0). ABS. National nutrition survey: nutrient intakes and physical measurements, Australia, 1995 (Cat. No. 4805.0). ABS. Year Book Australia 2004 (Cat. No. 1301.0). Australian Institute of Health and Welfare (AIHW). Australia’s health 2004. AIHW. Australian hospital statistics 2002-03. AIHW. The burden of disease and injury in Australia. AIHW National Perinatal Statistics Unit. Australia's Mothers and Babies 2001. AIHW and Australian Association of Cancer Registries (AACR). Cancer in Australia 2001. Australian Government Department of Health and Ageing. Communicable diseases intelligence, 27(4), Dec 2003. Australian Government Department of Health and Ageing. Communicable diseases intelligence, 28(1), March 2004. Australian Government Department of Health and Ageing. Communicable diseases intelligence, 28(3), September 2004. Organisation for Economic Co-operation and Development (OECD). Education at a glance 2004. Paris, OECD, 2004. OECD health data 2004: a comparative analysis of 30 countries (CD-ROM). Paris, OECD, 2004. Pregnancy Outcome Unit, Department of Human Services. Pregnancy outcome in South Australia 2001. Private Health Insurance Administration Council. Statistical trends, June 2004. Slaytor EK, Sullivan EA, King JF. Maternal deaths in Australia 1997-1999. Sydney, AIHW National Perinatal Statistics Unit, 2004 (AIHW Cat. No. PER 24). COUNTRY HEALTH INFORMATION PROFILES | 17 United Nations Development Programme (UNDP). Human development report 2004. New York, UNDP, 2004. United Nations. Millenium indicators database. World Health Organization. The world health report 2004. Geneva, WHO, 2004. 6. Addresses AUSTRALIAN DEPARTMENT OF HEALTH AND AGEING Office Address : Postal Address : The Secretary Australian Department of Health and Ageing Attention: Assistant Secretary Policy and International Branch G.P.O. Box 9848, MDP 84 Canberra, A.C.T. 2601 Australia Official Email Address : Telephone : Fax : (612) 6289 7087 Office Hours : Website : AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE Office Address : Australian Institute of Health and Welfare 6A Traeger Court, Fern Hill Park Bruce ACT 2617 Australia Postal Address : The Director Australian Institute of Health and Welfare GPO Box 570 Canberra ACT 2601 Australia Official Email Address : Telephone : (612) 6244 1000 Fax : (612) 6244 1299 Office Hours : Mon-Fri 0830-1700 Website : www.aihw.gov.au WHO REPRESENTATIVE There is no WHO Representative in Australia. Queries about WHO’s programme of collaboration with Australia should be directed to Director, Programme Management, WHO Regional Office for the Western Pacific. Office Address : Postal Address : Director, Programme Management World Health Organization Regional Office for the Western Pacific United Nations Avenue P.O. Box 2932, 1000 Manila, the Philippines Official Email Address : Telephone : Fax : Office Hours : AUSTRALIA 18 | COUNTRY HEALTH INFORMATION PROFILES Organization Chart: Department of Health and Ageing COUNTRY HEALTH INFORMATION PROFILE 19 AUSTRALIA WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 7692.02 2004 1 2 Estimated population ('000s) - Total 20 111.30 9994.50 10 116.80 June 2004 2 3 Annual population growth rate (%) 1.20 … … 2003-2004 2 4 Percentage of population - 0–14 years 19.80 20.40 19.20 June 2004 2 - 65+ years 13.00 11.70 14.20 June 2004 2 5 Urban population (%) 86.50 … … 2001 1 6 Crude birth rate (per 1000 population) 12.60 13.10 13.20 2003 3 7 Crude death rate (per 1000 population) 6.70 6.90 6.40 2003 4 8 Rate of natural increase of population (% per annum) 0.60 … … 2003-2004 2 9 Health-adjusted life expectancy (HALE) (years) - at birth … 77.80 82.80 2001-2003 2 - at age 60 … 16.90 19.50 2002 5 10 Adult literacy rate (%) 87.60 … … 2000 6 11 Neonatal mortality rate (per 1000 live births) 3.30 3.60 3.00 2003 4 12 Infant mortality rate (per 1000 live births) 4.80 5.20 4.30 2003 4 13 Under-five mortality rate (per 1,000 live births) 5.80 6.40 5.30 2003 4 14 Total fertility rate (women aged 15–49 years) 1.76 2003 3 15 Maternal mortality ratio (per 100 000 live births) 8.20 1997-1999 7 16 Percentage of newborn infants weighing at least 2500 g at birth 93.80 94.20 93.20 2001 8 17 Prevalence of underweight children under five years of age <0.50 … … 1995 28 18 Percentage of pregnant women with anaemia c 8.00 2002 9 19 Immunization coverage for infants (%) - BCG NR … … 2004 30 - DPT3 92.60 … … 2004 30 - OPV3 92.50 … … 2004 30 - Measles 93.60 … … 2004 30 - Tetanus II NR … … 2004 30 - Hepatitis B III 95.00 … … 2004 30 20 MCH coverage (pregnancies and deliveries) - Percentage of pregnant women cared for by trained health personnel 99.00 2001 29 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) 0.30 2001 8 - Percentage of deliveries in health facilities (as % of total deliveries) 99.30 2001 8 21 Percentage of women in the reproductive age group using modern contraceptive methods 65.00 2001 11 22 Condom use rate of the contraceptive prevalence rate 36.00 … … 2001 11 23 HIV prevalence among 15–24 year-old pregnant women … … 0.01 2004 est 12 24 Number of children orphaned by HIV/AIDS … … … AUSTRALIA 20 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 100.00 100.00 b 2002 13 26 Proportion of population with access to improved sanitation 100.00 100.00 100.00 b 2002 13 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) < 5.00 … … 2003 30 28 Proportion of households with access to secure tenure 99.50 d … … 2001 27 29 Proportion of vehicles using unleaded gasoline (%) 17.00 … … 2003 14 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.95 … … 2002 15 32 Per capita GDP at current market prices (US$) 27 927.00 2003-04 16 33 Rate of growth per capita GDP 7.2 2003-04 16 34 Health expenditure Total health expenditure - amount (in million US$) 33 753 2001-02 17 - total health expenditure on health as % of GDP 9.10 2001-02 17 - per capita total expenditure on health (in US$) 1739.00 2001-02 17 Government expenditure on health - amount (in million US$) 23 021 2001-02 17 - general government expenditure on health as % of total expenditure on health 68.20 2001-02 17 - general government expenditure on health as % of total general government expenditure 16.70 2001-02 17 External source of government health expenditure - external resources for health as % of general government expenditure on health NR Private health expenditure - private expenditure on health as % of total expenditure on health 31.80 2001-02 17 Exchange rate in US$ of local currency is: 1 US$ = … 35 Health insurance expenditure - health insurance coverage as % of total population 42.90 June 2004 18 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 54 800 36 500 18 300 27.20 36.50 18.10 Nov 2004 19 - dentists 9 400 6700 2700 4.70 6.70 2.70 Nov 2004 19 - pharmacists 18 600 6100 12 500 9.20 6.10 12.40 Nov 2004 19 - nurses 159 600 12 600 147 000 79.40 12.60 145.30 Nov 2004 19 - midwives 14 500 0 14 500 7.20 0.00 14.30 Nov 2004 19 - other nursing/ auxiliary staff 21 900 4100 17 800 10.90 4.10 17.60 Nov 2004 19 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 52 400 16 400 36 000 26.10 16.40 35.60 Nov 2004 19 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 11 400 2700 8700 5.70 2.70 8.60 Nov 2004 19 37 Yearly new graduates - physicians 2058 984 1074 2001 20 38 Yearly new graduates - nurses 8216 854 7362 2001 20 COUNTRY HEALTH INFORMATION PROFILE 21 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Upper respiratory tract infections (e.g. colds, acute sinusitis, tonsillitis, etc.) 43 399 250 20 794 610 22 604 640 237 012 228 310 245 632 1996 21 2. Dental caries 10 877 803 5 432 328 5 445 475 59 406 59 643 59 173 1996 21 3. Chronic back pain 6 035 367 3 141 141 2 894 226 32 960 34 488 31 450 1996 21 4. Diarrhoeal diseases 3 754 216 1 863 370 1 890 846 19 977 19 429 20 547 1996 21 5. Other musculoskeletal disorders 2 999 896 1 500 549 1 499 347 16 383 16 475 16 293 1996 21 6. Lower respiratory tract infections (e.g. bronchitis) 2 112 244 1 002 484 1 109 760 11 535 11 007 12 059 1996 21 7. Otitis media 1 025 664 481 852 543 812 5601 5290 5909 1996 21 8. Other unintentional injuries 901 839 454 309 447 530 4925 4988 4863 1996 21 9. Periodontal disease 399 688 195 310 204 378 2183 2144 2221 1996 21 10. Depression 362 683 106 687 255 996 1981 1171 2782 1996 21 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Malignant neoplasms 37 558 21 081 16 477 188.99 213.51 164.78 2003 22 2. Ischaemic heart disease 25 439 13 534 11 905 128.01 137.07 119.06 2003 22 3. Cerebrovascular disease (stroke) 12 240 4835 7405 61.59 48.97 74.06 2003 22 4. Chronic lower respiratory diseases (inc asthma, emphysema, bronchitis) 5985 3373 2612 30.12 34.16 26.12 2003 22 5. Accidents 4865 3100 1765 24.48 31.40 17.65 2003 22 6. Influenza and pneumonia 3566 1558 2008 17.94 15.78 20.08 2003 22 7. Diabetes mellitus 3389 1807 1582 17.05 18.30 15.82 2003 22 8. Organic (inc symptomatic) mental disorders 2696 889 1807 13.57 9.00 18.07 2003 22 9. Disease of arteries (inc atherosclerosis and aortic aneurism) 2542 1335 1207 12.79 13.52 12.07 2003 22 10. Heart failure 2432 969 1463 12.24 9.81 14.63 2003 22 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths C:2004, D:2003 C: 30 D: 22 - Diphtheria 0 0 0 0 0 0 - Pertussis (whooping cough) 8676 … … 0 0 0 - Tetanus 5 … … 0 0 0 - Neonatal tetanus 0 0 0 0 0 0 - Poliomyelitis 0 0 0 0 0 0 - Hib meningitis 22 … … 0 0 0 2003 C: 30 D: 22 - Measles 70 … … 0 0 0 - Mumps 106 … … 0 0 0 - Rubella 44 … … 0 0 0 - Congenital rubella syndrome 1 … … 0 0 0 AUSTRALIA 22 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A 315 … … 6 … … C: 2004 D: 2003 C: 23 D: 30 - Type B 6814 … … 4 … … C: 2004 D: 2003 C: 23 D: 30 - Type C 15 145 … … 0 0 0 C: 2004 D: 2003 C: 23 D: 30 - Unspecified 20 … … 3 1 2 C:2002, D:2003 C: 23 D: 22 Cholera 6 … … 0 0 0 C: 2004 D: 2003 C: 23 D: 30 Typhoid fever 74 … … 0 0 0 C: 2004 D: 2003 C: 23 D: 30 Encephalitis 3 … … 28 16 12 C: 2004 D: 2003 C: 23 D: 30 Plague 0 0 0 0 0 0 C: 2004 D: 2003 C: 23 D: 30 Syphilis 1627 … … 5 2 3 C:2002, D:2003 C: 23 D: 22 Gonorrhoea 6247 … … 0 0 0 C:2002, D:2003 C: 23 D: 22 Leprosy 4 … … 0 0 0 2003 C: 30 D: 22 Malaria 466 … … 3 2 1 C:2002, D:2003 C: 23 D: 22 Dengue/DHF 219 … … 0 0 0 C:2002, D:2003 C: 23 D: 22 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 2.40 … … 0.02 0.02 0.01 C:2002, D:2003 22, 23 - Proportion of population in malaria-risk areas using effective malaria prevention measures e … - Proportion of population in malaria-risk areas using effective malaria treatment measures f … 44 Tuberculosis Number of cases Number of deaths - All types 949 … … 45 24 21 2003 C: 30 D: 22 - New pulmonary tuberculosis (smear-positive) 113 … … 39 22 17 2003 C: 24 D: 22 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 6.00 … … 0.23 0.24 0.21 2003 C: 30 D: 22 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 9.00 … … 78.00 (2002) … … 2003 30 Number of cases Number of deaths 45 Acute respiratory infections 47 897 963 22 862 129 25 035 834 3675 1605 2070 C: 1996 D: 2003 C: 21 D: 22 46 Diarrhoeal diseases 3 754 216 1 863 370 1 890 846 153 60 93 C: 1996 D: 2003 C: 21 D: 22 COUNTRY HEALTH INFORMATION PROFILE 23 INDICATORS DATA Year Source Total Male Female Total Male Female 47 Cancers All cancers (malignant neoplasms only) 88 398 47 820 40 578 37 558 21 081 16 477 C: 2001 D: 2003 C: 25 D: 22 - Trachea, bronchus, and lung 8275 5384 2891 6976 4510 2466 - Stomach 1902 1202 700 1180 703 477 - Colon and rectum 12 619 6859 5760 4391 2391 2000 - Lip, oral cavity and pharynx 2686 1878 808 693 473 220 - Liver 853 617 236 904 615 289 - Cervix 735 NR 735 238 NR 238 - Leukaemia 2516 1465 1051 1404 808 596 48 Circulatory g All circulatory system diseases … … … 48 835 23 399 25 436 C:1996, D:2003 C: 21 D: 22 - Ischaemic heart disease 74 014 46 143 27 871 25 439 13 534 11 905 - Acute myocardial infarction 35 566 21 618 13 948 13 449 6938 6511 - Rheumatic fever and rheumatic heart diseases 887 319 568 287 97 190 - Cerebrovascular diseases 57 244 26 488 30 756 12 240 4835 7405 - Hypertension 2259 762 1497 1364 485 879 49 Maternal causes - Haemorrhage … … 1 1 2003 22 - Abortion … … 0 0 2003 22 - Eclampsia … … 1 1 2003 22 - Sepsis … … 0 0 2003 22 - Obstructed labour … … 0 0 2003 22 50 Diabetes mellitus 554 200 271 500 282,700 3389 1807 1582 C: 1996 D: 2003 C: 21 D: 22 51 Mental disorders g 2 383 100 1 151 600 1 231 500 3241 1243 1998 C: 1996 D: 2003 C: 21 D: 22 52 Injuries g - All types … … … 7749 5273 2476 C:1996, D:2003 C: 21 D: 22 - Motor and other vehicle accidents 116 225 77 524 38 701 1811 1336 475 - Suicide 28 151 12 056 16 095 2213 1736 477 - Homicide and violence 47 596 36 351 11 245 278 196 82 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 729 49 841 2002- 2003 26 - Specialized hospitals 19 2358 2002- 2003 26 - District/first-level referral hospitals … … - Primary health care centres … … Private hospitals 549 27 112 2002- 2003 26 AUSTRALIA 24 Notes: Red text Millennium Development Goals indicators … Data not available NR Not relevant. est. Estimate C Cases D Deaths a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b A relatively small number of indigenous people, particularly in remote areas, do not always have access to water which passes quality testing or access to adequate sewerage systems. c South Australia only d Persons without secure tenure include those sleeping rough (primary homeless), in stop-gap housing (secondary homeless) and boarding house residents (tertiary homeless) e Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. f Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. g Revised data Sources: 1 Year Book Australia 2004. Australian Bureau of Statistics (ABS), (Cat. No. 1301.0) 2 Australian Demographic Statistics, June Quarter 2004. ABS (Cat. No. 3101.0) 3 Births Australia 2003. ABS (Cat. No. 3301.0) [Number of live births registered in calendar year per 1000 population] 4 Deaths Australia 2003. ABS (Cat. No. 3302.0) [Number of deaths registered in calendar year per 1000 population] 5 The World Health Report 2000. Geneva, World Health Organization, 2000 6 Education At A Glance 2000. Organisation for Economic Co-operation and Development (OECD), [literacy defined as Levels 2-5 using OECD PISA (Programme for International Student Assessment) standards] 7 Slaytor EK, Sullivan EA & King JF. Maternal deaths in Australia 1997-1999. AUSTRALIAN Institute of Health and Welfare (AIHW) Cat. No. PER 24. Sydney: AIHW National Perinatal Statistics Unit, 2004. [Direct and indirect maternal deaths per 100 000 live births over the triennium 1997-1999] 8 Australia's Mothers and Babies 2001. AIHW National Perinatal Statistics Unit 9 Pregnancy Outcome in South Australia 2001. Pregnancy Outcome Unit, Department of Human Services 10 Communicable Diseases Intelligence 28(3), September 2004. Australian Government Department of Health and Ageing [Measles as at age 2] 11 National Health Survey Australia 2001. ABS (Cat. No. 4364.0, and unpublished). Percentage of women aged 18–49 (or their partners) reporting using contraceptive methods (including hysterectomy, tubal ligation and partner vasectomy) 12 National Centre in HIV Epidemiology and Clinical Research, personal communication 13 United Nations Millenium Indicators Database 14 Motor vehicle census, Australia, 2003. ABS (Cat. No. 9309.0) 15 Human Development Report 2004. UNDP 16 National Income, Expenditure and Product, June quarter 2004. ABS (Cat. No. 5206.0) 17 OECD Health Data 2004: a comparative analysis of 30 countries (CD-ROM). Paris, OECD. 18 Statistical Trends, June 2004. Private Health Insurance Administration Council 19 Labour force survey, Nov 2004. ABS (Cat. No. 6291.0.55.001) 20 Australia’s Health 2004. AIHW 21 The burden of disease and injury in Australia, (and unpublished), AIHW 22 Causes of Death, Australia 2003 . ABS(Cat. No. 3303.0) [Rate of deaths (in calendar year) per 100,000 population (at 30 June)] 23 Communicable Diseases Intelligence 28(1), March 2004. Australian Government Department of Health and Ageing 24 Communicable Diseases Intelligence 27(4), Dec 2003. Australian Government Department of Health and Ageing 25 Cancer in Australia 2001. AIHW & Australian Association of Cancer Registries (AACR), 26 Australian hospital statistics 2002-03. AIHW 27 Australian social trends 2004. ABS(Cat. No. 4102.0) 28 National Nutrition Survey: Nutrient intakes and physical measurements, Australia, 1995. ABS (Cat. No. 4805.0) [Ages 2-3] 29 Reproductive Health Indicators, Australia 2002. AIHW 30 WHO Regional Office for the Western Pacific, data received from technical units COUNTRY HEALTH INFORMATION PROFILES | 25 BRUNEI DARUSSALAM 1. DEMOGRAPHICS, GENDER AND POVERTY In 2004, Brunei Darussalam had an estimated population of 357 800, with around 33% below 15 years of age and around 2.2% above 65 years of age. Population growth was 2.35% over the previous year. The total fertility rate dropped to 2.10 in 2003 from 2.40 in 1999. Table 1. Core population and health data (2004 provisional) [Total] 357 800 [Both] … [0-14 years] 119 791 (33.48%) [Male] 74.4 (2003p) Population [65+ years] 8015 (2.24%) Life expectancy at birth (years) [Female] 77.4 (2003p) Crude birth rate (per 1000 population) 20.20 (2003) Total fertility rate 2.10 (2003p) [Total] 99.00 [Urban] … Crude death rate (per 1000 population) 2.90 (2003p) % of population served with safe water [Rural] … [Total] 80.00 (2002) [Urban] … Infant mortality rate (per 1000 live births) 9.50 (2003) % of population with adequate sanitary facilities [Rural] … Maternal mortality rate (per 100 000 live births) 28.40 (2003) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Brunei Darussalam is a constitutional sultanate. It achieved independence from the United Kingdom of Great Britain and Northern Ireland on 1 January 1984, and independence from British protection on 23 February 1984 (National Day). The constitution was established on 29 September 1959, with some provisions suspended under a State of Emergency since December 1962, others since independence on 1 January 1984. The legal system is based on English common law; for Muslims, Islamic Shari'a law supersedes civil law in a number of areas. The chief of state and head of government is His Majesty the Sultan and Yang Dipertuan Hassanal Bolkiah (since 5 October 1967). The Council of Cabinet Ministers is appointed and presided over by His Majesty and handles executive matters. The Religious Council (members appointed by His Majesty) advises on religious matters, the unicameral Legislative Council or Majlis Masyarat Megeri (members appointed by His Majesty) handles constitutional matters (legislative branch), and the Council of Succession (members appointed by His Majesty) determines the succession to the throne if the need arises. The monarchy is hereditary. For the judicial branch, His Majesty swears in a Supreme Court (chief justice and judges) for three-year terms. 2.2 Economic situation Following the announcement by the Ministry of Finance that the Government's financial year would now run from 1 April to 31 March each year, the Council of Cabinet Ministers, with the consent of His Majesty the Sultan and Yang Dipertuan of Brunei Darussalam, approved a budget BRUNEI DARUSSALAM 26 | COUNTRY HEALTH INFORMATION PROFILES totalling US$ 4 990 322 402 for the financial year from 1 April 2004 to 31 March 2005. The allocation to Public Utilities and Health amounted to US$ 208 108 000. Human resources development (HRD) is one of the crucial elements in the implementation of the economy's five-year national development plan. As such, a sum of US$ 250 million or 3.4% of the Eighth National Development Plan's total allocation has been allocated to the HRD Fund (HRDF). Its main objective is to facilitate training, retraining and other HRD-related programmes and projects aimed at better career development of the economy's human resources. Among other things, the HRDF includes special schemes for undergraduate, post-graduate and specialized studies, and pre- and post-employment for local job seekers, as well as pre-retirement programmes. This small, wealthy economy encompasses a mixture of foreign and domestic entrepreneurship, government regulation, welfare measures, and village tradition. Crude oil and natural gas production account for nearly half the GDP. Per capita GDP is far above most other developing countries (estimated at US$ 15 241 in 2004), and substantial income from overseas investment supplements income from domestic production. The Government provides for all medical services and subsidizes rice and housing. Brunei Darussalam served as chairman for the 2000 APEC (Asian Pacific Economic Cooperation) forum. Plans for the future include upgrading the labour force, reducing unemployment, strengthening the banking and tourist sectors, and further widening the economic base beyond oil and gas. 3. HEALTH SITUATION 3.1 Health trends The main diseases affecting health status (morbidity) are derived from hospital discharge summaries, outpatient morbidity and notifiable disease returns. The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD10) has been used since 1 January 1998 to code inpatient morbidity data. The leading causes of morbidity in 2003 were: abortions; acute lower respiratory infections; acute upper respiratory infections; asthma; and heart disease. In the same year, the leading causes of mortality were: heart disease; cancer; cerebrovascular disease; diabetes mellitus; and bronchitis, chronic and unspecified emphysema and asthma. 3.2 Health systems The people of Brunei Darussalam enjoy free medical and health care, which is provided via the government hospitals, health centres and health clinics throughout the country. In remote areas that are not accessible or are difficult to access by land or water, primary health care is provided by the Flying Medical Services. In addition to government hospitals in each district, there are also two private hospitals and five medical centres operated by the Ministry of Defence. The main referral hospital in the country is Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital, which is situated on a 32-acre site about 0.8 km from the heart of the capital. The hospital was officially opened on 28 August 1984 at a cost of B$ 162 million (US$ 97.63 million). It is equipped with modern, cutting-edge medical technology. However, patients who require very specialized treatment are sent abroad. All medical expenses incurred by citizens of Brunei Darussalam are borne by the Government. Public Health Services is the main division in the Ministry of Health responsible for providing community-based preventive and promotive primary health care services in the country. As a result of its monitoring and surveillance activities and preventive programmes, such as its immunization programme, the country is free from major communicable diseases. The decentralization programme, started in 2000, was a concerted and ongoing effort by the Ministry COUNTRY HEALTH INFORMATION PROFILES | 27 to provide access to primary health care for the general population throughout the country. Until 2003, a total of 15 primary health care centres operated in all four districts. The Ministry of Health has now categorized the respective health care services available in Brunei Darussalam into two main health services. The Directorate of Medical Services is responsible for hospital, nursing, laboratory, pharmaceutical and dental services, while the Directorate of Health Services oversees community health, environmental health and scientific services. 4. NATIONAL HEALTH PLAN AND PRIORITIES The Government is fully committed to continuously improving the health status of the people and considers government funding for health care as a major public investment in human development. It is the aspiration of the Government that the Ministry of Health’s agenda for the 21st century be health improvement for people-centred development. In this regard, health policies and programmes will be constantly reviewed in the context of changing economic, social and technological environments and health situations. In looking ahead to the future, the following four principles will be observed in the provision of health services for all citizens: • ensuring universal access to better health care; • enabling equity of access to comprehensive health services; • promoting partnerships and public participation in the concept of coproduction of efficient and effective health services for all; and • ensuring that the health service system is sustainable within the institutional capacity and financial resources of the Ministry of Health. The Government recognizes that it needs to continue its broad involvement in the provision of health care and, wherever possible, policy decision-making and proposed programmes will be strongly evidence-based. In this respect, the Ministry of Health intends to pursue the following set of goals or ‘policy objectives’, derived from a careful analysis of the strategic issues and themes. To facilitate understanding of these goals and their implementations, they are classified into two categories, strategic goals and instrumental goals, based on their logical relationships. The achievement of the strategic goals depends to a large extent on the prior achievement of the instrumental goals. Hence, an understanding of the relationship between these goals will provide a useful and pragmatic framework for future strategic actions. Strategic goals: • to promote primary health care; • to focus on the management of priority chronic diseases; • to pursue high quality in health care; • to achieve a more equitable allocation of funds for diverse health services and to venture into alternative sources of health care financing; and • to promote selected areas of excellence in health services. Instrumental goals: • to develop comprehensive health databases and information management systems which support operational, professional and managerial functions; • to improve the quality of policy-making and management decisions at higher levels of the organization so that the Ministry becomes an effective enterprise and its administrators effective managers; • to create and promote a disciplined workforce with positive work attitudes, through teamwork, a sense of belonging and responsibility, to achieve the organizational mission, goals and objectives; • to improve competency and standards among all health care professionals; BRUNEI DARUSSALAM 28 | COUNTRY HEALTH INFORMATION PROFILES • to enhance cost-effectiveness in the delivery of all aspects of health services; and • to improve the management of support services in order to contribute to the overall quality of health services. 5. MAJOR INFORMATION SOURCES Department of Economic Planning and Development (DEPD), Prime Minister’s Office Statistics Unit, Research and Development Section, Ministry of Health Ledger Section – Expenditure, Ministry of Finance Budget and Tender Section – Budget, Ministry of Finance 2001 Preliminary Census Report. DEPD, Prime Minister’s Office SEAMIC Health Statistics 2002. Southeast Asian Medical Information Center, International Medical Foundation of Japan. 6. ADDRESSES MINISTRY OF HEALTH Office Address : Jalan Menteri Besar Bandar Seri Begawan BB3910 Negara Brunei Darussalam Postal Address : Official Email Address : Telephone : (673) 238 1640 Fax : (673) 238 1440, 2380128 Office Hours : Website : http://www.moh.gov.bn WHO REPRESENTATIVE IN MALAYSIA, BRUNEI DARUSSALAM AND SINGAPORE Office Address : 1st Floor, Wisma UN, Block C, Komplek Pejabat Damansara, Jalan Dungun, Damansara Heights 50490 Kuala Lumpur, Malaysia Postal Address : PO Box 12550 50782 Kuala Lumpur Malaysia Official Email Address : who@maa.wpro.who.int Telephone : (603) 209 39908 / 209 21184 Fax : (603) 209 37446 Office Hours : COUNTRY HEALTH INFORMATION PROFILES | 29 ORGANIZATIONAL CHART: MINISTRY OF HEALTH MINISTER OF HEALTH PERMANENT SECRETARY POLICY & PLANNING ADMINISTRATION & FINANCE HEALTH CARE TECHNOLOGY SERVICES Scientif ic Services MEDICAL SERVICES HEALTH SERVICES Human Resource Development Risk Management Public Relations International Affairs Research & Development Human Resource Management Procurement, Supply & Tender Building Engineering Services & Transport Project Development Biomedical Engineering Health Informatics Hospital Services Nursing Services Laboratory Services Pharmaceutical Services Community Health Services Environmental Health Services Dental Services Quality Improvement Biomedical Sciences Research and Training Finance and Wages BRUNEI DARUSSALAM 30 BRUNEI DARUSSALAM WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 5.77 2004 1 2 Estimated population ('000s) 357.80 186.20 171.60 2004p 1 3 Annual population growth rate (%) 2.35 … … 2004p 1 4 Percentage of population - 0–14 years 33.48 33.56 33.39 2004p 1 - 65+ years 2.24 2.15 2.33 2004p 1 5 Urban population (%) 76.20 … … 2003 5 6 Crude birth rate (per 1000 population) 20.20 … … 2003 2 7 Crude death rate (per 1000 population) 2.90 … … 2003p 2 8 Rate of natural increase of population (% per annum) 1.73 … … 2003p 1 9 Health-adjusted life expectancy (HALE) (years) - at birth … 74.40 77.40 2003p 1 - at age 60 … 13.10 13.30 2002 6 10 Adult literacy rate (% ages 15 and above) 93.90 96.30 91.40 2002 7 11 Neonatal mortality rate (per 1000 live births) 7.20 … … 2003 2 12 Infant mortality rate (per 1000 live births) 9.50 … … 2003 2 13 Under-five mortality rate (per 1000 live births) 11.80 … … 2003 2 14 Total fertility rate (women aged 15–49 years) 2.10 2003p 1 15 Maternal mortality ratio (per 100 000 live births) 28.40 2003 2 16 Percentage of newborn infants weighing at least 2500 g at birth 93.00 … … 2003 2 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 99.40 … … 2004 9 - DTP3 91.70 … … 2004 9 - OPV3 92.20 … … 2004 9 - Measles 100.00 … … 2004 9 - Tetanus II 47.40 … … 2004 9 - Hepatitis B III 100.00 … … 2004 9 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 99.00 2003 2 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 21.00 2004 2 - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) 99.45 2003 2 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … COUNTRY HEALTH INFORMATION PROFILE 31 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 99.00 … … 2004 1 26 Proportion of population with access to improved sanitation 80.00 … … 2002 2 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.87 … … 2002 7 32 Per capita GDP at current market prices (US$) 15 240.85 … … 2004p 1 33 Rate of growth per capita GDP 1.70 … … 2004p 1 34 Health expenditure Total health expenditure (National medical care expenditure) - amount (in million BS$) 290.15 2003 3 - total health expenditure (MOH) on health as % of GDP 2.66 2003 3 - per capita total expenditure on health (in US$) 475.00 2003 3 Government expenditure on health - amount (in million BS$) 233.32 2004 4 - general government expenditure on health (MOH) as % of total expenditure on health … - general government expenditure on health (MOH) as % of total general government expenditure … External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = … 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 309 224 85 8.84 12.27 5.09 2003 2 - dentists 64 37 27 1.83 2.03 1.62 2003 2 - pharmacists 34 10 24 0.97 0.55 1.44 2003 2 - nurses (and assistant nurses) 1678 232 1446 48.00 12.71 86.54 2003 2 - midwives 685 0 685 19.59 0.00 40.99 2003 2 - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 195 85 110 5.58 4.66 6.58 2003 2 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 181 119 62 5.18 6.52 3.71 2003 2 37 Yearly new graduates - physicians 20 6 14 2003 2 38 Yearly new graduates - nurses 130 19 111 2003 2 BRUNEI DARUSSALAM 32 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Pregnancy with abortive outcome 969 NR 969 277.20 NR 579.90 2003 2 2. Acute upper respiratory infection 803 470 333 229.70 257.50 199.30 2003 2 3. Asthma 787 411 376 225.10 225.20 225.00 2003 2 4. Fractures of specified and multiple body regions 738 532 206 211.10 291.50 123.30 2003 2 5. Heart diseases 729 436 293 208.50 238.90 175.30 2003 2 6. Non-inflammatory disorders of female genital tract 694 NR 694 198.50 NR 415.30 2003 2 7. Maternal diseases classifiable but complicating pregnancy, childbirth and the puerperium (indirect obstetric causes) 690 NR 690 197.40 NR 412.90 2003 2 8. Acute lower respiratory infections 679 387 292 194.20 212.10 174.70 2003 2 9. Iron deficiency anaemia 645 300 345 184.50 164.40 206.50 2003 2 10. Diarrhoea and gastroenteritis of presumed infectious origin 630 340 290 180.20 186.30 173.50 2003 2 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Heart diseases (inc A.Rheumatic F) 213 115 98 60.90 63.00 58.60 2003 2 2. Cancer 156 87 69 44.60 47.70 41.30 2003 2 3. Diabetes mellitus 82 47 35 23.50 25.80 20.90 2003 2 4. Cerebrovascular diseases 77 39 38 22.00 21.40 22.70 2003 2 5. Bronchitis, chronic & unspecified emphysema and asthma 68 38 30 19.50 20.80 18.00 2003 2 6. Influenza and Pneumonia 59 39 20 16.90 21.40 12.00 2003 2 7. Hypertensive diseases 38 20 18 10.90 11.00 10.80 2003 2 8. Certain conditions originating in the perinatal period 36 20 16 10.30 11.00 9.60 2003 2 9. Transport accidents 26 19 7 7.40 10.40 4.20 2003 2 10. Congenital malformations, deformations and chromosomal abnormalities 25 10 15 7.20 5.50 9.00 2003 2 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2004 9 - Pertussis (whooping cough) 0 0 0 … … … 2004 9 - Tetanus 1 … … … 2004 9 - Neonatal tetanus 0 0 0 … … … 2004 9 - Poliomyelitis 0 0 0 … … … 2004 9 - Hib meningitis 0 0 0 … … … 2004 9 - Measles 16 … … … 2004 9 - Mumps 21 … … … 2004 9 - Rubella 0 0 0 … … … 2004 9 - Congenital rubella syndrome 0 0 0 … … … 2004 9 COUNTRY HEALTH INFORMATION PROFILE 33 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral 10 … … 0 0 0 2004 9 - Type A 9 … … 0 0 0 2004 9 - Type B 1 … … 0 0 0 2004 9 - Type C 0 0 0 0 0 0 2004 9 - Unspecified … … … … … … Cholera 0 0 0 0 0 0 2004 9 Typhoid fever (including paratyphoid fever) 4 … … 0 0 0 2004 9 Encephalitis 0 0 0 0 0 0 2004 9 Plague 0 0 0 0 0 0 2004 9 Syphilis 7 2 5 … … … 2003 8 Gonorrhoea 74 72 2 … … … 2003 8 Leprosy 2 … … … … … 2003 9 Malaria 17 12 5 … … … 2003 8 Dengue/DHF 160 84 76 0 0 0 2003 8 43 Malaria Prevalence rates a Death rates - Rates associated with malaria (per 100 000 population) 4.86 6.58 2.99 … … … 2003 8 - Proportion of population in malaria-risk areas using effective malaria prevention measures b … - Proportion of population in malaria-risk areas using effective malaria treatment measures c … 44 Tuberculosis Number of cases Number of deaths - All types 206 … … … … … 2003 9 - New pulmonary tuberculosis (smear-positive) 121 … … … … … 2003 9 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 61.00 … … 5.00 … … 2003 9 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 138.00 … … 84.00 (2002) … … 2003 9 Number of cases Number of deaths 45 Acute respiratory infections 1482 857 625 133 79 54 2003 2 46 Diarrhoeal diseases 1000 503 497 0 0 0 2003 9 47 Cancers All cancers (malignant neoplasms only) 232 112 120 156 87 69 2003 2 - Trachea, bronchus, and lung 34 19 15 26 17 9 2003 2 - Stomach 7 5 2 9 6 3 2003 2 - Colon and rectum 27 16 11 16 11 5 2003 2 - Lip, oral cavity and pharynx 17 11 6 9 5 4 2003 2 - Liver 10 8 2 13 8 5 2003 2 - Cervix 15 0 15 3 0 3 2003 2 - Leukaemia 8 3 5 5 3 2 2003 2 BRUNEI DARUSSALAM 34 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 48 Circulatory All circulatory system diseases 1540 877 663 334 175 159 2003 2 - Ischaemic heart disease 341 230 111 107 63 44 2003 2 - Acute myocardial infarction 85 58 27 52 28 24 2003 2 - Rheumatic fever and rheumatic heart diseases 19 9 10 2 2 0 2003 2 - Cerebrovascular diseases 137 68 69 77 39 38 2003 2 - Hypertension 505 278 227 38 20 18 2003 2 49 Maternal causes 2 2 2003 2 - Haemorrhage 12 12 … … 2003 2 - Abortion 969 969 … … 2003 2 - Eclampsia … … … … - Sepsis … … … … - Obstructed labour 1 1 … … 2003 2 50 Diabetes mellitus 621 297 324 82 47 35 2003 2 51 Mental disorders 75 46 29 0 0 0 2003 2 52 Injuries - All types 3649 2562 1087 73 54 19 2003 2 - Motor and other vehicle accidents 495 333 162 26 19 7 2003 2 - Suicide 59 19 40 5 4 1 2003 2 - Homicide and violence 78 51 27 11 6 5 2003 2 - Occupational injuries 120 … … … … … 2003 2 53 Proportion of population with access to affordable essential drugs on a sustainable basis (%) 100.00 2003 2 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 598 2003 2 - Specialized hospitals 1 … 2003 2 - District/first-level referral hospitals 3 283 2003 2 - Primary health care centres 16 NR 2003 2 Private hospitals 2 24 2003 2 Notes: Red text Millennium Development Goals indicators … Data not available p Preliminary / provisional est. Estimate FY Financial year a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. c Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. COUNTRY HEALTH INFORMATION PROFILE 35 Sources: 1 Department of Economic Planning and Development (DEPD), Prime Minister’s Office 2 Statistics Unit, Research and Development Section, Ministry of Health 3 Ledger Section – Expenditure, Ministry of Finance 4 Budget and Tender Section – Budget, Ministry of Finance 5 Urban and Rural Areas 2003. New York, United Nations. Department of Economic and Social Affairs Population Division, 2004 6 The World Health Report 2004. Changing history. Geneva, World Health Organization, 2004. 7 Human Development Report 2004. Nw York, UNDP, 2004. 8 Disease Control Division, Environmental Health Services, Ministry of Health 9 WHO Regional Office for the Western Pacific, data received from technical units 36 | COUNTRY HEALTH INFORMATION PROFILES CAMBODIA 1. DEMOGRAPHICS, GENDER AND POVERTY Cambodia’s latest population estimate, based on the 2004 intercensal survey, is 13 million. The median age is just under 20 years, with the proportion aged 0-24 being twice that of those aged 25-50. The total fertility rate is 3.3 (2004) and the annual population growth rate from 1998 to 2004 was 1.8%. Eighty-four per cent of the population lives in rural areas, but there is a significant urban drift, especially among young people. The Constitution guarantees women and men the same legal protection. However, women are disproportionately vulnerable in economic terms. While labour force participation for both is about 60%, over 60% of working women are in unpaid family work. More than 25% of households are headed by women. Sixty-seven per cent of Cambodian women are literate, compared with 82% for men. During the 1990s, the maternal mortality ratio declined; however, it is still high at 437 per 100 000 lives births (2000). War and serious internal conflict between 1968 and 1993 left Cambodia severely impoverished, with a significant depletion of skilled, educated professionals. In 1990, the Human Development Index (HDI) was 0.51, and by 2002 it had increased to 0.57, moving Cambodia from the low to the medium human development category. Despite this achievement, Cambodia still has some of the worst human development indicators in South-East Asia. In 2003, the per capita gross domestic product was US$ 306, with 36% of the total population still living below the official rural and urban poverty lines of US$ 0.46 and US$ 0.63 (1999). In some rural areas the percentage of the population living below the poverty line rises to 79%. Access to potable water has improved, but nearly two thirds of the rural population and one quarter of city dwellers still rely on unsafe sources. Less than one quarter of Cambodians have access to safe excreta disposal. Table 1. Core population and health data (2004) [Total] 13 091 000 [Both] … [0-14 years] 5 105 490 (39.00%) [Male] 56.40 (2001) Population [65+ years] 523 640 (4.00%) Health-adjusted life expectancy at birth (years) [Female] 60.30 (2001) Crude birth rate (per 1000 population) 25.00 Total fertility rate 3.34 [Total] 44.20 [Urban] 72.00 Crude death rate (per 1000 population) 6.70 % of population served with safe water [Rural] 39.60 [Total] 21.90 [Urban] 55.40 Infant mortality rate (per 1000 live births) 95.00 (2000) % of population with adequate sanitary facilities [Rural] 16.40 Maternal mortality rate (per 100 000 live births) 437.00 (2000) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Since completion of the UNTAC mission and promulgation of the 1993 Constitution of the Kingdom of Cambodia, increased political stability has allowed for economic growth, improvements in human development indicators, and re-integration of Cambodia into the international community. Poverty alleviation and governance are increasingly important items on the Government’s agenda. COUNTRY HEALTH INFORMATION PROFILES | 37 Following the July 2003 general election, coalition negotiations delayed formation of a new government for 12 months. In September 2004, the Royal Government issued its ‘Rectangular Strategy’, with reforms focusing on corruption, the judiciary, public administration and the military as core priorities for its current term. 2.2 Economic situation Cambodia has successfully maintained macroeconomic stability since 1993, allowing for an average annual growth rate of 6% for the period from 1996 to 2002. This growth has, however, increased inequality rather than substantially reducing poverty rates. Over 85% of the labour force is in the informal sector, with employment in industry (mainly the garment industry) growing substantially during the period from 1998 to 2004, stimulated by preferential trade status with the United States of America. This status has now ended. Agriculture, mainly rice production, accounts for 40% of the gross domestic product (GDP) and employs more than 70% of the workforce. Annual flooding and drought result in year-to-year fluctuations in agricultural production. 3. HEALTH SITUATION 3.1 Health trends Health indicators show a decline in infant and under-five mortality rates between 1990 and 2000, but there was a slowing down of this trend in the second half of the 1990s. There are indications that the trend has reverted due to an increase in post-neonatal mortality. In 2000, the infant mortality rate was estimated to be 95 deaths per 1000 live births and the under-five mortality rate was 124 per 1000 live births. Post-neonatal mortality is estimated at 58 per 1000 live births, the leading causes being acute respiratory infections, mainly pneumonia; diarrhoeal diseases; and neonatal conditions, including neonatal tetanus. Malnutrition among women and children is a major health problem. Fifteen per cent of children less than six months of age have stunted growth, increasing to 53% of children aged three to five years. Twenty-one per cent of 15-49 year-old women are underweight. Widespread nutritional deficiencies among women represent the biggest risk factor for childhood mortality. Poor infant and child feeding practices, lack of access to health services and inappropriate health-seeking behaviour are major contributing factors. Malaria and dengue fever pose a considerable burden of mortality and morbidity in certain remote geographical areas and during certain periods, with a malaria incidence rate (treated cases) of 1030 per 100 000, with 492 malaria deaths (routine HIS 2003), and a dengue fever rate of 78.2 per 100 000 (2004). Cambodia is ranked among the 22 countries worldwide with a high tuberculosis burden. In 2003, WHO estimated the incidence of all forms of tuberculosis as 508 per 100 000. Cambodia's case detection rate under DOTS was 60% in 2003, with the cure rate exceeding 90%. The prevalence of HIV infection among adults appears to have levelled off over the last few years, with a rate of 1.9% in 2003. However, this is still the highest prevalence in the Asia Pacific region, and 123 000 people are affected. The Government has accelerated the decentralized implementation of continuum-of-care services, currently available in 14 operational districts, including more than 5500 people living with HIV/AIDS who are undergoing antiretroviral therapy. Limited access to skilled health workers is reported to be a significant factor in the high maternal mortality ratio. The majority of deliveries are still attended by untrained birth attendants. Direct causes of maternal death include haemorrhage, eclampsia, sepsis and abortion; the indirect causes are related to poor access to emergency obstetric care. The contraceptive prevalence rate in 2000 was 19% for modern methods and 24% for all methods. The latest figures from the Ministry of Health suggest that the contraceptive prevalence rate has remained at 24%. In 2000, however, 32.6% of women stated that they wanted to limit or space their children. CAMBODIA 38 | COUNTRY HEALTH INFORMATION PROFILES Cambodia has the highest rate of amputation due to landmine injury in the world. Currently, there are about 40 000 people with amputations in the population. Since 1995, road traffic injuries have started to exceed those due to landmines. In 2002, the Department of Transport reported a fatality rate of 13 per 10 000 vehicles, one of the highest rates in ASEAN countries. There are few data on the prevalence of mental illness in Cambodia. However, several small studies have shown high levels of depression among adults and behavioural problems among children and adolescents. There are no official data available on the incidence of noncommunicable diseases. The prevalence of tobacco smoking, a major risk factor, is among the highest in the Region for men, with 54% of adult men smoking and more than 75% of households spending money on tobacco. The Framework Convention on Tobacco Control has been signed by Cambodia, and a comprehensive draft tobacco products control law is under consideration. The use of illicit drugs is becoming a concern. 3.2 Health systems In the 1990s, the Government introduced health system reforms to improve and extend primary health care through the implementation of a district health system that focuses on the distribution of facilities in accordance with a health coverage plan and the allocation of financial resources to provinces. Operational districts are composed of 100 000 to 200 000 people, with a referral hospital providing a ‘comprehensive package of activities’ and health centres delivering primary health care to a target population of 10 000 through a ‘minimum package of activities’. Government health expenditure has been increasing in recent years. In 1999, the approximate total government expenditure on health was US$ 2.85 per capita; that figure increased to US$ 3.30 per capita in 2003. Overall, health sector financing absorbs approximately 10% of GDP, the highest percentage among developing countries in Asia. An estimated 70% of health sector financing is from ‘out-of-pocket’ payments, representing approximately US$ 24 per capita, with donors paying approximately two-thirds of the remainder. Millennium Development Goals In 2003, the Royal Government of Cambodia issued the Cambodia Millennium Developments Goals Report, laying out country-specific goals (CMDGs) to be reached by 2015. Government and development partner planning and programming are being harmonized around the CMDGs, which will form the basis for the National Strategic Development Plan 2006-2010. Key health CMDGs include: • reducing the under-five mortality rate to 65 per 1000 live births; • reducing the infant mortality rate to 50 per 1000 live births; • reducing the maternal mortality ratio to 140 per 100 000 live births; • reducing HIV prevalence to 1.8%; • decreasing the number of malaria and dengue cases treated in the public health sector to 4.0 and 0.4 per 1000 population, respectively; • decreasing the smear-positive tuberculosis rate to 135 per 100 000 population; • increasing the proportions of rural and urban populations with access to safe water sources to 50% and 80%, respectively; and • increasing the proportions of rural and urban populations with access to improved sanitation to 30% and 74%, respectively. Cambodia seems to be on track for HIV, tuberculosis, dengue, malaria, water and sanitation. However, COUNTRY HEALTH INFORMATION PROFILES | 39 substantial investments will be needed to achieve the mother and child health targets. 4. NATIONAL HEALTH PLAN AND PRIORITIES In 2002, the first National Health Strategic Plan, a medium-term expenditure framework, and a monitoring and evaluation framework were developed and approved. The National Strategic Plan identifies a number of key challenges for the health sector: (1) Increasing the utilization of cost-effective health services: The overall utilization of public health facilities is around 0.3 visits per person per year. Except in a few areas where additional resources and semi-autonomous management have been provided, utilization rates are not increasing and, to date, the under- resourced publicly funded health services have had little to offer the rural poor. Most people are choosing to use legal or illegal pharmacies and traditional healers to access health care. (2) Improving the quality of care in both the public and private health sectors: Poor staff attitudes and practices in the public sector, uncertainty about user charges and lack of knowledge about available services are factors that contribute to the low utilization of health services. A number of initiatives have been introduced to promote a ‘client-centred’ approach to service delivery in health staff training programmes, and the newly established Medical Council is introducing a code of medical ethics in an attempt to improve professionalism among medical practitioners. (3) Improving the distribution of staff, particularly midwives, in the health sector: Currently, many referral hospitals and health centres, particularly in rural areas, have insufficient midwives to provide safe coverage for emergency obstetric care. A functional analysis process, initiated in 2002, has focused attention on the need to develop policy to address the maldistribution of staff. There has been an increase in the number of midwifery trainees in recent years. (4) Improving reproductive and adolescent health services: The main focus of reproductive health services is fertility control and antenatal care. In remote rural areas, however, the fertility rate has increased. The Health Sector Strategic Plan sets out the Ministry of Health's strategic objectives for 2003– 2007. Its eight essential objectives (strategies) are: (1) to improve coverage and access to health services, especially for the poor and other vulnerable groups; (2) to strengthen the delivery of high quality basic health services; (3) to strengthen the quality of care, especially for obstetric and paediatric care; (4) to improve the attitude of health providers to effectively communicate with customers; (5) to introduce a culture of quality in the public health services; (6) to increase the number of midwives through training and capacity-building; (7) to ensure a regular and adequate flow of funds to the health sector, especially for service delivery, through advocacy, and to increase financial resources and strengthen financial management; and CAMBODIA 40 | COUNTRY HEALTH INFORMATION PROFILES (8) to introduce organizational and management reform of structures and procedures to respond to change. These strategies are expected to result in reduced infant, child and maternal mortality; improved nutritional status among children and women; a reduced total fertility rate; reduced household health expenditure, especially among the poor; and a more efficient and effective health system. A monitoring and evaluation process has been established, and indicators to measure the achievement of the strategic objectives have been formulated. Annual targets are monitored at the Annual Joint Health Sector Review. Based on the findings of the Review, the National Health Congress issues directives for the next annual operational plan. 5. MAJOR INFORMATION SOURCES Cambodia Inter-Censal Population Survey 2004, General Report. Ministry of Planning, November 2004 National Institute of Statistics, Ministry of Planning Cambodia Demographic and Health Survey 2000 National Health Statistics Report of Cambodia 2003 Cambodia Integrated Fiduciary Assessment and Public Expenditure Review 2003. World Bank and Asian Development Bank. 6. ADDRESSES MINISTRY OF HEALTH Office Address : No. 151-153 Avenue Kampuchea Krom Phnom Penh, Cambodia Postal Address : Official Email Address : Telephone : (855-23) 722 933 Fax : (855 23) 426 034 / 426 841 Office Hours : 07:00 – 11:30 and 14:00 – 17:00 Website : WHO REPRESENTATIVE IN CAMBODIA Office Address : No. 177-179 corner Streets Pasteur (51) and 254 Postal Address : PO Box 1217 Sangkat Chak Tomok Khan Daun Penh Phnom Penh, Cambodia Official Email Address : who@cam.wpro.who.int Telephone : (855-23) 216 610 / 216 942 / 215 464 Fax : (855-23) 216 211 Office Hours : 07:30 – 12:00 and 14:00 – 17:30 COUNTRY HEALTH INFORMATION PROFILES | 41 ORGANIZATIONAL CHART: MINISTRY OF HEALTH ORGANIZATIONAL CHART OF THE MINISTRY OF HEALTH Minister of Health Secretaries of State Under-Secretaries of State Cabinet Directorate General for Health Directorate General for InspectionDirectorate General for Administration & Finance Secretariat Secretariat Department of Administration Department of Personnel Department of Budget and Finance National Institutes a National Hospitals b 4 Regional Schools of Technical Medical Care Department of Planning and Health Information Department of Human Resources Development Department of Drugs, Food and Cosmetics Department of Hospital Services Department of Preventive Medicine Department of Communicable Disease Control Bureau of ASEAN Affairs Bureau of International Relations Secretariat Bureau of Inspection Bureau of Control 24 Provincial Health Departments 76 Operational Districts Health 942 Health Centres69 Referral Hospitals 67 Health Posts Pasteur Institute National Pharmaceutical Factory UNIVERSITY OF MEDICAL SCIENCES Faculty of Medicine Faculty of Odontostomatology Faculty of Pharmacy School of Technical Medical Care NB: a. NCHADS, NCTB/Lepr, NCMalaria, NCMCH, NIPH, NCTraMed, NCDrugQuaCon, NCBloodTran b. Excluding Hopitals in NCMCH and NCTB/Lepr c. Battambang, Kampot, Kg. Cham and Stung Treng CAMBODIA 42 CAMBODIA WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 181.04 4 2 Estimated population ('000s) 13 091.00 6.32 6.76 2004 1 3 Annual population growth rate (%) 1.81 … … 1998-2004 1 4 Percentage of population - 0–14 years 39.00 41.10 36.20 2004 1 - 65+ years 4.00 3.30 4.50 2004 1 5 Urban population (%) 16.00 … … 2004 1 6 Crude birth rate (per 1000 population) 25.00 … … 2004 1 7 Crude death rate (per 1000 population) 6.70 … … 2004 1 8 Rate of natural increase of population (% per annum) 1.83 a … … 2004 1 9 Health-adjusted life expectancy (HALE) (years) - at birth … 56.40 60.30 2001 1 - at age 60 … 9.70 11.00 2002 21 10 Adult literacy rate (%) 74.40 82.10 67.40 2004 1 11 Neonatal mortality rate (per 1000 live births) 37.30 … … 2000 5 12 Infant mortality rate (per 1000 live births) 95.00 … … 2000 5 13 Under-five mortality rate (per 1000 live births) 124.40 … … 2000 5 14 Total fertility rate (women aged 15–49 years) 3.34 2004 1 15 Maternal mortality ratio (per 100 000 live births) 437.00 2000 5 16 Percentage of newborn infants weighing at least 2500 g at birth 77.00 … … 2000 6 17 Prevalence of underweight children under five years of age 45.20 44.30 46.30 2000 5 18 Percent age of pregnant women with anaemia 66.40 2000 5 19 Immunization coverage for infants (%) - BCG 95.00 … … 2004 12 - DTP3 85.00 … … 2004 12 - OPV3 86.00 … … 2004 12 - Measles 80.00 … … 2004 12 - Tetanus II 51.00 … … 2004 12 - Hepatitis B III … … … 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 38.00 2000 5 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 30.00 2000 5 - Percentage of deliveries at home by trained personnel (as % of total deliveries) 89.00 b 2000 5 - Percentage of deliveries in health facilities (as % of total deliveries) 9.90 2000 5 21 Percentage of women in the reproductive age group using modern contraceptive methods 19.00 2000 5 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15-24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … COUNTRY HEALTH INFORMATION PROFILE 43 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 44.20 72.00 39.60 2004 1 26 Proportion of population with access to improved sanitation 21.90 55.40 16.40 2004 1 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) >95.00 … … 2003 12 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.57 … … 2002 3 32 Per capita GDP at current market prices (US$) 306.00 … … 2003 17 33 Rate of growth of per capita GDP 2.60 … … 2003 15 34 Health expenditure Total health expenditure - amount (in million US$) 440.00 2003 est 5,18,19,20 - total health expenditure on health as % of GDP 10.00 2003 est 5,18,19,20 - per capita total expenditure on health (in US$) (government) 3.30 2003 est 5,18,19,20 Government expenditure on health - amount (in million US$) 42.80 2003 7 - general government expenditure on health as % of total expenditure on health 10.00 2003 est 5,18,19,20 - general government expenditure on health as % of total general government expenditure 8.00 2003 16 External sources of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health 70.00 2003 est 18 Exchange rate in US$ of local currency is: 1 US$ = 3980.00 riels 2003 16 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population a 36 Health workforce - doctors 2122 … … 1.62 … … 2004 22 - dentists 241 … … 0.18 … … 2004 22 - pharmacists 577 … … 0.44 … … 2004 22 - nurses c 4516 … … 3.45 … … 2004 22 - midwives c 1754 … … 1.34 … … 2004 22 - other nursing/ auxiliary staff 4449 … … 3.39 … … 2004 22 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 160 … … 0.12 … … 2004 22 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 1836 … … 1.40 … … 2000 6 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses 280 c … … 2002- 2004 22 CAMBODIA 44 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population a 1. Acute respiratory infections 940 839 … … 7182.77 … … 2000 6 2. Diarrhoea 309 933 … … 2366.00 … … 2000 6 3. Malaria (treated cases) 132 571 … … 1030.00 … … 2003 13 4. Cough (of at least 21 days) 54 695 … … 417.54 … … 2000 6 5. Gyneco-obstetrics 35 639 … … 272.06 … … 2000 6 6. Tuberculosis 28 386 … … 214.00 … … 2003 14 7. Dengue haemorrhagic fever 9983 … … 78.20 … … 2004 12 8. Road accidents 9823 … … 74.99 … … 2000 6 9. Measles 3925 … … 29.96 … … 2000 6 10. Dysentery 1976 … … 15.08 … … 2000 6 40 Ten leading causes of mortality Number Rate per 100 000 population a 1. Tuberculosis 661 … … 5.00 … … 2003 15 2. Malaria 492 … … 3.80 … … 2003 13 3. Acute respiratory infections 449 … … 3.43 … … 2000 6 4. Road accidents 184 … … 1.40 … … 2000 6 5. Meningitis 109 … … 0.83 … … 2000 6 6. Dengue haemorrhagic fever 90 … … 0.70 … … 2003 12 7. Diarrhoea 70 … … 0.53 … … 2000 6 8. Gyneco-obstetrics 20 … … 0.15 … … 2000 6 9. Neonatal tetanus 19 … … 0.15 … … 2000 6 10. Other tetanus 16 … … 0.12 … … 2000 6 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 4 … … … … … 2004 12 - Pertussis (whooping cough) 66 … … … … … 2004 12 - Tetanus 1041 … … … … … 2004 12 - Neonatal tetanus 146 … … … … … 2004 12 - Poliomyelitis 0 … … … … … 2004 12 - Hib Meningitis … … … … … … 2004 12 - Measles 352 … … … … … 2004 12 - Mumps … … … … … … 2004 12 - Rubella NR … … … … … 2004 12 - Congenital rubella syndrome … … … … … … 2004 12 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A … … … … … … - Type B 1410 … … … … … 2000 6 - Type C 536 … … … … … 2000 6 - Unspecified … … … … … … Cholera … … … … … … Typhoid fever … … … … … … Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … Gonorrhoea (gonococcal infections) … … … … … … Leprosy 509 … … … … … 2003 12 COUNTRY HEALTH INFORMATION PROFILE 45 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Malaria 71 258 (confirmed) … … 492 … … 2003 13 Dengue/DHF 9983 … … 90 … … 2004 12 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 504.00 … … 3.48 … … 2003 12 - Proportion of population in malaria-risk areas using effective malaria prevention measures d … - Proportion of population in malaria-risk areas using effective malaria treatment measures e … 44 Tuberculosis Number of cases Number of deaths - All types 28 216 … … … … … 2003 12 - New pulmonary tuberculosis (smear-positive) 18 923 … … … … … 2003 12 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 762.00 … … 95.00 … … 2003 12 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 60.00 … … 92.00 (2002) … … 2003 12 Number of cases Number of deaths 45 Acute respiratory infections 940 839 … … 449 … … 2000 6 46 Diarrhoeal diseases 309 933 … … 70 … … 2000 6 47 Cancers All cancers (malignant neoplasms only) 810 … … 134 … … 2000 6 - Trachea, bronchus, and lung … … … … … … - Stomach … … … … … … - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … … … … - Liver 167 … … 32 … … 2000 6 - Cervix 75 0 75 4 0 4 2000 6 - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … … … … - Ischaemic heart disease … … … … … … - Acute myocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … … … … - Hypertension 2492 … … 213 … … 2000 6 49 Maternal causes - Haemorrhage 1390 1390 … … 2000 6 - Abortion 1983 1983 … … 2000 6 - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … CAMBODIA 46 INDICATORS DATA Year Source Total Male Female Total Male Female 50 Diabetes mellitus 416 … … 29 … … 2000 6 51 Mental disorders 1237 … … 33 … … 2000 6 52 Injuries - All types … … … … … … - Motor and other vehicle accidents … … … 535 … … 2002 11 - Suicide … … … … … … - Homicide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis (%) … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals … … - Specialized hospitals 8 1770 2004 10 - District/first level referral hospitals 68 5712 2004 10 - Primary health care centres 961 … 2004 10 Private hospitals … … Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate a Computed by the Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Unspecified whether delivered by a trained personnel. c Primary nurses and midwives included in other nursing/auxiliary staff graduated between 2002-2004 (Ministry of Health) d Prevention is measured by the percentage of children aged 0–59 months sleeping under insecticide-treated bednets. e Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Cambodia Inter-Censal Population Survey 2004, General Report. Ministry of Planning, Department of Demographic Statistics, Censuses and Survey, November 2004. 2 National Institute of Statistics, Ministry of Planning, Cambodia (http://www.nis.gov.kh) 3 Millennium Development Goals: A compact among nations to end human poverty. Human Development Report 2003. New York, UNDP, 2003. 4 Information furnished by the WHO Representative for Cambodia, 09 March 2004 5 Cambodia Demographic and Health Survey 2000 6 National Health Statistics Report of Cambodia 2003 7 Ministry of Health, Department of Finance, data for 2003 8 Ministry of Health briefing note: Government Expenditure on Health in 1999, March 2000. 9 Information furnished by the WHO Representative for Cambodia 14 February 2004. 10 Ministry of Health Information – data for 2004, Cambodia. 11 Department of Transport 12 WHO Regional Office for the Western Pacific, data received from technical units 13 Annual report of the National Centre for Parasitology, Entomology and Malaria Control 14 Annual TB statistics 2003, furnished by the National Centre for Tuberculosis and Leprosy Control, Cambodia 15 IMF Cambodia Country Report 04/331. Phnom Penh, IMF, 2004 16 IMF Cambodia Country Report 04/330. Phnom Penh, IMF, 2004 (Table 13. Cambodia: Budgetary Expenditure by Ministry, 1999-2003) 17 GDP 2003 from IMF Country Report 04/331 COUNTRY HEALTH INFORMATION PROFILE 47 Sources: 18 Ministry of Health, Finance Department, 2003 19 Development Co-operation Report. Royal Government of Cambodia 2002-2003 20 Cambodia Development Council, October 2004 21 The World Health Report 2004. Changing history. Geneva, World Health Organization, 2004. 22 Human resources database, Ministry of Health, 2004 (civil service employees) 48 | COUNTRY HEALTH INFORMATION PROFILES CHINA 1. DEMOGRAPHICS, GENDER AND POVERTY At the end of 2004, the total population of China was 1.3 billion. In the same year, there were 15.93 million births, a crude birth rate of 12.29 per thousand population, a crude death rate of 6.42 per thousand population, and 8.32 million deaths. Net population growth in 2004 was 7.61 million, representing a natural growth rate of 5.87 per thousand, down by 0.014 percentage points from the previous year. In 2004, the per capita annual net income of rural households was RMB 2936 (US$ 356). The per capita disposable income of urban households was RMB 9422 (US$ 1138), a real increase of 7.7%. The population in absolute poverty in rural areas (with an annual per capita net income below RMB 668 or US$ 81) was 26.1 million at the end of 2004, a decline of 2.9 million from the previous year. The low-income population in rural areas (with annual per capita net income between RMB 669 and 924 or US$ 114) was 49.77 million, a decline of 6.4 million. Table 1. Core population and health data (2004 preliminary) [Total] 1 299 880 000 [Both] 71.40 (2000) [0-14 years] 279 470 000 (21.50%) [Male] 69.60 (2000) Population [65+ years] 98 570 000 (7.60%) Life expectancy at birth (years) [Female] 73.30 (2000) Crude birth rate (per 1000 population) 12.29 Total fertility rate 1.90 (2001) [Total] 83.55 (2002) [Urban] 94.00 (2002) Crude death rate (per 1000 population) 6.42 % of population served with safe water [Rural] 73.00 (2002) [Total] 50.92 [Urban] … Infant mortality rate (per 1000 live births) 30.00 (2001) % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 50.20 (2001) In the past 20 years, China has made considerable progress towards an improved standard of living for its population, including better health, reduced levels of poverty and strong macroeconomic growth. 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation In March 2003, the National People’s Congress elected Hu Jintao as President and Wen Jiabao was elected as Prime Minister. During the outbreak of severe acute respiratory syndrome (SARS), shortly after the formation of the new Government, China’s new leaders took decisive measures and successfully controlled the spread of the disease, limiting its impact on the country’s economy. The new administration is trying to maintain the country’s economic growth while avoiding overheating of the economy. It is also paying special attention to the development of China’s central and western regions and re-industrialization of the north-east, all of which have been lagging behind the eastern coastal regions in economic and social development. The Government has taken measures to reform the taxation, education and health care systems in rural areas. COUNTRY HEALTH INFORMATION PROFILES | 49 2.2 Economic situation The 16th Congress of the Chinese Communist Party has issued several communiqués and resolutions on improving the market economy, which indicate the new administration’s views on future economic development. Prominent among the Government’s strategies are the “Five Coordinations”: to coordinate urban and rural development, interregional development, socioeconomic development, harmonious advancement between humans and the environment, domestic development and opening-up. China has the second largest economy in Asia. It has been growing rapidly since the launch of economic reform and opening-up policies in the late 1970s. According to 2001 statistics, industry and construction account for 52.9% of the economy, services 32.3% and agriculture 14.8%. Foreign direct investment remains a strong element in the country’s remarkable economic growth. Trade linked with accession to the World Trade Organization has helped the country to maintain strong economic growth. Preliminary estimation indicated that the gross domestic product (GDP) in 2004 was RMB 13 651.50 billion (US$ 1649.39 billion), up by 9.5% from the previous year at comparable prices. Per capita GDP, calculated at the year-end exchange rate, was over US$ 1000. The total value of imports and exports in 2004 reached US$ 1154.8 billion, up 35.7% from the previous year, and the country had a trade surplus of US$ 32 billion, an increase of US$ 6.5 billion. In 2004, about 9.8 million new jobs were provided to urban residents, 800 000 more than the expected target, and 5.1 million laid-off workers were re-employed. The urban registered unemployment rate was 4.2% at the end of 2004, or 0.1 percentage point lower than in 2003. 3. HEALTH SITUATION 3.1 Health trends Improvements in health, especially in rural areas, were the direct result of political resolve by the Government in the 1960s and 1970s, when public-financed community and preventive health programmes provided access to basic care throughout the country. However, despite the overall positive aspects of some key health indicators, since the late 1990s, many health indicators appear to have reached a plateau. The rate of improvement in health-related indicators during the 1990s has been slower than in the 1970s and 1980s. Overall, people in China are living longer and healthier lives, and the country is largely on track to meet the Millennium Development Goals by 2015, although there are some areas of concern. The disease profile resembles that of a developed country: 85%–90% of deaths are due to noncommunicable diseases and injuries. National averages, however, mask considerable regional variation. For example, under-five mortality is two to three times higher in the poorer western provinces than in the more developed eastern provinces. Similar regional inequities can be seen for most basic health indicators. Poor urban migrants with less access to subsidized social services, including health and education, are also disproportionately affected. Among the leading causes of death in 2002, malignant tumours and cerebrovascular disease accounted for approximately 40% of all deaths in urban areas. The most common infectious causes of death are respiratory infections, liver cancer (two-thirds estimated to be caused by hepatitis B infection) and tuberculosis, which altogether account for approximately 6.5% of mortality. According to the WHO Global Burden of Disease 2002 Project, while patterns are similar for males and females, women are much more likely to die from self-inflicted injuries (seventh leading cause for women, tenth for men) and men are more likely to die from motor vehicle accidents (eighth leading cause for men). Among women, deaths due to perinatal conditions account for 3.3% of mortality and are the sixth leading cause of death (seventh overall). CHINA 50 | COUNTRY HEALTH INFORMATION PROFILES Smoking has been proven to be the single most important factor for the development of chronic diseases. As home to about a quarter of the World’s smokers, China is facing, and will continue to face, a high mortality rate and disease burden caused by tobacco use. The financial revenue generated by the tobacco industry, coupled with a lack of knowledge about the health effects of smoking, is inhibiting the recognition in China of the disastrous impact smoking will have on people’s health and the country’s health care system. 3.2 Health systems In the spring of 2003, an unprecedented global public health response was launched to eliminate severe acute respiratory syndrome or SARS, a disease caused by a new virus. Although SARS was beaten back less than eight months after it first started taking lives, the epidemic exposed the weaknesses in the country’s disease control and surveillance system, health facility infection control and medical scientific research. It raised questions about the structure of China’s public health system, and demonstrated how two decades of underfunding of public goods for health had left the country unprepared for public health emergencies. Excessive usage fees characterize the existing health service system in China. The health system is largely a system of private financing and public provision, with public expenditures left to fill the gaps, provide employment-based social health insurance and address shortfalls in public health services. In the past 20 years, an over-reliance on household payments to finance health care operating costs has led to increasing inequities in access to health services. As a proportion of GDP, the share of public social sector health expenditure has decreased steadily in real terms. National Health Accounts data show that, while total health expenditures have risen over time as a share of GDP, the government share of total health expenditures dropped from 36% to 15% from 1980 to 1999. The Urban Employee Basic Medical Insurance System, established in 1998, now covers over 100 million people. Reforms are underway to expand the coverage of the urban insurance system and improve the efficiency of service delivery. In rural areas, the central Government has decided to establish a new Rural Cooperative Medical System (RCMS). The proposed system includes a health service network with basic health facilities and equipment, a professional rural health service team and an efficient rural health management team. A number of pilot projects have been undertaken in selected poor counties in several central and western provinces. The success and effectiveness of the new rural health system will depend on the interpretation of the policy objectives, and the implementation and management of the new RCMS. Providing health services for the migrant population has become an important issue for the country, as China is experiencing, and will continue to experience, massive population migrations from rural to urban areas, from central/western to eastern regions. By the end of 2004, there were 277 000 health care institutions, including 62 000 general hospitals and health care stations, 3000 maternal and child health care institutions and 1718 specialized health institutions. General hospitals and health care institutions had a total of 3 004 000 beds. There were 4 343 000 health workers, including 1 892 000 practising doctors and assistant doctors and 1 286 000 registered nurses. China registered 3590 epidemic/disease prevention centres and stations, employing 160 000 health workers, and 1270 health monitoring institutions, with 27 000 health workers. There were 44 000 rural health care institutions, possessing 674 000 beds and employing 898 000 health workers. A total of 333 counties/cities had conducted experiments on the new joint medical care system in rural areas, covering approximately 106.91 million of the rural population, and attracting 80.4 million farmers to the system. COUNTRY HEALTH INFORMATION PROFILES | 51 Millennium Development Goals China has made enormous strides towards achieving its Millennium Development Goals. Progress towards the MDGs indicates that the country is currently on track, with impressive gains in poverty reduction, education and health over the past two decades. However, MDG targets for the environment and HIV/AIDS and TB control have been missed, and progress towards reduced childhood and maternal mortality targets is slowing. 4. NATIONAL HEALTH PLAN AND PRIORITIES In report to the People’s Congress, Prime Minister Wen Jiabao noted three national health priorities for the Government in the coming year: 1. Strengthen the public health system. Within three years, the Government will try to establish a fully functioning disease prevention and control system and an emergency medical aid system that covers both the urban and rural areas. The Government hopes that these systems would enhance the country’s capacity to deal with major epidemics and other public health emergencies. In the coming years, the Government will pay special attention to SARS, HIV/AIDS, tuberculosis, schistosomiasis and other major communicable diseases. 2. Improve health services in rural areas and continue pilot projects of the new rural cooperative medical system. The Government will increase the investment in rural areas to update the basic health care facilities and train rural health workers. The Government will also press ahead with the pilot projects for the new rural cooperative medical system. The Government’s goal is to establish a rural health care system based on voluntary participation of rural farmers and financial contributions from individuals, collectives and the Government. 3. Reform the urban health care financing health delivery system. The Government will continue the reform of the basic medical insurance system for urban employees, the health service delivery system and the pharmaceutical production and distribution system. Special attention will be given to the rational distribution and efficient utilization of health care resources and the improvement of community-based health care services. 4. As the one of the fastest growing economies in the world, China is facing enormous challenges in health, from reforming the hospitals to providing adequate health care to the rural farmers, from dealing with emerging and existing diseases to strengthening law and regulations on health and adjusting to WTO requirements. The Government and other partners in health have realized the importance and urgency to address some of the key health issues and will work together towards establishing an efficient and equitable health care system in the country. 5. MAJOR INFORMATION SOURCES Statistical communiqué of the People’s Republic of China on the 2004 National Economic and Social Development. National Bureau of Statistics of China (http://www.stats.gov.cn/english/newrelease/statisticalreports/), 28 February 2005 Ministry of Health Country Cooperation Strategy: WHO China [Strategic priorities for 2004-2008]. Beijing, The Office of the World Health Organization Representative in China, 31 July 2004. Millennium Development Goals: China’s progress (An assessment by the UN Country Team in China. Beijing. Office of the United Nations Resident Coordinator in China, 2004. National health statistics yearbook 2003 CHINA 52 | COUNTRY HEALTH INFORMATION PROFILES 6. ADDRESSES MINISTRY OF HEALTH Office Address : 1, Xi Xhi Men Wai Nan Lu Beijing, PR China 100044 Postal Address : Official Email Address : Telephone : Fax : Office Hours : Website : http://www.moh.gov.cn WHO REPRESENTATIVE IN THE PEOPLE’S REPUBLIC OF CHINA Office Address : World Health Organization China Office 401 Dongwai Diplomatic Office Building No. 23 Dongzhimenwai Dajie Chaoyang District Beijing 100600, PR China Postal Address : Official Email Address : who@chn.wpro.who.int Telephone : (8610) 65327189 to 92 Fax : (8610) 65322359 Office Hours : COUNTRY HEALTH INFORMATION PROFILE 53 CHINA WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 9600.00 2 2 Estimated population ('000s) 1 299 880.00 669 760.00 630 120.00 2004p 1 3 Annual population growth rate (%) 0.97 … … 2000 3 4 Percentage of population - 0–14 years 21.50 … … 2004p 1 - 65+ years 7.60 … … 2004p 1 5 Urban population (%) 41.80 … … 2004p 1 6 Crude birth rate (per 1000 population) 12.29 … … 2004p 1 7 Crude death rate (per 1000 population) 6.42 … … 2004p 1 8 Rate of natural increase of population (% per annum) 0.59 2004p 1 9 Health-adjusted life expectancy (HALE) (years) - at birth 71.40 69.60 73.30 2000 3 - at age 60 … 13.10 14.70 2002 5 10 Adult literacy rate (%) (15 years and above) 90.90 95.10 86.50 2002 4 11 Neonatal mortality rate (per 1000 live births) 21.00 … … 2000 est 9 12 Infant mortality rate (per 1000 live births) 30.00 … … 2001 3 13 Under-five mortality rate (per 1000 live births) 35.90 … … 2001 3 14 Total fertility rate (women aged 15–49 years) 1.90 2001 3 15 Maternal mortality ratio (per 100 000 live births) 50.20 2001 3 16 Percentage of newborn infants weighing at least 2500 g at birth 97.61 … … 2002 3 17 Prevalence of underweight children under five years of age 10.00 … … 2000 7 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 98.00 … … 2003 7 - DTP3 98.20 … … 2003 7 - OPV3 98.30 … … 2003 7 - Measles 97.90 … … 2003 7 - Tetanus II … … … - Hepatitis B III 96.70 … … 2003 7 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 90.14 2002 3 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) c 76.00 2001 8 21 Percentage of women in the reproductive age group using modern contraceptive methods 84.60 2002 est. 3 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … CHINA 54 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 83.55 94.00 73.00 2002 2 26 Proportion of population with access to improved sanitation 50.92 … … 2003 2 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) 80.00 … … 2003 7 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.74 … … 2002 4 32 Per capita GDP at current market prices (US$) 1268.91 a … … 2004p 1 33 Rate of growth per capita GDP 7.30 2001- 2002 6 34 Health expenditure Total health expenditure - amount (in million US$) … - total health expenditure on health as % of GDP 5.37 2002 3 - per capita total expenditure on health (in US$) 48.76 2002 3 Government expenditure on health - amount (in million US$) … - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure … External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 8.2765 RMB (year-end) 8.2773 RMB (year-end) 2004p 2002 1 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors (and assistant doctors) 1 892 000 … … 14.56 … … 2004p 1 - dentists … … … … … … - pharmacists 357 659 … … 27.84 … … 2002 2 - nurses 1 286 000 … … 9.89 … … 2004p 1 - midwives … … … … … … - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 209 144 … … 16.28 … … 2002 2 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … COUNTRY HEALTH INFORMATION PROFILE 55 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Five leading causes of morbidity among inpatients in city hospitals In City Hospitals (% of total cases) Rate per 100 000 population 1. Diseases of the respiratory system 11.20 … … … … … 2002 3 2. Diseases of the digestive system 11.00 … … … … … 2002 3 3. Pregnancy, childbirth and puerperium causes 10.68 … … … … … 2002 3 4. Injury and poisoning 9.13 … … … … … 2002 3 5. Malignant neoplasms 6.36 … … … … … 2002 3 40 Five leading causes of mortality in urban areas % of Total Deaths Rate per 100 000 population 1. Malignant tumours 23.75 … … 119.71 … … 2002 3 2. Cerebrovascular diseases 17.53 … … 88.37 … … 2002 3 3. Diseases of the respiratory system 15.49 … … 78.06 … … 2002 3 4. Heart diseases 14.71 … … 74.12 … … 2002 3 5. Injury and poisoning 8.62 … … 43.45 … … 2002 3 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 9 … … … … … 2003 7 - Pertussis (whooping cough) 858 … … … … … 2003 7 - Tetanus … … … … … … - Neonatal tetanus 2245 … … … … … 2003 7 - Poliomyelitis 0 0 0 … … … 2003 7 - Hib meningitis … … … … … … - Measles 71 879 … … … … … 2003 7 - Mumps … … … … … … - Rubella … … … … … … - Congenital rubella syndrome … … … … … … 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A 93 585 … … 40 … … 2004 7 - Type B 916 396 … … 783 … … 2004 7 - Type C 39 380 … … 82 … … 2004 7 - Unspecified 87 035 … … 115 … … 2004 7 Cholera 244 … … 1 … … 2004 7 Typhoid fever 49 332 … … 19 … … 2004 7 Encephalitis 8120 … … 365 … … 2004 7 Plague 22 … … 9 … … 2004 7 Syphilis 62 549 … … 20 … … 2002 3 Gonorrhoea … … … … … … Leprosy 1404 … … … … … 2003 7 Malaria 40 681 … … 52 … … 2003 7 Dengue/DHF 1557 … … … … … 2002 7 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 3.12 … … 0.00 0.00 0.00 2003 7 - Proportion of population in malaria-risk areas using effective malaria prevention measures e … - Proportion of population in malaria-risk areas using effective malaria treatment measures f … CHINA 56 INDICATORS DATA Year Source Total Male Female Total Male Female 44 Tuberculosis Number of cases Number of deaths - All types 615 868 … … … … … 2003 7 - New pulmonary tuberculosis (smear-positive) 267 414 … … … … … 2003 7 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 246.00 … … 18.00 … … 2003 7 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 43.00 … … 93.00 (2002) … … 2003 7 Number of cases Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases … … … … … … Mortality Rate per 100 000 population Urban Rural 47 Cancers All cancers (malignant neoplasms only) 119.71 … … 105.83 … … 2002 3 - Trachea, bronchus and lung 29.34 … … 18.47 … … 2002 3 - Stomach 18.91 … … 21.89 … … 2002 3 - Colon and rectum 7.90 … … 5.69 … … 2002 3 - Lip, oral cavity and pharynx 9.13 … … 10.84 … … 2002 3 - Liver 21.86 … … 25.09 … … 2002 3 - Cervix 1.41 … … 1.24 … … 2002 3 - Leukaemia 3.54 … … 2.92 … … 2002 3 48 Circulatory All circulatory system diseases 190.22 … … 183.53 … … 2002 3 - Ischaemic heart disease … … … … … … - Acute myocardial infarction 18.79 … … 12.00 … … 2002 3 - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases 97.46 … … 89.12 … … 2002 3 - Hypertension 14.19 … … 19.08 … … 2002 3 49 Maternal causes - Haemorrhage 0.06 … 0.25 … 2002 3 - Abortion 0.05 … 0.04 … 2002 3 - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … 50 Diabetes mellitus 11.36 … … 5.58 … … 2002 3 51 Mental disorders 3.16 … … 4.08 … … 2002 3 52 Injuries - All types 43.45 … … 52.16 … … 2002 3 - Motor and other vehicle accidents 6.39 … … 7.86 … … 2002 3 - Suicide 12.79 … … 15.32 … … 2002 3 - Homicide and violence 1.15 … … 1.02 … … 2002 3 - Occupational injuries … … … … … … 2002 3 COUNTRY HEALTH INFORMATION PROFILE 57 INDICATORS DATA Year Source 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals (and health care stations) 62 000 … 2004 1 - Specialized hospitals (including MCH institutions) 4718 … 2004 1 - District/first-level referral hospitals … … - Primary health care centres b 44 000 674 000 2004 1 Private hospitals … … General hospitals and health care institutions 277 000 3 004 000 2004 1 Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate p Preliminary a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Figure applies to rural health care institutions c Applies to hospitals only e Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. f Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Statistical Communique of the People’s Republic of China on the 2004 National Economic and Social Development. National Bureau of Statistics of China (http://www.stats.gov.cn/english/newrelease/index.htm), 28 February 2005 2 Information provided by the WHO Representative for China, 20 April 2004 3 Information furnished by Ministry of Health, 09 October 2003. 4 Human development report 2004. New York, UNDp, 2004. 5 World health report 2004. Changing history. Geneva, World Health Organization, 2004. 6 2002 World development indicators. Washington, D.C., The World Bank, 2002. 7 WHO Regional Office for the Western Pacific, data received from technical units 8 Millennium Development Goals: China’s progress (An assessment by the UN Country Team in China). Beijing, Office of the United Nations Resident Coordinator in China, 2004. 9 World health report 2005. Make every mother and child count. Geneva, World Health Organization, 2005. 58 | COUNTRY HEALTH INFORMATION PROFILES COOK ISLANDS 1. DEMOGRAPHICS, GENDER AND POVERTY The country’s population has been dropping steadily since 1996. In 2003, the estimated total population was 18 400, and the resident population was estimated to be 13 900. About 9000 people live on the main island of Rarotonga and the rest are spread over the other islands. Table 1. Core population and health data (2003 estimates) [Total] 18 400 [Both] 71.00 [0-14 years] (34.71%) [Male] 69.00 Population [65+ years] (5.79%) Life expectancy at birth (years) [Female] 73.00 Crude birth rate (per 1000 population) 21.20 Total fertility rate 2.80 [Total] 100.00 [Urban] 100.00 Crude death rate (per 1000 population) 6.30 % of population served with safe water [Rural] 100.00 [Total] 100.00 [Urban] 100.00 Infant mortality rate (per 1000 live births) 16.95 % of population with adequate sanitary facilities [Rural] 100.00 Maternal mortality ratio (per 100 000 live births) 0.00 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Cook Islands has a unicameral, democratic parliament with 25 elected members who serve parliamentary terms of five years. There were four government changes, however, from 1999 to 2003, and the next election was due before September 2004. The Government has given priority to education, health, human resources and outer island development. 2.2 Economic situation The country went through some economic difficulties during the period from 1996 to 1997. Since then, there have been public sector reforms, the sale of state assets, and the stimulation of the private sector, all of which have led to the growth and strengthening of financial and economic management. Tourism is the main industry and accounts for around 40% of gross domestic product (GDP). GDP was estimated at almost 239 million New Zealand dollars (US$ 169 million) and 12 965 New Zealand dollars (approximately US$ 9148) per capita in 2003. The growth rate of per capita GDP was 8%. The Government’s total revenue for the financial year 2002/2003 was 80 976 000 New Zealand dollars (US$ 57 103 000) and current expenditure was estimated at 88 128 000 New Zealand dollars (US$ 62 146 000). The country’s focus on development has been affected by challenges such as the emigration of skilled workers to New Zealand, an unstable political situation and the insufficient and inequitable distribution of resources. Of central importance is the delivery of health services to all the islands in Cook Islands. New Zealand remains the largest donor, while Australia and the Asian Development Bank (ADB) provide significant inflows geared towards capacity-building, outer island development and human resources development. WHO is the fourth largest donor and provides support for COUNTRY HEALTH INFORMATION PROFILES | 59 human development for health, health care delivery and outer island devolution. Other United Nations agencies, agencies based in the Pacific region, and two bilateral donors make up the remaining donor support to the country. Cook Islands has received ad hoc grants and technical support from China and Japan and, in the last 12 months, has progressed significantly in aid discussions with the European Union. 3. HEALTH SITUATION 3.1 Health trends In 2003, life expectancy at birth was estimated at 69 years for men and 73 years for women. The infant mortality rate was 16.95 per 1000 live births; the maternal mortality ratio has remained at zero since 1993. The crude birth rate is 21.2 per 1000 population, and the crude death rate is 6.3 per 1000 resident population. Almost 100% of the population has access to a clean safe water supply, adequate sewage sanitation disposal and primary health care. During the 2004-2005 financial year, the country’s Expanded Programme on Immunization (EPI) hopes to achieve 100% coverage. Infectious diseases are rarely seen and usually occur as imported cases. Parasitic intestinal worm disease has been greatly reduced by improved water and sanitation. A water supply and sanitation improvement programme, with the building of flush toilets in all schools and health centres on the outer islands, has enhanced the reduction in these diseases and probably also septic skin diseases, rheumatic fever and obstructive airways disease. Leprosy is rarely seen. There was no case of tuberculosis reported in 2003. The incidence of sexually transmitted infections (STI) varies. Gonorrhoea and syphilis are rare, while trichomoniasis and chlamydial infection are relatively common. The prevalence of condom use is low. The mass drug administration (MDA) programme for elimination of filariasis continues as part of the WHO Filariasis Elimination Programme. A small-scale blood survey was conducted before MDA 2001 in which 460 people from four different islands were randomly tested using ICT test kits. MDA coverage in 2001 was 91.3%, but dropped to 88% in 2003. The only infectious disease outbreak since the dengue outbreaks in 1992-1993 and 1995 was the dengue outbreak of 2002 (2491 cases reported). Noncommunicable diseases, such as hypertension, diabetes, cancer, coronary heart diseases, obesity, and injury and poisoning, continue to be major public health problems. According to a WHO consultancy in 2001, the prevalence of diabetes is 11.8% for males and 3.8% for females (not including patients with well-controlled pre-existing diabetes). The prevalence of obesity is 48.4% for males and 36.2% for females. According to hospital records, 66.8% of registered patients in 2003 were to have acquired hypertension disease, 15.3% having both hypertension and diabetes and 17.9% having diabetes only from 1980 to 2003. 3.2 Health systems While the population on the main island, Rarotonga, has access to the best health care in the country, those on the outer islands, especially the northern islands, do not. There is an urgent need to address and rectify this disparity. It is therefore of vital importance that the delivery of health services to the outer islands be addressed, especially the availability of drugs, the deficiency in equipment and the provision of properly trained health staff to provide services. National health expenditure was 4 285 000 New Zealand dollars in 2001. The health infrastructure is well developed. There is a general hospital with 80 beds in Rarotonga and seven primary health care centres. As of 2003, there were 27 doctors, 15 midwives, 60 nurses and 18 dentists and dental nurses. Since August 2002, responsibility for the administration of health services of the outer islands, with the exception of Rakahanga and Palmerston, has been returned to the central administration in Rarotonga. This has solved several of the problems identified in the document A review of the health sector of Cook Islands 2000. COOK ISLANDS 60 | COUNTRY HEALTH INFORMATION PROFILES During the past two years, the Ministry of Health has concentrated on providing sufficient general practitioners to provide health services in the outer islands. To date, there are only two islands, Palmerston and Rakahanga, without a resident doctor. However, there are health officers on these two islands. The Ministry of Health has also provided extra doctors at the Rarotonga Hospital so that service is provided 24 hours a day without any doctor having to work more than eight hours a day. In the absence of resident dental personnel, the Ministry of Health recently employed two flying dentists to visit the outer islands. Currently, in most of the islands there are no dental personnel, a lack of proper dental planning, and a lack of oral health promotion and education, preventive care and constant review. There are also no proper facilities and equipment. The high “decayed, missing or filled (DMF)” result clearly shows the lack of diagnosis of dental caries and the absence of restorative treatment for tooth decay. There is also a need to review and improve the oral health safety procedures to maintain the provision of quality health care services. In 2001, the Ministry of Health opened a new hospital wing that provides ample room for laboratory services, maternal health care, and statistics. There is also a library and a conference room to assist in continuous medical education. A telehealth venture is also being established, which will provide distance-learning education for doctors, nurses and other health staff in Rarotonga and some of the outer islands to improve human recourses development for health and to strengthen health services. At the same time, telehealth will be used to consult specialists overseas in regard to problematic cases. Efforts are also concentrated on continuing medical education and health staff training both in-country and overseas. 4. NATIONAL HEALTH PLAN AND PRIORITIES Partnerships will be built nationally, regionally and internationally in order to achieve the vision of “accessible quality health for all Cook Islanders”. In order to achieve this vision, nine health issues are being targeted for priority action. (1) Expanded programme on immunization: The current immunization coverage rate is 90% or more for childhood diseases. The expanded programme on immunization continues to pursue 100% coverage with the following objectives: to improve accessibility, particularly to outer islands and hard-to-reach communities; to upgrade the skills of existing health personnel; to upgrade equipment and facilities; to improve management, supervision and coordination; and to put in place protocols for quality. (2) Sexually transmitted infections, including HIV/AIDS: The prevalence of trichomoniasis and chlamydial infection is relatively high. The prevalence of condom use is low. The objective is to develop a strategy on STI control, intensify sexual health education and promotion of condom use, and explore the need for qualified counsellors. (3) Communicable disease surveillance and response: COUNTRY HEALTH INFORMATION PROFILES | 61 This programme focuses on increasing awareness, and formulating and developing a protocol on dengue management to avoid future epidemics of dengue fever, as well as improving vector control and surveillance. (4) Healthy settings and environment: A healthy environment will be created and promoted through a multisectoral approach and partnership to improve healthy lifestyles, to minimize the risk of disease and to reduce the need for hospital and other health services through: evaluating the effectiveness of health education and promotion activities and strengthening the concepts approach; and providing special training for health personnel and other stakeholder agencies in order to execute service deliveries satisfactorily. (5) Child and adolescent health and development: Child and adolescence health will be further strengthened through increasing awareness of risky behaviours, reducing teenage pregnancy and reducing STI, with emphasis on: conducting seminars that target adolescents to enhance knowledge of safer sex practices; and increasing knowledge on risky behaviours through awareness programmes on television and radio and through newspaper articles. (6) Reproductive health: There are insufficient trained and skilled personnel to provide quality reproductive health services at various levels of the health care system. At present, there is only one family planning nurse, assisted by a retired staff nurse. There is an immediate need to train younger nurses in technical and management skills. The responsibilities of husbands or male partners will be emphasized. Through training, their awareness and understanding of the reproductive health needs of women, care during pregnancy, childbirth, after delivery and family planning will be enhanced. (7) Noncommunicable diseases and mental health: A more vigorous effort will be made to change the attitudes of people through health education and promotion. Technical training of health educators in healthy living (e.g. diet, exercise) is part and parcel of this programme. Monitoring and management of noncommunicable diseases will be strengthened. Properly trained dental personnel are required for each island to strengthen preventive dental care and the treatment of common dental diseases. There is also a need to upgrade facilities, including rooms and dental equipment. (8) Tobacco Free Initiative: The Global Youth Tobacco Survey, conducted in 2002, needs to be extended to examine smoking prevalence and consumption among adults. The results of the survey will determine and guide development of the tobacco control programme and strengthen the nationwide promotion of healthy lifestyles, and will reduce the toll of tobacco-related mortality and associated diseases. (9) Human resource development: COOK ISLANDS 62 | COUNTRY HEALTH INFORMATION PROFILES Workforce planning has been identified as the key strategy to meet the need for skilled health workers. An increase in the number of qualified health workers with skills tailored toward specific needs of the population is critical if health objectives are to be met. Developing leadership and management skills will be essential in the transformation of the quality of care currently being delivered to the people of Cook Islands. Training is needed to help health personnel communicate with, inform and educate their patients. 5. MAJOR INFORMATION SOURCES Statistics Division (http://www.stats.gov.ck/) 2002 Annual Statistical Bulletin. Ministry of Health Medical Records Unit, November 2004. 2002 Annual Statistical Bulletin. Ministry of Health Medical Records Unit, July 2003. Key Indicators 2003 of Developing Asian and Pacific Countries, vol. 34. Manila, Asian Development Bank. Pacific Human Development Report 1999 (Creating Opportunities). New York, United Nations Development Programme, June 1999. 6. ADDRESSES MINISTRY OF HEALTH Office Address : Postal Address : P.O. Box 109, Avarua, Rarotonga, Cook Islands Official Email Address : dcsl@health.gov.ck Telephone : (682) 22664 (Hospital), (682) 29664 (Admin) Fax : (682) 22670 (Hospital), (682) 23109 (Admin) Office Hours : Website : WHO REPRESENTATIVE IN SAMOA Office Address : Ioane Viliamu Building Beach Road, Apia, Western Samoa Postal Address : P.O. Box 77, Apia, Western Samoa Official Email Address : who@sma.wpro.who.int Telephone : (685) 23756/ 23757 Fax : (685) 23765 Office Hours : COUNTRY HEALTH INFORMATION PROFILE 63 COOK ISLANDS WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 0.24 2004 1 2 Estimated population ('000s) 18.40 … … 2003 est 2 3 Annual population growth rate (%) 1.10 … … 2002 est 2 4 Percentage of population - 0–14 years 34.71 35.12 34.29 2003 est 3 - 65+ years 5.79 5.86 5.71 2003 est 3 5 Urban population (%) 62.23 … … 2003 4 6 Crude birth rate (per 1000 resident population) 21.20 … … 2003 4 7 Crude death rate (per 1000 resident population) 6.30 … … 2003 4 8 Rate of natural increase of population (% per annum) 1.49 a … … 2003 2 9 Health-adjusted life expectancy (HALE) (years) - at birth 71.00 69.00 73.00 2003 4 - at age 60 … 11.50 12.60 2002 11 10 Adult literacy rate (%) 100.00 … … 2003 4 11 Neonatal mortality rate (per 1000 live births) 12.00 b … … 2000 5 12 Infant mortality rate (per 1000 live births) 16.95 a … … 2003 4 13 Under-five mortality rate (per 1000 live births) 16.95 a … … 2003 4 14 Total fertility rate (women aged 15–49 years) 2.80 2003 4 15 Maternal mortality ratio (per 100 000 live births) 0.00 2003 4 16 Percentage of newborn infants weighing at least 2500 g at birth 97.60 … … 2003 4 17 Prevalence of underweight children under five years of age 10.00 … … 1997 6 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 100.00 … … 2004 7 - DTP3 100.00 … … 2004 7 - OPV3 100.00 … … 2004 7 - Measles 100.00 … … 2004 7 - Tetanus II 100.00 … … 2004 7 - Hepatitis B III 100.00 … … 2004 7 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 100.00 2000 8 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 92.00 2003 4 - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods (15-44 year old women using all methods) 40.85 a 2003 4 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … COOK ISLANDS 64 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 100.00 100.00 2003 4 26 Proportion of population with access to improved sanitation 100.00 100.00 100.00 2003 4 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) 10.90 … … 2001 6 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.82 … … 1998 9 32 Per capita GDP at current market prices (US$) 9148.22 … … 2003p 2 33 Rate of growth per capita GDP 8.00 … … 2003p 2 34 Health expenditure Total health expenditure - amount (in NZD) 4 285 000.00 2001 10 - total health expenditure on health as % of GDP 2.33 2001 10 - per capita total expenditure on health (in US$ 237.70 a 2001 10 Government expenditure on health - amount (in million US$) … - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure … External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 1.5133 NZD (average) 2003 7 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 27 … … 14.67 … … 2003 4 - dentists (includes 6 dental nurses) 18 … … 9.78 … … 2003 4 - pharmacists (including assistants) 2 … … 1.09 … … 2003 4 - nurses 60 … … 32.60 … … 2003 4 - midwives 15 … … 8.15 … … 2003 4 - other nursing/ auxiliary staff 55 … … 29.89 … … 2003 4 - other paramedical staff (e.g. medical assistants, laboratory technicians, X- ray technicians) 20 … … 10.87 … … 2003 4 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 14 … … 7.61 … … 2003 4 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … COUNTRY HEALTH INFORMATION PROFILE 65 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of (inpatients) morbidity in Rarotonga Number Rate per 100 000 population a 1. Injury, poisoning and certain other consequences of external causes 392 248 144 2130.43 … … 2003 4 2. Diseases of the circulatory system 311 167 144 1690.22 … … 2003 4 3. Diseases of the respiratory system 307 153 154 1668.48 … … 2003 4 4. External causes of morbidity and mortality 252 159 93 1369.57 … … 2003 4 5. Diseases of the digestive system 173 109 64 940.22 … … 2003 4 6. Diseases of the genitourinary system 144 37 107 782.61 … … 2003 4 7. Endocrine, nutritional and metabolic diseases 116 57 59 630.43 … … 2003 4 8. Symptoms, signs and abnormal clinical and laboratory findings 115 59 56 625.00 … … 2003 4 9. Diseases of the musculoskeletal system and connective tissue 107 68 39 581.52 … … 2003 4 10. Diseases of the skin and subcutaneous tissue 86 50 36 467.39 … … 2003 4 40 Five leading causes of mortality Number Rate per 100 000 population 1. Diseases of the circulatory system 19 … … 103.26 … … 2003 4 2. Endocrine, nutritional and metabolic diseases 19 … … 103.26 … … 2003 4 3. Neoplasms 15 … … 81.52 … … 2003 4 4. Symptoms, signs and ill-defined conditions 10 … … 54.35 … … 2003 4 5. Diseases of the respiratory system 8 … … 43.48 … … 2003 4 6. Injury and poisoning 4 … … 21.74 … … 2003 4 7. Diseases of the digestive system 4 … … 21.74 … … 2003 4 8. External causes of injury and poisoning 4 … … 21.74 … … 2003 4 9. Infectious and parasitic diseases 3 … … 16.30 … … 2003 4 10. Certain conditions originating in the perinatal period 3 … … 16.30 … … 2003 4 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2004 7 - Pertussis (whooping cough) 0 0 0 … … … 2004 7 - Tetanus 0 0 0 … … … 2004 7 - Neonatal tetanus 0 0 0 … … … 2004 7 - Poliomyelitis 0 0 0 … … … 2004 7 - Hib meningitis 0 0 0 … … … 2004 7 - Measles 0 0 0 … … … 2004 7 - Mumps 0 0 0 … … … 2004 7 - Rubella 0 0 0 … … … 2004 7 - Congenital rubella syndrome 0 0 0 … … … 2004 7 COOK ISLANDS 66 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral … … … 16 … … 2002 7 - Type A … … … … … … - Type B 23 … … … … … 2003 4 - Type C … … … … … ... - Unspecified ... ... … … … … Cholera 0 0 0 … … … 2002 7 Typhoid fever 1 … … … … … 2003 4 Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … Gonorrhoea 19 … … … … … 2003 4 Leprosy 0 0 0 … … … 2003 7 Malaria 1 … … … … … 2003 4 Dengue/DHF 1 … … … … … 2003 4 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures d … - Proportion of population in malaria-risk areas using effective malaria treatment measures e … 44 Tuberculosis Number of cases Number of deaths - All types 0 0 0 … … … 2003 7 - New pulmonary tuberculosis (smear-positive) 0 0 0 … … … 2003 7 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 59.00 … … 6.00 … … 2003 7 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 39.00 … … 100.00 … … 2002 7 Number of cases Number of deaths 45 Acute respiratory infections 8131 … … … … … 2003 4 46 Diarrhoeal diseases 835 … … … … … 2003 4 47 Cancers Reported number of cases Number of Deaths All cancers (malignant neoplasms only) 36 19 17 15 … … 2003 4 - Trachea, bronchus, and lung … … … 4 … … 2003 4 - Stomach … … … … … … 2003 4 - Colon and rectum … … … … … … 2003 4 - Lip, oral cavity and pharynx … … … … … … 2003 4 - Liver … … … 1 … … 2003 4 - Cervix … … … … … … 2003 4 - Leukaemia … … … … … … 2003 4 COUNTRY HEALTH INFORMATION PROFILE 67 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 48 Circulatory All circulatory system diseases 311 167 144 19 … … 2003 4 - Ischaemic heart disease … … … … … … 2003 4 - Acute myocardial infarction … … … 6 … … 2003 4 - Rheumatic fever and rheumatic heart diseases 175 … … … … … - Cerebrovascular diseases … … … 4 … … 2003 4 - Hypertension 1745 … … 3 … … 2003 4 49 Maternal causes - Haemorrhage 12 12 … … 2002 12 - Abortion 36 36 … … 2002 12 - Eclampsia 5 5 … … 2002 12 - Sepsis 3 3 … … 2002 12 - Obstructed labour 23 23 … … 2002 12 50 Diabetes mellitus 469 … … 17 … … 2003 4 51 Mental disorders 114 85 29 3 3 0 2002 12 52 Injuries - All types 392 248 144 4 … … 2003 4 - Motor and other vehicle accidents 128 c … … 3 … … 2003 4 - Suicide … … … … … … - Homicide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals (Rarotonga) 1 80 2004 10 - Specialized hospitals … … - District/first-level referral hospitals … … - Primary health care centres 7 … 2004 10 Private hospitals … … Notes: Red text Millennium Development Goals indicators … Data not available p Provisional est. Estimate a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific b Estimates derived by regression and similar estimation methods c In Rarotonga hospital d Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. e Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. COOK ISLANDS 68 Sources: 1 Pacific Island Populations 2004. Secretariat of the Pacific Community <http://www.spc.int/> 2 Cooks Island Statistics Office <http:///www.spc.int/prism/country/ck/> 3 Demographic Tables for the Western Pacific Region 2000-2005. Manila, WHO Regional Office for the Western Pacific, 2005. 4 2003 Annual Statistical Bulletin. Ministry of Health Medical Records Unit, November 2004. 5 The World Health Report 2005. Geneva, World Health Organization, 2005. 6 Pacific Islands Regional Millennium Development Goals Report 2004. Secretariat of the Pacific Community and UN/CROP MDG Working Group, November 2004. 7 WHO Regional Office for the Western Pacific, data received from the technical units. 8 2000 Annual Statistical Bulletin. Ministry of Health Medical Records Unit, October 2001. 9 Pacific Human Development Report 1999 (Creating Opportunities). New York, United Nations Development Programme, June 1999. 10 Information furnished by the WHO Representative in Samoa, 20 February 2004. 11 The World Health Report 2004. Changing history. Geneva, World Health Organization, 2004. 12 2002 Annual Statistical Bulletin. Ministry of Health Medical Records Unit, July 2003. COUNTRY HEALTH INFORMATION PROFILES | 69 FIJI 1. DEMOGRAPHICS, GENDER AND POVERTY Fiji has the largest population of the South Pacific island countries. The estimated multiethnic population for 2003 was 832 446 and it is growing slowly due to a moderately low level of fertility and a high level of emigration. The population occupies around two-thirds of the 322 Fiji islands and is concentrated on the two largest islands, Viti Levu (10 429 km2) and Vanua Levu (5556 km2), with the nation's capital of Suva located on Viti Levu. Life expectancy at birth is high for both women (70.7 years) and men (66.5 years). Infant, child and maternal mortality have been halved since the 1960s and are now low. There is a high level of adult literacy and almost universal primary school enrolment (98%), and around 40% of adolescents remain at school until the age of 18 years, up from a small minority a generation ago. In 2003, the ratio of girls to boys in primary education was 0.93, in secondary education 1.0 and in tertiary education 0.99. Of the adult population (all people over 15 years), the most disadvantaged group is Indo-Fijian female adults, of whom 14% in 1996 had no formal education, followed by Indo-Fijian male adults, of whom 8% had no formal education. The share of women in paid employment has grown considerably in Fiji over the past three decades. During the 1990s, female waged employment grew faster than male employment because more women were joining the labour force and the occupations where most women were employed were expanding. The latest urban National Household Income and Expenditure Surveys (HIES - 2002) found that women comprised 35.5% of the economically active population, but only 31% of people engaged in the cash economy. Of urban women who did work, 64% were engaged in the money economy; most others worked in non-monetary subsistence activities. Despite the prominence now given in national policy to reducing poverty, there are very few reliable or up-to-date data available. While HIES have been conducted, the most recent in 2003- 2004, the data have not yet been evaluated. The extent of poverty increased between 1977 and 1990-1991. In 1977, around 15% of Fiji households lived below the poverty line. By 1990-1991, that figure had risen to 25.5% (urban 27.6%, rural 22.4%), and the poverty gap ratio was 0.3% in 1990. Although there are as yet no firm data, there are signs that the extent of poverty has grown further during the 1990s and the 2000s. Table 1. Core population and health data (2004) [Total] 832 446 (2003 est) [Both] 68.60 [0-14 years] (35.30%) (2002) [Male] 66.50 Population [65+ years] (3.10%) (2002) Life expectancy at birth (years) [Female] 70.70 Crude birth rate (per 1000 population) 19.48 (2002) Total fertility rate 2.70 (2000) [Total] 65.00 (2002) [Urban] 95.00 (2002) Crude death rate (per 1000 population) 6.45 (2002) % of population served with safe water [Rural] 53.00 (2002) [Total] 60.00 (2002) [Urban] 90.00 (2002) Infant mortality rate (per 1000 live births) 17.76 (2002) % of population with adequate sanitary facilities [Rural] 50.00 (2002) Maternal mortality ratio (per 100 000 live births) 35.29 (2002) FIJI 70 | COUNTRY HEALTH INFORMATION PROFILES 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The return to full political stability after the coup in May 2000 was hampered by unresolved power struggles within the indigenous Fijian community over land and other resources and by constitutional uncertainty over the composition of the Government. Prime Minister Laisenia Qarase and former Prime Minister Mahendra Chaudhry held a series of informal talks to resolve the situation. The Republic of Fiji Military Forces [RFMF] has indicated that it will not support any forces to de-stabilize the Government. Court cases against several members within the ruling Government for their involvement in the 2000 crisis produced a certain degree of anxiety and uncertainty during 2004. The large-scale emigration of skilled labour, particularly among Indo-Fijians, which began in the wake of the 2000 coup, continues. This has had an impact on health care service delivery. Ongoing disputes over communally owned resources and land leases have adversely affected thousands of indigenous landowners as well as Indo-Fijian tenant farmers, many of whom have lost their livelihoods after being evicted from leasehold land. 2.2 Economic situation According to the Fiji National MDG Report for 2004, the national economy is barely growing. It rests primarily on sugar production and tourism, but is becoming more diverse, with manufacturing now an important employment sector. In the next few years, the fate of the sugar industry will probably have the greatest effect on the national economy. Sugar provides around 30% of Fiji’s domestic export earnings and employs around 13% of the labour force. The deepening unemployment problem is also contributing to instability and poverty. The economy is generating far fewer jobs than needed each year just to provide for school leavers. Emigration and skill loss is also having an impact on the economy. Fiji has long had a slow but steady exodus of professional and skilled workers, and emigration accelerated after the turbulent political events in 1987 and 2000. Since the 2000 coup, it has peaked at around 6300 persons in 2001 and 5800 in 2003 (Fiji Bureau of Statistics). Fiji still enjoys an abundance of forest, mineral and marine resources, and a well-developed tourism sector provides substantial income and employment. With a population of 872 985 in 2002 and a gross domestic product (GDP) of about US$ 1.7 billion, GDP per capita is nearly US$ 2000. The shock to the economy delivered by the 2000 coup was minimized by the quick action of the central bank to maintain stability and sharply reduce aggregate demand. The Reserve Bank of Fiji protected the value of the currency during the crisis, and thus inflation was not a factor in 2000, coming in at about 1%. In 2001, the inflation rate spiked to 4.3%, but that increase was due to increases in VAT rates and was not the result of demand pressures. However, given the weak global economy and the desire of the new Government to ensure economic growth, monetary policy was more expansionist in 2002 and 2003 and an inflation rate of 3%-4% is anticipated. The unemployment rate, which shot up to 12% in 2000 from 7.6% in 1999, has remained high despite the recovery in growth, although it is expected to continue to decline due to economic expansion and continued emigration. The successful return to constitutional government considerably improved Fiji's economic situation in 2004, as it restored normal relations with major trade and aid partners and eased potential tourists' fears about travelling to the country. COUNTRY HEALTH INFORMATION PROFILES | 71 3. HEALTH SITUATION 3.1 Health trends Fiji faces a number of health challenges. In addition to the continuing incidence of communicable diseases, they include an increasing prevalence of noncommunicable diseases (NCD), such as diabetes and hypertension, due to lifestyle changes, poor diet, smoking and changing patterns of physical activity, and continuing nutritional problems, particularly in schoolchildren and women. NCD have become the principal cause of ill-health and death. The NCD survey in 2002 showed an 11.9% prevalence rate for diabetes, and 19.1% for hypertension. A third of all deaths and half of those in the 40–59 year-old age group are due to circulatory diseases. Traffic accidents also represent an ever-increasing burden. All the above provides testimony to the ongoing epidemiological transition in Fiji and constitutes a typical example of a triple burden of diseases (communicable diseases, noncommunicable diseases and injuries) in a developing country. The leading causes of death and serious illness in young children are acute respiratory infections, diarrhoea, parasitic infections, meningitis and anaemia. Child mortality has remained fairly steady over the past decade. The under-five mortality rate dropped slightly from 27.8 in 1990 to 22.3 in 2002, while the infant mortality rate rose from 16.8 in 1990 to 17.8 in 2002. The latest estimate of the maternal mortality ratio was 35 in 2002, representing around six pregnancy-related deaths in that year. There is a good network of maternal and child health services throughout Fiji, and the proportion of women giving birth in hospital has risen steadily to 99% in 2002. A rapid increase has been recorded in HIV/AIDS (158 cases of confirmed HIV infection as of 31 December 2004) and sexually transmitted infections (STI). Despite the increasing burden of chronic and degenerative diseases, respiratory disease and infectious and parasitic diseases continue to represent the leading causes of admission to hospital. 3.2 Health systems The Fiji health sector was transformed in 2003 from a highly centralized system to one that is decentralized within the Ministry of Health. This transition has been taking place at a slower pace than originally conceived, and will continue to require substantial technical support and systems development to put it into place. Decentralization is taking place on two levels. The first is the delegation from the central agencies – the Ministry of Finance and the Public Service Commission (PSC) – to the Chief Executive Officer (former Permanent Secretary for Health). The second level is the delegation of powers by the Chief Executive Officer to the Divisional Directors of Health Services (DDHS) in the Western, Northern and Central-Eastern Divisions. Health care in Fiji is financed mainly by general taxation. The Government has been allocating about 8%-10% of total public expenditure for health care for the last 10 years. Total health expenditure is 3% of GDP, which is the lowest rate in the Pacific. Although the government budget for health care has been increasing each year, total health expenditure in terms of percentage of GDP has not increased. Of the appropriated allocation, 62%-67% is spent on personal emoluments at divisional and subdivisional hospitals. Only about 7.5% of the total government budget for health care has been allocated to drug procurement in recent years, compared with the 10%-20% allocated by other member countries of the Organisation for Economic Co-operation and Development (OECD). The allocation for health care facility maintenance has been very limited. Out-of-pocket payment for health care is estimated at 35% of total health expenditure, mostly in the private health sector. The Ministry of Health is aware of the limitations of the current health financing mechanism and the necessity for health care financing reform. In his 2003 budget address in Parliament, Mr Solomoni Naivalu, Honourable Minister for Health said: “… the best option that seems to FIJI 72 | COUNTRY HEALTH INFORMATION PROFILES emanate from these discussions is the option of a social health insurance scheme for both the formal and informal sectors that will help supplement the existing government health budget.” The Fiji National Provident Fund, a compulsory social savings scheme for formal sector employees, has become a significant player in the Fiji financial system. The Fund has a well developed infrastructure, with a head office in Suva and two branch offices in Lautoka and Labasa, and is interested in a medical benefit scheme for its members. The Ministry of Health is considering developing a social health insurance system and will carry out a community-based social health insurance pilot project. The Fiji Blood Transfusion Services are in a transitional period. The Fiji Red Cross Society (FRCS) has informed the Ministry of Health that, effective 1 January 2005, blood-related public awareness activities, blood donor recruitment and collection of blood will become the responsibility of the Ministry of Health. The Ministry has adopted measures to cope with the situation. Millennium Development Goals The MDG process in Fiji has been integrated into the mid-term review of Fiji’s Strategic Development Plan. This has enabled Fiji to incorporate and streamline measurable performance and outcome indicators, and to integrate existing information requirements into the MDGs. In 2003, a steering committee, comprising representatives of the Government and UNDP, was established to develop the national MDG report and to report regularly to nine summit working groups, representing the Government, nongovernmental organizations and the private sector. The Fiji National MDG Report was finalized in late 2004. The Pacific Islands Regional MDG Report was compiled in 2004 to ensure that all Pacific island countries and areas are represented in the United Nations Secretary-General’s 2005 report. Such a report is particularly appropriate in the Pacific region due to the high degree of regional cooperation on development-related issues. The 14 Pacific island countries and one territory covered by the report (Cook Islands, the Federated States of Micronesia, Fiji, Kiribati, the Marshall Islands, Nauru, Niue, Palau, Papua New Guinea, Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu and Vanuatu) are widely dispersed over a large geographical area. They differ significantly in size, population, resource endowments and development constraints, but nevertheless share a number of development challenges. The Pacific Islands Regional MDG Report is the sixth regional MDG report to be prepared worldwide. The main partners in MDG achievement are, in addition to the national line ministries, the United Nations and the Council of Regional Organisations of the Pacific (CROP), which is a high-level advisory body made up of the heads of the region’s 10 primary intergovernmental organizations. CROP is chaired by the Pacific Islands Forum Secretariat (PIFS). Other members comprise: Forum Fisheries Agency (FFA), Pacific Islands Development Program (PIDP), Secretariat of the Pacific Community (SPC), South Pacific Regional Environment Programme (SPREP), South Pacific Applied Geo-science Commission (SOPAC), University of the South Pacific (USP), South Pacific Tourism Organisation (SPTO), South Pacific Board for Educational Assessment (SPBEA), and Fiji School of Medicine. 4. NATIONAL HEALTH PLAN AND PRIORITIES The Fiji Government currently has two development plans: • The National Vision and Strategic Development Plan 2003-2005, and • “50/50 by 2020”: A 20-Year Development Plan for the Enhancement of Participation of Indigenous Fijians and Rotumans in the Socio-Economic Development of Fiji. These two planning documents are intended to be complementary. Both give a high priority to addressing issues of poverty and hardship throughout the various sections of society. COUNTRY HEALTH INFORMATION PROFILES | 73 Based on the above, the Fiji Ministry of Health developed the Strategic Plan for 2003 – 2005: Shaping Fiji’s Health, which provides the strategic framework for the development of the health sector. The Plan defines the goal of the Ministry of Health to provide quality health services for the citizens of Fiji. The vision is defined as: “an integrated and decentralized health system to foster good health and well-being.” A draft Ministry of Health Strategic Plan for 2005 – 2008 has been prepared and builds on the achievements of the previous period, outlining a series of priorities for the next four years. The strategic goals for the Ministry are the five Ps: Provision of health services Planning, integrated delivery and maintenance of appropriate, effective, efficient and quality health services (clinical, diagnostic, pharmaceutical, rehabilitative, preventative) to the people of Fiji. Protection of health Development and implementation of appropriate policies, legislation, regulations and standards to protect the health and well-being of the people of Fiji. Promotion of health Development and maintenance of effective partnerships that empower all stakeholders to reduce risk factors related to communicable and noncommunicable diseases. People in health Development and retention of a valued, skilled and high performance workforce to enhance the delivery of quality health services. Productivity in health Development and use of financial (FMIS), human resource (HRIS) and health information (HIS, PATIS) systems to maximize resources and promote continuous improvement at all levels of health service delivery. The ultimate goals for the collective work will be seven health outcomes. These health outcomes should be the end-result of health service activities (outputs), which are either internal business processes, such as staff development and retention (people) and resource management systems (productivity) or external business processes, such as provision, protection and promotion. The outcomes will also contribute to broader developmental goals, such the Millennium Development Goals. The seven health outcomes are as follows: Health outcome 1: Reduced burden of noncommunicable diseases Health outcome 2: Begun to reverse the spread of HIV/AIDS and preventing, controlling or eliminating other communicable diseases Health outcome 3: Improved maternal health and reduced maternal mortality Health outcome 4: Improved child health and reduced child mortality Health outcome 5: Improved adolescent health and reduced adolescent mortality Health outcome 6: Improved mental health and decreased disability due to mental illness Health outcome 7: Contributed to environmental sustainability At the operational level, the Ministry of Health’s Corporate Plan 2004 is an annual publication that articulates how the Ministry will meet the objectives of the Fiji National Plan for the Millennium (2001) and the Ministry of Health Strategic Plan. FIJI 74 | COUNTRY HEALTH INFORMATION PROFILES 5. MAJOR INFORMATION SOURCES Ministry of Health, data update, February 2005 Fiji National MDG Report,. July 2004 Corporate Plan 2004, 4/4/03-E, Ministry of Health Strategic Plan 2003 – 2005: Shaping Fiji’s Health, Ministry of Health Pacific Regional Millennium Development Goals Report, SPC/UNDP/UN-CROP MDG TWG, 2004, http://www.spc.int/mdgs/MDGReport/Reg_report.htm. Pacific Regional Information System (PRISM), SPC, http://www.spc.int/prism WHO mission reports on social health insurance in Fiji. WHO Western Pacific Regional Office, November 2003 and June 2004. Amnesty International Report 2003 Other United Nations agencies, http://www.un.org 6. ADDRESSES MINISTRY OF HEALTH Office Address : Dinem House, 88 Amy Street, Toorak, Suva Postal Address : Official Email Address : info@health.gov.fj Telephone : (679) 330 6177 Fax : (679) 330 6163 Office Hours : Website : WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4 Provident Plaza 1, Downtown Boulevard, 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@fij.wpro.who.int Telephone : (679) 330 4600 / 330 4631 Fax : (679) 330 0462 Office Hours : COUNTRY HEALTH INFORMATION PROFILE 75 FIJI WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 18.27 1 2 Estimated population ('000s) 832.45 … … 2003 est 2 3 Annual population growth rate (%) 0.74 a 2003 est. 2 4 Percentage of population - 0–14 years 35.30 … … 2002 est. 3 - 65+ years 3.10 … … 2002 est. 3 5 Urban population (%) 52.00 2001 2 6 Crude birth rate (per 1000 population) 19.48 … … 2002 3 7 Crude death rate (per 1000 population) 6.45 … … 2002 3 8 Rate of natural increase of population (% per annum) … … … 9 Health-adjusted life expectancy (HALE) (years) - at birth 68.60 66.50 70.70 2004 5 - at age 60 … 10.40 11.90 2002 10 10 Adult literacy rate (%) 93.20 95.20 91.20 2001 4 11 Neonatal mortality rate (per 1000 live births) 9.00 … … 2000 11 12 Infant mortality rate (per 1000 live births) 17.76 … … 2002 3 13 Under-five mortality rate (per 1000 live births) 22.35 … … 2002 4 14 Total fertility rate (women aged 15–49 years) 2.70 2000 2 15 Maternal mortality ratio (per 100 000 live births) 35.29 2002 3 16 Percent of newborn infants weighing at least 2500 g at birth 90.46 … … 1998 6 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 17.78 1998 6 19 Immunization coverage for infants (%) - BCG 100.00 … … 2003 9 - DTP3 94.00 … … 2003 9 - OPV3 100.00 … … 2003 9 - Measles 91.00 … … 2003 9 - Tetanus II 98.00 … … 2003 9 - Hepatitis B III 92.00 … … 2003 9 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 100.00 1998 6 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) 99.00 2002 5 21 Percentage of women in the reproductive age group using modern contraceptive methods 40.45 1998 6 22 Condom use rate of the contraceptive prevalence rate … … 14.80 2002 5 23 HIV prevalence among 15-24 year-old pregnant women < 0.01 2002 5 24 Number of children orphaned by HIV/AIDS … … … FIJI 76 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 65.00 95.00 53.00 2002 3 26 Proportion of population with access to improved sanitation 60.00 90.00 50.00 2002 3 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) 40.00 b … … 2003 9 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) a,b … … … 31 Human development index 0.76 … … 2002 4 32 Per capita GDP at current market prices (US$) 1896.44 a … … 2002 2 33 Rate of growth per capita GDP 6.16 a 2002 2 34 Health expenditure Total health expenditure - amount (in million US$) … - total health expenditure on health as % of GDP 3.00 2002 3 - per capita total expenditure on health (in US$) 60.61 a FY2003/4 2 Government expenditure on health - amount (in million US$) 90.10 FY2003/4 2 - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure 8.32 a FY2003/4 2 External sources of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 0.455 FJ$ 0.53 FJ$ 2002 2003 2 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population b 36 Health workforce - doctors 373 … … 4.49 … … 2003 7 - dentists 56 … … 0.67 … … 2003 7 - pharmacists 87 … … 1.05 … … 2003 7 - nurses (and assistant nurses) 1648 … … 19.82 … … 2003 7 - midwives … … … … … … - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 355 … … 4.27 … … 2003 7 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 963 … … 11.58 … … 2003 7 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … COUNTRY HEALTH INFORMATION PROFILE 77 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Five leading causes of morbidity Number Rate per 100 000 population 1. Respiratory disease … … … 614.05 … … 2001 3 2. Circulatory disease … … … 500.58 … … 2001 3 3. Injury and poisoning … … … 401.28 … … 2001 3 4. Infectious and parasitic disease … … … 364.34 … … 2001 3 5. Genitourinary disease … … … 321.60 … … 2001 3 40 Five leading causes of mortality Number Rate per 100 000 population 1. Circulatory disease … … … 329.96 … … 2001 3 2. Respiratory disease … … … 50.17 … … 2001 3 3. Infectious and parasitic disease … … … 45.76 … … 2001 3 4. Neoplasm … … … 37.98 … … 2001 3 5. Injury and poisoning … … … 31.71 … … 2001 3 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2003 9 - Pertussis (whooping cough) 0 0 0 … … … 2003 9 - Tetanus 0 0 0 … … … 2003 9 - Neonatal tetanus 0 0 0 … … … 2003 9 - Poliomyelitis 0 0 0 … … … 2003 9 - Hib Meningitis 96 … … … … … 2003 9 - Measles 305 … … … … … 2003 9 - Mumps 14 … … … … … 2003 9 - Rubella 65 … … … … … 2003 9 - Congenital rubella syndrome 0 0 0 … … … 2003 9 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A … … … … … … - Type B … … … … … … - Type C … … … … … … - Unspecified … … … … … … Cholera 0 0 0 … … … 2002 9 Typhoid fever … … … … … … Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … Gonorrhoea (gonococcal infections) … … … … … … Leprosy 2 … … … … … 2003 9 Malaria … … … … … … Dengue/DHF … … … … … … 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … 0.00 0.00 0.00 2002 9 - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … FIJI 78 INDICATORS DATA Year Source Total Male Female Total Male Female 44 Tuberculosis Number of cases Number of deaths - All types 179 … … … … … 2003 9 - New pulmonary tuberculosis (smear-positive) 70 … … … … … 2003 9 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 38.00 … … 4.00 … … 2003 9 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 63.00 … … 85.00 (2002) … … 2003 9 Number of cases (C) Number of deaths (D) 45 Acute respiratory infections 17 115 … … 0 0 0 C: 1998 D: 1999 C: 6 D: 8 46 Diarrhoeal diseases 12 272 … … 0 0 0 C: 1998 D: 1999 C: 6 D: 8 47 Cancers All cancers (malignant neoplasms only) 695 … … 229 61 168 C: 1998 C: 6 - Trachea, bronchus, and lung 6 … … 29 21 8 D: 1999 D: 8 - Stomach 35 … … 23 13 10 - Colon and rectum 18 … … 23 7 16 - Lip, oral cavity and pharynx 8 … … 0 0 0 - Liver … … … 0 0 0 - Cervix 89 0 … 60 0 60 - Leukaemia … … … 35 20 15 48 Circulatory All circulatory system diseases 4682 … … 1052 659 393 C: 1998 C: 6 - Ischaemic heart disease 1014 … … 421 341 80 D: 1999 D: 8 - Acute myocardial infarction 530 … … 421 341 80 - Rheumatic fever and rheumatic heart diseases 185 … … 29 8 21 - Cerebrovascular diseases 715 … … 461 241 220 - Hypertension 764 … … 140 68 72 49 Maternal causes - Haemorrhage 366 366 0 0 C: 1998 C: 6 - Abortion 53 53 1 1 D: 1999 D: 8 - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … 50 Diabetes mellitus 783 … … 185 93 92 C: 1998 D: 1999 C: 6 D: 8 51 Mental disorders 123 … … 0 0 0 C: 1998 D: 1999 C: 6 D: 8 52 Injuries - All types 4146 … … 54 … … 1998 6 - Motor and other vehicle accidents 551 … … 13 … … 1998 6 - Suicide 156 … … 8 … … 1998 6 COUNTRY HEALTH INFORMATION PROFILE 79 INDICATORS DATA Year Source Total Male Female Total Male Female 52 Injuries - Homicide and violence 359 … … 1 … … 1998 6 - Occupational injuries … … … … … … 1998 6 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities 99 2097 1999 1 - General hospitals … … - Specialized hospitals … … - District/first-level referral hospitals … … - Primary health care centres … … Private hospitals … … Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate FY Fiscal year C Cases D Deaths a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Modeled data. c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Fiji in Profile. Fiji Islands Statistics Bureau (http://www.statsfiji.gov.fj/f_demographic.html), updated 13 August 2003 2 Fiji Islands Bureau of Statistics (http://www.spc.int/prism/Country/FJ/stats/index.htm) 3 Ministry of Health, April 2004 4 Human Development Report 2004. UNDP 5 Ministry of Health, February 2005 6 Annual tabulation for 1998, Ministry of Health 7 Draft Master Plan of Social Health Insurance Development in Fiji 8 Fiji mortality statistics by gender, furnished by the WHO Representative in the South Pacific, 21 June 2001 9 WHO Regional Office for the Western Pacific, data received from technical units 10 The World Health Report 2004. Changing history. Geneva, World Health Organization, 2004. 11 The World Health Report 2005. Make every mother and child count. Geneva, World Health Organization, 2005. 80 | COUNTRY HEALTH INFORMATION PROFILES FRENCH POLYNESIA 1. DEMOGRAPHICS, GENDER AND POVERTY In 2003, French Polynesia had an estimated population of 247 018, with around 30% below 15 years of age and almost 5% above 65 years of age. Around 52% of the population are urban dwellers. There are 106 males for every 100 females. Table 1. Core population and health data (2003) [Total] 247 018 [Both] … [0-14 years] (30.30%) (2002) [Male] 69.20 (1998-2002) Population [65+ years] 11 363 (4.60%) Life expectancy at birth (years) [Female] 74.10 (1998-2002) Crude birth rate (per 1000 population) 18.20 Total fertility rate 2.40 (2002) [Total] 100.00 (2002) [Urban] 100.00 (2002) Crude death rate (per 1000 population) 4.50 % of population served with safe water [Rural] 100.00 (2002) [Total] 98.00 (2002) [Urban] 99.00 (2002) Infant mortality rate (per 1000 live births) 6.90 % of population with adequate sanitary facilities [Rural] 97.00 (2002) Maternal mortality ratio (per 100 000 live births) 0.00 (2002) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The final legal steps (an endorsement by France’s Constitutional Council) towards the attainment by French Polynesia of greater autonomy was expected to have been taken by late February 2004. Enabling legislation has already been approved by the French Senate and National Assembly and by French President Jacques Chirac to change the status of French Polynesia to a “French overseas country” instead of an overseas territory, with powers to restrict the now free admission of settlers, and with more powers to control land tenure and management, civil aviation and relations with other countries. Immigration powers are intended to reserve jobs for residents present for a minimum of 10 years. France will return control of military, financial and judicial matters. French Polynesia will be allowed to open overseas representative offices, but these will not have diplomatic status. Territorial President Gaton Flosse would like further concessions for autonomy, but rules out full independence from France. French Polynesia is expected to argue that its claim to have won more self-government qualifies it to be admitted as an observer at meetings of the Pacific Islands Forum. 2.2 Economic situation French Polynesia has reached a high level of health and socioeconomic development, as shown by the principal indicators. About 10% (US$ 300 million) of the GNP is currently spent on health. This favourable situation may be attributed to significant socioeconomic development and to the gradual implementation of an efficient health care system. 3. HEALTH SITUATION 3.1 Health trends Like many other countries, French Polynesia is experiencing an epidemiological transition where communicable diseases are decreasing while noncommunicable diseases are increasing. Nearly all COUNTRY HEALTH INFORMATION PROFILES | 81 of the population have ready access to quality health care, resulting in immunization coverage levels of over 90%, low infant mortality rates (6.90 infants deaths per 1 000 live births), a low maternal morality ratio and a high life expectancy at birth of 69.2 years for men and 74.1 years for women. While morbidity due to acute respiratory infections remains fairly high, especially in rural and poor urban districts, improvements in medical care have resulted in very low mortality for these conditions. The leading causes of mortality are noncommunicable diseases, especially cardiovascular diseases and cancers. 3.2 Health systems Collaboration with international and regional organizations such as WHO and the South Pacific Commission has taken on particular significance in recent years. In order to strengthen health services, one or two nurses have been assigned to each island in French Polynesia and are responsible for local coordination of the various public health programmes. They are the liaison persons for the programme managers and are responsible for implementation and evaluation. These nurse coordinators are regularly recalled to share their experiences and be informed on the status of the different public health programmes and their outcomes. About 15 nurses work in isolated communities where there is no doctor. 4. NATIONAL HEALTH PLAN AND PRIORITIES Although “Health for all by the year 2000” was adopted as a general objective of the health policy in the early 1980s, French Polynesia has not defined or implemented a health development strategy. Nevertheless, most primary health care services are delivered at the first contact level. The Direction de la Santé (Directorate for Health) is mandated by the Ministry of Health to prepare, every five years, a master plan for health as a high priority. Emphasis is placed on planning and management processes, and on decentralization. The recent reorganization of the administrative structure of the Direction de la Santé should facilitate the process. 5. MAJOR INFORMATION SOURCES Bureau de la Veille Sanitaire, Direction de la Santé en Polynésie Française Institut de la Statistique de Polynésie Française Secretariat of the Pacific Community, Pacific Regional Information System (PRISM) (http://www.spc.int/prism) 6. ADDRESSES MINISTRY OF HEALTH Office Address : Ministère de la Santé B.P. 611, 98713 Papeete TAHITI, Polynésie Française Postal Address : Official Email Address : Maheata.schyle@sante.gov.pf Telephone : (689) 46 00 56 Fax : (689) 46 00 59 Office Hours : WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4 Provident Plaza One Downtown Boulevard 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@fij.wpro.who.int Telephone : (679) 3-304600 / 3-304631 / 3-300727 Fax : (679) 3-300462 FRENCH POLYNESIA 82 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: DEPARTMENT OF HEALTH COUNTRY HEALTH INFORMATION PROFILE 83 FRENCH POLYNESIA WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 3.52 2004 7 2 Estimated population ('000s) 247.02 … … 2003 1 3 Annual population growth rate (%) 1.80 1996-2002 2 4 Percentage of population - 0–14 years 30.30 30.40 30.30 2002 2 - 65+ years 4.60 4.20 4.90 2003 2 5 Urban population (%) 52.10 … … 2003 5 6 Crude birth rate (per 1000 population) 18.20 … … 2003 1 7 Crude death rate (per 1000 population) 4.50 … … 2003 1 8 Rate of natural increase of population (% per annum) 1.37 2003 2 9 Health-adjusted life expectancy (HALE) (years) - at birth … 69.20 74.10 1998-2002 7 - at age 60 15.10 18.70 1997-2001 2 10 Adult literacy rate (%) … … … 11 Neonatal mortality rate (per 1000 live births) 4.00 … … 2002 1 12 Infant mortality rate (per 1000 live births) 6.90 … … 2003 2 13 Under-five mortality rate (per 1000 live births) 9.00 … … 2002 1 14 Total fertility rate (women aged 15–49 years) 2.40 2002 7 15 Maternal mortality ratio (per 100 000 live births) 0.00 2002 1 16 Percentage of newborn infants weighing at least 2500 g at birth 93.00 … … 2001 1 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 66.60 2002 3 19 Immunization coverage for infants (%) - BCG 99.00 2003 9 - DTP3 99.00 2003 9 - OPV3 99.00 2003 9 - Measles … - Tetanus II … - Hepatitis B III 98.00 2003 9 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 100.00 2000 8 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 100.00 2000 8 - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … FRENCH POLYNESIA 84 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 100.00 100.00 2002 4 26 Proportion of population with access to improved sanitation 98.00 99.00 97.00 2002 4 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index … … … 32 Per capita GDP at current market prices (US$) 15 063.30 a … … 2002 2 33 Rate of growth per capita GDP … … … 34 Health expenditure Total health expenditure - amount (in million US$) … - total health expenditure on health as % of GDP … - per capita total expenditure on health (in US$) … Government expenditure on health - amount (in million US$) … - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure … External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 126.93 F.CFP (average) 2002 9 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 447 a … … 17.80 … … 2004 est 2 - dentists (dental surgeons) 113 a … … 4.10 … … 2004 est 2 - pharmacists 100 a … … 4.00 … … 2004 est 2 - nurses c 824 … … 35.90 … … 2000 1 - midwives c 93 … … 15.80 … … 2000 1 - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) … … … … … … - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … COUNTRY HEALTH INFORMATION PROFILE 85 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Five leading causes of morbidity Number Rate per 100 000 population 1. Acute respiratory infections 27 259 … … 11 035.0 … … 2003 1 2. Influenza (flu-like syndrome) 18 357 … … 7 431.0 … … 2003 1 3. Infections of the skin and subcutaneous tissues 16 085 … … 6 511.0 … … 2003 1 4. Pharyngitis 7 544 3 054.0 … … 2003 1 5. Acute otitis media 6 294 … … 2 548.0 … … 2003 1 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Diseases of the circulatory system 260 139 121 105.3 … … 2003 1 2. Neoplasms 245 133 112 99.2 … … 2003 1 3. Injuries and external causes 122 100 22 49.4 … … 2003 1 4. Symptoms, signs and findings, not elsewhere classified 93 61 32 37.6 … … 2003 1 5. Diseases of the respiratory system 93 61 51 37.6 … … 2003 1 6. Diseases of the genitourinary system 47 29 18 19.0 … … 2003 1 7. Infectious and parasitic diseases 40 25 15 16.2 … … 2003 1 8. Endocrine diseases 38 20 18 15.4 … … 2003 1 9. Diseases of the digestive system 35 26 9 14.2 … … 2003 1 10. Diseases of the nervous system 23 15 8 9.3 … … 2003 1 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 … … 0 0 0 2003 1 - Pertussis (whooping cough) 1 … … 0 0 0 2003 1 - Tetanus 0 … … 0 0 0 2003 1 - Neonatal tetanus 0 0 0 0 0 0 2003 1 - Poliomyelitis 0 0 0 0 0 0 2003 1 - Hib meningitis 0 … … 2 1 1 2003 1 - Measles 0 … … 0 0 0 2003 1 - Mumps 12 … … 0 0 0 2003 1 - Rubella 3 … … 0 0 0 2003 1 - Congenital rubella syndrome … … … 0 0 0 2003 1 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A 0 … … 0 0 0 2003 1 - Type B 168 … … 0 0 0 2003 1 - Type C 43 … … 0 0 0 2003 1 - Unspecified 13 … … 0 0 0 2003 1 Cholera 0 0 0 0 0 0 2003 1 Typhoid fever 0 0 0 0 0 0 2003 1 Encephalitis … … … 0 0 0 2003 1 Plague 0 0 0 0 0 0 2003 1 Syphilis 0 … … 0 0 0 2003 1 Gonorrhoea 94 … … 0 0 0 2003 1 Leprosy 0 … … 1 1 0 2003 1 Malaria … … … 0 0 0 2003 1 Dengue/DHF 6 … … 0 0 0 2003 1 FRENCH POLYNESIA 86 INDICATORS DATA Year Source Total Male Female Total Male Female 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures b … - Proportion of population in malaria-risk areas using effective malaria treatment measures c … 44 Tuberculosis Number of cases Number of deaths - All types 50 … … … … … 2003 9 - New pulmonary tuberculosis (smear-positive) 21 … … … … … 2003 9 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 39.00 … … 5.00 … … 2003 9 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 65.00 … … 82.00 (2002) … … 2003 9 Number of cases (C) Number of deaths (D) 45 Acute respiratory infections 27 259 … … 0 0 0 2003 1 46 Diarrhoeal diseases 7 406 … … 9 5 4 2003 1 47 Cancers All cancers (malignant neoplasms only) 427 237 190 245 133 112 2003 1 - Trachea, bronchus and lung 57 48 9 64 45 19 2003 1 - Stomach 11 8 3 8 4 4 2003 1 - Colon and rectum 20 13 7 9 6 3 2003 1 - Lip, oral cavity and pharynx 13 9 4 8 7 1 2003 1 - Liver 17 14 3 14 8 6 2003 1 - Cervix 12 0 12 0 0 0 2003 1 - Leukaemia 18 11 7 9 5 4 2003 1 48 Circulatory All circulatory system diseases … … … 260 139 121 C: 2001 1 - Ischaemic heart disease … … … 54 32 22 D: 2003 1 - Acute myocardial infarction … … … 28 15 13 - Rheumatic fever and rheumatic heart diseases … … … 3 1 2 - Cerebrovascular diseases … … … 54 31 23 - Hypertension … … … 31 15 16 49 Maternal causes - Haemorrhage … … 0 0 2003 1 - Abortion … … 0 0 2003 1 - Eclampsia … … 0 0 2003 1 - Sepsis … … 0 0 2003 1 - Obstructed labour … … 0 0 2003 1 50 Diabetes mellitus … … … … … … 51 Mental disorders … … … … … … COUNTRY HEALTH INFORMATION PROFILE 87 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 52 Injuries - All types … … … 122 100 22 2003 1 - Motor and other vehicle accidents … … … 33 28 5 2003 1 - Suicide … … … 28 24 4 2003 1 - Homicide and violence … … … 0 0 0 2003 1 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 5 624 2003 1 - Specialized hospitals … … - District/first-level referral hospitals 13 62 (observation beds) 2003 1 - Primary health care centres 86 … 2003 1 Private hospitals 4 285 2003 1 Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate C Cases D Deaths a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. c Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Bureau de la Veille Sanitaire, Direction de la Santé en Polynésie Française 2 Institut de la Statistique de Polynésie Française (http://www.ispf.pf) 3 Service de Protection Maternelle, Direction de la Santé 4 Meeting the MDG drinking water and sanitation targets: A mid-term assessment of progress. WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2004. 5 Urban and rural areas 2003. New York, United Nations Department of Economic and Social Affairs, Population Division, 2004 6 Demographic tables for the Western Pacific Region 2000-2005. Manila, WHO Regional Office for the Western Pacific, 2005 7 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 8 Information furnished by the Bureau of Epidemiology and Health Statistics, 3 May 2002 9 WHO Regional Office for the Western Pacific, data received from the technical units 88 | COUNTRY HEALTH INFORMATION PROFILES GUAM 1. DEMOGRAPHICS, GENDER AND POVERTY The population of Guam was projected to be 166 090 in 2004, and it is estimated that there are 105 males for every 100 females. Population density is 307 per square kilometre. In 2003, preliminary estimation showed that life expectancy for both sexes was 77.80 years. Men were expected to live up to 74.82 years and women up to 81.03 years. Table 1. Core population and health data (2004 estimate) [Total] 166 090 [Both] 77.80 (2003p) [0-14 years] (31.68%) [Male] 74.82 (2003p) Population [65+ years] (4.54%) Life expectancy at birth (years) [Female] 81.03 (2003p) Crude birth rate (per 1000 population) 20.20 (2003p) Total fertility rate 2.70 (2003p) [Total] 100.00 (2003p) [Urban] … Crude death rate (per 1000 population) 4.30 (2003p) % of population served with safe water [Rural] … [Total] 100.00 (2003p) [Urban] … Infant mortality rate (per 1000 live births) 11.22 (2003p) % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 0.00 (2003p) p - preliminary 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The political situation on Guam remains stable, with elections for the mayors of municipal civil districts (villages) and the unicameral Legislature scheduled for the third quarter of 2004. Cooperation between the Executive Branch and the Legislative Branch is growing. 2.2 Economic situation Guam has been in a financial crisis since the 1994 fiscal year. The economic decline is related to the Asian economic crisis and unforeseen events such as supertyphoons (which have destroyed much of Guam’s infrastructure and left much of the island with little or no potable water for weeks and no electricity for two to three months in some areas), the war in Iraq, and the outbreak of severe acute respiratory syndrome (SARS). Guam’s economy is heavily reliant on the tourism industry, with the majority of visitors originating from Japan and the Pacific rim. Tourist arrivals and expenditures have dwindled due to the aforementioned events, although there are indications of an upswing in 2004. The most critical impact of the crisis has been in the employment area. According to the local Department of Labour office, Guam’s unemployment rate was 7.7 % as of March 2004. The latest statistics (2001) show a per capita income of US$ 10 872. This is significantly lower than the 2001 per capita income (US$ 22 794) and unemployment rate (5.7%) in the United States of America. COUNTRY HEALTH INFORMATION PROFILES | 89 3. HEALTH SITUATION 3.1 Health trends The provisional crude death rate in 2003 was 4.3 per 1000 population, a slight increase from 4.1 in 2002. However, the provisional infant mortality rate in 2003 was 11.22 per 1000 live births, a significant increase from the 2002 rate of 6.21 per 1000 live births. Although the health status of Guam’s population continues to improve, the five leading causes of death in 2002 remain as follows: diseases of the heart (130.39 per 1000 population), malignant neoplasm (76.99), cerebrovascular disease (32.29), all other accidents (14.28) and suicide (13.66). 3.2 Health systems Guam is faced with the challenge of maintaining a health care system that will adequately meet the needs of a predominantly young and growing population. At the same time, it is also faced with the added challenge of addressing the problems of the rapidly increasing number of older people, forecast to increase from 3.9% of the total population in 1990 to 7.5% in 2010. A reduction in human and financial resources has severely impacted the health system. An early retirement programme, instituted at the end of 1999, led many experienced health workers to retire. While the vacated positions have continued to be funded, there is not a large enough resource pool to fill all of them. Tightening government budgets have left some less critical positions vacant, and these vacancies have reduced the overall amount of services available to the uninsured and underinsured population. The vacancies have also affected progress in strengthening other health service priority areas, such as disposal of hazardous and toxic materials, environmental protection, vector control, and drug and alcohol abuse services. 4. NATIONAL HEALTH PLAN AND PRIORITIES Guam is dedicated to the attainment of health for all by the year 2010. In 1992, the Guam Health Planning and Development Agency identified 13 health service priority areas to be strengthened: • human resources development; • health planning; • wellness promotion; • health information systems; • communicable disease control; • disposal of hazardous and toxic materials; • availability and accessibility of health services; • environmental protection; • drug and alcohol abuse; • chronic disease prevention and control; • injury prevention; • maternal and child health; and • vector control. Although some improvement has been made in the area of health information systems, wellness promotion, and communicable disease control, the remaining areas continue to be top priorities. All public health services depend on having a basic infrastructure, especially in terms of personnel. Unfortunately, Guam is experiencing health workforce shortages due to the early retirement of its most experienced professionals. Human resources for health in critical areas are still lacking and must be developed locally to the greatest extent possible. The following training needs are priorities: environmental studies, with an emphasis in environmental law, policy, management, and planning and analysis; and short-term training in retail hazard analysis critical control point (HACCP), and in drugs, medical devices and controlled substances. GUAM 90 | COUNTRY HEALTH INFORMATION PROFILES The Guam Environmental Protection Agency (GEPA) relies heavily on its professional staff to provide technical expertise in all areas of environmental resource protection, management and policy. In addition, technical expertise in the areas of environmental protection, management and policy is needed for the young professionals within GEPA, as the fields of environmental protection and science are constantly changing. However, due to early retirement and voluntary separation, all personnel with over 10 years of professional and technical experience have left GEPA, leaving half (two out of four) of the remaining personnel with less than four years of professional GEPA experience. Combined with the local hiring freeze, it is anticipated that no new professionals will be hired within the next two to three years. The lack of well-educated and technically trained personnel is severely undermining the professional credibility of GEPA. To further complicate matters, GEPA also serves as the primary regulatory agency for all environmental issues and policies on Guam, and takes the lead for most other islands in Micronesia. The Division of Environmental Health of the Department of Public Health and Social Services (DPHSS) is also greatly understaffed. Over half of the Division's staff have fewer than five years experience, and staff generally lack specialized training. Training in retail HACCP is lacking. The United States Federal Drug Administration is urging all locales, states and territories to explore HACCP as a requirement in retail and food service establishments, and to develop a model food code that incorporates HACCP principles. All health care products, from toothbrushes to prescription medications, are regulated and enforced by the Drug and Medical Device Programme. Because of Guam's geographical location and the ethnic diversity of its people, various drugs and medical devices of foreign origin are imported, distributed and marketed. This includes many poorly labelled, misbranded and adulterated drugs, as well as hazardous medical devices. Training in the area of drug and medical devices is therefore necessary for Division of Environmental Health staff. Forged prescriptions, lack of accountability of controlled substances by businesses, and illegal dispensing of controlled substances are estimated to be significant problems. However, because of the lack of human resources, only urgent cases are pursued and investigated. 5. MAJOR INFORMATION SOURCES Office of Vital Statistics, Guam Department of Health and Social Services Department of Health and Social Services, Guam United States of America Bureau of the Census Secretariat of the Pacific Community (http://www.spc.int/prism/) 6. ADDRESSES DEPARTMENT OF HEALTH AND SOCIAL SERVICES Office Address : Postal Address : P.O. Box 2816, Agana, Guam 96910 Official Email Address : Telephone : (671) 735-7102 Fax : (671) 734-5910 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILES | 91 WHO REPRESENTATIVE There is no WHO Representative in Guam. Queries about WHO’s programme of collaboration with Guam should be directed to the Director (Programme Management): Office Address : World Health Organization Regional Office for the Western Pacific, United Nations Avenue, Manila, Philippines 1000 Postal Address : P.O. Box 2932, Manila, Philippines 1000 Official Email Address : Telephone : (632) 528-8001 (trunk line) Fax : Office Hours : 0700H-1530H http://www.wpro.who.int GUAM 92 GUAM WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 0.54 2004 1 2 Estimated population ('000s) 166.09 … … 2004 est 3 3 Annual population growth rate (%) 1.57 a … … 2003p 3 4 Percentage of population - 0–14 years 31.68 30.79 32.70 2004 est 2 - 65+ years 4.54 4.21 4.90 2004 est 2 5 Urban population (%) 93.00 … … 2000 1 6 Crude birth rate (per 1000 population) 20.20 … … 2003p 3 7 Crude death rate (per 1000 population) 4.30 … … 2003p 3 8 Rate of natural increase of population (% per annum) 1.70 ... … 2004 est 1 9 Health-adjusted life expectancy (HALE) (years) - at birth 77.80 74.82 81.03 2003p 3 - at age 60 … … … 10 Adult literacy rate (%) … … … 11 Neonatal mortality rate (per 1000 live births) 3.41 … … 2002 b 3 12 Infant mortality rate (per 1000 live births) 11.22 … … 2003p 3 13 Under-five mortality rate (per 1000 live births) 12.28 15.58 8.71 2001 5 14 Total fertility rate (women aged 15–49 years) 2.70 2003p 3 15 Maternal mortality ratio (per 100 000 live births) 0.00 2003p 6 16 Percentage of newborn infants weighing at least 2500 g at birth 92.00 92.32 91.75 2001 5 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 1.20 2001 5 19 Immunization coverage for infants (%) - BCG NR … …. 2004 4 - DTP3 87.00 … … 2004 4 - OPV3 79.00 … … 2004 4 - Measles 82.00 … … 2004 4 - Tetanus II NR … … 2004 4 - Hepatitis B III 85.00 … … 2004 4 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 92.05 2001 5 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … COUNTRY HEALTH INFORMATION PROFILE 93 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 … … 2003p 6 26 Proportion of population with access to improved sanitation 100.00 … … 2003p 6 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) <5.00 … … 2003 4 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index … … … 32 Per capita income at current market prices (US$) 10 872.00 … … 2001 6 33 Rate of growth per capita GDP … … … 34 Health expenditure Total health expenditure - amount (in million US$) 159 814 294.00 2000 5 - total health expenditure on health as % of GDP … - per capita total expenditure on health (in US$) 1032.36 2000 5 Government expenditure on health - amount (in US$) 34 347 000.00 FY2000 3 - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure 6.18 FY2000 3 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 166 … … 11.10 … … 1999 5 - dentists (dental surgeons) 31 … … 2.05 … … 1999 5 - pharmacists 57 … … 3.80 … … 1997 5 - nurses (including midwives) 647 … … 43.40 … … 1997 5 - midwives … … … … … … - other nursing/ auxiliary staff 164 … … 11.00 … … 1997 5 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) … … … … … … - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … GUAM 94 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. … … … … … … 2. … … … … … … 3. … … … … … … 4. … … … … … … 5. … … … … … … 6. … … … … … … 7. … … … … … … 8. … … … … … … 9. … … … … … … 10. … … … … … … 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Diseases of the heart 210 … … 130.39 … … 2002 3 2. Malignant neoplasm 124 … … 76.99 … … 2002 3 3. Cerebrovascular disease 52 … … 32.29 … … 2002 3 4. All other accidents 23 … … 14.28 … … 2002 3 5. Suicide 22 … … 13.66 … … 2002 3 6. Pneumonia 22 … … 13.66 … … 2002 3 7. Chronic obstructive pulmonary disease 20 … … 12.42 … … 2002 3 8. Bacterial diseases (septicemia) 18 … … 11.18 … … 2002 3 9. Diabetes mellitus 18 … … 11.18 … … 2002 3 10. Motor vehicle accidents 13 … … 8.07 … … 2002 3 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 … … … … … 2004 4 - Pertussis (whooping cough) 0 … … … … … 2004 4 - Tetanus 0 … … … … … 2004 4 - Neonatal tetanus 0 … … … … … 2004 4 - Poliomyelitis 0 … … … … … 2004 4 - Hib meningitis 0 … … … … … 2004 4 - Measles 2 … … … … … 2004 4 - Mumps 1 … … … … … 2004 4 - Rubella 1 … … … … … 2004 4 - Congenital rubella syndrome 0 … … … … … 2004 4 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral 17 … … 2 … … 2003 4 - Type A 2 … … 0 … … 2003 4 - Type B 10 … … 1 … … 2003 4 - Type C 5 … … 1 … … 2003 4 - Unspecified … … … … … … Cholera 0 0 0 0 0 0 2003 4 Typhoid fever 0 0 0 0 0 0 2003 4 Encephalitis 2 … … 0 0 0 2003 4 Plague 0 0 0 0 0 0 2003 4 Syphilis … … … … … … Gonorrhoea (gonococcal infections) … … … … … … Leprosy 1 … … … … … 2001 4 COUNTRY HEALTH INFORMATION PROFILE 95 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Malaria … … … … ... … Dengue/DHF … … … … … … 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 22 … … … … … 2003 4 - New pulmonary tuberculosis (smear-positive) 0 … … … … … 2003 4 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 105.00 … … 12.00 … … 2003 4 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 67.00 … … 68.00 … … 2002 4 Number of cases Number of deaths 45 Acute respiratory infections 137 … … 11 7 4 2000 5 46 Diarrhoeal diseases … … … 0 0 0 2000 5 47 Cancers All cancers (malignant neoplasms only) … … … 125 74 51 2000 5 - Trachea, bronchus, and lung … … … 36 22 14 2000 5 - Stomach … … … 7 3 4 2000 5 - Colon and rectum … … … 13 8 5 2000 5 - Lip, oral cavity and pharynx … … … 1 1 0 2000 5 - Liver … … … 7 6 1 2000 5 - Cervix … … … 2 0 2 2000 5 - Leukaemia … … … 4 1 3 2000 5 48 Circulatory All circulatory system diseases … … … 246 149 97 2000 5 - Ischaemic heart disease … … … 142 88 54 2000 5 - Acute myocardial infarction … … … 25 19 6 2000 5 - Rheumatic fever and rheumatic heart diseases … … … 2 2 0 2000 5 - Cerebrovascular diseases … … … 58 33 25 2000 5 - Hypertension … … … 15 10 5 2000 5 49 Maternal causes - Haemorrhage 57 … … 0 0 0 2000 5 - Abortion 76 … … 0 0 0 2000 5 - Eclampsia … … … … … … - Sepsis … … … … … … - Obstructed labour … … … … … … 50 Diabetes mellitus … … … 21 8 13 2000 5 51 Mental disorders … … … 0 0 0 2000 5 GUAM 96 INDICATORS DATA Year Source Total Male Female Total Male Female 52 Injuries - All types … … … 82 69 13 2000 5 - Motor and other vehicle accidents … … … 23 18 5 2000 5 - Suicide … … … 29 27 2 2000 5 - Homicide and violence … … … 4 2 2 2000 5 - Occupational injuries … … 5 4 1 2000 5 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 225 2000 5 - Specialized hospitals 0 0 2000 5 - District/first-level referral hospitals 0 0 2000 5 - Primary health care centres 2 0 2000 5 Private hospitals 0 0 2000 5 Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate p Provisional NR Not relevant FY Fiscal year a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific b Revised data c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Pacific Island Populations 2004. Secretariat of the Pacific Community 2 Demographic Tables for the Western Pacific Region 2000-2005. Manila, WHO Regional Office for the Western Pacific 3 Guam Bureau of Statistics and Plans <http://www.spc.int/prism> 4 WHO Regional Office for the Western Pacific, data received from the technical units 5 Information furnished by the Department of Health and Social Services, Guam, 16 January 2003 6 Information furnished by the Department of Health and Social Services, Guam, 21 June 2004 COUNTRY HEALTH INFORMATION PROFILES | 97 HONG KONG (CHINA) 1. DEMOGRAPHICS, GENDER AND POVERTY The population of Hong Kong (China) was 6 803 100 in 2003, comprising 3 294 000 men and 3 509 100 women. For more than three decades, life expectancy at birth has been rising steadily, reaching 78.54 years among males and 84.31 years among females in 2003. As a result of a decreasing birth rate and increasing life expectancy, Hong Kong's population has been ageing steadily. In 2003, 11.69% of the population were aged 65 and above (7.0% in 1983, 9.3% in 1993), while the elderly dependency ratio was 161 per 1000 population aged 15 to 64 (102 in 1983, 132 in 1993). Table 1. Core population and health data (2003) [Total] 6 803 100 [Both] … [0-14 years] 1 069 200 (15.72%) [Male] 78.54 Population [65+ years] 795 500 (11.69%) Life expectancy at birth (years) [Female] 84.31 Crude birth rate (per 1000 population) 7.01 Total fertility rate 0.94 [Total] 100.00 (2004) [Urban] 100.00 (2004) Crude death rate (per 1000 population) 5.35 % of population served with safe water [Rural] … [Total] 99.00 (2004) [Urban] … Infant mortality rate (per 1000 live births) 2.26* % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 4.19* Note: * Provisional figure. 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Hong Kong is a Special Administrative Region (SAR) of the People’s Republic of China. Under the Basic Law, Hong Kong (China) enjoys a high degree of autonomy except in defence, foreign affairs and other matters falling outside the autonomy of the SAR. Hong Kong exercises executive, legislative and independent judicial power, including that of final adjudication. The Government introduced a new accountability system for principal officials on 1 July 2002. Under the new system, the politically appointed principal officials accept total responsibility relating to their respective portfolios. 2.2 Economic situation Hong Kong is one of the world’s most successful communities. Within the space of two generations, economic growth has transformed the living standards of its 6.8 million people. Gross domestic product (GDP) grew at an average annual rate of 3.23% in real terms during the 10 years to 2003. Per capita GDP increased by 1.49% in money terms over the same period, reaching US$ 23 000 (HK$ 179 300) in 2003. The economy continued to perform well in 2004. For the financial year 2003-2004, public expenditure on health reached US$ 4.4 billion, representing 12.35% of total public expenditure. HONG KONG (CHINA) 98 | COUNTRY HEALTH INFORMATION PROFILES 3. HEALTH SITUATION 3.1 Health trends Hong Kong takes pride in having achieved health indices that rank among the best in the world. Infant and under-five mortality rates are consistently low, as is the maternal mortality ratio. Chronic degenerative diseases, among others, are the major causes of death. Preliminary figures in 2003 show the four major killers were malignant neoplasms (11 510 deaths), diseases of the heart (5309), pneumonia (3867) and cerebrovascular diseases (3462); they represented approximately 66.3% of all deaths. Children are immunized against tuberculosis, diphtheria, pertussis, poliomyelitis, tetanus, hepatitis B, measles, mumps and rubella. Due to high immunization coverage, diseases such as diphtheria and poliomyelitis have been virtually eradicated, and the incidence of preventable infectious diseases among children is relatively low. In 2003, the number of tuberculosis (TB) notifications was 5624, representing a decrease of 9.9% compared with 2002 figures. The TB notification rate was 79 per 100 000 population, largely due to the ageing population and overcrowded living environment. By the end of 2003, a cumulative total of 2244 cases of HIV infection and 669 AIDS patients had been reported. The Government has enhanced its capacity to manage disease outbreaks. The Centre for Health Protection was set up under the Department of Health on 1 June 2004 to achieve effective prevention and control of diseases, in collaboration with local and international stakeholders. 3.2 Health systems In 2003, there were 11 016 doctors, 1848 dentists, 1457 pharmacists, 43 782 registered and enrolled nurses, 4791 midwives, 4738 registered Chinese medicine practitioners, 3227 listed Chinese medicine practitioners, and 67 chiropractors. There were 8822 other health care personnel under statutory registration, including medical laboratory technologists, physiotherapists, occupational therapists, optometrists and radiographers. 4. NATIONAL HEALTH PLAN AND PRIORITIES The Government’s health care policy is that no one should be denied adequate medical treatment through lack of means. To this end, it provides a range of services and facilities through the Department of Health and the Hospital Authority to meet the needs of the public. These are complemented by health services provided in the private sector. The Department of Health is the Government’s health adviser and the agency charged with the responsibility of executing health care policies and statutory functions. It safeguards the community’s health through a range of promotional, preventive, curative and rehabilitative services. It is committed to providing quality client-oriented service. The Hospital Authority is a statutory body responsible for the management of all public hospitals. It provided medical treatment and rehabilitation services to patients through outreach services, specialist clinics and 38 public hospitals during 2003. The Government’s goal is to provide a health care system that is able to protect and promote health and to provide quality health care services to citizens at reasonable prices. To meet the changing needs of the community, the Government will continue to improve the quality of patient care and review the health care system to ensure the continued delivery of quality care at reasonable cost. COUNTRY HEALTH INFORMATION PROFILES | 99 5. MAJOR INFORMATION SOURCES Department of Health, Hong Kong Special Administrative Region Government (HKSARG) Lands Department, HKSARG Census and Statistics Department, HKSARG Planning Department, HKSARG Immigration Department, HKSARG Water Supplies Department, HKSARG Drainage Services Department, HKSARG Financial Services and the Treasury Bureau, Government Secretariat, HKSARG Hospital Authority of the HKSARG 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : 21/F Wu Chung House, 213 Queen’s Road East, Wan Chai, Hong Kong Postal Address : 21/F Wu Chung House, 213 Queen’s Road East, Wan Chai, Hong Kong Official Email Address : enquiries@dh.gov.hk Telephone : 29618989 Fax : 28360071 Office Hours : Mon to Fri: 9am-5pm; Sat: 9am-1pm; Sun & Public Holidays off Website : http://www.info.gov.hk/dh/ WHO REPRESENTATIVE There is no WHO Representative in Hong Kong (China). Queries about WHO’s programme of collaboration with Australia should be directed to Director, Programme Management, WHO Regional Office for the Western Pacific. Office Address : Director, Programme Management World Health Organization Regional Office for the Western Pacific United Nations Avenue P.O. Box 2932, 1000 Manila, the Philippines Postal Address : Official Email Address : Telephone : +6325288001 Fax : +6325211036 Office Hours : Website : http://www.wpro.who.int HONG KONG (CHINA) 100 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: DEPARTMENT OF HEALTH COUNTRY HEALTH INFORMATION PROFILE 101 HONG KONG (CHINA) WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 1.10 2004 2 2 Estimated population ('000s) 6803.10 3294.00 3509.10 2003 3 3 Annual population growth rate (%) 0.24 -0.18 0.63 2003 3 4 Percentage of population - 0–14 years 15.72 16.74 14.76 2003 3 - 65+ years 11.69 11.18 12.17 2003 3 5 Urban population (%) 94.60 … … 2003 4 6 Crude birth rate (per 1000 population) 7.01 a 7.49 a 6.55 a 2003 1, 3, 5 7 Crude death rate (per 1000 population) 5.35 a, b 6.21 a 4.55 a 2003 1, 3 8 Rate of natural increase of population (% per annum) 0.15 … … 2003 3 9 Health-adjusted life expectancy (HALE) (years) - at birth … 78.54 84.31 2003 3 - at age 60 … 21.86 26.24 2003 3 10 Adult literacy rate (%) 93.06 c 96.62 c 89.80 c 2003 3 11 Neonatal mortality rate (per 1000 live births) 1.20 a, h 1.30 a, h 1.09 a, h 2003 1, 3, 5 12 Infant mortality rate (per 1000 live births) 2.26 a, h 2.35 a, h 2.17 a, h 2003 1, 3, 5 13 Under-five mortality rate (per 1000 live births) 3.27 a, h 3.20 a, h 3.35 a, h 2003 1, 3, 5 14 Total fertility rate (women aged 15–49 years) 0.94 2003 3 15 Maternal mortality ratio (per 100 000 live births) 4.19 a, h 2003 1, 3, 5 16 Percentage of newborn infants weighing at least 2500 g at birth 94.48 d 95.14 d 93.76 d 2003 1, 3 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … … 2.02 e 2003 1 19 Immunization coverage for infants (%) - BCG 99.60 … … 2003 15 - DTP3 84.70 … … 2003 15 - OPV3 85.50 … … 2003 15 - Measles 80.50 … … 2003 15 - Tetanus II … … … - Hepatitis B III 85.60 … … 2003 15 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel About 100.00 2003 1 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) About 0.00 f 2003 1 - Percentage of deliveries in health facilities (as % of total deliveries) About 100.00 g 2003 1 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … HONG KONG (CHINA) 102 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 100.00 … 2004 6 26 Proportion of population with access to improved sanitation 99.00 … … 2004 7 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) 71.49 q … … 2003 11 30 Health care waste generation (metric tons per year) 2803.57 … … FY 2003- 2004 est 1, 9, 12 31 Human development index 0.90 … … 2002 13 32 Per capita GDP at current market prices (US$) 23 029.79 h … … 2003 3 33 Rate of growth per capita GDP -2.43 h … … 2003 3 34 Health expenditure Total health expenditure - amount (in million US$) 8445.49 h, i 2003 3, 8 - total health expenditure on health as % of GDP 5.39 h, j 2003 1, 3, 8 - per capita total expenditure on health (in US$) 1241.42 h, k 2003 1, 3, 8 Government expenditure on health - amount (in million US$) 4428.53 h, l FY 2003/04 8 - general government expenditure on health as % of total expenditure on health 52.44 h, m FY 2003/04 1, 3, 8 - general government expenditure on health as % of total general government expenditure 12.35 h, n FY 2003/04 8 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health 47.56 h, o 2003 1, 3, 8 Exchange rate in US$ of local currency is: 1 US$ = 7787 HK$ 2003 3 35 Health insurance expenditure - health insurance coverage as % of total population 26.40 p 2002 3 INDICATORS DATA Year Source Total Male Female Total Male Female Number q Rate per 10 000 population q, r 36 Health workforce - doctors s 11 016 8303 2713 16.09 12.13 3.96 2003 1, 3 - dentists s 1848 1386 462 2.70 2.02 0.67 2003 1, 3 - pharmacists 1457 757 700 2.13 1.11 1.02 2003 1, 3 - nurses t 43 782 4582 39 200 63.96 6.69 57.26 2003 1, 3 - midwives u 4791 0 4791 7.00 0.00 7.00 2003 1, 3 - registered Chinese medicine practitioners ah 4738 3491 1247 6.92 5.10 1.82 2003 1, 3 - listed Chinese medicine practitioners ai 3227 2461 766 4.71 3.60 1.12 2003 1, 3 - chiropractors af 67 55 12 0.10 0.08 0.02 2003 1, 3 COUNTRY HEALTH INFORMATION PROFILE 103 INDICATORS DATA Year Source Total Male Female Total Male Female Number q Rate per 10 000 population q, r 36 Health workforce - other nursing/ auxiliary staff … … … … … … - other health care personnel under statutory registration including medical laboratory technologists, occupational therapists, radiographers, optometrists and physiotherapists 8822 4737 4085 12.89 6.92 5.97 2003 1, 3 - other health personnel staff (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates - physicians ad 398 230 168 2003 14 38 Yearly new graduates - physicians ad 358 74 284 2003 14 39 Ten leading causes of morbidity Number v Rate per 100 000 population 1. Diseases of the genitourinary system 160 220 … … … … … 2003 1, 9 2. Diseases of the respiratory system 123 200 … … … … … 2003 1, 9 3. Neoplasms 110 996 … 2003 1, 9 4. Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified 110 903 … … … … … 2003 1, 9 5. Diseases of the circulatory system 103 757 … 2003 1, 9 6. Diseases of the digestive system 102 817 … … … … … 2003 1, 9 7. Pregnancy, childbirth and the puerperium 91 805 … … … … … 2003 1, 9 8. Factors influencing health status and contact with health services 76 207 … … … … … 2003 1, 9 9. Injury, poisoning and certain other consequences of external causes 71 926 … … … … … 2003 1, 9 10. Diseases of the musculoskeletal system and connective tissue 38 258 … … … … … 2003 1, 9 40 Ten leading causes of mortality Number a, h Rate per 100 000 population a, h 1. Malignant neoplasms 11 510 7156 4354 169.19 217.24 124.08 2003 1, 3 2. Diseases of the heart 5309 2701 2608 78.04 82.00 74.32 2003 1, 3 3. Pneumonia 3867 2092 1775 56.84 63.51 50.58 2003 1, 3 4. Cerebrovascular diseases 3462 1685 1777 50.89 51.15 50.64 2003 1, 3 5. Chronic lower respiratory diseases 2102 1454 648 30.90 44.14 18.47 2003 1, 3 6. External causes of morbidity and mortality 2044 1362 682 30.05 41.35 19.44 2003 1, 3 7. Nephritis, nephrotic syndrome and nephrosis 1184 518 666 17.40 15.73 18.98 2003 1, 3 8. Diabetes mellitus 783 312 471 11.51 9.47 13.42 2003 1, 3 9. Septicaemia 572 268 304 8.41 8.14 8.66 2003 1, 3 10. Aortic aneurysm and dissection 389 241 148 5.72 7.32 4.22 2003 1, 3 HONG KONG (CHINA) 104 INDICATORS DATA Year Source Total Male Female Total Male Female 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases h, y Number of deaths - Diphtheria 0 0 0 ... ... ... 2004 1 - Pertussis (whooping cough) 9 1 8 ... ... ... 2004 1 - Tetanus 3 2 1 ... ... ... 2004 1 - Neonatal tetanus 0 0 0 ... ... ... 2004 1 - Poliomyelitis 0 0 0 ... ... ... 2004 1 - Hib meningitis 0 0 0 ... ... ... 2004 1 - Measles 63 38 25 ... ... ... 2004 1 - Mumps 230 143 87 ... ... ... 2004 1 - Rubella 32 14 18 ... ... ... 2004 1 - Congenital rubella syndrome 0 0 0 ... ... ... 2004 1 42 Cases and deaths for selected communicable diseases Number of cases h, y Number of deaths a, h Hepatitis viral 232 148 84 8 4 4 2003 1 - Type A 107 68 39 1 1 0 2003 1 - Type B 98 64 34 4 3 1 2003 1 - Type C 0 0 0 0 0 0 2003 1 - Type E 19 14 5 1 0 1 2003 1 - Unspecified 8 2 6 2 0 2 2003 1 Cholera 7 3 4 0 0 0 2003 1 Typhoid fever 49 18 31 0 0 0 2003 1 Encephalitis ... ... ... ... ... ... Plague 0 0 0 0 0 0 2003 1 Syphilis ... ... ... ... ... ... Gonorrhoea ... ... ... ... ... ... Leprosy 7 2 5 0 0 0 2003 1 Malaria 28 20 8 0 0 0 2003 1 Dengue/DHF ... ... ... ... ... ... Dengue fever 49 36 13 0 0 0 2003 1 43 Malaria Prevalence rates h, ae Death rates - Rates associated with malaria (per 100 000 population) 0.54 0.39 0.15 … … … 2004 1 - Proportion of population in malaria-risk areas using effective malaria prevention measures ab … - Proportion of population in malaria-risk areas using effective malaria treatment measures ac … 44 Tuberculosis Number of cases Number of deaths - All types 5624 … … … … … 2003 15 - New pulmonary tuberculosis (smear-positive) 1779 … … … … … 2003 15 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 79.00 … … 7.00 … … 2003 15 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 58.00 … … 79.00 (2002) … … 2003 15 COUNTRY HEALTH INFORMATION PROFILE 105 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths h 45 Acute respiratory infections … … … 4 2 2 2003 1, 3 46 Diarrhoeal diseases … … … 20 10 10 2003 1, 3 47 Cancers All cancers (malignant neoplasms only) … … … 11 510 7156 4354 2003 1, 3 - Trachea, bronchus and lung … … … 3403 2332 1071 2003 1, 3 - Stomach … … … 680 416 264 2003 1, 3 - Colon and rectum … … … 1537 888 649 2003 1, 3 - Lip, oral cavity and pharynx … … … 542 436 106 2003 1, 3 - Liver … … … 1412 1 075 337 2003 1, 3 - Cervix … … … 106 NA 106 2003 1, 3 - Leukaemia … … … 236 125 111 2003 1, 3 48 Circulatory All circulatory system diseases … … … 9633 4831 4802 2003 1, 3 - Ischaemic heart disease … … … 3719 2027 1692 2003 1, 3 - Acute myocardial infarction … … … 1939 1131 808 2003 1, 3 - Rheumatic fever and rheumatic heart diseases … … … 129 29 100 2003 1, 3 - Cerebrovascular diseases … … … 3462 1685 1777 2003 1, 3 - Hypertension … … … 710 316 394 2003 1, 3 49 Maternal causes - Haemorrhage … … 0 0 2003 1, 3 - Abortion … … 0 0 2003 1, 3 - Eclampsia … … 0 0 2003 1, 3 - Sepsis … … 0 0 2003 1, 3 - Obstructed labour … … 0 0 2003 1, 3 - Other direct obstetric deaths … … 2 2 2003 1, 3 50 Diabetes mellitus … … … 783 312 471 2003 1, 3 51 Mental disorders … … … 271 79 192 2003 1, 3 52 Injuries - All types h … … … 2044 1362 682 2003 1, 3 - Motor and other vehicle accidents h … … … 173 117 56 2003 1, 3 - Suicide h … … … 1103 734 369 2003 1, 3 - Homicide and violence h … … … 61 31 30 2003 1, 3 - Occupational injuries 42 022 28 187 13 835 171 140 31 2003 10 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number q Number of beds q Public health facilities - General hospitals 38 29 539 2003 9 - Specialized hospitals … … - District/first-level referral hospitals … … - Primary health care centres 234 z 733 z 2003 1 Private hospitals 12 aa 2902 aa 2003 1 Nursing homes 24 aa 2352 aa 2003 1 HONG KONG (CHINA) 106 Notes: Red text Millennium Development Goals indicators … Data not available est Estimate NA Not applicable FY The financial year refers to the span from April 1 of respective year to March 31 next year. a The figures are compiled based on registered deaths and/ or registered births. b The figure includes unknown sex. c The figure refers to the percentage of population aged 15 and above with primary or above education attainment. d The figure excludes those with unknown birth weight. e The figure refers to the cases who had Hb<10g/dl and attending the maternal and child health centres for ante-natal checkups. f Nearly all newborns were delivered in health facilities. g The figure refers to the cases known to the maternity homes of Department of Health, public and private hospitals. h The figure is subject to revision later on (i.e. provisional figure). i The figure refers to the summation of public health expenditure in the financial year 2003/04 and private health expenditure in the calendar year 2003. j The figure compiled is based on the summation of public health expenditure in the financial year 2003/04 and private health expenditure in the calendar year 2003 as percentage of GDP in the calendar year 2003. k The figure is compiled based on the summation of public health expenditure in the financial year 2003/04 and private health expenditure in the calendar year 2003 per mid-2003 population. l The figure refers to the public health expenditure. m The figure refers to public health expenditure in the financial year 2003/04 as percentage of the summation of public health expenditure in the financial year 2003/04 and private health expenditure in the calendar year 2003. n The figure refers to public health expenditure as percentage of overall public expenditure. o The figure refers to private health expenditure in the calendar year 2003 as percentage of the summation of public health expenditure in the financial year 2003/04 and private health expenditure in the calendar year 2003. p The figure refers to the percentage of the population who were covered by medical insurance purchased by individuals. q The figures are at the position of end year. r The figure is compiled based on the number of healthcare personnel per overall Hong Kong resident population, including both males and females. s The number of doctors / dentists refers to the number of doctors / dentists with full registration on both the local and overseas lists. t The number of nurses refers to the number of registered nurses (all types) and enrolled nurses (general + mental). u The number of registered midwives dropped due to the removal of names of more than 7000 registered midwives from the register in 2002 in accordance with Section 6(3) of the Registered Ordinance (Cap.162). v The figures refer to the number of in-patient discharges including deaths by disease from pubic hospitals, private hospitals and correctional institutions. w Chronic lower respiratory diseases has been included as a disease group for the purpose of ranking the causes of death since 2001. x According to the ICD 10th revision, when the morbid condition is classifiable under Chapter XIX as “injury, poisoning and certain other consequences of external causes”, the codes under Chapter XX for “external causes of morbidity and mortality” should be used as the primary cause of death. y The figures refer to the cases reported to the Department of Health for the listed Statutory Notifiable Infectious Diseases. z The figure covers the clinics in the correctional institutions. aa The figure covers the institutions licensed under the Hospitals, Nursing Homes and Maternity Homes Registration Ordinance (Cap.165). ab Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. ac Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. ad The figures only cover graduates of full-time sub-degree and undergraduate programmes funded by the University Grants Committee in medicine, Chinese medicine, dental surgery and nursing at the end of the graduation year 2003. Graduates may not be engaged in work areas directly related to their discipline of study after graduation. ae The figures are compiled based on the cases reported to the Department of Health for the listed Statutory Notifiable Infectious Diseases per 100 000 mid-year population in Hong Kong. COUNTRY HEALTH INFORMATION PROFILE 107 Notes: (Continued…) af Mandatory requirement for registered chiropractors to practise only with valid practising certificates has come into effect since February 2003. ag Measles-mumps-rubella vaccines, instead of merely measles vaccines, have been administered to infants since January 1990. ah Figures are available since 2002. ai Figures are available since 2002. They can practise lawfully in Hong Kong but are required to pass the Registration Assessment or Licensing Examination before they can apply for registration. Sources: 1 Department of Health, Hong Kong Special Administrative Region Government (HKSARG) 2 Lands Department, HKSARG 3 Census and Statistics Department, HKSARG 4 Planning Department, HKSARG 5 Immigration Department, HKSARG 6 Water Supplies Department, HKSARG 7 Drainage Services Department, HKSARG 8 Financial Services and the Treasury Bureau, Government Secretariat, HKSARG 9 Hospital Authority of the HKSARG 10 Labour Department, HKSARG 11 Transport Department, HKSARG 12 Environmental Protection Department, HKSARG 13 Human Development Report 2003. New York, United Nations Development Programme, 2003. 14 University Grants Committee, HKSARG 15 WHO Regional Office for the Western Pacific, data received from technical units 108 | COUNTRY HEALTH INFORMATION PROFILES JAPAN 1. DEMOGRAPHICS, GENDER AND POVERTY As of 01 October 2004, the total population of Japan was estimated to be 127 687 000, comprising 62 295 000 males and 65 392 000 females, indicating a total population increase of 68 000 or 0.05% during the last year. With regards to distribution by age group, 13.9% of the population are aged 0-14 years, 66.6% 15-64 years and 19.5% 65 years and over. Table 1. Core population and health data (2004 estimates) [Total] 127 687 000 [Both] … [0-14 years] (13.89 %) [Male] 78.36 (2003) Population [65+ years] (19.48 %) Life expectancy at birth (years) [Female] 85.33 (2003) Crude birth rate (per 1000 population) 8.91 (2003) Total fertility rate 1.29 (2003) [Total] 96.90 (2003) [Urban] … Crude death rate (per 1000 population) 8.05 (2003) % of population served with safe water [Rural] … [Total] 77.70 (2003) [Urban] … Infant mortality rate (per 1000 live births) 2.99 (2003) % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 6.14 (2003) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The Japanese Government, a constitutional monarchy, is based on a parliamentary cabinet system. Executive power is vested in the Cabinet, which consists of the Prime Minister and not more than 17 ministers of state, who collectively are responsible to the Diet (legislature). In April 2001, Junichiro Koizumi was designated by the Diet as Japan's eighty-seventh Prime Minister. Prime Minister Koizumi is a member of the Liberal Democratic Party, the party currently holding the largest block of representation in both the House of Representatives and the House of Councillors, which together make up the Diet. 2.2 Economic situation Japan has the second largest economy in the world in terms of gross domestic product (GDP), after the United States of America. As of 2001, the GDP of Japan and the United States totalled 46.6% of the world GDP. Japan's GDP per capita in 2003 was US$ 33 727, one of the highest in the world. This economic scale was achieved largely due to high economic growth from 1955 to the late 1960s. Japan's long-term economic prospects are considered good, although the country is currently in its worst period of economic growth since the Second World War. Prime Minister Koizumi’s administration is committed to addressing economic issues, such as non-performing loans and deflation, and to conducting regulatory and other structural reforms in order to revive the economy. COUNTRY HEALTH INFORMATION PROFILES | 109 3. HEALTH SITUATION The health situation in Japan remains one of the best in the Region. The majority of health- related statistics, such as life expectancy and the under-five mortality rate, continue to improve. The health disparities within the country are also relatively small compared with those in other industrialized nations. 3.1 Health trends The average life expectancy remains the highest in the world. In 2003, it was 85.33 years for women and 78.36 years for men. The infant mortality rate fell to 2.99 per 1000 births in 2003. The crude death rate was 8.05 per 1000 persons in 2003. Malignant neoplasms have been the leading cause of death since 1981 and have continued to increase. They accounted for 30.5% of all deaths (245.40 per 100 000 population in) in 2003. Other major causes of death are lifestyle- related diseases, such as circulatory system disease (231.20 per 100 000 population), in which daily diet and behaviour play a significant role. Due to the increasingly complex social environment created by a high-tech and competition- oriented society, it is said that stress levels felt by all age groups are rising. There were 32 109 suicides in 2003 and the number has remained at approximately 30 000 since 1998. The suicide rate is relatively high for men aged from their mid-twenties to forties. Tuberculosis, infectious and difficult-to-treat diseases, such as AIDS, and new types of influenza are becoming serious threats to public health in Japan. 3.2 Health systems The basic principle governing the delivery of health care services is that all citizens should be able, at any time and place, to receive the care they require, with an affordable personal contribution. The health insurance system in Japan maintains universal coverage and there is free access to all health institutions. While this system has ensured equitable health care delivery across different socioeconomic groups and different areas of the country, it has given rise to an inefficient supply of services. Under the free access system, patients have a tendency to skip the general practitioner and go directly to hospitals for even relatively common illnesses. At the same time, the current fee-for- service payment scheme tends to invite overtreatment. For example, the average length of a hospital stay in Japan is more than three weeks, which is more than double that in the majority of developed countries. With increasing financial constraints, the Government is planning to introduce structural reforms in its heath system to create a more efficient system, while maintaining equity and quality of services. This reform is closely associated with the ongoing demographic transition – longer life expectancy and lower birth rate – which has resulted in a rapid increase in the percentage of elderly citizens. It is estimated that, by 2020, the elderly, defined as those aged 65 years and older, will constitute over 25% of the entire population. Currently, they make up 15%. The speed at which Japan’s population will age over the next few decades will be the fastest in human history. This ageing population will need to pay attention to lifestyle-related diseases. Maintaining healthy lifestyles and the early detection of disease could help reduce the incidence of the three major killer diseases: malignant neoplasms, cardiovascular diseases and cerebrovascular diseases. The new Health Promotion Law (2002) emphasizes the importance of establishing an environment conducive to healthier lifestyles as a key strategy for the ageing society. JAPAN 110 | COUNTRY HEALTH INFORMATION PROFILES As of 2002, there were 262 687 doctors and 1 097 326 nurses, public health nurses and assistant nurses. Due to population ageing, along with the growing sophistication and specialization of medical services among other factors, it is presumed that the demand for health, medical and welfare services personnel will increase in the future. National expenditure for medical care has been rising year after year. In the 2002 fiscal year, expenditure totalled about 31 trillion yen (US$ 260 736 000 000), about 8.6% of Japan’s national income. In the same fiscal year, expenditure on medical services for the aged was about 10.7 trillion yen, or about one-third of the total medical cost, and this proportion is increasing every year. The rapidly growing number of senior citizens has resulted in a sharp rise in medical costs for the elderly and is a major reason for the uptrend in medical care expenditures. The annual cost of medical care per capita averaged 244 200 yen (US$ 2046) in the 2002 fiscal year. Per capita medical care costs for the elderly averaged 645 600 yen a year. 4. NATIONAL HEALTH PLAN AND PRIORITIES National health promotion movement in the 21st Century (Healthy Japan 21) The Ministry of Health, Labour and Welfare announced a health promotion programme, National health promotion movement in the 21st Century (Healthy Japan 21) in 2000. The movement, unlike traditional programmes, emphasizes “primary prevention”, aiming at early detection and treatment of diseases. Under the campaign, particular areas that are going to be important for the health and medical care of nationals are selected and concrete numerical targets are set. These targets function as indicators for evaluation of the population’s health status. The goal of this programme, which is to be completed in 2010, is to realize a society where all the nationals live a healthy and happy life, free of disease. • Improving healthy dietary habits: The Ministry of Health, Labour and Welfare has carried out a national nutrition survey every year since 1945. The recommended dietary allowances (Dietary Reference Intakes) are revised every five years. In 1999, they underwent their sixth revision. Dietary Guidelines for Japanese, the benchmark for dietary improvement, were established in 2000. • Promoting good exercise habits: There were 12 736 health fitness instructors and 7892 health fitness programmers as of April 2000. In recent years, it has been recognized that exercise and hot spring therapy are effective methods for the treatment of various noncommunicable diseases. Therefore, the fees to use exercise/hot spring facilities have been made deductible as medical expenses for income tax purposes when the therapies are supplied at the instruction of a physician at a health promotion facility that meets certain requirements and is approved by the Ministry of Health, Labour and Welfare. • Promoting appropriate relaxation: The need for relaxation and the part it plays in maintaining and improving health is well recognized. Therefore, “relaxation and health of mind” is one of the targets in “Healthy Japan 21”. In addition, in 1994, the Ministry of Health, Labour and Welfare devised relaxation guidelines for health promotion that encourage and promote appropriate relaxation in daily life. • Smoking and health. Since cigarettes have a number of negative health effects, not only on smokers but also on the people around them, the Ministry of Health, Labour and Welfare is engaged in efforts to provide accurate information to all citizens about the effects of smoking. COUNTRY HEALTH INFORMATION PROFILES | 111 5. MAJOR INFORMATION SOURCES Ministry of Health Labour and Welfare (http://www.mhlw.go.jp/english/index.html) Statistics Bureau, Ministry of Public Management, Home Affairs, Posts and Telecommunications (http://www.stat.go.jp/english/index.htm) SEAMIC Health Statistics 2002. International Medical Foundation of Japan Abridged life table for Japan 2003. Ministry of Health, Labour and Welfare 6. ADDRESSES MINISTRY OF HEALTH, LABOUR AND WELFARE Office Address : Postal Address : The Honourable Minister of Health, Labour and Welfare Ministry of Health, Labour and Welfare Japanese Government l-2-2, Kasumigaseki, Chiyoda-ku Tokyo 100-8916, Japan Official Email Address : Telephone : Fax : Office Hours : Website : http://www.mhlw.go.jp/english/index.html WHO REPRESENTATIVE There is no WHO Representative in Japan. Queries about the WHO programme of collaboration with Japan should be directed to: Office Address : Postal Address : Director, Programme Management World Health Organization Regional Office for the Western Pacific United Nations Avenue P.O. Box 2932, 1000 Manila, the Philippines The WHO Technology Transfer Programme Office c/o International Medical Center of Japan 1-21-1 Toyama, Shinjuku-ku Tokyo 162-8655 Japan Official Email Address : Telephone : Fax : Office Hours : JAPAN 112 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: MINISTRY OF HEALTH, LABOUR AND WELFARE COUNTRY HEALTH INFORMATION PROFILE 113 JAPAN WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 377.89 2002 4, 10 2 Estimated population ('000s) 127 687 62 295 65 392 2004 1 3 Annual population growth rate (%) 0.05 -0.01 0.12 2004 1 4 Percentage of population - 0–14 years 13.89 14.59 13.22 2004 1 - 65+ years 19.48 16.86 21.98 2004 1 5 Urban population (%) 78.70 … … 2002 1 6 Crude birth rate (per 1000 population) 8.91 9.36 8.48 2003 3 7 Crude death rate (per 1000 population) 8.05 8.95 7.18 2003 3 8 Rate of natural increase of population (% per annum) 0.08 0.03 0.12 2004 3 9 Health-adjusted life expectancy (HALE) (years) - at birth … 78.36 85.33 2003 3 - at age 60 … 17.50 21.70 2002 est 13 10 Adult literacy rate (%) 99.00 … … 2000 est 2 11 Neonatal mortality rate (per 1000 live births) 1.67 1.69 1.65 2003 3 12 Infant mortality rate (per 1000 live births) 2.99 3.10 2.88 2003 3 13 Under-five mortality rate (per 1000 live births) 4.02 4.16 3.87 2003 3 14 Total fertility rate (women aged 15–49 years) 1.29 2003 3 15 Maternal mortality ratio (per 100 000 live births) 6.14 2003 3 16 Percentage of newborn infants weighing at least 2500 g at birth 90.90 91.90 89.90 2003 3 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 96.00 … … 2003 12 - DTP3 97.00 … … 2003 12 - OPV3 97.00 … … 2003 12 - Measles 100.00 … … 2003 12 - Tetanus II … … … - Hepatitis B III … … … 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel … - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percent of deliveries in health facilities (as % of total deliveries) 99.80 2003 3 21 Percentage of women in the reproductive age group using modern contraceptive methods 59.00 1995-2000 7 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … JAPAN 114 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 96.90 … … 2003 5 26 Proportion of population with access to improved sanitation 77.70 … … 2003 8, 9, 10 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) < 5.00 … … 2003 12 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) a,b 260 000 … … 2002 8 31 Human development index 0.94 … … 2002 6 32 Per capita GDP at current market prices (US$) 33 727.00 … … 2003 11 33 Rate of growth per capita GDP … 34 Health expenditure Total health expenditure (national medical care expenditure) - amount (in million US$) 260 736 FY2002 1 - total health expenditure on health as % of GDP (national income) 8.58 FY2002 1 - per capita total expenditure on health (in US$) 2045.74 FY2002 1 Government expenditure on health - amount (in million US$) … - general government expenditure on health as % of total expenditure on health 5.53 FY2002 1 - general government expenditure on health as % of total general government expenditure … External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 119.37 yen 2002 1 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 262 687 221 548 41 139 20.61 35.59 6.31 2002 1 - dentists 92 874 76 549 16 325 7.29 12.30 2.50 2002 1 - pharmacists 229 744 90 827 138 917 18.03 14.59 21.31 2002 1 - nurses 1 097 326 … … 86.11 … … 2002 1 - midwives 24 340 … … 1.91 … … 2002 1 - other nursing/ auxiliary staff 67 376 … … 5.31 … … 2000 2 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 276 070 … … 21.66 … … 2002 1 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 8499 … … 0.67 … … 2000 2 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … COUNTRY HEALTH INFORMATION PROFILE 115 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Influenza (grippe) 769 964 … … 604.88 … … 2000 2 2. Chickenpox 275 036 … … 216.07 … … 2000 2 3. Mumps (cases treated in large hospitals only) 132 877 … … 104.39 … … 2000 2 4. Other venereal diseases (cases treated in large hospitals only) 50 527 … … 39.69 … … 2000 2 5. Tuberculosis (all forms) 39 384 … … 30.94 … … 2000 2 6. Food poisoning (bacterial) 32 417 … … 25.47 … … 2000 2 7. Measles 22 978 … … 18.05 … … 2000 2 8. Gonococcal infections (cases treated in large hospitals only) 16 926 … … 13.30 … … 2000 2 9. Pertussis (whooping cough) 3804 … … 2.99 … … 2000 2 10. Rubella (cases treated in large hospitals only) 3123 … … 2.45 … … 2000 2 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Malignant neoplasms 309 543 186 912 122 631 245.40 303.30 190.10 2003 3 2. Heart disease 159 545 77 989 81 556 126.50 126.60 126.40 2003 3 3. Cerebrovascular diseases 132 067 63 274 68 793 104.70 102.70 106.60 2003 3 4. Pneumonia 94 942 50 614 44 328 75.30 82.10 68.70 2003 3 5. Accidents and adverse effects 38 714 23 969 14 745 30.70 38.90 22.90 2003 3 6. Suicide 32 109 23 396 8713 25.50 38.00 13.50 2003 3 7. Senility 23 449 6288 17 161 18.60 10.20 26.60 2003 3 8. Renal failure 18 821 8686 10 135 14.90 14.10 15.70 2003 3 9. Disease of liver 15 737 10 703 5034 12.50 17.40 7.80 2003 3 10. Chronic obstructive pulmonary disease 13 626 10 347 3279 10. 80 16. 80 5.10 2003 3 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases (C) Number of deaths (D) - Diphtheria 0 0 0 0 0 0 2003 C: 12, D: 3 - Pertussis (whooping cough) 1534 … … 1 1 0 2003 C: 12, D: 3 - Tetanus 69 … … 7 3 4 2003 C: 12, D: 3 - Neonatal tetanus … … … 0 0 0 2003 C: 12, D: 3 - Poliomyelitis 0 0 0 0 0 0 2003 C: 12, D: 3 - Hib Meningitis … … … 0 0 0 2003 C: 12, D: 3 - Measles 8286 … … 6 4 2 2003 C: 12, D: 3 - Mumps 84 672 … … 1 1 0 2003 C: 12, D: 3 - Rubella 2794 … … 1 0 1 2003 C: 12, D: 3 - Congenital rubella syndrome 1 … … … … … 2003 C: 12, D: 3 42 Cases and deaths for selected communicable diseases Number of cases (C) Number of deaths (D) Hepatitis viral 650 … … 5 805 3 112 2 693 2003 C: 12, D: 3 - Type A 12 … … 6 2 4 2003 C: 12, D: 3 - Type B … … … 856 553 303 2003 D: 3 - Type C … … … 4 530 2 321 2 209 2003 D: 3 - Unspecified 636 … … 359 216 143 2003 C: 12, D: 3 Cholera 25 … … 0 0 0 2003 C: 12, D: 3 Typhoid fever 62 … … 0 0 0 2003 C: 12, D: 3 Encephalitis 100 … … 77 43 34 2003 C: 12, D: 3 Plague 0 0 0 0 0 0 2003 C: 12, D: 3 JAPAN 116 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases (C) Number of deaths (D) Syphilis 759 … … 10 10 0 2000 C: 2,D: 3 Gonorrhoea (gonococcal infections) 16 926 … … 0 0 0 2000 C: 2,D: 3 Leprosy 8 … … 0 (2001) 0 (2001) 0 (2001) 2003 C: 12,D: 3 Malaria … … … 1 1 0 2003 D: 3 Dengue/DHF … … … 0 0 0 2003 D: 3 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … 0.00 0.00 0.00 2003 3 - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases (C) Number of deaths (D) - All types 31 638 … … 2337 1615 722 2003 C: 12,D: 3 - New pulmonary tuberculosis (smear-positive) 10 843 … … 7 5 2 2003 C: 12,D: 3 Prevalence rates (P) Death rates (D) - Rates associated with tuberculosis (per 100 000 population) 42.00 … … 4.00 … … 2003 12 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 40.00 … … 76.00 (2002) … … 2003 12 Number of cases Number of deaths 45 Acute respiratory infections … … … 410 173 237 2003 3 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (malignant neoplasms only) … … … 309 543 186 912 122 631 2003 3 - Trachea, bronchus, and lung … … … 56 720 41 634 15 086 2003 3 - Stomach … … … 49 535 32 142 17 393 2003 3 - Colon and rectum … … … 25 856 12 868 12 982 2003 3 - Lip, oral cavity and pharynx … … … 5618 4035 1583 2003 3 - Liver … … … 34 089 23 376 10 713 2003 3 - Cervix … … … 2378 NA 2378 2003 3 - Leukaemia … … … 7018 4088 2930 2003 3 48 Circulatory All circulatory system diseases … … … 312 382 151 469 160 913 2003 3 - Ischaemic heart disease … … … 73 353 40 080 33 273 2003 3 - Acute myocardial infarction … … … 46 073 25 004 21 069 2003 3 - Rheumatic fever and rheumatic heart diseases … … … 2415 765 1652 2003 3 - Cerebrovascular diseases … … … 132 067 63 274 68 793 2003 3 - Hypertension … … … 5597 2016 3581 2003 3 COUNTRY HEALTH INFORMATION PROFILE 117 INDICATORS DATA Year Source Total Male Female Total Male Female 49 Maternal causes - Haemorrhage … … 18 18 2003 3 - Abortion … … 0 0 2003 3 - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … 50 Diabetes mellitus … … … 12 879 6709 6170 2003 3 51 Mental disorders … … … 4175 1686 2489 2003 3 52 Injuries - All types … … … 75 638 50 292 25 346 2003 3 - Motor and other vehicle accidents … … … 10 913 7565 3348 2003 3 - Suicide … … … 32 109 23 396 8713 2003 3 - Homicide and violence … … … 705 412 293 2003 3 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities 1425 396 456 2001 2 - General hospitals … … - Specialized hospitals … … - District/first-level referral hospitals … … - Primary health care centres … … Private hospitals 7814 1 250 341 2001 2 Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate FY Fiscal year a The weight of all public and private solid and liquid waste generated by health care establishments in a fiscal year. b The method of calculation was changed in 2002. c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Statistics Bureau, Ministry of Public Management, Home Affairs, Posts and Telecommunications (http://www.stat.go.jp/english/index.htm) 2 SEAMIC health statistics 2002. International Medical foundation of Japan 3 Vital statistics of Japan. Ministry of Health, Labour and Welfare 4 Geographical Survey Institute, Japan 5 Journal of Health and Welfare Statistics, Japan 6 Cultural liberty in today’s diverse world. New York, UNDP, 2004. 7 2000 maternal and child health statistics in Japan. Maternal and Child Health Division, Children’s and Families Bureau, Ministry of Health and Welfare 8 Ministry of the Environment 9 Ministry of Agriculture, Forestry and Fisheries 10 Ministry of Land, Infrastructure and Transport 11 Economic and Social Research Institute, Japan. 12 WHO Regional Office for the Western Pacific, data received from technical units 13 The World Health Report 2004. Changing history. Geneva, World Health Organization, 2004. 118 | COUNTRY HEALTH INFORMATION PROFILES KIRIBATI 1. DEMOGRAPHICS, GENDER AND POVERTY Speaking one national language and sharing a common simple lifestyle, the 93 100 people of Kiribati inhabit a country of 33 atolls and reef islands stretching 5000 kilometres across the central-western Pacific. The total land area of 810 square kilometres falls into three island groups, lying within three exclusive economic zones, which together cover 3.5 million square kilometres. The people of Kiribati are Micronesian in origin. A growing population and fixed amount of domestic resources dominate concerns about the future of Kiribati. During 2000-2003, the total population is estimated to have increased by 6000 persons, with two-thirds of that increase taking place in South Tarawa. According to estimates by the Secretariat of the Pacific Community (SPC) and the United Nations, the total population will double by 2025, and the population of South Tarawa (which has an annual growth rate of 5.2%) will double by 2015. About 41% of the population is below 15 years of age. This demographic structure ensures increasing pressure for services and jobs and serious and growing environmental problems (water quality, waste, sanitation, lagoon pollution), exacerbated by South Tarawa’s congestion. Crowded and unsanitary conditions contribute to the high incidence of diarrhoeal diseases and th high death rate for young children. Table 1. Core population and health data (2004 estimate) [Total] 93 100 [Both] … [0-14 years] 38 115 (40.94%) [Male] 59.00 (2003 est) Population [65+ years] 3193 (3.43%) Life expectancy at birth (years) [Female] 70.00 (2003 est) Crude birth rate (per 1000 population) 33.40 (2002 est) Total fertility rate 4.30 (2000) [Total] 64.00 (2002) [Urban] 77.00 (2002) Crude death rate (per 1000 population) 7.20 (2002) % of population served with safe water [Rural] 53.00 (2002) [Total] 39.00 (2002) [Urban] 59.00 (2002) Infant mortality rate (per 1000 live births) 43.00 (2000) % of population with adequate sanitary facilities [Rural] 22.00 (2002) Maternal mortality ratio (per 100 000 live births) 103.00 (2002) est- estimate 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation A new government took office in July 2003 after a landslide victory for the Boutokaan te Koaua Party (BTK). The Government is now formulating national development strategies for 2004- 2007 with the catchphrase of “enhancing growth and ensuring equitable distribution”. The Government's lack of an absolute majority led to delayed implementation of the 2003 budget. The six main policy areas are economic growth, fair distribution, public sector performance, equipping people to manage change, conservation of physical assets, and sustainable use of financial reserves. COUNTRY HEALTH INFORMATION PROFILES | 119 2.2 Economic situation Kiribati is categorized as a least-developed country (LDC) because of its low per capita gross domestic product (GDP), limited human resources and high vulnerability to external forces. Foreign reserves have grown steadily in recent years to the equivalent of seven years’ imports, and investment income is currently about one-third of GDP. GDP has grown by about 1.6% annually since independence in 1979, well below population growth. The economy is dominated by public services, with state-owned enterprises (SOEs) accounting for 80% of paid employment and 30% of GDP. However, delivery of social services has been inefficient, subsidies to SOEs reduce opportunities for private job creation (under 20% of the working-age population is formally employed) and nearly two-thirds of all formal jobs are in the capital, South Tarawa. The Kiribati economy suffered a recession from 2000 to 2003, partly due to falling financial markets and economic uncertainties associated with international terrorism and the war in Iraq and also to reduced Exclusive Economic Zone (EEZ) access fees because of the effect of the oceanic weather cycle on fish catches. The major sources of revenues come from the EEZ access fee, the Government reserve fund (RERF), and remittances from Kiribati seamen and fisheries on overseas ships. From 2000 to 2003, official grants and loans from abroad amounted to AUD 105 million (US$ 79 million), providing about 30% of the Government's annual budget expenditures. According to the 2000 Census, 9200 persons work in the cash economy. Two-thirds of them work in the public sector, and two-thirds live in South Tarawa. GNP in 2002 is estimated to have been AUD 175 million or US$ 132 million (AUD 1987 or US$ 1502 per person). GDP is estimated to have been about AUD 98 million (US$ 74 million), and this is expected to decline due to the fall in EEZ access fees, which contribute 25% of total government revenue. The main exports are seaweed, aquarium fish and copra, which contribute 10%-20% of GDP. The Kiribati economy remains resilient, due in part to government reserve funds, which had a market value of AUD 576 million (US$ 435 million) at the end of 2002. There has been substantial progress on projects to improve the infrastructure and social services. A new 18 km pipeline has been laid for the water supply system in South Tarawa and 24 000 residential water tanks have been installed with funding from the Asian Development Bank. Japanese aid has funded a number of infrastructure projects. Two solid waste landfill sights have been developed for the sewerage system in South Tarawa. Two new 1.4 MW electricity generators and a new powerhouse have been installed. The power cable and transformers have been replaced at South Tarawa. A loan from the Bank of China will be used to install a digital radio concentrator system by the end of 2004, as well as satellite systems at five outer islands in Gilbert Islands. 3. HEALTH SITUATION 3.1 Health trends With an estimated life expectancy at birth of 59 years for males and 70 years for females in 2003, the I-Kiribati have a shorter life span than most other Pacific islanders. This is partly due to high child mortality from respiratory and diarrhoeal diseases. Nevertheless, continuous improvements in the standard of health care delivery over the last 10 years have led to a slow but steady improvement in health indicators (e.g. the morbidity rate of diarrhoeal diseases declined by 8.6% annually and lower respiratory infections by 7.7% annually during the period from 1992 to 2000). However, lifestyle-related diseases, such as diabetes and hypertension, have led to rapid increases in adult mortality compared with child mortality in the last ten years. If current trends continue, adult mortality may reach 50% of total mortality by 2008. KIRIBATI 120 | COUNTRY HEALTH INFORMATION PROFILES In 2002, acute respiratory infections, diarrhoeal diseases, conjunctivitis, skin diseases (including wound and sores), food poisoning, sexually transmitted infections and tuberculosis were major public health problems. In addition, lifestyle-related diseases are growing health concerns. 3.2 Health systems Government spending on health is about AUD 13 million or US$ 9.8 million (7.8%) of the government budget of AUD 167 million (US$ 126 million). Per capita total expenditure on health in 2003 was AUD 147 (US$ 111 million). Ten new clinics have developed in the outer islands in Gilbert Islands. The nurse to population ratio has decreased from 1:450 to 1:375. A Traditional Medicine Research Centre has been approved by the Government. A Tobacco Control Bill has been drafted. Following growing concerns about HIV/AIDS, legislation is being prepared. 4. NATIONAL HEALTH PLAN AND PRIORITIES In the new National Health Plan for 2004-2007, 12 priority areas are identified: • reproductive health, including sexual health, adolescent health and women’s health; • population and family planning; • maternal and child health (safe motherhood); • health education, health promotion and community development in the context of Healthy Islands; • immunization and childhood preventable diseases; • control of acute respiratory infections and diarrhoeal diseases; • control of communicable diseases, including HIV/AIDS, tuberculosis, leprosy, lymphatic filariasis and emerging health problems, including severe acute respiratory syndrome (SARS); • control of noncommunicable diseases, including hypertension, heart diseases, diabetes, cancer and tobacco and alcohol; • environmental health, including food safety, water and sanitation; • nutrition, including vitamin A deficiency and breast-feeding; • traditional medicine; and • information technology and evidence-based public health policies and legislation, including the Environment Act. In order to support these 12 priority areas, the "village welfare group" (VWG) will be strengthened as part of community development in outer islands during the period from 2004 to 2007. VWGs play a key role in providing health education and health data collection at the household level under the supervision of a public health nurse. 5. MAJOR INFORMATION SOURCES National Health Plan 2004-2007. Ministry of Health and Medical Services Kiribati statistical yearbook 2002. Statistics Office Ministry of Finance National development strategies 2004-7. Ministry of Finance and Economic Development Morbidity and mortality database. Health Information Centre, Ministry of Health and Medical Services COUNTRY HEALTH INFORMATION PROFILES | 121 6. ADDRESSES MINISTRY OF HEALTH AND MEDICAL SERVICES Office Address : P. O. Box 268, Bikenibeu, Tarawa, Republic of Kiribati Postal Address : Official Email Address : mhfp@tskl.net.ki Telephone : (686) 28100 Fax : (686) 28152 Office Hours : Website : WHO COUNTRY LIAISON OFFICER IN KIRIBATI Office Address : World Health Organization Bikenibeu, Tarawa, Kiribati Postal Address : World Health Organization P. O. Box 210 268, Bikenibeu, Tarawa, Kiribati Official Email Address : who@kir.wpro.who.int Telephone : (686) 28231 Fax : (686) 28188 Office Hours : KIRIBATI 122 | COUNTRY HEALTH INFORMATION PROFILES Organization Chart: Ministry of Health and Medical Services COUNTRY HEALTH INFORMATION PROFILE 123 KIRIBATI WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 0.81 2004 1 2 Estimated population ('000s) 93.10 … … 2004 est 1 3 Annual population growth rate (%) 1.70 … … 2000 1 4 Percentage of population - 0–14 years 40.94 42.24 39.66 2004 est 2 - 65+ years 3.43 2.87 3.99 2004 est 2 5 Urban population (%) 47.30 … … 2003 14 6 Crude birth rate (per 1000 population) e 33.40 45.50 21.80 2002 est 3 7 Crude death rate (per 1000 population) 7.20 … … 2002 4 8 Rate of natural increase of population (% per annum) 2.62 a … … 2002 9 Health-adjusted life expectancy (HALE) (years) - at birth e … 59.00 70.00 2003 est 3 - at age 60 … 11.50 11.60 2002 15 10 Adult literacy rate (%) (15-24 years old) 95.00 93.00 95.00 2000 3 11 Neonatal mortality rate (per 1000 live births) 27.00 b … … 2000 5 12 Infant mortality rate (per 1000 live births) 43.00 55.00 31.00 2000 3 13 Under-five mortality rate (per 1000 live births) 69.00 … … 2000 6 14 Total fertility rate (women aged 15–49 years) 4.30 2000 3 15 Maternal mortality ratio (per 100 000 live births) 103.00 2002 7 16 Percentage of newborn infants weighing at least 2500 g at birth 91.80 92.30 91.40 2002 7 17 Prevalence of underweight children under five years of age 13.00 … … 1999 6 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 94.50 … … 2004 8 - DTP3 63.40 … … 2004 8 - OPV3 60.70 … … 2004 8 - Measles 56.00 … … 2004 8 - Tetanus II 37.50 … … 2004 8 - Hepatitis B III 66.60 … … 2004 8 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel … - Percentage of pregnant women immunized with tetanus toxoid (TT2) 42.60 2002 7 - Percentage of deliveries at home by trained personnel (as % of total deliveries) 12.90 2002 7 - Percentage of deliveries in health facilities (as % of total deliveries) 76.00 2002 7 21 Percentage of women in the reproductive age group using modern contraceptive methods 22.00 2002 7 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … KIRIBATI 124 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 64.00 77.00 53.00 2002 9 26 Proportion of population with access to improved sanitation 39.00 59.00 22.00 2002 9 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.52 … … 1998 10 32 Per capita GDP at current market prices (US$) 611.45 … … 2002 11 33 Rate of growth per capita GDP … … … 34 Health expenditure Total health expenditure - amount (in million US$) 107 791 914.00 2003 12 - total health expenditure on health as % of GDP … - per capita total expenditure on health (in AUD) 147.00 2003 12 Government expenditure on health - amount (in million AUD) About 13.00 2003 12 - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure 7.80 2003 12 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 1.55 AUD (average) 1.83825 AUD (average) 2003 2002 8 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 20 16 4 2.20 … … 2004 14 - dentists 3 0 3 0.30 … … 2004 14 - pharmacists 2 0 2 0.20 … … 2004 14 - nurses 238 18 220 26.50 … … 2004 14 - midwives 32 4 28 3.60 … … 2004 14 - other nursing/ auxiliary staff 12 1 11 1.30 … … 2004 14 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 16 8 8 1.80 … … 2004 14 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 10 8 2 1.10 … … 2004 14 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … COUNTRY HEALTH INFORMATION PROFILE 125 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Eight leading causes of morbidity Number Rate per 100 000 population 1. Acute respiratory infections 76 836 37 776 39 060 179 483.00 … … 2002 7 2. Diarrhoeal diseases 20 750 10 412 10 338 46 305.00 … … 2002 7 3. Eye diseases 7527 3695 3832 17 582.00 … … 2002 7 4. Skin diseases 1977 980 997 4619.00 … … 2002 7 5. Injury and poisoning 1023 528 495 2392.00 … … 2002 7 6. Communicable diseases 987 540 447 2310.00 … … 2002 7 7. Noncommunicable diseases 793 402 391 1853.00 … … 2002 7 8. Nutrition and related diseases 565 292 273 1321.00 … … 2002 7 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Symptoms, signs and ill-defined conditions 117 60 57 133.76 … … 2002 7 2. Disease of the circulatory system 70 50 20 80.03 … … 2002 7 3. Disease of the digestive system 59 33 26 67.45 … … 2002 7 4. Infectious and parasitic system 57 33 24 65.16 … … 2002 7 5. Certain conditions originating in the perinatal 54 26 28 61.73 … … 2002 7 6. Endocrine, nutritional and metabolic 46 18 28 52.59 … … 2002 7 7. Disease of the respiratory system 35 18 17 40.01 … … 2002 7 8. Neoplasms 15 4 11 17.15 … … 2002 7 9. Factors influencing health status 11 7 4 12.58 … … 2002 7 10. Disease of the nervous system 10 7 3 11.43 … … 2002 7 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2004 8 - Pertussis (whooping cough) 0 0 0 … … … 2004 8 - Tetanus … … … … … … - Neonatal tetanus … … … … … … - Poliomyelitis … … … … … … - Hib meningitis 0 0 0 … … … 2004 8 - Measles 0 0 0 … … … 2004 8 - Mumps 0 0 0 … … … 2004 8 - Rubella 0 0 0 … … … 2004 8 - Congenital rubella syndrome 0 0 0 … … … 2004 8 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A … … … 1 … … 2004 8 - Type B … … … … … … - Type C … … … … … … - Unspecified 18 … … 5 … … 2004 8 Cholera 0 0 0 0 0 0 2004 8 Typhoid fever 0 0 0 0 0 0 2004 8 Encephalitis 0 0 0 0 0 0 2004 8 Plague 0 0 0 0 0 0 2004 8 Syphilis … … … … … … Gonorrhoea (gonococcal infections) … … … … … … Leprosy 21 … … … … … 2003 8 KIRIBATI 126 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Malaria … … … … … … Dengue/DHF … … … … … … 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 284 … … … … … 2003 8 - New pulmonary tuberculosis (smear-positive) 99 … … … … … 2003 8 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 60.00 … … 4.00 … … 2003 8 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 419.00 … … 94.00 (2002) … … 2003 8 Number of cases Number of deaths 45 Acute respiratory infections 76 836 37 776 39 060 35 18 17 2002 7 46 Diarrhoeal diseases 20 750 10 412 10 338 41 23 18 2002 7 47 Cancers All cancers (malignant neoplasms only) … … … 15 … … 2002 7 - Trachea, bronchus and lung … … … 2 2 0 2002 7 - Stomach … … … 1 1 0 2002 7 - Colon and rectum … … … 1 0 1 2002 7 - Lip, oral cavity and pharynx … … … 1 1 0 2002 7 - Liver … … … … … … - Cervix … … … 6 0 6 2002 7 - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … 70 … … 2002 7 - Ischaemic heart disease … … … 2 2 0 2002 7 - Acute myocardial infarction … … … 24 14 10 2002 7 - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … 40 31 9 2002 7 - Hypertension 4 3 1 2002 7 49 Maternal causes - Haemorrhage … … 2 2 2002 7 - Abortion … … … … - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … COUNTRY HEALTH INFORMATION PROFILE 127 INDICATORS DATA Year Source Total Male Female Total Male Female 50 Diabetes mellitus 310 142 168 29 13 16 2002 7 51 Mental disorders 59 37 22 … … … 2002 7 52 Injuries - All types … … … … … … - Motor and other vehicle accidents … … … 5 4 1 2002 7 - Suicide … … … 11 7 4 2002 7 - Homicide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 140 2004 7 - Specialized hospitals … … - District/first-level referral hospitals … … - Primary health care centres 90 … 2004 7 Private hospitals … … Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate a Computed by Health Information and Evidence for Policy Unit, WHO Regional Office for the Western Pacific b Estimates derived by regression and similar estimation methods c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. e Estimate based on 2000 Census Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 2 Demographic Tables for the Western Pacific Region 2000-2005. Manila, WHO Regional Office for the Western Pacific, 2005. 3 Report on the 2000 Census of Population. Statistics Office Ministry of Finance, 2000. 4 World development indicators 2003. Washington, D.C., World Bank, 2003. 5 World health report 2005. Make every mother and child count. Geneva, World Health Organization, 2004. 6 Pacific Island Regional Millennium Development Goals report 2004. Noumea, Secretariat of the Pacific Community, UN/ CROP MDG Working Group, November 2004. 7 Information furnished by the Health Information Centre, Ministry of Health and Medical Services, 2004. 8 WHO Regional Office for the Western Pacific, data received from the technical units. 9 Meeting the MDG drinking water and sanitation target: A mid-term assessment of progress. WHO and UNICEF, 2004 10 Development report 1999 (Creating opportunities). New York, United Nations Development Programme, 1999. 11 Statistics Office (http://www.spc.int/prism/) 12 Information furnished by the Statistics Office Ministry of Finance, 2004. 13 Information furnished by the Tungaru Central Hospital, 2004. 14 Urban and rural areas 2003. New York, Department of Economic and Social Affairs Population Division, United Nations, 2004. 15 World health report 2004. Changing history. Geneva, World Health Organization, 2004. 128 | COUNTRY HEALTH INFORMATION PROFILES LAO PEOPLE'S DEMOCRATIC REPUBLIC 1. DEMOGRAPHICS, GENDER AND POVERTY The Lao People’s Democratic Republic has a population of 5.7 million, a population growth rate of 2.8%, and a sparse population density of 23.3 per square kilometre (km2). The topography breaks into lowland areas along the Mekong River, which depend predominantly on paddy rice, and highland areas which depend on upland rice and the gathering of non-timber forest products for livelihoods. The population is young (44.1%< 15 years), with a total fertility rate of 4.9. The nation is rural (80%) with the beginnings of a rural-to-urban shift. There are 47 distinct ethnic groups identified in the 1995 census. The ethnic Lao comprise 52.5% of the total and predominate in the lowlands, while ethnic minorities predominate in the highlands, although mixing is common. The highlands have more poverty, worse health indicators, and fewer services available for multiple reasons, including remoteness, lower educational levels, and increasing land pressure, which limits food self-sufficiency. Ethnic diversity presents language problems for health systems. Women have lower literacy rates than men, and girls have lower school attendance rates than boys. These gaps are accentuated in the rural and highland areas. There is decreased treatment- seeking behaviour among women when ill, particularly when located at a distance from health facilities. There is no evidence of differential mortality rates between boys and girls. Female life expectancy is slightly higher than that of males. The official poverty rate has fallen steadily (46% in 1992/1993, 39% in 1997/1998, 32% in 2002/2003). Urban poverty (25.5%) is less than rural poverty in areas with roads (30.5%), which is less than poverty in road-less rural areas (47.8%). Lowland areas have less poverty (22.9%) than highland areas (56.5%). The decrease in the national income share of the poorest quarter of the population fell from 9.2% in 1992/1993 to 8.1% in 2002/2003. Table 1. Core population and health data (2004) [Total] 5 679 000 (2003) [Both] 59.00 (2000) [0-14 years] 2 504 439 (44.10%) [Male] 57.00 (2000) Population [65+ years] 215 802 (3.80%) Life expectancy at birth (years) [Female] 61.00 (2000) Crude birth rate (per 1000 population) 34.00 (2000) Total fertility rate 4.90 (2000) [Total] 63.80 [Urban] 75.00 Crude death rate (per 1000 population) 6.30 (2000) % of population served with safe water [Rural] 60.00 [Total] 44.25 [Urban] 70.00 Infant mortality rate (per 1000 live births) 82.20 (2000) % of population with adequate sanitary facilities [Rural] 35.00 Maternal mortality rate (per 100 000 live births) 530.00 (2000) COUNTRY HEALTH INFORMATION PROFILES | 129 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The Lao People’s Democratic Republic was founded in 1975 and is a one-party state under the leadership of the Lao Peoples’ Revolutionary Party (LPRP). Organs of government include the President, the Prime Minister and the National Assembly. A National Assembly election was held in 2002, with competition among a group of approved candidates. The Government works under the guidance of the LPRP which is given through periodic Party Congresses, as well as through the Politburo and Central Committee. The VIIth Party Congress will meet in 2006 and issue the next five-year socioeconomic development plan. 2.2 Economic situation Annual economic growth was 6% in the 1990s but fell to 4%, with 110% inflation, during the Asian financial crisis. Stabilization has since occurred and, in 2003, economic growth was 5.84%, with 15% inflation. Growth in 2004 is estimated at 6.0%. Revenue collection in 2003 was 10.9% of GDP, with government expenditure at 18.7% of GDP. In the same year, health spending made up 5.8% of total government spending, and there is a plan for 5.2% in 2004. Donors contributed 70.3% of total health spending in 2003 and 72% in the 2004 budget plan. Government health spending is about US$ 4.50-5.00 per person per year. 3. HEALTH SITUATION 3.1 Health trends Maternal, infant, and child mortality, as measured through national surveys, are falling, although they are still among the highest in the Region. Between 1995 and 2000, the maternal mortality ratio fell from 656 to 530 per 100 000 live births, the infant mortality rate from 104 to 82 per 1000 live births, and the under-five mortality rate from 170 to 107 per 1000 live birth. The next set of surveys will take place in 2005. There is no vital registration system and the health information system does not provide reliable morbidity and mortality estimates. Survey data for 2000 showed a two-week incidence of fever for all ages of 1.9%. For children, the two-week incidence was 2.9% for fever, 3% for acute respiratory infection, and 6.2% for diarrhoea. Access to clean water and adequate sanitation is increasing. In the 2000 survey, the completed immunization rate for children 12-23 months of age was only 32%, the rate for delivery by a skilled attendant was 21%, and the rate for delivery in a health facility was 12%. Immunization rates may be falling. Treatment-seeking behaviour surveys show that, of those with an acute illness, 52.9% practice self-medication or seek no care, while 47.1% seek some type of care, 18.7% through pharmacies, 24.4% through health workers, and 4% through a spiritualist/volunteers. Malaria is considered the leading cause of morbidity and mortality, with 70% of the population at risk. The 2000 survey showed 19.3% of the population sleeping under insecticide-treated bednets, although 2004 programme data show 2.2 million people protected by treated nets, 55% of the population at risk. Tuberculosis prevalence is high, at 327 smear-positives per 100 000 population. In 2004, the DOTS programme reached 100% of districts. The case detection rate is estimated at 56% and the treatment success rate at 78%. The prevalence of HIV is estimated at 0.06%, with a total of 1470 HIV-positive cases detected since 1993. HIV seroprevalence in 2000 among service women (entertainment workers, two- thirds of whom admitted to selling sex) was 0.9%, with a prevalence of 37.6% for gonorrhoea or chlamydial infection. Interventions have now been introduced for service women and their clients. Repeat HIV and STI survey data will be available in 2005. Antiretroviral treatment has LAO PEOPLE'S DEMOCRATIC REPUBLIC 130 | COUNTRY HEALTH INFORMATION PROFILES been introduced by a nongovernmental organization in Savannakhet and 153 people are under treatment. An outbreak of dengue occurred again in 2003, with 3458 confirmed cases. Dengue appears to be moving peripherally, with outbreaks recorded in smaller population centres. No cases of severe acute respiratory syndrome (SARS) have been identified. No human cases of avian influenza have been identified although there was an outbreak in poultry in early 2004. Surveillance systems have been strengthened as a response to these two illnesses. The most recent data show an intestinal helminth prevalence rate of 62% among schoolchildren. Pilot projects have demonstrated the feasibility of mass treatment of schoolchildren, and a project to scale up school deworming nationally will begin in 2005. There is evidence to suggest that schistosomiasis may re-emerge when control measures are discontinued. Road accidents are of increasing concern as roads improve and vehicle numbers increase. Mental health issues, particularly drug abuse, are also a growing concern. Other mental health issues include management of seizure disorders and psychoses. Nutrition is a neglected area, with 40% of children stunted and 48.2% of children and 31.3% of females with haemoglobin levels below 11 g/dl. Universal salt iodinization misses at least 7% of children, and vitamin A supplementation is far from universal. The rate of exclusive breast- feeding at three months of age is only 28.1%. The rate of obesity, defined as a body mass index of 30 or greater, is only 1.2% nationally, although it is two to three times higher in urban areas. Reliable rates for hypertension and diabetes are not known, although anecdotal reports from urban areas suggest an increase. 3.2 Health systems The public health system is organized by the Ministry of Public Health. Public health institutions are often underutilized, especially in peripheral areas. Qualified health workers are concentrated in urban areas. There are no private hospitals and a limited number of private clinics, mainly operated by civil servants during non-working hours. Total health care spending is about US$ 11.50 per person per year, with about 60% from household expenditure, 30% from donor sources, and 10% from government tax revenue. About two-thirds of the household expenditure is spent privately, mainly in the 2000 private pharmacies or the myriad drug sellers, and the remaining one-third is spent on user fees in public institutions. Provincial and central hospitals receive 48%-83% of their recurrent budgets from user fees. Social insurance, through either the mandatory SSO or voluntary community insurance schemes, covers less than 1% of the population, although both programmes are slated for expansion. Millennium Development Goals The MDGs are to be incorporated into all planning exercises, including the next National Socio- Economic Development Plan, the National Growth and Poverty Eradication Strategy (NGPES), and the United Nations Development Assistance Framework. An MDG progress report was produced in 2004. The report shows that, if the rate of progress remains the same, the Lao People’s Democratic Republic is on track to achieve the MDGs for child and maternal mortality. There is concern, however, that further progress may be more difficult, as some key sub-indicators, such as stunted growth in children, immunization coverage, and delivery by a skilled attendant, are stagnant. A difficult issue is that the NGPES calls for targeting of development investment in the poorest districts, which tend to be more remote and sparsely populated, while at the same time many of the MDG targets have not yet been met in the relatively more affluent and accessible districts. COUNTRY HEALTH INFORMATION PROFILES | 131 4. NATIONAL HEALTH PLAN AND PRIORITIES The health priorities of the Lao People’s Democratic Republic are articulated in three documents. The objectives of each are generally compatible. The goal of the nation, as articulated by the VIth Party Congress, is to leave behind underdeveloped country status by 2020. The Health Strategy to the Year 2020 has four basic concepts: • full health care service coverage and health care service equity; • development of early integrated health care services; • demand-based health care services; and • self-reliant health services. This then leads to six health development strategies, which are: • strengthening the ability of health care providers; • improving community-based health promotion and disease prevention; • improving and expanding hospitals at all levels and in remote areas; • promoting and strengthening the use of traditional medicine, integration of modern and traditional care, ensuring the quality, safety and rational use of food and drugs, and promoting national pharmaceutical products; • promoting operational health research; and • ensuring effective health administration and management and self-sufficient financial systems, and establishing health insurance. The Ministry of Health, with support from the Japan International Cooperation Agency (JICA) conducted the Lao Health Master Planning Study in 2001/2002. This study identifies seven ‘precedent programmes’ to be implemented and 31 ‘very high priority’ programmes in the fields of planning and management, human resources development, health financing, health education, infectious disease control, primary health care, maternal and child health, nutrition, hospital services, medical laboratory technology, and essential drugs. The need for sectorwide coordination is emphasized. The Lao Health Master Planning Study has not yet been completely harmonized with the Health Strategy to the Year 2020. A third major policy document is the National Growth and Poverty Eradication Strategy (NGPES), which focuses on poverty and the poorest districts; 72 poor, 47 poorest districts, as well as 10 districts for initial activities, have been identified. The health priorities in the NGPES are: • information, education and communication as an integrated part of health services; • expansion of the service network for the health promotion of the people in rural areas, including improved health care financing and management; • improving and upgrading the capacity of health workers from village to postgraduate level, with an emphasis on ethnic minorities, an appropriate gender balance, and incentives for retaining health workers in areas where there are shortages; • maternal and child health (MCH) promotion; • immunization; • water supply and environmental health; • communicable disease control; • control of sexually transmitted infections, including HIV/AIDS; • village drug revolving fund development; • food and drug safety; • promotion of traditional medicine integrated with modern medical treatment; and • strengthened sustainability, including financing, management, quality assurance and legal framework. LAO PEOPLE'S DEMOCRATIC REPUBLIC 132 | COUNTRY HEALTH INFORMATION PROFILES The NGPES is currently being costed, and initial estimates are that it would require a 43% increase in current spending to be implemented fully. A theme in all three plans is the need for improved coordination and integration. The health sector is extremely project- and donor-dependent, which has often led to competing and overlapping donor demands. The Minister of Health has called for more integrated approaches, particularly for MCH and immunization; decentralized service delivery methods; and a unified and simplified health information system. A new constitutional article obligates the Government to improve and extend the health network; improve disease prevention; create conditions so all people receive health care, especially mothers, children and the poor; and legalize private investment in health services. A new five-year National Socio-Economic and Development Plan will be promulgated in 2006 at the VIIth Party Congress. That plan will be developed in 2005. As part of the policy framework with the Bretton-Woods institutions, the Government has pledged to increase health spending. 5. MAJOR INFORMATION SOURCES Basic Statistics 2003. National Statistical Center, 2004. United Nations Development Assistance Framework for the Lao People’s Democratic Republic 2002-2006. New York, UNDP, July 2002. Lao Reproductive Health Survey 2000. State Planning Committee/National Statistical Center Common Country Assessment. New York, United Nations, December 2000. The National Growth and Poverty Eradication Strategy. Centre for Planning and Investment, 2004. Millennium Development Goals Progress Report, Lao People’s Democratic Republic – January 2004. Results from the Population Census 1995. State Planning Committee/National Statistics Centre, April 1997. Annual Report 2003. Bank of the Lao People’s Democratic Republic Statistical Report. Statistics Department, Ministry of Health, 2000. Health Status of the People in the Lao People’s Democratic Republic : Report on National Health Survey. January 2001. TB Statistics. National TB Centre, February 2004. HIV Surveillance Survey and Sexually Transmitted Infection Periodic Surveillance Survey , 2001. Mental Health Situation Analysis in the Lao People’s Democratic Republic. Ministry of Health/WHO, December 2002. Survey data from the Ministry of Health/WHO/the Korean Association for Health Promotion, 2000-2003. The Study on Improvement of Health and Medical Services in the Lao People’s Democratic Republic – Progress Report I. Ministry of Health/JICA Study Team, September 2001. Hospital Costing Study. Ministry of Health Planning and Budgeting Department and WHO, January 2004. Lao Health Master Planning Study. Ministry of Health/JICA Study Team, November 2002. Health Strategy up to the Year 2020 – A Discussion Paper for the Donor Round Table Meeting. Ministry of Health, May 2000. Lao Expenditure and Consumptions Survey 2002/03. National Statistical Centre, March 2004. Official Gazette, 11th Year. Ministry of Justice, July 2004. COUNTRY HEALTH INFORMATION PROFILES | 133 Grant Performance Report for the Global Fund. CMPE, Ministry of Health, October 2004. Report on the Roundtable Process. National Round Table Process Steering Committee, November 2004. 6. ADDRESSES MINISTRY OF HEALTH Office Address : Simuang Road, Vientiane, Lao People’s Democratic Republic Postal Address : Official Email Address : pomdohp@laotel.com (for Department of Prevention and Hygiene) Telephone : 856 (0)21 217607 Fax : 856 (0)21 214003 Office Hours : Website : WHO REPRESENTATIVE IN THE LAO PEOPLE’S DEMOCRATIC REPUBLIC Office Address : That Luang Rd., Ban Phonxay, Vientiane, Lao People’s Democratic Republic Postal Address : P.O. Box 343, Vientiane, Lao People’s Democratic Republic Official Email Address : wr-lao@lao.wpro.who.int Telephone : 856 (0)21 413431, 414264 Fax : 856 (0)21 413432 Office Hours : 7:30 a.m. – 4:00 p.m. LAO PEOPLE'S DEMOCRATIC REPUBLIC 134 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: DEPARTMENT OF HEALTH COUNTRY HEALTH INFORMATION PROFILE 135 LAO PEOPLE’S DEMOCRATIC REPUBLIC WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 236.80 2003 1 2 Estimated population ('000s) 5679.00 2806.70 2872.30 2003 1 3 Annual population growth rate (%) 2.80 … … 2002 4 4 Percentage of population - 0–14 years 44.10 45.60 42.90 2003 1 - 65+ years 3.80 3.70 3.90 2003 1 5 Urban population (%) 20.70 … … 2003 12 6 Crude birth rate (per 1000 population) 34.00 … … 2000 2 7 Crude death rate (per 1000 population) 6.30 … … 2000 2 8 Rate of natural increase of population (% per annum) 2.77 a … … 2000 9 Health-adjusted life expectancy (HALE) (years) - at birth 59.00 57.00 61.00 2000 2 - at age 60 … 9.60 10.10 2002 13 10 Adult literacy rate (%) (15 years and up) 74.00 85.00 64.00 2003 16 11 Neonatal mortality rate (per 1000 live births) 36.20 … … 2000 2 12 Infant mortality rate (per 1000 live births) 82.20 … … 2000 2 13 Under-five mortality rate (per 1000 live births) 106.90 h … … 2000 2 14 Total fertility rate (women aged 15–49 years) 4.90 2000 2 15 Maternal mortality ratio (per 100 000 live births) 530.00 2000 2 16 Percentage of newborn infants weighing at least 2500 g at birth 82.00 … … 1998 8 17 Prevalence of underweight children under five years of age 40.00 2000 5 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 60.00 … … 2004 6 - DTP3 45.00 … … 2004 6 - OPV3 46.00 … … 2004 6 - Measles 36.00 … … 2004 6 - Tetanus II 30.00 … … 2004 6 - Hepatitis B III 45.00 … … 2004 6 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 23.00 2000 2 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 37.00 2003 19 - Percentage of deliveries at home by trained personnel (as % of total deliveries) 9.00 2004 17 - Percentage of deliveries in health facilities (as % of total deliveries) 12.00 2000 2 21 Percentage of women in the reproductive age group using modern contraceptive methods (married women only) 28.90 h 2000 2 22 Condom use rate of the contraceptive prevalence rate … … 0.50 2000 2 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … LAO PEOPLE’S DEMOCRATIC REPUBLIC 136 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 63.80 75.00 60.00 2004 14 26 Proportion of population with access to improved sanitation 44.25 70.00 35.00 2004 14 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) 96.00 … … 2000 3 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) 30 Health care waste generation (metric tons per year) 31 Human development index 0.53 2002 11 32 Per capita GDP at current market prices (US$) 380.00 2004 10 33 Rate of growth per capita GDP 6.20 2004 10 34 Health expenditure Total health expenditure - amount (in million US$) 65.30 2002- 2003 15 - total health expenditure on health as % of GDP 3.20 2003 7 - per capita total expenditure on health (in US$) 11.50 2001- 2002 10 Government expenditure on health - amount (in million US$) 24.60 2002- 2003 15 - general government expenditure on health as % of total expenditure on health 37.70 2002- 2003 15 - general government expenditure on health as % of total general government expenditure 5.77 2002- 2003 15 External source of government health expenditure - external resources for health as % of general government expenditure on health 70.30 2003 15 Private health expenditure - private expenditure on health as % of total expenditure on health 55.60 2002 9 Exchange rate in US$ of local currency is: 1 US$ = 10 350 kips 35 Health insurance expenditure - health insurance coverage as % of total population <1.00 2004 10 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 1283 696 587 2.26 2.48 2.04 2003 19 - dentists 83 62 21 0.15 0.22 0.07 2003 19 - pharmacists 276 163 113 0.49 0.58 0.39 2003 19 - nurses 5291 1719 3572 9.32 6.12 12.44 2003 19 - midwives c … … … … … … - other nursing/ auxiliary staff … … … … … … - other paramedical staff(e.g. medical assistants, laboratory technicians, X-ray technicians) 2323 1123 1200 4.10 4.00 4.18 2003 19 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … COUNTRY HEALTH INFORMATION PROFILE 137 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Five leading causes of morbidity Number Rate per 100 000 population b 1. Malaria 104 434 … … 4083.17 … … 2000 5 2. Pneumonia 18 096 … … 728.44 … … 2000 5 3. Gastritis 17 132 … … 689.63 … … 2000 5 4. Influenza 12 987 … … 522.78 … … 2000 5 5. Diarrhoea 12 334 … … 496.49 … … 2000 5 40 Five leading causes of mortality Number Rate per 100 000 population b 1. Malaria 996 … … 40.09 … … 2000 5 2. Pneumonia 83 … … 3.34 … … 2000 5 3. Diarrhoea 34 … … 1.36 … … 2000 5 4. Heart failure 34 … … 1.36 … … 2000 5 5. Injury 33 … … 1.32 … … 2000 5 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 11 … … … … … 2004 6 - Pertussis (whooping cough) 199 … … … … … 2004 6 - Tetanus 49 … … … … … 2004 6 - Neonatal tetanus 14 … … … … … 2004 6 - Poliomyelitis 1 e … … … … … 2004 6 - Hib Meningitis … … … … … … - Measles 1491 … … … … … 2004 6 - Mumps … … … … … … - Rubella … … … … … … - Congenital rubella syndrome … … … … … … 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral 632 … … 0 0 0 2002 6 - Type A 10 … … 0 0 0 2002 6 - Type B 61 … … 0 0 0 2002 6 - Type C … … … … … … - Unspecified … … … … … … Cholera 1272 … … 1 … … 2002 6 Typhoid fever … … … … … … Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … Gonorrhoea … … … … … … Leprosy 156 … … … … … 2003 6 Malaria 18 894 … … 187 … … 2003 6 Dengue/DHF 3458 … … 11 … … 2004 6 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 332.00 … … 3.31 … … 2003 18 - Proportion of population in malaria-risk areas using effective malaria prevention measures f … - Proportion of population in malaria-risk areas using effective malaria treatment measures g … LAO PEOPLE’S DEMOCRATIC REPUBLIC 138 INDICATORS DATA Year Source Total Male Female Total Male Female 44 Tuberculosis Number of cases Number of deaths - All types 2780 … … … … … 2003 6 - New pulmonary tuberculosis (smear-positive) 1882 … … … … … 2003 6 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 327.00 … … 26.00 … … 2003 6 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 47.00 … … 78.00 (2002) … … 2003 6 Number of cases Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (malignant neoplasms only) … … … … … … - Trachea, bronchus, and lung … … … … … … - Stomach … … … … … … - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … … … … - Liver … … … … … … - Cervix … … … … … … - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … … … … - Ischaemic heart disease … … … … … … - Acute myocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … … … … - Hypertension … … … … … … 49 Maternal causes - Haemorrhage … … … … - Abortion … … … … - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … 50 Diabetes mellitus … … … … … … 51 Mental disorders … … … … … … 52 Injuries - All types … … … … … … - Motor and other vehicle accidents … … … … … … - Suicide … … … … … … - Homicide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … COUNTRY HEALTH INFORMATION PROFILE 139 INDICATORS DATA Year Source 54 Health infrastructure Number Number of beds Public health facilities - General hospitals c 18 1921 2003 1 - Specialized hospitals d 6 790 2003 1 - District/first level referral hospitals 125 2303 2003 1 - Primary health care centres 662 1241 2003 1 Private hospitals 0 0 2003 1 Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Calculated by Statistical Division of Ministry of Health. c Refers to central-level general hospitals, regional general hospitals and provincial general hospitals. d Refers to specialized hospitals at central level. e Vaccine-derived polio-virus f Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. g Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. h Revised data Sources: 1 Statistical Yearbook 2003. National Statistical Centre 2 Lao Reproductive Health Survey 2000. National Statistical Centre 3 Millennium Development Goals Progress Report. Lao People’s Democratic Republic, January 2004 4 National Statistics Centre, 2002 5 National Health Survey. National Statisical Centre and NIOPH, January 2001 6 WHO Regional Office for the Western Pacific, data received from technical units 7 Association of South-East Asia Nations – www.aseansec.org 8 United Nations Country Indicators – Lao People’s Democratic Republic. Last amendment, 14 February 2000 9 Lao Health Master Planning Study. Ministry of Health, Nov. 2002 10 Information furnished by WHO Representative in the Lao People’s Democratic Republic, 17 February 2004 11 Human Development Report 2004. New York, UNDP, 2004 – www.undp.org 12 Urban and Rural Areas 2003. Department of Economic and Social Affairs Population Division, United Nations, 2004 13 The World health report 2004. Changing history. Geneva, World Health Organization, 2004. 14 Report 2004. Water and Sanitation Centre of the Lao People’s Democratic Republic. 15 Official gazette. State Budget Revenue-Expenditure Implementation of FY 2002-2003. Ministry of Justice. 16 Lao Expenditure and Consumption Survey 2002/03. National Statistical Centre, March 2004. 17 Report 2004. Mother and Child Centre of the Lao People’s Democratic Republic. 18 Report 2003. Centre for Malaria, Parasite and Entomology of the Lao People’s Democratic Republic. 19 Report 2004. Expanded programme on immunization project of the Lao People’s Democratic Republic. 20 Ministry of Health 140 | COUNTRY HEALTH INFORMATION PROFILES MACAO (CHINA) 1. DEMOGRAPHICS, GENDER AND POVERTY Based on the results of the 2001 census and the data on population changes since then, the resident population of Macao (China) was estimated at 448 495 as at 31 December 2003, an increase of 1858 since December 2002, representing an annual growth rate of 1.5%. Among the resident population, 48.1% were males and 51.9% were females. As regards distribution by age group, 18.6% of the population were aged 0-14 and 7.9% 65 and above. Compared with 2002, the proportion of residents aged 0-14 dropped 14 percentage points, while those aged 65 and above went up 0.2 of a percentage point. The natural increase of the population is an important factor in population growth. In Macao, 3212 live births and 1474 deaths were recorded in 2003, up by 1.6% and 4.2% respectively compared with 2002. The natural growth rate was 0.4%. Population migration is another important factor in population growth. In 2003, there was an inflow of 6439 persons, including legal and illegal immigrants from Mainland China, persons authorized to reside in Macao and non-resident workers. In the same year, the estimated number of emigrants was 1319 persons. Table 1. Core population and health data (2003) [Total] 448 495 [Both] 78.9 (1998-2001) [0-14 years] 83 605 (18.64%) [Male] 77.2 (1998-2001) Population [65+ years] 35 504 (7.92%) Life expectancy at birth (years) [Female] 81.5 (1998-2001) Crude birth rate (per 1000 population) 7.2 Total fertility rate 0.84 [Total] 100.00 [Urban] … Crude death rate (per 1000 population) 3.3 % of population served with safe water [Rural] … [Total] 99.85 (1998-2001) [Urban] … Infant mortality rate (per 1000 live births) 0.62 % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 0.00 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Macao became the Macao Special Administrative Region (SAR) of China on 20 December 1999, entering a new era in its development with the return of its administration to China. Under its “one country, two systems” formula, China has promised Macao (China) a high degree of autonomy with its present political, judicial, social, cultural and economic systems for the next 50 years. On 29 August 2004, Mr. Edmund Ho was re-elected for a second term as the Chief Executive of the Macao Special Administrative Region with the massive support of 296 votes from the 299 Election Committee members present. COUNTRY HEALTH INFORMATION PROFILES | 141 2.2 Economic situation Macao (China) has a history of more than four centuries serving as an entrepot between China and the Western world. This fits in with the Government’s policy of establishing Macao as a regional service centre. Since China's accession to the World Trade Organization (WTO), Macao has been able strengthen itself as a bridge that connects the business community on the mainland with their counterparts abroad. Improvements have been made in Macao's social, economic and public security environment over the past few years, while, at the same time, the Macao Government has intensified its public relations campaigns to introduce its policies to the public. As a result of opening up the gaming sector and constantly improving the investment environment, the economy has been developing rapidly in recent years. The gross domestic product (GDP) growth rates for 2000, 2001 and 2002 were 1.5%, 0.2% and 8.9%, respectively. In 2003, the GDP growth rate reached 16.7%. At the beginning of the year, Moody's Investors Service upgraded Macao’s overall credit rating from Baa1 to A3, with a positive economic outlook. 3. HEALTH SITUATION 3.1 Health trends Having gone through the process of a demographic and epidemiological transition, the population of Macao enjoys a fairly low mortality rate and a long life expectancy. They also enjoy a high standard of health, as reflected in the general decline in the incidence of communicable diseases and the increase in life expectancy, as well as the improvement in health indices. Noncommunicable diseases are the main causes of morbidity and mortality. However, like other developed areas, the threat from re-emerging and newly emerging infectious diseases continues. Cancer is the leading cause of death; a rate of 244 per 100 000 population (1093 cases of cancer) was recorded in 2003. The most common cancers (with crude incidence rates per 100 000 population) were: cancer of the colon and rectum (33.2), cancer of the trachea, bronchus and lung (31.7), cancer of the nasopharynx (19.0), cancer of the stomach (17.2) and cancer of the liver (14.9). By rank, the most common cancer deaths (with annual rates per 100 000 population) were: cancer of the trachea, bronchus and lung (29.2), cancer of the liver (14.8), cancer of the stomach (12.5), cancer of the colon and rectum (10.2) and cancer of the nasopharynx (8.3). Some 500 deaths due to diseases of the circulatory system occur each year. Tuberculosis is one of the top communicable diseases. Morbidity and mortality of most vaccine- preventable communicable diseases have remained very low for many years. Safe water is available for almost 100% of the population, and the incidence of waterborne or foodborne infections remains low. There is no risk of malaria, but dengue fever occurs sometimes. The hepatitis B carrier rate among adults is around 11.5%, and is less than 1% among vaccinated children. HIV/AIDS prevalence remains low at less than 0.1%. 3.2 Health systems In the 1980s, the Government built a two-level health system, supported by a government budget, to provide free, universally accessible primary health care for all citizens through its health centres and comprehensive specialized care through the central hospital. At the beginning of the new century, the Government defined “efficacious medical care, with privilege in prevention” as its guiding principle in health. In developing its work in the area of preventive medicine, the Government cited WHO policies and the promotion of healthy lifestyles as main strategies. MACAO (CHINA) 142 | COUNTRY HEALTH INFORMATION PROFILES In 2003, there were 955 physicians, 237 traditional Chinese medicine doctors, 137 dentists and 1010 nurses. This gives a physician-to-population ratio of 1:470, a traditional Chinese medicine doctor-to-population ratio of 1:1892, a dentist-to-population ratio of 1:3274, and a nurse-to- population ratio of 1:444. For the 2003 financial year, the Government spent US$ 173 million, 11.42% of the total government budget, on health expenditure. The total expenditure on health per capita was around US$ 536. 4. NATIONAL HEALTH PLAN AND PRIORITIES The Government calls for “appropriate medical treatment based on adequate medical prevention”. The most crucial tasks to be achieved by the Government are to: • continue developing traditional Chinese medicine; • promote health education and healthy lifestyles; • structure a Healthy City Programme; • strengthen the layout of medical facilities; • consolidate communicable diseases control and prevention; • strengthen health legislation; • enhance the quality of health care services; and • safeguard food safety in the community. 5. MAJOR INFORMATION SOURCES Statistics and Census Service Department of Health Finance Services Bureau 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Postal Address : Caixa Postal 3002 – Macau Official Email Address : seg@ssm.gov.mo Telephone : (853) 313731 Fax : (853) 713105 Office Hours : Website : www.ssm.gov.mo WHO REPRESENTATIVE There is no WHO Representative in Macao (China). Queries about the WHO programme of collaboration with Macao (China) should be directed to: Office Address : Postal Address : Director, Programme Management World Health Organization Regional Office for the Western Pacific United Nations Avenue P.O. Box 2932, 1000 Manila, Philippines Official Email Address : Telephone : Fax : Office Hours : 7:00–15:30 Website : www.wpro.who.int COUNTRY HEALTH INFORMATION PROFILES | 143 ORGANIZATIONAL CHART: DEPARTMENT OF HEALTH Secretary for Social Affairs and Culture Director of Department of Health Research and Planning Office Medical Intern Training Committee Centre for Disease Control and Prevention Training Committee General Health Care Specialized Health Care General Administration and Support * Primary Health Care Department - Health Centres - Technical Units * Public Health Laboratory * Blood Transfusion Centre * Pharmaceutical Affairs Department * Hospital Administration Department - Hospitalization Division - Patient Services Division - Hospital Pharmacy Division * Medical Departments * Paramedical Departments * Finance Department * Human Resources Department * Information Technology and Organization Department * Facility and Equipment Department MACAO (CHINA) 144 MACAO (CHINA) WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 0.03 2003 1 2 Estimated population ('000s) 448.50 215.62 232.88 2003 1 3 Annual population growth rate (%) 1.55 … … 2003 1 4 Percentage of population - 0–14 years 18.64 20.13 17.27 2003 1 - 65+ years 7.92 7.06 8.71 2003 1 5 Urban population (%) 100.00 … … 2003 1 6 Crude birth rate (per 1000 population) 7.20 … … 2003 1 7 Crude death rate (per 1000 population) 3.30 … … 2003 1 8 Rate of natural increase of population (% per annum) 0.39 … … 2003 1 9 Health-adjusted life expectancy (HALE) (years) - at birth 78.90 77.20 81.50 1998-2001 1 - at age 60 … … … 10 Adult literacy rate (%) 91.30 95.30 87.80 2001 1 11 Neonatal mortality rate (per 1000 live births) 0.31 0.00 0.66 2003 1 12 Infant mortality rate (per 1000 live births) 0.62 0.59 0.66 2003 1 13 Under-five mortality rate (per 1000 live births) 1.56 1.18 1.99 2003 1 14 Total fertility rate (women aged 15–49 years) 0.84 2003 1 15 Maternal mortality ratio (per 100 000 live births) 0.00 2003 1 16 Percentage of newborn infants weighing at least 2500 g at birth 93.56 93.59 93.51 2003 1 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 96.20 … … 2004 4 - DTP3 90.20 … … 2004 4 - OPV3 90.20 … … 2004 4 - Measles 91.10 … … 2004 4 - Tetanus II … … … 2004 4 - Hepatitis B III 86.40 … … 2004 4 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 100.00 2003 2 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 68.00 2003 2 - Percentage of deliveries at home by trained personnel (as % of total deliveries) 0.00 2003 1 - Percentage of deliveries in health facilities (as % of total deliveries) 100.00 2003 1 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … ... ... 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … ... COUNTRY HEALTH INFORMATION PROFILE 145 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 … … 2003 2 26 Proportion of population with access to improved sanitation 99.85 … … 1998- 2001 2 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure 99.24 … … 2001 1 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.88 … … 2000 1 32 Per capita GDP at current market prices (US$) 17 782.14 n/a n/a 2003p 1 33 Rate of growth per capita GDP 15.2 … … 2003 1 34 Health expenditure Total health expenditure b - amount (US$) 238 059 955.10 2003 1 - total health expenditure on health as % of GDP 3.01 2003 1 - per capita total expenditure on health (in US$) 535.88 2003 1 Government expenditure on health - amount (in million US$) 173.00 2003 3 - general government expenditure on health as % of total expenditure on health 72.49 2002 3 - general government expenditure on health as % of total general government expenditure 11.42 2003 3 External source of government health expenditure - external resources for health as % of general government expenditure on health ... Private health expenditure c - private expenditure on health as % of total expenditure on health 27.51 2003 1 Exchange rate in US$ of local currency is: 1 US$ = 8.02(MOP) 2003 1 35 Health insurance expenditure - health insurance coverage as % of total population ... INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 1192 … … 26.58 … … 2003 2 - dentists 137 … … 3.05 … … 2003 2 - pharmacists ... ... ... ... ... ... - nurses 1010 49 961 22.52 2.27 41.27 2003 1 - midwives ... ... ... ... ... ... - other nursing/ auxiliary staff ... ... ... ... ... ... - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) ... ... ... ... ... ... - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) ... ... ... ... ... ... 37 Yearly new graduates - physicians ... ... ... 38 Yearly new graduates - nurses ... ... ... MACAO (CHINA) 146 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity (compulsory notifiable diseases) Number Rate per 100 000 population 1. Varicella (chickenpox) 1680 d 948 727 374.59 439.66 312.18 2004 2 2. Tuberculosis of lung 315 214 101 70.23 99.25 43.37 2004 2 3. Hand, foot and mouth disease 224 122 102 49.94 56.58 43.80 2004 2 4. Bacterial food intoxication 190 101 89 42.36 46.84 38.22 2004 2 5. Acute hepatitis C 101 66 35 22.52 30.61 15.03 2004 2 6. Acute gastroenteritis caused by Norovirus 84 40 44 18.73 18.55 18.89 2004 2 7. Mumps 67 40 27 14.94 18.55 11.59 2004 2 8. Gonococcal infections 63 28 35 14.05 12.99 15.03 2004 2 9. Asymptomatic HIV infection 28 d 18 8 6.24 8.35 3.44 2004 2 10. Acute hepatitis E 21 14 7 4.68 6.49 3.01 2004 2 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Malignant neoplasms 417 248 169 92.98 115.02 72.57 2003 2 2. Heart failure 332 144 188 74.02 66.78 80.73 2003 2 3. Cerebrovascular 115 54 61 25.64 25.04 26.19 2003 2 4. Pneumonia 99 54 45 22.07 25.04 19.32 2003 2 5. Bronchitis, emphysema, asthma 63 40 23 14.05 18.55 9.88 2003 2 6. Nephritis, nephrotic syndrome, nephrosis 60 24 36 13.38 11.13 15.46 2003 2 7. Suicide 59 35 24 13.15 16.23 10.31 2003 2 8. Accident and noxious effect 45 30 15 10.03 13.91 6.44 2003 2 9. Septicaemia 30 12 18 6.69 5.57 7.73 2003 2 10. Hypertension and hypertensive renal disease 17 9 8 3.79 4.17 3.44 2003 2 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2004 4 - Pertussis (whooping cough) 0 0 0 … … … 2004 4 - Tetanus 0 0 0 … … … 2004 4 - Neonatal tetanus 0 0 0 … … … 2004 4 - Poliomyelitis 0 0 0 … … … 2004 4 - Hib Meningitis 0 0 0 … … … 2004 4 - Measles 0 0 0 … … … 2004 4 - Mumps 67 40 27 … … … 2004 4 - Rubella 2 2 0 … … … 2004 4 - Congenital rubella syndrome 0 0 0 … … … 2004 4 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral 144 … … 0 0 0 2004 4 - Type A 3 2 1 … … … 2004 2 - Type B 19 10 9 … … … 2004 2 - Type C 101 66 35 … … … 2004 2 - Unspecified 0 0 0 … … … 2004 2 Cholera 0 0 0 … … … 2004 2 Typhoid fever 1 1 0 … … … 2004 2 Encephalitis 3 3 0 … … … 2004 2 Plague 0 0 0 … … … 2004 2 Syphilis 7 1 6 … … … 2004 2 COUNTRY HEALTH INFORMATION PROFILE 147 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Gonorrhoea (gonococcal infections) 63 28 35 … … … 2004 2 Leprosy 2 0 2 … … … 2004 2 Malaria 0 0 0 … … … 2004 2 Dengue/DHF 2 1 1 … … … 2004 2 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 0 0 0 0 0 0 2004 2 - Proportion of population in malaria-risk areas using effective malaria prevention measures e … - Proportion of population in malaria-risk areas using effective malaria treatment measures f … 44 Tuberculosis Number of cases Number of deaths - All types 371 … … … … … 2003 4 - New pulmonary tuberculosis (smear-positive) 138 … … … … … 2003 4 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 89.00 … … 10.00 … … 2003 4 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 76.00 … … 89.00 (2002) … … 2003 4 Number of cases Number of deaths 45 Acute respiratory infections … … … 11 7 4 2003 1 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (malignant neoplasms only) 1093 … … 417 248 169 2003 1 - Trachea, bronchus, and lung … … … 98 70 28 2003 1 - Stomach … … … 44 27 17 2003 1 - Colon and rectum … … … 45 24 21 2003 1 - Lip, oral cavity and pharynx … … … 27 22 5 2003 1 - Liver … … … 48 32 16 2003 1 - Cervix … … … 6 0 6 2003 1 - Leukaemia … … … 6 2 4 2003 1 48 Circulatory All circulatory system diseases … … … 477 213 264 2003 1 - Ischaemic heart disease … … … 150 66 84 2003 1 - Acute myocardial infarction … … … 43 22 21 2003 1 - Rheumatic fever and rheumatic heart diseases … … … 5 2 3 2003 1 - Cerebrovascular diseases … … … 115 54 61 2003 1 - Hypertension … … … 2 0 2 2003 1 MACAO (CHINA) 148 INDICATORS DATA Year Source Total Male Female Total Male Female 49 Maternal causes - Haemorrhage … … 0 0 2003 1 - Abortion … … 0 0 2003 1 - Eclampsia … … … … 2003 1 - Sepsis … … … … 2003 1 - Obstructed labour … … 0 0 2003 1 50 Diabetes mellitus … … … 8 4 4 2003 1 51 Mental disorders … … … 0 0 0 2003 1 52 Injuries - All types … … … 115 71 44 2003 1 - Motor and other vehicle accidents … … … 16 11 5 2003 1 - Suicide … … … 59 35 24 2003 1 - Homicide and violence … … … 6 2 4 2003 1 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 554 2003 1 - Specialized hospitals 0 0 2003 1 - District/first-level referral hospitals n/a n/a 2003 1 - Primary health care centres 8 n/a 2003 1 Private hospitals 1 601 2003 1 Notes: Red text Millennium Development Goals indicators … Data not available p Provisional figure n/a Not applicable a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Total health expenditure is sum of government and private expenditure on health c Derived from gross domestic product of Statistics and Census Service d Genders of some cases were not notified e Prevention is measured by the percentage of children aged 0–59 months sleeping under insecticide-treated bednets. f Treatment is measured by the proportion of children aged 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Statistics and Census Service 2 Department of Health 3 Finance Services Bureau 4 WHO Regional Office for the Western Pacific, data received from technical units COUNTRY HEALTH INFORMATION PROFILES | 149 MALAYSIA 1. DEMOGRAPHICS, GENDER AND POVERTY In 2003, the total population of Malaysia was 25 580 000, with about 33% below 15 years of age and 4% aged 65 years and above. The population density was around 76 persons per square kilometre in the same year. Women outnumbered men, with a sex ratio of 96 males for every 100 females. Table 1. Core population and health data (2004) [Total] 25 580 000 [Both] 73.50 [0-14 years] 8 490 000 (2003) [Male] 71.00 Population [65+ years] 1 053 896 (2003) Life expectancy at birth (years) [Female] 76.00 Crude birth rate (per 1000 population) 21.60 (2003) Total fertility rate 2.90 (2003) [Total] 97.40 (2003) [Urban] 99.10 (2003) Crude death rate (per 1000 population) 4.60 (2003) % of population served with safe water [Rural] 94.00 (2003) [Total] 99.70 (2003) [Urban] 99.90 (2003) Infant mortality rate (per 1000 live births) 5.80 (2003) % of population with adequate sanitary facilities [Rural] 99.00 (2003) Maternal mortality ratio (per 100 000 live births) 30.00 (2002) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Malaysia practises parliamentary democracy, based on the federation system, with a constitutional monarchy and three branches of government: the legislative, judicial and administrative or executive. Under the Federal Constitution, the states of Perlis, Kedah, Pulau Pinang, Perak, Selangor, Negeri Sembilan, Melaka, Johor, Pahang, Terengganu, Kelantan, Sarawak and Sabah have agreed to the concept of the formation of the country of Malaysia. The powers of state governments are limited by the Federal Constitution. The chief of state is the Paramount Ruler (Yang Di-Pertuan Agong), who is elected from and by the hereditary rulers of nine of the states for a five-year term. The Paramount Ruler has the power to safeguard the customs and traditions of the Malay people and the administration of the Islamic religion in each state. He is also the Highest Commander of the Armed Forces. Since December 2001, the Paramount Ruler has been Tuanku Syed Sirajuddin ibni Almarhum Tuanku Syed Putra Jamalullail, the Rajah of Perlis. The head of government is the Prime Minister, who appoints the Cabinet from among the members of Parliament with the consent of the Paramount Ruler. The current Prime Minister is Abdullah bin Ahmad Badawi (since October 2003). 2.2 Economic situation The Malaysian economy accelerated in the first half of 2004, after a strong take-off in 2003, and is expected to surpass earlier expectations with higher growth of 7% for the whole year. Positive signs of a firm economic recovery on the global front, as well as higher commodity prices, have contributed to further improvement in consumer and business sentiments. Growth has become MALAYSIA 150 | COUNTRY HEALTH INFORMATION PROFILES more broad-based, with all sectors registering positive trends. Domestic demand, particularly private consumption, has continued to sustain growth for five consecutive years, while private investment, which picked up in 2003, has become more entrenched, resulting in private-sector- led growth. The broad-based growth is evidence of the effective measures implemented by the Government to develop new sources of growth to reduce the nation’s vulnerability to the external environment. Expanding at 10.5%, the manufacturing sector, which has become more diversified with higher-end, value-added and new emerging industries and products, and new growth areas in information and communication technology (ICT), strong expansion in financial services, and revival in tourism activities have supported growth in the services sector, enabling it to maintain its premier position in terms of share of gross domestic product (GDP) at 57%. Meanwhile, the Government’s commitment to revitalizing the agriculture sector as the third engine of economic growth, particularly in food production, has resulted in expansion of output in fruits, aquaculture and livestock. The synchronised upswing in the global economy and upsurge in electronics demand, as well as the high prices of palm oil and crude oil, have continued to propel export volume and earnings. Import growth has been strong, particularly for intermediate and capital goods, reflecting robust domestic economic activities, fuelled by recovery in private investment and higher disposable incomes. The trade balance in July 2004 had remained in surplus for 81 consecutive months since November 1997. Better export earnings and inflow of foreign funds had increased international reserves to US$ 54.4 billion as of 14 August 2004, sufficient to finance 7.2 months of retained imports and five times the short-term external debt. The national resource position remains strong, with gross national savings at 36.5% of gross national product (GNP), providing ample liquidity to finance both public and private sector initiatives. The banking system continues to strengthen along with improvements in loan repayments amidst higher disbursements. The risk-weighted capital ratio has increased further, while the net non-performing loans ratio has improved in tandem with higher corporate earnings and productivity. In the equity market, Bursa Malaysia has been more active in the first half of 2005 and is expected to sustain its performance for the remainder of the year. Inflation remains low at 1.5% despite strong domestic demand and higher commodity prices. Labour market conditions continue to be stable, with the unemployment rate remaining low at 3.5%. With stronger growth in the economy, per capita gross national income is MYR 16 616 (US$ 4373.18), while purchasing power parity was higher, at US$ 10 163 in 2004. 3. HEALTH SITUATION 3.1 Health trends Life expectancy at birth for both genders has increased over the years, rising from 68.8 years for males and 73.5 for females in 1999 to 71 years for males and 76 for females in 2004. Over the same period, the crude birth rate decreased from 28.4 per 1000 live births to 21.3, and the crude death rate also fell from 4.7 per 1000 live births to 4.6. There have been gradual improvements in the infant mortality rate, perinatal mortality rate and the toddler mortality rate, with the infant mortality rate falling from 10.4 per 1000 live births in the 1995 to 5.8 in 2003. The perinatal mortality rate decreased from 9.8 per 1000 live births in 1995 to 6.3 in 2003, while the toddler mortality rate fell from 0.8 per 1000 live births in 1995 to 0.5 in 2003. However, the maternal mortality ratio increased slightly from 1995 to 2003, from 20 to 30 per 100 000 live births. Both communicable and noncommunicable diseases remain a burden in Malaysia. The country has begun experiencing a changing pattern of both diseases. The top five diseases are dominated by noncommunicable diseases, similar to the disease burden of a developed nation. However, the COUNTRY HEALTH INFORMATION PROFILES | 151 rise in the incidence of noncommunicable diseaes is accompanied by persistent incidence of some communicable diseases. Mental illness has also become an increasing problem. Faced with the above, the Ministry of Health, in collaboration with WHO, completed a study on the burden of disease using disability-adjusted life years (DALY) in 2004 (using 2000 data). The study, which took both mortality and morbidity into account, found that the five most common diseases in Malaysia were ischaemic heart disease followed by mental illness, cerebrovascular disease/stroke, road traffic injuries and cancers. 3.2 Health systems Health care in Malaysia is presently provided by the public and private sectors and nongovernmental organizations. The major provider and financier of health services is the Ministry of Health, which is responsible for the health of the population, as stated in the Federal Constitution. The private health sector, whose role has been increasing over the past few decades, provides health services through private hospitals and clinics, which have been mushrooming throughout the country, especially in urban areas. Other health care providers include traditional and complementary medicine (TCM) practitioners and nongovernmental organizations. TCM in Malaysia comprises traditional Malay, Chinese and Ayuverdic medicines among others and is well accepted by both rural and urban communities. Some nongovernmental organizations also contribute to the provision of health care by complementing tasks undertaken by the Ministry of Health. The emergence and rapid growth of private health care insurance and managed care organizations over the past few years may be an indication that health care, especially in the private sector, is becoming less affordable and market-oriented. The challenge is to fulfil the need for health care services to be affordable, comprehensive, equitable and accessible, both in the public and private sectors, for people of all levels of socioeconomic status, via an acceptable national health care financing mechanism. Millennium Development Goals The relatively favourable position that Malaysia now occupies in economic and social development owes much to the innovative policies and strategies for development put in place in the Outline Perpective Plan and implemented through the national five-year plans. Many of the issues that have since emerged internationally in the MDGs, and their related targets, were identified in early official policies and became progressively more explicit as initial aims were achieved. However, some of these issues still represent a significant challenge for the country as it seeks to maintain its developmental momentum. Malaysia’s success in reaching the MDGs is impressive by any standard. An analysis of the factors behind this success can further encourage Malaysia’s planners in their continued efforts and ma also be useful to other countries looking for ways to progress towards the MDGs. The Orang Asli and indigenous communities in Sabah and Sarawak in particular have still to benefit substantially from poverty-eradication measures. Various environmental challenges also still remain. Malaysia’s task in reaching the MDGs is an ongoing one. The way forward is to progress beyond current achievements and implement the strategies, programmes, and projects designed to achieve the National Vision Policy. 4. NATIONAL HEALTH PLAN AND PRIORITIES The objective of the health services is to raise and continuously improve the health status of individuals, families and communities. The essential services in the health system of the future are information and education of individuals to support wellness, as well as consultations to maintain health or provide early treatment of illness. Thus, the health system of the future will be different from the one today, and will not only focus on care using the present health care delivery system. The vision for health empowers individuals, families and communities, and emphasizes wellness and care as well as achieving an enhanced quality of life. MALAYSIA 152 | COUNTRY HEALTH INFORMATION PROFILES Maintaining wellness has been identified as the way forward for the Malaysian health system, and is one of the health services’ goals in designing and planning health care in the country. However, current health promotion and prevention services are still perceived to be disease- oriented rather than wellness-oriented, not only by health care providers but also by the people at large. In achieving the Vision for Health and Mission of the Ministry of Health, the activities carried out by the health sector must be in line with the eight goals of the health services: wellness; person-focused; informed person; self-help; care provided at home or closer to home; seamless, continuous care; services tailored to individual or group needs; and effective, efficient and affordable services. 5. MAJOR INFORMATION SOURCES Ministry of Health (http://www.moh.gov.my/) National Statistics Department (http://www.statistics.gov.my/) Parliament (http://www.parlimen.gov.my) Treasury Department (http://www.treasury.gov.my) Malaysia: Achieving the Millennium Development Goals, successes and challenges Policy review: Developing the Malaysian health system to meet the challenges of the future. 6. ADDRESSES MINISTRY OF HEALTH Office Address : Jalan Cenderasari, 50590 Kuala Lumpur, Malaysia Postal Address : Official Email Address : Telephone : (603) 2698 5077 Fax : (603) 2691 1259/ 2698 5964 Office Hours : Website : http://www.moh.gov.my/ WHO REPRESENTATIVE IN MALAYSIA, BRUNEI DARUSSALAM AND SINGAPORE Office Address : 1st Floor, Wisma UN, Block C, Komplek Pejabat Damansara, Jalan Dungun, Damansara Heights 50490 Kuala Lumpur, Malaysia Postal Address : P.O. Box 12550, 50782 Kuala Lumpur, Malaysia Official Email Address : who@maa.wpro.who.int Telephone : (603) 209 39908 Fax : (603) 209 37446 Office Hours : COUNTRY HEALTH INFORMATION PROFILES | 153 ORGANIZATIONAL CHART: MINISTRY OF HEALTH MALAYSIA 154 MALAYSIA WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 330.25 2003 1 2 Estimated population ('000s) 25 580.00 … … 2004 2 3 Annual population growth rate (%) 2.20 ... ... 2003 2 4 Percentage of population - 0–14 years 33.19 … … 2003 1 - 65+ years 4.12 … … 2003 1 5 Urban population (%) 63.90 … … 2003 3 6 Crude birth rate (per 1000 population) 21.30 … … 2004 9 7 Crude death rate (per 1000 population) 4.60 … … 2004 9 8 Rate of natural increase of population (% per annum) 1.70 a … … 2003 9 Health-adjusted life expectancy (HALE) (years) - at birth 73.50 71.00 76.00 2004 9 - at age 60 … 10.90 12.00 2002 8 10 Adult literacy rate (%) 94.00 … … 2002 2 11 Neonatal mortality rate (per 1000 live births) 3.50 … … 2002 1 12 Infant mortality rate (per 1000 live births) 5.80 … … 2003 1 13 Under-five mortality rate (per 1000 live births) 8.60 … … 2002 4 14 Total fertility rate (women aged 15–49 years) 2.90 2003 6 15 Maternal mortality ratio (per 100 000 live births) 30.00 2003 9 16 Percentage of newborn infants weighing at least 2500 g at birth 91.00 … … 2002 1 17 Prevalence of underweight children under five years of age 12.00 … … 2002 4 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 100.00 … … 2003 1 - DTP3 95.80 … … 2003 5 - OPV3 96.70 … … 2003 5 - Measles 92.20 … … 2003 5 - Tetanus II 83.70 … … 2003 5 - Hepatitis B III 95.00 … … 2003 5 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 73.60 2003 6 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 84.40 2003 6 - Percentage of deliveries at home by trained personnel (as % of total deliveries) 4.14 2002 6 - Percentage of deliveries in health facilities (as % of total deliveries) 95.86 2002 6 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Cumulative number of children orphaned by HIV/AIDS (under age 15) 5500 … … 2001 4 COUNTRY HEALTH INFORMATION PROFILE 155 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 97.40 99.10 94.00 2003 6 26 Proportion of population with access to improved sanitation 99.70 99.90 99.00 2003 6 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) <5.00 … … 2003 5 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.79 2002 7 32 Per capita GNI at current market prices (US$) 4372.63 2004 2 33 Rate of growth per capita GDP 4.50 2003 2 34 Health expenditure Total health expenditure - amount (in million US$) … - total health expenditure on health as % of GNP 1.70 2000 1 - per capita total expenditure on health (in US$) 79.47 2003 1 Government expenditure on health (budget) - amount (in million US$) 1988.42 2003 1 - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure 6.88 2003 1 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = (average) 3.80 RM 2004 2 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 18 191 … … 7.26 … … 2003 1 - dentists 2418 … … 0.96 … … 2003 1 - pharmacists 3104 … … 1.24 … … 2003 1 - nurses 36 784 … … 14.69 … … 2003 1 - midwives 11 610 … … 4.60 … … 2003 1 - other nursing/ auxiliary staff 7033 … … 2.80 … … 2003 6 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 10 879 … … 4.34 … … 2003 6 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 4396 … … 1.75 … … 2003 6 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … MALAYSIA 156 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of Hospitalisation in MOH hospitals Number Rate per 100 000 population 1. Normal delivery (single spontaneous delivery) 286 154 0 286 154 1 142.41 0.00 2327.14 2003 1 2. Complications of pregnancy, childbirth and the puerperium 202 669 0 202 669 809.11 0.00 1648.20 2003 1 3. Accidents (accidental injury) 157 152 115 289 41 863 627.40 904.09 340.45 2003 1 4. Diseases of the circulatory system 121 582 67 546 54 036 485.39 529.69 439.45 2003 1 5. Diseases of the respiratory system 115 357 65 361 49 996 460.54 512.56 406.59 2003 1 6. Certain conditions originating in the perinatal period 100 205 54 064 46 141 400.05 423.97 375.24 2003 1 7. Diseases of the digestive system 82 372 48 873 33 499 328.85 383.26 272.43 2003 1 8. Diseases of the urinary system 59 523 30 605 28 918 237.63 240.00 235.17 2003 1 9. Ill-defined conditions (symptoms and signs) 58 038 30 677 27 361 231.70 240.57 222.51 2003 1 10. Malignant neoplasms 48 018 22 584 25 434 191.70 177.10 206.84 2003 1 40 Ten leading causes of mortality in Ministry of Health hospitals Number Rate per 100 000 population 1. Septicaemia 5683 3235 2448 22.69 25.37 19.91 2003 1 2. Heart diseases and diseases of pulmonary circulation 5240 3137 2103 20.92 12.52 17.10 2003 1 3. Malignant neoplasms 3396 1882 1514 13.56 14.76 12.31 2003 1 4. Cerebrovascular diseases 3007 1612 1395 12.00 12.64 11.34 2003 1 5. Accident 2286 1869 417 9.13 14.66 3.39 2003 1 6. Pneumonia 1934 1175 759 7.72 9.21 6.17 2003 1 7. Certain conditions originating in the perinatal period 1621 907 714 6.47 7.11 5.81 2003 1 8. Diseases of the digestive system 1561 1063 498 6.23 8.34 4.05 2003 1 9. Nephritis, nephrotic syndrome and nephrosis 1375 806 569 5.49 6.32 4.63 2003 1 10. Chronic lower respiratory disease 1053 785 268 4.20 6.16 2.18 2003 1 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 11 … … … … … 2003 5 - Pertussis (whooping cough) 28 … … … … … 2003 5 - Tetanus 18 … … … … … 2003 5 - Neonatal tetanus 8 … … … … … 2003 5 - Poliomyelitis 0 … … … … … 2003 5 - Hib meningitis … … … … … … - Measles 632 … … … … … 2003 5 - Mumps … … … … … … - Rubella … … … … … … - Congenital rubella syndrome … … … … … … 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A 222 … … 0 0 0 2003 5 - Type B 2767 … … 2 … … 2003 5 - Type C 520 … … 1 … … 2003 5 - Unspecified 99 … … 0 0 0 2003 5 COUNTRY HEALTH INFORMATION PROFILE 157 INDICATORS DATA Year Sou5rce Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Cholera 135 … … 0 0 0 2003 5 Typhoid fever 785 … … 2 … … 2003 5 Encephalitis 71 … … 6 … … 2003 5 Plague 0 0 0 0 0 0 2003 5 Syphilis 1069 … … 0 0 0 2003 6 Gonorrhoea 824 … … 0 0 0 2003 6 Leprosy 219 … … … … … 2003 5 Malaria 6338 … … 21 … … 2003 5, 6 Dengue Fever/ DHF … … … … … … 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 22.42 … … 0.09 … … 2003 5 - Proportion of population in malaria-risk areas using effective malaria prevention measures b … - Proportion of population in malaria-risk areas using effective malaria treatment measures c … 44 Tuberculosis Number of cases Number of deaths - All types 15 671 … … … … … 2003 5 - New pulmonary tuberculosis (smear-positive) 7989 … … … … … 2003 5 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 136.00 … … 17.00 … … 2003 5 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 69.00 … … 76.00 (2002) … … 2003 5 Number of cases Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (malignant neoplasms only) 48 018 22 584 25 434 3396 1882 1514 2003 6 - Trachea, bronchus and lung 5097 3711 1386 727 525 202 2003 6 - Stomach 1221 711 510 160 103 57 2003 6 - Colon and rectum 5325 3056 2269 259 162 97 2003 6 - Lip, oral cavity and pharynx 3337 2264 1073 242 177 65 2003 6 - Liver 1332 943 389 236 167 69 2003 6 - Cervix 2829 - 2829 120 - 120 2003 6 - Leukaemia 6012 3381 2631 238 132 106 2003 6 48 Circulatory All circulatory system diseases 121 582 67 546 54 036 8468 4915 3553 2003 6 - Ischaemic heart disease 37 284 24 871 12 413 2697 1730 967 2003 6 - Acute myocardial infarction 7878 6006 1872 1716 1143 573 2003 6 - Rheumatic fever and rheumatic heart diseases 3499 1619 1880 78 26 52 2003 6 - Cerebrovascular diseases 15 674 8879 6795 3007 1612 1395 2003 6 - Hypertension 36 424 15 924 20 500 177 89 88 2003 6 MALAYSIA 158 INDICATORS DATA Year Source Total Male Female Total Male Female 49 Maternal causes - Haemorrhage 7081 7081 … … 2003 6 - Abortion 33 506 33 506 6 9 2003 6 - Eclampsia 418 418 3 3 2003 6 - Sepsis 168 168 2 … 2003 6 - Obstructed labour 766 766 0 0 2003 6 50 Diabetes mellitus 35 460 16 265 19 195 346 175 171 2003 6 51 Mental disorders 27 006 18 244 8 762 1 1 0 2003 6 52 Injuries - All types 167 707 121 375 46 332 2538 2049 489 2003 6 - Motor and other vehicle accidents 82 304 63 475 18 829 1757 1482 275 2003 6 - Suicide 2375 807 1568 144 98 46 2003 6 - Homicide and violence 5518 4074 1444 51 44 7 2003 6 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitalsd 124 31 545 2003 1 & 6 - Specialized hospitals 6 5456 2003 1 & 6 - District/first-level referral hospitals … … - Primary health care centrese 2922 … 2003 1 Private hospitals f 219 10 405 2003 1 Notes: Red text Millennium Development Goals indicators … Data not available p Preliminary a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific b Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. c Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. d Includes Ministry of Health government hospitals and seven non-Ministry government hospitals e Includes Ministry of Health clinics/ community polyclinics, Ministry of Health rural clinics, Ministry of Health maternal and child health clinics and Ministry of Health mobile clinics f Including maternity/ nursing homes Sources: 1 Health facts 2003. Ministry of Health 2 Department of Statistics <http://www.statistics.gov.my> 3 Urban and Rural Areas 2003. New York, United Nations Department of Economic and Social Affairs, Population Division, 2004. 4 Malaysia: Achieving the Millennium Development Goals, successes and challenges. United Nations Country Team and UNDP January 2005. 5 WHO Regional Office for the Western Pacific, data received from the technical units 6 Information and Documentation System Unit, Ministry of Health 7 Human DevelopmentReport 2004. New York, United Nations Development Programme, 2004. 8 The World health report 2004: Changing history. Geneva, World Health Organization, 2004. 9 Information furnished by WHO Representative for Malaysia, 17 March 2005 COUNTRY HEALTH INFORMATION PROFILES | 159 MARSHALL ISLANDS 1. DEMOGRAPHICS, GENDER AND POVERTY The Republic of the Marshall Islands has an area of 1826 square kilometres and comprises 29 atolls and five major islands that form two parallel groups – the Ratak (sunrise) chain and the Rali (sunset) chain. The Marshallese are of Micronesian origin. The matrilineal culture revolves around a complex system of clans and lineages tied to land ownership. The last census took place in 1999, and the next is scheduled for 2009. Therefore, available demographic data are either from the 1999 census, or are estimates derived from it. In the area of gender equality in primary and secondary education, the Marshall Islands is essentially on target to meet the MDG. Gross primary and secondary enrolment rates indicate female-to-male enrolment ratios of roughly 50:50. However, at both primary and secondary levels, female drop-out rates are higher than male, resulting in a higher proportion of males completing Grades 6, 8 and 12 than females. General consensus suggests that the increasing drop-out rates for females versus males are due to the following: • the rise in teenage pregnancy rates; • sociocultural expectations requiring females to be at home to help their parents take care of younger children and other family members; • the high mobility of parents and families between islands, resulting in students being unable to complete the school year (both male and female); and • cultural and familial expectations of young women requiring them to assist in events such as funerals, resulting in many students missing school for lengthy periods of time, often more than once during the school year (Unable to catch up, many students will simply drop out of school.). The Marshall Islands is fortunate not to have extreme poverty and hunger. However, current surveys and socioeconomic indicators suggest that poverty and hardship are on the rise. This presents concerns as to whether the country has been developing, implementing and monitoring poverty reduction strategies and programmes appropriately. Table 1. Core population and health data (2004 estimate) [Total] 55 400 [Both] 67.50 (1999) [0-14 years] 23 395 (42.23%) [Male] 65.70 (1999) Population [65+ years] 1080 (1.95%) Life expectancy at birth (years) [Female] 69.40 (1999) Crude birth rate (per 1000 population) 41.80 (1999) Total fertility rate 5.71 (1999) [Total] 85.00 (2002) [Urban] 80.00 (2002) Crude death rate (per 1000 population) 5.02 (2001 estimate) % of population served with safe water [Rural] 95.00 (2002) [Total] 82.00 (2002) [Urban] 93.00 (2002) Infant mortality rate (per 1000 live births) 29.00 (2002) % of population with adequate sanitary facilities [Rural] 59.00 (2002) Maternal mortality ratio (per 100 000 live births) 73.80 (2002) MARSHALL ISLANDS 160 | COUNTRY HEALTH INFORMATION PROFILES 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The Marshall Islands is a parliamentary democracy, constitutionally in free association with the United States of America. During the last elections, conducted in November 2002, President, H.E. Kessai Note was elected, along with 10 ministers. The Minister for Health and Environment is the Honourable Alvin Jacklick. The legislative branch of government consists of the Nitijela (Parliament) with an advisory council of high chiefs. The Nitijela has 33 members from 24 districts, elected for concurrent four-year terms. Members are called senators. The President is elected by the Nitijela from among its members. Presidents pick cabinet members from the Nitijela. The Marshall Islands has four court systems: Supreme Court, high court, district and community courts, and the traditional rights courts. Trial is by jury or judge. The jurisdiction of the traditional rights court is limited to cases involving titles or land rights or other disputes arising from customary law and traditional practices. The relatively new democratic political system is combined with a hierarchical traditional culture. The first two presidents were chiefs, while the current president is a commoner. The new Government, running on a reform platform, has publicly confirmed its commitment to an independent judiciary. 2.2 Economic situation Assistance from the United States of America is the mainstay of the island economy. The Government is the largest employer, employing 30.6% of the workforce, a reduction of 3.4% since 1988. The gross domestic product is derived mainly from payments made by the United States of America under the terms of the Compact of Free Association. Direct aid accounts for 60% of the Marshall Islands’ US$ 90 million budget. The Compact of Free Association II, as amended in 2002-2023, stipulates heavy emphasis on United States foreign aid to target education and health. The economy combines a small subsistence sector and a modern urban sector. There is a developing agrarian and service-oriented economy. Subsidies are designed to help reduce migration from outer atolls to densely populated Majuro and Ebeye. 3. HEALTH SITUATION 3.1 Health trends High population growth and crowded conditions in urban areas have caused the re-emergence and/or rise of certain communicable diseases, such as tuberculosis and leprosy. In addition, exposure to modern culture has brought about a rise in levels of adult obesity, noncommunicable diseases, teenage pregnancy, suicide, alcoholism and tobacco use. The Government focuses on training native Marshallese health professionals, strengthening community health care programmes, upgrading the quality of health care services, and improving the dissemination of health care information to the citizens of the Marshall Islands. Other health-related issues include the need to reduce population growth and urban population density, reduce malnutrition and strengthen the capacity of the health sector. Recent initiatives have included training basketball players in reproductive health issues so they can lead advocacy programmes. 3.2 Health systems During the 2004 fiscal year, the Ministry of Health received an annual government budget of US$ 15 756 334, equivalent to 14% of the nation’s budget. In line with its mission statement, the Ministry continues to explore avenues to provide the best quality health care possible to the people despite its meagre funding and limited human and capital resources. COUNTRY HEALTH INFORMATION PROFILES | 161 The current health indicators reveal a much improved health status and steady progress in community participation in implementing the theme “Health is a Shared Responsibility.” However, there is still a need to reflect more on the changing lifestyles associated with epidemiological transition from infectious to noncommunicable diseases. A significant proportion of health services are funded under external aid or grant programmes, including the United States Federal Health Grants and grants under the Compact of Free Association between the Marshall Islands and the United States of America. The Planning and Vital Statistics Department of the Ministry of Health is responsible for registration of birth, deaths and causes of death. Vital statistics are compiled from returns received by the Department from Majuro and Ebeye hospitals and from outer islands health service centres. Underreporting of births and deaths is a common problem in developing countries, including the Marshall Islands, where the geographically scattered population creates logistical challenges for the registration process. More generally, health information systems remain weak. Even where data are adequate, they are seldom used to drive policy development. Millennium Development Goals The overall progress of the Marshall Islands towards achieving the MDGs can still be described as slow. However, key institutional and legislative changes have been implemented in the last couple of years, which stand to ensure improved targeting of the MDGs, particularly in the education and health sectors. The two key factors that will influence the country’s MDG progress for the next twenty years will be: • the Compact of Free Association II as amended (2003-23), which stipulates heavy emphasis on United States foreign aid to target education and health; and • implementation of the new performance-based budgeting system in all government ministries and agencies, ensuring improved targeting and implementation of national development goals. In addition, in the last few years, the NGO sector has expanded exponentially. Social services targeting young people, women and outer-island, rural community development are now largely addressed by the NGO sector, which, although still small, has been effective in building a national and international support network for joint NGO and government initiatives and programmes. It is clear that one of the key ways to achieve the MDGs and sustain current efforts will be the strengthening of such types of collaborative efforts between the Government and civil society. The main issue in achieving the MDGs in the Marshall Islands is not so much the lack of financial resources, but rather the appropriate and effective targeting of available financial resources towards the development, implementation and monitoring of MDG-oriented initiatives and programmes. Additionally, the issue of human resource capacity continues to be a constraint to sustainability. The Marshall Islands’ national MDG Report had not been prepared as of the end 2004. However, the Pacific Islands Regional MDG Report was compiled in 2004 to ensure that all Pacific island countries and areas are represented in the United Nations Secretary-General’s 2005 report. Such a report is particularly appropriate in the Pacific region due to the high degree of regional cooperation on development-related issues. The 14 Pacific island countries and one territory covered by the report (Cook Islands, the Federated States of Micronesia, Fiji, Kiribati, the Marshall Islands, Nauru, Niue, Palau, Papua New Guinea, Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu and Vanuatu) are widely dispersed over a large geographical area. They differ significantly in size, population, resource endowments and development constraints, but nevertheless share a number of development challenges. The Pacific Islands Regional MDG Report is the sixth regional MDG report to be prepared worldwide. MARSHALL ISLANDS 162 | COUNTRY HEALTH INFORMATION PROFILES 4. NATIONAL HEALTH PLAN AND PRIORITIES In April 2000, the Ministry of Health and Environment (the title changed to the Ministry of Health in 2002), prepared a pivotal document to guide health policies: the “Fifteen Year Strategic Plan 2001-2015”. The document encompasses the “Fifteen Year Plan 2001 to 2015”, the “Strategic Five Year Plan 2001to 2005” and the “Operational Plan 2001 to 2005”. The overarching principle guiding activities of the Ministry of Health is stated in its mission statement as: “To provide high quality, effective, affordable, and efficient health services to all peoples of the Marshall Islands, through a primary health care programme 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, the Ministry of Health pursues these goals using the national facilities, staff and resources of the Republic of the Marshall Islands.” The national health priorities remain the same as in 2004 and are to: • develop and strengthen the capabilities of indigenous personnel; • institutionalize primary health care strategies, decentralize health care, promote community-based health care and take steps to make community-based health care systems as self-reliant as possible; • strengthen and develop the health information system; • secure a sustainable financial base from the Government, community and private sector for health care delivery; • reduce transmission of sexually transmitted diseases and develop HIV/AIDS/STI prevention programmes; • reduce population growth and urban densities; • address and manage causes and effects of malnutrition; • address, prevent and manage the rising number of cases of diabetes and their health and social impact; • coordinate and strengthen the provision of health education; and • coordinate all aspects of the health care delivery system through the National Health Services Board of the Ministry of Health. 5. MAJOR INFORMATION SOURCES Fifteen Year Strategic Plan 2001 – 2015. Ministry of Health and Environment, April 2000,. Ministry of Health Annual Report 2003– “Health is a Shared Responsibility”. Ministry of Health annual report 2004 – “Health is a Shared Responsibility”. Ministry of Health statistical abstract 1999-2001. Statistical yearbook 2003. Economic Policy Planning and Statistics Office, Office of the President, 16th Edition, Augtust 2004, Economic Policy, Planning and Statistics Office (EPPSO) (http://www.spc.int/prism) 6. ADDRESSES MINISTRY OF HEALTH Office Address : Postal Address : P.O. Box 16, Majuro, Marshall Islands Official Email Address : rmimohe@ntamar.com Telephone : + (692) 625 7246/5660/5661 Fax : + (692) 625 3432/4543/4372 Office Hours : 8:00 – 12:00 and 13:00 – 17:00 Website : COUNTRY HEALTH INFORMATION PROFILES | 163 WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4 Provident Plaza One Downtown Boulevard, 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@fij.wpro.who.int Telephone : (679) 3-304600/ 3-304631 Fax : (679) 3-300462 Office Hours : MARSHALL ISLANDS 164 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: MINISTRY OF HEALTH COUNTRY HEALTH INFORMATION PROFILE 165 MARSHALL ISLANDS WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 0.18 2004 1 2 Estimated population ('000s) 55.40 ... ... 2004 est 1 3 Annual population growth rate (%) 1.40 ... ... 1988-1999 1 4 Percentage of population - 0–14 years 42.23 42.50 41.94 2004 est 3 - 65+ years 1.95 1.76 2.13 2004 est 3 5 Urban population (%) 66.30 … … 2003 4 6 Crude birth rate (per 1000 population) 41.80 … … 1999 2 7 Crude death rate (per 1000 population) 5.02 a … … 2001 est 2 8 Rate of natural increase of population (% per annum) 4.90 … … 1999 2 9 Health-adjusted life expectancy (HALE) (years) - at birth 67.50 65.70 69.40 1999 2 - at age 60 … 9.80 10.70 2002 6 10 Adult literacy rate (%) 97.00 96.80 97.20 1999 7 11 Neonatal mortality rate (per 1000 live births) … … … 12 Infant mortality rate (per 1000 live births) 29.00 … … 2002 8 13 Under-five mortality rate (per 1000 live births) 48.00 … … 1999 8 14 Total fertility rate (women aged 15–49 years) 5.71 1999 2 15 Maternal mortality ratio (per 100 000 live births) 73.80 2002 8 16 Percentage of newborn infants weighing at least 2500 g at birth 88.00 … … 1999 7 17 Prevalence of underweight children under five years of age 27.00 … … 1999 8 18 Percentage of pregnant women with anaemia 8.00 1999 7 19 Immunization coverage for infants (%) - BCG 91.00 … … 2004 9 - DTP3 64.00 … … 2004 9 - OPV3 68.00 … … 2004 9 - Measles 70.00 … … 2004 9 - Tetanus II 50.00 … … 2004 9 - Hepatitis B III 72.00 … … 2004 9 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel … - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods b 34.00 2001 8 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … MARSHALL ISLANDS 166 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 85.00 80.00 95.00 2002 11 26 Proportion of population with access to improved sanitation 82.00 93.00 59.00 2002 11 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) 29.90 … … 1999 8 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.56 … … 1998 5 32 Per capita GDP at current market prices (US$) 1817.00 … … 2001 2 33 Rate of growth per capita GDP … … … 34 Health expenditure Total health expenditure - amount (in million US$) 12.7 1999 7 - total health expenditure on health as % of GDP 4.00 1999 7 - per capita total expenditure on health (in US$) 248.00 1999 7 Government expenditure on health (budget) - amount (in million US$) 15.76 FY2004 12 - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure 14.00 FY2004 12 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = n/a 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 24 … … 4.63 … … 2000 7 - dentists 4 … … 0.77 … … 2000 7 - pharmacists 2 … … 0.39 … … 2000 7 - nurses 152 … … 29.34 … … 2000 7 - midwives … … … … … … - other nursing/ auxiliary staff 7 … … 1.35 … … 2000 7 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 53 … … 10.23 … … 2000 7 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … COUNTRY HEALTH INFORMATION PROFILE 167 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Gastroenteritis 1010 … … 1614.22 … … 1998 2 2. Scabies 1003 … … 1603.03 … … 1998 2 3. Influenza 998 … … 1595.04 … … 1998 2 4. Conjunctivitis 890 … … 1422.43 … … 1998 2 5. Diarrhoea – adults 610 … … 974.92 … … 1998 2 6. Amoebiasis 340 … … 543.40 … … 1998 2 7. Diarrhoea – infantile 210 … … 335.63 … … 1998 2 8. Chickenpox 120 … … 191.79 … … 1998 2 9. Fish poisoning 99 … … 158.23 … … 1998 2 10. Typhoid and paratyphoid fever 32 … … 51.14 … … 1998 2 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Malnutrition 20 … … 31.96 … … 1998 2 2. Accidents (all types) 20 … … 31.96 … … 1998 2 3. Sepsis 17 … … 27.17 … … 1998 2 4. Pneumonia 12 … … 19.18 … … 1998 2 5. Cancer (all types) 12 … … 19.18 … … 1998 2 6. Prematurity 11 … … 17.58 … … 1998 2 7. Myocardial infarction 9 … … 14.38 … … 1998 2 8. End-stage renal disease 9 … … 14.38 … … 1998 2 9. Cerebrovascular accidents 9 … … 14.38 … … 1998 2 10. Septicaemia 8 … … 12.79 … … 1998 2 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2004 9 - Pertussis (whooping cough) 0 0 0 … … … 2003 9 - Tetanus 0 0 0 … … … 2004 9 - Neonatal tetanus 0 0 0 … … … 2004 9 - Poliomyelitis 0 0 0 … … … 2004 9 - Hib meningitis 0 0 0 … … … 2003 9 - Measles 0 0 0 … … … 2004 9 - Mumps 6 … … … … … 2003 9 - Rubella 0 0 0 … … … 2003 9 - Congenital rubella syndrome 0 0 0 … … … 2004 9 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A … … … … … … - Type B … … … … … … - Type C … … … … … … - Unspecified … … … … … … Cholera … … … … … … Typhoid fever … … … … … … Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … Gonorrhoea … … … … … … Leprosy 76 … … … … … 2003 9 MARSHALL ISLANDS 168 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Malaria … … … … … … Dengue/DHF … … … … … … 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 60 … … … … … 2003 9 - New pulmonary tuberculosis (smear-positive) 20 … … … … … 2003 9 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 60.00 … … 4.00 … … 2003 9 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 140.00 ... … 100.00 (2002) … … 2003 9 Number of cases Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (malignant neoplasms only) … … … 12 … … 1998 2 - Trachea, bronchus and lung … … … … … … - Stomach … … … … … … - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … … … … - Liver … … … … … … - Cervix … … … 4 0 4 1998 13 - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … … … … - Ischaemic heart disease … … … … … … - Acute myocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … … … … - Hypertension … … … … … … 49 Maternal causes - Haemorrhage … … … … - Abortion … … … … - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … 50 Diabetes mellitus 1612 … … … … … 1998 7 51 Mental disorders … … … … … … COUNTRY HEALTH INFORMATION PROFILE 169 INDICATORS DATA Year Source 52 Injuries - All types … … … … … … - Motor and other vehicle accidents … … … … … … - Suicide … … … … … … - Homicide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 80 1999 7 - Specialized hospitals … … - District/first-level referral hospitals 1 25 1999 7 - Primary health care centres 5 … 1999 7 Private hospitals … … Notes: Red text Millennium Development Goals indicators … Data not available n/a Not applicable est. Estimate FY Fiscal year a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific b Contraceptive prevalence rate c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community <http://www.spc.int> 2 Economic Policy, Planning and Statistics Office, Republic of Marshall Islands <http://www.spc.int/prism> 3 Demographic tables for the Western Pacific 2000-2005. Manila, WHO Regional Office for the Western Pacific, 2005. 4 Urban and rural areas 2003. New York, United Nations Department of Economic and Social Affairs, Population Division, 2004. 5 Pacific human development report 1999 (Creating opportunities). New York, United Nations Development Programme, June 1999. 6 The World health report 2004: Changing history. Geneva, World Health Organization, 2004. 7 Information furnished by the Ministry of Health and Environment of the Marshall Islands through the WHO Representative for the South Pacific in a memo dated 6 April 2001 8 Pacific Islands Regional Millennium Development Goals report 2004. Noumea, Secretariat of the Pacific Community/ Un/ CROP MDG Working Group, November 2004. 9 WHO Regional Office for the Western Pacific, data received from technical units 10 Information furnished by the Ministry of Health and Environment of the Marshall Islands through the WHO Representative for the South Pacific in a memo dated 19 April 2000 11 Meeting the MDG drinking water and sanitation target: A mid-term assessment of progress. WHO/ UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2004. 12 Information furnished by the Ministry of Health and Environment of the Marshall Islands through the WHO Representative in the South Pacific in a memo dated 10 February 2005 170 | COUNTRY HEALTH INFORMATION PROFILES FEDERATED STATES OF MICRONESIA 1. DEMOGRAPHICS, GENDER AND POVERTY In 2004, the estimated population of the Federated States of Micronesia was 112 700, 41.6% of which were below 15 years old while 3.5% were 65 years and over. For every 100 males, there are about 103 females. The average age of the population is estimated to be 18.9 years. Almost 30% of the population reside in urban areas. Table 1. Core population and health data (2004 estimate) [Total] 112 700 [Both] 70.00 (2003 est) [0-14 years] (41.62%) [Male] 68.00 (2003 est) Population [65+ years] (3.54%) Life expectancy at birth (years) [Female] 71.00 (2003 est) Crude birth rate (per 1000 population) 23.30 (2003) Total fertility rate 4.44 (2000) [Total] 59.00 (2003) [Urban] 87.00 (2003) Crude death rate (per 1000 population) 4.40 (2003) % of population served with safe water [Rural] 31.00 (2003) [Total] 48.00 (2003) [Urban] 84.00 (2003) Infant mortality rate (per 1000 live births) 21.00 (2003) % of population with adequate sanitary facilities [Rural] 12.00 (2003) Maternal mortality ratio (per 100 000 live births) 317.00*(2003) *Based on child-bearing age 15-44 years old 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The Constitution of the Federated States of Micronesia provides for three separate branches of government at the national level, executive, legislative and judicial. It contains a Declaration of Rights, similar to the Bill of Rights of the United States of America, specifying basic standards of human rights consistent with international norms. The Congress of the Federated States of Micronesia is unicameral and has 14 senators, one from each State elected for a four-year term and 10 who serve two-year terms, whose seats are apportioned by population. The President and Vice-President are elected to four-year terms by the Congress. 2.2 Economic situation Economic activity consists primarily of subsistence farming and fishing. The islands have few mineral deposits worth exploiting, except for high-grade phosphate. The potential for a tourist industry exists, but the remote location, lack of adequate facilities, and limited air connections hinder development. In November 2002, the country experienced a further reduction in future revenues from the Compact of Free Association, the agreement with the United States of America, by which Micronesia received US$ 1.3 billion in financial and technical assistance over a 15-year period until 2001. COUNTRY HEALTH INFORMATION PROFILES | 171 The country’s medium-term economic outlook appears fragile due, not only to the reduction in assistance from the United States of America, but also to the slow growth of the private sector. Geographical isolation and a poorly developed infrastructure remain major impediments to long- term growth. 3. HEALTH SITUATION 3.1 Health trends The overall health situation remained unchanged between 2000 and 2003, with the population showing continuing susceptibility to both communicable and noncommunicable diseases. Citizens of the Federated States of Micronesia enjoy a level of health care which is high in comparison with the rest of the Pacific Region. The United States of America Public Health Service provides doctors at the four State hospitals, and Micronesians are taking their place in the system through such programmes as the Medical Officer Training Programme in Pohnpei. Prenatal care is slowly improving in the State centres and is being expanded to remote areas. Death and illness due to diarrhoea and acute respiratory infections still form a large proportion of infant mortality and morbidity. The number of vaccine-preventable diseases has declined considerably. However, water and foodborne diseases are major causes of hospital admissions. Strategies to improve the coverage of immunization and other health programmes that address diseases need to be developed. The highest immunization coverage (84.1%) was in 1992 and was the result of heavy campaigning at that time due to outbreaks of measles and the hepatitis B immunization campaign. A strategic plan to continue improvement of health services, public health surveillance and information systems is needed. 3.2 Health systems The development of the health workforce remains a government priority. The need has been partially met through overseas fellowship training and by the several dozen graduates of the Pacific Basin Medical Officer Training Programme from 1991 to 1996, but serious constraints remain. These include the lack of a nursing school and gaps in speciality training for both nurses and physicians. Government health services also lack specialized allied health professional workers, particularly hospital administrators, epidemiologists, medical record administrators, laboratory technicians, radiologists and environmentalists. Due to limited resources, medical and nursing fellowships have been prioritized, based on the States' requests. 4. NATIONAL HEALTH PLAN AND PRIORITIES There are 10 key health system issues confronting the Federated States of Micronesia: • improving health status; • setting clear priorities to ensure the most efficient use of resources; • establishing clear lines of inter- and intra-government accountability; • establishing new health system funding and financial management approaches; • building managerial capacity; • testing innovative approaches in every aspect of the system to increase quality, including improving both access for, and responsiveness to, the community; • introducing cost-effective new technologies; • focusing on functions that constitute public goods; • establishing national policies, measurable outputs, and standards to be met, including their monitoring and regulation; and • developing the private health sector. FEDERATED STATES OF MICRONESIA 172 | COUNTRY HEALTH INFORMATION PROFILES 5. MAJOR INFORMATION SOURCES National Health Statistics Office, Department of Health, Education and Social Affairs, 23 March 2004 Federated States of Micronesia Statistics Division, Department of Economic Affairs (http://www.spc.int/prism/) 2000 Population and Housing Census report. Division of Statistics, Department of Economic Affairs, May 2002 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Postal Address : P.O. Box PS 70, Palikir, Pohnpei FM 96941, Federated States of Micronesia Official Email Address : fsmhealth@mail.fm Telephone : Fax : (691) 3205263 Office Hours : Website : WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4 Provident Plaza One Downtown Boulevard 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@fij.wpro.who.int Telephone : (679) 3-304600 / 3-304631 Fax : (679) 3-300462 Office Hours : COUNTRY HEALTH INFORMATION PROFILES | 173 ORGANIZATIONAL CHART: DEPARTMENT OF HEALTH SERVICES FEDERATED STATES OF MICRONESIA 174 FEDERATED STATES OF MICRONESIA WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) (land only) 0.70 2004 1 2 Estimated population ('000s) 112.70 … … 2004 est 1 3 Annual population growth rate (%) (average) 0.26 … … 2000 11 4 Percentage of population - 0–14 years 41.62 42.19 41.02 2004 est 2 - 65+ years 3.54 3.15 3.95 2004 est 2 5 Urban population (%) 29.00 … … 2003 3 6 Crude birth rate (per 1000 population) 23.30 … … 2003 4 7 Crude death rate (per 1000 population) 4.40 … … 2003 4 8 Rate of natural increase of population (% per annum) 1.89 a … … 2003 9 Health-adjusted life expectancy (HALE) (years) - at birth 70.00 68.00 71.00 2003 est 5 - at age 60 … 10.90 11.50 2002 est 12 10 Adult literacy rate (%) 92.40 92.90 91.90 2000 6 11 Neonatal mortality rate (per 1000 live births) 12.00 b … … 2000 est 5 12 Infant mortality rate (per 1000 live births) 21.00 … … 2003 4 13 Under-five mortality rate (per 1000 live births) 23.00 … … 2003 est 5 14 Total fertility rate (women aged 15–49 years) 4.44 2000 4 15 Maternal mortality ratio (per 100 000 live births) 317.00 c 2003 4 16 Percentage of newborn infants weighing at least 2500 g at birth 82.00 … … 2000 8 17 Prevalence of underweight children under five years of age 15.00 … … 1997 7 18 Percentage of pregnant women with anaemia 51.00 2000 8 19 Immunization coverage for infants (%) - BCG 62.00 … … 2004 9 - DTP3 78.00 … … 2004 9 - OPV3 82.00 … … 2004 9 - Measles 85.00 … … 2004 9 - Tetanus II NR … … 2004 9 - Hepatitis B III 80.00 … … 2004 9 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 80.00 2000 8 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods 70.00 2000 8 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … COUNTRY HEALTH INFORMATION PROFILE 175 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 59.00 87.00 31.00 2003 4 26 Proportion of population with access to improved sanitation 48.00 84.00 12.00 2003 4 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.57 … … 1998 10 32 Per capita GDP at current market prices (US$) 2058.00 … … FY2002 est 11 33 Rate of growth per capita GDP 0.60 a … … FY2002 est 11 34 Health expenditure Total health expenditure - amount (in million US$) 9 264 000.00 2000 8 - total health expenditure on health as % of GDP … - per capita total expenditure on health (in US$) 87.00 2000 8 Government expenditure on health - amount (in million US$) … - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure … External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = … 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors … … … 5.70 … … 2003 4 - dentists … … … 1.20 … … 2003 4 - pharmacists (only pharmacy technicians) … … … 1.50 … … 2003 4 - nurses … … … 21.10 … … 2003 4 - midwives … … … 1.80 … … 2003 4 - other nursing/ auxiliary staff … … … 6.70 … … 2003 4 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) … … … 2.40 … … 2003 4 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … 3.00 … … 2003 4 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses 115 … … 2001 11 FEDERATED STATES OF MICRONESIA 176 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Five leading causes of morbidity Number Rate per 100 000 population 1. Pregnancy, childbirth and diseases of the perperium … … … 2775.40 … … 2003 4 2. Diseases of the respiratory system … … … 1625.00 … … 2003 4 3. Infectious and parasitic diseases … … … 1167.00 … … 2003 4 4. Diseases of the circulatory system … … … 1129.00 … … 2003 4 5. Endocrine, nutritional and metabolic diseases … … … 1113.20 … … 2003 4 40 Five leading causes of mortality Number Rate per 100 000 population 1. Diseases of the circulatory system … … … 116.10 … … 2003 4 2. Neoplasms … … … 57.10 … … 2003 4 3. Diseases of the respiratory system … … … 55.30 … … 2003 4 4. Endocrine, nutritional and metabolic diseases … … … 54.40 … … 2003 4 5. Infectious and parasitic diseases … … … 40.00 … … 2003 4 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 … … … … … 2004 9 - Pertussis (whooping cough) 0 … … … … … 2004 9 - Tetanus 0 … … … … … 2004 9 - Neonatal tetanus 0 … … … … … 2004 9 - Poliomyelitis 0 … … … … … 2004 9 - Hib meningitis 0 … … … … … 2004 9 - Measles 0 … … … … … 2004 9 - Mumps 0 … … … … … 2004 9 - Rubella 0 … … … … … 2004 9 - Congenital rubella syndrome 0 … … … … … 2004 9 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A … … … 0 0 0 2004 9 - Type B … … ... 5 … … 2004 9 - Type C … … ... 0 0 0 2004 9 - Unspecified … … ... 0 0 0 2004 9 Cholera … … ... 0 0 0 2004 9 Typhoid fever … … ... 0 0 0 2004 9 Encephalitis … … ... 0 0 0 2004 9 Plague … … ... 0 0 0 2004 9 Syphilis 91 … … … … … 2002 11 Gonorrhoea (gonococcal infections) 50 … … … … … 2002 11 Leprosy 89 … … … … … 2003 9 Malaria … … … … … … Dengue/DHF 0 0 0 … … … 2002 11 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures d … - Proportion of population in malaria-risk areas using effective malaria treatment measures e … COUNTRY HEALTH INFORMATION PROFILE 177 INDICATORS DATA Year Source Total Male Female Total Male Female 44 Tuberculosis Number of cases Number of deaths - All types 99 … … … … … 2003 9 - New pulmonary tuberculosis (smear-positive) 27 … … … … … 2003 9 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 62.00 … … 6.00 … … 2003 9 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 92.00 … … 91.00 (2002) … … 2003 9 Number of cases Number of deaths f 45 Acute respiratory infections 8146 … … … … … 2002 11 46 Diarrhoeal diseases 1856 … … … … … 2002 11 47 Cancers All cancers (malignant neoplasms only) … … … 51 … … 2000 11 - Trachea, bronchus and lung … … … 8 … … 2000 11 - Stomach … … … 14 … … 2000 11 - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … 4 … … 2000 11 - Liver … … … … … … - Cervix … … … … … … - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … 84 … … 2000 11 - Ischaemic heart disease … … … 34 … … 2000 11 - Acute myocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … 3 … … 2000 11 - Cerebrovascular diseases … … … … … … - Hypertension … … … 6 … … 2000 11 49 Maternal causes - Haemorrhage … … 6 6 2000 11 - Abortion … … 4 4 2000 11 - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … 50 Diabetes mellitus … … … 47 … … 2000 11 51 Mental disorders … … … 0 0 0 2000 11 52 Injuries - All types … … … 21 … … 2000 11 - Motor and other vehicle accidents … … … 4 … … 2000 11 - Suicide … … … 11 … … 2000 11 - Homicide and violence … … … 6 … … 2000 11 - Occupational injuries … … … … … … FEDERATED STATES OF MICRONESIA 178 INDICATORS DATA Year Source 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities 125 329 2000 8 - General hospitals 0 0 2000 8 - Specialized hospitals 0 0 2000 8 - District/first-level referral hospitals (state hospitals) 4 303 2000 8 Dispensary / aid posts 109 0 2000 8 - Primary health care centres (community health centre) 7 18 2000 8 Private clinics (medical services) 5 8 2000 8 Private hospitals 0 0 2000 8 Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate NR Not relevant FY Financial year a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific b Estimates derived by regression and similar estimation records c Based on child-bearing age 15-44 years old d Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. e Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. f Deaths certificates based on underlying causes Sources: 1 Pacific islands populations 2004. Secretariat of the Pacific Community <http://www.spc.int/> 2 Demographic tables 2000-2005 for the Western Pacific Region. Manila, WHO Regional Office for the Western Pacific, 2005. 3 World population 2002. New York, United Nations Population Division Department of Economic and Social Affairs, 2002. 4 National Health Statistics Office, Department of Health, Education and Social Affairs, 23 March 2004. 5 The world health report 2005. Geneva, World Health Organization, 2005. 6 2000 Population and Housing Census report. Division of Statistics, Department of Economic Affairs, May 2002. 7 Pacific islands Regional Millennium Development Goals report 2004. Secretariat of the Pacific Community and UN/CROP MDG Working Group, November 2004. 8 Department of Health, Education and Social Affairs, 15 May 2002 9 WHO Regional Office for the Western Pacific, data received from technical units 10 Pacific human development report 1999 (creating opportunities). New York, United Nations Development Programme, June 1999. 11 The Federated States of Micronesia Statistics Division, Department of Economic Affairs <http://www.spc.int/prism> 12 The World health report 2004: Changing history. Geneva, World Health Organization, 2004. COUNTRY HEALTH INFORMATION PROFILES | 179 MONGOLIA 1. DEMOGRAPHICS, GENDER AND POVERTY Landlocked between the Russian Federation and China, Mongolia is the fifth largest country in Asia, with a total area of 1565 million square kilometres. In 2003, the population reached 2 504 023, with 58.5% classified as urban. The Human Development Index for 2004 gave Mongolia a ranking of 117. The birth rate has declined by nearly 52% over ten years as a result of a 40% drop in the marriage rate, greater use of contraceptives, legalization of abortions, delayed marriage and a longer interval between births. In 2003, the population growth rate was 11.7 per 1000 and life expectancy at birth was 63.63 (60.79 years for males and 66.50 years for females). The adult literacy rate is reported as 97.2%. By the end of 2002, the number of female-headed households had increased by 11.8% over that in 1999. The proportion of all households headed by females continues to increase. In 2000, an estimated 67% of the population had access to electricity. However, outside the urban centres, access to electricity drops to 34%. Table 1. Core population and health data (2003) [Total] 2 504 023 [Both] 63.63 [0-14 years] 817 200 (32.60%) [Male] 60.79 Population [65+ years] 88 000 (3.50%) Life expectancy at birth (years) [Female] 66.50 Crude birth rate (per 1000 population) 18.05 Total fertility rate 2.00 [Total] 41.50 (2002) [Urban] 62.10 (2002) Crude death rate (per 1000 population) 6.08 % of population served with safe water [Rural] 17.30 (2002) [Total] 40.20 (2002) [Urban] 45.30 (2002) Infant mortality rate (per 1000 live births) 22.80 % of population with adequate sanitary facilities [Rural] 37.50 (2002) Maternal mortality rate (per 100 000 live births) 98.80 The number of registered unemployed in Mongolia increased by 6.7% during 2004, with females accounting for 55.2% of the total registered unemployed. The end of the preferential textile export provisions on 1 January 2004 is expected to result in some 40 000 additional unemployed, the majority of whom will be female. Labour force participation rates are estimated at 64.4% for women and 67.6% for men. Educational enrolment rates at all levels for school-age girls continue to increase over those for school-age boys. Among the poor, female school enrolment rates greatly exceed those for boys, while for the non-poor female enrolment only marginally exceeds that for boys. Using a low poverty line (approximately US$ 20 per month per person), some 36.1% of the population are classified as poor. In urban areas, the poor account for 30% of the population, while in the rural areas they account for 43%. For all of Mongolia, the average consumption per person in 2003 was estimated at less than US$ 30 per month. With very harsh winters, poverty and homelessness are life-threatening issues in Mongolia. Gers accommodate 45% of the Mongolian population, with apartments accommodating 20%. Some 43.4% of the population living in gers are estimated to live on less than US$ 20 per month, with very limited access to safe water, sanitation and basic infrastructure services. The cost of heating a ger is not insignificant for MONGOLIA 180 | COUNTRY HEALTH INFORMATION PROFILES the poor, as the lowest temperature measured in 2004 reached -50C. Inequality, as measured by the Gini coefficient, is 0.33. As noted in the Household Income and Expenditure Survey (HIES) 2002-2003, spending on health care, on average, represents 5% of the average household’s consumption, with the non- poor spending more than three times as much as the poor. Expenditure on self-prescribed medicines represents almost half the total personal spending on health, representing two-thirds of the poor’s total health expenditure. Although more females than males report health complaints (7.6%/5.2%), there is little difference in their treatment-seeking behaviour (72%/70%). Similarly, the non-poor have more health complaints than the poor (7.4%/4.6%), while more of the non-poor seek treatment than the poor (74%/63%). 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation A new government was installed in Mongolia in August 2004, with an equal balance between the Mongolian People’s Revolutionary Party (MPRP) and a coalition of democratic parties. Subsequently, in December 2004, after agreeing on a joint action plan, the coalition dissolved, leaving the MPRP in essential control of Parliament. The various ministerial heads and vice- ministers are now equally balanced between the two major groups. The pre-election activities and the post-election delays in the appointment of ministers and vice-ministers, along with subsequent and continuing changes in senior staff of the Ministry of Health has not facilitated the implementation of health-related programmes. The Government approved the final Poverty Reduction Strategy Paper (PRSP) in 2003 and the first report to monitor Mongolia’s progress towards the Millennium Development Goals (MDGs) in January 2004. Linking the PRSP to support progress towards the MDGs will require additional government action. The Government’s new action plan does include limited financial support for the very poor. 2.2 Economic situation During the early years of economic transition, Mongolia experienced negative growth rates of 9.2% in 1991 and 9.5% in 1992. Since 1994, the country has been experiencing positive economic growth, despite recent natural disasters. Real GDP increased by 1% in 2001, 4% in 2002 and an estimated 10% in 2004, primarily as a result of growth in the mining sector. The inflation rate fell from 8% in 2000-2001 to 1.6% in 2002. However, inflation at the end of 2004 is reported to be 11%, based on the consumer price index for the end of 2003. Bank interest rates remain above 30%. By the end of 2004, the money supply had increased by 33.8% over that for 2003 and tax revenue by 37.5%. The main pillar of the economy continues to be the agricultural sector, including livestock, which provided 20% of GDP in 2003. The other main sectors in 2003 were trade and services (28.8%), transport and communication (15.1%), manufacturing (6.0%) and mining (9.5%), which accounted for two-thirds of the country’s exports. Macroeconomic stabilization measures, privatization of state enterprises, public sector reform and legal changes continue to be pursued in an effort to give the private sector the best chance of success in a competitive global economy. Land privatization, which started in 2003, gives Mongolians their first opportunity to own land. During 2002, the Mongolian Parliament passed the Public Sector Management and Finance Act, which has important implications for the management and financing of all public sector services and institutions. The Ministry of Health is now directly involved in the decision-making process for the allocation of public finances to health care institutions and programmes. COUNTRY HEALTH INFORMATION PROFILES | 181 The high cost of heating and the cost of both local and international transport are a very significant tax on all services. Mongolia is among those countries with the highest donor support per person. Official development assistance in 2001 accounted for 20% of GDP and amounted to US$ 84 per person. Income distribution is becoming more unequal in Mongolia, as evidenced by a 42% increase in the Geni-coefficient between 1995 and 2002. In 2003, it was estimated that the richest 20% of the population consume almost 5.5 times the amount consumed by the poorest 20%. The start of 2005 saw the implementation of Mongolia’s Government Financial Management Information System with the support of the World Bank. This system will facilitate the adoption and use of a system of national health accounts, which will be jointly supported by the World Bank and WHO. 3. HEALTH SITUATION 3.1 Health trends Since the beginning of the 1990s, the mortality pattern has shown a rapid epidemiological transition. Cardiovascular diseases, cancer and injuries and poisonings have increased, while deaths from communicable and respiratory diseases have declined. The end of the 1990s saw injuries and poisonings exceeding respiratory diseases as a cause of death. The high cost of travel for the rural population and especially for poor rural residents serves as a real barrier to their access to basic diagnostic and more advanced health care services. Excessive maternal mortality is a priority concern of the Ministry of Health. The maternal mortality ratio has been decreasing for the past four years to 98.8 per 100 000 live births in 2004 due to increased government attention, after being relatively stable at the level of 145-176 per 100 000 live births in 1996-2001. Although antenatal care has reached almost universal levels with no rich/poor divide, many rural women do not have physical ease of access to prenatal care. Although nationally one in five females aged 15-45 has had one or more abortions, urban females are more than twice as likely to have had such abortions than their rural counterparts, and the likelihood of having one or more abortions increases with education and income. Up to one- third of all females in the highest income and education group have had one or more abortions. Late trimester abortions are one of the causes of maternal mortality and primarily affect mothers residing in rural areas. The infant and under-5 mortality rates have had a four-year downward trend, partially as a result of high immunization coverage (almost 98% for all six EPI vaccines and hepatitis B in 2004). Other contributing actions include well-implemented programmes to reduce mortality for diarrhoeal diseases and respiratory infections and, more recently, the result of extended implementation of integrated management of childhood illness (IMCI) programmes. Mongolia, however, still suffers from excessive malnutrition, rickets, anaemia and iodine deficiency disorders, and there has been no significant improvement in the nutritional status of children during the last decade. In 2004, 31 324 cases of infectious diseases were registered, with an incidence rate of 125.7 per 10 000 population. Sexually transmitted infections (43.6% of all), viral hepatitis (19.6%) and tuberculosis (14.0%) continue to be the top infections. Sexually transmitted infections (STIs) are common and increasing among both the general adult population and vulnerable groups. A nationwide STI survey among pregnant women in 2001- 2002 revealed an STI prevalence rate of 31%. Surveys among sex workers in Ulaanbaatar in 2001 and 2002 reported that two-thirds of them had at least one STI. The high incidence and prevalence of STIs could facilitate the spread MONGOLIA 182 | COUNTRY HEALTH INFORMATION PROFILES of HIV/AIDS in the country. Despite the high likelihood of HIV spreading and the massive HIV epidemic in the two neighbouring countries (China and Russia), Mongolia is still a very low HIV prevalence country. A total of only five cases of HIV/AIDS have been reported to date and recent sentinel surveillance data revealed zero prevalence in all sentinel populations. Although the annual number of plague and anthrax cases generally remains below the teens, Mongolia maintains a strong response system under its Center for Diseases of Natural Foci. In 2003, the country reported nine probable cases of severe acute respiratory syndrome (SARS): eight imported and one locally transmitted. All nine recovered. There was no transmission among health care workers. In response, the Government established a strong outbreak response system to control the epidemic with both policy and financial support. Significant progress was achieved, with active isolation of cases and contact identification. Mongolia experiences high incidences of cardiovascular diseases, cancer, injuries and mental health problems. Because these noncommunicable diseases have been accounting for a growing share of all deaths, the Ministry of Health started to plan integrated prevention and control programme for NCDs in 2001, with WHO support. In addition, the Parliament has ratified the Framework Convention on Tobacco Control. In 1999, tobacco consumption was excessive, with 56.8% of males aged 35 to 44 cigarettes smoking daily. Females were less frequent users, with 5.9% smoking daily in 1999. Injuries, poisoning and other external causes is the third leading cause of death (at 83.9 per 100 000 population in 2003) and the fifth leading cause of outpatient morbidity. Alcohol is estimated to be directly involved in some 33% of all trauma and poisoning cases and in 42% of those in the population aged 18 and above. The number of individuals found frozen or dead in the streets in Ulaanbaatar is a worrisome issue. For Ulaanbaatar alone, some 187 individuals who died of frostbite were found frozen on the streets during 2004. An additional 210 individuals were found dead/frozen on the streets from an underlying cause of alcohol intoxication. During January 2005, some 67 persons were found dead on the streets of Ulaanbaatar from underlying causes ranging from traffic accidents (7), frostbite (12) and alcohol intoxication (14). Alcohol was involved to some degree in most of these deaths. Street deaths are thought to be a problem in all urban centres of Mongolia. Self-medication, including self-injection, is a problem, which mirrors the irrational use of drugs and injectables in health care settings. 3.2 Health systems Mongolia is experiencing the health problems associated with both developing and developed countries with a constrained economic base. The large number of hospitals in Ulaanbaatar with suboptimal laboratory, radiology and support services provides a real opportunity for consolidation and economies of scale. In 2003, the World Bank prepared a master plan for hospital restructuring and privatization in Ulaanbaatar. Implementation of the plan and the recommendations of the Asian Development Bank and WHO health systems experts have not shown any progress. Aggravating factors affecting the health system include a thin population spread over huge areas, growing patient expectations, and an overprovided health system (26.6 physicians and 73.02 beds per 10 000 population in 2003), with problems in cost-effectiveness (a high hospital admission rate of 207 per 1000 population and a average length of stay 10.0 days in 2003). The excessive admissions and long length of stay are thought to be related to the quality of diagnostic and care services and persuasive incentives. Traditional medicine is popular and plays a prominent role in the health care economy. Approximately 1235 drugs and bio-preparations are registered for use in Mongolia. However, it is very difficult for the National Inspection Agency to fully monitor imports to screen for counterfeit and unregistered drugs. COUNTRY HEALTH INFORMATION PROFILES | 183 Efforts to improve donor coordination and cooperation are under way, with the Ministry of Health and WHO co-chairing a donor coordination programme under the proctorship of the Ministry of Finance. The Ministry now has a website which lists all projects and donor contributions. With these two initiatives, it is hoped that donor coordination will significantly improve during 2005. In 2003, there were 231 family group practices (FGPs) in Mongolia for the purpose of improving the quality of primary health care and bringing services close to clients. In 2002, the services covered about 55% of population. One family doctor provides health care to 1460 persons (on average), with 3.6 outpatient visits per registered person. Nearly 60% of outpatient visits to family doctors are for preventive check-ups. In an effort to provide tertiary-level health services on a regional basis, three provincial hospitals were upgraded in 2002 to regional diagnostic and treatment centres, with the objective of also providing specialized services for neighbouring provinces. In the last few years, new equipment has been provided and new specialists recruited for these regional centres to improve coverage of the population in remote rural areas and ensure access to quality services. The structure and performance standard for inter-soum hospitals were approved in 2001. These hospitals have the mandate of providing higher levels of primary health care to the population of two or more neighbouring districts (soums). However, the populations served by soum hospitals have inadequate access to essential medicines. Additionally, very few soum hospitals have running water or acceptable sanitation facilities, and very few have indoor sanitation facilities. Many collect water in containers from unimproved and unprotected water sources. In April 2004, the Ministry of Health submitted a project proposal for new vaccine introduction and safe immunization to GAVI and the Vaccine Fund. The main objective of the project is to introduce the DTP-HepB-Hib combination vaccine and AD syringe into the routine EPI programme in order to decrease childhood mortality and morbidity caused by Hib infections and reduce the operational cost of the EPI programme. This five-year project was approved in July 2004 with a total fund of US$ 3 325 000. GAVI will provide 52 500 doses of pentavalent vaccine, 53 700 AD syringes, 29 200 reconstitution syringes and 925 safety boxes in 2005. The pentavalent vaccine was introduced in January 2005, initially in Ulaanbaatar city and two provinces (Gobi-Sumber and Dornogobi) following a three-dose schedule at two, three and four months. The Government has developed a plan for phased introduction of combination DTP- HepB-Hib vaccine over three years (2005-2007). Nationwide coverage will be achieved in 2008. In April 2004, the Ministry of Health submitted a proposal to the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM), requesting support for the HIV/AIDS and tuberculosis programmes. The tuberculosis subcomponent of the proposal was approved, with a budget of US$ 4 083 764 US dollars for the period from 2005 to 2009. The Grant Agreement process is now underway. The main activities of the project are: (1) nationwide support of DOTS, (2) increased access to tuberculosis treatment for prisoners and homeless people, and (3) a programme to tackle multidrug-resistant tuberculosis. This tuberculosis project support is the third grant from the GFATM, following the first-round tuberculosis proposal (US$ 1 730 000) and the second-round HIV/AIDS proposal (US$ 2 997 103), implemented since 2003. At the end of 2003, Mongolia had 611 private hospitals and clinics. The number of private hospitals increased by 25 during 2004 to reach 161. Most pharmacies are private. Despite the relatively high number of organizations, the private sector is not well developed due to low purchasing power, lack of managerial capacity and a traditionally large public sector. Most private health enterprises are located in the capital city. The number of Mongolians seeking health care in neighbouring countries is thought to be increasing as a result of the increased assets of the non-poor and because of poor maintenance and use of diagnostic equipment in Mongolia. The total number of health workers is 32 478, including 6637 doctors, 821 pharmacists and 7734 nurses in 2003. The continued overproduction of physicians has resulted in a high physician- nurse ratio of 1:1.16. A human resource development policy, approved in November 2003, is MONGOLIA 184 | COUNTRY HEALTH INFORMATION PROFILES focused on planning, development, distribution and management of human resources in 2004- 2013. Despite 2003 being designated as the year of the soum hospital and significant financial support from the Asian Development Bank to retain soum doctors, there was an almost 5% decrease in the number of doctors working in district, inter-soum and soum hospitals and family practices from 2002 to 2003. During this same period, there was a 10% increase in the number of doctors working in private institutions. The previous Directorate of Medical Services was reorganized into a National Center for Health Development in early 2005. The role of this new centre is not yet fully defined. The percentage of GDP spent on health has increased slightly in the last few years, reaching 4.7% in 2002, resulting in per capita health expenditure of US$ 23. The main financing sources are the state budget (64.1% in 2002), health insurance fund (28.5%) and out-of-pocket payments and other sources (7.4%). Donor aid has accounted for about 15%-20% of all health spending during recent years. In 2002, the provincial and district hospitals and the tertiary level centres consumed 54% of health spending, 6% lower than in 1999. During the same period, funding to rural district (soum) hospitals and family practices increased by 6.7%, in line with government policies to strengthen primary health care. Despite this increase, serious spatial inequalities persist. Social health insurance (introduced in 1994) covered 80% of population in 2002, with the state subsidizing the premiums for 73% of those insured. Over 90% of health insurance funds are spent on inpatient care, 7% on outpatient care, and about 2% on operational costs. Recent indicators of Mongolia’s efforts to reach the MDG targets present a mixed picture of achievements and problems. Clear advances have been made in reducing maternal and child mortality, which give an indication that the country can reach the MDG targets in these two areas with continued high-level government support. Additionally, with increased donor funding for tuberculosis control, the related target for Mongolia is clearly reachable. However, data from 2004 show that poverty is not decreasing and there is no evidence that the prevalence of underweight children is falling. Although significant donor resources are being directed towards improving the piped water supply to peri-urban ger communities, these communities are growing faster than new water transport systems are being installed. There are no significant developments for increased potable water supply systems outside of Ulaanbaatar. Aside from some scattered projects promoting VIP latrines, the Government has not yet started any programmes to increase access to improved sanitation facilities. Essentially all soum hospitals and soum boarding schools utilize outdoor basic sanitation facilities. With the adoption of a new maternal mortality reduction strategy in 2005, the Government is focusing new resources on that effort. Contributing and collaborating organizations include ADB, GTZ, UNFPA, UNICEF, World Vision and WHO. GTZ, UNICEF and WHO continue to support IMCI activities directed at reducing child mortality. The Global Fund and WHO support tuberculosis reduction efforts and ADB, UNICEF and World Bank and WHO support improved access to potable water. WHO will significantly increase its support for improved sanitation in 2006-2007. Millennium Development Goals Selected Mongolian targets for 2015 1990 2000 2015 Poverty headcount 36% 35% 18% Prevalence of underweight children 12% 12% 6% Gross secondary school enrolment (f/m) 1.12 1.20 1.00 Under-five mortality rate (per 1000) 87.5 42.4 29.2 COUNTRY HEALTH INFORMATION PROFILES | 185 Maternal mortality ratio (per 10 000) 200 158 50 Prevalence of tuberculosis (100 000) 79 125 40 Proportion of population using improved water sources 55 60 80 Proportion of population using adequate sanitation facilities 22 25 50 4. NATIONAL HEALTH PLAN AND PRIORITIES According to the Government's Plan of Action, the health priorities are to provide good quality primary health services, improve rural health care, develop the private health sector and expand health insurance coverage. In addition to the Plan of Action, the most important policy document is the state public health policy, approved in November 2001. There is no long-term national health policy, but in 2003 the Ministry of Health, with the support of the Government of Japan (JICWELS), started a project to develop a health sector master plan for the next 10 years. Although government approval is expected in the first half of 2005, significant new resources and major system changes will be required for its full implementation. Health legislation and most national health programmes have been updated in the last few years. However, programme implementation depends on international support, as government health spending is mainly used for inpatient care. Although government expenditure on public health programmes has increased in recent years, it was still only 1.4% of total health spending in 2002. In 2004, the following policies and programmes were initiated to address the most pressing health issues: ▶ State policies: • State policy to develop Mongolian traditional medicine; • State public health policy; • National drug policy; • Reform and privatization in the social sector; • Human resource policy for the health sector; • State policy on population. ▶ Health-related laws: • Health law of Mongolia; • Drug law of Mongolia; • Citizen's health insurance law of Mongolia; • Sanitation law of Mongolia; • Mental health law of Mongolia; • Immunization law of Mongolia; • Donor law of Mongolia; • Tobacco law of Mongolia; • Anti-alcohol law of Mongolia; • Law on salt iodization and prevention of iodine deficiency; • HIV/AIDS law of Mongolia; • Law on welfare and services for the elderly; • Law on social welfare for the disabled; • Law on control of narcotic drugs and other psychotropic substances; MONGOLIA 186 | COUNTRY HEALTH INFORMATION PROFILES • Spa resort law of Mongolia; ▶ National health programmes: • National programme to improve health and social welfare of the elderly, 1999- 2004; • National cancer programme, 1997–2005; • National programme on improving children's development and protection, 2002-2010; • National programme on population health education, 1998-2005; • Oral health programme, 2000-2005; • National programme on outsourcing some of the health services, 2000- (has been discontinued with the approval of State policy on social sector reform and privatisation); • National reproductive health programme, 2002-2006; • National mental health programme, 2002-2007; • National programme against iodine deficiency disorder, 2002-2006; • Soum hospital development programme, 2002-2008; • National programme on population physical fitness, 2002-2008; • National programme to combat infectious diseases, 2002-2010; • National programme on injury prevention, 2002-2008; • Cardiovascular disease prevention programme, 2001-2020; • Blindness prevention programme, 2000-2010; • National programme to develop spa resorts, 2003-2010; • National programme on health technology improvement, 2003-2008; • National programme on food supply, safety and nutrition, 2001- 2005; • National programme to improve the lives of the disabled, 1998-2004; • Strategic plan to reduce maternal mortality, 2001-2004. 5. MAJOR INFORMATION SOURCES Health sector 2002: Reducing maternal mortality. Ulaanbaatar, Ministry of Health, 2003. Health sector of Mongolia: 80 years. 2nd edition. Ulaanbaatar, Ministry of Health, 2002. Health indicators 2002. Ulaanbaatar, Directorate of Medical Services, 2003. Mongolian statistical yearbook 2002. Ulaanbaatar, National Statistical Office, 2003 Human development report, Mongolia, 2003. Implementation of the Millennium Development goals in Mongolia – National report 2004 Main Report of the “Household income and expenditure survey/living standards”. New York, United Nations Development Programme, 2004. Mongolia public expenditure and financial management review, 2003-2004. World Bank, 2004 COUNTRY HEALTH INFORMATION PROFILES | 187 6. ADDRESSES MINISTRY OF HEALTH Office Address : Ministry of Health Government Building-8 Olympic Street-2 Ulaanbaatar – 210648, Mongolia Postal Address : Official Email Address : moh@moh.mng.net Telephone : (976) 11-321569 Fax : (976) 11-320916 Office Hours : 0900H-1800H Website : http://www.moh.mn WHO REPRESENTATIVE IN MONGOLIA Office Address : Ministry of Health Government Building-8 Ulaanbaatar, Mongolia Postal Address : WHO Representative Office P.O. Box 663 Ulaanbaatar-13, Mongolia Official Email Address : who@mog.wpro.who.int Telephone : (976) 11-327870, 11-322430 Fax : (976) 11-324683 Office Hours : 0830H-1700H MONGOLIA 188 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: MINISTRY OF HEALTH Minister of Health Vice Minister of Health State Secretary Minister’s working team Public Administration Division Health Policy Coordination Division with attached Pharmaceuticals and Medical Equipment Department Medical Services Division Information, Monitoring and Evaluation Division International Cooperation Department Health Economics, Financial Planning and Management Division COUNTRY HEALTH INFORMATION PROFILE 189 MONGOLIA WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 1565.00 2003 1 2 Estimated population ('000s) 2504.02 1242.30 1261.70 2003 1 3 Annual population growth rate (%) 1.20 … … 2003 1 4 Percentage of population - 0–14 years 32.60 32.80 32.40 2003 1 - 65+ years 3.50 3.05 3.96 2003 1 5 Urban population (%) 58.50 … … 2003 1 6 Crude birth rate (per 1000 population) 18.05 18.82 17.35 2003 2 7 Crude death rate (per 1000 population) 6.08 7.08 5.01 2003 2 8 Rate of natural increase of population (% per annum) 1.20 a … … 2003 9 Health-adjusted life expectancy (HALE) (years) - at birth 63.63 60.79 66.50 2003 3 - at age 60 … 10.20 12.40 2002 12 10 Adult literacy rate (%) 97.80 98.00 97.50 2003 3 11 Neonatal mortality rate (per 1000 live births) 11.37 … … 2003 2 12 Infant mortality rate (per 1000 live births) 22.80 … … 2004 7 13 Under-five mortality rate (per 1000 live births) 29.10 … … 2004 7 14 Total fertility rate (women aged 15–49 years) 2.00 2003 4 15 Maternal mortality ratio (per 100 000 live births) 98.80 2004 7 16 Percentage of newborn infants weighing at least 2500 g at birth 96.40 … … 2004 7 17 Prevalence of underweight children under five years of age 12.50 … … 1999 11 18 Percentage of pregnant women with anaemia 14.40 2004 7 19 Immunization coverage for infants (%) - BCG 97.60 … … 2004 6 - DTP3 98.90 … … 2004 6 - OPV3 99.00 … … 2004 6 - Measles 98.80 … … 2004 6 - Tetanus II … … … - Hepatitis B III 98.20 … … 2004 6 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 95.70 2003 2 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) 36.70 2003 2 - Percentage of deliveries in health facilities (as % of total deliveries) 99.20 2003 2 21 Percentage of women in the reproductive age group using modern contraceptive methods 51.90 2003 2 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS 0 0 0 2000 13 MONGOLIA 190 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 41.50 62.10 17.30 2002 8 26 Proportion of population with access to improved sanitation 40.20 45.30 37.50 2002 8 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) 51.00 b … … 2003 6 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.67 … … 2002 10 32 Per capita GDP at current market prices (US$) 447.40 … … 2002 9 33 Rate of growth per capita GDP 3.90 2002 9 34 Health expenditure Total health expenditure - amount (in million US$) 51.79 2002 4 - total health expenditure on health as % of GDP 4.70 2002 4 - per capita total expenditure on health (in US$) 23.00 2002 4 Government expenditure on health - amount (in million US$) 33.19 2002 4 - general government expenditure on health as % of total expenditure on health 64.10 2002 4 - general government expenditure on health as % of total general government expenditure 10.50 2002 4 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health 7.40 2002 4 Exchange rate in US$ of local currency is: 1 US$ = 1119.30 MNT (average) 2003 35 Health insurance expenditure 28.50 2002 4 - health insurance coverage as % of total population 80.00 2002 4 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 6637 1338 5299 26.60 10.70 41.90 2003 2 - dentists 459 … … 1.84 … … 2003 2 - pharmacists 821 … … 3.29 … … 2003 2 - nurses 7734 … … 31.00 … … 2003 2 - midwives 593 … … 2.38 … … 2003 2 - other nursing/ auxiliary staff … … … … … … 2003 2 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 5115 … … 20.50 … … 2003 2 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 2003 2 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … COUNTRY HEALTH INFORMATION PROFILE 191 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of outpatient morbidity Number Rate per 100 000 population 1. Diseases of the respiratory system 239 550 113 116 126 434 9621.63 9324.35 10 006.50 2003 2 2. Diseases of the digestive system 177 751 78 112 99 639 7139.45 6438.91 7885.83 2003 2 3. Diseases of genitourinary system 161 686 39 985 121 701 6494.19 3296.03 9631.91 2003 2 4. Diseases of the circulatory system 119 354 48 833 70 521 4793.91 4025.39 5581.32 2003 2 5. Injuries, poisoning and other consequences of external causes 83 648 57 404 26 244 3359.76 4731.91 2077.06 2003 2 6. Diseases of the nervous system 47 702 20 996 26 706 1915.97 1730.74 2113.62 2003 2 7. Diseases of the skin and subcutaneous tissues 43 581 19 947 23 634 1750.45 1644.27 1870.49 2003 2 8. Infectious and parasitic diseases 29 451 12 495 16 956 1182.91 1029.98 1341.97 2003 2 9. Diseases of the eye and adnexa 28 170 12 049 16 121 1131.46 993.22 1275.88 2003 2 10. Disease of the musculoskeletel system and connective tissue 26 562 10 877 15 685 1066.87 896.61 1241.37 2003 2 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Diseases of the circulatory system 6074 3288 2786 243.96 271.04 220.50 2003 2 2. Tumours and neoplasms 3027 1689 1338 121.58 139.23 105.89 2003 2 3. Injuries, poisoning and other consequences of external causes 2089 1683 406 83.91 138.73 32.13 2003 2 4. Diseases of the digestive system 1220 687 533 49.00 56.63 42.18 2003 2 5. Diseases of the respiratory system 851 480 371 34.18 39.57 29.36 2003 2 6. Certain conditions originating in the perinatal period 413 252 161 16.59 20.77 12.74 2003 2 7. Diseases of genitourinary system 371 205 166 14.90 16.90 13.14 2003 2 8. Infectious and parasitic diseases 353 203 150 14.18 16.73 11.87 2003 2 9. Diseases of the nervous system 282 133 149 11.33 10.96 11.79 2003 2 10. Congenital malformations, deformations and chromosomal abnormalities 144 76 68 5.78 6.26 5.38 2003 2 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 7 - Pertussis (whooping cough) 0 0 0 0 0 0 2004 7 - Tetanus 0 0 0 0 0 0 2004 7 - Neonatal tetanus 0 0 0 0 0 0 2004 7 - Poliomyelitis 0 0 0 0 0 0 2004 7 - Hib meningitis 25 … … … … … 2004 6 - Measles 0 0 0 0 0 0 2004 7 - Mumps 417 … … 0 0 0 2004 7 - Rubella 36 … 0 0 0 2004 7 - Congenital rubella syndrome 0 0 0 … … … 2004 6 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral 6164 … … 39 … … 2004 7 - Type A 5236 … … 0 0 0 2004 7 - Type B 782 … … 0 0 0 2004 7 MONGOLIA 192 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths - Type C 142 … … 0 0 0 2004 7 - Unspecified 4 … … … … … 2004 7 Cholera 0 0 0 0 0 0 2004 7 Typhoid fever 14 … … 1 … … 2004 7 Encephalitis 67 … … 0 0 0 2004 7 Plague 3 … … 2 … … 2004 7 Syphilis 1775 … … 2 … … 2004 7 Gonorrhoea 5719 … … 0 0 0 2004 7 Leprosy 0 0 0 0 0 0 2004 7 Malaria 0 0 0 0 0 0 2004 7 Dengue/DHF 0 0 0 0 0 0 2004 7 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 3918 … … … … … 2003 6 - New pulmonary tuberculosis (smear-positive) 1541 … … … … … 2003 6 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 237.00 … … 32.00 … … 2003 6 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 68.00 … … 87.00 (2002) … … 2003 6 Number of cases Number of deaths 45 Acute respiratory infections 194 939 93 419 101 520 566 312 254 2003 2 46 Diarrhoeal diseases 13 938 7055 6883 142 75 67 2003 2 47 Cancers All cancers (malignant neoplasms only) 3511 1872 1639 3027 1689 1338 2003 2 - Trachea, bronchus and lung 392 297 95 351 263 88 2003 2 - Stomach 485 316 169 425 268 157 2003 2 - Colon and rectum 59 31 28 42 16 26 2003 2 - Lip, oral cavity and pharynx 52 29 23 26 15 11 2003 2 - Liver 1277 730 547 1154 639 515 2003 2 - Cervix 278 278 76 76 2003 2 - Leukaemia 22 12 10 16 8 8 2003 2 48 Circulatory All circulatory system diseases 119 354 48 833 70 521 6074 3288 2786 2003 2 - Ischaemic heart disease 24 192 11 169 13 023 1162 624 538 2003 2 - Acute myocardial infarction 1705 855 850 701 480 221 2003 2 - Rheumatic fever and rheumatic heart diseases 17 838 5612 12 226 76 46 30 2003 2 - Cerebrovascular diseases 11 935 5727 6208 2797 1445 1352 2003 2 COUNTRY HEALTH INFORMATION PROFILE 193 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 48 Circulatory - Hypertension 47 987 18 190 29 797 484 229 255 2003 2 49 Maternal causes - Haemorrhage … … 5 5 2003 2 - Abortion … … 0 0 2003 2 - Eclampsia … … 6 6 2003 2 - Sepsis … … 6 6 2003 2 - Obstructed labour … … … … 50 Diabetes mellitus 1225 630 595 28 16 12 2002 8 51 Mental disorders 25 105 13 717 11 388 72 35 37 2002 8 52 Injuries - All types 53 647 … … 1969 1589 380 2002 8 - Motor and other vehicle accidents 8719 ... ... 546 439 107 2002 8 - Suicide 268 ... ... 340 272 68 2002 8 - Homicide and violence 9497 ... ... 166 138 28 2002 8 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 33 2003 2 - Specialized hospitals 17 2003 2 - District/first -evel referral hospitals 12 / 324 18 180 2003 2 - Primary health care centres 231 2003 2 Private hospitals (and clinics) 611 2003 2 Notes: Red text Millennium Development Goals indicators … Data not available a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Modeled data c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 National Statistical Office of Mongolia 2 Health indicators 2003. Ulaanbaatar, Department for Health Statistics and Information, Directorate of Medical Services, 2004. 3 Human development report Mongolia 2003. Ulaanbaatar, National Statistical Office, 2003. 4 Health sector 2002, Ministry of Health yearbook. Ulaanbaatar, Ministry of Health, 2003. 5 Implementation of the Millennium Development Goals in Mongolia - national report. Ulaanbaatar, Government of Mongolia/ UNDP, 2004. 6 WHO Regional Office for the Western Pacific, data received from technical units 7 Monthly population morbidity and mortality report. Ulaanbaatar, Department for Health Statistics and Information, Centre for Health Development, January 2005. 8 Health indicators 2002. Ulaanbaatar, Department for Health Statistics and Information, Directorate of Medical Services, 2003. 9 Mongolian statistical yearbook – 2002. Ulaanbaatar, National Statistical Office of Mongolia, 2003. 10 Human development report 2004. New York, United Nations Development Programme, 2004 – www.undp.org 11 Synthesis paper. Second revised reprint. Ministry of Health, Mongolia, March 2004. 12 The World health report 2004: Changing history. Geneva, World Health Organization, 2004. 194 | COUNTRY HEALTH INFORMATION PROFILES NAURU 1. DEMOGRAPHICS, GENDER AND POVERTY Preliminary estimation of the population of Nauru for 2004 was 10 100, 42.18% of which were below 15 years old, while around 1.70% were 65 and above. It is estimated that there are 104 men for every 100 women. Table 1. Core population and health data (2004 estimate) [Total] 10 100 [Both] … [0-14 years] 4260 (42.18%) [Male] 52.50 (1997-2002) Population [65+ years] 172 (1.70%) Life expectancy at birth (years) [Female] 58.20 (1997-2002) Crude birth rate (per 1000 population) 31.20 (2002) Total fertility rate 3.90 (2000-2005) [Total] 100.00 (2003) [Urban] 100.00 (2003) Crude death rate (per 1000 population) 7.80 (2002) % of population served with safe water [Rural] … [Total] 100.00 (2003) [Urban] 100.00 (2003) Infant mortality rate (per 1000 live births) 12.70 (2002) % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 300.00 (2002) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The 18-member Parliament is elected every three years. The Parliament elects a President from among its members, who appoints a Cabinet of five to six people. The President is both head of state and head of government. There is a loose multi-party system; the two main parties are the Democratic Party and the Nauru Party. The period 1999-2003 was marked by considerable political instability. 2.2 Economic situation There are few comprehensive statistics on the Nauru economy, with estimates of Nauru’s per capita GDP varying widely. Traditionally, revenues of this tiny island have come from exports of phosphates, but reserves are expected to be exhausted within five to ten years. Phosphates are exported principally to Australia, Japan, New Zealand, the Philippines and the Republic of Korea. In anticipation of the exhaustion of the phosphate deposits, substantial amounts of phosphate income have been invested in trust funds to help cushion the transition to alternative sources of revenue and to provide for Nauru’s economic future. There are few other resources and most necessities are imported, including fresh water from Australia. There are frequent disruptions of supplies of food, fuel, equipment and materials. Air Nauru, the only airline servicing the country, faces repeated interruptions due to a shortage of funds for lease payments, fuel, maintenance and other running costs. The central plateau has limited agricultural value, but some 202-243 hectares, mainly around the coastal belt, are available for cultivation. Coconut, banana and papaya are the main fruit crops COUNTRY HEALTH INFORMATION PROFILES | 195 and small quantities of vegetables are also grown. However, cultivated crops are for home consumption only and, apart from fish, most food is imported from Australia and New Zealand. In 2001, a group of Afghani refugees rescued at sea were transferred to a camp in Nauru in exchange for a multi-million dollar aid package from Australia. 3. HEALTH SITUATION 3.1 Health trends In 2002, the crude birth rate was 31.20 and the crude death rate was 7.80 per 1000 population. The infant mortality rate was 12.7 per 1000 live births. As a result of an effective public health programme focused on water and sanitation, there were no outbreaks of infectious diseases in 2003. However, noncommunicable diseases, such as diabetes, hypertension, heart disease and cancer, have become leading causes of morbidity and mortality, together with respiratory diseases. Rates of obesity are very high. In 2003, the adult diabetes prevalence (30.2 %) was the highest in the world. 3.2 Health systems The Government plans to make available a balanced supply of health care providers, including physicians, nurses, other specialized staff and community health workers. Health care services will continue to be provided free of charge to all Nauruans. Nauru General Hospital (NGH) and National Phosphate Corporation (NPC) Hospital amalgamated in July 1999 to become the Republic of Nauru Hospital. The hospital has five doctors. Specialist treatment is restricted and usually has to be sought in Australia. In the 1995-1996 budget, health expenditure amounted to AUD 8.9 million (US$ 6.8 million), and accounted for 8.9% of the total government budget, compared with 2.5% in 1991-1992. Currently, 50% of professional staff are expatriates on contract, although training of local staff is planned. 4. NATIONAL HEALTH PLAN AND PRIORITIES The primary health care approach to acute respiratory infections and diarrhoeal diseases will be strengthened. The Expanded Programme on Immunization will expand coverage of target diseases. A survey of noncommunicable diseases using the WHO STEP-wise approach will be carried out. Health promotion and healthy lifestyles programmes will be carried out. The following priority areas have been identified: • diabetic services; • services enhancement to reduce overseas referrals; • emergency services; • pharmacy services; • lifestyle diseases; • school health programme; • public health legislation and ordinances; • national strategy; • effective health promotion, media strategy; • healthy eating; and • health promotion as part of curative health. NAURU 196 | COUNTRY HEALTH INFORMATION PROFILES 5. MAJOR INFORMATION SOURCES Nauru Bureau of Statistics Nauru population profile: A guide for planners and policy makers. Noumea, Secretariat of the Pacific Community. Republic of Nauru Hospital data 6. ADDRESSES DEPARTMENT OF PUBLIC HEALTH Office Address : Yaren District, Nauru Postal Address : Official Email Address : Telephone : Fax : Office Hours : Website : WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4 Provident Plaza One Downtown Boulevard 33 Ellery Street, Suva Postal Address : PO Box 113, Suva, Fiji Official Email Address : who@fij.wpro.who.int Telephone : (679) 3-304600 / 3-304631 Fax : (679) 3-300462 Office Hours : COUNTRY HEALTH INFORMATION PROFILE 197 NAURU WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 0.02 2004 1 2 Estimated population ('000s) 10.10 … … 2004 est 1 3 Annual population growth rate (%) 0.15 … … 2002 1 4 Percentage of population - 0–14 years 42.18 42.40 41.95 2004 est 2 - 65+ years 1.70 1.51 1.89 2004 est 2 5 Urban population (%) 100.00 … … 2003 3 6 Crude birth rate (per 1000 population) 31.20 … … 2002 4 7 Crude death rate (per 1000 population) 7.80 … … 2002 4 8 Rate of natural increase of population (% per annum) 2.34 a ... … 2002 9 Health-adjusted life expectancy (HALE) (years) - at birth … 52.50 58.20 1997-2002 est 5 - at age 60 … 8.70 10.50 2002 9 10 Adult literacy rate (%) 95.00 95.00 95.00 1998 6 11 Neonatal mortality rate (per 1000 live births) 6.30 … … 2002 4 12 Infant mortality rate (per 1000 live births) 12.70 … … 2002 4 13 Under-five mortality rate (per 1000 live births) 19.10 … … 2002 4 14 Total fertility rate (women aged 15–49 years) 3.90 2000-2005 2 15 Maternal mortality ratio (per 100 000 live births) 300.00 2002 7 16 Percentage of newborn infants weighing at least 2500 g at birth … … … 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 100.00 … … 2002 8 - DTP3 80.00 … … 2002 8 - OPV3 59.00 … … 2002 8 - Measles … … … - Tetanus II NR NR NR 2002 8 - Hepatitis B III 75.00 … … 2002 8 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 100.00 2003 est 3 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 100.00 2003 est 3 - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … NAURU 198 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 100.00 … 2003 3 26 Proportion of population with access to improved sanitation 100.00 100.00 … 2003 3 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.66 … … 1998 6 32 Per capita GDP at current market prices (US$) … … … 33 Rate of growth per capita GDP … … … 34 Health expenditure Total health expenditure - amount (in million US$) … - total health expenditure on health as % of GDP … - per capita total expenditure on health (in US$) … Government expenditure on health - amount (in US$) … - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure … External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population a 36 Health workforce - doctors 5 5 0 4.95 … … 2004 10 - dentists 1 1 0 0.99 … … 2004 10 - pharmacists (dispenser only) 4 0 4 3.96 … … 2004 10 - nurses 48 6 42 47.52 … … 2004 10 - midwives 2 0 2 1.98 … … 2004 10 - other nursing/ auxiliary staff 8 0 8 7.92 … … 2004 10 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 13 9 4 12.87 … … 2004 10 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 156 … … 154.46 … … 2004 10 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … COUNTRY HEALTH INFORMATION PROFILE 199 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity (hospital admissions) Number (estimates) Rate per 100 000 population a 1. Symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified 252 132 120 2495.05 … … 2004 11 2. Confinement (post partum care) 156 0 156 1544.55 … … 2004 11 3. Newborn 144 60 84 1425.74 … … 2004 11 4. Diabetes 72 36 36 712.87 … … 2004 11 5. Hypertension 72 60 12 712.87 … … 2004 11 6. Abscess cutaneous 60 24 36 594.06 … … 2004 11 7. Disease of the genitourinary system 48 0 48 475.25 … … 2004 11 8. Anaemia 36 24 12 356.44 … … 2004 11 9. Asthma 36 24 12 356.44 … … 2004 11 10. Carbuncle 24 24 0 237.62 … … 2004 11 40 Ten leading causes of mortality Number Rate per 100 000 population b 1. Diabetes 16 8 8 158.97 155.76 162.30 2003 12 2. Diseases of respiratory system 15 8 7 149.03 155.76 142.02 2003 12 3. Diseases of the circulatory system (excluding hypertension –cardiovascular) 12 7 5 119.23 136.29 101.44 2003 12 4. Neoplasms 8 0 8 79.48 0.00 162.30 2003 12 5. Transport accident and drowning 8 6 2 79.48 116.82 40.58 2003 12 6. Hypertension 7 3 4 69.55 58.41 81.15 2003 12 7. Septicaemia unspecified 4 3 1 39.74 58.41 20.29 2003 12 8. Fibrosis and cirrhosis of liver 4 4 0 39.74 77.88 0.00 2003 12 9. Renal failure 2 0 2 19.87 0.00 40.58 2003 12 10. Certain conditions originating in the perinatal period 2 1 1 19.87 19.47 20.29 2003 12 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2002 8 - Pertussis (whooping cough) 0 0 0 … … … 2002 8 - Tetanus 0 0 0 … … … 2002 8 - Neonatal tetanus 0 0 0 … … … 2002 8 - Poliomyelitis 0 0 0 … … … 2002 8 - Hib meningitis … … … … … … 2002 8 - Measles 0 0 0 … … … 2002 8 - Mumps … … … … … … 2002 8 - Rubella 0 0 0 … … … 2002 8 - Congenital rubella syndrome 0 0 0 … … … 2002 8 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A 0 0 0 0 0 0 2002 4 - Type B 0 0 0 0 0 0 2002 4 - Type C 0 0 0 0 0 0 2002 4 - Unspecified 0 0 0 0 0 0 2002 4 Cholera 0 0 0 0 0 0 2002 4 Typhoid fever 0 0 0 0 0 0 2002 4 NAURU 200 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Encephalitis 0 0 0 0 0 0 2002 4 Plague 0 0 0 0 0 0 2002 4 Syphilis … … … 0 0 0 2002 4 Gonorrhoea … … … 0 0 0 2002 4 Leprosy 3 … … … … … 2002 8 Malaria … … … … … … Dengue/DHF … … … … … … 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 3 … … … … … 2003 8 - New pulmonary tuberculosis (smear-positive) 1 … … … … … 2003 8 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 36.00 … … 4.00 … … 2003 8 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 57.00 … … 50.00 (2002) … … 2003 8 Number of cases (estimates) Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (malignant neoplasms only) … … … 13 5 8 2002 4 - Trachea, bronchus and lung … … … 5 4 1 2002 4 - Stomach … … … 1 0 1 2002 4 - Colon and rectum … … … 0 0 0 2002 4 - Lip, oral cavity and pharynx … … … 0 0 0 2002 4 - Liver … … … 2 1 1 2002 4 - Cervix … … … 1 0 1 2002 4 - Leukaemia … … … 4 0 4 2002 4 48 Circulatory All circulatory system diseases … … … 14 12 2 2002 4 - Ischaemic heart disease … … … 2 1 1 2002 4 - Acute myocardial infarction … … … 9 9 0 2002 4 - Rheumatic fever and rheumatic heart diseases … … … 0 0 0 2002 4 - Cerebrovascular diseases … … … 2 1 1 2002 4 - Hypertension 72 60 12 1 1 0 2002 4 COUNTRY HEALTH INFORMATION PROFILE 201 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases (estimates) Number of deaths 49 Maternal causes - Haemorrhage 1 1 1 1 2002 4 - Abortion 12 12 0 0 2002 4 - Eclampsia 0 0 0 0 2002 4 - Sepsis 0 0 0 0 2002 4 - Obstructed labour 0 0 0 0 2002 4 50 Diabetes mellitus 72 36 36 8 1 7 2002 4 51 Mental disorders … … … 0 0 0 2002 4 52 Injuries - All types … … … 12 9 3 2002 4 - Motor and other vehicle accidents … … … 0 0 0 2002 4 - Suicide … … … 1 1 0 2002 4 - Homicide and violence … … … 2 2 0 2002 4 - Occupational injuries … … … 0 0 0 2002 4 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 60 2004 10 - Specialized hospitals 0 0 2004 10 - District/first-level referral hospitals 0 0 2004 10 - Primary health care centres 1 0 2004 10 Private hospitals 0 0 2004 10 Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate NR Not relevant a Computed by Health Information and Evidence for Policy Unit, WHO Regional Office for the Western Pacific b Estimated by Health Information and Evidence for Policy Unit, WHO Regional Office for the Western Pacific using 2002 census population c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 2 Demographic tables for the Western Pacific Region 2000-2005. Manila, WHO Regional Office for the Western Pacific, 2005. 3 Health inspectors report in the Public Health Office (NGH) 4 Birth and death documents from Director of Public Health 2002 5 Nauru Bureau of Statistics Office 6 Pacific human development report 1999 (Creating opportunities). New York, United Nations Development Programme, 1999. 7 Nauru population profile. A guide for planners and policy makers. Noumea, Secretariat of the Pacific Community. 8 WHO Regional Office for the Western Pacific, data received from technical units 9 The World health report 2004: Changing history. Geneva, World Health Organization, 2004. 10 Republic of Nauru (RON) Hospital data (data from Health Planning Officer) 11 RON Hospital inpatient record study up to March 24 (data from Health Planning Officer) 12 RON Hospital 2003 mortality data analysis (data from Chief Nursing Officer) 202 | COUNTRY HEALTH INFORMATION PROFILES NEW CALEDONIA 1. DEMOGRAPHICS, GENDER AND POVERTY The estimated multiethnic population of New Caledonia was 217 729 in 2002. The population consists of 42.5% Melanesians, 37.1% Europeans, 8.4% Wallisians, 3.8% Polynesians, 3.6% Indonesians, 1.6% Vietnamese and 3% other nationalities. The population density is 11 persons per sq km. The natural per annum growth rate is 1.4% and life expectancy at birth is high for both women (77.6 years) and men (69.9 years). Infant, child and maternal mortality rates are low. In 2002, the infant mortality rate was 6.9 per 1000. The overall birth rate decreased from 28 per 1000 in 1981 to 19.3 per 1000 population in 2002. The fertility rate is 2.4 children per female. There is a high level of adult literacy, estimated to be 91% of the total population (male 92%, female 90%). Table 1. Core population and health data (2002) [Total] 217 729 [Both] 73.50 [0-14 years] 61 345 (28.17%) [Male] 69.90 Population [65+ years] 13 164 (6.05%) Life expectancy at birth (years) [Female] 77.60 Crude birth rate (per 1000 population) 19.30 Total fertility rate 2.40 [Total] … [Urban] … Crude death rate (per 1000 population) 5.20 % of population served with safe water [Rural] … [Total] … [Urban] … Infant mortality rate (per 1000 live births) 6.90 % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 31.56 (1991-2002) est.: estimate 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation New Caledonia was an overseas territory of France until May 1998, with the signing of the Noumea Accords, which were subsequently approved by the French National Assembly and Senate. It then become a self-governing French overseas country and was granted a new status, with more internal autonomy. New Caledonia consists of three provinces, Iles Loyaute, Nord, and Sud, and has a three-tiered system of administration: metropolitan France (represented by the High Commissioner), the territorial congress and the provincial assemblies. The Noumea Accords of 1998 diminished the hopes of those involved in the pro-independence movement, as the earliest date of possible independence for the country is now 2014. The President of France has been represented by High Commissioner Daniel Constantin since 3 July 2002. The President of the New Caledonian Government is elected by the members of The Territorial Congress. The last election was held 29 June 2004, when Marie-Noelle Themerau was elected. COUNTRY HEALTH INFORMATION PROFILES | 203 2.2 Economic situation New Caledonia has about 25% of the world’s known nickel resources. Only a small amount of the land is suitable for cultivation, and food accounts for about 20% of imports. In addition to nickel, substantial financial support from France (equal to more than 25% of GDP) and tourism are key to the economy. Substantial new investment in the nickel industry, combined with the recovery of the global nickel market, suggests a bright economic outlook for the next several years. The mainstays of New Caledonia’s booming economy are mining, cattle, shrimp farming, fishing, forestry agriculture and tourism. The main economic indicators in 1999 were: GDP 407.5 billion F.CFP (US$4.3 billion), and GDP per capita 1 962 750 F.CFP (US$20 627). The major exports are coffee, prawns, holoturies or bêche de mer, trochus, scallops, and tuna. The country has an Exclusive Economic Zone of 1 740 000 km2. 3. HEALTH SITUATION 3.1 Health trends New Caledonia enjoys a relatively high standard of living compared with most other Pacific island countries and areas, with a profile similar to that of fully industrialized countries. About 9.22% of GDP (1999) is spent on health. By and large, the health challenges to New Caledonia are similar to those across the Pacific region. The prevalence of noncommunicable diseases is growing, while the burden of communicable diseases is still present, although reduced. Traffic accidents also represent a considerable burden, though the occurrence has been relatively stable since 1993. All the above provides a testimony to the ongoing epidemiological transition in New Caledonia. The leading causes of death are neoplasms (26.5%), cardiovascular disease (23.4%), followed by injuries and poisoning (15.1%). In 2002, the four major communicable diseases of concern were dengue fever (105 new cases), leptospirosis (49 new cases), tuberculosis (66 new cases), and HIV/AIDS (17 new cases). The incidence of dengue shows marked annual variations. There were 2211 in 1995, 2121 in 1996, 251 in 1997, 2612 in 1998, 354 in 1999, 12 in 2000, 34 in 2001, 105 in 2002, 5673 in 2003 and 792 in 2004. Incidence of leptospirosis has decreased from 207 cases in 1997 to 132 in 1998, 200 in 1999, 28 in 2000, 23 in 2001 and 49 in 2002. For many years, emphasis has been placed on maternal and child health, immunization and communicable disease control. Today, the disease patterns traditionally associated with consumer societies are appearing; noncommunicable diseases are increasing while infectious diseases are tending to decrease. 3.2 Health systems The significant improvement in the health status of the population in recent years can be attributed to the economic growth of New Caledonia as well as to the quality of health care coverage. The whole population has access to health services. Various public mechanisms fund social welfare programmes, including national insurance, family allowances, industrial programmes and a pension scheme. Consequently, all citizens are comprehensively covered for health and welfare needs. However, it requires a constant effort to balance the distribution of these resources equally among all the population. As of 31 December 2002, there were 476 practising medical doctors, 243 of whom were specialists and 233 of whom practised general medicine. There were also 1128 nurses, 126 dentists, 83 midwives and 97 pharmacists. NEW CALEDONIA 204 | COUNTRY HEALTH INFORMATION PROFILES Millennium Development Goals The Pacific Islands Regional MDG Report was compiled in 2004 to ensure that all Pacific island countries and areas are represented in the United Nations Secretary-General’s 2005 report. Such a report is particularly appropriate in the Pacific region due to the high degree of regional cooperation on development-related issues. The 14 Pacific island countries and one territory covered by the report (Cook Islands, the Federated States of Micronesia, Fiji, Kiribati, the Marshall Islands, Nauru, Niue, Palau, Papua New Guinea, Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu and Vanuatu) are widely dispersed over a large geographical area. They differ significantly in size, population, resource endowments and development constraints, but nevertheless share a number of development challenges. The Pacific Islands Regional MDG Report is the sixth regional MDG report to be prepared worldwide. The main partners in MDG achievement are, in addition to the national line ministries, the United Nations and the Council of Regional Organisations of the Pacific (CROP), which is a high-level advisory body made up of the heads of the region’s 10 primary intergovernmental organizations. CROP is chaired by the Pacific Islands Forum Secretariat (PIFS). Other members comprise: Forum Fisheries Agency (FFA), Pacific Islands Development Program (PIDP), Secretariat of the Pacific Community (SPC), South Pacific Regional Environment Programme (SPREP), South Pacific Applied Geo-science Commission (SOPAC), University of the South Pacific (USP), South Pacific Tourism Organisation (SPTO), South Pacific Board for Educational Assessment (SPBEA), and Fiji School of Medicine. 4. NATIONAL HEALTH PLAN AND PRIORITIES The Government has endorsed ‘Health for All’ and primary health care is one of the priorities set by the health offices of all three provinces. The main elements of the health strategy are: • qualitative and quantitative improvements to health care; • prevention of communicable diseases through immunization; and • improvement of health status, housing and environment by means of health education 5. MAJOR INFORMATION SOURCES DASS – NC, 2005 update Situation sanitaire pour l’annee 2002. DASS-NC; http://www.dass.gouv.nc/publications/publication.jsp?PAGE=situation_sanitaire2002.htm DASS-NC, www.dass.gouv.nc Institut Territorial de la Statistique et des Etudes Economiques Secretariat of the Pacific Community, Pacific Regional Information System (PRISM), (http://www.spc.int/prism/country/NC/NC_index.html) COUNTRY HEALTH INFORMATION PROFILES | 205 6. ADDRESSES DIRECTION DES AFFAIRES SANITAIRES ET SOCIALES DE NOUVELLE-CALÉDONIE Office Address : DASS – NC, 5 rue Gallieni – Centre ville 98800 Noumea – Nlle- Caledonie Postal Address : BP N4 – 98851 Noumea – Nlle-Calédonie Official Email Address : dass@gouv.nc Telephone : (687) 24.37.00 Fax : (687) 24.37.02 Office Hours : 7h30-11h30 ; 12h15-16h00 Website : http://www.dass.gouv.nc WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4 Provident Plaza 1 Downtown Boulevard 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@sp.wpro.who.int Telephone : (679) 330 4600 / 330 4631/ 330 4635 / 331 7447 Fax : (679) 330 0462 / 331 1530 Office Hours : NEW CALEDONIA 206 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART : DIRECTION DES AFFAIRES SANITAIRES ET SOCIALES DE NOUVELLE-CALEDONIE COUNTRY HEALTH INFORMATION PROFILE 207 NEW CALEDONIA WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 19.10 2001 4 2 Estimated population ('000s) 217.73 110.75 106.98 2002 1 3 Annual population growth rate (%) 1.40 … … 2002 1 4 Percentage of population - 0–14 years 28.17 … … 2002 1 - 65+ years 6.05 … … 2002 1 5 Urban population (%) 60.30 2001 1 6 Crude birth rate (per 1000 population) 19.30 … … 2002 3 7 Crude death rate (per 1000 population) 5.20 6.30 3.90 2002 3 8 Rate of natural increase of population (% per annum) 1.40 … … 2002 3 9 Health-adjusted life expectancy (HALE) (years) - at birth 73.50 69.90 77.60 2002 3 - at age 60 … … … 10 Adult literacy rate (%) 91.00 92.00 90.00 2002 est 1 11 Neonatal mortality rate (per 1000 live births) 2.40 … … 2002 3 12 Infant mortality rate (per 1000 live births) 6.90 … … 2002 3 13 Under-five mortality rate (per 1000 live births) 9.06 … … 2002 3 14 Total fertility rate (women aged 15–49 years) 2.40 2002 3 15 Maternal mortality ratio (per 100 000 live births) 31.56 1991-2002 3 16 Percentage of newborn infants weighing at least 2500 g at birth 93.00 … … 2002 3 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG … … … - DTP3 … … … - OPV3 … … … - Measles … … … - Tetanus II … … … - Hepatitis B III … … … 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel … - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … NEW CALEDONIA 208 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source … … … 26 Proportion of population with access to improved sanitation … … … 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index … … … 32 Per capita GDP at current market prices (US$) 14 222.83 d 1999 2 33 Rate of growth per capita GDP 2.30 1997 1 34 Health expenditure Total health expenditure (National medical care expenditure) - amount (in million US$) 382.00 2002 2 - total health expenditure on health as % of GDP 9.22 1999 2 - per capita total expenditure on health (in euros) 1558.40 2002 2 Government expenditure on health - amount (in million US$) … - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure … External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 96.35 fcfp 2004 1 35 Health insurance expenditure - health insurance coverage as % of total population 99.90 2004 2 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 476 … … 22.04 … … 2002 2 - dentists 126 … … 5.84 … … 2002 2 - pharmacists 97 … … 4.49 … … 2002 2 - nurses 1128 … … 52.25 … … 2002 2 - midwives 83 … … 3.81 … … 2002 2 - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) … … … … … … - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … COUNTRY HEALTH INFORMATION PROFILE 209 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. … … … … … … 2. … … … … … … 3. … … … … … … 4. … … … … … … 5. … … … … … … 6. … … … … … … 7. … … … … … … 8. … … … … … … 9. … … … … … … 10. … … … … … … 40 Ten leading causes of mortality Number Rate per 100 000 population a 1. Malignant neoplasms 298 176 121 135.63 158.92 113.11 2002 2 2. Diseases of the circulatory system 261 158 103 119.19 142.66 96.27 2002 2 3. Injury, poisoning & certain other consequences of external causes 169 128 41 77.62 115.58 38.32 2002 2 4. Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified 110 57 53 50.23 51.47 49.54 2002 2 5. Diseases of the respiratory system 99 67 32 45.21 60.50 29.91 2002 2 6. Infectious and parasitic diseases 45 27 18 20.55 24.38 16.83 2002 2 7. Diseases of the digestive system 33 23 10 15.07 20.77 9.35 2002 2 8. Endocrine, nutritional and metabolic diseases 25 10 15 11.41 9.03 14.02 2002 2 9. Diseases of the nervous system 24 17 7 10.96 15.35 6.54 2002 2 10. Diseases of the genitourinary system 18 12 6 8.22 10.84 5.61 2002 2 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2003 5 - Pertussis (whooping cough) 0 0 0 … … … 2003 5 - Tetanus 0 0 0 … … … 2003 5 - Neonatal tetanus 0 0 0 … … … 2003 5 - Poliomyelitis 0 0 0 … … … 2003 5 - Hib Meningitis … … … … … … - Measles 0 0 0 … … … 2003 5 - Mumps … … … … … … - Rubella … … … … … … - Congenital rubella syndrome … … … … … … 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A … … … … … … - Type B 31 … … … … … 2002 2 - Type C 0 … … … … … 2002 2 - Unspecified … … … … … … Cholera … … … … … … Typhoid fever 0 … … … … … 2002 2 NEW CALEDONIA 210 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Encephalitis … … … … … … Plague … … … … … … Syphilis 10 5 5 … … … 2003 2 Gonorrhoea (gonococcal infections) 31 15 16 … … … 2003 2 Leprosy 8 5 3 … … … 2004 2 Malaria … … … … … … Dengue/DHF (7 sex unknown) 792 401 384 2 1 1 2004 2 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures b … - Proportion of population in malaria-risk areas using effective malaria treatment measures c … 44 Tuberculosis Number of cases Number of deaths - All types 83 45 38 1 (2002) 1 (2002) 0 (2002) 2004 2 - New pulmonary tuberculosis (smear-positive) 17 … … … … … 2004 2 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 103.00 … … 11.00 … … 2003 5 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 23.00 … … 85.00 (2002) … … 2003 5 Number of cases Number of deaths 45 Acute respiratory infections 21 642 9729 11 913 … … … 2000 2 46 Diarrhoeal diseases 1858 923 935 … … … 2000 2 47 Cancers All cancers (malignant neoplasms only) … … … 298 176 121 2002 2 - Trachea, bronchus, and lung 79 57 22 85 65 20 2002 2 - Stomach 14 10 4 10 5 5 2002 2 - Colon and rectum 30 15 15 12 5 7 2002 2 - Lip, oral cavity and pharynx 18 13 5 5 0 5 2002 2 - Liver 13 8 5 31 27 4 2002 2 - Cervix 22 0 22 7 0 7 2002 2 - Leukaemia 3 3 0 7 3 4 2002 2 48 Circulatory All circulatory system diseases … … … 262 158 104 2002 2 - Ischaemic heart disease … … … 85 64 21 2002 2 - Acute myocardial infarction … … … 56 45 11 2002 2 - Rheumatic fever and rheumatic heart diseases 94 … … 1 0 1 2002 2 - Cerebrovascular diseases … … … 49 19 30 2002 2 - Hypertension 7059 … … 26 12 14 2002 2 COUNTRY HEALTH INFORMATION PROFILE 211 INDICATORS DATA Year Source Total Male Female Total Male Female 49 Maternal causes - Haemorrhage … … 0 0 2000 2 - Abortion 612 612 0 0 2002 2 - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … 50 Diabetes mellitus 4 942 … … 12 4 8 2002 2 51 Mental disorders 2 159 … … 11 7 4 2002 2 52 Injuries - All types … … … 169 128 51 2002 2 - Motor and other vehicle accidents 662 … … 62 53 9 2002 2 - Suicide … … … 35 24 11 2002 2 - Homicide and violence … … … 13 10 3 2002 2 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 2 528 2002 2 - Specialized hospitals 1 108 (psychiatry) and 76 (geriatry) 2002 2 - District/first level referral hospitals … … - Primary health care centres … … Private hospitals 2 176 2002 2 Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. c Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. d Converted to US$ using available exchange rates nearest to the period Sources: 1 Institut Territorial de la Statistique et des Etudes Economiques 2 Department of Health and Social Affairs of New Caledonia 3 Health situation in New Caledonia, 01 January 2002 to 31 December 2002. Department of Health and Social Affairs of New Caledonia 4 Demographic tables for the Western Pacific Region 2000-2005. WHO Regional Office for the Western Pacific 5 WHO Regional Office for the Western Pacific, data received from technical units 212 | COUNTRY HEALTH INFORMATION PROFILES NEW ZEALAND 1. DEMOGRAPHICS, GENDER AND POVERTY The resident population of New Zealand on 30 June 2004 was estimated at 4 061 400, representing an increase of 52 200 or 1.3% over the previous year. There were an estimated 1 997 700 male and 2 063 700 female residents – around 103 women for every 100 men. Women have outnumbered men since the late 1960s. New Zealand continues to give priority to ensuring that ODA activities foster the role of women in development. The ODA program recognises that the roles that women play, their economic contribution and the constraints on their time and activity, are essential factors in sustainable development. The review of the Women in Development (WID) Plan Action concluded that significant progress had been made both in terms of increasing support for WID specific activities and in integrating gender considerations into all projects and programs. Table 1. Core population and health data (2004 estimates) [Total] 4 061 400 (resident) [Both] … [0-14 years] 885 390 (21.80%) [Male] 68.05 (2001) Population [65+ years] 485 743 (11.96%) Life expectancy at birth (years) [Female] 72.03 (2001) Crude birth rate (per 1000 population) 14.30 Total fertility rate 1.95 (2003) [Total] 78.00 (2002) [Urban] 97.00 (2002) Crude death rate (per 1000 population) 7.00 % of population served with safe water [Rural] 81.00 (2002) [Total] 100.00 (2002) [Urban] 100.00 (2002) Infant mortality rate (per 1000 live births) 5.58 % of population with adequate sanitary facilities [Rural] 100.00 (2002) Maternal mortality ratio (per 100 000 live births) 8.80 (2000) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Elections were last held in July 2002. A minority coalition Government was formed between two parties of the centre-left, the New Zealand Labour Party and the Progressive Party. Elections are held every three years under a mixed member proportional representation system. There are 120 seats in Parliament and there is no upper house. The next election is due in late 2005. 2.2 Economic situation Economic activity has been very strong over the past four years. Most recently, buoyancy due to immigration has outweighed the negative impulse from an appreciating exchange rate. This has left productive resources stretched. Rising housing prices are providing further impetus to domestic demand. However, the pace of activity should soon cool to more normal rates of growth. The moderate headline inflation rate reflects the net outcome of falling import prices and high domestically generated inflation. On current monetary policy settings, these factors are likely to continue balancing out and inflation should remain under control. COUNTRY HEALTH INFORMATION PROFILES | 213 The New Zealand economy has averaged 4.0% annual growth in the past six years. Over the period 2003-2005, the domestic economy, employment and income growth and high international commodity prices have been the main drivers of growth. Annual growth for the 2002/03 and 2003/04 years was 4.2% and 4.7% respectively, growing to 4.8% in 2004/05. 3. HEALTH SITUATION 3.1 Health trends New Zealand has been quite successful in raising the average life expectancy of its population over the past century. A newborn girl can expect to live 72.03 years and a newborn boy 68.05 years. A temperate climate, low population density, lack of heavy industry and good nutrition gave New Zealand an early advantage over other nations in terms of health conditions. The infant mortality rate has fallen steadily in association with a major reduction in infectious diseases (and respiratory diseases), which were previously the main causes of death in the country. AIDS was first diagnosed in New Zealand in 1983 and made a notifiable disease in 1984. As of 31 December 2004, 843 cumulative cases had been notified and 2261 people had been reported to have tested HIV-positive. Malignant neoplasms (cancer), ischaemic heart disease and cerebrovascular disease were the leading causes of death in New Zealand from 1997 to 2001. In 2001, they collectively accounted for almost 60% of deaths (cancer 27%, ischaemic heart disease 22%, cerebrovascular disease 10%). In terms of health risk factors influenced by individual behaviour, use of tobacco products declined significantly during the period from 1976 to 1992, levelling off from 1992 to 1996, but subsequently falling steadily. However, the rate of smoking is not even among all groups within the population. An estimated 50% of Mäori and 33% of Pacific island people smoke, compared with 23% of the New Zealand European population, a 30% decline since 1997. People are smoking fewer cigarettes per day. The Government is also concerned about reducing overconsumption of alcohol, especially by men and young people, reducing the average fat intake, and promoting physical exercise. Mean alcohol consumption in 2003 was 10.8 litres of pure alcohol for all drinkers. In 2003, 88.5% of men and 80.3% of women aged 15–64 years drank alcohol. In 2003, drinking and driving contributed to 141 deaths, 555 serious injuries and 1398 minor injuries, and 31% of all road deaths were caused by drinking-related crashes. New Zealand has low levels of air pollution compared with other similar countries, but a relatively high incidence of waterborne diseases, such as camphylobacteriosis, giardiasis and cryptosporidiosis compared with other developed countries. There is also evidence of pollution of recreational waters. It is estimated that 90.0% of the population have an improved drinking water source. 3.2 Health systems The New Zealand Health Strategy (NZHS) and the New Zealand Disability Strategy (NZDS) provide the framework for the health sector's overall direction. These strategies take a population approach to identify the areas where intervention will make a contribution to the goals of healthy and independent New Zealanders. The two strategies sit alongside each other and guide the development and implementation of more detailed service, health issue and population-group specific strategies and action plans. The Ministry of Health aims to ensure the health and disability support system works for New Zealanders. It is the Government's primary advisory on health policy and disability support services. District Health Boards (DHBs) have the responsibility for improving, promoting and protecting the health and independence of a geographically defined population. Twenty-one DHBs are in NEW ZEALAND 214 | COUNTRY HEALTH INFORMATION PROFILES place to plan, fund and ensure the provision of health and disability services (including hospital services) for their populations. The Government is placing particular emphasis on the role of primary care to achieve health improvements. DHBs are responsible for establishing, funding and monitoring primary health organisations (PHOs). PHOs have been established to ensure early and affordable access to primary care services and to focus on health promotion and disease prevention for their enrolled population. By April 2005, more than 3.8 million New Zealanders (95% of the population) were enrolled in PHOs. The Minister of Health has overall responsibility for the health and disability support system. The Minister determines the content of the NZHS, works through the Ministry of Health to enter into accountability arrangements with DHBs and agrees with government colleagues how much public money will be spent on the public delivery of services. Millennium Development Goals New Zealand has significant programmes in place to promote the wellness and wellbeing of mothers and children. These include well-child programmes, a national immunisation strategy to promote the uptake of general childhood immunisations, a specific programme for immunisation against meningococcal disease, social welfare and income support programmes which can impact positively on health, such as Support for Families, providing additional financial, housing and other social assistance when required, programmes against sexual and physical abuse, violence prevention, and programmes to intervene with families at risk. National programmes for HIV/AIDS awareness, prevention and management, including safe sex messages, needle exchange schemes, and access to anti-retroviral medications continue in this country. Through the New Zealand Agency for International Development (NZAID), New Zealand is also working extensively with neighbours in the Pacific to assist their achievement of the MDG and the promotion of sexual and reproductive health and rights. Improving the health status of those living in poverty is a cornerstone of NZAID's commitment to achieving a safe and just world free of poverty. NZAID focuses on improved health through approaches that strengthen local level capacity development in the health sector. Alongside direct programme support for achieving the health related MDGs, NZAID works at the policy level, helping partners incorporate MDG goals and targets into their health policies and plans. An example is Papua New Guinea, where rates of HIV/AIDS infection are now as high as two percent. In this case, NZAID has worked with the National Department of Health and other donors to ensure that HIV/AIDS is recognised as a top priority in the health Sector-Wide Approach (SWAp). 4. NATIONAL HEALTH PLAN AND PRIORITIES The Government’s overall direction for the health and disability sector places particular emphasis on improving population health outcomes and reducing disparities among all New Zealanders, including Mäori and Pacific peoples. Thirteen population health objectives, set out in the New Zealand Health Strategy, aim to: • reduce smoking; • improve nutrition; • reduce obesity; • increase the level of physical activity; • reduce the rate of suicide and suicide attempts; • minimize harm caused by alcohol and illicit and other drug use to both COUNTRY HEALTH INFORMATION PROFILES | 215 individuals and the community; • reduce the incidence and impact of cancer; • reduce the incidence and impact of cardiovascular disease; • reduce the incidence and impact of diabetes; • improve oral health; • reduce violence in interpersonal relationships, families, schools and communities; • improve the health status of people with severe mental illness; and • ensure access to appropriate child health care services, including ‘well child’ and family health care and immunization. Toolkits identify appropriate actions to address the priority objectives, while DHB accountability documents contain specific targets to give effect to the Strategy. The New Zealand Disability Strategy guides action to promote a more inclusive society which values disabled people’s lives and enhances their full participation in society. Population- or illness-specific strategies include the Child Health Strategy, Achieving Health for All People (public health), the Health of Older People Strategy, the Korowai Oronga (the Mäori Health Strategy), the Pacific Health and Disability Action Plan, the National Mental Health Strategy and the Primary Health Care Strategy. The Ministry of Health is responsible for planning the national response to health service emergencies of all kinds. The Ministry is working on a number of projects that will collectively form the National Health Emergency Plan (NHEP), of which this plan, for infectious diseases, is one part. NHEP describes the larger context within which the Ministry of Health and all New Zealand health services will function during any national health-related emergency, including New Zealand's responsibilities under international agreements and regulations. 5. MAJOR INFORMATION SOURCES New Zealand Ministry of Health New Zealand Health Information Service (http://www.nzhis.govt.nz) Statistics New Zealand (http://www.stats.govt.nz) 6. ADDRESSES MINISTRY OF HEALTH Office Address : 133 Molesworth St , P.O. Box 5013 , Wellington, New Zealand Telephone : 04 - 496-2000 Fax : 04 - 496-2340 Website : http://www.moh.govt.nz WHO REPRESENTATIVE FOR THE SOUTH PACIFIC Office Address : Level 4, Provident Plaza 1, Downtown Boulevard, 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@sp.wpro.who.int Telephone : (679) 3-304600/ 3-304631/ 3-300727 Fax : (679) 3-300462 NEW ZEALAND 216 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: MINISTRY OF HEALTH COUNTRY HEALTH INFORMATION PROFILE 217 NEW ZEALAND WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 270.69 b 2004 1 2 Estimated population ('000s) (resident) 4061.40 1997.70 2063.70 2004 est 1 3 Annual population growth rate (%) (resident) 1.80 ... ... 2003 est 1 4 Percentage of resident population - 0–14 years 21.80 … … 2004 est 1 - 65+ years 11.96 … … 2004 est 1 5 Urban population (%) 85.90 … … 2003 3 6 Crude birth rate (per 1000 resident population) 14.30 14.89 13.73 2004 1 7 Crude death rate (per 1000 resident population) 7.00 7.05 6.95 2004 1 8 Rate of natural increase of population (% per annum) 0.73 a … … 2004 9 Health-adjusted life expectancy (HALE) (years) - at birth … 68.05 72.03 2001 est 4 - at age 60 … 21.08 24.00 2001 est 4 10 Adult literacy rate (%) … … … 11 Neonatal mortality rate (per 1000 live births) 3.10 … … 2004 est 1 12 Infant mortality rate (per 1000 live births) 5.58 … … 2004 est 1 13 Under-five mortality rate (per 1000 live births) 6.34 … … 2003 1 14 Total fertility rate (women aged 15–49 years) 1.95 2003 1 15 Maternal mortality ratio (per 100 000 live births) 8.80c 2000 5 16 Percentage of newborn infants weighing at least 2500 g at birth 93.50 … … 2002 5 7 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 27.00 1998 4 19 Immunization coverage for infants (%) - BCG … … … - DTP3 … … … - OPV3 … … … - Measles … … … - Tetanus II … … … - Hepatitis B III … … … 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 100.00 2001 5 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) 96.60 2001 est 5 21 Percentage of women in the reproductive age group using modern contraceptive methods 72.00 2002 est 6 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … NEW ZEALAND 218 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 78.00 97.00 81.00 2002 7 26 Proportion of population with access to improved sanitation 100.00 100.00 100.00 2002 7 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) <5.00 … … 2003 8 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.93 … … 2002 9 32 Per capita GDP at current market prices (US$) 19 541.00 … … 2002 1 33 Rate of growth per capita GDP 2.80 … … 2002 1 34 Health expenditure Total health expenditure (National medical care expenditure) - amount (in million US$) 7480.00 2002 2 - total health expenditure on health as % of GDP 8.20 2001 2 - per capita total expenditure on health (in US$) 1899.00 2002 2 Government expenditure on health - amount (in million US$) 5.83 2002 2 - general government expenditure on health as % of total expenditure on health 77.90 2002 2 - general government expenditure on health as % of total general government expenditure 14.21 2002 2 External source of government health expenditure - external resources for health as % of general government expenditure on health 4.60 2002 2 Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 0.7004 NZD 2004 2 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 8790 5754 3036 21.92 29.19 14.90 2003 5 - dentists 1582 1182 400 3.95 6.00 1.96 2003 5 - pharmacists … … … … … … - nurses (registered) and midwives, there were 958 registered nurses without reported gender 34 660 2205 31 497 85.34 11.04 152.62 2004 5 - midwives, (also included in the registered nurses) there were 86 midwives without registered gender 3780 11 3683 9.31 0.06 17.85 2004 5 - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) … … … … … … - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … COUNTRY HEALTH INFORMATION PROFILE 219 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … 39 Ten leading causes of morbidity Number Rate per 100 000 , age-standardized to Segi's world population 1. Malignant neoplasms 41 571 22 179 19 392 758.20 856.84 685.97 2001/ 2002 5 2. Ischaemic heart diseases 28 128 17 187 10 941 485.67 660.72 324.69 2001/ 2002 5 3. Complications of labour and delivery 26 915 NA 26 915 698.32 NA 1367.11 2001/ 2002 5 4. Other forms of heart disease 20 675 10 960 9715 349.75 422.62 284.12 2001/ 2002 5 5. Maternal care related to the fetus and amniotic cavity and possible delivery problems 19 092 NA 19 092 488.14 NA 955.34 2001/ 2002 5 6. Chronic lower respiratory diseases 18 705 9028 9677 431.90 434.65 433.59 2001/ 2002 5 7. Arthropathies 18 363 9869 8494 393.13 454.01 333.28 2001/ 2002 5 8. Symptoms and signs involving the circulatory and respiratory systems 18 349 9185 9164 382.27 402.52 363.59 2001/ 2002 5 9. Symptoms and signs involving the digestive system and abdomen 17 662 6063 11 599 430.21 300.25 557.63 2001/ 2002 5 10. Pregnancy with abortive outcome 13 538 NA 13 538 357.60 NA 704.49 2001/ 2002 5 40 Ten leading causes of mortality 1. Malignant neoplasms 7810 4166 3644 125.85 149.54 108.99 2001 5 2. Ischaemic heart diseases 6371 3389 2982 83.33 112.75 58.98 2001 5 3. Cerebrovascular diseases 2784 1036 1748 33.33 33.04 32.81 2001 5 4. Chronic lower respiratory diseases 1872 993 879 24.91 31.95 20.64 2001 5 5. Other forms of heart disease 1245 546 699 15.75 19.19 12.72 2001 5 6. Diabetes mellitus 782 405 377 11.78 14.47 9.55 2001 5 7. Organic, including symptomatic, mental disorders 599 199 400 6.13 6.00 6.09 2001 5 8. Diseases of arteries, arterioles and capillaries 596 319 277 7.86 10.55 5.63 2001 5 9. Transport accidents 538 379 159 13.35 19.58 7.29 2001 5 10. Intentional self-harm 507 388 119 11.97 18.73 5.55 2001 5 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 … … … … … 2003 8 - Pertussis (whooping cough) 589 … … … … … 2003 8 - Tetanus 2 … … … … … 2003 8 - Neonatal tetanus 0 … … … … … 2003 8 - Poliomyelitis 0 … … … … … 2003 8 - Hib meningitis 6 … … … … … 2003 8 - Measles 66 … … … … … 2003 8 - Mumps 57 … … … … … 2003 8 - Rubella 28 … … … … … 2003 8 - Congenital rubella syndrome 0 … … … … … 2003 8 NEW ZEALAND 220 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A 49 18 31 0 0 0 2004 C: 8, D: 10 - Type B 39 23 16 16 12 4 2004 C: 8, D: 10 - Type C 26 … … 15 10 5 2004 C: 8, D: 10 - Unspecified 0 0 0 0 0 0 2004 10 Cholera 0 0 0 0 0 0 2004 8 Typhoid fever 20 … … 0 0 0 2004 8 Encephalitis 0 0 0 0 0 0 2004 8 Plague 0 0 0 0 0 0 2004 8 Syphilis … … … 0 0 0 2004 10 Gonorrhoea … … … 0 0 0 2004 10 Leprosy 4 … … … … … 2003 8 Malaria (1 unspecified gender case) 33 d 26 d 6 d 0 0 0 2004 10 Dengue/DHF 8 5 3 0 0 0 2004 10 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures e … - Proportion of population in malaria-risk areas using effective malaria treatment measures f … 44 Tuberculosis Number of cases Number of deaths - All types 386 … … … … … 2003 8 - New pulmonary tuberculosis (smear-positive) 106 … … … … … 2003 8 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 11.00 … … 1.00 … … 2003 8 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 57.00 … … 60.00 (2002) … … 2003 8 Cses = publicly funded hospital discharges (2000/2001) Number of deaths (2000) 45 Acute respiratory infections 28 740 15 470 13 270 436 153 283 5 46 Diarrhoeal diseases 6018 3105 2913 22 16 6 5 Cases = Registrations Number of deaths 47 Cancers All cancers (malignant neoplasms only) 17 913 9563 8350 7810 4166 3644 2001 10 - Trachea, bronchus and lung 1529 882 647 1435 841 594 2001 10 - Stomach 378 229 149 303 195 108 2001 10 - Colon and rectum 2354 1171 1183 1047 533 514 2001 10 - Lip, oral cavity and pharynx 278 181 339 113 81 32 2001 10 - Liver 151 91 60 120 76 44 2001 10 - Cervix 189 NA 189 63 NA 63 2001 10 - Leukaemia 629 363 266 252 136 116 2001 10 COUNTRY HEALTH INFORMATION PROFILE 221 INDICATORS DATA Year Source Total Male Female Total Male Female 48 Circulatory Cases = publicly funded hospital discharges (2001/2002) Number of deaths (2001) All circulatory system diseases 71 864 39 915 31 949 11 430 5463 5967 10 - Ischaemic heart disease 28 128 17 187 10 941 6371 3389 2982 10 - Acute myocardial infarction 10 045 6221 3824 3193 1725 1468 10 - Rheumatic fever and rheumatic heart diseases 761 317 444 141 50 91 10 - Cerebrovascular diseases 8787 4348 4439 2784 1036 1748 10 - Hypertension 940 364 576 231 98 133 10 49 Maternal causes - Haemorrhage 5472 5472 0 0 5 - Abortion 14 744 14 744 0 0 5 - Eclampsia 114 114 0 0 5 - Sepsis 369 369 0 0 5 - Obstructed labour 15 227 15 227 0 0 5 50 Diabetes mellitus 6755 3639 3116 782 405 377 5 51 Mental disorders 21 215 9974 11 241 599 199 400 5 52 Injuries Cases = publicly funded hospital discharges (2001/2002) - All types 134 033 72 408 61 625 1653 1117 536 D: 2001 5 - Motor and other vehicle accidents 12 905 8212 4693 538 379 159 D: 2001 5 - Suicide 5095 1721 3374 507 388 119 D: 2001 5 - Homicide and violence 4350 3302 1048 53 31 22 D: 2001 5 - Occupational injuries 229 489 170 448 59 041 85 80 5 D: 2002 7 53 Proportion of population with access to affordable essential drugs on a sustainable basis (%) … 54 Health infrastructure Number Number of beds Public health facilities 85 12 484 2002 5 - General hospitals … … - Specialized hospitals … … - District/first-level referral hospitals … … - Primary health care centres … … Private hospitals 360 11 341 2002 5 Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate NA Not applicable C Cases D Deaths a Computed by Health Information and Evidence for Policy Unit, WHO Regional Office for the Western Pacific b Excludes inland waters and oceanic areas c One of the direct maternal deaths occurred in 1932, but was registered in 2000 d Imported cases e Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. f Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. NEW ZEALAND 222 Sources: 1 Demographic trends 2004. Statistics New Zealand (http://www.stats.govt.nz) 2 Information furnished by the Ministry of Health, New Zealand, 27 February 2004 3 Urban and rural areas 2003. New York, United Nations Department of Economic and Social Affairs, Population Division, 2004 4 Information furnished by the Ministry of Health, New Zealand, 14 July 2005 5 New Zealand Health Information Service (http://www.nzhis.govt.nz) 6 2002 ESCAP population data sheet. Bangkok, Economic and Social Commission for Asia and the Pacific, 2002. 7 Information provided by WHO Representative in the South Pacific, 05 April 2004 8 WHO Regional Office for the Western Pacific, data received from technical units 9 Human development report 2004. New York, United Nations Development Programme, 2004. 10 Environmental science and research, New Zealand COUNTRY HEALTH INFORMATION PROFILES | 223 NIUE 1. DEMOGRAPHICS, GENDER AND POVERTY The population of Niue continues to decrease, from a peak of 5194 in 1966, to 2322 in 1991, and 1788 in 2001. The estimated population in 2004 was 1600. There is substantial emigration to New Zealand because of Niue’s lack of natural resources, isolation and insufficient social and economic development, and because Niueans are New Zealand citizens. The 2001 New Zealand census listed 20 148 Niueans in the New Zealand population. Population density is estimated at six persons per square kilometre and 34.0% of the population live in urban areas. Children under the age of 15 years of age make up 29.7% of the population, and adults 65 years and older 9.10%. The crude birth rate is 18.46 per 1000 population and the crude death rate is 7.8 per 1000. Table 1. Core population and health data (2004 estimate) [Total] 1600 [Both] 70.10 (2001) [0-14 years] (29.70%) [Male] 69.80 (2001) Population [65+ years] (9.10%) Life expectancy at birth (years) [Female] 71.20 (2001) Crude birth rate (per 1000 population) 18.46 (2001) Total fertility rate 3.01 (2001) [Total] 100.00 (2003) [Urban] … Crude death rate (per 1000 population) 7.80 (2001) % of population served with safe water [Rural] … [Total] 100.00 (2003) [Urban] … Infant mortality rate (per 1000 live births) 29.40 (2001) % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 0.00 (2003) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Niue is a self-governing nation in free association with New Zealand. The head of government is Premier Young Viviani of the Niue People's Party. The chief of state is Queen Elizabeth II of the United Kingdom of Great Britain and Northern Ireland. The Legislative Assembly is Niue’s supreme law-making body. It has 20 members, six elected from a common roll and 14 as village representatives. The Legislative Assembly is responsible for electing the Premier. Elections are held every three years by secret ballot under universal suffrage. 2.2 Economic situation The economy is dependent on limited agricultural exports and the sale of fishing rights. The sale of postage stamps to foreign collectors is also an important source of revenue. The gap between domestic production and demand for goods and services is very wide. The resulting trade deficit NIUE 224 | COUNTRY HEALTH INFORMATION PROFILES makes the economy heavily dependent on foreign aid, most of which comes from New Zealand and remittances from Niueans living abroad. In 2003, the gross domestic product (GDP) at current prices was NZD 17 252 000 (US$ 12 140 411); per capita GDP stood at NZD 10 048 (US$ 7070). The New Zealand High Commissioner’s Office, the only diplomatic mission in Niue, manages the projects of the New Zealand Official Development Assistance (NZODA). Niue also receives aid from the Australian Agency for International Development (AusAID), the Government of Japan and other international agencies. The World Health Organization contributed US$ 101 000 in 2000-2001, and US$ 97 000 in 2002-2003. With a deficit of NZD 1 199 772 (US$ 844 186), the Government is facing a financial crisis. The monthly boat between New Zealand and Niue, which provides essential supplies for daily living, illustrates Niue’s isolation. Plans to develop tourism are underway, but are necessarily limited by a dependence on other countries’ airlines to service Niue. Royal Tonga operates a small twin otter aircraft for passenger service three times a week between Nukualofa, Tonga and Niue. Polynesian Airlines has started a new service from Apia to Auckland via Niue twice a week. 3. HEALTH SITUATION 3.1 Health trends In general, health indicators are good, consistent with the country’s high literacy rate (100% in 2003) and its well educated population. Infant mortality is low and no maternal death was recorded from 1999 to 2003. Average life expectancy in 2001 was 70.1 years, 69.8 years for men and 71.2 years for women. The fertility rate is 3.04 (2001). The incidence of teenage pregnancy is relatively high (8%). Common childhood illnesses and traditional communicable diseases, such as tuberculosis and leprosy, have been substantially contained. The programme on elimination of filariasis is ongoing, with high coverage of mass drug administration (MDA). Niue has a 1.4% antigenemia rate, and is targeting filariasis elimination by 2005. No case of HIV/AIDS has been reported and sexually transmitted infections are rare. With support from WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS), the Department of Health has been active in working with communities, nongovernmental organizations and the private sector to increase public awareness on reproductive health and HIV/ AIDS. Although the prevalence of vectorborne parasitic diseases has been negligible in the past five years, mosquito control activities are ongoing. Because the mosquito population is large, control measures require strengthening. Lifestyle-related health problems are increasing and the prevalence of risk factors for chronic diseases is high. In a 1997 census, 30.8% of males and 13.6% of females smoked cigarettes. Alcohol consumption is also reported to be high: casual drinking (43%) and heavy drinking (3.2%). The National Nutritional Survey in 1987 noted a concern about the high consumption of sugar snacks and the low intake of vegetables and fruits. In 2001, the major causes of morbidity were hypertension, diabetes mellitus, infections of the skin and subcutaneous tissue, upper respiratory tract infections and influenza. The five leading causes of mortality were injuries from gunshots, diabetes and hypertension complications (cardiovascular and cerebrovascular diseases), premature births, pneumonia (one case) and accidental drowning (one case). COUNTRY HEALTH INFORMATION PROFILES | 225 Cancer incidence remains very low. Cervical screening procedures are available and women are encouraged to practise breast self-examination. Elderly males aged 55 and over are routinely checked for early signs of prostate problems. The groundwater supply is safe and potable for human consumption and coverage of safe water sanitation facilities is 100% (2003). AusAID supported the development of the national waste management plan. The Government is committed to the Healthy Islands programme and the Tobacco Free Initiative, which are supported by WHO. The Moui Olaola Project (a Healthy Islands health promotion project) was started in 1996. 3.2 Health systems The only hospital, Lord Liverpool Hospital, was destroyed by Cyclone Heta in January 2004. Hospital services have been set up in a youth centre in Fonuakula, and plans are underway to construct a new hospital in Kaimiti. Lord Liverpool Hospital had been the centre for all preventative and curative health services, dentistry services and school health services since the early 1990s. From June 2001 to May 2002 the hospital underwent a US$ 2 million renovation project, with financial assistance provided by WHO, the New Zealand Agency for International Development (NZAID) and AusAID. Community outreach is maintained through village visits by public health nurses and regular village inspections by public health officers. Medical services are free for local residents; however, payment is required for some prescribed medicines, such as contraceptives. The Department of Health is run by the Director of Health and a complement of three medical officers, two dental officers, one dental nurse, two technicians and one chairside assistant, 15 nurses (one principal nursing officer, 13 hospital nurses and one maternal and child health nurse), four paramedical staff, two public health officers, one health promotion coordinator, one health service manager, two office assistants and four drivers (2003). The workforce development plan for the health sector (2000-2003), which was prepared for the Niue Training and Development Council in June 2000, identified training needs. The government budget for non-trading expenditures for the fiscal year 2002-2003 was NZD 10 518 696 (US$ 7 403 525), down from NZD 11 850 683 (US$ 8341 037) for 2001-2002. The budget for health expenditures also dropped, from NZD 1 462 489 (US$ 1 029 289) for 2001-2002, to NZD 1 421 864 (US$ 1 000 364) (13.5% of non-trading expenditures) for 2002- 2003. Education gets more or less the same budget as health. Total government non-trading expenditures for personnel (364 employees) amounts to NZD 6 042 007 (US$ 4 251 106), and for health personnel (49 employees) NZD 830 264 (US$ 580 097). Health expenditures are distributed as follows: administration, NZD 339 742 (US$ 239 069); medical, NZD 535 332 (US$ 376 582); nursing, NZD 314 844 (US$ 221 540)); public health, NZD 114 713 (US$ 80 718); and dental, NZD 117 233(US$ 82 491). The health revenue from administration is NZD 30 500 (US$ 21 455). 4. NATIONAL HEALTH PLAN AND PRIORITIES National health priorities are focused on public health prevention strategies in order to reduce risk factors associated with causes of morbidity/mortality and lifestyle diseases. The national priorities are: • to make Niue the healthiest country in the Pacific in terms of having healthy people and a healthy environment; • to pursue health promotion, disease prevention and injury prevention strategies with more vigour; and • to strengthen the capacity of human resources to effectively deliver primary care NIUE 226 | COUNTRY HEALTH INFORMATION PROFILES services and public health programmes. 5. MAJOR INFORMATION SOURCES Boladuadua A. Mission report on primary health care services development. Manila, WHO Western Pacific Regional Office, 2001. Estimates of expenditure and revenue for year 2002/2003. Government of Niue, 2003. Report on the Nationwide Health Survey, May 2002. Health Department, 2002. Health Department statistics Niue statistics, 2000-2001 Niue Sustainable Human Development Situation Analysis, 2002. New York, UNDP, 2002. 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Postal Address : Official Email Address : Telephone : Fax : Office Hours : Website : WHO REPRESENTATIVE IN SAMOA Office Address : Ioane Viliamu Building Beach Road, Apia, Western Samoa Postal Address : P.O. Box 77 Apia, Samoa Official Email Address : who@sma.wpro.who.int Telephone : (685) 23756 Fax : (685) 23765 Office Hours : COUNTRY HEALTH INFORMATION PROFILE 227 NIUE WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 0.26 2004 1 2 Estimated population ('000s) 1.60 … … 2004 est 1 3 Annual population growth rate (%) -3.72 … … 2001 4 4 Percentage of population - 0–14 years 29.70 30.53 28.85 2004 est 2 - 65+ years 9.10 8.00 10.22 2004 est 2 5 Urban population (%) 34.00 … … 2001 2 6 Crude birth rate (per 1000 population) 18.46 … … 2001 3 7 Crude death rate (per 1000 population) 7.80 … … 2001 3 8 Rate of natural increase of population (% per annum) 1.10 … … 2001 1 9 Health-adjusted life expectancy (HALE) (years) - at birth 70.10 69.80 71.20 2001 3 - at age 60 … 11.60 12.80 2002 8 10 Adult literacy rate (%) 100.00 … … 2003 1 11 Neonatal mortality rate (per 1000 live births) … … … 12 Infant mortality rate (per 1000 live births) 29.40 … … 2003 4 13 Under-five mortality rate (per 1000 live births) … … … 14 Total fertility rate (women aged 15–49 years) 3.01 2001 3 15 Maternal mortality ratio (per 100 000 live births) 0.00 2003 4 16 Percentage of newborn infants weighing at least 2500 g at birth 100.00 … … 2001 4 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) b - BCG 100.00 … … 2003 6 - DTP3 … … … - OPV3 … … … - Measles … … … - Tetanus II … … … - Hepatitis B III … … … 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 100.00 2000 6 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … NIUE 228 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 … … 2003 1 26 Proportion of population with access to improved sanitation 100.00 … … 2003 1 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) 16.90 … … 2001 8 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.77 … … 1998 9 32 Per capita GDP at current market prices (NZ$) 10 048.00 … … 2003 10 33 Rate of growth per capita GDP 6.88 a … … 2003 11 34 Health expenditure Total health expenditure (National medical care expenditure) - amount (in million US$) … - total health expenditure on health as % of GDP … - per capita total expenditure on health (in US$) 417.32 2001- 2002 4 Government expenditure on health - amount (in NZ$) 1 421 864.00 FY2002- 2003 4 - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government (non-trading) expenditure 13.52 a FY2002- 2003 4 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 1.73 NZ$ (average) 2003 6 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 3 … … 18.18 … … 2003 4 - dentists 2 … … 12.12 … … 2003 4 - pharmacists … … … … … … - nurses 15 … … 90.91 … … 2003 4 - midwives … … … … … … - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 4 … … 24.24 … … 2003 4 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … COUNTRY HEALTH INFORMATION PROFILE 229 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Hypertension 343 … … 19 183.45 … … 2001 5 2. Diabetes mellitus 308 … … 17 225.95 … … 2001 5 3. Infection of the skin and subcutaneous tissue 271 … … 15 156.60 … … 2001 5 4. Upper respiratory tract infection, unspecified 270 … … 15 100.67 … … 2001 5 5. Influenza 156 … … 8724.83 … … 2001 5 6. Myalgia and myositis 148 … … 8277.40 … … 2001 5 7. Other disease of the skin 110 … … 6152.13 … … 2001 5 8. Open wounds 97 … … 5425.06 … … 2001 5 9. Bronchitis 78 … … 4362.42 … … 2001 5 10. Sprains and strains of joints and adjacent muscles 72 … … 4026.85 … … 2001 5 40 Five leading causes of mortality Number Rate per 100 000 population 1. Injuries from gunshots … … … … … … 2001 4 2. Diabetes and hypertension complications … … … … … … 2001 4 3. Premature births … … … … … … 2001 4 4. Pneumonia … … … … … … 2001 4 5. Accidental drowning … … … … … … 2001 4 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2003 6 - Pertussis (whooping cough) 0 0 0 … … … 2003 6 - Tetanus 0 0 0 … … … 2003 6 - Neonatal tetanus 0 0 0 … … … 2003 6 - Poliomyelitis 0 0 0 … … … 2003 6 - Hib meningitis 0 0 0 … … … 2003 6 - Measles 0 0 0 … … … 2003 6 - Mumps 0 0 0 … … … 2003 6 - Rubella 40 … … … … … 2003 6 - Congenital rubella syndrome 0 0 0 … … … 2003 6 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral … … … … … … - Type A … … … … … … - Type B … … … … … … - Type C … … … … … … - Unspecified … … … … … … Cholera … … … … … … Typhoid fever … … … … … … Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … Gonorrhoea (gonococcal infections) … … … … … … Leprosy 0 0 0 … … … 2003 6 Malaria … … … … … … Dengue/DHF … … … … … … NIUE 230 INDICATORS DATA Year Source Total Male Female Total Male Female 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 0 0 0 … … … 2003 6 - New pulmonary tuberculosis (smear-positive) 0 0 0 … … … 2003 6 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 59.00 … … 6.00 … … 2003 6 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 364.00 … … 100.00 … … 2002 6 Number of cases Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (malignant neoplasms only) … … … … … … - Trachea, bronchus and lung … … … … … … - Stomach … … … … … … - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … … … … - Liver … … … … … … - Cervix … … … … … … - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … … … … - Ischaemic heart disease … … … … … … - Acute myocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … … … … - Hypertension 343 … … … … … 2001 5 49 Maternal causes - Haemorrhage … … … … - Abortion … … … … - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … 50 Diabetes mellitus 308 … … … … … 2001 5 51 Mental disorders … … … … … … COUNTRY HEALTH INFORMATION PROFILE 231 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 52 Injuries - All types … … … … … … - Motor and other vehicle accidents … … … … … … - Suicide … … … … … … - Homicide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 12 2003 4 - Specialized hospitals … … - District/first-level referral hospitals … … - Primary health care centres … … Private hospitals … … Notes: Red text Millennium Development Goals indicators … Data not available FY Fiscal year a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific b Revised data c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Pacific island populations 2004. Secretariat of the Pacific Community (http://www.spc.int/) 2 Demographic tables for the Western Pacific Region 2000-2005. Manila, WHO Regional Office for the Western Pacific, 2005. 3 Statistics Niue (http://www.spc.int/prism) 4 Information furnished by WHO Representative in Samoa, 13 March 2004. 5 Niue sustainable human development situation analysis 2002. New York, United Nations Development Programme, 2002. 6 WHO Regional Office for the Western Pacific, data received from technical units. 7 Information furnished by the Health Department of the Government of Niue through the WHO Representative in Samoa, 3 May 2002. 8 The world health report 2004. Changing history. Geneva, World Health Organization, 2004. 9 Pacific islands Regional Millennium Development Goals report 2004. Secretariat of the Pacific Community and UN/CROP MDG Working Group, November 2004 10 1999 Pacific human development report (creating opportunities). New York, United Nations Development Programme, 1999. 11 Statistics Nuie (http://www.gov.nu/statsniue/) 232 | COUNTRY HEALTH INFORMATION PROFILES NORTHERN MARIANA ISLANDS 1. DEMOGRAPHICS, GENDER AND POVERTY The estimated multi-ethnic population of the Northern Mariana Islands was 78 252 in 2004 and comprised Chamorros, Carolinians, Micronesians, Japanese, Chinese, Filipinos, Koreans and Caucasians. Even though the three official languages are English, Chamorro and Carolinian, 86% of the population speak a language other than English at home. Of the fourteen islands that make up the island nation, only three were inhabited in 2000: Saipan, Rota, and Tinian. The population has an estimated growth rate of 2.71% (2004). The median age is 31.4 for men and 28.2 for women (2004 estimate). The country has an estimated crude birth rate of 19.77 births per 1000 population and an estimated crude death rate of 2.30 deaths per 1000 population. Table 1. Core population and health data (2004 estimates) [Total] 78 252 [Both] 75.67 [0-14 years] 15 911 (20.33%) [Male] 73.11 Population [65+ years] 1228 (1.57%) Life expectancy at birth (years) [Female] 78.38 Crude birth rate (per 1000 population) 19.77 Total fertility rate 1.33 [Total] 98.00 (2002) [Urban] 98.00 (2002) Crude death rate (per 1000 population) 2.30 % of population served with safe water [Rural] 97.00 (2002) [Total] 94.00 (2002) [Urban] 94.00 (2002) Infant mortality rate (per 1000 live births) 7.25 % of population with adequate sanitary facilities [Rural] 96.00 (2002) Maternal mortality ratio (per 100 000 live births) 0.00 (2000) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The Northern Mariana Islands are under the administration of the United States of America as part of the US Trust Territory of the Pacific. Negotiations for territorial status began in 1972 and a covenant to establish a commonwealth in political union with the United States of America was approved in 1975. A new government and constitution went into effect in 1978. At the last elections in January 2001, Governor Juan N. Babauta was elected for a four-year term until November 2005. The Secretary for Health is Dr James U. Hofschneider. 2.2 Economic situation The economy benefits substantially from financial assistance from the United States of America, but funding has declined as locally generated government revenues have grown. The tourist industry employs about 50% of the workforce and accounts for roughly one-quarter of gross domestic product (GDP). Japanese tourists predominate and annual tourist entries have exceeded half a million in recent years, although the financial recession in Japan has led to a recent slowdown. COUNTRY HEALTH INFORMATION PROFILES | 233 3. HEALTH SITUATION 3.1 Health trends The overall health status of the population is changing as the economy of the Commonwealth continues to grow and develop, and is moving away from the health profile of a developing nation towards that of a more industrialized one. Compared with the United States of America, the Northern Mariana Islands spends much less per capita on health care but enjoys a level of health that is comparable in terms of disease incidence and prevalence, with the exception of diabetes, certain cancers and some infectious diseases. Infectious diseases are once again emerging as a major public health concern. Of particular concern are tuberculosis, hepatitis B, hepatitis A, enteric foodborne illnesses, vaccine-preventable diseases, HIV infection and other sexually transmitted infections. The public health department has dealt with recent outbreaks of hepatitis A, measles and foodborne outbreaks involving salmonella, shigella and cholera. Obesity, diabetes, hypertension and atheroscierotic vascular disease are increasing concerns facing the ageing population. 3.2 Health systems In 1996, per capita health expenditure was US$ 1095. It dropped by more than half to US$ 519 in the 2000 fiscal year. To increase the effectiveness of available resources, the College of the Northern Mariana Islands has developed a nursing programme oriented towards public health nursing. In collaboration with the University of Hawaii, the School of Public Health is strengthening manpower training in public health. However, there have been difficulties in recruiting and retaining qualified personnel. The main obstacles include the small human resources pool from which to recruit, the ever-rising costs of maintaining the Commonwealth Health Centre and a lack of community participation in the health care system. Human resources development and upgrading of the knowledge and skills of primary health care personnel will be priorities for the coming years. There is a need for political commitment in the form of legislation to make primary health care services a priority, and the allocation of funds to primary health care services needs to increase. Future primary health care efforts must include strengthening of direct participation by the community and community-based agencies. Millennium Development Goals The Pacific Islands Regional MDG Report was compiled in 2004 to ensure that all Pacific island countries and areas are represented in the United Nations Secretary-General’s 2005 report. Such a report is particularly appropriate in the Pacific region due to the high degree of regional cooperation on development-related issues. The 14 Pacific island countries and one territory covered by the report (Cook Islands, the Federated States of Micronesia, Fiji, Kiribati, the Marshall Islands, Nauru, Niue, Palau, Papua New Guinea, Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu and Vanuatu) are widely dispersed over a large geographical area. They differ significantly in size, population, resource endowments and development constraints, but nevertheless share a number of development challenges. The Pacific Islands Regional MDG Report is the sixth regional MDG report to be prepared worldwide. The main partners in MDG achievement are, in addition to the national line ministries, the United Nations and the Council of Regional Organisations of the Pacific (CROP), which is a high-level advisory body made up of the heads of the region’s 10 primary intergovernmental organizations. CROP is chaired by the Pacific Islands Forum Secretariat (PIFS). Other members comprise: Forum Fisheries Agency (FFA), Pacific Islands Development Program (PIDP), Secretariat of the Pacific Community (SPC), South Pacific Regional Environment Programme (SPREP), South Pacific Applied NORTHERN MARIANA ISLANDS 234 | COUNTRY HEALTH INFORMATION PROFILES Geo-science Commission (SOPAC), University of the South Pacific (USP), South Pacific Tourism Organisation (SPTO), South Pacific Board for Educational Assessment (SPBEA), and Fiji School of Medicine. 4. NATIONAL HEALTH PLAN AND PRIORITIES The Public Health Division has set nine immediate objectives targeted at all Northern Mariana Islands residents: • to provide appropriate preventive health care and services to all communities, with an emphasis on women and children; • to provide appropriate reproductive health and family planning services to all women of child-bearing age and their partners; • to provide appropriate and timely health education, promotion and nutrition information to all residents; • to provide an adequate surveillance and monitoring system, and timely prevention information on communicable and infectious diseases; • to provide timely and appropriate noncommunicable disease prevention information and outreach services to all residents; • to strengthen the availability of health information and health planning by developing surveillance systems that accurately monitor the health status of the community; • to provide public health dental care and outreach dental health prevention services in schools; • to provide and improve the environmental health and sanitation services; and • to identify children who are developmentally delayed or ‘at risk’ in order to minimize their problems and enhance the quality of life for them and for their families. 5. MAJOR INFORMATION SOURCES Division of Public Health, Government of the Northern Mariana Islands Pacific Regional Information System (PRISM). Secretariat of the Pacific Community (http://www.spc.int/prism/) World factbook. CIA. (http://www.cia.gov/cia/publications/factbook/geos/cq.html) 6. ADDRESSES DEPARTMENT OF PUBLIC HEALTH Office Address : Postal Address : P.O. Box 560409, Saipan MP 96950, Commonwealth of the Northern Mariana Islands Official Email Address : Telephone : Fax : Office Hours : Website : WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4 Provident Plaza 1, Downtown Boulevard, 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@fij.wpro.who.int Telephone : (679) 3-304600 / 3-304631/ 3-300727 Fax : (679) 3-300462 Office Hours : COUNTRY HEALTH INFORMATION PROFILE 235 NORTHERN MARIANA ISLANDS WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 0.47 2004 1 2 Estimated population ('000s) 78.25 34.47 43.78 2004 est. 2, 3 3 Annual population growth rate (%) 2.71 … … 2004 est 2 4 Percentage of population - 0–14 years 20.33 24.04 17.41 2004 est. 3 - 65+ years 1.57 1.75 1.43 2004 est. 3 5 Urban population (%) 94.20 … … 2003 4 6 Crude birth rate (per 1000 population) 19.77 … … 2004 est 2 7 Crude death rate (per 1000 population) 2.30 … … 2004 est 2 8 Rate of natural increase of population (% per annum) 1.75 a … … 2004 est 1 9 Health-adjusted life expectancy (HALE) (years) - at birth 75.67 73.11 78.38 2004 est 2 - at age 60 … … … 10 Adult literacy rate (%) … … … 11 Neonatal mortality rate (per 1000 live births) … … … 12 Infant mortality rate (per 1000 live births) 7.25 7.18 7.32 2004 est 2 13 Under-five mortality rate (per 1000 live births) 7.43 … … 1999 5 14 Total fertility rate (women aged 15–49 years) 1.33 2004 est 2 15 Maternal mortality ratio (per 100 000 live births) 0.00 2000 5 16 Percentage of newborn infants weighing at least 2500 g at birth 81.01 … … 2000 5 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 4.55 2000 5 19 Immunization coverage for infants (%) - BCG … … … - DTP3 87.00 … … 2004 6 - OPV3 87.00 … … 2004 6 - Measles 82.00 … … 2004 6 - Tetanus II … … … - Hepatitis B III 89.00 … … 2004 6 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 75.67 2000 5 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods 64.00 2000 7 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15-24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … NORTHERN MARIANA ISLANDS 236 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 98.00 98.00 97.00 2002 8 26 Proportion of population with access to improved sanitation 94.00 94.00 96.00 2002 8 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index … 32 Per capita GDP at current market prices (US$) 28 734.49 1998 9 33 Rate of growth per capita GDP 7.85 1998 9 34 Health expenditure Total health expenditure - amount (in million US$) 42 135 748.00 2000 10 - total health expenditure on health as % of GDP … - per capita total expenditure on health (in US$) 519.00 2000 10 Government expenditure on health (Central government finance) - amount (in million US$) 52.40 2002 13 - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure 16.44 2002 13 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 31 … … 4.47 … … 1999 5 - dentists 3 … … 0.43 … … 1999 5 - pharmacists 4 … … 0.58 … … 1999 5 - nurses 123 … … 17.74 … … 1999 5 - midwives 14 … … 2.02 … … 1999 5 - other nursing/ auxiliary staff 25 … … 3.61 … … 1999 5 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 20 … … 2.88 … … 1999 5 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 14 … … 2.02 … … 1999 5 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … COUNTRY HEALTH INFORMATION PROFILE 237 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity (notifiable diseases) Number Rate per 100 000 population 1. Bacterial food poisoning 1219 … … 1758.00 … … 1999 11 2. Chlamydiosis 206 … … 297.00 … … 1999 11 3. Syphilis 97 … … 140.00 … … 1999 11 4. Hepatitis B 76 … … 110.00 … … 1999 11 5. Tuberculosis 58 … … 84.00 … … 1999 11 6. Salmonellosis 31 … … 45.00 … … 1999 11 7. Gonorrhoea 29 … … 42.00 … … 1999 11 8. Shigellosis 29 … … 42.00 … … 1999 11 9. Ciguatera 15 … … 22.00 … … 1999 11 10. HIV 4 … … 6.00 … … 1999 11 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Cardiovascular diseases 33 … … 54.08 … … 1998 5 2. Neoplasms 26 … … 39.06 … … 1998 5 3. Cerebrovascular diseases 14 … … 21.03 … … 1998 5 4. Perinatal conditions 13 … … 19.53 … … 1998 5 5. Motor vehicle accidents 7 … … 10.51 … … 1998 5 6. Pneumonia 6 … … 9.01 … … 1998 5 7. All other accidents 5 … … 7.51 … … 1998 5 8. Chronic liver diseases and cirrhosis 5 … … 7.51 … … 1998 5 9. Suicide 5 … … 7.51 … … 1998 5 10. Diabetes mellitus 4 … … 6.00 … … 1998 5 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2004 6 - Pertussis (whooping cough) 0 0 0 … … … 2004 6 - Tetanus 0 0 0 … … … 2004 6 - Neonatal tetanus 0 0 0 … … … 2004 6 - Poliomyelitis 0 0 0 … … … 2004 6 - Hib meningitis 0 0 0 … … … 2004 6 - Measles 0 0 0 … … … 2004 6 - Mumps 0 0 0 … … … 2004 6 - Rubella 0 0 0 … … … 2004 6 - Congenital rubella syndrome 0 0 0 … … … 2004 6 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A … … … … … … - Type B … … … … … … - Type C … … … … … … - Unspecified … … … … … … Cholera … … … … … … Typhoid fever … … … … … … Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … Gonorrhoea … … … … … … NORTHERN MARIANA ISLANDS 238 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Leprosy 4 … … … … … 2003 6 Malaria … … … … … Dengue/DHF … … … … … … 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures b … - Proportion of population in malaria-risk areas using effective malaria treatment measures c … 44 Tuberculosis Number of cases Number of deaths - All types 45 … … … … … 2003 6 - New pulmonary tuberculosis (smear-positive) 16 … … … … … 2003 6 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 67.00 … … 8.00 … … 2003 6 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 75.00 … … 71.00 (2002) … … 2003 6 Number of cases 2000 Number of deaths 1998 45 Acute respiratory infections 4242 … … … … … 5 46 Diarrhoeal diseases 10 … … 1 … … 5 47 Cancers All cancers (malignant neoplasms only) 437 … … 26 … … 5 - Trachea, bronchus and lung 12 … … 10 … … 5 - Stomach 1 … … 2 … … 5 - Colon and rectum 0 0 0 1 … … 5 - Lip, oral cavity and pharynx 0 0 0 0 0 0 5 - Liver 0 0 0 0 0 0 5 - Cervix 11 … … 3 … … 5 - Leukaemia 0 0 0 5 … … 5 48 Circulatory All circulatory system diseases 2265 … … … … … 5 - Ischaemic heart disease 28 … … 7 … … 5 - Acute myocardial infarction 16 … … 7 … … 4 - Rheumatic fever and rheumatic heart diseases 39 … … 0 0 0 5 - Cerebrovascular diseases 98 … … 14 … … 5 - Hypertension 1758 … … 2 … … 5 49 Maternal causes - Haemorrhage 0 0 0 0 2000 5 - Abortion 5 0 0 0 2000 5 - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … COUNTRY HEALTH INFORMATION PROFILE 239 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases 2000 Number of deaths 1998 50 Diabetes mellitus 2490 … … 4 … … 5 51 Mental disorders 1197 … … 2 … … 5 52 Injuries - All types 5742 … … … … … 2000 5 - Motor and other vehicle accidents 555 … … 7 … … 5 - Suicide 43 … … 5 … … 5 - Homicide and violence 389 … … 3 … … 5 - Occupational injuries 510 … … … … … FY1999 12 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals (Saipan) 1 74 2000 5 - Specialized hospitals 0 0 2000 5 - District/first-level referral hospitals (Rota and Tinian) 2 8 2000 5 - Primary health care centres 1 0 2000 5 Private hospitals 5 0 2000 5 Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate C Cases D Deaths a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. c Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community (http://www.spc.int) 2 United States Census Bureau, International Programs Center (http://www.spc.int/prism/) 3 The World Factbook 2004, updated 11 May 2004 (http://www.geoplace.com/hottopics/CIAwfb/factbook/geos/cq.html) 4 Urban and rural areas 2003. New York, United Nations Department of Economic and Social Affairs, 2004. 5 Data analyzed through the RPMS computerized system. Birth and Death Database Registry, Office of Health Planning and Statistics, Division of Public Health, Department of Public Health. 6 WHO Regional Office for the Western Pacific, data received from the technical units 7 Family Planning Programme, Division of Public Health, Department of Public Health. 8 Meeting the MDG drinking water and sanitation target: A mid-term assessment of progress. WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2004. 9 Census information from the Central Statistics Division, Department of Commerce. 10 Hospital Division, Department of Public Health. 11 Annual report on notifiable diseases to the Epidemiology and Surveillance Unit, Division of Public Health. 12 Data from Worker's Compensation Commission, Northern Mariana Islands Retirement Fund. 13 CNMI Central Statistics Division, Department of Finance (http://www.spc.int/prism) 240 | COUNTRY HEALTH INFORMATION PROFILES PALAU 1. DEMOGRAPHICS, GENDER AND POVERTY The estimated multi-ethnic population of Palau was 20 700 in 2004, with a natural per annum increase of 1.23%. The population consists of 70% Palauans (who are a conglomeration of Micronesian with Malayan and Melanesian admixtures), 28% Asians (mainly Filipinos, followed by Chinese, Taiwanese and Vietnamese) and 2% Caucasian (2000 est.). The 2004 estimate indicated a population density of 42 persons per square kilometre. Today, approximately 70% of the Palauan population live in the capital city of Koror on Koror Island. Since the 1990 census, life expectancy at birth has been higher for women than men; the 2003 estimate stood at 75.4 years for women and 65.51 years for men. In 2000 the ratio of girls to boys in primary school was 97.25 girls per 100 boys and the ratio of girls to boys in secondary school was 88 girls per 100 boys. Also in 2000, the share of women in employment in the non- agricultural sector (includes self-employed and unpaid) was 40.1%, and 3.7% of the seats in the national Parliament were held by women. Table 1. Core population and health data (2004 estimates) [Total] 20 700 [Both] 71.34 (2003 est) [0-14 years] (27.68%) [Male] 65.51 (2003 est) Population [65+ years] (5.21%) Life expectancy at birth (years) [Female] 75.40 (2003 est) Crude birth rate (per 1000 population) 19.02 (2003) Total fertility rate 1.55 (2003) [Total] 95.40 (2003) [Urban] 99.00 (2003) Crude death rate (per 1000 population) 6.70 (2003) % of population served with safe water [Rural] 89.00 (2003) [Total] 99.00 (2003) [Urban] 99.00 (2003) Infant mortality rate (per 1000 live births) 13.66 (2003) % of population with adequate sanitary facilities [Rural] 98.00 (2003) Maternal mortality ratio (per 100 000 live births) 0.00 (1998) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Palau is a democratic republic with directly elected executive and legislative branches. Presidential elections take place every four years to select the President and the Vice-President, who run on separate tickets. The Palau National Congress (Olbiil era Kelulau) has two houses. The Senate has nine members elected nationwide. The House of Delegates has 16 members, one from each of Palau's 16 states. All of the legislators serve four-year terms. Each state also elects its own governor and legislature. The Council of Chiefs is an advisory body to the President that contains the highest traditional chiefs from each of the 16 states. The Council is consulted on matters concerning traditional laws and customs. The judicial system consists of the Supreme Court, National Court, the Court of Common Pleas, and the Land Court. The Supreme Court has trial and appellate divisions and is presided over by the Chief Justice. COUNTRY HEALTH INFORMATION PROFILES | 241 The head of state is President Tommy Esang Remengesau, Jr. The Vice-President is Elias Camsek Chin. 2.2 Economic situation Palau’s real per capita GDP of US$ 5678 makes it one of the wealthier Pacific island states. The economy consists primarily of tourism, subsistence agriculture and fishing. The Government is the major employer of the workforce, relying heavily on financial assistance from the United States of America. Business and tourist arrivals numbered 87 462 in 2004. Long-term prospects for the key tourist sector have been greatly bolstered by the expansion of air travel in the Pacific, the rising prosperity of leading East Asian countries, and the willingness of foreigners to finance infrastructure development. 3. HEALTH SITUATION 3.1 Health trends The health of Palauans seems to have improved a little, as manifested in health indicators such as a decreased crude death rate, increased life expectancy at birth, and consistent zero maternal mortality ratio. Also, sanitation has improved, with the entire population having access to excreta disposal facilities. Tuberculosis remains a problem, while the prevalence of leprosy has increased slightly. Modern lifestyle-related diseases (circulatory diseases and cancer) remain at the top of the list of major causes of death. It is expected that environmental problems will increase with more foreign investment and workers on the islands in coming years. Water pollution is a major concern due to the lack of sufficient land area for proper waste disposal. Progressive industrial development will continue to worsen both air and marine quality. Marine life and reefs will be affected by the pollution. 3.2 Health systems Health for all remains a top priority in the socioeconomic development of Palau. The Government aims to provide enough trained and qualified staff to provide quality services in all outlying dispensaries, including the more remote areas and islands, as well as at the main hospital in Koror. Although health services are supported by grants and funds from the Federal Government of the United States of America, in addition to the provision of technical support by several United Nations agencies, resource requirements will still be dependent on successful economic development. A new hospital has been built, with United States funding, to accommodate more patients. More staff are needed as a result. Training of more local health workers is needed to replace the rather expensive expatriate staff. Subsequent to the enactment of a new mandatory retirement law, there is an urgent need to train younger people to replace older personnel who are close to retirement age. In 1998, Palau had a health workforce comprising 20 doctors, two dentists, 26 nurses, a midwife, a pharmacist and 106 other health personnel. In 2003, the number of doctors increased to 25. Plans are being made to develop a nursing school at Palau Community College to provide essential training for health personnel in-country and thereby avoid losing health workers who are trained abroad. PALAU 242 | COUNTRY HEALTH INFORMATION PROFILES Millennium Development Goals The Pacific Islands Regional MDG Report was compiled in 2004 to ensure that all Pacific island countries and areas are represented in the United Nations Secretary-General’s 2005 report. Such a report is particularly appropriate in the Pacific region due to the high degree of regional cooperation on development-related issues. The 14 Pacific island countries and one territory covered by the report (Cook Islands, the Federated States of Micronesia, Fiji, Kiribati, the Marshall Islands, Nauru, Niue, Palau, Papua New Guinea, Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu and Vanuatu) are widely dispersed over a large geographical area. They differ significantly in size, population, resource endowments and development constraints, but nevertheless share a number of development challenges. The Pacific Islands Regional MDG Report is the sixth regional MDG report to be prepared worldwide. The main partners in MDG achievement are, in addition to the national line ministries, the United Nations and the Council of Regional Organisations of the Pacific (CROP), which is a high-level advisory body made up of the heads of the region’s 10 primary intergovernmental organizations. CROP is chaired by the Pacific Islands Forum Secretariat (PIFS). Other members comprise: Forum Fisheries Agency (FFA), Pacific Islands Development Program (PIDP), Secretariat of the Pacific Community (SPC), South Pacific Regional Environment Programme (SPREP), South Pacific Applied Geo-science Commission (SOPAC), University of the South Pacific (USP), South Pacific Tourism Organisation (SPTO), South Pacific Board for Educational Assessment (SPBEA), and Fiji School of Medicine. 4. NATIONAL HEALTH PLAN AND PRIORITIES The national health priorities are: • to deliver quality health care, including community-based health care, in order to improve the health of the population and contribute towards building a balanced economy; • to increase the accessibility of health services through the establishment of outlying dispensaries/health centres; • to train and certify health workers and allied health workers in proper training institutions; • to establish a nursing school at Palau Community College; • to control communicable and noncommunicable diseases; • to improve the nutritional status of community members through the implementation of a national action plan for food and nutrition; and • to protect environmental health 5. MAJOR INFORMATION SOURCES Palau Government Statistics(http://www.palaugov.net) Palau Statistics (http://www.spc.int/prism) Bureau of East Asian and Pacific Affairs, United States of America Department of State (http://www.state.gov/r/pa/ei/bgn/1840.htm) Ministry of Health COUNTRY HEALTH INFORMATION PROFILES | 243 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Postal Address : P.O.Box 6027, Koror, Republic of Palau 96940 Official Email Address : Telephone : (680) 488 2552 / 488 2553 Fax : (680) 488 5618 Office Hours : Website : WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4 Provident Plaza 1, Downtown Boulevard, 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@fij.wpro.who.int Telephone : (679) 3-304600 / 3-304631 / 3-300727 Fax : (679) 3-300462 Office Hours : 8:00 a.m. to 5:00 p.m., Monday to Friday PALAU 244 PALAU WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 0.49 2004 4 2 Estimated population ('000s) 20.70 … … 2004 est. 4 3 Annual population growth rate (%) 1.64 a … … 2003 est. 5 4 Percentage of population - 0–14 years 27.68 27.02 28.44 2004 est. 6 - 65+ years 5.21 4.00 6.59 2004 est. 6 5 Urban population (%) 68.60 b … … 2003 2 6 Crude birth rate (per 1000 population) 19.02 … … 2003 1 7 Crude death rate (per 1000 population) 6.70 b … … 2003 5 8 Rate of natural increase of population (% per annum) 1.23 a … … 2003 9 Health-adjusted life expectancy (HALE) (years) - at birth 71.34 65.51 75.40 2003 est 5 - at age 60 … 10.20 12.00 2002 9 10 Adult literacy rate (%) … … … 11 Neonatal mortality rate (per 1000 live births) 14.00 c … … 2000 11 12 Infant mortality rate (per 1000 live births) 13.66 b 16.70 19.57 2003 5 13 Under-five mortality rate (per 1000 live births) 29.00 … … 2002 8 14 Total fertility rate (women aged 15–49 years) 1.55 2003 5 15 Maternal mortality ratio (per 100 000 live births) 0.00 1998 7 16 Percentage of newborn infants weighing at least 2500 g at birth 91.00 … … 1998 7 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 1.20 1998 7 19 Immunization coverage for infants (%) - BCG … … … 2004 10 - DTP3 98.00 … … 2004 10 - OPV3 98.00 … … 2004 10 - Measles 100.00 … … 2004 10 - Tetanus II 100.00 … … 2004 10 - Hepatitis B III 98.00 … … 2004 10 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 99.64 1998 7 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) 18.50 1998 7 21 Percentage of women in the reproductive age group using modern contraceptive methods (married women only) 17.20 2000 8 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … COUNTRY HEALTH INFORMATION PROFILE 245 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 95.40 99.00 89.00 2003 1 26 Proportion of population with access to improved sanitation 99.00 99.00 98.00 2003 1 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) 1.00 … … 2000 8 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.86 … … 1998 3 32 Per capita GDP at current market prices (US$) 5678.00 … … 2003 5 33 Rate of growth per capita GDP -1.73 a … … 2003 5 34 Health expenditure Total health expenditure - amount (in million US$) … - total health expenditure on health as % of GDP … - per capita total expenditure on health (in US$) … Government expenditure on health - amount (in US$) 10 124.00 FY2002/ 2003 5 - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure 14.26 FY2002/ 2003 5 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 25 … … 12.31 … … 2003 12 - dentists 2 … … 1.10 … … 1998 7 - pharmacists 1 … … 0.55 … … 1998 7 - nurses 26 … … 14.40 … … 1998 7 - midwives 1 … … 0.56 … … 1998 7 - other nursing/ auxiliary staff 87 … … 48.00 … … 1998 7 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 13 … … 7.20 … … 1998 7 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 6 … … 3.30 … … 1998 7 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … PALAU 246 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Injuries (all types) 2911 … … 16 073.99 … … 1998 7 2. Unspecified upper respiratory infection 1806 … … 9972.39 … … 1998 7 3. Unspecified otitis media 1625 … … 8972.94 … … 1998 7 4. Colitis, enteritis and gastroenteritis 687 … … 3793.48 … … 1998 7 5. Acute tonsilitis 591 … … 3263.39 … … 1998 7 6. Acute pharyngitis 531 … … 2932.08 … … 1998 7 7. Unspecified allergy 496 … … 2738.82 … … 1998 7 8. Unspecified gastritis and duodenitis 343 … … 1893.98 … … 1998 7 9. Acute lymphadenitis 343 … … 1893.98 … … 1998 7 10. Unspecified urinary tract infection 338 … … 1866.37 … … 1998 7 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Cardiovascular diseases 18 … … 99.39 … … 1998 7 2. Unknown and other 18 … … 99.39 … … 1998 7 3. Other circulatory diseases 16 … … 88.34 … … 1998 7 4. Other injuries 14 … … 77.31 … … 1998 7 5. Cancer 13 … … 71.78 … … 1998 7 6. Respiratory diseases 6 … … 33.13 … … 1998 7 7. Digestive diseases 6 … … 33.13 … … 1998 7 8. Suicide 5 … … 27.61 … … 1998 7 9. Car accidents 4 … … 22.08 … … 1998 7 10. Coronary heart disease 4 … … 22.08 … … 1998 7 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2004 10 - Pertussis (whooping cough) 0 0 0 … … … 2004 10 - Tetanus 0 0 0 … … … 2004 10 - Neonatal tetanus 0 0 0 … … … 2004 10 - Poliomyelitis 0 0 0 … … … 2004 10 - Hib meningitis 0 0 0 … … … 2004 10 - Measles 0 0 0 … … … 2004 10 - Mumps 0 0 0 … … … 2004 10 - Rubella 0 0 0 … … … 2004 10 - Congenital rubella syndrome 0 0 0 … … … 2004 10 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral (all forms) 4 2 2 … … … 2003 5 - Type A … … … … … … - Type B … … … … … … - Type C … … … … … … - Unspecified … … … … … … Cholera 0 0 0 … … … 2003 5 Typhoid fever … … … … … … Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … COUNTRY HEALTH INFORMATION PROFILE 247 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Gonorrhoea 3 0 3 … … … 2003 5 Leprosy 7 … … … … … 2003 10 Malaria 0 0 0 … … … 2003 5 Dengue/DHF (dengue fever) 12 … … … … … 2003 5 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures d … - Proportion of population in malaria-risk areas using effective malaria treatment measures e … 44 Tuberculosis Number of cases Number of deaths - All types 9 … … … … … 2003 10 - New pulmonary tuberculosis (smear-positive) 5 … … … … … 2003 10 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 76.00 … … 8.00 … … 2003 10 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 90.00 … … 38.00 (2002) … … 2003 10 Number of cases Number of deaths 45 Acute respiratory infections 2528 1214 1314 … … … 2003 5 46 Diarrhoeal diseases 86 44 42 … … … 2003 5 47 Cancers All cancers (malignant neoplasms only) 142 … … 13 … … 1998 7 - Trachea, bronchus and lung 6 … … 4 … … 1998 7 - Stomach 0 0 0 0 0 0 1998 7 - Colon and rectum 0 0 0 1 … … 1998 7 - Lip, oral cavity and pharynx 0 0 0 1 … … 1998 7 - Liver 2 … … 3 … … 1998 7 - Cervix 3 0 3 1 0 1 1998 7 - Leukaemia 0 0 0 0 0 0 1998 7 48 Circulatory All circulatory system diseases 738 … … 38 … … 1998 7 - Ischaemic heart disease 6 … … 2 … … 1998 7 - Acute myocardial infarction 8 … … 1 … … 1998 7 - Rheumatic fever and rheumatic heart diseases 3 … … 0 0 0 1998 7 - Cerebrovascular diseases 53 … … 2 … … 1998 7 - Hypertension 375 … … 9 … … 1998 7 49 Maternal causes - Haemorrhage 0 0 0 0 1998 7 - Abortion 28 … 0 0 1998 7 - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … PALAU 248 INDICATORS DATA Year Source Total Male Female Total Male Female 50 Diabetes mellitus 164 … … 3 … … 1998 7 51 Mental disorders … … … … … … 52 Injuries - All types 2911 … … 25 … … 1998 7 - Motor and other vehicle accidents 77 … … 4 … … 1998 7 - Suicide 3 … … … … … 1998 7 - Homicide and violence 20 … … 2 … … 1998 7 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 80 1998 7 - Specialized hospitals 0 0 1998 7 - District/first-level referral hospitals 0 0 1998 7 - Primary health care centres 12 10 1998 7 Private hospitals … … Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Revised data c Estimates derived by regression and similar estimation methods d Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. e Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Information furnished by WHO Representative for the South Pacific, draft copy, 19 April 2004 2 Urban and rural areas 2003. New York, United Nations Department of Economic and Social Affairs, 2004. 3 1999 Pacific human development report (Creating opportunities). New York Uited Nations Development Programme, 1999. 4 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 5 Palau Statistics (http://www.spc.int/prism) 6 Demographic tables for the Western Pacific Region 2000-2005. Manila, WHO Regional Office for the Western Pacific, 2005. 7 Information furnished by Ministry of Health, Republic of Palau, 23 April 1999 8 Pacific Island Regional Millennium Development Goals report 2004. Noumea, Secretariat of the Pacific Community, UN/ CROP MDG Working Group, November 2004. 9 World health report 2004. Changing history. Geneva, World Health Organization, 2004. 10 WHO Regional Office for the Western Pacific, data received from technical units 11 World health report 2005: Make every mother and child count. Geneva, World Health Organization, 2005. 12 Information furnished by WHO Representative for the South Pacific, 11 April 2005 COUNTRY HEALTH INFORMATION PROFILES | 249 PAPUA NEW GUINEA 1. DEMOGRAPHICS, GENDER AND POVERTY Papua New Guinea has an estimated population of around 5.7 million, with almost 87% living in rural areas. Around 800 languages are spoken and each language group has a distinct culture. There are large sociocultural differences between and within provinces. The official languages are English, Pidgin and Motu. Access to widely scattered rural communities is often difficult, slow and expensive. Only 3% of the country’s roads are paved. Many villages can only be reached on foot and much travel between provinces is by air. Papua New Guinea has made some progress in social development over the last 30 years. Literacy rates have risen from 32% to 56%. However, only half of all women aged 15 years and above and two-thirds of all men aged 15 years and older have ever attended school, and enrolment rates vary significantly across provinces. Life expectancy has risen from 49 to 53 years, and Papua New Guinea’s Human Development Index has risen from 0.43 to 0.54. However, in recent years, progress has slowed. Because of the economic stagnation as well as the widespread evidence of deterioration in public services, especially in the rural areas, it is a widely held view that living standards for a significant number of Papua New Guineans have declined since 1990. Furthermore, in spite of increasing cost of living, salaries have changed very little over a long period, contributing to a static or possibly worsening poverty situation, particularly in the urban sector. Papua New Guinea is now developing a poverty reduction strategy that is intended to give an added focus to poverty in the existing national Medium-Term Development Strategy (2003–2007). The country is a signatory to the Millennium Development Declaration. Table 1. Core population and health data (2004 estimates) [Total] 5 695 300 [Both] 53.00 (2000) [0-14 years] (41.68%) [Male] 52.50 (2000) Population [65+ years] (2.54%) Life expectancy at birth (years) [Female] 53.60 (2000) Crude birth rate (per 1000 population) 35.00 (2000) Total fertility rate 4.60 (2000) [Total] 39.00 (2002) [Urban] 88.00 (2002) Crude death rate (per 1000 population) 12.00 (2000) % of population served with safe water [Rural] 32.00 (2002) [Total] 45.00 (2002) [Urban] 67.00 (2002) Infant mortality rate (per 1000 live births) 64.00 (2000) % of population with adequate sanitary facilities [Rural] 41.00 (2002) Maternal mortality ratio (per 100 000 live births) 330.00 (2000) est – estimate 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Papua New Guinea is divided administratively into four regions: Southern Coastal (Papuan) Region, Northern Coastal (MOMASE) Region, Highlands Region, New Guinea Islands Region. PAPUA NEW GUINEA 250 | COUNTRY HEALTH INFORMATION PROFILES The governance system is a parliamentary democracy based on the Westminster model. As a member of the Commonwealth, the head of the Independent State of Papua New Guinea is Queen Elizabeth II of the United Kingdom of Great Britain and Northern Ireland, represented by the Governor-General, who is elected by the National Parliament for a five-year term. The current single-chamber parliament has 109 members, comprising one representative from each of the nineteen provinces and the National Capital District and one representative from each of the 89 open constituencies. Every five years, the political leaders are elected at the two tiers of government: national and local. Presently, there is only one women representative in the national Parliament. There is a decentralized system of government. At the subnational level, there are three levels of administration: provincial, district and local. 2.2 Economic situation During the 1990s, economic performance was mixed, although the economy benefited greatly from major mining and petroleum projects. While there was the potential for economic and social development, the period was largely characterized by negative economic growth and macroeconomic instability. As a result, the economy grew very little in real terms. Growth in the non-mining sector was more sluggish than that in the mining sector. The reasons for the economic stagnation are complex. External contributing factors included the worldwide economic depression, the negative development in commodity prices, and unfavourable trade conditions, among others, while internal factors included a series of inappropriate policy regimes and fiscal failures, the catastrophic civil war in Bougainville from 1989 to 1999, and a series of devastating national disasters. 3. HEALTH SITUATION 3.1 Health trends The health status of Papua New Guineans, the lowest in the Pacific region, steadily improved during the 1980s before declining in the 1990s. Life expectancy (2000) is estimated to be 52.5 years for men and 53.6 years for women, and 15% of a woman’s lifetime is estimated to be affected by some form of disability or morbidity. The infant mortality rate is estimated to be 64 per 1000 live births (2000 census) compared with 82 in 1991 and 72 from the 1981 National Census. The estimations of mortality and morbidity patterns in the population are very approximate, as data are almost entirely facility-based and laboratory confirmation of clinical diagnoses is rare. Communicable diseases remain the major causes of morbidity and mortality in all age groups. However, significant progress has been made in some areas. In 2000, the country was declared poliomyelitis-free. In addition, the national leprosy elimination target of less than one case per 10 000 population was reached. However, around 50% of all mortality is still due to communicable diseases. Malaria is the leading cause of all outpatient visits and the third leading cause of hospital admissions and deaths, and is now endemic in every province, including those that were once malaria-free. Malaria mortality rates for 2003 were estimated to be 9.40 per 100 000. Together, malaria and pneumonia account for one-third of all recorded deaths. Tuberculosis incidence is rising and the rate per 100 000 population is estimated to be 95.30. The number of measles cases decreased from 3863 cases in 2003 to 1385 cases in 2004. Diarrhoeal diseases remain common. Papua New Guinea was declared to have a generalized HIV/AIDS epidemic in 2003. HIV prevalence among women attending antenatal clinics is between 0.9% and 3% (2003). The main mode of transmission is heterosexual. Incidence of sexually transmitted infections is rising; incidence of sexual assaults on women is also high, which increases their risk of STI. COUNTRY HEALTH INFORMATION PROFILES | 251 Maternal and child morbidity and mortality are not improving. Maternal mortality estimates vary widely, but all are high. The 2000 figure is 330 per 100 000 live births. Causes of maternal mortality include postpartum haemorrhage, puerperal sepsis, antepartum haemorrhage, eclampsia and anaemia. Almost 45% of pregnant women are cared for by trained health personnel and about 45% of births are in health facilities. About 9% of women are using modern family planning methods. Perinatal conditions account for over 10% of all recorded deaths. Overall, 27% of children are considered moderately to severely malnourished. Forty-three per cent of children aged 0–5 are stunted, while wasting is comparatively low. Again, there are marked regional variations. Noncommunicable diseases are rising. Cases of tobacco- and alcohol-related illness appear to be increasing, while data from Port Moresby Hospital suggest that diabetes and hypertension are also on the increase. The three leading cancers in Papua New Guinea – oral, hepatic and cervical – have largely preventable causes. A major challenge to improving health in Papua New Guinea is related to perceptions of illness and health among the general population. There is a widespread lack of awareness of risk-related and health-promoting behaviour, and little involvement by local communities in health- promoting activities. Key risks include behaviour and environments that increase the risks of communicable disease; risks of noncommunicable disease, for example from tobacco consumption; and the risks associated with unsafe sexual behaviour. 3.2 Health systems Health services are provided by government and church providers (both of which are financed primarily from public sector funds), by enterprise-based services (e.g. the mines), by a small, modern private sector; and by traditional healers (undocumented amount). Within the public sector, management responsibility for hospitals and rural health services within provinces is divided. The National Department of Health manages the 19 provincial hospitals, while provincial and local governments are responsible for all other services (health centres and subcentres, rural hospitals and aid posts), known collectively as “rural health services”. Rural health services are poor and deteriorating. A Functional and Expenditure Review in 2001 described the health system in rural areas as being in a state of “slow breakdown and collapse, currently being saved from complete collapse by donors”. The review stated, “About 600 rural facilities are closed or not functioning effectively. Where services remain, the breadth and quality of services is diminishing.” At district level, there is either an absolute lack of services or limited use of services that do exist; limited clinical and managerial capacity among district health workers in a very decentralized health system; and limited and not very coordinated efforts at training and other approaches to capacity-building. In addition, there is a lack of district supervision and support; the existence of parallel systems for provincial hospitals and district health services; a scarcity and misdistribution of financial and human resources; and a lack of timely and reliable information for decision- making. The nurse-to-population ratio is 55:100 000. An additional 584 nurses, 619 community health workers and 96 midwives are estimated to be needed to fill vacant posts, and current production rates are insufficient to fill this gap. The doctor-to-population ratio is 5 per 100 000, with the majority being in Port Moresby. Churches are important providers of care, especially in rural areas, where they provide around 60% of health services. They share many of the problems of public facilities, but appear to perform better in a number of areas. Papua New Guinea trains most of its health workforce and the churches run five of the eight nursing schools and all of the community health worker training schools. PAPUA NEW GUINEA 252 | COUNTRY HEALTH INFORMATION PROFILES Overall health spending is falling despite receiving a high share of government funds. Total health expenditure as a share of GDP rose steadily from 3.2% to 4.4% between 1997 and 2001. However, total health expenditure per capita fell steadily from US$ 32 US dollars in 1997 to US$ 24 in 2001. About 70% of recurrent provincial health budgets were allocated to salaries in 2000. Papua New Guinea receives significant levels of official development assistance (ODA), estimated to have amounted to US$ 203 million, or 7.2% of GNP in 2001. The health sector receives around 15% of total ODA. Over the last five years, ODA for health has fluctuated, but has been around 20% of total health spending. Levels of aid have been falling in the last two to three years and are expected to fall further. Papua New Guinea has relatively few development partners. According to statistics provided by the Organisation of Economic Co-operation and Development (OECD), 96% of ODA for health in 1998-2000 was from Australia. Other major external agencies providing loans or grants are the Asian Development Bank (ADB), the Government of Japan and, until recently, the World Bank. ADB is currently preparing a new programme loan for health. The World Bank has not contributed to the health sector since 2001, but is currently considering a loan for HIV/AIDS. There have been smaller contributions from New Zealand, the United States Agency for International Development (USAID), the European Union and United Nations agencies. A major new source of funds for health in 2004 will be the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). The Fund has committed US$ 20 million for malaria over the next five years, and is considering a grant of about US$ 6 million for HIV/AIDS. Millennium Development Goals Since 1990, performance towards achieving the MDGs in Papua New Guinea has been mixed. Although progress has been made in some areas, in others there has been stagnation or even deterioration. Overall, progress has been limited due to the adverse development context, the restricted institutional framework, severe resource limitations and many other socioeconomic, cultural, political and other constraints. Furthermore, disparities in most MDG-related indices at the provincial and subprovincial level are very large by any standard. In some case, the gaps between the provinces have widened further. The most obvious and cost-effective, and easiest way of making progress towards achieving the MDGs, and in the process close the Millennium gaps within the country, is to concentrate on the low-achieving provinces. 4. NATIONAL HEALTH PLAN AND PRIORITIES Explicit priorities: The National Health Plan 2001-2010 and the Medium-Term Expenditure Framework 2004-2006 have identified some explicit priorities. These include maternal and child health, immunization, malaria control, HIV/AIDS, and water and sanitation programmes. Improved services through selected programme support: The Government is focusing its efforts on improving child health and reducing malaria, tuberculosis and AIDS through specific programmes. The malaria control strategy will receive a major injection of funds from GFATM, starting in 2004. For tuberculosis, the DOTS programme is gradually expanding: it is currently operational in eight provinces. Reasons for the somewhat slower-than-planned expansion of DOTS include a number of system constraints common to other disease control programmes: central-level staffing; weak infrastructure and support services; and delays in access to funds, which limits training, supervision and other local level support. Child health is being tackled through improved immunization and through the integrated management of childhood illness (IMCI) approach. Both DOTS and IMCI are seen COUNTRY HEALTH INFORMATION PROFILES | 253 as entry points for strengthening district health services more generally. For example, the two districts where IMCI has been introduced are now being assisted to meet the more general minimum standards developed by the National Department of Health. Further organizational reform: moving towards a unified provincial health system: The National Health Conference 2001 supported a proposal to create a unified provincial health system. If implemented, there will be a single provincial health authority responsible for both hospital and rural health services, headed by a provincial director of health who would report to both the national and provincial governments. Changes to selected financial and staff management procedures: Strategies to ease managerial difficulties include: amendment of selected public finance and management procedures; quarantining (earmarking) of health funds in provincial grants; delegation of powers over district health staff from the provincial administrator to the provincial health adviser; and alignment of treasury warrants to provincial budgets. Moving to a sectorwide approach: In the last few years, there have been major government and partner efforts to ensure a more unified approach to health sector development. The 2001-2010 National Health Plan was developed with extensive consultation. There is now one annual activity plan for the National Department of Health and all donor partners. A Medium-Term Expenditure Framework has been developed for 2004–2006. There are formal annual reviews of achievements, most importantly by the National Health Conference, attended by the National Department of Health, donor partners, churches and provincial government staff. Stronger monitoring mechanisms are being developed. A review of functions has recommended that provincial health budgets should make provision for each rural health facility individually, which may have implications for the current budget structure if all resources going to facilities from several different programme heads are to be comprehensively captured. 5. MAJOR INFORMATION SOURCES 2000 National Census. National Statistical Office (NSO) Papua New Guinea Demographic and Health Survey. National Statistical Office (NSO) Millennium Development Goals Progress Report for Papua New Guinea 2004. Government of Papua New Guinea and United Nations in Papua New Guinea, 2004. Papua New Guinea National Department of Health Information System, Monitoring and Research Branch Papua New Guinea National Health Plan 2001-2010 (volume II) Discharge Reports 2000, Monitoring and Research Branch Annual Health Sector Review, national report.: 2001 performance report. Department of Health, 2001. 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Postal Address : P.O. Box 807, Waigani, National Capital District, Papua New Guinea Official Email Address : Telephone : Fax : (675) 301-3604 Office Hours : Website : PAPUA NEW GUINEA 254 | COUNTRY HEALTH INFORMATION PROFILES WHO REPRESENTATIVE IN PAPUA NEW GUINEA Office Address : 4th Floor, AOPI CENTRE Waigani Drive Papua New Guinea Postal Address : World Health Organization P.O. Box 5896 Boroko, National Capital District, Papua New Guinea Official Email Address : who@png.wpro.who.int Telephone : (675) 325-7827/ 301-3698 / 325-2035 Fax : (675) 325-0568 Office Hours : ORGANIZATIONAL CHART: DEPARTMENT OF HEALTH COUNTRY HEALTH INFORMATION PROFILE 255 PAPUA NEW GUINEA WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 462.84 2004 1 2 Estimated population ('000s) 5695.30 ... ... 2004 est 1 3 Annual population growth rate (%) 3.20 ... ... 2000 4 4 Percentage of population - 0–14 years 41.68 42.08 41.23 2004 est 2 - 65+ years 2.54 2.66 2.40 2004 est 2 5 Urban population (%) 13.20 … … 2003 3 6 Crude birth rate (per 1000 population) 35.00 … … 2000 4 7 Crude death rate (per 1000 population) 12.00 … … 2000 4 8 Rate of natural increase of population (% per annum) 2.3 … … 2000 4 9 Health-adjusted life expectancy (HALE) (years) - at birth 53.00 52.50 53.60 2000 4 - at age 60 … 10.10 10.60 2002 18 10 Adult literacy rate (%) (population aged 10 years and over) 56.20 61.20 50.90 2000 4 11 Neonatal mortality rate (per 1000 live births) 32.00 … … 2000 est 5 12 Infant mortality rate (per 1000 live births) 64.00 67.00 61.00 2000 4 13 Under-five mortality rate (per 1000 live births) 88.00 93.00 83.00 2000 6 14 Total fertility rate (women aged 15–49 years) 4.60 2000 4 15 Maternal mortality ratio (per 100 000 live births) 330.00 2000 6 16 Percentage of newborn infants weighing at least 2500 g at birth 90.00 … … 2002 7 17 Prevalence of underweight children under five years of age 24.9 … … 2000 8 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 54.00 … … 2004 9 - DTP3 46.00 … … 2004 9 - OPV3 36.00 … … 2004 9 - Measles 44.00 … … 2004 9 - Tetanus II 10.00 … … 2004 9 - Hepatitis B III 45.00 … … 2004 9 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 44.80 2002 7 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 53.00 2002 7 - Percentage of deliveries at home by trained personnel (as % of total deliveries) 3.00 2002 7 - Percentage of deliveries in health facilities (as % of total deliveries) 44.80 2002 7 21 Percentage of women in the reproductive age group using modern contraceptive methods 9.50 2002 7 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … PAPUA NEW GUINEA 256 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 39.00 88.00 32.00 2002 10 26 Proportion of population with access to improved sanitation 45.00 67.00 41.00 2002 10 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) 90.00 … … 2003 9 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.54 … … 2002 11 32 Per capita GDP at current market prices (US$) 662.08 … … 2002 12 33 Rate of growth per capita GDP 1.50 … … 2002 13 34 Health expenditure Total health expenditure - amount (in million US$) … - total health expenditure on health as % of GDP 4.40 2001 16 - per capita total expenditure on health (in US$) 24.00 2001 16 Government expenditure on health - amount (in million US$) 104.50 2002 13 - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure 11.50 2002 13 External source of government health expenditure - external resources for health as % of general government expenditure on health 52.50 2002 13 Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 3.90 2002 12 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 275 … … 0.53 … … 2000 14 - dentists 90 … … 0.17 … … 2000 14 - pharmacists … … … … … … 2000 14 - nurses 2841 … … 5.47 … … 2000 14 - midwives … … … … … … 2000 14 - other nursing/ auxiliary staff 3680 … … 7.09 … … 2000 14 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 310 … … 0.60 … … 2000 14 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 1960 … … 3.78 … … 2000 14 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … COUNTRY HEALTH INFORMATION PROFILE 257 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population a 1. Normal deliveries (incl. BBA) 55 996 NA 55 996 1082.77 NA 2247.23 2000 15 2. Pneumonia 31 550 17 436 14 114 610.07 650.65 566.42 2000 15 3. Malaria 30 471 15 295 15 176 589.20 570.76 609.04 2000 15 4. Perinatal conditions 8508 4576 3932 164.52 170.76 157.80 2000 15 5. Direct obstetric causes 8284 NA 8284 160.18 NA 332.45 2000 15 6. Diarrhoea 7566 4210 3356 146.30 157.10 134.68 2000 15 7. Open wounds and injury to blood vessels 7085 4619 2466 137.00 172.37 98.97 2000 15 8. Diseases of the digestive system 7076 3476 3600 136.83 129.71 144.48 2000 15 9. Tuberculosis 5841 3082 2759 112.94 115.01 110.72 2000 15 10. Skin diseases 5700 3070 2630 110.22 114.56 105.55 2000 15 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Pneumonia 957 510 447 18.51 19.03 17.94 2000 15 2. Perinatal conditions 834 455 379 16.13 16.98 15.21 2000 15 3. Malaria 629 324 305 12.16 12.09 12.24 2000 15 4. Tuberculosis 502 305 197 9.71 11.38 7.91 2000 15 5. Meningitis 401 217 184 7.75 8.10 7.38 2000 15 6. Heart diseases 302 147 155 5.84 5.49 6.22 2000 15 7. Diseases of the digestive system 239 167 72 4.62 6.23 2.89 2000 15 8. Septicaemia 192 114 78 3.71 4.25 3.13 2000 15 9. Anaemia 180 82 98 3.48 3.06 3.93 2000 15 10. Diarrhoea 179 105 74 3.46 3.92 2.97 2000 15 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria … … … … … … 2004 9 - Pertussis (whooping cough) 2050 … … … … … 2004 9 - Tetanus 39 … … … … … 2004 9 - Neonatal tetanus 50 … … … … … 2004 9 - Poliomyelitis 0 0 0 … … … 2004 9 - Hib meningitis … … … … … … 2004 9 - Measles 1385 … … … … … 2004 9 - Mumps … … … … … … 2004 9 - Rubella … … … … … … 2004 9 - Congenital rubella syndrome … … … … … … 2004 9 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A … … … … … … 2002 7 - Type B 392 575 … … … … … 2002 7 - Type C … … … … … … 2000 7 - Unspecified 81 55 26 2 2 0 2000 15 Cholera 0 0 0 0 0 0 2000 15 Typhoid fever 5145 2546 2599 164 95 69 2000 15 Encephalitis … … … … … … 2000 15 Plague … … … … … … 2000 15 Syphilis 184 66 118 8 3 5 2000 15 Gonorrhoea 34 14 20 0 0 0 2000 15 PAPUA NEW GUINEA 258 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Leprosy 263 … … … … … 2003 9 Malaria 70 750 … … 537 … … 2003 9 Dengue/DHF 22 … … … … … 2002 9 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 1229.66 … … 9.40 … … 2003 9 - Proportion of population in malaria-risk areas using effective malaria prevention measures b … - Proportion of population in malaria-risk areas using effective malaria treatment measures c … 44 Tuberculosis Number of cases Number of deaths - All types 18405 … … … … … 2003 9 - New pulmonary tuberculosis (smear-positive) 3231 … … … … … 2003 9 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 529.00 … … 49.00 … … 2003 9 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 15.00 … … 53.00 (2002) 2003 9 Number of cases Number of deaths 45 Acute respiratory infections 300 160 140 3 1 2 2000 15 46 Diarrhoeal diseases 7566 4210 3356 179 105 74 2000 15 47 Cancers All cancers (malignant neoplasms only) 2694 1071 1623 268 137 131 2000 15 - Trachea, bronchus and lung 63 43 20 16 12 4 2000 15 - Stomach 31 12 19 4 2 2 2000 15 - Colon and rectum 36 16 20 9 6 3 2000 15 - Lip, oral cavity and pharynx 428 248 180 22 11 11 2000 15 - Liver 335 239 112 51 35 16 2000 15 - Cervix 656 NA 656 29 NA 29 2000 15 - Leukaemia 102 56 46 28 14 14 2000 15 48 Circulatory All circulatory system diseases - Ischaemic heart disease 123 67 54 8 3 5 2000 15 - Acute myocardial infarction 19 16 3 1 0 1 2000 15 - Rheumatic fever and rheumatic heart diseases 47 25 22 7 5 2 2000 15 - Cerebrovascular diseases 7 5 2 0 0 0 2000 15 - Hypertension 491 258 233 28 22 6 2000 15 49 Maternal causes - Haemorrhage 1698 1698 36 36 2000 15 - Abortion 3371 3371 6 6 2000 15 - Eclampsia 605 605 4 4 2000 15 - Sepsis 951 951 13 13 2000 15 - Obstructed labour 50 50 0 0 2000 15 COUNTRY HEALTH INFORMATION PROFILE 259 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 50 Diabetes mellitus 323 183 140 43 27 16 2000 15 51 Mental disorders 520 274 246 6 5 1 2000 15 52 Injuries - All types 20 420 12 404 8016 230 147 83 2000 15 - Motor and other vehicle accidents 504 346 158 19 12 7 2000 15 - Suicide 60 11 49 1 0 1 2000 15 - Homicide and violence 446 102 346 4 2 2 2000 15 - Occupational injuries 0 0 0 0 0 0 2000 15 53 Proportion of population with access to affordable essential drugs on a sustainable basis (%) … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 19 … 2000 14 - Specialized hospitals 4 … 2000 14 - District/first-level referral hospitals 201 … 2000 14 - Primary health care centres 2875 … 2000 17 Private hospitals … … Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate NA Not applicable a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific b Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. c Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 2 Demographic tables for the Western Pacific 2000-2005. Manila, WHO Regional Office for the Western Pacific, 2005. 3 Urban and rural areas 2003. New York, United Nations Department of Economic and Social Affairs, Population Division, 2004. 4 2000 National Census, National Statistical Office 5 World health report 2005: Make every mother and child count. Geneva, World Health Organization, 2005. 6 Millennium Development Goals progress report for Papua New Guinea 2004. Government of Papua New Guinea and United Nations in Papua New Guinea, 2004. 7 Papua New Guinea National Department of Health Information System, Monitoring and Research Branch 8 Pacific Island Regional Millennium Development Goals report 2004. Noumea, Secretariat of the Pacific Community/ UN/ CROP MDG Working Group, November 2004. 9 WHO Regional Office for the Western Pacific, data received from technical units 10 Meeting the MDG drinking water and sanitation target: A mid-term assessment of progress. WHO/ UNICEF Joint Monitoring Programme for Water Supply and Sanitation 2004 11 Human development report 2004. New York, United Nations Development Programme, 2004. 12 Papua New Guinea National Statistics Office <http:///www.spc.int/prism/country/pg/stats> 13 Papua New Guinea National Department of Health, Planning Division, Health Economist 14 National Inventory of Health Facilities 2000 15 Discharge Reports 2000, Monitoring and Research Branch 16 Information furnished by WHO Representative for Papua New Guinea, 08 April 2004 17 Annual Health Sector Review, National Report, 2001 Performance Report. National Department of Health, 2001. 18 World health report 2004: Changing history. Geneva, World Health Organization, 2004. 260 | COUNTRY HEALTH INFORMATION PROFILES PHILIPPINES 1. DEMOGRAPHICS, GENDER AND POVERTY As of 2004, the population of the Philippines was estimated at 82 663 560 and was growing at one of the highest rates in the world, with an estimated population growth rate of 2.36. The National Capital Region (NCR), which is the main artery of politics and commerce in the country, is inhabited by almost 10 million people, making it one of Southeast Asia’s most densely populated areas. The population is predominantly young, with the 0-14 age group representing 34.19% and those aged 65 years and above comprising only 4.34%. The Philippines has a strong tradition of gender equality in both urban and rural communities. Recent scanning of gender issues in the health sector revealed the persistence of several health- related gender concerns such as: a high fertility rate; a gap between desired and actual number of children; declining nutritional status for young and adult women; and increasing health consequences of gender-biased violence. The latest official poverty data indicate that, in 2003, about 3.97 million families, less than a quarter of the country’s total families, were living below the poverty line. The annual per capita poverty threshold reached PhP12 267 (US$ 220.64) in 2003, up by 7.1% compared with the 2000 level of PhP11 451 (US$ 205.96). Thus, a family of five should have an income of at least PhP5111 or around US$ 92 a month to be able to sustain their minimum basic needs, both food and non-food. Poverty remains a predominantly rural problem, accounting for nearly two-thirds of the poor in the country. The largest number of the poorest provinces, with the lowest literacy rates and life expectancy, are located in the Mindanao region, ravaged by intermittent outbursts of violence fuelled by Islamic separatist and communist movements since the early 1970s. The infant mortality rate among households in the poorest quintile is 2.3 times higher than that among those from the richest quintile, while the under-five mortality rate is 2.7 times higher. Such inequality is also evident in differences in the health-seeking behaviour of different income groups and in health outcomes in poor provinces and regions, resulting from continuing differences in access to health care services. Health care is still mainly financed through out-of- pocket payments, hence the financial burden of paying for services is a major obstacle to the poor’s access to health care and can make them even poorer. While wealthier families enjoy high quality, up-to-date health facilities, poor families must usually forgo health care or go into debt or sell their assets. With her renewed political mandate, President Gloria Macapagal-Arroyo has pledged to focus on continuing the battle against poverty by directing social development and anti-poverty measures towards enhancing the capability of the poor to find gainful income and employment. Meeting the basic needs, including health, of the poor is a top priority and emphasis on poverty alleviation will be put forward through specific targets such as the creation of ten million new jobs in six years; increasing GDP to a sustainable 7% or more up to 2010; reducing poverty incidence from 34% to 17%; increasing the investment rate from 19% to 28% of GDP in two years; increasing exports from US$ 38 billion to US$ 50 billion in two years; developing two million hectares of agribusiness land; and developing and supporting two million entrepreneurs. COUNTRY HEALTH INFORMATION PROFILES | 261 Table 1. Core population and health data (2004 estimates) [Total] 82 663 561 [Both] … [0-14 years] 28 262 377 (34.19%) [Male] 67.53 Population [65+ years] 3 586 589 (4.34%) Life expectancy at birth (years) [Female] 72.78 Crude birth rate (per 1000 population) 24.63 Total fertility rate 3.50 (2003) [Total] 80.00 (2002) [Urban] … Crude death rate (per 1000 population) 5.66 % of population served with safe water [Rural] … [Total] 86.10 (2002) [Urban] … Infant mortality rate (per 1000 live births) 29.00 (2003) % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 172.00 (1998) est- estimates 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The Philippines is a democratic, republican state with three branches of government: the executive, the legislative and the judicial. Executive power is vested in the President, who is elected by the people. The current President, Gloria Macapagal-Arroyo, is in her second term. In 1991, the Local Government Code transferred some of the powers of the national government to local government. The Code devolved basic services, including health, giving responsibility to local government units (LGUs). Administrative autonomy enables LGUs to raise local revenues, to borrow and to determine types of local expenditure, including expenditures on health care. The country is divided into 16 administrative regions, which are executive in function and are headed by a regional director. There are 79 provinces, 144 cities and 1496 municipalities, headed by mayors, and 41 495 barangays, headed by barangay chairpersons. A local chief executive heads each LGU. 2.2 Economic situation The Philippines is a middle-income country, but over 40% of the population is estimated to live on less than US$2.00 per day. The economy traditionally depends on agriculture, forestry, mining and fishing. However, in recent years, the manufacturing sector has grown rapidly. Economic growth is partly due to overseas deployment of Filipino workers. In recent years, the economy has grown under generally stable macroeconomic conditions, although the fiscal problem has emerged as a major threat to growth. Inflation rose to 4.8% in January to December 2004, and unemployment remained high, at 10.9%. The country’s real GNP from 2001 to 2003 expanded at an average of 4.5%, while real GDP grew by an average of 4.0%. Poverty has severely undermined the health status of Filipinos. The share of GNP being spent on health expenditure fell from 3.3% in 1998 to 2.7% in 2002. Total national government health expenditure in 2002 amounted to P16.7 billion (US$ 0.3 billion), down by P3.3 billion or 16.3% from 2001. 3. Health situation 3.1 Health trends The population growth rate presents serious challenges to the delivery of health services and there is a need to secure continuous investment in basic health services to ensure that the gaps PHILIPPINES 262 | COUNTRY HEALTH INFORMATION PROFILES between supply and demand do not widen. Furthermore, population pressure on the environment needs to be addressed. Urbanized areas are rapidly expanding, attracting migrants from rural communities and putting a great deal of pressure on cities to provide basic social services. In rural areas, people’s health is affected by difficult access to health services and the presence of locally endemic diseases like malaria, filariasis and schistosomiasis. The four leading causes of morbidity are communicable diseases, the fifth being hypertension. The prevalence of communicable diseases is still very high, while that of noncommunicable diseases is increasing and will continue to do so. This double burden of disease places a great toll on the health and economy of the people and of the nation as a whole. Unlike the leading causes of morbidity, deaths are mainly due to noncommunicable diseases. The infant mortality rate, although declining, is still high compared with those of neighbouring countries. The maternal mortality ratio barely improved from 1970 to 1995 and remains high, at 172.00 in 1998. Nutritional problems and parasitism are common among children. The prevalence of underweight preschool children (0-5 years old) is 27.6%, a slight decrease from 30.6% in 1998. The prevalence of stunting was 26.7% in 2002. Adolescents and young people account for 17% of total morbidity from notifiable diseases and 6.7% of total deaths. Accidents and other forms of violent death are also significant. Based on the 1994 YAFSS II survey, about 1.8 million boys and 670 000 girls aged 15–24 had had sexual relations, often leading to ill-timed or unwanted pregnancies, induced abortions (often in hazardous conditions), and sexually transmitted infections, including HIV. Young mothers in the 15–24 year-old age group comprise 21% of the total maternal mortality ratio and account for 17% of induced abortions and 6% of spontaneous abortions. During the period from 2000 to 2004, outbreaks of malaria, dengue, measles, cholera, typhoid, hepatitis A and diarrhoea were investigated. In the second half of 2004, an epidemic of acute gastroenteritis was reported and a water supply in the province of Pangasinan was found to be contaminated with Vibrio cholerae. There was also a meningococcemia outbreak in Baguio City in November 2004, resulting in a high case fatality ratio of 53% in the early period of the epidemic, and reports were also received from other contiguous sites. In 2004, the country also experienced both natural and man-made disasters, which caused the detour of health priorities to disaster-related resources and approaches Given the current rate of progress, the probability is low that some of the targets of the Millennium Development Goals will be met by 2015, including preventing hunger and halving the proportion of underweight children under five years of age, or reducing the maternal mortality ratio by 75%. 3.2 Health systems Factors contributing to the limited capacity of the country’s health care system to deliver better health outcomes may be summed up as follows: (1) poor health care financing; (2) the inappropriate health service delivery system, where there is excessive reliance on use of high-end hospital services rather than primary care, including an ineffective mechanism for providing public health programmes; (3) the brain drain of health professionals; (4) the excessively high price of medicines, leading to costly out-of-pocket payments and inadequate and irrational use; (5) inadequate enforcement of regulatory mechanisms; and (6) the insufficient effort expended on prevention and control of new diseases, particularly noncommunicable diseases. Data adequacy, accuracy and timeliness are other important and perennial issues to be addressed. The unavailability of timely and accurate data/information makes it difficult to make appropriate decisions on policies and programmes to improve health care. As the lead agency in health, the Department of Health maintains specialty hospitals, regional hospitals and medical centres. Regional field health offices (Centers for Health Development) COUNTRY HEALTH INFORMATION PROFILES | 263 are situated in 16 regions and manage provincial health teams and retained personnel. With the devolution of health services to LGUs, the provincial governments oversee provincial and district hospitals, while the municipal governments manage rural health units (RHUs) and barangay health stations. Issues such as geographical inequity, where people who live in rural and isolated communities receive less and lower quality health services, and socioeconomic inequity, where the poor do not receive health services due to inaccessibility and/or unaffordability, continue to abound in the country. Equally disturbing is the mass migration of doctors and nurses from both the public and private health sectors, making rural areas (60% of the population) even more vulnerable to human resources deficiencies. The University of the Philippines-Philippine General Hospital, the largest hospital in the country, loses 300 to 500 of their nurse workforce every year. Midwives who are in the front-line in providing health services are also seeking jobs as caregivers in other countries. Inadequate resources for the health sector continue to be a major concern. Per capita health expenditure decreased from PhP1484 (US$ 26.69) in 2001 to Php1435 (US$ 25.80) in 2002. The most common source of funds for health in the country today is still out-of-pocket payments (around 43%). In 2002, 77% of health expenditure was used on personal health care, while a meagre 11% was used for public health. In 2004, 33% of the Department of Health’s budget was allocated to public health, while 57% went to hospital services. There has been remarkable progress, however, in the National Health Insurance Program (NHIP), with present coverage of 81% of the country’s population. The NHIP has been successful in targeting indigents through its indigent programme, whereby national and local governments jointly subsidize the annual premiums of indigents in each community. Millennium Development Goals The first Philippine MDG progress report highlighted the improvements achieved in reducing poverty, enhancing gender equality and increasing school participation rates, as well as in providing access to safe water. However, it seems likely that the targets for malnutrition and maternal mortality will not be met without increased effort. Moreover, the potentials for an HIV/AIDS epidemic continue to be a significant threat. The Medium Term Philippine Development Plan (MTPDP), 2004-2010, is consistent with the MDG goals and targets. The Plan cites the MDGs, not just as top priority goals and targets, but as a commitment to ensure a brighter prospect for all Filipinos, especially the poor. The Government is scaling up the levels of investment in three critical areas to achieve the MDGs: people, physical environment and infrastructure. The MTPDP is the country’s detailed roadmap towards reducing poverty through, among others, job creation and enterprise development. Through a series of consultations and roundtable discussions among business executives and leaders of corporate foundations, corporate officers and chief executive officers, as well as partners from government, nongovernmental organizations and the donor community, the business sector has come up with a Philippine MDG Business Framework for Action. The Framework provides guidelines on how business can contribute to achieving the MDGs through three key mechanisms (core business, social investment and policy advocacy) and in four major areas of focus (poverty, education, health and environment). The business sector has also drafted and will soon publish and launch a separate MDG Business Report. The Philippines is one of the three countries, the others being Brazil and South Africa, identified as lead models to demonstrate how the business sector can actively engage with government and civil society for social development and MDG attainment. Of the 48 indicators that are being monitored to determine the country’s progress towards attainment of the MDGs, 29 can be obtained from various government surveys and administrative records. Eight indicators, however, are not available, while 11 are not applicable in the Philippines. For some of the eight indicators not available, country estimates are available from international organizations such as the UNAIDS, WHO, the World Bank and the International Telecommunications Unit (ITU). PHILIPPINES 264 | COUNTRY HEALTH INFORMATION PROFILES The biggest challenge for the Philippines is to increase its economic growth to at least 7% to 8% by 2009, as unemployment and poverty will not be addressed if the economy grows merely by its historical rate of around 4%. With the present fiscal difficulties, partnerships with local government units (LGUs), civil society, the government, microfinance and social security institutions, as well as international donor organizations have been mobilized to help implement the Millenium Project. 4. NATIONAL HEALTH PLAN AND PRIORITIES The thrust is to prioritize delivery of services to the masses and improve the quality of life of all Filipinos, especially the poor. The differences in health status among various groups and regions in the country have widened through the years, showing the need to reprioritize interventions to promote equity, fairness and immediate action. The health sector must, therefore, work to attain a common vision, and health sector reform is the overriding goal of the Department of Health. To this effect, the Government has developed the National Objectives for Health (NOH), a document that states the national goals for health, objectives and strategies to undertake a common vision in partnership with all stakeholders. The following are the priority health programmes of the Philippines: - GMA 50 - Gamot na Mabisa at Abot Kayang Halaga – To lower the price of medicines and make good quality health services affordable. - Social health insurance through the Philippine Health Insurance Corporation (PhilHealth) – To make quality primary, secondary and tertiary care services, as appropriate, more accessible to underserved rural and urban communities. PhilHealth has been expanded to enrol indigent families and to increase the enrolment of individually paying patients to 2.2 million by the end of 2002. In August 2001, the Sponsored (Indigent) Program was approved for inclusion as a national priority programme, making donations to the Program by private entities/individuals fully deductible from taxable income. - National Tuberculosis Programme (NTP) – Globally, the Philippines ranks eighth among countries with a high burden of tuberculosis. It is still estimated that there are 133 smear-positive cases per 100 000 population. Implementation of directly observed treatment, short-course (DOTS) in the public sector reached 100% of the population by the end of 2002. The case detection rate for sputum smear-positive cases reached approximately 68% in 2003 and the treatment success rate stood at 88.0% for the fourth year in a row. The NTP is implementing a public-private mix DOTS approach in order to increase the case detection rate and further improve the treatment outcome, with very encouraging early results. - Expanded Programme on Immunization – Fully immunized children (FIC) coverage is 73%, excluding HepB3 with coverage of 43%. Tetanus toxoid vaccine (TT2) coverage is estimated at 37.3% in pregnant women. The February-March 2004 mass measles immunization campaign for children below eight years of age reduced measles cases by 97.5%. The programme has conducted national training sessions, extensive national monitoring and interventions to reach those previously unreached with safe and effective vaccines. Five regions have conducted mid-level management training and four have conducted cold chain and logistics management training. - Micronutrient Programme (salt iodization and vitamin A) – 79% of children aged 9-59 months and 45% of lactating mothers have received vitamin A supplementation, and 38% of households claim they use iodized salt. The salt iodization programme is supported by the Asin (Salt) Law. COUNTRY HEALTH INFORMATION PROFILES | 265 - Maternal Care and Family Planning – The programme aims for safe deliveries and prevention of complications of pregnancy, and promotion of exclusive breast-feeding. However, the 2003 National Demographic Survey showed that only 33.5% of six- month-old children were being exclusively breast-fed, 22% of deliveries were at home by non-professional attendants, and the average women had one more child than she desired, although only 21.6% were using modern contraceptive methods. - Rabies Prevention and Control Programme – The programme promotes responsible pet ownership and availability of vaccines for dogs and for humans exposed to animal bites. It is also involved in community education and promotes participation of traditional healers in information dissemination and extension of services. - Malaria Control Programme – Malaria is the eighth leading cause of morbidity in the country, with 25 of the 66 endemic provinces accounting for 90% of malaria cases. This has largely been due to delayed consultation, unavailability of necessary drugs in peripheral health centres, and lack of training for hospital-based physicians in the proper management of severe malaria. The Roll Back Malaria (RBM) project, initially targeting three highly endemic municipalities in southern Mindanao and focusing on health worker training and procurement of essential malaria supplies, has scaled up activities by employing a five-pronged strategy that emphasizes working with local government health units. - HIV/AIDS/STI Prevention and Control Programme – According to the national registry, as of December 2004, there had been a total of 2200 HIV/AIDS cases, 69% of them asymptomatic, 31% with full-blown AIDS, and 263 resulting in death. Of the AIDS cases, 63% were males, and 69% belonged to the 20-39 age group. Sexual contact, predominantly heterosexual, is still the most common mode of transmission. The low level of condom use among high-risk groups (less than 35% consistent condom use), as well as the low level of knowledge on correct prevention methods (60% of those surveyed believed that they could not contract the disease), put the country at a higher threat for HIV/AIDS. Ten high-risk urban areas have programmes in place, including serological and behavioural surveillance, while a few other high-risk areas are starting prevention programmes. Partnership and collaboration are strong support mechanisms of the programme. A project funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) started in 2004. - Healthy lifestyle promotion, including responsible parenthood – This includes programmes to actively promote healthy diets, adequate physical activity and responsible parenthood, as well as prevention and cessation of smoking and alcohol and drug abuse. - The Ligtas Buntis 2005 Campaign is a nationwide response to address the family planning needs of men, women and couples which have not been met previously due to deficiencies in social structures and health care systems, as well as problems in availability, accessibility and affordability of family planning services. - The Sentrong Sigla Programme aims to promote availability of quality health services in health centres and hospitals and make these services accessible to every Filipino. Its main component is the certification and recognition programme that develops and promotes standards for health facilities. - As a strategy to effectively reduce tobacco consumption and exposure to tobacco smoke, the Department of Health is recommending the imposition of price and tax measures. Thereafter, the collected tax may, by law, be directed to fund crop diversification programmes and public health services including, but not limited to, the establishment and operation of smoking cessation clinics. PHILIPPINES 266 | COUNTRY HEALTH INFORMATION PROFILES - The Health Sector Reform Agenda is one of the concrete results of the collective efforts of several services, offices and agencies. It describes the major strategies, organizational and policy changes and public investments needed to improve the way health care is delivered, regulated and financed. 5. MAJOR INFORMATION SOURCES National Demographic and Health Survey 2003 Philippine Health Statistics, 2000 Department of Health Administrative Order No. 17-B s 2003 dated February 10, 2003: Philippine Quality in Health Program 2003-2007, 5-year Strategic Plan National Epidemiology Center scientific papers, vol. 15 no. 3-7, 2003 National Epidemiology Center scientific papers, vol. 16, 2002 HIV/AIDS country report. National Epidemiology Center, 2004 National Statistical Coordinating Board Philippine progress report on the Millennium Development Goals, January 2003 2nd Philippine progress report on the MDGs. NEDA, 2005 Field Health Information Service Information System 2002 annual report. Department of Health, 2002. 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : San Lazaro Compound, Tayuman, Sta. Cruz, Manila, Philippines 1003 Postal Address : Official Email Address : info@doh.gov.ph Telephone : (632) 743-8301 Fax : (632) 743-1829 Office Hours : 8 am to 5 pm Website : http://www.doh.gov.ph WHO REPRESENTATIVE IN THE PHILIPPINES Office Address : 2/f, bldg 9, Department of Health San Lazaro Hospital Compound, Sta. Cruz Manila, Philippines Postal Address : P.O. BOX 2932, 1000 Manila Official Email Address : who@phl.wpro.who.int Telephone : (632) 338-7479/ 338-8605 Fax : (632) 731-3914 Office Hours : 8 am to 5 pm COUNTRY HEALTH INFORMATION PROFILES | 267 ORGANIZATIONAL CHART: DEPARTMENT OF HEALTH PHILIPPINES 268 PHILIPPINES WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 300.00 2002 1 2 Estimated population ('000s) 82 663.56 41 612.13 41 051.43 2004 9 3 Annual population growth rate (%) 2.36 … … 2000 2 4 Percentage of population - 0–14 years 34.19 34.80 33.57 2004 9 - 65+ years 4.34 3.95 4.73 2004 9 5 Urban population (%) 61.00 … … 2003 3 6 Crude birth rate (per 1000 population) 24.63 … … 2004 7 7 Crude death rate (per 1000 population) 5.66 … … 2004 7 8 Rate of natural increase of population (% per annum) 1.90 … … 2004 7 9 Health-adjusted life expectancy (HALE) (years) - at birth … 67.53 72.78 2004 est 4 - at age 60 … 10.60 12.10 2002 20 10 Adult literacy rate (%) (15 years and above) 92.60 92.50 92.70 2002 5 11 Neonatal mortality rate (per 1000 live births) 17.00 21.00 13.00 1998-2003 11 12 Infant mortality rate (per 1000 live births) 29.00 35.00 25.00 1998-2003 11 13 Under-five mortality rate (per 1000 live births) 40.00 48.00 34.00 1998-2003 11 14 Total fertility rate (women aged 15–49 years) 3.50 2000-2003 11 15 Maternal mortality ratio (per 100 000 live births) 172.00 1998 18 16 Percentage of newborn infants weighing at least 2500 g at birth 54.80 … … 1998-2003 11 17 Prevalence of underweight children under five years of age 27.60 27.20 28.10 2003 10 18 Percentage of pregnant women with anaemia 43.90 2003 21 19 Immunization coverage for infants (%) - BCG 79.00 … … 2004 16 - DTP3 77.00 … … 2004 16 - OPV3 75.00 … … 2004 16 - Measles 81.00 … … 2004 16 - Tetanus II 52.00 … … 2004 16 - Hepatitis B III 43.00 … … 2004 16 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 87.60 1998-2003 11 - Percentage of pregnant women (who had a live birth) immunized with tetanus toxoid (TT2) 37.30 1998-2003 11 - Percentage of deliveries at home by trained personnel (as % of total deliveries) 35.20 1998-2003 11 - Percentage of deliveries in health facilities (as % of total deliveries) 38.00 1998-2003 11 21 Percentage of women in the reproductive age group using modern contraceptive methods 21.60 f 2003 11 22 Condom use rate of the contraceptive prevalence rate … … 1.90 2003 4 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … COUNTRY HEALTH INFORMATION PROFILE 269 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 80.00 … … 2002 17 26 Proportion of population with access to improved sanitation 86.10 … … 2002 17 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) 47.00 … … 2003 16 28 Proportion of households with access to secure tenure 66.50 … … 2002 17 29 Proportion of vehicles using unleaded gasoline (%) 30.20 … … 2003 19 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.75 2002 5 32 Per capita GDP at current market prices (US$) 963.80 … … 2003 est. 4 33 Rate of growth per capita GDP 6.10 … … 2003 est. 4 34 Health expenditure Total health expenditure - amount (in billion PHP) 115.40 2002 4 - total health expenditure on health as % of GDP 2.70 2002 4 - per capita total expenditure on health (in PHP) 1435.00 2002 4 Government expenditure on health - amount (in billion PHP) 16.70 2002 4 - general government expenditure on health as % of total expenditure on health 14.47 a 2002 4 - general government expenditure on health as % of total general government expenditure 0.41 2001 4 External source of government health expenditure - external resources for health as % of general government expenditure on health 21.41 2001 4 Private health expenditure - private expenditure on health as % of total expenditure on health 54.79 2001 4 Exchange rate in US$ of local currency is: 1 US$ = 54.203 2003 4 35 Health insurance expenditure - health insurance coverage as % of total population 54.00 2002 13 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population a 36 Health workforce - doctors 93 862 … … 11.35 … … 2004 12 - dentists 45 903 … … 5.55 … … 2004 12 - pharmacists 49 667 … … 6.01 … … 2004 12 - nurses 352 398 … … 42.63 … … 2004 12 - midwives 136 036 … … 16.46 … … 2004 12 - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 58 145 … … 7.03 … … 2004 12 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates - physicians 2788 2002 10 38 Yearly new graduates - nurses 5425 2002 10 PHILIPPINES 270 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number e Rate per 100 000 population 1. Pneumonia 734 581 372 717 348 022 924.00 931.10 881.70 2002 8 2. Diarrhea 726 310 352 699 332 636 913.60 881.10 842.70 2002 8 3. Bronchitis/bronchiolitis 629 968 299 482 315 287 792.40 748.10 798.80 2002 8 4. Influenza 484 388 226 527 245 779 609.30 565.90 622.70 2002 8 5. Hypertension 304 690 136 011 168 679 383.20 339.80 427.30 2002 8 6. Tuberculosis/ respiratory 114 221 64 439 44 826 143.70 161.00 113.60 2002 8 7. Cardiovascular diseases 52 237 23 296 26 459 65.70 58.20 67.00 2002 8 8. Malaria 39 994 21 420 16 812 50.30 53.50 42.60 2002 8 9. Chickenpox 28 600 13 518 14 058 36.00 33.80 35.60 2002 8 10. Measles 24 639 12 228 11 436 31.00 30.50 29.00 2002 8 40 Ten leading causes of mortality Number Rate per 100 000 population a 1. Cardiovascular diseases 60 417 34 356 26 061 78.97 89.18 68.62 2000 6 2. Diseases of vascular system 48 271 27 197 21 074 63.06 70.59 55.42 2000 6 3. Malignant neoplasms 36 414 19 597 16 817 47.60 50.87 44.28 2000 6 4. Pneumonia 32 637 16 549 16 088 42.66 42.95 42.36 2000 6 5. Accidents 32 355 26 009 6346 42.29 67.51 16.71 2000 6 6. Tuberculosis, all forms 27 557 18 590 8967 36.02 48.26 23.61 2000 6 7. Chronic obstructive diseases 15 904 10 770 5134 20.79 27.96 13.52 2000 6 8. Certain conditions originating in the perinatal period 15 098 9083 6015 19.73 23.58 15.84 2000 6 9. Diabetes mellitus 10 747 5147 5600 14.05 13.36 14.74 2000 6 10. Nephritis, nephrotic syndrome and nephrosis 7963 4642 3321 10.41 12.05 8.74 2000 6 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 89 … … … … … 2004 16 - Pertussis (whooping cough) 10 … … … … … 2004 16 - Tetanus 1293 … … … … … 2004 16 - Neonatal tetanus 250 … … … … … 2004 16 - Poliomyelitis 0 0 0 … … … 2004 16 - Hib meningitis … … … … … … - Measles 3025 … … … … … 2004 16 - Mumps … … … … … … - Rubella 25 … … … … … 2004 16 - Congenital rubella syndrome … … … … … … 42 Cases and deaths for selected communicable diseases Number of cases e Number of deaths Hepatitis viral 6408 3609 2657 966 693 273 C: 2002 D: 1998 C: 8 D: 6 - Type A … … … … … … - Type B … … … … … … - Type C … … … … … … - Unspecified … … … … … … Cholera 347 201 146 … … … 2002 8 Typhoid fever (and paratyphoid fever) 13 664 6787 5868 1120 651 469 C: 2002 D: 1998 8 6 (Meningitis) encephalitis 207 100 103 … … … 2001 8 COUNTRY HEALTH INFORMATION PROFILE 271 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases e Number of deaths Plague … … … … Syphilis 51 33 18 2002 8 Gonorrhoea (gonoccocal infection) 1535 533 989 0 0 0 2002 8 Leprosy 2397 … … … … … 2003 16 Malaria 44 702 … … 97 … … 2003 16 Dengue/DHF 18 474 … … 212 … … 2004 6 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 55.88 … … 0.12 … … 2003 16 - Proportion of population in malaria-risk areas using effective malaria prevention measures c 15.40 2003p 18 - Proportion of population in malaria-risk areas using effective malaria treatment measures d 7.50 2003p 18 44 Tuberculosis Number of cases Number of deaths - All types 134 375 … … … … … 2003 16 - New pulmonary tuberculosis (smear-positive) 72 670 48 282 24 388 2180 … … 2003 16 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 458.00 … … 49.00 … … 2003 16 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 68.00 … … 88.00 (2002) … … 2003 16 Number of cases Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases 726 310 352 699 332 636 4015 … … C: 2002 D: 2000 C: 8 D: 6 47 Cancers All cancers (malignant neoplasms only) 13 334 … … … … … 2002 8 - Trachea, bronchus and lung … … … 6395 … … 2000 9 - Stomach … … … 1385 807 578 1998 6 - Colon and rectum … … … 1860 1022 838 1998 6 - Lip, oral cavity and pharynx … … … 535 325 210 1998 6 - Liver … … … 1733 1054 679 1998 6 - Cervix … … … … … … - Leukaemia … … … 2219 … … 2000 9 48 Circulatory All circulatory system diseases … … … … … … - Ischaemic heart disease … … … 8597 4,546 4051 1998 6 - Acute myocardial infarction … … … 21 252 13 886 7366 1998 6 - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … 19 218 11 124 8094 1998 6 - Hypertension 304 690 136 011 168 679 … … … 2002 8 PHILIPPINES 272 INDICATORS DATA Year Source Total Male Female Total Male Female 49 Maternal causes - Haemorrhage … … 346 346 2000 6 - Abortion … … … … - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … 50 Diabetes mellitus … … … 10 747 5147 5600 2000 6 51 Mental disorders … … … 866 751 115 1998 6 52 Injuries - All types … … … … … … - Motor and other vehicle accidents … … … 5680 … … 2000 9 - Suicide … … … 885 666 219 1998 6 - Homicide and violence … … … 11 240 10 370 870 1998 6 - Occupational injuries … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 638 35 276 2002 14 - Specialized hospitals 23 10 119 2002 14 - District/first-level referral hospitals b 161 5834 2002 14 - Primary health care centres 2293 … 15 Private hospitals 1077 39 771 2002 14 Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate C Cases D Deaths p Provisional a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b District hospital can be general or special c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. e Totals may not tally due to some reported cases with no gender breakdown. f Revised data. COUNTRY HEALTH INFORMATION PROFILE 273 Sources: 1 2003 Philippine statistical yearbook. National Statistical Coordination Board (NSCB) 2 Population Commission, Department of Health – http://www.popcom.gov.ph 3 Urban and rural areas 2003. New York, United Nations Department of Economic and Social Affairs, Population Division, 2004. 4 National Statistical Coordination Board – http://www.nscb.gov.ph 5 Human development report 2004. New York, United Nations Development Programme, 2004. 6 National Epidemiology Center, Department of Health 7 National Statistics Office (http://www.census.gov.ph) 8 2002 Field Health Service Information System (FHSIS) annual report. Department of Health 9 Department of Health (http://www.doh.gov.ph) 10 Institute of Health Policy Development Studies, National Institute of Health, University of the Philippines 11 2003 National Demographic and Health Survey, Philippines 12 Philippine Regulation Commission 13 2002 Philippine Health Insurance Corporation (PHIC) annual report 14 Bureau of Health Facilities and Services, Department of Health 15 National Epidemiology Center, Department of Health 16 WHO Regional Office for the Western Pacific, data received from technical units 17 Annual Poverty Indicator Survey. National Statistics Office 18 Information provided by WHO Representative in the Philippines, 04 March 2005 19 Land transportation Office, Dept of Transportation and Communication 20 World health report 2004. Changing history. Geneva, World Health Organization, 2004. 21 Food and Nutrition Research Institute, Department of Science and Technology – http://www.fnri.dost.gov.ph 274 | COUNTRY HEALTH INFORMATION PROFILES PITCAIRN ISLANDS 1. DEMOGRAPHICS, GENDER AND POVERTY An estimated 46 people live on Pitcairn Island (2004). Two languages are spoken: English, the official language, and Pitcairnese which is a mixture of an 18th century English dialect and a Tahitian dialect. Outmigration, primarily to New Zealand, has thinned the population from a peak of 233 in 1937 to less than 50 today. Table 1. Core population and health data (2004 estimate) [Total] 46 [Both] … [0-14 years] … [Male] … Population [65+ years] … Life expectancy at birth (years) [Female] … Crude birth rate (per 1000 population) … Total fertility rate … [Total] … [Urban] … Crude death rate (per 1000 population) … % of population served with safe water [Rural] … [Total] … [Urban] … Infant mortality rate (per 1000 live births) … % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) … 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Pitcairn Island is the smallest British protectorate in the world and is governed from the United Kingdom of Great Britain and Northern Ireland by an appointed Governor, whose office is in Wellington, New Zealand. A Commissioner for the island, who handles most ongoing, practical matters for Pitcairn is located in Auckland, New Zealand. Pitcairn Island is held by the United Kingdom to have come under the jurisdiction of the British High Commission for the Western Pacific in 1898, and in 1952 the Pitcairn Island Order in Council transferred the responsibility for administration to the person of the Governor of Fiji, following separation of the offices of Governor and High Commissioner. When Fiji gained independence in 1971, the administration was transferred to Auckland, within the jurisdiction of the British High Commissioner to New Zealand, who conjointly holds office as Governor of Pitcairn. 2.2 Economic situation Pitcairn islanders exist on fishing, subsistence farming, handicrafts and postage stamps. The fertile soil of the valleys produces a wide variety of fruits and vegetables, including citrus, sugarcane, watermelons, bananas, yams and beans. Bartering is an important part of the economy. The major sources of revenue are the sale of postage stamps to collectors and the sale of handicrafts to passing ships. In October 2004, more than one-quarter of Pitcairn's labour force was arrested, which negatively affected the economy as they were thus unable to supply their services to load and unload passing ships. COUNTRY HEALTH INFORMATION PROFILES | 275 3. HEALTH SITUATION 3.1 Health trends No available information 3.2 Health systems No available information 4. NATIONAL HEALTH PLAN AND PRIORITIES No available information 5. MAJOR INFORMATION SOURCES Pitcairn Island http://www. pitcairn.pn World Factbook. CIA http://www.cia.gov/cia/publications/factbook/geos/ Pitcairn Islands Study Center http://library.puc.edu/pitcairn/ 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Mrs. Susan E O'Malley Medical Officer Pitcairn Islands Postal Address : Official Email Address : <co@pitcairn.gov.pn> Telephone : Fax : (872) 7623 37767 Office Hours : Website : WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4, Provident Plaza 1, Downtown Boulevard, 33 Ellery Street, Suva, Fiji Postal Address : Official Email Address : who@sp.wpro.who.int Telephone : (679) 330 4600 / 330 4631/ 330 4635 / 331 7447 Fax : (679) 330 0462 / 331 1530 Office Hours : 276 | COUNTRY HEALTH INFORMATION PROFILES REPUBLIC OF KOREA 1. Demographics, Gender and Poverty The Republic of Korea has experienced rapid socioeconomic change during the past three decades. Rapid economic growth and industrialization have accelerated urbanization, and by 2003 about 80% of the population was urbanized. In the Human Development Index prepared by the United Nations Development Programme (Human Development Report 2004), the Republic of Korea ranks 28th out of 177 nations. The recent socioeconomic development has transformed the Republic of Korea from a recipient country into a donor country. As a result, WHO and other development partners have gradually changed their role within the country, moving chiefly to liaison and resource mobilization. Table 1. Core population and health data (2004) [Total] 48 082 163 [Both] 77.00 (2002) [0-14 years] 9 417 397 (19.59%) [Male] 73.38 (2002) Population [65+ years] 4 181 772 (8.70%) Life expectancy at birth (years) [Female] 80.44 (2002) Crude birth rate (per 1000 population) 10.20 (2003) Total fertility rate 1.19 (2003) [Total] 89.40 (2003) [Urban] … Crude death rate (per 1000 population) 5.10 (2003) % of population served with safe water [Rural] … [Total] 78.70 (2003) [Urban] … Infant mortality rate (per 1000 live births) 5.01 (2003) % of population with adequate sanitary facilities [Rural] … Maternal mortality rate (per 100 000 live births) 15.00 (2000) Socioeconomic factors, such as poverty and gender, have a decisive impact on national health status and serving as a major cause of health inequalities. The Government of the Republic of Korea has made consistent efforts to prevent these factors from undermining the quality of life of its citizens. In particular, efforts have been made to sever the link between low income and unequal access to health services. People in the low-income bracket receive state assistance when they suffer from intractable diseases. The Government is extending the coverage of this medical aid. Gender mainstreaming is another goal of Korean health policy, aiming to eliminate gender-based inequality in health services by reflecting the perspective of women in devising policy measures. To this end, initiatives have been in place to guarantee a minimum standard of living for single mothers, women involved in the sex trade, and female victims of domestic and sexual violence. In addition, health-related legal provisions that are considered at odds with women’s rights will be amended or removed 2. Political and Socioeconomic Situation 2.1 Political Situation The tension between the Republic of Korea and the Democratic People's Republic of Korea continues to play a major role in life and decision-making on the Korean peninsula. The summit COUNTRY HEALTH INFORMATION PROFILES | 277 meeting of both heads of states in 2001 symbolized improving relations and many activities have taken place since that historic meeting. Several rounds of family reunions have taken place, and a reunion centre is planned at Mt. Kumgang. Construction is nearly complete on the two rail and road links between south and north—Gyeongui in the west and Donghae on the eastern coast. However, in October 2002, a crisis developed when the Democratic People's Republic of Korea acknowledged its nuclear capability. Nevertheless, both the current President of the Republic of Korea, Roh Moo-hyun, and the former president, Kim Dae-jung, have called for continued dialogue and further assistance to the Democratic People's Republic of Korea. The Republic of Korea National Security Council has officially designated WHO as the channel of support for the health sector in Democratic People's Republic of Korea. Since 2001, the Government of the Republic of Korea has successfully donated a quantity of malaria control supplies to the Government of Democratic People's Republic of Korea through the WHO offices in each country. The total value of the materials provided in 2005 was approximately US$ 1 million. 2.2 Economic Situation Since the beginning of the first Five-Year Economic Development Plan in 1962, the Republic of Korea's economy and quality of life have rapidly improved. The Republic of Korea's gross national income of US$ 578.4 billion in 2004 was the 13th largest in the world. GDP per capita was US$ 12 030 in 2004. The foundation and launch on 10 December 2003 of the Korean International Foundation for Health and Development (KIFHAD) reflects the Republic of Korea's interest in increasing its contribution to international health development. KIFHAD’s objectives are primarily medical relief and health system support for developing countries, emergency aid for disaster areas, and health care support for the Democratic People's Republic of Korea. KIFHAD was active in delivering emergency relief and medical assistance to the disaster areas, such as Ryongchon in the Democratic People's Republic of Korea after a train explosion in April 2004 and to South-East Asian countries hit by the tsunami in December 2004. 3. Health Situation 3.1 Health Trends In recent years, the health and quality of life of citizens in the Republic of Korea has improved steadily. There has been a significant rise in life expectancy, in part due to progress in medical services and increases in the number of medical facilities and medical staff. These improvements have also greatly contributed to reductions in the infant mortality rate and the maternal mortality ratio. Average life expectancy in the Republic of Korea for males rose from 51.1 years in the 1960s to 73.38 in 2002, and for females from 53.7 to 80.44 over the same period. However, the disparity between males and females in part reflects a relatively high mortality rate for males in their forties and fifties. The infant mortality rate fell from 61.0 per 1000 live births in the 1960s to an estimated 5.01 in 2003, while the maternal mortality ratio stood at 15 per 100 000 live births in 2000. The country’s health policies have been guided by two strategic documents • Health Vision 2010 • Welfare Vision 2010 The Ministry of Health and Welfare has published a Health Care Development Plan for the 21st century, which focuses on the following four major areas: • establishing a lifetime health maintenance system; REPUBLIC OF KOREA 278 | COUNTRY HEALTH INFORMATION PROFILES • establishing an efficient health care delivery system; • fostering the health care industry; and • revising the health care law and the administrative system to establish an advanced social welfare system. In order to maintain or reduce the incidence of chronic diseases, the Government has enlarged its focus to include external factors, such as pollution and health promotion, including eating habits, nutrition, exercise and leisure-time use. In addition, the Government also intends to establish a comprehensive health care system at the community level. The state of the health industry is directly linked to improvements in public health and the quality of life, and is a highly value-added and knowledge-based industry. The government is planning to establish a "Bio Health Technopolis" at Osong in Chungcheongbuk-do Province, in the south- western part of Republic of Korea by 2006. Changes in socioeconomic structures and lifestyles, and improvements to health and medical care, have drastically modified the leading causes of death on the Korean peninsula. In the past, the main causes of death were acute and communicable diseases, but these have been replaced with chronic and noncommunicable diseases. As the elderly population grows and the number of people suffering from chronic degenerative diseases increases, treatment-focused health care policies are being increasingly supplemented by prevention-focused and health promotion policies. These changes have also contributed to decreasing infant and maternal mortality. The great majority of malaria cases are associated with activity along the demilitarized zone (DMZ) separating the Republic of Korea and the Democratic People's Republic of Korea and are most frequently found in military or former military personnel. The decrease in the number of cases is a reflection of the success since 2001 of the malaria prevention and control programme in both countries, and was facilitated by the donation by the Government of Republic of Korea of malaria control supplies to the Democratic People's Republic of Korea. 3.2 Health Systems Expenditures by the Government of the Republic of Korea for health and social welfare have risen every year. The budget of the Ministry of Health and Welfare for 2004 amounted to approximately US$ 9.7 billion, 7.7% of the total government budget, or an increase of 8.6% compared with 2003. There were 95 881 physicians, 20 446 dentists, 54 381 pharmacists and 192 480 nurses in the country in 2004. The demands for higher quality health service have greatly increased with improvements to living standards, greater consciousness of health and longer life expectancy. Moreover, the extension of health insurance to the whole population has led to greater demands for health care, which resulted in the need for a larger health workforce and more facilities. Thanks to the wide coverage of its social security system, the Republic of Korea has been able to build a basic framework for social security institutions. However, the increasing demands of the Korean people will require improvements to both the quality and the content of the existing system, as well changes to its current supplier-focused orientation The existing social welfare system is divided into: • social insurance (National Health Insurance Scheme [NHIS], National Pension Scheme [NPS], Employment Insurance, Industrial Accident Compensation Insurance); • public assistance (livelihood protection, medical aid, veterans relief, disaster relief); and • social welfare services (for the disabled, seniors, children, women and the COUNTRY HEALTH INFORMATION PROFILES | 279 mentally handicapped). The Ministry of Health and Welfare is primarily responsible for administering social security schemes, such as the NPS, NHIS, Public Assistance and Social Welfare Services. There are 12 WHO collaborating centres in the Republic of Korea. Administrative procedures are being carried out in 2005 to establish one more: • WHO Collaborating Centre for Cancer Registration, Prevention and Early Detection at the Korea National Cancer Centre. Millennium Development Goals The mortality risk of infants and young children, as well as pregnant women, has dramatically decreased in the Republic of Korea. Now the focus of public health programmes in this area is not just reducing the mortality rate of this group, but improving health for a longer period by developing the group’s health potential. For example, a life-course approach has been taken to deal with age- specific needs for good health. Medical check-ups are made available to infants and pregnant women at health centres across the country. Medical advice and services are available to promote the health of infants and young children in a timely manner. Pre- and post-pregnancy services are also provided to detect and control any health risks related to pregnancy. The Republic of Korea will continue its effort to fight AIDS, malaria and other diseases. Effective vaccination and consistent efforts towards vaccine development have dramatically reduced the cases of vaccine-preventable diseases. In the case of measles, more than 30 000 cases were reported in 2000, but the number of cases dropped to only 1500 in 2003. For tuberculosis, BCG vaccination has been implemented nationwide, together with early detection, testing, surveillance and registry programmes. The Government of the Republic of Korea has also undertaken a national AIDS programmes encompassing public awareness campaigns, as well as regular health examinations and counselling services for high-risk populations in response to the steady increase of AIDS cases in the country. Increasing international exchange and travel raised the need for enhanced control of emerging and re- emerging diseases, prompting the Government to strengthen preparedness against SARS, avian influenza and other newly emerging diseases. As part of this effort, the Korean Centre for Disease Control and Prevention was established in December 2003 and is playing a major role in building an advanced infrastructure for disease control. 4. National Health Plan and Priorities The Republic of Korea has passed through an epidemiological transition. During the past few decades, the incidence of infectious diseases has decreased while the incidence of chronic degenerative diseases has consistently increased. As most chronic degenerative diseases need to be treated, often with long-term care, the importance of prevention and health promotion has been stressed. The Government will strengthen health promotion programmes using the National Health Promotion Fund. These programmes consist of health education, disease prevention, improvements to nutrition, and the encouragement of healthy lifestyles as defined in the 1995 National Health Promotion Act. The objectives of health policy are to enhance the quality of life and the life span by encouraging healthy lifestyles, improving accessibility to preventive services and formulating a social environment that encourages healthy lifestyles. In order to achieve the above objectives, the strategies are: • encourage healthy lifestyles; REPUBLIC OF KOREA 280 | COUNTRY HEALTH INFORMATION PROFILES • strengthen health education; • promote a nationwide movement for the practice of healthy lifestyles; • improve access to preventive services; • strengthen preventive services at health centres; • activate preventive programmes of nongovernmental organizations; • strengthen health examination programmes at schools and workplaces; • create a social environment that encourages healthy lifestyles; and • establish health promotion facilities such as exercise and recreation facilities, and enforce legal regulations on tobacco and alcohol marketing and advertisements. 5. Major Information Sources Korea National Statistical Office: Statistical Handbook of Korea 2002. Health Insurance and Review Agency: Health Insurance Review and Evaluation, December 2001 Human Development Report 2004. New York, UNDP, 2004. Health and Welfare Services 2003, Ministry of Health and Welfare, The Republic of Korea Health and Welfare Facts Books 2005, Ministry of Health and Welfare, Republic of Korea 6. Addresses MINISTRY OF HEALTH AND WELFARE Office Address : Government Complex-Gwacheon, 1, Jungang-dong, Gwacheon-si 427- 721, Gyeonggi-do, Republic of Korea Postal Address : Official Email Address : Telephone : (822) 503-7524 Fax : (822) 504-6418 Office Hours : Website : http://www.mohw.go.kr COUNTRY LIAISON OFFICER IN SOUTH KOREA Office Address : Room 306, 2-dong, Government Complex-Gwacheon, 1 Chungang- dong, Kwachon City, 427-760, Kyonggido, Republic of Korea Postal Address : Central P.O. Box 540, Seoul, Republic of Korea Official Email Address : clokor@wpro.who.int Telephone : (822) 503-7533/7592 Fax : (822) 502-7818 Office Hours : COUNTRY HEALTH INFORMATION PROFILES | 281 Organization Chart: Ministry of Health and Welfare REPUBLIC OF KOREA 282 REPUBLIC OF KOREA WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 99.60 2003 1 2 Estimated population ('000s) 48 082.16 24 228.21 23 853.95 2004 2 3 Annual population growth rate (%) 0.49 … … 2004 2 4 Percentage of population - 0–14 years 19.59 20.52 18.63 2004 2 - 65+ years 8.70 6.87 10.55 2004 2 5 Urban population (%) 80.30 … … 2003 3 6 Crude birth rate (per 1000 population) 10.20 … … 2003 4 7 Crude death rate (per 1000 population) 5.10 … … 2003 4 8 Rate of natural increase of population (% per annum) 0.51 … … 2003 4 9 Health-adjusted life expectancy (HALE) (years) - at birth 77.00 73.38 80.44 2002 5 - at age 60 … 13.20 17.10 2002 15 10 Adult literacy rate (%) (15 years and above) 97.90 99.20 96.60 2002 9 11 Neonatal mortality rate (per 1000 live births) 3.80 4.10 3.40 1999 7 12 Infant mortality rate (per 1000 live births) 5.01 a … … 2003 5 13 Under-five mortality rate (per 1000 live births) 6.66 a … … 2003 5 14 Total fertility rate (women aged 15–49 years) 1.19 2003 4 15 Maternal mortality ratio (per 100 000 live births) 15.00 2000 7 16 Percent of newborn infants weighing at least 2500 g at birth 95.90 96.30 95.60 2003 4 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 87.00 … … 2003 16 - DTP3 97.00 … … 2003 16 - OPV3 94.00 … … 2003 16 - Measles 96.00 … … 2003 16 - Tetanus II … … … - Hepatitis B III 91.00 … … 2003 16 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 100.00 2000 6 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) 0.10 2000 6 - Percentage of deliveries in health facilities (as % of total deliveries) 99.90 2000 6 21 Percentage of women in the reproductive age group using modern contraceptive methods 79.30 2000 6 22 Condom use rate of the contraceptive prevalence rate 16.50 … … 2000 6 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … COUNTRY HEALTH INFORMATION PROFILE 283 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 89.40 … … 2003 8 26 Proportion of population with access to improved sanitation 78.70 … … 2003 8 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) < 5.00 … … 2003 16 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) 37.00 … … 2003 8 31 Human development index 0.89 … … 2002 9 32 Per capita GDP at current market prices (US$) 12 030.00 … … 2004 18 33 Rate of growth per capita GDP 10.01 … … 2003 10 34 Health expenditure Total health expenditure - amount (in US$) 27 910 000 000.00 2002 11 - total health expenditure on health as % of GDP 5.60 2003 11 - per capita total expenditure on health (in US$) 586.00 2002 11 Government expenditure on health - amount (in million US$) 9700.00 2004 18 - general government expenditure on health as % of total expenditure on health 49.40 2003 11 - general government expenditure on health as % of total general government expenditure 7.70 2004 18 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health 41.90 2003 11 Exchange rate in US$ of local currency is: 1 US$ = 1251.09 Won 2002 11 35 Health insurance expenditure - health insurance coverage as % of total population 98.29 f 2003 12 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 95 881 79 160 16 721 20.01 32.84 7.04 2003 12 - dentists 20 446 15 969 4477 4.27 6.62 1.89 2003 12 - pharmacists 54 381 20 626 33 755 11.35 8.56 14.22 2003 12 - nurses 192 480 … … 40.16 … … 2003 12 - midwives 8996 … … 1.88 … … 2003 12 - other nursing/ auxiliary staff 86 222 h … … 17.99 h … … 2003 12 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 126 411 c 43 837 c 82 574 c 26.38 c 18.19 c 34.78 c 2003 12 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 143 778 g 28 523 g 115 255 g 30.00 g 11.83 g 48.54 g 2003 12 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … REPUBLIC OF KOREA 284 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Diseases of the respiratory system 674 238 308 661 365 577 1415.30 1287.00 1545.40 2002 13 2. Diseases of the musculoskeletal system & connective tissues 307 048 106 836 200 212 644.50 445.40 846.40 2002 13 3. Diseases of the digestive system 301 691 140 763 160 928 633.30 586.90 680.30 2002 13 4. Injury, poisoning and certain other consequences of external causes 150 792 81 817 68 975 316.50 341.10 291.60 2002 13 5. Diseases of the circulatory system 105 467 44 736 60 731 221.40 186.50 256.70 2002 13 6. Diseases of the genitourinary system 84 626 22 219 62 407 177.60 92.60 263.80 2002 13 7. Diseases of the skin and subscutaneous tissue 83 950 39 215 44 735 176.20 163.50 189.10 2002 13 8. Diseases of the eye and adnexa 63 748 24 864 38 884 133.80 103.70 164.40 2002 13 9. Certain infectious and parasitic diseases 58 971 27 580 31 391 123.80 115.00 132.70 2002 13 10. Factors influencing health status and contact with health services 49 310 13 851 35 459 103.50 57.80 149.90 2002 13 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Malignant neoplasms 63 685 40 322 23 363 131.80 166.4 97.00 2003 14 2. Cerebrovascular diseases 36 495 17 239 19 256 75.50 71.1 80.00 2003 14 3. Heart diseases 17 188 8915 8273 35.60 36.8 34.40 2003 14 4. Diabetes mellitus 12 100 6021 6079 25.00 24.8 25.30 2003 14 5. Intentional self-harm 10 932 7541 3391 24.00 33.2 14.90 2003 14 6. Diseases of the liver 9934 8035 1899 20.60 33.2 7.90 2003 14 7. Transport accidents 9224 6745 2479 19.10 27.8 10.30 2003 14 8. Chronic lower respiratory diseases 9213 5233 3980 19.10 21.6 16.50 2003 14 9. Hypertensive diseases 5149 1733 3416 10.70 7.2 14.20 2003 14 10. Falls 3519 2121 1398 7.30 8.8 5.80 2003 14 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2003 17 - Pertussis (whooping cough) 5 2 3 … … … 2003 17 - Tetanus 8 4 4 … … … 2003 17 - Neonatal tetanus NR NR NR … … … 2003 17 - Poliomyelitis 0 0 0 … … … 2003 17 - Hib meningitis NR NR NR … … … 2003 17 - Measles 33 … … … … … 2003 16 - Mumps 1518 1012 506 … … … 2003 17 - Rubella 8 3 5 … … … 2003 17 - Congenital rubella syndrome 0 0 0 … … … 2003 17 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A 362 … … … … … 2004 16 - Type B 585 … … … … … 2004 16 - Type C 1658 … … … … … 2004 16 - Unspecified … … … … … … Cholera 10 … … 0 0 0 2004 16 COUNTRY HEALTH INFORMATION PROFILE 285 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Typhoid fever 174 … … 0 0 0 2004 16 Encephalitis 0 0 0 0 0 0 2004 16 Plague 0 0 0 0 0 0 2004 16 Syphilis 939 b 514 b 425 b ... … … 2003 17 Gonorrhoea 10 834 b 7056 b 3778 b … … … 2003 17 Leprosy 17 … … … … … 2003 16 Malaria 1107 … … 0 0 0 2003 16 Dengue/DHF 14 8 6 … … … 2003 17 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 2.30 … … 0.00 0.00 0.00 2003 16 - Proportion of population in malaria-risk areas using effective malaria prevention measures l … - Proportion of population in malaria-risk areas using effective malaria treatment measures m … 44 Tuberculosis Number of cases Number of deaths - All types 33 888 … … … … … 2003 16 - New pulmonary tuberculosis (smear-positive) 10 976 … … … … … 2003 16 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 118.00 … … 10.00 … … 2003 16 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 23.00 … … 83.00 (2002) … … 2003 16 Number of cases Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases … … … 102 d 43 d 59 d 2003 14 47 Cancers All cancers (malignant neoplasms only) … … … 63 685 40 322 23 363 2003 14 - Trachea, bronchus and lung … … … 12 725 9345 3380 2003 14 - Stomach … … … 11 752 7612 4140 2003 14 - Colon and rectum … … … 5509 3014 2495 2003 14 - Lip, oral cavity and pharynx … … … 876 691 185 2003 14 - Liver … … … 10 994 8262 2732 2003 14 - Cervix … … … 1113 1113 2003 14 - Leukaemia … … … 1457 795 662 2003 14 48 Circulatory All circulatory system diseases … … … 60 262 28 656 31 606 2003 14 - Ischaemic heart disease … … … 11 866 6382 5484 2003 14 - Acute myocardial infarction … … … 8545 4783 3762 2003 14 - Rheumatic fever and rheumatic heart diseases … … … 327 125 202 2003 14 - Cerebrovascular diseases … … … 36 495 17 239 19 256 2003 14 - Hypertension … … … 5149 1733 3416 2003 14 REPUBLIC OF KOREA 286 INDICATORS DATA Year Source Total Male Female Total Male Female 49 Maternal causes - Haemorrhage … … 21 21 2000 7 - Abortion … … 5 5 2000 7 - Eclampsia … … 4 4 2000 7 - Sepsis … … 2 2 2000 7 - Obstructed labour … … 0 0 2000 7 50 Diabetes mellitus … … … 12 500 6021 6079 2003 14 51 Mental disorders … … … 4578 1916 2662 2003 14 52 Injuries - All types … … … 31 558 21 600 9958 2003 14 - Motor and other vehicle accidents … … … 9224 6745 2479 2003 14 - Suicide … … … 10 932 7541 3391 2003 14 - Homicide and violence … … … 837 454 383 2003 14 - Occupational injuries 94 924 … … 2923 … … 2003 16 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number (2003) Number of beds (2004) 12, 18 Public health facilities 135 e - General hospitals 58 - Specialized hospitals 22 k 426 489 a - District/first-level referral hospitals … - Primary health care centres 3416 j Private hospitals 1 290 i Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate NR Not relevant p Preliminary estimate a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Data from a hospital survey, incidence case c Including licensed medical technicians (clinical pathology technicians, radiological technicians, physical therapists, occupational therapists, dental technicians, dental hygienists, medical records officers) d Including ICD code A01-A09 e Not including primary health care centres f Not including medical aid g Figures for licensed sanitary workers, licensed dietitians and opticians. 70 quasi-medical practitioners(bone setters, acupuncturists, moxibustioners) and 6350 massuers/masseuses are excluded from these figures (gender not classified) h Only other nursing personnel in medical facilities, midwifery clinics, health centres, sub-health centres and primary health care (PHC) posts i Only hospitals, not including clinics j Including health centres, sub-health-centres and PHC posts k Including mental, tuberculosis and leprosy hospitals l Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. m Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. COUNTRY HEALTH INFORMATION PROFILE 287 Sources: 1 Cadastral statistical annual report 2004. Ministry of Government Administration and Home Affairs, 2004. 2 Population projections for Korea. National Statistical Office. 3 Urban and rural areas 2003. New York, United Nations Department of Economic and Social Affairs, Population Division, 2004. 4 2003 annual report on live births and deaths statistics. National Statistical Office, 2003. 5 Statistical database. National Statistical Office (http://www.nso.go.kr) 6 National Fertility and Family Health Survey 2000. Korea Institute for Health and Social Affairs. 7 Maternal and infant mortality survey report in 1999-2000. Ministry of Health and Welfare. 8 Environmental statistics yearbook 2004. Ministry of Environment. 9 Human development report 2004. New York, United Nations Development Programme, 2004. 10 Economic statistics yearbook 2004. The Bank of Korea. 11 OECD health data 2005: How does Korea compare, OECD 12 Yearbook of health and welfare statistics 2004. Ministry of Health and Welfare. 13 Patient survey report 2002. Ministry of Health and Welfare. 14 Annual report on the cause of death statistics 2003. National Statistical Office. 15 World health report 2004. Changing history. Geneva, World Health Organization, 2004. 16 WHO Regional Office for the Western Pacific, data received from the technical units 17 Communicable diseases statistical yearbook 2003. Korea Center for Disease Control and Prevention. 18 Information provided by Ministry of Health and Welfare through Country Liaison Officer for Republic of Korea, 28 June 2005. 288 | COUNTRY HEALTH INFORMATION PROFILES SAMOA 1. DEMOGRAPHICS, GENDER AND POVERTY In 2004, estimates put Samoa’s population at 182 700, with around 39% composed of young people aged less than 15 years and only 4% of people aged 65 years and over. The country is divided into four major statistical regions: Apia Urban Area (AUA), North West Upolu (NWU), Rest of Upolu (including Manono and Apolima Islands) and Savaii. AUA represents the urban area, while the other three regions make up the rural population. Table 1. Core population and health data (2004 estimate) [Total] 182 700 [Both] 72.80 (2001) [0-14 years] (39.17%) [Male] 71.80 (2001) Population [65+ years] (4.03%) Life expectancy at birth (years) [Female] 73.80 (2001) Crude birth rate (per 1000 population) 29.00 (2001) Total fertility rate 4.40 (2001) [Total] 88.00 (2002) [Urban] 91.00 (2002) Crude death rate (per 1000 population) 1.50 (2001) % of population served with safe water [Rural] 88.00 (2002) [Total] 100.00 (2002) [Urban] 100.00 (2002) Infant mortality rate (per 1000 live births) 19.30 (2001) % of population with adequate sanitary facilities [Rural] 100.00 (2002) Maternal mortality ratio (per 100 000 live births) 19.60 (2002) Gender issues, such as the promotion and protection of women's rights, gender equity and women and HIV/AIDS are of high importance in Samoan society. The level of women’s participation in the paid labour force is relatively high, and their access to education and achievement in the formal educational system is virtually equal to men. Women occupy a number of senior positions in the public sector. The church plays a key role in influencing public opinion and in education through the provision of schools at all levels. The UNDP Human Development Index (HDI) ranks Samoa 75th out of 177 countries. Based on the HDI, Samoa has one of the higher levels of social development rankings in the Pacific, showing higher overall educational and health standards than other Pacific islands. 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Democratic traditions and a strong social system based on village communities and extended family ties continue to play a major role in maintaining peace in Samoan society. The extended family, the aiga, is the foundation of the fa’a-samoa (traditional way of life). The head of each aiga is the matai (customary chief), who is elected by family members. Traditionally, the family matai is responsible for maintaining the family’s dignity and well-being by administrating family affairs. More than 80% of the population lives under the matai system. Particularly strong in the rural areas and at village level, it functions as a safety net in providing social and financial security. Many Samoans who are resident abroad continue to honour their ‘social obligations’ by sending significant amounts of money to their extended family and churches. The national system of government is based on the British Westminster model, with a combination of traditional and democratic features. Universal suffrage has applied since 1991, COUNTRY HEALTH INFORMATION PROFILES | 289 but, with the exception of two seats reserved for voters considered to be outside the governance of the matai system (out of a total of 49 seats), only matai can stand for parliament. The Human Rights Protection Party has been in power continuously for 18 years. The coalition forming the opposition comprises the Samoan National Development Party and eight independent members. During 40 years of independence, Samoa has been able to create a stable political environment and to stimulate economic growth through sound macroeconomic management. Over the past 10 years, it has sought to address the challenges of social and economic reforms. Since the early 1990s, the Government has committed itself to the promotion of good governance. Human rights are respected overall. The ongoing Economic and Public Sector Reform Programme (since 1996) has instigated institutional reforms in public services and in several public sector agencies, which has led to improvement of the governance framework. Performance budgeting has encouraged greater efficiency, accountability and transparency. Equally, economic reforms are considered to be crucial for Samoa in the pursuit of the Government’s goals to improve the living standards and the welfare of the people. Since 1996/1997, the Government’s national policy framework and development strategies have been set out in the annual Statement of Economic Strategy (SES), the Strategy for the development of Samoa 2002–2004: Opportunities for all, which highlights the medium-term vision as follows: “For every Samoan to enjoy an improved quality of life premised on a competitive economy with sustained economic growth, improved education, enhanced health standards and strengthened cultural and traditional values”. 2.2 Economic situation The economy of Samoa has traditionally been dependent on development aid, family remittances from overseas, and agriculture and fishing. Agriculture still plays an important role in the economy. Village agriculture provides food security and support to the agro-based industries, such as coconut cream, oil and desiccated coconut, which have been major export products in the past. The manufacturing sector mainly processes agricultural products. Tourism is an expanding sector. The Government has called for deregulation of the financial sector, encouragement of investment, and continued fiscal discipline, while protecting the environment. Development efforts in the area of trade, at both national and international levels, are considered relatively advanced compared with other Pacific islands. However, Samoa is ecologically fragile and vulnerable to natural disasters, such as cyclones and disease infestations. Gross domestic product (GDP) per capita in 2001 was US$ 1442.67 US dollars. Economic growth in the same year was estimated at 6.5%, with an annual rate of inflation of 4% by the end of 2001. Manufacturing, transport and communications, and commerce contributed most to the growth. Agriculture production, on the other hand, dropped by 12% as a direct result of the limited market outlets for copra, cocoa, kava and coconut cream. Gross tourism receipts rose only marginally, by 0.7%. The sharp slowdown in growth was seen as a direct result of the September 11 terrorist attack in the United States of America. While exports improved by 16.8% compared with 2000, imports increased by 28% in 2001. As a result, the current account deficit widened to 11.2% of GDP. Remittances inflows continued to increase at a lower rate than in 2000. At the current level, they are equivalent to 18% of GDP. At the end of 2001, foreign reserves stood at WST 174 .84 million (US$ 66.7 million), equivalent to approximately 4.1 months of import cover. Grants from development partners in 2000/2001 added up to WST 65.09 million (US$ 23 million), equalling some 25% of total revenue. 3. HEALTH SITUATION 3.1 Health trends The health status of the population has improved significantly, and Samoans now enjoy a relatively good health status. Life expectancy is 72.8 years for the total population. The infant SAMOA 290 | COUNTRY HEALTH INFORMATION PROFILES mortality rate is 19.3 per 1000 live births, the maternal mortality ratio is 19.6 per 100 000 live births, and the under-five mortality rate is 13.7 per 1000 live births. Poliomyelitis, tetanus and diphtheria have been virtually eradicated in Samoa. The whole of the Pacific region is poliomyelitis-free. Remaining high mortality and high morbidity rates for communicable diseases call for a renewed control, management and surveillance commitment. Typhoid and dengue are both endemic and periodically reach epidemic levels. Lymphatic filariasis is also endemic, with a standardized antigen prevalence rate of 1.6% in 2003. As the Government has made a firm commitment to elimination of lymphatic filariasis by 2005, intensive mass drug administration (MDA) campaigns have been carried out, with 96% coverage in 2001, 60.3% in 2002 and 80% in 2003. The DOTS coverage and enrolment rate is 100% for all tuberculosis cases, but the case detection rate was 51% for all types and 51% for smear-positives in 2003, based on WHO estimates. No HIV testing is done among old or new reported cases of tuberculosis. The main challenges to the effectiveness of the tuberculosis control programme include nursing staff shortages, low awareness about tuberculosis passive case-finding, insufficient management skills and coordination, and limited laboratory capacity. The first HIV/AIDS case was reported in 1990. Since then, a total of 12 HIV/AIDS cases (10 adults and two infants) have been reported. Eight have died and the four remaining HIV- positive cases have not yet manifested AIDS. A survey funded by WHO in 2000 revealed a high prevalence of sexually transmitted infections (31.0% for chlamydiosis and 20.8% for trichomoniasis) in a population of 472 pregnant women aged between 18 and 45 years. Noncommunicable diseases are causing a great deal of morbidity and are replacing communicable diseases as the main causes of death. Cardiovascular diseases are the number one killer. The prevalence of hypertension among adults aged 44–60 was 31% for men and 25% for women in 1995. Cancer was the ninth leading cause of death in 2002. The leading cancers for both sexes are cancer of the digestive organs and of the lungs, claiming almost two-thirds of cancer deaths in 1995. The leading cancers for females are cervical cancer and breast cancer. Diabetes prevalence was 11.5% of the adult population aged 25-74 years in 1991, almost a two- fold increase from the 6.4% only 13 years previously, and it is significantly higher in urban areas. Most patients, especially in rural areas, present very late and often in advanced stages with serious complications such diabetic sepsis, blindness, stroke and disability. Samoans have high rates of hyperlipidaemia. More than one-third of people in every age and sex category, even young people, have at least one lipid abnormality. A large proportion of the population suffers from obesity. The absolute prevalence of obesity (BMI >30 kg/m²) in adults aged 25-74 increased by up to 32.9% over the period from 1978 to 1991 in urban and rural locations. Smoking prevalence rates in 1995 were: 56% in males aged 29-43; 60% in males aged 43-60; 27% in females aged 29-43; and 22% in females aged 43-60. In the late 1970s and early 1980s, about 100 people attempted suicide each year. From 1983 to 2001, the average yearly number of suicide attempts was 36, with a death rate of 57%, or around 20 deaths. The suicide rate is 12 deaths per 100 000 population. Young people make the majority of suicide attempts. There is a lack of systematic studies and data on the mental health burden, and there is no overarching mental health programme in Samoa, although community-based mental health nursing services are available. There is no national alcohol and drug control programme. Major issues include a lack of a qualified psychiatrist and trained staff, the limited availability of medications and insufficient financial resources. The Government and civil society have taken a series of actions to review and develop mental health legislation and a comprehensive strategy and policy. COUNTRY HEALTH INFORMATION PROFILES | 291 3.2 Health systems The national health care system is dominated by the public health sector. The Ministry of Health provides primary, secondary and limited tertiary care through a public health network. Tertiary care, which is basically unavailable in-country, is provided overseas, generally in New Zealand or Australia. Major costs arising from overseas treatment are particularly related to renal failure and dialysis treatment, cardiac surgery and ophthalmology. It is thought, however, that the provision of such specialized care in Samoa would be too costly to establish and maintain. Over the last few years the profit-based private health sector has been expanding. An extensive network of women's committees co-manages publicly funded rural health services. Approximately 5.8% of GDP and 18.1% of total government expenditure is spent on the health sector. Per capita health expenditure amounts to US$ 86. Government spending on health as a proportion of its total expenditure increased notably from 10.2% in 1991 to 17% in 2001. For health care financing, 63% is from public sources and 21% from private sources (out-of-pocket for private sector services, including traditional healers). The remaining 16% is provided by international donors and other sources. It is estimated that 44% of total health expenditure occurs in the public sector, 18% in the private sector, 19% in pharmacies (public and private), and the remaining 19% is related to overseas treatment. 4. NATIONAL HEALTH PLAN AND PRIORITIES National priorities in health, which are identified in the Strategy for the development of Samoa 2002- 2004: Opportunities for all, include: • improving primary health care and health promotion services; • improving community services; • improving health facilities; • strengthening partnership with the private sector; and • strengthening Department of Health management. The principles of primary health care, health promotion and Healthy Islands have inspired health sector development in Samoa since 1983. Values such as equity, sustainability, quality and appropriateness of health services, including the concept of culturally friendly services, are the foundations on which the health sector is based. The Ministry of Health’s vision is: “By the year 2003, all Samoans will be living in healthy environments, be well informed on, and participating in health matters, living healthy lifestyles and accessing essential primary, secondary and tertiary health services provided by the most appropriate health services providers in a safe, ethical, caring and empowering environment”. The economic and public sector reforms that have been undertaken since 1996 have influenced the current policies, strategies and priorities being devised by the Ministry of Health significantly. One of the Government's public sector measures is the devolution of financial and human resource management to line departments, within the context of strategic and corporate development focusing on key public functions. Health sector reforms have resulted in the Department of Health taking on a more strategic role in regulating and monitoring the health sector. Focus has shifted from the operational management of public services to strategic management and health policy development, in addition to operational service delivery. There has also been an intensification and development of partnerships with the rest of the health sector (formal and informal private health subsectors), the community, nongovernmental organizations and other government agencies in national health services plans for both rural and urban areas. By introducing the “Health Sector Strategic Plan 1998-2003”, the Department of Health set out to achieve the reform challenges and embarked on a programme across three priority areas. SAMOA 292 | COUNTRY HEALTH INFORMATION PROFILES (1) Institutional strengthening: Institutional strengthening is being addressed on two levels: the health sector level and Department of Health organizational level. Sector-level reforms respond to government economic policies and private health sector expansion and provide an agenda of key policy areas that are being addressed and developed during a five-year implementation phase that formally started in mid-2001. The Department of Health organizational reforms aim to improve the Department’s effectiveness and efficiency by implementing public sector reforms aimed at improving policy development, strategic planning, human resource and financial management, service delivery and developing partnerships between the Department and other sectors. Through intensive collaboration with various development agencies, policy development has been a main focus, with successful endorsement of national drug policy and national HIV policy, and drafting of national blood safety policy and tobacco control policy (with references to obligations set out by the WHO Framework Convention on Tobacco Control [FCTC]). A comprehensive legislation review has been conducted, with the development of a tobacco bill, and preparation for mental health legislation and HIV legislation. National health financing policy and strategy have been established, together with a national health account, and the health insurance scheme has been revised. (2) Primary health care and health promotion with a specific focus on noncommunicable diseases, children’s and women’s health issues and communicable diseases surveillance and responses: Noncommunicable disease policy and strategy are under development. Coordinating mechanisms, contingency plans and capacity in the Ministry of Health for communicable disease control, surveillance and outbreak response were established and strengthened during the outbreak of severe acute respiratory syndrome (SARS). Child health policy and strategy were developed, aimed at rheumatic fever prevention policy, as well as an injury prevention policy to protect the health of Samoan children. Due to the success of the National Plan of Action on Nutrition, food safety issues have been reviewed, with specific policy recommendations. (3) Improvements in public health facilities: These include establishment of a national health care waste management system; strengthening of strategic planning, management and quality control for the national hospital laboratory; infection control in clinical settings; and health information and data and medical record management. 5. MAJOR INFORMATION SOURCES Strategy for the development of Samoa 2002-2004: Opportunities for all Samoa National Health Service Planning Framework April 2002. Department of Health Report of the PacELF 5th Annual Meeting 2003. Tuberculosis control in the WHO Western Pacific Region: 2002 report Review of the National Tuberculosis Control Programme in Samoa from the internal medicine perspective. Dr Viali Lameko et al., 20 June 2002. Review of the National Tuberculosis Control Programme in May 2001 (WHO mission report by Dr Pierre Yves Norval) Department of Health Annual Report 1999-2000 (leading cause of mortality) Collins V, Dowse GK, Toelupe et al. Increasing prevalence of NIDDM in Pacific Islands population. COUNTRY HEALTH INFORMATION PROFILES | 293 Hodge AM, Dowse GK, Toelupe et al. Dramatic increase in the prevalence of obesity in Western Samoa over the 13 years period of 1978-1991. International journal of obesity, 1994; 18:419-428. Samoa Suicide Prevention Strategy 2002-2006: An introduction ‘Faataua le Ola’ (FLO) Samoa National Health Account for FY 2000/2001. Executive summary. Ministry of Health and the World Bank 6. ADDRESSES MINISTRY OF HEALTH Office Address : Postal Address : P.O Box 2268, Apia, Samoa Official Email Address : Telephone : Fax : (685) 25057 Office Hours : Website : WHO REPRESENTATIVE IN SAMOA Office Address : Ioane Viliamu Building Beach Road, Apia, Western Samoa Postal Address : P.O. Box 77 Apia, Western Samoa Official Email Address : who@sma.wpro.who.int Telephone : (685) 23756; (685) 24976 Fax : (685) 23765 Office Hours : SAMOA 294 SAMOA WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 2.94 2004 1 2 Estimated population ('000s) 182.70 ... ... 2004 est 1 3 Annual population growth rate (%) 1.00 ... ... 2001 4 4 Percentage of population - 0–14 years 39.17 38.98 39.38 2004 est 2 - 65+ years 4.03 3.64 4.46 2004 est 2 5 Urban population (%) 22.30 … … 2003 3 6 Crude birth rate (per 1000 population) 29.00 … … 2001 4 7 Crude death rate (per 1000 population) 1.50 … … 2001 4 8 Rate of natural increase of population (% per annum) 2.75 a … … 2001 9 Health-adjusted life expectancy (HALE) (years) - at birth 72.80 71.80 73.80 2001 4 - at age 60 … 10.90 11.60 2002 5 10 Adult literacy rate (%) 97.40 97.60 97.50 1999 6 11 Neonatal mortality rate (per 1000 live births) 4.20 … … 2002 7 12 Infant mortality rate (per 1000 live births) 19.30 19.50 19.00 2001 4 13 Under-five mortality rate (per 1000 live births) 13.70 8.90 4.70 2002 7 14 Total fertility rate (women aged 15–49 years) 4.40 2001 4 15 Maternal mortality ratio (per 100 000 live births) 19.60 2002 7 16 Percentage of newborn infants weighing at least 2500 g at birth 97.40 … … 2003 8 17 Prevalence of underweight children under five years of age 1.90 … … 1999 9 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 93.00 … … 2004 10 - DTP3 68.00 … … 2004 10 - OPV3 41.00 … … 2004 10 - Measles 25.00 … … 2004 10 - Tetanus II 4.00 … … 2004 10 - Hepatitis B III 70.00 … … 2004 10 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 97.00 2003 8 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) 8.00 2003 8 - Percentage of deliveries in health facilities (as % of total deliveries) 92.00 2003 8 21 Percentage of women in the reproductive age group using modern contraceptive methods 42.40 1999 6 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … COUNTRY HEALTH INFORMATION PROFILE 295 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 88.00 91.00 88.00 2002 11 26 Proportion of population with access to improved sanitation 100.00 100.00 100.00 2002 11 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) 62.90 … … 2001 9 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.77 … … 2002 12 32 Per capita GDP at current market prices (US$) 1442.67 … … 2001 4 33 Rate of growth per capita GDP … … … 34 Health expenditure Total health expenditure - amount (in US$) 14 633 266.00 2000- 2001 13 - total health expenditure on health as % of GDP 5.80 2000- 2001 13 - per capita total expenditure on health (in US$) 86.00 2001 14 Government expenditure on health - amount (in million US$) … - general government expenditure on health as % of total expenditure on health 17.30 2000- 2001 13 - general government expenditure on health as % of total general government expenditure 18.10 2002- 2003 4 External source of government health expenditure - external resources for health as % of general government expenditure on health 12.00 2000- 2001 13 Private health expenditure - private expenditure on health as % of total expenditure on health 23.00 2000- 2001 13 Exchange rate in US$ of local currency is: 1 US$ = 3.4928 WST 2001 4 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce (Ministry of Health) - doctors 43 26 17 2.43 … … 2002 15 - dentists 6 4 2 0.34 … … 2002 15 - pharmacists 16 10 6 0.90 … … 2002 15 - nurses 333 … … 18.83 … … 2002 15 - midwives 13 0 13 0.73 0.00 … 2002 15 - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) … … … … … … - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … SAMOA 296 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Spontaneous vertex delivery 2113 0 2113 1196.00 0.00 2495.90 2002 7 2. Pneumonia, unspecified 990 483 507 560.00 524.70 598.90 2002 7 3. First-degree perineal laceration during delivery 606 0 606 342.90 0.00 715.80 2002 7 4. Diarrhoea 266 134 132 150.50 145.60 155.90 2002 7 5. Acute bronchiolitis, unspecified 262 148 114 148.30 160.80 134.70 2002 7 6. Typhoid fever 252 145 107 142.60 157.50 126.40 2002 7 7. Neonatal aspiration of meconium 186 102 84 105.30 110.80 99.20 2002 7 8. Cellulitis of other parts of limb 163 109 54 92.20 118.40 63.80 2002 7 9. Congestive heart failure 130 67 63 73.60 72.80 74.40 2002 7 10. Unspecified appendicitis 118 75 43 66.80 81.50 50.80 2002 7 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Cerebrovascular diseases 43 26 17 24.30 28.20 20.10 2002 7 2. Septicaemia 34 24 10 19.20 26.10 11.80 2002 7 3. Congestive heart failure 28 11 17 15.80 12.00 20.10 2002 7 4. Pneumonia 28 10 18 15.80 10.90 21.30 2002 7 5. Myocardial infarction 24 6 18 13.60 6.50 21.30 2002 7 6. Renal failure 17 5 12 9.60 5.40 14.20 2002 7 7. Old age 10 4 6 5.70 4.30 7.10 2002 7 8. Leukaemia 9 3 6 5.10 3.30 7.10 2002 7 9. Cancer of the liver 6 4 2 3.40 4.30 2.40 2002 7 10. Cardiovascular accident 6 2 4 3.40 2.20 4.70 2002 7 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2004 10 - Pertussis (whooping cough) 0 0 0 … … … 2004 10 - Tetanus 0 0 0 … … … 2004 10 - Neonatal tetanus 0 0 0 … … … 2004 10 - Poliomyelitis 0 0 0 … … … 2004 10 - Hib meningitis 4 … … … … … 2004 10 - Measles 0 0 0 … … … 2004 10 - Mumps 0 0 0 … … … 2004 10 - Rubella 0 0 0 … … … 2004 10 - Congenital rubella syndrome 1 … … … … … 2004 10 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral 8 4 4 0 0 0 2002 7 - Type A 2 1 1 0 0 0 2002 7 - Type B 4 2 2 0 0 0 2002 7 - Type C 0 0 0 0 0 0 2002 7 - Unspecified 2 1 1 0 0 0 2002 7 Cholera 0 0 0 0 0 0 2002 7 Typhoid fever 252 145 107 6 4 2 2002 7 Encephalitis 3 2 1 1 1 0 2002 7 Plague 0 0 0 0 0 0 2002 7 Syphilis 1 1 0 0 0 0 2002 7 Gonorrhoea (gonococcal infections) 1 1 0 0 0 0 2002 7 COUNTRY HEALTH INFORMATION PROFILE 297 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Leprosy 11 … … … … … 2003 10 Malaria … … … … … … Dengue/DHF … … … … … … 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures b … - Proportion of population in malaria-risk areas using effective malaria treatment measures c … 44 Tuberculosis Number of cases Number of deaths - All types 27 … … … … … 2003 10 - New pulmonary tuberculosis (smear-positive) 12 … … … … … 2003 10 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 44.00 … … 5.00 … … 2003 10 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 51.00 … … 84.00 (2002) … … 2003 10 Number of cases Number of deaths 45 Acute respiratory infections 281 161 120 0 0 0 2002 7 46 Diarrhoeal diseases 134 132 266 6 4 2 2002 7 47 Cancers All cancers (malignant neoplasms only) 169 87 82 30 20 10 2002 7 - Trachea, bronchus and lung 15 9 6 2 2 0 2002 7 - Stomach 14 5 9 1 0 1 2002 7 - Colon and rectum 5 4 1 1 1 0 2002 7 - Lip, oral cavity and pharynx 6 4 2 1 1 0 2002 7 - Liver 9 6 3 3 2 1 2002 7 - Cervix 10 0 10 0 0 0 2002 7 - Leukaemia 19 15 4 4 3 1 2002 7 48 Circulatory All circulatory system diseases 510 258 252 61 34 27 2002 7 - Ischaemic heart disease 7 4 3 0 0 0 2002 7 - Acute myocardial infarction 15 11 4 3 2 1 2002 7 - Rheumatic fever and rheumatic heart diseases 35 15 20 2 1 1 2002 7 - Cerebrovascular diseases 120 58 62 32 15 17 2002 7 - Hypertension 88 35 53 3 1 2 2002 7 49 Maternal causes - Haemorrhage 20 20 0 0 2002 7 - Abortion 183 183 0 0 2002 7 - Eclampsia 19 19 0 0 2002 7 - Sepsis 23 23 1 1 2002 7 - Obstructed labour 41 41 0 0 2002 7 SAMOA 298 INDICATORS DATA Year Source Total Male Female Total Male Female 50 Diabetes mellitus 232 109 123 7 2 5 2002 7 51 Mental disorders 7 6 1 0 0 0 2002 7 52 Injuries - All types 733 556 177 22 13 9 2002 7 - Motor and other vehicle accidents 129 103 26 4 3 1 2002 7 - Suicide 32 20 12 16 11 5 2002 7 - Homicide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis (%) … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 33 320 2002 7 - Specialized hospitals … … - District/first-level referral hospitals 11 320 2002 7 - Primary health care centres 12 0 2002 7 Private hospitals 1 21 2004 11 Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific b Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. c Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 2 Demographic tables for the Western Pacific Region 2000-2005. Manila, WHO Regional Office for the Western Pacific, 2005. 3 Urban and rural areas 2003. New York, United Nations Department of Economic and Social Affairs Population Division, 2004. 4 Ministry of Finance, Statistical Services Division (http://www.spc.int.prism) 5 World health report 2004. Changing history. Geneva, World Health Organization, 2004. 6 Demographic and Health Survey 1999 (Analytical Report). Department of Statistics, Apia, Samoa 7 Ministry of Health statistical bulletin 2002 – review 1999-2002 8 2003 Annual Report. Reproductive Health Services 9 Pacific Island Regional Millennium Development Goals report 2004. Noumea, Secretariat of the Pacific Community, UN/CROP MDG Working Group, November 2004. 10 WHO Regional Office for the Western Pacific, data received from technical units 11 Meeting the MDG drinking water and sanitation target, A mid-term assessment of progress. WHO and UNICEF, 2004 12 Human development report 2004. New York, UNDP, 2004. 13 National Health Accounts for Financial Year 2000/2001 14 Information provided by WHO Representative in Samoa, 16 February 2004 15 Ministry of Corporate Services: Ministry of Health Workforce financial year 2002/2003: Alema Tunufai Tamala Leave Records Clerk 16 Promoting the Millennium Development Goals in Asia and the Pacific: Meeting the challenges of poverty reduction 2003. ESCAP/UNDP, 2003. 17 Samoa Health Sector Strategy Plan 2004-2013 COUNTRY HEALTH INFORMATION PROFILES | 299 SINGAPORE 1. DEMOGRAPHICS, GENDER AND POVERTY Singapore is a small country with a total land area of about 700 square kilometres. The total population is about 4.24 million, with a resident population of 3.49 million in 2004. Singapore has a relatively young population, with only 8% of the resident population above 65 years of age. However, the percentage over 60 years of age is projected to increase to 27% by the year 2030. Table 1. Core population and health data (2004 provisional) [Total] 3 486 900 (resident) [Both] 79.30 [0-14 years] 702 200 (20.10%) [Male] 77.40 Population [65+ years] 278 600 (8.00%) Life expectancy at birth (years) [Female] 81.30 Crude birth rate (per 1000 resident population) 10.10 Total fertility rate 1.25 [Total] 100.00 [Urban] … Crude death rate (per 1000 resident population) 4.30 % of population served with safe water [Rural] … [Total] 100.00 [Urban] … Infant mortality rate (per 1000 resident live births) 1.90 % of population with adequate sanitary facilities [Rural] … Maternal mortality rate (per 100 000 resident live births) 5.36 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Singapore is a parliamentary republic that obtained independence from Malaysia on 9 August 1965. The constitution was established on 3 June 1959 and amended in 1965 (based on the pre- independence State of Singapore Constitution). The legal system is based on English common law. The chief of state is President Sellapan Rama Nathan (since 1 September 1999), the head of government is Prime Minister Lee Hsien Loong (since 12 August 2004), and the Deputy Prime Ministers are Tony Tan Keng Yam (since 1 August 1995) and S Jayakumar (since 12 August 2004). The Cabinet is appointed by the President and is responsible to the Parliament. The President is elected by popular vote for a six-year term; elections were last held on 28 August 1999. The legislative branch is a unicameral parliament (94 seats; members elected by popular vote to serve five-year terms). The judicial branch has a supreme court headed by the Chief Justice, who is appointed by the President on the advice of the Prime Minister. 2.2 Economic situation Singapore is characterized by a highly developed and successful free-market economy, a highly open and corruption-free business environment, stable prices, the 27th (in 2002) highest per capita Gross National Income (GNI) in the world, and the fifth highest per capita gross domestic product (GDP) in the world (US$ 21 825 in 2003). Exports, particularly in electronics and chemicals, and services are the main drivers of the economy. The Government promotes high SINGAPORE 300 | COUNTRY HEALTH INFORMATION PROFILES levels of savings and investment through a mandatory savings scheme and spends heavily on education and technology. Government-linked companies (GLCs) that operate as commercial entities account for 13% of GDP. As Singapore looks to a future increasingly marked by globalization, the country is positioning itself as a leading global city and a hub of talent, enterprise and innovation. In 2003, the GDP purchasing power parity was US$ 125 billion, the GDP real growth rate was 1.1% and the GDP per capita purchasing power parity was US$ 29 600. In 2002, Singapore spent about 5.8 billion Singapore dollars(US$ 3.5 billion) or 3.7% of GDP on health care. Per capita health care spending was S$ 1703 (US$ 1023). Government subsidies for public health care services amounted to S$ 1714 million (US$ 1030 million) or approximately 1.0% of GDP in 2004. 3. HEALTH SITUATION 3.1 Health trends Health status in Singapore is good by international standards. The infant mortality rate in 2004 stood at 1.90 per 1000 resident live births, while the average life expectancy was 79.30 years. Rising standards of living, high standards of education, good housing, a safe water supply and sanitation, a high level of medical services and the active promotion of preventive medicine have all helped to significantly boost the health of Singaporeans. The leading causes of morbidity and mortality are currently the major noncommunicable diseases such as cancer, coronary heart diseases, pneumonia, strokes, accidents and injuries. Cancer and cardiovascular diseases together accounted for approximately 60% of the total causes of death in 2004. 3.2 Health systems Health services for the country are provided through three co-operating ministries, as well as by the private sector. The Ministry of Health is responsible for providing preventive, curative and rehabilitative health services. The Ministry formulates national health policies, coordinates the development and planning of the private and public health sectors, and regulates health standards. The Ministry of the Environment manages Singapore’s water resources and the supply of drinking water to the nation. It is responsible for weather forecasting services; environmental and public health services, such as collection and treatment of used water, pollution and toxic chemicals and poisons; control of vectors that could spread diseases; and the hygienic preparation of food. The Ministry also licenses food stall proprietors and looks after all public markets and food centres, public toilets and public cemeteries and crematoria. The Ministry of Manpower is responsible for the health, safety and welfare of employed persons. The Ministry enforces requirements on working conditions under the Employment Act, has provisions in the Factories Act to safeguard the health and safety of the workforce, and administers the Workmen’s Compensation Act to ensure fair compensation for persons with work-related injuries and diseases. There is a dual system of health care delivery. The public system is managed by the Government, while the private system is provided by private hospitals and general practitioners. The health care delivery system comprises primary health care provision at outpatient polyclinics and private medical practitioners’ clinics and secondary and tertiary specialist care in the public and private hospitals. Eighty per cent of primary health care services are provided by private practitioners, while government polyclinics provide the remainder. For hospital care, the reverse occurs, with 80% provided by the public sector and the remainder by the private sector. COUNTRY HEALTH INFORMATION PROFILES | 301 In 1999, the public health care delivery system was reorganized into two vertically integrated delivery networks, the National Healthcare Group (NHG) and Singapore Health Services (SHS). This enabled more integrated and better quality health care services through greater cooperation and collaboration among public sector health care institutions. Patients are free to choose their health care providers within the dual health care delivery system, and can walk in for a consultation at any private clinic or any government polyclinic. For emergency services, patients can access the 24-hour accident and emergency departments located in government hospitals. The Singapore Civil Defence Force runs an emergency ambulance service to transport accident and trauma cases and medical emergencies to the acute general hospitals. Primary health care involves the provision of primary medical treatment, preventive health care and health education. Primary health care is provided through an island network of 17 outpatient polyclinics and 2080 private medical practitioners’ clinics, run by 1900 practitioners. Each polyclinic serves as a one-stop health centre, providing outpatient medical care, follow-up of patients discharged from hospitals, immunization, health screening and education, investigative facilities and pharmacy services. The private clinics are located in close proximity to population centres in the city, housing estates and satellite towns. The average outpatient consultation fee (inclusive of medication) is between S$10 (US$6.00) to S$15 (US$9.00), well within the means of Singaporeans. At the government polyclinics, Singapore citizens aged 65 and above, children up to 18 years of age and all schoolchildren are given a discount of up to a 75% on their consultation and treatment fees. Other Singapore citizens are given a 50% discount. There are about 11 840 hospital beds in the 29 public and private hospitals and speciality centres, giving a ratio of 2.8 beds per 1000 population. Seventy-four per cent of the beds are in the 13 public sector specialty centres and hospitals, each with between 185 and 2430 beds. The 16 private sector hospitals are smaller, with a capacity ranging from 16 to 505 beds. The Government’s role as the dominant health care provider allows it to manage the supply of hospital beds, the adoption of high-tech/high-cost medicine, and cost increases in the public sector, which serves as a price benchmark for the private sector. The seven public hospitals comprise five acute general hospitals and two specialized hospitals (obstetrics and gynaecology, and psychiatry). The general hospitals provide multidisciplinary acute inpatient and specialist outpatient services and a 24-hour accident and emergency service. In addition, there are six specialty centres for cardiology, neuroscience, ophthalmology, dermatology, oncology and dentistry. Tertiary specialist care in the areas of cardiology, renal medicine, haematology, neurology, oncology, radiotherapy, plastic and reconstructive surgery, paediatric surgery, neurosurgery, cardiothoracic surgery and transplant surgery is centralized in two of the larger general hospitals, the Singapore General Hospital and the National University Hospital. The private hospitals have similar specialist disciplines and comparable facilities. The Government has restructured all its 13 hospitals and speciality institutes into private companies wholly owned by the Government and managed like not-for-profit organizations. This has granted the public hospitals management autonomy and flexibility to respond more promptly to the needs of patients. In the process, greater financial discipline and accountability have been introduced. Unlike private hospitals, the restructured public hospitals receive an annual government subvention or subsidy for the provision of subsidized medical services to subsidized patients. Public hospitals are subject to broad government policy guidance through the Ministry of Health. The Government has also introduced low-cost community hospitals for intermediate health care for the convalescent sick and aged who do not require the more expensive care provided by the acute general hospitals. In 2004, Singapore had 6492 doctors in its health care delivery system (40% in the private sector), giving a doctor-to-population ratio of 1:650. Thirty-six per cent of the doctors were trained specialists with postgraduate medical degrees and advanced speciality training. In the same year, SINGAPORE 302 | COUNTRY HEALTH INFORMATION PROFILES there were 1227 dentists (66% in private practice), giving a ratio of one dentist to 3460 residents, and about 19 330 nurses (45% in the private sector), giving a nurse-to-population ratio of 1:220. The Singapore health care philosophy emphasizes the building of a healthy population through preventive health care programmes and the promotion of healthy living. The population is encouraged through the public health education programme to adopt a healthy lifestyle and be responsible for their health, and is made aware of the adverse consequences of harmful habits like smoking, alcohol consumption, bad diet and sedentary lifestyles. The child immunization programme, which targets infectious diseases like tuberculosis, poliomyelitis, diphtheria, whooping cough, tetanus, measles, mumps, rubella and hepatitis B, is offered at government polyclinics. Health screening programmes have been introduced for the early detection of common ailments such as cancer, heart disease, hypertension and diabetes mellitus. The Government ensures that good and affordable basic medical services are made available to all Singaporeans through heavily subsidized medical services at public hospitals and government clinics. The basic medical package reflects up-to-date medical practice, which is of proven value, and is delivered cost-effectively by trained personnel using appropriate facilities. There is no guarantee of the latest and best of everything, and nonessential or cosmetic services, experimental drugs and procedures of unproven value are excluded. All private hospitals, medical clinics, clinical laboratories and nursing homes are required to maintain a good standard of medical services through licensing by the Ministry of Health. The health care delivery system is based on individual responsibility, coupled with Government subsidies, to keep basic health care affordable. Patients are expected to pay part of the cost of medical services that they use, and pay more when they demand a higher level of service. The principle of co-payment applies even to the most heavily subsidized wards to avoid the pitfalls of providing completely “free” medical services. Patients who choose to be accommodated in the lower classes of wards in public hospitals have up to 80% of their hospitalization expenses subsidized by the Government. Individuals are encouraged to take responsibility for their own health by saving for medical expenses. Under the Medisave scheme, every working person is required by law to save 6%-8% of his or her income in a personal Medisave Account, which can be used to pay for hospitalization expenses incurred by the person or by immediate family members. MediShield, a catastrophic illness insurance scheme, is designed to help individuals meet medical expenses from major or prolonged illnesses. Medifund acts as a safety net of last resort for those who are truly indigent. Therefore, no Singaporean is denied access into the health care system or turned away by the public hospitals because of inability to pay. The median waiting time for elective surgery is one week. Patients requiring emergency or urgent surgery are admitted immediately. Support services for the hospital and primary health care programmes include forensic pathology, pharmaceutical services and the blood transfusion service. Except for forensic pathology and the blood transfusion service, which are centralized in the Ministry of Health, the other services can be found in both the public and private sectors. 4. NATIONAL HEALTH PLAN AND PRIORITIES The eight priorities of the Ministry of Health focus on the following key areas: 1) Building a healthy population: • to promote healthy lifestyles in a sustained and comprehensive way. 2) Managing diseases in a holistic manner: • to ensure long-term effectiveness and sustainability in managing diseases. 3) Exploiting IT to the maximum: COUNTRY HEALTH INFORMATION PROFILES | 303 • to increase productivity, enhance patient care and manage costs. 4) Countering disease outbreaks: • to enhance surveillance and enable effective responses. 5) Managing medical inflation: • to spend within available means, manage limited resources and moderate patients’ expectations. 6) Ensuring long-term health care financing: • to enhance the financing framework (Medisave, Medifund and Medishield). 7) Safeguarding medical standards: • to ensure quality, reliability and cost-effectiveness; develop manpower and facilities; and regulate appropriately. 8) Establishing Singapore as a regional medical hub • to ensure the competitiveness of Singapore as a regional hub for medical services. 5. MAJOR INFORMATION SOURCES Ministry of Health (http://www.moh.gov.sg) Singapore Department of Statistics (http://www.singstat.gov.sg) The World Factbook 2003. CIA 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : College of Medicine Building, 16 College Road, Singapore 169854 Postal Address : As above Official Email Address : moh_info@moh.gov.sg Telephone : (65) 6325 9220 Fax : (65) 6224 1677 Office Hours : 8.30am – 6.00pm (Mon to Thu) 8.30am – 5.30pm (Fri) Website : http://www.moh.gov.sg WHO REPRESENTATIVE IN MALAYSIA, BRUNEI DARUSSALAM AND SINGAPORE Office Address : 1st Floor, Wisma UN, Block C, Kompleks Pejabat Damansara, Jalan Dungun, Damansara Heights, 50490 Kuala Lumpur Postal Address : P.O. Box 12550, 50782 Kuala Lumpur, Malaysia Official Email Address : who@maa.wpro.who.int Telephone : (603) 2093-9908 Fax : (603) 2093 7446 Office Hours : SINGAPORE 304 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: DEPARTMENT OF HEALTH COUNTRY HEALTH INFORMATION PROFILE 305 SINGAPORE WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 0.70 2004 1 2 Estimated resident population ('000s) 3486.90 … … 2004p 1 3 Annual resident population growth rate (%) 1.40 … … 2004 1 4 Percentage of resident population - 0–14 years 20.10 … … 2004p 1 - 65+ years 8.00 … … 2004p 1 5 Urban population (%) 100.00 2004 1 6 Crude birth rate (per 1000 resident population) 10.10 … … 2004p 2 7 Crude death rate (per 1000 resident population) 4.30 … … 2004p 2 8 Rate of natural increase of population (% per annum) 0.58 a … … 2004 2 9 Health-adjusted life expectancy (HALE) (years) - at birth (resident) 79.30 77.40 81.30 2004p 1 - at age 60 21.60 20.20 22.90 2003p 1 10 Adult literacy rate (%) 94.60 … … 2004 1 11 Neonatal mortality rate (per 1000 resident live births) 1.20 … … 2004 1 & 4 12 Infant mortality rate (per 1000 resident live births) 1.90 … … 2004p 1 13 Under-five mortality rate (per 1000 resident live births) 3.35 a 3.68 a 3.00 a 2004p 4 14 Total fertility rate (women aged 15–49 years) 1.25 2004p 1 15 Maternal mortality ratio (per 100 000 resident live births) 5.36 a 2004p 4 16 Percentage of newborn infants weighing at least 2500 g at birth 91.60 … … 2002 3 17 Prevalence of underweight children under five years of age 14.00 … … 1995-2003 12 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 99.00 … … 2004 12 - DTP3 94.00 … … 2004 12 - OPV3 94.00 … … 2004 12 - Measles 94.00 … … 2004 12 - Tetanus II … … … - Hepatitis B III 93.00 … … 2004 12 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 100.00 2003 2 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) 99.70 2002 3 21 Percentage of women in the reproductive age group using modern contraceptive methods 72.50 2003 5 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … SINGAPORE 306 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 … … 2004p 2 26 Proportion of population with access to improved sanitation 100.00 … … 2004p 2 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) < 5.00 … … 2003 12 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.90 … … 2002 11 32 Per capita GDP at current market prices (US$) 25 191.39 … … 2004 1 33 Rate of growth per capita GDP 14.14 a … … 2004 1 34 Health expenditure Total health expenditure - amount (in million US$) 3184.10 FY2002 1, 2 - total health expenditure on health as % of GDP 3.70 FY2002 1 - per capita total expenditure on health (in S$) 1703.00 FY2002 1, 2 Government expenditure on health b - amount (in million S$) 1714.00 FY2004 est 2 - general government expenditure on health as % of total expenditure on health 27.00 FY2002 2 - general government expenditure on health as % of total general government expenditure 5.90 FY2004 est 2, 6 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health 73.00 FY2002 1, 2 Exchange rate in US$ of local currency is: 1 US$ = 1.6903 S$ (average) 2004 1 35 Health insurance expenditure - health insurance coverage as % of total population c 75.00 FY2002 2 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 6492 4451 2041 15.31 … ... 2004 7 - dentists 1227 749 478 2.89 … ... 2004 8 - pharmacists 1288 375 913 3.04 … ... 2004 9 - nurses (and assistant nurses) 19 330 1343 17 621 55.40 … ... 2004 10 - midwives 365 … 365 0.86 … ... 2004 10 - other nursing/ auxiliary staff … … … … … ... - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) … … … … … ... - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … ... … ... 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … COUNTRY HEALTH INFORMATION PROFILE 307 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 resident population a 1. Accidents, poisoning and violence 31 017 … … 889.53 … … 2004p 2 2. Cancer 18 878 … … 541.40 … … 2004p 2 3. Ischaemic heart diseases 13 425 … … 385.01 … … 2004p 2 4. Pneumonia 8169 … … 234.28 … … 2004p 2 5. Cerebrovascular disease 8123 … … 232.96 … … 2004p 2 6. Other heart diseases 7889 … … 226.25 … … 2004p 2 7. Chronic obstructive lung disease 7552 … … 216.58 … … 2004p 2 8. Complications related to pregnancy 7423 … … 212.88 … … 2004p 2 9. Dengue 6662 … … 191.06 … … 2004p 2 10. Infections of skin and subcutaneous tissue 6464 … … 185.38 … … 2004p 2 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Cancer 4339 2463 1876 124.44 … … 2004p 2 2. Ischaemic heart diseases 2974 1791 1183 85.29 … … 2004p 2 3. Pneumonia 2220 1165 1055 63.67 … … 2004p 2 4. Cerebrovascular disease 1556 708 848 44.62 … … 2004p 2 5. Accidents, poisoning and violence 650 … … 18.64 … … 2004p 2 6. Other heart diseases 535 372 163 15.34 … … 2004p 2 7. Chronic obstructive lung disease 491 … … 14.08 … … 2004p 2 8. Diabetes mellitus 474 215 259 13.59 … … 2004p 2 9. Nephritis, nephrotic syndrome and nephrosis 260 115 145 7.46 … … 2004p 2 10. Chronic liver disease and cirrhosis 108 68 40 3.10 … … 2004p 2 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 … … … … … 2004 12 - Pertussis (whooping cough) 0 … … … … … 2004 12 - Tetanus 0 … … … … … 2004 12 - Neonatal tetanus 0 … … … … … 2004 12 - Poliomyelitis 0 … … … … … 2004 12 - Hib meningitis 2 … … … … … 2004 12 - Measles 96 … … … … … 2004 12 - Mumps 1003 … … … … … 2004 12 - Rubella 141 … … … … … 2004 12 - Congenital rubella syndrome 0 … … … … … 2004 12 42 Cases and deaths for selected communicable diseases Number of cases (C) Number of deaths (D) C: 2004p D: 2003 C: 2 D: 12 Hepatitis viral 192 145 47 26 … … - Type A 67 47 20 … … … - Type B 98 80 18 20 … … - Type C 27 18 9 … … … - Unspecified 0 0 0 … … … Cholera 11 5 6 0 0 0 Typhoid fever 52 32 20 0 0 0 (Viral) Encephalitis 16 12 4 … … … Plague 0 0 0 … … … SINGAPORE 308 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths C: 2004p D: 2003 C: 2 D: 12 Syphilis 961 696 265 0 0 0 Gonorrhoea (gonococcal infections) 2644 2242 402 … … … Leprosy 14 7 7 … … … Malaria 152 119 33 1 1 0 2004 D: 4 Dengue/DHF 9459 5818 3641 … … … 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) NR NR NR … … … 2004p 2 - Proportion of population in malaria-risk areas using effective malaria prevention measures d … - Proportion of population in malaria-risk areas using effective malaria treatment measures e … 44 Tuberculosis Number of cases Number of deaths - All types 1364 … … … … … 2004p 2 - New pulmonary tuberculosis (smear-positive) 586 … … … … … 2003 12 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 42.00 … … 5.00 … … 2003 12 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 44.00 … … 87.00 (2002) … … 2003 12 Number of cases Number of deaths 45 Acute respiratory infections 6 525 … … 2004p 2, 4 46 Diarrhoeal diseases … … … 2004p 2, 4 47 Cancers All cancers 18 878 … … 4339 2463 1876 2004p 2, 4 - Trachea, bronchus, and lung 2080 … … 1042 724 318 2004p 2, 4 - Stomach 928 … … 310 185 125 2004p 2, 4 - Colon and rectum 2639 … … 657 360 297 2004p 2, 4 - Lip, oral cavity and pharynx 650 … … 144 106 38 2004p 2, 4 - Liver 1433 … … 408 298 110 2004p 2, 4 - Cervix 565 … 88 88 2004p 2, 4 - Leukaemia 1218 … … 90 58 32 2004p 2, 4 48 Circulatory All circulatory system diseases 37 568 … … 5005 2764 2241 2004p 2, 4 - Ischaemic heart disease 13 425 … … 2974 1791 1183 2004p 2, 4 - Acute myocardial infarction 4504 … … 1658 1018 640 2004p 2, 4 - Rheumatic fever and rheumatic heart diseases 220 … … 18 7 11 2004p 2, 4 - Cerebrovascular diseases 8123 … … 1556 708 848 2004p 2, 4 - Hypertension 1574 … … 362 178 184 2004p 2, 4 COUNTRY HEALTH INFORMATION PROFILE 309 INDICATORS DATA Year Source Total Male Female Total Male Female 49 Maternal causes - Haemorrhage 1872 … 0 0 2004p 2, 4 - Abortion 3591 … 1 1 2004p 2, 4 - Eclampsia … … 0 0 2003p 2, 4 - Sepsis … … 0 0 2003p 2, 4 - Obstructed labour 151 … 0 0 2004p 2, 4 50 Diabetes mellitus 3683 … … 474 215 259 2004p 2, 4 51 Mental disorders 6991 … … 0 0 0 2004p 2, 4 52 Injuries - All types … … … 535 372 163 2004p 2, 4 - Motor and other vehicle accidents … … … 177 137 40 2004p 2, 4 - Suicide … … … 197 116 81 2004p 2, 4 - Homicide and violence … … … 15 10 5 2004p - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities 13 8813 2004 2 - General hospitals 5 … 2004 2 - Specialized hospitals 2 … 2004 2 - District/first-level referral hospitals 6 … 2004 2 - Primary health care centres 17 … 2004 2 Private hospitals 16 3027 2004 2 Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate p Preliminary / provisional figures NR Not relevant a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Excludes expenditure on environmental health. c Using the more relevant population. Excludes cash and employer-based plans. d Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. e Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Statistics Singapore (http://www.singstat.gov.sg) 2 Ministry of Health (http://www.moh.gov.sg) 3 Report on Registration of Births and Deaths 2002. Registry of Births and Deaths, Immigration and Checkpoints Authority 4 Singapore Demographic Bulletin March 2005. Registry of Births and Deaths, Immigration and Checkpoints Authority 5 Study on Marriage and Procreation, Perception and Policies in Singapore, 2003. Ministry of Community Development and Sports 6 Ministry of Finance 7 Singapore Medical Council 8 Singapore Dental Council 9 Singapore Pharmacy Board 10 Singapore Nursing Board 11 Human Development Report 2003. New York, UNDP, 2003. 12 WHO Regional Office for the Western Pacific, data received from technical units 310 | COUNTRY HEALTH INFORMATION PROFILES SOLOMON ISLANDS 1. DEMOGRAPHICS, GENDER AND POVERTY The total population for 2004 is estimated to be 460 110, compared with census figures of 409 042 in 1999 and 444 564 in 2002. About 84% live in rural areas. According to the 1999 national population census, 93% of the total population of Solomon Islands are Melanesians, 4% are Polynesians and 3% are of other ethnic origins. This ethnic distribution of the population is reported to be the same for the projected population for 2003. Estimated figures for 2004 indicate: a life expectancy for males of 61.9 years and 63.1 for females; a crude birth rate of 34.0 per 1000 population; and a crude death rate of 8.0 per 1000 population. In 1999, the total fertility rate was 4.84 and the infant mortality rate was 66 per 1000 live births. . Solomon Islands has a young population, with 40% below 15 years of age. The majority of the population are males, who outnumber the female population by a ratio of 107 males to 100 females. Table 1. Core population and health data (2004 estimates) [Total] 460 110 [Both] … [0-14 years] 184 320 (40.06%) [Male] 61.90 Population [65+ years] 14 724 (3.20%) Life expectancy at birth (years) [Female] 63.10 Crude birth rate (per 1000 population) 34.00 Total fertility rate 4.84 (1999) [Total] 70.00 (2002) [Urban] 94.00 (2002) Crude death rate (per 1000 population) 8.00 % of population served with safe water [Rural] 65.00 (2002) [Total] 31.00 (2002) [Urban] 98.00 (2002) Infant mortality rate (per 1000 live births) 66.00 (1999) % of population with adequate sanitary facilities [Rural] 18.00 (2002) Maternal mortality rate (per 100 000 live births) 295.00 (2003) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation By mid-2003, Solomon Islands’ economy was heading towards total collapse as a result of the ethnic conflict that peaked between 1999 and 2003. By the beginning of 2003, the country’s main sources of income (palm oil, fishing and fish-cannery, logging/timber, copra, cocoa, coffee, gold/silver mining and tourism), had either been shut down or reduced to minimal production levels. The poor economic situation was further affected by the temporary suspension of financial support by the World Bank and the European Union. Meanwhile, other countries such as Australia (AusAID), Japan (JICA), New Zealand (NZODA) and Taiwan (China) continued to provide financial and technical support, but on a well controlled and a regularly revised rate. The poor economy disrupted and affected all government and public services, including health. During the same period, there was an almost total breakdown of law and order in most parts of the country. More than one thousand internally displaced people (IDP) fled their villages in the Weather Coast area of Guadalcanal Province and settled in overcrowded, makeshift shelters in the capital city of Honiara. COUNTRY HEALTH INFORMATION PROFILES | 311 In June 2003, Prime Minister Sir Allen Kemakeza sought the assistance of Australia in re- establishing law and order; the following month, an Australian-led multinational force arrived to restore peace and disarm ethnic militias. The arrival of the Regional Assistance Mission to Solomon Islands (RAMSI) in July 2003 was an important political event that, not only helped restore law and order in the country, but also helped in the rebuilding of the economy and saved the country from becoming a ‘failed state’. In terms of security, most of the country is still classified as Phase 1. Malaita Province and areas outside a 10 km radius of Honiara town are classified as Phase 2. The security and law and order situation has improved substantially since the arrival of RAMSI. Achievements include: establishment of a climate of security and restoration of law and order in most parts of the country; a positive and confirmed plan for the return of IDP to the Weather Coast; collection and destroying of 3680 firearms; arrest and imprisonment of notorious criminals and militant outlaws; arrest and prosecution of Government senior officials and special constables that were involved in corruption acts and other criminal activities; commercial businesses and enterprises like the commercial banks are fully operational; and establishment of new police posts throughout the country. These achievements have contributed to the gradual return of government services, including health services. Most hospitals, health centres, clinics and nurse- aide posts were operational by the end of 2003. The main question in the political arena is whether the Government will be in a position to maintain law and order if RAMSI leaves the country. Many political observers are not certain and would like to see RAMSI remaining in the country for a longer period. 2.2 Economic situation As mentioned above, the main sources of the country’s economy had been either shut down or reduced to minimal production levels by mid-2003. Correspondingly, the per capita gross domestic product (GDP) was SBD 3438 (US$ 494.68) in 2002, while the external and internal government debts stood at SBD 1087.3 million (US$ 149.50 million) and SBD 458.6 million (US$ 63.05 million), respectively, for the same period. The external reserve was also estimated to be SBD 129.9 million (US$ 29.4 milllion), representing an import cover of only about 1.5 months. However, by the end of 2003 (six months after the arrival of RAMSI), the country’s economy showed some positive recovery along with the restoration of law and order. The total revenue collection up to the end of September 2003 was SBD 257 million (US$ 35.33 million), compared with the estimated SBD 195 million (US$ 26.81 million). The palm oil factory and the gold/silver mines (major revenue earners) are still closed, but the others are gradually returning to normal operation. Although the Government is the major source of funding for health services at both the central and provincial levels, it had to rely heavily on outside financial assistance during the years of ethnic conflict. Nevertheless, the positive recovery of the economy prompted the Government to increase the Ministry of Health and Medical Services’ recurrent budget for 2004 from SBD 41 492 746 (US$ 5 705 253) in 2003 to SBD 52 980 902 (US$ 7 284 874), an increase of 27.7%. This increase will undoubtedly strengthen the provision of quality health care services. The total estimated contribution by donor and development partners in terms of supplies/equipment, operating cost and technical assistance for 2004-2005 is SBD 141 756 316 (US$ 19 491 494). Both the World Bank and the European Union indicated their intention of resuming their financial assistance to the country in 2004. SOLOMON ISLANDS 312 | COUNTRY HEALTH INFORMATION PROFILES 3. HEALTH SITUATION 3.1 Health trends The reduction in childhood mortality and morbidly from diarrhoeal diseases is attributed to the improved status of sanitation, water supply, personal hygiene and breast-feeding. The reduction of mortality due to neonatal causes is attributed to the improved status of maternal/safe motherhood programmes and services, supported by much improved paediatric care and the current focus on the integrated management of childhood illness (IMCI) approach. The maternal mortality ratio in 2003 was 295 per 1000 live births, compared with 125 per 1000 live births in 1999. The unfavourable effect of the ethnic conflict on the provision of maternal health care services is being mentioned as a major contributing factor to this notable increase. The impressive impact of the five-year malaria programme, based on the 1993 National Malaria Control Policy, which resulted in the achievement of several set targets, was severely disrupted and affected during the years of ethnic conflict (1999-2003), with the number of reported new cases of malaria increasing from 74 865 in 2002 to 90 606 in 2003. The total number of tuberculosis cases for 2003 was 293. The Honiara National Referral Hospital reported 647 confirmed positive smears in 2001 and 421 in 2002. However, usually one positive patient has two or three positive smears, and it is not clear whether these positive smears were taken from new patients or re-infected patients. Other leading causes of morbidity include eye infections (10 311 new cases in 2003) and sexually transmitted infections (1987 cases in 2001). The re-emergence of yaws (17 609 cases in 2001) as one of the leading causes of morbidity has been a major concern, but it now seems to be on the decline. Although, infectious diseases are still the major causes of morbidity and mortality, there is some evidence that noncommunicable diseases like cancer (cervical and breast cancers are reported to be the most common, followed by lung cancer), diabetes mellitus, hypertension, tobacco-related diseases and mental illness are increasing noticeably. Solomon Islands is in an epidemiological transition phase. Having to face both the control of infectious diseases and the increasing incidence of noncommunicable diseases, with very limited resources, poses a major challenge for the Government at this difficult stage of recovery from years of ethnic conflict. The Government, with the support of WHO and other international and regional development partners in health, plans to develop new policies, programme, action plan and implementation activities to effectively combat these challenges. However, the Ministry of Health and Medical Services is fully aware that overall monitoring, programming and planning for health is severely limited by the unavailability of up-to-date and reliable data. Therefore, one of the major challenges to be tackled is to collect, compile, analyse and make available reliable data for realistic programming, planning and effective implementation. The Ministry has thus prioritized the need to coordinate and strengthen the health statistical system, which was severely affected and disrupted during the ethnic conflict. There was no major disease outbreak in 2002/2003. However, the worldwide threat of severe acute respiratory syndrome (SARS) and HIV/AIDS resulted in the development of new policies and strategies to strengthen and revitalize disease prevention, control and surveillance, as well as preparedness for action. COUNTRY HEALTH INFORMATION PROFILES | 313 3.2 Health systems There are eight public and three private hospitals in the country. Seven of the nine provinces have a public hospital. Guadalcanal Province is served by the National Referral Hospital, and Rennel/Bellona Province has no hospital. Additionally, there is one private hospital in the Western Province, one in Malaita Province and one in Choiseul Province. The public hospital in Choiseul has recently been upgraded from health centre status, while the Central Province hospital is still without a doctor. The total number of available hospital beds is yet to be confirmed, as most hospitals were operating with a reduced number of wards and beds during the period of ethnic conflict. The area and rural health centres and nurse aide posts are well distributed throughout the provinces, based on the size and geographical distribution of the population. By the end of 2003, all hospitals were fully operational, but most were in need of repairs, refurbishing and supplies (certain equipment and drugs). At the end of 2003, a total of 57 doctors (ratio of 1 doctor per 7176 population) were employed by the Government and working in the country (the minimum need is 75 doctors). Of these 57 doctors, 29 (50.8%) were based at the Honiara National Referral Hospital, 21 in the other eight provincial hospitals, four at the Guadalcanal Province and Honiara City Council, and three at the Ministry of Health and Medical Services Headquarters. In terms of nurses, a total 605 nurses (including 61 nurse aides) were employed by the Ministry of Health and Medical Services (a ratio of 1 nurse per 676 population) during the same period (the minimum needed is 730 registered nurses). Unlike doctors, nurses are more or less evenly distributed among the hospitals and the area and rural centres and clinics. There are also five private medical practitioners, practising mainly in Honiara and Gizo. The shortage of staff is still a major problem and is affecting larger provinces, mainly Malaita, Guadalcanal and Western provinces. The hospital in Malaita needs more doctors, while the main National Referral Hospital urgently needs a consultant physician. At the same time, the Public Health Division needs an epidemiologist. Human resource development in health is thus still a priority programme. To this end, a number of doctors are currently undertaking postgraduate training in pathology, psychiatry, internal medicine and obstetric/gynaecology. The Ministry of Health and Medical Services also established a six-month midwifery course in 2002 in Honiara. The first seven midwife graduates are now employed in provincial hospitals and health centres. The midwifery course was not implemented in 2003 due to the suspension of the World Bank’s financial support, but the Ministry is determined to reopen it in 2004. Millennium Development Goals Solomon Islands has made some progress towards a number of Millennium Development Goals and expects to achieve some of the MDG targets. The major constraint in the assessment of MDG progress is the lack of data, as well as the inconsistency of some of the available data. This is an essential issue that has to be dealt with, not only for MDG reporting, but also for policy-making and monitoring progress in the implementation of government policies and programmes. 4. NATIONAL HEALTH PLAN AND PRIORITIES The Ministry of Health and Medical Services’ priority health programmes, based on the following eight core issues under its 1999-2003 National Health Policies and Development Plans, were reviewed and evaluated at the end of 2003: • improvement of management and supervision of services; • access and improvement of care and quality of services; • human resources development for health; • morbidity and mortality reduction; • environmental health; SOLOMON ISLANDS 314 | COUNTRY HEALTH INFORMATION PROFILES • health promotion and education; • reproductive health, family planning and population concerns; and • developing partnership in health development. The results of this review and evaluation exercise are being finalized. The Ministry of Health and Medical Services has indicated that its National Health Plan for 2004-2005 will be based on the results. To this end, the development of the Plan, which entails the future directions in terms of strategies and plans for the next 20 months, is of paramount importance. It is being finalized and should be available by mid-2004. Several of the above stated core issues will be addressed again. However, improving public health and primary health care functions, focusing on the prevention and control of noncommunicable diseases and STI/HIV/AIDS, will be among the top priority programmes. The Government finalized and endorsed its 2003-2006 National Economic Recovery, Reform and Development Plan (NERRDP) at the end of 2003. The programmes will focus on five main priority areas, one being to “restore basic social services in health and education”. In terms of restoring health services, the Government has identified the following indicators as the main indicators to monitor progress: • reduce the malaria rate from 170 per 1000 population (2001) to less than 80 per 1000 by end 2005 (The to-be-confirmed rate in 2003 was 200 per 1000 population, which is much higher than the 2001 figure.); • reduce the infant mortally rate from 66 per 1000 live births in 1999 to less than 50 per 1000 live births by the end of 2005; • reduce the maternal mortality ratio from 125 per 100 000 live births in 1999 to less than 80 by the end 2005 (The confirmed MMR for 2003, however, is 295 per 100 000 live births.); • achieve 90% coverage of immunization of children by the end of 2004; and • determine the child mortality rate for Solomon Islands as a whole, as well as for each province, by 2004. The National Health Plan for 2004-2005 is also aimed at achieving these NERRDP’s indicators, which will result in a collective contribution towards the attainment of health-related Millennium Development Goals. The Ministry of Health and Medical Services has developed a number of health strategies and policies as follows: • National Tobacco Control Legislation (Policy) was completed and finalized in 2002. It is still awaiting endorsement by the Cabinet and to be introduced into Parliament to be legally adopted. • National Blood Safety Policy was completed/finalized in 2003 and is awaiting endorsement by the Government. • National Health Promotion Policy was completed/finalized in 2003 and is awaiting endorsement. • National EPI Policy is being reviewed and revised. • HIV/AIDS Strategy was completed and adopted in 2003. • Food Hygiene Regulation was completed/finalized and is awaiting adoption. 5. MAJOR INFORMATION SOURCES National Economic Recovery, Reform and Development Plan 2003-2005. Solomon Island Government. 2003 report on major health policy objectives and outputs-achievements. Ministry of Health and Medical Services Solomon Islands human development report, 2002. Core information for the development of immunization policy. Geneva, World Health Organization, 2002. COUNTRY HEALTH INFORMATION PROFILES | 315 WHO Recommended strategies for the prevention and control of communicable diseases, 2001. 6. ADDRESSES MINISTRY OF HEALTH AND MEDICAL SERVICES Office Address : Postal Address : P.O. Box 349, Honiara, Solomon Islands Official Email Address : Telephone : Fax : (677) 20085 Office Hours : Website : WHO COUNTRY LIAISON OFFICER IN SOLOMON ISLANDS Office Address : Ministry of Health Bldg. Chinatown Honiara, Solomon Islands Postal Address : World Health Organization P.O. Box 22 Honiara, Solomon Islands Official Email Address : who@sol.wpro.who.int Telephone : (677) 23406 Fax : (677) 21344 Office Hours : Organizational Chart: Ministry of Health and Medical Services Health Care System Organizational Structure Community Provincial Nursing Nursing Community Psychiatry Psychiatric Provincail Hospitals Hospitals (NRH) Provincial distribution centres Pharmacy Provincial Planning Policy & Planning Undersecrertary Health Care Provincial SWO Social Welfare Provincial VBDCP VBDCP Provincial RHD RHD (MCH) Provincial EHD/RWSS EHD/RWSS Provincial HEPD HEPD Provincial Coordinators DPCC TB/LEP NCD HIV/STI Undersecretary Health Improvement Permanent Secretary Minister of Health SOLOMON ISLANDS 316 SOLOMON ISLANDS WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 28.37 2004 1 2 Estimated population ('000s) 460.11 237.63 222.48 2004 est 2 3 Annual population growth rate (%) 2.80 … … 1999 4 4 Percentage of population - 0–14 years 40.06 40.47 39.63 2004 est 2 - 65+ years 3.20 3.29 3.09 2004 est 2 5 Urban population (%) 16.50 h … … 2003 3 6 Crude birth rate (per 1000 population) 34.00 … … 2004 est 2 7 Crude death rate (per 1000 population) 8.00 … … 2004 est 2 8 Rate of natural increase of population (% per annum) 2.60 a … … 2004 est 2 9 Health-adjusted life expectancy (HALE) (years) - at birth … 61.90 63.10 2004 est 2 - at age 60 … 10.90 11.60 2002 5 10 Adult literacy rate (%) 77.00 84.00 67.00 1999 6 11 Neonatal mortality rate (per 1000 live births) 12.00 a … … 2000 7 12 Infant mortality rate (per 1000 live births) 66.00 67.00 65.00 1999 2 13 Under-five mortality rate (per 1000 live births) 73.00 … … 1999 10 14 Total fertility rate (women aged 15–49 years) 4.84 1999 5 15 Maternal mortality ratio (per 100 000 live births) 295.00 2003 8 16 Percentage of newborn infants weighing at least 2500 g at birth … … … 17 Prevalence of underweight children under five years of age 21.00 … … 1999 10 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 82.00 … … 2004 11 - DTP3 80.00 … … 2004 11 - OPV3 75.00 … … 2004 11 - Measles 72.00 … … 2004 11 - Tetanus II 65.00 … … 2004 11 - Hepatitis B III 72.00 … … 2004 11 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 76.00 2003 9 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) f 43.00 2003 19 21 Percentage of women in the reproductive age group using modern contraceptive methods 19.00 1999 14 22 Condom use rate of the contraceptive prevalence rate 2.4 … … 2001 10 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … COUNTRY HEALTH INFORMATION PROFILE 317 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 70.00 94.00 65.00 2002 12 26 Proportion of population with access to improved sanitation 31.00 98.00 18.00 2002 12 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) 95.00 b … … 2003 11 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.62 … … 2002 13 32 Per capita GDP at current market prices (US$) 494.68 2002 2 33 Rate of growth per capita GDP … … … 34 Health expenditure Total health expenditure - amount (in million US$) … - total health expenditure on health as % of GDP 5.60 1999 6 - per capita total expenditure on health (in US$) … Government expenditure on health - amount (in million US$) 52 980 902.00 2004 8 - general government expenditure on health as % of total expenditure on health 97.30 1999 6 - general government expenditure on health as % of total general government expenditure 11.10 1999 6 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 6.95 SBD 2002 2 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 57 … … 1.25 … … 2003 8 - dentists 26 … … 0.63 … … 1999 16 - pharmacists 28 … … 0.70 … … 1999 16 - nurses (including nurse aids) 605 … … 13.24 … … 2003 8 - midwives 23 … … 0.50 … … 1999 16 - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) … … … … … … - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … SOLOMON ISLANDS 318 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population c 1. Acute respiratory infections 156 021 … … 36 382.52 … … 2001 15 2. Malaria 131 266 … … 30 609.91 … … 2001 15 3. Fever (syndromic) 123 368 … … 28 768.17 … … 2001 15 4. Skin diseases (excluding yaws) 36 894 … … 8603.31 … … 2001 15 5. Ear infections 20 831 … … 4857.58 … … 2001 15 6. Yaws 17 609 … … 4106.24 … … 2001 15 7. Conjunctivitis (red eye) 12 066 … … 2813.67 … … 2001 15 8. Diarrhoeal diseases 10 390 … … 2422.84 … … 2001 15 9. STI 1987 … … 463.35 … … 2001 15 10. Tuberculosis 286 … … 66.69 … … 2001 15 40 Five leading causes of mortality Number Rate per 100 000 population 1. Neoplasm … … … … … … 1999 8 2. Neonatal causes … … … … … … 1999 8 3. Malaria … … … … … … 1999 8 4. Cardiovascular diseases (cerebrovascular accident or CVA as the leading causes) … … … … … … 1999 8 5. Respiratory diseases (pneumonia as the leading causes) … … … … … … 1999 8 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2004 11 - Pertussis (whooping cough) 0 0 0 … … … 2004 11 - Tetanus 0 0 0 … … … 2004 11 - Neonatal tetanus 0 0 0 … … … 2004 11 - Poliomyelitis 0 0 0 … … … 2004 11 - Hib meningitis … … … … … … - Measles 0 0 0 … … … 2004 11 - Mumps … … … … … … - Rubella … … … … … … - Congenital rubella syndrome … … … … … … 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A … … … … … … - Type B … … … … … … - Type C … … … … … … - Unspecified … … … … … … Cholera … … … … … … Typhoid fever … … … … … … Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … Gonorrhoea … … … … … … Leprosy 5 … … … … … 2003 11 Malaria 90 606 … … 71 … … 2003 11 Dengue/DHF … … … … … … COUNTRY HEALTH INFORMATION PROFILE 319 INDICATORS DATA Year Source Total Male Female Total Male Female 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 18 994.97 … … 14.88 … … 2003 11 - Proportion of population in malaria-risk areas using effective malaria prevention measures d … - Proportion of population in malaria-risk areas using effective malaria treatment measures e … 44 Tuberculosis Number of cases Number of deaths - All types 293 … … … … … 2003 11 - New pulmonary tuberculosis (smear-positive) 138 … … … … … 2003 11 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 60.00 … … 4.00 … … 2003 11 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 107.00 … … 90.00 (2002) … … 2003 11 Number of cases Number of deaths 45 Acute respiratory infections 156 021 … … … … … 2001 15 46 Diarrhoeal diseases 10 390 … … … … … 2001 15 47 Cancers All cancers (malignant neoplasms only) … … … … … … - Trachea, bronchus and lung … … … … … … - Stomach … … … … … … - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … … … … - Liver … … … … … … - Cervix … … … … … … - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases - Ischaemic heart disease … … … … … … - Acute myocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … … … … - Hypertension … … … … … … 49 Maternal causes - Haemorrhage … … … … - Abortion … … … … - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … 50 Diabetes mellitus … … … … … … 51 Mental disorders … … … … … … SOLOMON ISLANDS 320 INDICATORS DATA Year Source Total Male Female Total Male Female 52 Injuries - All types … … … … … … - Motor and other vehicle accidents … … … … … … - Suicide … … … … … … - Homicide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number (2003) Number of beds (1999) Public health facilities 8 691 2003 8, 17 - General hospitals … … - Specialized hospitals … … - District/first-level referral hospitals g … … - Primary health care centres … … Private hospitals 3 190 2003 8, 17 Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate a Estimates derived by regression and similar estimation methods b Modelled data c Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific using 2001 estimated population d Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. e Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. f Applies to clinics only g Total of eight provincial/ district hospitals/ first level referral hospitals (five public hospitals plus three private hospitals) h Revised data COUNTRY HEALTH INFORMATION PROFILE 321 Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 2 Solomon Islands Statistics (http://www.spc.int/prism) 3 Urban and rural areas 2003. New York, Department of Economic and Social Affairs Population Division, United Nations, 2004. 4 A report on 1999 population and housing census, basic tables and census description. Solomon Islands Government, March 2001. 5 World health report 2004: Changing history. Geneva, World Health Organization, 2004. 6 Report on current health care system in Solomon Islands 2002. Ministry of Health, Solomon Islands, 11 November 2002 7 World health report 2005: Make every mother and child count. Geneva, World Health Organization, 2005. 8 Information furnished by the Country Liaison Officer for Solomon Islands, 17 June 2004 9 Solomon Islands Millennium Development Goals report 2004: Scoring fundamental goals (Draft). Department of National Reform and Planning, United Nations Country Team for Solomon Islands 10 Pacific Island Regional Millennium Development Goals report 2004. Noumea, Secretariat of the Pacific Community, UN/CROP MDG Working Group, November 2004. 11 WHO Regional Office for the Western Pacific, data received from technical units 12 Meeting the MDG drinking water and sanitation target: A mid-term assessment of progress. WHO and UNICEF, 2004. 13 Human development report 2004. New York, United Nations Development Programme, 2004. 14 Pikacha J and Iniakwala D. Ministry of Health presentation for the IMCI orientation workshop. WHO/ UNICEF sponsored workshop on IMCI, Suva, Fiji, 2001. 15 Health Information System, annual report 2001. Statistics Unit, Policy, Planning and Research Division, Ministry of Health. 16 The national health policies and development plans 1999-2003, Solomon Islands Government 17 National Health Report Review, Evaluation of the National Health Status 1997-1999, June 2000, Ministry of Health, Solomon Islands 322 | COUNTRY HEALTH INFORMATION PROFILES TOKELAU 1. DEMOGRAPHICS, GENDER AND POVERTY The last census, conducted in October 2001, recorded a population of 1515, a slight increase from the 1996 census of 1500. The estimated population in 2004 is 1500, 41% of whom are below 15 years of age, while almost 6% are above 65 years of age. Life expectancy at birth is 68 years for males and 71 years for females (1997-2000). The crude birth rate is 31.0 per 1000 population (1997-2001), the crude death rate is 7.0 per 1000 population (1997-2001), and the total fertility rate is 4.9 (1997-2001). The infant mortality rate is 33.0 per 1000 live births (1997- 2000), the under-five mortality rate is 0 per 1000 live births (1999), and the maternal mortality ratio is 0 per 100 000 live births (2001-2002). Table 1. Core population and health data (2004 estimate) [Total] 1500 [Both] ... [0-14 years] (41.38%) [Male] 68.40 (1997-2000) Population [65+ years] (5.80%) Life expectancy at birth (years) [Female] 71.30 (1997-2000) Crude birth rate (per 1000 population) 31.00 (1997-2001) Total fertility rate 4.90 (1997-2001) [Total] 89.00 (2002) [Urban] 0.00 (2002) Crude death rate (per 1000 population) 7.00 (1997-2001) % of population served with safe water [Rural] 89.00 (2002) [Total] 74.00 (2002) [Urban] 0.00 (2002) Infant mortality rate (per 1000 live births) 33.00 (1997-2000) % of population with adequate sanitary facilities [Rural] 74.00 (2002) Maternal mortality rate (per 100 000 live births) 0.00 (2001-2002) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The constraints of atoll life and limited opportunities have led some 6000 Tokelauans to settle in New Zealand and a few hundred more in Samoa. Tokelauans have linguistic, family and cultural links with other Pacific islands, notably Samoa and Tuvalu. The family and extended family constitute the core of social organization, with the village (nuku) being the foundation of Tokelauan society. Community welfare is paramount in what has been traditionally a subsistence environment. 2.2 Economic situation Per capita gross national product (GNP) is US$ 612.50 or about NZ$ 1000 (2003). The economy is basically subsistence, although cash is now becoming an important part of everyday life. The country’s resource base is fragile as very little land is available for any agricultural endeavour without substantial preparation and support. The marine resources have not been fully explored as yet, and ocean and lagoon fish form a stable constituent of the local diet. While there is no significant agricultural activity owing to the limited and infertile coral land, Tokelauans raise pigs and chickens and have access to traditional crops such as coconut and breadfruit, as well as COUNTRY HEALTH INFORMATION PROFILES | 323 limited quantities of pandanus fruit and taro. However, there is increasing evidence of over- reliance on imported, processed foods, which is contributing to lifestyle-related diseases. 3. HEALTH SITUATION 3.1 Health trends The overall health status is reasonably good, but changes have been observed in the last few years. There has been an increase in noncommunicable diseases, with cerebrovascular disease seen as the leading cause of death. The mortality rate due to cardiovascular diseases increased from 31.0% of the total in 1981 to 37.8% in 2003. Blood pressure recordings of 90 mm Hg diastolic and greater are seen in 36% of women and 23% of men of 30 years of age and over. Random blood sugar levels of 7 mmol/litre and above for the same group appear in 18% of men and 28% of women. Tobacco and alcohol consumption is relatively high among the adult population, but is more prominent in males. Obesity is common and is attributed to diet and physical inactivity, with prevalence rates of 70% for men and 83% for women between 30 and 39 years of age. There is an observable diet shift from local to imported foods. 3.2 Health systems The Health Department has its main office in Atafu. Each of the three atolls has a 12-bed hospital, manned by a medical officer, four to five staff nurses, one dental nurse, four to five nurse’s aides and a handyman. There is ongoing renovation of the three hospitals and the bed capacity has been reduced to six each. There are only three dentists working in Tokelau (2003). The doctor-to-population ratio is 1:757, the dentist-to-population ratio 1:757, and the nurse-to- population ratio is 1:151. In December 2003, there were three doctors on the island plus the Director of Health, who is also a practising medical officer. Tokelau relies on the “locum” scheme in recruiting doctors. It is envisioned that this will go on for the next three years by which time new graduates will be expected to fill the vacancies. In 2002-2003, Tokelau experienced an unexpected shortage of nurses. This was attributed to the fact that local nurses migrated overseas, specifically to New Zealand. The three hospitals are similarly equipped. The only X-ray facility is available in the Nukunonu hospital. The department also has an office in the Tokelau Apia Liaison Office (TALO) in Samoa. Its main purpose is to facilitate referral of patients in Samoa and to New Zealand. The TALO Health Office also serves as the storage and distribution point for medical supplies. For the financial year 2003/04, the Tokelau GNP national forecast was NZ$ 11 381 770 (US$ 8 115 604). Health was allocated 12.5%, about NZ$ 1 424 502 (US$ 1 015 452). For the previous financial year, health was allocated 8.2%. The national budget is made up of locally generated resources and a grant from the New Zealand Government as part of its constitutional responsibility for Tokelau. Other assistance comes from international partner agencies including WHO, UNDP, UNICEF, UNFPA and the Australian Agency for International Development (AusAID). 4. NATIONAL HEALTH PLAN AND PRIORITIES (1) Healthy islands and communities: Support existing community groups and structures that will enhance the ability to provide a healthy environment for the people. (2) Promotion of healthy lifestyles: Support community members and health workers to lead healthy and improved diverse lifestyles. TOKELAU 324 | COUNTRY HEALTH INFORMATION PROFILES (3) Development of health partnerships: Establish long-term strategic relationships with key partners in government, external donors, other relevant institutions and community groups in health development. (4) Development of accessible primary health care services: Develop and improve primary health care services that are effective and relevant to communities. (5) Successful community participation: Develop a successful participative strategy for an effective, combined approach to service delivery by community groups and health service providers. (6) Development and improvement of health service system: Improve the accessibility and quality of health services, which will increase people’s confidence and participation in the total health system and add value to existing services. 5. MAJOR INFORMATION SOURCES Tokelau Census Tokelau Department of Health World Factbook. CIA, 2003 (http://www.cia.gov/cia/publications/factbook/index.html) 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Nukunonu, Tokelau Postal Address : Official Email Address : tokelau.health@clear.net.nz , talo.health@clear.net.nz Telephone : (690) 4132 Fax : (690) 4290 Office Hours : Website : WHO REPRESENTATIVE IN SAMOA Office Address : Ioane Viliamu Building Beach Road, Apia, Western Samoa Postal Address : P.O. Box 77, Apia, Western Samoa Official Email Address : who@sma.wpro.who.int Telephone : (685) 23756; (685) 24976 Fax : (685) 23765 Office Hours : COUNTRY HEALTH INFORMATION PROFILE 325 TOKELAU WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 0.01 2004 1 2 Estimated population ('000s) 1.50 ... ... 2004 est 1 3 Annual population growth rate (%) 0.40 ... ... 2001 1 4 Percentage of population - 0–14 years 41.38 42.48 40.29 2004 est 2 - 65+ years 5.80 5.32 6.27 2004 est 2 5 Urban population (%) 0.00 … … 2003 3 6 Crude birth rate (per 1000 population) 31.00 … … 1997-2001 1 7 Crude death rate (per 1000 population) 7.00 … … 1997-2001 1 8 Rate of natural increase of population (% per annum) 2.4 … … 1997-2001 1 9 Health-adjusted life expectancy (HALE) (years) - at birth … 68.40 71.30 1997-2000 1 - at age 60 … … … 10 Adult literacy rate (%) (15-24 years old) 86.50 … … 2003 6 11 Neonatal mortality rate (per 1000 live births) 40.00 a … … 2003 5 12 Infant mortality rate (per 1000 live births) 33.00 … … 1997-2000 1 13 Under-five mortality rate (per 1000 live births) 0.00 … … 1999 7 14 Total fertility rate (women aged 15–49 years) 4.90 1997-2001 1 15 Maternal mortality ratio (per 100 000 live births) 0.00 2001-2002 8 16 Percentage of newborn infants weighing at least 2500 g at birth 100.00 … … 2003 5 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 0.00 1999 7 19 Immunization coverage for infants (%) - BCG 100.00 … … 2004 9 - DTP3 99.00 … … 2004 9 - OPV3 99.00 … … 2004 9 - Measles 82.00 … … 2004 9 - Tetanus II … … ... - Hepatitis B III 99.00 … … 2004 9 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 100.00 1999 10 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods 13.40 1999 10 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … TOKELAU 326 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 89.00 … 89.00 2002 4 26 Proportion of population with access to improved sanitation 74.00 … 74.00 2002 4 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) 14.50 … … 2001 6 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index … … … 32 Per capita GNP at current market prices (US$) 612.50 2003 8 33 Rate of growth per capita GDP 3.20 1999 7 34 Health expenditure Total health expenditure - amount (in NZ$) 514 000.00 1999- 2000 7 - total health expenditure on health as % of GDP … - per capita total expenditure on health (in NZ$) 341.07 1999- 2000 7 Government expenditure on health - amount (in NZ$) 1 424 502.00 FY2003- 2004 8 - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure 12.50 FY2003- 2004 8 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = … 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 3 … … 20.00 … … 2003 8 - dentists 3 b … … 20.00 … … 2003 8 - pharmacists 0 0 0 0.00 0.00 0.00 2000 7 - nurses 10 … … 66.67 … … 2003 8 - midwives 3 … … 20.00 … … 2000 7 - other nursing/ auxiliary staff 7 … … 46.67 … … 2003 7 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 1 … … 6.67 … … 2000 7 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 1 … … 6.67 … … 2000 7 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … COUNTRY HEALTH INFORMATION PROFILE 327 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Five leading causes of health clinic morbidity Number of cases reported Rate per 100 000 population a 1. Upper and lower respiratory diseases 1000 … … 65 061.81 … … 2003 5 2. Diseases of the skin and subcutaneous tissues 439 … … 28 562.13 … … 2003 5 3. Diseases of the digestive system 400 … … 26 024.72 … … 2003 5 4. Diseases of the musculoskeletal system 151 … … 9824.33 … … 2003 5 5. Diseases of the circulatory system 73 … … 4749.51 … … 2003 5 40 Five leading causes of mortality Deaths reported (%) Rate per 100 000 population 1. Diseases of the circulatory system 37.80 … … … … … 2003 5 2. Diseases of the respiratory system 20.70 … … … … … 2003 5 3. Neoplastic diseases 15.90 … … … … … 2003 5 4. Ill-defined and undiagnosed conditions 11.00 … … … … … 2003 5 5. Congenital anomalies 4.90 … … … … … 2003 5 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2004 9 - Pertussis (whooping cough) 0 0 0 … … … 2004 9 - Tetanus 0 0 0 … … … 2004 9 - Neonatal tetanus 0 0 0 … … … 2004 9 - Poliomyelitis 0 0 0 … … … 2004 9 - Hib meningitis 0 0 0 … … … 2004 9 - Measles 0 0 0 … … … 2004 9 - Mumps 0 0 0 … … … 2004 9 - Rubella 0 0 0 … … … 2004 9 - Congenital rubella syndrome 0 0 0 … … … 2004 9 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A … … … … … … - Type B … … … … … … - Type C … … … … … … - Unspecified … … … … … … Cholera … … … … … … Typhoid fever … … … … … … Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … Gonorrhoea (gonococcal infections) … … … … … … Leprosy 0 0 0 … … … 2003 9 Malaria … … … … … … Dengue/DHF … … … … … … TOKELAU 328 INDICATORS DATA Year Source Total Male Female Total Male Female 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 0 0 0 … … … 2003 9 - New pulmonary tuberculosis (smear-positive) 0 0 0 … … … 2003 9 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 59.00 … … 6.00 … … 2003 9 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) … … … … … … Number of cases Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (malignant neoplasms only) … … … … … … - Trachea, bronchus and lung … … … … … … - Stomach … … … … … … - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … … … … - Liver … … … … … … - Cervix … … … … … … - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … … … … - Ischaemic heart disease … … … … … … - Acute myocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … … … … - Hypertension … … … … … … 49 Maternal causes - Haemorrhage … … … … - Abortion … … … … - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … 50 Diabetes mellitus … … … … … … 51 Mental disorders … … … … … … COUNTRY HEALTH INFORMATION PROFILE 329 INDICATORS DATA Year Source Total Male Female Total Male Female 52 Injuries - All types … … … … … … - Motor and other vehicle accidents … … … … … … - Suicide … … … … … … - Homicide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities 3 18 2003 8 - General hospitals … … - Specialized hospitals … … - District/first-level referral hospitals … … - Primary health care centres … … Private hospitals … … Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific b Revised data c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 2 Demographic tables for the Western Pacific Region 2000-2005. Manila, WHO Regional Office for the Western Pacific, 2005. 3 Urban and rural areas 2003. New York, United Nations Department of Economic and Social Affairs Population Division, 2004. 4 Meeting the MDG drinking water and sanitation target: A mid-term assessment of progress. WHO/ UNICEF Joint Monitoring Programme for Water Supply and Sanitation 2004. 5 Tokelau Statistics Unit <http://www.spc.int/prism/country/tk> 6 Pacific Island Regional Millennium Development Goals Report 2004. Noumea, Secretariat of the Pacific Community, UN/ CROP MDG Working Group, November 2004. 7 Information furnished by the Tokelau Department of Health, 17 May 2001 8 Information furnished by WHO Representative in Samoa, 25 February 2004 9 WHO Regional Office for the Western Pacific, data received from technical units 10 Hospital records 330 | COUNTRY HEALTH INFORMATION PROFILES TONGA 1. DEMOGRAPHICS, GENDER AND POVERTY According to the 1996 census (next census 2006), the projected population for 2004 is 101 865, with a population density of 156.7 per square kilometre. About 33% of the population live in urban settings, although the differences between rural and urban living conditions are not clearly defined. The fertility rate fell from 4.1 to 3.4 between 1986 and 2003. The comparatively slow population growth of 0.3% is explained by the high net emigration rate of 19.8% between 1986 and 1996. About 37.91% (38 617) of the population is below 15 years of age. It is estimated that more than 50 000 Tongans live abroad, mainly in Australia, New Zealand and the United States of America. All children attend primary school and the literacy rate is 98.8%. Secondary education is in English. The education rate is similar for both genders, but the number of women in leading positions is still limited. There are no female members of parliament. Tonga has not signed the Convention on Elimination of all forms of Discrimination Against Women (CEDAW). The standard of living has improved dramatically over the last 50 years and there is little absolute poverty today. However, many families still live at subsistence levels and are dependent for food security on what they can produce on their farmland. It has been estimated that about 4% of the population live on less than US$1.00 per day. Since poverty is a relative term and has a major impact on health outcomes, the Government uses the term ‘hardship’ to describe economically disadvantaged groups. Hardship is defined as “having difficulties in meeting basic needs, such as education and transport”. When translated into monetary terms, hardship is the equivalent of living on less than TOP 28.17 (US$ 14.79) per week (indexed value), and today an estimated 23% of the population falls into that category. Most people experiencing hardship live on the outer islands, where access to education and health care is poor and transport costs are high. Table 1. Core population and health data (2004) [Total] 101 865 (2004 est.) [Both] 70.00 (2003) [0-14 years] (37.91%) est [Male] 70.00 (2003) Population [65+ years] (5.29%) est Life expectancy at birth (years) [Female] 72.00 (2003) Crude birth rate (per 1000 population) 24.20 (2002) Total fertility rate 3.40 (2003) [Total] 97.00 (2003) [Urban] … Crude death rate (per 1000 population) 5.80 (2002) % of population served with safe water [Rural] … [Total] 78.20 (2002) [Urban] … Infant mortality rate (per 1000 live births) 14.60 % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 83.30 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Tonga is a constitutional monarchy that, in theory, gives almost absolute power to the King, Taufa’ahau Tupou IV. The King’s Cabinet consists of the Prime Minister, the ministers of the COUNTRY HEALTH INFORMATION PROFILES | 331 Crown and the governors of Vava’au and Ha’apai, who are all directly appointed by the King. As of 2005, two of the cabinet ministers have to be selected from among the people’s representatives. The unicameral parliament consists of the cabinet members, the Speaker , who is appointed by the King, nine nobles elected by the nobles from among Tonga’s 33 hereditary title holders, and nine democratically elected peoples’ representatives. The 86-year-old King Taufa’ahau Tupou IV has reigned since 1965. His third-born son, Prince ‘Ulukalala Lavaka Ata, is the appointed Prime Minister. The political situation is stable and peaceful, although tensions have grown in recent years. There is a pro-democracy movement that is demanding a fairer electoral system. Tonga has been a member of the United Nations since 1999 and has signed the Declaration of Human Rights and the Convention of the Rights of the Child, although the country has so far failed to report as required. The churches and the traditional hierarchy play important roles in government decision-making processes and policy development. 2.2 Economic situation The backbone of the economy is agriculture, and the export of pumpkins for the Japanese market is a particularly important foreign exchange earner. The second biggest industry, fishing, is in recession because of decreasing catches. Tourism is slowly increasing in importance, but Tonga is unlikely to develop a mass-tourism industry. Remittances from abroad also play an important role in the economy. The total value of private remittances was estimated at TOP 200 million (US$ 105 million) in 2004, roughly 55% of GDP, which was estimated at TOP 361 million (US$ 189.6 million). Economic development has been poor in recent years, with a high inflation rate of 10.1% in the twelve-month period ending 30 June 2004, and devaluations against the Australian and New Zealand currencies. Price increases for imported goods strongly influence the overall inflation rate. Import prices increased by 12.5% while domestic prices increased by 5.2% for the same period. GDP growth slowed down to 1.6% for the 2003-2004 economic year from above 3 % in the period from 1997 to 2002. The trade deficit is huge, with the value of imports ten times that of exports. Total imports were valued at TOP 169 million (US$ 88.76 million) in 2003-04, with a record trade deficit of TOP 140.8 million (US$ 79.95 million). The Government has liberalized the economy in recent years and has abolished government monopolies in several areas, including telecommunications, power supply and civil aviation. The heavily subsidized Royal Tongan Airlines went bankrupt in 2004 and a private company is now operating domestic flight services. Tonga is expected to join the World Trade Organization (WTO) in 2005 and it will then abolish many trade barriers. A 15% consumer tax on goods and services was introduced in April 2005. The pa’anga lost about 30% of its value against the New Zealand and Australian dollars between 2001 and 2003 and this has resulted in more expensive imports. The tax base is small, only about 4000 people earn a taxable income, and income tax is low (10%) and non-progressive. Government revenue from income taxation is less than TOP 2 million (US$ 1.05 million) per year. The unemployment rate in 2000 was 32.9% for women and 34.7% for men. 3. HEALTH SITUATION 3.1 Health trends Tonga has gone through an epidemiological transition since the 1950s, with increasing life expectancy and falling fertility rates, childhood mortality rates and maternal mortality ratios. Life expectancy at birth increased from 40 years in 1939 to 70 years for males and 72 years for females in 2003. The proportion of deaths caused by infectious diseases fell from 32% in the 1950s to 6% in the 1990s, while the proportion of deaths from diseases of the circulatory system grew from 5.6% to 38% during the same period. The post-mortem examination rate is low and death certificates are based on clinical findings. More importantly, as many as 18% of deceased TONGA 332 | COUNTRY HEALTH INFORMATION PROFILES people do not have a proper death certificate stating the cause of death, and unknown cause of death actually ranks as number 2 when included in the list of leading causes of death. While the mortality data are considered to be fairly reliable for those who have death certificates, there are obvious distortions caused by misclassifications at reporting level, particularly for communicable diseases. The steep increase in the burden of noncommunicable diseases is the most important health problem today. Thus, while communicable diseases have largely been brought under control, obesity, diabetes and cardiovascular diseases have increased to epidemic proportions and prevalence rates now surpass those of most industrialized countries. Tonga developed a multisectoral national strategy to prevent and control noncommunicable diseases in 2003. Noncommunicable diseases: There are multiple reasons for the growing burden of noncommunicable diseases, of which the most important are: the increasing rates of overweight and obesity; reduced physical activity; smoking; and, to some extent, the ageing population. Economic development and the adoption of “foreign” behaviour have impacted negatively on people’s diets, physical activity levels, smoking rates and alcohol consumption. A nationwide STEPS-survey on biological and behavioural risk factors for NCDs conducted in 2004 will provide valuable information. Food, gifts of food and feasting traditionally play an important role in Tongan culture. Higher economic standards, improved communications and better access to processed and high fat and high sugar foods have led to a rapidly increasing overweight and obesity problem. There are indications that people are developing overweight and obesity earlier and earlier in life. This is particularly true for girls and young women, who tend to gain weight during adolescence and pregnancy. Many people still perceive fatty food as something desirable, a taste that may partly be explained by the scarcity of fat in the traditional fishing and farming society and by historic periods of food shortage. Other findings indicate that the quantity of food consumed by Tongan adults is as much to blame as the composition of the intake. Studies have shown that the average Tongan male consumes double the quantity of food and amount of calories consumed by the average Australian male. The overall adult obesity rate (BMI>30) was 60% in the last survey. Women are more overweight than men (mean BMI 34.5 compared with 31.0 for men), while men have a higher prevalence of other risk factors, including hypertension, elevated blood lipids and smoking. The prevalence of diabetes type II has doubled from 7% to 15% over the last 25 years. A community survey in 2000 showed that as many as 80% of people with diabetes remain undiagnosed and untreated. Access to health services for people with diabetes and its complications has improved, but the health system does not have the capacity to provide quality care for all who need it, and primary and secondary prevention have so far not been enough. The number of registered diabetic patients at the specialist clinic at the referral hospital on Tongatapu increased by 54% in five years, from 1463 in 1999 to 2247 in 2003, which corresponds to more than 9% of the serviced population aged 30 years and more. A hereditary predisposition towards impaired glucose tolerance is likely to play some role in the high rates of diabetes, but this is a non-modifiable factor and has in itself little to contribute to the design of public health interventions. Physical inactivity is thought to be an important cause of overweight, particularly for women and middle-aged people. It is unusual today for people to walk or bicycle, as the number of vehicles is rapidly increasing. The increasing number of cars on the roads, together with outdated traffic safety measures contributed to the record 24 deaths in the traffic in 2003, a figure that puts Tonga ahead of the United States of America in number of traffic deaths per 100 000 population. Seatbelts are not compulsory and only 1% of drivers were found to be using them in a Ministry of Health survey in 2004. The single most important cause of traffic injury is driving under the influence of alcohol, kava and marijuana. All 24 deaths in 2003 were caused directly or indirectly by intoxication. The section on alcohol in the current Traffic Act is antiquated and, in practice, COUNTRY HEALTH INFORMATION PROFILES | 333 not enforceable. The health services do not have the equipment to measure blood alcohol or to breathalize motorists, and nor does the police force. The health and social problems caused by the harmful use of alcohol has received increasing attention in Tonga lately and this will hopefully result in measures aimed at reducing access to alcohol and enforcing drink-driving control in the future. Malignancies are perceived as an increasing burden of ill-health, but weaknesses in diagnosis, surveillance and reporting do not allow for reliable analysis of trends. The sharp increase in overall cancer incidence is likely to be partly or entirely explained by changes in reporting rather than by a true increase. Diagnostic capacity is limited for many malignancies, and it is not always obvious when the reported figure refers to cytological diagnoses or when clinical (non- confirmed) diagnoses have been included. A cancer register was established in 2004 to capture both clinically determined cancers and laboratory-confirmed cases. Although this important development will improve the statistical information on cancer incidence, the proportion of cytologically and histologically confirmed cancer cases remains low compared with overall cancer incidence, and the autopsy rate is very low. A pilot project on Pap-smear screening for cervical cancer will start in 2005. Mammography is not available. Liver cancer, which is closely related to hepatitis B virus infection (HBV), is common in Tonga, where prevalence rates in the adult population are hyperendemic (10%-14%). It will take another two to three generations until immunization against HBV, which was introduced in 1989, impacts on the incidence of liver cancer. Lung cancer now ranks among the three most common cancers, a result of smoking, and it is expected that the incidence will continue to increase. Maternal and child health: More than 99% of pregnant women attend antenatal clinics, 98% deliver in a health facility and 99% of deliveries are attended by trained staff. The maternal mortality ratio (MMR) was 83.3 per 100 000 live births in 2004, which translates into two fatalities. Many of the indicators that are based on relatively uncommon events, such as MMR and IMR, show large variations between years due to chance. It is often more informative either to compare absolute numbers or to calculate rates over five-year or 10-year periods. The mean MMR for the five-year period from 1999 to 2003 was 39.4 per 100 000 live births. The low infant mortality rate baseline figure of 9.1 deaths per 1000 live births in 1990, and the fact that the IMR has remained unchanged for so long, make Tonga the best performing country in the Pacific in terms of infant mortality, but make it unrealistic for the country to achieve the Millennium Development Goals (MDGs) for infant mortality. There are multiple explanations for the low IMR, but at the core is the Government’s commitment to delivering key interventions, such as immunizations, antenatal care and trained delivery care to the entire population, and it shows that it is possible to provide high coverage of essential services in an island state with isolated populations. Also of importance is the fact that there is no absolute poverty in Tonga, no important nutrient deficiencies and no malaria, all factors that contribute to well-nourished and healthy mothers, newborn babies and infants. The comparatively low teenage (<20 years) pregnancy rate (4.1% in the 2000-2003 period) is also a contributing factor. Breast- feeding promotion is receiving increasing attention as an important public health intervention and a goal has been set to establish Vaiola Hospital as a baby-friendly hospital in 2005. This would mean that two-thirds of all children in Tonga would be born in a baby-friendly environment. Work has started to translate the International Code on Marketing of Breastmilk Substitutes into national law and regulations. The challenge for child health in Tonga lies in protecting the impressive gains made so far while at the same time identifying and implementing affordable and sustainable interventions that will reduce IMR further. A review of developments in child health is planned for 2006 and is expected to help in identifying the way forward. Currently, 67% of under-five mortality is in the 0-1 age group and investments in perinatal and neonatal care are likely to be important in reducing infant mortality. Similarly, the burden of death from Haemophilus Influenzae type B (Hib) infection lies almost entirely in the 0-1 age group, and the introduction in 2005 of routine TONGA 334 | COUNTRY HEALTH INFORMATION PROFILES childhood immunizations against Hib is one example of an affordable new intervention for improving child health. Of the 17 hospital certified deaths in the 1-4 age group in 2003, eight were from infectious causes, one from dehydration, two from malignancies and two from road trauma. Of the eight children who died as a result of infection, six were from septicaemia and CNS infection, one from dengue fever and one from pneumonia. The picture resembles more the situation in an industrialized country than a poor developing country. There is limited information available on childhood morbidity, but the two deaths from road trauma indicate that child safety is a potential area for improving child health. Communicable diseases: Infectious diseases have to a large extent been brought under control in the last 30-40 years, with some important exceptions. Immunization rates are higher than in many industrialized countries, there is no neonatal tetanus or poliomyelitis, and the last confirmed case of measles was in 1998. Rubella vaccine (MR vaccine) was added to the immunization schedule in 2002 in response to a large outbreak of the disease. The immunization campaign with MR vaccine included all children of 0-15 yrs and all women up to 45 years of age. There were no cases of congenital rubella syndrome (CRS). The introduction of Hib vaccine in April 2005 is estimated to prevent one to two infant deaths per year caused by meningitis. The fourth round of mass drug administration (MDA) against lymphatic filariasis took place in 2004. A nationwide survey the same year showed that Tongatapu is now free of filariasis, but that pockets of transmission remain on isolated islands in the Ha’apai group and in the Niuas. Leprosy has in practice been eradicated, although an imported case from American Samoa was diagnosed in 2004. Hepatitis B is highly endemic in Tonga. Screening of blood donors, government employees and visa applicants shows that more than 10% of both men and women are positive for HbsAg. A survey in pregnant women in 2005 found an HbsAg-positive rate of 13.9% Childhood immunization against hepatitis B started in 1989 and the first immunized cohorts are about to enter reproductive life. A seroprevalence study of 211 preschool children in 1998 found that 3.8% had chronic hepatitis B infection, indicating a lower-than-expected efficacy of hepatitis B immunization. A study using convenience testing for HbsAg in children admitted to Vaiola Hospital will start in 2005 for surveillance purposes, and increasing efforts are now being made to improve the timeliness of hepatitis B vaccine delivery. Poor household hygiene and sanitation and contamination of drinking water sources are thought to contribute to the 10-20 cases of typhoid fever recorded each year (22 confirmed cases in 2003). The importance of finding and treating asymptomatic chronic typhoid carriers is emphasized. Tonga should have the resources to eliminate typhoid fever through coordinated efforts to treat carriers, improve sanitation and ensure safe water supply in all villages. Tonga experienced a large outbreak of dengue fever (serotype 1) in 2003, causing six deaths in children, and transmission has continued into 2005. While the outbreak was confined to the main island of Tongatapu in the first year, transmission has now spread to all island groups except the Niuas. Two adult deaths were recorded during the first four months of 2005. Although the possibility of dengue becoming endemic is a reality, it is generally believed that the outbreak will die out in 2005, as has been the case with previous outbreaks. However, because vector control is generally poor, there is a clear risk of new epidemics in the future when other dengue serotypes are introduced. Twelve new cases of tuberculosis (all types) were reported in 2004. All tuberculosis treatment follows the DOTS strategy and there is active contact tracing. The cure rate for patients diagnosed between 2000 and 2003 was 87%. COUNTRY HEALTH INFORMATION PROFILES | 335 HIV prevalence remains very low in Tonga. Fourteen people have been diagnosed with HIV infection over the last 15 years and in March 2005 there was only one person known to be living with HIV. The volume of HIV serology testing is high, with an average of 2500-3000 HIV tests carried out annually as part of screening of blood donors, government employees and visa applicants. An estimated 45 000 HIV tests have been carried out since their introduction in the 1980s. A pilot trial with voluntary counselling and testing (VCT) at the antenatal clinic at the referral hospital will run throughout 2005. Risk behaviour surveillance and high-risk group serosurveillance started in 2005 and should provide more information about the risk of transmission. Antiretroviral drugs are not yet available in the country and there are no officially endorsed treatment guidelines for HIV infection or prevention of mother-to-child transmission. The diagnostic capacity for STIs is limited to gonorrhoea and syphilis (with the exception of HIV). The true number of cases is thought to be much higher than recorded as many patients are treated by private practitioners whose records are not included in Ministry of Health statistics. Others are treated privately by relatives or friends working in the health care system. It should be noted that there are many times more men than women diagnosed with gonorrhoea, an indication that contact tracing is poor and that there is a lack in services for women. In 2000, the only year for which official figures for both men and women are available, the ratio was 40:3 for men and women respectively. Figures from other sources confirm that the ratio of men to women who seek treatment for STIs is about 10: 1. 3.2 Health systems Government health services are provided free of charge and physical access to care is good for the majority, with the exception of small populations living on isolated islands. There are four hospitals in Tonga: the tertiary Vaiola Hospital in Nuku’alofa with 191 beds; and three district hospitals, Prince Ngu’s hospital in Vava’u (61 beds), Niu’ui hospital in Ha’apai (28 beds) and Niu’eki hospital in Eua (16 beds). The overall bed occupancy rate was 34% in 2003. Due to problems with transportation between islands, acute referrals are uncommon. The four hospitals tend to serve the populations on their respective islands with primary health care and they all run busy outpatient and emergency departments. A major renovation of Vaiola Hospital, supported by a grant from the Government of Japan and a World Bank loan, has commenced in 2005 and is expected to be completed in 2007. Primary curative care and preventive services are delivered through a system of 14 health centres and 34 maternal health clinics. There are large variations in equipment, staffing and catchment populations depending on location but, on average, a health centre serves 7200 people and is typically staffed by a health officer and one to three nurses. There 32 filled medical officer posts in 2003 (3.9 doctors per 10 000 population) to which should be added 18 filled health officer posts. In the same year, there were 342 filled nursing posts (33.7 nurses per 10 000 population). There are 13 dental officers and 10 dental therapists. The number of private providers is increasing, but the majority of private doctors remain government employees and run part-time private clinics, usually in their homes. Patients requiring specialist care that is not available in Tonga can be referred to New Zealand under two treatment schemes, one funded by the Government of Tonga and one by the Government of New Zealand. The decision whether to refer is made on a case-by-case basis by the Medical Transfer Board. Specialist treatment teams in such areas as eye surgery, plastic surgery, corrective orthopaedic surgery and rheumatic heart disease regularly visit Tonga. The Ministry of Health works with four programme areas: (1) policy formulation and administration; (2) preventive health services; (3) curative health services; and (4) dental health services. It had a total of 945 established posts in 2002, with an overall vacancy rate of 25%, making it one of the biggest employers in the country. Doctors normally train in Australia, Fiji, or New Zealand, often on bilateral scholarships or WHO fellowships. Three-year health officer training courses are organized by the Ministry of Health when required. Nurses train at the Queen Salote School of Nursing in Tonga. On average, 20-25 nurses graduate each year from TONGA 336 | COUNTRY HEALTH INFORMATION PROFILES the basic nursing training programme. A decision has been made to increase the intake several fold in order to make up for the continuous loss of nurses to Australia, New Zealand and the United States of America. The nursing school also runs a post-graduate certificate training programme in collaboration with the nursing department at the Auckland University of Technology, New Zealand. The first training programme in intensive care nursing started in 2005 and there are plans to conduct post-graduate training programmes in midwifery, internal medicine, surgery and public health in 2006-2007. A 2003 household survey on health care expenditure showed that 89% of all health services were delivered by public hospitals and only 6.2% by health centres. The Government covers 45% of total expenditure on health, households 23% and donors 32%. However, when expenditure on traditional healers and international referrals is excluded, it becomes obvious that the Government covers the absolute majority of both curative and preventive care, and that “out-of- pocket” payments on health care are low. About 12% of the population have some kind of health insurance. The private sector is still small and consists mainly of traditional healers and after- hours practising government-employed doctors. About 14% of total expenditure on health is for traditional healers, although they are mostly paid in kind. Expenditure on drugs accounts for approximately 7.8% of total expenditure on health. There is a health insurance system, but it covers only government employees. 4. NATIONAL HEALTH PLAN AND PRIORITIES Health care financing: The recurrent health budget has been around 10%–11% of the government budget for a long period and it is unlikely that the share for health will increase substantially in the future. Since government income is likely to grow only slowly in the coming years, there will be little space for growth in health sector spending with the current health financing system. At the same time, the pressure on the health system will increase with the increasing burden of noncommunicable diseases and the ageing population. Identifying alternative sources for health care financing is thus one of the top priorities of the Ministry of Health. Tonga has already achieved many of the health goals within its reach given the existing health spending level, and new solutions to increase the resources for both health promotion and health care are needed if the health status of the population is to be improved still further. Such solutions need to take into account the cultural and social situation in Tonga and should be based on the vision of an equitable health system for the entire population, as expressed in the Ministry of Health’s corporate plan. National health accounts have recently been established and the Government has obtained a loan from the World Bank to develop and implement a new health financing system in the next three years. Tonga does not have a social security system to identify who is eligible for free public health care. Prevention and control of noncommunicable diseases: The increase in noncommunicable diseases has now reached epidemic proportions. In addition to human suffering, NCDs can have a negative impact on family economies. The loss of income due to disease and the cost of treating chronic conditions can put enormous strain on families and destroy years of work to improve a family’s situation. Ultimately there will be a negative impact on the country’s economic development as more resources have to be used for health care and productive and experienced middle-aged people in the workforce are lost to death and chronic illness. Identifying and implementing effective population-targeted preventive measures that can slow the increase of disease and, in the future, reverse the trend, are of the highest priority. The national multisectoral strategy for the control and prevention of noncommunicable diseases, developed in 2003, is a sign that the Government takes the issue very seriously. There are plans to establish a Health Promotion Foundation with funding from dedicated taxation on tobacco and alcohol. Such a mechanism could provide crucial resources for health promotion, COUNTRY HEALTH INFORMATION PROFILES | 337 an area of health that is heavily dependent on external support today. Improved access to and better quality of care for noncommunicable diseases: There is a recognized need to improve both the quality of and access to health care, particularly for noncommunicable diseases, in view of the increasing burden of an ageing population. A large proportion of patients with diabetes and cardiovascular diseases are undiagnosed and untreated today. Appropriate treatment and care can greatly reduce the risk of fatal incidences and a progression to more severe disease. It is therefore a priority both to increase access to care and to improve the quality of care for people with noncommunicable diseases. This must include solutions for financing the treatment of chronic conditions and for increasing patients’ knowledge of their condition and responsibility for care. Active participation in treatment and patient empowerment are essential for successful treatment of chronic conditions. Health information and surveillance: There is a need to strengthen both the collection of information and the analysis and dissemination of health statistics for decision-making. The outcomes of investments in health care financing and prevention of noncommunicable disease must be able to be evaluated so that strategies can be modified when needed. The information must be easily available, cheap and reliable and should therefore be based on ongoing surveillance rather than repeated and costly surveys. A first step towards such a system is the strengthening of vital statistics of births and deaths, as well as a consistent hospital-based diagnosis registration system. The Government has already started important work in this area, but there is a need to strengthen the system of data collection as well as increase the capacity to process and interpret the information. The Ministry of Health is expected to invest substantially in the area of health information in the coming years, partly with resources made available through a World Bank loan. 5. MAJOR INFORMATION SOURCES Annual Reports of the Minister of Health 1995 to 2004 Ministry of Health Corporate Plan 2001-2004 Ministry of Health Corporate Plan 2005-2008 National Health Accounts report of July 2004 Tonga’s health 2000 Health Sector Support Project (HSSP/WB) Project Implementation Plan (PIP) EPI and Reproductive Health Services annual reports 2000-2003 WHO/UNICEF joint reporting form on immunization for Tonga 2004 Tonga’s report on progress towards the Millennium Development Goals (MDGs) Annual report of the National Reserve Bank 2003-2004 Government of Tonga statistics, http://www.spc.int/prism/country/to/stats TONGA 338 | COUNTRY HEALTH INFORMATION PROFILES 6. ADDRESSES MINISTRY OF HEALTH Office Address : Postal Address : P.O. Box 59, Nuku’alofa, Kingdom of Tonga Official Email Address : mohtonga@kalianet.to Telephone : (676) 23 200 Fax : (676) 24 291 Office Hours : Website : COUNTRY LIAISON OFFICER IN TONGA Office Address : Ministry of Health Nuku’alofa, Tonga Postal Address : P.O. Box 70, Nuku’alofa, Tonga Official Email Address : who@ton.wpro.who.int Telephone : (676) 23217 / 25522 Fax : (676) 23 938 Office Hours : 08.30 – 16.30 Time zone Manila +5 hrs, CET + 12 hrs COUNTRY HEALTH INFORMATION PROFILES | 339 ORGANIZATIONAL CHART: MINISTRY OF HEALTH TONGA 340 TONGA WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 0.65 2004 1 2 Estimated population ('000s) 101.87 … … 2004 est. 4 3 Annual population growth rate (%) 0.30 2001 7 4 Percentage of population - 0–14 years 37.91 39.11 36.69 2004 est 15 - 65+ years 5.29 5.04 5.55 2004 est 15 5 Urban population (%) 33.40 … … 2003 13 6 Crude birth rate (per 1000 population) 24.20 … … 2002 10 7 Crude death rate (per 1000 population) 5.80 … … 2002 10 8 Rate of natural increase of population (% per annum) 1.84 … … 2002 10 9 Health-adjusted life expectancy (HALE) (years) - at birth 70.00 70.00 72.00 2003 9 - at age 60 … 11.90 12.00 2002 12 10 Adult literacy rate (%) 98.80 … … 2000 6 11 Neonatal mortality rate (per 1000 live births) 10.00 c … … 2000 11 12 Infant mortality rate (per 1000 live births) 14.60 … … 2004 4 13 Under-five mortality rate (per 1000 live births) 16.59 … … 2001 2 14 Total fertility rate (women aged 15–49 years) 3.40 2003 9 15 Maternal mortality ratio (per 100 000 live births) 83.30 2004 4 16 Percentage of newborn infants weighing at least 2500 g at birth 97.50 … … 2002 10 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 99.60 … … 2004 14 - DTP3 99.30 … … 2004 14 - OPV3 99.30 … … 2004 14 - Measles 99.60 … … 2004 14 - Tetanus II 88.80 … … 2004 14 - Hepatitis B III 99.20 … … 2004 14 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 98.00 2004 4 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 93.00 2003 9 - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) 98.00 2004 4 21 Percentage of women in the reproductive age group using modern contraceptive methods 23.10 2002 10 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … COUNTRY HEALTH INFORMATION PROFILE 341 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 97.00 … … 2003 9 26 Proportion of population with access to improved sanitation 78.20 … … 2002 10 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) 56.00 b … … 2003 14 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.79 … … 2002 8 32 Per capita GDP at current market prices (US$) 1614.00 … … FY2002- 2003 2 33 Rate of growth per capita GDP … 34 Health expenditure Total health expenditure - amount (in million US$) … - total health expenditure on health as % of GDP … - per capita total expenditure on health (in US$) (government only) 49.00 FY2002- 2003 4 Government expenditure on health - amount (in US$) 4 950 000.00 FY2002- 2003 4 - general government expenditure on health as % of total expenditure on health 45.00 FY2002- 2003 4 - general government expenditure on health as % of total general government expenditure 10.00 FY2002- 2003 4 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors (government) 32 … … 3.90 … … 2003 4 - dentists (dental officers and dental therapists) 23 … … 2.27 … … 2003 4 - pharmacists 4 3 1 0.40 … … 2002 10 - nurses 342 … … 33.70 … … 2003 4 - midwives 21 0 21 2.08 … … 2002 10 - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 26 18 8 2.57 … … 2002 10 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 22 18 4 2.18 … … 2002 10 TONGA 342 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … 39 Five leading causes of morbidity Number Rate per 100 000 population a 1. Acute respiratory infections 20 819 … … 20 437.83 … … 2004 4 2. Influenza 20 057 … … 19 689.79 … … 2004 4 3. Bronchiopneumonia 1947 … … 1911.35 … … 2004 4 4. Diarrhoea (adult) 1011 … … 992.49 … … 2004 4 5. Diarrhoea (children) 671 … … 658.71 … … 2004 4 40 Five leading causes of mortality Number Rate per 100 000 population 1. Diseases of the circulatory system 146 … … 190.10 … … 2002 4 2. Neoplasms 67 … … 77.23 … … 2002 4 3. Symptoms, signs and ill-defined conditions 51 … … 53.47 … … 2002 4 4. Diseases of the respiratory system 37 … … 49.50 … … 2002 4 5. Endocrine, nutritional and metabolic conditions 33 … … 43.56 … … 2002 4 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2004 14 - Pertussis (whooping cough) 0 0 0 … … … 2004 14 - Tetanus 0 0 0 … … … 2004 14 - Neonatal tetanus 0 0 0 … … … 2004 14 - Poliomyelitis 0 0 0 … … … 2004 14 - Hib meningitis 16 … … … … … 2004 14 - Measles 0 0 0 … … … 2004 14 - Mumps 0 0 0 … … … 2004 14 - Rubella 0 0 0 … … … 2004 14 - Congenital rubella syndrome 0 0 0 … … … 2004 14 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral 7 4 3 0 0 0 2002 3 - Type A 2 0 2 0 0 0 2002 3 - Type B 5 4 1 5 3 2 2002 3 - Type C 0 0 0 0 0 0 2002 3 - Unspecified 0 0 0 0 0 0 2002 3 Cholera 0 0 0 0 0 0 2002 3 Typhoid fever 23 … … … … … 2003 4 Encephalitis 2 … … … … … 2003 2 Plague 0 0 0 0 0 0 2002 3 Syphilis 0 0 0 0 0 0 2002 3 Gonorrhoea 42 … … … … … 2003 2 Leprosy 0 0 0 … … … 2003 2 Malaria … … … … … … Dengue/DHF 194 … … … … … 2003 2 COUNTRY HEALTH INFORMATION PROFILE 343 INDICATORS DATA Year Source Total Male Female Total Male Female 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … 1.00 … … 2000 est 12 - Proportion of population in malaria-risk areas using effective malaria prevention measures d … - Proportion of population in malaria-risk areas using effective malaria treatment measures e … 44 Tuberculosis Number of cases Number of deaths - All types 16 … … … … … 2003 14 - New pulmonary tuberculosis (smear-positive) 11 … … … … … 2003 14 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 44.00 … … 5.00 … … 2003 14 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 80.00 … … 83.00 (2002) … … 2003 14 Number of cases Number of deaths 45 Acute respiratory infections 16 038 … … … … … 2003 3 46 Diarrhoeal diseases 2320 … … … … … 2003 3 47 Cancers All cancers (malignant neoplasms only) 101 46 55 76 42 34 2002 10 - Trachea, bronchus and lung 7 7 0 13 11 2 2002 10 - Stomach 8 6 2 5 4 1 2002 10 - Colon and rectum 3 3 0 0 0 0 2002 10 - Lip, oral cavity and pharynx 6 3 3 3 0 3 2002 10 - Liver 6 3 3 8 6 2 2002 10 - Cervix 7 0 7 3 0 3 2002 10 - Leukaemia 1 0 1 1 0 1 2002 10 48 Circulatory All circulatory system diseases … … … 192 121 71 2002 10 - Ischaemic heart disease 34 18 16 7 7 0 2002 10 - Acute myocardial infarction 34 26 8 28 19 9 2002 10 - Rheumatic fever and rheumatic heart diseases 21 9 12 1 1 0 2002 10 - Cerebrovascular diseases 41 15 26 21 9 12 2002 10 - Hypertension 1154 634 520 7 4 3 2002 10 49 Maternal causes - Haemorrhage 0 0 1 1 2002 10 - Abortion 114 114 0 0 2002 10 - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … 50 Diabetes mellitus 2035 787 1248 35 14 21 2002 10 51 Mental disorders 199 130 69 0 0 0 2002 10 TONGA 344 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 52 Injuries - All types … … … … … … - Motor and other vehicle accidents 109 80 29 0 0 0 2002 10 - Suicide 0 0 0 1 1 0 2002 10 - Homicide and violence 0 0 0 1 1 0 2002 10 - Occupational injuries 0 0 0 0 0 0 2002 10 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 191 2004 5 - Specialized hospitals … … - District/first-level referral hospitals 3 105 2004 5 - Primary health care centres … … Private hospitals … … Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate FY Financial year (1st July – 20th June) a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Modelled data c Estimates derived by regression and similar estimation methods. d Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. e Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004 2 Tonga Statistics Department (http://www.spc.in/prism) 3 Information Unit, Ministry of Health 4 Information provided by Country Liaison Officer for Tonga, 10 May 2005 5 Information provided by Country Liaison Officer for Tonga, 05 March 2004 6 Report of the Minister of Education – Year 2000 7 Report of the Minister of Health – Year 2001 8 Human development report 2004. New York, United Nations Development Programme, 2004. 9 Report of the Minister of Health for the year 2003 10 Report of the Minister of Health for the year 2002 11 World health report 2005: Make every mother and child count. Geneva, World Health Organization, 2005. 12 World health report 2004: Changing history. Geneva, World Health Organization, 2004. 13 Urban and rural areas 2003. New York, United Nations Department of Economic and Social Affairs, Population Division, 2004. 14 WHO Regional Office for the Western Pacific, data received from technical units 15 Demographic tables for the Western Pacific Region 2000-2005. Manila, WHO Regional Office for the Western Pacific, 2005. COUNTRY HEALTH INFORMATION PROFILES | 345 TUVALU 1. DEMOGRAPHICS, GENDER AND POVERTY Tuvalu is one of the smallest independent countries in the world, comprising nine low-lying atolls with a total land area of only 25.63 square kilometres. With an estimated population of 9600 in 2004, the country has a very high population density. About 47% of the population reside in urban areas. Gender equality has been achieved in primary and secondary school enrolment. Tuvalu’s main resource is considered to be its ocean, but the country will need vast financial resources, technology and manpower to fully tap its potential. The poor sandy soil requires intensive agricultural input so that vegetable and fruit can be grown. There is very little industry, although there are small government and family-owned businesses that cater for tourists, and a new fishing industry is being developed. In 2002, (39%) of the population were employed. Of these, the majority (54%) owned their businesses, 9% were selling fish, handicrafts and other local items, 2% were in other forms of employment, and 6.2% earned no income. Table 1. Core population and health data (2004 estimate) [Total] 9600 [Both] 65.00 (2002) [0-14 years] (31.33%) [Male] 64.00 (2002) Population [65+ years] (6.57%) Life expectancy at birth (years) [Female] 67.00 (2002) Crude birth rate (per 1000 population) 27.10 (2002) Total fertility rate 3.70 (2002) [Total] 100.00 (2002) [Urban] 100.00 (2002) Crude death rate (per 1000 population) 9.90 (2002) % of population served with safe water [Rural] 100.00 (2002) [Total] 100.00 (2002) [Urban] 100.00 (2002) Infant mortality rate (per 1000 live births) 21.60 (2003) % of population with adequate sanitary facilities [Rural] 100.00 (2002) Maternal mortality rate (per 100 000 live births) 0.00 (2002) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Tuvalu is a member if the Pacific Islands' Forum and is associated with the European Union as a member of the African Caribbean Pacific Group. In 2000, the country acceded to full membership of both the United Nations and the Commonwealth. Tuvalu has a high Commissioner in Suva, Fiji; Consuls-General in Australia and New Zealand; and Honorary Consuls in Germany, Belgium, Japan and the Vatican. There has been a Tuvalu mission to the United Nations in New York since 2002. A national election took place in July 2002 and new cabinet members were appointed in October 2003. TUVALU 346 | COUNTRY HEALTH INFORMATION PROFILES 2.2 Economic situation Foreign fishing licence fees support the Tuvalu economy to a substantial degree, in addition to interest from the Tuvalu Trust Fund established by donors and the Government of Tuvalu in 1987. Remittances from Tuvaluans working abroad in the phosphate industry on Nauru or as seamen on overseas ships provide a further source of foreign exchange. Windfall gains from commercial marketing of its “.tv” Internet country domain name have boosted Tuvalu’s finances considerably in recent years. The country has bilateral fishing agreements with the United States of America, the Republic of Korea, Japan and Taiwan (China). Australia presented Tuvalu with a patrol boat and support team in late 1993, which improved enforcement of the Tuvalu fisheries zone. The Government and the population are conscious of the potential long-term negative impact of global warming on the country’s landmass, although scientific evidence at this stage remains controversial. At present, the biggest fear is a tidal wave or hurricane. The last hurricane occurred in 1972. Tuvalu has also inquired about buying land in Fiji for resettlement of some of its people both to ease pressure on the country’s limited land and as a long-term hedge against a possible rise in the sea level. An appeal to New Zealand for assistance resulted in a migratory scheme that permits 70 Tuvaluans to migrate to New Zealand each year. It was agreed that this woul only be a start and would not solve the problem, but would only slightly alleviate population pressure on limited living space. This migratory scheme continues to fall behind the targeted number each year. It is assumed that the problem will have to be examined over the long term and other countries like Australia will be approached. The major sources of income for the people of Tuvalu are the sale of copra and fishing rights, wages paid for employment, remittance from relatives living overseas and seamen's wages sent home to their families. Per capita gross domestic product was 2872 Australian dollars (approximately US$ 2096) in 2002. 3. HEALTH SITUATION 3.1 Health trends Communicable diseases are the major cause of morbidity, with alarming numbers of skin infections, acute respiratory infections and eye infections reported. An increase in tuberculosis prevalence has resulted in strengthening of the programme and a filariasis mass drug programme is in place. Vector control is an ongoing activity. Lifestyle diseases are also evident. 3.2 Health systems Health services are working to meet the new demands of the changing lifestyles (especially regarding diet) of the population. Few economies of scale exist in terms of human resources. While health workers have most of the key skills, they have little depth in their human resources. Therefore, there is often no one to take over core responsibilities if someone goes on sabbatical or fellowship, changes jobs due to a promotion or transfer, or acquires additional responsibilities. This situation applies in remote communities as well as in urban areas. Such a situation requires that development efforts be designed differently from those for large economies, where economies of scale are possible. Rainwater is the main source of fresh water in Tuvalu. Thus, any period of drought poses very serious consequences for the health and well-being of the population. COUNTRY HEALTH INFORMATION PROFILES | 347 Millennium Development Goals The Pacific Islands Regional MDG Report was compiled in 2004 to ensure that all Pacific island countries and areas are represented in the United Nations Secretary-General’s 2005 report. Such a report is particularly appropriate in the Pacific region due to the high degree of regional cooperation on development-related issues. The 14 Pacific island countries and one territory covered by the report (Cook Islands, the Federated States of Micronesia, Fiji, Kiribati, the Marshall Islands, Nauru, Niue, Palau, Papua New Guinea, Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu and Vanuatu) are widely dispersed over a large geographical area. They differ significantly in size, population, resource endowments and development constraints, but nevertheless share a number of development challenges. The Pacific Islands Regional MDG Report is the sixth regional MDG report to be prepared worldwide. The main partners in MDG achievement are, in addition to the national line ministries, the United Nations and the Council of Regional Organisations of the Pacific (CROP), which is a high-level advisory body made up of the heads of the region’s 10 primary intergovernmental organizations. CROP is chaired by the Pacific Islands Forum Secretariat (PIFS). Other members comprise: Forum Fisheries Agency (FFA), Pacific Islands Development Program (PIDP), Secretariat of the Pacific Community (SPC), South Pacific Regional Environment Programme (SPREP), South Pacific Applied Geo-science Commission (SOPAC), University of the South Pacific (USP), South Pacific Tourism Organisation (SPTO), South Pacific Board for Educational Assessment (SPBEA), and Fiji School of Medicine. 4. NATIONAL HEALTH PLAN AND PRIORITIES The national health policy goals for Tuvalu are: • to prevent diseases, promote healthy lifestyles, and raise the standard of living; • to provide high quality primary, secondary and tertiary health services; • to continually improve the effectiveness and efficiency of its health care delivery system; • to develop all health services to be customer-focused; and • to produce and retain high quality personnel for its health services. Along these lines, major activities of the Ministry of Health are geared towards: • strengthening the existing communicable diseases programme (special attention is to be given to tuberculosis, filariasis, skin infections and primary eye care); and • assessing the prevalence and incidence of noncommunicable diseases and developing corresponding preventive and control programme (particular attention is given to diabetes mellitus and hypertension). 5. MAJOR INFORMATION SOURCES 2002 Tuvalu annual report Tuvalu Central Statistics Division (http://www.spc.int/prism) TUVALU 348 | COUNTRY HEALTH INFORMATION PROFILES 6. ADDRESSES MINISTRY OF HEALTH Office Address : Postal Address : P.O. Box 36, Funafuti, Tuvalu Official Email Address : Telephone : Health Division: (688) 20765 Fax : Health Division: (688) 20481 Office Hours : 0800-1600 Website : WHO REPRESENTATIVE IN SOUTH PACIFIC Office Address : Level 4, Provident Plaza 1, Downtown Boulevard, 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@fij.wpro.who.int Telephone : (679) 3-304600 / 3-304631 Fax : (679) 3-300462 Office Hours : 0800H-1700H COUNTRY HEALTH INFORMATION PROFILES | 349 Organization Chart: Ministry of Health TUVALU 350 TUVALU WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 0.03 2004 1 2 Estimated population ('000s) 9.60 … … 2004 est 1 3 Annual population growth rate (%) (average) 0.60 … … 2002 4 4 Percentage of population - 0–14 years 31.33 32.98 29.75 2004 est 2 - 65+ years 6.57 5.08 8.00 2004 est 2 5 Urban population (%) 47.00 … … 2002 1 6 Crude birth rate (per 1000 population) 27.10 … … 2002 4 7 Crude death rate (per 1000 population) 9.90 … … 2002 4 8 Rate of natural increase of population (% per annum) 1.60 … … 2002 1 9 Health-adjusted life expectancy (HALE) (years) - at birth 65.00 64.00 67.00 2002 5 - at age 60 … 9.70 10.30 2002 11 10 Adult literacy rate (%) 95.00 95.00 95.00 1998 7 11 Neonatal mortality rate (per 1000 live births) … … … 12 Infant mortality rate (per 1000 live births) 21.60 … … 2003 6 13 Under-five mortality rate (per 1000 live births) 32.40 … … 2003 6 14 Total fertility rate (women aged 15–49 years) 3.70 2002 4 15 Maternal mortality ratio (per 100 000 live births) 0.00 2002 8 16 Percentage of newborn infants weighing at least 2500 g at birth 95.00 … … 2000 9 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 100.00 … … 2004 10 - DTP3 98.00 … … 2004 10 - OPV3 98.00 … … 2004 10 - Measles 98.00 … … 2004 10 - Tetanus II 96.00 … … 2004 10 - Hepatitis B III 98.00 … … 2004 10 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 99.00 2001 9 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods 28.50 2001 9 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … COUNTRY HEALTH INFORMATION PROFILE 351 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 100.00 100.00 2002 5 26 Proportion of population with access to improved sanitation 100.00 100.00 100.00 2002 5 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.58 … … 1998 7 32 Per capita GDP at current market prices (AUS$) 2096.35 … … 2002 4 33 Rate of growth per capita GDP … … … 34 Health expenditure Total health expenditure - amount (in AUS$) 250 000.00 2002 9 - total health expenditure on health as % of GNP 7.10 1998 9 - per capita total expenditure on health (in AUS$) 141.48 1998 9 Government expenditure on health - amount (in million US$) … - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure … External source of government health expenditure … - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 1.37 2002 4 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 4 … … 4.18 … … 2003 5 - dentists 2 … … 2.09 … … 2003 5 - pharmacists 2 … … 2.09 … … 2003 5 - nurses (bachelor and diploma graduate nurses) 30 … … 31.38 … … 2003 5 - midwives 10 … … 10.46 … … 2003 5 - other nursing/ auxiliary staff 12 … … 12.55 … … 2003 5 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 5 … … 5.23 … … 2003 5 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 23 … … 24.06 … … 2003 5 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … TUVALU 352 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Five leading causes of morbidity Number Rate per 100 000 population a 1. Septic sores/ wounds 4758 … … 49 764.67 … … 2003 12 2. Influenza 3663 … … 38 311.89 … … 2003 12 3. Acute respiratory infection 2950 … … 30 854.51 … … 2003 12 4. Headache 2303 … … 24 087.44 … … 2003 12 5. Cough 1890 … … 19 767.80 … … 2003 12 40 Five leading causes of mortality Number Rate per 100 000 population a 1. Heart problem 21 … … 219.64 … … 2003 12 2. Senility 11 … … 115.05 … … 2003 12 3. Undiagnosed 10 … … 104.59 … … 2003 12 4. Diabetes 5 … … 52.30 … … 2003 12 5. Hypoglycaemia 5 … … 52.30 … … 2003 12 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2004 10 - Pertussis (whooping cough) 0 0 0 … … … 2004 10 - Tetanus 0 0 0 … … … 2004 10 - Neonatal tetanus 0 0 0 … … … 2004 10 - Poliomyelitis 0 0 0 … … … 2004 10 - Hib meningitis 0 0 0 … … … 2004 10 - Measles 0 0 0 … … … 2004 10 - Mumps 0 0 0 … … … 2004 10 - Rubella 0 0 0 … … … 2004 10 - Congenital rubella syndrome 0 0 0 … … … 2004 10 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A 0 0 0 0 0 0 2001 10 - Type B 0 0 0 0 0 0 2001 10 - Type C 0 0 0 0 0 0 2001 10 - Unspecified 23 … … 0 … … 2001 10 Cholera 0 0 0 0 0 0 2001 10 Typhoid fever … … … … … … Encephalitis 0 0 0 0 0 0 2001 10 Plague 0 0 0 0 0 0 2001 10 Syphilis … … … … … … Gonorrhoea (gonococcal infections) … … … … … … Leprosy 0 0 0 … … … 2003 10 Malaria … … … … … … Dengue/DHF … … … … … … 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures b … - Proportion of population in malaria-risk areas using effective malaria treatment measures c … COUNTRY HEALTH INFORMATION PROFILE 353 INDICATORS DATA Year Source Total Male Female Total Male Female 44 Tuberculosis Number of cases Number of deaths - All types 30 … … … … … 2003 10 - New pulmonary tuberculosis (smear-positive) 0 0 0 … … … 2003 10 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 59.00 … … 6.00 … … 2003 10 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) … … … … … … Number of cases Number of deaths 45 Acute respiratory infections 2950 … … … … … 2003 8 46 Diarrhoeal diseases 967 … … 1 … … 2002 8 47 Cancers All cancers (malignant neoplasms only) 1 … … 0 … … 2001 9 - Trachea, bronchus and lung … … … … … … - Stomach … … … … … … - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … … … … - Liver … … … … … … - Cervix … … … … … … - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … … … … - Ischaemic heart disease … … … … … … - Acute myocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … … … … - Hypertension 344 … … … … … 2002 8 49 Maternal causes - Haemorrhage … … … … - Abortion … … … … - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … 50 Diabetes mellitus 281 … … … … … 2002 8 51 Mental disorders … … … … … … 52 Injuries - All types … … … … … … - Motor and other vehicle accidents 1 … … 0 0 0 2001 9 - Suicide … … … … … … - Homicide and violence … … … … … … - Occupational injuries 32 … … … … … 2002 8 53 Proportion of population with access to affordable essential drugs on a sustainable basis … TUVALU 354 INDICATORS DATA Year Source Total Male Female Total Male Female 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 40 2001 9 - Specialized hospitals … … - District/first-level referral hospitals … … - Primary health care centres 8 16 2001 9 Private hospitals 0 0 2001 9 Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific b Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. c Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community (http://www.spc.int) 2 Demographic tables for the Western Pacific 2000-2005. Manila, WHO Regional Office for the Western Pacific 3 Information furnished by the WHO Representative for the South Pacific, 24 February 2005 4 Tuvalu Central Statistics Division (http://www.spc.int/prism) 5 Information furnished by the Health Department through the WHO Representative for theSouth Pacific, 02 April 2004 6 Pacific Island Regional Millennium Development Goals report 2004. Noumea, Secretariat of the Pacific Community UN/ CROP MDG Working Group, November 2004. 7 1999 Pacific human development report (Creating opportunities). New York, United Nations Development Programme, 1999. 8 PMH health report 2002. Ministry of Health 9 Information furnished by the Health Department, Government of Tuvalu, 18 March 2003 10 WHO Regional Office for the Western Pacific, data received from technical units 11 World health report 2004. Changing history. Geneva, World Health Organization, 2004. COUNTRY HEALTH INFORMATION PROFILES | 355 VANUATU 1. DEMOGRAPHICS, GENDER AND POVERTY According to the national census in 1999, the population of Vanuatu was 186 678; the 2004 estimated population is 215 541. Around 41% of the population is below 15 years of age. The crude birth rate, according to the 1999 census, is 28.2 per 1000 population, the total fertility rate is 4.8, and the infant mortality rate is 27 per 1000 live births. Most of the population are employed in subsistence agriculture; the rest are employed in government posts, service industries and light industry. Table 1. Core population and health data (2004 estimates) [Total] 215 541 [Both] 68.60 (2002 revised) [0-14 years] 88 786 (41.19%) [Male] 67.40 (2002 revised) Population [65+ years] 6789 (3.15%) Life expectancy at birth (years) [Female] 70.40 (2002 revised) Crude birth rate (per 1000 population) 28.20 (1999) Total fertility rate 4.80 (1999) [Total] 60.00 (2002) [Urban] 85.00 (2002) Crude death rate (per 1000 population) 6.00 (1999) % of population served with safe water [Rural] 52.00 (2002) [Total] 50.00 (2002) [Urban] 78.00 (2002) Infant mortality rate (per 1000 live births) 27.00 (1999) % of population with adequate sanitary facilities [Rural] 42.00 (2002) Maternal mortality ratio (per 100 000 live births) 96.30 (1998) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Vanuatu has had a relatively prolonged period of political stability. The current Government is a coalition, formed on 19 November 2003, comprising the Vanua’aku Party, under Prime Minister Edward Natepei; the National United Party; the People’s Progressive Party (PPP); the Green Coalition Party; and the Alliance for the Development of Vanuatu. Due to shifting alliances and coalitions, the Minister of Health has changed three times since June 2002. The opposition is a wide coalition of numerous parties, led by the Union of Moderate Parties. 2.2 Economic situation For a number of years, economic growth has been stagnant or recessive. Employment has also stagnated or declined. Local industries (ice cream and tinned meat) are threatened by cheaper imports, which, under Melanesian Spear Head Group trade agreements, have increased because of reduced or eliminated tariffs between member countries. Recent revisions to the agreement reintroduced tariffs in Vanuatu for ice cream, tinned meat and other products, but the local economic effects will be minimal. The economy is moving towards complete dependence on the tourism industry, which will not be sustainable for economic development. Very few new jobs are created annually in all sectors of the economy, especially for returned trainees and graduates. In spite of the poor economic reports and forecasts, there appears to be a growing middle class with economic power. There are more new vehicles on the roads, new public transportation vehicles, mobile telephones and more people eating lunch at restaurants. This could be the result VANUATU 356 | COUNTRY HEALTH INFORMATION PROFILES of increased activity in the construction industry, at least in Port Vila. A number of new construction projects are underway because of damage caused by an earthquake on 3 January 2002. In any event, it is not clear whether the perceived local economic upturn has substance in fact. The traditional economic staples, copra and kava, are not likely to sustain economic growth into the future. Copra is currently subsidized by the Government and demand is not increasing to meet production. Kava (Rhizoma Piperis Methystici) has been the victim of investigations into its possible detrimental effect on health, specifically liver toxicity. Cocoa could be an important export if sufficient quantities can be produced. 3. HEALTH SITUATION 3.1 Health trends Two natural disasters affected Vanuatu in 2002: a major earthquake, measuring 7.5 on the Modified Mercalli Scale, hit Port Vila on 3 January; and torrential rains caused landslides and flash floods on the island of Tanna on 23 December. There was no loss of life caused by the earthquake and damage was limited to unoccupied buildings. The landslides and flash floods on Tanna caused some injuries and are blamed for an outbreak of malaria. The Ministry of Health's major health concerns are malaria, tuberculosis and noncommunicable diseases, such as diabetes. The Directorate of Public Health, which has managed an extensive vectorborne disease programme for over 20 years, is implementing DOTS and has initiated more focus on noncommunicable diseases. The incidence of malaria has been rising in certain areas, which will require further investigation. An outbreak of plasmodium falciparum malaria on Tanna in January 2003 is blamed on the landslides and flash floods in December 2002. From 2 to 13 January 2003, 46 cases were reported; the number of cases increased to 61 by 15 January. A team from the vectorborne disease control programme responded with WHO support. The Rotary Against Malaria project has begun in Sanma and Malampa provinces, funded through the Bill and Melinda Gates Foundation. Tuberculosis is a serious national concern in both urban and rural areas. DOTS has been introduced in two national hospitals, but has not yet taken hold. There is currently a shortage of laboratory technicians capable of reading sputum slides. Consequently, many cases in treatment are found to not have tuberculosis when diagnosed by X-ray or symptomatically. The number of new cases varies from year to year. Noncommunicable diseases, especially diabetes and hypertension, have come to the attention of the Ministry of Health in the last few years. The number of new outpatient cases of hypertension increased from 636 in 1995, to 770 in 1996, to 1000 in 1997. Outpatient cases of diabetes grew from 112 in 1995, to 163 in 1996, to 247 in 1997. Lifestyle changes and a growing urban population appear to be the main culprits. Sexually transmitted infections (STI) have always been suspected of being highly prevalent, and data from health facilities indicate high prevalence and incidence rates. A 20002 survey in of women under 25 visiting the antenatal clinic at the Vila Central Hospital during their first pregnancy showed incidence rates of 27.5% for Trichomonal vaginalis and 21.5% for Clamydia trachomatis. Pap smear screening and an STI survey on the island of Ambae in February 2000 showed incidence rates of 5.2% for Trichomonal vaginalis and 1.5% for Clamydia trachomatis in a sample population of 406 women aged 15–>50 years. It is of concern that the results showed 8.2% of the women tested positive for HBs antigen. Vanuatu officially reported its first HIV-positive case on 25 September 2002. There was considerable public interest in the case, giving impetus to health services improvements in the COUNTRY HEALTH INFORMATION PROFILES | 357 areas of counselling, blood safety and testing. There has been an increase in the number of people requesting AIDS tests. A successful campaign for mass drug administration (MDA) against yaws was carried out in Sanma Province in December 2001 with WHO support, in collaboration with other health partners. Since that time, cases have been reported again in Sanma, which will require further investigation. There are also reports of yaws on the island of Ambae and possibly on Tanna. MDA against filariasis has been included in the vectorborne disease programme. Other major health concerns are acute respiratory infections (ARI) and diarrhoeal diseases, which contribute significantly to the morbidity burden. Children under two years of age account for about 50% of all hospital admissions for ARI. The introduction of the integrated management of childhood illness (IMCI) strategy in Vanuatu and the support for integrated health services may reduce the burden on the health system of advanced cases of ARI and diarrhoeal diseases. 3.2 Health systems The Ministry of Health receives approximately 11%–12% of the national budget. However, the Government's worsening cash-flow situation has resulted in the amount distributed being less than that budgeted; cash releases are currently around 80% of the budgeted amount. The Ministry of Health shifted the balance of expenditures for salaries and recurrent costs from approximately 56% and 44%, respectively in 1997, to 71% and 29% in 2001. This put considerable constraints on activities and services supported through the government budget. As a requirement of the Ministry of Finance and Economic Management, the Ministry of Health produces corporate and business plans, which are universally regarded as the blueprint for development of the health sector. While the health system and services cover the country adequately in terms of facilities and access to facilities, the quality of services delivered by the health system will be improved through planned multitasking of health workers and integration of programmes for greater efficiency. There have been developments in the management of human resources in the Ministry of Health towards rationalizing salary levels and looking at career options for health workers. Currently there are no career structures in the Ministry of Health. Salary and career advancement will be tied to the new performance appraisal system. 4. NATIONAL HEALTH PLAN AND PRIORITIES There is a continuing need to consolidate rather than expand health services. Available resources for programme implementation are scarce and unreliable. More emphasis will be placed on creating added value in programmes through amalgamation of resources. Objectives include: • improving case management for communicable and noncommunicable diseases; • improving management of service delivery nationally; • improving communication between all levels of the health system; • improving the rationale for staffing and distribution; • improving community participation; and • integrating clinical health services. The overall goal for the Ministry of Health is the implementation of health service delivery from two autonomous areas of health: the Northern Health Care Group and the Southern Health Care Group. This strategy will meet the objectives and priorities of the Ministry of Health, in keeping with national primary health care policy. VANUATU 358 | COUNTRY HEALTH INFORMATION PROFILES 5. MAJOR INFORMATION SOURCES Health Workforce Plan, 2003. Development of the Health Workforce Plan, 2003. Budget and expenditure planning for the Ministry of Health 2004-2006. 2003. Country health profile, 2003. Analysis of the function and structure of the Ministry of Health. 2003 Further options for the overall management of the Ministry of Health. 2001 Health seeking practices in ural Vanuatu. 2000 6. ADDRESSES MINISTRY OF HEALTH Office Address : Postal Address : Private Mail Bag 009, Port Vila, Vanuatu Official Email Address : Telephone : (678) 22512 Fax : (678) 26 204 Office Hours : Website : COUNTRY LIAISON OFFICER IN VANUATU Office Address : George Pompidou Building, PO Box 177, Port Vila, Vanuatu Postal Address : World Health Organization PO Box 177 Port Vila, Vanuatu, South Pacific Official Email Address : who@van.wpro.who.int Telephone : (678) 27 683 Fax : (678) 22691 Office Hours : COUNTRY HEALTH INFORMATION PROFILES | 359 ORGANIZATIONAL CHART: MINISTRY OF HEALTH VANUATU 360 VANUATU WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 12.19 2004 1 2 Estimated population ('000s) 215.54 110.14 105.40 2004 est 2 3 Annual population growth rate (%) 2.70 … … 1999 3 4 Percentage of population - 0–14 years 41.19 41.70 40.66 2004 est 2 - 65+ years 3.15 3.24 3.05 2004 est 2 5 Urban population (%) 22.80 … … 2003 14 6 Crude birth rate (per 1000 population) 28.20 1999 3 7 Crude death rate (per 1000 population) 6.00 1999 3 8 Rate of natural increase of population (% per annum) 2.22a 1999 9 Health-adjusted life expectancy (HALE) (years) - at birth 68.60 67.40 70.40 2002 est g 4 - at age 60 … 11.10 11.70 2002 13 10 Adult literacy rate (%) 74.00 … … 1999 3 11 Neonatal mortality rate (per 1000 live births) 19.00 b … … 2000 est 5 12 Infant mortality rate (per 1000 live births) 27.00 27.00 26.00 1999 3 13 Under-five mortality rate (per 1000 live births) 33.00 33.00 31.00 1999 3 14 Total fertility rate (women aged 15–49 years) 4.80 1999 3 15 Maternal mortality ratio (per 100 000 live births) 96.30 1998 6 16 Percentage of newborn infants weighing at least 2500 g at birth 97.00 … … 2003 7 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 7.00 2003 7 19 Immunization coverage for infants (%) - BCG 63.00 … … 2003 8 - DTP3 49.00 … … 2003 8 - OPV3 53.00 … … 2003 8 - Measles 48.00 … … 2003 8 - Tetanus II 63.00 … … 2003 8 - Hepatitis B III 56.00 … … 2003 8 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 91.00 2003 7 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 22.00 2003 7 - Percentage of deliveries at home by trained personnel (as % of total deliveries) 3.00 2003 7 - Percentage of deliveries in health facilities (as % of total deliveries) 84.00 2003 7 21 Percentage of women in the reproductive age group using modern contraceptive methods 15.00 2001 9 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … COUNTRY HEALTH INFORMATION PROFILE 361 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 60.00 85.00 52.00 2002 10 26 Proportion of population with access to improved sanitation 50.00 78.00 42.00 2002 10 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) 79.00c … … 2003 8 28 Proportion of households with access to secure tenure 90.00 … … 1998 2 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.57 … … 2002 4 32 Per capita GDP at current market prices (US$) 1179.08 … … 2002 2 33 Rate of growth per capita GDP … … … 34 Health expenditure Total health expenditure - amount (in million US$) 6.60 2001 9 - total health expenditure on health as % of GDP … - per capita total expenditure on health (in US$) 76.22 2001 9 Government expenditure on health - amount (in million US$) … - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure … External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 138.21 Vatu (average) 2002 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 29 … … 1.35 … … 2004 est 11 - dentists … … … … … … - pharmacists … … … … … … - nurses (includes nurse practitioners and nurse aids) 312 … … 14.48 g … … 2004 est 11 - midwives 50 … … 2.32 … … 2004 est 11 - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) … … … … … … - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 51 … … 2.37 … … 2004 est 11 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … VANUATU 362 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Acute respiratory infections - all ages 42 802 …. …. 20 227.00 …. …. 2003 7 2. Malaria 22 037 …. …. 10 414.00 …. …. 2003 7 3. Scabies and skin diseases 7900 …. …. 3733.00 …. …. 2003 7 4. Worms 4496 …. …. 2125.00 …. …. 2003 7 5. Diarrhoea 3187 …. …. 1506.00 …. …. 2003 7 6. Tooth / gum diseases 2979 …. …. 1408.00 …. …. 2003 7 7. Eye infection 1853 …. …. 1558.00 …. …. 2003 7 8. Arthritis 2535 1216 1319 1198.00 1121.00 1279.00 2003 7 9. Injuries 1746 …. …. 825.00 …. …. 2003 7 10. Conjunctivitis 1646 …. …. 778.00 …. …. 2003 7 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Ashtma 24 12 12 11.00 11.00 12.00 2003 7 2. Stroke 18 9 9 9.00 8.00 9.00 2003 7 3. Heart failure 18 12 6 9.00 11.00 6.00 2003 7 4. Diabete mellitus 18 6 12 9.00 6.00 12.00 2003 7 5. Malaria 15 10 5 7.00 9.00 5.00 2003 7 6. Pneumonia 12 6 6 6.00 6.00 6.00 2003 7 7. Cardiac arrest 11 7 4 5.00 6.00 4.00 2003 7 8. Tuberculosis 7 4 3 3.00 4.00 3.00 2003 7 9. Septicaemia 6 2 4 3.00 2.00 4.00 2003 7 10. Malignant neoplasm - bronchus and lung 4 4 0 2.00 4.00 0.00 2003 7 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria … … ... … … … - Pertussis (whooping cough) … … ... … … … - Tetanus 0 0 0 … … … 2003 8 - Neonatal tetanus 3 … ... … … … 2003 8 - Poliomyelitis 0 0 0. … … … 2003 8 - Hib meningitis 20 … ... … … … 2003 8 - Measles 165 … ... … … … 2003 8 - Mumps NR … ... … … … 2003 8 - Rubella NR … ... … … … 2003 8 - Congenital rubella syndrome NR … ... … … … 2003 8 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A 26 … … 1 … … 2004 8 - Type B 18 … … 2 … … 2004 8 - Type C 1 … … 0 0 0 2004 8 - Unspecified 17 … … 1 … … 2004 8 Cholera 0 0 0 0 0 0 2004 8 Typhoid fever 20 … … 0 0 0 2004 8 Encephalitis 4 … … 1 … … 2004 8 Plague 0 0 0 0 0 0 2004 8 Syphilis … … … … … … Gonorrhoea (gonococcal infections) … … … … … … COUNTRY HEALTH INFORMATION PROFILE 363 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Leprosy 7 … … … … … 2003 8 Malaria 15 240 … … 0 0 0 2003 8 Dengue/DHF … … … … … … 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 7 188.68 … … 0.00 … … 2003 8 - Proportion of population in malaria-risk areas using effective malaria prevention measures d … - Proportion of population in malaria-risk areas using effective malaria treatment measures e … 44 Tuberculosis Number of cases Number of deaths - All types 104 … … … … … 2003 8 - New pulmonary tuberculosis (smear-positive) 40 … … … … … 2003 8 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 71.00 … … 8.00 … … 2003 8 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 70.00 … … 79.00 (2002) … … 2003 8 Number of cases Number of deaths 45 Acute respiratory infections 42 802 …. …. 41 19 22 2003 7 46 Diarrhoeal diseases 3187 …. …. … … … 2003 7 47 Cancers All cancers (malignant neoplasms only) 151 52 99 38 … … 2003 7 - Trachea, bronchus and lung 22 9 13 4 4 0 2003 7 - Stomach 3 3 0 1 1 0 2003 7 - Colon and rectum 7 4 3 1 1 0 2003 7 - Lip, oral cavity and pharynx …. …. …. … … … 2003 7 - Liver 15 10 5 3 1 2 2003 7 - Cervix 21 21 3 3 2003 7 - Leukaemia 8 3 5 5 2 3 2003 7 48 Circulatory All circulatory system diseases 402 229 173 46 …. …. 2003 12 - Ischaemic heart disease 19 14 5 3 … … 2003 12 - Acute myocardial infarction 7 7 0 3 3 0 2003 12 - Rheumatic fever and rheumatic heart diseases 30 18 12 2 1 1 2003 12 - Cerebrovascular diseases … … … … … … - Hypertension 225 100 125 3 2 1 2003 7 49 Maternal causes - Haemorrhage 72 72 … … 2003 7 - Abortion 123 123 … … 2003 12 - Eclampsia 8 8 … … 2003 7 - Sepsis 5 5 … … - Obstructed labour 25 25 … … 2003 12 VANUATU 364 INDICATORS DATA Year Source Total Male Female Total Male Female 50 Diabetes mellitus 48 13 35 18 6 12 2003 7 51 Mental disorders 133 …. …. …. …. …. 2003 7 52 Injuries f - All types 1746 …. …. 7 …. …. 2003 7 - Motor and other vehicle accidents 30 …. …. … … … 2003 7 - Suicide 29 6 23 1 0 1 2003 12 - Homicide and violence 223 73 150 …. …. …. 2003 7 - Occupational injuries 1192 …. …. 1 …. …. 2003 7 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 135 2003 7 - Specialized hospitals … … - District/first-level referral hospitals 4 262 2003 7 - Primary health care centres 25 …. 2003 7 Private hospitals … … Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate NR Not relevant a Computed by Health Information and Evidence for Policy Unit, WHO Regional Office for the Western Pacific b Estimates derived by regression and similar estimation methods c Modeled data d Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. e Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. f Deaths are underreported. Also, deaths caused by injuries represent only hospital data. Information represents only 43% of the annual monthly returns (710 monthly reports out of 1644), Information has not been received for Norsup Hospital since July 2003. g Revised data Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 2 Vanuatu Statistics Office (http://www.spc.int/prism) 3 1999 Census 4 Human development report 2004. New York, United Nations Development programme, 2004. 5 World health report 2005. Make every mother and child count. Geneva, World Health Organization, 2004. 6 Pacific Island Millennium Development Goals report 2004. Noumea, Secretariat of the Pacific Community, UN/CROP MDG Working Group, November 2004. 7 Health Information System Ministry of Health 8 WHO Regional Office for the Western Pacific, data received from technical units 9 National Health Statistics Office 10 Meeting the MDG drinking water and sanitation target: A mid-term assessment of progress. WHO and UNICEF, 2004. 11 Information furnished by the Country Liaison Officer for Vanuatu, 11 February 2004. 12 Inpatients data. Ministry of Health. 13 World health report 2004. Changing history. Geneva, World Health Organization, 2004. 14 Urban and rural areas 2003. New York. United Nations Department of Economic and Social Affairs, Population Division, 2004. COUNTRY HEALTH INFORMATION PROFILES | 365 VIET NAM 1. DEMOGRAPHICS, GENDER AND POVERTY The population of Viet Nam rose to 80 902 400 people in 2003, with 74.2% living in rural areas. Migration to urban areas continues at an ever-increasing rate. The percentage of the population aged below 15 years has decreased, while that of those over 64 years has increased, as in previous years. This is placing pressure on the health care system to deal with problems arising from an ageing population. The population growth rate in 2003 was 1.47%, an 11.36% increase compared with 2002 and contrary to a gradually reducing trend in recent decades. This reflects a certain degree of instability in family planning - the introduction of the new government ordinance on population, which clearly indicates the rights of couples to decide how many children they have, is a key contributing factor. The total fertility rate was estimated to be 2.10 in 2003, still following the declining trend of previous years. The crude birth rate decreased accordingly by 8.6% compared with the figure in 2002. The crude death rate remained unchanged at the country level, but, contrary to previous years, increased by 4.44% in urban areas, while decreasing by 5.00% in rural areas. Table 1. Core population and health data (2003 estimates) [Total] 80 902 400 [Both] 71.30 (2002) [0-14 years] 23 700 000 (29.25%) [Male] 70.00 (2002) Population [65+ years] 5 300 000 (6.53%) Life expectancy at birth (years) [Female] 73.00 (2002) Crude birth rate (per 1000 population) 17.50 Total fertility rate 2.10 [Total] 70.10 [Urban] ... Crude death rate (per 1000 population) 5.80 % of population served with safe water [Rural] 54.00 [Total] 25.30 (2002) [Urban] 68.30 (2002) Infant mortality rate (per 1000 live births) 21.00 % of population with adequate sanitary facilities [Rural] 11.50 (2002) Maternal mortality ratio (per 100 000 live births) 85.00 (2003) According to the UNDP classification, Viet Nam’s gender development index ranked at 89 among 162 countries in 2001. Gender inequity in the country is less serious than in many other countries in the Region or in other low-income countries around the world. However, it varies at different levels across regions, particularly in the North West and the Central Highlands. The incidence of ill-health, both in general and by age group, ethnicity, educational level, poverty status, disability, residence and seasons, is generally higher in females than in males. Women are more likely to buy drugs for self-treatment, and to use private health facilities and traditional medicine, but less likely to access preventive services and health facilities at higher levels, to remain in hospital for longer periods, to refer to higher levels for consultation and treatment or to visit village health workers. Per capita health expenditure among females is lower than among males. Similarly, coverage of health insurance for females is lower than for males, except for the poor, who are provided with free health insurance. Poverty reduction is one of the greatest successes of economic development in Viet Nam. The poverty rate nationwide has decreased from two-thirds to one-third in the last decade, a faster VIET NAM 366 | COUNTRY HEALTH INFORMATION PROFILES rate than in other countries at a similar level of development, but with considerable variation across regions. The Central Highlands ranks as the poorest, followed by the Northern Uplands and the Northern Central Coast. Ethnic minorities show widespread poverty, with less progress made in poverty reduction, and will remain poor for longer. The disparities in poverty coverage and reduction are consistent with those in health status and access to health services. Although the general health status of the Vietnamese people has improved in the last decade, as indicated by continuing improvements in the infant mortality rate, the maternal mortality ratio and other basic health indicators, the gaps between the poor and the non-poor in terms of health status, as well as access to health services, have widened. Improvements have resulted mostly among the non-poor. Significant progress has been made in developing water and sanitation infrastructure in the last decade. Improved water and sanitation facilities are less widespread in rural than in urban areas, but are developing at a higher rate. There is also a wide gap between the poor and the non-poor in terms of access to clean water and hygienic sanitation facilities 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Viet Nam is a socialist republic and one-party state, governed by the Communist Party of Viet Nam. The National Assembly is designated the highest representative body of the people and is the only organ with constitutional and legislative power. Beyond central government, the People’s Committees in localities are responsible for daily administration at corresponding levels. Mass organizations, such as the Women’s Union, Farmers’ Union and Youth Union, exist to accommodate the interests of the people and to serve as a link between the people and the Party. Although the political system is stable, the country’s senior leaders have raised concerns on a number of occasions about the lack of transparency, administrative inefficiency and corruption. Steps have been taken to strengthen open public debate and effective rule of law from the central to local level. 2.2 Economic situation Vietnamese authorities have moved to implement a free-market economy with socialist orientation, to modernize the economy and to produce more competitive, export-driven industries. This led to a strong GDP growth rate, averaging around 9% per year from 1993 to 1997. Following the 1997 Asian financial crisis, the annual GDP growth rate fell to 5% in 1999, and then rose to 7.7% in 2004, at an average rate of 7.04% per year. The unemployment rate in urban areas, after increasing from 5.88% to 6.44% during the period from 1996 to 2000, gradually decreased to 5.78% in 2003, while the rate of working time, used in rural areas, gradually increased from 72.28% in 1996 to 77.66% in 2003. Unemployment is a greater problem for young urban males than any other group. 3. HEALTH SITUATION 3.1 Health trends Good progress has been made in child survival over past decades. From 1993 to 2003, the infant mortality and under-five mortality rates decreased rapidly by 52.5% and 40.8% (approximately 2 per 1000 live births per year) to the current rates of 21.0 and 32.8 respectively. Viet Nam, however, remains among the 42 countries accounting for 90% of under-five deaths in the world, COUNTRY HEALTH INFORMATION PROFILES | 367 and neonatal deaths represent more than 75% of infant deaths and more than 50% of under-five deaths. Despite a gradual decrease, maternal mortality remains relatively high, mainly among ethnic minorities and in remote areas. Child nutrition has improved dramatically, with rapid annual reductions of around 2% in both the underweight rate and stunting rate among children under five between 1993 and 2003. However, the current rates are still high, at about 28.4% and 31.4%, respectively, and micronutrient deficiencies are still a significant problem. Large disparities in health status exist between different geographical regions and population groups. Health indicators in the Central Highlands, the Northern Uplands, and the Northern Central Coast are considerably worse than in the rest of the country. Health status in rural areas is poorer than urban areas, with ethnic minorities and people in mountainous areas lowest on the scale. Maternal and infant mortality among ethnic minority groups can be as much as four times higher than the national average. In remote and mountainous areas, maternal and infant mortality rates are increasing among the poorest 20% of the population. The incidence of communicable diseases has fallen in recent decades, represented in a decrease in total morbidity and mortality rates from 55.5% and 53.05% in 1976 to 27.44% and 17.42% in 2003, respectively. Acute respiratory infections (ARI), diarrhoea and gastroenteritis with presumed infectious origin, and parasitic diseases were among leading causes of morbidity in 2003, while pneumonia, respiratory tuberculosis and HIV/AIDS have been among the leading causes of mortality in recent years. ARI, diarrhoea and parasitic infections remain the most common childhood diseases. New or re-emerging diseases, such as tuberculosis (TB), HIV/AIDS, dengue fever and Japanese encephalitis, are increasing. On average, there are more than 68 500 new TB patients every year. In 2003, 4.3% of TB patients were HIV-positive. As of 2003, 77 709 HIV cases had been reported, with 6884 deaths. However, reported cases significantly understate the scale of the problem, and it is estimated that at least 150 000 people are infected with HIV, the majority in the 20-40 age group. The proportion of HIV infections among persons under 30 years of age has been increasing in recent years. Severe acute respiratory syndrome (SARS) was detected in its early stages in Viet Nam. Fatality remained relatively low, with five deaths out of 63 cases. The situation contributed to the reinforcement of infection control measures in the country and sensitized health workers and the population to ‘universal precautions’. Highly pathogenic avian influenza (HPAI) was first recognized in late 2003 and subsequently caused three waves of extensive outbreaks by February 2005, affecting most provinces and resulting in the culling of twelve million poultry. The influenza A/H5N1 virus causing these poultry outbreaks had the ability to infect humans and had led to the death of 29 out of 37 reported cases of infected persons by February 2005. The circulation and spread of HPAI in poultry continues to present an immediate threat to human health. The emergence of an altered H5N1 virus with the ability to be transmitted efficiently from person to person would result in an influenza pandemic, possibly with devastating consequences in Viet Nam. Noncommunicable diseases have shown a tendency to increase in the last two decades, with total morbidity rising from 39% in 1986 to 60.61% in 2003, and mortality from 41.08% to 59.12%. Cardiovascular diseases, cancer and diabetes are significant contributing factors. Intracerebral haemorrhage has an extremely high prevalence in emergency/intensive care units and has been among the leading causes of deaths in recent years. Heart disease is the second most common cause of death in hospitals. The number of cancer cases is rising, with an estimated 150 000 newly reported cases annually. There is no national cancer control programme as yet and diagnosis tends to be made in the late stages. VIET NAM 368 | COUNTRY HEALTH INFORMATION PROFILES Lifestyle-related health problems are becoming increasingly important, particularly tobacco use, alcohol and drug abuse, injuries due to road accidents, violence, suicide and mental health. Accidents are set to overtake infectious diseases as the most common causes of mortality, accounting for more than 20% of total deaths. Drug abuse is a growing concern and the vast majority of the 97 000 registered drug users are under the age of 30. Viet Nam is witnessing the emergence of high drug resistance to common antibiotics and has yet to formulate a strategy to tackle the problem. 3.2 Health systems The health system in Viet Nam is a mixed public-private provider system, in which the public system still plays a key role in health care, especially in prevention, research and training. The private sector has grown steadily since the ‘reform’ of the health sector in 1989, but is mainly active in outpatient care; inpatient care is provided essentially through the public sector. Only 26% of private health facilities participate in primary health care activities. In treatment areas, specialized hospitals and clinics account for only 11.36% of health facilities and are therefore often overloaded. The ratio of nurses to doctors is still very low. Health care is strengthened by national health programmes, especially those for important public health problems. The tuberculosis control programme is now considered to be one of the best, with treatment success rates of more than 90%. However, coverage in poor communities and mountainous areas is limited, usually only 50-60%. An extended immunization programme is also considered a successful child health care programme, with a high reduction in vaccine-preventable diseases, the elimination of polio, and gradual elimination of newborn tetanus. However, current conditions for vaccine maintenance, vaccination timing and safety, as well as high staff turnover, are among the current challenges to ensure the continued quality of child immunization. Total health expenditure in 2003 was 4.21% of GDP. Government expenditure accounts for only 30%, the majority of which is allocated to treatment, with increasing rates from 71.29% in 1991 to 85.02% in 2000. Budget allocation rates for prevention remain low and continue to decrease. Generally speaking, health insurance policies have not been implemented in the private sector. Pro-poor policies, such as providing health insurance cards for the poor, direct exemption from hospitalization fees, and the establishment of health care funds for the poor, are being actively implemented, but with limited coverage because of budget shortages. The current, most pressing issues are improving the quality of care, rationalizing and training health staff, and increasing public funding for health care through extension of health insurance coverage. Inequity is highest in outpatient and rehabilitation services. A large disparity in access to health care facilities exists across regions and population groups, particularly in mountainous areas and among minority ethnic groups and the poor. Access to blood transfusion services is also variable throughout the country and paid blood donors are still the main sources of blood for transfusion. The volume of blood collected, however, does not meet the needs of patients. Millennium Development Goals Viet Nam has made impressive progress towards achieving many MDGs by the target year, 2015. The process of country broad-based policy and institutional reform, launched in 1986, is a key contributing factor to this progress. Poverty has been more than halved since 1990 and continues to decline, as do child and maternal mortality. Net primary school rates already exceed 90% and continue to increase, with a virtual gender balance. Effective implementation of new policies and laws in recent years offers considerable scope for further progress towards gender equity. On the environmental front, access to clean water has been further widened, as has forest cover. Recent legislation on strengthening the role in budgetary oversight of the National Assembly and local People’s Councils is a potentially significant step towards increasing transparency, people’s participation and effective use of available resources. COUNTRY HEALTH INFORMATION PROFILES | 369 Despite these achievements, some possible setbacks and challenges have been emerging. Following steady improvements from 1993 to 1998, food poverty and hunger among the poorest of the poor, mainly ethnic minorities, appears to have worsened in most regions of the country in recent years. Gaps and disparities in human well-being are widening between the rich and the poor, and between those in rural and urban areas. Recent evidence of possible underestimation of maternal, infant and under-five mortality indicate the remaining distance to achieve some MDGs is greater than previously estimated. A number of quantitative achievements continue to mask significant shortcomings in quality. Significant gender gaps are still persistent in some important areas. 4. NATIONAL HEALTH PLAN AND PRIORITIES The Law on People’s Health Protection, issued by the National Assembly in 1989, sets out the responsibilities and rights of citizens, government, social organizations and enterprises in the protection and improvement of the population’s health, and provides the legal basis for all health activities in Viet Nam. In January 1993, the Executive Committee of the Central Communist Party released Central Resolution No. 4, which set out three key issues for the health sector: • the need to increase the government budget for health; • the need to consolidate and develop the basic health care network, with a special focus on poor and disadvantaged areas; and • the role of the Government, Party authorities and social organizations in the leadership and supervision of health care. The Government has set out ambitious goals and targets in the Ten-Year Socio-Economic Development Strategy, the Comprehensive Poverty Reduction and Growth Strategy and the National Strategy for People’s Health Care 2001–2010. These include substantially improving the human development index of the country and providing prevention and treatment services to all people. Basic health targets to be achieved by 2010 and set by the Government in the National Strategy for Peoples Health Care 2001–2010 are: • to increase the average life expectancy to 71 years; • to reduce the maternal mortality ratio to below 70 per 100 000 live births; • to reduce the infant mortality rate to below 25 per 1000 live births; • to reduce the under-five mortality rate to below 32 per 1000 live births; • to reduce the percentage of low-birth-weight infants to below 6%; • to reduce the percentage of malnourished under-five children to below 20%; • to increase the average height of young people to at least 160 cm; • to increase the ratio of medical doctors per population to 4.5/10 000 people; and • to increase the ratio of college-trained pharmacists to 1/10 000 people. The National Strategy recognizes the important role of health and the need to invest in health for accelerated socioeconomic development and to improve the quality of life of each individual. The strategy is based on four principles: • equity and efficiency of the health sector; • the fight against the broad social determinants of bad health; • the integration of traditional and modern medicines; and • an appropriate public-private mix, with the Government in a position to protect the public interest. The strategy outlines the Government’s main policies and proposals for improving the overall level and distribution of health among the entire population (ethnic minority groups, women, children, poor and the elderly). These include: • using the government budget more effectively and moving to prepayment VIET NAM 370 | COUNTRY HEALTH INFORMATION PROFILES schemes in the medium term to finance health; • reviewing and strengthening the organization of the health sector, and consolidating and developing primary health care/community-based services; • strengthening preventive care and health promotion, improving curative care, and putting in place an effective referral system; • developing human resources according to the needs of each level, and improving training; • developing traditional medicine and implementing the national drug policy in order to promote the rational and effective use of modern and traditional drugs; • developing new technology to catch up with other countries in the Region; and • improving the capacity of planning and management in all areas within the health sector. As it stands today, the National Strategy provides a broad basis for further planning and can be seen as an orientation document for the development of the health sector. However, it does not provide specific solutions on how to: (1) ensure equal access to health care; (2) improve the performance of the health system and the quality of care; (3) rationalize the use of and expenditure on drugs; and (4) respond to new public health problems, including noncommunicable diseases. Some recent policies have begun to address the solutions. In October 2002, the Prime Minister signed Decree 139 to establish the Health Care Fund for the Poor, which aims to provide free health services for 14.6 million people. As of December 2003, 11 million people had received health care through this financing mechanism. Earlier, in January 2002, the Ministry of Health published the Directive on Consolidating and Strengthening the Basic Health Care Network (06-CT/TW). However, Viet Nam still faces a number of key challenges, such as: • achieving adequate recognition that improved health outcomes are central to poverty reduction and economic growth and that health improvements require an intersectoral approach to address broad health determinants; • developing a clear consensus among policy-makers on the road to developing an efficient equity-orientated health sector; • achieving better coordination among ministries and across departments in the Ministry of Health and among partners; • strengthening pro-poor health policies to meet the needs of the disadvantaged and ethnic minorities; particularly to address the problems of financial access and the lack of responsiveness of health services to the needs of the poor; • strengthening the public health agenda to address the incomplete agenda of infectious diseases and the problems brought about by urbanization, changing lifestyles and an ageing population; • strengthening capacities at district and provincial levels to prioritize and implement successful interventions within an increasingly decentralized health system; and • improving the enforcement of regulations and speeding up the implementation of public administration reform. COUNTRY HEALTH INFORMATION PROFILES | 371 5. MAJOR INFORMATION SOURCES Health Statistical Year Books, 1998-2003. Hanoi, Ministry of Health, 1999-2004. Statistical Year Book 2003. Hanoi, General Statistics Office, 2004. Vietnam Development Report: Poverty. Joint Donor Report to the Vietnam Consultative Group Meeting. Hanoi, 2003. Reports on National Health Survey 2001-2002. Hanoi, Ministry of Health and General Statistics Office, 2003. Millennium Development Goals: Closing to the Millennium Gaps. Hanoi, United Nations, 2003. Health Policies and Guidelines. Hanoi, Health Policy Unit, Ministry of Health, 2002. http://www.moh.gov.vn/tinbyt/ http://www.gso.gov.vn/ 6. ADDRESSES MINISTRY OF HEALTH Office Address : 138A Giang Vo, Hanoi, Viet Nam Postal Address : Official Email Address : Telephone : (84 4) 846 1325 Fax : (84 4) 846 4051 Office Hours : Website : http://www.moh.gov.vn/tinbyt/ WHO REPRESENTATIVE IN VIET NAM Office Address : 63 Tran Hung Dao Street, Hoan Kiem District Ha Noi, Socialist Republic of Viet Nam Postal Address : P.O. Box 52, Ha Noi, Socialist Republic of Vietnam Official Email Address : who@vtn.wpro.who.int Telephone : (84 4) 943 3734 Fax : (84 4) 943 3740 Office Hours : VIET NAM 372 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: MINISTRY OF HEALTH COUNTRY HEALTH INFORMATION PROFILE 373 VIET NAM WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 332.60 2003 1 2 Estimated population ('000s) 80 902.40 39 755.40 41 146.90 2003 est. 1 3 Annual population growth rate (%) 1.47 1.42 1.52 2003 est. 1 4 Percentage of population - 0–14 years 29.25 30.23 27.87 2003 est 1 - 65+ years 6.53 5.33 7.68 2003 est 1 5 Urban population (%) 25.80 … … 2003 1 6 Crude birth rate (per 1000 population) 17.50 … … 2003 est 1 7 Crude death rate (per 1000 population) 5.80 … … 2003 est 1 8 Rate of natural increase of population (% per annum) 1.50 … … 2003 1 9 Health-adjusted life expectancy (HALE) (years) - at birth 71.30 70.00 73.00 2002 1 - at age 60 … 11.40 13.10 2002 11 10 Adult literacy rate (%) 92.70 94.50 90.90 2002 2 11 Neonatal mortality rate (per 1000 live births) … … … 12 Infant mortality rate (per 1000 live births) 21.00 … … 2003 est 1 13 Under-five mortality rate (per 1000 live births) 32.80 … … 2003 est 1 14 Total fertility rate (women aged 15–49 years) 2.10 2003 est 1 15 Maternal mortality ratio (per 100 000 live births) 85.00 2003 1 16 Percentage of newborn infants weighing at least 2500 g at birth 94.20 … … 2003 1 17 Prevalence of underweight children under five years of age 28.40 … … 2003 1 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 95.60 … … 2004 10 - DTP3 96.20 … … 2004 10 - OPV3 96.30 … … 2004 10 - Measles 97.10 … … 2004 10 - Tetanus II 87.80 … … 2004 10 - Hepatitis B III 94.20 … … 2004 10 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel 86.00 2001 3 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 91.00 2003 1 - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) 79.00 2002 5 21 Percentage of women in the reproductive age group using modern contraceptive methods 76.90 2002 4 22 Condom use rate of the contraceptive prevalence rate 32.80 … … 2003 1 23 HIV prevalence among 15–24 year old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … VIETNAM 374 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 70.10 … 54.00 2003 est 1 26 Proportion of population with access to improved sanitation 25.30 68.30 11.50 2002 4 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) 70.00 ... ... 2003 10 28 Proportion of households with access to secure tenure ... ... ... 29 Proportion of vehicles using unleaded gasoline (%) ... ... ... 30 Health care waste generation (metric tons per year) ... ... ... 31 Human development index 0.69 ... ... 2002 2 32 Per capita GDP at current market prices (‘000 VND) 7484.22 ... ... 2003 est 1 33 Rate of growth per capita GDP 11.30 ... ... 2003 1 34 Health expenditure Total health expenditure - amount (in US$) 1 667 000 000.00 2003 est 1, 7 - total health expenditure on health as % of GDP 4.21 2003 est 1, 6 - per capita total expenditure on health (in US$) 20.60 2003 est 1 Government expenditure on health - amount (in US$) 500 000 000.00 2003 est 1 - general government expenditure on health as % of total expenditure on health 30.00 2003 est 7 - general government expenditure on health as % of total general government expenditure 4.50 2002 est 1 External source of government health expenditure - external resources for health as % of general government expenditure on health 3.55 2003 est 1 Private health expenditure - private expenditure on health as % of total expenditure on health 71.50 2000 8 Exchange rate in US$ of local currency is: 1 US$ = 15 500.00 VND (average) 2003 35 Health insurance expenditure - health insurance coverage as % of total population 16.00 2002 9 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors 47 587 … … 5.88 … … 2003 1 - dentists … … … … … … - pharmacists 24 596 … … 3.04 … … 2003 1 - nurses 48 157 … … 5.95 … … 2003 1 - midwives 16 218 … … 2.00 … … 2003 1 - other nursing/ auxiliary staff … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 57 962 … … 5.89 … … 2002 1 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 46 978 … … 5.80 … … 2003 1 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … COUNTRY HEALTH INFORMATION PROFILE 375 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Urolithiasis 304 200 … … 376.01 … … 2003 1 2. Pneumonia 287 899 … … 355.86 … … 2003 1 3. Acute bronchitis and acute bronchiolitis 193 063 … … 238.64 … … 2003 1 4. Diarrhoea and gastroenteritis of presumed infectious origin 175 142 … … 216.49 … … 2003 1 5. Influenza 135 070 … … 166.95 … … 2003 1 6. Transport accident 132 679 … … 164.00 … … 2003 1 7. Essential (primary) hypertension 112 032 … … 138.48 … … 2003 1 8. Gastritis and duodenitis 91 684 … … 113.33 … … 2003 1 9. Diseases of appendix 89 262 … … 110.33 … … 2003 1 10. Cataract and other disorders of the lens 70 870 … … 87.60 … … 2003 1 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Intracranial injury 2327 … … 2.88 … … 2003 1 2. Pneumonia 1374 … … 1.70 … … 2003 1 3. Human immuno deficiency virus disease 1260 … … 1.56 … … 2003 1 4. Transport accident 1230 … … 1.52 … … 2003 1 5. Intracerebral haemorrhage 1181 … … 1.46 … … 2003 1 6. Stroke, not specified as haemorrhage or infarction 922 … … 1.14 … … 2003 1 7. Heart failure 779 … … 0.96 … … 2003 1 8. Acute myocardial infarction 733 … … 0.91 … … 2003 1 9. Respiratory tuberculosis 723 … … 0.89 … … 2003 1 10. Septicemia 638 … … 0.79 … … 2003 1 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases (C) Number of deaths (D) - Diphtheria 49 … … 6 … … C:2004 D: 2002 C: 10 D: 1 - Pertussis (whooping cough) 328 … … 1 … … C:2004 D: 2002 C: 10 D: 1 - Tetanus 72 … … 19 … … C:2004 D: 2002 C: 10 D: 1 - Neonatal tetanus 46 … … 52 … … C:2004 D: 2002 C: 10 D: 1 - Poliomyelitis 0 0 0 … … … 2004 10 - Meningitis … … … 15 … … 2002 1 - Measles 217 … … 0 0 0 C:2004 D: 2002 C: 10 D: 1 - Mumps … … … … … … - Rubella … … … … … … - Congenital rubella syndrome … … … … … … 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral 7079 … … 2 … … 2003 1 - Type A … … … … … … - Type B … … … … … … - Type C … … … … … … - Unspecified … … … … … … Cholera 343 … … 0 … … 2003 1 VIETNAM 376 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Typhoid fever 5946 … … 2 … … 2003 1 Encephalitis 2095 … … 125 … … 2003 1 Plague 0 … … 0 … … 2003 1 Syphilis 2892 … … 0 … … 2003 1 Gonorrhoea 6885 … … 0 … … 2003 1 Leprosy 949 … … … … … 2003 10 Malaria (confirmed) 37 416 … … 50 … … 2003 10 Dengue/DHF 49 751 … … 72 … … 2003 1 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 46.00 ... ... 0.06 ... ... 2003 10 - Proportion of population in malaria-risk areas using effective malaria prevention measures b … - Proportion of population in malaria-risk areas using effective malaria treatment measures c … 44 Tuberculosis Number of cases Number of deaths - All types 92 741 … … … … … 2003 10 - New pulmonary tuberculosis (smear-positive) 55 937 … … … … … 2003 10 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 240.00 ... ... 23.00 ... ... 2003 10 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 86.00 ... ... 92.00 (2002) ... ... 2003 10 Number of cases Number of deaths 45 Acute respiratory infections 258 750 … … 148 … … 2003 1 46 Diarrhoeal diseases 175 145 … … 121 … … 2003 1 47 Cancers All cancers (malignant neoplasms only) 98 849 … … 784 … … 2003 1 - Trachea, bronchus, and lung 5893 … … 146 … … 2003 1 - Stomach 4912 … … 146 … … 2003 1 - Colon and rectum 2753 … … 77 … … 2003 1 - Lip, oral cavity and pharynx 2338 … … 15 … … 2003 1 - Liver 4401 … … 130 … … 2003 1 - Cervix 2643 … … 11 … … 2003 1 - Leukaemia 2328 … … 72 … … 2003 1 48 Circulatory All circulatory system diseases 323 049 … … 4294 … … 2003 1 - Ischaemic heart disease 17 052 … … 93 … … 2003 1 - Acute myocardial infarction 7627 … … 733 … … 2003 1 - Rheumatic fever and rheumatic heart diseases 14 761 … … 31 … … 2003 1 - Cerebrovascular diseases 22 565 … … 133 … … 2003 1 - Hypertension 125 797 … … 320 … … 2003 1 COUNTRY HEALTH INFORMATION PROFILE 377 INDICATORS DATA Year Source Total Male Female Total Male Female 49 Maternal causes - Haemorrhage 3263 3263 69 69 2003 1 - Abortion 30 130 30 130 2003 1 - Eclampsia 558 558 13 13 2003 1 - Sepsis 479 479 6 6 2002 1 - Obstructed labour … … … … 50 Diabetes mellitus 14 562 … … 110 … … 2003 1 51 Mental disorders 4490 … … 2 … … 2003 1 52 Injuries - All types 244 541 … … 2258 … … 2003 1 - Motor and other vehicle accidents 132 679 … … 1230 … … 2003 1 - Suicide 16 911 … … 392 … … 2003 1 - Homicide and violence 14 186 … … 68 … … 2003 - Occupational injuries 1407 … … 62 … … 2002 1 53 Proportion of population with access to affordable essential drugs on a sustainable basis ... 54 Health infrastructure Number Number of beds Public health facilities 13 102 184 440 2003 1 - General hospitals 717 (excluding district hospitals) 91 366 2003 1 - Specialized hospitals 101 (polyclinic, maternity homes, etc.) 20 580 2003 1 - District/first level referral hospitals 908 9203 2003 1 - Primary health care centres 11 161 45 995 2003 1 Private hospitals … … Notes: Red text Millennium Development Goals indicators … Data not available est. Estimate a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. c Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Health Statistics Yearbook 2003: HSID. Planning and Finance Department, Ministry of Health. 2 Human Development Report 2004. UNDP 3 Health Statistics Yearbook 2001: HSID. Planning and Finance Department, Ministry of Health. 4 Health Statistics Yearbook 2002: HSID. Planning and Finance Department, Ministry of Health. 5 Demography and Health Survey. Hanoi, Vietnam Commission for Population, Family and Children, 2003. 6 Statistical Year Book 2003. Hanoi, General Statistics Office, 2004 7 National Health Account: The process of implementation and development in Vietnam. Hanoi, Ministry of Health, 2004. 8 National Health Accounts 2000. Planning and Finance Department, Ministry of Health. 9 Viet Nam Social Security (VSS) Statistics Yearbook 2002 10 WHO Regional Office for the Western Pacific, data received from technical units 11 The World health report 2004: Changing history. Geneva, World Health Organization, 2004. 378 | COUNTRY HEALTH INFORMATION PROFILES WALLIS AND FUTUNA 1. DEMOGRAPHICS, GENDER AND POVERTY The population of Wallis and Futuna, as of the latest census in 2003, was 14 944, comprising 7494 males and 7450 females. Overall, the life expectancy was 74.3 years, 73.1 for males and 75.5 for females. The average age of the population was 23.9 years. Table 1. Core population and health data (2003) [Total] 14 944 [Both] 74.30 (est) [0-14 years] (35.54%) (est) [Male] 73.10 (est) Population [65+ years] (5.27%) (est) Life expectancy at birth (years) [Female] 75.50 (est) Crude birth rate (per 1000 population) 19.40 Total fertility rate 3.10 (est) [Total] 80.90 [Urban] … Crude death rate (per 1000 population) 5.90 % of population served with safe water [Rural] … [Total] 68.50 [Urban] … Infant mortality rate (per 1000 live births) 5.90 (est) % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) … (est): Estimate 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Wallis and Futuna is a French overseas territory. The Chief of State is President Jacques Chirac of France, and the head of government is the President of the Territorial Assembly, Patalione Kanimoa. There are three traditional kings with limited powers; the kingdoms are Uvea, Alo and Sigave. 2.2 Economic situation The economy of Wallis and Futuna is limited to traditional subsistence agriculture, with about 80% of labour force earnings from agriculture (coconut and vegetables), livestock (mostly pigs) and fishing. About 4% of the population is employed by the Government. Revenues come from French Government subsidies, licensing of fishing rights to Japan and the Republic of Korea, import taxes, and remittances from expatriate workers in New Caledonia. 3. HEALTH SITUATION 3.1 Health trends Dengue outbreaks in Wallis and Futuna were reported in 1976 (Type I), 1988 (Type II) and 1989 (Type II and III). The last outbreak started in September 2002. The total number of dengue cases reported was 2045, including 1535 suspected cases, 166 cases confirmed, 280 cases hospitalized and two cases resulting in death. Other data for health indicators are not available. COUNTRY HEALTH INFORMATION PROFILES | 379 3.2 Health systems As of 2003, there were one hospital and three dispensaries in Wallis, and one hospital and two dispensaries in Futuna. As for the health workforce, there were five physicians in Wallis and three in Futuna, two midwives in Wallis and one in Futuna, three dentists in Wallis and one in Futuna. Only Wallis has a chemist, biologist, gynaecologist, surgeon, anaesthetist and an internist. Wallis and Futuna each have a physical therapist. 4. NATIONAL HEALTH PLAN AND PRIORITIES There is no information available. 5. MAJOR INFORMATION SOURCES Secretariat of the Pacific Community (http://www.spc.int/prism/wf/) Draft of WHO mission report by Dr K.Ichimori to Wallis and Futuna from 9-13 May 2003. WHO Western Pacific Regional Office. Pacific Magazine, January 2004 http://www.pacificislands.cc World Factbook , CIA (http://www.cia.gov/cia/publications/factbook/geos/wf.html) 6. ADDRESSES MINISTRY OF HEALTH AND WELFARE Office Address : Postal Address : B.P. 4G Mata’utu, 98600 Uvea Official Email Address : sante.wf@wallis.co.nc Telephone : Fax : (681) 72-23-99 Office Hours : Website : WHO REPRESENTATIVE IN SOUTH PACIFIC Office Address : Level 4, Provident Plaza 1, Downtown Boulevard, 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@sp.wpro.who.int Telephone : (679) 330 4600 / 330 4631 / 330 4635 / 331 7447 Fax : (679) 330 0462 / 331 1530 Office Hours : WALLIS AND FUTUNA 380 WALLIS AND FUTUNA WESTERN PACIFIC REGION HEALTH DATABANK, 2005 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 0.14 2003 1 2 Estimated population ('000s) 14.94 7.49 7.45 2003 5 3 Annual population growth rate (%) 1.00 a … … 2003 est 1 4 Percentage of population - 0–14 years 35.54 36.99 34.14 2003 est 2 - 65+ years 5.27 4.60 5.92 2003 est 2 5 Urban population (%) 0.00 … … 2003 1 6 Crude birth rate (per 1000 population) 19.40 … … 2003 5 7 Crude death rate (per 1000 population) 5.90 … … 2003 5 8 Rate of natural increase of population (% per annum) 1.63 … … 2003 1 9 Health-adjusted life expectancy (HALE) (years) - at birth 74.30 73.10 75.50 2003 est 5 - at age 60 … … … 10 Adult literacy rate (%) (19 to 80+ years) 78.80 78.20 78.20 2003 5 11 Neonatal mortality rate (per 1000 live births) … … … 12 Infant mortality rate (per 1000 live births) 5.90 … … 2003 est 5 13 Under-five mortality rate (per 1000 live births) … … … 14 Total fertility rate 3.10 2003 est 5 15 Maternal mortality ratio (per 100 000 live births) … 16 Percentage of newborn infants weighing at least 2500 g at birth … … … 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 73.50 … … 2002 3 - DTP3 100.00 … … 2002 3 - OPV3 100.00 … … 2002 3 - Measles 100.00 … ... 2002 3 - Tetanus II 69.50 … … 2002 3 - Hepatitis B III 100.00 … … 2002 3 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by trained health personnel … - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by trained personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS … … … COUNTRY HEALTH INFORMATION PROFILE 381 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 80.90 … … 2003 5 26 Proportion of population with access to improved sanitation 68.50 … … 2003 5 27 Proportion of the population using solid/biomass fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index … … … 32 Per capita GDP at current market prices (US$) … … … 33 Rate of growth per capita GDP … … … 34 Health expenditure Total health expenditure - amount (in million US$) … - total health expenditure on health as % of GDP … - per capita total expenditure on health (in US$) … Government expenditure on health - amount (in US$) 4 789 274.05 2003 est 5 - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure 7.58 a 2003 5 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 104.7351 CFP (average) 2003 5 35 Health insurance expenditure - health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - doctors (physicians and specialists) 11 … … 7.36 b … … 2003 4 - dentists 4 … … 2.70 … … 2003 4 - pharmacists … … … … … … - nurses … … … … … … - midwives 5 … … 3.38 … … 2003 4 - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 2 … … 1.34 … … 2003 4 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates - physicians … … … 38 Yearly new graduates - nurses … … … WALLIS AND FUTUNA 382 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. … … … … … … 2. … … … … … … 3. … … … … … … 4. … … … … … … 5. … … … … … … 6. … … … … … … 7. … … … … … … 8. … … … … … … 9. … … … … … … 10. … … … … … … 40 Ten leading causes of mortality Number Rate per 100 000 population 1. … … … … … … 2. … … … … … … 3. … … … … … … 4. … … … … … … 5. … … … … … … 6. … … … … … … 7. … … … … … … 8. … … … … … … 9. … … … … … … 10. 41 Cases and deaths for selected diseases under the WHO-EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2002 3 - Pertussis (whooping cough) 0 0 0 … … … 2002 3 - Tetanus 0 0 0 … … … 2002 3 - Neonatal tetanus 0 0 0 … … … 2002 3 - Poliomyelitis 0 0 0 … … … 2002 3 - Hib meningitis 0 0 0 … … … 2002 3 - Measles 0 0 0 … … … 2002 3 - Mumps 2 … … … … … 2002 3 - Rubella 1 … … … … … 2002 3 - Congenital rubella syndrome … … … … … … 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Hepatitis viral - Type A … … … … … … - Type B … … … … … … - Type C … … … … … … - Unspecified … … … … … … Cholera … … … … … … Typhoid fever … … … … … … Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … Gonorrhoea (gonococcal infections) … … … … … … Leprosy 0 0 0 … … … 2003 3 COUNTRY HEALTH INFORMATION PROFILE 383 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases Number of deaths Malaria … … … … … … Dengue/DHF 166 … … 2 … … 2002 4 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 15 … … … … … 2003 3 - New pulmonary tuberculosis (smear-positive) 7 … … … … … 2003 3 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 30.00 … … 2.00 … … 2003 3 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 356.00 … … 100.00 (2002) … … 2003 3 Number of cases Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (malignant neoplasms only) … … … … … … - Trachea, bronchus and lung … … … … … … - Stomach … … … … … … - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … … … … - Liver … … … … … … - Cervix … … … … … … - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … … … … - Ischaemic heart disease … … … … … … - Acute myocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … … … … - Hypertension … … … … … … 49 Maternal causes - Haemorrhage … … … … - Abortion … … … … - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … 50 Diabetes mellitus … … … … … 51 Mental disorders … … … … … … WALLIS AND FUTUNA 384 INDICATORS DATA Year Source Total Male Female Total Male Female 52 Injuries - All types … … … … … … - Motor and other vehicle accidents … … … … … … - Suicide … … … … … … - Homicide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 2 74 2003 7 - Specialized hospitals … … - District/first -level referral hospitals … … - Primary health care centres (dispensaries) 5 … 2003 7 Private hospitals … … Notes: Red text Millennium Development Goals indicators … Data not available est Estimate a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Revised data c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Pacific island populations 2004. Secretariat of the Pacific Community (http://www.spc.int) 2 Demographic tables for the Western Pacific Region 2000-2005. Manila, WHO Regional Office for the Western Pacific, 2005. 3 WHO Regional Office for the Western Pacific, data received from technical units 4 Information furnished by the WHO Representative to the South Pacific, 30 March 2004 5 Service territorial de la statistique (http://www.spc.int/prism/wf/) Statistical Tables STATISTICAL TABLES 386 American Samoa 2004 est 62.60 0.20 313.00 Australia 2004 20 111.30 7692.02 2.61 Brunei Darussalam 2004p 357.80 5.77 62.01 Cambodia 2004 13 091.00 181.04 72.31 China 2004p 1 299 880.00 9600.00 135.40 Cook Islands 2003 est 18.40 0.24 76.67 Fiji 2003 est 832.45 18.27 45.56 French Polynesia 2003 247.02 3.52 70.18 Guam 2004 est 166.09 0.54 307.57 Hong Kong (China) 2003 6803.10 1.10 6184.64 Japan 2004 127 687.00 377.89 337.89 Kiribati 2004 est 93.10 0.81 114.94 Lao People's Democratic Republic 2003 5679.00 236.80 23.98 Macao (China) 2003 448.50 0.03 14 950.00 Malaysia 2004 25 580.00 330.25 77.46 Marshall Islands 2004 est 55.40 0.18 307.78 Micronesia, Federated States of 2004 est 112.70 0.70 161.00 Mongolia 2003 2504.00 1565.00 1.60 Nauru 2004 est 10.10 0.02 505.00 New Caledonia 2002 217.73 19.10 11.40 New Zealand 2004 est 4061.4 a 270.69 b 15.00 Niue 2004 est 1.60 0.26 6.15 Northern Mariana Islands 2004 est 78.25 0.47 166.49 Palau 2004 est 20.70 0.49 42.24 Papua New Guinea 2004 est 5695.30 462.84 12.31 Philippines 2004 82 663.56 300.00 275.55 Pitcairn Islands 2004 est 0.05 0.04 1.25 Republic of Korea 2004 48 082.16 99.60 482.75 Samoa 2004 est 182.70 2.94 62.14 Singapore 2004p 3486.90 a 0.70 4981.29 Solomon Islands 2004 est 460.11 28.37 16.22 Tokelau 2004 est 1.50 0.01 150.00 Tonga 2004 est 101.87 0.65 156.72 Tuvalu 2004 est 9.60 0.03 379.75 Vanuatu 2004 est 215.54 12.19 17.68 Viet Nam 2003 est 80 902.40 332.60 243.24 Wallis and Futuna 2003 14.94 0.14 106.71 WESTERN PACIFIC REGION 2004 est 1 743 700.56 ... ... Table 1 Demographic indicators ... Data not available est Estimate p Preliminary a Resident population b Excludes inland waters and oceanic areas Country/area Year Total Population Surface Area Population Density (‘000s) (in 1000 sq km) (per sq km) STATISTICAL TABLES 387 Year Urban Year Growth Year < 15 years 65+ years Aged 60 years or older by (%) Rate (%) (%) gender (2004) (%) Male Female Percent Distribution of PopulationPopulation 2003 54.00 2000 2.00 2004 est 38.95 3.58 49.18 50.82 2001 86.50 2003-2004 1.20 2004 19.80 13.00 45.92 54.08 2003 76.20 2004p 2.35 2004p 33.48 2.24 51.31 48.69 2004 16.00 1998-2004 1.81 2004 39.00 4.00 36.67 63.33 2004p 41.80 2000 0.97 2004p 21.50 7.60 47.64 52.36 2003 62.23 2002 est 1.10 2003 est 34.71 5.79 51.72 48.28 2001 52.00 2003 est 0.74 d 2002 est 35.30 3.10 46.56 53.44 2003 52.10 1996-2002 1.80 2002 30.30 (2003) 4.60 49.25 50.74 2000 93.00 2003p 1.57 d 2004 est 31.68 4.54 50.17 49.79 2003 94.60 2003 0.24 2003 15.72 11.69 48.71 51.29 2002 78.70 2004 0.05 2004 13.89 19.48 43.76 56.24 2003 47.30 2000 1.70 2004 est 40.94 3.43 42.28 57.71 2003 20.70 2002 2.80 2003 44.10 3.80 46.17 53.83 2003 100.00 2003 1.55 2003 18.64 7.92 45.87 54.13 2003 63.90 2003 2.20 2003 33.19 4.12 47.46 52.54 2003 66.30 1988-1999 1.40 2004 est 42.43 1.95 48.78 51.34 2003 29.00 2000 0.26 2004 est 41.62 3.54 46.98 53.02 2003 58.50 2003 1.20 2003 32.60 3.50 45.60 54.40 2003 100.00 2002 0.15 2004 est 42.18 1.70 51.34 48.41 2001 60.30 2002 1.40 2002 28.17 6.05 47.62 52.38 2003 85.90 2003 est 1.80 a 2004 est 21.80 a 11.96 a 45.37 54.63 2001 34.00 2001 -3.72 2004 est 29.70 9.10 45.22 54.78 2003 94.20 2004 est 2.71 2004 est 20.33 1.57 54.68 45.32 2003 68.60 c 2003 est 1.64 d 2004 est 27.68 5.21 43.68 56.38 2003 13.20 2000 3.20 2004 est 41.68 2.54 54.59 45.41 2003 61.00 2000 2.36 2004 34.19 4.34 46.05 53.95 ... ... ... ... 50.00 50.00 2003 80.30 2004 0.49 2004 19.59 8.70 42.37 57.63 2003 22.30 2001 1.00 2004 est 39.17 4.03 49.29 50.70 2004 100.00 2004 1.40 a 2004p 20.10 a 8.00 a 45.56 53.44 2003 16.50 c 1999 2.80 2004 est 40.06 3.20 56.31 43.69 2003 0.00 2001 0.40 2004 est 41.38 5.80 41.79 57.46 2003 33.40 2001 0.30 2004 est 37.91 5.29 48.54 51.45 2002 47.00 2002 0.60 e 2004 est 31.33 6.57 38.42 61.58 2003 22.80 1999 2.70 2004 est 41.19 3.15 53.04 46.98 2003 25.80 2003 est 1.47 2003 est 29.25 6.53 45.60 54.40 2003 0.00 2003 est 1.00 d 2003 est 35.54 5.27 44.28 55.80 2000 est 39.00 2000-2005 0.78 2004 est 23.11 7.96 46.68 53.32 c Revised data d Computed by WHO e Refers to average annual rate of population growth STATISTICAL TABLES 388 ... Data not available est Estimate p Preliminary a Resident population c Revised data d Computed by WHO f The figures are compiled based on registered deaths and/ or registered births g Estimate based on 2000 estimate Table 1 Demographic indicators (continued) Year Crude Birth Rate Crude Death Rate Dependency Ratio Year Total Fertility Rate Country/area (per 1000 popn) (per 1000 popn) 2004 (women 15-49 yrs) (%) American Samoa 2002 26.70 (2000) 3.90 74.02 2000-2005 4.50 Australia 2003 12.60 6.70 47.47 2003 1.76 Brunei Darussalam 2003 20.20 2.90p 49.82 2003p 2.10 Cambodia 2004 25.00 6.70 79.14 2004 3.34 China 2004p 12.29 6.42 42.38 2001 1.90 Cook Islands 2003 21.20 a 6.30 a 68.57 2003 2.80 Fiji 2002 19.48 6.45 58.59 2000 2.70 French Polynesia 2003 18.20 4.50 55.79 2002 2.40 Guam 2003p 20.20 4.30 56.79 2003p 2.70 Hong Kong (China) 2003 7.01 f 5.35 f 35.86 2003 0.94 Japan 2003 8.91 8.05 49.51 2003 1.29 Kiribati 2002 33.4 est g 7.20 79.76 2000 4.30 Lao People's Democratic Republic 2000 34.00 6.30 82.34 2000 4.90 Macao (China) 2003 7.20 3.30 34.66 2003 0.84 Malaysia 2004 21.30 4.60 59.89 2003 2.90 Marshall Islands 1999 41.80 (2001 est) 5.02 d 79.12 1999 5.71 Micronesia, Federated States of 2003 23.30 4.40 82.36 2000 4.44 Mongolia 2003 18.05 6.08 53.57 2003 2.00 Nauru 2002 31.20 7.80 78.19 2000-2005 3.90 New Caledonia 2002 19.30 5.20 53.97 2002 2.40 New Zealand 2004 14.30 a 7.00 a 51.20 2003 1.95 Niue 2001 18.46 7.80 63.38 2001 3.01 Northern Mariana Islands 2004 est 19.77 2.30 40.28 2004 est 1.33 Palau 2003 19.02 6.70 c 49.00 2003 1.55 Papua New Guinea 2000 35.00 12.00 79.25 2000 4.60 Philippines 2004 24.63 5.66 65.11 2000-2003 3.50 Pitcairn Islands ... ... 130.00 ... Republic of Korea 2003 10.20 5.10 39.54 2003 1.19 Samoa 2001 29.00 1.50 76.05 2001 4.40 Singapore 2004p 10.10 a 4.30 a 39.97 2004p 1.25 Solomon Islands 2004 est 34.00 8.00 93.08 1999 4.84 Tokelau 1997-2001 31.00 7.00 89.35 1997-2001 4.90 Tonga 2002 24.20 5.80 76.06 2003 3.40 Tuvalu 2002 27.10 9.90 61.03 2002 3.70 Vanuatu 1999 28.20 6.00 81.27 1999 4.80 Viet Nam 2003 est 17.50 5.80 55.31 2003 est 2.10 Wallis and Futuna 2003 19.40 5.90 66.80 2003 est 3.10 WESTERN PACIFIC REGION 2000-2005 14.90 7.00 45.07 1995-2000 2.00 STATISTICAL TABLES 389 FY Fiscal year h The figure refers to the % of population aged 15 and above with p Preliminary primary or above educational attainment PPP Purchasing power parity i Applies to population aged 15 years and above GNI Gross national income j Applies to population aged 15-24 years old GNPGross national product k Converted to US$ using available exchange rates nearest to the period Table 2 Socioeconomic indicators Country/area Year Total Male Female Year Per capita GDP (%) (%) (%) (in US$ ) Adult literacy rate American Samoa ... ... ... 2000 est PPP 8000 Australia 2000 87.60 ... ... 2003-2004 27 927 Brunei Darussalam 2002 93.90 96.30 91.40 2004p 15 241 Cambodia 2004 74.40 82.10 67.40 2003 306 China 2002 90.90 95.10 86.50 2004p 1269 d Cook Islands 2003 100.00 ... ... 2003p 9148 Fiji 2001 93.20 95.20 91.20 2002 1896 d French Polynesia ... ... ... 2002 15 063 d Guam ... ... ... 2001 income 10 872 Hong Kong (China) 2003 93.06 h 96.62 h 89.80 h 2003p 23 030 Japan 2000 est 99.00 ... ... 2003 33 727 Kiribati 2000 95.00 93.00 95.00 2002 611 Lao People's Democratic Republic 2003 74.00 i 85.00 i 64.00 i 2004 380 Macao (China) 2001 91.30 95.30 87.80 2003p 17 782 Malaysia 2002 94.00 ... ... 2004 GNI 4373 Marshall Islands 1999 97.00 96.80 97.20 2001 1817 Micronesia, Federated States of 2000 92.40 92.90 91.90 FY2002 est 2058 Mongolia 2003 97.80 98.00 97.50 2002 447 Nauru 1998 95.00 95.00 95.00 ... New Caledonia 2002 est 91.00 92.00 90.00 1999 14 223 k New Zealand ... ... ... 2002 19 541 Niue 2003 100.00 ... ... 2003 5808 Northern Mariana Islands ... ... ... 1998 28 734 Palau ... ... ... 2003 5678 Papua New Guinea 2000 56.20 61.20 50.90 2002 662 Philippines 2002 92.60 92.50 92.70 2003 est 964 Pitcairn Islands ... ... ... ... Republic of Korea 2002 97.90 i 99.20 i 96.60 i 2004 12 030 Samoa 1999 97.40 97.60 97.50 2001 1443 Singapore 2004 94.60 ... ... 2004 25 191 Solomon Islands 1999 77.00 84.00 67.00 2002 495 Tokelau 2003 86.50 j ... ... 2003 GNP 612 Tonga 2000 98.80 ... ... FY2002-2003 1614 Tuvalu 1998 95.00 95.00 95.00 2002 1530 Vanuatu 1999 74.00 ... ... 2002 1179 Viet Nam 2002 92.70 94.50 90.90 2003 est 483 Wallis and Futuna 2003 78.80 78.20 78.20 ... WESTERN PACIFIC REGION ... ... ... ... STATISTICAL TABLES 390 Year Per capita As % of National As % of Year Country/area (US$/Local Currency) Budget GDP Human Development Index (HDI) value Health Expenditure American Samoa 2003 US$ 500 14.00 ... ... Australia 2001-2002 US$ 1739 16.70 9.10 2002 0.95 Brunei Darussalam 2003 US$ 475 ... 2.66 2002 0.87 Cambodia 2003 US$ 3 est l 8.00 10.00 est 2002 0.57 China 2002 US$ 49 ... 5.37 2002 0.74 Cook Islands 2001 US$ 238 d ... 2.33 1998 0.82 Fiji FY 2003-2004 US$ 61 d 8.32 d (2002) 3.00 2002 0.76 French Polynesia ... ... ... ... Guam 2000 US$ 1032 (FY2000) 6.18 ... ... Hong Kong (China) 2003 US$ 1241p m (FY2003-04) 12.35p n 5.39p o 2002 0.90 Japan FY2002 US$ 2046 ... 8.58 p 2002 0.94 Kiribati 2003 AUD 147 7.80 ... 1998 0.52 Lao People's Democratic Republic 2001-2002 US$ 12 (2002-2003) 5.77 (2003) 3.20 2002 0.53 Macao (China) 2003 US$ 536 11.42 3.01 2000 0.88 Malaysia 2003 US$ 80 (2003) 6.88 (2000) GNP 1.70 2002 0.79 Marshall Islands 1999 US$ 248 (FY2004) 14.00 4.00 1998 0.56 Micronesia, Federated States of 2000 US$ 87 ... ... 1998 0.57 Mongolia 2002 US$ 23 10.50 4.70 2002 0.67 Nauru ... ... ... 1998 0.66 New Caledonia 2002 EUR 1558 ... (1999) 9.22 ... New Zealand 2002 US$ 1899 14.21 (2001) 8.20 2002 0.93 Niue 2001-2002 US$ 417 (FY2002-2003) 13.52 d ... 1998 0.77 Northern Mariana Islands 2000 US$ 519 (2002) 16.44 ... ... Palau FY2002-2003 ... 14.26 ... 1998 0.86 Papua New Guinea 2001 US$ 24 (2002) 11.50 4.40 2002 0.54 Philippines 2002 PHP 1435 (2001) 0.41 2.70 2002 0.75 Pitcairn Islands ... ... ... ... Republic of Korea 2002 US$ 586 (2004) 7.70 (2003) 5.60 2002 0.89 Samoa 2001 US$ 86 (2002-2003) 18.10 (2000-2001) 5.80 2002 0.77 Singapore FY2002 S$ 1703 (FY2004 est) 5.90 3.70 2002 0.90 Solomon Islands 1999 ... 11.10 5.60 2002 0.62 Tokelau 1999-2000 NZ$ 341 (FY2003-2004) 12.50 ... ... Tonga FY2002-2003 US$ 49 l 10.00 ... 2002 0.79 Tuvalu 1998 AUD 141 ... GNP 7.10 1998 0.58 Vanuatu 2001 US$ 76 ... ... 2002 0.57 Viet Nam 2003 est US$ 21 (2002) 4.50 4.21 2002 0.69 Wallis and Futuna 2003 ... 7.58 d ... ... WESTERN PACIFIC REGION ... ... ... ... Table 2 Socioeconomic indicators ... Data not available n Figure refers to public health expenditure as % of overall public est Estimate expenditure FY Fiscal year o Figure is compiled based on the summation of public health GNPGross national product expenditure in the financial year 2003/04 and private health d Computed by WHO expenditure in the calendar year 2003 as % of GDP in the calendar l Refers to per capita government health expenditure year 2003 m Figure compiled based on the summation of public health p As % of national income expenditure in the financial year 2003/04 and private health expenditure in the calendar year 2003 per mid 2003 population STATISTICAL TABLES 391 Year Total Male Female Year Neonatal Infant Under-5 Year Maternal mortality (years) (years) (years) (per 1000 (per 1000 (per 1000 ratio (per livebirths) (livebirths) livebirths) 100 000 livebirths) Life Expectancy at Birth Table 3 Health status indicators 2000 ... 69.00 76.00 2000 6.20 (2001 est) 8.50 (2002) 4.90 2002 123.00 2001-2003 ... 77.80 82.80 2003 3.30 4.80 5.80 1997-1998 8.20 2003p ... 74.40 77.40 2003 7.20 9.50 11.80 2003 28.40 2001 ... 56.40 60.30 2000 37.30 95.00 124.40 2000 437.00 2000 71.40 69.60 73.30 2001 (2000 est) 21.00 30.00 35.90 2001 50.20 2003 71.00 69.00 73.00 2003 (2000) 12.00 q 16.95 d 16.95 d 2003 0.00 2004 68.60 66.50 70.70 2002 (2000) 9.00 17.76 22.35 2002 35.29 1998-2002 ... 69.20 74.10 2002 4.00 (2003) 6.90 9.00 2002 0.00 2003p 77.80 74.82 81.03 2002 3.41 q (2003p) 11.22 (2001) 12.28 2003p 0.00 2003 ... 78.54 84.31 2003p 1.20 f 2.26 f 3.27 f 2003p 4.19 f 2003 ... 78.36 85.33 2003 1.67 2.99 4.02 2003 6.14 2003 est ... 59.00 g 70.00 g 2000 27.00 q 43.00 69.00 2002 103.00 2000 59.00 57.00 61.00 2000 36.20 82.20 106.90 c 2000 530.00 1998-2001 78.90 77.20 81.50 2003 0.31 0.62 1.56 2003 0.00 2004 73.50 71.00 76.00 2003 (2002) 3.50 5.80 (2002) 8.60 2003 30.00 1999 67.50 65.70 69.40 1999 ... (2002) 29.00 48.00 2002 73.80 2003 est 70.00 68.00 71.00 2000 est 12.00 q (2003) 21.00 (2003 est) 23.00 2003 317.00 r 2003 63.63 60.79 66.50 2004 (2003) 11.37 22.80 29.10 2004 98.80 1997-2002 est ... 52.50 58.20 2002 6.30 12.70 19.10 2002 300.00 2002 73.50 69.90 77.60 2002 2.40 6.90 9.06 1991-2002 31.56 2001 est ... 68.05 72.03 2004 est 3.10 5.58 (2003) 6.34 2000 8.80 s 2001 70.10 69.80 71.20 2003 ... 29.40 ... 2003 0.00 2004 est 75.67 73.11 78.38 2004 est ... 7.25 (1999) 7.43 2000 0.00 2003 est 71.34 65.51 75.40 2000 14.00 q (2003) 13.66 c (2002) 29.00 1998 0.00 2000 53.00 52.50 53.60 2000 32.00 est 64.00 88.00 2000 330.00 2004 est ... 67.53 72.78 1998-2003 17.00 29.00 40.00 1998 172.00 ... ... ... ... ... ... ... 2002 77.00 73.38 80.44 2003 (1999) 3.80 5.01 d 6.66 d 2000 15.00 2001 72.80 71.80 73.80 2002 4.20 (2001) 19.30 13.70 2002 19.60 2004p 79.30 a 77.40 a 81.30 a 2004 1.20 a 1.90p a 3.35p a,d 2004p 5.36 a,d 2004 est ... 61.90 63.10 1999 (2000) 12.00 q 66.00 73.00 2003 295.00 1997-2000 ... 68.40 71.30 2003 40.00 d (1997-2000) 33.0 (1999) 0.00 2001-2002 0.00 2003 70.00 70.00 72.00 2000 10.00 q (2004) 14.60 (2001) 16.59 2004 83.30 2002 65.00 64.00 67.00 2003 ... 21.60 32.40 2002 0.00 2002 est 68.60 c 67.40 c 70.40 c 2000 est 19.00 q (1999) 27.00 (1999) 33.00 1998 96.30 2002 71.30 70.00 73.00 2003 est ... 21.00 32.80 2003 85.00 2003 est 74.30 73.10 75.50 2003 est ... 5.90 ... ... 2000 t A:80.90 A:77.30 A:84.20 2000-2005 ... 33.80 39.50 2000 est 81.00 B:70.40 B:68.20 B:72.70 p Preliminary s One of the direct maternal deaths occurred in 1932 but was registered in 2000 a Resident population t To aid in demographic analysis, the 192 Member States of WHO have been c Revised data divided into mortality strata on the basis of their level of child (5q0) and adult f The figures are compiled based on registered deaths and/or mortality (45q15). For the Western Pacific Region, the division is as follows: registered births A=Very low child, very low adult; B=Low child, low adult. Countries belonging to g Estimate based on 2000 census strata A are Australia, Brunei Darussalam, Japan, New Zealand and Singapore. q Estimates derived by regression and similar estimation methods Countries belonging to strata B are Cambodia, China, Cook Islands, Fiji, Kiribati, r Based on child bearing age 15-44 years old Lao PDR, Malaysia, Marshall Islands, Federated States of Micronesia, Mongolia, Nauru, Niue, Palau, Papua New Guinea, Philippines, Republlic of Korea, Samoa, Solomon Islands, Tonga, Tuvalu, Vanuatu and Viet Nam. Mortality Rates STATISTICAL TABLES 392 Table 4 Maternal, child care and nutritional indicators % of women of reproductive age % of delivery at home Country/area Year (15-49 yrs) using modern Year % of deliveries in Year assisted by skilled contraceptive methods health facilities birth attendants (%) (%) (%) Maternal and Child Care American Samoa 2000 33.00 2002 99.00 2002 1.00 Australia 2001 65.00 2001 99.30 2001 0.30 Brunei Darussalam ... 2003 99.45 ... Cambodia 2000 19.00 2000 9.90 2000 89.00 aa China 2002 est 84.60 2001 76.00 x ... Cook Islands 2003 40.85 d,u ... ... Fiji 1998 40.45 2002 99.00 ... French Polynesia ... ... ... Guam ... ... ... Hong Kong (China) ... 2003 About 100.00 y 2003 About 0 ab Japan 1995-2000 59.00 2003 99.80 ... Kiribati 2002 22.00 2002 76.00 2002 12.90 Lao People's Democratic Republic 2000 28.90 c,v 2000 12.00 2004 9.00 Macao (China) ... 2003 100.00 2003 0.00 Malaysia ... 2002 95.86 2002 4.14 Marshall Islands 2001 34.00 w ... ... Micronesia, Federated States of 2000 70.00 ... ... Mongolia 2003 51.90 2003 99.20 2003 36.70 Nauru ... ... ... New Caledonia ... ... ... New Zealand 2002 est 72.00 2001 est 96.60 ... Niue ... ... ... Northern Mariana Islands 2000 64.00 ... ... Palau 2000 17.20 v 1998 18.50 ... Papua New Guinea 2002 9.50 2002 44.80 2002 3.00 Philippines 2003 21.60 c 1998-2003 38.00 1998-2003 35.20 Pitcairn Islands ... ... ... Republic of Korea 2000 79.30 2000 99.90 2000 0.10 Samoa 1999 42.40 2003 92.00 2003 8.00 Singapore 2003 72.50 2002 99.70 ... Solomon Islands 1999 19.00 2003 43.00 z ... Tokelau 1999 13.40 ... ... Tonga 2002 23.10 2004 98.00 ... Tuvalu 2001 28.50 ... ... Vanuatu 2001 15.00 2003 84.00 2003 3.00 Viet Nam 2002 76.90 2002 79.00 ... Wallis and Futuna ... ... ... WESTERN PACIFIC REGION ... ... ... ... Data not available w Contraceptive prevalence rate Est Estimate x Applies to hospitals only c Revised data y The figure refers to the cases known to the maternity homes of DOH, public and private d Computed by WHO z Data applies to clinics only u Applies to women aged 15-44 years old aa Unspecified whether delivered by a trained personnel using all contraceptive methods ab Nearly all newborns were delivered in health facilities v Figure refers to married women only STATISTICAL TABLES 393 Maternal and Child Care % of women given % of newborn infants weighing at least 2 doses of Year of < 2 SD < 2 SD < 2 SD Year at least 2500 grams at birth Year tetanus toxoid TT2+ survey weight/age height/age weight/height 2000 97.00 ... ... ... ... ... ... 2001 93.80 94.20 93.20 ... 1995-1996 0.00 ad 0.00 ad 0.00 ad 2003 93.00 ... ... 2004 21.00 1995-1996 14.00 13.00 3.60 2000 77.00 ... ... 2000 30.00 2000 45.20 44.60 15.00 2002 97.61 ... ... ... 2000 10.00 14.20 2.20 2003 97.60 ... ... 2003 92.00 ... ... ... 1998 90.46 ... ... ... 1993 7.90 2.70 8.20 2001 93.00 ... ... 2000 100.00 ... ... ... 2001 92.00 92.32 91.75 ... ... ... ... 2003 94.48 ac 95.14 ac 93.76 ac ... ... ... ... 2003 90.90 91.90 89.90 ... ... ... ... 2002 91.80 92.30 91.40 2002 42.60 1985 12.90 28.30 10.80 1998 82.00 ... ... 2003 37.00 2000 40.00 40.70 15.40 2003 93.56 93.59 93.51 2003 68.00 ... ... ... 2002 91.00 ... ... 2003 84.40 2002 11.30 ... ... 1999 88.00 ... ... ... 1998 22.0 (M)/33.0 (F) 32.0 (M)/40.0 (F) 5.8 (M)/7.0 (F) 2000 82.00 ... ... ... ... ... ... 2004 96.40 ... ... ... 1999 12.50 24.60 3.60 ... ... ... 2003 est 100.00 ... ... ... 2002 93.00 ... ... ... 1996 1.60/ 4.40 ae ... ... 2000 93.50 ... ... ... ... ... ... 2001 100.00 ... ... ... ... ... ... 2000 81.01 ... ... ... ... ... ... 1998 91.00 ... ... ... 1997 1.40 ... ... 2002 90.00 ... ... 2002 53.00 1982-1983 29.90 af 43.20 af 5.50 af 1998-2003 54.80 ... ... 1998-2003 37.30 2003 27.60 (1998) 32.10 (1998) 6.50 ... ... ... ... ... ... ... 2003 95.90 96.30 95.60 ... 1997 3.00 ag ... ... 2003 97.40 ... ... ... 1999 1.90 4.20 0.90 2002 91.60 ... ... ... 2000 ... 2.20 2.40 ... ... ... ... 1989 21.30 27.30 6.60 2003 100.00 ... ... ... ... ... ... 2002 97.50 ... ... 2003 93.00 1986 ... 1.30 0.90 2000 95.00 ... ... ... ... ... ... 2003 97.00 ... ... 2003 22.00 1996 12.00 20.00 6.00 2003 94.20 ... ... 2003 91.00 2003 28.40 32.00 7.20 ... ... ... ... ... ... ... Total Male Female (%) (%) (%) (%) National underweight, stunting and wasting prevalence (age 0-59 months) NR Not relevant M Male F Female ac The figure excludes those with unknown birthweight ad Figure applies to age group 24-95 months ae 1.60% in the southern province; 4.40% in the northern province af Figure applies to national rural (covering >85% of total population) ag Data from a subnational survey STATISTICAL TABLES 394 Table 4 Maternal, child care and nutritional indicators (continued) Proportion of infants Vitamin A Proportion of babies aged 6-9 months supplementation Year of exclusively breastfed receiving breastmilk to children Country/area survey for the first 6 months and semi-solid food 6-59 months old (%) (%) (%) American Samoa 1997 20.00 (at 4 months) ... ... Australia 2001 46.00 ... ... Brunei Darussalam 2003 14.60 ... ... Cambodia 2000 15.00 (0-3 months) 77.00 (2002) 34.00 China 2000 48.7 (urban); 60.4 (rural) (<4 months) ... ... Cook Islands 1998 19.00 45.00 ... Fiji 1995 53.00 52.00 ... French Polynesia 2001 19.00 ... ... Guam ... ... ... Hong Kong (China) ... ... ... Japan 2000 41.00 (<4 months) 97.90 ... Kiribati 1995-2003 80.00 (<4 months) ... ... Lao People's Democratic Republic 2000 28.00 (<4 months) (1995-2003) 10.00 (2002) 58.00 Macao (China) ... ... ... Malaysia 1995-2003 29.00 (<4 months) ... ... Marshall Islands 1995-2003 63.00 (<4 months) ... (2002) 51.00 Micronesia, Federated States of 1995-2003 60.00 (<4 months) ... (2002) 71.00 Mongolia 2001 88.00 (<4 months) 55.00 (2002) 84.00 Nauru ... ... ... New Caledonia ... ... .. New Zealand ... ... ... Niue ... ... ... Northern Mariana Islands ... ... ... Palau 1995-2003 59.00 (<4 months) ... ... Papua New Guinea 1995-2003 59.00 74.00 ... Philippines 2003 33.50 57.90 75.00 Pitcairn Islands ... ... ... Republic of Korea 1998 14.00 (at 4 months) 92.00 ... Samoa 1999 58.30 (at 4 months) ... ... Singapore ... ... ... Solomon Islands 1995-2003 65.00 (<4 months) ... ... Tokelau ... ... ... Tonga 1999 61.00 (<4 months) 37.00 ... Tuvalu ... ... ... Vanuatu 1996 73.00 (at 4 months) ... ... Viet Nam 2000 28.00 (<4 months) (2002) 89.30 (7-9 months) (2002) 55.00 Wallis and Futuna ... ... ... WESTERN PACIFIC REGION ... ... ... ... Data not available STATISTICAL TABLES 395 Year of Year of survey BMI > 25 survey BMI > 30 Age group Total Male Female Age group Total Male Female (yrs) (yrs) Percentage prevalence overweight Percentage prevalence obese ... ... ... ... ... ... 1999/2000 25+ 59.90 67.70 52.20 1999/2000 25+ 20.80 19.40 22.00 ... ... ... ... ... ... 2000 15-49 ... ... 6.40 2000 15-49 ... ... 0.70 2002 18+ 22.80 ah ... ... 2002 18+ 7.10 ai ... ... 2003 25-64 89.20 90.10 88.30 2003 25-64 62.40 58.60 66.30 2002 25-64 56.70 46.40 68.40 2002 25-64 22.80 13.20 33.70 1995 16+ 73.70 75.20 72.50 1995 16+ 40.90 36.30 44.30 ... ... ... ... ... ... 1995/1996 25-74 ... 38.00 34.00 1995/1996 25-74 ... 5.00 7.00 2002 20+ 25.50 28.80 22.70 ... ... ... ... ... ... ... ... ... 2000 15+ 8.50 5.90 10.80 2000 15+ 1.20 0.70 1.60 ... ... ... ... ... ... 1996 20+ 26.50 24.10 29.00 1996 20+ 5.80 4.00 7.60 2002 25-64 80.60 78.00 83.50 2002 25-64 45.20 38.50 52.70 2002 25-64 73.90 65.40 83.10 2002 25-64 43.50 30.50 57.30 1999 35+ 52.00 44.00 57.00 ... ... ... 2004 25-64 93.30 92.80 93.80 2004 25-64 74.70 72.10 77.30 1992-1994 30-59 ... ... 70.40 ... ... ... 2002-2003 15+ 57.00 63.00 51.10 2002-2003 15+ 22.50 21.90 23.20 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1998 20+ 20.20 17.00 23.30 1998 20+ 3.30 2.10 4.40 ... ... ... ... ... ... 1998 19+ 26.30 26.00 26.50 1998 19+ 2.40 1.70 3.00 2002 25-64 86.10 82.20 90.80 2002 25-64 57.30 48.40 67.90 1998 18-69 30.40 33.90 27.00 1998 18-69 6.00 5.30 6.70 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1998-2000 15-70 56.00 ... ... ... ... ... 1983 ... ... 75.00 50.00 1998 20+ 48.90 45.90 51.90 1998 20+ 15.90 12.20 19.60 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ah The recommended cut-off point for overweight for Chinese people is BMI at 24 ai The recommended cut-off point for obesity for Chinese people is BMI at 28 STATISTICAL TABLES 396 Year of Country/area survey Age group Total Male Female (yrs) Table 4 Maternal, child care and nutritional indicators (continued) American Samoa ... ... ... Australia ... ... ... Brunei Darussalam ... ... ... Cambodia 2000 15-49 ... ... 17.80-23.40 China ... ... ... Cook Islands 2003 25-64 32.90 32.50 33.40 Fiji 2002 25-64 26.60 25.20 28.10 French Polynesia 1995 16+ 29.40 23.10-34.50 22.60-37.00 Guam ... ... ... Hong Kong (China) ... ... ... Japan ... ... ... Kiribati ... ... ... Lao People's Democratic Republic ... ... ... Macao (China) ... ... ... Malaysia 1996 20+ 22.90 22.70 23.10 Marshall Islands 2002 25-64 29.90 28.90 31.00 Micronesia, Federated States of 2002 25-64 29.50 27.70 31.40 Mongolia 1999 35+ 26.00 25.00 26.60 Nauru 2004 25-64 35.10 34.60 35.60 New Caledonia 1992-1994 30-59 22.80-33.20 22.50-31.70 23.10-34.50 New Zealand 2002-2003 15+ 26.60 26.90 26.40 Niue 1981 20+ 27.00 26.10 27.80 Northern Mariana Islands ... ... ... Palau ... ... ... Papua New Guinea ... ... ... Philippines 1998 20+ 22.50 22.40 22.60 Pitcairn Islands ... ... ... Republic of Korea ... ... ... Samoa 2002 25-64 31.70 30.00 33.40 Singapore ... ... ... Solomon Islands ... ... ... Tokelau ... ... ... Tonga 1998-2000 15-70 32.30 30.20 33.80 Tuvalu ... ... ... Vanuatu 1998 20+ 25.60 21.20-29.20 20.90-31.10 Viet Nam 1987-1989 15+ 17.00-21.20 16.90-21.30 17.00-21.20 Wallis and Futuna ... ... ... WESTERN PACIFIC REGION ... ... ... Mean BMI ... Data not available STATISTICAL TABLES 397 Youth prevalence on tobacco use Table 5 Environmental health and tobacco use prevalence indicators Estimated smoking prevalence among adults Year of Total Male Female Year of Male Female Access to Adequate excreta survey aj (%) (%) (%) survey (%) (%) Year safe water Year disposal facilities (%) (%) Percentage of population with ... ... ... 1985 41.00 16.20 2004 99.00 2004 99.00 ... ... ... 2001 28.00 21.00 2002 100.00 2002 100.00 ... ... ... 1997 36.10 6.40 2004 99.00 2002 80.00 2003 8.80 11.40 3.20 1999 66.00 (urban) 8.00 2004 44.20 2004 21.90 ... ... ... 1996 66.90 4.20 2002 83.55 2003 50.92 2003 43.60 39.90 46.70 1998 34.40 71.10 2003 100.00 2003 100.00 1999 18.90 24.10 13.40 1988 50.50-59.30 13.99-30.60 2002 65.00 2002 60.00 ... ... ... 1995 36.00 36.00 2002 100.00 2002 98.00 ... ... ... 1999 37.70 26.90 2003p 100.00 2003p 100.00 ... ... ... 1998 27.10 2.90 2004 100.00 2004 100.00 ... ... ... 2000 47.40 11.50 2003 96.90 2003 77.70 ... ... ... 1999 56.50 32.30 2002 64.00 2002 39.00 ... ... ... 1995 41.00 15.00 2004 63.80 2004 44.25 2001 8.00 9.40 6.20 1997 31.58 4.18 2003 100.00 1998-2001 99.85 ... ... ... 1986 41.00 4.00 2003 97.40 2003 99.70 ... ... ... ... ... 2002 85.00 2002 82.00 ... ... ... ... ... 2003 59.00 2003 48.00 ... ... ... 1997 55.00 19.00 2002 41.50 2002 40.20 ... ... ... 1975 53.00 59.00 2003 100.00 2003 100.00 ... ... ... 1992 28.00 34.00 ... ... ... ... ... 1999 26.00 25.00 2002 78.00 2002 100.00 ... ... ... 1980 58.00 17.00 2003 100.00 2003 100.00 2000 62.40 68.40 57.10 ... ... 2002 98.00 2002 94.00 2001 71.00 ... ... 1997 18.10 (no breakdown) 2003 95.40 2003 99.00 ... ... ... 1990 46.00 28.00 2002 39.00 2002 45.00 2000 27.10 37.30 18.40 1999 53.80 11.00 2002 80.00 2002 86.10 ... ... ... ... ... ... ... ... ... ... 1997 65.00 4.40 2003 89.40 2003 78.70 ... ... ... 1994 33.90 12.70 2002 88.00 2002 100.00 2000 11.30 ak 13.40 ak 8.80 ak 2001 24.20 3.50 2004p 100.00 2004p 100.00 ... ... ... 1989 ... 23.00 2002 70.00 2002 31.00 ... ... ... 1991 67.60 42.00 2002 89.00 2002 74.00 ... ... ... 1991 64.80 13.00 2003 97.00 2002 78.20 ... ... ... 1976 51.00 31.00 2002 100.00 2002 100.00 ... ... ... 1998 49.00 5.00 2002 60.00 2002 50.00 ... ... ... 1997 50.00 3.40 2003 est 70.10 2002 25.30 ... ... ... 1996 42.00 18.00 2003 80.90 2003 68.50 ... ... ... ... ... 2002 78.00 2002 45.00 Est Estimate p Preliminary aj Smoked cigarettes or used other tobacco products within 30 days preceeding the survey ak Cigarette use only STATISTICAL TABLES 398 American Samoa 2003 49 6.00 2003 15 2.50 Australia 2004 54 800 27.20 2004 9400 4.70 Brunei Darussalam 2003 309 8.84 2003 64 1.83 Cambodia 2004 2122 1.62 2004 241 0.18 China 2004p 1 892 000 al 14.56 ... ... Cook Islands 2003 27 14.67 2003 18 ao 9.78 Fiji 2003 373 4.49 2003 56 0.67 French Polynesia 2004 est 447 d 17.80 2004 est 113 d,ap 4.10 Guam 1999 166 11.10 1999 31 ap 2.05 Hong Kong (China) 2003 11 016 am 16.09 a 2003 1848 am 2.70 a Japan 2002 262 687 20.61 2002 92 874 7.29 Kiribati 2004 20 2.20 2004 3 0.30 Lao People's Democratic Republic 2003 1283 2.26 2003 83 0.15 Macao (China) 2003 1192 26.58 2003 137 3.05 Malaysia 2003 18 191 7.26 2003 2418 0.96 Marshall Islands 2000 24 4.63 2000 4 0.77 Micronesia, Federated States of 2003 ... 5.70 2003 ... 1.20 Mongolia 2003 6637 26.60 2003 459 1.84 Nauru 2004 5 4.95 2004 1 0.99 New Caledonia 2002 476 22.04 2002 126 5.84 New Zealand 2003 8790 21.92 2003 1582 3.95 Niue 2003 3 18.18 2003 2 12.12 Northern Mariana Islands 1999 31 4.47 1999 3 0.43 Palau 2003 25 12.31 1998 2 1.10 Papua New Guinea 2000 275 0.53 2000 90 0.17 Philippines 2004 93 862 11.35 2004 45 903 5.55 Pitcairn Islands ... ... ... ... Republic of Korea 2003 95 881 20.01 2003 20 446 4.27 Samoa 2002 43 2.43 2002 6 0.34 Singapore 2004 6492 15.31 2004 1227 2.89 Solomon Islands 2003 57 1.25 1999 26 0.63 Tokelau 2003 3 20.00 2003 3 c 20.00 Tonga 2003 32 an 3.90 2003 23 aq 2.27 Tuvalu 2003 4 4.18 2003 2 2.09 Vanuatu 2004 est 29 1.35 ... ... Viet Nam 2003 47 587 5.88 ... ... Wallis and Futuna 2003 11 7.36 c 2003 4 2.70 WESTERN PACIFIC REGION ... ... ... ... Table 6 Health workforce and infrastructure indicators ... Data not available am Refers to the number of doctors/ dentists with full registration on both the local and overseas lists Est Estimate an Refers to government doctors only p Preliminary ao Includes six dental nurses a Resident population ap Refers to dental surgeons c Revised data aq Includes dental officers and dental therapists d Computed by WHO al Includes assistant doctors Country/area Physicians Health workforce Year Number Rate per 10 000 Year Number Rate per 10 000 Dentists STATISTICAL TABLES 399 ar Includes assistant nurses aw Including nurse aides as Primary nurses and midwives included in other ax Includes Bachelor and Diploma graduate nurses nursing auxiliary staff graduated between 2002-2004, MOH ay Includes nurse practitioners and nurse aides at Includes midwives az Includes observation beds au Refers to the number of registered nurses (all types) and ba The figure covers the correctional institutions and institutions licensed enrolled nurses (general and mental) under the hospitals, nursing homes and maternity homes registration ordinance av Includes registered nurses and midwives bb Data includes 640 beds dated as of 2002 reference period Health workforce (continued) Year Number Rate per 10 000 Year No. of hospital beds Rate per 1000 population Nurses Health Infrastructure 2003 127 21.00 2003 128 2.13 2004 159 600 79.40 2002-2003 79 311 3.99 2003 1678 ar 48.00 2003 905 2.59 2004 4516 as 3.45 2004 7482 0.57 2004p 1 286 000 9.89 2004 3 004 000 2.31 2003 60 32.60 2004 80 5.71 2003 1648 ar 19.82 1999 2097 2.61 2000 824 35.90 2003 971 az 3.93 1997 647 at 43.40 2000 225 1.45 2003 43 782 au 63.96 a 2003 35 526 ba 5.22 2002 1 097 326 86.11 2001 1 646 797 12.94 2004 238 26.50 2004 140 1.50 2003 5291 9.32 2003 6255 1.10 2003 1010 22.52 2003 1155 2.58 2003 36 784 14.69 2003 47 406 1.89 2000 152 29.34 1999 105 2.07 2003 ... 21.10 2000 329 3.07 2003 7734 31.00 2003 18 180 7.26 2004 48 47.52 2004 60 5.94 2002 1128 52.25 2002 888 4.08 2004 34 660 av 85.34 2002 23 825 5.99 2003 15 90.91 2003 12 7.27 1999 123 17.74 2000 82 1.18 1998 26 14.40 1998 90 4.97 2000 2841 5.47 ... ... 2004 352 398 42.63 2002 91 000 1.14 ... ... ... ... 2003 192 480 40.16 2004 426 489 d 8.87 2002 333 18.83 2004 661 bb 3.62 c 2004 19 330 ar 55.40 2004 11 840 2.79 2003 605 aw 13.24 aw 1999 881 2.15 2003 10 66.67 2003 18 12.00 2003 342 33.70 2004 296 2.91 2003 30 ax 31.38 2001 56 5.56 2004 est 312 ay 14.48 c 2003 397 c 1.91 c 2003 48 157 5.95 2003 184 440 2.28 ... ... 2003 74 4.95 ... ... ... ... STATISTICAL TABLES 400 ... Data not available p Preliminary bc Confirmed cases bd Imported cases Table 7 Mortality and morbidity indicators Country/area Year Cases Deaths Year Cases Deaths Cholera Malaria Communicable Diseases American Samoa 2003 0 0 ... ... Australia 2004 6 (2003) 0 2002 466 (2003) 3 Brunei Darussalam 2004 0 0 2003 17 ... Cambodia ... ... 2003 71 258 bc 492 China 2004 244 1 2003 40 681 52 Cook Islands 2002 0 ... 2003 1 ... Fiji 2002 0 ... ... ... French Polynesia 2003 0 0 2003 ... 0 Guam 2003 0 0 ... ... Hong Kong (China) 2003 7 0 2003 28 0 Japan 2003 25 0 2003 ... 1 Kiribati 2004 0 0 ... ... Lao People's Democratic Republic 2002 1272 1 2003 18 894 187 Macao (China) 2004 0 ... 2004 0 ... Malaysia 2003 135 0 2003 6338 21 Marshall Islands ... ... ... ... Micronesia, Federated States of 2004 ... 0 ... ... Mongolia 2004 0 0 2004 0 0 Nauru 2002 0 0 ... ... New Caledonia ... ... ... ... New Zealand 2004 0 0 2004 33 bd 0 Niue ... ... ... ... Northern Mariana Islands ... ... ... ... Palau 2003 0 ... 2003 0 ... Papua New Guinea 2000 0 0 2003 70 750 537 Philippines 2002 347 ... 2003 44 702 97 Pitcairn Islands ... ... ... ... Republic of Korea 2004 10 0 2003 1107 0 Samoa 2002 0 0 ... ... Singapore 2004p 11 (2003) 0 2004 152 1 Solomon Islands ... ... 2003 90 606 71 Tokelau ... ... ... ... Tonga 2002 0 0 ... ... Tuvalu 2001 0 0 ... ... Vanuatu 2004 0 0 2003 15 240 0 Viet Nam 2003 343 0 2003 37 416 50 Wallis and Futuna ... ... ... ... WESTERN PACIFIC REGION 2400 2 397 656 1512 STATISTICAL TABLES 401 Year Cases Deaths Year Cases Dengue fever Communicable Diseases Leprosy 2002 1185 0 2003 2 2002 219 (2003) 0 2003 4 2003 160 0 2003 2 2004 9983 90 2003 509 2002 1557 ... 2003 1404 2003 1 ... 2003 0 ... ... 2003 2 2003 6 0 2003 0 ... ... 2001 1 2003 49 0 2003 7 2003 ... 0 2003 8 ... ... 2003 21 2004 3458 11 2003 156 2004 2 ... 2004 2 ... ... 2003 219 ... ... 2003 76 2002 0 ... 2003 89 2004 0 0 2004 0 ... ... 2002 3 2004 792 2 2004 8 2004 8 0 2003 4 ... ... 2003 0 ... ... 2003 4 2003 12 ... 2003 7 2002 22 ... 2003 263 2004 18 474 212 2003 2397 ... ... 2002 0 2003 14 ... 2003 17 ... ... 2003 11 2004p 9459 ... 2004p 14 ... ... 2003 5 ... ... 2003 0 2003 194 ... 2003 0 ... ... 2003 0 ... ... 2003 7 2003 49 751 72 2003 949 2002 166 2 2003 0 95 512 389 6191 STATISTICAL TABLES 402 Table 7 Mortality and morbidity indicators (continued) American Samoa (2003) 0 (2003) 0 (2003) NR (2003) NR (2003) 0 (2003) 0 Australia 0 70 0 5 8676 0 Brunei Darussalam 0 16 0 1 0 0 Cambodia 4 352 146 1041 66 0 China (2003) 9 (2003) 71 879 (2003) 2245 ... (2003) 858 (2003) 0 Cook Islands 0 0 0 0 0 0 Fiji (2003) 0 (2003) 305 (2003) 0 (2003) 0 (2003) 0 (2003) 0 French Polynesia (2003) 0 (2003) 0 (2003) 0 (2003) 0 (2003) 1 (2003) 0 Guam 0 2 0 0 0 0 Hong Kong (China) 0p 63p 0p 3p 9p 0p Japan (2003) 0 (2003) 8286 ... (2003) 69 (2003) 1534 (2003) 0 Kiribati 0 0 ... ... 0 ... Lao People's Democratic Republic 11 1491 14 49 199 1 be Macao (China) 0 0 0 0 0 0 Malaysia (2003) 11 (2003) 632 (2003) 8 (2003) 18 (2003) 28 (2003) 0 Marshall Islands 0 0 0 0 (2003) 0 0 Micronesia, Federated States of 0 0 0 0 0 0 Mongolia 0 0 0 0 0 0 Nauru (2002) 0 (2002) 0 (2002) 0 (2002) 0 (2002) 0 (2002) 0 New Caledonia (2003) 0 (2003) 0 (2003) 0 (2003) 0 (2003) 0 (2003) 0 New Zealand (2003) 0 (2003) 66 (2003) 0 (2003) 2 (2003) 589 (2003) 0 Niue (2003) 0 (2003) 0 (2003) 0 (2003) 0 (2003) 0 (2003) 0 Northern Mariana Islands 0 0 0 0 0 0 Palau 0 0 0 0 0 0 Papua New Guinea ... 1385 50 39 2050 0 Philippines 89 3025 250 1293 10 0 Pitcairn Islands ... ... ... ... ... ... Republic of Korea (2003) 0 (2003) 33 (2003) NR (2003) 8 (2003) 5 (2003) 0 Samoa 0 0 0 0 0 0 Singapore 0 96 0 0 0 0 Solomon Islands 0 0 0 0 0 0 Tokelau 0 0 0 0 0 0 Tonga 0 0 0 0 0 0 Tuvalu 0 0 0 0 0 0 Vanuatu ... (2003) 165 (2003) 3 (2003) 0 ... (2003) 0 Viet Nam 49 217 46 72 328 0 Wallis and Futuna (2002) 0 (2002) 0 (2002) 0 (2002) 0 (2002) 0 (2002) 0 WESTERN PACIFIC REGION 173 88 083 2762 2600 14 353 1 Neonatal Total Country/area Diphtheria Measles tetanus tetanus Pertussis Poliomyelitis 2004 2004 2004 2004 2004 2004 Vaccine Preventable Diseases - Number of Reported Cases ... Data not available NR Not relevant p Preliminary be Vaccine-derived poliovirus STATISTICAL TABLES 403 Congenital Yellow fever Hib meningitis Mumps Rubella rubella AFP 2004 2004 2004 2004 2004 2003 Vaccine Preventable Diseases - Number of Reported Cases (2003) NR (2003) 0 (2003) 0 (2003) 0 (2003) 0 0 0 (2003) 22 106 44 1 27 0 0 21 0 0 2 ... ... ... NR ... 161 (2003) NR ... ... ... ... 5105 0 0 0 0 0 0 (2003) 0 (2003) 96 (2003) 14 (2003) 65 (2003) 0 9 ... (2003) 0 (2003) 12 (2003) 3 ... 0 0 0 1 1 0 0 (2003) 0 0p 230p 32p 0p 12 (2003) 0 ... (2003) 84 672 (2003) 2794 (2003) 1 0 ... 0 0 0 0 0 ... ... ... ... ... 73 0 0 67 2 0 0 (2003) 0 ... ... ... ... 98 0 (2003) 0 (2003) 6 (2003) 0 0 0 NR 0 0 0 0 0 0 25 417 36 0 9 ... ... ... (2002) 0 (2002) 0 0 (2003) 0 ... ... ... ... 0 (2003) 0 (2003) 6 (2003) 57 (2003) 28 (2003) 0 9 (2003) 0 (2003) 0 (2003) 0 (2003) 40 (2003) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ... ... ... ... ... 17 ... ... ... 25 ... 466 ... ... ... ... ... ... (2003) 0 (2003) NR (2003) 1518 (2003) 8 (2003) 0 23 0 4 0 0 1 0 0 2 1003 141 0 5 0 ... ... ... ... 1 0 0 0 0 0 0 NR 16 0 0 0 0 0 0 0 0 0 0 (2003) NR (2003) 20 (2003) NR (2003) NR (2003) NR 0 NR ... ... ... ... 380 ... (2002) 0 (2002) 2 (2002) 1 ... 0 0 191 88 126 3220 3 6397 STATISTICAL TABLES 404 Table 7 Morbidity and mortality indicators (continued) American Samoa (2003) NR (2003) 99.00 (2003) 98.00 (2003) 94.00 (2003) 93.00 (2003) 89.00 Australia NR ... ... 92.60 92.50 95.00 Brunei Darussalam 99.40 99.20 100.00 91.70 92.20 100.00 Cambodia 95.00 ... 92.00 85.00 86.00 ... China (2003) 98.00 ... (2003) 98.20 (2003) 98.20 (2003) 98.30 (2003) 96.70 Cook Islands 100.00 100.00 100.00 100.00 100.00 100.00 Fiji (2003) 100.00 (2003) 96.00 (2003) 97.00 (2003) 94.00 (2003) 100.00 (2003) 92.00 French Polynesia (2003) 99.00 (2003) 99.00 (2003) 99.50 (2003) 99.00 (2003) 99.00 (2003) 98.00 Guam NR 99.00 ... 87.00 79.00 85.00 Hong Kong (China) (2003) 99.60 (2003) 99.70 (2003) 87.80 (2003) 84.70 (2003) 85.50 (2003) 85.60 Japan (2003) 96.00 ... (2003) 100.00 (2003) 97.00 (2003) 97.00 ... Kiribati 94.50 ... 75.10 63.40 60.70 66.60 Lao People's Democratic Republic 60.00 2.00 66.00 45.00 46.00 45.00 Macao (China) 96.20 99.70 94.60 90.20 90.20 86.40 Malaysia (2003) 100.00 (2003) 90.20 (2003) 95.30 (2003) 95.80 (2003) 96.70 (2003) 95.00 Marshall Islands 91.00 91.00 71.00 64.00 68.00 72.00 Micronesia, Federated States of 62.00 83.00 83.00 78.00 82.00 80.00 Mongolia 97.60 97.70 98.80 98.90 99.00 98.20 Nauru (2002) 100.00 ... ... (2002) 80.00 (2002) 59.00 (2002) 75.00 New Caledonia ... ... ... ... ... ... New Zealand ... ... ... ... ... ... Niue (2003) 100.00 (2003) 100.00 (2003) 100.00 ... ... ... Northern Mariana Islands ... 98.70 96.00 87.00 87.00 89.00 Palau ... 100.00 100.00 98.00 98.00 98.00 Papua New Guinea 54.00 (2003) 21.00 60.00 46.00 36.00 45.00 Philippines 79.00 (2003) NR 81.00 77.00 75.00 43.00 Pitcairn Islands ... ... ... ... ... ... Republic of Korea (2003) 87.00 (2003) 92.00 (2003) 97.00 (2002) 97.00 (2003) 94.00 (2003) 91.00 Samoa 93.00 58.00 90.00 68.00 41.00 70.00 Singapore 99.00 99.00 95.00 94.00 94.00 93.00 Solomon Islands 82.00 (2003) 76.00 84.00 80.00 75.00 72.00 Tokelau 100.00 99.00 99.00 99.00 99.00 99.00 Tonga 99.60 100.00 99.90 99.30 99.30 99.20 Tuvalu 100.00 91.00 100.00 98.00 98.00 98.00 Vanuatu (2003) 63.00 ... ... (2003) 49.00 (2003) 53.00 (2003) 56.00 Viet Nam 95.60 59.50 91.60 96.20 96.30 94.20 Wallis and Futuna (2002) 73.50 ... ... (2002) 100.00 (2002) 100.00 (2002) 100.00 WESTERN PACIFIC REGION (2003) 94.50 ... ... (2003) 94.37 (2002) 94.28 (2003) 94.30 HepB birth Hepatitis Country/area BCG dose DTP1 DTP3 OPV3 B3 2004 2004 2004 2004 2004 2004 Immunization Coverage (%) ... Data not available NR Not relevant STATISTICAL TABLES 405 Hib3 MCV1 MCV2 Vitamin A1 2004 2004 2004 2004 Immunization Coverage (%) (2003) 90.00 (2003) 89.00 (2003) 76.00 (2003) NR 94.80 93.60 84.80 NR 91.70 100.00 96.60 NR (2003) NR 80.00 (2003) NR 75.00 (2003) NR (2003) 97.90 (2003) 96.40 (2003) NR NR 100.00 86.00 ... (2003) 88.00 (2003) 91.00 ... ... (2003) 98.00 ... ... ... 83.00 82.00 ... NR ... (2003) 80.50 (2003) 98.60 (2003) NR ... (2003) 100.00 ... ... ... 56.00 ... 58.30 ... 36.00 29.00 42.00 NR 91.10 83.80 NR (2003) NR (2003) 92.20 (2003) NR (2003) NR 46.00 70.00 (2003) 90.00 46.00 65.00 85.00 74.00 NR ... 98.80 97.80 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... (2003) 85.70 ... 70.00 82.00 82.00 ... 98.00 100.00 98.00 ... ... 44.00 37.00 ... (2003) NR 81.00 (2003) NR 89.00 ... ... ... ... ... (2003) 96.00 (2003) 95.00 ... ... 25.00 ... ... NR 94.00 95.00 ... NR 72.00 NR ... 99.00 82.00 (2003) NR (2003) NR ... 99.60 98.60 ... ... 98.00 ... ... (2003) NR (2003) 48.00 NR (2003) NR NR 97.10 NR 82.60 ... (2002) 100.00 ... ... ... (2003) 92.81 ... ... STATISTICAL TABLES 406 Table 7 Morbidity and mortality indicators (continued) American Samoa ... ... Australia 2003 0.10 ... Brunei Darussalam 2003 <0.01 ... Cambodia 2004 1.90 bf (2003) 20.80 bf (indirect SW) China 2003 0.10 bg ... Cook Islands ... ... Fiji 2003 0.10 ... French Polynesia ... ... Guam ... ... Hong Kong (China) ... ... Japan 2003 <0.10 ... Kiribati ... ... Lao People's Democratic Republic 2003 0.10 (2001) 1.10 (among SW) Macao (China) ... ... Malaysia 2003 0.40 bg ... Marshall Islands ... ... Micronesia, Federated States of ... ... Mongolia 2003 <0.10 ... Nauru ... ... New Caledonia ... ... New Zealand 2003 0.10 ... Niue ... ... Northern Mariana Islands ... ... Palau ... ... Papua New Guinea 2003 1.70 bf (2004) 19.90 bf,bh Philippines 2003 <0.10 <0.03 (among SW) Pitcairn Islands ... ... Republic of Korea 2003 <0.10 ... Samoa ... ... Singapore 0.20 ... Solomon Islands ... ... Tokelau ... ... Tonga ... ... Tuvalu ... ... Vanuatu ... ... Viet Nam 2003 0.40 bg 32.0 bg (among IDU); 16 bg (among SW) Wallis and Futuna ... ... WESTERN PACIFIC REGION ... ... Percentage in general population based Percentage in a high risk group based Country/area Year on HIV estimates in adults on sentinel surveillance HIV Prevalence (status of the epidemic) HIV / AIDS ... Data not available SW Sex workers IDU Injecting drug users bf Generalized epidemic (>1% in general population) bg Concentrated epidemic (<1% in general population but >5% in specific vulnerable groups such as sex workers (SW), injecting drug users (IDU), etc.) bh Among STI patients in Port Moresby STATISTICAL TABLES 407 % of people with HIV/AIDS in need of and receiving Year % of condom use Year adequate treatment including antiretroviral therapy (ART) HIV / AIDS ... ... ... ... ... ... 2001 89.80 bi (direct SW) 2004 23.00 ... 2004 7.00 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2001 60.00 bj (among SW) ... ... ... 2003p 51.00 bj (among SW) ... ... ... ... ... 2003 66.00 bk (among SW) ... ... ... ... ... ... ... ... ... ... ... ... ... 2004 22 bl=M (among STI); 56 bl=F (among STI) 2003 < 5.00 2003 27.00 bi (among SW) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2001 55-79 bk,bm (street SW) 2004 1.00 ... ... ... ... p Preliminary bj Consistent condom use in the last month M Male bk Consistent condom use in the last year F Female bl Consistent condom use in the last three months with non-regular partners SW Sex workers bm With one-time clients STI Sexually transmitted infections bi Consistent condom use in the past week STATISTICAL TABLES 408 Table 7 Morbidity and mortality indicators (continued) Country/area All Smear positive All Smear positive 2003 2003 cases cases cases cases Prevalence rate (per 100 000 population) 2003 Incidence rate (per 100 000 population) 2003 American Samoa 70.00 3 54 23 30 13 Australia ... ... 6 3 6 3 Brunei Darussalam ... ... 61 25 54 25 Cambodia ... 0 762 300 508 225 China ... ... 246 113 102 46 Cook Islands 88.00 4 59 27 30 13 Fiji 62.00 2 38 18 30 13 French Polynesia 90.00 4 39 18 30 13 Guam ... ... 105 53 60 27 Hong Kong (China) ... ... 79 36 77 35 Japan ... ... 42 19 31 14 Kiribati 49.00 3 60 27 60 27 Lao People's Democratic Republic ... ... 327 138 157 71 Macao (China) ... ... 89 44 82 37 Malaysia ... 0 136 59 106 47 Marshall Islands 68.00 2 60 27 60 27 Micronesia, Federated States of 100.00 1 62 29 60 27 Mongolia ... ... 237 116 194 87 Nauru ... ... 36 19 30 13 New Caledonia ... 0 103 47 60 27 New Zealand ... ... 11 5 11 5 Niue 78.00 4 59 27 30 13 Northern Mariana Islands ... ... 67 34 60 27 Palau ... ... 76 30 60 27 Papua New Guinea ... 0 529 268 235 105 Philippines 74.00 3 458 187 296 133 Pitcairn Islands ... ... ... ... ... ... Republic of Korea ... ... 118 56 87 39 Samoa 80.00 5 44 20 30 13 Singapore ... ... 42 20 41 18 Solomon Islands ... ... 60 27 60 27 Tokelau ... ... 59 27 30 13 Tonga 91.00 3 44 16 30 13 Tuvalu 83.00 3 59 27 30 13 Vanuatu 87.00 4 71 35 60 27 Viet Nam 87.00 1 240 90 178 80 Wallis and Futuna 65.00 2 30 13 30 13 WESTERN PACIFIC REGION ... ... 236 106 112 50 Tuberculosis ... Data not available Reported MDA coverage among Number of total population (%) MDA rounds Lymphatic Filariasis STATISTICAL TABLES 409 Cure rate Case detection rate of TB notification rate Mortality rate (smear-positive cases) smear positive cases DOTS (per 100 000 population) (All cases) in DOTS areas) 2003 coverage 2003 2003 2002 2003 DOTS Total Tuberculosis 6 100 24 24 100 5 3 0.23 78 9 22 63 5 1 5 84 138 138 100 58 34 95 92 60 60 100 199 134 18 93 43 45 91 47 21 6 100 (2002) 39 0 100 0 0 4 85 63 63 100 21 8 5 82 65 65 100 20 9 12 68 (2002) 67 0 100 14 0 7 79 58 73 100 80 25 4 76 40 60 64 25 8 4 94 419 419 100 324 113 26 78 47 47 85 49 33 10 89 76 80 100 80 30 17 76 69 69 100 64 33 4 100 140 140 100 113 38 6 91 92 92 90 91 25 32 87 68 68 100 151 59 4 50 57 57 100 23 8 11 85 23 23 100 16 6 1 60 57 57 100 10 3 6 100 (2002) 364 0 90 0 0 8 71 75 75 100 57 20 8 38 90 90 100 44 24 49 53 15 54 46 322 57 49 88 68 68 100 168 91 ... ... ... ... ... ... ... 10 83 23 59 100 71 23 5 84 51 51 100 15 7 5 87 44 75 100 38 14 4 90 107 107 100 61 29 6 ... ... 0 0 0 0 5 83 80 80 100 15 11 6 ... ... 0 0 283 0 8 79 70 70 100 49 19 23 92 86 86 100 114 69 2 100 356 356 90 102 48 19 91 50 52 90 57 26 All cases Smear-positive cases STATISTICAL TABLES 410 Table 7 Morbidity and mortality indicators (continued) Country/area Year Cases Deaths Year Deaths Year Deaths Year Male Female Motor and other Diseases of the Suicide vehicle accidents Cancer circulatory system (per 100 000 population) Non-communicable diseases American Samoa 2002 101 5 2002 37 2002 88 ... ... Australia 1996 116 225 (2003) 1811 2003 37 558 2003 48 835 2003 17.59 4.77 Brunei Darussalam 2003 495 26 2003 156 2003 334 2003 2.19 0.60 Cambodia 2002 ... 535 2000 134 ... ... ... China 2002 ... bn 2002 bp 2002 bq 1999 13.00 br 14.80 br Cook Islands 2003 128 bo 3 2003 15 2003 19 ... ... Fiji 1998 551 13 1999 229 1999 1052 ... ... French Polynesia 2003 ... 33 2003 245 2003 260 ... ... Guam 2000 ... 23 2000 125 2000 246 2000 34.10 2.64 Hong Kong (China) 2003p ... 173 2003 11 510 2003 9633 2003p 22.28 10.52 Japan 2003 ... 10 913 2003 309 543 2003 312 382 2003 37.55 13.34 Kiribati 2002 ... 5 2002 15 2002 70 ... ... Lao People's Democratic Republic ... ... ... ... ... ... Macao (China) 2003 ... 16 2003 417 2003 477 2003 16.23 10.31 Malaysia 2003 82 304 1757 2003 3396 2003 8468 2003 0.77 0.37 Marshall Islands ... ... 1998 12 ... ... ... Micronesia, Federated States of 2000 ... 4 2000 51 2000 84 ... ... Mongolia 2002 8719 546 2003 3027 2003 6074 2002 22.15 5.45 Nauru 2002 ... 0 2002 13 2002 14 2002 19.46 0.00 New Caledonia 2002 662 62 2002 298 2002 262 2002 21.67 10.28 New Zealand 2001/2002 12 905 (2001) 538 2001 7810 2001 11 430 2001 20.43 6.08 Niue ... ... ... ... ... ... Northern Mariana Islands 2000 555 (1998) 7 1998 26 ... ... ... Palau 1998 77 4 1998 13 1998 38 ... ... Papua New Guinea 2000 504 19 2000 268 ... 2000 0.00 0.04 Philippines 2000 ... 5680 ... ... 1993 2.50 1.70 Pitcairn Islands ... ... ... ... ... ... Republic of Korea 2003 ... 9224 2003 63 685 2003 60 262 2003 31.28 14.28 Samoa 2002 129 4 2002 30 2002 61 2002 11.95 bs 5.91 bs Singapore 2004p ... 177 2004p 4339 2004p 5005 2004p 6.69 a 4.62 a Solomon Islands ... ... ... ... ... ... Tokelau ... ... ... ... ... ... Tonga 2002 109 0 2002 76 2002 192 ... ... Tuvalu 2001 1 0 2001 0 ... ... ... Vanuatu 2003 30 ... 2003 38 2003 46 ... ... Viet Nam 2003 132 679 1230 2003 784 2003 4294 ... ... Wallis and Futuna ... ... ... ... ... ... WESTERN PACIFIC REGION 356 174 32 805 443 850 469 626 ... ... ... Data not available bq Mortality rate (per 100 000 population) of circulatory p Preliminary system diseases in urban areas=190.22 and in rural a Resident population areas=183.53 bn Mortality rate (per 100 000 population) of motor & other vehicle accidents br Refers to selected urban areas and rural areas in mainland in urban areas=6.39 and in rural areas=7.86 China bo Rarotonga cases only bs Suicide rate for Samoa was derived based on the bp Mortality rate (per 100 000 population) of cancer in urban areas=119.71 latest population size available (by gender) and in rural areas=105.83 Annex Charts ANNEX CHARTS 412 Figure 1 In vivo antimalarial drug treatment failures for falciparum malaria in Asian countries of the Region, 1981-2004 Note: Summary of published and unpublished studies of malaria drug resistance 1981-2004. Dose and length of treatment course, and sampling methods, vary between studies. ANNEX CHARTS 413 Figure 2 In vivo antimalarial drug treatment failures for falciparum malaria in the Pacific, 1991-2003 Note: Summary of published and unpublished studies of malaria drug resistance 1991-2003. Dose and length of treatment course, and sampling methods, vary between studies. ANNEX CHARTS 414 Figure 3 Annual incidence rate of confirmed malaria per 1000 population, 1987-2003 ANNEX CHARTS 415 Figure 4 Annual malaria mortality rate per 100 000 population, 1987-2003 ANNEX CHARTS 416 Figure 5 Insecticide-treated mosquito net coverage among the populations living at risk of malaria, 2002 and 2003 (reported distribution data from 7 countries) ANNEX CHARTS 417 Figure 6 Reported number of dengue cases and case fatality rate (CFR) of dengue in the Western Pacific Region, 1992-2004 ANNEX CHARTS 418 Figure 7 Incidence rate of dengue fever per 10 000 population in south-east Asian countries of the Western Pacific, 2003 ANNEX CHARTS 419 Figure 8 HIV prevalence among newly detected TB patients, 1992-2002 ANNEX CHARTS 420 Figure 9 Multi-drug resistance in previously untreated cases, 1997-2004 ANNEX CHARTS 421 Figure 10 Major emergencies in the Western Pacific Region, 2004-2005 Appendix: Glossary of Terms 423 Acute respiratory infections. The number of cases of and or recorded or estimated deaths from respiratory infections during the most recent year for which valid statistics are available. Admission. Formal acceptance, by a health facility, of a patient who is to receive medical or paramedical care while occupying a health facility bed. Healthy babies born in hospital should not be counted if they do not require special care. Adult literacy rate. The percentage of persons (male or female, or both sexes) aged 15 years and over who can, with understanding, both read and write a short simple statement on their everyday lives. If the national definition of literacy is different, it should be stated. Adult literacy rate is obtained through population census or special survey. Annual population growth rate. A measure of population growth (in the absence of migration) comprising addition of newborn infants to the population and subtraction of deaths. The result, known as the natural rate of increase, is calculated as (Live bir ths during the year - Deaths during the year) x 1000 Mid-year population Area. The total surface area in square kilometres, comprising land area and all inland waters. Bed. A bed regularly maintained and staffed for the accommodation and full-time care of a succession of inpatients and which is situated in wards or a part of the hospital where continuous medical care for inpatients is provided. The total of such beds constitutes the normally available bed complement of the hospital. Cribs and bassinets maintained for use by healthy newborn babies who do not require special care should not be included. Body mass index (BMI). Calculated as weight in kilograms (kg) divided by height in square meters (m2). Cancers. The number of cases and deaths due to cancer during the most recent year for which valid statistics are available. Cases and deaths for selected communicable diseases. The number of cases and deaths due to hepatitis viral types A, B and C and unspecified, cholera, typhoid fever, encephalitis, plague, syphilis, gonorrhoea, leprosy, malaria and dengue/DHF in a given year. Cases and deaths for selected diseases under the WHO expanded programme on immunization (EPI). The number of cases and deaths due to a specific disease among selected preventable diseases (diphtheria, pertussis, tetanus, neonatal tetanus, poliomyelitis, hib meningitis, measles, mumps, rubella and congenital rubella syndrome) in a specific country or area over a given year. Causes of morbidity. (See Leading causes of morbidity) Causes of mortality. (See Leading causes of mortality). Circulatory system diseases. The number of cases and deaths resulting from any form of circulatory disease during the most recent year for which valid statistics are available. Condom use rate of the contraceptive prevalence rate. The number of women aged 15-49 in marital or consensual unions who are practising contraception by using condoms as a proportion of all women of the same age group in consensual unions who are practising, or whose sexual partners are practising, any form of contraception. Crude birth rate*. The number of live births in a given period per 1000 people in the same period. Usually expressed per year. Crude death rate*. The number of deaths per 1000 people in a given year. Dependency ratio. The ratio of the population defined as dependent (those under 15 years old and those over 65 years old) with respect to the working-age population aged 15-64 years. Diabetes mellitus. The prevalence (or number of existing cases) of and deaths due to diabetes mellitus during the most recent year for which valid statistics are available. Diarrhoeal diseases. The number of cases of and/or recorded or estimated deaths from diarrhoeal diseases during the most recent year for which valid statistics are available. Discharges (including deaths). The number of persons, living or dead, whose stay in a health care facility has terminated 424 and whose departure has been officially recorded. DOTS. Directly observed treatment, short- course (DOTS) is the recommended strategy for tuberculosis control. It comprises: 1) government commitment to ensuring sustained, comprehensive tuberculosis control activities; 2) case detection by sputum-smear microscopy among symptomatic patients self-reporting to health services; 3) standardized short-course chemotherapy using regimens of six to eight months, for at least all confirmed smear-positive cases (Good case management includes DOT during the intensive phase for all new sputum-smear-positive cases, the continuation phase of rifampicin-containing regimens and the whole re-treatment regimen.); 4) a regular, uninterrupted drug supply of all essential antituberculosis drugs; and 5) a standardized recording and reporting system that allows assessment of case- finding and treatment results for each patient and of the tuberculosis control programme’s performance overall. DOTS coverage. (See Tuberculosis DOTS coverage) Estimated population. (See Population) General government expenditure on health. General government expenditure on health refers to expenditures incurred by central, state/regional and local government authorities, excluding social security schemes. Included are non- market, non-profit institutions that are controlled and mainly financed by government units. Health-adjusted life expectancy (HALE). HALE is based on life expectancy at birth but includes an adjustment for time spent in poor health. It is most easily understood as the equivalent number of years in full health that a newborn baby (or a person at age 60) can expect to live based on current rates of ill-health and mortality. Health care waste generation (metric tons per year). The total weight of all solid and liquid waste generated by all public and private health care establishments, health research facilities, and health-related laboratories plus waste generated by home health care activities such as dialysis, insulin injections, etc. during the course of a calendar year. (Method of computation: The indicator may be computed as the sum of the weight of all solid and liquid waste generated by health care establishments, health research facilities, and health-related laboratories plus waste generated by home health care activities in a calendar year, expressed as tons per year.) Health facilities. (See Health infrastructure) Health infrastructure. • General hospital. A hospital which provides a range of different services for patients of various age groups and with varying disease conditions. • Specialized hospital. A hospital admitting primarily patients suffering from a specific disease or affection of one system, or reserved for the diagnosis and treatment of conditions affecting a specific age group or of a long-term nature. • District/first-level referral hospital A hospital at the first referral level that is responsible for a district or a defined geographical area containing a defined population and governed by a politico- administrative organization such as a district health management team. The role of district hospitals in primary health care has been expanded beyond being dominantly curative and rehabilitative to include promotional, preventive and educational roles as part of a primary health care approach. The district hospital has the following functions: (1) It is an important support for other health services and for health care in general in the district. (2) It provides wide-ranging technical and administrative support and education and training for primary health care. (3) It provides an effective, affordable health care service for a defined population, with their full participation, in cooperation with agencies in the district that have similar concerns. • Primary health care centre. A centre that provides services which are usually the first point of contact with a health professional. They include services provided by general practitioners, dentists, community nurses, pharmacists and midwives, among others. Health workforce. • Physicians. All graduates of any faculty or school of medicine, actually Appendix: Glossary of Terms 425 working in the country in any medical field (practice, teaching, administration, research, laboratory, etc.) • Dentists. All graduates of any faculty or school of dentistry, odontology or stomatology, actually working in the country in any dental field. • Midwives. All persons who have completed a programme of midwifery education, and have acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery, and are actually working in the country. The person may or may not have prior nursing education. • Nurses. All persons who have completed a programme of basic nursing education and are qualified and registered or authorized to provide responsible and competent service for the promotion of health, prevention of illness, care of the sick, and rehabilitation, and are actually working in the country. • Pharmacists. All graduates of any faculty or school of pharmacy, actually working in the country in pharmacies, hospitals, laboratories, industry, etc. • Other paramedical staff. This includes medical assistants, laboratory technicians and X-ray technicians, among others. • Other health care providers (including community health workers). Other health care providers include all workers who respond to the national definition of health care providers and are not physicians, midwives, nurses, dentists or pharmacists. HIV prevalence among 15–24 year-old pregnant women. Percentage of pregnant women aged 15–24 whose blood samples test positive for HIV. Hospital bed. (See Bed) Human Development Index (HDI). The HDI measures the average achievements in a country in three basic dimensions of human development – longevity, knowledge and a decent standard of living. A composite index, the HDI thus contains three variables: life expectancy, educational attainment (adult literacy and combined primary, secondary and tertiary enrolment) and real GDP per capita (in purchasing power parity or PPP$). Immunization coverage for infants. (See Percentage of infants fully immunized with BCG, DPT3, OPV3, measles and hepatitis B3). Infant mortality rate. The number of deaths of infants below one year of age (between 0-364 days after birth) per 1000 live births during a given period of time. Injuries. The number of recorded or estimated number of diseases/injuries and/or deaths related to work accidents, motor and other vehicle accidents, suicide, homicide and violence which have occurred in the general population during the latest year for which valid statistics are available. A work accident is defined as an occurrence arising out of or in the course of work which results in an occupational injury. Inpatient. A person who is formally admitted to a health care facility and who is discharged after one or more days. Leading causes of morbidity. The most frequently occurring causes of morbidity (usually 10) for which the greatest number of cases have been reported during a given year. Morbidity can be described in terms of the incidence and/or prevalence of certain diseases. It is usually expressed as a rate: the number of cases of disease per 100 000 persons. The WHO Expert Committee on Health Statistics noted in its Sixth Report (1959) that morbidity could be measured in terms of three units: (1) persons who were ill; (2) the illnesses (periods or spells of illness) that those persons experienced; and (3) the duration (days, weeks, etc.) of those illnesses. Leading causes of mortality. The most frequently occurring causes of mortality (usually 10) under which the greatest number of deaths have been reported during a given year. Causes of mortality are all those diseases, morbid conditions, or injuries which either resulted in or contributed to death, and the circumstances of the accident or violence which produced any such injuries. • Mortality rate. An estimate of the proportion of a population that dies during a specified period. The numerator is the number of persons dying during the period; the denominator is the total number of people in the population, usually estimated as the mid-year population. This rate is an estimate of the person- time death rate, i.e., the death rate 426 per 10n person-years. If the rate is low, it is also a good estimate of the cumulative death rate. This rate is also called the crude death rate. Life expectancy at birth. The number of years a newborn baby would live if prevailing patterns of mortality at the time of its birth were to stay the same throughout the child’s life. Live birth. The complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached. Each product of such a birth is considered liveborn. Malaria prevalence rate. The number of cases of malaria per 100 000 people. Malaria death rate. The number of malaria deaths per 100 000 population. Maternal causes. Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. It should be subdivided into two groups: (1) direct obstetric deaths, resulting from obstetric complications of the pregnant state (pregnancy, labour and the puerperium), from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above; and (2) indirect obstetric deaths, resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but was aggravated by the physiological effects of pregnancy. Maternal mortality ratio. The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes, expressed per 100 000 live births. Mental disorders. Any form of mental disorder, i.e. clinically behavioural or psychological syndrome, characterized by the presence of distressing symptoms or significant impairment of functioning. National underweight, stunting and wasting prevalence. • Underweight. Low weight for age or weight for age more than a standard deviation of 2 below the median value of the reference (healthy) population. • Stunting. Low height for age or height for age more than a standard deviation of 2 below the median value of the reference (healthy) population. • Wasting. Low weight for height or weight or weight for height more than a standard deviation of 2 below the median value of the reference (healthy) population. Neonatal mortality rate. Number of deaths in the neonatal period during a given time period per 1000 live births during the same time period. Neonatal period. Commences at birth and ends 28 completed days after birth. Neonatal deaths (deaths among live births during the first 28 completed days of life) may be subdivided into early neonatal deaths, occurring during the first seven days of life, and late neonatal deaths, occurring after the seventh day but before 28 completed days of life. Number of children orphaned by HIV/AIDS. The estimated number of children who have lost their mother, father or both parents to AIDS before age 15. In practice, the impact of the AIDS epidemic on orphans is measured through the ratio of orphans to non-orphans who are in school through the ratio of school attendance of orphans to school attendance of non-orphans aged 0-14. Obesity. A person is considered obese when his/ her calculated body mass index (BMI) is greater than or equal to 30 kg/m2 Outpatient. A person who goes to a health care facility for a consultation and who leaves the facility within three hours of the start of consultation. An outpatient is not formally admitted to the facility. Overweight. A person is considered overweight when his/ her calculated body mass index (BMI) is greater than or equal to 25 kg/m2 Appendix: Glossary of Terms 427 Per capita gross domestic product (GDP). Gross domestic product divided by mid-year population (or population size if mid-year population is not available). Per capita gross national income (GNI). Gross national income divided by mid-year population (or population size if mid-year population is not available). GNI is the sum of value added by all resident producers plus any product taxes (less subsidies) not included in the valuation of output plus net receipts of primary income (compensation of employees and property income) from abroad. Per capita gross national product (GNP). The per capita GNP is obtained by dividing the total gross national product by the total population. The GNP comprises: (1) the gross domestic product (GDP), which measures the total output of goods and services for final use produced by residents and non- residents, regardless of the allocation to domestic and foreign claims, plus (2) net factor income from abroad, which is the income residents receive from abroad for factor services (labour and capital) less similar payments made to non- residents who contributed to the domestic economy. Per capita health expenditure (US$). The average health expenditure (in United States dollars) per person in a year. Per capita income. Income per person in a population. Per capita income is often used to measure a country’s standard of living. Percentage of deliveries at home attended by skilled health personnel. Percentage of total deliveries that take place at home and are attended by personnel who are trained to give the necessary supervision, care and advice to women during pregnancy, labour and the post-partum period. Percentage of deliveries in health facilities. Percentage of total deliveries that take place in public and private hospitals, clinics and health centres irrespective of who attended the delivery at those facilities. Percentage of infants fully immunized with BCG, DPT3, OPV3, measles, and hepatitis B3. Percentage of children under one year of age who have received immunization against tuberculosis (BCG), diphtheria, pertussis, tetanus (DPT3), poliomyelitis (OPV3), measles (at least one dose) and hepatitis B3. Percentage of newborn babies weighing at least 2500 grams at birth. The percentage of children whose birth weight is equal or greater than 2500 grams, the measurement being taken preferably within the first hours of life, before significant postnatal weight loss has occurred. Percentage of population below 15 years of age or above 65 years of age. The percentage of the total population below 15 years of age or above 65 years of age, which are often considered the “dependent” ages, during a given period of time. Percentage of pregnant women attended by trained health personnel. The percentage of pregnant women who have had at least one consultation with a trained health worker during pregnancy. Since the number of pregnant women is generally not available, the number of live births is used as the denominator. Percentage of the population with access to excreta disposal facilities. The percentage of the population with access to a sanitary facility for human excreta disposal in the dwelling or immediate vicinity. Percentage of women immunized with tetanus toxoid (TT2) during pregnancy. A pregnant woman is considered adequately immunized against tetanus when she has received at least two doses of tetanus toxoid during pregnancy. Since the number of pregnant women is generally not available, the number of live births or estimated newborn babies is used as the denominator. Percentage of women of child-bearing age using modern contraceptive methods. Women of child-bearing age are generally defined as aged 15-49 years. If figures available are for a population different from all women of child-bearing age (e.g. married women only) this should be clearly stated. Users of family planning are defined as women who are practising, or whose male partners are practising, any form of contraception, including female and male sterilization, injectable and oral contraceptives, intrauterine devices, diaphragms, spermicides, condoms, rhythm method, withdrawal and abstinence, among others. 428 Percentage of women of child-bearing age with anaemia. Percentage of women aged 15 to 49 years with a blood concentration of haemoglobin below 120 grams per litre of blood for non-pregnant women, and 110 grams per litre (or 6.83 millimoles per litre) or by an haematocrit below 33% for pregnant women. Person with midwifery skills. A person who has successfully completed the prescribed course in midwifery and is able to give the necessary supervision, care and advice to women during pregnancy, labour and the postpartum period, to conduct deliveries alone, to provide lifesaving obstetric care, and to care for the newborn and the infant. Population. All the inhabitants of a given country or area considered together. Estimates are based on a recent census, official national data or United Nations projections. Prevalence rate. The proportion of the population that has the health problem or disease under study. The prevalence rate is expressed as the number of existing cases of the disease at a specified point in time in the total population. The ratio is expressed per 100, 1000, 10 000 or 100 000. Prevalence of tobacco use. Includes smoking, oral tobacco and snuff on more than one occasion in the 30 days preceding the survey. Prevalence of underweight children under five years of age. Percentage of children under five years of age whose weight for age is less than two standard deviations from the median for the international reference population (often referred to as the National Centre for Health Statistics/ WHO reference population) aged 0-59 months. Proportion of households with access to secure tenure is 1 minus the percentage of the urban population that lives in slums. In the absence of data on the number of slum dwellers, the United Nations Human Settlements Programme (UN-HABITAT) produces estimates based on a definition of slums as agreed by the Expert Group Meeting on Urban Indicators in 2002. Proportion of the population in malaria- risk areas using effective malaria prevention measures. Percentage of children aged 0–59 months sleeping under insecticide-treated bednets. Proportion of the population in malaria- risk areas using effective malaria treatment measures. Proportion of children aged 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Proportion of the population using solid fuels. The proportion of the population that relies on biomass (wood, charcoal, crop residues and dung) and coal as the primary source of domestic energy for cooking and heating. Proportion of the population with access to affordable, essential drugs on a sustainable basis. The percentage of the population that has access to a minimum of 20 of the most essential drugs. Access is defined as having drugs continuously available and affordable at public or private health facilities or drug outlets that are within one hour’s walk of the population. Essential drugs are drugs that satisfy the health care needs of the majority of the population. Proportion of the population with access to improved sanitation. Percentage of the population with access to facilities that hygienically separate human excreta from human, animal and insect contact. Facilities such as sewers or septic tanks, pour-flush latrines and simple pit or ventilated improved pit latrines are assumed to be adequate, provided that they are not public, according to the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) Global Water Supply and Sanitation Assessment 2000 Report. To be effective, facilities must be correctly constructed and properly maintained. Proportion of the population with sustainable access to an improved water source. The percentage of the population who use any of the following types of water supply for drinking: piped water, public tap, borehole or pump, protected well, protected spring or rainwater. Improved water sources do not include vendor-provided waters, bottled water, tanker trucks or unprotected wells and springs. Proportion of vehicles using unleaded gasoline (%). The proportion of motor vehicles that use unleaded gasoline as their primary fuel. The indicator may be computed as the ratio of motor vehicles using unleaded gasoline as their primary Appendix: Glossary of Terms 429 fuel, to the total number of motor vehicles, expressed as a percentage. Public health facilities. (See Health infrastructure) Purchasing power parity (PPP). The rates of conversion that equalize purchasing power across the full range of goods and services contained in total expenditure and gross domestic product of a country. Rate of growth of per capita GNP (%). The annual percentage change in a country’s GNP per capita. Secure tenure refers to households that own or are purchasing their homes, are renting privately are in social housing or are subtenants. Households without secure tenure are defined as squatters (whether or not they pay rent), the homeless and households with no formal agreement. Skilled health personnel or skilled birth attendants. Doctors (specialist or non- specialist), and/or persons with midwifery skills who can diagnose and manage obstetrical complications as well as normal deliveries. Slum. A slum household is defined by UN- HABITAT as a group of individuals living under the same roof that lack one or more (in some cities, two or more) of the following conditions: security of tenure, structural quality and durability of dwellings, access to safe water, access to sanitation facilities and sufficient living area. Smoking prevalence among adults. The proportion of the adult population (15 years and over) who are smokers (both daily and occasional) at a point in time. Stunting. (See National underweight, stunting and wasting prevalence) Surface area. (See Area) Total fertility rate. The number of children who would be born per woman if the woman was to live to the end of her child- bearing years and bear children at each age in accordance with prevailing age- specific fertility rates. Total expenditure on health as percentage of GDP (or GNP). Indicates the share of total expenditure on health with respect to a country’s GDP (or GNP). National health expenditure includes: (1) Public expenditure, i.e. current and capital expenditure of the Ministry of Health and other ministries with responsibilities in the health sector, and social security expenditure. It also includes external aid for the health sector. (2) Private expenditure, i.e. out-of- pocket health expenditure, patient co-payments, private health insurance premiums, health expenditures by nongovernmental organizations. (3) Health expenditure covers expenditure on hospitals, maternity and dental centres, clinics with a major medical component; on national health and medical insurance schemes; and on family planning and preventive care. Trained traditional birth attendant. A traditional birth attendant (TBA) who initially acquired her ability by delivering babies herself or through apprenticeship to other TBAs and who has undergone subsequent extensive training and is now integrated into the formal health care system. Tuberculosis case. A patient in whom tuberculosis has been bacteriologically confirmed or diagnosed by a clinician. • All cases. The sum of new smear- positive pulmonary, relapse, new smear-negative and extrapulmonary cases. • Smear-positive cases. A patient who has never received treatment for tuberculosis or has taken anti- tuberculosis drugs for less than four weeks and who has one of the following: (1) two or more initial sputum smear examinations positive for acid fast bacilli (AFB); (2) one sputum examination positive for AFB plus radiographic abnormalities consistent with active pulmonary tuberculosis, as determined by a treating medical officer; or (3) one sputum specimen positive for AFB and at least one sputum that is culture-positive for AFB. Tuberculosis cure rate. (See Tuberculosis success rate) Tuberculosis incidence rate. Number of new cases of tuberculosis per year Tuberculosis death rate. Deaths caused by tuberculosis per 100 000 people. 430 Tuberculosis DOTS coverage. The percentage of the national population living in areas where health services have adopted DOTS. Tuberculosis detection rate under directly observed treatment, short- course (DOTS). The percentage of estimated new infectious tuberculosis cases detected under the DOTS case detection and treatment strategy. It is calculated by dividing the number of DOTS-detected cases by the estimated number of cases. Tuberculosis prevalence rates Number of cases of tuberculosis per 100 000 people. Tuberculosis success rate under directly observed treatment, short-course (DOTS). The percentage of new, registered smear-positive (infectious) cases that were cured or in which a full course of DOTS was completed. It is calculated by adding cured cases and cases in which a DOTS course was completed, and dividing by the total number of cases. Under-five mortality rate. The probability (expressed as a rate per 1000 live births) of a child born in a specified year dying before reaching the age of five if subject to current age-specific mortality rates. Urban population. The percentage of the total population living in areas termed as “urban” by that country. Typically, the population living in towns of 2000 or more or in national and provincial capitals is classified as “urban”. Underweight. (See National underweight, stunting and wasting prevalence) Vitamin A supplementation to children 6-59 months old. Percentage of children aged 6-59 months who have received a high dose of vitamin A capsules within the last six months. Wasting. (See National underweight, stunting and wasting prevalence) Women of reproductive age (or women of child-bearing age). Refers to all women aged 15 to 49 years unless otherwise specified. NOTE: * These rates are often referred to as “crude rates” since they do not take a population’s age structure into account.
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Western Pacific country health information profiles : 2005 revision
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