WESTERN PACIFIC Country Health Information Profiles 2008 REVISION ii WHO Library Cataloguing in Publication Data Western Pacific country health information profiles: 2008 edition 1. Health status indicators 2. National health programs 3. Health priorities ISBN-13 978-92-9061-395-4 (NLM Classification : WA 900) © World Health Organization 2008 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 List of Acronyms vii American Samoa ………………………………………………………….... 1 Australia …………………………………………………………………..... 12 Brunei Darussalam ………………………………………………………..... 28 Cambodia ………………………………………………………………….. 42 China ………………………………………………………………………. 60 Cook Islands ……………………………………………………………….. 82 Fiji …………………………………………………………………………. 94 French Polynesia …………………………………………………………… 108 Guam ……………………………………………………………………..... 119 Hong Kong (China) ………………………………………………………... 130 Japan ……………………………………………………………………….. 145 Kiribati ……………………………………………………………………... 155 Lao Peoples' Democratic Republic ………………………………………..... 170 Macao (China) ……………………………………………………………... 189 Malaysia ……………………………………………………………………. 201 Marshall Islands ……………………………………………………………. 216 Micronesia, Federated States of …………………………………………….. 227 Mongolia ………………………………………………………………….... 243 Nauru ……………………………………………………………………..... 259 New Caledonia …………………………………………………………… 271 New Zealand ……………………………………………………………….. 282 Niue ………………………………………………………………………... 300 Northern Mariana Islands, Commonwealth of the …………………………. 310 Palau ……………………………………………………………………….. 324 Papua New Guinea ………………………………………………………..... 338 Philippines ………………………………………………………………...... 354 Pitcairn Islands ……………………………………………………………... 370 Republic of Korea ………………………………………………………….. 373 Samoa ……………………………………………………………………..... 387 Singapore …………………………………………………………………... 401 Solomon Islands …………………………………………………………..... 418 Tokelau …………………………………………………………………….. 429 Tonga ……………………………………………………………………..... 438 Tuvalu …………………………………………………………………….... 454 Vanuatu ……………………………………………………………………. 465 Viet Nam …………………………………………………………………... 480 Wallis and Futuna …………………………………………………………... 496 iv Statistical Tables …………………………………………………………..... 505 Table 1. Demographic indicators………………………………… 506 Table 2. Socioeconomic indicators……………………………… 508 Table 3. Health and human rights instruments…………………… 509 Table 4. Poverty- and Gender-related development indicators…… 510 Table 5. Health status indicators………………………………… 511 Table 6. Maternal, child care and nutritional indicators…………… 512 Table 7. Environmental health and prevalence of tobacco use indicators…………………………………………………………. 516 Table 8. Health workforce and infrastructure indicators…………... 517 Table 9. Morbidity and mortality indicators……………………….. 519 Table 10. Noncommunicable risk factors…………………………. 527 Table 11. Millennium development goals indicators……………… 531 Annex Charts ………………………………………………………….......... 543 Figure 1. Annual incidence rate of confirmed malaria cases (per 1000 population), Western Pacific Region, 1994-2006…………….. 544 Figure 2. Annual malaria mortality rate (per 100 000 population), Western Pacific Region, 1994-2006……………………………….. 545 Figure 3. Trend in the number of dengue cases in selected WPR countries, 1991-2007……………………………………………… 546 Figure 4. Trend in the number of dengue deaths in selected WPR countries, 1991-2007……………………………………………… 547 Figure 5. Emergencies and disasters in the Western Pacific Region, 2007-2008……………………………………………………….... 548 Appendix. Definition of Terms…………………………………………… 549 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 others, writing reports, drafting plans of action and verifying statistical data. CHIPS then became a resource tool used by other United Nations agencies, international organizations, government agencies and the general public. The 2008 edition of CHIPS comprises the country profiles and the health databanks for each country and area of the WHO Western Pacific Region. It contains crude data that are supplied either by the health ministries/departments or compiled from national databases and reference libraries. Estimates and adjusted data from various published sources are also used. Every effort is made to update the figures and analyses in CHIPS annually in response to ever-growing demands for current data and information. Clearance by the respective governments is also sought prior to publication. However, data reliability and data coverage may vary for each indicator and from country to country. The country profiles provide readers with background on each country’s demographic, political and socioeconomic situation as related to health-seeking behaviour and prevailing health conditions. Trends in major disease conditions afflicting specific age groups and the population as a whole are also illustrated. The health system is detailed to provide information as to the country's priorities, policies, strategies and resources to address health problems and improve the health and lives of its people. Specifically, the country profiles provide information as to: • Country context – Provides a picture of the country's population size and distribution, as well as its rate of population growth and movement. The political structure and situation are also described to show how major government initiatives and political events impact on health. Major economic determinants of health, such as economic performance, level of poverty, employment and working conditions, as well as government spending on health, are also explained and quantified. An overview of the environmental conditions and prevailing gender and human-rights issues affecting health is given, and the country’s major vulnerabilities, which may be natural, biological, technological or societal in nature, are illustrated. • Health situation and trend – Illustrates the major communicable and noncommunicable diseases afflicting the country, its health transition experience and the leading causes of morbidity and mortality. Maternal health conditions, as well as diseases specifically affecting children and infants, are discussed. Burden-of-disease estimates are also presented, as well as results of national surveys on health risk factors. • Health system – Orients readers on the mission, vision and objectives of the Ministry of Health. The organization of the country’s health services and delivery systems, such as the public and private sector set-up, the public health administrative levels and the health facility network, are described. In addition, the framework for health policy, planning and regulation is vi presented. The Government’s long-term objectives for the health sector are outlined, highlighting policies and directions, legislation recently passed or pending, health reform proposals and health system strengthening strategies. An overview is given of the health care financing system and major financing issues, and key areas and priorities in relation to human resources for health are presented. • Major information sources – Lists key resources for additional information on the country. Includes websites, major publications and policy documents, surveys and databases. • Contact information for the Ministry/Department of Health and the WHO Representative or Country Liaison Officer for WHO (if applicable) • Health ministry/department organizational chart (if available) A country health databank is annexed to each country profile and is more detailed in containing different sets of indicators to reflect the country’s: • demographic and socioeconomic conditions; • the health status regarding leading causes of morbidity and mortality; and the number of cases and deaths from selected diseases; • the health system as regards health workforce and infrastructure; • health service coverage, such as immunization of infants; and • status in relation to the health-related Millennium Development Goals. To facilitate intercountry comparisons, a statistical annex is made available at the end of the publication. It summarizes most of the information in the health databanks and includes other indicators on selected health conditions and practices, such as HIV and obesity, smoking and drinking behaviour and child care. It also contains human-rights, poverty and gender-related development indicators, as well as major emergencies in the Region over the last two years. 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, 2005, 2006 and 2007 revisions, 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. vii List of Acronyms ADB Asian Development Bank AFB Acid-fast bacillus AIDS Acquired immunodeficiency syndrome APEC Asia-Pacific Economic Cooperation ARI Acute respiratory infection ART Antiretroviral treatment AusAID Australian Agency for International Development BMI Body mass index CD Communicable disease CEDAW Convention on the Elimination of all Forms of Discrimination Against Women CFR Case fatality rate CNS Central nervous system COPD Chronic obstructive pulmonary disease CRC Convention on the Rights of the Child CRS Congenital rubella syndrome CVD Cardiovascular disease DALY Disability-adjusted life years DOTS Directly observed treatment short-course EPI Expanded programme on immunization EU European Union FAO Food and agriculture organization GAVI Global Alliance for Vaccine and Immunization GDI Gender-related development index GDP Gross domestic product GEM Gender empowerment measure GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GMP Good manufacturing practices GNI Gross national income GNP Gross national product HBsAg Hepatitis B antigen HBV Hepatitis B virus HDI Human development index HFMD Hand, foot and mouth disease HIB Haemophilus influenzae type b HIS Health information system HIV Human immunodeficiency virus HRDF Human Resources Development Fund ICD International classification of diseases ICT Information and communication technology IMCI Integrated management of childhood illness IMF International Monetary Fund IMR Infant mortality rate JICA Japan International Cooperation Agency LBW Low birth weight LDC Least developed countries MCH Maternal and child health MDA Mass drug administration MDG Millennium Development Goals MDR TB Multidrug resistance Tuberculosis MICS Multiple Indicator Cluster Survey MMR Maternal mortality ratio NCD Noncommunicable disease NDHS National Demographic and Health Survey NGO Non-governmental organization NHA National health accounts viii NMDS National minimum data set NSO National Statistics Office NZAID New Zealand Agency for International Development OCHA Office for the Coordination of Humanitarian Affairs ODA Official Development Assistance OECD Organisation for Economic Cooperation and Development POLHN Pacific Open Learning Health Network PPP Purchasing power parity PRISM Pacific Regional Information System PYLL Potential years of life lost RHS Reproductive health survey RPR Rapid plasma reagin SAR Special Administrative Region SARS Severe acute respiratory syndrome SPC Secretariat of the Pacific Community STEPS STEPwise approach to chronic disease risk factor surveillance STI Sexually transmitted infection SWAp Sector wide approach TB Tuberculosis TCM Traditional Chinese Medicine TFR Total fertility rate TT Tetanus toxoid UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNDAF United Nations Development Assistance Framework UNESCO United Nations Educational, Scientific and Cultural Organization UNFPA United Nations Population Fund UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children’s Fund UNIFEM United Nations Development Fund for Women USAID United States Agency for International Development U5MR Under-five mortality rate WB World Bank WFP World Food Programme WHO World Health Organization WTO World Trade Organization YLD Years lost due to disability YLL Years of life lost COUNTRY HEALTH INFORMATION PROFILES | 1 AMERICAN SAMOA 1. CONTEXT 1.1 Demographics In 2007, American Samoa had an estimated population of 68 200, 92% residing in urban areas. Based on 2007 population estimates, around 34% of the population is below 15 years of age, while 5% is above 65 years. Life expectancy at birth for men is estimated to be 72 years, while for women it is 80 years. The crude birth rate dropped from 30.0 per 1000 population in 2000 to 21.6 per 1000 population in 2007. The crude death rate in the same year was 4.0 per 1000 population. 1.2 Political situation American Samoa was defined by an 1899 treaty 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 non-voting member from Swains Island, which is privately owned). There is also an independent judiciary. 1.3 Socioeconomic 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% comes from the small tourism industry and the service sector. Transfers from the United States Government add substantially to the country’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 (goods and services) was estimated at US$ 8052 in 2003. 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. However, although 99% of the population have adequate excreta disposal facilities, solid waste disposal is still a problem. Waste collection systems have improved significantly, but space for solid waste landfill operations is very limited. 1.4 Vulnerabilities and hazards No available information. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition The most serious health issues relate 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, AMERICAN SAMOA 2 | COUNTRY HEALTH INFORMATION PROFILES 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 HIV infection 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 a coverage rate of 52% for the target population. This represents a 50% improvement compared with the 1999 MDA, which had a coverage rate of only 19%. 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. 2.2 Outbreaks of communicable diseases No available information. 2.3 Leading causes of mortality and morbidity 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. Based on hospital discharge data and notifiable disease records, the leading causes of morbidity in 2001 were dengue fever, chickenpox, dog bites, road traffic injuries and food poisonings. Heart diseases and malignant neoplasms remained the leading causes of mortality in 2005. Other common causes of death are diabetes mellitus, cerebrovascular diseases, chronic obstructive pulmonary and allied conditions, pneumonia and influenza, hypertension, accidents, perinatal conditions and septicaemia. 2.4 Maternal, child and infant diseases There has been considerable progress in primary health care in recent years. The total fertility rate for women aged 15-49 years was 3.25 in 2005, while the maternal mortality ratio was 123 per 100 000 live births in 2002. In 2000, 33% of women of reproductive age were using modern contraceptive methods. The infant mortality rate dropped from 15.2 per 1000 live births in 2004 to 11.8 in 2007. The under-five mortality rate was 4.9 per 1000 live births in 2002. 2.5 Burden of disease No available information. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives 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. COUNTRY HEALTH INFORMATION PROFILES | 3 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. 3.2 Organization of health services and delivery systems See Section 3.1. 3.3 Health policy, planning and regulatory framework See Section 3.1. 3.4 Health care financing 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 towards 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 per year to the LBJ Tropical Medical Center (16% of its funding), most of which is used to purchase medicines 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. An alternative plan to renovate and expand the existing facility is being implemented. 3.5 Human resources for health The health infrastructure consists of one hospital (LBJ Tropical Medical Center) and five primary health centres. The LBJ Tropical Medical Center, a 128-bed general acute-care hospital, is the only hospital in the territory. It provides a reasonable range of general inpatient and outpatient services covering: medicine; surgery; obstetrics and gynaecology; ear, nose and throat (ENT); eye; paediatrics; mental health; and renal dialysis. AMERICAN SAMOA 4 | COUNTRY HEALTH INFORMATION PROFILES The 2003 health workforce included 49 physicians (American doctors, Fiji School 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. However, the absence of an available health workforce pool in a small island population, along with 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 to fund 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 to health development. Human resource development for health has therefore been identified as a priority area for national health development, particularly for WHO collaboration. Training of nurses takes place both 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 postgraduate training is also 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 postgraduate training through short-term courses and attachments is 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 to practise as doctors after their training. 3.6 Partnerships No available information. 3.7 Challenges to health system strengthening No available information. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Statistical yearbook 2006 Operator : Statistics Division, American Samoa Department of Commerce Web address : http://www.asdoc.info/statistics/statshp.htm Title 2 : Demographic tables for the Western Pacific Region 2005-2010 Operator : WHO Regional Office for the Western Pacific, 2005. Web address : http://www.wpro.who.int Title 3 : American Samoa population: 2007 Operator : ASG Department of Commerce, Statistics Division Web address : http://www.asdoc.info/2007_Mid-year_population_estimate.pdf COUNTRY HEALTH INFORMATION PROFILES | 5 5. ADDRESSES DEPARTMENT OF HEALTH Office Address : Pago Pago, American Samoa 98799 Telephone : (684) 633 4606 Fax : (684) 633 5379 Office Hours : Pago Pago, American Samoa 98799 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 6. ORGANIZATIONAL CHART: Department of Health Year Source Demographics 1 0.20 2006 1 2 68.20 … … 2007 est 4 3 2.00 … … 2007 est 4 4 12.00 12.10 12.00 2007 est 3 21.60 21.60 21.60 2007 est 3 5.10 4.30 5.80 2007 est 3 5 92.00 … … 2007 est 9 6 21.60 … … 2007 4 7 4.00 … … 2007 4 8 1.76 a … … 2007 4 9 75.84 72.27 79.62 2005 8 … … … 10 3.25 2005 8 11 … … … 12 8 052.00 b 2003 est 1 13 … 14 … 15 … … … 16 … … … 17 <5 … … 0 0 0 2003 5 <5 … … 0 0 0 2003 5 <5 … … 0 0 0 2003 5 … … … … … … 0 0 0 0 0 0 2003 5 0 0 0 0 0 0 2003 5 0 0 0 0 0 0 2003 5 0 0 0 0 0 0 2003 5 41 30 11 0 0 0 2003 5 6 … … … … … 2006 6 … … … … … … 0 0 0 0 0 0 2003 5 3 1 2 0 0 0 2003 5 <5 … … 0 0 0 2003 5 Hepatitis viral Cholera FemaleMaleTotal Male Communicable and noncommunicable diseases - Type E - Type C Dengue/DHF Gonorrhoea - Unspecified Per capita GDP at current market prices (US$) Environmental indicators Total Urban Human development index Rate of growth of per capita GDP (%) Selected communicable diseases - Type A Syphilis - Type B Number of new cases Rural Number of deaths Female Total 6 | COUNTRY HEALTH INFORMATION PROFILES Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Rate of natural increase of population (% per annum) Malaria Plague Typhoid fever Encephalitis - 65 years and above Urban population (%) Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 0–4 years - 5–14 years Estimated population ('000s) Annual population growth rate (%) Percentage of population COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male AMERICAN SAMOA Leprosy AMERICAN SAMOA Year Source 18 … … … 11 … … 2002 5 19 … … … 0 0 0 2002 5 20 4 … … … … … 2006 6 3 … … … … … 2006 6 21 58 … … 37 … … 2002 5 … … … … … … 7 … … 3 … … 2002 5 7 4 2002 5 … … … … … … 2 … … 2 … … 2002 5 4 … … 0 … … 2002 5 2 … … 6 … … 2002 5 7 … … 5 … … 2002 5 2 … … 7 … … 2002 5 22 … … … 88 … … 2002 5 … … … … … … … … … 17 … … 2002 5 … … … 9 … … 2002 5 … … … … … … … … … … … … 23 2 417 1 119 1 298 29 … … 2002 5 24 135 … … 0 0 0 2003 5 25 1 500 … … 26 … … 2002 5 130 … … 10 … … 2002 5 101 … … 5 … … 2002 5 … … … 1 … … 2002 5 35 … … 4 … … 2002 5 26 3 196 … … 5 380.47 … … 2001 2 325 … … 547.14 … … 2001 2 319 … … 537.04 … … 2001 2 182 … … 306.40 … … 2001 2 79 … … 132.99 … … 2001 2 Leading causes of morbidity (inpatient care) Leading causes of mortality and morbidity - Ischaemic heart disease - Colon and rectum - Cervix - Oesophagus - Stomach 1. Dengue fever 2. Chickenpox 7. 3. Dog bites Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections - Breast Tuberculosis - All forms - New pulmonary tuberculosis (smear-positive) Cancers All cancers (malignant neoplasms only) 4. Road traffic injuries 5. Food poisoning Number of new cases Female Total Male Female Male Female Rate per 100 000 population TotalTotal Male 6. 8. 9. - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders Diabetes mellitus DATA Male 10. - Leukaemia - Trachea, bronchus, and lung Total Number of cases Number of deaths Female - Occupational injuries - Motor and other vehicular accidents - Acute myocardial infarction Circulatory - Cerebrovascular diseases - Liver - Lip, oral cavity and pharynx INDICATORS - Suicide All types - Homicide and violence COUNTRY HEALTH INFORMATION PROFILES | 7 - Hypertension All circulatory system diseases AMERICAN SAMOA Year Source 27 45 … … 68.70 … … 2005 2 36 … … 54.96 … … 2005 2 33 … … 50.38 … … 2005 2 25 … … 38.17 … … 2005 2 21 … … 32.06 … … 2005 2 12 … … 18.32 … … 2005 2 12 … … 18.32 … … 2005 2 11 … … 16.79 … … 2005 2 7 … … 10.69 … … 2005 2 5 … … 7.63 … … 2005 2 28 33.00 2000 5 29 … 30 32.00 2002 5 31 6.20 … … 2007 4 32 97.15 c … … 2006 2 33 NR NR NR 2005 6 87.00 … … 2006 6 87.00 d … … 2006 6 74.00 … … 2006 6 34 … … … … … … … … … … 35 0 0 0 … … … 2006 6 0 0 0 … … … 2006 6 0 0 0 … … … 2006 6 0 0 0 … … … 2006 6 0 0 0 … … … 2006 6 0 0 0 … … … 2006 6 0 0 0 … … … 2006 6 0 0 0 … … … 2006 6 0 0 0 … … … 2006 6 0 0 0 … … … 2006 6 - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) - Measles 1. Heart diseases Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth Percentage of pregnant women with anaemia 7. Hypertension - Sepsis 8. Accidents 9. Perinatal conditions Percentage of women in the reproductive age group using modern contraceptive methods - Obstructed labour - Total Tetanus - Neonatal tetanus - Rubella - Abortion 4. Cerebrovascular diseases 10. Septicaemia 6. Pneumonia and influenza Maternal causes - POL3 - Hepatitis B III INDICATORS Number of cases - Eclampsia - Haemorrhage Male Number of deaths Male Total Total Male Female Female Rate per 100 000 population Male Number of deaths Male FemaleTotal Female Selected diseases under the WHO-EPI - Diphtheria - Congenital rubella syndrome - Pertussis (whooping cough) - Hib meningitis Immunization coverage for infants (%) - Poliomyelitis DATA Female Total Maternal, child and infant diseases 5. Chronic obstructive pulmonary and allied conditions Total 2. Malignant neoplasm - BCG - DTP3 8 | COUNTRY HEALTH INFORMATION PROFILES 3. Diabetes mellitus Leading causes of mortality AMERICAN SAMOA Year Source 36 37 Public health facilities 1 128 2003 5 … … … … 5 0 2003 5 Private health facilities … … … … 38 32.30 2003 7 … 500.00 2003 7 31.80 2003 7 98.00 2003 7 14.00 2003 7 70.00 2003 7 2.00 2003 7 … 39 … Year Source 40 Physicians - Number 49 36 13 … … … … 2003 5 - Rate per 1000 population 7.83 … … … … … … 2003 5 Dentists - Number 15 8 7 … … … … 2003 5 - Rate per 1000 population 2.40 … … … … … … 2003 5 Pharmacists - Number 2 2 0 … … … … 2003 5 - Rate per 1000 population 0.20 0.32 0.00 … … … … 2003 5 Nurses - Number 127 4 123 … … … … 2003 5 - Rate per 1000 population 20.29 … … … … … … 2003 5 Midwives - Number 1 0 1 … … … … 2003 5 - Rate per 1000 population 0.16 0.00 0.16 … … … … 2003 5 Paramedical staff - Number 146 63 83 … … … … 2003 5 - Rate per 1000 population 23.32 … … … … … … 2003 5 Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … Facilities with HIV testing and counseling services Annual number of graduates - total expenditure on health as % of GDP - amount (in million US$) - Hospitals - Outpatient clinics Health facilities INDICATORS Health infrastructure - General hospitals - Specialized hospitals - District/first-level referral hospitals - Primary health care centres M al e F em al e T o ta l INDICATOR - general government expenditure on health as % of total expenditure on health - external resources for health as % of general government expenditure on health - general government expenditure on health as % of total general government expenditure Health care financing - amount (in million US$) - per capita total expenditure on health (in US$) Government expenditure on health Total health expenditure Number U rb an DATA Number of beds R u ra l P u b lic Exchange rate in US$ of local currency is: 1 US$ = Human resources for health Health insurance coverage as % of total population External source of government health expenditure Private health expenditure - private expenditure on health as % of total expenditure on health DATA P ri va te … COUNTRY HEALTH INFORMATION PROFILES | 9 AMERICAN SAMOA Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 11.80 … … 2007 4 45 4.90 … … 2002 5 46 … … … 47 123.00 2002 5 48 100.00 2002 5 1.00 2002 5 99.00 2002 5 49 … … … 50 … 51 Antenatal care coverage - At least one visit 70.00 2002 5 - At least four visits … 52 … … … 53 … … … 54 … … … 55 … … … 56 … … … 57 … … … 58 … … … 59 … … … 60 12.00 … … 2006 6 61 1.00 … … 2006 6 62 115.00 … … 2006 6 63 75.00 … … 2005 6 64 99.00 99.00 99.00 2004 5 65 99.00 99.00 99.00 2004 5 66 … … … Male Annual number of graduates Contraceptive prevalence rate Prevalence of underweight children under five years of age Infant mortality rate (per 1000 live births) RuralUrban Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Proportion of population in malaria-risk areas using effective malaria treatment measures Maternal mortality ratio (per 100 000 live births) Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Unmet need for family planning Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Adolescent birth rate Health-related Millennium Development Goals (MDGs) Total Proportion of population with access to affordable essential drugs on a sustainable basis Total Tuberculosis prevalence rate per 100 000 population DATA P ri va te R u ra l INDICATORS DATA U rb an P u b lic Proportion of population using an improved sanitation facility Malaria death rate per 100 000 population Malaria incidence rate per 100 000 population Estimated HIV prevalence in adults e Percentage of people with advanced HIV infection receiving ART HIV prevalence among population aged 15-24 years Workforce losses/ Attrition INDICATORS T o ta l M al e F em al e Tuberculosis death rate per 100 000 population Female 10 | COUNTRY HEALTH INFORMATION PROFILES Proportion of population using an improved drinking water source Proportion of population in malaria-risk areas using effective malaria prevention measures AMERICAN SAMOA … p est NR a b c d e 1 2 3 4 5 6 7 8 9 United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). Statistical Yearbook 2006 . Health Information System, ASG Department of Health, American Samoa. Demographic Tables for the Western Pacific 2005-2010 . Manila, World Health Organization Regional Office for the Western Pacific, 2005. American Samoa Population: 2007 [http://www.asdoc.info/2007_Mid-year_population_estimate.pdf] Department of Health, American Samoa. WHO Regional Office for the Western Pacific, data received from the technical units. ASG Department of Commerce, Statistics Division, American Samoa [www.asdoc.info/Statistics/statshp.htm]. US Census Bureau [www.census.gov]. Provisional Given as inactivated polio vaccine (IPV) Estimate Notes: Data not available Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific COUNTRY HEALTH INFORMATION PROFILES | 11 American Samoa Factsheet . ASG Department of Commerce, Statistics Division, American Samoa [www.adsoc.info/AS%20Factsheet.htm]. Not included in the official list of MDG indicators Sources: Not relevant Figure refers to per capita GDP (goods and services) Figure refers to birthweight equal to 2501 grams and above 12 | COUNTRY HEALTH INFORMATION PROFILES AUSTRALIA 1. CONTEXT 1.1 Demographics Australia had a population of 21 097 100 in 2007; 10 492 500 males and 10 604 600 females. The average age of the population was 37.8 years, with a life expectancy at birth of 78.7 years for men and 83.5 years for women. It is one of the world’s most urbanized countries, with 88.2% of the population living in urban areas. Most of the population is concentrated along the eastern seaboard and the south-eastern corner of the continent. Australia’s population is ageing, with the number of persons aged 65 years or more expected to double by 2051. 1.2 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 Federal Government. 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. A federal election held in late 2007 resulted in a change of government for the first time in 11 years. 1.3 Socioeconomic situation In 2005, Australia’s total expenditure on health goods and services, based on the OECD System of Health Accounts definition of total health expenditure, was estimated at AUS$ 85 billion (US$ 74 billion) or 8.8% of GDP. Total health expenditure increased by 8.2% per year on average for the decade from 1995 to 2005—more than the increase in GDP (6.4% per year)—which resulted in an increase in the health-to-GDP ratio. In 2005, Australia had a health-to-GDP ratio that was comparable to Italy and New Zealand, was more than the United Kingdom and considerably lower than the United States. In 2005, Australia’s general government expenditure on health accounted for 67% of total expenditure on health and 17% of total general government expenditure. Private expenditure on health made up 33% of total expenditure on health. Between 1995 and 2005, the average rate of general inflation was 2.7% per year. Health inflation during that period averaged 3.1% per year, giving an excess health inflation rate of 0.4% per year. In 2005, government funding of health expenditure was AUS$ 59 billion (US$ 51 billion) (68%), COUNTRY HEALTH INFORMATION PROFILES | 13 with the Australian Government contributing AUS$ 37 billion (US$ 32 billion) (43%) and state, territory and local governments contributing AUS$ 22 billion (US$ 19 billion) (25%). The non- government sector (households, private health insurance and other non-government) funded the remaining AUS$ 28 billion (US$ 24 billion)(32%). For 2005, estimated per capita health expenditure averaged AUS$ 4226 (US$ 3681). Real growth in per capita health expenditure between 1995 and 2005 averaged 3.8% per year, compared with 5.1% for total national health expenditure. The difference between these two growth rates is the result of growth in the overall size of the Australian population. Out-of-pocket recurrent expenditure by individuals on health goods and services accounted for an estimated AUS$ 15.4 billion (US$ 13.4 billion), the majority for medications (34%), dental services (23%) and aids and appliances (13%). The largest proportion of real growth in recurrent health expenditure between 2003 and 2005 was on hospitals (42%)—public hospital services (38%) and private hospitals (4%)—medications (17%) and medical services (14%). The number of unemployed people in Australia has been declining over the last decade, with the trend unemployment rate falling from 7.8% in February 1998 to 4.1% in February 2008. Over the same period, the trend participation rate increased from 63.2% to 65.2%. 1.4 Vulnerabilities and hazards Biological hazards, such as avian influenza and severe acute respiratory syndrome continue to pose an imminent risk to Australia. In preparation, the country hosted the Asia-Pacific Economic Cooperation (APEC) Avian Influenza Preparedness and Response Meeting in Brisbane in 2005 and led the APEC Pandemic Response Exercise in June 2006. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition 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 an increasing incidence of chronic disease and the rise and partial fall of two burdens of disease, coronary heart disease and lung cancer. There have been substantial improvements in a number of health behaviours and risk factors over recent years. Programmes to reduce smoking have resulted in one of the lowest smoking rates in the world. Other risk factors remain of concern, however, including overweight and obesity, and diabetes. The rate of overweight and obesity among adults has doubled over the last two decades. Emerging data show that an increase in obesity predisposes individuals to diabetes. Although most Australians enjoy good health today, some population groups continue to suffer poor health, particularly Aboriginal and Torres Strait Island peoples. Australians living in regional and remote areas generally experience poorer health than their major city counterparts. An example of the Government’s response to communicable disease is its actions to combat HIV/AIDS, where it is guided by the principles and priorities outlined in the National HIV/AIDS Strategy 2005–2008. In contrast to comparable countries, Australia has low HIV/AIDS prevalence rates in all populations. The country’s achievements in relation to HIV/AIDS have been largely attributed to the cooperative partnership between all levels of AUSTRALIA 14 | COUNTRY HEALTH INFORMATION PROFILES government; community organizations; the medical, health care and scientific communities; and people living with or affected by HIV/AIDS. The National HIV/AIDS Strategy 2005–2008 identifies five priority areas for action to be addressed over the life of the strategy: developing a targeted prevention education and health promotion programme for HIV/AIDS; improving the health of people living with HIV/AIDS; developing an effective response to the changing care and support needs of people living with HIV/AIDS; reviewing the National HIV Testing Policy; and undertaking focused research to underpin prevention policies and programmes. 2.2 Outbreaks of communicable diseases The Federal Government provides expert advice and actions to support communicable disease (including foodborne disease) surveillance activities, both nationally and internationally. There are 66 nationally notifiable diseases in Australia, including bloodborne, sexually transmitted, quarantinable, gastrointestinal and vaccine-preventable diseases. Diseases most often notified during 2006 included chlamydiosis (47 030 cases), campylobacteriosis (15 397 cases) and hepatitis C (13 408 cases). Australia is working to ascertain and minimize the incidence and impact of foodborne illness in the country. This is being achieved by collaborating with government agencies, state and territory health and primary industry portfolios, consumers and the food industry to facilitate improved food safety practices and to assess their effectiveness and impact through active surveillance, such as OzFoodNet, and applied research projects. Pandemic preparedness is also a significant area of health protection being addressed by the Government. Activities include: • national health sector pandemic planning; • establishment of the National Influenza Pandemic Action Committee; and • development of the Pandemic Influenza Communication Strategy. Major activities and programmes include: • coordination of the health sector implementation of the outcomes of ‘Exercise Cumpston '06’; • publication and ongoing review of the Australian Health Management Plan for Pandemic Influenza and associated annexes and technical papers; • provision of support for the National Influenza Pandemic Action Committee and the Chief Medical Officer's Expert Advisory Group; • development and implementation of the Pandemic Influenza Communication Strategy; • coordination of information regarding developments in international pandemic preparedness; and • consultation with external stakeholders on pandemic preparedness issues. The universal vaccination programmes funded under the national immunization programme target the following vaccine-preventable diseases in children: measles, mumps, rubella, polio, pneumococcal disease, pertussis (whooping cough), rotavirus, varicella (chicken pox), diphtheria, tetanus, hepatitis B and meningococcal C. Incentives are available for both parents and general practitioners to maximize vaccination coverage. The national immunization coverage rate for infants at 12 months of age reached 91.5% in December 2007, compared with rates as low as 53% 20 years ago. 2.3 Leading causes of mortality and morbidity Significant increases in life expectancy occurred throughout the twentieth century, reductions in infant and child mortality being the most significant contributing factors. Life expectancy at birth continues to increase, reflecting the general decrease in death rates. A boy born in 2004–2006 could expect to live 78.7 years, while a girl could expect to live 83.5 years. Over the last 20 years, life expectancy at birth has increased by 5.8 years for males and 4.3 years for females, but COUNTRY HEALTH INFORMATION PROFILES | 15 continues to vary between the states and territories of Australia by up to eight years, for both males and females. Many of the health conditions that significantly affect Australians are associated with lifestyle and health risk factors, often 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 cardiovascular diseases, diabetes mellitus and its complications, and arthritis. In 2004-2005, cardiovascular disease was reported in 18.0% of the population, diabetes mellitus in 3.6% and arthritis in 15.3%. The proportion of the population reporting arthritis, asthma and hypertension remained steady over the period from 1995 to 2004-2005, while the proportions reporting diabetes mellitus, high cholesterol and osteoporosis increased. Reported mental and behavioural problems increased between 1995 and 2001, but were steady between 2001 and 2004-2005. In 2004-2005, asthma was reported by 10.2% of the population, while hypertension, high cholesterol, osteoporosis and mental and behavioural problems affected 10.7%, 6.8%, 3.0% and 10.7%, respectively. There were 133 739 deaths registered in 2006, 68 556 male and 65 183 female, an increase of 2.3% on the corresponding total figure from 2005 (130 714). Despite this, there has been a steady decline in the standardized death rate over the past decade, from 7.6 deaths per 1000 population in 1997 to 6.0 in 2006, the lowest on record. The leading single underlying cause of death in 2005 was ischaemic heart disease, with 23 570 deaths, giving a rate of 115.9 deaths per 100 000 population. The second most common cause was cerebrovascular disease, with 11 513 deaths, giving a rate of 56.6 deaths per 100 000 population. Collectively, malignant neoplasms were another major cause of death in 2005, accounting for 38 380 registered deaths. Seven of the 20 leading underlying causes of death were attributable to some form of malignant cancer, cancer of the trachea and lung being the third major cause of death, with 7399 deaths, giving a rate of 36.3 deaths per 100 000 population. Injuries accounted for 8015 deaths in 2005. Transport accidents and suicide were the major contributors, with 1638 and 2101 deaths, respectively. Males were more likely to commit suicide than females, with 1657 deaths, compared with 444 deaths for females. 2.4 Maternal, child and infant diseases The neonatal mortality rate for 2006 was 3.2 deaths per 1000 live births and the infant mortality rate was 4.7 deaths per 1000 live births, a decrease from 5.0 in 2005. The 2006 under-five mortality rate was 5.6 deaths per 1000 live births. The current infant and child death rates are low by international standards. Although infant and child deaths form only a small proportion (less than 1%) of all deaths, they nevertheless have important public health policy significance. There has also been a dramatic decline in mortality rates for women during childbirth. 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 maternal deaths following childbirth. In the triennium 2000-2002, the maternal mortality ratio (MMR) was 11 deaths per 100 000 confinements. The MMR for Aboriginal and Torres Strait Islander women, however, continues to be higher than the rate for non-indigenous women, with an MMR of 45.9 deaths for 100 000 confinements, five times higher than the MMR of 8.7 for non-indigenous women. Although this comparison should be treated with caution owing to the very small number of indigenous maternal deaths and the lack of completeness of indigenous identification, there is justification for continuing concern about this disparity. 2.5 Burden of disease In 2003, the leading causes of disease and injury in Australia were cancers (19%) and cardiovascular disease (18%), with cancer overtaking cardiovascular disease as the greatest cause AUSTRALIA 16 | COUNTRY HEALTH INFORMATION PROFILES for the first time. The leading cancers were lung, colorectal and breast cancer. Ischaemic heart disease, stroke and peripheral vascular disease were the leading specific causes of cardiovascular disease. Mental disorders (13%) and neurological and sense disorders (12%) were the next largest contributors to the burden of disease and injury in 2003. Mental disorders contributed to 3367 deaths during 2005. Females accounted for 2139 of these, nearly double the number of male deaths due to mental and behavioural disorders In terms of new cases of disease, upper respiratory tract infections (26 237 596), diarrhoeal diseases (17 457 098) and back pain (9 045 837) had the highest incidence rates during 2003. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives Australia’s health care system is a partnership between the Federal, State and Territory, and local governments. Through the Health and Ageing portfolio, the Federal Government provides national leadership, determines national policies and outcomes, and shares responsibility for funding services. Australia’s goal is to manage, prevent and respond to health risks faced by the population. Policy is based and implemented on evidence-based and targeted programmes, which contribute to the sustainability of the Australian health system by reducing preventable illness and mortality. The Health and Ageing portfolio provides strategic leadership in health surveillance, biosecurity and emergency preparedness, food policy, chronic and communicable disease control, health promotion and the reduction of harm from substance abuse. A key focus is the integration of the country’s capacity to respond to a range of new and emerging threats to health. The vision of the Department of Health and Ageing is of better health and active ageing for all Australians. This is achieved by improving health and well-being by strengthening evidence-based policy advice, improving programme management, research, regulation, and partnerships with other government agencies, consumers and stakeholders. Australia aims to achieve this by: • focusing the health and aged care system more on healthy lifestyles, prevention and early intervention and a ‘best practice’ handling of chronic disease; • improving the transparency, accessibility, accountability and quality of public and private health and aged care service provision through financing and agreements with stakeholders, industry and state and territory Governments; • consolidating and progressing reforms to ensure choice and access to quality aged care services; • working together with the States and Territories to reduce duplication and gaps, and to deliver efficient, value-for-money health and aged care services through an adaptable and sustainable health and aged care workforce; • working towards improved health for Aboriginal and Torres Strait Islander peoples through whole-of-government arrangements for policy development and service delivery, and improved access to, and responsiveness of, the mainstream health system; • improving choice for consumers through strong private sector involvement, effectively integrated with the public sector; and • leading a whole-of-government approach to strengthening Australia’s readiness for disease threats, national emergencies and other large-scale health incidents. COUNTRY HEALTH INFORMATION PROFILES | 17 3.2 Organization of health services and delivery systems The organization of the Australian public health system is strongly influenced by the federal system, where responsibility and funding for health is shared between the Federal, State and Territory governments. The system is complex, with delivery provided by both the public and private sectors. The Federal Government funds medical and pharmaceutical benefits, private health insurance subsidies and university training places for health workers, and shares responsibility with the States and Territories for funding of public hospital services. The Federal Government also has a national leadership role in strategies to tackle significant health issues, as well as regulatory responsibilities. The States and Territories provide public hospital services, community and public health services; assist with training of health workers through clinical training in public hospitals; and regulate private hospitals. Private practitioners provide medical, dental and allied health services. The aim of the Australian health system is to give universal access to health care under what is known as ‘Medicare’, while allowing choice for individuals through substantial private sector involvement in delivery and financing. The three pillars of Medicare, funded by the Federal Government, are: (1) The Medicare Benefits Schedule —a universal programme that provides consumers with access to privately provided medical services, and may include co-payments by users where the cost of services is not fully covered by the rebate. (2) The Pharmaceutical Benefits Scheme —subsidization of a wide range of prescription medications, supplied by community pharmacies. (3) Funding provided to States and Territories to assist them to provide access to public hospital services. The Federal Government funds a system of private health insurance rebates that subsidize the cost of premiums to private health insurance. Every Australian can elect to be treated as a private patient in a public hospital in order to have a choice of doctor. In addition, private hospitals provide an alternative to the public hospital system for many procedures. A large proportion of the health workforce is employed by the private sector, and corporatization is increasingly becoming a key organizing factor for the delivery of services, such as general medicine, pathology and diagnostic imaging. 3.3 Health policy, planning and regulatory framework The core values of the Australian health system include ensuring the affordability and accessibility of health care, as well as equitable access to necessary care, and reducing disparities in health outcomes. Providing consumers with choice in their health care is also a key principle of the system. The reform agenda of the Federal Government aims to improve health system efficiency and access to services including: • greater focus on prevention and primary care; • initiatives to improve the health and well-being of Australian children; • initiatives to improve the health and well-being of indigenous Australians including indigenous children; • working collaboratively and more effectively with state and territory governments; • initiatives to address health workforce supply issues; AUSTRALIA 18 | COUNTRY HEALTH INFORMATION PROFILES • a nationally consistent approach to activity-based funding of public hospitals within an improved performance and assessment framework; • an increased focus on research and treatment of cancer; • improved patient access to necessary health services; and • better integration of acute hospitals and aged-care facilities. A key reform initiative has been the establishment of the National Health and Hospitals Reform Commission to provide advice on performance benchmarks and practical reforms to the Australian health system that could be implemented in both the short and long term. Furthermore, a national registration and accreditation scheme for the health professions has been agreed upon by all Australian governments and will replace state-based schemes by July 2010. The objectives of the national scheme are: to provide for protection of public safety; to facilitate workforce mobility; to reduce red tape for practitioners; and to facilitate the provision of education, training and assessment of overseas-trained practitioners. 3.4 Health care financing Medicare is a compulsory insurance system financed largely by general taxation revenue, some of which is raised by an income-related levy collected by the Federal Government. While the States and Territories have a larger role in health service delivery, the Federal Government is the major funder of health services. In addition to funding Federal Government health programmes, the Federal Government contributes a significant amount of funding to State and Territory Governments for public hospital services. Through the Council of Australian Governments (COAG), all Australian governments have committed to a more cooperative approach to health, including more streamlined financing arrangements. 3.5 Human resources for health Australia’s health workforce is influenced by a number of complex and interrelated factors. These include an increase in life expectancy, a greater number and a greater proportion of people aged over 65 years, medical and technical advances that create a need for new specialist knowledge and skills, and increasing consumer awareness and demand for a more sophisticated mix of services. Although the overall number of health professionals is increasing in Australia, growth in workforce demand has partly offset, and in some cases, outstripped growth in supply. For example, the increase in general practitioner numbers has barely kept pace with population growth. Reduced working hours has also counteracted the perceived growth in workforce supply. Although precise quantification of workforce shortages is difficult, there are currently shortages in general practice, various medical specialty areas, dentistry, nursing and some key allied health areas. Health workforce shortages are more acute in rural and remote areas. Future health workforce supply will be influenced by developments in the broader labour market, the level of workforce re-entry, retention rates and overseas recruitment and supply pressures, as well as how effectively the existing workforce is deployed. The demand for health services will be strongly stimulated by increasing incomes and community expectations, technological advances and changes in disease burdens. An affluent Australian lifestyle and an ageing population has dramatically moved the burden of disease from acute, episodic conditions to chronic disease, which is expected to impose heavier burdens on the demand for health services, even as new threats emerge. 3.6 Partnerships Australia manages relationships with international bodies such as WHO, the Organisation for Economic Co-operation and Development (OECD) and the Asia Pacific Economic Cooperation COUNTRY HEALTH INFORMATION PROFILES | 19 (APEC). Australia also manages a number of bilateral health agreements and partnerships with other countries, primarily within the Asia-Pacific region. 3.7 Challenges to health system strengthening Australia’s health care system is a complex combination of public and private sectors with services provided by a wide range of professions. It needs to provide care to all members of the community, from the very young to the very old, and to address the health needs of the chronically ill and people from diverse backgrounds and places of origin. Overall, Australians experience good health but still suffer from the major health burdens of the developed world (e.g. cancer, heart and vascular disease, mental illness, bone and muscular diseases, obesity and diabetes) and, in some communities, most notably many indigenous communities, diseases of the developing world. There are a number of issues that are currently beginning to influence decisions on health priorities 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; changing disease patterns; advances in medical technologies; and increasing consumer expectations. The identified national health priorities are: asthma; cancer; diabetes; heart, stroke and vascular disease; injury prevention and control; arthritis and musculoskeletal conditions; and mental health. In addition, there is an increasing recognition of the need to focus on prevention of disease and management of chronic disease. Other priority areas include Aboriginal and Torres Strait Islander health and hospital services. The growing burden of chronic disease presents a challenge to the health system as it is currently structured. Better coordination and integration of primary and acute services, public and private sectors, and across health professions are important policy goals. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Australia’s Health Operator : Australian Institute of Health and Welfare Specification : Biennial report on patterns of health and illness, determinants of health, the supply and use of health services, and health services expenditure Web address : http://www.aihw.gov.au Title 2 : Annual Report 2006-2007 Operator : Department of Health and Ageing Web address : http://www.health.gov.au Title 3 : Year Book Australia Operator : Australian Bureau of Statistics Web address : http://www.abs.gov.au AUSTRALIA 20 | COUNTRY HEALTH INFORMATION PROFILES 5. ADDRESSES AUSTRALIAN DEPARTMENT OF HEALTH AND AGEING Office Address : The Secretary Australian Department of Health and Ageing Attention: Assistant Secretary International Strategies Branch Scarborough House Woden ACT Australia Postal Address : The Secretary Australian Department of Health and Ageing Attention: Assistant Secretary International Strategies Branch GPO Box 9848, MDP 85 Canberra ACT 2601 Australia Official Email Address : enquiries@health.gov.au Telephone : (612) 6289 1555 Fax : (612) 6289 7087 Office Hours : Mon-Fri 0830-1700 Website : www.health.gov.au WHO REPRESENTATIVE There is no WHO Representative in Australia. Queries about the WHO 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 Postal Address : United Nations Avenue, P.O. Box 2932, 1000, Manila The Philippines Official Email Address : postmaster@wpro.who.int Telephone : (63 2) 528 8001/ 303 1000 Fax : (63 2) 526 0279 Office Hours : 7:00 -15:30 Website : http://www.wpro.who.int COUNTRY HEALTH INFORMATION PROFILES | 21 6. ORGANIZATIONAL CHART: Australian Department of Health and Ageing Therapeutic Goods Administration National Health and Medical Research Council Office of the Gene Technology Regulator General Counsel Audit & Fraud Control National Industrial Chemicals Notification and Assessment Health and Ageing Sector Divisions Cross Portfolio Divisions Population Health Division Office of Health Protection Acute Care Division Primary & Ambulatory Care Division Portfolio Strategies Division Office for Aboriginal & Torres Strait Islander Health Regulatory Policy & Governance Division Business Group Ageing and Aged Care Division Office of Aged Care Quality and Compliance Pharmaceutical Benefits Division Mental Health & Workforce Division Medical Benefits Division Chief Medical Officer Deputy Secretaries Executive Secretary AUSTRALIA Year Source Demographics 1 7 692.02 2008 1 2 21 097.10 k 10 492.50 10 604.60 2007 2 3 1.53 1.58 1.49 2006–07 2 4 6.30 6.50 6.10 2007 2 13.10 13.50 12.60 2007 2 13.10 11.90 14.30 2007 2 5 89.00 k … … 2007 est 26 6 12.80 13.30 12.40 2006 3 7 6.50 6.70 6.30 2006 4 8 0.67 … … 2006-07 2 9 … 78.70 83.50 2004-06 4 18.90 17.10 20.50 2003 5 10 1.81 … … 2006 3 11 88.20 j … … 2003 6 12 44 700.00 b 2007 7 13 7.30 2006-07 7 14 0.96 2005 27 15 78.10 … … 2006 28 16 … … … 17 164 86 78 2 1 1 C:2007 D:2005 8, 9 7815 n 4206 3524 19 15 4 C:2007 D:2006 8, 10 13 408 n 8396 4946 55 n 31 14 C:2007 D:2005 8, 9 18 14 4 0 0 0 C:2007 D:2005 8, 9 32 … … 1 0 1 C:2006 D:2005 8, 9 3 2 1 0 0 0 C:2007 D:2005 8, 9 324 172 152 0 0 0 C:2007 D:2005 8, 9 … … … 28 13 15 2005 8, 9 7621 n 5033 2580 0 0 0 C:2007 D:2005 8, 9 12 10 2 0 0 0 C:2007 D:2005 8, 9 580 n 384 192 1 1 0 C:2007 D:2005 8, 9 0 0 0 0 0 0 C:2007 D:2005 8, 9 3 142 n 2 347 785 1 1 0 C:2007 D:2005 8, 9 91 47 44 0 0 0 C:2007 D:2005 8, 9 Typhoid fever 22 | COUNTRY HEALTH INFORMATION PROFILES COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km 2 ) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male Estimated population ('000s) Annual population growth rate (%) Percentage of population Rate of natural increase of population (% per annum) Urban population (%) - 0–4 years - 5–14 years Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above Per capita GDP at current market prices (US$) Human development index Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Encephalitis Leprosy Malaria Plague Selected communicable diseases Rate of growth of per capita GDP (%) Number of new cases Total Male FemaleFemale Total Number of deaths Rural Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Male Environmental indicators Total Urban - Type A Syphilis - Type B - Type C Dengue/DHF Gonorrhoea - Unspecified Cholera - Type E Communicable and noncommunicable diseases Hepatitis viral AUSTRALIA Year Source 18 26 237 596 12 310 741 13 926 855 3 158 1 389 1 769 C:2003 D:2005 9, 11 19 17 457 098 7 867 069 9 590 029 160 62 98 C:2003 D:2005 9, 11 20 1 159 … … 14 12 2 2005 C: 31 D: 9 269 … … 14 12 2 2005 C: 31 D: 9 21 98 336 54 870 43 466 38 380 21 609 16 771 C: 2004 D: 2005 9, 12 12 235 109 12 126 2 736 17 2 719 C: 2004 D: 2005 9, 12 12 977 n 7 160 5 871 4 113 2 302 1 811 C: 2004 D: 2005 9, 12 718 216 C: 2004 D: 2005 9, 12 1 208 807 401 1 147 791 356 C: 2004 D: 2005 9, 12 2 665 1 578 1 087 1 414 800 614 C: 2004 D: 2005 9, 12 2 653 1 833 820 652 468 184 C: 2004 D: 2005 9, 12 989 680 309 942 596 346 C: 2004 D: 2005 9, 12 1 946 1 275 671 1 090 699 391 C: 2004 D: 2005 9, 12 9 096 5 826 3 270 7 399 4 694 2 705 C: 2004 D: 2005 9, 12 22 … … … 46 134 n 21 597 24 177 2005 9 … … … 11 861 6 004 5 857 2005 9 19 627 9129 10 498 11 513 4 668 6 845 C: 2003 D: 2005 9, 13 … … … 1 445 508 937 2005 9 38 675 24 651 14 024 23 570 12 433 11 137 C: 2003 D: 2005 9, 13 1 925 635 1 290 284 100 184 C: 2003 D: 2005 9, 13 23 700 000 est … … 3 529 1 775 1 754 C:2004-05 D:2005 9, 14 24 494 619 308 669 185 950 3 367 1 228 2 139 C:2003 D:2005 9, 13 25 309 026 183 853 125 173 8 015 5 364 2 651 C:2003 D:2005 9, 13 16 986 n 13 356 3 631 199 130 69 C:2003 D:2005 9, 13 25 381 n 17 618 7 764 1 638 1 224 414 C:2003 D:2005 9, 13 … … … … … … 24 385 9 533 14 852 2 101 1 657 444 C:2003 D:2005 9, 13 26 888 245 527 340 360 905 4320.00 5161.00 3490.00 2005-06 11 303 218 142 675 160 543 1475.00 1396.00 1552.00 2005-06 11 155 088 66 925 88 163 754.00 654.00 852.00 2005-06 11 113 336 46 023 67 313 551.00 450.00 651.00 2005-06 11 106 557 36 398 70 159 518.00 356.00 678.00 2005-06 11 101 564 51 479 50 085 494.00 504.00 484.00 2005-06 11 77 721 46 049 31 672 378.00 451.00 306.00 2005-06 11 77 242 48 882 28 360 376.00 478.00 274.00 2005-06 11 65 594 26 355 39 239 319.00 258.00 379.00 2005-06 11 55 070 34 585 20 485 268.00 338.00 198.00 2005-06 11 All types - Homicide and violence - Motor and other vehicular accidents - Occupational injuries 1. Care involving dialysis 2. Other medical care 9. Embedded and impacted teeth All cancers (malignant neoplasms only) - Hypertension All circulatory system diseases - Acute myocardial infarction - Liver - Trachea, bronchus, and lung - Stomach Circulatory - Cerebrovascular diseases Cancers Tuberculosis Number of deaths Female Number of new cases INDICATORS DATA Total COUNTRY HEALTH INFORMATION PROFILES | 23 8. Angina pectoris 3. Rehabilitation 4. Other cataract 5. Abdominal and pelvic pain Male TotalFemale Mental disorders Total Number of cases - Rheumatic fever and rheumatic heart diseases Injuries - Suicide Diabetes mellitus 10. Internal derangement of knee Female - Leukaemia - Lip, oral cavity and pharynx - New pulmonary tuberculosis (smear-positive) - Breast Male - All forms Rate per 100 000 population Male Female 7. Other malignant neoplasms of the skin Leading causes of mortality and morbidity 6. Pain in throat and chest Total Male Leading causes of morbidity (inpatient care) - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections - Ischaemic heart disease AUSTRALIA Year Source 27 38 380 m 21 609 m 16 771 m 188.70 m 213.50 m 164.10 m 2005 9 23 570 12 433 11 137 115.90 123.00 109.00 2005 9 11 513 4 668 6 845 56.60 46.20 67.00 2005 9 5 428 3 025 2 403 26.70 29.90 23.50 2005 9 5 267 3 317 1 950 25.90 32.80 19.10 2005 9 3 529 1 775 1 754 17.40 17.60 17.20 2005 9 3 034 1 331 1 703 14.90 13.20 16.70 2005 9 2 838 908 1 930 14.00 9.00 18.90 2005 9 2 386 1 217 1 169 11.70 12.00 11.40 2005 9 2 225 835 1 390 11.00 8.30 13.60 2005 9 28 65.00 l 2001 15 29 … 30 6.20 c 2005 16 31 3.20 2006 4 32 93.60 2005 17 33 … … … 92.10 … … 2007 22 92.10 … … 2007 22 94.40 … … 2007 22 34 … 0 2005 9 … 0 2005 9 … 1 2005 9 … 0 2005 9 … 0 2005 9 35 1 … … 0 0 0 C:2007 D:2005 8, 9 0 0 0 0 0 0 C:2007 D:2005 8, 9 17 8 9 1 0 1 C:2007 D:2005 8, 9 11 7 4 0 0 0 C:2007 D:2005 8, 9 584 330 253 0 0 0 C:2007 D:2005 8, 9 0 0 0 0 0 0 C:2007 D:2005 8, 9 5 462 3 153 2 297 0 0 0 C:2007 D:2005 8, 9 1 1 0 0 0 0 C:2007 D:2005 8, 9 35 15 20 0 0 0 C:2007 D:2005 8, 9 3 2 1 1 0 1 C:2007 D:2005 8, 9 2. Ischaemic heart disease (I20-I25) DATA Leading causes of mortality Female 2.90 Male FemaleTotal Number of deaths 93.10 Female Number of cases Male INDICATORS - Diphtheria 1. Malignant neoplasms (C00-C97) - Pertussis (whooping cough) Total MaleFemale - Poliomyelitis - Eclampsia - Haemorrhage - Obstructed labour - Sepsis 3. Cerebrovascular disease (I60-I69) Male Female Total - Total Tetanus - Neonatal tetanus - Measles - Mumps - Abortion Selected diseases under the WHO-EPI Immunization coverage for infants (%) - POL3 - BCG - DTP3 5. Accidents (V01-X59) Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth Maternal causes - Rubella - Congenital rubella syndrome 24 | COUNTRY HEALTH INFORMATION PROFILES - Hib meningitis Male Total 94.10 Percentage of pregnant women with anaemia 3.60 Total Percentage of pregnant women immunized with tetanus toxoid (TT2) Percentage of women in the reproductive age group using modern contraceptive methods - Hepatitis B III 7. Influenza & pneumonia (J10-J18) 6. Diabetes mellitus (E10-E14) 4. Chronic lower resp disease (J40-J47) Maternal, child and infant diseases 8. Organic (inc symptomatic) mental (F00-F09) 9. Diseases of arteries (I70-I79) 10. Heart failure (I50) Number of deaths Rate per 100 000 population AUSTRALIA Year Source 36 … Year 37 Public health facilities 736 52 236 2005-06 11 19 d 2 366 d 2005-06 11 … … … … Private health facilities 536 27 217 2005-06 11 … … 38 64 658.68 i 2006p 30 8.77 2006p 30 3 180.61 2006p 30 43 344.64 i 2006p 30 67.04 2006p 30 16.98 2006p 30 0.00 2006p 30 32.96 2006p 30 1.31 i 2006p 30 39 44.40 m 2007 18 Year Source 40 Physicians - Number 57 000 37 600 19 400 … … … … 2007 19 - Rate per 1000 population 2.77 1.78 0.92 … … … … 2007 19 Dentists - Number 8900 6300 2600 … … … … 2007 19 - Rate per 1000 population 0.43 0.30 0.12 … … … … 2007 19 Pharmacists - Number 17 300 9300 8000 … … … … 2007 19 - Rate per 1000 population 0.84 0.44 0.38 … … … … 2007 19 Nurses - Number 182 200 13 000 169 200 … … … … 2007 19 - Rate per 1000 population 8.84 0.62 8.02 … … … … 2007 19 Midwives - Number 16 800 0 16 800 … … … … 2007 19 - Rate per 1000 population 0.82 0.00 0.80 … … … … 2007 19 Paramedical staff - Number 58 900 15 600 43 300 … … … … 2007 19 - Rate per 1000 population 2.86 0.74 2.05 … … … … 2007 19 Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians 1787 e … … … … … … 2007 19 Dentists … … … … … … … Annual number of graduates COUNTRY HEALTH INFORMATION PROFILES | 25 Exchange rate in US$ of local currency is: 1 US$ = Human resources for health Health insurance coverage as % of total population Number of bedsNumber R u ra l P u b lic DATA U rb an P ri va te M al e F em al e Private health expenditure - private expenditure on health as % of total expenditure on health - general government expenditure on health as % of total expenditure on health INDICATORS - Primary health care centres Health care financing DATA - General hospitals - Specialized hospitals Government expenditure on health Total health expenditure - District/first-level referral hospitals Health facilities Facilities with HIV testing and counseling services Health infrastructure - Hospitals - Outpatient clinics - per capita total expenditure on health (in US$) - total expenditure on health as % of GDP - amount (in million US$) - external resources for health as % of general government expenditure on health T o ta l INDICATOR External source of government health expenditure - general government expenditure on health as % of total general government expenditure - amount (in million US$) AUSTRALIA Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 4.70 5.30 4.10 2006 4 45 5.57 6.16 4.95 2006 4 46 94.20 f … … 2007 22 47 11.00 g 2000-2002 25 48 99.60 2005 17 0.20 2005 17 99.40 2005 17 49 … … 65.00 2001 15 50 8.49 h 2005 17 51 Antenatal care coverage - At least one visit 99.00 2001 29 - At least four visits … 52 … … … 53 … … … 54 0.00 … … 2006 23 55 70.00 … … 2005 est 23 56 0.40 1.00 0.00 2007 8 57 0.01 0.00 0.00 2005 9 58 NR NR NR 59 NR NR NR 60 7.00 … … 2006 31 61 1.00 … … 2006 31 62 40.00 … … 2006 31 63 12.00 … … 2005 31 64 100.00 100.00 100.00 2006 32 65 100.00 100.00 100.00 2006 32 66 … … … Workforce losses/ Attrition 26 | COUNTRY HEALTH INFORMATION PROFILES Tuberculosis death rate per 100 000 population Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Proportion of population with access to affordable essential drugs on a sustainable basis INDICATORS DATA Female T o ta l M al e Annual number of graduates U rb an F em al e Malaria incidence rate per 100 000 population INDICATORS DATA Health-related Millennium Development Goals (MDGs) Prevalence of underweight children under five years of age - Percentage of deliveries in health facilities (as % of total deliveries) Maternal mortality ratio (per 100 000 live births) Proportion of births attended by skilled health personnel Proportion of population using an improved sanitation facility Malaria death rate per 100 000 population Proportion of population using an improved drinking water source Total Male R u ra l P u b lic P ri va te Estimated HIV prevalence in adults a Proportion of 1 year-old children immunised against measles Contraceptive prevalence rate Infant mortality rate (per 1000 live births) Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Proportion of population in malaria-risk areas using effective malaria treatment measures Adolescent birth rate Tuberculosis prevalence rate per 100 000 population Percentage of people with advanced HIV infection receiving ART Unmet need for family planning HIV prevalence among population aged 15-24 years Proportion of population in malaria-risk areas using effective malaria prevention measures Total Urban Rural AUSTRALIA … p est NR a Not included in the official list of MDG indicators b c d Figures refer to psychiatric hospitals e f At 24-27 months g h Births to girls under 20 i j k l m n 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Special focus on Sanitation. UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] Year Book Australia 2008 . Australian Bureau of Statistics (ABS) Cat. No. 1301.0 Australian Demographic Statistics , September Quarter 2007. ABS Cat. No. 3101.0 Births Australia 2006. ABS Cat. No. 3301.0 Deaths Australia 2006. ABS Cat. No. 3302.0 Causes of Death Australia 2006. ABS Cat. No. 3303.0 COUNTRY HEALTH INFORMATION PROFILES | 27 Estimated figure includes Other Territories comprising Jervis bay Territory, Chrsitmas Island and the Cocos (Keeling) Islands Sullivan EA & King JF (eds) 2006. Maternal deaths in Australia 2000–2002. Cat. no. PER 32. Sydney: AIHW National Perinatal Statistics Unit Diabetes: Australian Facts 2008. AIHW cat. No. CVD 40 National Health Survey Australia 2001. ABS Cat. No. 4364.0, and unpublished Chan A, Scott J, Nguyen A-M, Sage L 2006. Pregnancy outcome in South Australia 2005. Adelaide: Pregnancy Outcome Unit, South Australian Department of Health Laws PJ, Abeywardana S, Walker J & Sullivan EA 2007. Australia's mothers and babies 2005. AIHW cat. No. PER 40 Private Health Insurance Administration Council 2007. Quarterly Statistics. (www.phiac.gov.au/statistics/membershipcoverage) Labour force, Australia, detailed, quarterly, Feb 2007. ABS Cat. No. 6291.0.55.003, Table E08 Learning for tomorrow's world - First results from PISA 2003. Organisation for Economic Cooperation and Development (OECD) Australian Institute of Health and Welfare (AIHW) National Mortality Database AIHW National Hospital Morbidity Database Percentage of women aged 18-49 (or their partners) reporting using contraceptive methods (including hysterectomy, tubal ligationand partner vasectomy) Estimate based on South Australia Estimate Provisional Notes: Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world . United Nations Development Programme, United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006 . Wallchart (United Nations publication, Sales No. E.08.XIII.3). Department of Education, Employment and Workplace Relations. Students 2005: selected higher education statistics. (www.dest.gov.au) National Nutrition Survey: Nutrient intakes and physical measurements, Australia, 1995. ABS Cat. No. 4805.0 Australian Childhood Immunisation Register (ACIR) statistics as at September 2007. (www.medicareaustralia.gov.au) National Centre in HIV Epidemiology and Clinical Research (NCHECR). Reserve Bank of Australia (www.rba.gov.au, viewed 4 Apr 2008) Data not available Not relevant Based on exchange rate for 30 June, 2005 Figure includes those with unknown sex National Notifiable Diseases Surveillance System. (www9.health.gov.au/cda/Source/Rpt_5_sel.cfm). Australian National Accounts 2007. ABS Cat. No. 5206.0 Sources: The number of physician graduates is the same as general medical graduates, so this is an estimate This is the latest data for both direct and indirect maternal deaths. More recent data for direct maternal deaths is available. Data for 15-year-old schoolchildren. Literacy defined as Levels 2-5 using OECD PISA (Programme for International Student Assessment) standards. Exchange rate as of 7 April 2008 Revised figure World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: Ford J, Nassar N, Sullivan EA, Chambers G & Lancaster P 2003. Reproductive health indicators Australia 200 2. AIHW cat. No. PER 20. Canberra: AIHW NPSU. New York USA 2007. [http://hdr.undp.org/en/reports/global/hdr2007-2008/] World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf] WHO Regional Office for the Western Pacific, data received from the technical units Motor vehicle census Australia 2006. ABS Cat. No. 9309.0. Begg S, Vos T, Barker B, Stevenson C, Stanley L & Lopez A 2007. The burden of disease and injury in Australia 2003. AIHW Cat. No. PHE 82. Canberra: AIHW AIHW National Cancer Statistics Clearing House (www.aihw.gov.au) Begg S, Vos T, Barker B, Stevenson C, Stanley L & Lopez A 2007. The burden of disease and injury in Australia 2003 . AIHW Cat. No. PHE 82. Canberra: AIHW 28 | COUNTRY HEALTH INFORMATION PROFILES BRUNEI DARUSSALAM 1. CONTEXT 1.1 Demographics The population of Brunei Darussalam is estimated to have been 383 000 in 2006 and is increasing at 3.5% per annum. With an area of 5 765 square kilometre, the country’s population density is 66 persons per square kilometre, although 73.5% of the population are considered urban. The population comprises 203 300 (53.1%) males and 179 700 (46.9%) females, giving a gender ratio of 113 males per 100 females. The population structure is essentially that of a young population; about 12.8% and 31.6% of the population is under-five and under-15 years respectively, and only 2.7% are 65 years or over. Brunei Darussalam has a multi-ethnic population, with Malays comprising 66.7%, the predominant ethnic community, and Chinese, with 11.2%, the next major group. Other races, such as Indians, other ethnic groups and expatriates, make up the rest of the population. In 2006, life expectancy at birth was 74.1 years for males and 77.7 years for females, the crude birth rate had declined from 18.7 in 2005 to 17.1 per 1000 population, the crude death rate was 2.9 per 1000 population, and the total fertility rate was 2.2. The country’s health services are ranked among the best in Asia. The Ministry of Health works hand in hand with WHO and continues to meet the targets of a better health status. The country has achieved almost all indicators stipulated by WHO, including those outlined in the Millennium Development Goals. For instance, the infant mortality rate decreased from 7.4 in 2005 to 6.6 per 1000 live births in 2006 and the under-five mortality rate from 9.4 in to 9.2 per 1000 live births, while the death rate among mothers giving birth was 15.3 per 100 000 live births. 1.2 Political situation Brunei Darussalam is an independent sovereign Sultanate governed on the basis of a written constitution, and achieved full independence on 1 January 1984. The Head of State, the Head of Government and the Supreme Executive Authority is His Majesty, the Sultan and Yang Di- Pertuan. His Majesty also holds the Defence and Finance portfolios in the Cabinet, and is the Supreme Commander of the Royal Brunei Armed Forces, the Inspector-General of the Royal Brunei Police Force, and the supreme head of religious affairs in the Sultanate. Brunei’s first written Constitution came into force in 1959 and has been subject to important amendments in 1971 and 1984. The 1959 Constitution provides for the Sultan as the Head of State, with full executive authority. The Sultan is assisted and advised by five councils—the Religious Council, the Privy Council, the Council of Ministers (the Cabinet), the Legislative Council and the Council of Succession. The Council of Cabinet Ministers is appointed and presided over by His Majesty and handles executive matters. The Religious Council advises on religious matters, the unicameral Legislative Council or Majlis Mesyuarat Negeri handles constitutional matters (legislative branch), and the Council of Succession determines the succession to the throne if the need arises. For the judicial branch, His Majesty swears in a Supreme Court (chief justice and judges) for a three-year term. COUNTRY HEALTH INFORMATION PROFILES | 29 1.3 Socioeconomic situation The 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 of gross domestic product (GDP). Per capita GDP is far above most developing countries (US$ 30 490 in 2006), and substantial income from overseas investments supplements income from domestic production. The Government provides for all medical services and subsidizes rice and housing. Human resources development (HRD) is a crucial element in 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, postgraduate and specialized studies, and pre- and post-employment for local job-seekers, as well as pre-retirement programmes. 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. 1.4 Vulnerabilities and hazards Natural hazards, such as typhoons, earthquakes and severe flooding, are very rare in Brunei Darussalam. However, there has been seasonal smoke/haze resulting from forest fires in neighbouring countries in recent years. A National Committee on Disaster Management has been formed to strengthen the country’s preparedness and planned response to any possible disaster. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition The trend in the major causes of death has changed over the past 30 years from infectious diseases to chronic, degenerative diseases related to sedentary lifestyles. The five leading causes of death in 2006 were cancer, heart disease, diabetes mellitus, cerebrovascular disease and hypertensive disease. Most of these noncommunicable diseases involve similar modifiable behavioural risk factors, namely unhealthy diet, obesity, lack of physical activity, and smoking— all of which can be addressed through health-promotion strategies, as well as legislation. Brunei Darussalam has an enviable record in being almost entirely free of major communicable diseases. WHO declared the country malaria-free in 1987 and, in 2000, along with other countries in the WHO Western Pacific Region, it was declared poliomyelitis-free. A total of 55 communicable diseases are notifiable in the country, and authorities have been vigilant in detecting and preventing the invasion of newly emerging infectious diseases, such as severe acute respiratory syndrome (SARS) and avian influenza. The country has a comprehensive child immunization programme to protect against vaccine- preventable diseases. All these services are free. Medical advances in vaccines have been made widely available through the Expanded Programme on Immunization, which is incorporated into the Child Health Services and School Health Services. The country’s health services are monitoring developments to ensure immunization measures and facilities continue to be in line with best practice for disease prevention. The overall improvement in general sanitation, housing, food hygiene, regular screening and counselling of food handlers, safe drinking water and health education measures have successfully kept foodborne and waterborne diseases under control in the country. BRUNEI DARUSSALAM 30 | COUNTRY HEALTH INFORMATION PROFILES 2.2 Outbreaks of communicable diseases There have been no recent major outbreaks of communicable disease in Brunei Darussalam. In 2006, there were a number of cases of hand, mouth and foot disease, and a very small number of food poisoning and dengue cases, all of which were contained. To prepare for the possibility of an outbreak of avian influenza, the National Committee on Influenza Pandemic have developed a National Preparedness Plan, including measures for improved surveillance, communications and logistics. 2.3 Leading causes of mortality and morbidity 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 five leading causes of morbidity in 2006 were: asthma, diabetes mellitus, acute lower respiratory infections, abortions, and acute upper respiratory infections. As regards mortality, the leading causes were: cancer, heart disease, diabetes mellitus, cerebrovascular disease, and hypertensive disease. In 2006, there were 1095 deaths registered in Brunei Darussalam. Males accounted for 137 more deaths than females. Cancer, the prime cause of mortality, constituted 20.1% of total deaths. The second was heart disease, accounting for 17.2%, followed by diabetes mellitus (10.6%). The most common type of heart disease is ischaemic heart disease, while the most common types of cancer are of the trachea, lung and bronchus; colon and rectum; and breast. 2.4 Maternal, child and infant diseases Infant mortality has been reduced as a result of higher standards of living, improved sanitation, improved levels of education and literacy, the increasing empowerment of women, and the rising standards of infant care services. Maternal health has also improved dramatically and, in 2006, there was only one maternal death, giving a maternal mortality ratio of 15.3 per 100 000 live births. To maintain these outcomes, Brunei Darussalam is striving to ensure the availability and practice of antenatal care, skilled care during childbirth and postnatal care, and quality health services. Currently, 99.63% of all births are delivered in hospitals and 99.7% of all deliveries are attended by skilled health personnel. 2.5 Burden of disease No available information. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The Ministry of Health is responsible for all aspects of health care services in the country and its vision is to become a highly reputable health service organization that is comparable to the best in the Region and that enables every citizen and resident of the nation to attain a high quality of life by being socially, economically and mentally productive throughout the life span. The Ministry’s mission is to improve the health and well-being of the people of Brunei Darussalam through a high quality and comprehensive health care system that is effective, efficient, responsive, affordable, equitable and accessible to all in the country. The Government is fully committed to continuously improving the health status of the people and considers government funding for health care 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 should focus on health improvement for people-centred development. In this COUNTRY HEALTH INFORMATION PROFILES | 31 regard, health policies and programmes will continue to be constantly reviewed in the context of the 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 partnership and public participation in the concept of co-production 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 will continue to pursue the following set of goals, or ‘policy objectives’, derived from careful analysis of the strategic issues and themes. These goals and their implementations measures are classified into two categories, strategic goals and instrumental goals, based on their logical relationships. 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 that 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; • 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. Measures being implemented to help achieve these goals: • generation of additional revenue and sending of price signals to users and providers; • better definition of the range of health services that should be provided by the public sector; • implementation of the shift to corporatization of hospitals; and • pursuing of initiatives on dealing with national health emergencies. With noncommunicable diseases now the dominating causes of morbidity and mortality, Brunei Darussalam has identified health promotion as one of the major initiatives in its National Health Care Plan 2000-2010. This strategy provides the basis for a more integrated health programme. In recognition of the need for the promotion of positive health measures, a multidisciplinary committee has been established. The National Committee on Health Promotion BRUNEI DARUSSALAM 32 | COUNTRY HEALTH INFORMATION PROFILES aims to increase public awareness of these problems, as well as develop strategies to modify the public’s behaviour in favour of a healthier lifestyle through community participation and intersectoral collaboration. The Committee has identified seven priority areas for action: nutrition; food safety; tobacco control; mental health; physical activity; health environments/settings; and women’s health. These priorities are promoted by special events, publicity on major health issues, and appropriate measures for modifying lifestyles. 3.2 Organization of health services and delivery systems The people of Brunei Darussalam enjoy free medical and health care, provided via government hospitals, health centres and health clinics. A large network of health centres and clinics located throughout the country provides primary health care services, including those for mother and child. 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. As of 2006, there were four government general hospitals, 15 health centres, 15 maternal and child health clinics, eight travelling health clinics and four Flying Medical Services teams for remote areas. The Ministry of Defence also operates five medical centres that mainly provide services for its personnel and their families. In addition to the government hospitals in each district, there is one private hospital. The main referral government hospital in the country is Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital, situated on a 32-acre site about 0.8 km from the heart of the capital. The hospital was officially opened in August 1984 and is equipped with modern, cutting-edge medical technology. The hospital also offers a very wide and comprehensive range of medical and surgical services, currently totalling 28 different specialties and subspecialties. 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 immunization, the country is free from major communicable diseases. The decentralization programme, started in 2000, is a concerted and ongoing effort by the Ministry to provide access to primary health care for the general population throughout the country. The Ministry of Health has now categorized the respective health care services available in Brunei Darussalam into two main services. The Directorate of Medical Services is responsible for hospital, nursing, laboratory, pharmaceutical, dental and renal services, while the Directorate of Health Services oversees community health, environmental health and scientific services. 3.3 Health policy, planning and regulatory framework The provision of a comprehensive health care system for the people is a priority for the Government of His Majesty and Yang Di-Pertuan of Negara Brunei Darussalam. The Ministry of Health formulates the National Health Policy, which is designed to provide the highest level of health care that is cost-effective and to provide a high quality of life for the whole population in a clean and healthy environment. To attain the target of ‘Health For All’, emphasis has been given to the development of a health care system that is based on primary health care, aimed at providing a wide range of preventive, promotive, curative and rehabilitative health care and support services to meet the needs of the population. The main policy objectives are: reduction of infant mortality, diseases and disabilities, and premature deaths, thereby increasing life expectancy; improvement of the environment; and control of communicable diseases. 3.4 Health care financing Provision of services is primarily funded by the General Treasury. The budget for health care is allocated by the Ministry of Finance and administered by the Ministry of Health. User fees COUNTRY HEALTH INFORMATION PROFILES | 33 currently constitute a very small amount of the total funds available to health care. Data regarding private health care spending are very limited. However, an estimate in 2000 stated that the ratio of public to private spending was approximately 97.2% public versus 2.8% private spending. Private insurance is offered in several markets. Since the Government provides and pays for comprehensive health care services, there is a limited market for private insurance for citizens and permanent residents. Employers of foreign nationals typically purchase health insurance locally unless the employer is multinational company (e.g. banks, oil companies), in which case the corporation provides health insurance through international insurance companies. 3.5 Human resources for health In 2006, a total of 399 physicians and 75 dentists were registered to practise. The doctor-to - population ratio was 1:960. A comprehensive manpower development programme for the community, as well as hospital-based health personnel, is to be extended to strengthen health care services throughout the country, with emphasis on the primary health care approach. 3.6 Partnerships The Government continues to forge stronger partnerships among various stakeholders to provide the necessary synergy to reach the shared vision of improved health. The main common stakeholders are other government agencies, academic institutions and other organizations, both local and international. Government agencies provide support in many national health programmes. For some health programmes, the Ministry of Health works very closely with international organizations and global initiatives to strengthen priority health programmes. Assistance for the health sector comes mainly in the form of grants and technical assistance. At present, a sectorwide development approach between the Government and partners is being initiated to ensure maximization of investment and generation of necessary resources, not just for the health sector, but also for other sectors. 3.7 Challenges to health system strengthening The Ministry of Health has embarked on several health care reforms that present a challenge to the nation’s health system. These have been necessitated by the rising costs of health care, changing disease patterns and lifestyles, changing population demography, advancements in health technology and increased public expectation of receiving better quality health care. Over time, the role of the Ministry will evolve from that of a provider of health services to that of a facilitator and regulator. Delivery of services will be enhanced to improve the quality and efficiency of care. Regarding the challenges faced by the Ministry of Health, six aspects may be highlighted: fiscal problems relating to escalating health costs; the paradigm shift in health care (formal and informal activities to preserve and maintain health status); the epidemiological transition (from communicable to noncommunicable diseases and the relationship to lifestyle); and the demographic transition (the increasing number of older people with different needs and demands for health care services). Others include the paradigm shift in public sector management (innovations in the style of managing public services) and the technological revolution. Critical success factors include the priority given by the Government to the importance of health, as manifested through: the recurrent and development budget; comprehensive health care that is of high quality and is cost-effective in the areas of prevention, health promotion and education, treatment and rehabilitation; the control of major communicable diseases; the potential development of the information and communication system; effective and committed leadership; and the availability of highly qualified and competent staff to provide high quality, comprehensive and cost-effective service. Other success factors include collaboration with other government and nongovernmental organizations, as well as the private sector; support and participation from the public in improving services and health status; and establishing RIPAS Hospital as a centre of medical excellence and a referral hospital, as well as a centre for the treatment of more complicated diseases. BRUNEI DARUSSALAM 34 | COUNTRY HEALTH INFORMATION PROFILES 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : 2001 Preliminary Census Report Operator : Department of Economic Planning and Development, Prime Minister’s Office Title 2 : Statistics Unit, Research and Development Section, Ministry of Health Title 3 : Disease Control Division, Environmental Health Services, Ministry of Health 5. ADDRESSES MINISTRY OF HEALTH Office Address : Jalan Menteri Besar Bandar Seri Begawan BB3910 Brunei Darussalam Telephone : (673) 238 1640 Fax : (673) 238 1440 / 238 0128 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 : P. O. Box 12550 50782 Kuala Lumpur Malaysia Official Email Address : who@maa.wpro.who.int Telephone : (603) 2093 9908 / 2092 1184 Fax : (603) 2093 7446 COUNTRY HEALTH INFORMATION PROFILES | 35 6. ORGANIZATIONAL CHART: Ministry of Health Year Source Demographics 1 5.77 2006 1 2 383.00 203.30 179.70 2006 1 3 3.50 … … 2006 1 4 12.80 12.70 12.90 2006 1 18.80 18.60 19.00 2006 1 2.70 2.30 3.10 2006 1 5 74.00 … … 2007 est 6 6 17.10 … … 2006p 2 7 2.90 … … 2006p 2 8 1.40 … … 2006 1 9 … 74.10 77.70 2006 1 … 13.10 13.30 2002 4 10 2.20 2006p 1 11 92.70 95.20 90.20 2004 5 12 30 490.30 2006p 1 13 15.20 2006p 1 14 0.89 2005 5 15 … … … 16 … … … 17 6 5 1 0 0 0 2006 3 0 0 0 0 0 0 2006 3 2 2 0 0 0 0 2006 3 0 0 0 0 0 0 2006 3 0 0 0 0 0 0 2006 3 0 0 0 0 0 0 2006 3 68 53 15 0 0 0 2006 3 0 0 0 0 0 0 2006 3 327 285 42 0 0 0 2006 3 2 1 1 .. … … 2006 7 6 5 1 0 0 0 2006 3 0 0 0 0 0 0 2006 3 13 6 7 0 0 0 2006 3 3 b 2 b 1 b 0 0 0 2006 3 Cholera Rate of growth of per capita GDP (%) - Type A Human development index - Unspecified Communicable and noncommunicable diseases - Type E Hepatitis viral Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Syphilis Rural Female Selected communicable diseases Total Number of deaths Environmental indicators Total Urban Male Female Number of new cases MaleTotal - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Per capita GDP at current market prices (US$) Malaria Plague Gonorrhoea - Type B - Type C Dengue/DHF Typhoid fever Encephalitis Leprosy Estimated population ('000s) Annual population growth rate (%) Percentage of population Rate of natural increase of population (% per annum) Urban population (%) Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Life expectancy (years) - at birth - 0–4 years - 5–14 years Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male BRUNEI DARUSSALAM 36 | COUNTRY HEALTH INFORMATION PROFILES BRUNEI DARUSSALAM Year Source 18 3 720 2 044 1 676 113 66 47 2006 2 19 324 c 187 c 137 c 0 0 0 2006 3 20 202 … … … … … 2006 7 128 … … … … … 2006 7 21 396 186 210 220 108 112 2006 2 26 1 25 20 0 20 2006 2 44 26 18 29 18 11 2006 2 47 9 2006 2 2 1 1 2 1 1 2006 2 5 4 1 2 2 0 2006 2 10 8 2 16 13 3 2006 2 10 5 5 12 6 6 2006 2 13 10 3 11 5 6 2006 2 54 39 15 39 23 16 2006 2 22 1 700 926 774 352 192 160 2006 2 58 46 12 61 43 18 2006 2 149 88 61 102 55 47 2006 2 801 394 407 52 22 30 2006 2 149 93 56 37 23 14 2006 2 15 8 7 2 1 1 2006 2 23 1 038 450 588 116 71 45 2006 2 24 58 30 28 0 0 0 2006 2 25 3 145 2 147 998 82 62 20 2006 2 72 53 19 15 10 5 2006 2 415 275 140 39 31 8 2006 2 141 … … … … … 2006 2 45 12 33 10 6 4 2006 2 26 1 051 562 489 274.40 276.40 272.10 2006 2 1 038 450 588 271.00 221.30 327.20 2006 2 958 514 444 250.10 252.80 247.10 2006 2 942 942 246.00 524.20 2006 2 903 523 380 235.80 257.30 211.50 2006 2 900 505 395 235.00 248.40 219.80 2006 2 890 890 232.40 495.30 2006 2 801 394 407 209.10 193.80 226.50 2006 2 612 612 159.80 340.60 2006 2 561 329 232 146.50 161.80 129.10 2006 2 9. Maternal Diseases Classifiable but Complicating Pregnancy, Childbirth and The Puerperium (Indirect Obstetric Causes) 2. Diabetes Mellitus 10. Heart Diseases 7. Inflammatory Disorders of Female Genital Tract 6. Diarrhoea and Gastroenteritis of Presumed Infectious Origin 8. Hypertensive Diseases 5. Acute Upper Respiratory Infections Total Male Male Female Rate per 100 000 population - New pulmonary tuberculosis (smear-positive) Cancers All cancers (malignant neoplasms only) All circulatory system diseases - Hypertension TotalFemale 4. Pregnancy With Abortive Outcome - Rheumatic fever and rheumatic heart diseases Injuries - Suicide All types - Homicide and violence - Motor and other vehicular accidents - Ischaemic heart disease - Occupational injuries Mental disorders Diabetes mellitus Leading causes of mortality and morbidity Leading causes of morbidity (inpatient care) 3. Acute Lower Respiratory Infections 1. Asthma - Stomach - Cerebrovascular diseases Male Number of cases - Trachea, bronchus, and lung FemaleFemale Total Male Number of new cases Total - Liver - Leukaemia - Lip, oral cavity and pharynx DATA Number of deaths Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections Tuberculosis - All forms - Oesophagus - Colon and rectum - Cervix - Acute myocardial infarction Circulatory INDICATORS - Breast COUNTRY HEALTH INFORMATION PROFILES | 37 BRUNEI DARUSSALAM Year Source 27 220 108 112 57.40 53.10 62.30 2006 2 188 108 80 49.10 53.10 44.50 2006 2 116 71 45 30.30 37.90 25.00 2006 2 102 55 47 26.60 27.10 26.20 2006 2 52 22 30 13.60 10.80 16.70 2006 2 48 28 20 12.50 13.80 11.10 2006 2 39 31 8 10.20 15.20 4.50 2006 2 37 24 13 9.70 11.80 7.20 2006 2 21 8 13 5.50 3.90 7.20 2006 2 17 12 5 4.40 5.90 2.80 2006 2 28 … 29 79.00 2006 2 30 … 31 4.70 … … 2006p 2 32 90.60 … … 2005 2 33 99.90 … … 2006 2 100.00 100.00 100.00 2006 2 100.00 100.00 100.00 2006 2 100.00 100.00 100.00 2006 2 34 942 … 2006 2 … … 21 … 2006 2 14 1 2006 2 … … 35 0 0 0 0 0 0 2006 2 0 0 0 0 0 0 2006 2 0 0 0 0 0 0 2006 2 13 5 8 0 0 0 2006 2 35 18 17 0 0 0 2006 2 0 0 0 0 0 0 2006 2 0 0 0 0 0 0 2006 2 0 0 0 0 0 0 2006 2 0 0 0 0 0 0 2006 2 0 0 0 0 0 0 2006 2 INDICATORS Male Number of cases Male - Neonatal tetanus - Measles 1. Cancer Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth Maternal causes - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) - Total Tetanus 38 | COUNTRY HEALTH INFORMATION PROFILES 7. Transport Accidents 6. Bronchitis, Chronic & Unspecified Emphysema & Asthma 4. Cerebrovascular Diseases 2. Heart Diseases (including Acute Rheumatic Fever) 5. Hypertensive Diseases 8. Influenza and Pneumonia 9. Certain Conditions Originating in the Perinatal Period - Hepatitis B III Percentage of pregnant women with anaemia 10. Congenital Malformations, Deformations & Chromosomal Abnormalities Percentage of women in the reproductive age group using modern contraceptive methods Maternal, child and infant diseases - Poliomyelitis - Obstructed labour - Eclampsia - Haemorrhage - Hib meningitis Immunization coverage for infants (%) - Pertussis (whooping cough) - Diphtheria - Sepsis - Abortion Selected diseases under the WHO-EPI Male Rate per 100 000 population Male FemaleTotal Female Female - Rubella - Congenital rubella syndrome - DTP3 Total DATA Total Total Total Number of deaths FemaleMaleFemale Number of deaths - POL3 - BCG 3. Diabetes Mellitus Leading causes of mortality BRUNEI DARUSSALAM Year Source 36 … 37 Public health facilities 1 550 2006 2 1 … 2006 2 3 409 2006 2 15 0 2006 2 Private health facilities 1 110 2006 2 … … 38 207.60 2006p 8 1.80 2006p 8 543.30 2006p 8 165.40 2006p 8 79.70 2006p 8 5.10 2006p 8 … 20.30 2006p 8 1.59 2006p 8 39 … Year Source 40 Physicians - Number 399 261 138 … … 344 55 2006 2 - Rate per 1000 population 1.04 0.68 0.36 … … 0.90 0.14 2006 2 Dentists - Number 75 39 36 … … 61 14 2006 2 - Rate per 1000 population 0.2 0.10 0.09 … … 0.16 0.04 2006 2 Pharmacists - Number 41 … … … … 25 16 2006 2 - Rate per 1000 population 0.11 … … … … 0.07 0.04 2006 2 Nurses - Number 1 783 … … … … 1 712 71 2006 2 - Rate per 1000 population 4.66 … … … … 4.47 0.19 2006 2 Midwives - Number 429 … … … … 400 29 2006 2 - Rate per 1000 population 1.12 … … … … 1.04 0.08 2006 2 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians 70 … … … … … … 2006 2 Dentists 75 … … … … … … 2006 2 - amount (in million US$) Facilities with HIV testing and counseling services Health infrastructure - Hospitals - Outpatient clinics Health care financing Health facilities INDICATORS - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals - Primary health care centres - per capita total expenditure on health (in US$) Government expenditure on health Total health expenditure - total expenditure on health as % of GDP Health insurance coverage as % of total population P ri va te M al e F em al e T o ta l INDICATOR - general government expenditure on health as % of total expenditure on health Exchange rate in US$ of local currency is: 1 US$ = R u ra l U rb an Number of beds Private health expenditure - private expenditure on health as % of total expenditure on health - external resources for health as % of general government expenditure on health External source of government health expenditure DATA Number DATA P u b lic COUNTRY HEALTH INFORMATION PROFILES | 39 Human resources for health Annual number of graduates BRUNEI DARUSSALAM Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 6.60 … … 2006p 2 45 9.20 … … 2006p 2 46 100.00 100.00 100.00 2006 2 47 15.30 2006p 2 48 99.73 2006 2 0.10 2006 2 99.63 2006 2 49 … … … 50 … 51 Antenatal care coverage - At least one visit 99.60 2004 2 - At least four visits … 52 … … … 53 … … … 54 <0.10 … … 2005 7 55 … … … 56 0.00 0.00 0.00 2006 3 57 0.00 0.00 0.00 2006 3 58 … … … 59 … … … 60 99.00 … … 2006 7 61 11.00 … … 2006 7 62 91.00 … … 2006 7 63 66.00 … … 2005 7 64 99.00 … … 2005 1 65 80.00 … … 2002 2 66 100.00 … … 2003 2 Workforce losses/ Attrition Contraceptive prevalence rate Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Under-five mortality rate (per 1000 live births) Maternal mortality ratio (per 100 000 live births) INDICATORS Annual number of graduates Total Urban Rural Proportion of population with access to affordable essential drugs on a sustainable basis Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source 40 | COUNTRY HEALTH INFORMATION PROFILES Proportion of population in malaria-risk areas using effective malaria treatment measures Adolescent birth rate Tuberculosis death rate per 100 000 population Malaria incidence rate per 100 000 population Unmet need for family planning Estimated HIV prevalence in adults a Malaria death rate per 100 000 population HIV prevalence among population aged 15-24 years Tuberculosis prevalence rate per 100 000 population Percentage of people with advanced HIV infection receiving ART DATA Health-related Millennium Development Goals (MDGs) Infant mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Total Male U rb an Proportion of population in malaria-risk areas using effective malaria prevention measures Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) P ri va te F em al e P u b lic R u ra l INDICATORS DATA Female T o ta l M al e BRUNEI DARUSSALAM … p est NR a b c 1 2 3 4 5 6 7 8 Notes: Data not available World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf] Department of Economic Planning and Development (DEPD), Prime Minister's Office. Statistics Unit, Research and Development Section, Ministry of Health. Disease Control Division, Environmental Health Services, Ministry of Health. The World Health Report 2004. Changing Hostory. Geneva, World Health Organization, 2004. Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world . United Nations Development Programme, New York USA 2007. [http://hdr.undp.org/en/reports/global/hdr2007-2008/] United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006 . Wallchart (United Nations publication, Sales No. E.08.XIII.3). WHO Regional Office for the Western Pacific, data received from the technical units Sources: Not relevant Figure includes paratyphoid cases Estimate Provisional Not included in the official list of MDG indicators Gastroenteritis cases COUNTRY HEALTH INFORMATION PROFILES | 41 42 | COUNTRY HEALTH INFORMATION PROFILES CAMBODIA 1. CONTEXT 1.1 Demographics Based on the 2004 intercensal survey, Cambodia’s population is projected to have been around 14.3 million by the end of 2007. The population density is 74 per square kilometre. The median age is just under 20 years, with the proportion aged 0-24 being twice that of those aged 25-50. The male-to-female ratio is gradually normalizing after the distortions caused by 30 years of war during the last century. Eighty-five per cent of the population lives in rural areas, but there is a significant urban drift, especially among young people. Mainly due to a decline in early mortality, life expectancy increased in the period from 1998 to 2003 from 52 to 60 years for males and from 56 to 65 for females. The total fertility rate dropped from 4.0 births per woman in 2000 to 3.4 in 2005, achieving the Cambodian Millennium target for 2010, predominantly occurring as a result of a decline in fertility among rural women; the annual population growth rate between 1998 and 2005 declined from 2.5% to 1.9%. Forty per cent of women use contraceptives, 27.0% of them modern methods. One quarter of currently married women have an unmet need for family planning, which is especially high among women in the lowest wealth quintile and women with no education. The Cambodian Demographic Health Survey (CDHS) 2005 concluded that both education and wealth have an effect on fertility. The interval between births is relatively long, at a median of 36.8 months. The CDHS 2005 reports a maternal mortality ratio of 472 deaths per 100 000 live births, which does not show significant change from the CDHS 2000 and is one of the highest in the Region. Infant and under-five mortality rates have both declined significantly over the past 25 years, with the most dramatic declines happening since the late 1990s: comparison between the two most recent five-year periods in the CDHS 2005 shows infant and under-five mortality declining by 39% and 35%, respectively, to 66 and 83 deaths per 1000 live births. Socioeconomic characteristics, such as living in an urban environment, the mother’s educational level and the mother’s household wealth, influence infant and child survival substantially. 1.2 Political situation Since completion of the United Nations Transitional Authority in Cambodia (UNTAC) mission and promulgation of the 1993 Constitution of the Kingdom of Cambodia, increased political stability has allowed economic growth, improvements in human development indicators and reintegration of the country into the international community. Parliamentary elections are held every five years, the next being scheduled for 2008. Poverty alleviation and governance are increasingly important items on the Government’s agenda. In September 2004, the Government issued its "Rectangular Strategy", with reforms focusing on corruption, the judiciary, public administration and the military as core priorities for its current term. The National Strategic Development Plan 2006-2010, combining previous poverty- reduction strategy papers and socioeconomic development plans, specifies the prioritized goals, targets and actions, including the Cambodian Millennium Development Goals, and was drafted in collaboration with development partners. 1.3 Socioeconomic situation Cambodia has successfully maintained macroeconomic stability since 1993, allowing for an average annual growth rate of 7.1% for the period from 1994 to 2004, increasing to 13.5% in 2005, and 10.4% in 2006. The year 2007 showed lower economic performance, at 8.5%, but was COUNTRY HEALTH INFORMATION PROFILES | 43 still higher than the initial projection of around 7%. This growth, while reducing poverty by 10%- 15%, has increased inequality, as reflected in a Gini coefficient of 42.0 in 2004. 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. Although this status has now ended, the change does not seem to have affected growth. Increases in tourism and construction are the other recent drivers of economic growth. Agriculture, mainly rice production, accounts for 40% of gross domestic product (GDP) and employs more than 70.0% of the workforce. Annual flooding and drought result in year-to-year fluctuations in agricultural production. Diversifying this rather narrow income base and strengthening rural development are government priorities. Thirty years of war and serious internal conflict at the end of the last century left Cambodia severely impoverished, with a significant depletion of skilled, educated professionals. In 1990, the Human Development Index (HDI) was 0.51, but by 2005 it had increased to 0.60, moving Cambodia from the low to the medium human development category. Despite this achievement, the country still has some of the worst human development indicators in South-East Asia. In 2006, per capita GDP was US$ 419, with 35% 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 79.0%. 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, and women head more than 25% of households. 1.4 Vulnerabilities and hazards Like many developing countries, Cambodia faces a range of vulnerabilities and risks, including traditional, modern and emerging health and environmental risks. These risks emanate from unsafe water and inadequate sanitation; unsafe food supplies, especially from street vendors; indoor air pollution and solid fuel use; as well as disease-vector transmission. However, the country is also subject to emerging issues, including health risks related to changes in the global environment (e.g. climate change and biodiversity loss); development, consumption and production of new products and technologies; consumption and production of more energy sources; and the increasing number and use of chemicals. There are also increasing health risks related to changes in lifestyle, urbanization and working conditions. According to the latest WHO/UNICEF Joint Monitoring Programme (JMP) Report on Drinking Water and Sanitation, 65% of the total population has sustainable access to an improved water source (80% in urban and 61% in rural areas) and only 28% to improved sanitation (62% in urban and 19% in rural areas) in 2006. Other environmental health hazards include bacteriological contamination of drinking water, the most important health-related concern; arsenic in groundwater, which poses a health threat in seven provinces, exposing around 2.24 million people; indoor and urban air pollution, which is a serious health threat due to almost 98 % of the population using biomass fuels for cooking or heating; use of banned pesticides and fertilizers, which has the potential to contaminate food and water; and finally, the serious environmental health impacts from solid and hazardous wastes, including health care waste. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition The Cambodian surveillance system includes an indicator-based weekly surveillance system that reports morbidity and mortality from 12 reportable diseases and syndromes, and a ‘rumour- based’ system that detects outbreaks and unusual health events in a timely manner. Training in surveillance is ongoing at all levels of the health care system. The leading reportable diseases CAMBODIA 44 | COUNTRY HEALTH INFORMATION PROFILES remain unchanged, being ARI and acute watery and/or bloody diarrhoea. However, with the large dengue outbreak in 2007, the number of reported dengue cases and deaths increased dramatically. Malaria continues to affect mostly the poorer communities living in forested areas, where approximately 2 million people are at risk. The total number of treated malaria cases in public health facilitiesdeclinedsteadily from 133 000 in 2003 to 60 000 in 2007, although there was an increase to 101 000 in 2006. Similarly, the number of reported malaria deaths in public health facilities fell from 492 in 2003 to 241 in 2007, but went up to 396 in 2006. The factors that contributed to the increases in 2006 include: the early start of the rainy season, prolonging the transmission period; delayed and inadequate bed-net distribution/re-impregnation; and increasing population movement to malaria-risk areas. The management of severe malaria has improved and the case fatality rate among severe malaria patients at referral hospitals decreased from 10.4% in 2005 to 8.3% in 2007. The proportion of confirmed malaria among all cases treated in public health facilities increased steadily from 54% in 2003 to 78% in 2006, but fell to 71% in 2007. With improvements in diagnosis, treatment and personal protection at the community level, morbidity and mortality due to malaria are expected to reduce in the coming years. However, the country is also right at the centre of a global multidrug-resistant malaria problem, because of the presence of artemisinin-tolerant malaria parasites, especially in the Cambodia-Thailand border area. At the moment, an intensified containment effort, with the aim of eliminating the tolerant parasites, is a priority for Cambodia. Dengue fever and dengue haemorrhagic fever have become serious public health problems in the last two decades, the latter being the number one cause of mortality in paediatric wards during the dengue transmission season. The national dengue incidence rate from hospitalized cases decreased from 0.9 per 1000 populations in 2003 to 0.7 per 1000 in 2005. In 2006, however, the rate increased to 1.3 per 1000 due to outbreaks in several provinces, characteristic of the three-to- five-year cyclical pattern of dengue disease. The worst year for dengue on record was 2007, when 39 851 cases, with 407 deaths, were reported (CFR = 1.03%). As a result of the improved clinical management of DHF and increasing awareness among the general population, the case-fatality rate declined steadily from more than 4% in 1995 to about 1% in 2007. The national immunization programme continued to improve its coverage in 2007. The official DPT-HepB3 coverage rate increased from 80% in 2006 to 82% in 2007, representing 12 000 additional children under one year of age immunized. The measles vaccine coverage rate also increased from 78% in 2006 to 79% in 2007. However, the limited support for the routine operational costs of immunization activities makes it difficult for the programme to maintain high quality services. To address this, the Governemnt will need to balance the support between outreach activities and fixed-site immunization at health centres. Despite a decrease in tuberculosis incidence by 1% per year, Cambodia has the highest incidence in the Western Pacific Region, at 500 cases/100 000 population/year. In 2006, the number of notifications of new cases fell for the first time since 1995 to 35 466. The treatment success rate has been maintained consistently at above 90% for the last decade. TB-HIV co-infection is declining, as indicated by the last TB-HIV prevalence survey (2007), which shows an HIV prevalence rate of 7.8% among TB patients. The identification and treatment of multidrug- resistant (MDR) TB has begun on a small scale, and it is expected that MDR TB services will be scaled up in the coming years. The HIV prevalence rate among adults aged 15-49 years decreased from 2% in 1998 to 0.9% in 2006. Services for people living with HIV/AIDS are provided through a continuum-of-care package available in 39 operational districts, with more than 26 000 patients on antiretroviral treatment in December 2007. More than 80% of the estimated adults in need of ART in 2007 were actually receiving it at the end of 2007. A national survey in 2006 found hepatitis B virus among 3.4% of five-year-old children. Data collected from 27 000 blood donors in 2006 showed infection rates of 1.5% for HIV, 8.4% for COUNTRY HEALTH INFORMATION PROFILES | 45 HBV, 1.6% for HCV, 2% for syphilis and 0.4% for malaria. In 2007, 80% of blood donations were from paid or replacement donors. With current efforts to strengthen the national blood transfusion programme, including development of regulations for the Blood Transfusion Services, it is expected that the challenges related to blood safety will be addressed. Although Cambodia suffered several decades of war and civil unrest, as well as more recent rapid socioeconomic development, there is little information on the prevalence of mental illness, although several small studies have shown high levels of depression among adults and behavioural problems among children and adolescents. Mental health services are available at 35 health centres nationwide and at 25 outpatient departments; there is one psychosocial rehabilitation centre in operation and two psychiatric inpatient units have been established. In 2005, 8800 psychiatric cases were assisted and 56 000 consultations provided by the Government’s national programme for mental health, which does not include the more substantial services offered by NGOs around the country. Increasing use of illicit drugs, especially amphetamine-type stimulant use by young people, sex workers and those in labour-intensive activities, are putting such people at risk of contracting HIV/AIDS and other health problems. Currently, there are virtually no services for most drug users, although Government-approved, basic harm-reduction services are available in Phnom Penh through NGOs. Cambodia has a significant and growing burden of noncommunicable disease. Two recent epidemiological surveys indicated that, in urban areas, 10% of adults had diabetes and 25% high blood pressure, while in a poor rural community, 5% of adults had diabetes and 12% were found to be hypertensive. In total, 300 000 Cambodians are estimated to have diabetes and, if no action is taken, it is estimated that the number will rise to 1.2 million by 2021. In 2005, a nationwide survey of adult tobacco use found that 48% of men and 3.6% of women smoked cigarettes, while 17% of women and 1% of men chewed tobacco. Alcohol consumption is on the increase, and the number of violent incidents, traffic accidents and domestic violence incidents linked to alcohol is alarming. Due to rapid economic growth and changes in lifestyle, the burden of environment-related disease is an increasing concern, accounting for 26% of the total burden of disease in Cambodia, according to recent WHO estimates. When compared with other countries in the Region, Cambodia has the second highest environmental disease burden. While environmental risk factors are generally associated with noncommunicable diseases and injuries, in Cambodia they are also strongly associated with communicable diseases. 2.2 Outbreaks of communicable diseases The first poultry outbreaks of H5N1 avian influenza in Cambodia were reported in January 2004, more than a year before the first Cambodian human case was detected in Viet Nam, where the patient had gone for treatment. Three additional human cases were reported in 2005 and two in 2006, together with outbreaks in poultry. In April 2007, the seventh human case was detected, also related to poultry H5N1 in the patient’s village. Cambodia’s most serious dengue outbreak due to DEN-3 occurred in 2007, with 39 851 reported hospitalized cases and 407 fatalities. Outbreaks were reported during the dry season, which is unusual, with a monthly average of 635 dengue and dengue haemorrhagic fever cases per month in the first quarter. The highest number of cases was reported during the second quarter (6310 cases per month), with the peak occurring in week 28. There were 312 cases per 100 000 population, more than double the number in 2006. Over 97% of reported cases occurred in children under the age of 15, with similar reported rates of infection in males and females. 2.3 Leading causes of mortality and morbidity Infectious diseases still constitute the main causes of mortality and morbidity, but Cambodia is facing an epidemiological transition. Currently, acute respiratory infections are the leading cause CAMBODIA 46 | COUNTRY HEALTH INFORMATION PROFILES of both mortality and morbidity, with gastroenteric infections contributing substantially to the morbidity burden of the population and dengue outbreaks exacerbating the situation. In addition, the country is still classified as one of the 22 worldwide with a high burden of tuberculosis. Notably, HIV prevalence has decreased substantially and a high proportion of people living with HIV/AIDS are receiving antiretroviral therapy. Preventing and treating noncommunicable diseases and injuries will be the challenge in the near future. The number of road accidents is rising very rapidly as a leading cause for mortality due to improved infrastructure and rapid socioeconomic development. Some surveys have indicated high levels of diabetes (5%-10%) and hypertension (12%-25%) in rural and urban areas, both major risk factors for ischemic heart disease and stroke. As half of the male population smokes and alcohol consumption is rising, the composition of the table for leading causes of morbidity and mortality is expected to change in the near future. 2.4 Maternal, child and infant diseases The maternal mortality ratio is high, at 472 per 100 000 live births, and remained unchanged between the last two Cambodia Demographic and Health Surveys in 2000 and 2005. Postpartum haemorrhage is the leading cause of death, followed by infections, complications from abortions and hypertension. Maternal death contributes 17% to mortality in women aged 15- 49 years. The majority of births (78%) take place at home, with 44% of all births attended by a health professional, an increase from 32% in 2000. A Midwifery Review in 2006 showed a low level of competence, particularly in life-saving skills, even among midwives. There are multiple reasons for the high and unchanged maternal mortality ratio, but poor access to professional delivery and postpartum services and the low facility delivery rate stand out as the most important. Barriers to delivery services include official and unofficial fees in the public service system, poor physical access for rural populations and the sometimes unprofessional conduct of staff. Limited emergency obstetric care services, including emergency blood transfusion, are factors that impact negatively on delivery outcomes in hospitals. There is a chronic shortage of midwives and the current number in training does not meet that required to fill the gap in the foreseeable future. A High-level Midwifery Taskforce was formed in 2007 and has been charged with developing a plan for a comprehensive reform of midwifery services. The Government has introduced financial incentives (cash payments per assisted delivery) as a short-term measure to raise the skilled-birth-attendance rate, and there are indications that it has had positive effects. Infant and under-five mortality rates decreased by about 30% over the five-year period up to 2005, bringing Cambodia on target to meet MDG 4 in 2015. The prevalence of child malnutrition was recalculated based on the new WHO growth standards in 2007: wasting decreased from 17% to 8%, underweight from 39% to 28% and stunting from 49% to 43%. Four out of 10 newborn infants are weighed at birth and the proportion of low-birth-weight babies is 8%. Respiratory infection remains the leading cause of death among children under five years of age (30%), followed by diarrhoea (27%), dengue haemorrhagic fever (11%), severe acute malnutrition and measles. The proportion of deaths in the neonatal period is increasing. One quarter of children who die in the neonatal period have a history of poor feeding after initially feeding well, indicating sepsis, while 7% have symptoms suggestive of neonatal tetanus. Infant and young child feeding practices have improved. The rate of exclusive breast-feeding for the first six months of life improved significantly from 11% in 2000 to 60% in CDHS 2005. A step towards full adherence to the International Code of Marketing of Breastmilk Substitutes was taken in 2007 when the Government issued a Joint Prakas on the implementation of the sub- Decree of the Code. The anaemia rate among woman of reproductive age (15-49 years) decreased from 58% in 2000 to 47% in 2005, and from 66% to 57% among pregnant women. Anaemia in children aged 6-59 months remained at 62%. A national nutrition strategy for the period 2008-2015 was completed in 2007. There are indications of increasing disparities in both health outcomes and service utilization between rich and poor, and between urban and rural populations. The Government is committed COUNTRY HEALTH INFORMATION PROFILES | 47 to improving maternal and child health and to achieving MDGs 4 and 5, but the available resources, government and external, are not on par with the challenges. The Ministry of Health has taken important steps to reduce child mortality at the policy and planning level, but it will take substantially larger investments to achieve universal coverage of the 12 Child Survival Score Card interventions by 2015. 2.5 Burden of disease A burden-of-disease study is planned as part of implemention of the new Health Sector Stratetic Plan 2008-2015. The main risks factors are still posed by exposure to communicable diseases, facilitated by environmental circumstances. A high prevalence of diabetes, hypertension and tobacco use has been recognized and, in combination with changing lifestyles and increased traffic accidents, this points to an epidemiological transition. Annually, around 1500 women die due to pregnancy-related complications and almost 30 000 children die before the age of five, outnumbering any disease-related cause. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The first national Health Sector Strategic Plan, in 2002, presented the mission of the Ministry of Health as a commitment to ensure sectorwide, equitable, quality health care for all the people of Cambodia through targeting of resources, especially towards the poor and areas in greatest need. To achieve this mission, a ministry policy statement asserts that all people in Cambodia, of whatever gender, age, place of residence or ability to pay, should have equal access to good quality basic and essential specialized health services, staffed by competent health professionals, at a cost that people can afford; and that they should have information that empowers them to make informed choices about matters affecting the health and the well-being of themselves and their families. To guide progress in fulfilling its mission and policy statement, the Ministry has adopted eight essential objectives (strategies): (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 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 (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 National Health Congress and Joint Annual Performance Review and directives for the next CAMBODIA 48 | COUNTRY HEALTH INFORMATION PROFILES Annual Operational Plan issued. A Three-year Rolling Plan provides medium-term guidance. The new Health Sector Strategic Plan will be released in early 2008 and synchronized with the five- year cycles of the National Strategic Development Plan. 3.2 Organization of health services and delivery systems The Ministry of Health initiated a health sector reform process in the early 1990s and, in 1996, approved the Health Coverage Plan, formulated with WHO support, which divides the country into 73 operational districts within the 24 provinces. Each operational district covers a population of 100 000-200 000 and comprises 10-20 health centres, each covering populations of about 10 000, and a referral hospital. Health centres are expected to deliver a ‘minimum package of activities’ that includes basic curative, preventive and promotional services provided both in the facility and through outreach. Community participation is obtained through health centre management committees. Referral hospitals provide a ‘complementary package of activities’. National institutes, national hospitals, national programmes and training institutions provide the third level of services. As of 2007, there were eight national hospitals, 77 operational districts, 76 referral hospitals, 881 functional health centres and 79 health posts. The Ministry of Health comprises three directorates at central level—health services, finance and administration, and inspection—with the Minister of Health as chief executive. The structure, roles and functions are being reviewed as part of an institutional strengthening process. The private health sector has been expanding rapidly in the past decade, absorbing a substantial part of out-of-pocket expenditure. Many public health civil servants have initiated private activities to complement their official government salaries to earn a living wage. In addition, not-- for-profit NGO providers supply a significant volume of hospital and diagnostic services. Enforcement of private practice regulation needs to become a more prominent aspect of the Ministry of Health’s work. 3.3 Health policy, planning and regulatory framework In order to strengthen its stewardship over the health sector, the Ministry of Health has been developing tools to apply sectoral resources where they are most needed, through direct allocation as well as through advocacy, influence and regulation. The Ministry recently developed a comprehensive system of sectoral operational planning to support implementation of the Health Sector Strategic Plan. Strategic planning, aligned with the National Strategic Development Plan, is operationalized through Annual Operational Plans, forming the basis for Three-year Rolling Plans, which link mid-term operational and investment planning. This is consolidated planning, encompassing the entire public health sector. It is bottom up, with each facility or administrative unit preparing annual plans based on sectorwide priorities, but accounting for its own specific goals, capacities and challenges. The year 2007 marked the third year of the Annual Operational Plans, which will become an increasingly useful tool for resource allocation as the links between planning and budgeting processes are strengthened in coming years. Implementation of strategic and operational plans is monitored through the Ministry of Health’s health information systems, which inform the Joint Annual Performance Review (JAPR) and the Health Sector Congress. This consultative event reviews performance toward strategic goals and identifies priorities for action during the coming year. At the 2007 Joint Annual Performance Review, key bottlenecks to improvement of maternal, reproductive and child health were identified, and a set of priority interventions was recommended for which resource allocations within individual operational plans should increase by 20%. Health facility development is guided by the Health Coverage Plan, which will become an important strategic management tool for the health sector once linkages with human resources planning and national capital investment planning are strengthened. Regulation of the rapidly growing private pharmacy and medical services sector is a priority for the Ministry of Health. However the Ministry’s enforcement ability is constrained by weaknesses in the Police and Judiciary. Nevertheless, registration, as well as the development and approval of COUNTRY HEALTH INFORMATION PROFILES | 49 codes of practice, are proceeding. As most private practitioners are also civil servants, these steps are expected to have some impact. 3.4 Health care financing The government budget for health has been increasing steadily over recent years, reaching US$ 6 per capita for the recurrent budget of the Ministry of Health. The challenge, however, lies not only in adequate finances, but also in allocation and management. Although overall disbursement at the end of budget execution is acceptable (around 98%), provinces and districts face irregular and untimely disbursement. Cambodia is also still highly dependant on donor funding (US$ 7 per capita in 2007) and the challenge is to coordinate action to cover national priorities. Despite the increasing investment in health from government and external sources, the largest portion of health expenditure comes from out-of-pocket sources and goes towards unregulated private health care. The World Bank Poverty Assessment 2006 estimates out-of-pocket expenditure to be US$ 15 per capita per year (secondary analysis of Cambodian Socio-Economic Survey CSES 2004), while the WHO NHA website estimates the figure at US$ 18. More recent figures from the CDHS 2005 seem to indicate even higher out-of-pocket spending, almost US$ 25 per capita per year, with potential underreporting in the CSES and overreporting in the CDHS. The Ministry of Health’s Health Financing Charter was introduced in 1996 and allows establishment of user-fee schemes in health facilities. Of this income, 60% is redistributed as incentives for staff, while 39% is used for operating costs and quality improvement (1% is paid in tax to the Treasury). A positive impact of user fees on access has been to reduce under-the-table payments, but the costs of health care remain a substantial obstacle for a large portion of the population. In this context, Cambodia has, in recent years, developed several alternative financing mechanisms for health, such as contracting, and community-based health insurance. At the same time, health equity funds have been scaled up to cover 39 districts (out of 76) and six national hospitals. Lessons from these experiments are the basis for the formulation of Cambodia’s priorities in health care financing: (1) Increase government resource allocation for health and improve budgeting and financial management capacity at all levels, under the framework of Public Financial Management Reform. (2) Improve and coordinate donor resource allocation for health, including a sustainable long-term approach through the Government’s Action Plan on Harmonization and Alignment for Results 2006-10. (3) Enable development of universal social health protection mechanisms, including health safety nets for vulnerable groups, based on prepaid financing systems, following the Master Plan for Social Health Insurance in Cambodia. 3.5 Human resources for health The war years had a disproportionate impact on the professional classes, with the health sector suffering severe losses in human resources, both in terms of deaths and emigration, as well as truncated education and years lost. While the country’s recovery has been striking and the total number of health workers in Cambodia is no longer particularly low by international standards, staff shortages persist throughout the public health sector, particularly in remote areas. Staff remuneration is one of the key challenges facing the public health sector. With over 15 000 staff members, the Ministry of Health salary budget for 2007 was just over US$ 3 million, with an average monthly salary of US$ 61. This is a major contributing factor to the serious maldistribution of staff. Health professionals tend to come from urban backgrounds. As a result, it is extremely difficult to recruit and place staff in remote rural areas. This problem is particularly acute for midwives, who are key staff members at all health centres across the country. Recruitment and training of new staff from remote areas is therefore a Ministry of Health priority. CAMBODIA 50 | COUNTRY HEALTH INFORMATION PROFILES Many staff must supplement their salaries through side practices in the private sector, which compounds staffing problems for facilities and results in curtailed opening hours and diminished quality of service. It is recognized that this is a widespread practice, and that it will be necessary to either substantially increase public sector remuneration or develop workable models for dual practice if it is to be addressed successfully. To date, the main response to the staff salaries problem has been the use of donor-funded staff incentives for priority areas, as well as payment of a per diem for key activities. As is to be expected with such partial solutions, the effect has been mixed. While many staff are now reasonably remunerated, uncoordinated donor funding has resulted in human resource imbalances between external and Cambodian priorities. Similarly, reliance on a per diem for income supplementation creates incentives that may adversely affect the staff’s ability to accomplish their core functions. To address these issues, the Ministry of Health and other relevant ministries and health partners are finalizing a comprehensive scheme for providing merit-based salary support across the sector. An important component of facility-level remuneration is user fees, 60% of which flow to staff incentives. Attracting more clients through improved quality of care will increase staff incentives, but it is not realistic to expect the requisite improvements in staff morale without first ensuring a living wage. Contracting models have been successfully employed in selected operational districts to increase salaries, strengthen human resource management, and improve staff morale and the quality of care. 3.6 Partnerships Cambodia's health sector is a crowded field where the Ministry of Health is joined by some 20 bilateral and multilateral donors, development agencies and global health partnerships, as well as 100+ international and national NGOs. The Ministry generally welcomes the contribution of health partners and the Health Sector Strategic Plan explicitly promotes public and private partnerships for basic and specialist care. Sectorwide management, introduced and led by the Ministry of Health as the primary mechanism for sector dialogue, has been reviewed in order to strengthen coordination and implementation of the new Strategic Plan to be adopted in 2008. With the multidonor Health Sector Support Project being the only significant example of a coordinated direct partnership with the Government, coordination of partners and their activities has taken on an increasingly important role in the sector. In its efforts to achieve more effective stewardship, including through the creation of a new Department of International Cooperation, the Ministry is finding it difficult to manage aid as it is delivered (mostly project-based). More broadly, the Government of Cambodia is taking greater ownership of its development processes, assisted by a global agenda for greater harmonization and alignment, to which Cambodia contributes as a pilot country for monitoring of progress. These efforts are also embedded in the National Strategic Development Plan 2006-2010 and were reflected in the move to a more Government-led Cambodia Development Cooperation Forum in mid-2007. While the general contribution of partners to the improving health status is unquestioned, their support to Cambodia's health system could be increased considerably if donors were to adapt to more harmonized and efficient modes of cooperation that take into account existing systems at country level. To enable this in-country process, the Ministry of Health signed the International Health Partnership Compact in 2007, as one of the seven first-wave countries globally. 3.7 Challenges to health system strengthening The Health Sector Strategic Plan 2003-2007 identified a number of key challenges for the health sector that remain valid or have become more pressing: 1. Increasing the utilization of cost-effective health services: The overall utilization of public health facilities is around 0.5 visits per person per year. Except in a few areas where additional resources and semiautonomous management have been provided, utilization rates are not increasing substantially and, to date, the underresourced publicly funded health services have had little to offer the rural poor. Most people are choosing to use the private sector for treatment, particularly pharmacies. COUNTRY HEALTH INFORMATION PROFILES | 51 2. Improving the quality of care in both the public and private health sectors: The low utilization of health services may be affected by unfavourable staff attitudes and practices in the public sector, an irregular and inadequate flow of funds to service delivery, limited management and leadership capacity, uncertainty about user charges, and a lack of knowledge about available services. The Ministry of Health published the National Policy for Quality in Health in 2005 and the Operational Guidelines for Clients' Right and Providers' Rights-Duties in 2007 to address these issues. 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: The persistence of a high maternal mortality ratio in the CDHS 2005 confirms the pertinence of this challenge. Currently, many referral hospitals and health centres, particularly in rural areas, have insufficient midwives to provide safe coverage for emergency obstetric care. A continuing functional analysis process, initiated in 2002, has focused attention on the need to develop policy to address the maldistribution of staff, and there has been an increase in the number of midwifery trainees in recent years. However, a recent comprehensive midwifery review indicated serious gaps in the skills of the current midwife workforce. 4. Improving reproductive and adolescent health services: Cambodia has a recently declining fertility rate and a youthful population, with half under 20 years of age. The main focus of reproductive health services is fertility control and antenatal care. Establishing a continuum of quality care for adolescent and maternal and child health, including a functional referral system, will become increasingly important to continue to improve the indicators, which until now have been substantially influenced by an improving socioeconomic situation. A new challenge has gradually become more apparent: prevention and treatment of noncommunicable diseases and injuries. Recent surveys have revealed a high prevalence of diabetes (5%-10%) and hypertension among rural and urban populations. In combination with the fact that about 50% of men in Cambodia smoke and the rapid increase in life expectancy, an epidemiological transition is imminent. Rapid socioeconomic development constantly changes the social determinants of health, and improved road infrastructure has resulted in a steeply rising number of deaths and injuries due to traffic accidents. Health staff will need to be trained and provided with the means to promote healthy lifestyles and treat chronic diseases or disabilities. The burden of environment-based diseases is also an increasing concern for the country. These are mainly related to unimproved drinking water and sanitation, indoor and outdoor air pollution and occupational health risks (occupational carcinogens and particulates). A multipronged challenge will be to improve the effectiveness and efficiency of allocation and disbursement of the scarce financial and human resources. As an Organisation for Economic Co- operation and Development (OECD) pilot country for Aid Effectiveness, the Government is assuming a growing leadership role and is taking forward an action plan to facilitate harmonization and alignment processes. This includes improved governance procedures, public financial management reforms and decentralization and deconcentration policies, requiring the involvement of a multitude of government institutions. The international funding institutions need to determine how to move from the current situation of coordinated, but quite fragmented support for the health sector, to more policy coherence and balanced funding of country priorities. Engaging global health programmes meaningfully and managing the institutional burden will be a particularly demanding undertaking for the Ministry of Health, and improved management information systems are essential to guide analysis of its efficiency and effectiveness. CAMBODIA 52 | COUNTRY HEALTH INFORMATION PROFILES 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Cambodia Demographic and Health Survey 2005 Operator : National Institute of Public Health, Ministry of Health and National Institute of Statistics, Ministry of Planning Specification : Contains information on demographics, family planning, maternal mortality, infant and child mortality, domestic violence, women's status and health-related information such as breast-feeding, antenatal care, child immunization, childhood diseases and HIV/AIDS Web address : http://www.measuredhs.com Title 2 : National Health Statistics 2007 Operator : Health Information Bureau, Department of Planning and Health Information, Ministry of Health Specification : Provides health data, tables and graphs based on statistics generated from the nationwide Health Information System (HIS) Web address : http://www.nis.gov.kh Title 3 : Demographic Estimates and Revised Population Projections 2005 Operator : National Institute of Statistics, Ministry of Planning Specification : Presents population projections, estimations of fertility and mortality, and provides tables based on the 2004 CIPS data Title 4 : Cambodia Inter-Censal Population Survey 2004 Operator : National Institute of Statistics, Ministry of Planning Features : Includes information on population characteristics, household facilities and amenities. Title 5 : Cambodia-Halving Poverty by 2015-Poverty Assessment 2006 Operator : The World Bank Specification : Lays out the key facts on the nature of poverty, poverty trends, education, health and wealth based on the Cambodia Socio-Economic Survey (CSES). Web address : http://www.worldbank.org 5. ADDRESSES MINISTRY OF HEALTH Office Address : No. 151-153 Avenue Kampuchea Krom, Phnom Penh, Cambodia Telephone : (855-23) 722 933 Fax : (855-23) 426 034/426 841 Office Hours : 0700 – 1130 and 1400 – 1700 Website : http://www.moh.gov.kh WHO REPRESENTATIVE IN CAMBODIA Office Address : No. 177 – 179 corner Streets Pasteur (51) and 254 Postal Address : P.O. Box 1217 Official Email Address : who@cam.wpro.who.int Telephone : (855-23) 216 610/ 216 942/ 215 464 Fax : (855-23) 216 211 Office Hours : 0730 – 1200 and 1400 – 1730 COUNTRY HEALTH INFORMATION PROFILES | 53 6. 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 Inspection Directorate General for Administratio n & Finance Department of Administration Department of Personnel Department of Budget and Finance National Institutes a Nationa l Hospitals b 4 Regional Schools of Technical Medical Care c Department of Human Resource Information Development Cosmetics Department of Hospital Services Department of Preventive Medicine Department of Communicable Disease Control Bureau of Inspection Bureau of Control 24 Provincial Health Departments 77 Operational Districts Health 881 Health Centres 76 Referral Hospitals 97 Health Posts Pasteur Institute National Pharmaceutical Factory Faculty of Pharmacy UNIVERSIT Y OF MEDICAL SCIENCES Faculty of Medicine Faculty of Odontostomatology School of Technical Medical Care . Department of Drugs, Food and Department of Planning and Health Department of International Cooperation Department of Internal Audit NB a National center for HIV/AIDS and STD Control, National Center for Tuberculosis and Leprosy Control, National Center for Parasitology, Entomology and Malaria Control, National Maternal and Child Health Center, National Institute of Public Health, National Center for Traditional Medicine, National Center for Drug Quality Control, National Blood Transfusion Center, National Center for Health Promotion, National Immunization Programme. b Excluding Hospitals in NCMCH and NCTB/Leprosy. Calmetter, National Pediatric, Kossomak, Khmer-Soviet Friendship, Ang Duong, and Kuntha Bupha hospitals. c Battambang, Kampot, Kg. Cham and Stung Treng. CAMBODIA Year Source Demographics 1 181.04 3 2 14 331.27 6 982.53 7 348.74 2007 9 3 1.90 … … 2005 8 4 11.50 12.20 10.90 2005 1 27.40 29.30 25.80 2005 1 4.60 3.90 5.30 2005 1 5 21.00 … … 2007 est 20 6 25.00 … … 2004 6 7 6.70 … … 2004 6 8 1.90 … … 2005 8 9 … 60.00 65.00 2003 8 … 9.70 11.00 2002 9 10 3.40 2005 1 11 73.60 84.70 64.10 2004 6 12 419.00 2006 2 13 10.80 2006 2 14 0.60 2005 18 15 … … … 16 … … … 17 … … … … … … 400 … … 10 … … 2006 13 … … … … … … … … … … … … … … … … … … … … … … … … 39 851 19 782 20 069 407 222 185 2007 15 1 825 … … 67 … … 2007 5 … … … … … … 429 … … … … … 2005 17 78 696 … … 396 … … 2006 17 … … … … … … … … … … … … … … … … … … Malaria Plague Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km 2 ) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Estimated population ('000s) Annual population growth rate (%) Male Percentage of population - 0–4 years - 5–14 years Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above Rate of natural increase of population (% per annum) Urban population (%) Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Urban Rural Number of new cases Total Number of deaths Female 54 | COUNTRY HEALTH INFORMATION PROFILES Selected communicable diseases Gonorrhoea - Unspecified - Type E Cholera Syphilis - Type B - Type C Dengue/DHF Leprosy Encephalitis Per capita GDP at current market prices (US$) Environmental indicators Total Human development index Rate of growth of per capita GDP (%) Male FemaleMaleTotal Communicable and noncommunicable diseases Hepatitis viral Typhoid fever - Type A CAMBODIA Year Source 18 337 511 … … 147 … … 2007 5 19 48 579 … … 6 … … 2007 5 20 34 660 … … … … … 2006 17 19 294 … … … … … 2006 17 21 … … … … … … 268 … … 8 … … 2007 13 … … … … … … 433 7 2007 13 … … … … … … … … … … … … … … … … … … 345 … … 20 … … 2007 13 … … … … … … 178 … … 11 … … 2007 13 22 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 23 1 158 … … 47 … … 2007 13 24 2 000 … … 10 … … 2007 13 25 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 26 57 941 … … 404.30 g … … 2007 13 36 580 … … 255.25 g … … 2007 13 18 767 … … 130.95 g … … 2007 13 17 211 … … 120.09 g … … 2007 13 15 093 … … 105.32 g … … 2007 13 10 305 … … 71.91 g … … 2007 13 9 923 … … 69.24 g … … 2007 13 7 110 a … … 49.61 a,g … … 2007 13 5 433 … … 37.91 g … … 2007 13 5 162 … … 36.02 g … … 2007 13 INDICATORS - Acute myocardial infarction 10. High blood pressure Circulatory - Ischaemic heart disease - Hypertension - Rheumatic fever and rheumatic heart diseases 8. AIDS Leading causes of mortality and morbidity - Stomach - Cerebrovascular diseases Mental disorders Diabetes mellitus Injuries 5. Tuberculosis 1. Acute respiratory infections 2. Dengue Leading causes of morbidity (inpatient care) - Leukaemia - Lip, oral cavity and pharynx - Liver - Suicide All types - Homicide and violence - Motor and other vehicular accidents - Occupational injuries - Trachea, bronchus, and lung All circulatory system diseases - Breast All cancers (malignant neoplasms only) Tuberculosis - All forms - New pulmonary tuberculosis (smear-positive) Cancers DATA Number of deaths Total Female Male Number of cases FemaleFemale Total Male TotalFemale Male Rate per 100 000 population Number of new cases COUNTRY HEALTH INFORMATION PROFILES | 55 Total Male 6. Typhod fever 4. Diarrhoea 9. Cataract 7. Genecological Pathology 3. Traffic accident - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections CAMBODIA Year Source 27 1 087 … … 7.58 g … … 2007 13 548 a … … 3.82 g … … 2007 13 461 … … 3.22 g … … 2007 13 448 … … 3.13 g … … 2007 13 388 … … 2.71 g … … 2007 13 345 … … 2.41 g … … 2007 13 266 … … 1.86 g … … 2007 13 191 … … 1.33 g … … 2007 13 183 … … 1.28 g … … 2007 13 25 … … 0.17 g … … 2007 13 28 27.20 2005 1 29 50.00 2007 12, 17 30 57.10 2005 1 31 28.00 … … 2005 1 32 90.00 b 2005 1 33 90.00 … … 2007 12, 17 82.00 … … 2007 12, 17 82.00 … … 2007 12, 17 82.00 … … 2007 12 34 2 797 5 2007 13 527 1 2007 13 1 941 8 2007 13 1 200 … 2007 13 177 2 2007 13 35 NR NR NR NR NR NR 2007 17 2 c … … … … … 2007 12 NR NR NR NR NR NR 2007 12 394 … … … … … 2007 12, 17 NR NR NR NR NR NR 2007 12, 17 50 … … … … … 2007 12, 17 561 … … … … … 2007 12, 17 0 0 0 0 0 0 2007 12, 17 174 c … … … … … 2007 12 242 … … … … … 2007 12 INDICATORS 3. Dengue … … 2. AIDS Percentage of women in the reproductive age group using modern contraceptive methods 7. Tuberculosis Leading causes of mortality 10. Other tetanus Immunization coverage for infants (%) Maternal, child and infant diseases 9. Meningitis - Pertussis (whooping cough) DATA Male Number of cases Number of deaths FemaleMaleTotal FemaleMale Male FemaleTotal Total Rate per 100 000 population - Rubella - Congenital rubella syndrome - Sepsis - Diphtheria - Hib meningitis - Total Tetanus - Poliomyelitis 56 | COUNTRY HEALTH INFORMATION PROFILES - Eclampsia - Haemorrhage - Abortion Selected diseases under the WHO-EPI - Obstructed labour - Neonatal tetanus - Measles 1. Acute respiratory infections Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth Maternal causes - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) - Hepatitis B III 4. Traffic accident - POL3 - BCG - DTP3 5. High blood pressure Percentage of pregnant women with anaemia 6. Liver cancer 8. Cardiopath Number of deaths Male Female Total Female Total CAMBODIA Year Source 36 197 2007 10 37 Public health facilities … … 8 … 2007 13 76 … 2007 13 881 … 2007 13 Private health facilities … … … … 38 488.65 2006p 4 6.80 2006p 4 34.00 2006p 4 111.17 2006p 4 22.80 2006p 4 10.70 2006p 4 19.50 d 2006p 4 77.20 2006p 4 4 103.30 2006p 4 39 0.00 2006 4 Year Source 40 Physicians - Number 2 122 … … … … … … 2004 11 - Rate per 1000 population 0.16 … … … … … … 2004 11 Dentists - Number 241 … … … … … … 2004 11 - Rate per 1000 population 0.02 … … … … … … 2004 11 Pharmacists - Number 577 … … … … … … 2004 11 - Rate per 1000 population 0.04 … … … … … … 2004 11 Nurses - Number 4 516 … … … … … … 2004 11 - Rate per 1000 population 0.35 … … … … … … 2004 11 Midwives - Number 1 754 … … … … … … 2004 11 - Rate per 1000 population 0.13 … … … … … … 2004 11 Paramedical staff - Number 160 … … … … … … 2004 11 - Rate per 1000 population 0.01 … … … … … … 2004 11 Community health workers - Number 1 638 … … … … … … 2004 11 - Rate per 1000 population 0.13 … … … … … … 2004 11 41 Physicians … … … … … … … Dentists … … … … … … … COUNTRY HEALTH INFORMATION PROFILES | 57 - private expenditure on health as % of total expenditure on health - external resources for health as % of general government expenditure on health R u ra l Exchange rate in US$ of local currency is: 1 US$ = Health insurance coverage as % of total population P u b lic DATA Number of beds DATA Number P ri va te T o ta l - amount (in million US$) - per capita total expenditure on health (in US$) Government expenditure on health Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) INDICATOR U rb an - 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 Private health expenditure Human resources for health M al e F em al e Health facilities INDICATORS Facilities with HIV testing and counseling services Health infrastructure - Hospitals - Outpatient clinics - General hospitals - Specialized hospitals - District/first-level referral hospitals - Primary health care centres Health care financing Annual number of graduates CAMBODIA Year Source 41 Pharmacists … … … … … … … Nurses 208 e … … … … … … 2002-2004 11 Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 35.55 35.30 38.80 2005 1 44 66.00 … … 2005 1 45 83.00 … … 2005 1 46 79.00 … … 2007 12 47 472.00 2005 1 48 44.00 … … 2005 1 22.00 2005 1 22.00 2005 1 49 24.10 … … 2005 1 50 5.20 2005 1 51 Antenatal care coverage - At least one visit 44.40 2005 1 - At least four visits 27.00 2005 1 52 25.00 … … 2005 1 53 … … … 54 0.90 … … 2006 10 55 82.60 … … 2007 10 56 554.00 … … 2006 17 57 2.79 … … 2006 17 58 … … … 59 … … … 60 665.00 … … 2006 17, 19 61 92.00 … … 2006 17, 19 62 62.00 … … 2006 17 63 89.00 … … 2005 17 64 65.00 80.00 61.00 2006 16 65 28.00 62.00 19.00 2006 16 66 … … … … Malaria death rate per 100 000 population 58 | COUNTRY HEALTH INFORMATION PROFILES T o ta l M al e U rb an P ri va te Tuberculosis death rate per 100 000 population Total Malaria incidence rate per 100 000 population Contraceptive prevalence rate HIV prevalence among population aged 15-24 years Proportion of population in malaria-risk areas using effective malaria treatment measures Proportion of population using an improved sanitation facility Proportion of population in malaria-risk areas using effective malaria prevention measures Total Male INDICATORS Prevalence of underweight children under five years of age Proportion of births attended by skilled health personnel Female R u ra l P u b lic DATA Health-related Millennium Development Goals (MDGs) INDICATORS - Percentage of deliveries in health facilities (as % of total deliveries) Infant mortality rate (per 1000 live births) Maternal mortality ratio (per 100 000 live births) Proportion of 1 year-old children immunised against measles - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Adolescent birth rate Estimated HIV prevalence in adults f Percentage of people with advanced HIV infection receiving ART Unmet need for family planning Rural Proportion of population with access to affordable essential drugs on a sustainable basis Proportion of population using an improved drinking water source Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Tuberculosis prevalence rate per 100 000 population Urban Annual number of graduates Workforce losses/ Attrition DATA F em al e Under-five mortality rate (per 1000 live births) CAMBODIA … p est NR a b c d e f g 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] Joint Programme Review Report, National Tuberculosis Programme Cambodia 2006, Ministry of Health, National Centre for Tuberculosis and Leprosy Control, WHO, JICA, Annual Report of the National Centre for Parasitology, Entomology and Malaria Control. Demographic Estimates and Revised Population Projections 2007, National Institute of Statistics, Ministry of Planning National Center for HIV/AIDs, Dermatology and STI, Ministry of Health Human Resources Database, Minstry of Health, 2004 (civil service employees) COUNTRY HEALTH INFORMATION PROFILES | 59 Phnom Penh, Cambodia and Calverton, Maryland, USA. National Institute of Statistics and ORC Macro. <http://www.measuredhs.com>. National Institute of Public Health, National Institute of Statistics (Cambodia) and ORC Macro, 2006. Cambodia Demographic and Health Survey 2005. Provisional WHO Regional Office for the Western Pacific, data received from technical units. [http://hdr.undp.org/en/reports/global/hdr2007-2008/] Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world . United Nations Development Programme, New York USA 2007. Global Tuberculosis Control: surveillance, financing, planning. WHO Report 2007. Geneva, World Health Organization. WHO/HTM/TB/2007.376 WHO/UNICEF Joint Reporting Form (JRF) on Immunization 2007 National Health Statistics 2007, Cambodia. Communicable Disease Control Database (CAM EWARN), Ministry of Health Cambodia Inter-Censal Population Survey 2004, General Report, Ministry of Planning, Department of Demographic Statistics, Censuses and Survey, November 2004 National Tuberculosis Program, Ministry of Health Demographic Estimates and Revised Population Projections 2005, National Institute of Statistics, Ministry of Planning National Accounts of Cambodia 1993-2006, Ministry of Planning Estimate Figure refers to registered cases in clinics only Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific External resources for health as % of Total Expenditure on Health (Orginal: External resources for health as % of General governemt expenditure) Primary nurses and midwives included in other nursing/auxiliary staff graduated between 2002-2004, Ministry of Health Figure refers to children with normal birthweight among approximately 40% of children in Cambodia with reported birthweight Laboratory confirmed cases Not relevant Sources: Not included in the official list of MDG indicators Notes: Data not available World Health Organization-National Health Accounts Series <http://www.who.int/nha/country/khm/en Information furnished by the WHO Representative for Cambodia, 09 March 2004 60 | COUNTRY HEALTH INFORMATION PROFILES CHINA 1. CONTEXT 1.1 Demographics China is the most populous country in the world, with an estimated 1.3 billion citizens. Population growth rates have slowed and life expectancy has risen in recent decades (Figure 1).1 While a child born in China in the 1950s could expect to live 46 years, one born in 2000 could expect to live for over 71 years. Fig 1. Life expectancy at birth and total fertility rates, 1950-1955 to 2025-2030 projections Rapid success in reducing fertility, however, has had several important impacts. First, the 2000 census estimates that 117 boys were born for every 100 girls for first births, but this ratio quickly rises to 152 for every 100 for second births.2 In addition, China's population is ageing rapidly. One in four people living in the country in 2035 will be aged 60 years or older.3 Population ageing leads to a shift towards chronic diseases and disabilities and pressures on the health system to address more complex health conditions that generate higher costs. In addition, the tradition of providing long-term care at home for elderly parents and grandparents will be challenged in the light of the one-child policy. Fig 2. Population of China by age group (%), 1964, 2000, 2035 40 23 17 6 10 24 0% 20% 40% 60% 80% 100% 1964 2000 2035 0-14 yrs 15 -19 yrs 60+ yrs In line with the Government’s policy to accelerate urbanization, half of the population will be living in urban areas by 2030 (Figure 3),4 placing great pressure on water, air and electricity resources. 1 EarthTrends. World Resources Institute. 2 Population Reference Bureau 3 Population Reference Bureau 4 Op cit. Ref 1. 71.2 76.3 Life expectancy at birth, years 46 1.91.8 Total fertility rate 6.2 20 30 40 50 60 70 80 1950 1960 1970 1980 1990 2000 2025 0 1 2 3 4 5 6 7 COUNTRY HEALTH INFORMATION PROFILES | 61 Fig 3. Urban population (%), 1970, 2000, 2030 1.2 Political situat 1.2 Political situation China's 11th Five Year Plan (2006-2010) forms the basis of the Government's current economic and social development efforts. In continuity with the 10th Five Year Plan, the 11th Plan aims to sustain the rapid and steady development of China's ‘socialist market economy’ while, in addition, aiming to achieve the ‘five balances’: • Balance between urban and rural development: The gap between urban and rural areas increased during the 1990s for some important economic and health indicators. • Balance in regional development: The Government is promoting development in the western regions in an effort to address the regional imbalances that have grown over time. • Balance in social and economic development: The Government has made a commitment to focus more on social issues, including poverty, education, medical care and public health, in its overall goal to build a well-rounded better-off society and achieve socialist modernization. • Balance between human beings and nature: Industry, agriculture and humans are competing for scarce resources, including water and air. • Balance between domestic and international development: This balance promotes international cooperation and emphasizes the importance of fulfilling international commitments. The 11th Plan includes two key quantitative targets: • to achieve an annual gross domestic product (GDP) growth rate of 7.5%, with the goal of doubling 2000 GDP per capita by 2010; and • to reduce energy consumption per unit of GDP by 20%, and the total discharge of major pollutants by 10%, by 2010. It also includes a number of strategic priorities and major tasks, including: rebalancing China's pattern of growth; deepening reforms and opening up further to the outside world; constructing a ‘new socialist countryside’; promoting more balanced development among the different regions; and increasing capacity for independent innovation. To enable a larger proportion of the population to take advantage of the opportunities afforded by economic growth, future programmes aim to reduce poverty; develop the education, health, technology, scientific and cultural fields, among others; and strengthen the social safety net. The 17.4 32.1 50.3 0% 50% 100% 1970 2000 2030 rural urban CHINA 62 | COUNTRY HEALTH INFORMATION PROFILES Plan is referred to as a ‘people's agenda’ because it focuses on inclusive social development that will make a measurable difference in people’s lives by 2020. 1.3 Socioeconomic situation China has made impressive gains in improving living standards, reducing poverty and maintaining strong economic growth since initiating market reforms in 1979. GDP averaged a real annual growth rate of 10% during the period from 1979 to 2006. During 1979-1984, economic growth was driven by the shift of labour from agriculture to rural industry. Between 1985 and 1992, growth benefited from improved efficiency in capital allocation stemming from price liberalization and from opening up to foreign trade. Further opening up of the economy to foreign direct investment in the 1990s stimulated technological progress. China’s real GDP grew at a rate of 11.4% in 2007 and is projected to continue growing at a rate of 9.6% in 2008. Current growth is driven by investment, consumption and exports. China’s earlier high health standards have played a pivotal role in the country’s economic success. Impressive growth performance has been correlated with reductions in poverty and advancements in social development. Using the standard international poverty line of US$ 1 per day, an estimated 400 million people in China have been lifted out of poverty over the past 30 years. This is primarily a result of the liberalization of agriculture and other rural industries. At China’s official poverty line, the rural population living in absolute poverty with an annual per capita net income below 668 Yuan (US$ 87) decreased from 250 million in 1978 (31% of the rural population) to 24 million in 2005 (3% of the rural population). New estimates of poverty using purchasing power parity (PPP) suggest even greater gains in poverty from 71%-77% in 1981 to 13%-17%. By whatever measure, China alone has accounted for over 75% of poverty reduction in the developing world over the last 30 years. The linkages between health and economic growth intensify as China seeks to sustain economic growth. The benefits of this growth, however, have not been shared equally and gaps exist in socioeconomic indicators between geographic regions, rich and poor households, urban and rural residents, and migrant and resident populations within cities. Up to 30% of poor people state that health is the single most important cause of their poverty. Ill-health can lead to poverty through reduced earning capacity and high out-of-pocket medical expenses that can be financially catastrophic. Poor health contributes to cycles of poverty that reduce physical capacity and erode economic productivity. 1.4 Vulnerabilities and hazards China’s socioeconomic development is based on a sound footing, as the Government continues to enhance its macroeconomic, structural and social policies. The key economic challenge is to rebalance the economy to further strengthen sustainable economic and social development. The State Council's 2007 document on stimulating the service sector sets the stage for future policy action, and many new policy initiatives support equitable growth. Health vulnerabilities arise as the by-product of changes in social and economic development. Urbanization, environmental damage, and increasing tobacco consumption and motor vehicles have resulted in a high prevalence of risk factors for chronic diseases. Some 23% of the population is overweight and 160 million people are suffering from hypertension, most of whom are between the ages of 18 and 59 years. Diabetes prevalence is projected to double by 2030 to more than 42 million cases. Some 350 million people smoke in China. Smoking prevalence is 66% among men and 3% among women, and uptake is occurring at younger ages. Smoking is a primary contributor to lung cancer mortality, estimated at more than 300 000 deaths annually. It is projected that, by 2020, tobacco use will account for one-third of all deaths—among which half will occur between the ages of 35 and 64 years. COUNTRY HEALTH INFORMATION PROFILES | 63 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition Health outcomes Publicly financed health programmes provided access to basic care during the 1960s and 1970s, especially in rural areas. Health outcomes continued to improve between 1980 and 2005, although at a slower pace. Figure 4 shows the increase in life expectancy over almost 50 years in comparison to economic growth. Other health indicators improved as well. By 2005, the maternal moratlity ratio had declined to 44.7 per 100 000, and the infant and under-five mortality rates to 19.00 and 22.5 per 1000, respectively, levels comparable with middle-income countries.1,2 Immunization coverage of one-year-olds against tuberculosis and measles exceeded 90%, while malnutrition rates among the under-fives had declined to less than 10%. Fig 4. Life expectancy and GDP, 1952-2003. 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 52 19 55 19 58 19 61 19 64 19 67 19 70 19 73 19 76 19 79 19 82 19 85 19 88 19 91 19 94 19 97 20 00 20 03 Primary-agriculture, mining Secondary-construction, industry Tertiary-service 80 60 40 20 (years)(100 million RMB) Source: China Statistical Yearbook 2004 and UNIDO analysis Life expectancy Despite the tremendous progress made over the past 50 years in controlling communicable diseases, they remain a problem in China. More than 360 000 children under five years of age die annually, with about 70% of those deaths due to a few conditions that could be addressed through quality care: perinatal and maternal conditions, respiratory infections and infectious diseases. A critical health challenge in China relates to inequality in health outcomes. Infant and child mortality rates in many western provinces are three to five times higher than in more developed coastal areas. In terms of rural-urban disparity across provinces, China National Maternal and Child Surveillance reports the 2004 rates for maternal, infant and under-5 mortality in rural areas as two to three times greater than those in urban areas. Furthermore, life expectancy is also generally lower in rural provinces and those with higher poverty rates. Health problems As might be expected, the disease burden varies by age group. It is estimated that 70% of deaths among children less than five years of age are attributable to maternal, perinatal or nutritional 1 National Maternal and Child Surveillance System. 2 Joint review of maternal and child survival strategies in China. Beijing, Ministry of Health, WHO, UNICEF and UNFPA, 2006. CHINA 64 | COUNTRY HEALTH INFORMATION PROFILES conditions, many of which could be addressed through high quality health care. Sepsis, pneumonia, diarrhoea, measles and tetanus remain important causes of childhood death and illness. Among children aged five to 14 years, the number of deaths is a very small part of the total disease burden; however, most of these deaths are attributable to injuries and accidents, including drowning and road accidents. Mental health problems and suicide are important causes of disability and death, particularly among 15 to 34 year-olds and women in rural areas. Some 69% of disability and 80% of deaths among adults and older people are due to noncommunicable diseases. Much of the disability and death attributable to chronic diseases, particularly among working-age adults, could be reduced through a reduction in risk factors, including improvements in air quality, water and sanitation; reductions in tobacco and alcohol use; improvements in diet and nutrition; and increased exercise. It is projected that the disability and deaths related to chronic diseases will result in a US$ 550 billion loss in productivity between 2005 and 2015. Emerging disease threats include HIV/AIDS, SARS and human and avian influenza. Health risks The major health threats in the underdeveloped areas of rural China include unsafe water, lack of sanitation, undernutrition, vitamin and mineral deficiencies, and indoor pollution. However, significant progress has occurred in these areas thanks to targeted Government programmes. Emerging health threats related to the environment, workplace and lifestyle are becoming more evident. Air pollution and water contamination by industrial and municipal waste, as well as overuse of chemical fertilizers and pesticides annually cost China over 400 000 lives.1, 2 Among the lifestyle-related health risks, smoking and associated exposure to second-hand smoke are particularly serious in both rural and urban areas of the country. 2.2 Outbreaks of communicable diseases China is one of 22 high-burden countries for tuberculosis, with the prevalence for all forms of TB estimated at 208 per 100 000 people in 2000. WHO estimates that, in 2006, there were 1.3 million new active TB cases in China, of which 600 000 were the highly infectious, smear- positive pulmonary disease.3 Every year, approximately 200 000 people in China die due to TB infection. An estimated 700 000 people were living with HIV at the end of 2007. Although HIV prevalence in China is currently low (0.05%), several provinces in central, southern and western areas of the country face serious concentrated epidemics, with the epidemic spilling into the general population in some areas. Yunnan, Henan and Guangxi provinces are the worst affected, with over 30 000 cumulative HIV cases reported in 2005. Sexual transmission is now the main mode of transmission. Among those living with HIV reported between January and October 2007, 37.9% of infections were through heterosexual transmission, 3.3% through homosexual transmission, and 29.4% via injecting drug use.4 There are also indications of increasing HIV infection rates at antenatal sites. Emerging infectious diseases, such as severe acute respiratory disease syndrome (SARS) or avian influenza (H5N1), are becoming increasingly important because of their epidemic potential. In addition to the illness and death they bring, they can cause social instability and considerable 1 Guang X. An estimate of the economic consequences of environmental pollution in China. In: Smil V, Yushi M, eds. Project on environmental scarcities, state capacity and civil violence. Cambridge, Committee on International Security Studies, 1997. 2 Relatively easy availability of pesticides in rural markets and homes is also associated with China’s internationally very high suicide rates among young rural women. 3 Global tuberculosis control 2008: surveillance, planning, financing. Geneva, World Health Organization, 2008. 4 Joint assessment of HIV/AIDS prevention, treatment and care in China. Beijing, United Nations China, State Council AIDS Working Committee Office and United Nations Theme Group on AIDS in China, 2007. COUNTRY HEALTH INFORMATION PROFILES | 65 financial and economic loss. The SARS outbreak in 2003 affected 5327 people in mainland China and killed 348. Since 2003, 25 people in China have been reported to have H5N1 and 26 of them have died. While China remains vulnerable to the health threats posed by emerging and re-emerging infectious diseases, known and preventable diseases like influenza, malaria, cholera, schistosomiasis and filariasis continue to occur in the country, despite the availability of effective preventative measures. The large-scale national malaria control programme, launched in 1955, successfully reduced the 30 million malaria cases that had been occurring annually before 1949. However, China still faces major malaria control issues in the border areas of the country's tropical south, and in the central area of the country, where malaria has re-emerged since 2001. In 2006, an estimated 10.5 million people were living in high-risk areas, with a reported malaria incidence rate of more than one case per 1000 people. 2.3 Leading causes of mortality and morbidity Overall, people in China are living longer and healthier lives. The disease profile resembles that of a developed country, with some 85% to 90% of deaths due to noncommunicable diseases and injuries. Figure 5 shows causes of death by age in China in 2003. Among the remaining infectious diseases, hepatitis B infection, TB and lower respiratory infections still account for significant mortality and lost DALYs. National averages, however, mask considerable regional variations and disparities across socioeconomic groups, genders and geographic localities. Fig 5. Number of deaths by cause and age, 2003 0 0.5 1 1.5 2 2.5 0 to 4 5 to 14 15 to 29 30 to 44 45 to 59 60 to 69 70 to 79 > 80 Age (years) Source: WHO World Health Report (2005) Number of deaths (million) Injury Noncommunicable disease Communicable, maternal, perinatal and nutritional disease According to the Third National Health Service Survey, conducted in 2003, a decline in infectious diseases of the respiratory and digestive systems was seen from 1998 to 2003, while circulatory, endocrine, nutritious and kinetic system disorders rose continually over the same period. The following table provides more detailed information. CHINA 66 | COUNTRY HEALTH INFORMATION PROFILES Table 1. Two-week morbidity rate per 1000 population, by major disease. National Health Service Survey 2003 Total Urban Rural Disease Morbidity rate % Disease Morbidity rate % Disease Morbidity rate % 1 Acute upper respiratory tract infection 20.4 14.3 Hypertension 21.9 14.3 Acute upper respiratory tract infection 21.3 15.3 2 Acute nasopharyngitis 17.8 12.5 Acute upper respiratory tract infection 18.0 11.8 Acute nasopharyngitis 19.8 14.2 3 Hypertension 11.9 8.3 Acute nasopharyngitis 12.0 7.8 Gastroenteritis 11.3 8.1 4 Gastroenteritis 10.5 7.4 Gastroenteritis 8.3 5.4 Hypertension 8.4 6.1 5 Influenza 5.8 4.1 Cerebrovascular diseases 6.4 4.2 Flu 6.4 4.6 6 Rheumatoid arthritis 5.1 3.6 Diabetes 6.3 4.1 Rheumatoid arthritis 5.4 3.9 7 COPD 3.8 2.6 Ischaemic heart disease 4.9 3.2 COPD 3.8 2.8 8 Cerebrovascular diseases 3.7 2.6 Rheumatoid arthritis 4.2 2.7 Cerebrovascular diseases 2.7 2.0 9 Intervertebral disc disorders 2.8 2.0 Intervertebral disc disorders 4.2 2.7 Dislocations, sprains, injuries 2.7 1.9 10 Conditions relating to the gall bladder 2.5 1.7 Influenza 4.1 2.7 Intervertebral disc disorders 2.4 1.7 Source: Health situation assessment of the People’s People's Republic of China. Beijing, United Nations Health Partners Group in China, 2005. 2.4 Maternal, child and infant diseases In order to attain the Millennium Development Goals (MDGs) related to the reduction of child mortality (MDG4) and the improvement of maternal health (MDG5)1, the Government of China has designed a series of targeted policies and interventions and has made impressive achievements. The 11th Five Year Plan also sets 2010 targets for infant mortality (17 per 100 000) and maternal mortality (40 per 100 000). The country has remained polio-free since 1994 and the incidence of immunization-targeted diseases, such as measles and diphtheria, has declined significantly. Currently the Expanded Programme on Immunization also includes hepatitis B vaccine, with a rate of 88% for timely Hep B birth dose delivery in 2006. The Government recently expanded the immunization programme to include vaccines to prevent 12 diseases (TB, poliomyelitis, diphtheria, tetanus, pertussis, measles, hepatitis B, Japanese encephalitis, meningococcal meningitis, hepatitis A, rubella, mumps and measles, as well as leptospirosis, anthrax and epidemic hemorrhagic fever). Vaccines now exist for pneumonia and diarrhoea in young children and the Government will be considering whether and how to introduce these vaccines in the future. The 11th Five Year Plan stipulates that the immunization rate should reach more than 90% by 2010. However, the country still faces many challenges with regard to maternal and child health. Since the mid-1980s, the infant and under-five mortality rates in China have continued to fall, although the rate of decline has slowed considerably since the mid-1990s. Regional disparities result in significant discrepancies in child mortality rates as well as maternal mortality ratios (MMR); vulnerable migrant and remote and rural poor populations do not seem to be covered by maternal and child health services. National statistics show that the MMR decreased from 80 to 41.1 per 100 000 live births between 1996 and 2006,2,1 and reductions occurred in the infant mortality rate (IMR) and under-five 1 These goals aim to reduce the under-five mortality rate by two-thirds and the maternal mortality ratio by three-quarters between 1990 and 2015. 2 National Maternal and Child Health Surveillance System COUNTRY HEALTH INFORMATION PROFILES | 67 mortality rate (U5MR) of 17.2 and 20.6 per 1000 live births, respectively, in 2006.2 Despite steady progress, however, the decline in maternal and child mortality has slowed in recent years and China has been identified as one of seven priority countries in the Region that has a high total number of maternal mortality deaths, and as one of six countries in the Region with the highest burden of under-five deaths.3 In addition, MMR, IMR and U5MR are much higher in western China compared with coastal areas. For example, in 2004, the MMR in inland and remote areas was 4.1 and 7.7 times higher, respectively, than in coastal areas.4 Girls also continue to be disadvantaged. Significantly, the U5MR is much higher for girls (41 per 1000 live births) than for boys (30 per 1000 live births). A comprehensive policy and legal framework has been established to address maternal and child health issues. This includes the Law on Maternal and Infant Health Care, two national programmes with women and children’s development as core components, and various legislation ranging from national health policy to specific laws protecting maternal and child health. Direct causes affecting maternal mortality Postpartum haemorrhage is the leading cause of maternal death in China, followed by pregnancy- induced hypertension, embolism, antepartum haemorrhage and puerperal sepsis. In rural areas, postpartum haemorrhage explains 35.2% of all deaths; the rates were 5.7 times higher than in urban areas for the period from 2000 to 2004. The second most important cause of mortality is pregnancy-induced hypertension, particularly in rural areas. Indirect causes, which include mainly pregnancy-associated heart disease, hepatitis, anaemia, deep vein thrombosis and other infections, cause only 14.3% of all maternal deaths. The maternal mortality review data show that over 75% of all maternal deaths in China are caused by factors that can either be prevented or averted successfully through the provision of essential obstetric care. Direct causes affecting neonatal, infant and under-five mortality In 2004, 63.9% of all child deaths were attributed to neonatal conditions, with most neonatal deaths (79% of total neonatal mortality) occurring within seven days of delivery. Neonatal asphyxia and trauma (4.9%), preterm delivery, low birth weight (LBW), hypothermia (5.4‰), severe infection (2.3%) and congenital malformation (2.5%) explain 89% of all neonatal deaths. Among these factors, asphyxia and trauma, and preterm delivery, LBW and hypothermia are the leading causes of neonatal mortality, explaining up to 38.7% of under-five deaths, while severe infections is the third leading cause of neonatal mortality in rural areas. Another important cause of neonatal death is congenital malformation. Pneumonia represents the leading cause of post-neonatal mortality in poor rural areas. In richer areas, injury is the leading cause of post-neonatal death. Diarrhoea is the third leading cause of death for children aged one month to five years in most rural areas where there might still be a lack of proper sanitation. 1 Millennium Development Goal Indicators: the official United Nations site for the MDG Indicators. New York, United Nations Statistics Division, Department of Economic and Social Affairs. Available from: http://millenniumindicators.un.org/unsd/mdg/Default.aspx 2 National Maternal and Child Health Surveillance System 3 Progress towards achieving the MDGs. Fifty-eighth session of the Regional Commission for the Western Pacific, Jeju Island, Republic of Korea, 2007. Available from: http://www.wpro.who.int/NR/rdonlyres/149403D5-105B-4DBC-AA8A- A91049EDEE14/0/RC5805Item11_0MDG.pdf 4 Joint review of maternal and child survival strategies in China. Beijing, Ministry of Health, WHO, UNICEF and UNFPA, 2006. CHINA 68 | COUNTRY HEALTH INFORMATION PROFILES Indirect causes of death: maternal vitamin and mineral deficiencies and nutritional status Research shows that maternal nutritional status is not satisfactory and that micronutrient/vitamin deficiency may be inducing a number of pregnancy-associated complications and increasing the risks of maternal mortality. The 2002 National Nutrition and Health Survey (NNHS) revealed a high prevalence of maternal anaemia (Hb<110g/L) among women aged 18-44, with an average of 28.9% (25.3% in urban areas and 30.4% rural areas). The NNHS also showed that 7.7% of women aged 18-44 were suffering from undernutrition (BMI<18.5). Another significant problem is the insufficient intake of calcium, which could be linked to eclampsia and pregnancy-induced hypertension. According to the 2002 NNHS, the average daily intake of calcium is 438.6mg in urban areas and 369.6mg in rural areas, equivalent to only 54.8% and 46.2% of the daily calcium intake of 800 mg recommended by the Nutrition Society. Vitamin/micronutrient deficiency during pregnancy is still found in China, and regional research has revealed that folic acid deficiency is prevalent in the north of the country. Insufficient folic acid intake seriously affects normal fetal growth and development. Indirect causes of child mortality Over the last decade, childhood nutritional status has significantly improved in China. The national stunting and underweight rates among children dropped by more than a half during the period from 1990 to 2005 in both urban and rural areas. Stunting and underweight rates, however, remain three times higher in rural than in urban areas. Childhood anaemia incidence varies from 10.6% to 38.3%, according to age. Vitamin and mineral deficiencies are still prevalent throughout the country, with significant regional disparities. For example, the proportion of children aged 3-12 suffering from vitamin A deficiency in rural areas is 11.2%, 3.7 times higher than in urban areas (3%). 2.5 Burden of disease Communicable diseases remain a significant cause of death in China, particularly among young children. In addition, noncommunicable diseases have become increasingly prevalent. Global burden-of-disease estimates produced by WHO indicate that 80% of deaths in China are due to noncommunicable diseases and injuries. Cerebrovascular disease, chronic obstructive pulmonary disease and heart disease account for nearly 50% of all deaths. The rankings based on disability-adjusted life years (DALYs)1 also highlight the emergence of noncommunicable chronic diseases and injuries as the predominant health conditions. Among the remaining infectious diseases, hepatitis B, TB and lower respiratory infections still account for significant mortality and lost DALYs. While infectious diseases attract enormous interest both domestically and internationally, injuries and violence contribute to about 11% of total mortality each year, compared with 8.6% attributed to infectious diseases. For those between the ages of five and 44 years, injuries and violence account for an even larger share of deaths, at over 50%. In 2007, most injury deaths were attributed to suicide (28%), road traffic injuries (25%) and drowning (11%), with the suicide rate for women estimated to be 25% higher than that for men, and traffic injury mortality rates twice as high for males than for females.2 Mental and neurological disorders are responsible for about 20% of the overall disease burden in China. Sixteen million people suffer from severe mental disorders and another 35 million suffer depression-related disorders. More than 30 million children and adolescents under 17 years of age 1 DALY is a statistical formulation widely used to put a specific number on the combined loss of health and loss of years of life due to disability from disease or injury. 2Turning the tide: injury and violence prevention in China. Beijing, World Health Organization, 2006. COUNTRY HEALTH INFORMATION PROFILES | 69 have behavioural and emotional problems, of which about 50%-70% need mental health services, but remain untreated.1 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives China’s political commitment to health system reform was declared at the highest level when President Hu Jintao stated in October 2006 that all Chinese people should have access to affordable essential health services. The Chinese Government’s Scientific Concept and Five Balances of Development acknowledge that investments in social services, including health, are crucial to achieving sustainable development. China’s 11th Five-Year Plan for 2006-2010 accordingly emphasizes investment in human capital. The following points were proposed as the major measures and actions to be taken in the period from 2006 to 2010 (the period of the 11th Five-Year Plan): • increasing government investment in health and improving the public health and clinical service delivery system; • improving capacity in disease prevention and control and establishing a medical safety net for the poor; making great efforts to control killer diseases, such as HIV/AIDS, schistosomiasis and hepatitis B; and actively preventing occupational and endemic diseases; • strengthening maternal and child health care and promoting the development of community health services; • deepening health system reform and allocating health resources rationally; better regulating pharmaceutical production/products and the market; and • supporting the development of traditional Chinese medicine (TCM) and fostering a modern TCM industry. 3.2 Organization of health services and delivery systems Economic growth has enabled wealthier households to benefit more from access to health care and medical technologies. However, most low-income households face important barriers in accessing affordable essential health services and medicine. Despite large-scale government infrastructure investment, the cost of health services remains a major barrier to accessing quality services, particularly for people in remote and rural areas.2 Increasing levels of user fees are resulting in low usage of health services among low-income households, as medical care expenditure and the cost of health services are rapidly outpacing average incomes. Lack of attention to communicable disease treatment, in particular, could have a negative impact on the health of the community as a whole..3 While health insurance coverage is increasing, especially in rural areas, many people are underinsured and continue to face high out-of-pocket costs. The new Rural Cooperative Medical Scheme (RCMS) targets 100% coverage by the end of 2008. However, benefits are often limited to catastrophic illness and inpatient medical services, frequently require pre-payment , and 1National Project on Mental Health (2002-2010), Beijing, China Department for Disease Control and Prevention, Ministry of Health 2002. 2 An analysis report of the National Health Services Survey in 2003. Tables 3-8-9 and 3-8-6. Beijing, Ministry of Health, 2004. 3 Hu S, Liu X, Peng Y. Assessment of antibiotic prescription in hospitalized patients at a Chinese university hospital. Journal of infection, 2003, 46(3):161-163. CHINA 70 | COUNTRY HEALTH INFORMATION PROFILES reimbursement could be as low as 20%-30% of the total bill.1 The technical quality of care is affected by incentives in the existing provider payment mechanisms. Benefits are also not portable across localities; this is a major concern for migrant workers. The implementation of the Medical Financial Assistance (MFA) scheme for both the urban and rural poor depends on local fiscal capacity and thus access is inequitable across regions. For example, richer municipalitie, such as Beijing and Shanghai, can offer MFA to families living below the poverty line, but rural counties are generally supported by more modest local government budgets. Large geographical differences exist in health outcomes. Remote and rural regions face problems in making available specialized care to their populations, including emergency obstetric services and trauma, adequate facilities, and trained health professionals. This presents a major problem in implementing universal health care coverage. The availability and affordability of life-saving and common medicines needs to be improved. Inadequate access, quality and use of medical products and technologies are rooted in three main factors: (1) the absence of a clear national medicines policy to guide and coordinate different stakeholders and policies in the pharmaceutical sector; (2) an inappropriate pricing policy and the absence of a generics-substitution policy, which undermines the availability of essential medicines; and (3) perverse financial incentives in the health care system that contribute to irrational use of medicines. Senior-level officials have publicly recognized the problems in the pharmaceutical sector and the insufficient access to essential medicines. The Government is in the process of outlining relevant reforms to improve monitoring and law enforcement systems, and to strengthen governance in medicine production and distribution systems in order to enhance drug safety 3.3 Health policy, planning and regulatory framework Market-oriented financing reforms have brought millions of people out of poverty. However, the privatization of the health system has had a negative impact on access, quality and professionalism in service delivery. President Hu Jintao has demonstrated the political commitment to raise government spending on health and to ensure that all Chinese citizens have access to essential health care. While there is strong political commitment and progress in improving health sector governance, however, there is a need to better define government roles in the health sector in the areas of planning, policy- making and implementation. Important efforts have been made to reduce ambiguity and redundancy in responsibilities, as well as the competing interests among departments and in government roles in health across agencies. Regulations related to public health and health care delivery systems are underdeveloped and weakly enforced, and monitoring capacity is weak. Most health facilities lack clinical governance systems, and important gaps exist in the regulatory system to ensure the quality of care. For example, hospital accreditation is not linked to comprehensive safety records, and doctors and health institutions are not restricted in their engagement in commercial incentive programmes. Deficiencies in clinical quality have resulted from financial incentives in the delivery system, lack of clinical treatment guidelines, inadequate government resource allocation, weak regulation among service providers, and the low capacity of health care personnel. Safety standards and health regulations – pertaining to food, environment, roads and traffic, occupational and living conditions, drugs, blood, hospitals, medicines and laboratories, among others – are inconsistent in their design and enforcement across sectors and localities. Weaknesses in safety regulation and enforcement are particularly apparent in rural areas, where township and village enterprises operate in a largely unregulated fashion and generate the majority of occupational diseases, disabilities and deaths in China. 1 Among many studies, including: Liu Y. Development of the rural health insurance system in China. Health policy and planning, 2004, 19(3):159-165. COUNTRY HEALTH INFORMATION PROFILES | 71 The overwhelming majority of the Chinese population seek out traditional Chinese medicine (TCM) to address their health problems. The Government promotes the development of a modern TCM industry, as well as the integration of TCM into the national health care system and integrated training of health care practitioners. In 2008, the Minister of Health identified several key priorities for TCM development, including increasing policy support to TCM development, strengthening research on key TCM issues and building capacity for TCM research, training prominent TCM doctors and establishing well-known TCM hospitals and departments, improving and adapting TCM services to meet public needs, increasing access and quality of services in rural and urban communities, and strengthening international cooperation and communication on TCM.1 However, a number of challenges to further development of TCM remain. There is a lack of unified, systematic regulations for assessing the safety and efficacy, and ensuring the quality of TCM products. In addition, there are no national TCM standards or guidelines for clinical trials to prove the efficacy of TCM products. Evidenced-based TCM product testing and research are still needed. In view of the vast differences in the qualifications of TCM practitioners, the quality of TCM education needs to be strengthened and the management and supervision of TCM institutions need to be regulated. 3.4 Health care financing Total health expenditures rose from 3% of GDP in 1978 to 4.7% of GDP, or RMB 748.8 (US$ 93.94 at the exchange rate of 7.97 set by China National Health Account Report 2007) per capita in 2006.2 Of this total, the Government contributed 18.1%, social health expenditure amounted to 32.6%, and individual out-of-pocket payments to 49.3%. Contributions from both the Government and social health expenditure have declined as a proportion of total health expenditure. For example, the Government's share represented 32% of total health spending in 1978. The decline in the Government's contribution and the increase in individual out-of-pocket payments is partly a result of rapidly escalating health care costs and the lack of incentives for cost or quality control in the health delivery system. Public resource allocation is highly decentralized.34 Township, county, prefecture and provincial governments administer about 90% of all government spending on health. While localities are given the responsibility to finance health care, however, local governments are unable to raise revenue through taxes to finance basic public services, especially in resource-poor communities. Government spending on health tends to be lower in provinces with higher numbers of rural poor. Thus poor localities have access to fewer and lower quality services, for which they must pay out of pocket. Decentralization of responsibilities without sufficient funding creates unfunded mandates in impoverished areas, leading to vast inequalities. Equalization grants from the Central Government are helping poor regions to pay for public services; however, the current level of public subsidy is insufficient to fund a basic health service package. Per capita government health spending largely mirrors regional GDP, with some exceptions, such as Tibet, which receives more generous intergovernmental fiscal subsidies. The Government has substantially increased health investment in rural counties of western provinces, but resources mainly reach counties and townships and fail to trickle down to the village level where most rural patients need care.5 Local health departments and other health care providers are expected to generate a significant share of their own operating budgets.6 This provides an incentive to focus on more profitable 1 Word Report by Minister Chen Zhu at the Annual Health Conference, 2008. 2China National Health Account report (2007). Beijing, National Health Economic Institute, 2007. 3 In China, subnational governments are responsible for 70% of government expenditures. In contrast, in most industrialized countries, subnational governments are responsible for less than 30% of the government budget. 4 China - National development and sub-national finance : a review of provincial expenditures. Washington DC, World Bank, 2002. 5 National Health Services Survey (2003). 6 Liu XZ, Xu LZ: Evaluation of the reform of public health financing in China. Chinese health resource, 1998,1(4):151-154. CHINA 72 | COUNTRY HEALTH INFORMATION PROFILES curative care and medicines to generate larger profit margins.1 Service fees are applied to public health goods, such as immunization and communicable disease control programmes that have broader economic benefits, leading to underutilization of health services by the poor and underinvestment in these programmes from a societal welfare standpoint. Insufficient attention to preventive services and health promotion could contribute to preventable morbidity and mortality, as well as higher long-run health care costs for end-stage clinical care. 3.5 Human resources for health Key challenges in improving human resources for health include: improving the human resource strategy for health development; increasing capacity and technical qualifications; distributing staff more evenly nationwide; and creating a more rational balance among different health care professions. Over the last several decades, the Government has prioritized increasing the quality and technical capacity of health personnel with two to six years of professional training. However, capacity issues remain: 47% of health professionals have only technical secondary school diplomas and only 14% of health professionals have bachelor degrees or above.2 In addition, qualified staff are not well distributed across the country.3 As in many other countries, poor and rural areas have not been able to attract and retain qualified medical staff.4 After economic reforms were initiated, many experienced health professionals moved to hospitals in cities and areas with well-paying clinics. This poses an enormous barrier to the delivery of quality basic health services in remote and rural regions. China is one of the few countries where doctors outnumber nurses. In 2006, China had 1.6 physicians per 1000 population and 1.1 nurses per 1000 population (compared with 15.0 physicians and 44.0 nurses per 10 000 people in Singapore, and 19.4 physicians and 38.2 nurses per 10 000 people in the Republic of Korea).5 The relatively high number of doctors compared with nurses raises questions about public investment in training and deployment to achieve the most cost-effective means of service delivery. 3.6 Partnerships The Government has made many international commitments to a wide range of health targets, best exemplified by its acceptance of the Millennium Development Goals (MDGs). Six of the eight MDGs either directly or indirectly relate to health, calling for reductions in child malnutrition, child mortality and maternal mortality and combating of communicable diseases such as HIV/AIDS, malaria and tuberculosis. The focus on health in the MDGs emphasizes the importance played by health in reducing poverty and improving the living standards of the world’s population. Supporting China towards achievement of the MDGs provides an important organizational framework for donor coordination in the country, and the majority of donors have reflected this in their country assistance plans. The United Nations Theme Group on Health (UNTGH) is an important government-donor forum for cooperation on health issues in China. WHO chairs and acts as Secretariat for the UNTGH, which comprises United Nations agencies, bilateral and multilateral donors, government agencies and international nongovernmental organizations. China is ahead of schedule in achieving most of the MDGs, benefiting from the positive effects of both rapid economic growth and targeted government programmes. However, closer 1 Liu XZ, Liu YL, Chen NS. The Chinese experience of hospital price regulation. Health policy and planning, 2003,15:157- 163. 2 Zhang JH, Situation and development of the health workforce in China. Beijing, Health Human Resources Development Center (HHRDC) Ministry of Health, China, 2007. 3 Wu XL, Rao KQ. 2001. An analysis of health resource development in China since 1980. China health economics, 2001,11:38-41. 4 Rao K. Initial analysis of the 3rd National Health Service Investigation. Beijing, Ministry of Health, July 1, 2004. 5 Core Health Indicators (2005). Geneva, World Health Organization. COUNTRY HEALTH INFORMATION PROFILES | 73 examination of the situation reveals that, despite improvements in some indicators, the pace of development across disadvantaged and poor localities is slow, and targeted government actions are seeking to address some of the specific gaps. Box 1 provides a brief overview of China’s progress and actions towards achievement of the MDGs in health. Box 1 China’s progress toward achieving the MDGs in health China has achieved remarkable progress in reducing the prevalence of malnutrition and combating tuberculosis and HIV/AIDS. A closer look beyond the aggregate figures, however, reveals major challenges at the local level. To address these challenges, China particularly needs to build the institutional capacities of local governments to implement targeted programmes and deliver public services. The rate of decline in malnutrition exceeds the MDG target in aggregate. The task for the Government is now to address the slower pace of decline among children in rural areas. In tuberculosis, the detection rate has been improving rapidly since 2002, reaching 70% by the end of 2005. Over 90% of the population now has access to free tuberculosis treatment in the Government-sponsored directly observed treatment, short-course (DOTS) programme, and more than 90% of patients have been treated successfully. Tuberculosis, however, is far from being controlled, with persistently high rates of multidrug resistance, and remains at the top of Government’s health agenda. China’s response to the HIV/AIDS epidemic has been effective, particularly in terms of commitment by the national leadership and provision of treatment, care and support. Clusters of high prevalence are constrained geographically and are among specific sub-groups. However, the wider population is at risk. With the onset of the epidemic occurring later than in most other developing countries, China is still on the upward phase of the epidemic’s distribution curve, which adds to the challenge of meeting the HIV/AIDS-related MDG. The Government is working toward enhancing public awareness and is considering options for scaling up its pilot projects that target high-risk groups. Regarding maternal and child mortality, the aggregate progress masks major disparities. These are particularly related to the inequities and gaps in access to essential maternal and child preventive and survival health services. In line with its commitment to the MDGs, China has been strengthening its policies toward promoting maternal and child survival. The Ministry of Health, together with WHO, UNICEF and UNFPA, has completed a Joint Review of Maternal and Child Survival Strategies in China, with the goal of defining an equitable and affordable essential package of maternal and child care to be made universally accessible and financed from public sources. The results of the Joint Review indicate that enhancing maternal and child survival will require strong government commitment to ensure equitable access to essential health services and to other public services (such as safe water, sanitation and health promotion) that are strongly correlated with health. China has been taking a leading role in improving public health in the Region and the world, and has organized several important regional and global health events, promoting both multilateral and bilateral partnerships. In 2005, China initiated a resolution on Public Health in the United Nations, recommending that public health be further integrated into national economic and social development schemes as a basis for promoting sustainable growth with equity around the world. China also made an important commitment to better health by signing the Framework Convention on Tobacco Control in November 2003. Ratified by China’s National People’s Congress in August 2005, the convention became effective in January 2006. Since this momentous pledge, China’s Ministry of Health has taken further steps to improve public awareness of the health risks related to smoking and inhaling second-hand smoke, and to reduce smoking in public areas. 3.7 Challenges to health system strengthening It is widely recognized that increasing the level of government spending needs to be done in conjunction with reform and regulatory programmes that provide incentives for quality, performance and health outcomes. WHO provides assistance to the Government in implementing its health sector reforms and national strategies that aim to achieve universal coverage of essential health care services by 2020 and to improve quality, equity and efficiency. CHINA 74 | COUNTRY HEALTH INFORMATION PROFILES Since 2006, the Government has made an enormous effort to define its role in health more clearly. As many countries around the world attest, launching comprehensive health system reforms is very difficult on political and ethical, as well as technical grounds, and such reforms are further complicated by complex governance structures. China has made a very significant step in the right direction by establishing a 14-ministry working group in charge of outlining future health care reforms, and by appointing the National Development Reform Commission and the Ministry of Health to lead this group. Indeed, even beyond the preparation of large-scale health care sector reforms, a coordinating body is needed to direct health-related ministries and relevant institutions to work together more efficiently. This working group has recently finalized plans for health reforms, which the Government will begin piloting in 2008. Overall, health reform progress has been made in recent years, as evidenced by multidepartmental cooperation and the establishment of special institutional arrangements to address specific problems. Some examples include recent improvements in infectious disease surveillance, avian flu preparedness, tuberculosis and HIV/AIDS control and treatment, and child delivery support. WHO will support the implementation of health sector reforms by assisting the Government in its efforts to design, pilot and evaluate the reform platform and support evidenced-based policies aimed towards a basic health services scheme. Most importantly, achieving greater equity in health requires immense political resolve. In China, as in other countries, the single biggest challenge is securing the political will to balance the influence of interest groups and promote the well-being of the entire population, regardless of political influence, socioeconomic status or cultural background. Since 2006, the Government and the Communist Party of China have used every opportunity to express their commitment to strengthening the basis for improving the health of the poor and disadvantaged population groups. The involvement of many stakeholders in the current health policy reform process gives every hope that China will succeed and set yet another example of successful reform that can inspire other countries. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : 中华人民共和国国民经济和社会发展第十一个五年规划纲要 Specification : China’s 11th Five-Year Plan Web address : www.china.org Title 2 : 2007 NPC & CPPCC Sessions Features : The National People’s Congress (NPC) approved reports on government work, economic and social development, the central and local budgets, the work of the NPC Standing Committee, and the work of the Supreme People's Court and the Supreme People's Procuratorate Web address : www.china.org Title 3 : Report on China's Economic and Social Development Plan Features : Report on the Implementation of the 2006 Plan for National Economic and Social Development and on the 2007 Draft Plan for National Economic and Social Development, delivered at the Fifth Session of the Tenth National People's Congress on March 5, 2007 Web address : www.china.org Title 4 : Building a new socialist countryside Features : China's central Government recently released an important policy document on "building a new socialist countryside," and established it as one of the primary objectives of the 11th Five-Year Guidelines for National Economic and Social Development (2006-10) Web address : www.china.org Title 5 : The outline of the Eleventh Five-Year Plan Web address : http://en.ndrc.gov.cn/ COUNTRY HEALTH INFORMATION PROFILES | 75 Title 6 : Health, poverty and economic development Operator : WHO and China State Council Development Research Center. Beijing. 2006. Web address : http://www.wpro.who.int/china Title 7 : A health situation assessment of the People’s Republic of China. Operator : United Nations Health Partners Group in China, July 2005. Web address : http://www.wpro.who.int/china 5. ADDRESSES MINISTRY OF HEALTH Office Address : 1, Xi Zhi Men Wai Nan Lu Beijing, PR China 100044 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 Official Email Address : who@chn.wpro.who.int Telephone : (8610) 65327189 to 92 Fax : (8610) 65322359 Website : http://www.wpro.who.int/china CHINA Year Source Demographics 1 9 600.00 2007 2 2 2007 1 3 … … …. 4 … … … 19.40 b … … 2007 1 8.10 … … 2007 1 5 44.90 … … 2007 1 6 12.09 … … 2006 3 7 6.81 … … 2006 3 8 0.53 … … 2006 3 9 71.40 69.60 73.70 2000 3 … 13.10 14.70 2002 4 10 1.90 2001 5 11 88.96 94.14 83.85 2005 6 12 2 018.07 d 2006 13 13 9.80 2005 1 14 0.77 2005 7 15 … … … 16 … … … 17 1 334 859 … … 1 352 … … 2006 17 68 667 … … 37 … … 2006 17 1 109 130 … … 995 … … 2006 17 70 681 … … 160 … … 2006 17 19 007 … … 54 … … 2006 17 67 374 … … 106 … … 2006 17 159 … … 2 … … 2006 3 362 … … 0 0 0 2007 14 1 669 … … 156 … … 2006 3 158 795 … … 3 … … 2006 3 1 506 … … … … … 2006 14 60 193 … … 34 … … 2006 17 1 … … 0 0 0 2006 3 167 370 … … 86 … … 2006 3 16 317 … … 13 … … 2006 3 640 810.00 76 | COUNTRY HEALTH INFORMATION PROFILES Typhoid fever Encephalitis Leprosy Malaria Plague Syphilis COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male - 0–4 years - 5–14 years Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) 1 321 290.00 680 480.00 Rate of natural increase of population (% per annum) Urban population (%) Estimated population ('000s) Annual population growth rate( %) Percentage of population Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Number of deaths Total Rural Number of new cases Total Urban Selected communicable diseases - Type A - Type B - Type C Dengue/DHF Gonorrhoea - Unspecified Per capita GDP at current market prices (US$) Environmental indicators Human development index Rate of growth of per capita GDP (%) Communicable and noncommunicable diseases - Type E Hepatitis viral Cholera Male FemaleTotal Male Female CHINA Year Source 18 … … … … … … 19 … … … … … … 20 1 311 184 … … … … … 2006 14 589 619 … … … … … 2006 14 21 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 22 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 23 … … … … … … 24 … … … … … … 25 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 26 Total Male Female Total Male Female … … … 11.20 f … … 2002 19 … … … 11.00 f … … 2002 19 … … … 10.68 f … … 2002 19 … … … 9.13 f … … 2002 19 … … … 6.36 f … … 2002 19 COUNTRY HEALTH INFORMATION PROFILES | 77 7. 9. 10. - Homicide and violence - Motor and other vehicular accidents - Occupational injuries 4. Injury and poisoning - Suicide Leading causes of morbidity (inpatient care) Tuberculosis - All forms - New pulmonary tuberculosis (smear-positive) Cancers All cancers (malignant neoplasms only) - Hypertension All circulatory system diseases - Acute myocardial infarction INDICATORS Circulatory - Cerebrovascular diseases - Liver - Stomach Male - Trachea, bronchus, and lung Leading causes of mortality and morbidity 6. 3. Pregnancy, childbirth and puerperium causes 1. Disease of the respiratory system 2. Disease of the digestive system 5. Malignant neoplasms - Ischaemic heart disease All types Male Total - Leukaemia - Lip, oral cavity and pharynx Total Number of deaths DATA Female - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders Diabetes mellitus 8. - Breast Rate per 100 000 populationNumber of cases Female - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections Number of new cases CHINA Year Source 27 … … … 136.53 … … 2006 3 … … … 100.30 … … 2006 3 … … … 80.13 … … 2006 3 … … … 78.07 … … 2006 3 … … … 40.08 … … 2006 3 … … … … 17.59 g 17.00 h 2006 3 … … … … 15.10 g 8.16 h 2006 3 … … … … 7.28 g 6.65 h 2006 3 … … … … 4.95 g 6.65 h 2006 3 … … … … 3.44 g 3.77 h 2006 3 28 84.60 2002 est 19 29 … 30 18.45 2006 15 31 12.00 … … 2006 3 32 97.78 … … 2006 13 33 94.00 … … 2007 14 93.00 … … 2007 14 94.00 … … 2007 14 92.00 … … 2007 14 34 … … … … … … … … … … 35 … … … … … … 0 0 0 … … … 2007 14 … … … … … … 109 023 … … … … … 2007 14 252 701 … … … … … 2007 14 2 112 … … … … … 2007 14 … … … … … … 0 0 0 … … … 2007 14 74 746 … … … … … 2007 14 … … … … … … 5. Injury and poisoning 78 | COUNTRY HEALTH INFORMATION PROFILES Leading causes of mortality Percentage of pregnant women with anaemia 1. Malignant neoplasms 2. Cerebrovascular diseases 4. Diseases of respiratory system INDICATORS 3. Heart diseases Total Total Rate per 100 000 population Total Male Female Total Number of cases Female Number of deaths Male Female Total Male Female Female Male Number of deaths Male - Congenital rubella syndrome - Pertussis (whooping cough) - Poliomyelitis - Hib meningitis - Measles - Mumps - Rubella - Diphtheria - Eclampsia - Haemorrhage - Sepsis - Obstructed labour Maternal causes Maternal, child and infant diseases - Total Tetanus Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth Percentage of women in the reproductive age group using modern contraceptive methods 7. Diseases of the digestive system 6. Endocrine, nutritional and metabolic disease 10. Mental disorders 8. Disease of the genitourinary system 9. Disease of the nervous system - Neonatal tetanus Percentage of pregnant women immunized with tetanus toxoid (TT2) Immunization coverage for infants (%) - POL3 - BCG - DTP3 - Abortion - Hepatitis B III Selected diseases under the WHO-EPI DATA CHINA Year Source 36 … 37 Public health facilities 13 120 1 902 894 2006 3 3 022 320 503 2006 3 2 738 … 2006 3 40 791 c 710 308 2006 3 Private health facilities … … … … … … 38 2006 9 4.67 2006 9 93.94 2006 9 50 209.00 2006 9 40.65 2006 9 1.00 2006p 21 0.23 e 2006p 21 59.35 2006 9 7.97 2006 9 39 … Year Source 40 Physicians - Number 1 994 854 … … … … … … 2006 3 - Rate per 1000 population 1.55 … … … … … … 2006 3 Dentists - Number 136 520 … … … … … … 2001 12 - Rate per 1000 population 0.11 … … … … … … 2001 12 Pharmacists - Number 353 565 … … … … … … 2006 3 - Rate per 1000 population 0.27 … … … … … … 2006 3 Nurses - Number 1 426 339 … … … … … … 2006 3 - Rate per 1000 population 1.11 … … … … … … 2006 3 Midwives - Number 42 000 … … … … … … 2001 12 - Rate per 1000 population 0.03 … … … … … … 2001 12 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … 123 477.00 R u ra l P u b lic DATA U rb an P ri va te M al e COUNTRY HEALTH INFORMATION PROFILES | 79 Number of beds - general government expenditure on health as % of total general government expenditure - amount (in million US$) F em al e Number External source of government health expenditure Private health expenditure - private expenditure on health as % of total expenditure on health Human resources for health Health insurance coverage as % of total population T o ta l INDICATOR Exchange rate in US$ of local currency is: 1 US$ = Health care financing Health facilities INDICATORS - General hospitals - external resources for health as % of general government expenditure on health - general government expenditure on health as % of total expenditure on health Government expenditure on health Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) - per capita total expenditure on health (in US$) Facilities with HIV testing and counseling services Health infrastructure DATA Annual number of graduates - Hospitals - Outpatient clinics - Specialized hospitals - District/first-level referral hospitals - Primary health care centres CHINA Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … .. .. .. .. .. .. 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … .. .. .. .. .. .. Paramedical staff … … … … … … … Community health workers … .. .. .. .. .. .. Year Source 43 7.80 … … 2002 16 44 17.20 … … 2006 20 45 20.60 … … 2006 20 46 94.00 … … 2007 14 47 41.10 2006 20 48 97.80 2006 3 … 88.40 2006 3 49 … … … 50 … 51 Antenatal care coverage - At least one visit 90.14 2002 5 - At least four visits … 52 … … … 53 … … … 54 0.05 … … 2007 18 55 37.45 … … 2007 18 56 4.60 … … 2006 10 57 0.00 … … 2006 10 58 … … … 59 … … … 60 201.00 … … 2006 8, 14 61 15.00 … … 2006 8, 14 62 79.00 … … 2006 8, 14 63 92.00 … … 2005 8, 14 64 88.00 98.00 81.00 2006 11 65 65.00 74.00 59.00 2006 11 66 … … … 80 | COUNTRY HEALTH INFORMATION PROFILES Proportion of population with access to affordable essential drugs on a sustainable basis Female Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures P ri va te M al e T o ta l INDICATORS DATA Malaria incidence rate per 100 000 population Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source Proportion of population in malaria-risk areas using effective malaria treatment measures Tuberculosis prevalence rate per 100 000 population Tuberculosis death rate per 100 000 population Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) F em al e U rb an R u ra l P u b lic Total Male - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) INDICATORS Infant mortality rate (per 1000 live births) Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel Maternal mortality ratio (per 100 000 live births) Under-five mortality rate (per 1000 live births) Percentage of people with advanced HIV infection receiving ART Adolescent birth rate - Percentage of deliveries in health facilities (as % of total deliveries) Unmet need for family planning Estimated HIV prevalence in adults a Contraceptive prevalence rate HIV prevalence among population aged 15-24 years Total Urban Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Rural DATA Annual number of graduates Workforce losses/ Attrition Health-related Millennium Development Goals (MDGs) CHINA … p est NR a b c d e f g h 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Not included in the official list of MDG indicators Not relevant Estimate Provisional Notes: Data not available COUNTRY HEALTH INFORMATION PROFILES | 81 World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf] MCH Surveillance State Council AIDS Working Committee Office, UN Theme Group on AIDS in China. A joint assessment of HIV/AIDS prevention, treatment and care in China (2007). Information furnished by Ministry of Health, 2003, 2004 and 2005. China CDC webiste [http://www.chinacdc.net.cn/n272442/n272530/n272757/16423.html] Midterm Evaluation report on the Implementation of the National Programme of Action for Child Development in China(2001-2005),NWCCW National Nutrition Survery,2002 WHO Office for the Western Pacific, data received from the technical units 2008 Global TB Report Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific Figure applies to rural areas Human Development Report 2006, UNDP Sources: Chinese Health Statistical Digest 2006.2007 World Health Report 2004. Changing History . Geneva, World Health Organization, 2004. China Health Statistical Yearbook 2007 Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] China Statistical Yearbook 2007 World health Report 2006. Working together for health . Geneva, World Health Organization, 2006. World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation : China National Health Accounts Report 2007 Figure refers to urban street and rural township health center Figure RMB 16 084 was converted to US$ using the exchange rate US$ 1= RMB 7.97 Figure refers to 0-14 years old. Statistical Communique of the People’s Republic of China on the 2007 National Economic and Social Development. National Bureau of Statistics of China (http://www.stats.gov.cn/english/) Government of China. [www.gov.cn] Figure refers to leading causes of morbidity among inpatients in city hospitals (% of total cases) Figure applies to urban areas Information furnished by Ministry of Health, 2003, 2004 and 2005. China Statistical Yearbook 2006 82 | COUNTRY HEALTH INFORMATION PROFILES COOK ISLANDS 1. CONTEXT 1.1 Demographics The population of Cook Islands dropped between 1996 and 2001 due to outmigration, but increased again in 2007, with an estimated population of 21 100 people. Around 34% are below 15 years of age and about 5% are 64 years and above. In 2005, overall life expectancy at birth was estimated at 69 years: 65 years for men and 73 years for women. The crude birth rate was 23.0 per 1000 population, and the crude death rate 6.6 per 1000 resident population in 2007. 1.2 Political situation Cook Islands has a unicameral, democratic parliament with 25 elected members who serve parliamentary terms of five years. However, there have been four government changes since 1999. In the September 2004 elections, Jim Marurai was elected Prime Minister. The Government has given priority to education, health, human resources and outer island development. 1.3 Socioeconomic 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. The four leading generators of income are tourism, fishing, agriculture and financial services. Tourism is the main industry and accounts for around 54% of gross domestic product (GDP). GDP was estimated at almost 280 million New Zealand dollars (approximately US$ 182 million) and 13 158 New Zealand dollars (approximately US$ 9299) per capita in 2006. The country’s focus on development has been affected by various 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 2006, about 95% of the population had access to a clean, safe water supply and 100% had adequate sewage sanitation disposal facilities. 1.4 Vulnerabilities and hazards No available information. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition 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 COUNTRY HEALTH INFORMATION PROFILES | 83 disease, rheumatic fever and obstructive airways disease. There was no case of leprosy in 2006. 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 the 2001 MDA, 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. Noncommunicable diseases, such as hypertension, diabetes, cancer, coronary heart disease, obesity, and injuries and poisonings, continue to be major public health problems. According to a WHO consultancy report 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, 65% of registered patients in 2005 were reported to have acquired hypertension, 16% having both hypertension and diabetes and 19% having diabetes only. 2.2 Outbreaks of communicable diseases The only infectious disease outbreak since the dengue outbreaks in 1992-1993 and 1995 was the dengue outbreak of 2002 (2491 cases reported). 2.3 Leading causes of mortality and morbidity The leading causes of morbidity and mortality are noncommunicable diseases. In 2005, 33% of deaths were caused by circulatory system diseases. 2.4 Maternal, child and infant diseases There has been no case of maternal mortality since 1993. The infant mortality rate was 10.5 per 1000 live births in 2007. During the 2004-2005 financial year, the country’s expanded programme on immunization aimed to achieve 100% coverage. 2.5 Burden of disease No available information. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives To achieve the vision of “accessible quality health for all Cook Islanders”, the following health issues are being targeted for priority action. (1) Sexually transmitted infections, including HIV/AIDS: The prevalence of trichomoniasis and chlamydial infection is relatively high, while 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. (2) Communicable disease surveillance and response: 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. (3) Healthy settings and environment: COOK ISLANDS 84 | COUNTRY HEALTH INFORMATION PROFILES A healthy environment will be created and promoted through a multisectoral approach and partnerships to improve healthy lifestyles, minimize the risk of disease and reduce the need for hospital and other health services through: • evaluation of the effectiveness of health education and promotion activities and strengthening of the concepts approach; and • provision of special training for health personnel and other stakeholder agencies to enable them to deliver services satisfactorily. (4) 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 their knowledge of safer sex practices; and • increasing knowledge on risky behaviours through awareness programmes on television and radio and in newspaper articles. (5) 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 and childbirth and after delivery, and family planning will be enhanced. (6) 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. (7) Tobacco Free Initiative: The Global Youth Tobacco Survey, conducted in 2002, needs to be extended to examine smoking prevalence among adults. The results of the survey will determine and guide the 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. (8) Human resource development: 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 towards 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. COUNTRY HEALTH INFORMATION PROFILES | 85 3.2 Organization of health services and delivery 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. 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 resource development and strengthen health services. At the same time, telehealth will be used to consult specialists overseas in regard to problematic cases. Efforts are also being concentrated on continuing medical education and health staff training, both in-country and overseas. 3.3 Health policy, planning and regulatory framework No available information. 3.4 Health care financing In 2006, total health expenditure was 13 million New Zealand dollars (US$ 8.4 million), with per capita expenditure on health of US$ 444.2. 3.5 Human resources for health During recent 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 services are 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, on 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 or equipment. The high level of “decayed, missing or filled (DMF)” reports 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 oral health safety procedures to maintain the provision of quality health care services. The health infrastructure is well developed. There is a general hospital with 70 beds in Rarotonga and seven primary health care centres. As of 2004, there were 22 physicians, 11 midwives, 52 nurses and 20 dentists. 3.6 Partnerships New Zealand remains the largest donor, while Australia and the Asian Development Bank provide significant inflows geared towards capacity-building, outer island development and human resource development. WHO is the fourth largest donor and provides support for 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 the governments of China and Japan and has progressed significantly in aid discussions with the European Union. COOK ISLANDS 86 | COUNTRY HEALTH INFORMATION PROFILES 3.7 Challenges to health system strengthening No available information. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : 2005 Annual statistical bulletin. Operator : Ministry of Health Medical Records Unit Web address : http://www.health.gov.ck Title 2 : Cook Islands statistical bulletin, Census of Population and Dwellings 2006: Preliminary result Operator : Statistics Office Web address : http://www.stats.gov.ck Title 3 : Key indicators 2003 of developing Asian and Pacific countries, vol. 34. Operator : Asian Development Bank 5. ADDRESSES MINISTRY OF HEALTH 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) Website : http://www.health.gov.ck/stats_statistics.as WHO REPRESENTATIVE IN SAMOA Office Address : Ioane Viliamu Building Beach Road, Apia, Western Samoa Postal Address : P.O. Box 77, Apia, Western Samo Official Email Address : who@sma.wpro.who.int Telephone : (685) 23756/ 23757 Fax : (685) 23765 COUNTRY HEALTH INFORMATION PROFILES | 87 6. ORGANIZATIONAL CHART: Ministry of Health Year Source Demographics 1 0.24 2006 1 2 21.10 … … 2007p 2 3 … … … 4 12.20 12.20 12.20 2007 est 3 21.50 21.50 21.50 2007 est 3 5.00 4.30 5.80 2007 est 3 5 72.00 … … 2007 est 4 6 23.00 a … … 2007p 2 7 6.60 a … … 2007p 2 8 1.64 … … 2007p 2 9 69.00 65.00 73.00 2005 5 … 11.50 12.60 2002 6 10 2.80 2005 5 11 100.00 100.00 100.00 2005 5 12 9 299.62 2006 7 13 … 14 … 15 … … … 16 … … … 17 … … … … … … 41 b 18 b 23 b … … … 2005 5 0 b 0 b 0 b 0 0 0 2005 5 … … … … … … … … … … … … 0 b 0 b 0 b 0 0 0 2005 1 0 b 0 b 0 b 0 0 0 2005 1 … … … … … … 29 b 21 b 8 b … … … 2005 1 0 0 0 … … … 2006 8 0 b 0 b 0 b 0 0 0 2005 1 0 b 0 b 0 b 0 0 0 2005 1 1 b 0 b 1 b 0 0 0 2005 1 0 b 0 b 0 b 0 0 0 2005 1 Typhoid fever Encephalitis Leprosy Malaria Plague Gonorrhoea 88 | COUNTRY HEALTH INFORMATION PROFILES Health care waste generation (metric tons per year) COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male - 0–4 years - 5–14 years - 65 years and above Estimated population ('000s) Annual population growth rate (%) Percentage of population Rate of natural increase of population (% per annum) Urban population (%) Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - Type A Syphilis - Type B - Type C Female Rate of growth of per capita GDP (%) Selected communicable diseases MaleTotal Total Total Urban Human development index Dengue/DHF Number of new cases Number of deaths FemaleMale Rural Proportion of vehicles using unleaded gasoline (%) Per capita GDP at current market prices (US$) Environmental indicators Communicable and noncommunicable diseases - Unspecified - Type E Hepatitis viral Cholera COOK ISLANDS COOK ISLANDS Year Source 18 5 488 … … 0 0 0 2005 5 19 1 370 … … 0 0 0 2005 5 20 1 … … … … … 2006 8 0 … … … … … 2006 8 21 18 7 11 7 2 5 2005 5 2 0 2 2 0 2 2005 5 0 0 0 0 0 0 2005 5 0 0 2005 5 0 0 0 0 0 0 2005 5 0 0 0 0 0 0 2005 5 0 0 0 0 0 0 2005 5 1 0 1 2 1 1 2005 5 0 0 0 0 0 0 2005 5 3 0 3 1 1 0 2005 5 22 312 182 130 31 23 8 2005 5 … … … … … … 22 16 6 2 2 0 2005 5 118 56 62 11 8 3 2005 5 34 25 9 7 4 3 2005 5 … … … … … … 23 47 … … 10 4 6 2005 5 24 60 42 18 2 1 1 2005 5 25 348 226 122 9 8 1 2005 5 0 0 0 0 0 0 2005 5 105 67 38 6 5 1 2005 5 0 0 0 0 0 0 2005 5 4 3 1 3 3 0 2005 5 26 127 c 76 c 51 c 628.71 c … … 2005 5 118 c 56 c 62 c 584.16 c … … 2005 5 104 c 52 c 52 c 514.85 c … … 2005 5 98 c 57 c 41 c 485.15 c … … 2005 5 96 c 60 c 36 c 475.25 c … … 2005 5 90 c 55 c 35 c 445.54 c … … 2005 5 88 c 56 c 32 c 435.64 c … … 2005 5 64 c 39 c 25 c 316.83 c … … 2005 5 52 c 31 c 21 c 257.42 c … … 2005 5 52 c 44 c 8 c 257.42 c … … 2005 5 - Occupational injuries - Suicide 7. Injuries to the hip, thigh, knee, lower leg, ankle and foot 10. Injuries to the shoulder, upper arm, elbow, forearm, wrist and hand COUNTRY HEALTH INFORMATION PROFILES | 89 - All forms INDICATORS - Hypertension All circulatory system diseases - Acute myocardial infarction Circulatory - Cerebrovascular diseases Male 1. Influenza and pneumonia 2. Hypertensive diseases Diabetes mellitus DATA Total Total Number of deathsNumber of new cases - Trachea, bronchus, and lung - Breast - Leukaemia - Lip, oral cavity and pharynx - Stomach Cancers All cancers (malignant neoplasms only) - Liver Female - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders Number of cases Total Male All types - Homicide and violence Rate per 100 000 population Total Male FemaleFemale MaleFemale 6. Toxic effects of substances chiefly nonmedicinal as to source 8. Accidental poisoning by and exposure to noxious substances 9. Infections of skin and subcutaneous tissue - Ischaemic heart disease Leading causes of morbidity (inpatient care) Leading causes of mortality and morbidity - Motor and other vehicular accidents 3. Diabetes Mellitus 4. Diseases of pulmonary circulation & other forms of heart diseases 5. Motorcycle rider injured in transport accident - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections - New pulmonary tuberculosis (smear-positive) Tuberculosis COOK ISLANDS Year Source 27 11 8 3 88.70 d … … 2005 1 11 10 1 88.70 d … … 2005 1 10 4 6 80.60 d … … 2005 1 7 4 3 56.50 d … … 2005 1 7 2 5 56.50 d … … 2005 1 6 5 1 48.40 d … … 2005 1 6 4 2 48.40 d … … 2005 1 4 3 1 32.30 d … … 2005 1 4 4 0 32.30 d … … 2005 1 4 3 1 32.30 d … … 2005 1 28 39.87 2005 5 29 67.00 2007 8 30 … 31 9.90 … … 2005 5 32 97.70 … … 2005 5 33 100.00 … … 2007 8 100.00 … … 2007 8 100.00 … … 2007 8 100.00 … … 2007 8 34 31 0 2005 5 9 0 2005 5 9 0 2005 5 27 0 2005 5 … … 35 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 … … … … … … 2007 8 1 … … … … … 2007 8 420 … … … … … 2007 8 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 3. Diabetes Mellitus Leading causes of mortality Immunization coverage for infants (%) INDICATORS Total Female DATA Total Number of deaths FemaleTotal Male Female - Poliomyelitis Number of deaths Total Female Female Total Number of cases Male Maternal causes - BCG - DTP3 Percentage of pregnant women with anaemia Male 1. Hypertension - Obstructed labour - Diphtheria - Eclampsia - Haemorrhage - Congenital rubella syndrome - Sepsis - Abortion - Total Tetanus - Neonatal tetanus - Measles - Mumps - Pertussis (whooping cough) - Rubella 90 | COUNTRY HEALTH INFORMATION PROFILES - Hib meningitis Selected diseases under the WHO-EPI Maternal, child and infant diseases 2. Pneumonia 10. Diseases of the genitourinary system Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth 5. Neoplasms Rate per 100 000 population Male Male 7. Symptoms, Signs & Ill-defined conditions 6. Transport Accidents 4. Ischaemic heart disease Percentage of women in the reproductive age group using modern contraceptive methods 8. Heart Failure 9. Diseases of the digestive system - Hepatitis B III Percentage of pregnant women immunized with tetanus toxoid (TT2) - POL3 COOK ISLANDS Year Source 36 … 37 Public health facilities 1 70 2005 4 0 0 2005 4 7 57 2005 4 73 e 0 2005 4 Private health facilities … … 5 … 2005 4 38 8.44 2006p 9 4.50 2006p 9 444.21 2006p 9 7.79 2006p 9 91.40 2006p 9 12.40 2006p 9 2.38 2006p 9 8.60 2006p 9 1.54 2006p 9 39 … Year Source 40 Physicians - Number 22 … … … … 22 … 2004 10 - Rate per 1000 population 12.20 … … … … 12.20 … 2004 10 Dentists - Number 20 … … … … 20 … 2004 10 - Rate per 1000 population 11.09 … … … … 11.09 … 2004 10 Pharmacists - Number 1 1 0 … … 1 0 2004 10 - Rate per 1000 population 0.55 1.07 0.00 … … 1.07 0 2004 10 Nurses - Number 52 0 52 … … 52 0 2004 10 - Rate per 1000 population 28.85 0.00 59.61 … … 28.85 0.00 2004 10 Midwives - Number 11 0 11 … … 11 0 2004 10 - Rate per 1000 population 6.10 0.00 12.61 … … 6.10 0.00 2004 10 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … COUNTRY HEALTH INFORMATION PROFILES | 91 - private expenditure on health as % of total expenditure on health - general government expenditure on health as % of total expenditure on health Exchange rate in US$ of local currency is: 1 US$ = DATA INDICATOR R u ra l DATA U rb an Number P u b lic P ri va te T o ta l Number of beds Human resources for health M al e F em al e Health care financing - external resources for health as % of general government expenditure on health - total expenditure on health as % of GDP - amount (in million US$) External source of government health expenditure INDICATORS Health facilities - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals - per capita total expenditure on health (in US$) Government expenditure on health Total health expenditure Facilities with HIV testing and counseling services Health infrastructure - Hospitals - Outpatient clinics - Primary health care centres Private health expenditure Health insurance coverage as % of total population Annual number of graduates COOK ISLANDS Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 10.50 … … 2007p 2 45 11.00 … … 2005 5 46 98.00 … … 2007 8 47 0.00 2005 5 48 100.00 2005 5 0.37 2005 5 99.63 2005 5 49 … … … 50 … 51 Antenatal care coverage - At least one visit 100.00 2005 5 - At least four visits … 52 … … 53 … … 54 … … 55 … … 56 … … 57 … … 58 … … 59 … … 60 24.00 … 2006 8 61 3.00 … 2006 8 62 77.00 … 2005 8 63 100.00 … 2005 8 64 95.00 98.00 88.00 2006 11 65 100.00 100.00 100.00 2006 11 66 … … … 92 | COUNTRY HEALTH INFORMATION PROFILES Workforce losses/ Attrition INDICATORS DATA Tuberculosis death rate per 100 000 population Tuberculosis prevalence rate per 100 000 population HIV prevalence among population aged 15-24 years Female T o ta l M al e Proportion of 1 year-old children immunised against measles F em al e U rb an R u ra l … Malaria death rate per 100 000 population … … … Total Male Proportion of population in malaria-risk areas using effective malaria prevention measures Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source Proportion of population with access to affordable essential drugs on a sustainable basis … … … … … Total Urban Unmet need for family planning Estimated HIV prevalence in adults f INDICATORS Health-related Millennium Development Goals (MDGs) Contraceptive prevalence rate Maternal mortality ratio (per 100 000 live births) Proportion of births attended by skilled health personnel P ri va te DATA P u b lic - Percentage of deliveries in health facilities (as % of total deliveries) Infant mortality rate (per 1000 live births) Prevalence of underweight children under five years of age Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Proportion of population in malaria-risk areas using effective malaria treatment measures Adolescent birth rate Percentage of people with advanced HIV infection receiving ART Malaria incidence rate per 100 000 population Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Rural … … … Annual number of graduates COOK ISLANDS … p est NR a b c d e f 1 2 3 4 5 6 7 8 9 10 11 COUNTRY HEALTH INFORMATION PROFILES | 93 Cook Islands Statistics Office http://www.stats.gov.ck/index.htm. Figure is computed per thousand resident population as of 1992 Census of Population and Dwellings 2006, Preliminary Result. Cook Islands Statistical Bulletin. http://www.spc.int/prism/Country/CK/stats/. WHO Regional Office for the Western Pacific, data received from the technical units. Not relevant Provisional Estimate Notes: Data not available Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] Sources: Figure includes 9 out-patient clinics, 8 dental clinics, 6 health centres and 50 child welfare clinics Not included in the official list of MDG indicators World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation : World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf]. Annual Bulletin 2004. Cooks Islands Ministry of Health. http://www.health.gov.ck/default.asp. World health report 2004. Changing history . Geneva, World Health Organization, 2004. Population Estimates and Vital Statistics [http://www.stats.gov.ck/Statistics/Demography/popn_estimate.htm] United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006 . Wallchart (United Nations publication, Sales No. E.08.XIII.3). Demographic Tables for the Western Pacific 2005-2010 . Manila, World Health Organization Regional Office for the Western Pacific, 2005 Annual Statistical Bulletin 2005. Cooks Islands Ministry of Health. http://www.health.gov.ck/default.asp. Figure refers to registered cases Figure applies to Rarotonga only Rates are calculated per 100 000 resident population 94 | COUNTRY HEALTH INFORMATION PROFILES FIJI 1. CONTEXT 1.1 Demographics Fiji has the largest population of all the South Pacific island countries. The estimated multiethnic population for 2007 was 860 743, with 478 496 ethnic Fijians, 310 093 Indo-fijians and 72 154 people of other ethnic groups. The average annual growth rate stands at 0.8%, this trend of slow growth being due to a moderately low level of fertility and a high level of emigration, especially among Indo-fijians. Fiji’s Economic Exclusive Zone contains 332 islands covering a total land area of 18 333 square kilometres in 1.3 million square kilometres of the South Pacific Ocean. The population occupies around one-third of the 330 islands and is concentrated on the two largest islands, Viti Levu (10 429 square kilometres) and Vanua Levu (5556 square kilometres), with the nation's capital, Suva, located on Viti Levu. People in Fiji are living longer, with life expectancy at 68 years for males and 72 years for females. 1.2 Political situation Fiji's military chief, Commodore Frank Bainimarama, announced in a televised address on 5 December 2006 that he had taken over the running of the country. The following day he sent troops to close Parliament. In January 2007, he took on the role of interim Prime Minister, as decreed by the President, with individuals appointed by the military chief occupying key posts as part of the interim administration. The interim administration says it will call elections in 2010, restoring parliamentary democracy, but there has been local and international pressure to hold them much earlier. The military leader accused the deposed Prime Minister, Laisenia Qarase, of leading Fiji down a “path of doom”. 1.3 Socioeconomic situation With a population of 853 445 in 2006 and a gross domestic product (GDP) of FJD 4 647.7 million (US$ 2 686.5 million), GDP per capita was FJD 5474 (US$ 3164.2). The per capita GDP growth rate was 9.7%. Government income comes largely from customs duties and port dues, as well as taxation. The political situation has affected the economy of the country. Just a week after the coup, the Fiji Employers Federation revealed that its members had laid off nearly 1000 workers because of the downturn in business. Many of these workers, the Federation said, were in the tourism business. One of the country's biggest multimillion dollar tourism and land development projects at Momi near Nadi International Airport is being halted because of the uncertainty, sending home hundreds of construction workers and labourers. Around 1500 more workers were left jobless overnight when Fiji's sole mining operation, Emperor Gold Mine, decided to close. Gold exports last year totalled F$ 218 million (US$ 136 million), representing 7% of total exports of a country that is already suffering from poor export receipts and a rising import bill. 1.4 Vulnerabilities and hazards With the military coup that has taken place and the many international pressures on the interim administration, Fiji is vulnerable to suffer economically, especially when the main income earner, tourism, is the first industry to be affected. The sugar industry should be undergoing reform in an COUNTRY HEALTH INFORMATION PROFILES | 95 effort to improve efficiency and production, but this too remains vulnerable due to the current prevailing political situation. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition Like many developing countries, Fiji is still undergoing an epidemiological transition and is faced with a double burden of communicable and noncommunicable disease. In addition, however, the alarming rise in injuries and accidents is producing a third burden that is projected to become a real concern in terms of both intentional and unintentional injuries. The national health indicators compare favourably with other developing countries. Infant and child mortality rates, the maternal mortality ratio and the incidence of low birth weight have all shown gradual decreases over the last decade. Noncommunicable diseases (NCDs) such as diabetes, heart disease, high blood pressure, respiratory diseases and cancers, have now replaced infectious and parasitic diseases as the principal causes of mortality and morbidity. The revelation of the magnitude of NCD risk factors by the 2002 NCD STEPS survey highlighted the reasons: around 65% of population take one or less servings of fruits a day, 37% currently smoke tobacco, and there is a low rate of physical activity (25%) and a high rate of binge drinking (77.3% of current drinkers). This information led to the formulation of the National NCD Strategy to scale up efforts to curb the growing epidemic, which resulted in an excellent commitment from the Government (a 300% increase in the national NCD budget in the first year). There are three health goals under the Millennium Development Declaration. The two mortality goals have been largely achieved, but the target for HIV/AIDS is still a major challenge for Fiji. As of September 2006, there were 229 HIV-positive individuals, a large proportion of them between the ages of 20 and 29. With a window of five to 10 years from the time of infection to detection, it is clear that many are becoming infected while still in their teens. A strategic plan to prevent and control the spread and impact of HIV/AIDS and sexually transmitted infections (STIs) has been developed, and is being supported through a dedicated government budget, under the coordination of the National Advisory Committee on AIDS. The threat of emerging and re-emerging communicable diseases, like TB, SARS, and avian influenza (HPAI H5N1), that pose international threats and would have socioeconomic impacts on Fiji has highlighted the need for vigilance in surveillance, border control, detection capacity, investigation capacity and capacity to respond in a timely and coordinated manner. Regional elimination initiatives include those for lymphatic filariasis (Pac ELF) and measles elimination. Control of hepatitis B is also being addressed. Fiji is a committed partner in these initiatives, which are being coordinated by WHO. 2.2 Outbreaks of communicable diseases In February 2006, there was a report of three infants being admitted to a divisional hospital with suspected measles, which was confirmed by serological testing at the national laboratory on 23 February 2006. This result was verified by the WHO measles regional reference laboratory at the Victoria Infectious Diseases Reference Laboratory in Australia, where the H1 measles genotype was identified. Between 17 February 2006 and 9 June 2006, 136 suspected cases of measles were reported to the Ministry of Health, including 22 that were laboratory-confirmed (by the presence of anti-measles IgM antibodies). Among the 136 reported cases, 58% occurred among those aged less than five years, with the highest incidence among children aged 6–11 months. Of the 41 children aged from 12 to 59 months for whom the Ministry of Health could obtain detailed case investigation data, 12 (29%) had received the first dose of measles-rubella vaccine, 10 (24%) had not been vaccinated, and the immunization status of 19 (46%) was unknown. Altogether, FIJI 96 | COUNTRY HEALTH INFORMATION PROFILES 31 (24%) patients required hospitalization, mainly for pneumonia. No deaths were reported. In 2007, no measles case was reported. The Ministry of Health rapidly achieved high measles immunization coverage by implementing an outbreak response that targeted the appropriate age group. At the same time, a sharp decrease in reported cases occurred among all age groups. Fiji’s intersectoral, comprehensive and timely response to this outbreak was exemplary. The strong commitment from the Ministry of Health and its partners to reach at least 95% of targeted children was critical to the successful interruption of measles virus transmission and preventing it spreading to other, equally vulnerable Pacific islands. The threat of dengue virus infection and outbreaks will continue in Fiji given the many factors that could introduce the virus. To reduce disease-burden and case-fatality rates, epidemiological and entomological surveillance must continue to improve, including better emergency preparedness to prevent and control epidemics, effective case management through sensitive diagnostics, infrastructure improvements and strengthened vector control activities in an integrated vector-management mode. Leptospirosis represents an underdiagnosed, underreported and misdiagnosed zoonotic infection that continues to spread to humans, with evidence showing shifts in clinical presentations and humans pathogenic serovars. With the advent of eco-tourism, humans are facing increased risk of acquiring the pathogenic organisms in the environment. Research and identification of animal reservoirs is planned. The Government has made a budgetary provision of F$ 500 000 (US $295 857) for the control of diseases. This is the largest budget allocation for any one health programme and has continued to increase, from F$ 150 000 (US $78 947) in 2003, to F$ 300 000 (US $173 410) in 2004, to the current level. 2.3 Leading causes of mortality and morbidity By 2007, around 82% of deaths in Fiji were due to noncommunicable diseases (NCD), 10% to communicable diseases and another 8% to other causes. Over the past 10 years the leading causes of adult morbidity and mortality have been noncommunicable diseases, with cardiovascular disease being the leading cause of death. While infectious diseases used to claim the majority of lives, they no longer do so due to the vigorous immunization programme and improved living conditions. Diabetes continues to be a devastating disease, with a prevalence of 16%. Estimates reveal that one in every eight people is affected in some way by the disease. Figures from hospital admissions reveal that around 80% of all admissions into medical and surgical wards are diabetes- related. 2.4 Maternal, child and infant diseases Maternal, child and infant diseases have continued to decline in Fiji. The infant mortality rate has fallen by 62% in the past 20 years and is now about 18.4 deaths per 1000 live births. Good obstetrical services are contributing to the lower infant death rate, with about 98.5% of births being attended by trained medical personnel. The existence of protein energy malnutrition among children less than five years of age, although minimal, remains a concern for public health, especially when these few are infected with diarrhoea and other infectious disease that could make them vulnerable to fatality. The introduction of the integrated management of childhood illness (IMCI) strategy has strengthened what used to be the vertical ARI/CDD programme, and a similar integrated approach has been adopted for antenatal care. COUNTRY HEALTH INFORMATION PROFILES | 97 2.5 Burden of disease Although no proper burden of disease studies have been carried out, the triple burden of communicable diseases, noncommunicable diseases and injuries is plaguing the health system in Fiji. The prematurity of NCD deaths especially is becoming an economic and development issue, as the age of men dying from CVD falls every year. In a 2002 study carried out by the World Bank and the Secretariat of the Pacific Community (SPC), it was revealed that 38.8% of all treatment costs could be attributed to NCD and 18.5% to communicable diseases. Oral hygiene is another concern, as oral health is integral to total health. The two most common oral afflictions in Fiji are dental caries and periodontal diseases, as revealed in the 2004 National Oral Health Survey report. The strategies currently being pursued are: the Fissure Sealant Programme, the Oral Health Education Programmes in schools and communities, making oral health services more accessible to the people, and enabling public health agencies to promote oral health. More specific target interventions on oral health packages are being addressed to kindergarten children in response to findings of this National Oral Health Survey. 3. HEALTH SYSTEM The Ministry of Health underwent a health reform programme in 1999-2003, funded by the Australian Agency for International Development (AusAID), whereby the divisional health management structure was reviewed and strengthened to support the now decentralized health service structure. The Ministry of Health provides services to two types of users: internal (provision of health care to citizens); and external (monitoring of compliance with statues and regulation; issue of permits, certificates and reports; professional boards function; provision of health care to visitors; provision of accommodation and meals for staff; provision of training to health staff of the region). Basic health care is provided to all residents through a hierarchy of village health workers, nursing stations, health centres, subdivisional hospitals and divisional and specialized hospitals. Tertiary health care services are currently offered by the divisional hospitals. Subdivisional hospitals offer primary care and limited secondary health care services. In 2004-2008, the Fiji Health Sector Improvement programme was implemented by AusAID to strengthen the divisional structure in four specific areas: good governance, public health and infrastructure, clinical services, and health systems strengthening. 3.1 Ministry of Health's mission, vision and objectives The Ministry of Health endorses the statement in the preamble to the WHO Constitution that: The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition. In support of the above statement, the Ministry acknowledges that it is the right of every citizen of the Republic of Fiji, irrespective of race, sex, colour, creed or socioeconomic status, to have access to a national health system that provides a high quality health service. The principle function of this system is to promote and maintain the health and well-being of the citizens of Fiji to the maximum extent possible with available resources. Fiji generally has a good standard of health and compares well with other Pacific island nations. The country’s health status meets or exceeds most of the WHO goals for the Year 2000. Such a status is due to improved health standards, sound comprehensive health care programmes and the untiring efforts of the Ministry of Health in promoting healthy living for the population. FIJI 98 | COUNTRY HEALTH INFORMATION PROFILES The Mission of the Ministry is to provide quality health services through strengthened divisional health structures for the people of Fiji. The Ministry’s Vision is of a well financed health care delivery system that fosters good health and well-being for all citizens. The work of the Ministry is based on the following values: Customer focus (being genuinely concerned that customers receive quality health care, respecting the dignity of all people); Equity (striving for an equitable health system and being fair in all dealings, irrespective of ethnicity, religion, political affiliation, disability, gender and age); Quality (pursuing high quality outcomes in all facets of activities); Integrity (committing to the highest ethical standards in all activities); and Responsiveness (responsive to the health needs of the population, noting the need for speed in delivery of urgent health services). The Ministry of Health’s Strategic Plan for 2007-2011 focuses on five main thematic areas: • Provision of affordable, well planned, quality health services to everyone in Fiji. • Protection of the health of citizens through the review of formulations and appropriate policies, legislation, regulations and standards that safeguard health. • Promotion of health through the development and maintenance of effective partnerships that empower all stakeholders of health promotion so as to reduce risk factors related to communicable and noncommunicable diseases. • Development and retention of a valued, committed and skilled workforce to enhance the delivery of quality health services. • Development and use of an integrated management system to empower managers to maximize resources and promote continuous improvement at all levels of health service delivery. 3.2 Organization of health services and delivery systems Health services are delivered through 900 village clinics, 124 nursing stations, three area hospitals, 76 health centres, 19 subdivisional medical centres and three divisional hospitals and three speciality hospitals, with TB, leprosy and medical rehabilitation units at Tamavua Hospital and St Giles Mental Hospital. Fiji plays a key role in the development of public health surveillance of eight priority infectious diseases (Pac NET), public health laboratory networks (Lab NET) and targeted outbreak response (Epi NET) under the Pacific Public Health Surveillance Network (PPHSN). The country hosts level 2 public health laboratories at Mataika House and is now venturing into the Regional Measles Laboratory Network. There is also an initiative to coalesce public health laboratory functions at Mataika House through collaboration between the clinical and public health laboratories. HIV/AIDS laboratory testing in Fiji has undergone assessment and validation testing and has commenced confirmatory testing under the guidance of the National Reference Laboratory (Melbourne, Australia)-WHO Collaborating Centre for HIV/AIDS and funding from the Global Fund. Testing will be for diagnosis, surveillance and monitoring of patients on antiretroviral treatment. 3.3 Health policy, planning and regulatory framework The Ministry of Health Strategic Plan 2007-2011 was developed through extensive consultations with major stakeholders, including the private sector, nongovernmental organizations, central government agencies and senior staff of the Ministry of Health. The Strategic Plan has been developed in recognition of the Government’s international commitments, the Government’s Strategic Development Plan 2007 to 2011, the major health priorities for the people of Fiji and the planning requirements of the Ministry of Finance and National Planning. The Strategic Plan is also expected to form the framework for the development of annual corporate plans for the Ministry of Health for each successive year, from 2007 to 2011 inclusive. COUNTRY HEALTH INFORMATION PROFILES | 99 3.4 Health care financing The public health care system is heavily dependent on general taxation. The increasing demand for and cost of health care, coupled with limited resources, requires the Ministry of Health to place a greater focus on health care financing and cost-recovery strategies. The Ministry is examining a range of health-financing options, including social insurance. Moreover, the proposed financial management reform is expected to provide opportunities for revenue generation and retention. Hospital fees and charges for services, as determined in the Public Hospital and Dispensary Act, need to be reviewed. However, any cost-recovery strategies and fees introduced must ensure that disadvantaged groups in the community are not adversely affected. Increasing demand for services has led to an expansion in the number of private general practitioners and specialists practising in Fiji under the Fiji Medical Council. The immediate priority of the Government is aimed at reducing long queues, reducing long waiting lists and turnaround times and facilitating patient flow. 3.5 Human resources for health Emigration of health professionals, including doctors, nurses and paramedics, has increased over the last few years. The Ministry of Health is reviewing their workforce plan to ensure that the Ministry of Health Budget 2002 - 2006 106,620,100 116,527,600 134,608,800 136,880,800 144,968,800 0 20,000,000 40,000,000 60,000,000 80,000,000 100,000,000 120,000,000 140,000,000 160,000,000 2002 2003 2004 2005 2006 Year $ ( m ill io n ) Health Budget against GDP 3 2.6 2.88 2.87 2.92 2.4 2.5 2.6 2.7 2.8 2.9 3 3.1 2002 2003 2004 2005 2006 Year Pe rc en ta ge (% ) FIJI 100 | COUNTRY HEALTH INFORMATION PROFILES training of doctors and nurses is aligned with the requirements of the health system. A review of the various professional structures in health is being undertaken and appropriate strategies will be put in place in the lifespan of this plan. A focus will also be placed on the retaining existing staff, training nurse practitioners, employing part-time highly skilled staff and increasing the training opportunities for health professionals. 3.6 Partnerships With the idea of health being a collective responsibility, the Ministry of Health engages with other partners in delivering the best health care services for the people of Fiji. For noncommunicable disease (NCD), health promotion, HIV/AIDS and suicide prevention there are national multisectoral committees that oversee and coordinate national implementation of the respective strategic plans developed by the same multi-stakeholders. These three committees are usually chaired by the Minister of Health, and members are from permanent secretary or directorate level of government, non-state actors and civil society groups, including faith-based ones. The Ministry also works in close partnership with the autonomous Fiji School of Medicine, the University of the South Pacific, Fiji Institute of Technology and other academic institutions for training of its staff members. At the regional level, WHO and the SPC are the main partners. 3.7 Challenges to health system strengthening Maintenance of appropriate levels of infrastructure and facility is vital for the delivery of health services. Over recent years, new facilities have been built and are in full operation at Nadi, Levuka, Vunidawa, and Taveuni. New infrastructure development will include the completion of Labasa Hospital, relocation of Navua Hospital, construction of a new hospital in Ba, Nausori and the relocation of St Giles Hospital. As an ongoing activity, the Ministry of Health will continue to concentrate on maintaining and improving existing facilities. Fiji has a well developed health system with an infrastructure of base hospitals in three geographical divisions, supported by area and subdivisional hospitals, health centres and nursing stations in the smaller towns and rural and remote areas. Clinical services for surgery, medicine, paediatrics, obstetrics and gynaecology, orthopaedics, ENT, emergency medicine and relevant support services, however, need to be strengthened. During the course of the Health Strategic Plan 2007-2011, clinical services will be strengthened for cardiology, oncology, nephrology and hyperbaric medicine. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Fiji today 2006/2007 Operator : Ministry of Information & communications Web address : http://www.fiji.gov.fj Title 2 : Ministry of Health, data update, April 2007 Operator : Health Information Unit Title 3 : Corporate Plan 2007, Ministry of Health Operator : Ministry of Health Title 4 : Strategic Plan 2007 – 2011: Ministry of Health Operator : Ministry of Health Title 5 : Pacific Regional Information System (PRISM), SPC, Operator : Secretariat of the Pacific Community Web address : http://www.spc.int/prism COUNTRY HEALTH INFORMATION PROFILES | 101 5. ADDRESSES MINISTRY OF HEALTH Office Address : Ministry of Health, 88 Amy Street., Toorak Postal Address : PO Box 2223, Govt Bulding, Suva Official Email Address : info@health.gov.fj Telephone : 679-3306177 Fax : 679-3 306163 Office Hours : 8am – 4:30pm WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : World Health Organization - South Pacific Office , Level 4 Provident Plaza One, Downtown Boulevard, 33 Ellery Street, Suva Postal Address : PO Box 113, Suva, Fiji. Official Email Address : who@sp.wpro.who.int Telephone : 679-3304 600 Ext. 127 Fax : 679-3300 462 or 3311 530 6. ORGANIZATIONAL CHART: Ministry of Health Year Source Demographics 1 18.33 2007 1 2 860.74 … … 2007p 1 3 0.83 … … 2006p 2 4 11.60 11.80 11.40 2007 est 3 20.40 20.50 20.20 2007 est 3 4.10 3.40 4.70 2007 est 3 5 52.00 … … 2007 est 4 6 20.99 … … 2005 5 7 7.02 … … 2005 5 8 1.40 … … 2005 5 9 … 68.00 72.00 2007 6 … 10.40 11.90 2002 7 10 2.60 2003 1 11 92.90 a … … 2002 8 12 3 164.16 2006p 2 13 9.70 2006p 2 14 0.76 2005 9 15 … … … 16 … … … 17 72 … … … … … 2005 5 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 0 0 0 0 0 0 2005 5 100 … … … … … 2007 10 0 0 0 0 0 0 2005 5 885 782 103 … … … 2005 5 4 … … … … … 2006 10 0 0 0 0 0 0 2005 5 0 0 0 0 0 0 2005 5 870 361 509 … … … 2005 5 116 … … … … … 2005 5 Plague Typhoid fever Number of deaths Female Rural Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Total Urban COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male FIJI Estimated population ('000s) Annual population growth rate (%) Percentage of population Rate of natural increase of population (% per annum) Urban population (%) Crude death rate (per 1000 population) - 0–4 years - 5–14 years Crude birth rate (per 1000 population) - 65 years and above Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Number of new cases MaleTotal 102 | COUNTRY HEALTH INFORMATION PROFILES Leprosy Syphilis Total Gonorrhoea - Unspecified Hepatitis viral Cholera Human development index Rate of growth of per capita GDP (%) - Type A - Type B Per capita GDP at current market prices (US$) Environmental indicators Selected communicable diseases Encephalitis - Type C Dengue/DHF Communicable and noncommunicable diseases - Type E Malaria Male Female FIJI Year Source 18 10 124 5 208 4 916 … … … 2005 5 19 6 309 3 388 2 921 … … … 2005 5 20 114 … … … … … 2006 10 73 … … … … … 2006 10 21 395 129 266 … … … 2005 5 … … … … … … 10 7 3 … … … 2005 5 69 … 2005 5 … … … … … … 24 16 8 … … … 2005 5 15 9 6 … … … 2005 5 4 2 2 … … … 2005 5 10 8 2 … … … 2005 5 1 1 0 … … … 2005 5 22 3 304 … … … … … 2005 5 376 … … … … … 2005 5 277 … … … … … 2005 5 346 … … … … … 2005 5 353 … … … … … 2005 5 99 … … … … … 2005 5 23 208 92 116 … … … 2005 5 24 … … … … … … 25 3 174 … … … … … 2005 5 … … … … … … 745 … … 76 … … 2005p 1 … … … … … … 77 … … … … … 2005p 1 26 3 827 … … 452.32 b … … 2005 5 3 304 … … 390.50 b … … 2005 5 3 174 … … 375.14 b … … 2005 5 2 800 … … 330.93 b … … 2005 5 2 153 … … 254.46 b … … 2005 5 - Suicide 8. Number of cases - Motor and other vehicular accidents 3. Injury poisoning - Occupational injuries - Liver - Stomach - Breast - Colon and rectum - Hypertension All circulatory system diseases - Acute myocardial infarction Circulatory - Cerebrovascular diseases Acute respiratory infections COUNTRY HEALTH INFORMATION PROFILES | 103 Tuberculosis - All forms All types INDICATORS Total - Rheumatic fever and rheumatic heart diseases Injuries Total Male - Trachea, bronchus, and lung - Leukaemia - Lip, oral cavity and pharynx Female Diabetes mellitus 6. 5. Disease of digestive system 10. 9. 7. Male Female Mental disorders Leading causes of morbidity (inpatient care) Leading causes of mortality and morbidity 2. Circulatory disease 4. Infectious and parasitic disease - Ischaemic heart disease Number of new cases - Homicide and violence Female Number of deaths Total Male DATA Male 1. Respiratory disease Rate per 100 000 population Female - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases - New pulmonary tuberculosis (smear-positive) Cancers All cancers (malignant neoplasms only) Total FIJI Year Source 27 366 … … 43.26 b … … 2005 5 185 … … 21.86 b … … 2005 5 149 … … 17.61 b … … 2005 5 120 … … 14.18 b … … 2005 5 105 … … 12.41 b … … 2005 5 28 42.29 2005 5 29 … 30 … 31 15.37 … … 2005 5 32 91.00 … … 2005 5 33 89.90 … … 2007 10 83.40 … … 2007 10 83.50 … … 2007 10 83.90 … … 2007 10 34 1 0 2005 5 0 0 2005 5 0 0 2005 5 0 0 2005 5 1 0 2005 5 35 0 0 0 … … … 2007 10 0 0 0 … … … 2007 10 … … … … … … 0 0 0 … … … 2007 10 827 … … … … … 2007 10 0 0 0 … … … 2007 10 0 0 0 … … … 2007 10 0 0 0 … … … 2007 10 0 0 0 … … … 2007 10 0 0 0 … … … 2007 10 Number of deaths Number of deaths Rate per 100 000 population Total Female DATA Total Total Male FemaleTotal Male Female Immunization coverage for infants (%) - Pertussis (whooping cough) Female 104 | COUNTRY HEALTH INFORMATION PROFILES Male - Rubella Maternal, child and infant diseases 2. Infectious and parasitic disease 3. Neoplasm 1. Circulatory disease 8. 9. 6. 4. Respiratory disease INDICATORS Leading causes of mortality - Measles - Congenital rubella syndrome - Sepsis - Poliomyelitis - Total Tetanus Total Number of cases - Obstructed labour Male 5. Disease of the genitourinary system Percentage of pregnant women with anaemia 10. Percentage of women in the reproductive age group using modern contraceptive methods - Abortion Percentage of newborn infants weighing at least 2500 g at birth - Neonatal tetanus Maternal causes - Mumps - Hib meningitis - Diphtheria Selected diseases under the WHO-EPI - Eclampsia - Haemorrhage 7. - BCG - DTP3 - Hepatitis B III Percentage of pregnant women immunized with tetanus toxoid (TT2) Neonatal mortality rate (per 1000 live births) - POL3 Male Female FIJI Year Source 36 … 37 Public health facilities 3 958 2005 5 3 227 2005 5 22 576 2005 5 76 0 2005 5 Private health facilities 1 7 2005 5 … … 38 124.28 2006p 11 4.00 2006p 11 149.19 2006p 11 87.86 2006p 11 70.90 2006p 11 9.10 2006p 11 2.69 2006p 11 29.10 2006p 11 1.73 2006p 11 39 … Year Source 40 Physicians - Number 315 … … … … … … 2006 5 - Rate per 1000 population 0.37 b … … … … … … 2006 5 Dentists - Number 42 … … … … … … 2006 5 - Rate per 1000 population 0.05 b … … … … … … 2006 5 Pharmacists - Number 40 … … … … … … 2006 5 - Rate per 1000 population 0.05 b … … … … … … 2006 5 Nurses - Number 1 673 … … … … … … 2006 5 - Rate per 1000 population 1.96 b … … … … … … 2006 5 Midwives - Number … … … … … … … - Rate per 1000 population … … … … … … … Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … COUNTRY HEALTH INFORMATION PROFILES | 105 Exchange rate in US$ of local currency is: 1 US$ = External source of government health expenditure Private health expenditure Human resources for health Health insurance coverage as % of total population INDICATOR DATA - private expenditure on health as % of total expenditure on health - general government expenditure on health as % of total expenditure on health - external resources for health as % of general government expenditure on health - general government expenditure on health as % of total general government expenditure DATA Number of bedsNumber Health facilities INDICATORS - per capita total expenditure on health (in US$) Total health expenditure P ri va te M al e F em al e T o ta l R u ra l P u b lic U rb an - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals Government expenditure on health - total expenditure on health as % of GDP - amount (in million US$) Health care financing - Hospitals - Outpatient clinics - Primary health care centres Annual number of graduates Facilities with HIV testing and counseling services Health infrastructure FIJI Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 18.40 … … 2007 6 45 25.81 … … 2005 5 46 100.00 100.00 100.00 2006 10 47 50.49 2005 5 48 98.50 2007 6 … … 49 43.00 … … 2007 6 50 … 51 Antenatal care coverage - At least one visit 100.00 2005 5 - At least four visits … 52 … … … 53 … … … 54 0.10 … … 2007 10 55 … … … 56 … … … 57 … … … 58 … … … 59 … … … 60 30.00 … … 2006 10 61 3.00 … … 2006 10 62 88.00 … … 2006 10 63 71.00 … … 2005 10 64 47.00 43.00 51.00 2006 12 65 71.00 87.00 55.00 2006 12 66 … … … 106 | COUNTRY HEALTH INFORMATION PROFILES INDICATORS DATA U rb an R u ra l P u b lic Annual number of graduates Proportion of population using an improved sanitation facility Tuberculosis death rate per 100 000 population Maternal mortality ratio (per 100 000 live births) Tuberculosis prevalence rate per 100 000 population Percentage of people with advanced HIV infection receiving ART Workforce losses/ Attrition Proportion of population using an improved drinking water source Unmet need for family planning Estimated HIV prevalence in adults c Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) HIV prevalence among population aged 15-24 years Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures Proportion of population in malaria-risk areas using effective malaria treatment measures T o ta l Health-related Millennium Development Goals (MDGs) Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles - Percentage of deliveries in health facilities (as % of total deliveries) Contraceptive prevalence rate - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Infant mortality rate (per 1000 live births) Under-five mortality rate (per 1000 live births) Proportion of population with access to affordable essential drugs on a sustainable basis INDICATORS DATA P ri va te Female M al e F em al e Total Male Proportion of births attended by skilled health personnel Malaria incidence rate per 100 000 population Adolescent birth rate Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Total Urban Rural FIJI … p est NR a b c 1 2 3 4 5 6 7 8 9 10 11 12 COUNTRY HEALTH INFORMATION PROFILES | 107 Sources: Demographic Tables for the Western Pacific 2005-2010 . Manila, World Health Organization Regional Office for the Western Pacific, 2005. United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world . United Nations Development Programme, New York USA 2007. Ministry of health annual report 2005 Fiji Islands Ministry of Health. 2007 Facts and figures . Fiji Islands Bureau of Statistics [http://www.spc.int/prism/country/fj/stats/index.htm]. Fiji Islands Bureau of Statistics [http://www.spc.int/prism/country/fj/stats/index.htm]. Not relevant Not included in the official list of MDG indicators Figure refers to 1999/2000 schoolyear and census data Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific Provisional Estimate Notes: Data not available Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf]. Information furnished by WHO Representative in the South Pacific, 16 May 2008. World health report 2004. Changing history . Geneva, World Health Organization, 2004. Human development report 2004, New York, United Nations Development Programme, 2005. WHO Regional Office for the Western Pacific, data received from the technical units. World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation : [http://hdr.undp.org/en/reports/global/hdr2007-2008/] 108 | COUNTRY HEALTH INFORMATION PROFILES FRENCH POLYNESIA 1. CONTEXT 1.1 Demographics French Polynesia covers an area of 4167 million square kilometres, with a land area of 3521 square kilometres, and is made up of 35 volcanic islands and about 183 low-lying coral atolls in five archipelagos. Its nearest neighbours are Kiribati to the north-west and Cook Islands to the west. The small, uninhabited island of Clipperton, located far to the north-east, some 600 kilometres off the coast of Mexico, is administered from French Polynesia, under the direct jurisdiction of the High Commissioner. Some 75% of the country’s inhabitants live in the Society Islands, which constitute about one-half of the land area (census 2002). The most important and most populated island is Tahiti. As of 1 January 2007 the estimated population was 259 800, with 43.10 % below 20 years of age and 6.10% above 65 years. About 83% of the population are Polynesian, 12% European and 5% from Asia. The life expectancy is 73 for males and 76.9 for females. 1.2 Political situation Since 2004, French Polynesia has had the special status of ‘French overseas country’ with extended political independence. However, the core state functions, such as justice, security and public order, defence, foreign policy are still under the authority of France, which is represented by a High Commissioner. Since December 2006, Gaston Tong Sang has been President of French Polynesia. 1.3 Socioeconomic situation In 2003, the gross domestic product (GDP) per capita was US$ 17 000, with a total GDP of US$ 4.5 billion, relying heavily on transfers from France. French Polynesia has reached a high level of health and socioeconomic development, as shown by its principal indicators. About 10% (US$ 300 million) of the gross national product 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. 1.4 Vulnerabilities and hazards The main challenges facing French Polynesia and its health system are linked to its geography; the spread of its atolls and islands over a vast ocean area; differences between urban and rural areas in terms of social, economic and cultural activities; and the density of the population on Tahiti island, mainly in its urban area, representing 70% of the total population. All these factors make achievement of a really equitable system difficult. The challenges are also linked to the rapid mutation towards a society based on consumption, but with economic and social inequalities, leading to important differences in living standards. The consequences are an increasing number of environmental issues (habitat, waste management, air, drinking water, water quality, resources and pollution of the lagoons), for which policies are currently being developed. The main risk factors for health are therefore linked to environmental health factors; tobacco; obesity (diabetes and food habits); mental health in its broader context, taking into account the difficulties of a rapidly changing society; habitat; water; and internal and external air quality. COUNTRY HEALTH INFORMATION PROFILES | 109 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition Like many countries, French Polynesia is experiencing an epidemiological transition where communicable diseases are decreasing while noncommunicable diseases are increasing. Nearly all the population have ready access to quality health care, resulting in immunization coverage levels of over 90%, a low infant mortality rate (5.30 infant deaths per 1000 live births) and low maternal mortality. 2.2 Outbreaks of communicable diseases In 2006-2007, French Polynesia faced an outbreak of dengue serotype 1, circulating since the last outbreak in 2001 and partially linked to a reservoir of the population who had not been immunized. Dengue, leptospirosis and filariasis are endemic. A more intensive surveillance system targeting these diseases has been organized and a stronger vector control programme is now in place. There is a specific programme and surveillance system for tuberculosis. 2.3 Leading causes of mortality and morbidity 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. 2.4 Maternal, child and infant diseases See Section 2.1 2.5 Burden of disease While diarrhoea does not represent a major issue, as in most of developed countries, respiratory infections remain a problem. The impact of noncommunicable diseases is very high, particularly cancer and cardiovascular disease. Regarding cancers, the main characteristic in French Polynesia is the issue of cancers in females: uterine, thyroid, but mainly lung cancer, with a heavy death burden and type of pathology (years of life lost). Regarding cardiovascular diseases, the main burden is due to strokes and endocarditic diseases of various origins. The consequences of preventable diseases or conditions are also important (suicides, road accidents and drowning). Prevention programmes targeting tobacco use, diabetes and obesity should be intensified. The rheumatic fever and rheumatic heart disease programme should be reactivated. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives 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 a master plan for health every five years, 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. FRENCH POLYNESIA 110 | COUNTRY HEALTH INFORMATION PROFILES 3.2 Organization of health services and delivery systems Both the private and the public systems deliver curative services. The hospital system includes five public and four private hospitals, including one for ambulatory treatment and one for physiotherapy. The public hospitals include: the Main Hospital of French Polynesia (Centre Hospitalier de Polynésie Française), which is the referral hospital, offering child and adult resuscitation, neurosurgery, oncology and cardiovascular surgery; and four hospitals managed by the Directorate of Health: one general hospital in the Leeward Islands (UTUROA Raiatea), one hospital in the Marquesas Islands, with surgery, emergencies and medical wards (TAIOAHE Nuku Hiva), one hospital with a medical ward, an emergency ward and a long-stay ward in TARAVAO (TAHITI Winward Islands), and one hospital with medical and surgical wards in Moorea (Winward Islands). Primary health care is also delivered through the private and public systems. The private system is concentrated on the Winward Islands and the Leeward Islands. However, the number of health professionals working in the private sector (medical practitioners, nurses, physiotherapists, dentists) whose services are refunded under the Social Health Insurance scheme, based on agreed fees, is limited. Primary health care is also delivered through the public sector: dispensaries and aid posts are spread across all archipelagos and are managed by the Directorate of Health. On a number of islands, mainly in remote and isolated areas, the public sector is the only one present. The whole system is under the authority of the Directorate of Health (Département Planification et Organisation des Soins: DPOS ), except the Main Hospital of French Polynesia, which is under the direct authority of the Ministry of Health. 3.3 Health policy, planning and regulatory framework In 2000, the Strategic Health Plan was developed. The health priorities, as defined in the 1999 Plan for Health, were validated in 2006 after an evaluation of the Plan. These priorities are mainly linked to those diseases responsible for a high number of years of life lost. The objectives of the prevention programmes should be revised after assessment. 3.4 Health care financing The prevention programmes are funded by the Government of French Polynesia for a total of 844 824 385 CFP (US$ 9 498 462), including 315 000 000 CFP (US$ 3 543 141) for vaccination. Curative services are funded by the Social Provident Fund. Data are not available. 3.5 Human resources for health Collaboration with international and regional organizations, such as WHO and the Secretariat of the Pacific Community, has taken on particular significance in recent years. In order to strengthen health services, one or two nurses have been assigned to each island and given responsibility 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. 3.6 Partnerships French Polynesia had signed partnership conventions with various agencies involved in health, security and surveillance, particularly the Institut de Veille Sanitaire (INVS), the Agence Française desProduits de Santé (AFFSAPS), and national referral centres. For data on mortality, a partnership has been developed with the National Referral Centre CEDIC PC in St Maurice, France. A convention is under development. COUNTRY HEALTH INFORMATION PROFILES | 111 The national cancer register is linked with the Association Internationale des Registres des Cancers (IARC), the Fédération Française des Registres (FRANCIM) and the INVS. 3.7 Challenges to health system strengthening French Polynesia is currently facing a number of challenges, the major one being related to gaining better control over the cost of curative services while improving the accessibility and quality of care, mainly primary health care, in the most remote and isolated areas. Defining the level of care appropriate to each geographical area is another challenge. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Observatoire de la Santé, Direction de la Santé en Polynésie Française Title 2 : Institut de la Statistique de Polynésie Française Web address : http://www.ispf.pf Title 3 : Site officiel Présidence de la Polynésie Française Web address : http://www.presidence.pf Title 4 : Secretariat of the Pacific Community, Pacific Regional Information System (PRISM) Web address : http://www.spc.int/prism.html 5. ADDRESSES MINISTRY OF HEALTH Office Address : Ministère de la Santé B.P. 611, 98713 Papeete TAHITI, Polynésie Française Official Email Address : heitiare.heiata@sante.gov.pf georgette.manutahi@sante.gov.pf Telephone : (689) 46 00 56 Fax : (689) 46 00 59 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@sp.wpro.who.int Telephone : (679) 3-304600 / 3-304631 / 3-300727 Fax : (679) 3-300462 FRENCH POLYNESIA 112 | COUNTRY HEALTH INFORMATION PROFILES 6. ORGANIZATIONAL CHART: Ministry of Health MINISTERE DE LA SANTE DIRECTION DE LA SANTE Institut L. MALLARDE CENTRE HOSPITALIER DE POLYNESIE FRANCAISE Centre de Transfusion Sanguine SERVICES CENTRAUX Bureau juridique DPP DPOS DAF BRH ORS SERVICES SPECIALISES Santé scolaire Protection maternelle Protection infantile hygiène dentaire Hygiene et salubrite publique Psychiatrie infanto juvénile SUBDIVISIONS Hôpital Centres de santé Dispensaires- infirmeries centres médicaux postes de secours Services de soins Organisation déconcentrée Services spécialises Hygiène publique DPOS :Cellule Offre de soins DPP :Cellule de prévention DAF PMI-Santé scolaire –hygiène dentaire- Santé mentale Year Source Demographics 1 3.52 2006 1 2 259.80 … … 2007 2 3 1.40 … … 2006 2 4 … … … 43.10 a … … 2006 2 6.10 … … 2006 2 5 52.00 … … 2007 est 3 6 17.80 … … 2006 2 7 4.40 … … 2006 4 8 1.40 … … 2006 2 9 … 73.00 76.90 2006 2 … 17.10 20.60 1984-2004 2 10 2.20 2006 2 11 … … … 12 17 000.00 2003 5 13 … 14 … 15 … … … 16 … … … 17 2 b … … 0 0 0 2005 6,4 10 b … … 0 0 0 2005 6,4 0 b 0 0 0 0 0 2005 6,4 … … … … … … 61 b … … 0 0 0 2005 6,4 0 b 0 0 0 0 0 2005 6,4 1 897 … … … … … 2007 7 … … … 0 0 0 2005 6,4 0 b 0 0 0 0 0 2005 6,4 8 … … … … … 2006 7 0 0 0 0 0 0 2005 6,4 0 0 0 0 0 0 2005 6,4 0 0 0 0 0 0 2005 6,4 0 0 0 0 0 0 2005 6,4 FRENCH POLYNESIA Communicable and noncommunicable diseases - Type E Hepatitis viral Selected communicable diseases Male FemaleMaleTotal Female - Type A Syphilis - Type B - Type C Dengue/DHF Gonorrhoea - Unspecified Cholera Encephalitis Leprosy Per capita GDP at current market prices (US$) Environmental indicators Total Urban Human development index Rate of growth of per capita GDP (%) Rural Number of new cases Number of deaths Total Typhoid fever COUNTRY HEALTH INFORMATION PROFILES | 113 Rate of natural increase of population (% per annum) Urban population (%) Crude death rate (per 1000 population) Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Male - 0–4 years - 5–14 years Crude birth rate (per 1000 population) - 65 years and above Estimated population ('000s) Annual population growth rate (%) Percentage of population Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Malaria Plague FRENCH POLYNESIA Year Source 18 12 906 … … 0 0 0 2005 6,4 19 … … … 3 1 2 2005 6,4 20 69 … … … … … 2006 7 24 … … … … … 2006 7 21 … … … 293 c 167 124 2005 6,4 … … … … … … … … … 14 6 8 2005 6,4 … 4 2005 6,4 … … … … … … … … … 6 3 3 2005 6,4 … … … 10 8 2 2005 6,4 … … … 20 15 5 2005 6,4 … … … 15 9 6 2005 6,4 … … … 87 c 57 29 2005 6,4 22 … … … 319 c 181 136 2005 6,4 … … … 12 6 6 2005 6,4 … … … 85 41 44 2005 6,4 … … … 27 14 13 2005 6,4 … … … 70 51 19 2005 6,4 … … … 4 3 1 2005 6,4 23 … … … 18 12 6 2005 6,4 24 … … … 7 4 2 2005 6,4 25 … … … 133 d 97 35 2005 8,4 … … … 2 c,d 1 d 1 d 2005 8,4 … … … 37 d 27 d 9 d 2005 8,4 … … … 6 d 3 d 3 d 2005 8,4 … … … 38 d 31 d 7 d 2005 8,4 26 12 906 b … … 5 069.13 e … … 2005 6 12 235 b … … 4 805.58 e … … 2005 6 5 581 b … … 2 192.06 e … … 2005 6 4 706 b … … 1 848.39 e … … 2005 6 Leading causes of mortality and morbidity - Ischaemic heart disease 4. Pharyngitis 5. - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections Leading causes of morbidity (inpatient care) 8. 9. 6. 7. DATA Total - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders - Trachea, bronchus, and lung - Breast Diabetes mellitus Number of cases Total Male Number of new cases Male Female Total Male Number of deaths Total Female Rate per 100 000 population Cancers All cancers (malignant neoplasms only) - Hypertension All circulatory system diseases - Acute myocardial infarction Circulatory - Cerebrovascular diseases - Liver - Leukaemia - Lip, oral cavity and pharynx Tuberculosis - All forms - New pulmonary tuberculosis (smear-positive) INDICATORS - Stomach 1. Acute respiratory infections 2. Infections of the skin and subcutaneous tissues 10. - Suicide 114 | COUNTRY HEALTH INFORMATION PROFILES Female Male Female All types - Homicide and violence - Motor and other vehicular accidents - Occupational injuries 3. Acute otitis media FRENCH POLYNESIA Year Source 27 317 b 181 b 136 b 124.51 e … … 2005 4 291 b 167 b 124 b 114.30 e … … 2005 4 138 b 74 b 64 b 54.20 e … … 2005 4 132 b 97 b 35 b 51.85 e … … 2005 4 109 b 74 b 35 b 42.81 e … … 2005 4 55 b 22 b 33 b 21.60 e … … 2005 4 31 b 16 b 15 b 12.18 e … … 2005 4 30 b 20 b 10 b 11.78 e … … 2005 4 27 b 10 b 17 b 10.60 e … … 2005 4 21 b 10 b 11 b 8.25 e … … 2005 4 28 … 29 NR 2006 7 30 66.60 2002 6 31 3.80 … … 2005 4 32 93.08 … … 2004 5 33 99.00 … … 2007 7 98.00 … … 2007 7 98.00 … … 2007 7 99.00 … … 2007 7 34 … 0 2005 6,4 … 0 2005 6,4 … 0 2005 6,4 … 0 2005 6,4 … 0 2005 6,4 35 … … … … … … 0 0 0 … … … 2007 7 … … … … … … 0 0 0 … … … 2007 7 9 … … … … … 2007 7 0 0 0 … … … 2007 7 6 … … … … … 2007 7 0 0 0 … … … 2007 7 NR NR NR … … … 2007 7 0 0 0 … … … 2007 7 Percentage of women in the reproductive age group using modern contraceptive methods Percentage of newborn infants weighing at least 2500 g at birth - Obstructed labour Male 7. Endocrine diseases 6. Infectious and parasitic diseases 4. Injuries and external causes Number of deaths Rate per 100 000 population DATA Maternal, child and infant diseases 9. Diseases of the genitourninary system Total - POL3 - BCG - DTP3 - Poliomyelitis - Pertussis (whooping cough) Percentage of pregnant women with anaemia - Diphtheria Selected diseases under the WHO-EPI Immunization coverage for infants (%) - Total Tetanus - Neonatal tetanus Maternal causes - Hib meningitis - Mumps - Eclampsia - Haemorrhage - Abortion Neonatal mortality rate (per 1000 live births) Percentage of pregnant women immunized with tetanus toxoid (TT2) FemaleTotal Male Female Total Leading causes of mortality Female 2. Neoplasms 5. Symptoms, signs and findings, not elsewhere classified 1. Diseases of the circulatory system 10. Diseases of the nervous system INDICATORS 3. Diseases of the respiratory system - Rubella - Congenital rubella syndrome - Sepsis 8. Diseases of the digestive system Number of deathsNumber of cases Male Female Female COUNTRY HEALTH INFORMATION PROFILES | 115 - Measles - Hepatitis B III Male Total Total Male FRENCH POLYNESIA Year Source 36 … 37 Public health facilities 1 452 2005 10 1 f 15 2005 10 4 177 2005 10 89 0 2005 10 Private health facilities 4 262 2005 10 … … 38 … … … … … … … … … 39 … Year Source 40 Physicians - Number 676 … … … … … … 2005 11 - Rate per 1000 population 2.60 … … … … … … 2005 11 Dentists - Number 114 g … … … … … … 2005 11 - Rate per 1000 population 0.44 … … … … … … 2005 11 Pharmacists - Number 158 … … … … … … 2005 11 - Rate per 1000 population 0.61 … … … … … … 2005 11 Nurses - Number 1 141 … … … … … … 2005 11 - Rate per 1000 population 4.39 … … … … … … 2005 11 Midwives - Number 131 … … … … … … 2005 11 - Rate per 1000 population 0.50 … … … … … … 2005 11 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … Facilities with HIV testing and counseling services Annual number of graduates - per capita total expenditure on health (in US$) Health care financing - Hospitals - Outpatient clinics Health infrastructure - Primary health care centres - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals Government expenditure on health Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) - general government expenditure on health as % of total expenditure on health INDICATOR Human resources for health - 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$ = Health insurance coverage as % of total population P u b lic DATA U rb an P ri va te M al e F em al e T o ta l External source of government health expenditure Number Health facilities INDICATORS R u ra l Number of beds DATA 116 | COUNTRY HEALTH INFORMATION PROFILES FRENCH POLYNESIA Year Source 41 Pharmacists … … … … … … … Nurses 13 … … … … … … 2005 11 Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 3.10 7.40 … 2004 5 44 5.30 … … 2005 4 45 14.70 … … 2005 4 46 96.00 … … 2006 7 47 0.38 2005 4 48 99.97 2004 5 0.96 2004 5 99.01 d 2004 5 49 … … … 50 … 51 Antenatal care coverage - At least one visit 99.10 2004 5 - At least four visits … 52 … … … 53 … … … 54 … … … 55 … … … 56 … … … 57 0.00 0.00 0.00 2005 6,4 58 … … … 59 … … … 60 29.00 … … 2006 7 61 3.00 … … 2006 7 62 78.00 … … 2006 7 63 89.00 … … 2005 7 64 100.00 100.00 100.00 2006 12 65 98.00 99.00 97.00 2006 12 66 … … … Contraceptive prevalence rate Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Proportion of population in malaria-risk areas using effective malaria treatment measures Tuberculosis prevalence rate per 100 000 population Adolescent birth rate Percentage of people with advanced HIV infection receiving ART Estimated HIV prevalence in adults h Tuberculosis death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures HIV prevalence among population aged 15-24 years Total Urban Rural Proportion of population with access to affordable essential drugs on a sustainable basis - Percentage of deliveries in health facilities (as % of total deliveries) Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Maternal mortality ratio (per 100 000 live births) Proportion of births attended by skilled health personnel Infant mortality rate (per 1000 live births) Annual number of graduates P ri va te U rb an INDICATORS DATA Unmet need for family planning Health-related Millennium Development Goals (MDGs) Total Male Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Female Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source Malaria incidence rate per 100 000 population Workforce losses/ Attrition INDICATORS DATA R u ra l COUNTRY HEALTH INFORMATION PROFILES | 117 Malaria death rate per 100 000 population P u b lic T o ta l M al e F em al e FRENCH POLYNESIA … p est NR a b c d e f g h 1 2 3 4 5 6 7 8 9 10 11 12 Institute de la Statistique de Polynesie Francaise http://www.ispf.pf. Figure refers to 0-19 years old Figure refers to children hospital open during the day only Figure refers to dental surgeons Pacific Island Populations - Estimates and projections 2005-2015, Secretariat of the Pacific Community, Noumea, 2006. http://www.spc.int/demog/en/index.html. Estimate Notes: Data not available Provisional Not relevant Not included in the official list of MDG indicators Department of planification et Offre de Soins DPOS, Direction de la sante en Polynesie Francaise. Sources: Figure provided by dispensaries and isolated aid posts only. It does not represent the whole public and private data Totals may not tally due to some reported cases with no gender breakdown Revised figures Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific Service de Protection Maternelle, Direction de la Sante en Polynesie Francaise. Department des Programme de Prevention; DPP, Direction de la Sante en Polynesie Francaise. World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation : Direction de la Sante en Polynesie Francaise. United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). Observatoire de la Sante,Direction de la Sante en Polynesie Francaise. Service de Protection Infantile Direction de la Sante en Polynesie Francaise. Centre hospitalier de Polynesie francaise. 118 | COUNTRY HEALTH INFORMATION PROFILES Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] WHO Regional Office for the Western Pacific, data received from the technical units. COUNTRY HEALTH INFORMATION PROFILES | 119 GUAM 1. CONTEXT 1.1 Demographics The population of Guam was estimated to be 167 370 in 2006, with 104 males for every 100 females. Population density is 310 per square kilometre. Total life expectancy for both sexes is 78.40 years. Men are expected to live to 75.3 years of age and women to 81.6 years. The crude birth rate decreased slightly from 20.6 in 2004 to 19.03 in 2005. The crude death rate in 2005 was 4.41 per 1000 population, a slight increase from 4.2 in 2004. 1.2 Political situation The political situation on Guam remains stable, with elections for the mayors of municipal civil districts (villages) and the unicameral legislature held in 2004. Cooperation between the Executive Branch and the Legislative Branch is growing. 1.3 Socioeconomic 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. 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. In 2002, the reported per capita gross island product was US$ 15 439. 1.4 Vulnerabilities and hazards No available information. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition No available information. 2.2 Outbreaks of communicable diseases There were two food poisoning outbreaks in 2006. The first occurred in September 2006 among over 100 students and four adults at Chief Brodie Elementary School. Victims complained of abdominal cramps, diarrhoea and vomiting, but none required hospitalization. The definite cause of the outbreak was not determined. However, the rapid onset and recovery from symptoms experienced by those affected suggests that it may have been due to Bacillus cereus or Staphylococcus aureaus intoxication, problems that may be facilitated when transporting food. GUAM 120 | COUNTRY HEALTH INFORMATION PROFILES The Department Public Health and Social Services was notified of another food poisoning outbreak in October 2006 among 49 tourists staying in a local hotel. Investigation revealed that tourists complained of nausea, vomiting, diarrhoea and headache, but no hospitalization was required. The affected persons had eaten at a number of regulated establishments prior to their illnesses; no significant food establishment violations that might have contributed to this outbreak were identified. 2.3 Leading causes of mortality and morbidity Based on inpatient data, the leading causes of morbidity in 2005 were pregnancy, childbirth and the puerperium; influenza and pneumonia; certain infectious and parasitic diseases; ischaemic heart disease; and malignant neoplasm. Leading causes of death in 2003 were: diseases of the heart (119.4 per 100 000 population), malignant neoplasms (68.4), cerebrovascular diseases (31.2), accidents (17.4) and bacterial diseases such as septicaemia (16.2). 2.4 Maternal, child and infant diseases In 2003, there was no maternal death. About 87% of total deliveries in 2004 occurred in health facilities. In the same year, the infant mortality rate was 12.3 per 1000 live births, a significant increase from the 2002 rate of 6.21 per 1000 live births. In 2006, the coverage rate for poliomyelitis and measles immunization was 85%, while it was 89% for DTP3, and 91% for hepatitis B3. 2.5 Burden of disease No available information. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives Guam is dedicated to the attainment of health for all by 2010. In 1992, the Guam Health Planning and Development Agency identified 13 health service priority areas to be strengthened: • human resource 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. 3.2 Organization of health services and delivery systems No available information. COUNTRY HEALTH INFORMATION PROFILES | 121 3.3 Health policy, planning and regulatory framework See Section 3.1. 3.4 Health care financing Total health expenditure amounted to US$ 159.8 million in 2000, with per capita total expenditure on health of US$ 1032.4. As of 30 September, government expenditure on public health for 2005 was US$ 64 million, about 9% of total government expenditure. 3.5 Human resources for health 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 are still lacking in critical areas and must be developed locally to the greatest extent possible. The following training needs are priorities: environmental studies, with an emphasis on environmental law, policy, management, and planning and analysis; and short-term training on retail hazard analysis critical control point (HACCP), as well as on drugs, medical devices and controlled substances. 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. At the same time, this technical expertise 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 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 monitored 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. These include 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 staff of the Division of Environmental Health. 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. 3.6 Partnerships No available information. 3.7 Challenges to health system strengthening 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 facing GUAM 122 | COUNTRY HEALTH INFORMATION PROFILES 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. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Guam statistical yearbook 2005 Operator : Bureau of Statistics and Plans, Office of the Governor Web address : http://bsp.guam.gov/ Title 2 : Office of Vital Statistics, Guam Department of Health and Social Services Web address : http://dphss.guam.gov/ Title 3 : United States of America Bureau of the Census Web address : http://www.census.gov/ Title 4 : Secretariat of the Pacific Community Web address : http://www.spc.int/prism/ 5. ADDRESSES DEPARTMENT OF PUBLIC HEALTH AND SOCIAL SERVICES Postal Address : 123 Chalan Kareta Mangilao, Guam 96913-6304 Website : http://dphss.guam.gov/ 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 Telephone : (632) 528-8001 (trunk line) Office Hours : 0700H-1530H Website : http://www.wpro.who.int COUNTRY HEALTH INFORMATION PROFILES | 123 6. ORGANIZATIONAL CHART: Department of Public Health and Social Services Year Source Demographics 1 0.54 2006 1 2 167.37 85.34 82.03 2006 est 1 3 1.10 … … 2006-10 1 4 10.50 10.40 10.70 2006 est 2 19.90 19.70 20.30 2006 est 2 6.20 6.00 6.70 2006 est 2 5 94.00 … … 2007 est 12 6 19.03 … … 2005 3 7 4.41 … … 2005 3 8 1.46 … … 2005 3 9 78.40 75.34 81.64 2005 3 … … … 10 2.60 2005 3 11 … … … 12 a 2002 4 13 … 14 … 15 … … … 16 … … … 17 3 … … … … … 2006 5 159 … … … … … 2006 5 66 … … … … … 2006 5 … … … … … … … … … … … … 0 0 0 0 0 0 2006 5 1 … … … … … 2007 6 2 … … 0 0 0 2003 6 98 … … … … … 2006 5 3 … … … … … 2006 6 3 j … … … … … 2006 5 0 0 0 0 0 0 2003 6 3 … … … … … 2006 5 0 0 0 … … … 2006 5 Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Selected communicable diseases - Type E Hepatitis viral Cholera COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male GUAM Estimated population ('000s) Annual population growth rate (%) Percentage of population Rate of natural increase of population (% per annum) Urban population (%) Crude death rate (per 1000 population) - 0–4 years - 5–14 years Crude birth rate (per 1000 population) - 65 years and above Dengue/DHF Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Typhoid fever Encephalitis Leprosy Malaria Plague Total 124 | COUNTRY HEALTH INFORMATION PROFILES Gonorrhoea - Unspecified Rural Number of new cases Number of deaths Female Male Female Total Urban Per capita GDP at current market prices (US$) Environmental indicators Human development index Rate of growth of per capita GDP (%) MaleTotal 15 439.00 - Type A Syphilis - Type B - Type C Communicable and noncommunicable diseases GUAM Year Source 18 137 … … 11 7 4 2000 7 19 … … … 0 0 0 2000 7 20 44 … … … … … 2006 6 21 … … … … … 2006 6 21 … … … 125 74 51 2000 7 … … … … … … … … … 13 8 5 2000 7 … 2 2000 7 … … … … … … … … … 4 1 3 2000 7 … … … 1 1 0 2000 7 … … … 7 6 1 2000 7 … … … 7 3 4 2000 7 … … … 36 22 14 2000 7 22 … … … 246 149 97 2000 7 …. …. …. 25 19 6 2000 7 … … … 48 33 25 2000 7 … … … 15 10 5 2000 7 … … … 142 88 54 2000 7 … … … 2 2 0 2000 7 23 … … … 21 8 13 2000 7 24 … … … 0 0 0 2000 7 25 … … … 82 69 13 2000 7 … … … 4 2 2 2000 7 … … … 23 18 5 2000 7 … … … 5 4 1 2000 7 … … … 29 27 2 2000 7 26 3 892 b …. …. 2 308.97 …. …. 2005 8 645 b …. …. 382.65 …. …. 2005 8 583 b …. …. 345.87 …. …. 2005 8 521 b …. …. 309.09 …. …. 2005 8 370 b …. …. 219.51 …. …. 2005 8 ... …. …. ... …. …. ... …. …. ... …. …. ... …. …. ... …. …. ... …. …. ... …. …. … … … … … … 10. COUNTRY HEALTH INFORMATION PROFILES | 125 - Suicide All types - Homicide and violence - Motor and other vehicular accidents - Occupational injuries - Cerebrovascular diseases - New pulmonary tuberculosis (smear-positive) Cancers - Acute myocardial infarction - Leukaemia - Lip, oral cavity and pharynx - Stomach Circulatory - Liver INDICATORS Tuberculosis - All forms Number of new cases Number of deaths Female Number of cases Total Male DATA Total Male - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders Diabetes mellitus 6. 8. 9. 7. Female Total Male TotalFemale Rate per 100 000 population Male Female Leading causes of mortality and morbidity Leading causes of morbidity (inpatient care) 4. Ischaemic heart disease 5. Malignant neoplasm 1. Pregnancy, childbirth and the puerperium 2. Influenza and pneumonia 3. Certain infectious and parasitic diseases - Ischaemic heart disease - Trachea, bronchus, and lung - Breast All cancers (malignant neoplasms only) - Hypertension All circulatory system diseases - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections GUAM Year Source 27 199 … … 119.45 … … 2003 8 114 … … 68.43 … … 2003 8 52 … … 31.21 … … 2003 8 29 … … 17.41 … … 2003 8 27 … … 16.21 … … 2003 8 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 28 … 29 NR 2006 6 30 1.20 2001 7 31 5.20 … 5.20 2003 8 32 91.54 c … … 2004 9 33 … … … 2006 6 89.00 … … 2006 6 85.00 d … … 2006 6 91.00 … … 2006 6 34 76 0 2000 7 … … 57 0 2000 7 … … … … 35 0 0 0 … … … 2007 6 0 0 0 … … … 2007 6 … … … … … … 0 0 0 … … … 2007 6 0 0 0 … … … 2007 6 0 0 0 … … … 2007 6 0 0 0 … … … 2007 6 0 0 0 … … … 2007 6 0 0 0 … … … 2007 6 0 0 0 .. … … 2007 6 - Haemorrhage - Abortion Female Number of cases Total - Eclampsia Male INDICATORS 3. Cerebrovascular disease Leading causes of mortality Total Male Number of deaths 126 | COUNTRY HEALTH INFORMATION PROFILES FemaleTotal Male Female Total Male Number of deaths Rate per 100 000 population - Poliomyelitis DATA Male Female Total Female - Rubella Maternal, child and infant diseases 2. Malignant neoplasm 8. 9. 10. - Congenital rubella syndrome - Sepsis Selected diseases under the WHO-EPI - Diphtheria - Mumps - Pertussis (whooping cough) Percentage of women in the reproductive age group using modern contraceptive methods Percentage of pregnant women immunized with tetanus toxoid (TT2) - POL3 - BCG - DTP3 Immunization coverage for infants (%) Percentage of pregnant women with anaemia - Hepatitis B III - Hib meningitis - Obstructed labour - Total Tetanus - Neonatal tetanus - Measles 1. Diseases of the heart Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth Maternal causes 7. 6. 4. All other accidents 5. Bacterial diseases (septicaemia) GUAM Year Source 36 … 37 Public health facilities 2 e 187 2005 8 0 0 2005 8 0 0 2005 8 77 f 0 2005 8 Private health facilities 0 0 2005 8 … … 38 159.81 2000 7 … 1 032.36 2000 7 64.07 g 2005 8 … 8.71 h 2005 8 … … NA 39 … Year Source 40 Physicians - Number 244 i … … … … 244 0 2005 8 - Rate per 1000 population 1.41 … … … … 1.41 0 2005 8 Dentists - Number … … … … … … … - Rate per 1000 population … … … … … … … Pharmacists - Number … … … … … … … - Rate per 1000 population … … … … … … … Nurses - Number … … … … … … … - Rate per 1000 population … … … … … … … Midwives - Number … … … … … … … - Rate per 1000 population … … … … … … … Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … COUNTRY HEALTH INFORMATION PROFILES | 127 Health facilities Number of bedsNumber DATA P u b lic DATA U rb an Human resources for health R u ra l P ri va te External source of government health expenditure Private health expenditure - private expenditure on health as % of total expenditure on health M al e - external resources for health as % of general government expenditure on health F em al e T o ta l INDICATOR Exchange rate in US$ of local currency is: 1 US$ = Health insurance coverage as % of total population - general government expenditure on health as % of total expenditure on health INDICATORS - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals - Primary health care centres - per capita total expenditure on health (in US$) Government expenditure on health Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) Health care financing Health infrastructure - Hospitals - Outpatient clinics Facilities with HIV testing and counseling services Annual number of graduates GUAM Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 12.30 … … 2004 8 45 10.00 … … 2005 est 2 46 85.00 … … 2006 6 47 0.00 2003 10 48 … … 87.22 2004 8 49 … … … 50 … 51 Antenatal care coverage - At least one visit 92.05 2001 7 - At least four visits … 52 … … … 53 … … … 54 … … … 55 … … … 56 … … … 57 … … … 58 … … … 59 … … … 60 49.00 … … 2006 6 61 6.00 … … 2006 6 62 73.00 … … 2006 6 63 85.00 … … 2005 6 64 100.00 100.00 100.00 2006 11 65 99.00 99.00 98.00 2006 11 66 … … … Tuberculosis death rate per 100 000 population Female T o ta l M al e Unmet need for family planning Estimated HIV prevalence in adults k INDICATORS P ri va te 128 | COUNTRY HEALTH INFORMATION PROFILES Health-related Millennium Development Goals (MDGs) Total INDICATORS DATA Workforce losses/ Attrition Male F em al e U rb an DATA Proportion of population in malaria-risk areas using effective malaria prevention measures HIV prevalence among population aged 15-24 years Malaria death rate per 100 000 population Percentage of people with advanced HIV infection receiving ART Adolescent birth rate Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Malaria incidence rate per 100 000 population Tuberculosis prevalence rate per 100 000 population R u ra l P u b lic Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Infant mortality rate (per 1000 live births) Maternal mortality ratio (per 100 000 live births) Proportion of population with access to affordable essential drugs on a sustainable basis Contraceptive prevalence rate Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Proportion of population in malaria-risk areas using effective malaria treatment measures Total Urban Rural Proportion of population using an improved drinking water source Proportion of population using an improved sanitation facility Annual number of graduates GUAM … p est NR a b c d e f g h i j k 1 2 3 4 5 6 7 8 9 10 11 12 COUNTRY HEALTH INFORMATION PROFILES | 129 Special focus on Sanitation. UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). Pacific Island Populations - Estimates and projections 2005-2015, Secretariat of the Pacific Community, Noumea, 2006. http://www.spc.int/demog/en/index.html. US Census Bureau [www.census.gov]. Asia Pacific in Figures 2004. United Nations Economic and Social Commission for Asia and the Pacific [www.unescap.org/stat/data/apif/index.asp]. Information furnished by the Department of Health and Social Services, Guam 16 June 2003. Guam Statistical Yearbook 2005. Bureau of Statistics and Plans, Office of the Governor, Guam, 2006. Information furnished by the Department of Health and Social Services, Guam 21 June 2004. Guam Bureau of Statistics and Plans [www.spc.int/prism]. Sources: Figure includes one civilian hospital and one naval hospital Figure refers to clinics which includes specialized services but excludes eye and dental clinics Demographic Tables for the Western Pacific 2005-2010. Manila, World Health Organization Regional Office for the Western Pacific, 2005. Annual Summary of Notifiable Disease Guam- 2006. Office of Epidemiology & Research, Department of Public Health and Social Services. Government of Guam. WHO Regional Office for the Western Pacific, data received from the technical units. Disease contracted "off-island" Not included in the official list of MDG indicators Figure refers to total expenditure on public health as of 30 Septermber 2005 (audited) Figure refers to inpatients in Guam Memorial Hospital Figure refers to birth weight equal to 2501 grams and above Data not available Not relevant Figure refers to percentage total expenditure on public health as to total government expenditure Figure refers to physicians in Guam Memorial Hospital and includes licensed military physicians working on part-time basis Provisional Estimate Notes: Figure reported as Gross Island Product Given as inactivated polio vaccine (IPV) 130 | COUNTRY HEALTH INFORMATION PROFILES HONG KONG (CHINA) 1. CONTEXT 1.1 Demographics Hong Kong (China) had an estimated mid-year population of 6 925 900 in 2007, representing an increase of 1.0% over mid-2006. There were 904 males for every 1000 females. Population density was 6410 persons per square kilometre, and about 95.0% of the population were city dwellers. Both births and the inflow of one-way permit holders from mainland China were important constituents of the overall population increase. The population were 95% ethnic Chinese, the major non-Chinese ethnic groups being Filipinos and Indonesians. In 2007, life expectancy at birth was 79.3* years for males and 85.4* years for females. The registered crude birth rate was 10.2 per 1000 and the registered crude death rate was 5.8 per 1000. The total fertility rate was one known live birth per woman. As a result of increasing life expectancy, Hong Kong's population has been ageing steadily. In 2007, 12.6% were aged 65 years and above (10.3% in 1997), while those aged 14 and below made up 13.3% of the population (18.2% in 1997). There was one registered maternal death recorded in 2007*. The number of registered infant deaths was 121* and infant mortality rate was 1.7* per 1000 registered live births. The under-five mortality rate was 2.1* per 1000 registered live births. Note: * Provisional figure. 1.2 Political situation Hong Kong is a Special Administrative Region of the People’s Republic of China. Under the Basic Law, Hong Kong (China) has a high degree of autonomy, except in defence and foreign affairs, and enjoys executive, legislative and independent judicial power, including that of final adjudication. There are currently 12 bureaux, each headed by a Director. Together, they form the Government Secretariat. The Government introduced a new accountability system for principal officials on 1 July 2002. Under the new system, the politically appointed principal officials are held accountable for matters occurring within their respective portfolios. 1.3 Socioeconomic situation The gross domestic product (GDP) grew at an average annual rate of 3.8% in real terms during the 10 years to 2007. Per capita GDP increased by 1% in money terms over the same period, reaching US$ 29 847 (HK$ 232 836) in 2007. The major source of government income is taxation. In the financial year 2006-2007, about 40% of government revenue was collected from direct taxes and 25% from indirect taxes. Other sources of revenue include fines; forfeitures and penalties; utilities; fees and charges; income from properties and investments; reimbursements and contributions; loan repayments; net proceeds from issuance of bonds and notes; land premiums; and capital revenue. Based on the results of the General Household Survey, the size of the total labour force in 2007 was 3.6 million, of whom 54% were male. This represents 61.4% of the total population aged 15 and over. A total of 3 495 000 persons were employed, of whom 53.7% were male. The unemployment rate was 4.0%, lower than the 4.8% rate in 2006, while the underemployment rate was 2.2%. COUNTRY HEALTH INFORMATION PROFILES | 131 In the past decade, “wholesale, retail and import/export trades, restaurants and hotels” and “community, social and personal services” have been the two largest employment sectors, with their share together increasing from 52% to 59% during the period. The proportion of the working population in the “finance, insurance, real estate and business services” sector increased and it became the third largest sector. In contrast, there was a significant decline in the number of workers in the manufacturing industry, with its share decreasing from 14% in 1997 to 6% in 2007. In 2007, nearly 100% of the population had sustainable access to an improved water source, while 99% had access to improved sanitation. 1.4 Vulnerabilities and hazards Hong Kong is geologically stable. It is occasionally hit by tropical cyclones between June and October. The close approach of tropical cyclones can bring strong winds and heavy rain. Landslips and flooding sometimes cause considerably more damage than the winds. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition Hong Kong takes pride in having achieved health indices that rank among the best in the world. Like many other developed economies, Hong Kong has gone through an epidemiological transition in mortality from communicable to noncommunicable diseases (NCD). With gradual urbanization, adoption of more affluent lifestyles and medical advances over the past few decades, the proportion of registered deaths due to infectious and parasitic diseases dropped from 15.3% in 1961 to less than 3.0% in 2007. In 2007, the four major chronic NCD—cancer, heart diseases, stroke and chronic lower respiratory diseases—accounted for more than three- fifths (60.9%*) of all registered deaths. The age-standardized mortality rates of these four major NCD for males and females have declined gradually over recent decades, although there has been an increase in the absolute number of registered deaths as a result of population ageing and population growth. The number of new cancer cases has shown an increasing trend, while the age-standardized incidence rate has shown a decreasing trend over past decades. Many NCD are closely related to behavioural risk factors, such as overweight and obesity, unhealthy diet, physical inactivity, smoking and drinking of alcohol. A periodic telephone survey in 2007, which interviewed around 2000 people aged 18-64, reported that about two-fifths (38.4%) of those aged 18-64 were overweight/obese. A significantly higher proportion of males (50.3%) than females (28.0%) were classified as overweight/obese. More than four-fifths (81.1%) of the population failed to meet the WHO recommendation of having at least five servings of fruit and vegetables per day (86.3% for males and 76.6% for females). As regards physical activity, around one-fifth (18.9%) of the population were classified as having a low level of physical activity, with females being more sedentary than males (20.9% versus 16.6%). Around one in six (15.9%) were daily smokers and one in eleven (8.9%) were binge drinkers. Both smoking (26.2% versus 6.8%) and binge drinking (14.6% versus 3.8%) were more common among males. In terms of communicable diseases, the Quarantine and Prevention of Disease Ordinance in Hong Kong provides the legal framework for their management and defines a list of infectious diseases that are of public health importance and require to be reported to the Director of Health. In 2007, there were 32 infectious diseases on the list. A total of 25 343* cases of notifiable diseases were reported in 2007, 12.0%* higher than reported in 2006. The top three most commonly reported diseases were chickenpox (17 949* cases), tuberculosis (5545* cases) and food poisoning (621* cases), constituting 95.0%* of all notifications among the 32 listed conditions. When compared with the average notifications in the preceding five years, whooping HONG KONG (CHINA) 132 | COUNTRY HEALTH INFORMATION PROFILES cough, scarlet fever and dengue fever showed a more than 50%* increase. On the other hand, meningococcal infections, bacillary dysentery, amoebic dysentery and leprosy showed a more than 50%* decrease. In 2007, there were 5545* tuberculosis notifications, giving a notification rate of 80.1* per 100 000 population. For HIV/AIDS, by the end of 2007, a cumulative total of 3612 cases of HIV infection and 934 AIDS patients had been reported. Note: * Provisional figure. 2.2 Outbreaks of communicable diseases Schools, residential care homes and other community institutions are strongly encouraged to report any suspected communicable disease outbreak to the Department of Health for investigation and early intervention. In 2007, the most commonly reported outbreaks were influenza-like illness, hand-foot-mouth disease and acute gastroenteritis. Throughout the year, 165* confirmed influenza outbreaks occurred in institutions, affecting 1376* persons, with peak numbers recorded in March and July. There were 104* acute gastroenteritis outbreaks occurring in institutions, confirmed to be caused by norovirus, affecting 1111* persons; and 155* institutional outbreaks of hand-foot-mouth disease, affecting 1071* persons. Note: * Provisional figure. 2.3 Leading causes of mortality and morbidity There were 39 963* registered deaths in 2007, with NCD-related causes predominating. Among the top ten leading causes of death, six were NCD, including cancer, heart disease, stroke, chronic lower respiratory disease, injury and poisoning, and diabetes. They contributed to a total of 26 943* registered deaths (cancer: 12 630*; heart disease: 6100*; stroke: 3477*; chronic lower respiratory disease: 2130*; injury and poisoning: 2059*; and diabetes: 547*) and accounted for 67.4%* (cancer: 31.6%*; heart disease: 15.3%*; stroke: 8.7%*; chronic lower respiratory disease: 5.3%*; injury and poisoning: 5.2%*; and diabetes: 1.4%*) of all registered deaths. In terms of morbidity, there were 1 441 164 episodes of hospital discharge and death in all hospitals in 2006. Similar to mortality data, a substantial proportion of hospitalizations were due to NCD, including cancer, heart disease, stroke, injury and poisoning, chronic lower respiratory disease and diabetes. In total, they accounted for 21.6% (310 905 episodes) of hospitalization, while infectious and parasitic diseases only accounted for 3% (43 037 episodes). 2.4 Maternal, child and infant diseases Infant and under-five mortality rates are consistently low, as is the maternal mortality ratio. Maternal and child health services provided by the Department of Health are delivered through a network of 31 easily accessible maternal and child health centres (MCHCs) located throughout the territory. In 2007, 56% of newborn babies were delivered in public hospitals and 44% in private hospitals. About 90% of babies born to local mothers patronize the MCHCs. Children are immunized against tuberculosis, hepatitis B, poliomyelitis, diphtheria, tetanus, pertussis, measles, mumps and rubella. A cross-sectional survey conducted in 2006 for children aged two to five years revealed that the immunization coverage rates of all vaccines for local-born children were over 97%. 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. Breast-feeding surveys conducted regularly in MCHCs show that the ever-breast-fed rate increased from 50% for babies born in 1997 to 70% for those born in 2006. The exclusive breast-feeding rate for those over four to six months increased from 6% to 13% in the corresponding period. COUNTRY HEALTH INFORMATION PROFILES | 133 2.5 Burden of disease Apart from mortality and hospitalization data, the prevalence rates of diseases or risk factors can also reflect the disease burden in the community. The Heart Health Survey 2004-05, which involved over 1200 people aged 15-84, showed that 6.9% had diabetes and 33.3% had high blood cholesterol levels. Another survey, the Population Health Survey 2003-04, which interviewed more than 7000 people aged 15 and above, showed that more than one-quarter (27.2%) of the population had hypertension. Diabetes, high blood cholesterol and hypertension are important risk factors for many NCD, such as heart disease and stroke. The Population Health Survey 2003-04 also revealed that the prevalence rates for coronary heart disease, chronic obstructive pulmonary disease, cancer and stroke were 1.6%, 1.4%, 1.3% and 1.1%, respectively. As regards injuries, 14.3% of the population reported that they had sustained injuries that were serious enough to limit their normal activities in the 12 months preceding the survey. In terms of potential years of life lost (PYLL), at age 75, which provides a good estimate of the overall level of premature deaths in the population, cancer accounted for over two-fifths (41.7%) of total PYLL in 2006. Although injury and poisoning only ranked fifth as the leading cause of death in 2006, it accounted for around one-fifth (18.4%) of the total PYLL. This indicates that injury and poisoning is an important health problem, especially among young people. For heart disease, stroke and chronic lower respiratory disease, the proportions of PYLL were 9.3%, 4.9% and 1.6%, respectively. In total, these five NCD accounted for 75.8% of all PYLL in 2006. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The mission of the Food and Health Bureau is to enhance the well-being of every member of the community and to build a healthy and caring society, seeking to ensure quality, equitable, efficient, cost-effective and accessible health care systems and to organize the infrastructure for coordinated health care delivery through an interface of public and private systems. 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. 3.2 Organization of health services and delivery systems Primary health care services, which include a range of health-promotion, preventive and curative services, are provided by the Department of Health, the Hospital Authority and the private sector. Most health-promotion and preventive services are provided by the public sector. For curative services, private practitioners of Western medicine account for more than half (55.8%) of consultations. Most private practitioners are in solo practices and usually work on a fee-for- service basis. The traditional Chinese medicine practitioner is the principal alternative primary care provider in Hong Kong outside the mainstream Western medical system. Many patients use both systems in parallel, taking Western medicine to suppress symptoms and Chinese medicine to restore the body to its natural balance. In contrast to curative primary care services, the public sector is the dominant provider of secondary and tertiary services in Hong Kong. Hospital services are subsidized by the Government to a large extent. The Department of Health provides a wide range of health-promotion and disease-prevention services, covering programmes on maternal and child health, student health, elderly health, dental health and port health. The Department also operates a number of specialized clinics, including HONG KONG (CHINA) 134 | COUNTRY HEALTH INFORMATION PROFILES 20 methadone clinics, 19 tuberculosis and chest clinics, seven social hygiene clinics, four dermatology clinics, two integrated treatment centres, four clinical genetic clinics, six child- assessment centres, two travel-health centres and other clinical services. In June 2004, the Centre for Health Protection was set up under the Department of Health to strengthen the prevention and control of communicable diseases and other public health hazards. The Hospital Authority provides medical treatment and rehabilitation services to patients through public hospitals, general outpatient and specialist clinics and outreach services. The Authority was managing a total of 27 784 hospital beds in 38 public hospitals at the end of 2007, which represents around four* public hospital beds per 1000 population. The Hospital Authority also operates 74 general outpatient clinics throughout the territory, targeted primarily at serving low-income families, patients with chronic diseases and other vulnerable groups. The private sector plays a complementary role in providing health care and there were around 3000 private clinics providing primary and specialist medical care in 2007. The Thematic Household Survey, conducted from November 2005 to March 2006, showed that, of a total of 2 227 800 doctor consultations during the 30 days before enumeration, 71% (or 1 584 500 consultations) were with private medical practitioners, while 82% of all hospital admissions were managed by public hospitals. There were 12 private hospitals operating a total of 3438 hospital beds at the end of 2007. Their market share in terms of inpatient discharges and deaths on attendance was about 19.4% in 2006. There were also 31 private nursing homes, providing about 2945 beds, in 2007. With regard to pharmaceutical services, public hospitals and clinics provide the more essential medicines to patients at a nominal cost. Private hospitals and clinics supply a broader range of medicines, which are paid for by the patients themselves. All medicines available in Hong Kong must first be registered with the Pharmacy and Poisons Board, a statutory body whose membership comprises mainly doctors, academics and pharmacists. All manufacturers of medicines must meet the requirements of the good manufacturing practices (GMP) guidelines promulgated by the Pharmacy and Poisons Board, which are adopted from the GMP guidelines recommended by WHO. Medicines are classified into three broad categories in terms of control of sale: prescription-only medicines, pharmacy medicines and general-sale medicines. There are currently about 20 000 registered medicines in total, of which about 40% are prescription-only medicines, 14% are pharmacy medicines and 46% are general-sale medicines. Note: * Provisional figure. 3.3 Health policy, planning and regulatory framework The Government’s health care policy is that no one in Hong Kong is deprived of medical care because of lack of means. The Food and Health Bureau is the policy-making body responsible for health. It oversees the Department of Health and the Hospital Authority. The Department of Health is the Government’s health adviser and the agency responsible for executing health care policies and statutory functions. The Hospital Authority is the statutory body responsible for the management of all public hospitals. 3.4 Health care financing Total health care expenditure in 2004/2005 amounted to 5.2% of GDP, including the public sector (55%) and the private sector (45%). Public expenditure on health reached US$ 4.8 billion, representing 14.5% of total public expenditure. As there are no social security funds, all public finances for health care services come from general government. The health services provided by the public sector are heavily subsidized, with subsidy levels at about 97% of total cost for inpatient services and 83% for general outpatient services in 2006/2007. Health-promotion and disease-prevention activities, such as treatment of tuberculosis and childhood immunization, are provided free of charge. COUNTRY HEALTH INFORMATION PROFILES | 135 The private health care sector was financed largely by household out-of-pocket payments (70%) and, to some extent, private insurance (11%) and employer-provided group medical benefits (17%) in 2004/2005. 3.5 Human resources for health Health care manpower is monitored regularly through surveys to ensure that workforce planning is in line with the needs of the community. The Hong Kong Government also makes projections on health care manpower demand from time to time. When making manpower projections, the views of major employers from both the public and private sectors are taken into account. Advice is given to the University Grants Committee in relation to publicly-funded places on health care programmes, which serves as a reference for institutions in formulating their academic plans. On the regulatory front, various statutory boards and councils, such as the Medical Council, the Dental Council, and the Pharmacy and Poisons Boards, have been established under relevant ordinances to handle the registration, conduct and discipline of their respective health care professionals. Under existing legislation, 12 types of health care professional are required to be registered with their respective boards or councils before being allowed to practise in Hong Kong. In addition, an independent statutory body, the Hong Kong Academy of Medicine, has the authority to approve, assess and accredit specialist training within the medical and dental professions. The medical and health care professionals registered with respective statutory boards and councils are encouraged to enrol in continuing medical education and continuous professional development (CME/CPD) programmes to update their knowledge and promote development of competencies relevant to their practice. Medical practitioners and dentists on the Specialist Register must fulfil the CME/CPD requirements of their respective councils in order to maintain their specialist status. 3.6 Partnerships Locally, the Government maintains good working relationships and collaborates with various partners, including professional and community associations, in health-promotion activities for the prevention and control of communicable as well as noncommunicable diseases. For instance, a comprehensive disease notification system is maintained with health care providers and institutions from the public and private sectors. The latest outbreak news and surveillance results are shared and dialogue is maintained among health care providers and professional associations. The Government also partners with the Hospital Authority and other voluntary agencies in handling public health emergencies. On the regional front, close alliances with regional authorities, including the Ministry of Health of the People’s Republic of China, the Health Department of Guangdong Province and the Macao Health Bureau, facilitate regular exchanges of information on selected diseases. Bilateral and multilateral meetings and forums are held from time to time to strengthen cooperation and communication among regional authorities. Internationally, the Government liaises closely with WHO and engages in collaborative projects with overseas health protection agencies and academic institutions. The signing of a memorandum of understanding with the Health Protection Agency of England and Wales in May 2004 opened up opportunities for collaboration in public health training, laboratory technical support, emergency preparedness planning and infectious disease modelling. 3.7 Challenges to health system strengthening Over the years, Hong Kong has built an enviable health care system that provides high quality services. However, that system is now facing major challenges due to the ageing population and the need to keep pace with rapid developments in medical technology. The ratio of working-age HONG KONG (CHINA) 136 | COUNTRY HEALTH INFORMATION PROFILES (between 15 and 64) to elderly populations (65 or above) is 6:1, and it is estimated that it will be 5:1 in 10 years and 3:1 in 20 years. On the other hand, overall public health expenditure is projected to increase to about US$ 9.9 billion in 2015 and about US$ 16.3 billion in 2025. To uphold the principle of no one in Hong Kong being deprived of medical care because of lack of means, the Government of Hong Kong launched a consultation exercise in March 2008 on health care reform and supplementary financing options aimed at building a consensus to reform the health care system and make it sustainable and more responsive to the increasing needs of the community. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Statistics on demographic and socioeconomic situation Operator : Census and Statistics Department Web address : http://www.censtatd.gov.hk/home/index.jsp Title 2 : Statistics on mortality, morbidity, healthcare professionals and services, and communicable diseases Operator : Department of Health Web address : http://www.chp.gov.hk/index.asp?lang=en Title 3 : Behavioural Risk Factor Survey Operator : Department of Health Specification : The survey collected information on health-related behaviours of the Hong Kong adult population. Results were obtained from samples of at least 2000 randomly selected land-based, non-institutionalized persons aged 18 to 64 years Web address : http://www.chp.gov.hk/behavioural.asp?lang=en&pid=10&id=280 Title 4 : Population Health Survey Operator : Department of Health Specification : The survey collected information on general health status, the prevalence and incidence of major health conditions, mental health status, health behaviour relating to major causes of mortality and morbidity, preventive health practices, health-promoting behaviours, health service utilization, social and financial support, and the quality of life of the population. Results were obtained from over 7000 land-based, non-institutionalized persons of Hong Kong aged 15 and over, representing 5.68 million persons, after applying population weights. The household response rate was 72%. Web address : http://www.chp.gov.hk/epidemiology.asp?lang=en&id=363&pid=362&ppid=134 Title 5 : Thematic Household Survey Specification : The survey collected information on the health status of Hong Kong residents and their patterns with respect to doctor consultation, hospitalization, dental consultation, the provision of medical benefits by employers/ companies and the coverage of medical insurance purchased by individuals. Some 10 000 households within a scientifically selected sample were successfully enumerated, constituting a response rate of 79%. Web address : http://www.censtatd.gov.hk/products_and_services/products/publications/ statistical_report/social_data/index_cd_B1130230_dt_detail.jsp Title 6 : Statistics on health expenditure Operator : Food and Health Bureau Specification : It presents the estimates of domestic health expenditure in Hong Kong between the fiscal years 1989/90 and 2004/05 based on the latest OECD guidelines, with breakdown by financing source, provider and function over time. Web address : http://www.fhb.gov.hk/statistics/en/dha.htm COUNTRY HEALTH INFORMATION PROFILES | 137 5. 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-5:30pm; Sat, Sun & Public Holidays off Website : http://www.dh.gov.hk WHO REPRESENTATIVE There is no WHO Representative in Hong Kong (China). Queries about WHO’s programme of collaboration with Hong Kong (China) 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 Postal Address : United Nations Avenue, P.O. Box 2932, 1000 Manila, Philippines Official Email Address : postmaster@wpro.who.int Telephone : +632 528 8001 Fax : +632 521 1036 Office Hours : 0730 – 1530 M-F Website : http://www.wpro.who.int HONG KONG (CHINA) 138 | COUNTRY HEALTH INFORMATION PROFILES 6. ORGANIZATIONAL CHART: Department of Health Year Source Demographics 1 1.10 2007 1 2 6 925.90 3 287.40 3 638.50 2007 2 3 1.00 0.53 1.44 2007 2 4 3.10 3.39 2.84 2007 2 10.20 11.06 9.42 2007 2 12.58 12.25 12.88 2007 2 5 95.02 … … 2007 3 6 10.16 a 11.31 a 9.13 a 2007 2,4 7 5.77 a,b 6.88 a 4.76 a 2007 2,4 8 0.44 … … 2007p 2 9 … 79.27 85.37 2007p 2 … 22.24 27.19 2007p 2 10 1.00 2007p 2 11 94.47 c 97.35 c 91.92 c 2007 2 12 29 846.94 2007p 2,4 13 8.18 2007p 2,4 14 0.94 2005 5 15 73.28 d … … 2007 6 16 2 500.00 … … 2007 7 17 211 e 147 e 64 e 4 a 3 a 1 a 2007p 2,4 67 e 40 e 27 e 0 a 0 a 0 a 2007p 2,4 74 e 59 e 15 e 2 a 1 a 1 a 2007p 2,4 2 e 2 e 0 e 1 a 1 a 0 a 2007p 2,4 64 e 44 e 20 e 1 a 1 a 0 a 2007p 2,4 4 e 2 e 2 e 0 a 0 a 0 a 2007p 2,4 3 e 1 e 2 e 0 a 0 a 0 a 2007p 2,4 59 k 27 k 32 k 0 a 0 a 0 a 2007p 2,4 … … … … … … 1 481 f 1 277 f 204 f … … … 2007p 2,4 2 e 1 e 1 e 0 a 0 a 0 a 2007p 2,4 33 e 26 e 7 e 0 a 0 a 0 a 2007p 2,4 0 e 0 e 0 e 0 a 0 a 0 a 2007p 2,4 939 f 492 f 447 f … … … 2007p 2,4 46 e 15 e 31 e 0 a 0 a 0 a 2007p 2,4 HONG KONG (CHINA) Hepatitis viral (ICD10: B15-B17, B19) Cholera (ICD10: A00) MaleTotal COUNTRY HEALTH INFORMATION PROFILES | 139 Total Per capita GDP at current market prices (US$) Environmental indicators Selected communicable diseases - Type A (ICD10: B15) Syphilis (ICD10: A50-A53) - Type B (ICD10: B16) - Type C (ICD10: B17.1) Dengue/DHF Total Urban Number of deaths Rate of growth of per capita GDP (%) Rural Proportion of vehicles using unleaded gasoline (%) Communicable and noncommunicable diseases Human development index Number of new cases Health care waste generation (metric tons per year) - Unspecified (ICD10: B19) - Type E (ICD10: B17.2) Female Male Female Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Estimated population ('000s) Annual population growth rate (%) Percentage of population Rate of natural increase of population (% per annum) Urban population (%) - 0–4 years - 5–14 years Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male Typhoid fever (ICD10: A01.0) Encephalitis (ICD10: G04) Leprosy (ICD10: A30) Malaria (ICD10: B50-B54) Plague (ICD10: A20) Gonorrhoea (ICD10: A54) HONG KONG (CHINA) Year Source 18 … … … 5 a 5 a 0 a 2006 2,4 19 … … … 10 a 7 a 3 a 2006 2,4 20 5 545 e 3 553 e 1 992 e 239 a 191 a 48 a 2007p 2,4 1 680 e 1 170 e 510 e … … … 2007p 4 21 … … … 12 093 a 7 386 a 4 707 a 2006 2,4 … … … 465 a 2 a 463 a 2006 2,4 … … … 1 628 a 923 a 705 a 2006 2,4 … 133 a 2006 2,4 … … … 359 a 283 a 76 a 2006 2,4 … … … 254 a 144 a 110 a 2006 2,4 … … … 526 a 399 a 127 a 2006 2,4 … … … 1 462 a 1075 a 387 a 2006 2,4 … … … 635 a 391 a 244 a 2006 2,4 … … … 3 531 a 2 396 a 1 135 a 2006 2,4 22 … … … 9 680 a 4 862 a 4 818 a 2006 2,4 … … … 1 686 a 969 a 717 a 2006 2,4 … … … 3 302 a 1 603 a 1 699 a 2006 2,4 … … … 806 a 371 a 435 a 2006 2,4 … … … 3 749 a 2 049 a 1 700 a 2006 2,4 … … … 96 a 28 a 68 a 2006 2,4 23 … … … 511 a 232 a 279 a 2006 2,4 24 … … … 298 a 120 a 178 a 2006 2,4 25 … … … 1 961 a 1 264 a 697 a 2006 2,4 … … … 35 a 20 a 15 a 2006 2,4 … … … 157 a 98 a 59 a 2006 2,4 46 937 29 619 17 318 187 a 163 a 24 a 2006 8 … … … 1 042 a 630 a 412 a 2006 2,4 26 177 790 g … … 2 592.79 g … … 2006 2,4,9 135 068 g … … 1 969.75 g … … 2006 2,4,9 131 287 g … … 1 914.61 g … … 2006 2,4,9 127 154 g … … 1 854.34 g … … 2006 2,4,9 125 155 g … … 1 825.19 g … … 2006 2,4,9 118 990 g … … 1 735.28 g … … 2006 2,4,9 118 480 g … … 1 727.84 g … … 2006 2,4,9 105 254 g … … 1 534.96 g … … 2006 2,4,9 71 705 g … … 1 045.70 g … … 2006 2,4,9 46 492 g … … 678.01 g … … 2006 2,4,9 - Ischaemic heart disease (ICD10: I20-I25) 140 | COUNTRY HEALTH INFORMATION PROFILES Total 5. Diseases of the digestive system (ICD10: K00-K93) 4. Diseases of the respiratory system (ICD10: J00-J99) - Cervix (ICD10: C53) - Oesophagus (ICD10: C15) Communicable and noncommunicable diseases Diarrhoeal diseases (ICD10: A00-A09) Acute respiratory infections (ICD10: J00-J06, J20-J22) Leading causes of morbidity (inpatient care) 1. Diseases of the genitourinary system (ICD10: N00-N99) 2. Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (ICD10: R00-R99) 3. Neoplasms (ICD10: C00-D48) 10. Diseases of the musculoskeletal system and connective tissue (ICD10: M00-M99) Male Male 7. Factors influencing health status and contact with health services (ICD10: Z00-Z99) Female Number of new cases Rate per 100 000 population Injuries Total Male Total Mental disorders (ICD10: F00-F99) Diabetes mellitus (ICD10: E10-E14) Leading causes of mortality and morbidity 6. Diseases of the circulatory system (ICD10: I00-I99) 8. Pregnancy, childbirth and the puerperium (ICD10: O00-O99) 9. Injury, poisoning and certain other consequences of external causes (ICD10: S00-T98) - Trachea, bronchus, and lung (ICD10: C33-C34) - Breast (ICD10: C50) - Leukaemia (ICD10: C91-C95) - Lip, oral cavity and pharynx (ICD10: C00-C14) Number of cases - Rheumatic fever and rheumatic heart diseases (ICD10: I00-I09) - Stomach (ICD10: C16) DATA Total Male Female Female Number of deaths Female - New pulmonary tuberculosis (smear-positive) Cancers All cancers (malignant neoplasms only) (ICD10: C00-C97) - Hypertension (ICD10: I10-I15) All circulatory system diseases (ICD10: I00-I99) - Acute myocardial infarction (ICD10: I21-I22) Circulatory - Cerebrovascular diseases (ICD10: I60-I69) - Liver (ICD10: C22) - Colon and rectum (ICD10: C18-C21) Tuberculosis - All forms INDICATORS - Suicide (ICD10 : X60-X84) All types (ICD10: V01-Y89) - Homicide and violence (ICD10 : X85-Y09) - Motor and other vehicular accidents (ICD10: V01-V89) - Occupational injuries HONG KONG (CHINA) Year Source 27 12 093 a 7 386 a 4 707 a 176.36 a 225.86 a 131.22 a 2006 2,4 5 619 a 2 831 a 2 788 a 81.94 a 86.57 a 77.73 a 2006 2,4 4 201 a 2 264 a 1 937 a 61.26 a 69.23 a 54.00 a 2006 2,4 3 302 a 1 603 a 1 699 a 48.15 a 49.02 a 47.37 a 2006 2,4 1 961 a,h 1 264 a,h 697 a,h 28.60 a,h 38.65 a,h 19.43 a,h 2006 2,4 1 924 a 1 382 a 542 a 28.06 a 42.26 a 15.11 a 2006 2,4 1 287 a 634 a 653 a 18.77 a 19.39 a 18.20 a 2006 2,4 676 a 322 a 354 a 9.86 a 9.85 a 9.87 a 2006 2,4 511 a 232 a 279 a 7.45 a 7.09 a 7.78 a 2006 2,4 364 a 246 a 118 a 5.31 a 7.52 a 3.29 a 2006 2,4 28 … 29 … 30 1.60 i 2007 4 31 1.08 a,b 1.02 a 1.11 a 2007p 2,4 32 94.89 b,j 95.54 j 94.17 j 2006 2,4 33 95.00 … … 2007 14 95.00 … … 2007 14 95.00 … … 2007 14 95.00 … … 2007 14 34 … 0 a 2006 2,4 … 0 a 2006 2,4 … 0 a 2006 2,4 … 0 a 2006 2,4 … 0 a 2006 2,4 35 0 e 0 e 0 e 0 a 0 a 0 a 2007p 2,4 0 e 0 e 0 e 0 a 0 a 0 a 2007p 2,4 3 m 2 m 1 m 0 a 0 a 0 a 2007p 2,4 88 e 54 e 34 e 0 a 0 a 0 a 2007p 2,4 181 e 113 e 68 e 0 a 0 a 0 a 2007p 2,4 0 e 0 e 0 e 0 a 0 a 0 a 2007p 2,4 31 e 20 e 11 e 0 a 0 a 0 a 2007p 2,4 0 e 0 e 0 e 0 a 0 a 0 a 2007p 2,4 38 e 23 e 15 e 0 a 0 a 0 a 2007p 2,4 1 e 0 e 1 e 0 a 0 a 0 a 2007p 2,4 Number of deaths COUNTRY HEALTH INFORMATION PROFILES | 141 7. Nephritis, nephrotic syndrome and nephrosis (ICD10: N00-N07, N17-N19, N25-N27) - Neonatal tetanus (ICD10: A33) - Measles (ICD10: B05) Male Number of cases Male Female 1. Malignant neoplasms (ICD10: C00-C97) Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500g at birth 6. Chronic lower respiratory diseases (ICD10: J40-J47) 4. Cerebrovascular diseases (ICD10: I60-I69) - DTP3 5. External causes of morbidity and mortality (ICD10: V01-Y89) - Hepatitis B III - Hib meningitis (ICD10: G00.0) Maternal causes - BCG - Tetanus (ICD10: A35) - Mumps (ICD10: B26) - Diphtheria (ICD10: A36) - Eclampsia (ICD10: O15) - Haemorrhage (ICD10: O46, O67, O72) - Abortion (ICD10: O02.1, O03-O07) Selected diseases under the WHO-EPI Percentage of pregnant women with anaemia 10. Chronic liver disease and cirrhosis (ICD10: K70, K73-K74) Percentage of pregnant women immunized with tetanus toxoid (TT2) Percentage of women in the reproductive age group using modern contraceptive methods 2. Diseases of heart (ICD10: I00-I09, I11, I13, I20-I51) Leading causes of mortality - Obstructed labour (ICD10: O64-O66) Male Immunization coverage for infants (%) - POL3 INDICATORS 3. Pneumonia (ICD10: J12-J18) FemaleTotal - Rubella (ICD10: B06) - Congenital rubella syndrome (ICD10: P35.0) - Sepsis (ICD10: O85) 8. Septicaemia (ICD10: A40-A41) 9. Diabetes mellitus (ICD10: E10-E14) Total Male Female Total Maternal, child and infant diseases DATA - Pertussis (whooping cough) (ICD10: A37.0) - Acute Poliomyelitis (ICD10: A80) Number of deaths Total Total Male Female Female Rate per 100 000 population HONG KONG (CHINA) Year Source 36 … 37 Public health facilities 38 d 27 784 d 2007 9 … … … … 291 d,n 761 d,n 2007 4,9 Private health facilities 12 d,o 3 438 d,o 2007 4 - Nursing homes 31 d,o 2 945 d,o 2007 4 3 000 d … 2007 2 38 8 707.00 q FY 2004/ 2005 2,4,10 5.20 r FY 2004/ 2005 2,4,10 1 283.00 s FY 2004/ 2005 2,4,10 4 774.00 t FY 2004/ 2005 2,4,10 55.00 u FY 2004/ 2005 2,4,10 14.50 v FY 2004/ 2005 2,4,10 … … 45.00 w FY 2004/ 2005 2,4,10 7.79 2004 2 39 38.50 x 2005-2006 2 Year Source 40 Physicians d,y - Number 11961 z 8704 z 3257 z 11961 z … … … 2007 4 - Rate per 1000 population 1.72 z 1.26 z 0.47 z 1.73 z … … … 2007p 2,4 Dentists d,y - Number 2025 aa 1479 aa 546 aa 2025 aa … … … 2007 4 - Rate per 1000 population 0.29 aa 0.21 aa 0.08 aa 0.29 aa … … … 2007p 2,4 Pharmacists d,y - Number 1722 859 863 1722 … … … 2007 4 - Rate per 1000 population 0.25 0.12 0.12 0.25 … … … 2007p 2,4 Nurses d,y - Number 36965 ab 4107 ab 32858 ab 36965 ab … … … 2007 4 - Rate per 1000 population 5.31 ab 0.59 ab 4.74 ab 5.34 ab … … … 2007p 2,4 Midwives d,y - Number 4693 0 4693 4693 … … … 2007 4 - Rate per 1000 population 0.67 0.00 0.68 0.68 … … … 2007p 2,4 Paramedical staff d,y - Number 9590 ac 4997 ac 4593 ac 9590 ac … … … 2007 4 - Rate per 1000 population 1.38 ac 0.72 ac 0.66 ac 1.38 ac … … … 2007p 2,4 Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians 320 ae … … … … … … 2007 11 Dentists 47 ae … … … … … … 2007 11 142 | COUNTRY HEALTH INFORMATION PROFILES Total health expenditure Annual number of graduates - total expenditure on health as % of GDP U rb an Facilities with HIV testing and counseling services Health infrastructure - Hospitals - Outpatient clinics - Primary health care centres - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals - per capita total expenditure on health (in US$) Government expenditure on health - amount (in million US$) Health care financing Health facilities INDICATORS - private expenditure on health as % of total expenditure on health - general government expenditure on health as % of total expenditure on health External source of government health expenditure Private health expenditure - external resources for health as % of general government expenditure on health - general government expenditure on health as % of total general government expenditure Human resources for health Health insurance coverage as % of total population P ri va te M al e F em al e T o ta l INDICATOR R u ra l P u b lic DATA Number DATA Exchange rate in US$ of local currency is: 1 US$ = Number of beds HONG KONG (CHINA) Year Source 41 Pharmacists 26 ae … … … … … … 2007 11 Nurses 481 ae … … … … … … 2007 11 Midwives … … … … … … … 2007 11 Paramedical staff 253 ae … … … … … … 2007 11 Community health workers … … … … … … … 2007 11 42 Physicians 79 … … … … … … 2007 4 Dentists 14 … … … … … … 2007 4 Pharmacists 8 … … … … … … 2007 4 Nurses 563 … … … … … … 2007 4 Midwives 4 … … … … … … 2007 4 Paramedical staff 131 … … … … … … 2007 4 Community health workers 0 … … … … … … 2007 4 Year Source 43 … … … 44 1.72 a,b 1.77 a 1.63 a 2007p 2,4 45 2.15 a,b 2.21 a 2.05 a 2007p 2,4 46 95.00 … … 2007 14 47 1.42 a 2007p 2,4,12 48 100.00 2007 4 0.00 af 2007 4 100.00 ag 2007 4 49 … … … 50 4.14 2006 2,4 51 Antenatal care coverage - At least one visit 100.00 2006 4 - At least four visits … 52 … … … 53 … … … 54 <0.10 … … 2007 4 55 86.00 ah … … 2007 4 56 0.48 e 0.79 e 0.19 e 2007p 2,4 57 0.00 a 0.00 a 0.00 a 2007p 2,4 58 … … … 59 … … … 60 64.00 … … 2006 14 61 5.00 … … 2006 14 62 56.00 … … 2006 14 63 74.00 … … 2005 14 64 100.00 … … 2007 13 65 99.00 … … 2007 7 66 … … … COUNTRY HEALTH INFORMATION PROFILES | 143 Annual number of graduates Workforce losses/ Attrition Total Proportion of population with access to affordable essential drugs on a sustainable basis Proportion of population in malaria-risk areas using effective malaria treatment measures Adolescent birth rate Percentage of people with advanced HIV infection receiving ART Total Urban Rural - Percentage of deliveries in health facilities (as % of total deliveries) Infant mortality rate (per 1000 live births) Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel Maternal mortality ratio (per 100 000 live births) Estimated HIV prevalence in adults l Malaria incidence rate per 100 000 population Health-related Millennium Development Goals (MDGs) Tuberculosis prevalence rate per 100 000 population Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source Tuberculosis death rate per 100 000 population Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Male Unmet need for family planning INDICATORS DATA P ri va te HIV prevalence among population aged 15-24 years Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures Contraceptive prevalence rate Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Prevalence of underweight children under five years of age INDICATORS DATA Female T o ta l M al e F em al e U rb an R u ra l P u b lic HONG KONG (CHINA) … p a b c d e f g h i j k l m n o q r s t u v w x y z aa ab ac ad ae af ag ah 1 2 3 4 5 6 7 8 9 10 11 12 13 14 144 | COUNTRY HEALTH INFORMATION PROFILES Provisional Notes: Data not available Immigration Department, HKSARG The figure includes unknown sex. The figure refers to the cases known to the maternity homes, public and private hospitals. Labour Department, HKSARG The figure refers to the percentage of population aged 15 and above with primary or above educational attainment. The figure(s) is/are as at end of the year. The figure refers to the cases reported to the Department of Health for the listed Statutory Notifiable Infectious Diseases. The figure refers to the number of new cases seen in public Sexually Transmitted Diseases clinics and those in prisons. The figure refers to the number of in-patient discharges including deaths on attendances basis by disease from public hospitals, private hospitals and correctional institutions. 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 The figure is compiled based on registered deaths and/or registered births. University Grants Committee, HKSARG The figure refers to the cases reported to the Department of Health. WHO Regional Office for the Western Pacific, data received from the technical units. Lands Department, Hong Kong Special Administrative Region Government (HKSARG) Census and Statistics Department, HKSARG Planning Department, HKSARG Department of Health, HKSARG Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world. United Nations Development Programme, New York USA 2007. Transport Department, HKSARG Environmental Protection Department, HKSARG Water Supplies Department, HKSARG The figure refers to the cases who had Hb<10g/dl and attending the maternal and child health centres for ante-natal checkups. The figure excludes those with unknown birth weight. The figure refers to the cases reported to the Department of Health for the listed Statutory Notifiable Infectious Diseases and includes 58 dengue fever cases Not included in the official list of MDG indicators The figure covers the out-patient clinics, health education centres and travel health centres under the Department of Health, general out-patient clinics under the Hospital Authority a The figure covers the institutions licensed under the Hospitals, Nursing Homes and Maternity Homes Registration Ordinance (Cap.165). The figure refers to the summation of public health expenditure and private health expenditure in the financial year 2004/05. The figure is compiled based on the summation of public health expenditure and private health expenditure in the financial year 2004/05 as percentage of GDP in the financial year The figure is compiled based on the summation of public health expenditure and private health expenditure in the financial year 2004/05 per mid-2004 population. The figure refers to the public health expenditure. The figure refers to public health expenditure as percentage of the summation of public health expenditure and private health expenditure in the financial year 2004/05. The figure refers to public health expenditure as percentage of overall public expenditure. The figure only covers graduates of full-time sub-degree and undergraduate programmes funded by the University Grants Committee at the end of the graduation year 2007. The figure refers to the percentage of the population who were entitled to medical benefits provided by employers/companies or covered by medical insurance purchased by individuals, The number of healthcare personnel regardless of whether they are actually working in the profession or not. Figure refers to the number of doctors with full registration on both the local and overseas lists, excluding Chinese medicine practitioners. The number of dentists refers to the number of dentists with full registration on both the local and overseas lists. currently employed or retired, and their eligible dependants by their employers/companies in the private sector or by the Government in whatever form. Nearly all newborns were delivered in health facilities. Hospital Authority, HKSARG Food and Health Bureau, HKSARG [http://hdr.undp.org/en/reports/global/hdr2007-2008/] The figure only reflects those attending Department of Health's specialist clinic. Sources: Graduates may not be engaged in work areas directly related to their discipline of study after graduation. Chapter XX for “external causes of morbidity and mortality” should be used as the primary cause of death. and the out-patient clinics/hospitals in the correctional institutions. 2004/05. or had both kinds of medical protection. Medical benefits provided by employers/companies referred to medical benefits provided to employees, irrespective of whether they were (27 males and 31 females) The figure refers to the number of registered nurses and enrolled nurses. Paramedical staff include Medical Laboratory Technologists, Occupational Therapists, Radiographers, Optometrists and Physiotherapists. The figure refers to private health expenditure as percentage of the summation of public health expenditure and private health expenditure in the financial year 2004/05. Assume all human resources for health in Hong Kong are in urban area. COUNTRY HEALTH INFORMATION PROFILES | 145 JAPAN 1. CONTEXT 1.1 Demographics As of 1 November 2007, the total population of Japan was estimated to be 127 775 000, comprising 62 304 000 males and 65 471 000 females. With regards to distribution by age group, 13.5% of the population are aged 0-14 years, 64.9% 15-64 years and 21.5% 65 years and over. The average life expectancy remains the highest in the world. In 2006, it was 85.81 years for women and 79.00 years for men. In 2006, the crude birth rate was 8.7 per 1000 persons and the crude death rate was 8.6 per 1000 persons. 1.2 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 are collectively responsible to the Diet (legislature). In September 2007, Mr. Yasuo Fukuda was designated by the Diet as Japan's 91st Prime Minister. He is a member of the Liberal Democratic Party, which currently holds the largest block of representation in the House of Representatives. 1.3 Socioeconomic 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 2006, the GDP of Japan and the United States totaled 36.4% of the world’s GDP. Japan's GDP per capita in 2006 was US$ 34 181. This economic scale was achieved largely due to high economic growth from 1955 to the late 1960s. In the 2006 financial year, the economy as a whole improved, as did the employment/unemployment situation, while some severe aspects remained. The jobless rate dropped 0.3 of a percentage point year on year to 4.1% on the 2006 average. The active ratio of jobs to applicants in the same period increased 0.11 point to 1.06 times. Water supply coverage has reached a high level of 100% (2006). 1.4 Vulnerabilities and hazards No available information. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition 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. JAPAN 146 | COUNTRY HEALTH INFORMATION PROFILES Due to the increasingly complex social environment created by a high-tech and competitive society, it is said that the stress levels felt by all age groups are rising. There were 29 921 suicides in 2006; the number has remained stable at approximately 30 000 since 1998. Tuberculosis, infectious and difficult-to-treat diseases, such as HIV infection and new types of influenza, are becoming serious threats to public health in Japan. 2.2 Outbreaks of communicable diseases No available information. 2.3 Leading causes of mortality and morbidity With advancement of the ageing society, disease patterns have shifted to lifestyle-related diseases, such as cancer, heart disease, cerebrovascular disease and diabetes. These diseases account for 60% of mortality and this trend is expected to continue. 2.4 Maternal, child and infant diseases The infant mortality rate was 2.6 per 1000 live births and the maternal mortality ratio was 4.9 per 100 000 live births in 2006. Activities carried out by the municipalities include distribution of the Maternal and Child Health Handbook, health care guidance, home visits and health check-ups for pregnant women. They also operate maternal and child health programmes, including parenting classes. 2.5 Burden of disease No available information. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives 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 Ministry of Health, Labour and Welfare announced a health promotion programme, the 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 the programme, which is to be completed in 2012, is to realize a society where all nationals live healthy and happy lives, free of disease. • Improving healthy dietary habits: The Ministry of Health, Labour and Welfare has carried out the National Health and Nutrition Survey every year since 1945. The recommended dietary allowances (Dietary Reference Intakes) are revised every five years. In 2004, they underwent their seventh revision. Dietary guidelines for Japanese, the benchmark for dietary improvement, were established in 2000. • Promoting physical activities and exercise: Healthy Japan 21 encourages people to take physical exercise. In 2006, the Ministry of Health, Labour and Welfare drew up “Exercise Criteria for Health Promotion 2006”, describing the amount of physical activity and exercise needed to prevent lifestyle diseases, with updated evidence. COUNTRY HEALTH INFORMATION PROFILES | 147 • Promoting appropriate rest and sleep: 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 2003, the Ministry of Health, Labour and Welfare drew up guidelines for good sleeping as a tool for achieving the sleep target in Healthy Japan 21. • Smoking and health: The Ministry of Health, Labour and Welfare publicizes accurate information about smoking and its harm to human health, not only for smokers but also generally. The Ministry tries to prevent juveniles being tempted to smoke through health education, promotes efficient separation of smoking areas in public places or offices to reduce second-hand smoking, and assists smokers who want to quit smoking through support programmes. Medical insurance covers treatment for nicotine-dependent patients. 3.2 Organization of health services and delivery systems No available information. 3.3 Health policy, planning and regulatory framework With increasing financial constraints, the Government is planning to introduce structural reforms in the heath system to increase efficiency while maintaining equity and quality of services. These reforms are closely associated with the ongoing demographic transition—longer life expectancy and lower birth rate—that has resulted in a rapid increase in the percentage of elderly citizens. Japanese society is ageing at an unprecedented speed compared with other developed countries. In 2005, Japan’s ageing rate reached 21.0%, showing that the country is still ageing at a high speed. According to population projections, the ageing trend will continue and the ageing rate will exceed 35% in 2050. This ageing population will need to pay attention to lifestyle-related diseases. Maintaining healthy lifestyles and the early detection of disease could help to 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. 3.4 Health care financing National expenditure on health has been rising year after year. In 2006, total health expenditure reached US$ 343 872.2 million, about 7.9% of GDP. 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 upward trend in medical care expenditure. The average per capita total expenditure on health in 2006 was US$ 2 690.4. 3.5 Human resources for health As of 2006, there were 277 927 doctors and 1 234 312 nurses, public health nurses and assistant nurses in Japan. 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 service personnel will increase in the future. 3.6 Partnerships No available information. 3.7 Challenges to health system strengthening 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 JAPAN 148 | COUNTRY HEALTH INFORMATION PROFILES 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 over-treatment. For example, the average length of a hospital stay in Japan is more than three weeks, more than double that in the majority of developed countries. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Summary of vital statistics Operator : Ministry of Health Labour and Welfare Features : Includes information on health and labour Web address : http://www.mhlw.go.jp/english/index.html Title 2 : Japan in figures; Japan statistical yearbook Operator : Statistics Bureau, Ministry of Internal Affairs and Communications Web address : http://www.stat.go.jp/english/index.htm 5. ADDRESSES MINISTRY OF HEALTH, LABOUR AND WELFARE Office Address : l-2-2, Kasumigaseki, Chiyoda-ku, Tokyo 100-8916, Japan 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 Director, Programme Management, WHO Regional Office for the Western Pacific. Office Address : Director, Programme Management, World Health Organization Regional Office for the Western Pacific Postal Address : United Nations Avenue, P.O. Box 2932, 1000, Manila, the Philippines Official Email Address : postmaster@wpro.who.int Telephone : (63 2) 5288001/ 303 1000 Fax : (63 2) 526 0279 Office Hours : 7:00-15:30 Website : http://www.wpro.who.int/ Year Source Demographics 1 377.91 a 2005 1 2 127 775.00 62 304.00 65 471.00 2007 est 2 3 … … … 4 4.25 … … 2007 est 2 9.28 … … 2007 est 2 21.49 … … 2007 est 2 5 66.00 … … 2007 est 4 6 8.70 9.10 8.20 2006 3 7 8.60 9.40 7.80 2006 3 8 0.10 -0.30 0.50 2006 3 9 … 79.00 85.81 2006 3 … 17.50 21.70 2002 est 5 10 1.32 2006 3 11 99.00 … … 2000 est 6 12 34 181.00 2006 12 13 … 14 0.95 2005 7 15 … … … 16 260.00 … … 2002 8 17 … … … 5 815 2 856 2 959 2006 3 … … … 5 3 2 2006 3 … … … 689 435 254 2006 3 … … … 4 786 2 245 2 541 2006 3 … … … 2 2 … 2006 3 … … … 270 144 126 2006 3 56 … … … … … 2006 3 74 … … … … … 2006 3 189 … … 86 44 42 2006 3 … … … … … … 2006 3 7 … … … … … 2006 9 67 … … 1 … 1 2006 3 … … … 2006 3 543 … … 16 14 2 2006 3 50 … … … … … 2006 3 COUNTRY HEALTH INFORMATION PROFILES | 149 - Type A Syphilis - Type B - Type C Dengue/DHF Gonorrhoea - Unspecified - Type E Male Communicable and noncommunicable diseases Selected communicable diseases Total Per capita GDP at current market prices (US$) Environmental indicators Human development index Rate of growth of per capita GDP (%) Female Hepatitis viral Cholera Total Female Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Rate of natural increase of population (% per annum) Urban population (%) Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above Estimated population ('000s) Annual population growth rate (%) Percentage of population - 0–4 years - 5–14 years COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male JAPAN Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Typhoid fever Encephalitis Leprosy Malaria Plague RuralTotal Urban Number of deaths Male Number of new cases JAPAN Year Source 18 … … … 266 118 148 2006 3 19 … … … … … … 20 25 304 … … 2 269 1 517 752 2006 9, 3 10 159 … … … … … 2006 9 21 … … … 329 314 198 052 131 262 2006 3 … … … 11 274 97 11 177 2006 3 … … … 41 056 22 392 18 664 2006 3 … 2 481 2006 3 … … … 11 345 9 650 1 695 2006 3 … … … 7 429 4 382 3 047 2006 3 … … … 6 018 4 310 1 708 2006 3 … … … 33 662 22 576 11 086 2006 3 … … … 50 415 32 745 17 670 2006 3 … … … 63 255 45 941 17 314 2006 3 22 … … … 324 786 155 787 168 999 2006 3 … … … 45 067 24 554 20 513 2006 3 … … … 128 268 61 348 66 920 2006 3 … … … 5 810 2 095 3 715 2006 3 … … … 75 429 41 296 34 133 2006 3 … … … 2 468 800 1 668 2006 3 23 … … … 13 650 7 268 6 382 2006 3 24 … … … 5 168 1 833 3 335 2006 3 25 … … … 73 112 47 631 25 481 2006 3 … … … 580 314 266 2006 3 … … … 9 048 6 258 2 790 2006 3 … … … … … … … … … 29 921 21 419 8 502 2006 3 26 769 964 … … 604.88 … … 2000 6 275 036 … … 216.07 … … 2000 6 132 877 b … … 104.39 b … … 2000 6 50 527 b … … 39.69 b … … 2000 6 39 384 … … 30.94 … … 2000 6 32 417 … … 25.47 … … 2000 6 22 978 … … 18.05 … … 2000 6 16 926 b … … 13.30 b … … 2000 6 3 804 … … 2.99 … … 2000 6 3 123 b … … 2.45 b … … 2000 6 150 | COUNTRY HEALTH INFORMATION PROFILES Number of new cases - Ischaemic heart disease Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections - Colon and rectum - Cervix - Oesophagus Leading causes of morbidity (inpatient care) Leading causes of mortality and morbidity 6. Food poisoning (bacterial) 8. Gonococcal infections 4. Other venereal diseases 5. Tuberculosis (all forms) 1. Influenza (grippe) 2. Chickenpox 10. Rubella - Rheumatic fever and rheumatic heart diseases Injuries 9. Pertussis (whooping cough) TotalTotal - Breast MaleTotalFemale Number of cases Male Rate per 100 000 population Male FemaleFemale Diabetes mellitus - Leukaemia - Lip, oral cavity and pharynx Mental disorders - New pulmonary tuberculosis (smear-positive) DATA Female Cancers All cancers (malignant neoplasms only) - Hypertension All circulatory system diseases - Acute myocardial infarction Circulatory - Cerebrovascular diseases - Liver - Stomach - Trachea, bronchus, and lung Tuberculosis - All forms INDICATORS Total Number of deaths Male - Suicide All types - Homicide and violence - Motor and other vehicular accidents - Occupational injuries 7. Measles 3. Mumps JAPAN Year Source 27 329 314 198 052 131 262 261.00 321.70 203.20 2006 3 173 024 82 811 90 213 137.20 134.50 139.70 2006 3 128 268 61 348 66 920 101.70 99.60 103.60 2006 3 107 242 56 572 50 670 85.00 91.90 78.50 2006 3 38 270 23 329 14 941 30.30 37.90 23.10 2006 3 29 921 21 419 8 502 23.70 34.80 13.20 2006 3 27 764 6 872 20 892 22.00 11.20 32.30 2006 3 21 158 9 714 11 444 16.80 15.80 17.70 2006 3 16 267 10 909 5 358 12.90 17.70 8.30 2006 3 14 357 10 904 3 453 11.40 17.70 5.30 2006 3 28 43.90 2004 est 10 29 42.90 2007 9 30 … 31 1.30 1.40 1.20 2006 3 32 90.40 91.50 89.30 2006 3 33 94.00 … … 2007 9 98.20 … … 2007 9 95.20 … … 2007 9 … … … … 34 … 2 2005 3 … 2 2005 3 … … … .. … … 35 0 0 0 … … … 2007 9 0 0 0 … … … 2007 9 … … … … … … 520 … … … … … 2007 9 200 614 … … … … … 2007 9 … … … … … … 1 504 … … … … … 2007 9 0 0 0 … … … 2007 9 509 … … … … … 2007 9 117 … … … … … 2007 9 COUNTRY HEALTH INFORMATION PROFILES | 151 - Eclampsia - Haemorrhage - Abortion Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth 5. Accidents and adverse effects 3. Cerebrovascular diseases 1. Malignant neoplasms 2. Heart disease 4. Pneumonia Maternal causes - DTP3 - BCG 6. Suicide - Hepatitis B III Percentage of pregnant women with anaemia Percentage of women in the reproductive age group using modern contraceptive methods - POL3 - Total Tetanus - Measles - Sepsis - Obstructed labour 7. Senility 8. Renal failure 9. Disease of liver 10. Chronic Obstructive pulmonary disease Percentage of pregnant women immunized with tetanus toxoid (TT2) - Rubella - Congenital rubella syndrome - Mumps - Poliomyelitis - Pertussis (whooping cough) - Diphtheria - Neonatal tetanus FemaleTotal Selected diseases under the WHO-EPI FemaleTotal Male - Hib meningitis FemaleTotal Female Total Number of deaths Rate per 100 000 population Male Male Immunization coverage for infants (%) Total Male Maternal, child and infant diseases Female Number of deathsNumber of cases Male DATAINDICATORS Leading causes of mortality JAPAN Year Source 36 … 37 Public health facilities 6 176 c 476 825 c 2006 3 … … … … … … Private health facilities 7 300 1 155 099 2006 3 94 076 154 563 2006 3 38 343 872.17 2006p 11 7.90 2006p 11 2 690.43 2006p 11 282 762.84 2006p 11 82.20 2006p 11 17.70 2006p 11 0.00 2006p 11 17.80 2006p 11 116.30 2006p 11 39 … Year Source 40 Physicians - Number 277 927 229 998 47 929 … … … … 2006 3 - Rate per 1000 population 2.18 1.80 0.38 … … … … 2006 3 Dentists - Number 97 198 78 254 18 944 … … … … 2006 3 - Rate per 1000 population 0.76 0.61 0.15 … … … … 2006 3 Pharmacists - Number 252 533 98 802 153 731 … … … … 2006 3 - Rate per 1000 population 1.98 0.77 1.20 … … … … 2006 3 Nurses - Number 1 234 312 d 61 831 d 1 172 481 d … … … … 2006 3 - Rate per 1000 population 9.66 0.48 9.18 … … … … 2006 3 Midwives - Number 25 775 … 25 775 … … … … 2006 3 - Rate per 1000 population 0.20 … 0.20 … … … … 2006 3 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … 152 | COUNTRY HEALTH INFORMATION PROFILES - per capita total expenditure on health (in US$) - private expenditure on health as % of total expenditure on health Human resources for health Health insurance coverage as % of total population - external resources for health as % of general government expenditure on health - general government expenditure on health as % of total general government expenditure Annual number of graduates External source of government health expenditure - Hospitals - Outpatient clinics T o ta l Exchange rate in US$ of local currency is: 1 US$ = INDICATOR - Specialized hospitals - District/first-level referral hospitals - Primary health care centres Government expenditure on health Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) - General hospitals INDICATORS Health infrastructure Facilities with HIV testing and counseling services Health facilities DATA Number Health care financing R u ra l DATA U rb an F em al e Private health expenditure P ri va te P u b lic - amount (in million US$) - general government expenditure on health as % of total expenditure on health M al e Number of beds JAPAN Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 2.60 2.80 2.50 2006 3 45 3.60 3.80 3.40 2006 3 46 97.80 … … 2007 9 47 4.90 2006 3 48 99.90 2006 3 0.19 2006 3 99.76 2006 3 49 … … … 50 … 51 Antenatal care coverage - At least one visit … - At least four visits … 52 … … … 53 … … … 54 … … … 55 … … … 56 0.05 … … 2006 3 57 0.00 0.00 0.00 2006 3 58 … … … 59 … … … 60 29.00 … … 2006 9 61 3.00 … … 2006 9 62 79.00 … … 2006 9 63 38.00 … … 2005 9 64 100.00 100.00 100.00 2006 11 65 100.00 100.00 100.00 2006 11 66 … … … Workforce losses/ Attrition Annual number of graduates T o ta l DATA Total Urban Rural Proportion of population with access to affordable essential drugs on a sustainable basis Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source COUNTRY HEALTH INFORMATION PROFILES | 153 Malaria incidence rate per 100 000 population Percentage of people with advanced HIV infection receiving ART R u ra l P u b lic P ri va te M al e F em al e U rb an - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) - Percentage of deliveries in health facilities (as % of total deliveries) Contraceptive prevalence rate Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Health-related Millennium Development Goals (MDGs) Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Tuberculosis death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria treatment measures Adolescent birth rate Unmet need for family planning Estimated HIV prevalence in adults e Proportion of births attended by skilled health personnel Infant mortality rate (per 1000 live births) Under-five mortality rate (per 1000 live births) Maternal mortality ratio (per 100 000 live births) FemaleTotal Male INDICATORS DATA HIV prevalence among population aged 15-24 years Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures Tuberculosis prevalence rate per 100 000 population INDICATORS JAPAN … p est NR a b c d e 1 2 3 4 5 6 7 8 9 10 11 12 154 | COUNTRY HEALTH INFORMATION PROFILES Figure refers to public health facilities Figure includes nurses, public nurses and assistant nurses Data not available Notes: Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world . United Nations Development Programme, New York USA 2007. Not included in the official list of MDG indicators Figure refers to cases treated in large hospitals only World health report 2004. Changing history . Geneva, World Health Organization, 2004. SEAMIC Health Statistics 2002. International Medical Foundation of Japan. Sources: Cabinet Office <http://www.esri.cao.go.jp/index-e.html>. Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] Japan in Figures 2007 . Statistics Bureau and Statistical Research and Training Institute, Ministry of Internal Affairs and Communications. [http://www.stat.go.jp/english/data/figures/index.htm#a.] Statistics Bureau, Ministry of Internal Affairs and Communications. [http://www.stat.go.jp/data/getujidb/zuhyou/b02.xls] Ministry of Health,Labour and Welfare［http:www.mhlw.go.jp/english/index.html］ United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006 . Wallchart (United Nations publication, Sales No. E.08.XIII.3). WHO Regional Office for the Western Pacific, data received from the technical units United Nations, Department of Economic and Social Affairs, Population Division (2007). World Contraceptive Use 2007 . Wallchart (United Nations publication, Sales No. E.08.XIII.6). World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation : Ministry of the Environment, Japan. Provisional Estimate Not relevant Figure excludes some areas of which boundaries are not yet fixed [http://hdr.undp.org/en/reports/global/hdr2007-2008/] COUNTRY HEALTH INFORMATION PROFILES | 155 KIRIBATI 1. CONTEXT 1.1 Demographics The Republic of Kiribati, located in the Pacific, consists of 33 low-lying atoll islands in three main island groups, the Gilbert, Phoenix and Line Islands. The country spreads over 3.5. million kilometres of ocean, but has a total land area of only 811 square kilometres. With an annual population growth rate of 1.9% (2006-2010), the 2006 estimated population of Kiribati is 93 706. The average population density is 115 per square kilometre, but this varies widely from 13 people per square kilometre in Kiritimati Island to 2558 in South Tarawa . Between 1995 and 2000, there was significant in-migration of people from the Outer Islands to South Tarawa, resulting in an urban growth rate of 5.2%, compared with a national growth rate of 1.7%. In-migration plateaued during 2000-2005, when the overall growth rate in South Tarawa reduced to 1.9%. Overcrowding in South Tarawa persists, however, putting stress on the environment and infrastructure. New ‘urban’ settlements have emerged since 2000, especially in Northern Tarawa and Kiritimati Island. Between 2000-2005, North Tarawa’s growth rate was 4.8% and Kirimati Island’s 8%, compared with 2.2.% and 1.2 %, respectively, during the period 1995-2000. The total fertility rate was 3.5 in 2005, representing a decline from the 1990s, when it was reported to be about 4.5. Kiribati has a young population, with a median age of 20.7 years; 34.9% of the population is under 15 years of age and only 5 % over 64 years. The sex ratio was 97 males to 100 females in 2006. There has been a steady improvement in health indicators over the last decade, but people in Kiribati still have a shorter life span than those in most other Pacific islands. In 2005, life expectancy at birth was estimated at 58.9 for males and 63.1 for females. 1.2 Political situation Kiribati has a two-tier system of Government at central and local levels. The central Government (Maneaba ni Maungatabu) consists of 42 democratically elected members led by the President. The local level consists of 23 elected and appointed Councils, three in urban areas and 20 in the Outer Islands. Kiribati has enjoyed political stability since the election of the Boutokaan to Koaua Party in 2003. The guiding development document of the Government, the National Development Plan for 2008-2011 sets out the main policy areas, and strategies are operationalized through respective line ministries. While politically administration and service delivery is decentralized, line ministries and councils appear to have few decision-making powers and little authority. A project to strengthen governance in the Outer Islands has recently been launched by the United Nations Development Programme (UNDP). The Government places considerable importance on its international commitments to health and recently became a signatory to the Framework Convention on Tobacco Control and the International Health Regulations. At the national level, food safety legislation was approved by Parliament in 2006. Tobacco legislation has been drafted, but has not yet been put before Parliament. KIRIBATI 156 | COUNTRY HEALTH INFORMATION PROFILES 1.3 Socioeconomic situation Kiribati is categorized as a least-developed country (LDC) because of its low per capita gross national product (GNP), limited human resources and high vulnerability to external forces. During the 1990s, the buoyant global economy, the use of the Australian dollar as domestic currency, access to external assistance and sound fiscal management of the Revenues Equalising Reserve Funds (RERF), derived from previous phosphate deposits, allowed achievment of relative macroeconomic stability. The Kiribati economy remains relatively resilient, due to government reserve funds, which had a market value of US$ 336 million in 2003, and domestic income from fishing licences (approximately 23%), grants and loans (approximately 30%), remittances and a narrow domestic production base of marine products and copra (approximately 10%-20%). In 2004, there was a decline in GNP per capita from US$ 1040 in 1999 to US$ 970, largely due to a decline in the number of fishing licences issued. The 2005 Census found that 64% of people above the age of 15 were “economically active”, but only 23% had regular paid employment; 53% of those employed were in public administration, while the remainder were employed mainly as subsistence farmers or fishermen. Subsidies to public entities are thought to reduce opportunities for private job creation. The lack of regular paid employment, particularly in urban settlements, is associated with an increase in youth violence and abuse of alcohol. Kiribati is a signatory to the Convention for the Elimination of All Forms of Discrimination Against Women and there is evidence that gender equality is improving. Women now comprise 51.8% of the workforce and girls outnumber boys in secondary and tertiary education. Women, however, are still underrepresented at all levels of decision-making, and domestic violence, linked to alcohol abuse, is an increasing problem. In 2006, 65.0% of the population had access to an improved water source. South Tarawa and Kiritimati Island have public water supply infrastructures, with over 3500 households in South Tarawa and 400 in Kirimati connected to a reticulated, treated water system. The remaining population rely on rainwater supplies and well-water. The protection of the well-water and the water sources from pollution, mainly from nearby sanitations systems, is a constant public health concern. In 2006, 33% of the population had access to improved sanitation. According to the 2005 Census, approximately 2000 premises are connected to a waterborne sewage system in the main settlements of South Tarawa, but most of the population reported using the beach, sea or bush for toileting facilities. Two solid-waste landfill sights have been developed to dispose of solid waste, although one is facing problems of seawater seepage. A solid-waste collection service is now operating in South Tarawa. Despite these developments, sanitation in South Tarawa is inadequate and the environment unhealthy 1.4 Vulnerabilities and hazards The low-lying atolls of Kiribati, rising no higher than three meters above sea-level, makes the country very vulnerable to climate change and rises in sea-level. It is estimated (World Bank Regional Economic Report 2000) that, without appropriate adaptation measures, 25%-54% of the land in areas of South Tarawa and 55%-80% in North Tarawa will be inundated by 2050. The natural environment in urban areas is under pressure due to groundwater depletion, marine- life and sea-water contamination from human and solid waste, over-fishing of the reefs and lagoons, ad hoc construction of seawalls, coastal erosion and illegal beach mining, and contamination. The country is also facing considerable socioeconomic difficulities due to the ad hoc management of urban growth. COUNTRY HEALTH INFORMATION PROFILES | 157 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition A number of environmental factors are increasing the risk of communicable diseases in Kiribati. High-density housing and overcrowding in urban areas, such as South Tarawa, is facilitating the transmission of infectious diseases. For instance, tuberculosis incidence in Kiribati has now surpassed that of other Pacific island countries, and most reported cases (70% in 2005) are found in the urban settlement of Betio in South Tarawa. Other health indicators suggest that the health status of people living in South Tarawa is now worse that of people living in the Outer Islands. In the 2005 Census, for example, the infant mortality rate in South Tarawa was higher than that in the Outer Islands. Inadequate water supplies, unsafe drinking water, variable standards of personal hygiene, poor food handling and storage, and poor sanitation are all contributing to the high number of cases of diarrhoeal, respiratory, eye and skin infections. Diarrhoeal diseases and respiratory infections are major causes of mortality among children. There is a high prevalence of STIs, with a surveillance study in 2004 showing that approximately 15% of pregnant women were infected. HIV was first confirmed in Kiribati in 1991 and the number of people infected continues to rise. As of the end of 2006, Kiribati had a cumulative total of 50 HIV/AIDS cases, of whom 24 are known to have died. Since 2006, seven people living with HIV have been enrolled in a care and treatment programme. One has since died. Kiribati achieved leprosy elimination status in 2000, but has since reverted to pre-elimination status. Data suggest that the prevalence of noncommunicable diseases is increasing. Smoking is a significant risk factor contributing to noncommunicable diseases. Around 70% of males between the ages of 30 and 54 are regular smokers, compared with less than 50% of the adult female population, while 32% of young males aged 15-19 smoke (2005 census). The gift of tobacco (Mweaka) remains closely tied to spiritual beliefs in the Outer Islands and in urban areas a gift of tobacco is still considered polite. Economic development and modernization has increased reliance on imported, processed food, such as rice and noodles, and on motorized transport. These changes, together with a strong tradition of feasting, have led to overnutrition and reduced activity in adults, increasing the risk of noncommunicable disease. Draft results from the 2004-2005 STEPs survey show approximately 20% of the adult population have diabetes, and diseases of the circulatory system are now the second leading cause of mortality. Kiribati faces a double-edged health problem related to diet and nutrition: overnutrition in adults and undernutrition in children. Although nationally representative nutrition data are scarce, infant mortality and routine health facility data suggest undernutrition and vitamin and mineral deficiencies are major contributing factors to under-five mortality. Draft results of a STEPs survey in 2004-2005 showed an anaemia prevalence of 17% for non-pregnant women and 22% among women aged 15-24. Vitamin A deficiency was highly prevalent in an assessment in 1989. Morbidity due to diarrhoeal disease and pneumonia among children suggests vitamin A deficiency remains a public health problem. In the late 1990s, the infection rate for chronic hepatitis B was 27.4% among students aged 10- 13 years, increasing the burden of chronic liver disease and cancer. The introduction of hepatitis B vaccination in 2002 will reduce this burden of disease in the future. KIRIBATI 158 | COUNTRY HEALTH INFORMATION PROFILES 2.2 Outbreaks of communicable diseases Anecdotal reports of outbreaks of diarrhoea are common, but few official reports are available. No outbreak of a vaccine-preventable disease has been reported since 2004. 2.3 Leading causes of mortality and morbidity The causes of mortality and morbidity remained fairly consistent between 2002 and 2005. Acute respiratory infections and diarrhoeal diseases are the two major causes of morbidity and are among the five leading causes of mortality. There has been an increase in reported cases of respiratory disease and eye infection since 2002. The leading causes of mortality and morbidity reported from health facilities in 2005 were: Morbidity 2002 2005 Mortality 2002 2005 Acute respiratory diseases 76 836 102 148 Signs and symptoms and ill-defined 117 127 Diarrhoeal disease 20 750 22 647 Diseases of the circulatory system 70 84 Eye diseases 7527 10 247 Infections and parasitic diseases 57 70 Skin diseases 1977 795 Perinatal conditions 54 63 Communicable diseases 987 694 Diseases of the respiratory system 35 62 Noncommunicable diseases 793 450 Diseases of the digestive system 59 55 Nutrition-related diseases 565 318 Endocrine, nutritional and metabolic diseases 46 49 Injuries /poisonings 1023 87 External causes 35 Neoplasms 15 28 Diseases of the blood 9 There have been increases in mortality from diseases of the circulatory system, respiratory system and cancers. Perinatal conditions are still a leading cause of mortality for infants. 2.4 Maternal, child and infant diseases Maternal health is improving. Approximately 90% of all births are now attended by trained health personnel and the total fertility rate has declined, falling from 4.5 in 1995 to 3.5 in 2005. The maternal mortality ratio, based on hospital records, is now 158 per 100 000 live births (2005 Census Report), a significant reduction from the previously reported ratio and consistent with (a) the reduction in the total fertility rate, and (b) the continued high percentage of women attended by trained staff. Infant mortality has also improved over the last decade. The infant mortality rate was estimated at 52 per 1000 live births in the 2005 census, significantly lower than the 67 reported in 1995, but still high compared with many other Pacific island counties. Perinatal conditions, diarrhoeal diseases and pneumonia are the main causes of infant mortality and morbidity. Malnutrition, iron and vitamin A deficiency, and worm infestation among children are contributing factors. An expanded immunization programme, introduced in the early 1980s, and supplementary measles campaigns in 1997 and 1998 have resulted in few reported outbreaks of vaccine- preventable diseases. Kiribati was declared polio-free in 2002. 2.5 Burden of disease Kiribati faces a double burden of disease, with high mortality and morbidity from both communicable and noncommunicable diseases. Data on the burden of disease caused by injury, disability and mental health are scarce. A recent national survey on disabilities found 3840 people with 4358 disabilities. Physical disabilities COUNTRY HEALTH INFORMATION PROFILES | 159 accounted for 32% of all disabilities; blindness and vision impairment 27%; deafness and hearing impairment 23%; and intellectual disability, epilepsy or psychiatric illness approximately 17 %. Twenty three per cent of disabilities are in the under-20 age group. The number of these disabilities that are due to birth injuries and childhood infections is unknown. Data on consumption of alcohol and its impact on the burden of disease are also very limited, but alcohol consumption among young people is seen as a “common social problem faced by society”. Excessive alcohol consumption is commonly linked with road traffic accidents and domestic violence. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The overall goal of the Ministry of Health, as stated in the National Development Plan 2004- 2007, is “Continuous improvement in the provision and delivery of preventative and curative health services and equitable distribution of the benefits attained nationwide through effective and efficient allocation of scarce resources and good governance (accountability and transparency)”. The Ministry is in the process of developing its sectorwide plan for the period 2008-2011 to focus its attention and coordinate donor support to achieve this goal. The proposed objectives are to: (1) improve health status in priority areas; (2) improve access to and utilization of curative health services that are efficient, effective, and responsive to patients and delivered to a high standard nation-wide; (3) improve the quality, sustainability and coverage of public health services through increased responsiveness, efficiency and effectiveness nation- wide; (4) improve, manage and maintain appropriate legislation, plans, policies protocols systems and structures within the Ministry of Health and Medical Services; (5) improve the quality of health information and data in terms of accuracy, timeliness and dissemination, for better planning, decision making, allocation of resources and monitoring and evaluating performance; and (6) develop a well-performing, highly skilled and supported workforce to enhance the delivery of quality health services. The strategic objectives set out in the National Development Plan for the period 2008-2011 guide the formulation of the Ministry of Health’s annual operational plans. 3.2 Organization of health services and delivery systems Kiribati has a well established, publicly funded, formal health system administered by the central Ministry of Health. A parallel traditional health system exists, provided by traditional healers and offering local medicines, massage and antenatal, childbirth and postnatal care. Most people use both traditional and formal health services, but there is no coordination between the two systems. A national referral hospital, situated in South Tawara, provides a comprehensive range of secondary curative services, while Kiritimati Island has a hospital providing basic surgical, medical and maternity services. A new hospital is under construction in North Tabiteuea to serve the Northern District of the Gilbert Islands. A small hospital providing basic medical services is also located in Betio, South Tarawa. These hospitals and one health centre in South Tarawa are the only facilities with medical doctors present. People requiring tertiary curative services are referred overseas for treatment if they fulfil the clinical criteria set out by the Ministry of Health. Comprehensive primary health care services are offered through a network of 92 health centres and dispensaries. Health centres are headed by a medical assistant - a registered nurse who has undertaken additional training - who also supervises up to eight dispensaries staffed by nurses and nurse aids employed by the Island Council. Six principle Nursing Officers, based in Tarawa, KIRIBATI 160 | COUNTRY HEALTH INFORMATION PROFILES are responsible for the support and oversight of health services in each district and for selected national programmes. The Ministry of Health faces a number of challenges related to the quality of health service delivery, the availability of supplies and equipment and the maintenance of equipment. 3.3 Health policy, planning and regulatory framework The Ministry of Health works within a comprehensive framework for policies, plans and legislation, the implementation and enforcement of which is variable. The Government has introduced an annual performance-based planning process that requires all line ministries to develop annual output-based operational plans known as Ministry Operational Plans or MOPs. Public health legislation primarily falls under the Environmental Health Ordinance. The Ordinance, which is over 30 years old, primarily covers water and sanitation issues. The Ordinance and other legislation, including the Medicines Act and mental health legislation, are in need of review to meet current public health requirements. 3.4 Health care financing Kiribati has a publicly funded, publicly provided health system. Government spending on health was US$ 9.8 million in 2006 and has remained fairly consistent over the last four years. In 2006, approximately 13% of total Government expenditure was on health. Revenue generated by the Ministry of Health were mostly generated from the sale of pharmaceuticals and medical supplies. Most Government expenditure is on curative services, pharmaceuticals and staff. A total of AUS$ 26.9 million (US$ 23 million) in development assistance was approved for health in 2006. This includes AUS$ 12 million (US$ 10.2 million) to strengthen Outer Island health services over a period of four years. A further AUS$ 34 741 (US$ 29 738) was approved to extend hospital facilities in the main referral hospital. Public health services are mainly reliant on donor support. 3.5 Human resources for health Kiribati has an ageing health workforce and relies on retired health staff employed on contract to fill some nursing and medical positions. The current intake of health workers for training is unlikely to meet future employment requirements. A total of 238 locally trained nurses and midwives made up 80% of the health workforce in 2004. Doctors make up the next largest group of health workers. The number of doctors increased from 20 to 30 in 2006 with the recruitment of 10 doctors from Cuba. Basic nurse training is provided locally through a three-year, hospital-based training programme. Approximately 25 nurses are enrolled in the programme each year. Post-basic training is offered in midwifery and public health. In 2007, about 20 school-leavers were recruited for training as first-level nurses in Australia. These nurses will able to work in Australia and those who are able will be given the opportunity to undertake second-level nursing training. It is anticipated that some of these trained nurses will return to Kiribati and will be available for employment in the health sector in the future. Locally recruited medical students are usually trained in the Fiji School of Medicine. In 2007, an additional 23 medical students were recruited to undertake medical training in Cuba. Once graduated, doctors in Kiribati receive additional training through short courses and workshops, provided mainly through regional health programmes. There is a serious shortage of paramedical and support staff. The retirement of a pharmacist in 2006 left only one qualified pharmacist in the country. Most staff employed in laboratory and radiography services, health promotion, environmental health and health information units lack basic qualifications, relying on local in-service training and short courses overseas to learn their skills. There is no pathologist or radiologist employed in the Ministry of Health. COUNTRY HEALTH INFORMATION PROFILES | 161 The Ministry of Health has a workforce training plan to guide the awarding of overseas fellowships, but there is no systematic process in place to ensure the ongoing competency of health workers, and no routine clinical supervision or support. Absenteeism and attrition is thought to impact on productivity, and staff motivation is reported to be a human resources management problem. 3.6 Partnerships The Ministry of Health receives significant technical and financial support from development partners. WHO provides funding and technical support to: epidemic alert and response; HIV care and treatment; health promotion, including tobacco control; environmental health; essential health technologies and medicines; health information; and health system development. UNFPA supports reproductive health activities and UNICEF supports the expanded programme on immunization, nutrition and infant feeding, and IMCI. The South Pacific Community supports the control of tuberculosis, HIV/STIs, noncommunicable diseases, disease surveillance and pandemic preparedness. Considerable support is also provided by the Australian Agency for International Development, the New Zealand Agency for International Development, and the governments of Cuba and Taiwan (China). A large Outer Island project funded by the European Union is refurbishing Outer Island health facilities, providing in-country training courses from the Fiji School of Medicine and developing primary health care capacity in the Outer Islands. 3.7 Challenges to health system strengthening Kiribati has a well established health system. Its faces many of the challenges faced by other Pacific island countries, but its geography, isolation and extremely small population exacerbate these challenges, which include: • developing logistical systems that ensure adequate essential medicines and medical supplies are available and accessible at all times; • recruiting, coordinating, rationalizing and ensuring the quality of basic health-worker training and in-service training, be it local or overseas; • improving staff competency and performance; • increasing utilization and the responsiveness of curative and public health services to reduce child mortality, improve maternal health, reduce the incidence of NCDs and reduce the transmission of tuberculosis, STIs and HIV; • ensuring there is sufficient accurate, timely and relevant health information to inform planning, policy development and monitoring of health sector performance; • ensuring that there is a responsive disease surveillance and response system in place and that reporting meets international requirements; • managing health sector resources more efficiency to impact on health status, improve planning and donor coordination and strengthen the monitoring of health plans and interventions; and • updating legislation, regulations and policies. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Kiribati 2005 Census volume 2 : Analytical report January 2007 Operator : Ministry of Finance and Economic Development Comments : Supported by SPC Title 2 : National Development Strategies 2004-2007 Operator : Ministry of Finance and Economic Development Comments : To be reviewed in 2008 KIRIBATI 162 | COUNTRY HEALTH INFORMATION PROFILES Title 3 : Morbidity and mortality data Operator : Health Information Centre, Ministry of Health and Medical Services Features : Ministry of Health database 5. ADDRESSES MINISTRY OF HEALTH AND MEDICAL SERVICES Office Address : Nawerewere, Tarawa, Kiribati Postal Address : PO Box 268, Bikenibeu (Nawerewere), Tarawa, Kiribati Official Email Address : mhfp@tskl.net.ki Telephone : (686) 28100 Fax : (686) 28152 Office Hours : 0800 - 12.30 - 1330 – 1615 WHO COUNTRY LIAISON OFFICER IN KIRIBATI Office Address : World Health Organization, Nawerewere , Tarawa, Kiribati Postal Address : PO Box 210, Bikenibeu, Tarawa, Kiribati Official Email Address : who@kir.wpro.who.int Telephone : (686) 28231 Fax : (686) 28188 Office Hours : 0800-1230 -1230-1700 Website : www.wpro.who.int COUNTRY HEALTH INFORMATION PROFILES | 163 6. ORGANIZATIONAL CHART: Ministry of Health and Medical Services Year Source Demographics 1 0.81 2005 1 2 93.71 46.23 47.48 2006 est 1 3 1.90 … … 2006-10 1 4 12.40 12.30 12.40 2006 est 2 22.50 22.40 22.60 2006 est 2 5.00 4.70 5.30 2006 est 2 5 49.00 … … 2007 est 3 6 26.80 … … 2005 4 7 8.70 … … 2005 4 8 1.81 … … 2005 4 9 61.00 58.90 63.10 2005 4 … 11.50 11.60 2002 5 10 3.50 2005 4 11 91.00 … … 2005 4 12 789.78 2004 est 6 13 … 14 … 15 … … … 16 … … … 17 … … … … … … … … … 4 1 3 2005 7 … … … … … … … … … … … … 51 25 26 9 5 4 2005 7 0 0 0 0 0 0 2005 7 0 0 0 0 0 0 2005 8 0 0 0 0 0 0 2005 7 278 175 103 0 0 0 2005 7 41 … … … … … 2006 8 … … … … … … … … … … … … … … … … … … 0 0 0 0 0 0 2005 7 Rural Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male - 0–4 years - 5–14 years - 65 years and above Estimated population ('000s) Annual population growth rate (%) Percentage of population Rate of natural increase of population (% per annum) Urban population (%) Crude death rate (per 1000 population) Total fertility rate (women aged 15–49 years) Crude birth rate (per 1000 population) Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Malaria Plague Typhoid fever Number of new cases Selected communicable diseases Syphilis - Type B - Type C - Type A Communicable and noncommunicable diseases - Unspecified Dengue/DHF Gonorrhoea Encephalitis Leprosy Per capita GDP at current market prices (US$) Environmental indicators Total Urban Human development index Rate of growth of per capita GDP (%) Number of deaths Male FemaleMaleTotal TotalFemale 164 | COUNTRY HEALTH INFORMATION PROFILES - Type E Hepatitis viral Cholera KIRIBATI KIRIBATI Year Source 18 101 954 50 097 51 857 … … … 2005 7 19 22 548 11 664 10 884 41 24 17 2005 7 20 378 … … … … … 2006 8 129 … … … … … 2006 8 21 … … … 27 … … 2005 7 … … … … … … … … … 1 0 1 2005 7 … 7 2005 7 … … … … … … … … … 3 2 1 2005 7 … … … 1 0 1 2005 7 … … … … … … … … … 2 1 1 2005 7 … … … 2 2 0 2005 7 22 … … … 84 58 26 2005 7 … … … 0 0 0 2005 7 … … … 47 37 10 2005 7 190 87 103 6 4 2 2005 7 … … … 0 0 0 2005 7 … … … 4 3 1 2005 7 23 248 112 136 23 12 11 2005 7 24 8 6 2 1 1 0 2005 7 25 … … … … … … … … … … … … … … … 3 2 1 2005 7 … … … … … … … … … 21 17 4 2005 7 26 102 148 50 190 51 958 110 390.89 110 036.83 110 735.07 2005 7 22 647 11 709 10 938 24 474.51 25 670.88 23 311.52 2005 7 10 247 4948 5299 11 073.89 10 848.02 11 293.45 2005 7 795 398 397 859.15 872.58 846.10 2005 7 694 383 311 750.00 839.69 662.82 2005 7 450 206 244 486.31 451.64 520.02 2005 7 318 161 157 343.66 352.98 334.60 2005 7 87 44 43 94.02 96.47 91.64 2005 7 COUNTRY HEALTH INFORMATION PROFILES | 165 1. Acute respiratory infections 6. Non-communicable deseases 8. Injury and poisoning 4. Skin diseases 5. Communicable diseases - Oesophagus - Lip, oral cavity and pharynx - Liver All cancers (malignant neoplasms only) - Cervix - Leukaemia 2. Diarrhoeal diseases - Trachea, bronchus, and lung Circulatory - Cerebrovascular diseases - Suicide All types - Homicide and violence - Stomach Total - Motor and other vehicular accidents - Occupational injuries Female - Breast - Rheumatic fever and rheumatic heart diseases Injuries - Ischaemic heart disease - Colon and rectum Mental disorders Diabetes mellitus - Hypertension All circulatory system diseases - Acute myocardial infarction Total Leading causes of morbidity (inpatient care) Leading causes of mortality and morbidity 10. 7. Nutrition and related diseases Male TotalFemale Rate per 100 000 populationNumber of cases Total Male Male Female Male Female Number of new cases Number of deaths DATAINDICATORS 3. Eye diseases 9. Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections Tuberculosis - All forms - New pulmonary tuberculosis (smear-positive) Cancers KIRIBATI Year Source 27 127 72 55 137.25 157.85 117.22 2005 7 84 58 26 90.78 127.16 55.41 2005 7 70 27 43 75.65 59.19 91.64 2005 7 63 34 29 68.08 74.54 61.81 2005 7 62 31 31 67.00 67.96 66.07 2005 7 55 35 20 59.44 76.73 42.62 2005 7 49 24 25 52.95 52.62 53.28 2005 7 35 31 4 37.82 67.96 8.52 2005 7 28 9 19 30.26 19.73 40.49 2005 7 9 5 4 9.73 10.96 8.52 2005 7 28 18.46 2005 1 29 42.90 2007 8 30 … 31 27.00 a … … 2000 9 32 91.80 92.30 91.40 2005 7 33 90.10 … … 2007 8 93.90 … … 2007 8 92.60 … … 2007 8 95.50 … … 2007 8 34 2 2 2004 7 … … 2 2 2004 7 … … … … 35 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 … … … … … … 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 166 | COUNTRY HEALTH INFORMATION PROFILES Number of deaths Total 2. Disease of the circulatory system Leading causes of mortality INDICATORS Male 3. Infectious and parasitic system 1. Symtoms, signs and ill-defined conditions Number of deaths Rate per 100 000 population Female Number of cases FemaleTotal Female DATA FemaleTotal Male Female Total Percentage of women in the reproductive age group using modern contraceptive methods - BCG Immunization coverage for infants (%) - Hepatitis B III Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth Male - Abortion Selected diseases under the WHO-EPI Male - POL3 - Obstructed labour - DTP3 5. Diseases of the respiratory system Percentage of pregnant women with anaemia 10. Diseases of the blood & blood-forming organs - Total Tetanus - Neonatal tetanus - Measles - Rubella - Poliomyelitis - Pertussis (whooping cough) Maternal causes - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) - Eclampsia - Haemorrhage - Congenital rubella syndrome - Sepsis - Diphtheria - Hib meningitis Male 7. Endocrine, nutritional and metabolic 6. Diseases of the digestive system 4. Certain conditions originating in the perinatal 8. External causes of mortality 9. Neoplasms Total Maternal, child and infant diseases KIRIBATI Year Source 36 … 37 Public health facilities 1 140 2005 7 … … … … 92 b … 2005 7 Private health facilities … … … … 38 10.53 2006p 10 12.70 2006p 10 111.98 2006p 10 9.77 2006p 10 92.40 2006p 10 13.00 2006p 10 0.43 2006p 10 7.60 2006p 10 1.33 2006p 10 39 … Year Source 40 Physicians - Number 30 … … … … … … 2006 7 - Rate per 1000 population 0.32 … … … … … … 2006 7 Dentists - Number 3 0 3 … … … … 2004 7 - Rate per 1000 population 0.03 0 0.03 … … … … 2004 7 Pharmacists - Number 1 0 1 … … … … 2006 7 - Rate per 1000 population 0.01 0 0.01 … … … … 2006 7 Nurses - Number 238 18 220 … … … … 2004 7 - Rate per 1000 population 26.50 … … … … … … 2004 7 Midwives - Number 32 4 28 … … … … 2004 7 - Rate per 1000 population 3.60 … … … … … … 2004 7 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … COUNTRY HEALTH INFORMATION PROFILES | 167 Number DATA U rb an DATA Number of beds P u b lic Exchange rate in US$ of local currency is: 1 US$ = Human resources for health Health insurance coverage as % of total population INDICATOR R u ra l External source of government health expenditure Private health expenditure - private expenditure on health as % of total expenditure on health - general government expenditure on health as % of total expenditure on health - external resources for health as % of general government expenditure on health - general government expenditure on health as % of total general government expenditure P ri va te M al e F em al e T o ta l - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals - Primary health care centres - per capita total expenditure on health (in US$) Government expenditure on health Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) Health care financing Health facilities INDICATORS Annual number of graduates Facilities with HIV testing and counseling services Health infrastructure - Hospitals - Outpatient clinics KIRIBATI Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 52.00 53.00 51.00 2005 4 45 69.00 71.00 67.00 2005 4 46 61.00 … … 2006 8 47 158.00 2005 4 48 89.65 c 2005 7 4.65 d 2005 7 85.00 d 2005 7 49 … … … 50 … 51 Antenatal care coverage - At least one visit 100.00 2005 11 - At least four visits … 52 … … … 53 … … … 54 … … … 55 … … … 56 … … … 57 … … … 58 … … … 59 … … … 60 402.00 … … 2006 8 61 45.00 … … 2006 8 62 82.00 … … 2006 8 63 62.00 … … 2005 8 64 65.00 77.00 53.00 2006 12 65 33.00 46.00 20.00 2006 12 66 … … … 168 | COUNTRY HEALTH INFORMATION PROFILES INDICATORS DATA Female T o ta l Proportion of births attended by skilled health personnel Infant mortality rate (per 1000 live births) Proportion of 1 year-old children immunised against measles P ri va te HIV prevalence among population aged 15-24 years INDICATORS DATA Male - Percentage of deliveries in health facilities (as % of total deliveries) Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) P u b lic Workforce losses/ Attrition U rb an R u ra l M al e F em al e Estimated HIV prevalence in adults e Malaria incidence rate per 100 000 population Proportion of population using an improved drinking water source Percentage of people with advanced HIV infection receiving ART Adolescent birth rate Health-related Millennium Development Goals (MDGs) Total Prevalence of underweight children under five years of age Annual number of graduates Maternal mortality ratio (per 100 000 live births) Total Urban Rural Proportion of population with access to affordable essential drugs on a sustainable basis Proportion of population using an improved sanitation facility Contraceptive prevalence rate Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Proportion of population in malaria-risk areas using effective malaria treatment measures Tuberculosis prevalence rate per 100 000 population Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Tuberculosis death rate per 100 000 population Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures Unmet need for family planning KIRIBATI … p est NR a b c d e 1 2 3 4 5 6 7 8 9 10 11 12 COUNTRY HEALTH INFORMATION PROFILES | 169 World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: Not relevant Estimates derived by regression and similar estimation methods Not included in the official list of MDG indicators Sources: Demographic Tables for the Western Pacific 2005-2010. Manila, World Health Organization Regional Office for the Western Pacific, 2005. United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] Kiribati Statistics Office (http://www.spc.int/prism/). World health report 2005. Make every mother and child count. Geneva, World Health Organization, 2005. World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf]. Pacific Island Regional Millennium Development Goals report 2004. Noumea, Secretariat of the Pacific Community, UN/ CROP MDG Working Group, November 2004 Health Information Centre, Ministry of Health. WHO Regional Office for the Western Pacific, data received from the technical units. Kiribati 2005 Census Volume 2: Analytical Report January 2007. Ministry of Finance and Economic Development. Estimate Notes: Data not available Provisional World health report 2004. Changing history. Geneva, World Health Organization, 2004. Figure refers to health centers and dispensaries Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific Best estimated figure Pacific Island Populations - Estimates and projections 2005-2015, Secretariat of the Pacific Community, Noumea, 2006. http://www.spc.int/demog/en/index.html. 170 | COUNTRY HEALTH INFORMATION PROFILES LAO PEOPLE'S DEMOCRATIC REPUBLIC 1. CONTEXT 1.1 Demographics The Lao People’s Democratic Republic has a population of 5.6 million (2005), a population growth rate of 2%, a sparse population density (23.7 per square kilometre) with large inter- provincial variations, and an average household size of 5.9 persons. The topography breaks into lowland areas along the Mekong River that depend predominantly on paddy rice, and highland areas that depend on upland rice and the gathering of non-timber forest products for livelihoods. The population is young, but there are signs of changes in the demographic structure; the percentage of the population under 15 years of age decreased from 43.6% to 39% between 1995 and 2005. The nation is rural, with the beginnings of a rural-to-urban shift, as indicated by the increase in urban areas; the percentage of the population living in rural areas decreased from 83% to 72.9% from 1995 to 2005. The latest census identified 47 distinct ethnic groups. The ethnic Lao comprise 52.5% of the total population 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 education levels, land that is less agriculturally productive and increasing land pressure, and limited rural health care services. Ethnic diversity presents a major challenge in health care delivery and education due to cultural and linguistic barriers. Women have lower literacy rates than men and girls have lower school completion rates. These gaps are accentuated in the rural and highland areas, where poverty is highest. There is some evidence of decreased treatment- seeking behaviour for women when ill. Despite recent efforts, statistics are still relatively weak and major capacity strengthening is still necessary in the area of surveillance data, official statistics collection and vital registration. National health indicators have been improving steadily over the past three decades, but despite the efforts of the national authorities, they remain below international standards, being some of the lowest in the Region. The infant mortality rate declined from 137 to 56 per 1000 live births from 1990 to 2005. Over the same period, the maternal mortality ratio fell from 750 to 405 deaths per 100 000 live births. The crude death rate also declined, from 15.1 to 9.8 deaths per 1000 inhabitants, while the total fertility rate (average number of children per women) fell from 5.6 in 1995 to 4.1 in 2005, and the crude birth rate (number of births per 1000 inhabitants) from 41.3 to 34.3. At the same time, life expectancy at birth rose 10 years in a decade, from 51 years in 1995 to 61 in 2005. Female life expectancy is slightly higher than that of males. Safe water is accessible to 51% of the population and improved sanitation to 30% (2004). 1.2 Political situation The Lao People’s Democratic Republic was founded in 1975. The organs of government are the President, the Prime Minister and the National Assembly. The Government operates under the guidance of the Lao Peoples’ Revolutionary Party (LPRP) through five-yearly Party Congresses, the Politburo and the Central Committee. The VIIIth Party Congress was held in early 2006. A COUNTRY HEALTH INFORMATION PROFILES | 171 National Assembly (NA) election was held in April 2006, with competition among a group of LPRP-approved candidates and outstanding participation by the population. The National Assembly as the main legislative organ is composed of 115 members, of which 29 are women; 113 members are LPRP members. The NA elected a new President, Lt. Gen. Choummaly Sayasone, in June 2006. At the same time, a new Prime Minister, Mr Bouasone Bouphavanh, was appointed by the President for a five-year term, with the approval of the NA. The rule of law has continuously been strengthened by new laws, including several health sector laws in respect of public health, curative services, food safety, drugs and medical devices. The Government reports to the NA on the implementation of its 6th National Social and Economic Development Plan 2006-10 (NSEDP), which includes national strategies on poverty eradication. The last report to the NA was made in June 2007. During this session, the participation of NA members was dynamic and a request was made to the Government to report regularly on the implementation and achievements of the NSEDP. Until January 2006, the country comprised 16 provinces and one special administrative zone under military administration. In early 2006, the special administration status over Xaysomboune region was released and the concerned district allocated to Xiengkhouang and Vientiane provinces. The security in the country is considered stable. 1.3 Socioeconomic situation Lao People’s Democratic Republic ranks 130th out of 177 nations on the Human Development Index in 2005. Literacy has improved in the last decade, attaining 73% in the population above 15 years of age in 2005, compared with 60% in 1995. Schooling has improved for children from 6 to 16 years of age, but boys still have higher attendance than girls: 75% for boys and 68% for girls in 2005 compared with 66% for boys and 56% for girls in 1995. The official poverty rate fell from 39% in 1997 to 33.5% in 2002. Poverty is higher in remote and highland areas and inversely correlates with road or river access. Compared with international standards in 2006, 71% of the population lives on less than PPP US$ 2 a day and 23% live on less than PPP US$ 1 a day. Inequalities remain important, with the share of the national economy of the lowest and the highest quintile being 7.6% and 45%, respectively. Proxy indicators of poverty, such as access to sanitation and electricity, also point to the vulnerability of the population. The latest Lao Reproductive Health Survey found that, in 2005, 50% of households had no toilets and over 40% had no electricity. Disparities between urban and rural areas are still pronounced. For example, 96% of urban households have access to electricity, compared with only 33.3% in rural areas without road access. The World Bank estimated that per capita gross national income was US$ 500 in 2006, with 7.6% economic growth. Agriculture makes up 42% of the gross domestic product (GDP), industry (mainly hydropower, mining and textiles) 32.5%, and services 26%. Revenue collection has been above national targets for the last two years but remains very low, estimated at 14.3% of 2006 GDP. The budget deficit has therefore declined and fiscal space has widened. Major public management reforms are ongoing, but implementation is still below desirable targets. One persisting major issue is the management of customs and taxes. In 2007, collection of taxes and revenues was recentralized by Prime Ministerial decree. New budget and state audit laws still need to be fully implemented. In its official will to provide better service to the rural population and eradicate slash-and-burn agriculture and opium cultivation, the Government has strengthened its policy of resettlement of villagers from the highlands to lowland areas closer to roads and essential public facilities. This resettlement policy brings with it tremendous challenges in delivering social services for these resettled communities. International NGOs and, more recently, the World Food Programme have pointed out that the vulnerability of the resettled populations is a major source of concern. The traditional cultivation techniques of highland populations are inadequate to enable them to access subsistence crops and their traditional reliance on non-timber products, combined with increased environmental pressure, has contributed to a deterioration of their nutritional and LAO PEOPLE'S DEMOCRATIC REPUBLIC 172 | COUNTRY HEALTH INFORMATION PROFILES health status. This situation may have been accelerated by the need to resettle villages and populations in areas affected by the building of new hydropower projects and other programmes exploiting natural resources. 1.4 Vulnerabilities and hazards Locked between Thailand, Viet Nam, China and Myanmar, the Lao People’s Democratic Republic is facing major challenges as the country opens up to external influences. Despite its low level of prevalence, the HIV/AIDS epidemic is gaining attention. The latest round of surveillance (2004) showed an accelerated rate of transmission among sex workers in two of the 17 provinces. With the recent trend in opening of offshore trade zones with China and Viet Nam, the important investment in casinos throughout the country and the ease of migration formalities, the country faces important challenges with regards to spread of HIV/AIDS and other communicable diseases. Until early 2007, there were only limited reported outbreaks of avian influenza in poultry and no human cases of infection with the H5N1 virus in the country. However, in early 2007, the country faced a series of outbreaks in poultry and its first two human cases in the capital, Vientiane. The economy continues to rely heavily on natural resources (hydropower, timber and minerals) and concern has been raised by international environmental agencies that biodiversity and resources are being overexploited, particularly timber. In 1998, the Lao People’s Democratic Republic ranked as the third largest illicit opium producer in the world, after Afghanistan and Myanmar, and had one of the highest opium addiction rates. Through its high-level commitment to fighting drug production and abuse, the Government managed, in less than a decade, from 1998 to 2005, to reduced opium cultivation by 93% and opium addiction by 68%. These changes, however, have brought new challenges for the authorities as there is a need for sustainable economic alternatives for highland former opium farmers. New synthetic drugs have emerged, however, raising concern for public health and amphetamine-type stimulants pose the most serious and fastest-growing drug threat in the country. In the mid-1990s, the Government, with assistance from its partners, started prevention and treatment programmes for drug abusers. The country ranks among the least-developed in the world and, despite a steadily increasing GDP, growth is still slow and inequalities serious. The country is also facing major challenges in addressing transparency and corruption issues; in 2007, it was classified by Transparency International, as 168th on the Corruption Perception Index of 179 countries. As a comparison, in 2005, it ranked 77th of 158 countries. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition Health indicators from the routine health information system are not robust or universal. Therefore, many of the most reliable indicators are from national surveys, most of which were conducted in 2000 and reported in 2001. A national census was conducted in 2005 and official results were published in 2006 that showed important improvements in the maternal mortality ratio, the crude death rate, the total fertility rate, the crude birth rate and other macro-indicators. The methodologies used in the calculations of these indicators have, however, been criticized by international development partners, particularly those concerning maternal mortality; the actual numbers may be underestimated. A multiple-indicator cluster survey was conducted in early 2006 and it is expected that results will be published in 2008. The results of these last two exercises, when available, will update many health indicators. There is a general perception that there will be further improvement in many areas. COUNTRY HEALTH INFORMATION PROFILES | 173 The Lao People’s Democratic Republic is a low-HIV-prevalence country, with an estimated adult seroprevalence rate of 0.1%. At the end of 2007, the official cumulative number of people identified with HIV since 1993 was 2630, of whom 1675 were known to be living with AIDS. Of the reported HIV cases, 55% were male. Based on cumulative HIV case reports, the majority of those infected are between the ages of 20 and 39 years. Of those whose mode of transmission was known, 85% had been transmitted through heterosexual sexual contact, 3.5% transmitted from mother to child, 0.7% through homosexual sexual contact, 0.3% through blood products and 0.2% through use of unsterilized needles (the remainder unknown). Preliminary results from a second round of second generation surveillance have shown the HIV-positive seroprevalence rate in female sex workers increasing from 0.9% in 2001 to 2% in 2005. Chlamydial infection and gonorrhoea are common in sex workers, with an estimated combined infection rate of 37.6%. A total of 375 individuals are currently receiving antiretroviral treatment at a single treatment site. 2.2 Outbreaks of communicable diseases Dengue fever incidence seems to have increased in recent years, with 96.9 cases per 100 000 inhabitants in 2006. In the same year, outbreaks of dengue accounted for a total 6356 cases (5556 cases of dengue fever and 800 cases of dengue hemorrhagic fever/shock syndrome), and six resultant deaths were reported. This represents an increase to an incidence of 110.6 cases per 100 000 inhabitants using the Census 2005 population projections at mid-year. Dengue appears to be moving peripherally, with cases recorded in smaller population centres in recent years. In 2007, 5648 cases were estimated, although this may be an underestimation. Until early 2007, there were only limited reported outbreaks of avian influenza in poultry and no human cases of infection with the H5N1 virus in the country. However, in February 2007, the Ministry of Agriculture confirmed an outbreak of avian influenza, H5N1, in commercial poultry farms and backyard poultry in the capital city, Vientiane. Since then, other outbreaks in poultry have been reported and confirmed from four other provinces in the north, centre and south of the country. Control activities targeted at poultry have been conducted successfully and passive surveillance has been reinforced. In early 2008, several new outbreaks in poultry were reported in the northern region bordering China and Myanmar. The first two human cases were confirmed in early 2007, both resulting in death. The first reported case was a 15-year-old girl from Vientiane city. She developed symptoms and died after a long period of hospitalization. The second case was a 42-year-old woman from Vientiane province. Both cases had recent histories of poultry exposure. Public health activities targeting avian influenza have intensified since the first case was confirmed. There is now a health-care-facility-based avian-influenza-surveillance system in place. At the national level, as well as in several provinces, there are alert telephone numbers for reporting of suspected human avian influenza cases. The National Influenza Laboratory (NIL), based at the National Centre for Laboratory and Epidemiology (NCLE) has been operational since the beginning of January 2007. In December 2007, a cholera outbreak was reported in the south of the country, in Sekong province, with more then 350 cases and three fatalities. There was a substantial number of measles outbreaks in 2007, accounting for 1678 cases, mostly in the north of the country. A national measles immunization campaign was conducted in November 2007 for children aged nine months to 15 years and this activity vaccinated more than 2 million children, achieving 96% coverage. The campaign was carried out with the support of WHO and other international partners. Although it is expected that the campaign will lower the incidence of measles for the next two to three years, large outbreaks will occur again unless routine immunization coverage improves or a follow-up campaign is conducted. 2.3 Leading causes of mortality and morbidity Malaria is considered the leading cause of morbidity and mortality, with 70% of the population at risk. This assumption is still made despite the availability of recent data on other major sources of morbidity. In 2006, the total number of reported malaria cases fell to 18 058, corresponding to an incidence rate of 319 cases per 100 000 population. LAO PEOPLE'S DEMOCRATIC REPUBLIC 174 | COUNTRY HEALTH INFORMATION PROFILES Programme data showed 75.5% of those at risk using preventive measures in 2006. A total of 2 702 339 people (population at risk 3.6 million) were being protected with bednets as of the end of 2005. The number of probable and confirmed malaria deaths in hospitals decreased from 187 (2001) to 21 (2006), while the annual incidence of confirmed malaria cases per 1000 population decreased from 5.5 in 2003 to 3.19 in 2006. Artemesinin-based combination treatment was introduced in 2004 following increasing malaria-drug resistance. 2.4 Maternal, child and infant diseases The maternal mortality ratio (MMR) fell from 656 to 405 deaths per 100 000 live births from 1995 to 2005, the infant mortality rate (IMR) from 104 to 56 deaths per 1000 live births, and the under-five mortality rate (U5MR) from 170 to 97.6 (est. census 2005) deaths per 1000 live births. However, these numbers are probably underestimates. The IMR varies a great deal between provinces, with the lowest rate in Vientiane Capital (18) and the highest in Sekong (122). While the mortality rate in Vientiane Capital is only 26% of the national rate, Sekong has a mortality rate that is 183% higher than the average for the country. The latest National Health Survey shows that children have a two-week fever incidence rate of 2.9%, an ARI incidence rate of 3%, and a diarrhoea incidence rate of 6.2%. The Lao Reproductive Health Survey 2005 revealed that only 18.5% of deliveries take place with the participation of a trained birth attendant, only 11% of deliveries are in a health facility, and only 32% of children aged 12 to 23 months are fully immunized. The preliminary results of the Lao Reproductive Health Survey, conducted in 2005, were disseminated in late 2007. The survey shows a slow but significant improvement in intermediary health outcomes related to reproductive health. Progress was observed in usage of modern contraceptive methods (28.9% in 2000, to 36.6% in 2005, for married women). The total fertility rate has declined (4.88 between 1995 and 1999, to 4.07 between 2002 and 2005). This highlights the improvements in family planning observed over the period. Progress in antenatal care and skilled birth attendance has not been significant in the general population, despite some improvement in younger women. In 2005, the percentage of women not seeking antenatal care was 71.5, compared with 75.8 in 2000; 86% of women still deliver at home, compared with 89% in 2000; and only 18.5% were receiving assistance from skilled health workers, compared with 17.4 in 2000. 2.5 Burden of disease Tuberculosis prevalence was estimated at 71 smear-positive cases per 100 000 population in 2003. A total of 3041 smear-positive cases were reported in 2006, an increase from 2806 in 2005. The directly observed treatment, short-course (DOTS) programme reaches 100% of districts. The estimated smear-positive case-detection rate was 77% in 2006 and the treatment success rate was 85% in 2005. The most recent data show an intestinal helminth prevalence rate of 62% (2002) among schoolchildren. De-worming for children aged 12-59 months has now been established, with child-health days and a national measles campaign, reaching more than 500 000 children (>80%) in 2007. There is evidence to show that schistosomiasis has been re-emerging in southern parts of the country since control programmes have ended. Road accidents are a growing problem as traffic and the speed of vehicles due to road improvements increase. Mental health issues, particularly drug abuse, are also a growing concern. Other mental health and neurological diseases 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 iodization misses at least 7% of children, and vitamin A supplementation in the past has been far from universal. A new bi- annual child-health-day approach has been used recently, however, achieving >80% of the target COUNTRY HEALTH INFORMATION PROFILES | 175 600 000+ children aged six to 59 months, for both rounds, in 2007. The rate of exclusive breast- feeding at three months of age is only 28.1%. Food insecurity has also been pointed out as alarming by international partners like the World Food Programme (WFP). In 2006, WFP conducted a comprehensive food security and vulnerability study. The initial conclusions of the study pointed out that …”the chronic malnutrition in the Lao People’s Democratic Republic is at an alarmingly high level. Every second child in the rural areas is chronically malnourished, affecting, not only their physical development, but also their cognitive capacity”…”. ”Chronic malnutrition is as high today as it was 10 years ago. 30% of the rural households have either poor or borderline food consumption.” ”Sino-Tibetan ethnic groups are the most disadvantaged and food insecure, followed by the Hmong-Mien and the Austro-Asiatic.” There are no official national data available on risk factors for noncommunicable diseases (NCD). The national authorities are planning to conduct a STEP-wise approach survey (STEPS) for the assessment of national NCD risk factors in 2008, with WHO support. Tobacco and alcohol consumption remains a concern, although no actual figures on consumption and effects on public health are available. However, the Government has taken note of the risks related to their abuse and has made important efforts regarding prevention and control of alcohol and tobacco consumption. In 2006, major legal steps towards tobacco consumption control were taken, the country ratified the International Framework Convention on Tobacco Control, and a series of regulations was passed concerning health warnings on cigarette packs, importation of tobacco and smoke-free areas in the national University. In 2007, a law was drafted for national implementation of the Framework Convention. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The national health priorities are articulated in three documents: (1) the Health Strategy to the Year 2020; (2) the Lao Health Master Planning Study; and (3) the National Growth and Poverty Eradication Strategy (NGPES). The principles and visions of these documents have been included in the Sixth National Socio and Economical Development Plan (2006-10) (see paragraph 3.3) The Health Strategy to the Year 2020 was promulgated by the VIIth Party Congress in 2001 and 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 policies: • strengthening the ability of providers; • community-based health promotion and disease prevention; • hospital improvement and expansion at all levels, including remote areas; • promotion of traditional medicine, integration of modern and traditional care, rational use of quality and safe food and drugs, and national pharmaceutical product promotion; • operational health research; and • effective health administration and management, self-sufficient financial systems, and health insurance. 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 maternal and child health and immunization, decentralized service delivery methods, improved methods of health care financing, a unified and simplified health LAO PEOPLE'S DEMOCRATIC REPUBLIC 176 | COUNTRY HEALTH INFORMATION PROFILES information system, and an emphasis on quality improvement in the next five years, rather than quantity improvement, which was emphasized over the past five years. 3.2 Organization of health services and delivery systems The public health system is predominant, although a private alternative is growing. There are no private hospitals, but there are around 1865 private pharmacies and 254 private clinics, mainly in urban areas. The state system is underutilized, especially in the peripheral areas. In its efforts to increase access through village volunteers and village revolving drug funds, the Government has managed to reach 5226 villages. There are four administrative strata in the health system: central (ministry, college of health technology and reference/specialized centres), provincial (provincial health office, provincial and regional hospitals, and auxiliary nursing schools), district (district health offices and district hospitals) and village (health centres) levels. The main network for health care services provision remains the public system. In 2005, its health facilities consisted of four central teaching and referral hospitals; five regional hospitals, including one teaching hospital; 13 provincial hospitals; 127 district hospitals; and about 746 health centres. District hospitals are further classified as category A or B, category A meaning that the facilities have surgery capacities, unlike category B. A total of 5081 hospital beds were available in 2005, 0.9 beds per 1000 inhabitants. The Government has announced future autonomy for public health facilities. In 2007, the Lao Health Maintenance Organisation was created, which foresees the opening of the first fully private hospital in the country by 2009. 3.3 Health policy, planning and regulatory framework In 2001/2002, the Ministry of Health, with support from the Japan International Cooperation Agency (JICA), conducted the Lao Health Master Planning Study. The study identified seven ‘precedent programmes’ to be implemented and 31 ‘very high priority’ programmes in the fields of planning and management, human resource 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 in the study report and initial steps toward such coordination have been taken since 2005 with the support of the sectorwide coordination process financed by the Japanese Government in close collaboration with major donors, WHO and other United Nations agencies working in the health sector. A third major policy document is the National Growth and Poverty Eradication Strategy (NGPES). The NGPES focuses on poverty and the poorest districts, of which 72 poor, 47 poorest, and 10 for initial activities have been identified. The health priorities in the NGPES are: • information, education and communication for health; • expansion of the service network for the health promotion of people in rural areas; • improving and upgrading the capacity of health workers from village to post-graduate level, with an emphasis on ethnic minorities, gender balance, and incentives for retaining health workers in areas of shortage; • maternal and child health (MCH) promotion; • immunization; • water supply and environmental health; • communicable disease control; COUNTRY HEALTH INFORMATION PROFILES | 177 • control of sexually transmitted infections, including HIV/AIDS; • village revolving drug 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. To a large extent, all documents are superseded by the Sixth National Socio-Economical Development Plan (2006-10) (NSEDP), which was promulgated by the VIIIth Party Congress and the National Assembly in 2006. The NGPES has been fully integrated into the draft 6th NSEDP and serves as its core. The NSEDP was presented to and discussed widely with both internal and external partners, but there remains a large funding gap for implementation in all sectors, including health. Despite the constant fall in the share of health expenditure in the public budget and as a percentage of GDP, the Government has pledged to increase health spending within the framework of it policy dialogue with the Bretton-Woods institutions (World Bank and International Monetary Fund). A new constitutional article (2004) 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. In August 2007, the 6th National Health Conference (NHC) reviewed the achievements and implementation of the 2001-2005 National Health Plan and provided recommendations for the 2006-2010 five-year national plan. The actual strategy of the Ministry of Health is based on a "healthy village model" that will include the eight components of primary health care (PHC), as expressed in national PHC policy, and will provide health for all. It is aimed at enabling development from the grassroots level up. The 6th NHC calls for: (1) a general increase in funding for health; (2) establishment of the University of Health Sciences under the direct supervision of the Ministry of Health; (3) implementation of the Complex of Hospital-Insituto- Projecto-University (CHIPU); (4) creation of new posts; and (5) increased incentives for health workers in rural areas. 3.4 Health care financing Current estimated per capita health expenditure is US$ 19, about 80% coming from households, 10% from donors, and 10% from the Government. Hospitals are highly dependent on user fees for recurrent expenditure. There are nascent health insurances systems for both the formal and non-formal sectors and a civil service scheme is being reformed. Equity funds are under discussion and limited piloting has occurred. Health expenditure made up 3.3% of total government spending in 2006, and donor spending is estimated to have made up 52% of total public sector health spending in the same year. Salaries account for the bulk of domestic public expenditure on health (75.3%). 3.5 Human resources for health The Lao People’s Democratic Republic faces similar challenges to all low-income countries as regards issues of human resources for health (HRH): under-funding of salaries and wages, maldistribution of qualified staff among geographic and health system levels, limited number of qualified health workers, and low staff productivity. The country faces a general shortage of qualified health workers. The total health workforce in 2005 numbered 18 017 workers, corresponding to a ratio per 1000 inhabitants of 3.21. This included regular staff (civil servants) under the Ministry of Public Health, as well as contractual staff. It also included the health workers under the two other Ministries that manage non-public health facilities: the Ministry of Defence and the Ministry of Public Security. Around 70% of all LAO PEOPLE'S DEMOCRATIC REPUBLIC 178 | COUNTRY HEALTH INFORMATION PROFILES health workers are under the Ministry of Health. High- and mid-level medical staff under the Ministry of Health, defined as physicians, nursing staff and midwives with more than two years of formal training, account only for 23% (4123, i.e. 0.74 workers per 1000 inhabitants). Less then 50% of all health workers are in public health facilities managed by the Ministry of Health. The 8942 regular health workers under the Ministry work in hospitals, health centres and district health offices/hospitals, with district-level facilities accounting for the majority. However, the bulk of the staff at district level are mid- and low-level (88%) health workers. Physicians represent only 6% of district-level staff. Health centres are almost totally served by low- and mid- level staff, at respectively 81% and 18%. There are only eight doctors working in health centres. Maldistribution of staff, both geographically and by level of facility, accentuates the crisis. There are only 2992 regular high- and mid-level medical staff at health-facility level, corresponding to 0.53 workers per 1000 inhabitants, far below the recommended WHO target of 2.5. These workers tend to be concentrated in socioeconomically better-off regions to cope with the limitations of their salaries and wages. Rural areas, where living conditions are difficult, are not attractive to newly trained, competent workers. Compared with international standards, the productivity of health workers in the Lao People’s Democratic Republic could be considered low. This is mainly due to the lack of financial and material incentives available to them (In 2005, the average annual salary for health workers was estimated to be US$ 405.). This forces health workers to rely on coping strategies and secondary occupations to ensure their livelihood. This situation, combined with the limited number of new posts created in recent years (The workforce has grown more slowly than the population in the last decade.), limits the development of the health system and its response to the needs of the population. In 2007, with WHO support, a national HRH database was designed and tested. A national conference on HRH was held and the drafting of a framework for the development of HRH in the Lao People’s Democratic Republic was initiated. 3.6 Partnerships The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) has been a major contributor in the country, with more then US$ 45.5 million in grants allocated between 2003 and 2006. The majority of this funding was allocated to reducing the malaria disease burden (US$ 27.2 million). In total, at the actual approved state of proposals, the Global Fund will have made available more than US$ 62 million of the US$ 95 million requested. In 2007, the country applied for grants as part of Round 7 of the Global Fund call for proposals, and two of its proposals were assessed positively by the Fund’s Technical Review Panel. The requested funds amount to US$ 25.6 million to fight malaria and US$ 10.9 million to fight tuberculosis. Since 2002, the Global Alliance for Vaccination and Immunization (GAVI) has supported the Lao People’s Democratic Republic in immunization services and introduction of new vaccines. This support included the rolling out of DTP-HepB tetravalent vaccine to all districts (2004) along with injection-safety improvements. GAVI’s five-year estimated commitment to the country (2002-2007) currently stands at US$ 7.1 million. Other major health sector development partners and donors include: the Asian Development Bank, the World Bank, and the governments of Japan, Luxembourg and France. Avian influenza preparation has also beneficiated from the important support of Australia, the European Union and the United States of America. Most of the United Nations funds and specialized agencies are represented in the country. In 2006, the United Nations Country Team finalized with the national authorities the 2007-2011 United Nations Development Assistance Framework (UNDAF), based on the Common Country Assessment conducted in 2005. WHO led the health working group for the preparation of these COUNTRY HEALTH INFORMATION PROFILES | 179 documents. The UNDAF will be the leading guideline for actions carried out by the United Nations Country Team in future years. 3.7 Challenges to health system strengthening Underfinancing of the health sector is placing a major burden on the management and implementation of national policies for prevention and care. The efforts begun in recent decades to improve primary health care and respond to the demands of those populations most at need are still ongoing. Financial barriers to service access are important, which is not surprising in a country were around 70% of the population lives on less then US$ 0.4 a day. Risk-pooling and prepayment has been introduced through social security for the formal sector and health insurance for the public sector. Voluntary community schemes have been piloted and are now part of the national instruments for health care financing. However, all these instruments cover only a small part of the population. A road map to universal coverage stills need to be adopted and implemented, despite major efforts in recent years. For the poor, the Government has decided to pilot health equity funds to replace the former exemption policy, which has proved to be inefficient. The sustainability of such funds remains questionable, however, and their nationwide implementation will require national commitment and external resources. The main network for health care service provision remains the public system. There were a total of 5018 hospital beds in 2005, or 0.9 beds per 1000 inhabitants. The shortage of health workers is evident when the ratio of health workers per bed is analysed. This situation is worsened by the uneven distribution of staff among different types of health facility and the shortage of non- medical staff to implement essential administrative and support tasks. Central hospitals have high ratios of high- and mid-level medical staff (see paragraph 3.5) compared with other types of facility. In central hospitals the ratio of high- and mid-level medical staff per bed is 0.9, which could be considered good if there was not a very high doctor-to-nurse ratio (0.63 at central hospitals), which raises concerns that inefficiency in hospitals may have structural origins. Health worker productivity is low in most national hospitals for various reasons. At the moment only one province provides a comprehensive incentive system. Such a system at the national level might ensure health workers’ best performance and attract new staff to remote and difficult regions. Moving towards such an approach would, however, require a significant increase in the health budget and a reorientation of expenditure towards recurrent costs for national and donor funding sources. This would only be possible if transparency and accountability were to be reinforced and clear mechanisms for performance and quality assessment of the provided services established. Such efforts have been initiated by the Ministry of Health, but much still remains to be done. Coordination among sector donors and partners has improved in recent years, as shown through exercises like avian influenza pandemic and outbreak preparation and response. Following the 2005 Paris Declaration on Aid Effectiveness, donors and partners in the Lao People’s Democratic Republic signed the local Vientiane Declaration on Aid Effectiveness in November 2006. A task force was created to elaborate a country action plan for implementation of this declaration and to ensure harmonization and alignment among the signatories. The country action plan (CAP) was developed and approved by the Government and its partners in early 2007 and a first local survey for the Paris Declaration Monitoring Survey (OECD DAC) was conducted in parallel. The survey was a challenging process because of complexity of the task and the scarcity of reliable data, even at individual development-partner level. A significant number of development partners did not participate in the process, putting the collected information in question. The findings of the survey point out that much still has to be done to achieve the objectives of the Paris Declaration. Only 16% of capacity development interventions in the country were being carried out in a coordinated fashion, compared with the targeted 50%, and only 17% of total ODA had been disbursed following national procurement systems and procedures. On bilateral disbursement for the fiscal year 2005/2006, of US$ 223 million, only US$ 14 million was LAO PEOPLE'S DEMOCRATIC REPUBLIC 180 | COUNTRY HEALTH INFORMATION PROFILES reported to be for the health sector. The multilateral situation was little better, with US$ 22 million of US$ 245 million. The health sector therefore accounted for only 7.6% of the ODA disbursements. In order to operationalize the Vientiane Declaration on Aid Effectiveness in the health sector, the Ministry of Health has been engaged in developing a sectorwide coordination mechanism, according to the CAP. In November 2007, the structure of the new coordination mechanism for the health sector was presented by the Ministry. The new structure will include multiple layers of technical and policy dialogue between development partners and the Government. In 2007, the former Committee on Planning and Investment was converted into the Ministry for Planning and Investment (MPI) and the Directorate of International Cooperation (DIC) was transferred from the Ministry of Foreign Affaires to this newly created structure. The DIC is now responsible for supervising ODA in all sectors and for monitoring implementation of the CAP. Health information from surveillance and surveys still needs to be framed by national policy. WHO, and recently the Health Metrics Network, have supported the Government in developing a new health information system extending from village to district and provincial level. This system has been discussed widely with the major donors and project implementers nationwide, and has been adopted by the World Bank and ADB as a part of their support actions in the south and north of the country. However, nationwide implementation of the system still needs to be carried out and evaluated. Further, other aspects of the health information system still need to be reinforced, such as vital registration and information collection and analysis. Hospital financial management systems are being reinforced as part of the ‘good-governance’ efforts of the Government and the Ministry of Health, but they also need to be integrated into a broader information system to ensure timely, evidence-based decision-making. Prevention activities, like vaccinations, have been the centre of a major focus by the Ministry of Health in the last year. Immunization rates had been falling and corrective actions were needed. The trend has been reversed, but this has brought up certain questions about the adequacy of the health system in providing regular basic services to the population. The traditional outreach approach has been questioned and the primary barrier to the effective delivery of services is thought to be the absence of routine vaccination services at health centres and district hospitals (fixed sites). Integrating vaccination activities and other essential primary prevention and health care services for mother and child has been advocated as a solution to improve the situation. This is now one of the priorities of the Ministry of Health. A comprehensive package of services and the cost of providing it to the population in a constant and regular way still need to be defined. Several United Nations agencies, including WHO, are working on these issues. However, the implementation of this package will also need a change in the current financial- incentive approach, which relies on payment for outreach activities rather than on performance. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Population Census 2005 Operator : National Statistics Centre Specification : Includes the latest available official demographic data for Lao PDR Web address : http://www.nsc.gov.la/PopulationCensus2005.htm Title 2 : Lao Info 4.1 Operator : National Statistics Centre Specification : Povides a key statistical tool for monitoring the Millennium Development Goals (MDGs) Web address : http://www.nsc.gov.la/Lao_Info.htm Title 3 : World Bank country website Specification : Includes most recent links and documents produced by the World Bank on Lao PDR Web address : www.worldbank.org/lao COUNTRY HEALTH INFORMATION PROFILES | 181 Title 4 : Asian Development Bank country website Features : Includes most recent links and documents produced by the ADB on Lao PDR Web address : http://www.adb.org/LaoPDR/ Title 5 : Sixth National Socio Economic Development Plan (2006-2010) Operator : Committee for Planning and Investment Title 6 : United Nations Common Country Assessment for the Lao People’s Democratic Republic 2005 Operator : Government of Lao PDR and the United Nations System Web address : http://www.undplao.org/ Title 7 : United Nations Common Country Assessment for the Lao People’s Democratic Republic 2005 Operator : Government of Lao PDR and the United Nations System Web address : http://www.undplao.org/ Title 8 : Lao Reproductive Health Survey 2005 Operator : National Statistics Centre and UNFPA Features : Includes the latest available data on reproductive health in Lao PDR Web address : http://www.nsc.gov.la/ Title 9 : Nam Saat Central Web Site Operator : Nam Saat Central, MoH Features : Includes a repository of the main national regulations and legislation Specification : Web Site form the National Centre for Environmental Health and Water Supply Web address : http://www.nsc.gov.la/ Title 10 : National Round Table Process Web Site Operator : Department for International Cooperation, Ministry of Planning and Investment; United Nations Development Programme Features : Includes a repository of the main national regulations and legislation Specification : Web Site form the National Centre for Environmental Health and Water Supply Web address : http://www.nsc.gov.la/ 5. ADDRESSES MINISTRY OF HEALTH Office Address : Simuang Road, Vientiane, Lao People’s Democratic Republic Official Email Address : pomdohp@laotel.com (for Department of Prevention and Hygiene) Telephone : 856 (0)21 217607 Fax : 856 (0)21 214003 WHO REPRESENTATIVE IN THE LAO PEOPLE'S DEMOCRATIC REPUBLIC Office Address : 125 SaphanthongRd., Ban Saphanthongtai, Sisattanak District, Vientiane Postal Address : P.O. Box 343, Vientiane, Lao People’s Democratic Republic Official Email Address : who.laos@wpro.who.int Telephone : 856 (0)21 353 902, -3 & -4 Fax : 856 (0)21 353 905 Office Hours : 08:00 a.m. – 05:00 p.m. LAO PEOPLE'S DEMOCRATIC REPUBLIC 182 | COUNTRY HEALTH INFORMATION PROFILES 6. ORGANIZATIONAL CHART: Ministry of Health Year Source Demographics 1 236.80 2005 1 2 5 621.00 2 800.00 2 821.00 2005 1 3 2.10 … … 1995-2005 1 4 12.45 12.56 12.33 2005 1 26.56 27.44 26.67 2005 1 4.00 4.00 4.00 2005 1 5 27.10 … … 2005 1 6 34.30 … … 2005 1 7 9.80 … … 2005 1 8 2.77 a … … 2000 2 9 61.00 59.10 63.00 2005 1 … 9.60 10.10 2002 3 10 4.07 2002-2005 5 11 73.00 … … 2005 1 12 580.00 g 2007 7 13 5.70 2007 7 14 0.60 2005 8 15 … … … 16 … … … 17 632 … … 0 0 0 2002 10 10 … … 0 0 0 2002 10 61 … … 0 0 0 2002 10 … … … … … … … … … … … … 628 … … 0 0 0 2007 15 1 272 … … … … … 2002 10 4 943 … … 4 … … 2007 10 12 … … 0 0 0 2007 15 … … … … … … 150 … … … … … 2006 10 18 058 … … … … … 2006 10 0 0 0 0 0 0 2007 15 … … … … … … 1 246 … … … … … 2007 15 Communicable and noncommunicable diseases - Type E Hepatitis viral Cholera MaleTotal - Type A COUNTRY HEALTH INFORMATION PROFILES | 183 Syphilis - Type B - Type C Dengue/DHF Gonorrhoea - Unspecified Plague Selected communicable diseases Rate of growth of per capita GDP (%) Total Male FemaleFemale Number of deathsNumber of new cases Environmental indicators Total Urban Human development index Adult literacy rate (%) Typhoid fever Encephalitis Leprosy Proportion of vehicles using unleaded gasoline (%) Malaria Per capita GDP at current market prices (US$) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Total fertility rate (women aged 15–49 years) Rate of natural increase of population (% per annum) Urban population (%) Crude birth rate (per 1000 population) Estimated population ('000s) Annual population growth rate (%) Percentage of population - 0–4 years - 5–14 years COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision LAO PEOPLE'S DEMOCRATIC REPUBLIC Total Male Rural Crude death rate (per 1000 population) - 65 years and above Health care waste generation (metric tons per year) LAO PEOPLE'S DEMOCRATIC REPUBLIC Year Source 18 375 … … 3 … … 2007 15 19 4 925 … … 10 … … 2007 15 20 3 958 … … … … … 2006 10 3 041 … … … … … 2006 10 21 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 22 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 23 … … … … … … 24 … … … … … … 25 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 26 104 434 … … 4 083.17 … … 2000 6 18 096 … … 728.00 … … 2000 6 17 132 … … 690.00 … … 2000 6 12 987 … … 523.00 … … 2000 6 12 334 … … 496.49 … … 2000 6 4. Influenza Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections - New pulmonary tuberculosis (smear-positive) - Oesophagus Diabetes mellitus - Hypertension Leading causes of morbidity (inpatient care) Cancers All cancers (malignant neoplasms only) - Colon and rectum - Cervix - Breast - Rheumatic fever and rheumatic heart diseases Injuries 5. Diarrhoea 7. 6. 8. 9. Mental disorders Leading causes of mortality and morbidity Male Rate per 100 000 population All types - Homicide and violence - Motor and other vehicular accidents - Occupational injuries - Suicide - Leukaemia - Lip, oral cavity and pharynx - All forms Number of new cases DATA Number of deaths Male Female Number of cases Total Total FemaleMale 184 | COUNTRY HEALTH INFORMATION PROFILES Female Total Male FemaleTotal Circulatory - Cerebrovascular diseases - Liver - Stomach - Trachea, bronchus, and lung All circulatory system diseases - Acute myocardial infarction Tuberculosis INDICATORS - Ischaemic heart disease 1. Malaria 2. Pneumonia 10. 3. Gastritis LAO PEOPLE'S DEMOCRATIC REPUBLIC Year Source 27 996 … … 40.09 … … 2000 6 83 … … 3.34 … … 2000 6 34 … … 1.36 … … 2000 6 34 … … 1.36 … … 2000 6 33 … … 1.32 … … 2000 6 28 36.60 2005 5 29 26.00 2007 10 30 … 31 26.00 … … 2005 5 32 … … … 33 56.00 … … 2007 10 50.00 … … 2007 10 46.00 … … 2007 10 50.00 … … 2007 10 34 … … … … … … … … … … 35 NR NR NR NR NR NR 2007 10 2 … … … … … 2007 10 … … … … … … 1 678 … … … … … 2007 10 NR NR NR NR NR NR 2007 10 15 … … … … … 2007 10 13 … … … … … 2007 10 0 … … … … … 2007 10 1 … … … … … 2007 10 17 … … … … … 2007 10 2. Pneumonia Leading causes of mortality 1. Malaria - DTP3 5. Injury 8. 9. Percentage of pregnant women with anaemia 10. Percentage of women in the reproductive age group using modern contraceptive methods Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth Percentage of pregnant women immunized with tetanus toxoid (TT2) - Hepatitis B III Immunization coverage for infants (%) Maternal causes - Obstructed labour - Eclampsia - Haemorrhage - Abortion Selected diseases under the WHO-EPI - Diphtheria - Total Tetanus COUNTRY HEALTH INFORMATION PROFILES | 185 - Neonatal tetanus - Measles - Mumps Number of deaths Rate per 100 000 population Number of cases MaleTotal Total Total Male 7. 6. 4. Heart Failure - Rubella - Congenital rubella syndrome - Sepsis - Poliomyelitis - Hib meningitis Female Maternal, child and infant diseases - POL3 - BCG Male Male Female FemaleMale Female - Pertussis (whooping cough) Number of deaths DATA Female Total Total INDICATORS 3. Diarrhoea LAO PEOPLE'S DEMOCRATIC REPUBLIC Year Source 36 36 2007 16 37 Public health facilities 22 b 2 555 2005 11 3 c 160 2005 12 127 2 366 2005 12 746 1 658 2005 12 Private health facilities 0 0 2005 12 254 … 2008 18 38 106.01 2006 13 3.90 2006 13 18.86 2006 13 21.17 2006 13 20.20 2006 13 3.30 2006 13 52.00 a 2006 13 79.80 2006 13 10 655.20 2006 13 39 9.20 2007 14 Year Source 40 Physicians - Number 1 283 … … … … … … 2005 11 - Rate per 1000 population 0.23 … … … … … … 2005 11 Dentists - Number 83 … … … … … … 2005 11 - Rate per 1000 population 0.02 … … … … … … 2005 11 Pharmacists - Number 276 … … … … … … 2005 11 - Rate per 1000 population 0.05 … … … … … … 2005 11 Nurses - Number 5 291 d … … … … … … 2005 11 - Rate per 1000 population 0.93 … … … … … … 2005 11 Midwives - Number … … … … … … … - Rate per 1000 population … … … … … … … Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … 186 | COUNTRY HEALTH INFORMATION PROFILES Health infrastructure Facilities with HIV testing and counseling services Annual number of graduates - Hospitals - Outpatient clinics Health care financing - Primary health care centres - general government expenditure on health as % of total general government expenditure - amount (in million US$) - per capita total expenditure on health (in US$) Government expenditure on health F em al e T o ta l U rb an Health facilities Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals Health insurance coverage as % of total population INDICATORS INDICATOR - external resources for health as % of general government expenditure on health Number of bedsNumber DATA R u ra l P u b lic DATA P ri va te M al e Exchange rate in US$ of local currency is: 1 US$ = - general government expenditure on health as % of total expenditure on health External source of government health expenditure Private health expenditure - private expenditure on health as % of total expenditure on health Human resources for health LAO PEOPLE'S DEMOCRATIC REPUBLIC Year Source 41 Pharmacists 53 … … … … … … 2005 11 Nurses 30 e … … … … … … 2005 11 Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 40.00 … … 2000 6 44 56.00 … … 2005 5 45 68.00 … … 2005 5 46 40.00 … … 2007 10 47 405.00 2005 1 48 18.50 2005 5 7.50 2005 5 11.00 2005 5 49 38.40 … … 2005 5 50 … 51 Antenatal care coverage - At least one visit 28.50 2005 5 - At least four visits … 52 … 53 … … … 54 0.20 … … 2007 16 55 100.00 100.00 100.00 2007 16 56 319.00 … … 2006 10 57 0.36 … … 2006 10 58 75.50 … … 2006 17 59 … … … 60 292.00 … … 2006 10 61 24.00 … … 2006 10 62 77.00 … … 2006 10 63 85.00 … … 2006 10 64 60.00 86.00 53.00 2006 9 65 48.00 87.00 38.00 2006 9 66 … … … COUNTRY HEALTH INFORMATION PROFILES | 187 Proportion of population with access to affordable essential drugs on a sustainable basis Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Adolescent birth rate Tuberculosis prevalence rate per 100 000 population Percentage of people with advanced HIV infection receiving ART Annual number of graduates Workforce losses/ Attrition - Percentage of deliveries in health facilities (as % of total deliveries) Contraceptive prevalence rate Urban RuralTotal Infant mortality rate (per 1000 live births) Unmet need for family planning Estimated HIV prevalence in adults f Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Malaria incidence rate per 100 000 population Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures Proportion of population in malaria-risk areas using effective malaria treatment measures Tuberculosis death rate per 100 000 population Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Total Male INDICATORS DATA Female Health-related Millennium Development Goals (MDGs) Maternal mortality ratio (per 100 000 live births) Under-five mortality rate (per 1000 live births) DATAINDICATORS P u b lic P ri va te T o ta l M al e F em al e U rb an R u ra l HIV prevalence among population aged 15-24 years LAO PEOPLE'S DEMOCRATIC REPUBLIC … p est NR a b c d e f g 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 188 | COUNTRY HEALTH INFORMATION PROFILES Not included in the official list of MDG indicators Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] Provisional Includes only nurses trained at university. Due to a reformulation of the curricula there has not been any graduate from the nursing schools for the past two years. Figure refers to Atlas method Lao expenditure and consumption survey 2002/03. National Statistical Centre, March 2004. Lao PDR Economic Monitor, World Bank Office Laos, April 2008 Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world . United Nations Development Programme, New York USA 2007. Government of Lao PDR Official Gazette, State Budget Revenue - Expenditure: Implementation of FY 2006-2007 & Plan for FY 2007-2008 [http://hdr.undp.org/en/reports/global/hdr2007-2008/] World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: Refers to tertiary hospitals (central, regional and provincial) Refers to specialized hospitals at central level Not relevant Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific Includes medical assistants Estimate Notes: Data not available Not included in the official list of MDG indicators World Bank. Poverty Reduction Support Operation. Vientiane, April 2008 Population census 2005. National Statistical Centre, 2006 - http://www.nsc.gov.la/PopulationCensus2005.htm . Population and Housing Census Year 2005. Preliminary report, National Statistics Centre, September 2005. WHO Regional Office for the Western Pacific, data received from the technical units. Information furnished by National Ministry of Health, Department of Personal and Organization. Lao reproductive health survey 2000. National Statistical Centre 2001. World health report 2004. Changing history. Geneva, World Health Organization, 2004. Lao reproductive health survey 2005. National Statistical Centre 2007. Lao national health survey. National Statistical Centre and NIOPH, January 2001. Sources: National Centre for Laboratory and Epedemiology, Vientiane 2007 National Centre for HIV/AIDS, Vientiane 2007. Lao Ministry of Health, unpublished records, 2008 National Centre for Malaria, Parasitology and Entomology, Vientiane 2006 COUNTRY HEALTH INFORMATION PROFILES | 189 MACAO (CHINA) 1. CONTEXT 1.1 Demographics With an annual growth rate of 4.7%, Macao (China) had a year-end estimated resident population of 538 100 in 2007, 50.6% female and 49.4% male; 13.5% of the population were aged 0-14 and 7.1% were 65 years and above. The population density was 18 428 persons per square kilometre, with the entire resident population urban dwellers. In 2007, there were 4537 live births, up by 11.8% compared with 2006, while mortality decreased by 1.3% to 1545. The natural growth rate for the same year was 5.7, with a crude birth rate of 8.6 and a crude death rate of 2.9 per 1000 population. The infant mortality rate was 2.4 per 1000 live births and the under-five mortality rate 3.5 per 1000 live births, while the total fertility rate was 1.0 birth per woman (aged 15-49), with no recorded maternal mortality. Life expectancy at birth for males was 79.0 years in 2003-2006, and 83.8 years for females. Besides natural increases, migration flow is another important factor in determining population growth. In 2007, an estimated inflow of 22 500 persons was recorded, including legal and illegal immigrants from Mainland China, persons authorized to reside in Macao and non-resident workers. 1.2 Political situation Macao became a Special Administrative Region of the People’s Republic of China on 20 December 1999. The constitutional document, the Basic Law of the Macao Special Administrative Region, came into force on the same day. It stipulates the system to be practised in Macao, and lays down the political and administrative framework for 50 years from 1999. Under the Basic Law, Macao is entitled to a high degree of autonomy in all areas except defence and foreign affairs. The principles of “One country, two systems”, “Macao people governing Macao” and “a high degree of autonomy” have passed their initial tests with flying colours, and are now broadly recognized in Macao and infused into its social and political culture. The first Chief Executive, Edmund Ho Hau Wah, is currently serving his second term of office. The Government will soon begin preparing for the elections of the third-term Chief Executive and the fourth-term Legislative Assembly in 2009. 1.3 Socioeconomic situation With the support of Mainland China, the economy of Macao has remained strong. The real gross domestic product (GDP) growth rate for 2007 was 27.3% higher than for 2006 in real terms and per capita GDP rose by 26% year on year. Prosperity in the gaming and tourism sector has brought about a large amount of investment, which has soared on the back of the construction in gaming and tourism facilities and has become an impetus for economic growth, along with improvements in residents’ employment conditions and the rise in income-stimulated private consumption expenditure. Exports of services have continued to be bolstered by the growth in the number of tourists from Mainland China. On the other hand, the cancellation of the global textile and garment quota system and the weak economy in the Euro Zone have resulted in a fall in exports. The health expenditure share of GDP was 2.2% in 2006, less than the 2.6% in 2005, with government expenditure accounting for 69.3%. MACAO (CHINA) 190 | COUNTRY HEALTH INFORMATION PROFILES Macao has maintained sound economic and trade relations with more than 120 countries and regions, particularly with the European Union and Portuguese-speaking countries. In 2007, the total local labour force was estimated to be 309 800, of which 300 400 were employed, giving an unemployment rate of 3.1%, down by 0.7% compared with 2006; the underemployment rate held stable at 1.0%. 1.4 Vulnerabilities and hazards Located at the Pearl River Delta of the southeastern coast of Mainland China, Macao is humid and rainy in spring and summer. Thunderstorms and heavy rain always occur from May to September. Macao is occasionally hit by tropical storms, tropical cyclones and typhoons during summer and autumn, causing traffic disruption and, on occasions, major floods and landslips, but seldom casualties. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition 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. The HIV/AIDS incidence rate is increasing. 2.2 Outbreaks of communicable diseases There was a dengue fever outbreak in 2001. Outbreaks of influenza and norovirus gastroenteritis occur from time to time. 2.3 Leading causes of mortality and morbidity In 2007, cancer was the leading cause of mortality, followed by heart diseases; pneumonia and influenza; hypertension; diabetes mellitus; bronchitis, emphysema and asthma; nephritis; suicide, unintentional and adverse; and cerebrovascular diseases. Among the 1545 deaths, 32.2% were attributable to neoplasms, 23.9% to diseases of the circulatory system and 15.7% to diseases of the respiratory system. In terms of causes of morbidity, the top three most common notifiable diseases in 2007 were varicella (60.5%), tuberculosis of the lung (15.6%) and enterovirus infection (6.2%). Morbidity and mortality from most vaccine-preventable communicable diseases have remained very low for many years. 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%. 2.4 Maternal, child and infant diseases Maternal, child and infant care services are available in all highly accessible health centres, half of them equipped with prenatal ultrasound examination equipment. More than 95% of pregnant women receive prenatal care and almost 100% deliver in hospital. No maternal death was recorded during the period from 1992 to 2007. Diarrhoea among infants and children is common, but rarely causes death. COUNTRY HEALTH INFORMATION PROFILES | 191 2.5 Burden of disease A study in 1999 indicated injury and intoxication and cancer as the leading causes of potential years of life lost (PYLL) in Macao. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives In line with the Government’s policy of building a quality society, a long-term objective of Macao’s health authorities is to enhance the quality of medical and health care, thus safeguarding and improving the public’s health. The Health Bureau is tasked with coordinating the activities of public and private organizations in the domain of public health and assuring the health of citizens through specialized and primary health care services, as well as disease prevention and health promotion. 3.2 Organization of health services and delivery systems Medical and health service providers in Macao are classified as either governmental or nongovernmental. The former mainly include government health centres that provide primary health care, as well as the Conde S. Januário Hospital, which provides specialist medical services. Nongovernmental providers include medical entities subsidized by the Government and other institutions, such as Kiang Wu Hospital, the University Hospital, the Workers’ Clinic and Tung Sin Tong Clinic, as well as various private clinics and laboratories. The departments of Conde S. Januário Hospital include Inpatient, Outpatient, Emergency, Surgery, Intensive Care, Coronary Intensive Care, Burns Service, Physiotherapy and Rehabilitation Medicine, Haemodialysis and Peritoneal Dialysis, Medical Imaging, Laboratory, and Haematological Oncology. The 73 types of service offered by the Outpatient Department include anaesthesiology, cardiology, chest clinic, surgery, plastic and reconstructive surgery, dermatology, stomatology, gynaecology and obstetrics, haematological oncology, physiotherapy and rehabilitation, internal medicine, general medicine, nephrology, neurosurgery, ophthalmology, orthopaedics, otorhinolaryngology, paediatrics, psychiatry and urology. With regards to the private sector, there are two nongovernmental hospitals that play complementary roles in providing health care services. Founded in 1871, Kiang Wu Hospital has three departments: Emergency, Outpatient and Inpatient. It is a modern general hospital that integrates treatment, prevention, teaching and research. The University Hospital, established on 25 March 2006, integrates clinical services, teaching and scientific research, and is Macao’s first hospital dedicated to both Chinese and Western medicine. To realise the objective of “Health for All” advocated by WHO, Macao’s health authorities have established a primary health care network with health centres as the operational units offering all residents easy access to primary health care services in their own neighbourhoods. There are six health centres and two health stations distributed throughout the various districts of Macao. Of these, the Fai Chi Kei Health Centre and Areia Preta Health Centre also have traditional Chinese medicine clinics. By the end of 2007, 105 doctors (including general practitioners, practitioners of Chinese medicine and dentists) and 146 nurses had provided primary health care services to 449 657 outpatients during the year. Most outpatients had attended the adult health care, child health care and family planning clinics, which accounted for 59.6%, 13.5% and 9.0%, respectively, of total outpatient visits. 3.3 Health policy, planning and regulatory framework “A sound health care system and putting prevention first” is the Government’s policy. In particular, it focuses on promoting health education, disease-prevention awareness and a healthy lifestyle. MACAO (CHINA) 192 | COUNTRY HEALTH INFORMATION PROFILES The Health Bureau is a public entity, endowed with administrative, financial and patrimonial autonomy, under the supervision of the Secretary for Social Affairs and Culture. The Health Bureau’s task is to assure the health of citizens, prevent diseases, provide health care and rehabilitation services, train professional health workers, supervise and support entities in the health sector, and provide forensic services. 3.4 Health care financing The health system in Macao is financed mainly by the Macao Government, which attaches great importance to the resources allocated to medical and health care. In 2006, it spent US$ 224.6 million on related services, up by 5.9% from the US$ 212 million in 2005. The medical services provided by health centres and the Tung Sin Tong Clinic are basically free of charge. All legal residents of Macao, regardless of their age or occupation, are entitled to free services at health centres (except for physical check-ups required for driving licence applications or renewals) and supplementary check-ups at Conde S. Januário Hospital by referral from health centres. Nonresidents pay for such services according to rates established by the Health Bureau. 3.5 Human resources for health Human resources for health (HRH) planning in Macao is based on the Government’s policy objectives in terms of its programmes and activities. The Human Resources Department of the Health Bureau is responsible for collecting and compiling HRH opinions from sub-units of the Health Bureau, analysing human resource needs, integrating those needs and drawing up the annual human resources programme, and coordinating the recruitment of relevant human resources. According to the Public Administration Reform Roadmap of 2007-2009, the Macao Government is currently studying the feasibility of introducing a central recruitment system for the public services. For 2008, recruitment of medical personnel has been identified as one of the priorities, particularly specialized physicians for the Department of Accident and Emergency and the relevant manpower to launch an aged psychiatry service, as well as fulfilling the terms of the Framework Convention on Tobacco Control. At the same time, the health authorities are conducting a review of the existing grade structures of doctors and nurses, as well as diagnostic and therapeutic personnel. This is considered necessary given the rapid development and increasing medical and health care demands. People are the most important asset and assuring quality of care through provision of a more motivating and positive work environment is one of the key objectives of the reform. To remain in line with the development of Macao, collaboration with neighbouring countries and regions will be further enhanced, launching various training programmes in the health domain. 3.6 Partnerships Maintaining good communications and cooperation with nearby regions and international organizations is key to preventing infectious diseases and improving other health-related work. In 2006, the Macao Government continued to strengthen connections with the health authorities of the central Government of China, Guangdong Province and Hong Kong (China), and signed several mutual agreements. To strengthen exchanges of ideas and experiences in health care, the Fifth Joint Meeting of Senior Health Officials of the Mainland, Hong Kong and Macao was held in November 2006. There were in-depth discussions on issues such as emergency response cooperation, tobacco control, health systems, community health, traditional Chinese medicine and hospital management. Since the signing of Memorandum of Understanding in the Area of Health between the governments of Macao and Singapore in October 2005, the two have persisted in strengthening COUNTRY HEALTH INFORMATION PROFILES | 193 cooperation and information exchange, as well as developing and continuing all-round, multilevel academic exchanges, professional training and technical support. 3.7 Challenges to health system strengthening The health authorities continue to follow their policies and plans to create a favourable environment and conditions for medical consultation and to ensure that Macao residents receive a satisfying and convenient community medicare service, hence strengthening public health and improving the quality of life of the population. However, factors such as a population increase, population ageing, rising health consciousness among the public and changes in lifestyles, mean the demand for medical services is increasing continuously. In addition, driven by the completion of the construction of a series of tourism-resort facilities and a sports stadium, as well as the holding of large-scale international conferences and sports activities, the recent mobile population of Macao has grown rapidly. According to statistics, the resident population surged to 538 100 in 2007. Statistics from the Conde de S. Januário Hospital indicate that hospital admissions increased from 14 056 in 2003 to 15 746 in 2007, an increase of 12.%. Outpatient and emergency consultations were up by 27.4% and 12.9%, respectively. In 2007, the bed occupancy rate stood at 85.7%, and patients stayed at the hospital for an average of nine days. To respond to the rising demand for medical services, the health authorities are studying the feasibility of establishing a second public hospital in Taipa. Meanwhile, they intend to extend the service hours of two health centres and to hire more physicians from different regions. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Health statistics Operator : Statistics and Census Service Specification : Contains analyses and tables in relation to health care of Macao Web address : http://www.dsec.gov.mo/index.asp?src=/english/indicator/e_dem_indicator.html Title 2 : Principal statistical indicators Operator : Statistics and Census Service Specification : Provides principal statistical indicators of Macao. Web address : http://www.dsec.gov.mo/index.asp?src=/english/indicator/e_piem_indicator.html Title 3 : 2007 Macao in figures Operator : Statistics and Census Service Specification : Includes latest general information Web address : http://www.dsec.gov.mo/index.asp?src=/english/indicator/e_mn_indicator.aspx Title 4 : Macao yearbook 2007 Operator : Government Information Bureau Specification : Outlines major events, progresses and changes on a yearly basis Web address : http://yearbook.gcs.gov.mo 5. ADDRESSES HEALTH BUREAU Office Address : Estrada do Visconde de S. Januário, Macau Postal Address : Caixa Postal 3002 – Macau Official Email Address : seg@ssm.gov.mo Telephone : (853) 28313731 Fax : (853) 28713105 Website : http://www.ssm.gov.mo MACAO (CHINA) 194 | COUNTRY HEALTH INFORMATION PROFILES 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 : Director, Programme Management World Health Organization Regional Office for the Western Pacific United Nations Avenue P.O. Box 2932, 1000 Manila, Philippines Postal Address : P.O. Box 2932, 1000 Manila, Philippines Official Email Address : postmaster@wpro.who.int Telephone : (632) 528 8001 (632) 3031000 Fax : (632) 5260279 Office Hours : 7:00–15:30 Website : http://www.wpro.who.int 6. ORGANIZATIONAL CHART: Health Bureau Secretary for Social Affairs and Culture Director of Health Bureau 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) Year Source Demographics 1 0.03 2007 1 2 538.10 a 265.70 a 272.40 a 2007 1 3 4.70 … … 2007 1 4 3.40 3.60 3.20 2007 1 10.10 10.60 9.70 2007 1 7.10 6.30 7.80 2007 1 5 100.00 100.00 100.00 2007 1 6 8.60 … … 2007 1 7 2.90 … … 2007 1 8 0.60 … … 2007 1 9 81.50 79.00 83.80 2003-06 1 … … … 10 1.00 … … 2007 1 11 95.00 b 97.70 b 92.40 b 2007 1 12 36 357.00 … … 2007 1 13 20.40 … … 2007 1 14 0.93 2005 1 15 … … … 16 189 718.01 c … … 2007 1 17 8 5 3 0 0 0 2007 2 16 8 8 0 0 0 2007 2 18 16 2 0 0 0 2007 2 1 1 0 0 0 0 2007 2 0 0 0 0 0 0 2007 2 0 0 0 0 0 0 2007 2 8 6 2 0 0 0 2007 2 5 2 3 0 0 0 2007 2 21 d 13 7 0 0 0 2007 2 0 0 0 0 0 0 2006 4 0 0 0 0 0 0 2007 2 0 0 0 0 0 0 2007 2 10 7 3 0 0 0 2007 2 0 0 0 0 0 0 2007 2 Estimated population ('000s) Percentage of population COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Gonorrhoea Encephalitis Communicable and noncommunicable diseases Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) - Type B - Type C Dengue/DHF - Unspecified - Type E - 0–4 years Annual population growth rate (%) - 5–14 years Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above Urban population (%) Rate of natural increase of population (% per annum) Number of deaths Female COUNTRY HEALTH INFORMATION PROFILES | 195 Selected communicable diseases Number of new cases Total Typhoid fever Hepatitis viral Cholera - Type A Syphilis Leprosy Malaria Plague Per capita GDP at current market prices (US$) Environmental indicators Total Human development index Rate of growth of per capita GDP (%) Urban Rural Male FemaleMaleTotal MACAO (CHINA) Year Source 18 … … … 10 3 7 2007 2 19 … … … … … … 20 283 … … … … … 2006 4 127 … … … … … 2006 4 21 1 223 622 601 538 325 213 2006 2 138 138 27 27 2006 2 152 75 77 65 29 36 2006 2 40 10 2006 2 15 12 3 23 18 5 2006 2 29 16 13 15 11 4 2006 2 91 62 29 44 35 9 2006 2 68 53 15 65 54 11 2006 2 53 39 14 30 17 13 2006 2 164 109 55 126 85 41 2006 2 22 … … … 369 182 187 2007 2 … … … 26 17 9 2007 2 … … … 28 16 12 2007 2 … … … 145 69 76 2007 2 … … … 80 45 35 2007 2 … … … 4 1 3 2007 2 23 … … … 65 23 42 2007 2 24 … … … 5 3 2 2007 2 25 … … … 101 74 27 2007 2 … … … 7 5 2 2007 2 … … … 18 11 7 2007 2 … … … 1 0 1 2007 2 … … … 49 37 12 2007 2 26 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … - Motor and other vehicular accidents - Occupational injuries 7. 3. Female Total Male Female - Rheumatic fever and rheumatic heart diseases Injuries - Liver - Stomach - Hypertension All circulatory system diseases - Acute myocardial infarction Circulatory - Cerebrovascular diseases INDICATORS Male Number of deaths Total DATA Communicable and noncommunicable diseases Diarrhoeal diseases Mental disorders Diabetes mellitus - Trachea, bronchus, and lung Total Leading causes of mortality and morbidity Leading causes of morbidity (inpatient care) Number of cases Male - Suicide All types - Homicide and violence Acute respiratory infections Cancers - Lip, oral cavity and pharynx Tuberculosis - All forms - New pulmonary tuberculosis (smear-positive) - Colon and rectum - Cervix - Oesophagus - Breast - Leukaemia All cancers (malignant neoplasms only) 4. 5. 1. 2. 10. 6. 196 | COUNTRY HEALTH INFORMATION PROFILES 8. 9. Rate per 100 000 population Male FemaleTotalFemale Number of new cases - Ischaemic heart disease MACAO (CHINA) Year Source 27 488 284 204 92.82 109.61 76.50 2007 2 168 80 88 31.95 30.88 33.00 2007 2 151 69 82 28.72 26.63 30.75 2007 2 145 69 76 27.58 26.63 28.50 2007 2 65 23 42 12.36 8.88 15.75 2007 2 60 42 18 11.41 16.21 6.75 2007 2 53 24 29 10.08 9.26 10.88 2007 2 49 36 13 9.32 13.89 4.88 2007 2 33 26 7 6.28 10.03 2.63 2007 2 28 16 12 5.33 6.18 4.50 2007 2 28 … 29 … 30 … 31 1.50 1.70 1.40 2007 1 32 93.10 94.20 91.90 2007 1 33 99.70 … … 2007 2, 4 90.20 … … 2007 2, 4 90.00 … … 2007 2, 4 90.00 … … 2007 2, 4 34 … 0 2007 2 … 0 2007 2 … 0 2007 2 … 0 2007 2 … 0 2007 2 35 0 0 0 0 0 0 2007 2, 4 0 0 0 0 0 0 2007 2, 4 0 0 0 0 0 0 2007 2 0 0 0 0 0 0 2007 2, 4 54 32 22 0 0 0 2007 2, 4 0 0 0 0 0 0 2007 2, 4 0 0 0 0 0 0 2007 2, 4 0 0 0 0 0 0 2007 2, 4 4 2 2 0 0 0 2007 2, 4 0 0 0 0 0 0 2007 2, 4 2. Heart disease MaleFemaleTotal Total Number of deaths Female - POL3 - BCG - Rubella - Congenital rubella syndrome - Sepsis - Measles - Mumps Percentage of newborn infants weighing at least 2500 g at birth Percentage of pregnant women immunized with tetanus toxoid (TT2) - DTP3 Percentage of pregnant women with anaemia Neonatal mortality rate (per 1000 live births) Immunization coverage for infants (%) INDICATORS Leading causes of mortality Female TotalMale Maternal, child and infant diseases Female 8. Suicide 9. Unintentional injuries & adverse effects Total 5. Diabetes Mellitus 1. Malignant neoplasms 10. Cerebrovascular disease Total DATA Male Female - Total Tetanus COUNTRY HEALTH INFORMATION PROFILES | 197 Number of cases - Obstructed labour - Diphtheria - Eclampsia - Haemorrhage - Abortion Selected diseases under the WHO-EPI Male - Hepatitis B III - Hib meningitis - Pertussis (whooping cough) - Poliomyelitis - Neonatal tetanus Maternal causes Percentage of women in the reproductive age group using modern contraceptive methods 3. Pneumonia and influenza Male 7. Nephritis 6. Bronchitis, emphysema, asthma 4. Hypertension Number of deaths Rate per 100 000 population MACAO (CHINA) Year Source 36 3 2 37 Public health facilities 1 553 2007 1 0 0 2007 1 … … 8 g 0 2007 1 Private health facilities 2 602 2007 1 684 … 2007 2 38 323.90 2006 1 2.20 2006 1 648.70 2006 1 224.60 2006 1 69.30 2006 1 10.30 2006 1 … 30.70 2006 1 8.00 2006 3 39 … Year Source 40 Physicians - Number 1 666 h 981 685 1 666 360 1306 2007 1 - Rate per 1000 population 3.10 1.82 1.27 3.10 0.67 2.43 2007 1 Dentists - Number 177 126 51 177 13 164 2007 1 - Rate per 1000 population 0.33 0.23 0.09 0.33 0.02 0.3 2007 1 Pharmacists - Number 170 62 108 … … … 2006 2 - Rate per 1000 population 0.34 0.12 0.20 … … … 2006 2 Nurses - Number 1 335 82 1 253 1 335 783 552 2007 1 - Rate per 1000 population 2.48 0.15 2.33 2.48 1.46 1.03 2007 1 Midwives - Number … … … … … … - Rate per 1000 population … …. … … … … Paramedical staff - Number 1 207 456 751 1 207 … … 2006 1 - Rate per 1000 population 2.35 0.89 1.46 2.35 … … 2006 1 Community health workers - Number 817 279 538 817 … … 2006 1 - Rate per 1000 population 1.59 0.54 1.05 1.59 … … 2006 1 41 Physicians … … … … … … Dentists … …. … … … … Exchange rate in US$ of local currency is: 1 US$ = Human resources for health - private expenditure on health as % of total expenditure on health DATA 198 | COUNTRY HEALTH INFORMATION PROFILES Number of bedsNumber Health facilities Health care financing - total expenditure on health as % of GDP Annual number of graduates R u ra l P u b lic DATA U rb an Health insurance coverage as % of total population P ri va te INDICATORS Facilities with HIV testing and counseling services Health infrastructure - Hospitals - Outpatient clinics - Primary health care centres - General hospitals - Specialized hospitals - District/first-level referral hospitals Total health expenditure - amount (in million US$) - general government expenditure on health as % of total general government expenditure - amount (in million US$) - general government expenditure on health as % of total expenditure on health External source of government health expenditure Private health expenditure - external resources for health as % of general government expenditure on health T o ta l - per capita total expenditure on health (in US$) Government expenditure on health M al e F em al e INDICATOR MACAO (CHINA) Year Source 41 Pharmacists … … … … … … Nurses … …. … … … … Midwives … … … … … … Paramedical staff … …. … … … … Community health workers … …. … … … … 42 Physicians … … … … … … Dentists … …. … … … … Pharmacists … … … … … … Nurses … …. … … … … Midwives … … … … … … Paramedical staff … …. … … … … Community health workers … …. … … … … Year Source 43 … … … 44 2.40 3.00 1.80 2007 1 45 3.50 4.30 2.70 2007 1 46 89.90 … … 2007 2, 4 47 0.00 2007 1 48 100.00 2007 1 0.00 2007 1 100.00 2007 1 49 … … … 50 3.40 2007 1 51 Antenatal care coverage - At least one visit 89.20 e 2007 2 - At least four visits … 52 … … … 53 … … … 54 0.06 … … 2007 2 55 … … … 56 0.00 0.00 0.00 2007 1 57 0.00 0.00 0.00 2007 1 58 … … … 59 … … … 60 59.00 … … 2006 4 61 4.00 … … 2006 4 62 113.00 … … 2006 4 63 93.00 … … 2005 4 64 100.00 100.00 2007 1 65 100.00 100.00 2007 1 66 … … P ri va te HIV prevalence among population aged 15-24 years Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures P u b lic R u ra l Proportion of 1 year-old children immunised against measles Proportion of population using an improved sanitation facility Health-related Millennium Development Goals (MDGs) Proportion of population using an improved drinking water source Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) COUNTRY HEALTH INFORMATION PROFILES | 199 Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Adolescent birth rate Estimated HIV prevalence in adults a Malaria incidence rate per 100 000 population Percentage of people with advanced HIV infection receiving ART Unmet need for family planning DATA Female T o ta l M al e F em al e INDICATORS INDICATORS Annual number of graduates Workforce losses/ Attrition DATA Infant mortality rate (per 1000 live births) Maternal mortality ratio (per 100 000 live births) Total Male U rb an Prevalence of underweight children under five years of age Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Tuberculosis death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria treatment measures Tuberculosis prevalence rate per 100 000 population Contraceptive prevalence rate Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Total Urban Rural Proportion of population with access to affordable essential drugs on a sustainable basis MACAO (CHINA) … p est NR a b c d e f g h 1 2 3 4 200 | COUNTRY HEALTH INFORMATION PROFILES Sources: Notes: Data not available Provisional Estimate WHO Regional Office for the Western Pacific, data received from the technical units Statistics and Census Service, Macao, SAR Health Bureau, Macao (SSM) Monetory Authority of Macao Figure refers to general practitioners and practicitioners of Chinese medicine Not included in the official list of MDG indicators Figure refers to 6 health centres and 2 health stations dormitory and elderly home. Source form the Employment Survey of Statistics and Census Service, Macao SAR. Not relevant Figure refers to resident population Figure refers to resident population, but excludes the marine population and those residing in collective living quarters, such as military camp, hospital, prison, student Figure refers to 7 689.72 metric tons of general solid waste, 237.29 metric tons pathological solid waste and 181 791 m 3 liquid effluent from hospital Figure includes 1 case of unknown gender Figure refers to services provided by public health facilities COUNTRY HEALTH INFORMATION PROFILES | 201 MALAYSIA 1. CONTEXT 1.1 Demographics In 2007, the population of Malaysia was estimated to be 27 173 600. Covering an area of 329 876 square kilometres, the population density is 82.0 persons per square kilometre. Malaysia is a multiracial country consisting of Malays, Chinese, Indian and other ethnic groups. In 2007, an estimated 1 907 800 non-Malaysian citizens were living in the country. Malaysia has a young population, with 8 748 600 (32.2%) below the age of 15 years, while those aged 15-64 years account for 17 238 000 (63.4 %) and those 64 years or older for about 1 186 900 (4.4 %). Life expectancy at birth for both genders has increased over the years, rising from 56 years for males and 58 for females in 1957 to 71.9 years for males and 76.4 years for females in 2007. Over the same period, the crude death rate also fell from 12.4 per 1000 population to 5.0 in 1985 and further decreased to 4.5 in 2007. The crude birth rate in 2007 was 17.5 per 1000 population and the crude rate for natural increased was 13.2 per 1000 population. 1.2 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 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 early 2007, the Paramount Ruler has been Sultan Mizan Zainal Abidin, the Raja of Terengganu. 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 Y.A.B Dato’ Seri Haji Abdullah bin Ahmad Badawi (since 8 March 2008). 1.3 Socioeconomic situation Malaysia’s fifty years of nationhood marks another milestone in its economic development. Upon independence, the nation was highly reliant on tin and rubber and more than half of the population were living in poverty. Today, Malaysia is a broad-based and diversified economy. It is the 19th largest trading nation in the world, with trade in excess of RM 1 trillion. The country continues to enjoy political stability, with a diverse yet united population. At the same time, per capita income has increased 26 times to RM 22 345 (US$ 6725.98) and the incidence of poverty has been reduced to less than 6.0%. The 2007 Budget was formulated as a building block towards achieving the targets set in the 9th Malaysia Plan and onwards to realise Vision 2020. Towards this end, the National Mission articulates five key development policy thrusts: to move the economy up the value chain; to raise the capacity for knowledge and innovation and nurture ‘first class mentality’to address persistent socioeconomic inequalities constructively and productively; to improve the standard and sustainability of the quality of life; and to strengthen institutional and implementation capacity. MALAYSIA 202 | COUNTRY HEALTH INFORMATION PROFILES Therefore, the 2007 Budget was formulated with the theme ‘Implementing the National Mission towards Achieving the National Vision ’ to translate the National Mission into programmes and projects to sustain economic growth. In 2007, total expenditure is expected to increase by 14.8% to RM 164 743 million (US$ 49 574.67 million). The increased spending is based on better revenue performance from both tax and non-tax sources, which are expected to contribute RM 96 196 million (US$ 28 945.79 million) and RM 45 593 million (US$ 13 718.97 million), respectively, to total revenue in 2007. With increased expenditure matched by higher revenue, the Government will further consolidate the fiscal deficit at 3.2% of nominal GDP. This deficit will be secured by striking a balance between long-term economic growth and fiscal sustainability. The manufacturing sector is expected to pick up gradually and expand by 3.1%, following the anticipated recovery in global electronics demand in the second half of the year. On the demand side, growth will be driven by resilient public and private sector expenditure, following stronger consumer sentiment, business confidence and higher government spending. Nominal gross national product (GNP) is estimated to increase by 9.4% to RM 607 212 million (US$ 182 710.20 million), with per capita income increasing by 7.2% to RM 22 345 (US$ 6725.98) (2006: 9.9%, RM 20 841 [US$ 6271.06]). In terms of purchasing power parity (PPP), per capita income is expected to increase by 13.9% to reach US$ 13 289 in 2007 (2006: 13.00%; US$ 11 663). The total labour force in the fourth quarter of 2007 was 10 999 000 and the unemployment rate (% of the total labour force) was 3%. The Malaysian economy is expected to register robust growth in 2008, with real GDP expanding between 6% and 6.5%. This translates to a 6.8% growth in nominal per capita income, rising from RM 22 345 in 2007 to RM 23 864 in 2008 or in PPP terms from US$ 13 289 to US$ 14 206. With an unemployment rate of 3.3%, the economy will continue to operate under full employment. In tandem with the Government’s efforts to ensure fiscal sustainability, the fiscal deficit will continue to decline to 3.1% of GDP. Malaysia’s balance of payments position is expected to remain strong with the current account recording a surplus for the eleventh consecutive year. The current account surplus, amounting to 13% of GDP, will emanate from the goods and travel account. These developments augur well for all Malaysians and keep the nation on track towards realizing Vision 2020. 1.4 Vulnerabilities and hazards As a whole, Malaysia did not face any major catastrophes in 2007, except for a few incidences of flash flooding that affected certain parts of the country during heavy downpours. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition The top five main notifiable diseases in 2007 were dengue fever, tuberculosis, food poisoning, hand food and mouth disease (HFMD) and HIV/AIDS. The incidence rates were was 80.6 per 100 000 population for dengue fever, 61.9 per 100 000 for tuberculosis, 52.6 per 100 000 for food poisoning, 46.1 per 100 000 for HFMD, and 16.0 per 100 000 for HIV/AIDS. Malaysia has been classified by WHO as an intermediate-TB-burden country. In the last 20 years, the TB situation has stagnated, with a slight upward curve in 1999. In 2006, 26 877 new cases were registered and the incidence rate for TB (all forms) was 103.0 per 100 000 population. From 1986 until the end of 2007, a cumulative total of 80 966 HIV infections and 13 636 AIDS cases were reported., with 10 337 AIDS-related deaths. A total of 4577 new HIV infections, 1132 AIDS cases and 1182 AIDS-related death were reported in 2007. Case analysis shows that 89.8% of the total new cases in 2007 were in the age group 20-49 years. The Ministry of Health has COUNTRY HEALTH INFORMATION PROFILES | 203 introduced a harm-reduction programme as a new initiative to curb the spread of HIV among drug users. This programme consists of two components: the Needle and Syringe Exchange Programme (NSEP) and drug substitution therapy (DST). With the introduction of various national vaccination programmes, a significant decrease was observed in the incidence of specific vaccine-preventable diseases, such as whooping cough, with an incidence rate of 0.06 per 100 000 population. No case of diptheria was notified in 2007. The underlying causes of the NCD epidemic are demographic changes and an increase in the level of population risk factors resulting from social and economic changes. In 2005, an NCD survey was conducted to establish an NCD surveillance system that would provide information to determine the extent of NCD risk factors in the country. That survey collected a broad range of information on the sociodemographic status and NCD risk factors of people aged 25-64 years. The following prevalence rates were revealed: 25.7% for raised blood pressure; 11.0% for raised blood glucose; 53.5% for hypercholesterolemia; 31.6% for overweight; 16.3% for obesity; 48.6% for central obesity or abdominal obesity; 25.5% for current smokers; 60.1% for physical inactivity; 72.8% for non-meeting of dietary guidelines for vegetable and fruit intake; 12.2% for alcohol consumption; and 18.1%, 29.7%, 28.4%, 13.8% and 7.0%, respectively, for having one, two, three, four and more than four NCD risk factors. In 2007, 1 361 781 foreign workers were screened. Of these, 41 342 (3.03%) were certified as unsuitable to work in Malaysia. The number was slightly lower than in 2006 (45 368). Tuberculosis wss the most common disease found, with 16 240 cases (39.2%); followed by hepatitis B, with 10 957 cases (26.5%); sexually transmitted infections, with 2830 cases (6.8%); and HIV/AIDS, with 686 cases (1.6%). From the second report of the National Cancer Registry, compiled in 2003, it was found that the crude cancer rate for males was 97.4 per 100 000 population and 127.6 per 100 000 population for females. The age-standardized incidence rate for all cancers in 2003 was 134.3 per 100 000 males and 154.2 per 100 000 females. Cancer was occuring at all ages, with the median age at diagnosis in Malaysian males being 59 years, and 53 years for Malaysian females. The five most common cancers in children (0-14 years old) were leukaemia, cancers of the brain, lymphoma, and cancers of the connective tissue and kidney. In young adults (15-49 years old), the most common cancers were leukaemia, lymphoma, and cancers of the nasopharynx, lung, colon and rectum in men, and cancers of the breast, cervix, ovary, uterus, thyroid gland and leukaemia in women. In older subjects (50 years old and above), cancers of the lung, colon, rectum, nasopharynx, prostate and stomach were predominant among men, while cancers of the breast, cervix, colon, uterus, lung and rectum occurred commonly in women. The overall male crude cancer incidence rate of 97.4 per 100 000 population was lower than the female crude incidence rate of 127.6 per 100 000 population. The male-to-female ratio of cancer incidence was 1:1.3. The most common cancer in males in 2003 was cancer of the lung (13.8% of all male cancers), while among females, the most frequent cancer was cancer of the breast (31.0% of all female cancers). 2.2 Outbreaks of communicable diseases In 2007, 48 846 cases of dengue were reported, of which 46 095 (94.4%) were dengue fever and 2720(5.6%) dengue haemorrhagic fever. The dengue incidence rate was 179.2 per 100 000 population, compared with 144.7 per 100 000 population in 2006. Federal Territory, Kuala Lumpur showed the highest incidence rate, followed by the States of Selangor, Kelantan and Penang. There was also an increase in the number of episodes of food poisoning reported from various States, the majority of outbreaks occurring in schools. The major factor contributing to the outbreaks was unsafe food handling practices, which accounted for more than 50%. A committee within the Ministry of Education was set up to overcome these issues. MALAYSIA 204 | COUNTRY HEALTH INFORMATION PROFILES 2.3 Leading causes of mortality and morbidity The 10 top causes of admission to Ministry of Health hospitals in 2006 were normal deliveries (ICD-10: O80), which constituted 14.9% of total admissions; complications of pregnancy, childbirth and the puerperium (ICD-10: O00-O75, O81-O99), accounting for 12.4%; accident (ICD-10:V01-X59), 9.15%; diseases of the respiratory system (ICD-10:J00-J99), 7.3%; diseases of the circulatory system, 7.3%; certain conditions originating in the perinatal period, 6.6%; diseases of the digestive system, 5.2%; diseases of the urinary system, 3.8%; ill-defined conditions (symptoms and signs), 3.4%; and malignant neoplasm, 3.1%. The 10 top causes of death in Ministry hospitals in 2006 were septicaemia (16.8%); heart disease and disease of the pulmonary system (15.5%); malignant neoplasms (10.4%); cerebrovascular diseases (8.5%); pneumonia (5.7%); accidents (5.5%); diseases of the digestive system (4.5%); certain conditions originating in the perinatal period (4.2%); nephritis, nephritic syndrome and nephrosis (3.8%); and ill-defined conditions (3.0%). 2.4 Maternal, child and infant diseases The total fertility rate among Malaysian women is declining and was estimated to be 2.4 per woman in 2006. Socioeconomic development, together with efforts to promote health and expand family planning programmes, have resulted in rapid declines in fertility and mortality and increased the life span. Urbanization, late marriages and increased access to education and health care services, as well as more employment opportunities, have also contributed significantly to the decline in fertility. The national maternal mortality ratio showed a reduction from 280 per 100 000 live birth in 1957 to 30 per 100 000 live birth in 2006. There has also been a gradual trend of improvement in the infant mortality rate (from 13.1 per 1000 live births in 1990 to 6.6 in 2006), the perinatal mortality rate (from 13.0 per 1 000 live births in 1990 to 7.3 per 1 000 live births in 2006) and the toddler mortality rate (from 0.9 per 1 000 live births in 1990 to 0.5 per 1000 live births in 2006). 2.5 Burden of disease Both communicable and noncommunicable diseases remain a burden in Malaysia. The country has begun experiencing changing patterns in both types of disease. The top five diseases are dominated by noncommunicable disease, similar to the disease burden of a developed nation. However, some communicable diseases persist along with the rising incidence of noncommunicable disease. Mental illness has also become an increasing problem. In response to the situation, 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). Taking both mortality and morbidity into account, it was found that the five leading diseases in Malaysia are ischaemic heart disease followed by mental illness, cerebrovascular disease/stroke, road traffic injuries and cancers. It was also found that, in 2000, the top 30 diseases out of 111 studied accounted for 82% of the country's disease burden, or about 2.3 million DALY. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The vision of the Ministry of Health is that Malaysia is to be a nation of healthy individuals, families and communities, through a health system that is equitable, affordable, efficient, technologically appropriate, environmentally adaptable and consumer-friendly, with emphasis on quality, innovation, health promotion and respect for human dignity and which promotes individual responsibility and community participation towards an enhanced quality of life. COUNTRY HEALTH INFORMATION PROFILES | 205 The Ministry’s mission is to built partnerships for health to facilitate and support and motivate the people to: attain fully their potential in health, appreciate health as a value asset and take positive action to improve and sustain their health status to enjoy a better quality of life. 3.2 Organization of health services and delivery systems The Malaysian population is served by a dual health system where both the public and private sectors complement each other. While the Ministry of Health continues to play a pivotal role as the main provider of health services in the country, there is a need to harness the collective involvement of all stakeholders in health to improve the health of the nation. Health, ultimately, is the responsibility of every Malaysian. As the nation matures, so does the health system of the country. With growth, development and maturity, it is expected that greater demands will be made on the health system. In response to this, health care delivery by the public and private sectors must be sustainable and affordable to their clientele, as well as responsive to public expectations. Quality, efficiency and integration in all health matters must be the byword of all health care providers. To enable the nation to manage and deliver on heightened expectations, greater commitment and immense efforts within, between and among the public and private sectors are required to achieve better health through consolidation of services. This is the focus of the 9th Malaysia Plan. 3.3 Health policy, planning and regulatory framework Health planning in the Ministry of Health began in 1956 with the inception of the first Five-Year Malaya Plan (1956-1960). Subsequently, health planning has been carried out on a five-yearly cycle in the context of national long-term and medium-term plans. Each five-year Plan provides the direction for health and health-related agencies to address the health needs of the population. The need for a national health policy was identified at the mid-term review of the 6th Malaysia Plan. This idea was proposed to enhance integration among health and health-related agencies towards achieving desired national objectives, the Vision for Health and ultimately help to realize Vision 2020. Since then, several drafts of a ‘national health policy’ documents have been developed. In 2005, a national health policy framework was formulated and a draft entitled, The Malaysian National Health Policy Edition 1, 2007 (MNHP) was prepared. This draft delineated three main policy goals or objectives to be met over the next 15 years up to 2020 in the areas of: population health; national capacity building for health; and national capacity building towards competitiveness in the health market. As health is a shared responsibility, it is imperative that views from all relevant stakeholders in health be considered. A meeting on the National Health Policy, held in 2007 to discuss the proposed MNHP draft, saw active participation of members of 93 organizations from both the public and private sectors, including nongovernmental organizations. The proposed MNHP draft was amended, taking into consideration the input and recommendations of the participating organizations. The final draft was approved by the Planning and Policy Committee of the Ministry of Health, was subsequently endorsed by the Minister of Health and will be submitted to the Cabinet for approval. 3.4 Health care financing Since the 8th Malaysia Plan, the Ministry of Health Malaysia and the Economic Planning Unit (EPU) have renewed their efforts to develop a national health care financing mechanism. The need for such a mechanism was further emphasized in the 9th Malaysia Plan 2006-2010. In early 2005, engagement of a national health financing mechanism (NHFM) consultancy service was approved by the EPU. This consultancy service was funded by the United Nations Development Programme (UNDP) and a consultancy consortium was officially engaged in March 2006. A corollary study on the benefit package already being provided by government hospitals was also funded by UNDP and conducted by a consultant from the National University; the final report was submitted in May 2007. The outcome of this survey will be used as input in the development of the essential benefit package in the NHFM. MALAYSIA 206 | COUNTRY HEALTH INFORMATION PROFILES The NHFM project team will continue to work on development the NHFM design. Building blocks have been identified and a Gantt chart produced for the period 2008–2011. Both human resource and funds have been requested for the project. The activities to be implemented in the near future include health care costing studies,a public-perception survey, a survey on accuracy of diagnosis survey, and social marketing. Other major activities will include the development of essential benefit package options, an appropriate provider payment mechanism, legislation and social marketing, as well as institutional development (National Health Financing Authority). In order to strengthen the NHFM core team, emphasis is also being given to capacity building and human resource development. The Malaysia National Health Accounts Unit was established in 2005 with the main objective of providing the Government, on an annual basis, with information on total health expenditures for Malaysia, using a framework that is internationally accepted. Following the completion of the MNHA Project and upon recommendation of the Steering Committee, Malaysia is currently using a framework that has been adapted from Organization of Economics Cooperation and Development (OECD) countries. The first report on national health expenditures for the years 1997–2002 was published in 2006 and has been distributed to the main stakeholders of the health system, particularly the main data sources for MNHA. A policy dialogue was held in December 2006 with all main stakeholders. The MNHA unit is now under the supervision of the Planning and Development Division, Ministry of Health. 3.5 Human resources for health The optimal utilization of available resources for delivery of health services requires, among others, enhancement of human capital, consolidation of physical facilities and services, strengthening of primary health care, greater integration in health, intensification of quality, and enhancement of the stewardship and governance role of the Ministry of Health. There is a need to formulate and implement strategic human resource planning and managementmechanisms in terms of capacity and capability building. Research shows that investment in health promotion and prevention services is more efficient and effective in improving health status than investment solely in curative treatment. Therefore, in the 9th Malaysia Plan, priority in human resource allocation will have to be given to health promotion and prevention activities, with the correct number and category of personnel allocated to various fields. However, the quality and expertise of specialists in curative treatment cannot be ignored and must be improved in accordance with the needs of the population. Issues regarding the shortage and misdistribution of human resources, the ‘brain drain’ and carrier development must be given special emphasis. Presently, the Ministry of Health has more than 140 000 posts, with 149 service schemes, making it the third largest government agency. However, a large number of these posts remain empty, with an avereage of 3.2% being filled annually. Relatively rapid facility expansion that is out of step with the human resource planning process may have contributed to the vacancies. 3.6 Partnerships The health system consists of various stakeholders, the Ministry of Health, local government, the academic community, professional organizations, the private sector and others. The Ministry of Health works very closely with all these organizations to strengthen its health priority areas. Effective collaboration and coordination minimizes the gaps between agencies. Considering the marked improvement in health status of the nation and the existing issues and challenges, it is inevitable that great commitment and efforts will be required to achieve better health. Therefore, in view of the limited resources and the current urgency, the thrust of the 9th Malaysia Plan is more focused towards achieving better health through consolidation of services than the 8th Plan, which was geared towards greater integration in health and the promotion of partnerships. COUNTRY HEALTH INFORMATION PROFILES | 207 3.7 Challenges to health system strengthening Although the health sector makes up one the largest government agencies in the country, resources for health are not limitless. Due to resource constraints, not all the issues and challenges identified can be addressed with equal zest. Prioritization is vital if significant changes are to be achieved. The numerous issues and challenges faced by the nation have created a need for change and reform. A higher standard of living, demographic changes and rapid advances in medical technology have led to rising consumer demand for better health care using modern technology. Changes in the disease burden and disease pattern due to lifestyle are among the challenges facing the nation. Others include the need to enhance human capital, research and development, including research into vaccines and biotechnology and crisis and disaster management. The threats versus the opportunities of globalization, the liberalization of health, the harnessing of health technology and ICT, the strengthening of the health management information system, intersectoral coordination and collaboration and maximization of the role of the private sector and NGOs are also important challenges that need to be addressed. Realizing these issues and challenges, and to ensure that national health care provision meets required world class standards, the Ministry of Health strongly advocates the implementation of various quality assurance initiatives. Guided by the Vision for Health, the Mission of the Ministry of Health and Vision 2020, Malaysia is striving towards achieving a healthy and wealthy nation. At the onset of the 8th Malaysia Plan, the Government presented its national vision, outlining the country’s priorities for the next 10 years. It is essential that new knowledge, new technology and innovations are implemented appropriately and effectively. Currently, the 9th Plan has as its theme the achievement of better health through consolidation of services. To achieve this, six major goals have been set to ensure more efficient and equitable health. These are: to prevent and reduce the disease burden; to enhance the health care delivery system; to optimize resources; to enhance research and development; to manage crises and disasters effectively; and to strengthen the health information management system 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Social Statistics Bulletin Operator : Department of Statistics, Malaysia Specification : Includes Information on population, socioeconomic indicators Web address : www.statistics.gov.my Title 2 : Economic report 2007/2008 Operator : Treasury department Ministry of Finance, Malaysia Specification : Chapter 1, Economic Management and Outlook Web address : www.treasury.gov.my Title 3 : Country Health Plan, 9th Malaysia Plan 2006-2010 Operator : Planning and Development Division, MOH Specification : Framework of 9th Malaysia Plan, National Health Priorities, Programme and activities Title 4 : Draft of Disease Control Division Annual Report 2007 (Malay version) Operator : Disease Control Division, Ministry of Health Specification : Report on communicable and non communicable disease report, outbreaks of diseases Web address : www.dph.gov.my Title 5 : Drafts on women’s health for report on health status of the nation Operator : Family Health Division, Ministry of Health MALAYSIA 208 | COUNTRY HEALTH INFORMATION PROFILES Title 6 : Burden of Disease, Malaysia Operator : Public Health Institute Specification : Findings on Borden of Disease study base on 2000 data Title 7 : Second Report of the National Cancer Registry, Cancer Incidence in Malaysia, 2003 Operator : Clinical Research Centre (CRC) Specification : Findings on the incidence of Cancer in Malaysia Web address : http://www.crc.gov.my 5. ADDRESSES MINISTRY OF HEALTH Office Address : MINISTRY OF HEALTH Block E1, E6, E7 & E10, Parcel E Federal Government Complex Administrative Centre 62590 PUTRAJAYA, MALAYSIA Postal Address : As above Official Email Address : webmaster@moh.gov.my Telephone : Tel: 603-8883 3888 Office Hours : 7.30 am – 5.30 pm 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 COUNTRY HEALTH INFORMATION PROFILES | 209 6. ORGANIZATIONAL CHART: Ministry of Health MALAYSIA Year Source Demographics 1 329 876.00 2007 11 2 27 173.60 13 833.00 13 340.60 2007 1 3 1.90 … … 2006 1 4 11.45 5.91 5.54 2007 1 20.72 10.68 10.04 2007 1 4.36 2.03 2.33 2007 1 5 63.40 … … 2007 11 6 17.50 17.70 17.20 2007p 11 7 4.50 5.10 3.80 2007p 11 8 14.20 13.89 14.50 2007 est 2 9 74.05 71.90 76.40 2006 est 3 … 10.90 12.00 2002 est 13 10 2.40 2006 2 11 95.10 … … 2004 12 5 937.00 2007 3 13 5.30 2007 3 14 0.81 2005 14 15 … … … 16 … … … 17 94 … … 0 0 0 2007p 4 1 052 … … 18 … … 2007p 4 1 410 … … 26 … … 2007p 4 … … … … … … … … … … … … 133 … … 2 … … 2007p 4 22 980 … … 64 … … 2007p 4 30 … … 2 … … 2007p 4 644 … … 0 0 0 2007p 4 237 … … … … … 2006 12 5 294 … … 22 … … 2006 12 0 0 0 0 0 0 2007p 4 855 … … 1 … … 2007p 4 323 … … 6 … … 2007p 4 Typhoid fever Encephalitis Leprosy Malaria Plague 210 | COUNTRY HEALTH INFORMATION PROFILES COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male - 0–4 years - 5–14 years Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above Adult literacy rate (%) Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Annual population growth rate (%) Percentage of population Estimated population ('000s) Socioeconomic indicators Rate of natural increase of population (% per annum) Urban population (%) Total fertility rate (women aged 15–49 years) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Number of deaths Female Male FemaleMaleTotal Number of new cases Total Urban Rural Selected communicable diseases - Type A Syphilis Per capita GDP at current market prices (US$) Environmental indicators Total Human development index Rate of growth of per capita GDP (%) - Type C Dengue/DHF Gonorrhoea - Unspecified Cholera Communicable and noncommunicable diseases - Type E Hepatitis viral - Type B MALAYSIA Year Source 18 75 544 41 446 34 098 2 385 1 432 953 2006 5 19 … … … … … … 20 26 877 … … … … … 2006 12 11 798 … … … … … 2006 12 21 59 363 27 447 31 916 4 229 2 355 1 874 2006 5 8 157 77 8 080 409 2 407 2006 5 8 387 4 711 3 676 376 234 142 2006 5 3 164 126 2006 5 860 552 308 91 62 29 2006 5 5 598 3 397 2 201 277 165 112 2006 5 3 793 2 627 1 166 251 173 78 2006 5 1 948 1 368 580 320 232 88 2006 5 1 448 892 556 167 110 57 2006 5 5 672 4 148 1 524 842 643 199 2006 5 22 138 111 77 426 60 685 9 977 5 851 4 126 2006 5 10 924 7 949 2 975 1 800 1 177 623 2006 5 19 359 11 084 8 275 3 445 1 880 1 565 2006 5 36 533 15 911 20 622 146 80 66 2006 5 43 703 29 101 14 602 3 613 2 283 1 330 2006 5 3 641 1 908 1 733 70 29 41 2006 5 23 41 579 18 850 22 729 404 190 214 2006 5 24 28 866 19 256 9 610 8 4 4 2006 5 25 156 976 117 229 39 738 2 122 1 741 381 2006 5 6 201 4 229 1 972 54 42 12 2006 5 85 109 65 376 19 733 1 675 1 400 275 2006 5 … … … … … … 3 073 1 055 1 982 84 53 31 2006 5 26 283 757 c 2 170 c 2006 5 235 734 c 1 803 c 2006 5 173 801 c 125 527 c 48 274 c 652 c 925.50 c 369.10 c 2006 5 138 686 c 77 996 c 60 690 c 521 c 575.00 c 464.00 c 2006 5 138 111 c 77 426 c 60 685 c 518 c 570.90 c 464.00 c 2006 5 124 466 c 66 823 c 57 643 c 467 c 492.70 c 440.80 c 2006 5 98 955 c 57 908 c 41 047 c 372 c 427.00 c 313.90 c 2006 5 71 173 c 36 007 c 35 166 c 267 c 265.50 c 268.90 c 2006 5 65 311 c 34 784 c 30 527 c 245 c 256.50 c 233.40 c 2006 5 59 363 c 27 447 c 31 916 c 223 c 202.40 c 244.10 c 2006 5 COUNTRY HEALTH INFORMATION PROFILES | 211 - Suicide 1. Normal delivery (single spontaneous delivery) 2. Complications of pregnancy, childbirth and the puerperium 10. Malignant neoplasms 7. Diseases of the digestive system 3. Accidents (accidental injury) All types - Homicide and violence - Motor and other vehicular accidents - Occupational injuries 6. Certain conditions originating in the perinatal period 8. Diseases of the urinary system Tuberculosis - All forms - Stomach - Trachea, bronchus, and lung Mental disorders Diabetes mellitus - Breast - Rheumatic fever and rheumatic heart diseases INDICATORS DATA Cancers All cancers (malignant neoplasms only) - Hypertension All circulatory system diseases - Acute myocardial infarction Circulatory - Cerebrovascular diseases - Liver - Leukaemia Total Number of new cases Total Male Total Male Female Number of deaths Female Male Number of cases Female Rate per 100 000 population - Lip, oral cavity and pharynx - New pulmonary tuberculosis (smear-positive) Injuries Leading causes of mortality and morbidity 9. Ill-defined conditions (symptoms and signs) Leading causes of morbidity (inpatient care) 4. Diseases of the respiratory system 5. Diseases of the circulatory system - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections (J00-J22) - Ischaemic heart disease FemaleTotal Male MALAYSIA Year Source 27 6 819 d 3 761 d 3 058 d 25.60 d 27.70 d 23.40 d 2006 5 6 282 d 3 792 d 2 490 d 23.60 d 28.00 d 19.00 d 2006 5 4 229 d 2 355 d 1 874 d 15.90 d 17.40 d 14.30 d 2006 5 3 445 d 1 880 d 1 565 d 12.90 d 13.90 d 12.00 d 2006 5 2 315 d 1 415 d 900 d 8.70 d 10.40 d 6.90 d 2006 5 2 251 d 1 831 d 420 d 8.50 d 13.50 d 3.20 d 2006 5 1 809 d 1 268 d 541 d 6.80 d 9.40 d 4.10 d 2006 5 1 721 d 960 d 761 d 6.50 d 7.10 d 5.80 d 2006 5 1 526 d 858 d 668 d 5.70 d 6.30 d 5.10 d 2006 5 1 223 d 768 d 455 d 4.60 d 5.70 d 3.50 d 2006 5 28 4.30 2006 8 29 90.00 2006 12 30 1.90 2006 7 31 3.90 … … 2006p 9 32 89.90 … … 2006p 9 33 95.00 e … … 2006 12 90.00 e … … 2006 12 90.00 e … … 2006 12 90.00 e … … 2006 12 34 36 364 6 2006 5 429 4 2006 5 8 137 1 2006 5 1 578 0 2006 5 118 2 2006 5 35 … … … … … … 2 … … 0 0 0 2007 4 … … … … … … 972 … … 0 0 0 2007p 4 … … … … … … … … 14 … … 0 0 0 2007p 4 15 … … 0 0 0 2007p 4 0 0 0 0 0 0 2007p 4 … … … … … … 36 … … 1 … … 2007p 4 212 | COUNTRY HEALTH INFORMATION PROFILES INDICATORS 3. Malignant neoplasms Leading causes of mortality 2. Heart diseases and diseases of pulmonary circulation Number of deathsNumber of cases Maternal, child and infant diseases Percentage of pregnant women with anaemia 10. Ill defined conditions Selected diseases under the WHO-EPI - Total Tetanus - Neonatal tetanus Total DATA Total Female Total MaleFemale FemaleMale - Rubella - Congenital rubella syndrome Male FemaleTotal Male Female Total 1. Septicaemia - Abortion 8. Certain conditions originating in the perinatal period 9. Nephritis, ephritic syndrome and nephrosis - Obstructed labour Percentage of women in the reproductive age group using modern contraceptive methods Maternal causes - Eclampsia - Haemorrhage - Sepsis - Diphtheria - Measles Immunization coverage for infants (%) - POL3 - BCG - DTP3 - Pertussis (whooping cough) - Poliomyelitis - Hepatitis B III - Hib meningitis 5. Pneumonia - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth 7. Diseases of the digestive system Male 6. Accident 4. Cerebrovascular diseases Number of deaths Rate per 100 000 population MALAYSIA Year Source 36 … 37 Public health facilities 14 13 290 2007 6 6 18 145 2007 6 116 5 058 2007 6 2848 0 2007 6 Private health facilities 195 11 291 2007 6 5950 0 2007 6 38 6 655.86 2006 est 15 4.30 2006 est 15 254.88 f 2006 est 15 3 009.54 2006 est 15 45.20 2006 est 15 7.00 2006 est 15 0.09 f 2006 est 15 54.80 2006 est 15 3.67 2006 15 39 … Year Source 40 Physicians - Number 23 738 … … … … 14 298 9440 2007p 6 - Rate per 1000 population 0.87 … … … … 0.53 0.35 2007p 6 Dentists - Number 3165 … … … … 1540 1625 2007p 6 - Rate per 1000 population 0.12 … … … … 0.06 0.06 2007p 6 Pharmacists - Number 4292 … … … … 889 3403 2007p 6 - Rate per 1000 population 0.15 … … … … 0.03 0.13 2007p 6 Nurses - Number 48 196 0 48 196 … … 36 150 12 766 2007p 6 - Rate per 1000 population 1.77 0.00 1.77 … … 1.33 0.47 2007p 6 Midwives - Number 16 883 0 16 883 … … 16 550 333 2007p 6 - Rate per 1000 population 0.62 0.00 0.62 … … 0.61 0.01 2007p 6 Paramedical staff - Number 7948 … … … … 7411 537 2007p 6 - Rate per 1000 population 0.29 … … … … 0.27 0.02 2007p 6 Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … COUNTRY HEALTH INFORMATION PROFILES | 213 Exchange rate in US$ of local currency is: 1 US$ = External source of government health expenditure - private expenditure on health as % of total expenditure on health - external resources for health as % of general government expenditure on health Human resources for health Health insurance coverage as % of total population INDICATOR Private health expenditure Number of bedsNumber R u ra l P u b lic DATA U rb an DATA P ri va te M al e F em al e T o ta l - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals INDICATORS Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) Health facilities - Specialized hospitals - District/first-level referral hospitals - Primary health care centres - general government expenditure on health as % of total expenditure on health - per capita total expenditure on health (in US$) Government expenditure on health Health care financing Facilities with HIV testing and counseling services Health infrastructure - Hospitals - Outpatient clinics Annual number of graduates MALAYSIA Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 10.10 … … 2006 9 44 6.30 6.70 5.9. 2007p 11 45 8.10 8.70 7.50 2007p 11 46 90.00 e … … 2006 12 47 30.00 2006 2 48 100.00 2006 7 2.60 2006 7 97.40 2006 7 49 4.30 … … 2006 8 50 … 51 Antenatal care coverage - At least one visit 60.20 2006 7 - At least four visits … 52 … … … 53 0.10 … … 2006-07 12 54 0.30 … … 2007 12 55 35.00 … …. 2007 12 56 20.00 … … 2006 12 57 0.80 … … 2006 12 58 … … … 59 … … … 60 125.00 … … 2006 12 61 17.00 … … 2006 12 62 80.00 … … 2006 12 63 69.00 … … 2005 12 64 99.00 100.00 96.00 2006 10 65 94.00 95.00 93.00 2006 10 66 … … … 214 | COUNTRY HEALTH INFORMATION PROFILES INDICATORS DATA Female M al e F em al e P u b lic P ri va te U rb an R u ra l HIV prevalence among population aged 15-24 years INDICATORS Malaria incidence rate per 100 000 population Health-related Millennium Development Goals (MDGs) T o ta l Total Male DATA Unmet need for family planning Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Adolescent birth rate - Percentage of deliveries in health facilities (as % of total deliveries) Infant mortality rate (per 1000 live births) Maternal mortality ratio (per 100 000 live births) Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Proportion of population in malaria-risk areas using effective malaria treatment measures Proportion of population with access to affordable essential drugs on a sustainable basis Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of population using an improved sanitation facility Total Urban Rural Proportion of births attended by skilled health personnel Estimated HIV prevalence in adults a Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Tuberculosis death rate per 100 000 population Tuberculosis prevalence rate per 100 000 population Percentage of people with advanced HIV infection receiving ART Contraceptive prevalence rate Proportion of population using an improved drinking water source Workforce losses/ Attrition Annual number of graduates Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures MALAYSIA … p est NR a b c d e f 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 COUNTRY HEALTH INFORMATION PROFILES | 215 Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world. United Nations Development Programme, New York USA 2007. World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation : Figure refers to probable and confirmed deaths WHO Regional Office for the Western Pacific, data received from technical units The World health report 2004, Changing history . Geneva, World Health Organization, 2004. Figure refers to leading causes of hospitalization in Ministry of Health (MOH) hospitals Figure refers to leading causes of mortality in Ministry of Health (MOH) hospitals Revised data Sources: HIMS Subsystem Report, Family Planning, Health Informatics Centre (HIC), Planning & Development Division, Ministry of Health, Malaysia World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf] Social Statistics Bulletin,Malayisa 2007, Department of Statistics Vital Statistics Malaysia, Special Edition(2001-2006), Department of Statistics Statistics Handbook, Malaysia 2007, Department of Statistics Disease Control Division, Ministry of Health, Malaysia HIMS Subsystem Report, Medical Care, Health Informatics Centre (HIC), Planning & Development Division, Ministry of Health, Malaysia. Health Facts 2007 (draft), Health Informatics Centre, Ministry of Health, Malaysia HIMS Subystem Report, Family Health, Health Informatics Centre (HIC), Planning & Development Division, Ministry of Health, Malaysia Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] Department of Statistics, Malaysia [http://www.statistics.gov.my] Estimate Provisional Notes: Data not available [http://hdr.undp.org/en/reports/global/hdr2007-2008/] Health Facts 2006, Ministry of Health, Malaysia Not relevant Not included in the official list of MDG indicators Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific 216 | COUNTRY HEALTH INFORMATION PROFILES MARSHALL ISLANDS 1. CONTEXT 1.1 Demographics The Republic of the Marshall Islands covers an area of 181 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 Millennium Development Goals. 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. 1.2 Political situation During the last election, conducted in November 2003, President, H.E. Kessai Note and ten ministers were elected and assumed their portfolios. The Minister for Health and Environment is the Honourable Alvin Jacklick. The legislative branch of the 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 and picks cabinet members from the Nitijela. The Republic of the Marshall Islands has four court systems: the Supreme Court, the 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. Citizens of the Marshall Islands live with a relatively new democratic political system combined with a hierarchical traditional culture. The first two presidents were chiefs, while the current one COUNTRY HEALTH INFORMATION PROFILES | 217 is a commoner. The new Government, running on a reform platform, has publicly confirmed its commitment to an independent judiciary. 1.3 Socioeconomic situation Government assistance from the United States of America is the mainstay of this tiny island economy. Agricultural production, primarily subsistence, is concentrated on small farms; the most important commercial crops are coconuts and breadfruit. Small-scale industry is limited to handicrafts, tuna processing and copra. The tourist industry, now a small source of foreign exchange employing less than 10% of the labour force, remains the best hope for future added income. The islands have few natural resources, and imports far exceed exports. Under the terms of the Amended Compact of Free Association, the United States will provide millions of dollars per year to the Marshall Islands (RMI) until 2023, at which time a Trust Fund made up of United States and RMI contributions will begin perpetual annual payouts. Government downsizing, drought, a drop in construction, the decline in tourism, and less income from the renewal of fishing licenses have held gross domestic product (GDP) growth to an average of 1% over the past decade. 1.4 Vulnerabilities and hazards The country is affected by rising a sea level, desertification, pollution from ships, coral reef erosion and infrequent typhoons. Bikini and Enewetak atolls are former United States nuclear tests sites (67 atmospheric bomb tests from 1946 to 1958). 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition 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 disease, 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 its citizens. Other health-related issues include the need to reduce population growth, urban population density and 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. 2.2 Outbreaks of communicable diseases No available information. 2.3 Leading causes of mortality and morbidity The latest available data (1999-2004) on major causes of morbidity and mortality still refer to communicable diseases, but cancer and other noncommunicable diseases are anecdotally emerging as the leading causes of disease and death. 2.4 Maternal, child and infant diseases Sepsis and prematurity are reported as major causes of mortality among children under 12 months of age, whereas severe malnutrition, drowning and vehicular accidents accounted for the majority of child deaths in 2004. No data are available on the prevalence of childhood diseases. 2.5 Burden of disease No available information. MARSHALL ISLANDS 218 | COUNTRY HEALTH INFORMATION PROFILES 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The overarching principle guiding the activities of the Ministry of Health is stated in its mission statement: “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.” 3.2 Organization of health services and delivery systems Medical and Health Services in the Marshall Island are delivered in two distinct settings: hospitals—in the urban areas of Majuro and Ebeye—and medical dispensaries on the outer islands. 3.3 Health policy, planning and regulatory framework 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 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. 3.4 Health care financing In 2006, government expenditure on health amounted to US$ 18 million, equivalent to 15.1% of the nation’s total government expenditure. In line with its mission statement, the Ministry of Health continues to explore avenues to provide the best quality health care possible to the population despite its meagre funding and limited human and capital resources. A significant proportion of health services are funded under external aid or grant programmes, including United States Federal Health Grants and grants under the Compact of Free Association between the Marshall Islands and the United States of America. 3.5 Human resources for health In 2004, the health work force comprised 31 physicians, 4 dentists, 2 pharmacists, 115 nurses, 7 nursing/auxiliary staff, 53 other paramedical staff and 97 other health personnel. COUNTRY HEALTH INFORMATION PROFILES | 219 3.6 Partnerships No available information. 3.7 Challenges to health system strengthening The reliability of data, staff turnover and migration, and donors’ multiple reporting requirements are current challenges. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Fifteen Year Strategic Plan 2001-2015 Operator : Ministry of Health and Environment, April 2000 Title 2 : Ministry of Health annual report 2004-"Health is a shared responsibility" Operator : Ministry of Health and Environment Title 3 : Ministry of Health statistical abstract 1999-2001 Operator : Ministry of Health and Environment Title 4 : Statistical yearbook 2003. Operator : Economic Policy Planning and Statistics Office Title 5 : Economic Policy, Planning and Statistics Office (EPPSO) interview Web address : http://www.spc.int/prism Title 6 : CIA world fact book Web address : http://www.cia.gov 5. ADDRESSES MINISTRY OF HEALTH 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 : 0800 – 1200 and 1300 – 1700 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@sp.wpro.who.int Telephone : (679) 3-304600/ 3-304631 Fax : (679) 3-300462 MARSHALL ISLANDS 220 | COUNTRY HEALTH INFORMATION PROFILES 6. ORGANIZATIONAL CHART: Ministry of Health Year Source Demographics 1 0.18 2006 1 2 55.98 28.65 27.33 2006 est 1 3 1.00 … … 2006-10 1 4 12.30 12.30 12.40 2007 est 2 22.30 22.20 22.40 2007 est 2 5.10 4.70 5.40 2007 est 2 5 67.00 … … 2007 est 3 6 24.70 a,b … … 2004 est 4 7 4.05 a,b 5.56 a,b 4.04 a,b 2004 est 4 8 2.07 a … … 2004 est 4 9 … 67.00 70.60 2004 5 … 9.80 10.70 2002 6 10 … 11 … … … 12 2 426.00 FY2004 7 13 … 14 … 15 … … … 16 … … … 17 12 … … … … … 2002 8 31 … … … … … 2002 8 … … … … … … … … … … … … … … … … … … 0 0 0 0 0 0 2005 9 0 0 0 0 0 0 2005 9 … … … … … … 230 … … … … … 2002 8 42 … … … … … 2006 9 … … … … … … … … … … … … 172 … … … … … 2004 5 14 … … … … … 2005 9 Communicable and noncommunicable diseases - Unspecified Cholera Typhoid fever Plague Encephalitis Syphilis Total RuralUrban MaleTotal Number of deathsNumber of new cases Male Female Per capita GDP at current market prices (US$) Environmental indicators Human development index Rate of growth of per capita GDP (%) Selected communicable diseases - Type E Hepatitis viral - Type A - Type B - Type C Female Total COUNTRY HEALTH INFORMATION PROFILES | 221 Adult literacy rate (%) Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Leprosy Malaria Dengue/DHF Gonorrhoea Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Total fertility rate (women aged 15–49 years) Estimated population ('000s) Annual population growth rate (%) Percentage of population Rate of natural increase of population (% per annum) Urban population (%) Crude death rate (per 1000 population) - 0–4 years - 5–14 years Crude birth rate (per 1000 population) - 65 years and above COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male MARSHALL ISLANDS MARSHALL ISLANDS Year Source 18 3 703 … … … … … 2002 8 19 1 954 … … … … … 2002 8 20 138 … … … … … 2006 9 45 … … … … … 2006 9 21 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 22 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 23 … … … … … … 24 … … … … … … 25 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 26 5 170 … … 8 444.95 … … 2004 5 2 632 … … 4 299.25 … … 2004 5 2 041 … … 3 333.88 … … 2004 5 1 640 … … 2 678.86 … … 2004 5 778 … … 1 270.82 … … 2004 5 426 … … 695.85 … … 2004 5 312 … … 509.64 … … 2004 5 251 … … 410.00 … … 2004 5 172 … … 280.95 … … 2004 5 - New pulmonary tuberculosis (smear-positive) Cancers Tuberculosis - Hypertension All circulatory system diseases - Acute myocardial infarction - Colon and rectum - Cervix - Oesophagus - Trachea, bronchus, and lung Circulatory - Breast - Leukaemia - Lip, oral cavity and pharynx All cancers (malignant neoplasms only) Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections - All forms 9. Syphilis - Ischaemic heart disease 5. Scabies 1. Influenza 2. Conjunctivities 7. Amoebias 3. Gastroenteritis - Rheumatic fever and rheumatic heart diseases Leading causes of mortality and morbidity Number of new cases DATA Female TotalFemale Leading causes of morbidity (inpatient care) Male 4. Diarrhoea, Infantile Injuries Diabetes mellitus 6. Chicken pox 8. Fish poisoning Mental disorders Total Number of cases Number of deaths Rate per 100 000 population Female - Cerebrovascular diseases - Liver - Stomach - Suicide All types - Homicide and violence - Motor and other vehicular accidents Total Male INDICATORS 10. 222 | COUNTRY HEALTH INFORMATION PROFILES - Occupational injuries FemaleMaleTotal Male MARSHALL ISLANDS Year Source 27 46 … … 75.13 … … FY 2004 5 23 … … 37.57 … … FY 2004 5 15 … … 24.50 … … FY 2004 5 14 … … 22.67 … … FY 2004 5 13 … … 21.23 … … FY 2004 5 12 … … 19.60 … … FY 2004 5 10 … … 16.33 … … FY 2004 5 8 … … 13.07 … … FY 2004 5 6 … … 9.80 … … FY 2004 5 5 … … 9.80 … … FY 2004 5 28 34.00 c 2001 11 29 90.00 2007 9 30 … 31 12.27 … … FY2004 5 32 87.63 … … FY2004 5 33 92.00 … … 2007 9 93.00 … … 2007 9 91.00 … … 2007 9 93.00 … … 2007 9 34 … … … … … … … … … … 35 0 0 0 2007 9 0 0 0 2007 9 … … … 0 0 0 2007 9 0 0 0 2007 9 0 0 0 2007 9 1 … … 2007 9 0 0 0 2007 9 0 0 0 2007 9 0 0 0 2007 9 Maternal, child and infant diseases Male 7. Drowning 6. End stage renal disease and cerebrovascular disease 4. Pneumonia 5. Suicide 10. Congestive Heart Failure and Hepatitis B - Total Tetanus - Neonatal tetanus - Measles 1. Sepsis/ Septicemia Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth - Hepatitis B III - Hib meningitis - Obstructed labour - Haemorrhage - Abortion Selected diseases under the WHO-EPI 9. Trauma Percentage of pregnant women immunized with tetanus toxoid (TT2) - POL3 - BCG - DTP3 Maternal causes Immunization coverage for infants (%) - Rubella - Congenital rubella syndrome - Sepsis - Diphtheria - Mumps - Pertussis (whooping cough) COUNTRY HEALTH INFORMATION PROFILES | 223 Male FemaleTotal Male Female Total Female Number of deaths Rate per 100 000 population Male Total Male DATA 2. Cancer (All types) Number of deaths Total Percentage of women in the reproductive age group using modern contraceptive methods Percentage of pregnant women with anaemia INDICATORS 3. Myocardial Infarction Leading causes of mortality - Eclampsia 8. Prematurity - Poliomyelitis FemaleFemale Number of cases Total MARSHALL ISLANDS Year Source 36 … 37 Public health facilities … … … … … … … … Private health facilities … … … … 38 19.00 2006p 11 15.30 2006p 11 301.59 2006p 11 18.00 2006p 11 97.10 2006p 11 15.10 2006p 11 77.16 2006p 11 2.90 2006p 11 1.00 2006p 11 39 … Year Source 40 Physicians - Number 31 … … … … … … 2004 8 - Rate per 1000 population 0.51 … … … … … … 2004 8 Dentists - Number 4 … … … … … … 2004 8 - Rate per 1000 population 0.07 … … … … … … 2004 8 Pharmacists - Number 2 … … … … … … 2004 8 - Rate per 1000 population 0.03 … … … … … … 2004 8 Nurses - Number 115 … … … … … … 2004 8 - Rate per 1000 population 1.88 … … … … … … 2004 8 Midwives - Number … … … … … … … - Rate per 1000 population … … … … … … … Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … Annual number of graduates Facilities with HIV testing and counseling services Health infrastructure - Hospitals - Outpatient clinics - per capita total expenditure on health (in US$) Government expenditure on health Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) - external resources for health as % of general government expenditure on health - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals - Primary health care centres Health facilities INDICATORS T o ta l INDICATOR M al e F em al e P ri va te Private health expenditure Exchange rate in US$ of local currency is: 1 US$ = DATA R u ra l Human resources for health Health insurance coverage as % of total population P u b lic - private expenditure on health as % of total expenditure on health - general government expenditure on health as % of total expenditure on health U rb an External source of government health expenditure Number of beds Health care financing Number DATA 224 | COUNTRY HEALTH INFORMATION PROFILES MARSHALL ISLANDS Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 23.00 … … FY2004 5 45 … … … 46 91.00 … … 2007 9 47 0.00 FY 2004 5 48 … … … 49 34.00 … … 2001 12 50 … 51 Antenatal care coverage - At least one visit … - At least four visits … 52 … … … 53 … … … 54 … … … 55 … … … 56 … … … 57 … … … 58 … … … 59 … … … 60 241.00 … … 2006 9 61 28.00 … … 2006 9 62 79.00 … … 2006 9 63 85.00 … … 2005 9 64 87.00 82.00 96.00 2004 12 65 82.00 93.00 58.00 2004 12 66 … … … Annual number of graduates Total Urban Rural Proportion of population with access to affordable essential drugs on a sustainable basis Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Infant mortality rate (per 1000 live births) Maternal mortality ratio (per 100 000 live births) Contraceptive prevalence rate Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Proportion of population in malaria-risk areas using effective malaria treatment measures Adolescent birth rate Tuberculosis prevalence rate per 100 000 population Unmet need for family planning Estimated HIV prevalence in adults d P u b lic Health-related Millennium Development Goals (MDGs) INDICATORS DATA M al e F em al e U rb an Total Male R u ra l HIV prevalence among population aged 15-24 years Percentage of people with advanced HIV infection receiving ART Workforce losses/ Attrition INDICATORS Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Female T o ta l P ri va te Malaria incidence rate per 100 000 population Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures Tuberculosis death rate per 100 000 population DATA COUNTRY HEALTH INFORMATION PROFILES | 225 Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source MARSHALL ISLANDS … p est NR a b c d 1 2 3 4 5 6 7 8 9 10 11 12 WHO and UNICEF 2006. [http://www.wssinfo.org/en/40_mdg2006]. WHO Regional Office for the Western Pacific, data received from the technical units. Meeting the MDG Drinking Water and Sanitation target: The urban and rural challenge of the Decade . Joint Monitoring Programme for Water Supply and Sanitation. Demographic Tables for the Western Pacific 2005-2010. Manila, World Health Organization Regional Office for the Western Pacific, 2005. Economic Planning, Policy and Statistics Office, Marshall Islands http://spc.int/prism/country/mh/stats/Index.htm . Provisional Estimate Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office of the Western Pacific Figure based on projected population for 2004. Figure refers to contraceptive prevalence rate Notes: Data not available Millennium Development Goals National Progress Report. Republic of the Marshall Islands. A joint RMI-UNDP Publication with the Economic Policy, Planning and Statistics Office and Ministy of Health Annual Report (Health is a shared responsibility) Fiscal Year 2004, [http://www.rmiembassyus.org/Health/RMI%20MOH%20Annual%20Report%20FY%202004.pdf]. Sources: Pacific Island Populations - Estimates and projections 2005-2015, Secretariat of the Pacific Community, Noumea, 2006. http://www.spc.int/demog/en/index.html. World health report 2004. Changing history . Geneva, World Health Organization, 2004. World Health Organization. National health accounts [http://www.who.int/entity/nha/country/MYS.pdf]. Information furnished by the Ministry of Health and Environment of the Marshall Islands through the WHO Representative for South Pacific in a memo dated 19 April 2000. Not included in the official list of MDG indicators United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). the RMI United Nationsl Development Program Office, September 2005. Ministry of Health Services, Marshall Islands. Not relevant 226 | COUNTRY HEALTH INFORMATION PROFILES COUNTRY HEALTH INFORMATION PROFILES | 227 MICRONESIA, FEDERATED STATES OF 1. CONTEXT 1.1 Demographics The Federated States of Micronesia contains 607 volcanic islands and atolls scattered over 1 million square miles of the Pacific Ocean. The land area totals 270.5 square miles (704.6 square kilometres), with 2777 square miles of lagoon. There are four States: Chuuk, Kosrae, Pohnpei and Yap. From east to west, Kosrae has 43.2 square miles of land, Pohnpei contains 133.4 square miles among six islands, and Chuuk includes six major island groups with a total land area of 49.2 square miles. Chuuk proper is a complex of 98 islands (14 mountainous volcanic islands and 24 outer low islands and atolls). Yap State includes Yap proper and 15 outer islands with a total land area of 45.9 square miles. In 2007, the estimated population was 108 031, 37.3% below 15 years of age and 3.4% 65 years and over. It is estimated that, despite migration, primarily to the United States and its territories, the population has increased by 6.6% since 2000. For every 100 females, there are about 101 males. The average age of the population is estimated to be 18.9 years. About 22% of the population reside in urban areas. Approximately 50% live in Chuuk State, 32% in Pohnpei, 11% in Yap and 7% in Kosrae. 1.2 Political situation The Federated States of Micronesia is a constitutional federation of four States: Chuuk, Kosrae, Pohnpei and Yap. The capital is located in Palikir, Pohnpei. The constitution provides for three separate branches of government at the national level: executive, legislative and judicial. It has 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 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. There are no formal political parties. The President and Vice-President are elected to four-year terms by the Congress. Elections were last held in March 2007 and, in May 2007, Congress elected Emmanuel Mori as President and Alik L. Alik as Vice-President. The Division of Health is part of the Department of Health, Education and Social Affairs. The Secretary for Health, Education and Social Affairs is a cabinet-level position, nominated by the President and requiring congressional confirmation. Currently, the Government is considering a proposal to split the Department into two cabinet-level departments, one for Health and one for Education and Social Affairs. 1.3 Socioeconomic situation Economic activity consists primarily of subsistence farming and fishing. Primary farm products include black pepper, tropical fruits and vegetables, coconuts, cassava, betel nuts, sweet potatoes, pigs and chickens. The islands have few mineral deposits worth exploiting, except for high-grade MICRONESIA, FEDERATED STATES OF 228 | COUNTRY HEALTH INFORMATION PROFILES 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. Under the new compact, the country will receive approximately US$ 92 million a year until 2023, including contributions to a jointly managed trust fund. A Joint Economic Management Committee (JEMCO), consisting of representatives of both countries, has been established to manage this compact assistance. Additional funding from the United States totalled US$ 57 million in 2004. Employment declined from 16 119 in 2000 to 15 897 in 2005. Pohnpei had the highest number of employees, at 7060, and Kosrae had the lowest number, at 1366. The three largest employers were the private sector, the State Government and government agencies. Around 43% were in the public sector, 19.8% in wholesale trade and repair and 7% in education. The unemployment rate is 16% and the average real wage rate is US$ 6037. The country has a severe trade deficit. In 2005, total imports were valued at US$ 117.5 million and exports were valued at only US$ 1.3 million. The tourism sector is small, with only 13 415 tourists reported for 2005. Private remittances are also limited, especially compared with other Pacific island countries. The estimated gross domestic product (GDP) for the 2006 fiscal year was estimated to be US$ 244.7 million, representing a real growth rate of -0.7% over 2005. GDP is supplemented by grant in aid averaging US$ 100 million annually. The nominal GDP per capita was estimated to be US$ 2254 for 2006, an increase of US$ 65 or 3% over 2005. The inflation rate is estimated at 1%. 1.4 Vulnerabilities and hazards 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. Telecommunication costs have fallen, however Internet access is still expensive and most residential access is provided via dial-up accounts. This lack of affordable broadband Internet access is a significant barrier to business growth and to improving education. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition The overall health situation in the Federated States of Micronesia remained unchanged between 2000 and 2005, with the population showing continuing susceptibility to both communicable and noncommunicable diseases. Citizens enjoy a high level of health care in comparison with the rest of the Pacific region. Micronesian doctors are taking the place of United States doctors in the health system as a result of such programmes as the, now defunct, Medical Officer Training Programme in Pohnpei. 2.2 Outbreaks of communicable diseases The number of vaccine-preventable diseases has declined considerably. However, waterborne and foodborne diseases are major causes of hospital admission. Strategies to improve the coverage of immunization and other health programmes that address diseases need to be developed. The highest immunization coverage rate (84.1%) was in 1992 and was the result of COUNTRY HEALTH INFORMATION PROFILES | 229 heavy campaigning at that time due to outbreaks of measles and the hepatitis B immunization campaign. A strategic plan is needed to continue improving health services, public health surveillance and information systems. 2.3 Leading causes of mortality and morbidity The reporting of mortality and morbidity is a problem due mainly to late reporting and a standardized reporting system. The problem with mortality data has to do with late filing of death certificates for mortality coding. This function is performed at the national level. However, based on current information (2006) collected from the four States with respect to mortality and morbidity data, the leading causes of mortality are endocrine, nutritional and metabolic diseases; diseases of the respiratory system; diseases of the circulatory system; and diseases of the digestive system. Incidence of neoplasms is also on the rise. As for the leading causes of morbidity, diseases of the respiratory and circulatory systems, certain infectious and parasitic diseases, injuries, poisonings and certain other consequences of external causes, along with external causes of morbidity and mortality (traffic accidents), are all evident. Pregnancy, childbirth and puerperium conditions continue to be the leading causes of outpatient visits and hospitalization for women of child-bearing age. 2.4 Maternal, child and infant diseases Prenatal care is slowly improving in the state centres and is being expanded to remote areas. Deaths and illnesses due to diarrhoea and acute respiratory infections still make up a large portion of infant mortality and morbidity. In 2006, the country started implementing the WHO integrated management of childhood illness (IMCI) approach curriculum as a way to strengthen the skills and capacity of health care workers, particularly those involved in maternal and child health, to reduce childhood illness. 2.5 Burden of disease Although certain infectious and parasitic diseases are prevalent in the Federated States of Micronesia, the disease burden also includes chronic and noncommunicable diseases. Diabetes and endocrine, nutritional and metabolic diseases are major health problems. Contributing factors to these health conditions are believed to be a change in diet, lack of exercise, gender, age, occupation and, in some cases, drug abuse. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The Division of Health has established five strategic health goals with the objective of improving health services: • to improve primary health care services; • to improve secondary health care services; • to prioritize health promotion and services for major health problems; • to develop a sustainable health care financing mechanism; and • to improve capacity and accountability systems. Ten outcome measures were developed and used during the period from 2003 to 2005 to indicate progress in meeting these goals. In 2005, modifications were proposed involving the addition of four new measures. These modifications will be effective when endorsed by all four State Directors, the Secretary, Assistant Secretary and programme managers, and will be effective for the next five years. The proposed outcome measures involve increasing access to health services, improving immunization coverage, improving the availability of essential drugs, increasing the functionality of biomedical equipment, decreasing the average hospital stay, reducing infant mortality, reducing MICRONESIA, FEDERATED STATES OF 230 | COUNTRY HEALTH INFORMATION PROFILES mental illness, increasing the number of individuals enrolled in a health insurance plan, reducing off-island medical referral costs, increasing the number of children under seven years of age receiving tooth sealant, reducing the incidence of diarrhoeal disease, reducing the incidence of hospitalization for diabetes, and implementing an efficient quality assurance system in all States. Baseline data have been collected in each of these areas and specific goals have been established to measure progress. 3.2 Organization of health services and delivery systems The Division of Health of the Department of Health, Education and Social Affairs does not have a direct role in the provision of health services. The Department of Health Services (DHS) in each State has primary responsibility for curative, preventive and public health services. This responsibility includes the main hospital, peripheral health centres and dispensaries (primary health centres). Only residents of urban centres have direct access to the main hospital in each State, with transportation issues often preventing residents who live on the outer islands from accessing these hospitals. The location of the dispensaries is based on population, need and political considerations. Dispensaries (similar to health clinics) are located in municipalities and outlying islands and are part of the State Health Department. Local mayors and the dispensary supervisors are responsible for their day-to-day operation. Diagnosis and treatment of common ailments are the primary services provided, with more advanced cases being referred to central hospitals. The Secretary of the Department of Health, Education and Social Affairs is responsible for the oversight of all health programmes and ensures compliance with all laws and executive directives. The major functions include: • providing overall supervision for the Division; • setting priorities within financial, manpower and material constraints, as approved by the Secretary; • conducting annual program and staff performance audits and evaluations; • enforcing departmental and national policies; • improving accountability within the Division • implementing national health strategies and the Strategic Development Plan, in accordance with the Secretary’s directives; • increasing external funding to support the implementation of health strategies; • monitoring the compliance of both national and state programmes; • developing and implementing property inventory systems; and • coordinating financial support and assistance to the States. The State-based delivery system is an effective way of administering health care. Given the geographical dispersal, remote nature and cultural diversity of the many island communities, the system has the best chance of developing more responsive and effective services to meet the needs of the community. In this environment of politically independent States, there are constraints on the implementation of national policies. 3.3 Health policy, planning and regulatory framework The Division of Health of the Department of Health, Education and Social Affairs provides health planning, donor coordination, and technical and training assistance. It also coordinates and manages the preventive medicine and public health programmes funded by the United States Department of Health and Human Services. While the Division does not have a direct role in the provision of health services, it has significant influence on their provision as a result of its managerial responsibilities. Most of the state health departments have very limited planning and programming capabilities. COUNTRY HEALTH INFORMATION PROFILES | 231 3.4 Health care financing In 2007, the Federated States of Micronesia, with WHO support, conducted a series of exercises to estimate its national health care expenditure for 2005, which amounted to a total of US$ 30.6 million (Table 1). Table 1. National Health Expenditures and Indicators: Federated States of Micronesia, 1997-2005. Year NHE (in million US$) Per capita Health Spending (in US$) Health expenditure Indicators (in percent) NHE by Financing Agent (in percent) Nominal value Real value Nominal value Real value NHE/GDP GGHE/GGE National Government State Government Social Health Insurance Household Out-of- Pocket All FAs 1997 16.1 16.4 151 155 8.4 10.3 14.5 69.1 10.2 6.2 100.0 1998 15.3 15.3 144 144 7.4 7.9 13.9 67.3 11.8 6.9 100.0 1999 16.7 16.2 156 152 8.1 8.2 13.0 65.6 15.0 6.4 100.0 2000 18.3 17.6 171 164 8.4 8.0 10.3 63.4 20.1 6.1 100.0 2001 20.4 19.4 190 181 9.3 9.7 11.4 65.5 17.6 5.6 100.0 2002 19.0 18.2 177 169 8.5 9.6 9.9 66.3 17.7 6.1 100.0 2003 23.3 22.3 217 207 10.1 10.3 14.7 61.2 19.0 5.1 100.0 2004 24.8 23.3 230 216 11.1 12.7 13.8 61.7 19.8 4.7 100.0 2005 30.6 27.4 281 253 12.8 14.7 15.6 59.2 21.2 4.0 100.0 Health funds came mostly from rest-of-the-world or ROW sources (Figure 1): 56% from the Compact 2 health sector grant; 16% from United States Federal Government agencies grants; and 2% from other bilateral and multilateral grants and loans, such as those from the Asian Development Bank (ADB), WHO and the United Nations Population Fund (UNFPA). The remaining 16% and 10% came from private sources (household budgets and private sector employer funds) and from government domestic revenue sources, respectively. Figure 1. Health Expenditures by Type of Financing Source: Federated States of Micronesia, 2005 public revenue 10% private funds 16% ROW- compact2 56% ROW-U.S. federal grants 16% ROW-other 2% MICRONESIA, FEDERATED STATES OF 232 | COUNTRY HEALTH INFORMATION PROFILES About 75% of health funds were channelled through the public sector (Figure 2). The state Departments of Health Services operate state hospitals, dispensaries and public health clinics and thus state government spending accounted for about 60% of total health spending in 2005. The National Government’s health spending primarily went towards supporting the operations of public health clinics and state hospitals. Social health insurance spending came to a significant 21% share, while household out-of-pocket spending accounted for the lowest share, at about 4%. In 2005, there were two social health insurance schemes: MiCare, with national coverage; and the Chuuk Health Care Plan, covering only residents of Chuuk State. The sources of financing for each government financing agent (National Government and individual States) are shown in Figure 3. While State Governments obtain most of their health funds from Compact 2 (more than 90% for the State of Chuuk), the National Government relies more heavily on grants from United States Federal Government agencies (about 70%). Of total national health expenditures of US$ 30.6 million, about US$ 27 million could be directly assigned as spending specific to a State. Expenditures such as those for national government general administration and for the management and operation of MiCare and the Chuuk Health Care Plan are among those not assigned to States. The distribution of expenditures by State is shown in Figure 4, with one bar showing the distribution for each category of financing agent. For example, the bar for National Government (representing expenditures totalling US$ 3.5 million) shows that about 10% benefited the Figure 2. Health Expenditures by Type of Spender (Financing Agent): Federated States of Micronesia, 2005 national government 16% state governments 59% social health insurance 21% household out- of-pocket 4% Figure 3. Government Health Expenditures by Financing Source: Federated States of Micronesia, 2005 0% 20% 40% 60% 80% 100% Chuuk Kosrae Pohnpei Yap Nat.Gov Financing Agent Pe rc en t LocalRevenue OthDonor Compact2 USFedGrant US$6.0 US$2.2 US$6.6 US$2.8 US$4.9 COUNTRY HEALTH INFORMATION PROFILES | 233 State of Yap, 35% Pohnpei, 18% Kosrae and 37% Chuuk. A bar showing the distribution of population by State has also been included as a reference. When the distribution of health expenditure by the national and state Governments is compared with population distribution by State, the bars clearly show that the Kosrae’s share of expenditures is larger than its population share (i.e. about 18% of national government spending and about 12% of all state government spending versus a population share of about 7%). On the other hand, Chuuk accounts for about 37% of national government spending and about 33% of all state government spending versus a population share of about 50%. Figure 4 additionally shows the distribution of medical claims paid by MiCare by State of residence of the member. Two bars are shown for MiCare, the first bar showing all claims paid for Pohnpei members combined and the second bar showing the claims paid for Pohnpei members split between national government employees and other Pohnpei members. The National Government is located in Pohnpei and all claims made by its employees would therefore be reflected as Pohnpei claims. Even adjusting for national government employee claims, MiCare claims went mostly towards payment for the health care for Pohnpei residents, close to 50% of claims versus 30% of the population. Per capita health spending (covering all financing agent expenditures) is shown in Figure 5 for the national and state levels. The patterns observed in the state shares of health expenditures in Figure 4 are reflected in the per capita values derived. As expected, the Kosrae and Pohnpei had the highest per capita health expenditures, while Chuuk had the lowest. Yap came closest to the national level for per capita health spending. Figure 4. Financing Agent Spending by State: Federated States of Micronesia, 2005 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% (Population Distribution) National-gov Exp. Dist. State-gov Exp. Dist. MiCare(1) Exp. Dist. MiCare(2) Exp. Dist. Financing Agent Pe rc en t Yap NationalGov Pohnpei Kosrae Chuuk 108,000 US$3.5 US$18.0 US$6.0 US$6.0 MICRONESIA, FEDERATED STATES OF 234 | COUNTRY HEALTH INFORMATION PROFILES 3.5 Human resources for health 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. However, the National Government, in collaboration with the College of Micronesia, is currently planning to establish a nursing school. In addition, Yap State has established a relationship with Palau Community College for the training of nurses. Government health services also lack specialized allied health professional workers, particularly hospital administrators, epidemiologists, medical record administrators, pharmacists, laboratory technicians, radiologists and environmentalists. Due to limited resources, medical and nursing fellowships have been prioritized, based on state requests. Four Pacific Open Learning Health Network (POLHN) centres have been established, one in each of the four States, and are providing access to online courses and resources. A full-time Coordinator is being hired to provide support for local health professionals in accessing and participating in online courses and continuing education. 3.6 Partnerships Aside from the usual hospital-based health care, community participation in health promotion and disease prevention is critical to successful partnership in the Federated States of Micronesia. Local civil societies, nongovernmental organizations and church groups have all played key roles in increasing public awareness on important health issues. External partnerships with United States health agencies are largely in the form of funding assistance for programme activities. With the exception of funding through the Amended Compact, infrastructure and capacity development have been on an ad-hoc basis. The ADB-funded loan, Basic Social Services, is approaching its end. The project was set up to assist the Government in providing capacities in health and education. Activities include training in primary health care and medical coding. Figure 5. Per Capita Health Expenditures by State: Federated States of Micronesia, 2005 0 50 100 150 200 250 300 350 400 450 500 NATIONAL Chuuk Kosrae Pohnpei Yap State Pe r Ca pi ta (U S$ ) COUNTRY HEALTH INFORMATION PROFILES | 235 3.7 Challenges to health system strengthening 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-governmental 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. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : National Health Statistics Office Title 2 : 2000 Population and Housing Census report Operator : Statistics Division, Department of Economic Affairs Web address : http://www.spc.int/prism/ Title 3 : FSM 2005 National Health Accounts Title 4 : Department of Health, Education and Social Affairs 5. ADDRESSES DEPARTMENT OF HEALTH, EDUCATION AND SOCIAL SERVICES Postal Address : P.O. Box PS 70, Palikir, Pohnpei FM 96941, Federated States of Micronesia Official Email Address : health@fsmhealth.fm Fax : (691) 3205263 Office Hours : 0800 – 1700 Mon. – Fri. 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@sp.wpro.who.int Telephone : (679) 330 4600 / 330 4631 Fax : (679) 330 0462 / 331 1530 Office Hours : 0800 – 1700 Mon. – Fri. MICRONESIA, FEDERATED STATES OF 236 | COUNTRY HEALTH INFORMATION PROFILES 6. ORGANIZATIONAL CHART: Department of Health, Education and Social Services Year Source Demographics 1 0.70 2006 1 2 108.03 54.40 53.63 2007 est 2 3 0.50 … … 2006-10 1 4 13.20 13.60 12.90 2007 est 3 24.10 24.50 23.70 2007 est 3 3.40 3.00 3.70 2007 est 3 5 22.00 … … 2007 est 4 6 23.30 … … 2003 5 7 4.40 … … 2003 5 8 1.89 a … … 2003 5 9 69.00 67.00 70.00 2006 est 6 … 10.90 11.50 2002 est 7 10 4.40 2000 5 11 92.40 92.90 91.90 2000 8 12 2 254.00 FY2006 est 9 13 0.60 a FY2002 est 10 14 … 15 … … … 16 … … … 17 2 … … 0 0 0 2006 5 1 … … 5 … … 2006 5 1 … … 0 0 0 2006 5 … … … … … … 11 … … 0 0 0 2006 5 0 0 0 0 0 0 2006 5 6 … … … … … 2007 11 0 0 0 0 0 0 2006 5 55 … … … … … 2005 10 151 … … … … … 2006 11 … … … … … … 0 0 0 0 0 0 2006 5 293 … … … … … 2005 10 0 0 0 0 0 0 2005 11 Female COUNTRY HEALTH INFORMATION PROFILES | 237 Malaria Plague Selected communicable diseases - Type C Dengue/DHF Gonorrhoea - Unspecified Total Urban Human development index Rate of growth of per capita GDP (%) - Type A Syphilis - Type B - Type E Cholera FemaleMaleTotal Total Number of deaths Male Number of new cases Adult literacy rate (%) Typhoid fever Encephalitis Leprosy Per capita GDP at current market prices (US$) Communicable and noncommunicable diseases Hepatitis viral Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Total fertility rate (women aged 15–49 years) Crude death rate (per 1000 population) - 0–4 years - 5–14 years Crude birth rate (per 1000 population) - 65 years and above COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total MICRONESIA, FEDERATED STATES OF Male Rural Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Environmental indicators Estimated population ('000s) Annual population growth rate (%) Percentage of population Rate of natural increase of population (% per annum) Urban population (%) MICRONESIA, FEDERATED STATES OF Year Source 18 10 964 … … … … … 2006 5 19 3 326 … … … … … 2006 5 20 104 … … … … … 2006 11 41 … … … … … 2006 11 21 … … … 51 b … … 2000 10 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 4 b … … 2000 10 … … … … … … … … … 14 b … … 2000 10 … … … 8 b … … 2000 10 22 2 864 … … … … … 2005 5 … … … … … … … … … … … … 2 022 … … … … … 2005 5 … … … … … … … … … … … … 23 8 686 … … … … … 2005 5 24 … … … 0 0 0 2000 10 25 1 313 … … … … … 2006 12 … … … 6 b … … 2000 10 … … … 4 b … … 2000 10 … … … … … … … … … 11 b … … 2000 10 26 10 063 … … 9 129.92 … … 2006 5 2 864 … … 2 598.44 … … 2006 5 2 026 … … 1 838.14 … … 2006 5 1 739 1 739 1 577.75 3 209.08 i 2006 5 787 … … 714.03 … … 2006 5 - Ischaemic heart disease Leading causes of morbidity (inpatient care) Leading causes of mortality and morbidity Rate per 100 000 population Male Female DATA Number of new cases 6. 8. 9. - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders Diabetes mellitus - Trachea, bronchus, and lung - Breast - Lip, oral cavity and pharynx - Stomach - Colon and rectum - Cervix - Liver - Leukaemia - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections Male 1. Diseases of the respiratory system 2. Diseases of the circulatory system 4. Pregnancy, childbirth and diseases of the puerperium 5. Endocrine, nutritional and metabolic diseases 238 | COUNTRY HEALTH INFORMATION PROFILES Number of cases Male FemaleTotal Number of deaths Total Male Female - New pulmonary tuberculosis (smear-positive) Cancers All cancers (malignant neoplasms only) - Hypertension All circulatory system diseases - Acute myocardial infarction Circulatory - Cerebrovascular diseases Tuberculosis - All forms INDICATORS 10. 7. 3. Infectious and parasitic diseases - Homicide and violence - Motor and other vehicular accidents All types - Occupational injuries - Suicide TotalFemaleTotal MICRONESIA, FEDERATED STATES OF Year Source 27 55 … … 49.90 … … 2006 5 50 … … 45.36 … … 2006 5 45 … … 40.83 … … 2006 5 30 … … 27.22 … … 2006 5 15 … … 13.60 … … 2006 5 28 70.00 2000 12 29 NR 2007 11 30 51.00 2000 12 31 11.00 … … 2004 est 6 32 82.00 … … 2000 12 33 82.00 … … 2007 11 79.00 … … 2007 11 79.00 … … 2007 11 90.00 … … 2007 11 34 … 4 2000 10 … … … 6 2000 10 … … … … 35 0 0 0 … … … 2007 11 0 0 0 … … … 2007 11 … … … … … … 0 0 0 … … … 2007 11 0 0 0 … … … 2007 11 0 0 0 … … … 2007 11 47 … … … … … 2007 11 0 0 0 … … … 2007 11 0 0 0 … … … 2007 11 0 0 0 … … … 2007 11 COUNTRY HEALTH INFORMATION PROFILES | 239 Male 7. 6. 4. Infectious and parasitic diseases Number of deaths Rate per 100 000 population - Total Tetanus - Neonatal tetanus - Measles 1. Endocrine, nutritional and metabolic diseases Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth Maternal causes - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) - BCG - DTP3 5. Neoplasms Percentage of pregnant women with anaemia 10. - Hib meningitis - Rubella - Hepatitis B III - POL3 8. 9. Immunization coverage for infants (%) Percentage of women in the reproductive age group using modern contraceptive methods - Obstructed labour - Diphtheria - Eclampsia - Congenital rubella syndrome - Sepsis Number of cases Selected diseases under the WHO-EPI Male Female - Haemorrhage - Abortion FemaleTotal - Poliomyelitis DATA Maternal, child and infant diseases 2. Diseases of the respiratory system MaleTotal - Pertussis (whooping cough) Male FemaleTotal Total Male Female Total Number of deaths INDICATORS 3. Diseases of the circulatory system Leading causes of mortality Female MICRONESIA, FEDERATED STATES OF Year Source 36 … 37 Public health facilities 0 0 2006 12 0 0 2006 12 4 c 303 c 2006 12 6 d 18 d 2006 12 Private health facilities 6 e 44 e 2006 12 … … 38 30.60 2005 13 12.80 2005 13 281.00 2005 13 … … 14.70 2005 13 … … NR 39 … Year Source 40 Physicians - Number 62 … … … … … … 2005 5 - Rate per 1000 population 0.54 … … … … … … 2005 5 Dentists - Number 13 … … … … … … 2005 5 - Rate per 1000 population 0.11 … … … … … … 2005 5 Pharmacists - Number 16 f … … … … … … 2005 5 - Rate per 1000 population 0.14 … … … … … … 2005 5 Nurses - Number 229 … … … … … … 2005 5 - Rate per 1000 population 2.01 … … … … … … 2005 5 Midwives - Number 20 … … … … … … 2005 5 - Rate per 1000 population 0.18 … … … … … … 2005 5 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … 240 | COUNTRY HEALTH INFORMATION PROFILES Annual number of graduates Facilities with HIV testing and counseling services Health infrastructure - Hospitals - Outpatient clinics - Primary health care centres - per capita total expenditure on health (in US$) Government expenditure on health Total health expenditure - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals Health facilities - total expenditure on health as % of GDP - amount (in million US$) INDICATORS T o ta l INDICATOR Health care financing Number of beds External source of government health expenditure Private health expenditure - private expenditure on health as % of total expenditure on health - general government expenditure on health as % of total expenditure on health - external resources for health as % of general government expenditure on health Exchange rate in US$ of local currency is: 1 US$ = R u ra l P u b lic DATA U rb an Human resources for health Health insurance coverage as % of total population P ri va te M al e F em al e Number DATA MICRONESIA, FEDERATED STATES OF Year Source 41 Pharmacists … … … … … … … Nurses 115 … … … … … … 2001 10 Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 33.00 33.00 33.00 2006 est 6 45 41.00 41.00 41.00 2006 est 6 46 92.00 … … 2007 11 47 317.00 g 2003 5 48 … … … 49 … … … 50 … 51 Antenatal care coverage - At least one visit 80.00 2000 12 - At least four visits … 52 … … … 53 … … … 54 … … … 55 … … … 56 … … … 57 … … … 58 … … … 59 … … … 60 109.00 … … 2006 11 61 12.00 … … 2006 11 62 82.00 … … 2006 11 63 75.00 … … 2005 11 64 94.00 95.00 94.00 2006 14 65 25.00 61.00 14.00 2006 14 66 … … … COUNTRY HEALTH INFORMATION PROFILES | 241 Annual number of graduates Total Urban Rural Under-five mortality rate (per 1000 live births) Proportion of population in malaria-risk areas using effective malaria treatment measures Maternal mortality ratio (per 100 000 live births) Percentage of people with advanced HIV infection receiving ART Malaria incidence rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Contraceptive prevalence rate Estimated HIV prevalence in adults a INDICATORS Adolescent birth rate Health-related Millennium Development Goals (MDGs) Proportion of population using an improved sanitation facility Proportion of population with access to affordable essential drugs on a sustainable basis Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Female Proportion of population using an improved drinking water source Tuberculosis prevalence rate per 100 000 population Tuberculosis death rate per 100 000 population Malaria death rate per 100 000 population T o ta l M al e F em al e U rb an P ri va te DATA MaleTotal Workforce losses/ Attrition INDICATORS DATA P u b lic R u ra l HIV prevalence among population aged 15-24 years Unmet need for family planning Infant mortality rate (per 1000 live births) MICRONESIA, FEDERATED STATES OF … p est NR a b c d e f g h i 1 2 3 4 5 6 7 8 9 10 11 12 13 14 242 | COUNTRY HEALTH INFORMATION PROFILES Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] Estimate Notes: Data not available Revised data Death certificates based on underlying causes Figure refers to community health centers Figure refers only to pharmacy technicians Figure is based on child-bearing age 15-44 years old World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: National Health Expenditures and Indicators: Federated States of Micronesia, 1997-2005. World Health Statistics 2008. Geneva, World Health Organization, 2008. FSM Department of Finance and Administrationl FSM Social Security Administration [www.spc.int/prism/country/fm/stats/Economic/Nacc't/gdp-current.htm]. 2000 Population and Housing Census report. Division of Statistics, Department of Economic Affairs, May 2002. World health report 2004. Changing history . Geneva, World Health Organization, 2004. Provisional Pacific Island Populations - Estimates and projections 2005-2015 , Secretariat of the Pacific Community, Noumea, 2006. http://www.spc.int/demog/en/index.html. Figure includes 1 private hospital with 36 beds and 5 private clinics with 8 beds Not relevant Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific Sources: Not included in the official list of MDG indicators Department of Health, Education and Social Affairs. The Federated States of Micronesia Statistics Division, Department of Economic Affairs [www.spc.int/prism]. WHO Regional Office for the Western Pacific, data received from the technical units. Figure refers to state hospitals United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). National Health Statistics Office, Department of Health, Education and Social Affairs. FSM - Population Estimates and Projections . Division of Statistics, Federated States of Micronesia [http://www.spc.int/prism/country/fm/stats/Projections/proj-index.htm] Demographic Tables for the Western Pacific 2005-2010 . Manila, World Health Organization Regional Office for the Western Pacific, 2005. COUNTRY HEALTH INFORMATION PROFILES | 243 MONGOLIA 1. CONTEXT 1.1 Demographics Mongolia is the fifth largest country in Asia, with a total area of 1565 million square kilometres. In 2007, the population reached 2.6 million, giving an overall population density of 1.7 persons per square kilometre, making it the least densely populated country in the world. The population is predominantly young, with 28.6% under the age of 15 years, 67% between five and 64 years of age, and only 4.1% 65 years or over. Of the total population, 61% is living in cities. Males comprise 48.7% of the total population. The adult literacy rate is reported to be 97.8%. Since 1990, Mongolia has been undergoing a demographic transition defined by a reduction in fertility and death rates and an increase in ageing. The population growth rate decreased from 2.7% in 1990 to 1.17% in 2003-2006. In 2007, the rate reached 1.55%. The crude birth rate per 1000 population fell by half from 1990 to 2003, from 35.3 to 18. It then remained fairly stable, before increasing to 21.7 in 2007. The total fertility rate fell by half during the period from 2000 to 2003 compared with the rate (4.3) in 1990. The rate was stable at 1.9 from 2004 to 2006, before increasing to 2.36 in 2007. Due to increased urbanization and socioeconomic development in recent years, rural-to-urban migration has been increasing. In 2007, 39.4% of the population were residing in rural areas, a decrease from 42.8% in 2000 1.2 Political situation Mongolia is a democratic parliamentary country. The centralized governmental structure is divided into three branches: the executive, which is the Government, chaired by the Prime Minister; the legislative, represented at the national level by the Ikh Khural (the Parliament); and the judicial, led by the Supreme Court. The President of Mongolia is a figurehead for the country and is directly elected for a four-year term. Political parties that have seats in Parliament are eligible to nominate their candidates to the Presidential election. Although most political power is held by the Prime Minister and Parliament, the President is Commander-in-Chief of the armed forces and heads the National Security Council, as well as appointing all the judges, the Prosecutor General, the Deputy Prosecutor General and ambassadors. The parliamentary and presidential elections take place once every four years and will next be held in 2008 and 2009, respectively. 1.3 Socioeconomic situation The Mongolian Statistical Yearbook shows that, in 2006, total government revenue increased by 23.9% more than expected due to increases in the prices of gold and copper on the world market. Compared with 2005, social security expenditure in the current year increased by 31% and social assistance expenditure by 79.2% as a result of increases in salaries, pensions and welfare payments, while government expenditure and net lending increased by 2.3% more than expected. The government budget surplus has been increasing since 1999. The budget surplus as a percentage of GDP was 9.2% in 2005; in 2006, it increased by 2.5 points to 11.7%, based on preliminary GDP figures. MONGOLIA 244 | COUNTRY HEALTH INFORMATION PROFILES The main pillar of Mongolia’s economy is still agriculture, including livestock husbandry, which plays an important role in the economy, employment and export revenues of the country. To date, 20.2% of GDP is produced by the agricultural sector, 90.1% of it from livestock husbandry. The preliminary GDP figures for 2006 show an increase of 8.4% or 112.9 billion tugriks (US$ 97 million) compared with the previous year, 4.4% of the increase coming from the service sector, 2% from the industrial sector and 2% from the agricultural sector. Per capita GDP at current prices has reached 1.23 million tugriks (US$ 1065.14), an increase of 239 500 tugriks (US$ 207.36) compared with 2005. The report of 2006 Household Income and Expenditure Survey indicates that monthly average household income has increased by 16.4% in terms of 2005 prices. Comparison of poverty incidence, based on the results of the 2006 Household Income and Expenditure Survey and the 2002-2003 Living Standard Measurement Survey, shows that the poverty headcount, the poverty gap and poverty severity have all decreased since 2002. The main indicator showing labour-market development and the economic activities of the population is the labour force participation rate. The rate reached 64.4% in 2006, a 0.9% increase from 2005. The number of people registered as unemployed remains at the same level as the previous year, with females accounting for 57%. 1.4 Vulnerabilities and hazards Mongolia has a unique geographical structure, with steppes, semi-deserts and deserts, high mountain ranges and dry, lake-dotted basins. The climatic conditions are predominantly reflected by its desert steppe, with diverse soil and vegetation patterns, by its range of natural biological features, and by its geomorphological structure. The climate is defined as semi-arid continental, with dry and very dry and cool-to-warm ranges. The average altitude is 1580 metres above sea level and the average rainfall is 203 millimetres per year. The country is prone to natural hazards, including drought, flood, steppe and forest fires, and human and animal epidemic diseases. As the Mongolian economy is heavily reliant on herding and agriculture, harsh winters and periodic droughts, not only have adverse effects on livestock and agriculture, but also on the health status of the disaster-affected population. Policy measures have been taken in recent years to improve emergency preparedness and response. The Disaster Protection Law was approved by Parliament in 2003. Subsequently, the State General Directorate for Emergency was established in 2004 by integrating the State Board of Civil Defence, the Fire Fighting Department and the State Reserve Authority and, in 2005, was reorganized as the National Emergency Management Agency (NEMA), which is responsible for nationwide disaster response. The annual report of NEMA indicates that, in 2007, a total of 228 steppe and forest fires were registered, affecting 1.3 million hectares of land and causing the loss of 338.8 billion tugriks (US$ 239 million). In the same year, 41 natural hazards, such as storms, flood, heavy rain and thunder occurred, resulting in the deaths of 16 people and 10 200 head of livestock. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition 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 exceed respiratory diseases as a cause of death. The Mongolian Steps Survey on the Prevalence of Non-Communicable Disease Risk Factors 2006, conducted by the Ministry of Health, revealed that nine out of every 10 people (90.6% of the surveyed population) had at least one risk factor for developing a noncommunicable disease COUNTRY HEALTH INFORMATION PROFILES | 245 (NCD), one in five people (20.7%) had three or more risk factors or were at high risk, and one in every two males aged 45 years and above were at high risk of developing an NCD. The National Programme on NCD Control and Prevention for 2006-2015 aims to reduce risk factors, thus contributing to a reduction in NCD morbidity and mortality. 2.2 Outbreaks of communicable diseases In 2007, 41 082 cases of infectious disease were registered, with an incidence rate of 157.1 per 10 000 population, an increase from 140.8 in 2006. Sexually transmitted infections (29.7%), viral hepatitis (24.4%), rubella (2.3%) and tuberculosis (10.6%) are the most common infections. The HIV epidemic in Mongolia is classified by WHO as low-prevalence. Although HIV/AIDS prevalence is low, however, the country is at high risk of an epidemic due to its relatively young population, the steady increase in cases of STIs in recent years, increased population migration, and growing HIV/AIDS epidemics in neighbouring countries, China and Russia. Since the first HIV infection was reported in 1992, 36 have been reported, 31 of them registered during the years 2005-2007. Four of the reported cases died of AIDS-related conditions between 1992 and 2006. Mongolia is among the seven countries in the WHO Western Pacific Region with the highest tuberculosis (TB) incidence. In recent years, TB incidence has remained high, with new TB cases comprising 10.6% of all reported communicable diseases in 2007, and TB incidence increasing from 79 per 100 000 population in 1990 to 188 per 100 000 population in 2006. However, the country has succeeded in reducing TB case fatality as a result of directly observed treatment, short-course (DOTS) implementation since 1995, with the proportion of TB cases cured under DOTS increasing from 87.0% in 2000 to 82.0% in 2005, and the TB mortality rate per 100 000 population decreasing to 15 in 2006 from 4.8 in 1990. The Government has also been implementing the TB Sub-Programme of the National Programme on Combating Communicable Diseases for 2002-2010, which has set targets of 70% detection and an 85% cure rate for TB, thus facilitating the goal of halving TB morbidity and mortality in the country by 2010. Despite the fact that TB diagnosis and treatment have improved and the number of TB-related deaths has been decreasing, however, TB incidence is on the rise, making attainment of MDG targets by 2015 a challenge. 2.3 Leading causes of mortality and morbidity Mongolia has been experiencing a gradual epidemiological transition in morbidity and mortality patterns since 1990. Consequently, lifestyle- and behaviour-dependent diseases, such as circulatory system diseases, cancer and injuries have become the leading causes of morbidity and mortality. As of 2007, the leading causes of morbidity per 10 000 population were diseases of the respiratory (883.82), digestive (793.42), genito-urinary (714.45), and circulatory (577.79) systems and injuries and poisoning (409.12). For example, the rates for genito-urinary, circulatory and digestive system diseases have increased year by year in the past five years, with 2007 rates showing an increase of 25%-40% compared with 2001. Diseases of the circulatory system, neoplasms and injuries have remained the leading causes of population mortality since 2000. The statistics show that, in 2007, the leading causes of mortality per 10 000 population were diseases of the circulatory system (21.92), neoplasms (12.21), injuries and poisonings (11.69), diseases of digestive system (5.54), diseases of respiratory system (2.34). Deaths due to these diseases are increasing every year. Each year 5500-6000 people (one in every three deaths) die due to diseases of the circulatory system, which remains the leading cause of mortality. Neoplasms have remained the second leading cause of population mortality for the past 10 years. The gender-specific mortality rates for cancer per 10 000 population are 13.25 for males and 9.50 MONGOLIA 246 | COUNTRY HEALTH INFORMATION PROFILES for females. Among males, the leading types of cancer are of the liver, stomach, lung, oesophagus and prostate. Among females they are of the liver, cervix, uterus, stomach, oesophagus and lung. Mortality due to injuries and poisonings has increased sharply in recent years and was ranked the fifth leading cause of mortality in 1990, before moving to fourth place in 1994. It has been ranked third since 2000. The mortality rate per 10 000 population almost doubled from 2000 to 2007, from 7.6 to 11.69. 2.4 Maternal, child and infant diseases As a result of successful implementation of the State Policy on Population Development, the State Policy on Public Health, the Maternal Mortality Reduction Strategy, the National Programme on Reproductive Health, and the Integrated Management of Childhood Illness (IMCI) strategy, maternal and child mortality has continued to fall in recent years. The national maternal mortality ratio (MMR) per 100 000 live births for 1990-2000 was considered high compared with regional and developed countries (170 per 100 000 in 1996) but, by 2006, it had fallen to 69.7, the lowest for 10 years. According to 2007 health statistics, however, the ratio reached 89.6, an increase of 19.9 compared with the preceding year, due to the dramatic increase in the number of births in 2007, from 47 361 in 2006 to 55 634. A short child health programme review in 2007 revealed that the proportion of maternal deaths due to haemorrhage has fallen. Extragestational diseases, such as heart and kidney problems, are now reported to be the main reason for maternal death, while eclampsia continues to be the second most common cause. The under-five mortality rate per 1000 live births decreased almost fourfold from 87.5 in 1990 to 22.1 in 2007. In addition, the infant mortality rate per 1000 live births decreased to 17.8 in 2007 from 63.4 in 1990. These figures indicate that Mongolia has already achieved its MDG goals to reduce the under-five mortality rate to 29.2 per 1000 live births and the infant mortality rate to 22 per 1000 live births by 2015. According to the 2007 short programme review for child health, the proportion of child deaths due to acute respiratory infection and diarrhoea has fallen, while neonatal causes and injuries have increased as proportional causes. Neonatal deaths represent 62% of infant deaths, and 80% of newborn deaths occur in the first week of life. Prevalence rates for wasting, underweight and stunting have generally fallen since 2000; stunting rates have decreased less rapidly, with 21% of children still stunted. Prevalence rates for iodine and iron deficiency have fallen in the last two to three years, but remain a problem, with 22% of children under five years of age being anaemic. 2.5 Burden of disease As mentioned before, Mongolia has been experiencing an epidemiological transition over the last decade. The prevalence of lifestyle-related chronic diseases is increasing and has become an important public issue. Currently, circulatory diseases, cancer, injuries and accidents are the leading causes of mortality. Respiratory and gastrointestinal diseases still dominate the morbidity pattern. Morbidity due to infectious diseases is, however, still likely to rise. Infectious diseases like HIV/AIDS, STI, TB, viral hepatitis and zoonotic diseases, which are related primarily to risk factors such as behaviour, lifestyle choices and living conditions, are showing a tendency to increase. In the last few years, an increasing number of deaths have been caused by suicide, homicide and traffic accidents. The suicide rate is seven times higher among men than women and the homicide rate five times higher, and men are five times more likely than women to die as a result of traffic accidents. The First Mongolian Steps Survey on the Prevalence of NCD Risk Factors, conducted in 2005, showed that the surveyed population are exposed to many risk factors leading to COUNTRY HEALTH INFORMATION PROFILES | 247 noncommunicable diseases. The overall prevalence of current smokers was 28.0%, of which 24.2% were daily smokers and 3.4% non-daily smokers. The Survey showed that, over the preceding 12 months, about 60.8% (±0.02) of the population (65.1% of males and 56.2% of females) had been drinking occasionally, 5.0% had consumed alcohol in moderation (8.8% of males and 1.0% of females) and only 0.7 (±0.04)% had been drinking frequently (1.1% of males and 0.2% of females) indicating that a relatively small proportion of the population tends to drink alcohol on a frequent basis. In addition, about 23% of the surveyed population reported low levels of physical activity. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The Ministry of Health is the Government’s central administrative body responsible for health policy formulation, planning, regulation and supervision, and for ensuring implementation of health-related activities and standards by its implementing institutions and agencies. The Ministry’s mission is to build favourable living condition for people by upgrading the quality of health care, public health services and health care preventive actions to international standards. Within the scope of its mission, the Ministry of Health aims to fulfil the following strategic objectives: • to make and harmonize sectorwide policies and actions, to prioritize and ensure implementation, and to expand international cooperation; • to regulate policies and actions on medicine and medical supplies, and to upgrade health management and health service delivery, quality and effectiveness; • to regulate policies and actions on health economics and financing; and • to evaluate the implementation and output results of health interventions, to provide information for clients and for priority-setting Priority actions include: • providing comments, advice, support and assistance to the Minister of Health and the Government; • building the capacity of health sector management; • ensuring equitable provision of and access to health care and public health services, and to ensuring rational resource allocation; and • maintaining the proper ratio between public and private health organizations. 3.2 Organization of health services and delivery systems Health care system in Mongolia is characterized by three levels of care and its prevailing principle is to deliver an equitable, accessible and quality health care service to every person. Primary health care is provided mainly by family group practices in Ulaabaatar, the capital city, in aimag centres, and in soum and inter-soum hospitals in aimags. Secondary care takes place in district general hospitals in Ulaanbaatar and in aimag general hospitals. Tertiary care is provided in major hospitals and specialized centres in Ulaanbaatar. By 2007, 15 specialized hospitals, three regional diagnostic and treatment centres, 18 aimag general hospitals, 12 district general hospitals, four rural general hospitals, 35 inter-soum hospitals, 288 soum hospitals, 229 family group practices and 857 private clinics were delivering health care and services to the population. MONGOLIA 248 | COUNTRY HEALTH INFORMATION PROFILES 3.3 Health policy, planning and regulatory framework Numerous laws, policies and national public health programmes are being implemented in the health sector. Health priorities include providing good quality primary health services, improving rural health care, developing the private health sector and expanding health insurance coverage, as stated in the Government's Plan of Action. The State Public Health Policy, approved in November 2001, is an important policy document that clearly defines the policy principles, directions and implementation mechanisms. With the support of the Government of Japan, the Ministry of Health has developed the Health Sector Master Plan, a long-term policy framework for 2006-2015, which represents the Ministry’s first comprehensive documentation of its future direction and incorporates the Government’s commitment to the MDGs. The Mid-Term Implementation Framework of the Health Sector Master Plan for the period of 2007-2010 was approved by the Health Minister’s Order #43 of 2007. In the Health Sector Master Plan, seven key areas and 24 strategies have been incorporated to facilitate the delivery of socially responsive, equitable, accessible and quality services to all. The overall outcomes to be achieved by 2015 include increased life expectancy; a reduction in the infant mortality rate; a reduced child mortality rate; a reduced maternal mortality ratio; improved nutritional status, particularly micronutrient status among children and women; improved access to safe drinking water and basic sanitation; prevention of HIV/AIDS; sustainable population growth; reduced household health expenditure, especially among the poor; a more effective, efficient and decentralized health system; and an increase in the number of client-centred and user-friendly health facilities and institutions. 3.4 Health care financing In recent years, there has been a steady increase in the state budget for the health sector in terms of percentages of both GDP and government expenditure. Health expenditure as a percentage of GDP was stable at 3.3% in 2005-2006 and increased to 4.5% in 2007, resulting in per capita health expenditure of US$ 51.3. Total health expenditure also increased in 2007, by 1.7 times compared with 2000. An overview of the health sector budget for the period from 2000 to 2007 by its main sources reveals the Government (76.5%) and the Health Insurance Fund (20.2%) as the major contributors, followed by revenues from fees for services and supplementary activities (3.3%). Health insurance coverage (introduced in 1994) reached 78.3% of the population in 2007, an increase from 74.4% in the previous year. Health insurance fund income and expenditure have been increasing, year by year, since 2000. As of 2007, over 83% of health insurance fund expenditure was on inpatient care, 8% on outpatient care, and the remaining 9% on discounted drugs, sanatoriums and other costs. As total health expenditure increases, the major part of financing is being spent on curative services. As evidenced by the statistics for 2007, almost 80.0% of health financing was allocated to curative care. In addition, the health expenditure breakdown by level of care is: 26.6% to tertiary care, 42.2% to secondary care and 28.8% to primary health care. 3.5 Human resources for health Despite government efforts to protect the health of the population, improve health care services, enhance health systems, create a favourable legal environment, increase the efficiency of public financing and improve the social protection of health workers, many challenging human resource issues remain. In particular, there is a shortage of health professionals in rural areas owing to great discrepancies in distribution. Rural health facilities, particularly soum and intersoum hospitals, are experiencing critical shortages of doctors and other health professionals, leaving almost 40% of the population without adequate access to primary health care. As of 2007, there were 18.1 physicians per 10 000 population in rural areas, while there were 44.4 in Ulaanbaatar city, and seven soums had no medical doctors. In addition, the continued overproduction of physicians COUNTRY HEALTH INFORMATION PROFILES | 249 has resulted in a high physician-nurse ratio of 1:1.21, which is very distorted compared with international standards. There is a shortage of nurses, midwives and other mid-level personnel, and the situation is further compounded by the overspecialization of medical doctors, which is contributing to the shortage of physicians at the primary health care level. Health workforce security is weak, with low wages, harsh working conditions and a lack of proper incentive packages negatively affecting ethics and productivity. These conditions could lead to a deterioration in the quality and availability of health services, a failure to meet population health needs and loss of confidence in the health system, factors that have the potential to seriously affect attainment of the MDGs. Most health sector human resource issues require the involvement and cooperation of multiple sectors. In this regard, a high level Inter-sectoral Coordinating Committee on Health Sector Human Resources, comprising representatives of the Government, ministries and international donors, has been established with a view to improving political commitment and donor support and funding to coordinate the implementation of health sector human resource policies and strategies at the national level. Recently, priority areas and strategy for action for the Committee have been approved by the Prime Minister and the Committee Chairman. Within the action plan, priority actions have been identified, including, among others, introducing a separate and independent labour-norm- and performance-based salary system for health professionals, varying according to differences in responsibility and geographical location; developing multiple-choice incentive packages to encourage specialists to work in rural, remote areas; and revising and renewing the accreditation criteria for medical training institutions. 3.6 Partnerships As a developing country, external support plays an important role in the health sector of Mongolia, and the Ministry of Health has started initiatives to coordinate the support rendered by international organizations and donor countries. The Health Sector Master Plan, a policy framework for the health sector, includes a strategy to strengthen and integrate ongoing health sector reform using a sectorwide approach. Mongolia supports global initiatives to protect and improve the population’s health status. In 2007, the Government joined the Statement of Commitment, acknowledging the importance of Global Elimination of Congenital Syphilis as vital to meeting the MDGs for improving maternal health, reducing child mortality and combating HIV/AIDS. HIV/AIDS and TB projects supported by the Global Fund have been implemented successfully in Mongolia since 2002. During the 14th Board Meeting of the Global Fund, held in Kunming, China, Round 7 grants for two projects in Mongolia were approved, HIV/AIDS prevention and strengthening activities to combat tuberculosis, to be implemented over five and six years, respectively, from 2008. 3.7 Challenges to health system strengthening Aggravating factors affecting the health system include a sparse population spread over huge areas and an overprovided health system (28.33 physicians and 69.52 beds per 10 000 population in 2007) with problems in cost-effectiveness (a high hospital admission rate of 2 392 per 10 000 population and an average length of stay 8.7 days in 2007). The excessive admissions and long length of stays are related to the efficiency of health system financing. As health expenditure has risen, the funding for each health care level has also increased. However, in past years, the expenditure increase for preventive health care and public health services has been lower than that for curative care. In 2007, out of total health expenditure, 68.8 % was spent on the secondary and tertiary health care levels (26.6% for tertiary-level car and 42.2% for secondary-level care), while 28.8 % was allocated to the primary health care level. MONGOLIA 250 | COUNTRY HEALTH INFORMATION PROFILES Total health expenditure has increased year by year due to growth in the economy and increases in GDP. However, increasing funding to the health sector does not necessarily solve all problems. The main incentive for improving the quality, outcome and efficiency of health services and for providing sustainability for health sector reforms is an appropriate financing mechanism. Although hospitals have begun to be financed by the Health Insurance Fund on the basis of a case-mix approach, in accordance with recent amendments to Health Package Laws, this financing mechanism is currently only in the theoretical, preparatory stage, as neither hospitals nor financing organizations find the change the change satisfactory and performance monitoring is weak. The ownership of the Health Insurance Fund and the control over its operations is split and this makes its management, use and monitoring cumbersome and contributes to poor management and weaknesses in reimbursement and payment methods. Ensuring a regular and increasing flow of funds to the health sector and strengthening the financial management system to improve the efficiency and effectiveness in the use of health sector financial and related resources and the health insurance system have been identified as strategies to enhance access, equity and effectiveness, and improve resource mobilization and allocation and use of health services. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Health Sector Strategic Master Plan 2005 Operator : Ministry of Health (MoH) Specification : Contains analyses, tables and graphs depicting the patterns of health care spending in the country Web address : http://moh.mn/moh%20db/HealthReports.nsf Title 2 : Health indicators book 2007 Operator : National Center for Health Development (NCHD) Specification : Describes trends in child mortality causes and morbidity, identifies areas in need of interventions and assesses progress towards the MDGs for child and maternal health Web address : http://nchd.mn Title 3 : Mongolian Steps Survey on the Prevalence of Non-Communicable Disease Risk Factors, 2006 Operator : Ministry of Health Specification : The first national representative survey on the prevalence of NCD risk factors, supported by WHO. Web address : http://www.moh.mn/ Title 4 : Statistical year book 2006 Operator : National Statistics Office Specification : Includes information on the social and economic indicators of the country. Title 5 : Memorandum of understanding on health sector human resource development in Mongolia Operator : Ministry of Health, 2006 Specification : Health and non-health sectors, including education, social welfare, justice and economy, as well as international organizations, have agreed to collaborate on health sector human resource development issue to collectively fulfill action strategies Title 6 : Priority areas and strategy for action for the Intersectoral Coordinating Committee on Health Sector Human Resource Development Operator : Ministry of Health, 2007 Specification : Plan of action in human resources development in the health sector approved by the Prime Minister of Mongolia and Chairman of the Committee Title 7 : Introduction to the Ministry of Health, Mongolia Operator : Ministry of Health, 2007 Specification : The brochure, published in Ulaanbaatar in 2007, includes information COUNTRY HEALTH INFORMATION PROFILES | 251 regarding the mission and functions of Ministry of Health, departmental duties and organizational structure, as well as listing principal health policy documents etc. Title 8 : Let’s prevent together, No.12 of 2008 Operator : Ministry of Health and Global Fund supported project on HIV/AIDS and Tuberculosis Specification : Quarterly newsletter of the Global Fund supported project on HIV/AIDS and TB Title 9 : Annual report of the National Emergency Management Agency for 2007 Operator : National Emergency Management Agency Features : Unpublished report Specification : The report provides information on the numbers and types of emergencies that occurred, losses due to emergency situations and responses taken Web address : http://www.disasterinfo.mn/nema/ Title 10 : Report of the Short Programme Review for Child Health Operator : WHO, 2007 Features : Meeting report Specification : The report was prepared by the WHO Regional Office for the Western Pacific for Governments of Member States in the Region and for those who participated in the Short Programme Review for Child Health, held in Mongolia in 2007 5. ADDRESSES MINISTRY OF HEALTH Office Address : Ministry of Health Postal Address : Government Building-8, Olympic Street-2 Ulaanbaatar-210648, Mongolia Telephone : (976-11) 260392 Fax : (976-11) 320916 Website : http://www.moh.mn/ WHO REPRESENTATIVE IN MONGOLIA Office Address : Government Building-8, Olympic Street-2 Ulaanbaatar-210648, Mongolia Telephone : (976-11) 327870; (976-11) 322430 Fax : (976-11) 324683 MONGOLIA 252 | COUNTRY HEALTH INFORMATION PROFILES 6. ORGANIZATIONAL CHART: Ministry of Health MONGOLIA Year Source Demographics 1 1 567.00 2007 1 2 2 635.20 1 284.40 1 350.70 2007 1 3 1.55 … … 2007 1 4 8.90 9.20 8.60 2007 1 19.69 9.90 9.76 2007 1 4.12 3.65 4.56 2007 1 5 60.70 … … 2007 1 6 21.70 … … 2007 1 7 6.20 … … 2007 1 8 1.50 … … 2007 1 9 66.54 63.13 70.23 2007 1 … … … 10 2.30 2007 1 11 97.80 98.00 97.50 2007 1 12 1 042.89 e 2006 1 13 … 14 0.70 2005 11 15 … … … 16 … … … 17 8 928 4 655 4 273 … … … 2007 3 914 544 370 34 19 15 2007 3 145 77 68 … … … 2007 3 …. …. … … … … 2007 3 …. …. … … … … 2007 3 0 0 0 0 0 0 2007 3 …. …. … … … … 52 35 17 0 0 0 2007 3 4 556 2 050 2 506 0 0 0 2007 3 0 0 0 … … … 2006 9 …. …. … … … … 3 3 1 1 0 2007 3 3 306 1 050 2 256 3 0 3 2007 3 6 4 2 2 1 1 2007 3 Hepatitis viral Dengue/DHF Gonorrhoea - Unspecified Cholera - Type B - Type C - Type E Number of deaths RuralUrban MaleTotal Total Communicable and noncommunicable diseases Number of new cases - Type A Female Selected communicable diseases Per capita GDP at current market prices (US$) Environmental indicators Total Human development index Rate of growth of per capita GDP (%) Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Annual population growth rate (%) Encephalitis Leprosy Malaria Plague Syphilis COUNTRY HEALTH INFORMATION PROFILES | 253 Female Male Urban population (%) Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Rate of natural increase of population (% per annum) Percentage of population - 0–4 years - 5–14 years Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above Typhoid fever COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male Estimated population ('000s) MONGOLIA Year Source 18 178 599 88 301 90 298 385 202 183 2007 2 19 23 715 12 153 11 562 78 36 42 2007 2 20 4 893 … … … … … 2006 9 2 201 … … … … … 2006 9 21 3 521 1 854 1 667 2 933 1 672 1 261 2007 4 76 0 76 36 1 35 2007 4 79 36 43 67 24 43 2007 4 265 102 2007 4 269 136 133 248 138 110 2007 4 56 31 25 34 21 13 2007 4 39 22 17 31 17 14 2007 4 1380 817 563 1281 759 522 2007 4 516 345 171 463 285 178 2007 4 286 224 62 304 233 71 2007 4 22 149 617 58 648 90 969 5 677 3 182 2 495 2007 2 1 643 825 818 864 620 244 2007 2 14 169 6754 7415 2 349 1 287 1 062 2007 2 55 512 20 350 35 162 406 190 216 2007 2 37 871 16 430 21 441 1 400 750 650 2007 2 23 910 7210 16 700 91 45 46 2007 2 23 5 228 2 483 2 745 67 39 28 2007 2 24 29 242 14 998 14 244 25 14 11 2007 2 25 105 940 69351 36 589 3 028 2 547 481 2007 2 … … … 346 286 60 2007 2 … … … 550 463 87 2007 2 … … … … … … … … … 497 433 64 2007 2 26 85 033 43 575 41 458 3 226.81 3 392.63 3 069.37 2007 2 90 449 42 270 48 179 3 432.34 3 291.03 3 566.96 2007 2 88 254 24 480 63 774 3 349.04 1 905.95 4 721.55 2007 2 82 471 34 308 48 163 3 129.59 2 671.13 3 565.78 2007 2 43 636 20 113 23 523 1 655.89 1 565.94 1 741.54 2007 2 27 427 18 508 8919 1 040.79 1 440.98 660.32 2007 2 26 861 13 602 13 259 1 019.32 1 059.01 981.64 2007 2 17 523 8499 9024 664.96 661.71 668.10 2007 2 12 918 6983 5935 490.20 543.68 439.40 2007 2 7166 3440 3726 271.93 267.83 275.86 2007 2 4. Diseases of the circulatory system 5.Diseases of the nervous system 8. Diseases of the skin and subcutaneous tissues 6. Injuries, poisoning and other consequences of external causes 1. Diseases of the respiratory system 9.Mental and behavioural disorders 7. Infectious and parasitic diseases Cancers Diarrhoeal diseases Acute respiratory infections - All forms 3.Diseases of the genitourinary system 2. Diseases of the digestive system - Oesophagus Leading causes of mortality and morbidity All circulatory system diseases - Acute myocardial infarction Circulatory - Trachea, bronchus, and lung Female 10. Diseases of the eye and adnexa Diabetes mellitus Total Male - New pulmonary tuberculosis (smear-positive) - Breast - Stomach Female Male Total Number of deaths DATA Total Total Male Injuries Mental disorders - Cerebrovascular diseases - Hypertension - Ischaemic heart disease - Cervix - Rheumatic fever and rheumatic heart diseases - Lip, oral cavity and pharynx Female - Leukaemia - Colon and rectum All cancers (malignant neoplasms only) Number of new cases Male Rate per 100 000 population Female Number of cases 254 | COUNTRY HEALTH INFORMATION PROFILES Leading causes of morbidity (inpatient care) INDICATORS - Liver Communicable and noncommunicable diseases - Suicide All types - Homicide and violence - Motor and other vehicular accidents - Occupational injuries Tuberculosis MONGOLIA Year Source 27 5 677 3 182 2 495 215.43 247.74 184.72 2007 2 3 162 1 817 1 345 119.99 141.47 99.58 2007 2 3 028 2 547 481 114.91 198.30 35.61 2007 2 1435 844 591 54.46 65.71 43.76 2007 2 605 339 266 22.96 26.39 19.69 2007 2 494 291 203 18.75 22.66 15.03 2007 2 371 248 123 14.08 19.31 9.11 2007 2 275 150 125 10.44 11.68 9.25 2007 2 272 161 111 10.32 12.54 8.22 2007 2 169 81 88 6.41 6.31 6.52 2007 2 28 52.84 2007 2 29 … 30 11.50 2007 2 31 8.80 … … 2007 2 32 96.20 … … 2007 2 33 99.00 … … 2007 9 97.80 … … 2007 9 98.70 … … 2007 9 98.00 … … 2007 9 34 15 817 0 2007 2 9 046 8 2007 2 1 152 3 2007 2 4 351 16 2007 2 143 6 2007 2 35 0 0 0 … … … 2007 9 0 0 0 … … … 2007 9 … … … … … … 12 … … … … … 2007 9 965 … … … … … 2007 9 0 0 0 … … … 2007 9 0 0 0 … … … 2007 9 0 0 0 … … … 2007 9 6 363 … … … … … 2007 9 2 … … … … … 2007 9 Maternal causes - Eclampsia - Haemorrhage - Congenital rubella syndrome - Sepsis Selected diseases under the WHO-EPI Number of deaths - Mumps - Diphtheria - Measles - Rubella - Total Tetanus Male FemaleTotal Male Female Total - Neonatal tetanus - Hib meningitis Percentage of newborn infants weighing at least 2500 g at birth - Abortion - Obstructed labour - Hepatitis B III - DTP3 - BCG Immunization coverage for infants (%) - POL3 Number of cases MaleTotal Male Female Total Female Total Male Female Rate per 100 000 population DATA 9.Diseases of the nervous system 5.Diseases of the respiratory system 10.Congenital malformations, deformations and chromosomal abnormalities 1. Diseases of the circulatory system 3. Injuries, poisoning and other consequences of external causes 7. Infectious and parasitic diseases 4.Diseases of the digestive system INDICATORS Neonatal mortality rate (per 1000 live births) Percentage of women in the reproductive age group using modern contraceptive methods Percentage of pregnant women immunized with tetanus toxoid (TT2) Percentage of pregnant women with anaemia Maternal, child and infant diseases Leading causes of mortality 8. Diseases of the genitourinary system 6.Certain conditions originating in the perinatal period - Poliomyelitis - Pertussis (whooping cough) COUNTRY HEALTH INFORMATION PROFILES | 255 Number of deaths 2. Tumours and neoplasms MONGOLIA Year Source 36 30 2007 3 37 Public health facilities 34 4 471 2007 2 15 3 970 2007 2 332 5 432 2007 2 229 … 2007 2 Private health facilities 165 2 232 2007 2 698 … 2007 2 38 137.27 2006p 10 5.10 2006p 10 52.69 2006p 10 114.82 2006p 10 83.60 2006p 10 11.00 2006p 10 2.39 b 2006p 10 16.40 2006p 10 1 179.70 2006p 10 39 78.30 2007 2 Year Source 40 Physicians - Number 7 336 1 765 5 571 4 472 2 864 5 976 1 360 2007 2 - Rate per 1000 population 2.78 0.67 2.10 1.70 1.09 2.30 0.52 2007 2 Dentists - Number 539 … … 398 141 212 327 2007 2 - Rate per 1000 population 0.20 … … 0.15 0.04 0.08 0.12 2007 2 Pharmacists - Number 844 67 777 655 189 … … 2007 2 - Rate per 1000 population 0.32 0.02 0.29 0.65 0.11 … … 2007 2 Nurses - Number 8 633 149 8 484 4 023 4 610 7 834 799 2007 2 - Rate per 1000 population 3.27 0.05 3.24 3.99 2.91 3.02 0.30 2007 2 Midwives - Number 649 7 642 125 524 632 17 2007 2 - Rate per 1000 population 0.25 0 0.24 0.12 0.20 0.24 0.01 2007 2 Paramedical staff - Number 5 855 611 5 244 2 184 3 671 4 260 1 595 2007 2 - Rate per 1000 population 2.23 0.23 1.99 2.17 2.31 1.54 0.72 2007 2 Community health workers - Number 33 c … … 20 c 13 c … … 2007 2 - Rate per 1000 population 0.01 c … … 0.02 c 0.01 c … … 2007 2 41 Physicians 602 … … … … … … 2007 6 Dentists 82 … … … … … … 2007 6 Annual number of graduates - Specialized hospitals - District/first-level referral hospitals Exchange rate in US$ of local currency is: 1 US$ = Total health expenditure Health facilities INDICATORS Facilities with HIV testing and counseling services - Primary health care centres - general government expenditure on health as % of total expenditure on health - external resources for health as % of general government expenditure on health Health infrastructure - Hospitals - Outpatient clinics - General hospitals Health care financing - per capita total expenditure on health (in US$) INDICATOR - general government expenditure on health as % of total general government expenditure - amount (in million US$) DATA External source of government health expenditure Private health expenditure - private expenditure on health as % of total expenditure on health Government expenditure on health DATA F em al e U rb an R u ra l P u b lic T o ta l P ri va te M al e Number Number of beds Human resources for health Health insurance coverage as % of total population - total expenditure on health as % of GDP - amount (in million US$) 256 | COUNTRY HEALTH INFORMATION PROFILES MONGOLIA Year Source 41 Pharmacists 85 … … … … … … 2007 6 Nurses 368 … … … … … … 2007 6 Midwives 107 … … … … … … 2007 6 Paramedical staff 0 … … … … … … 2007 6 Community health workers 46 c … … … … … … 2007 6 42 Physicians 731 … … … … … … 2007 2 Dentists … … … … … … … Pharmacists 49 … … … … … … 2007 2 Nurses 685 … … … … … … 2007 2 Midwives 64 … … … … … … 2007 2 Paramedical staff 731 … … … … … … 2007 2 Community health workers … … … … … … … Year Source 43 6.30 5.90 6.60 2007 1 44 17.80 19.20 16.30 2007 2 45 22.10 23.30 20.70 2007 2 46 98.40 … … 2007 9 47 89.60 2007 2 48 99.70 2007 2 0.10 2007 2 99.60 2007 2 49 52.84 … … 2007 2 50 6.30 2007 2 51 Antenatal care coverage - At least one visit … - At least four visits 83.70 d 2007 2 52 … … … 53 0.00 0.00 0.00 2007 3 54 0.00 0.00 0.00 2007 3 55 … … 11.50 2007 7 56 … … … 57 … … … 58 … … … 59 … … … 60 191.00 … … 2006 9 61 15.00 … … 2006 9 62 97.00 … … 2006 9 63 82.00 … … 2005 9 64 72.00 90.00 48.00 2006 12 65 50.00 64.00 31.00 2006 12 66 70.00 … … 2005 5 Adolescent birth rate Annual number of graduates Workforce losses/ Attrition Health-related Millennium Development Goals (MDGs) Infant mortality rate (per 1000 live births) Prevalence of underweight children under five years of age Under-five mortality rate (per 1000 live births) HIV prevalence among population aged 15-24 years DATA Percentage of people with advanced HIV infection receiving ART Contraceptive prevalence rate - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) P u b lic P ri va te - Percentage of deliveries in health facilities (as % of total deliveries) Proportion of 1 year-old children immunised against measles Maternal mortality ratio (per 100 000 live births) Total Male Female INDICATORS Proportion of births attended by skilled health personnel Estimated HIV prevalence in adults a Unmet need for family planning INDICATORS DATA T o ta l M al e F em al e U rb an R u ra l Proportion of population in malaria-risk areas using effective malaria treatment measures Proportion of population in malaria-risk areas using effective malaria prevention measures Malaria death rate per 100 000 population Malaria incidence rate per 100 000 population Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Tuberculosis death rate per 100 000 population Tuberculosis prevalence rate per 100 000 population Proportion of population with access to affordable essential drugs on a sustainable basis Proportion of population using an improved sanitation facility Rural Proportion of population using an improved drinking water source Total Urban COUNTRY HEALTH INFORMATION PROFILES | 257 MONGOLIA … p est NR a b c d e 1 2 3 4 5 6 7 8 9 10 11 12 [http://hdr.undp.org/en/reports/global/hdr2007-2008/] World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: Notes: Not relevant Not included in the official list of MDG indicators Figure converted using 2006 exchange rate = 1179.7 tugriks/ US$ Estimate Provisional Data not available Figure refers to pregnant women with antenatal care for at least six times during pregnancy Sources: Mongolia Statistical Yearbook 2007. National Statistics Office of Mongolia Health Indicators 2007 . National Center for Health Development Statistical Report 2007, National Center for Communicable Disease Statistical Report 2007, National Center for Cancer Ministry of Health, Mongolia, 2006 Mongolia Statistical Yearbook 2006. National Statistics Office of Mongolia UNGASS Country Progress Report 258 | COUNTRY HEALTH INFORMATION PROFILES Mongolia Statistical Yearbook 2005. National Statistics Office of Mongolia WHO Regional Office for the Western Pacific, data received from the technical units Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] Computed by Health Information and Evidence for Policy Unit Figure refers to Public health specialists World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf] Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world . United Nations Development Programme, New York USA 2007. COUNTRY HEALTH INFORMATION PROFILES | 259 NAURU 1. CONTEXT 1.1 Demographics The population of Nauru was estimated at 14 540 for 2007, about 34.6% below 15 years of age and around 5% 65 years and above. 1.2 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. On 18 April 2008, President Stephen declared a state of emergency and dissolved Parliament. This action was prompted by a stalemate in Parliament over the Speaker’s introduction of a Bill to ban Members of Parliament holding dual citizenship. The last election was held on 26 April 2008 and President Stephen was re-elected. 1.3 Socioeconomic situation Until recently, Nauru was a self-reliant country. Traditionally, revenues of this tiny island have come from exports of phosphate. At the height of phosphate mining activities, the country’s gross domestic product (GDP) was one of the highest in the Pacific and living standards were comparable with those of high income countries. However, phosphate reserves are expected to be exhausted soon, and the drastic decline in phosphate revenue has been followed first by a decrease in disposable income, and then by aid-dependence. The rehabilitation of mined land and the replacement of income from phosphate are serious long-term challenges. In anticipation of the exhaustion of Nauru’s phosphate deposits, substantial amounts of phosphate income were invested in trust funds to help cushion the transition and provide for the country’s economic future. As a result of heavy spending from the trust funds, however, the Government is facing bankruptcy. To cut costs, the Government has frozen wages and reduced overstaffed public service departments. There are few resources other than phosphate. The central plateau has limited agricultural value, but some 202-243 hectares, mainly around the costal belt, are available for cultivation. Coconut, banana and papaya are the main fruit crops 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, including water. There are frequent disruptions of supplies of food, fuel, equipment and materials. In 2001, a group of Afghani refugees rescued at sea was transferred to a camp on Nauru in exchange for a multimillion dollar aid package from Australia. Use of Nauru’s isolated location and its Offshore Processing Centre was discontinued in February 2008 following a change in Australia’s policy of holding asylum seekers on Nauru. Already heavily dependent on foreign support, mainly from Australia and Taiwan (China), Nauru has expressed a need for extra support now that Australia’s Offshore Processing Centre has been closed. 1.4 Vulnerabilities and hazards Nauru is particularly vulnerable due to its isolation, with overdependence on the national air carrier and its single aircraft. The lack of a safe harbour for berthing of ships hinders marine transportation links beyond container freight and phosphate carriers. NAURU 260 | COUNTRY HEALTH INFORMATION PROFILES 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition As a result of an effective public health programme focused on water and sanitation, there have been no recent infectious disease outbreaks. Noncommunicable diseases, such as diabetes, hypertension, heart disease and cancer, have become leading causes of morbidity and mortality. Rates of obesity are very high. The recent STEPS survey reports diabetes prevalence among the 15-64 age group is 16.3%. Diabetes increases in prevalence with age and was found to be 24.1% in the 35-44 age group, 37.4 % among 45-55 year-olds and 45 % in the 55-64 age group. 2.2 Outbreaks of communicable diseases See Section 2.1. 2.3 Leading causes of mortality and morbidity See Section 2.1. 2.4 Maternal, child and infant diseases According to the preliminary report of the 2007 Nauru Demographic and Health Survey (NDHS), almost all pregnant women (94.5%) reported having consulted with a health professional—doctor, nurse or midwife—at least once for prenatal care for the most recent birth in the five-year period before the survey. Ninety-seven per cent of births are delivered by a health professional. The 2006 estimated infant mortality rate (IMR) for Nauru was 25.0 per 1000 live births. The most common causes of childhood mortality are acute respiratory illness and dehydration caused by severe diarrhoea. According to the NDHS, only 5% of Nauruan children are underweight (2007). Boys are slightly more likely to be underweight than girls. Almost a quarter (24%) of Nauruan children are stunted and 1% are wasted. 2.5 Burden of disease No available information. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives Mission statement for the health system: “To cater for the health needs of Nauru and to enhance the quality of life of the People of Nauru through appropriate and effective health care; and to reform and improve the health infrastructure through a well structured, co-ordinated long term policy of: • recruitment; • capacity building; • purchasing and maintenance of equipment and facilities.” Mission statement for curative services: “With a clear understanding of the health needs of the people and a full appreciation of the Nauruan culture, we shall provide an appropriate, accessible and affective health service that applies judicious use of all available resources to ensure the health of all patients on Nauru is enhanced; and provide a range of improved and efficient health services through a combination of: COUNTRY HEALTH INFORMATION PROFILES | 261 • educational programs; • screening procedures; • registrations of disease • establishing emergency protocols and the provision of service to meet the needs of all Nauruans.” Mission statement for public health services: “We shall implement and sustain a range of public health policies and programmes that will enhance the quality of life for the people of Nauru by targeted risk factors reduction and promoting a healthy island lifestyle, and set in place a developed and legislated Healthy National Policy which promotes community awareness and participation to induce healthy choices, early, easy, exciting and everywhere.” Values: “Customer focus: We aim to provide quality health care, respecting the dignity of all people. Equity: We strive to be fair in all our dealings: irrespective of ethnicity, religion, political affiliation, disability, gender and age. Quality: We seek a high quality outcome in all facets of our activities. Integrity: We are committed to the achievement of the highest ethical standards in all that we do.” 3.2 Organization of health services and delivery systems Nauru General Hospital (NGH) and the National Phosphate Corporation (NPC) Hospital amalgamated in July 1999 to become the Republic of Nauru Hospital. The Hospital has five doctors and employs a complement of nursing and clinical support staff. 3.3 Health policy, planning and regulatory framework The Ministry of Health Operational Plan 2007 aims to complement the major goal of the Nauru National Sustainable Development Strategy 2005-2025 (NNSDS): “A future where individual, community, business and government partnerships contribute to a sustainable quality of life for all Nauruans”. Specific goals of the NNSDS include: • stable, trustworthy, fiscally responsible government; • provision of enhanced social, infrastructure and utilities services; • development of an economy based on multiple sources of revenue; • rehabilitation of mined-out lands for livelihood sustainability; and • development of domestic food production. Health-specific goals of the NNSDS include the provision of effective preventative health services to reduce lifestyle-related illness. The recent Nauru NCD Risk Factors STEPS Report further highlighted that Nauru has the poorest health indicators for NCDs (cardiovascular disease, diabetes, cancer and respiratory diseases) in the region. The Ministry of Health has responded by developing the Nauru NCD Action Plan, which details specific activities to reverse the declining health of the population and implement strategies that are known to be effective and have relevance and acceptability to the people of Nauru. Of significant interest to health under other categories in the NNSDS are: – Infrastructure : • provide a reliable supply of clean water. NAURU 262 | COUNTRY HEALTH INFORMATION PROFILES Cross-cutting: • governance, policy and institutional reforms; • improve human resource development, including strategic management capacity; • bring about an attitudinal change in the work ethic; and • strengthen partnerships between government, civil society, the private sector and the donor community. Further, page 19 of the NNSDS states: “Decreasing financial resources has led to a sharp drop in the provision of basic health services. Policies, programs and projects are inadequate and regulations are largely ineffective. Limited programs to prevent malnutrition exist and implementation is weak. There are limited standards and epidemiological information available. Limited funding is available for preventative and curative services. Public resources do not achieve intended goals, especially community education. Limited policies for HIV/AIDS and TB are in place but awareness is inadequate. A growing proportion of the population cannot afford the financial burdens of illnesses including the care of women and children.” The Ministry of Health intends to focus attention on the major issues outlined above during 2007-2008. Like many developing countries, Nauru has committed to a range of Millennium Development Goals (MDGs). As a signatory to UN Conventions and Treaties, the Government of Nauru has obligations to meet the requirement of these, which encompass the principles espoused in conventions such as the WHO Constitution, the Framework Convention on Tobacco Control, the International Convention on Population Development, Women Plan of Action and the Convention on Rights of the Child. Specific MDGs included in the NNSDS are: • Reduce child mortality: ⇒ Reduce by two thirds the under five mortality rate between 1990 and 2015. • Improve maternal health: ⇒ Reduce by three quarters the maternal mortality ratio between 1990 and 2015. • Combat HIV/AIDS, malaria, and other diseases: ⇒ Have halted by 2015 and begun to reverse the spread of HIV/AIDS. ⇒ Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases. • Ensure environmental sustainability: ⇒ Halve by 2015 the proportion of people without sustainable access to safe drinking water. • Develop a global partnership for development: ⇒ In cooperation with pharmaceutical companies provide access to affordable essential drugs in developing countries. These MDGs have been included as high-level outcomes in the Ministry of Health’s Operational Plan. It is a priority for the Ministry of Health to improve the reliability of the current health information system (HIM). In the absence of a robust HIM, the development of this plan has relied on the resources of the Nauru Bureau of Statistics, the data contained in the Nauru NCD Risk Factors Steps Report and information contained in the Health Status and Health System Report 2003. The primary health care approach to acute respiratory infections and diarrhoeal diseases will be strengthened and the Expanded Programme of Immunization will expand its coverage of target diseases. COUNTRY HEALTH INFORMATION PROFILES | 263 3.4 Health care financing Over the last two financial years, the Ministry of Health has embarked on a greatly improved system of budget development. The health budget is prepared by senior staff in accordance with the NSDS guidelines by early May, refined and then presented to the Finance Department. Subsequently, the Secretary for Health is required to attend Cabinet to speak to the budget and answer any relevant questions that may arise. As part of the financial management reform process, departmental heads now receive a monthly financial statement detailing current expenditure and projected year-end results against allocated budgets. In 2006, total health expenditure was estimated at US$ 6.0 million or 10.8% of GDP. Government expenditure on health was US$ 3.8 million or 55.3% of total health expenditure. 3.5 Human resources for health The Government plans to make available a balanced supply of health care providers, including physicians, nurses and other specialized staff and community health workers. Currently 50% of professional staff are expatriates on contract, and investment in training of Nauruan nationals is well underway. Course Number Country Status Medicine Pre Med 3 1 2 Cuba x 2 Fiji Nauru USP campus 1st Year 3rd Year Science/English Radiology 1 Fiji 2nd Year Pre Pharmacy 3 Nauru USP campus Science/English Pre Physiotherapy 1 Nauru USP campus Science/English Pre Laboratory 1 Nauru USP campus Science/English Pre Dentistry 1 Nauru USP campus Science/English Nursing Pre Nursing 4 3 1 4 1 4 Fiji Fiji Fiji Kiribati Kiribati Nauru USP campus Final Year 2nd Year 1st Year 2nd Year 1st Year Science/English 3.6 Partnerships The Ministry of Health has partnerships with WHO, the Secretariat of the Pacific Community (SPC), the United Nations Children’s Fund (UNICEF), the University of the South Pacific, the Global Fund and the Australian Agency for International Development (AusAID). Visiting medical specialists have included a team from the AusAID-funded PIPS programme, a mobile medical team from Taiwan (China), and Cuban and Israeli specialists. 3.7 Challenges to health system strengthening The Nauru Ministry of Health endorses the statement in the preamble to the constitution of the World Health Organization that: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” In support of this, the Ministry acknowledges that it is the right of every citizen of the Republic of Nauru, irrespective of race, sex, colour, creed or socio economic status, to have access to a national health system that provides a quality, affordable health service, the principle function of which is to promote and maintain the health and well-being of the citizens of Nauru to the maximum extent possible within available resources. The Ministry of Health also acknowledges that peoples’ lifestyles and the conditions in which they live, work and play strongly influence their health. Recognized social determinants of health include: NAURU 264 | COUNTRY HEALTH INFORMATION PROFILES • the need for policies that prevent people from falling into long-term disability and disadvantage; • the impact of the social, psychological and physical environment on health; • the importance of ensuring a good environment in early childhood and adolescent; • the impact of work on health; • the problems of unemployment and job insecurity; • the role of family, friendship and social cohesion; • the dangers of social exclusion; • the effects of tobacco, alcohol and other drugs; • the need to ensure access to supplies of healthy food choices for everyone; • the need for effective transport systems. All of the above social determinants are experienced differently for men and women, and these gender-based differences need to be recognised as the Ministry of Health seeks to increase the health status of the population. A comprehensive integrated approach to addressing social determinants of good health for men and women requires the mainstreaming of gender concerns into the day-to-day operations of the Ministry of Health. This will ensure that the basic right of every citizen, irrespective of sex, to have access to a national health system that provides a high quality of care appropriate to their needs is respected. Whilst the Ministry of Health cannot address all of these issues alone, it recognizes the need to develop health outcomes and health improvements that are measured through improved health status of the population. The value of both health protection and promotion are now recognized as essential components when developing health outcome measures with the move away from evaluating services based on activity alone. The Ministry’s commitment to the principles and philosophy of primary health care is based on the belief that success in achieving and maintaining health is not the responsibility of hospitals and the medical and/or curative model of care alone, but will come from a health-system-wide approach working with all government departments, the nongovernmental sector and civil society. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Nauru Bureau of Statistics Web address : http://www.spc.int/prism/country/nr/stats Title 2 : Nauru Demographic and Health Survey 2007 (Preliminary report) Operator : Bureau of Statistics Nauru, Secretariat of the Pacific Community, Macro International Inc. Title 3 : Republic of Nauru hospital data 5. ADDRESSES MINISTRY OF HEALTH Office Address : Government Offices, Yaren District, Nauru Official Email Address : secretary.health@naurugov.nr Telephone : + 674 444 3805 Ext 261/262 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) 3-304600/ 3-304631/ 3-300727 Fax : (679) 3-300462 Year Source Demographics 1 0.02 2004 1 2 14.54 7.50 7.04 7.04 2007 est 2 3 0.30 … … … 2006-10 1 4 12.30 12.30 12.40 2007 est 2 22.30 22.20 22.50 2007 est 2 5.10 4.70 5.40 2007 est 2 5 100.00 100.00 100.00 2007 est 3 6 31.20 … … 2002 4 7 7.80 … … 2002 4 8 2.34 a … … 2002 4 9 61.00 59.00 64.00 2006 est 5 … 8.70 10.50 2002 6 10 3.40 2007 7 11 … … … 12 2 671.00 2005-06 8 13 … 14 … 15 … … … 16 … … … 17 0 0 0 0 0 0 2002 4 0 0 0 0 0 0 2002 4 0 0 0 0 0 0 2002 4 … … … … … … 0 0 0 0 0 0 2002 4 0 0 0 0 0 0 2002 4 0 0 0 0 0 0 2002 4 0 0 0 0 0 0 2002 4 … … … 0 0 0 2002 4 1 … … … … … 2006 9 … … … … … … 0 0 0 0 0 0 2002 4 … … … … … … 0 0 0 0 0 0 2002 4 Hepatitis viral Cholera COUNTRY HEALTH INFORMATION PROFILES | 265 Male FemaleFemaleMaleTotal Syphilis - Type B - Type C Dengue/DHF Gonorrhoea - Unspecified Plague - Type E Per capita GDP at current market prices (US$) Environmental indicators Total Urban Human development index Rate of growth of per capita GDP (%) Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Leprosy Malaria Rate of natural increase of population (% per annum) Urban population (%) Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 0–4 years - 5–14 years - 65 years and above Estimated population ('000s) Annual population growth rate (%) Percentage of population COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male NAURU Rural Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Encephalitis Number of deathsNumber of new cases Total Selected communicable diseases - Type A Communicable and noncommunicable diseases Typhoid fever NAURU Year Source 18 2 511 1 248 1 263 2 1 1 2007 11 19 547 306 241 0 0 0 2007 11 20 12 … … … … … 2006 9 2 … … … … … 2006 9 21 2 1 1 5 2 3 2007 11 3 0 3 0 0 0 2007 11 1 0 1 3 0 3 2002 4 … … … … … … … … … … … … … … … … … 2 0 2 2002 4 … … … … … … … … … 1 1 0 2002 4 … … … … … … 22 2 2 0 12 6 6 2002 4 0 0 0 12 7 5 2002 4 3 2 1 0 0 0 2002 4 23 11 12 2 1 1 2002 4 0 0 0 1 1 0 2002 4 9 1 8 1 0 1 2002 4 23 125 59 66 19 12 7 2002 4 24 15 … … 1 1 0 2002 4 25 … … … … … … … … … … … … … … … 1 1 0 2002 4 … … … … … … … … … … … … 26 246 0 246 1 691.88 0.00 3 494.32 2007 10 135 55 80 928.47 733.33 1 136.36 2007 10 85 46 39 584.59 613.33 553.98 2007 10 69 35 34 474.55 466.67 482.95 2007 10 41 25 16 281.98 333.33 227.27 2007 10 37 21 16 254.47 280.00 227.27 2007 10 33 7 26 226.96 93.33 369.32 2007 10 20 8 12 137.55 106.67 170.45 2007 10 11 6 5 75.65 80.00 71.02 2007 10 10 0 10 68.78 0.00 142.05 2007 10 266 | COUNTRY HEALTH INFORMATION PROFILES - Colon and rectum - Cervix - Oesophagus - Breast Tuberculosis - All forms All cancers (malignant neoplasms only) - Ischaemic heart disease Leading causes of morbidity (inpatient care) Leading causes of mortality and morbidity 4. Disease of the skin and subcutaneous tissue 5. Symptons, signs and abnormal clinical and laboratory findings not elsewhere specifiied Female 6. Infectious and parasitic diseases 8. Diseases of the digestive system 9. Diseases of the cirulatory system Number of new cases Male Female Total MaleTotal TotalFemale Rate per 100 000 population MaleMale - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders Diabetes mellitus - Leukaemia - Lip, oral cavity and pharynx DATA Number of deaths Number of cases Female Total - Trachea, bronchus, and lung INDICATORS - New pulmonary tuberculosis (smear-positive) Cancers Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections - Hypertension All circulatory system diseases - Acute myocardial infarction Circulatory - Cerebrovascular diseases - Liver - Stomach 7. Diseases of the genitourinary system 3. Diseases of the respiratory system 10. Diseases of the musculosketal system and connective tissue All types - Homicide and violence - Occupational injuries - Suicide - Motor and other vehicular accidents 1. Pregnancy, childbirth and the pueperium 2. Endocrine, nutritional and metabolic diseases NAURU Year Source 27 31 20 11 213.20 266.67 156.25 2007 11 22 7 15 151.31 93.33 213.07 2007 11 6 5 1 41.27 66.67 14.20 2007 11 4 4 0 27.51 53.33 0.00 2007 11 4 0 4 27.51 0.00 56.82 2007 11 2 1 1 13.76 13.33 14.20 2007 11 2 1 1 13.76 13.33 14.20 2007 11 1 1 0 6.88 13.33 0.00 2007 11 1 0 1 6.88 0.00 14.20 2007 11 28 … 29 … 30 … 31 6.30 … … 2002 4 32 … … … 33 100.00 100.00 100.00 2007 9 100.00 100.00 100.00 2007 9 100.00 100.00 100.00 2007 9 100.00 100.00 100.00 2007 9 34 16 … 2002 4 1 … 2002 4 2 … 2002 4 4 … 2002 4 1 … 2002 4 35 0 0 0 … … … 2007 9 0 0 0 … … … 2007 9 … … … … … … 0 0 0 … … … 2007 9 0 0 0 … … … 2007 9 0 0 0 … … … 2007 9 0 0 0 … … … 2007 9 0 0 0 … … … 2007 9 0 0 0 … … … 2007 9 0 0 0 … … … 2007 9 COUNTRY HEALTH INFORMATION PROFILES | 267 Male 7. Diseases of the respiratort system 6. Diseases of the digestive system 4. Injury, poisoning ad certain other consequences of external causes Number of deaths Rate per 100 000 population - Total Tetanus - Neonatal tetanus - Measles 1. Endocrine, nutritional and metabolic diseases Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth Maternal causes - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) Maternal, child and infant diseases - Hepatitis B III - Hib meningitis Number of cases - Obstructed labour - Diphtheria - Eclampsia - Haemorrhage - Abortion Selected diseases under the WHO-EPI Male Female - Rubella - Congenital rubella syndrome - Sepsis 8. Diseases of the nervous system 9. Diseases of the genitourinary system Male Female Female Total Male Female Total DATA - Poliomyelitis 2. Diseases of the cicrulatory system 5. Neoplasm Percentage of pregnant women with anaemia 3. Pregnancy, chidlbirth and the puerperium 10. FemaleTotal MaleTotal Number of deaths Total Leading causes of mortality INDICATORS - Pertussis (whooping cough) - POL3 - BCG - DTP3 Percentage of women in the reproductive age group using modern contraceptive methods Immunization coverage for infants (%) NAURU Year Source 36 … 37 Public health facilities 1 51 2007 11 0 0 2007 11 0 0 2007 11 0 0 2007 11 Private health facilities … … … … 38 6.02 2006p 12 10.80 2006p 12 601.50 2006p 12 3.76 2006p 12 55.30 2006p 12 25.00 2006p 12 0.00 2006p 12 44.70 2006p 12 1.33 2006p 12 39 … Year Source 40 Physicians - Number 5 5 0 … … … … 2004 11 - Rate per 1000 population 4.95 0.5 0.00 … … … … 2004 11 Dentists - Number 1 1 0 … … … … 2004 11 - Rate per 1000 population 0.99 0.1 0.00 … … … … 2004 11 Pharmacists - Number 4 b 0 4 b … … … … 2004 11 - Rate per 1000 population 3.96 0.00 0.4 … … … … 2004 11 Nurses - Number 48 6 42 … … … … 2004 11 - Rate per 1000 population 47.52 0.59 4.16 … … … … 2004 11 Midwives - Number 2 0 2 … … … … 2004 11 - Rate per 1000 population 1.98 0.00 0.20 … … … … 2004 11 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … 268 | COUNTRY HEALTH INFORMATION PROFILES Facilities with HIV testing and counseling services Health infrastructure - per capita total expenditure on health (in US$) - Hospitals - Outpatient clinics - Primary health care centres - external resources for health as % of general government expenditure on health - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals Health facilities INDICATORS Health care financing Number DATA External source of government health expenditure Private health expenditure - private expenditure on health as % of total expenditure on health T o ta l Human resources for health Exchange rate in US$ of local currency is: 1 US$ = Health insurance coverage as % of total population INDICATOR R u ra l P u b lic DATA U rb an P ri va te M al e F em al e Annual number of graduates Number of beds - general government expenditure on health as % of total expenditure on health - District/first-level referral hospitals Government expenditure on health Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) NAURU Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 25.00 23.00 28.00 2006 est 5 45 30.00 28.00 32.00 2006 est 5 46 100.00 100.00 100.00 2007 9 47 300.00 2002 13 48 97.00 2007 7 1.00 2007 7 96.00 2007 7 49 … … … 50 … 51 Antenatal care coverage - At least one visit 94.50 2007 7 - At least four visits … 52 … … … 53 … … … 54 … … … 55 … … … 56 … … … 57 … … … 58 … … … 59 … … … 60 134.00 … … 2006 9 61 15.00 … … 2006 9 62 42.00 … … 2006 9 63 0.00 … … 2005 9 64 100.00 100.00 NR 2007 11 65 100.00 100.00 NR 2007 11 66 … … … Rural COUNTRY HEALTH INFORMATION PROFILES | 269 Annual number of graduates Proportion of population with access to affordable essential drugs on a sustainable basis Urban Proportion of population using an improved sanitation facility Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel Total Maternal mortality ratio (per 100 000 live births) Under-five mortality rate (per 1000 live births) - Percentage of deliveries in health facilities (as % of total deliveries) Infant mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Proportion of population in malaria-risk areas using effective malaria treatment measures Adolescent birth rate Percentage of people with advanced HIV infection receiving ART Unmet need for family planning Estimated HIV prevalence in adults a Malaria incidence rate per 100 000 population HIV prevalence among population aged 15-24 years Contraceptive prevalence rate Total Male DATAINDICATORS INDICATORS DATA P ri va te Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Proportion of population using an improved drinking water source Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Tuberculosis prevalence rate per 100 000 population Tuberculosis death rate per 100 000 population Female T o ta l M al e F em al e U rb an R u ra l P u b lic Workforce losses/ Attrition Health-related Millennium Development Goals (MDGs) NAURU … p est NR a b c 1 2 3 4 5 6 7 8 9 10 11 12 13 Birth and death documents from Director of Public Health 2007 World Health Statistics 2008. Geneva, World Health Organization, 2008 Provisional Figure refers to dispensers only Demographic Tables for the Western Pacific 2005-2010 . Manila, World Health Organization Regional Office for the Western Pacific, 2005. Computed by Health Information and Evidence for Policy Unit of WHO Regional Office for the Western Pacific. Notes: Data not available 270 | COUNTRY HEALTH INFORMATION PROFILES Macro International Inc. Calverton, Maryland, U.S.A., April 2008. Nauru Bureau of Statistics. [http://www.spc.int/prism/country/nr/stats/Statistics/Economics/GDP/gdp_sum.htm] WHO Regional Office for the Western Pacific, data received from technical units Estimate Nauru population profile. A guide for planners and policy makers. Noumea, Secretariat of the Pacific Community. United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). Republic of Nauru (RON) Hospital data (data from Health Planning Officer) RON Hospital inpatient record study up to March 24 (data from Health Planning Officer) World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf] World health report 2004. Changing history . Geneva, World Health Organization, 2004. Nauru Demographic and Health Survey 2007 (Preliminary report) . Bureau of Statistics Nauru, Secretariat for the Pacific Community, Noumea, New Caledonia, Not relevant Not included in the official list of MDG indicators Sources: Pacific island populations- estimates and projections 2005-2015, Secretariat of the Pacific Community, Noumea, 2006. [http://www.spc.int/demog/en/index.html] COUNTRY HEALTH INFORMATION PROFILES | 271 NEW CALEDONIA 1. CONTEXT 1.1 Demographics New Caledonia is an archipelago consisting of a main island, the Grande Terre, and several smaller islands (the Belep archipelago, the Loyalty Islands, the Ile des Pins, the Chesterfield Islands and the Bellona Reefs). Noumea, located in the main island, is the capital. According to the national census in 2004, the population of New Caledonia was 230.8 inhabitants; the 2007 estimated population is 244 600 inhabitants. In 2007, the crude birth was 17.5 per 1000 population, the crude death rate was 4.7 per 1000 population and rate of annual increase of population was 1.3 per 1000 population. The total fertility rate is 2.2, and the infant mortality rate is 6.6 per 1000 live births. The urban population was estimated to be 64% of the total population by 2007. Life expectancy at birth is 71.9 for males and 78.6 females (2005 est.). There is a high level of adult literacy, estimated to be 91% of the total population (male 92%, female 90%). 1.2 Political situation New Caledonia was an overseas territory of France until the signing of the Noumea Accords in May 1998 and their subsequent approval 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. Administratively, the archipelago is divided into three provinces (South Province; North Province; and Loyalty Islands Province) 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 Government of France has been represented by High Commissioner Yves Dassonville since 9 November 2007. The President of the New Caledonian Government is elected by the members of the Territorial Congress. The last election was held on 7 August 2007, when Harold Martin was elected. 1.3 Socioeconomic situation New Caledonia has about 25% of the world’s known nickel resources. Only a small amount of the country’s 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 few years. The mainstays of New Caledonia’s booming economy are mining, cattle, shrimp farming, fishing, forestry agriculture and tourism. In 2001, GDP per capita was US$19 190.5. 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 square kilomtres. NEW CALEDONIA 272 | COUNTRY HEALTH INFORMATION PROFILES 1.4 Vulnerabilities and hazards New Caledonia is vulnerable for natural hazards. Cyclones are common from November to March. Erosion caused by mining exploitation and forest fires are among the environmental issues. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition Communicable diseases remain public health problems in New Caledonia. Acute respiratory tract infections, including pneumonia, diarrhoeal diseases, sexually transmitted infections, HIV infection and rheumatic heart disease, are among the common infections. In 2006, 3727 cases of acute respiratory infection, including pneumonia, 515 ear infections, 133 influenza cases (103 cases in 2007), 357 cases of diarrhoeal diseases, 48 cases of tuberculosis (the incidence is 27.1/100 000) and two cases of leprosy were reported. The prevalence of rheumatic heart disease was estimated to be 5.7 per 1000 population. Sexually transmitted infections (STI) have always been suspected of being highly prevalent, with 852 cases notified in 2007, of which 17.4% wee chlamydial infections, 9.6% were gonorrhoea, and 4.3% were syphilis. As of December 2007, 316 cumulative HIV cases and 111 AIDS cases had been reported, with 58 AIDS-related deaths since 1986. Twenty-one new HIV infections were recorded in 2007. Dengue and leptospirosis are endemic in the country, with 47 and 53 cases, respectively, in 2007. Noncommunicable diseases also constitute a major disease burden, cardiovascular diseases, diabetes mellitus and cancers being the most common. In 2007, the most common conditions requiring long-term treatment included cardiovascular conditions (20 180 cases; 45.5%), diabetes mellitus (7822 cases; 17.6%), and psychosis (4004 cases; 9%). In 2006, there were 3886 cases of malignant tumour notified. This was followed by chronic respiratory failure (3642 cases; 8.2%) and renal failure (969 cases, 2.2%). 2.2 Outbreaks of communicable diseases Earlier in 2008, the emergence of dengue cases was notified by the health authorities, with 882 reported cases as of June. There was an increase in the number of acute respiratory infections in 2007, with 40 cases reported by August. 2.3 Leading causes of mortality and morbidity The leading causes of mortality during 2005 included: tumours (312 cases); diseases of the circulatory system (299 cases); traumatic injuries and poisoning (144); diseases of the respiratory system (85 cases); diseases of the digestive system (39 cases); infectious and parasitic diseases (37 cases); diseases of the genitourinary system (28 cases); endocrine, nutritional and metabolic diseases (28 cases); diseases of the nervous system (18 cases); and perinatal conditions (13 cases). 2.4 Maternal, child and infant diseases New Caledonia has a well-functioning family planning programme. In 2005, it was estimated that 29.3% of the female population (one in every three women.) was using contraception and 155 women per 1000 had used medical abortion as a mean of contraception in 2005. In 2006, 23 700 Pap smears were performed. Based on a 2006 survey among seven-year-olds, vaccination coverage was 98% for BCG, 100% for DPT3, 100% for POL3, 98.6% for measles and 99% for hepatitis B. COUNTRY HEALTH INFORMATION PROFILES | 273 2.5 Burden of disease Chronic health conditions that requires long-term hospitalization constitute a major burden for the health system. At the same time, some communicable diseases, such as STI, HIV and acute respiratory infections, remain major public health issues for the country. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives 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 the environment by means of health education. 3.2 Organization of health services and delivery systems At provincial level, public health care services are provided by 26 medicosocial constituencies, managed by the Directions Provinciales des Affaires Sanitaires. The integrated services are delivered through seven medical-social centres, with a 46-hospital-bed capacity, and 19 medical centres, covering 14 nursing stations, 55 consultation facilities and 22 dental-care stations. There are four specialized medical centres based in Noumea (the Multi-Specialty Centre, the Mother and Child Health Centre, the School Health Centre and the Family Planning Centre). At the territorial level, there are three public hospital (CHT Gaston Bourret – CHT Magenta and CHN) and three private hospitals (Clinique BDC – Anse-Vata and Clinique Magnin). 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. 3.3 Health policy, planning and regulatory framework No available information. 3.4 Health care financing In 2003, health expenditures amounted to 50 514.43 million XPF (US$ 476.59 million). The country spent 8.7% of its GDP on health. Per capita expenditure on health was 205.777 XPF (US$ 1941.48). 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 of the population. 3.5 Human resources for health As of 1 September 2007, there were 536 practising medical doctors, 48.9% of whom were specialists and 51.1% of whom were practising general medicine. There were also 1082 nurses, 116 dentists, 88 midwives and 150 pharmacists. 3.6 Partnerships In addition to its direct link with the French Government, la Direction des Affaires Sanitaires et Sociales works closely with its partners. The Secretariat of the Pacific Community and WHO are the main development partners in the health sector. New Caledonia is committed to NEW CALEDONIA 274 | COUNTRY HEALTH INFORMATION PROFILES implementing various global health initiatives, such as the International Health Regulations and the Stop TB Programme. 3.7 Challenges to health system strengthening No available information. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Institut Territorial de la Statistique et des Etudes Economiques Web address : http://www.isee.nc/ Title 2 : New Caledonia Health Profile. Key Features 2005-2006 Operator : La Direction des Affaires Sanitaires et Sociales Web address : http://www.dass.gouv.nc/static/publications/chiffre.htm Title 3 : Demographic tables for the Western Pacific 2005-2010 Operator : World Health Organisation, Regional Office for the Western Pacific Web address : http://www.wpro.who.int/information_sources/databases/ regional_statistics/rstat_demographics.htm Title 4 : Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: the 2006 Revision and the World Urbanization Prospects: the 2007 Revision, http://esa.un.org/unup Operator : United Nations Population Division Web address : http://www.un.org/esa/population/unpop.htm Title 5 : La Situation Sanitaire pour l'année 2007 Operator : La Direction des Affaires Sanitaires et Sociales Web address : http://www.dass.gouv.nc/static/publications/chiffre.htm Title 6 : Rapport conjoint OMS/UNICEF de notification des activités de vaccination pour la période janvier-décembre 2007 Operator : WHO Office for South Pacific Title 7 : WHO Report 2008. Global Tuberculosis Control. Surveillance, Planning, Financing Operator : Wold Health Organization 5. 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 COUNTRY HEALTH INFORMATION PROFILES | 275 6. ORGANIZATIONAL CHART: Direction Des Affaires Sanitaires et Sociales de Nouvelle-Caledonie 2006 Year Source Demographics 1 19 100.00 2007 1 2 244.60 … … 2007p 1 3 2.50 … … 2006 2 4 8.70 8.30 9.20 2007 est 3 18.80 19.00 18.60 2007 est 3 5.90 5.50 6.40 2007 est 3 5 64.00 … … 2007 est 4 6 17.50 … … 2007p 1 7 4.70 … … 2007p 1 8 1.28 … … 2005 2 9 75.20 71.90 78.60 2006 2 … … … 10 2.20 2005 2 11 91.00 92.00 90.00 2007 1 12 19 190.49 a 2001 1 13 … 14 … 15 … … … 16 … … … 17 922 … … … … … 2005 9 31 14 17 … … … 2007 2 2 1 1 … … … 2007 2 … … … … … … … … … … … … … … … … … … 47 27 20 0 0 0 2007 2 … … … … … … 82 52 30 … … … 2007 2 7 … … … … … 2006 8 0 0 0 … … … 2006 2 … … … … … … 37 b 12 24 … … … 2007 2 1 1 0 … … … 2007 2 Typhoid fever Encephalitis Leprosy Malaria Plague Syphilis Rural Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Estimated population ('000s) Annual population growth rate (%) Percentage of population Rate of natural increase of population (% per annum) Urban population (%) - 0–4 years - 5–14 years COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total NEW CALEDONIA Male Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Total fertility rate (women aged 15–49 years) - Unspecified Adult literacy rate (%) Selected communicable diseases - Type A - Type B - Type C Communicable and noncommunicable diseases - Type E Hepatitis viral Per capita GDP at current market prices (US$) Number of deaths Total Number of new cases Male Female Total Total Environmental indicators Urban Human development index Rate of growth of per capita GDP (%) Male Female Cholera Gonorrhoea Dengue/DHF 276 | COUNTRY HEALTH INFORMATION PROFILES NEW CALEDONIA Year Source 18 3 727 … … … … … 2006 2 19 357 … … … … … 2006 2 20 48 … … … … … 2006 8 9 … … … … … 2006 8 21 671 … … … … … 2005 2 87 … … … … … 2005 2 63 … … … … … 2005 2 60 c … 2005 2 6 … … … … … 2005 2 32 … … … … … 2005 2 21 … … … … … 2005 2 7 … … … … … 2005 2 107 d … … … … … 2005 2 92 … … … … … 2005 2 22 … … … … … … 250 … … … … … 2007 2 … … … … … … 10 114 … … … … … 2007 2 … … … … … … 1 812 … … … … … 2007 2 23 7 822 … … … … … 2007 2 24 4 004 … … … … … 2007 2 25 … … … … … … … … … … … … 667 … … … … … 2007 2 3 636 … … … … … 2007 2 45 … … … … … 2007 2 26 2 572 … … 1 069.93 … … 2006 5 1 570 … … 653.11 … … 2006 5 1 340 … … 557.43 … … 2006 5 927 … … 385.62 … … 2006 5 870 … … 361.91 … … 2006 5 867 … … 360.66 … … 2006 5 739 … … 307.42 … … 2006 5 323 … … 134.36 … … 2006 5 355 … … 147.68 … … 2006 5 370 … … 153.92 … … 2006 5 All types - Homicide and violence - Motor and other vehicular accidents - Occupational injuries - Suicide COUNTRY HEALTH INFORMATION PROFILES | 277 - All forms INDICATORS Diarrhoeal diseases Total DATA - Oesophagus - Ischaemic heart disease - Liver - Stomach Circulatory - Cerebrovascular diseases 1. Obstetric conditions 2. Orthopedic and rheumatogical conditions - Acute myocardial infarction Total 7. Heart conditions 3. Digestive conditions Male - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders Diabetes mellitus Rate per 100 000 population Male Female Number of cases Female Total 10. Opthalmic conditions 4. Respiratory conditions 5. Neurological conditions 8. Uro-nephrological conditions 9. Chemotherapy, radiotherapy, blood transfusion - New pulmonary tuberculosis (smear-positive) Leading causes of morbidity (inpatient care) - Trachea, bronchus, and lung - Breast - Leukaemia - Lip, oral cavity and pharynx - Hypertension All circulatory system diseases - Colon and rectum - Cervix Tuberculosis Communicable and noncommunicable diseases Acute respiratory infections Total Male Female Number of deathsNumber of new cases Male Female Cancers All cancers (malignant neoplasms only) Leading causes of mortality and morbidity 6. Cutaneous and sub-cutaneous conditions ( incl operation linked with obesity) NEW CALEDONIA Year Source 27 312 … … 129.79 … … 2006 2 299 … … 124.38 … … 2006 2 144 … … 59.90 … … 2006 2 85 … … 35.36 … … 2006 2 39 … … 16.22 … … 2006 2 37 … … 15.39 … … 2006 2 28 … … 11.65 … … 2006 2 28 … … 11.65 … … 2006 2 18 … … 7.49 … … 2006 2 13 … … 5.41 … … 2006 2 28 33.00 2005 10 29 … 30 … 31 2.50 … … 2005 9 32 91.50 … … 2006 5 33 98.00 … … 2007 8 100.00 … … 2007 8 100.00 … … 2007 8 97.80 .. … 2007 8 34 … 0 2006 2 … … … … … … … … 35 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 13 … … … … … 2007 8 0 0 0 … … … 2007 8 … … … … … … 0 0 0 … … … 2007 8 1 … … … … … 2007 8 0 0 0 … … … 2007 8 … … … … … … 0 0 0 … … … 2007 8 FemaleTotal Total Number of deaths DATA FemaleFemale Number of deaths Rate per 100 000 population - Total Tetanus - Abortion Selected diseases under the WHO-EPI - Diphtheria - Poliomyelitis - Pertussis (whooping cough) Maternal, child and infant diseases 2. Diseases of the circulatory system 1. Tumors 5. Diseases of the digestive system 4. Diseases of the respiratory system 10. Perinatal conditions 8. Endocrinic, nutritional and metabolic diseases 9. Diseases of the nervous system 3.Traumatic injuries and poisoning Male Leading causes of mortality Number of cases Female FemaleMale Total Male Total Male Male Total - POL3 Maternal causes - Obstructed labour - Eclampsia - Haemorrhage - Rubella - Congenital rubella syndrome - Sepsis - Hib meningitis - Neonatal tetanus - Measles - BCG - DTP3 Immunization coverage for infants (%) - Hepatitis B III INDICATORS Percentage of pregnant women with anaemia 7. Diseases of the genito-urinary system 6. Infectious and parasitic diseases Percentage of women in the reproductive age group using modern contraceptive methods Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) 278 | COUNTRY HEALTH INFORMATION PROFILES NEW CALEDONIA Year Source 36 25 2008 2 37 Public health facilities 3 … 2006 5 4 184 e 2005 9 7 … 2006 5 19 … 2006 5 Private health facilities 3 … 2006 3 … … 38 476.59 2003 2 8.70 2003 10 1 941.48 2003 2 476.59 2003 9 … … … … 76.73 2008 8 39 … Year Source 40 Physicians - Number 536 … … … … 283 236 2007 2 - Rate per 1000 population 2.19 … … … … 1.16 0.96 2007 2 Dentists - Number 116 … … … … … … 2007 2 - Rate per 1000 population 0.47 … … … … … … 2007 2 Pharmacists - Number 150 … … … … … … 2007 2 - Rate per 1000 population 0.61 … … … … … … 2007 2 Nurses - Number 1082 … … … … 760 198 2007 2 - Rate per 1000 population 4.42 … … … … 3.11 0.81 2007 2 Midwives - Number 88 … … … … 60 2 2007 2 - Rate per 1000 population 0.36 … … … … 0.25 0.01 2007 2 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … Number of beds R u ra l P u b lic DATA External source of government health expenditure Private health expenditure - private expenditure on health as % of total expenditure on health Human resources for health INDICATORS Number DATA - external resources for health as % of general government expenditure on health P ri va te M al e F em al e T o ta l Health insurance coverage as % of total population INDICATOR U rb an Exchange rate in US$ of local currency is: 1 US$ = Health facilities - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals - Primary health care centres - per capita total expenditure on health (in US$) Government expenditure on health - general government expenditure on health as % of total expenditure on health - Hospitals Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) Health care financing Health infrastructure - Outpatient clinics Facilities with HIV testing and counseling services Annual number of graduates COUNTRY HEALTH INFORMATION PROFILES | 279 NEW CALEDONIA Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 6.60 … … 2007p 1 45 9.06 … … 2002 6 46 98.60 … … 2007 8 47 29.60 … … 2006 5 48 91.97 … … 2005 7 4.37 … … 2005 7 87.60 … … 2005 7 49 … … … 50 … … … 51 Antenatal care coverage - At least one visit … … … - At least four visits … … … 52 … … … 53 … … … 54 … … … 55 … … … 56 0.00 0.00 0.00 2006 2 57 0.00 0.00 0.00 2006 2 58 0.00 0.00 0.00 2006 2 59 0.00 0.00 0.00 2006 2 60 35.00 … … 2006 8 61 4.00 … … 2006 8 62 32.00 … … 2006 8 63 88.00 … … 2005 8 64 … … … 65 … … … 66 … … … Total Male INDICATORS M al e F em al e DATA P u b lic U rb an R u ra l Proportion of population using an improved drinking water source Proportion of population with access to affordable essential drugs on a sustainable basis Proportion of population using an improved sanitation facility DATA Female T o ta l P ri va te INDICATORS Malaria death rate per 100 000 population Health-related Millennium Development Goals (MDGs) HIV prevalence among population aged 15-24 years Unmet need for family planning Percentage of people with advanced HIV infection receiving ART Adolescent birth rate Tuberculosis death rate per 100 000 population Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Infant mortality rate (per 1000 live births) Tuberculosis prevalence rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria treatment measures Malaria incidence rate per 100 000 population Annual number of graduates Total Estimated HIV prevalence in adults f Urban Rural 280 | COUNTRY HEALTH INFORMATION PROFILES Workforce losses/ Attrition Under-five mortality rate (per 1000 live births) Proportion of population in malaria-risk areas using effective malaria prevention measures Maternal mortality ratio (per 100 000 live births) Contraceptive prevalence rate Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) NEW CALEDONIA … p est NR a b c d e f 1 2 3 4 5 6 7 8 9 10 COUNTRY HEALTH INFORMATION PROFILES | 281 Sources: Figure refer to cancer of digestive organs Figure was converted to US$ using available exchange rate nearest to the period i.e. 2003 Totals may not tally due to some reported cases with no gender breakdown Figure refers to 108 beds for psychiatric cases and 76 beds for geriatric cases. Not relevant Not included in the official list of MDG indicators Information furnsihed by WHO Representative in the South Pacific, 25 June 2008. Institut Territorial de la Statistique et des Etudes Economiques (www.isee.nc) La Direction des Affaires Sanitaires et Sociales. New Caledonia Health Profile . Key Feature 2005-2006. Demographic Tables for the Western Pacific 2005-2010. Manila, World Health Organization Regional Office for the Western Pacific, 2005. Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: the 2006 Revision Department of Health and Social Affairs of New Caledonia. WHO Regional Office for the Western Pacific, data received from the technical units La direction des affaires sanitaires et sociales..La Situation Sanitaire pour l'annee 2006. Health situation in New Caledonia , 01 January 2002 to 31 December 2002. Department of Health and Social Affairs, New Caledonia. Figure refer to cancer of female genital organs Provisional Estimate Notes: Data not available La Situation sanitaire pour l'annee 2005. La direction des affaires sanitaires et sociales. and the World Urbanization Prospects: the 2007 Revision, http://esa.un.org/unup 282 | COUNTRY HEALTH INFORMATION PROFILES NEW ZEALAND 1. CONTEXT 1.1 Demographics New Zealand’s 2006 Census of Population and Dwellings was held on 7 March 2006. There were 4 143 279 people in New Zealand on census night, an increase of 322 530 (8.4%) since the 2001 Census. Usual residents accounted for 4 027 947 and overseas visitors for 115 334. In the 10 years to March 2006, New Zealand's census-night population increased by nearly half a million (up 461 733 or 12.5%), and it has almost doubled in the last 50 years, from 2 174 061 in 1956 to 4 143 279 in 2006. There were 1 965 621 male and 2 062 328 female residents counted, around 104 women for every 100 men. Women have outnumbered men since the late 1960s. The median age of usual residents was 35.9 in the 2006 Census; in 1996, it was 33.0 years. This increase in the median age reflects the country's ageing population. The median age for males was 35.1 years, while the median age for females was 36.7 years, reflecting the longer life expectancy for women than for men. 2006 Census results show that the ethnic make-up of New Zealand has continued to change. • The Mäori ethnic group has increased by 39 048 (7.4%) and now totals 565 329. One in seven people identified with the Mäori ethnic group. • 'New Zealander' was a separate category for the first time in 2006; it was previously counted in the European category. Of those who identified themselves as New Zealanders, 12.9% also identified with at least one other ethnic group. New Zealander was the third-largest ethnic group, with 429 429 people or 11.1% of those who stated their ethnicity. • Asian ethnic groups grew the fastest, increasing from 238 176 in 2001 to reach 354 552 in 2006 (an increase of almost 50%). The number of people identifying with the Asian ethnic groups has doubled since 1996, when it was 173 502. Those identifying with Pacific peoples ethnic groups had the second-largest increase from the 2001 Census, up 14.7% to total 265 974. • European remains the largest of the major ethnic groups, totaling 2 609 592 (67.6%) in 2006. 1.2 Political situation Elections were last held in September 2005. 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 2008. 1.3 Socioeconomic situation While the economy in New Zealand slowed over the course of 2007, economic activity has been very strong over the past year, by and large. The 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. COUNTRY HEALTH INFORMATION PROFILES | 283 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. The New Zealand economy has averaged 4.0% annual growth in recent years. Over the period 2003-2006, the domestic economy, employment and income growth and high international commodity prices have been the main drivers of growth. Annual growth for the 2002/2003 and 2003/2004 years was 4.2% and 4.7%, respectively, growing to 4.8% in 2004/2005. New Zealand continues to give priority to ensuring that overseas development assistance (ODA) activities foster the role of women in development. The ODA programme recognizes 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 of 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 programmes. 1.4 Vulnerabilities and hazards Vulnerabilities and hazards derive from the geographical set up of a relatively small island country in the Pacific Ocean with limited natural resources. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition 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 and, at total population level, the country’s health continues to improve. Impressive longevity gains have been recorded, and the infant mortality rate continues to decrease, reducing from 5.5 per 1000 live births to 4.8 per 1000 over the year ending June 2006. 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. Avoidable mortality decreased by approximately 40% from 1980 to 2003. Related good news is the steady decline in cardiovascular disease mortality for the total population, reflecting both incidence reduction (improvements in smoking, diet and control of blood cholesterol and blood pressure) as well as case-fatality reduction (improved treatment of coronary heart disease and stroke) in about equal measure. Malignant neoplasms (cancer), ischaemic heart disease and cerebrovascular disease were the leading causes of death in New Zealand from 1997 to 2004. 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 the 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. Obesity is one of the headline indicators of health system outcome and is one of the most important modifiable risk factors for a number of important diseases such as type 2 diabetes, NEW ZEALAND 284 | COUNTRY HEALTH INFORMATION PROFILES ischaemic heart disease and stroke. Obesity and overweight are major health issues affecting over half the adult population and just under one-third of New Zealand children. AIDS was first diagnosed in New Zealand in 1983 and was 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. The HIV prevalence reported in the 2006 Human Development Report is 0.1% in ages 15-49. 2.2 Outbreaks of communicable diseases Compared with other developed countries, a relatively high incidence of waterborne diseases, including camphylobacteriosis, giardiasis and cryptosporidiosis, is reported in New Zealand. The Ministry of Health has acknowledged capability and capacity in the leadership and coordination of sector activity during possible emergency events, such as outbreaks of severe acute respiratory syndrome (SARS) and aviation flu. During 2005/2006, the focus of the Ministry’s work in this area was on developing the New Zealand Influenza Pandemic Action Plan. The information in the plan is the outcome of work undertaken over the year by intersectoral work groups covering health, biosecurity, law and order, emergency services, civil defense emergency management, welfare, education, border response, the economy, external response (international) infrastructure and workplaces. The resulting New Zealand National Influenza Pandemic Preparedness Plan serves as a valuable model for the whole Pacific region. The Ministry of Health is responsible for planning the national response to health service emergencies of all kinds, including outbreaks of communicable diseases. The Ministry is working on a number of projects that will collectively form the National Health Emergency Plan (NHEP), of which the 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. 2.3 Leading causes of mortality and morbidity Chronic or long-term conditions are the leading cause of preventable morbidity, mortality and unequal health outcomes in New Zealand. They include diabetes and cardiovascular disease, cancer, respiratory conditions, mental health conditions, such as anxiety and depression, and arthritis. Comprehensive estimates of prevalence for cardiovascular disease (CVD) and type 2 diabetes in New Zealand populations are not currently available. However, an estimated 7800 people have been diagnosed with diabetes (2003-2004). The crude death rates (per 100 000) for leading causes are: malignant neoplasms—197.5; ischaemic heart disease—155.4; cerebrovascular disease—69.1; chronic lower respiratory disease—45.6; other forms of heart disease—29.7; diabetes mellitus—20.8; organic, including symptomatic, mental disorders—20.4; transport accidents—12.8; diseases of arteries, arterioles and capillaries—12.5; and intentional self-harm—12.0. 2.4 Maternal, child and infant diseases New Zealand’s infant mortality rate was 4.8 deaths per 1000 live births in June 2006, an improvement from 5.5 per 1000 in June 2005, and continues the decrease from 6.7 in 1996 and 13.9 in 1976. In 2003, 99.3% (55 119) of total hospital births were live-born babies, while the remaining 0.7% (414) were stillbirths. Neonatal deaths remain relatively uncommon, accounting for 182 cases (0.3%) of all hospital births. Despite the generally low death rates, neonatal deaths for Mäori and Pacific babies remain markedly higher than for European babies. Neonatal deaths tend to occur at lower birth weights and gestational ages, with 70% occurring at birth weights of COUNTRY HEALTH INFORMATION PROFILES | 285 less than 2500 grams or at less than 37 gestational weeks. The proportions of babies born pre- term or with low birth weight remain largely stable, at 7.2% and 5.9% of all live births, respectively. The three major causes of infant mortality in New Zealand are sudden infant death syndrome (SIDS), congenital abnormalities and perinatal conditions (such as prematurity, perinatal infections and low birth weight). The information provided on the NZHIS website in 2007 shows that, in 2003, 55 289 live babies were born in New Zealand. Hospital births accounted for 55 119 live babies, delivered to 54 581 women. This is 98.2% of the 56 134 live babies born in 2003, as registered under Births, Deaths and Marriages. The National Minimum Dataset (NMDS) has achieved complete coverage for all hospital births. The Maternal and Newborn Information System (MNIS) has made significant progress, with coverage increasing from approximately 70% of all registrations under Births, Deaths and Marriages in 2002 to 83% in 2003. The median age of women giving birth in hospital in 2003 was 30.2 years. This continued a gradual increase from previous years and, for the first time, was over 30 years. Nearly one-third (30.8%) of all mothers were in the 30-34 age group, which marks the peak of the reproductive age group. A delayed fertility pattern was particularly noticeable among women of European and Asian ethnic groups. There is also some evidence of delayed child-bearing among Pacific women. Among the 54 581 mothers in 2003, two-thirds (67.4%) gave birth by normal vaginal delivery, 9.5% by operative vaginal birth, and the remaining 23.1% by caesarean section. 2.5 Burden of disease Although mortality due to cardiovascular disease (CVD) has decreased significantly in the last 25 years, it is still the leading cause of death in New Zealand and a major source of disparity in health between Mäori and non-Mäori. For the first time, however, there are initial indications that the present decline in CVD risks may be starting to plateau, possibly due to the increasing prevalence of obesity and type 2 diabetes. Within the scope of health and disability services, unequal health outcomes in New Zealand can largely be attributed to the disproportionate burden imposed by chronic or long-term conditions, especially CVD and type 2 diabetes, on Mäori and Pacific peoples and those on low incomes. CVD is the leading cause of death, accounting for 40% of all deaths. Data show that one in 10 New Zealand adults has been diagnosed with heart disease and 1 in 48 with stroke. Modern sedentary lifestyles and high-energy diets, combined with the effects of an ageing population and improvements in the management of acute CVD, have resulted in an increase in the number of people living with the disease. The prevalence of overweight adults was relatively stable from 1977 to 2003, averaging 41% in males and 27% in females. In contrast, the prevalence of obesity doubled from 1977 to 2003, increasing from 9% to 20% in males and from 11% to 22% in females. Most of the increase in the prevalence of obesity has occurred since 1989. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The vision of the Ministry of Health is to facilitate the development of the health and disability support sector to maximize the potential of people with disabilities and the health of New Zealand people—‘Healthy New Zealanders’. The mission of the Ministry is to be an effective facilitator of desired change, actively linked with an understanding of the total health and disability system—‘Leading Health’. This mission NEW ZEALAND 286 | COUNTRY HEALTH INFORMATION PROFILES statement encapsulates the key expectations for the Ministry—able to make the best informed and most innovative judgements on the directions and options for the health and disability sector and the opportunities to promote the health of New Zealanders. The conceptual link between the Ministry, the whole health and disability sector and the overall goal of healthy New Zealanders is demonstrated in the Ministry’s outcomes framework. The framework, drawn from the Ministry’s Statement of Intent, reflects the directions established by the two overarching strategies: the New Zealand Health Strategy and the New Zealand Disability Strategy. The outcomes framework has three levels that are logically connected: • Ministry outcomes—ensuring the system works for all New Zealanders: these are outcomes that reflect the levers the Ministry has available to it to achieve a well functioning health and disability support system. These outcomes are largely determined by the functions the Ministry performs. • System outcomes—a fair and functional health system: these are outcomes that reflect the health and disability support system’s achievements, encompassing how people access services, the quality and effectiveness of services, the extent to which the system uses public resources in the best way, and how the system interacts with other sectors to enhance health and independence outcomes. • Societal outcomes—healthy New Zealanders: these are the health and disability support outcomes valued by the Government and citizens that are necessary for healthy New Zealanders. They are influenced by the health and disability sector and broader activities of the Government and society. The Ministry of Health aims to ensure that the health and disability support system works for all New Zealanders. The Ministry has eight key responsibilities: • to provide policy advice on improving health outcomes, reducing inequalities and increasing participation; • to act as a Minister’s agent; • to monitor the performance of District Health Boards; • to implement, administer and enforce relevant legislation and regulations; • to provide health information and process payments; • to facilitate collaboration and coordination within and across the sector; • to provide nationwide planning and maintenance of service agreements; and • to plan and fund public health, disability support service and other service areas retained centrally. The New Zealand Health Strategy and the New Zealand Disability Strategy provide the framework for the health sector's overall direction. These strategies take a population approach to identify those areas where intervention would 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 services, as well as more health-issue-specific and population-group-specific strategies and action plans. The New Zealand Health Strategy identifies seven fundamental principles that should be reflected across the health and disability sector: • acknowledging the special relationship between Mäori and the Crown under the Treaty of Waitangi; • good health and well-being for all New Zealanders throughout their lives; • an improvement in the health status of those currently disadvantaged; • collaborative health promotion and disease and injury prevention by all sectors; COUNTRY HEALTH INFORMATION PROFILES | 287 • timely and equitable access for all New Zealanders to a comprehensive range of health and disability services, regardless of ability to pay; • a high-performing system in which people have confidence; and • active involvement of consumers and communities at all levels. The New Zealand Disability Strategy was launched in April 2001. It is an intersectoral strategy which is relevant across the whole public sector. The Ministry of Social Development’s Office for Disability Issues oversees the strategy’s implementation. The New Zealand Disability Strategy identifies 15 objectives, underpinned by detailed actions, to advance New Zealand towards being a fully inclusive society. The objectives are: • to encourage and educate for a non-disabling society; • to ensure rights for disabled people; • to provide the best education for disabled people; • to provide opportunities in employment and economic development for disabled people; • to foster leadership by disabled people; • to foster an aware and responsive public service; • to create long-term support systems centred on the individual; • to support quality living in the community for disabled people; • to support lifestyle choices, recreation and culture for disabled people; • to collect and use relevant information about disabled people and disability issues; • to promote the participation of disabled Mäori people; • to promote the participation of disabled Pacific people; • to enable disabled children and youth to lead full and active lives; • to promote the participation of disabled women in order to improve their quality of life; and • to value families, whānau and people providing ongoing support. The Ministry of Health aims to ensure the health and disability support system works for all New Zealanders. It is the Government's primary advisory on health policy and disability support services. 3.2 Organization of health services and delivery systems 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 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 organizations (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 populations. There are now 82 PHOs with more than 3.9 million enrollees (more than 95% of the New Zealand population) involving the vast majority of general practitioners and practice nurses. Governed by non-profit boards of directors, PHOs contract with DHBs to offer a range of preventive and curative services, as well as an increasing array of population health services. Public hospitals, some services such as assessment, treatment and rehabilitation services, and the majority of public health services (discussed below) come under the umbrella of DHBs. General practitioners (GPs), PHOs, rest homes and midwives are independent and/or contracted to supply services by DHBs or the Ministry. The Minister of Health has overall responsibility for the health and disability support system. The Minister determines the content of the New Zealand Health Strategy, works through the NEW ZEALAND 288 | COUNTRY HEALTH INFORMATION PROFILES Ministry of Health to enter into accountability arrangements with DHBs and agrees with government colleagues how much public money will be spent on the delivery of public services. 3.3 Health policy, planning and regulatory framework 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: (1) to reduce smoking; (2) to improve nutrition; (3) to reduce obesity; (4) to increase the level of physical activity; (5) to reduce the rate of suicide and suicide attempts; (6) to minimize harm caused by alcohol and illicit and other drug use to both individuals and the community; (7) to reduce the incidence and impact of cancer; (8) to reduce the incidence and impact of cardiovascular disease; (9) to reduce the incidence and impact of diabetes; (10) to improve oral health; (11) to reduce violence in interpersonal relationships, families, schools and communities; (12) to improve the health status of people with severe mental illness; and (13) to 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. 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. A wide range of health information is collected nationally and held in various collections. • The National Minimum Dataset is a single integrated collection of secondary and tertiary hospital health discharge data. • The Cancer Registry is a population-based tumour register of all primary malignant diseases, active since 1948. • The Mortality Register contains coded causes of death for New Zealanders who die in New Zealand and is based on the legal death certificate, or coroner’s report, and autopsy reports. • The Mental Health Information National Collection contains information on specialist mental health and alcohol and drug services. This collection contains comprehensive information from DHBs and approximately 10% of NGOs. • The National Booking Reporting System provides information, by health specialty and booking status, on how many patients are waiting for treatment, and also how long they have had to wait before receiving treatment. • HealthPAC provides information and reports relating to payment and other health data. COUNTRY HEALTH INFORMATION PROFILES | 289 3.4 Health care financing Public sector funding is the major source of funding for health and disability support services in New Zealand. It accounts for approximately 80% of all health expenditure in the country, with out-of-pocket expenditure and private insurance being the other main contributors. Vote Health is the Government’s main contributor to publicly funded health and disability services expenditure. The total Vote Health in 2006/2007 was NZ$ 10.64 billion (US$ 7.56 billion) (exclusive of GST), rising to NZ$ 10.860 billion (US$ 7.71) in 2007/2008. In 2007/2008, DHB appropriations total NZ$ 8.550 billion (US$ 6.07 billion). Most DHB funding is allocated using the population-based funding formula (PBFF). The PBFF gives each DHB the same opportunity, in terms of resources, to respond to its population’s needs. New Zealand has historically had a system of cost-sharing for doctor’s visits and prescription drugs. The Commonwealth Fund survey shows relatively few New Zealanders had no out-of- pocket medical costs in 2006. As part of the ongoing roll-out of the Primary Health Care Strategy, lower GP fees and lower patient charges for pharmaceuticals were introduced for people aged between 45 and 64 years on 1 July 2006, providing nearly 700 000 more New Zealanders with cheaper access to doctors. From 1 July 2007, all New Zealanders have lower-cost access to primary health care. 3.5 Human resources for health A number of complex and interrelated factors are influencing health workforce development in New Zealand. These factors include an increase in life expectancy, a greater number and a greater proportion of people aged over 65 years, medical and technical advances that create a need for new specialist knowledge and skills, and increasing consumer awareness and demand for a more sophisticated mix of services. Global demand for qualified health workers is projected to increase, and competition for workers in the health sector labour market will be vigorous. New Zealand will need to retain local graduates and attract suitable numbers of trained workers from overseas. Skill transfer and enhancement and collaboration between all disciplines is needed if high-quality, flexible and continuous services are to be delivered equitably to all New Zealanders. The New Zealand health and disability workforce delivers services to over 4 million people and comprises over 130 000 health workers, over 5% of all workers in the country. Of these 130 000 health workers, 80 000 are registered practitioners and the remainder includes care and support workers1, community health promoters, some technicians, service and food workers and administrators. District Health Boards (DHBs) are the largest health sector employers in New Zealand and directly employ approximately 65 000 health workers. Others work in residential or community settings in the private sector and in nongovernmental organizations. In some cases, these NGOs are funded for particular services by the Ministry or DHBs. The current health and disability workforce can be characterized as: • being increasingly feminized, with women now representing 37% of doctors, compared with 16.4% in 1980; • being an ageing workforce with 74% of dental therapists, 70% of midwives and 67% of nurses aged over 40; • having an increasing number of specialists; • having a growing care and support workforce that is currently unregulated; 1 Care and support workforce: the paid workforce that delivers services in the community in both residential and home-based settings, providing non-specialist support services to people with lifelong disabilities and older people. NEW ZEALAND 290 | COUNTRY HEALTH INFORMATION PROFILES • being highly reliant on overseas trained doctors (40%) and nurses (25%) when compared with other OECD countries. Planning for and development of the health and disability workforce is undertaken by a number of parties including the Ministry of Health, other government agencies, DHBs, education providers, service providers and health professional groups. The Ministry and DHBs have developed a number of national strategies and action plans for priority areas, including priority workforce groups like nursing, midwifery and care and support. The Ministry is developing a stronger and coordinated national approach to strategic workforce planning and development to ensure a future workforce that is fit for purpose. There is now a greater focus on population health outcomes. This is directed by key national strategies, such as the New Zealand Health Strategy and the Primary Health Care Strategy. The Ministry of Health is driving implementation of these strategies to ensure there are appropriate health services to meet the current and future needs of the population and is developing processes to ensure workforce planning and development is driven by service needs and builds on lessons learnt in mental health workforce development around integrating workforce development and service delivery change. The Ministry of Health has a key role in developing national workforce plans1 that will build capacity and capability in the health and disability workforce, and ensure an appropriate regulatory environment through legislation, such as the Public Health and Disability Act 2000 and the Health Practitioners Competence Assurance Act 2003. In addition, the 21 DHBs have developed a Future Workforce framework focusing on DHB collective priorities and actions for developing its workforce. Policy and planning is informed by workforce information collected by the regulated professions, DHBs and the Ministry of Health. This information is used for a range of purposes, including forecasting, identifying workforce trends and providing a snapshot of the health and disability workforce. Work is underway to determine how best to collate information about the health and disability workforce that is currently unregulated and how best to progress its development. Government agencies and health employers play key roles in enabling entry into the health and disability workforce. As part of the new Tertiary Education Commission (TEC) reform, tertiary educational institutions are now required to develop three-yearly investment plans that reflect the needs of sectors, including health. The Ministry of Health continues to strengthen its links with organizations such as education, TEC and DHBs. Recruitment is a key issue for employers and there are various initiatives in place to attract and facilitate entry into the health and disability workforce. These range from scholarships, support programmes, such as mentoring, and a health career brand entitled ‘More than you can imagine’, to initiatives to locate and attract back skilled workers who have left the industry at both national and international levels. Retention is another key issue for employers and DHBs work with the health unions at all levels to improve this. The Tripartite Health Sector Relationship Agreement between Government, DHBs and the New Zealand Council of Trade Unions (CTU) commits the parties to a partnership approach when issues around workforce arise. However, there are still a significant minority of health sector unions that are outside the CTU. The Ministry of Health is a significant funder of post-entry clinical training and development. A significant proportion of this funding is spent on vocational training programmes provided by medical colleges. Other post-entry training is mostly self-funded by health workers or by their employers, who are largely DHBs. 1 Investing in Health: A framework for activating primary health care nursing in New Zealand, Raranga Tupuake: The Mäori Health and Disability Workforce Development Plan, Tauawhitia te Wero – Embracing the Challenge: National Mental Health and Addiction Workforce Development Plan 2006-2009, National Screening Unit Workforce Development Strategy and Action Plan, Pacific Health and Disability Workforce Development Plan 2004, Te Uru Kahikatea: Public Health Workforce Development Plan 2007-2016, Mäori Public Health Workforce Development Plan, and The New Zealand Cancer Control Strategy and Action Plan. COUNTRY HEALTH INFORMATION PROFILES | 291 Trends within New Zealand predict increasing health service demands based on an ageing population, growth in chronic diseases, and ongoing health inequalities for Mäori and Pacific peoples. Workforce planning and development must be driven by these demands to assure a workforce that can deliver the services needed. Planning for the right workforce, at the right time, in the right place is a challenge. Although there are a number of workforce plans focusing on building the capacity and capability of the current workforce, the focus needs to shift from the current workforce to the future workforce needed. New Zealand is developing a stronger and coordinated national approach to strategic workforce planning and development. Key priority areas for workforce planning and development include those under significant pressure: midwives, resident medical officers, senior medical officers, nurses, dieticians, pharmacists, occupational therapists, physiotherapists, care and support workers. Increasing ethnic representation across all workforce groups is also very important. Mäori and Pacific peoples are underrepresented in the health workforce in almost all areas of the sector. Raranga Tupuake: Mäori Health Workforce Development Plan aims to build a competent, capable, skilled and experienced Mäori health and disability workforce over the next 10 to 15 years. There are three goals to achieve the vision: • Goal 1: Te Raranga Tuatahi: Tuia te muka tangata i takea mai i hawaiiki: Increase the number of Mäori in the health and disability workforce. • Goal 2: Te Raranga Tuarua: Te Whiri i te mauri Mäori ki roto I ngamahi: Expand the skill base of the Mäori health and disability workforce. • Goal 3: Te Raranga Tuatoru: Te hononga ki nga‾ kete ako: Enable equitable access for Mäori to training opportunities. 3.6 Partnerships New Zealand is one of the three dominant development partners in the South Pacific, together with Australia and the European Union, with collaboration and partnerships at both bilateral and multilateral levels. Based on the Pacific Leaders’ vision, the Pacific Plan was adopted by Pacific Forum countries in November 2005 as a blue print for strengthening regional cooperation and integration. It covers in broad lines the most significant common development challenges the Pacific Island countries face and is seen to be not just regionally, but also nationally owned. Health is embodied in the Pacific Plan under the strategic objective No. 6. – Improved Health. 3.7 Challenges to health system strengthening While progress is being made in reducing inequalities in health outcomes between population groups, some inequalities still remain. Mäori and Pacific peoples have poorer health than non- Mäori-non-Pacific people, and people with low socioeconomic status have poorer health than those with higher socioeconomic status. Five-year cancer survival rates, cardiovascular disease mortality and diabetes diagnosis show marked disadvantage for Mäori compared with non-Mäori, and Mäori and Pacific women and women living in deprived areas are less likely to receive cervical or breast cancer screening. The causes of inequality are complex. The health and disability sector needs to continue to provide services that act to reduce inequalities between groups and to work across sectors to address the unequal distribution of the social determinants of health. NEW ZEALAND 292 | COUNTRY HEALTH INFORMATION PROFILES 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Annual report 2005/06 (including The Health and independence teport - annual Rrport for the year ended 30 June 2006) Operator : Ministry of Health, New Zealand Web address : http://www.moh.govt.nz/moh.nsf/indexmh/annual-reports Title 2 : New Zealand Ministry of Health Web address : http://www.moh.govt.nz/moh.nsf Title 3 : New Zealand Health Information Service (NZHIS) Operator : Ministry of Health, New Zealand Features : The New Zealand Health Information Service (NZHIS) is a group within the New Zealand Ministry of Health responsible for the collection and dissemination of health-related data. Web address : http://www.nzhis.govt.nz/ Title 4 : Statistics New Zealand Comments : Provides, among others, the 2006 Census data Web address : http://www.stats.govt.nz/default.htm Title 5 : Human development report 2006 Operator : United Nations Development Programme Features : Beyond Scarcity – Power, poverty and the global water crisis Web address : http://hdr.undp.org 5. 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 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) 3-304600/ 3-304631/ 3-300727 Fax : (679) 3-300462 Office Hours : COUNTRY HEALTH INFORMATION PROFILES | 293 6. ORGANIZATIONAL CHART: Ministry of Health NEW ZEALAND Year Source Demographics 1 270.69 a 2006 1 2 4 027.95 b 1 965.62 b 2 062.33 b 2006 1 3 1.00 … … 2006 2 4 6.83 b 7.14 b 6.53 b 2006 1 14.70 b 15.45 b 14.00 b 2006 1 12.32 b 11.25 b 13.30 b 2006 1 5 86.00 … … 2007 est 3 6 14.10 … … 2005 2 7 6.60 … … 2005 2 8 0.75 c … … 2005 2 9 78.81 77.50 81.70 2003-05 4 … 16.00 18.20 2002 5 10 2.00 2005 2 11 89.00 d … … 2006 6 12 24 996.00 e 2005 7 13 4.80 2004-05 1 14 0.94 2005 7 15 … … … 16 … … … 17 49 18 31 0 0 0 2004 C:8 D:9 39 23 16 16 12 4 2004 C:8 D:9 24 f 14 9 15 10 5 2004 C:8 D:9 … … … … … … … … … … … … 1 … … 0 0 0 2005 8 8 5 3 0 0 0 2004 9 0 0 0 0 0 0 2005 8 … … … 0 0 0 2004 9 2 … … … … … 2005 8 33 g 26 g 6 g 0 0 0 2004 9 0 0 0 0 0 0 2005 8 … … … 0 0 0 2004 9 30 … … 0 0 0 2005 8 Encephalitis Leprosy Malaria Plague Gonorrhoea 294 | COUNTRY HEALTH INFORMATION PROFILES COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km 2 ) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male Estimated population ('000s) Annual population growth rate (%) Percentage of population - 0–4 years - 5–14 years Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above Rate of natural increase of population (% per annum) Urban population (%) Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Typhoid fever Rural Number of deaths Total Male Female Per capita GDP at current market prices (US$) Environmental indicators Human development index Urban Rate of growth of per capita GDP (%) - Type B - Type C Dengue/DHF - Unspecified - Type E Cholera Syphilis - Type A Selected communicable diseases Total Health care waste generation (metric tons per year) Communicable and noncommunicable diseases Number of new cases Female Proportion of vehicles using unleaded gasoline (%) MaleTotal Hepatitis viral NEW ZEALAND Year Source 18 29 108 15 707 13 401 491 175 316 C:2003-04 D:2004 10 19 6 333 3 182 3 151 15 3 12 C:2003-04 D:2004 10 20 352 … … … … … 2006 8 158 … … … … … 2006 8 21 19 223 10 143 9 080 8 023 4 173 3 850 2004 10 2 361 22 2 339 646 4 642 2004 10 2 735 1 370 1 365 1 173 570 603 2004 10 154 71 2004 10 253 181 72 206 132 74 2004 10 671 367 304 291 146 145 2004 10 292 191 101 101 66 35 2004 10 164 121 43 176 119 57 2004 10 368 211 157 301 186 115 2004 10 1 819 1 070 749 1 555 929 626 2004 10 22 68 384 h 37 928 h 30 456 h 11 293 5 400 5 893 C:2003-04 D:2004 10 12 127 h 7 555 h 4 572 h 3 204 1 722 1 482 C:2003-04 D:2004 10 8 474 h 4 061 h 4 413 h 2 806 1 050 1 756 C:2003-04 D:2004 10 894 h 346 h 548 h 283 104 179 C:2003-04 D:2004 10 26 251 h 16 076 h 10 175 h 6 313 3 366 2 947 C:2003-04 D:2004 10 684 h 309 h 375 h 123 48 75 C:2003-04 D:2003 10 23 7 754 h 4 132 h 3 622 h 843 438 405 C:2003-04 D:2004 10 24 20 898 h 9 872 h 11 026 h 828 307 521 C:2003-04 D:2004 10 25 137 869 i 73 261 i 64 608 i 1 710 i 1 131 i 579 i C:2003-04 D:2004 10 4 242 i 3 243 i 999 i 47 i 34 i 13 i C:2003-04 D:2004 10 13 125 i 8 384 i 4 741 i 520 i 366 i 154 i C:2003-04 D:2004 10 … … … … … … 5 402 i 1 744 i 3 658 i 488 i 379 i 109 i C:2003-04 D:2004 10 26 43 123 22 548 20 575 1 075.49 1 143.81 1 009.42 2003-04 10 29 160 29 160 727.25 1 430.60 2003-04 10 26 251 16 076 10 175 654.70 815.50 499.19 2003-04 10 20 090 10 747 9 343 501.05 545.17 458.37 2003-04 10 19 934 9 672 10 262 497.16 490.64 503.46 2003-04 10 19 878 9 828 10 050 495.76 498.55 493.06 2003-04 10 19 182 19 182 478.40 941.08 2003-04 10 18 726 6 342 12 384 467.03 321.72 607.57 2003-04 10 17 636 9 372 8 264 439.84 475.42 405.44 2003-04 10 14 733 7 231 7 502 367.44 366.81 368.05 2003-04 10 - All forms Circulatory - Cerebrovascular diseases - Liver - Stomach - Leukaemia Leading causes of morbidity (inpatient care) Leading causes of mortality and morbidity 10. General symptoms and signs (R50-R69) INDICATORS Mental disorders Male Male Female Total Number of cases DATA Number of deaths Female Tuberculosis - Lip, oral cavity and pharynx 2. Complications of labour and delivery (060-075) 7. Maternal care related to the fetus and amniotic cavity and possible delivery problems 3. Ischaemic heart diseases (120-125) 6. Symptoms and singns involving the circulatory and respiratory systems (R00-R09) - Hypertension All circulatory system diseases - Trachea, bronchus, and lung - Breast - Acute myocardial infarction - Suicide All types - Homicide and violence - Motor and other vehicular accidents - Occupational injuries Injuries 1. Malignant neoplasms (C00-C96) 8. Symptoms and signs involving the digestive system and abdomen (R10-R19) 9. Arthropathies (M00-M25) Total TotalFemale Rate per 100 000 population Male Female Diabetes mellitus - Ischaemic heart disease 4. Other forms of heart disease (130-152) 5. Chronic lower respiratory diseases (J40-J47) - Rheumatic fever and rheumatic heart diseases - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases All cancers (malignant neoplasms only) Acute respiratory infections Number of new cases Male - New pulmonary tuberculosis (smear-positive) Cancers Total COUNTRY HEALTH INFORMATION PROFILES | 295 NEW ZEALAND Year Source 27 8 023 4 173 3 850 197.49 208.83 186.51 2004 10 6 313 3 366 2 947 155.40 168.44 142.77 2004 10 2 806 1 050 1 756 69.07 52.54 85.07 2004 10 1 854 944 910 45.64 47.24 44.08 2004 10 1 205 532 673 29.66 26.62 32.60 2004 10 843 438 405 20.75 21.92 19.62 2004 10 828 307 521 20.38 15.36 25.24 2004 10 520 366 154 12.80 18.32 7.46 2004 10 508 277 231 12.50 13.86 11.19 2004 10 488 379 109 12.01 18.97 5.28 2004 10 28 72.00 2002 est 11 29 NR 2006 8 30 … 31 5.76 6.59 4.89 2006 est 1 32 94.18 … … 2006 10 33 … … … 87.00 … … 2007 8 87.00 … … 2007 8 88.00 … … 2007 8 34 14 604 1 C:2003-04 D:2003 10 71 0 C:2003-04 D:2003 10 4 624 0 C:2003-04 D:2003 10 3 119 0 C:2003-04 D:2003 10 287 0 C:2003-04 D:2003 10 35 0 0 0 0 0 0 2007 8 0 0 0 0 0 0 2007 8 … … … … … … 25 … … … … … 2007 8 75 … … … … … 2007 8 0 0 0 0 0 0 2007 8 331 … … … … … 2007 8 0 0 0 0 0 0 2007 8 10 … … … … … 2007 8 1 … …. … … … 2007 8 2. Ischaemic heart diseases (I20-I25) - Pertussis (whooping cough) Immunization coverage for infants (%) FemaleTotal DATA FemaleTotal INDICATORS Female Male - Poliomyelitis - Diphtheria - Eclampsia Male - Abortion Male FemaleTotal Rate per 100 000 population - Congenital rubella syndrome - Sepsis Number of deathsNumber of cases Maternal, child and infant diseases 3. Cerebrovascular diseases (I60-I69) Female - Rubella Total Number of cases Total Male - Haemorrhage Selected diseases under the WHO-EPI - Obstructed labour - Hib meningitis - Neonatal tetanus - Measles Leading causes of mortality - POL3 - Total Tetanus 6. Diabetes melitus (E10-E14) 4. Chronic lower respiratory diseases (J40-J47) Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth Percentage of pregnant women with anaemia 10. Intentional self-harm (X60-X84) Percentage of women in the reproductive age group using modern contraceptive methods 8. Transport accidents (V01-V99) Male 7. Organic, including symptomatic, mental disorders (F00-F09) - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) - Hepatitis B III - BCG - DTP3 Maternal causes 1. Malignant neoplasms (C00-C96) 8. Diseases of arteries, arterioles and capillaries (I70-I79) 5. Other forms of heart disease (I30-I52) 296 | COUNTRY HEALTH INFORMATION PROFILES NEW ZEALAND Year Source 36 … 37 Public health facilities 85 12 484 2002 10 … … … … … … Private health facilities 360 11 341 2002 10 … … 38 2006p 12 9.40 2006p 12 2 420.05 2006p 12 7 801.29 2006p 12 77.80 2006p 12 18.60 2006p 12 0.00 2006p 12 22.20 2006p 12 1.54 2006p 12 39 … Year Source 40 Physicians - Number 9 547 5 983 3 564 7 245 2 287 5 128 4 316 2006 10 - Rate per 1000 population 2.30 1.40 0.90 1.80 0.57 1.20 1.00 2006 10 Dentists - Number 1 718 1 218 500 1 415 320 126 1 563 2006 10 - Rate per 1000 population 0.40 0.30 0.10 0.35 0.08 0.00 0.40 2006 10 Pharmacists - Number 3 808 … … … … … … 2006 10 - Rate per 1000 population 0.90 … … … … … … 2006 10 Nurses - Number 40 212 2 647 37 560 33 838 8 329 28 735 11 477 2006 10 - Rate per 1000 population 9.60 0.60 9.00 8.40 2.06 7.13 2.70 2006 10 Midwives - Number 2 511 5 2 501 … … 1 457 908 2006 10 - Rate per 1000 population 0.60 0.00 0.60 … … 0.30 0.20 2006 10 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … Annual number of graduates Exchange rate in US$ of local currency is: 1 US$ = Number Number of beds DATA R u ra l P u b lic DATA P ri va te 10 021.43 - external resources for health as % of general government expenditure on health U rb an M al e T o ta l F em al e - general government expenditure on health as % of total expenditure on health External source of government health expenditure Private health expenditure Human resources for health Health insurance coverage as % of total population INDICATOR - private expenditure on health as % of total expenditure on health - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals - Primary health care centres - per capita total expenditure on health (in US$) Government expenditure on health Health care financing Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) Facilities with HIV testing and counseling services Health infrastructure - Hospitals Health facilities - Outpatient clinics INDICATORS COUNTRY HEALTH INFORMATION PROFILES | 297 NEW ZEALAND Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 4.80 … … 2006 4 45 6.34 … … 2003 1 46 98.00 … … 2007 8 47 6.81 2004 10 48 100.00 2001 10 … 95.30 2004 est 10 49 … … … 50 … 51 Antenatal care coverage - At least one visit 100.00 2005 10 - At least four visits … 52 … … … 53 … … … 54 0.10 … … 2007 8 55 … … … 56 … … … 57 … … … 58 … … … 59 … … … 60 9.00 … … 2006 8 61 1.00 … … 2006 8 62 61.00 … … 2006 8 63 0.00 … … 2005 8 64 … 100.00 … 2006 13 65 … … … 66 … … … M al e DATA Total Male P u b lic F em al e U rb an R u ra l HIV prevalence among population aged 15-24 years Malaria death rate per 100 000 population Malaria incidence rate per 100 000 population Contraceptive prevalence rate Tuberculosis death rate per 100 000 population Female Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source Proportion of population in malaria-risk areas using effective malaria prevention measures INDICATORS DATA T o ta l Health-related Millennium Development Goals (MDGs) Annual number of graduates Workforce losses/ Attrition INDICATORS P ri va te Proportion of population in malaria-risk areas using effective malaria treatment measures Proportion of population with access to affordable essential drugs on a sustainable basis Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Total Urban Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Unmet need for family planning Prevalence of underweight children under five years of age Adolescent birth rate Maternal mortality ratio (per 100 000 live births) Percentage of people with advanced HIV infection receiving ART Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Estimated HIV prevalence in adults j Rural Infant mortality rate (per 1000 live births) Tuberculosis prevalence rate per 100 000 population 298 | COUNTRY HEALTH INFORMATION PROFILES NEW ZEALAND … p est NR a b c d e f g h i j 1 2 3 4 5 6 7 8 9 10 11 12 13 COUNTRY HEALTH INFORMATION PROFILES | 299 Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world . United Nations Development Programme, New York USA 2007. [http://hdr.undp.org/en/reports/global/hdr2007-2008/] WHO Regional Office for the Western Pacific, data received from technical units New Zealand Health Information Service (http://www.nzhis.govt.nz) Environmental science and research, New Zealand. 2002 ESCAP population data sheet. Bangkok, Economic and Social Commission for Asia and the Pacific, 2002. World health report 2004. Changing history. Geneva, World Health Organization, 2004. Provisional Estimate Figure refers to hospitalization in 2003-04 Figure includes one case with unspecified gender Imported cases Computed by Health Information and Evidence for Policy Unit, WHO Regional Office for the Western Pacific Literacy defined as levels 2-5 using OECD PISA (Programme for Internaitonal Student Achievement) standards 2006, Statistics New Zealand (http://www.stats.govt.nz) Figure refers to usual resident population. Usual resident population includes those residents who are present and those who are temporarily elsewhere in New Zealand. The MOH Annual Report 2005/06 including The Health and Independence Report - Annual Report for the year ended 30 June 2006 Figure refers to GNP per capita (PPP US$). Figure excludes inland waters and oceanic areas Residents who are temporarily overseas were not counted. Not relevant Notes: Data not available United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: Figure refers to hospitalization- 1st reported e-code Not included in the official list of MDG indicators World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf] Sources: Education at a Glance 2000, Organisation for Economic Cooperation and Development (OECD). Information furnished by the Ministry of Health, New Zealand, 27 February 2004 300 | COUNTRY HEALTH INFORMATION PROFILES NIUE 1. CONTEXT 1.1 Demographics The population of Niue decreased from a peak of 5194 in 1966, to 2322 in 1991, 1788 in 2001 and an estimated residents of 1538 in 2006, with 756 males and 782 females. There is substantial emigration to New Zealand because of Niue’s lack of natural resources, its isolation and insufficient social and economic development, and because Niueans hold New Zealand citizenship. The 2001 New Zealand census listed 20 148 Niueans in the New Zealand population. Population density is estimated at six persons per square kilometre, with 38% living in urban areas. Children under the age of 15 years make up 26.7% of the population, and adults 65 years and older 10.7%. The crude birth rate is 15.8 per 1000 population and the crude death rate 9.3 per 1000 population. The groundwater supply is safe and potable for human consumption and coverage of safe water sanitation facilities is 100% (2004). AusAID supported the development of the national waste management plan. 1.2 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 head 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 a system of universal suffrage. 1.3 Socioeconomic 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 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$ 10 030 232); per capita GDP stood at NZD 10 048 (US$ 5841.9). 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. WHO 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 under way, but are necessarily limited by a dependence on other countries’ airlines to service Niue. Royal Tonga operates a COUNTRY HEALTH INFORMATION PROFILES | 301 small twin otter aircraft for passenger service three times a week between Nukualofa, Tonga and Niue. Polynesian Airlines has a service from Apia to Auckland via Niue twice a week. 1.4 Vulnerabilities and hazards No available information. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition In general, health indicators are good, consistent with the country’s high literacy rate (100% in 2003) and its well educated population. 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 (>80% eligible population) of mass drug administration (MDA). Niue has a 0.2% antigenemia rate and is targeting filariasis elimination. 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 last 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 the 2006 census, 23% of residents aged 15 years and older said they smoked, with smoking twice as prevalent among men (31%) than women (16%). The proportion of alcohol drinkers is equal to the proportion of non-drinkers, but there are more male drinkers (62.7%) than female drinkers (37.4%). 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 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. 2.2 Outbreaks of communicable diseases No available information. 2.3 Leading causes of mortality and morbidity 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). NIUE 302 | COUNTRY HEALTH INFORMATION PROFILES 2.4 Maternal, child and infant diseases Niue residents enjoy good maternal and child health care. No maternal death was recorded from 1999 to 2006. The fertility rate is 2.6 (2001-2006). There was one infant death in 2006. In 2007, there was 99% immunization coverage against vaccine-preventable diseases. 2.5 Burden of disease No available information. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives 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 chair-side 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 (2005). 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. National health priorities are focused on public health prevention strategies 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 services and public health programmes. 3.2 Organization of health services and delivery systems Community outreach is maintained through village visits by public health nurses and regular village inspections by public health officers. While medical services are free for local residents, payment is required for some prescribed medicines, such as contraceptives. 3.3 Health policy, planning and regulatory framework See Section 3.1. 3.4 Health care financing Niue's estimated total health expenditure in 2006 was US$ 1.9 million, with per capita total health expenditure of US$ 974.0. General government expenditure on health was US$ 1.9 million representing 98.6% of total health expenditure. 3.5 Human resources for health The only hospital, Lord Liverpool Hospital, was destroyed by Cyclone Heta in January 2004. Hospital services were set up subsequently in a youth centre in Fonuakula, Alofi, which is near the airport, until a new hospital was constructed in Kaimiti, an inland location rather than a coastal area. Lord Liverpool Hospital had been the centre for all preventative and curative health services, dentistry services and school health services since the early 1990s and, 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 COUNTRY HEALTH INFORMATION PROFILES | 303 AusAID. The new hospital, constructed in 2005 with funding from WHO, the European Union and NZAid, is named Niue Foou Hospital. ‘Foou’ literally means new. 3.6 Partnerships No available information. 3.7 Challenges to health system strengthening No available information. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Niue statistics Web address : http://www.who.int/entity/nha/country/MYS Title 2 : National health accounts series Operator : World Health Organization Web address : http://www.who.int/entity/nha/country/MYS Title 3 : Niue population profile based on 2006 Census of Population and Housing: A guide for planner and policy-makers Operator : Niue Economics, Planning, Development & Statistics Unit SPC Statistics and Demography Programme Noumea, New Caledonia Title 4 : Niue Millennium Development Goals 2006 report Operator : Economics Planning Development and Statistics Unit 5. ADDRESSES 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 Year Source Demographics 1 0.26 2006 1 2 1.54 a 0.76 a 0.78 a 2006 est 2 3 -2.40 a … … 2001-06 2 4 9.17 a,b 3.70 a,b 5.46 a,b 2006 est 2 17.56 a,b 9.04 a,b 8.52 a,b 2006 est 2 10.73 a,b 4.49 a,b 6.24 a,b 2006 est 2 5 38.00 … … 2007 est 3 6 15.80 … … 2001-06 2 7 9.30 … … 2001-06 2 8 0.65 … … 2001-06 2 9 … 67.00 c 76.00 2001-06 2 … 11.60 12.80 2002 4 10 2.60 2001-06 2 11 100.00 100.00 100.00 2003 5 12 5841.86 2003 6 13 6.88 d 2003 6 14 … 15 … … … 16 … … … 17 0 0 0 0 0 0 2005 7 0 0 0 0 0 0 2005 7 0 0 0 0 0 0 2005 7 0 0 0 0 0 0 2005 7 … … … … … … … … … … … … 0 0 0 0 0 0 2005 7 0 0 0 … … … 2005 8 0 0 0 0 0 0 2005 7 0 0 0 0 0 0 2005 7 0 0 0 … … … 2006 8 0 0 0 0 0 0 2005 7 0 0 0 0 0 0 2005 7 0 0 0 0 0 0 2005 7 0 0 0 0 0 0 2005 7 304 | COUNTRY HEALTH INFORMATION PROFILES FemaleMaleTotal Syphilis - Type B - Unspecified Cholera Per capita GDP at current market prices (US$) Environmental indicators Total Urban Human development index Rate of growth of per capita GDP (%) Number of deaths Female Total Number of new cases Male Adult literacy rate (%) Proportion of vehicles using unleaded gasoline (%) Encephalitis Leprosy - Type A Communicable and noncommunicable diseases Hepatitis viral Selected communicable diseases - Type E - Type C Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Total fertility rate (women aged 15–49 years) Estimated population ('000s) Annual population growth rate (%) Percentage of population Rate of natural increase of population (% per annum) Urban population (%) Crude death rate (per 1000 population) - 0–4 years - 5–14 years Crude birth rate (per 1000 population) - 65 years and above COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male NIUE Health care waste generation (metric tons per year) Malaria Dengue/DHF Gonorrhoea Plague Typhoid fever Rural NIUE Year Source 18 … … … … … … 19 … … … … … … 20 0 0 0 … … … 2006 8 0 0 0 … … … 2006 8 21 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 22 … … … … … … … … … … … … … … … … … … 343 … … … … … 2001 9 … … … … … … … … … … … … 23 308 … … … … … 2001 9 24 … … … … … … 25 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 26 343 … … 19 183.45 … … 2001 9 308 … … 17 225.95 … … 2001 9 271 … … 15 156.60 … … 2001 9 270 … … 15 100.67 … … 2001 9 156 … … 8 724.83 … … 2001 9 148 … … 8 277.40 … … 2001 9 110 … … 6 152.13 … … 2001 9 97 … … 5 425.06 … … 2001 9 78 … … 4 362.42 … … 2001 9 72 … … 4 026.85 … … 2001 9 - Colon and rectum - Cervix - Oesophagus - Ischaemic heart disease Male COUNTRY HEALTH INFORMATION PROFILES | 305 Total TotalFemale Male Female Total Male Number of new cases Rate per 100 000 population Male Female - Breast - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders Diabetes mellitus - Leukaemia - Lip, oral cavity and pharynx Number of cases Circulatory - Cerebrovascular diseases All circulatory system diseases 2. Diabetes mellitus - Hypertension - Acute myocardial infarction Leading causes of mortality and morbidity 7. Other disease of the skin 8. Open wounds 9. Bronchitis Leading causes of morbidity (inpatient care) 3. Infection of the skin and subcutaneous tissue 6. Myalgia and myositis 4. Upper respiratory tract infection, unspecified 5. Influenza Total Number of deaths DATA Female - Liver - Stomach - Trachea, bronchus, and lung INDICATORS Tuberculosis - All forms - New pulmonary tuberculosis (smear-positive) Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections Cancers All cancers (malignant neoplasms only) 10. Sprains and strains of joints and adjacent muscles - Suicide All types - Homicide and violence - Motor and other vehicular accidents 1. Hypertension - Occupational injuries NIUE Year Source 27 … … … … … … … … … … … … … … … … … … 1 … … … … … 2001 10 1 … … … … … 2001 10 28 22.00 2005 7 29 NR 2007 7 30 2.00 2005 7 31 0.00 0.00 0.00 2005 5 32 100.00 100.00 100.00 2005 7 33 99.00 … … 2007 8 99.00 … … 2007 8 99.00 … … 2007 8 99.00 … … 2007 8 34 … … … … … … … … … … 35 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 … … … … … … 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 0 0 0 … … … 2007 8 Male 306 | COUNTRY HEALTH INFORMATION PROFILES 7. 6. 4. Pneumonia 1. Injuries from gunshots Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth 5. Drowning - Obstructed labour Maternal causes - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) - Eclampsia - Diphtheria Selected diseases under the WHO-EPI - Total Tetanus - Neonatal tetanus - Measles - Haemorrhage - Abortion - BCG - Hepatitis B III - Hib meningitis Female Female Number of deaths Male Total 8. 9. Number of cases 10. Percentage of women in the reproductive age group using modern contraceptive methods - DTP3 Percentage of pregnant women with anaemia Number of deaths - Congenital rubella syndrome - Sepsis - Pertussis (whooping cough) Male Female Rate per 100 000 population Total - Poliomyelitis DATA - Rubella FemaleTotal MaleMale FemaleTotal Maternal, child and infant diseases 2. Diabetes and hypertension complications Total INDICATORS 3. Premature births Leading causes of mortality - POL3 Immunization coverage for infants (%) NIUE Year Source 36 … 37 Public health facilities 1 8 2006 7 … … … … … … Private health facilities … … … … 38 1.95 2006p 11 13.60 2006p 11 974.03 2006p 11 1.95 2006p 11 98.60 2006p 11 10.80 2006p 11 66.30 2006p 11 1.40 2006p 11 1.54 2006p 11 39 … Year Source 40 Physicians - Number 4 1 3 … … … … 2006p 7 - Rate per 1000 population 23.12 12.47 d 36.45 d … … … … 2006p 7 Dentists - Number 3 3 0 … … … … 2006p 7 - Rate per 1000 population 17.34 37.40 d 0 … … … … 2006p 7 Pharmacists - Number 1 1 0 … … … … 2006p 7 - Rate per 1000 population 5.78 12.47 d 0 … … … … 2006p 7 Nurses - Number 13 1 12 … … … … 2006p 7 - Rate per 1000 population 75.14 12.47 d 145.8 d … … … … 2006p 7 Midwives - Number 2 0 2 … … … … 2006p 7 - Rate per 1000 population 11.56 0.00 24.3 d … … … … 2006p 7 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … - Primary health care centres - Outpatient clinics - Hospitals Facilities with HIV testing and counseling services Health infrastructure - District/first-level referral hospitals - external resources for health as % of general government expenditure on health - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals INDICATORS M al e F em al e T o ta l - per capita total expenditure on health (in US$) Government expenditure on health Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) - general government expenditure on health as % of total expenditure on health P ri va te INDICATOR P u b lic DATA U rb an External source of government health expenditure Private health expenditure - private expenditure on health as % of total expenditure on health Annual number of graduates COUNTRY HEALTH INFORMATION PROFILES | 307 Exchange rate in US$ of local currency is: 1 US$ = R u ra l Human resources for health Health insurance coverage as % of total population Number Health facilities Number of beds DATA Health care financing NIUE Year Source 41 Pharmacists … … … … … … … Nurses 0 0 0 0 0 0 0 2006p 7 Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 0.00 0.00 0.00 2005 7 44 0.00 e 0.00 0.00 2006 12 45 0.00 0.00 0.00 2006 12 46 99.00 … … 2007 8 47 0.00 2006 12 48 100.00 2006 12 0.00 2006 12 100.00 2006 12 49 22.60 … … 2001 12 50 … 51 Antenatal care coverage - At least one visit 10.00 2005 7 - At least four visits … 52 … … … 53 … … … 54 … … … 55 … … … 56 … … … 57 … … … 58 … … … 59 … … … 60 85.00 … … 2006 8 61 9.00 … … 2006 8 62 … … … 63 … … … 64 100.00 100.00 100.00 2006 13 65 100.00 100.00 100.00 2006 13 66 … … … Under-five mortality rate (per 1000 live births) Maternal mortality ratio (per 100 000 live births) Total Infant mortality rate (per 1000 live births) Proportion of population with access to affordable essential drugs on a sustainable basis Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Contraceptive prevalence rate Annual number of graduates Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Percentage of people with advanced HIV infection receiving ART Estimated HIV prevalence in adults f INDICATORS DATA Total Male HIV prevalence among population aged 15-24 years - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source Malaria incidence rate per 100 000 population Tuberculosis prevalence rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria treatment measures Proportion of population in malaria-risk areas using effective malaria prevention measures Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Urban Rural 308 | COUNTRY HEALTH INFORMATION PROFILES Malaria death rate per 100 000 population Adolescent birth rate Health-related Millennium Development Goals (MDGs) Unmet need for family planning P ri va te INDICATORS DATA F em al e U rb an R u ra l P u b lic Workforce losses/ Attrition Tuberculosis death rate per 100 000 population Female T o ta l M al e NIUE … p est NR a b c d e f 1 2 3 4 5 6 7 8 9 10 11 12 13 COUNTRY HEALTH INFORMATION PROFILES | 309 Provisional Notes: Data not available World health report 2004. Changing history. Geneva, World Health Organization, 2004. Much care is advised in interpreting these data, as they are based on only 76 reported deaths in Niue between 2001 and 2006 Not relevant Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific Sources: Niue Population Profile based on 2006 Census of Population and Housing: A Guide for Planners and Policymakers . Niue Economics, Planning, Development & Statistics Unit, Figure refers/applies to resident population Pacific Island Populations 2004. Secretariat of the Pacific Community [www.spc.int/demog/]. and the SPC Statistics and Demography Programme, Noumea, New Caledonia, 2008. [http://www.spc.int/prism/country/nu/stats/NU_Reports/Census%202006/NIUE%20PROFILE-25-02WEB.pdf] Estimate Not included in the official list of MDG indicators World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf]. Revised figure Niue Millennium Development Goals 2006 Report . Economics Planning Development and Statistics Unit, Niue, 2007. Stats at a glance, 2006 Census. Niue Statistics, Economic Planning Development and Statistics [www.spc.int/prism/country/niu/stats]. United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). Niue sustainable human development situation analysis 2002. New York, United Nations Development Programme, 2002. Information furnished by WHO Representative in Samoa, 13 March 2004. Statistics Niue [www/spc/int/prism]. Niue Foou Hospital Data Sources, 2006. WHO Regional Office for the Western Pacific, data received from the technical units. Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: There is only 1 infant death in 2006 310 | COUNTRY HEALTH INFORMATION PROFILES NORTHERN MARIANA ISLANDS, COMMONWEALTH OF 1. CONTEXT 1.1 Demographics The Commonwealth of the Northern Mariana Islands (CNMI) comprises 14 islands with a total land area of 176.5 square miles spread out of 264 000 square miles of the Pacific Ocean. The Commonwealth’s population lives primarily on three islands; Saipan, the largest and most populated island, is 12.5 miles long and 5.5 miles wide. The other two populated islands are Tinian and Rota and the nine far northern islands are very sparsely inhabited with a combined population of about six people. Since the 1980s, the number of residents has more than quadrupled. In the 2000 census, the total population numbered 69 221, with approximately 90% living in Saipan and 5% each in Tinian and Rota. With an estimated growth rate of 3.2%, the total population figures were estimated in 2006 at 84 487 people. Local residents are primarily Chamorros and Carolinians, the two indigenous ethnic groups. Additionally, the “Compacts of Free Association” permit the free movement of people between the freely associated states, flag territories, Hawaii and the mainland United States. These “Compact” islands include the Republic of Palau; the Republic of the Marshall Islands; and the islands comprising the Federated States of Micronesia, Kosrae, Chuuk, Pohnpei, and Yap. The Department of Public Health estimated in 1996 that it provided health care costing US$ 1480 000 to “Compact Impact” residents. The impact of meeting the chronic health care needs of these Micronesian residents within the struggling national health care system plays an important role in overwhelming the capacity of the system. Foreign contract workers from Asia (primarily Chinese and Filipino) represent almost half of the population, though a recent slowdown in the garment industry has resulted in a decline in contract workers. These contract labourers work in the private and public sector in difficult-to-fill positions. 1.2 Political situation The Northern Mariana Islands is a commonwealth of the United States of America, formed in 1978, formerly of the United Nation’s Trust Territory of the Pacific region of Micronesia within Oceania. 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. Residents (excluding foreign contract workers) are United States citizens, but do not vote in federal elections and do not pay United States taxes. It is important to note that the Commonwealth of the Northern Mariana Islands, its governing system and its infrastructure as an independent entity within a commonwealth agreement with the United States is only approaching 30 years old. The present administration was elected in November 2005, with the Honourable Governor Benigno Fitial taking office in January 2006 and appointing Joseph Kevin Villagomez as Secretary of Public Health. There are three branches of government: the executive, legislative and judicial. COUNTRY HEALTH INFORMATION PROFILES | 311 The Secretary of Public Health serves as an Executive Cabinet member and head of the Department of Public Health. 1.3 Socioeconomic situation In addition to funds received from the United States, the economy largely depends on two major industries: tourism and garment manufacturing. In a 2007 report by the United States Government Accountability Office, it was stated that “the CNMI’s (Commonwealth of the Northern Mariana Islands) economic potential is constrained, in part, by its lack of diversification and faces serious challenges owing to declines in garment manufacturing and tourism, its two major industries. Among factors affecting the garment industry, liberalization in trade law in the early 2000s reduce the CNMI’s trade advantage relative to low-wage countries such as China, causing CNMI exports to fall. The CNMI’s tourism industry has been subject to fluctuations due to Asian economic trends in the late 1990s, as well as recent changes in airline practices. Until 2007, the CNMI’s workforce was subject to a minimum wage set by the CNMI Government that was lower than the U.S. mainland’s; however, Congress enacted a law in 2007 that applied the U.S. minimum wage to the CNMI and will gradually increase the CNMI minimum wage until it meets federal minimum wage requirements.” 1.4 Vulnerabilities and hazards No available information. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition Infectious diseases are once again emerging as a major public health concern. Of particular concern are tuberculosis, enteric food borne illnesses, vaccine-preventable diseases, HIV infection and other sexually transmitted infections. At the same time, obesity, diabetes, hypertension and atherosclerotic vascular disease are increasing concerns facing the aging population. 2.2 Outbreaks of communicable diseases The Department of Public Health has recently dealt with foodborne disease outbreaks involving salmonella and shigella. 2.3 Leading causes of mortality and morbidity The Vital Statistics Office of the Department of Public Health monitors the number of deaths and the cause of death in the country each year. The Medical Director reviews these events to examine the data for trends in order to focus preventive health efforts. In 2005, there were 183 total deaths, 79 females and 104 males. Since there is no resident forensic pathologist, autopsies for non-suspicious deaths are not performed routinely. The leading cause of death in 2005 was heart disease, followed by cancer, stroke, renal disease and sepsis. The number of deaths due to strokes and heart attacks has been increasing in the last three years; with strokes becoming the third leading cause of death in 2005. Some of the increase in mortality from strokes and heart attacks is among individuals under the age of 50. This disturbing trend is probably due to high rates of untreated diabetes and hypertension in the population. There is also growing evidence that use of methamphetamine (“ice”) can contribute to deaths from heart attacks and strokes; ice use is prevalent in the Commonwealth of the Northern Mariana Islands. NORTHERN MARIANA ISLANDS, COMMONWEALTH OF 312 | COUNTRY HEALTH INFORMATION PROFILES Cancer diagnoses and most chemotherapy are carried out nationally, but radiation therapy is not available in the country and there is no resident oncologist. The Department of Public Health is increasing its public health efforts to improve cancer prevention in the community. A significant example was the launching, in 2007, of the HPV Vaccination Campaign aimed at vaccinating girls in high school with the human papillomavirus (HPV) vaccine that immunizes against four HPV strains that can cause cervical cancer. 2.4 Maternal, child and infant diseases Under the United States Division of Public Health, the Maternal and Child Health (MCH) Programme oversees primary and preventive health care services to the maternal and child population, including children with special health care needs, and is federally funded by a grant under the Health Resources and Services Administration (HRSA) within the Department of Health and Human Services (DHHS). The MCH Programme authorizes appropriations to the Commonwealth of the Northern Mariana Islands to improve the health of all mothers and children applicable to health status goals and national health objectives. It enables the country to: • provide and assure mothers and children access to maternal and child health services; • reduce infant mortality and the incidence of preventable diseases, increase the number of children appropriately immunized against disease, and otherwise promote the health of mothers and infants by providing prenatal and postpartum care and to promote the health of children by providing preventive and primary care services; and • provide and promote family-centred, community-based coordinated care for children with special health care needs. The priority MCH concerns include, among others, childhood obesity, lack of or little prenatal care, access to women’s health services, identification and referrals of infants for early intervention services, decreasing sexually transmitted infection among teenagers. In addition, more effort is being put into decreasing the burden of dental caries in children. An assessment of 480 Head Start students for the school year 2007-2008 found that every child had six or more dental caries. Despite many challenges with prenatal care, CNMI has an exceptionally low rate of infant mortality rate (IMR) is exceptionally low, reported at 7.1 in 2005. This number compares favourably to the United States IMR of 6.5 for the same year, and only seven nations reported a lower rate. However, in view of the small numbers and large statistical variation, the Department of Public Health will continue to strive for improvements in perinatal care. The most common diseases among infants during 2007 were acute upper respiratory infections, fetal/neonatal jaundice, and acute bronchiolitis. In the 1-4 years age group, the most common diseases were acute upper respiratory infections and otitis media 2.5 Burden of disease No available information. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives Health care in the Commonwealth of the Northern Mariana Islands (CNMI) is facing major challenges in the areas of quality of care and financing of health care delivery. These problems have been recognized for many years but, with the recent deepening financial crisis, there is increasing pressure to find solutions. COUNTRY HEALTH INFORMATION PROFILES | 313 The current leadership at the Department of Public Health has been working on many different plans to improve the current situation. Among the highest priorities have been stabilizing and improving the financial status of the Commonwealth Health Center (CHC) and restructuring of the Department of Public Health in order to build a foundation that will allow overall improvements in the quality of health care delivery. The overall goal is to improve the health of the people. As a way of focusing restructuring efforts, a strategic plan has been developed for prioritizing and implementing solutions to some of the more immediate problems affecting health care delivery, with financial stability the top priority. The key elements of the strategic plan are outlined below. Mission Statement for the Department of Public Health To provide compassionate, quality health care and promote health for all people in the Commonwealth of the Northern Mariana Islands. Vision to guide Department of Public Health’s priorities in attaining its stated mission The Department of Public Health will deliver the best possible health care by improving its financial stability. Goals for attaining the Department of Public Health’s vision The goals were chosen from all the possible discussed solutions as being the most likely to allow the Department of Public Health to attain its vision. Highest priority was placed on goals that could be attained relatively quickly within the current resources of the Department. The goals include: (1) Move towards more autonomy for CHC in the areas of operations, supply chain and finance (over-arching goal). (2) Install a new hospital information system and financial management programme (VISTA – a programme through the VA system). (3) Improve billing and processing of collections for CHC to improve revenue and cash flow. (4) Medicaid reform to improve available resources to CHC and on-island medical providers. (5) Autonomy for recruitment and retention of Department of Public Health personnel. This is an ambitious list to accomplish in a relatively short time, but the achievement of these goals will allow the development of more adequate resources to improve direct patient care and the overall health of the people of the Commonwealth of the Northern Mariana Islands. The plan will guide efforts in working towards the vision of creating a financially stable hospital to improve the health of all citizens. 3.2 Organization of health services and delivery systems The Department of Public Health is the sole provider of comprehensive health care services in the Commonwealth of the Northern Mariana Islands. The Department, through the Commonwealth Health Center (CHC), provides a wide range of preventative (public health) and curative health services aimed at protecting and improving the health and quality of life for the population. NORTHERN MARIANA ISLANDS, COMMONWEALTH OF 314 | COUNTRY HEALTH INFORMATION PROFILES The Department is made up of three divisions: The Division of Public Health, which provides preventive and community health programmes; the Hospital Division; and the Community Guidance Center (CGC), which delivers mental health and substance-abuse programmes. The Department of Public Health also oversees the Medicaid Program and the Medical Referral Program. The Department of Public Health’s primary health care facility is the Commonwealth Health Center (CHC) on the island of Saipan. CHC is an 86-bed, Medicare-certified hospital, which opened in 1986 and expanded in 2007. The hospital’s scope of services includes emergency medicine, obstetrics, postpartum care, adult and neonatal intensive care, surgery, general medicine, paediatrics, physical therapy, dialysis, mental health and various outpatient services. CHC is a busy community hospital, with more than 60 000 outpatient visits each year. The hospital is also very full, with a daily census nearing 90% of capacity. Sub-hospitals are located on the islands of Rota and Tinian and one Public Health Wellness Clinic is also located on the island of Saipan. There are six private clinics, all on Saipan, and the nearest United States tertiary medical centre is in Honolulu, Hawaii, over eight hours away by air. The Department of Public Health strives to maintain full staffing of its health care workforce. Almost all CHC physicians are from the United States of America or Canada, despite challenges to recruiting and retaining of clinicians due to highly competitive salaries in the United States. The Department of Public Health also supports efforts to increase training opportunities for the local health care workforce. 3.3 Health policy, planning and regulatory framework The Department of Public Health is under the umbrella of the Commonwealth of the Northern Mariana Islands Government. PL 1-8, Chapter 12, SS2 gives the Department the power and responsibility to: • maintain and improve health and sanitary conditions; • minimize and control communicable disease; • establish and administer programmes regarding vocational rehabilitation, crippled children’s services, infant care, Medicaid, Medicare, mental health and related programmes, including substance abuse; • establish standards for water quality; and • administer all government-owned health care facilities. 3.4 Health care financing The total health expenditure for CHC in 2005 amounted to US$ 44 741 490. For the fiscal year 2007, health expenditure represented 25.4% of the total general government expenditures of US$ 170 556 456. It is notable that total health expenditure is declining because the budget is decreasing; in the last fiscal year, the health budget was only US$ 39 million, a fall from US$ 42 million in the previous year. Significant efforts are being made to maintain critical services in a world of soaring health care costs. CHC will likely privatize adult outpatient services in the near future to continue to improve patient access to the private sector. 3.5 Human resources for health The need to build and improve local health care manpower to sustain public health programmes is imperative to improving the delivery of services to the community. This is also in line with the strategic plan for future health initiatives stated in the Institute of Medicine (IOM) report. One of the four recommended approaches includes promoting the education and training of the health care workforce. Through the University of Hawaii, John A. Burns School of Medicine, the Commonwealth of the Northern Mariana Islands has an Area Health Education Center (AHEC) COUNTRY HEALTH INFORMATION PROFILES | 315 grant. The AHEC's mission is to improve the health services of the Commonwealth by establishing a sustainable health care manpower programme through strengthening the country's capacity to recruit and retain allied health professions to serve the health needs of the islands. The programme will develop competent, committed and compassionate health professionals. Its vision is to improve the quality of health care services and reduce disparities in health conditions in the Commonwealth. In addition, there are currently two Division staff attending the Maternal and Child Health Certificate Program through a grant at the University of Hawaii; there is ongoing collaboration with WHO in supporting training for oral health and sanitation; and in collaboration with the Pacific Islands Health Officers Association (PIHOA), a series of courses dealing with public health disease surveillance and investigation have been sponsored. A PIHOA consultant will visit the Commonwealth during 2008 to conduct a strategic planning meeting for HRH capacity building. 3.6 Partnerships The Department of Public Health recognizes the need for partnerships with various governmental and private agencies, non-profit organizations and other organizations, on-island, regionally, and internationally, to sustain and build effective health care programmes and services. Key partners both on-island and abroad include, among others: • The Public School System • Northern Marianas College • The Department of Community & Cultural Affairs • The Department of Commerce • The Workforce Investment Agency • The Developmental Disabilities Council • Karidat • The Ayuda Network, Inc. • The Commonwealth Cancer Association • The Diabetes Coalition • NAPU Life • The Substance Abuse Prevention Coalition (SAPC) • The University of Hawaii, John A. Burns School of Medicine – Area Health Education Center (AHEC) and Maternal and Child Health Certificate Program through HRSA. • Western Michigan University (Project Familia) • The Secretariat of the Pacific Community (SPC) • The World Health Organization (WHO) • The Pacific Islands Health Officers Association (PIHOA) • The United States Centers for Disease Control and Prevention (CDC) • The Health Resources and Services Administration (HRSA) • The Joint Task Force Homeland Defense • The Pacific Substance Abuse and Mental Health Collaborating Council (PSAMHCC) • The Pacific Islands Mental Health Network (PIMHnet) • The National Prevention Network (NPN) • The National Asian Pacific American Families Against Substance Abuse, Inc. (NAPAFASA) 3.7 Challenges to health system strengthening One of the greatest challenges facing the Commonwealth of the Northern Mariana Islands is the difficulty in recruiting and retaining qualified personnel. Some of the main obstacles include the small human resources pool from which to recruit, the ever-rising costs of maintaining the NORTHERN MARIANA ISLANDS, COMMONWEALTH OF 316 | COUNTRY HEALTH INFORMATION PROFILES Commonwealth Health Center, and the limited local funding available to sustain quality health care delivery. Another challenge is the need to improve the Department of Public Health’s data infrastructure, which impacts the way the Department plans activities for its programmes and evaluates the effectiveness of services provided to the community. In addition, the isolation and disparities apparent in the Commonwealth of the Northern Mariana Islands create unique and challenging barriers to a struggling health care system. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Commonwealth Health Center Website Operator : CNMI Department of Public Health’s Commonwealth Health Center Features : Organization Description, Jobs, Island Lifestyle Web address : http://www.dphsaipan.com/ Title 2 : Pacific Island Populations - Estimates and projections 2005-2015 Operator : Secretariat of the South Pacific Features : Demographic Information for the Pacific Islands Web address : http://www.spc.int/demog/en/index.html Title 3 : Urban and rural areas 2005 Operator : Population Division Department of Economic and Social Affairs, UN New York 2006 Features : World Population Prospects, International Migration and Development Web address : http:///www.unpopulation.org 5. ADDRESSES DEPARTMENT OF PUBLIC HEALTH Office Address : CHC, Lower Navy Hill Postal Address : P.O. Box 500409 CK, Saipan MP 96950, Commonwealth of the Northern Mariana Islands Telephone : (670) 234-8950 Fax : (670) 234-8930 Website : http://www.dphsaipan.com 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) 3-304600 / 3-304631/ 330 4635/ 331 7447 Fax : (679) 3-300462 / 331 1530 COUNTRY HEALTH INFORMATION PROFILES | 317 6. ORGANIZATIONAL CHART: Department of Public Health Year Source Demographics 1 0.47 2004 1 2 84.49 38.00 46.49 2006 est 1 3 3.20 … … 2006-10 1 4 12.30 12.30 12.40 2006 est 4 22.50 22.40 22.80 2006 est 4 5.00 4.70 5.30 2006 est 4 5 94.50 … … 2005 est 2 6 19.27 … … 2005 est 3 7 2.30 … … 2005 est 3 8 1.75 a … … 2005 est 3 9 75.88 93.31 78.61 2005 est 3 … … … 10 1.27 2005 est 3 11 … … … 12 … 13 … 14 … 15 … … … 16 … … … 17 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 7 … … … … … 2006 6 … … … … … … … … … … … … … … … … … … … … … … … … Rural 318 | COUNTRY HEALTH INFORMATION PROFILES Estimated population ('000s) Annual population growth rate (%) Percentage of population Rate of natural increase of population (% per annum) Urban population (%) - 0–4 years - 5–14 years COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above Total fertility rate (women aged 15–49 years) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Per capita GDP at current market prices (US$) Environmental indicators Communicable and noncommunicable diseases Human development index Rate of growth of per capita GDP (%) Adult literacy rate (%) Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Number of deathsNumber of new cases Typhoid fever Encephalitis Leprosy Malaria Plague FemaleTotalFemale - Type A Selected communicable diseases - Type E Syphilis Total Urban MaleMaleTotal Hepatitis viral Cholera - Type B - Type C Dengue/DHF Gonorrhoea - Unspecified NORTHERN MARIANA ISLANDS, COMMONWEALTH OF NORTHERN MARIANA ISLANDS, COMMONWEALTH OF Year Source 18 4 242 … … … … … 2000 5 19 10 … … … … … 2000 5 20 51 … … … … … 2006 6 15 … … … … … 2006 6 21 437 … … … … … 2000 5 … … … … … … 0 0 0 … … … 2000 5 11 … 2000 5 … … … … … … 0 0 0 … … … 2000 5 0 0 0 … … … 2000 5 0 0 0 … … … 2000 5 1 … … … … … 2000 5 12 … … … … … 2000 5 22 2 265 … … … … … 2000 5 16 … … … … … 2000 5 98 … … … … … 2000 5 1 758 … … … … … 2000 5 28 … … … … … 2000 5 39 … … … … … 2000 5 23 2 490 … … … … … 2000 5 24 1 197 … … … … … 2000 5 25 5 742 … … … … … 2000 5 389 … … … … … 2000 5 555 … … … … … 2000 5 510 … … … … … 2000 5 43 … … … … … 2000 5 26 COUNTRY HEALTH INFORMATION PROFILES | 319 All types - Homicide and violence - Motor and other vehicular accidents - Occupational injuries All circulatory system diseases Male - Suicide 7. 3. 6. 8. 1. Leading causes of mortality and morbidity Leading causes of morbidity (inpatient care) 4. 5. 10. Number of cases Total 2. - Trachea, bronchus, and lung - Colon and rectum - Cervix - Oesophagus - Leukaemia - Lip, oral cavity and pharynx - New pulmonary tuberculosis (smear-positive) Tuberculosis - All forms INDICATORS - Cerebrovascular diseases - Liver - Stomach Number of deaths Male TotalFemale Cancers All cancers (malignant neoplasms only) - Hypertension Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections - Breast - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders Diabetes mellitus Number of new cases Female 9. DATA TotalFemaleMale Rate per 100 000 population Male FemaleTotal - Ischaemic heart disease - Acute myocardial infarction Circulatory NORTHERN MARIANA ISLANDS, COMMONWEALTH OF Year Source 27 … … … … … … 2005 10 … … … … … … 2005 10 … … … … … … 2005 10 … … … … … … 2005 10 … … … … … … 2005 10 Female 28 64.00 2000 7 29 NR 2006 6 30 4.55 2000 5 31 … … … 32 81.01 … … 2000 5 33 NR NR NR 2007 6 78.00 … … 2007 6 79.00 … … 2007 6 80.00 … … 2007 6 34 0 0 2000 5 … … 0 0 2000 5 … … … … 35 0 0 0 0 0 0 2007 6 … … … … … … … … … … … … 0 0 0 0 0 0 2007 6 0 0 0 0 0 0 2007 6 0 0 0 0 0 0 2007 6 … … … … … … 0 0 0 0 0 0 2007 6 0 0 0 0 0 0 2007 6 0 0 0 0 0 0 2007 6 Total Male 320 | COUNTRY HEALTH INFORMATION PROFILES INDICATORS 1. Heart disease Leading causes of mortality FemaleTotal 3. Stroke FemaleMaleTotalFemaleMaleTotal - Rubella - Congenital rubella syndrome - Sepsis - Pertussis (whooping cough) - Total Tetanus Immunization coverage for infants (%) - POL3 10. Percentage of women in the reproductive age group using modern contraceptive methods Percentage of pregnant women with anaemia - Poliomyelitis Female Number of cases Male Number of deaths Total Selected diseases under the WHO-EPI Maternal, child and infant diseases Male Number of cases DATA 2. Cancer 5. Sepsis - Measles Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth - Obstructed labour - Eclampsia - Hepatitis B III - Hib meningitis - Diphtheria 4. Renal disease - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) Maternal causes - BCG - DTP3 - Abortion - Haemorrhage 8. 9. 7. 6. - Neonatal tetanus Rate per 100 000 population NORTHERN MARIANA ISLANDS, COMMONWEALTH OF Year Source 36 … 37 Public health facilities 1 74 2000 5 0 0 2000 5 2 8 2000 5 1 0 2000 5 Private health facilities 5 0 2000 5 6 … 2007 10 38 42.14 2000 9 … 519.00 2000 9 170.56 FY 2007 10 25.39 FY 2007 10 … … … NR 39 … Year Source 40 Physicians - Number … … … … … … … - Rate per 1000 population … … … … … … … Dentists - Number … … … … … … … - Rate per 1000 population … … … … … … … Pharmacists - Number … … … … … … … - Rate per 1000 population … … … … … … … Nurses - Number … … … … … … … - Rate per 1000 population … … … … … … … Midwives - Number … … … … … … … - Rate per 1000 population … … … … … … … Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … COUNTRY HEALTH INFORMATION PROFILES | 321 Health insurance coverage as % of total population R u ra l DATA U rb an Human resources for health INDICATOR P u b lic P ri va te M al e F em al e T o ta l - District/first-level referral hospitals - Primary health care centres - per capita total expenditure on health (in US$) - general government expenditure on health as % of total expenditure on health Exchange rate in US$ of local currency is: 1 US$ = Private health expenditure - private expenditure on health as % of total expenditure on health External source of government health expenditure Number DATA Number of beds Health facilities INDICATORS Annual number of graduates Health infrastructure Facilities with HIV testing and counseling services - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - Hospitals - Outpatient clinics - external resources for health as % of general government expenditure on health Government expenditure on health Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) Health care financing NORTHERN MARIANA ISLANDS, COMMONWEALTH OF Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 7.11 7.05 7.17 2005 est 3 45 … … … 46 71.00 … … 2007 6 47 0.00 2000 5 48 … … … 49 64.00 … … 2000 7 50 … 51 Antenatal care coverage - At least one visit 75.67 2000 5 - At least four visits … 52 … … … 53 … … … 54 … … … 55 … … … 56 … … … 57 … … … 58 … … … 59 … … … 60 90.00 … … 2006 6 61 10.00 … … 2006 6 62 54.00 … … 2006 6 63 73.00 … … 2005 6 64 98.00 98.00 97.00 2006 8 65 94.00 94.00 96.00 2006 8 66 … … … 322 | COUNTRY HEALTH INFORMATION PROFILES Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures INDICATORS DATA Female T o ta l M al e F em al e U rb an DATA Total Male P ri va te Tuberculosis death rate per 100 000 population Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Proportion of population with access to affordable essential drugs on a sustainable basis Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Malaria incidence rate per 100 000 population Unmet need for family planning Estimated HIV prevalence in adults b INDICATORS HIV prevalence among population aged 15-24 years Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Infant mortality rate (per 1000 live births) Maternal mortality ratio (per 100 000 live births) Contraceptive prevalence rate R u ra l P u b lic Percentage of people with advanced HIV infection receiving ART Adolescent birth rate Health-related Millennium Development Goals (MDGs) Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Tuberculosis prevalence rate per 100 000 population Annual number of graduates Workforce losses/ Attrition Total Urban Rural Proportion of population in malaria-risk areas using effective malaria treatment measures NORTHERN MARIANA ISLANDS, COMMONWEALTH OF … p est NR a b 1 2 3 4 5 6 7 8 9 10 COUNTRY HEALTH INFORMATION PROFILES | 323 Hospital Division, Department of Public Health. Pacific Island Populations - Estimates and projections 2005-2015, Secretariat of the Pacific Community, Noumea, 2006. http://www.spc.int/demog/en/index.html. Urban and rural areas 2005 . Population Division Department of Economic and Social Affairs, UN New York 2006. [http:///www.unpopulation.org]. WHO Regional Office for the Western Pacific, data received from the technical units. World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: Not relevant Family Planning Programme, Division of Public Health, Department of Public Health. Demographic Tables for the Western Pacific 2005-2010 . Manila, World Health Organization Regional Office for the Western Pacific, 2005. 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. United States Census Bureau, International Programs Center (http://www.spc.int/prism). Sources: Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] Information furnished by the WHO Representaitive in the South Pacific, 15 April 2008. Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific Provisional Not included in the official list of MDG indicators Estimate Notes: Data not available 324 | COUNTRY HEALTH INFORMATION PROFILES PALAU 1. CONTEXT 1.1 Demographics The multi-ethnic population of Palau was estimated as numbering 20 227 in 2007, with an estimated annual population growth rate of 0.01%. The population consists of 69.9% Palauans (who are a conglomeration of Micronesian with Malayan and Melanesian admixtures), 15.3% Filipinos, 4.9% Chinese, 2.4% other Asian, 1.9% Causacian, 1.4% Carolinian and 4.2% other or unspecified groups (2000 est.). The 2006 estimate indicates a population density of 41 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 2007 estimate stood at 75.7 years for women and 67.8 years for men. It was estimated that the ratio of male to female was 1:12 for the entire population, with 1:06 at birth, 1:06 for children under 15 years of age and 1:17 among the population aged 15-64 years. 1.2 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 will run on the same ticket starting with the 2008 general elections. The current President, who is head of state, is President Tommy Esang Remengesau, Jr.; the Vice-President is Elias Camsek Chin. The Palau National Congress (Olbiil era Kelulau) has two houses. The Senate currently has nine members, elected nationwide, but this will increase to 13 members in 2008. The House of Delegates has 16 members, one from each of Palau's states. All of the legislators serve four-year terms, for a maximum of three cycles or 12 years. 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. 1.3 Socioeconomic situation Palau’s real per capita gross domestic product (GDP) of US$ 5 678 (2003 estimate) 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 89 151 in 2007. 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. COUNTRY HEALTH INFORMATION PROFILES | 325 1.4 Vulnerabilities and hazards The population of Palau is at risk for a high number of hazards, including a uniquely high hydrometeorological and geological risk. Due to its geographical location as the United States of America’s westernmost border with Asia, Palau is also more vulnerable to hazards emerging in Asia, such as infectious diseases. Table 1: Summary of vulnerability analysis scores for the health sector Vulnerability Analysis Mean Score (F) Critical facilities 1.32 (S) Socioeconomic 1.35 (H) Health 2.89 (G) Geospatial 4.56 (P) Preparedness 1.22 Estimation of public health vulnerability: VPH = [F x S x H x G] P 2005 Public Health Vulnerability Factor, VPH = [(1.32) (1.35) (2.89) (4.56)] = 19.25 (1.22) Vulnerability analysis shows that Palau is 19.25 times more vulnerable to hazards than the United States of America. Vulnerability scores can be useful for comparative study as rough estimates of vulnerability, and for mitigation planning. Public health officials and planners may apply these values to compare levels of vulnerability before and after implementation of a capacity-building program and/or an emergency event itself. By offering a broader scope of potential vulnerability (i.e. both facility-based and population-based indictors), the decision- maker is also engaged in a more comprehensive approach that involves addressing the many causes of vulnerability among disaster-affected populations. It should not be understated that the most significant risk factor in vulnerability to disasters is poverty. The population of Palau is made of 70% Palauans, as well as a large population of young, impoverished, foreign worker households mixed with smaller population factions of local lower- and middle-class households. Economic stability is dependent upon United States federal support, immigration, tourism, and the United States and Asian stock, commodity and import/export markers, as well as fuel/energy prices. It is unfortunate that this most difficult of vulnerabilities to alter is also the most significant. Palau’s isolation from the United States mainland increases logistical demands. Supply chains, communication networks and air runways are limited options. Improving long-distance communication and logistical coordination that may lessen the “tyranny of distance” for any emergency response measure would help to reduce Palau’s vulnerability to public health disasters. Over the past five years, public health preparedness in Palau has improved significantly, but there is still much to do. A comprehensive all-hazard public health emergency operations plan has been developed, but it still needs to be tested and validated by field exercise and is lacking standard operating procedures. The Department of Public Health has developed an extensive level of awareness regarding disaster preparedness and response, yet much still has to be done in terms of education of clinicians and the public. All components of preparedness, planning, PALAU 326 | COUNTRY HEALTH INFORMATION PROFILES training, hazard monitoring, warning, population protection are much more cost-effective than emergency response after the event.1 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition The population of Palau faces a large burden of both infectious and chronic diseases. Like many developing nations, the country has recently undergone an epidemiological shift from diseases of the developing world, such as malnutrition and infectious diseases, to an increasing burden of diseases of the developed world, like diabetes, heart disease, obesity and kidney failure. This places an inordinate burden on the already low human, material and fiscal resources. 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 a low maternal mortality ratio. Sanitation coverage has declined in 2006, with 67% of 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 pollution. Other negative health impacts of globalization, such as reduced physical activity and consumption of processed foods rather than locally produced foods, are already encroaching insidiously beyond Koror and Airai, where over 77% of the population resides. 2.2 Outbreaks of communicable diseases Palau has one of the best communicable diseases surveillance systems of all the Pacific island countries and regularly reports outbreaks of infectious disease on PacNet. In 2007, the Palau Ministry of Health reported a large gastroenteritis outbreak due to norovirus, a varicella outbreak and a dengue outbreak. Collaborative initiatives among principal health officials, health specialists and multisectoral community leaders have been a positive step forward in monitoring of events and communicable diseases outbreaks. 2.3 Leading causes of mortality and morbidity Based on information furnished by the Ministry of Health, the reported leading causes of mortality for 2007 were heart disease; injuries; cancer; cerebrovascular accidents; septicaemia; respiratory disease and kidney disease. The leading causes of hospitalization were diseases of the respiratory system; diseases of the genitourinary system; disease of the digestive system; normal childbirth and delivery; endocrine and metabolic system; diseases of the circulatory system; infectious and parasitic diseases; injury and poisoning; diseases of the nervous system; and complications of pregnancy, childbirth and puerperium. 2.4 Maternal, child and infant diseases Great progress is being made toward improving maternal health in Palau, with a zero maternal mortality rate in 1998. Under-five mortality was 34 per 1000 live births in 1990 and 7.2 in 2007, a fairly low level among Pacific island countries. However, the percentage decline in the 1990s was lower than during the 1 Rykken D, Keim M. Republic of Palau, Public Health Hazard Vulnerability Assessment, June 2006. COUNTRY HEALTH INFORMATION PROFILES | 327 pre-1990s, indicating that further reduction in under-five mortality becomes progressively more difficult as the mortality rate declines. Infant mortality decreased from 25 to 17 per 1000 live births in the 1990s, then further to 7.2 per 1000 live births in 2007. Based on 2007 WHO-UNICEF joint reporting form on immunization, official estimated coverage for DTP3 was 94% and for first dose of MMR 91%. 2.5 Burden of disease To paraphrase the 11th Annual Report on the Republic of Palau’s Implementation of the Compact of Free Association fiscal year 2006, the best description for health in Palau is “in transition”. The transition of culture, political systems, economic development and technology has moved health emphasis from communicable to non-communicable diseases. Of the reported 10 leading causes of death, eight were due to noncommunicable diseases related to lifestyle- associated risk factors, and are therefore preventable. Such a transitional status has led to pending issues that need to be evaluated, such as the cost of off-island medical referrals, the cost of hemodialysis services and intensive care services and the financial sustainability of a secondary health care facility in a small island community such as Palau. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives Health for all remains a top priority in the socioeconomic development of Palau. The Government aims to provide sufficient 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. 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 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 • 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 National Insurance policy; and • to improve and enhance the Health Information System. 3.2 Organization of health services and delivery systems A high percentage of health services are supported by grant funds and technical assistance from the Federal Government of the United States of America, in addition to the provision of technical support and limited funding from a number of United Nations agencies. However, future resource requirements to sustain the operations of the health system will still be dependent on successful economic development The Belau National Hospital (BNH), built with United States funding, is the main health facility in the country. BNH has undergone recent upgrades that will significantly mitigate its vulnerability to both national and technological disasters, including: installation of two generators PALAU 328 | COUNTRY HEALTH INFORMATION PROFILES to allow for one month of independent power generation; enhancement of respiratory isolation and PPE capabilities; equipping and training of hazardous materials teams; updating of the hospital disaster plan; and upgrading of staff communications. Challenges remain, however, in that, by nature, the BNH represents a centralized dependency for inpatient and outpatient care that increases the vulnerability of the health system. It is not economically feasible to decentralize inpatient care, but steps to build inpatient capacity and capabilities in the other islands may add some limited additional secondary capability. Mitigating BNH’s vulnerabilities would reduce Palau’s vulnerability to disasters, and maintaining the continuity of BNH should be of paramount concern. Four community health centres, known as super dispensaries, are located strategically throughout Palau, three in the big island of Babeldaob and one in the Southern Island of Peleliu for the Southern Lagoon population. In addition, four additional satellite dispensaries serve hard-to- reach outlying localities, Kayangel in the north, and Angaur and the South-West Islands in the south. 3.3 Health policy, planning and regulatory framework In June 2005, the Ministry of Health adopted a vision and a mission statement, framed by Article VI of the Constitution of the Republic of Palau, which embraced a holistic definition of health that stated that the health of Palauans is influenced by health services, the environment, behaviour and heredity. These issues were discussed at the 1st Public Health Convention in December 2005. During the Leadership Symposium (February 2006), certain priorities were identified, including addressing the burden of non-communicable diseases, solid and liquid waste management, human resources in health; and improvement of legal frameworks for health in Palau. Operationalization of the health system is based on a conscious decision to make health a domain owned by the community. This clarifies certain strategies that will help move Palau toward a more sustainable health care system. Strategic health planning, improved fiscal control, enhanced primary health care through community health centres, strengthening of community advocacy through the creation of a community advocacy program, and improvements to the health information system, has all given the health sector in Palau the ability to plan better for the future. These activities are also enhanced by the decision to address human resource, procurement and grant issues. All these initiatives at the Ministry of Health and at the national level to increase accountability and promote sound and sustainable development, have provided the impetus for implementation of the Integrated Planning Process 2006-2008 for the entire executive branch national government. This process will streamline health systems development and ensures more productivity from health care workers and an improvement in health status for all people living in Palau. 3.4 Health care financing The total expenditure on health in Palau was 10.7% of GDP in 2006, with 92.5% coming from the Government. External resources for health accounted for 12.5% of the total health expenditure. The total expenditure on health per capital was US $ 850. 3.5 Human resources for health 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. In 2005, there were 111 nurses. In 2006, there were 26 doctors, 117 nurses and one midwife. In 2007, there were three dentists and one pharmacist. More staff are needed as a result of the expanded main health facility and the completion of the super dispensaries, and training of more local health workers is required to replace the rather expensive expatriate staff. Subsequent to the enactment of the mandatory retirement law, rapid reduction in the number of health workers took place, reducing particularly the nursing workforce and the allied health areas due to COUNTRY HEALTH INFORMATION PROFILES | 329 retirement of ageing staff. This resulted in a critical shortage of health workers in Palau, particularly among the nursing force and allied health personnel. Vigorous efforts are underway between the Ministry of Health and the Ministry of Education to ensure that an increased number of high school graduates can stream into health careers. These include a United States federal grant from the Department of Education to the Ministry of Education to develop a Health Academy in the only public high school in Palau- the Palau High School. The Ministry of Health is a key partner in this initiative. Marketing efforts to increase the number of high school students choosing nursing, medicine and allied health professions as careers are under way through development of two marketing videos – “Careers in nursing” and “Careers in health for Palau, the region and the world”. A Nursing programme was established in the Palau Community College in 1998 and continues to produce a minimum of two graduates a year, but numbers are insufficient to meet the current staffing requirements in nursing. Bridging programmes in nursing and other allied health fields are currently in place in the Palau Community College and within the Ministry of Health. Since 2001, the Ministry of Health has been partnered with Palau Community College to participate in the College’s Palau Area Health Education Center (AHEC), which is funded through the United States Department of Health & Human Services/Health Resources and Services Administration. The Palau AHEC is part of the Hawaii-Pacific Basin AHEC, which is managed by the John A. Burns School of Medicine (JABSOM)/University of Hawaii. JABSOM has funneled over US$ 2 million since 2001 to promote health worker training in Palau and Micronesia. The Palau AHEC has sponsored most of the 98 courses conducted by the Fiji School of Medicine School of Public Health (now Department of Public Health) and all courses conducted by the University of Auckland Faculty of Medicine (8) in the region. Fifty-six physicians, nurses, environmental health workers, health administrators, and nutrition workers from Palau (39) have graduated with FSMed undergraduate and postgraduate certificates and diplomas. Four physicians from Palau were awarded Postgraduate Diplomas in General Practice from the University of Auckland Faculty of Medicine. Most of this activity has been through the efforts of the Ministry of Health– PCC AHEC partnership. 3.6 Partnerships Partnerships developed by the Ministry of Health fall under three levels: bilateral, regional and institutional. The Ministry has developed bilateral relationships with the governments of Czechoslovakia, India, Israel, Japan (JICA), the Philippines, the Republic of Korea, Spain, and the United States of America, among others. Regional partnership include the Pacific Islands Health Officers Association (PIHOA), the Secretariat of the Pacific Community (SPC), the Pacific Forum, the Pacific Emergency Health Initiative (PEHI), the Health Research Council of the Pacific (HRCP) (formerly Pacific Health Research Council), and the Pacific Open Learning Health Net (POLHN). Partner institutions in various countries in the region have been developed for the purpose of training and medical referrals for patients requiring tertiary care and services not provided by Belau National Hospital. Partner institutions for education and training include the Fiji School of Medicine (FSMed), and the Good Samaritan Hospital in Los Angeles, California, United States of America, among others. Other partner institutions provide specialized services in adult and paediatric cardiology, EENT and ophthalmology, either on an annul basis or every two years. Recent developments will add to the current list of services provided by visiting specialists on an ad hoc basis. As a training site for other higher institutions of learning, Ministry of Health physicians and other health professionals provide training for student interns in partner institutions such as the University of Washington in Seattle, United States of America, and the University of Hawaii, among others. PALAU 330 | COUNTRY HEALTH INFORMATION PROFILES 3.7 Challenges to health system strengthening • The numbers and distribution of the health workforce (in medicine, nursing, allied health fields) are inadequate, and this continues to be a challenge in Palau. In addition, the majority of those already working are underprepared. • A health resource development services department is needed within the Ministry of health to provide the necessary support services to Ministry personnel. • Quality assurance performance measures are needed, not only for service providers, but for all personnel. • Infrastructure development in the country, particularly in the health sector, is still limited, which hinders the maximum utilization of limited resources for service provision in all aspects of health services, from primary care to secondary and tertiary care, including off- island medical referrals. • Health care financing is inadequate and will continue to be, necessitating ongoing lobbying with local legislature and vigorous solicitation efforts for assistance from regional and international organizations and institutions, as well as bilateral negotiations for sources of support via various forms of technical assistance. • The health information system (HIS) infrastructure is already established, the hardware is already in place and qualified personnel are on board, but not in sufficient numbers and in the necessary specialized areas. There is a great need to increase the capacity of the HIS for monthly compilation, analysis and reporting of data from the various data sources. Integration of data and better management still need to take place. Much progress has taken place, but further support and development is needed to respond to all the competing reporting requirements and needs of the Ministry of Health. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Palau Government statistics Operator : Palau Government Features : Government website Web address : http://www.palaugov.net Title 2 : World fact book, 2007 Operator : Central Intelligence Agency, United States of America Features : Website Comments : Most updated information about the country Web address : https://www.cia.gov/library/publications/the-world- factbook/print/ps.html Title 3 : Palau statistics and key health indicators Operator : Secretariat of the Pacific Community Features : Website Comments : Information related to MDG goals Web address : http://www.spc.int/mdgs/MDG_DB, http://www.spc.int/prism Title 4 : Health indicators Operator : Ministry of Health Features : Reports Title 5 : National Expenditure on Health Operator : WHO Features : Website Web address : http://www.who.int/nha/country/plw/en/ COUNTRY HEALTH INFORMATION PROFILES | 331 5. ADDRESSES MINISTRY OF HEALTH Office Address : One Hospital Road, Meyuns, Koror Postal Address : P.O.Box 6027, Koror, Republic of Palau 96940 Official Email Address : moh@palau-health.net Telephone : (680) 488 2552 / 488 2553 Fax : (680) 488 1211 Office Hours : 7:30 a.m. -4:30 p.m. Monday to Friday 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@sp.wpro.who.int Telephone : (679) 32344100 Fax : (679) 3234166/3234177 Office Hours : 8:00 a.m. to 5:00 p.m., Monday to Friday PALAU Year Source Demographics 1 0.46 2006 1 2 20.23 10.87 9.36 2007 est 2 3 0.01 … … 2007 est 2 4 6.84 6.40 7.36 2007 est 2 17.25 16.53 18.10 2007 est 2 5.70 4.32 7.31 2007 est 2 5 77.00 78.00 76.00 2007 est 20 6 13.80 14.99 12.39 2007 2 7 7.50 9.29 5.45 2007 3 8 6.30 d … … 2007 1 9 1 … 67.80 75.70 2007 est 20 … 10.20 12.00 2002 14 10 2.00 2007 2 11 99.90 h 99.90 h 99.80 h 2005 17 12 5 678.00 2003 est 17 13 -1.73 d 2003 17 14 … 15 16 i 2007 4 17 0 0 0 0 0 0 2007 5 67 42 25 0 0 0 2007 5 17 14 3 0 0 0 2007 5 0 0 0 0 0 0 2007 5 ... ... ... ... ... ... 0 0 0 0 0 0 2007 5 80 j 50 j 30 j 1 0 1 2007 5 0 0 0 0 0 0 2007 5 17 5 12 0 0 0 2007 5 2 1 1 0 0 0 2007 5 0 0 0 0 0 0 2007 5 0 0 0 0 0 0 2007 5 12 8 4 0 0 0 2007 5 0 0 0 0 0 0 2007 5 Total Urban Rural Typhoid fever Encephalitis Leprosy Malaria Plague Syphilis Proportion of vehicles using unleaded gasoline (%) … … Health care waste generation (metric tons per year) ... ... 83.00 … COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male Estimated population ('000s) Annual population growth rate (%) Percentage of population - 0–4 years - 5–14 years Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above Urban population (%) Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Total Number of deathsNumber of new cases Male FemaleFemaleMaleTotal Selected communicable diseases Rate of natural increase of population (% per annum) Per capita GDP at current market prices (US$) Environmental indicators - Type A - Type B - Type C Dengue/DHF Gonorrhoea - Type E Human development index Rate of growth of per capita GDP (%) Communicable and noncommunicable diseases Hepatitis viral - Unspecified Cholera 332 | COUNTRY HEALTH INFORMATION PROFILES PALAU Year Source 18 1 984 ... ... 0 0 0 2007 3, 12 19 987 494 493 0 0 0 2007 3, 12 20 10 … … … … … 2006 18 5 … … … … … 2006 18 21 36 16 20 22 13 9 2007 3, 6 3 0 3 3 0 3 2007 3, 6 1 1 0 0 0 0 2007 3, 6 2 0 2 2 0 2 2007 3, 6 0 0 0 0 0 0 2007 3, 6 2 1 1 0 0 0 2007 3, 6 5 1 4 0 0 0 2007 3, 6 4 3 1 5 3 2 2007 3, 6 0 0 0 0 0 0 2007 3, 6 5 5 0 5 5 0 2007 3, 6 22 4185 … … … … … 2007 12 14 k ... ... 10 5 5 2007 3, 12 721 k ... ... 18 13 5 2007 3, 12 2176 k ... ... 7 6 1 2007 3, 12 155 k ... ... 9 7 2 2007 3, 12 399 k ... ... 3 1 2 2007 3, 12 23 2754 k ... ... 21 l 5 6 2007 3, 12 24 707 k ... ... 7 6 1 2007 3, 12 25 3493 k ... ... 22 19 3 2007 3, 12 21 k ... ... 0 0 0 2007 3, 12 95 k ... ... 2 2 0 2007 3, 12 ... ... ... ... ... ... 12 k ... ... 6 5 1 2007 3, 12 26 211 ... ... 1043.00 ... ... 2007 12 170 ... ... 840.00 ... ... 2007 12 136 ... ... 672.00 ... ... 2007 12 128 ... ... 634.00 ... ... 2007 12 118 ... ... 583.00 ... ... 2007 12 112 ... ... 554.00 ... ... 2007 12 109 ... ... 539.00 ... ... 2007 12 103 ... ... 509.22 ... ... 2007 12 98 ... ... 485.00 ... ... 2007 12 74 ... ... 366.00 ... ... 2007 12 - Suicide All types - Homicide and violence - Motor and other vehicular accidents - Occupational injuries 1. Disease of the Respiratory System 2. Disease of the Genitourinary System 10. Complications of Pregnancy,Childbirth, and Puerperium Tuberculosis - All forms INDICATORS Acute respiratory infections Leading causes of mortality and morbidity 6. Disease of the Circulatory System 8. Injury and Poisoning 9. Disease of the Nervous System 7. Infectious and Parasitic Diseases Leading causes of morbidity (inpatient care) 4. Normal Childbirth and Delivery 5. Endocrine & Metabolic System - New pulmonary tuberculosis (smear-positive) Cancers All cancers (malignant neoplasms only) - Hypertension All circulatory system diseases - Acute myocardial infarction Circulatory - Cerebrovascular diseases - Liver - Stomach Number of deaths DATA Total Male COUNTRY HEALTH INFORMATION PROFILES | 333 Rate per 100 000 populationNumber of cases - Leukaemia - Lip, oral cavity and pharynx - Trachea, bronchus, and lung - Breast - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders Diabetes mellitus FemaleFemale Total Male TotalFemale Male FemaleTotal Male Number of new cases 3. Disease of the Digestive System - Ischaemic heart disease PALAU Year Source 27 31 20 11 153.26 183.98 117.57 2007 3 22 19 3 108.77 174.79 32.06 2007 3 22 13 9 108.77 119.58 96.19 2007 3 18 13 5 88.99 119.58 53.44 2007 3 16 8 8 79.1 73.59 85.51 2007 3 16 11 5 79.1 101.19 53.44 2007 3 8 8 0 39.55 73.59 0.00 2007 3 28 22.83 2006 2 29 20.00 2007 18 30 … 31 7.17 6.13 8.62 2007 4 32 91.00 91.40 90.52 2007 2 33 NR m NR m NR m 2007 9, 18 94.00 … … 2007 9, 18 94.00 … … 2007 9, 18 91.00 … … 2007 9, 18 34 30 0 2007 13 9 0 2007 13 3 0 2007 13 8 0 2007 13 7 0 2007 13 35 0 0 0 0 0 0 2007 3, 12, 18 0 0 0 0 0 0 2007 3, 12, 18 0 0 0 0 0 0 2007 3, 12 0 0 0 0 0 0 2007 3, 12, 18 0 0 0 0 0 0 2007 3, 12, 18 0 0 0 0 0 0 2007 3, 12, 18 0 0 0 0 0 0 2007 3, 12, 18 0 0 0 0 0 0 2007 3, 12, 18 0 0 0 0 0 0 2007 3, 12, 18 0 0 0 0 0 0 2007 3, 12, 18 INDICATORS 3. Cancer Leading causes of mortality 2. Injury (intentional and unintentional) Total Male Male Number of deaths - Pertussis (whooping cough) Total DATA Male Number of cases Female Total Female - Rubella - Congenital rubella syndrome - Sepsis Female FemaleTotal Number of cases Rate per 100 000 population Total Female Immunization coverage for infants (%) - POL3 - BCG - DTP3 - Abortion Selected diseases under the WHO-EPI - Total Tetanus - Neonatal tetanus - Obstructed labour Percentage of pregnant women with anaemia Percentage of women in the reproductive age group using modern contraceptive methods - Diphtheria - Poliomyelitis - Eclampsia - Haemorrhage - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) - Measles Male - Hepatitis B III - Hib meningitis 1. Heart Disease Male 7. Kidney Disease 6. Respiratory Disease 4. Cerebrovascular Accidents 5. Septicemia Maternal, child and infant diseases 8. 9. 10. Maternal causes Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth 334 | COUNTRY HEALTH INFORMATION PROFILES PALAU Year Source 36 2 2007 8 37 Public health facilities 1 90 2007 10 0 0 2007 10 0 0 2007 10 5 10 2007 10 Private health facilities 0 0 2007 10 2 0 2007 10 38 17.00 2006p 19 10.70 2006p 19 850.00 2006p 19 16.00 2006p 19 92.50 2006p 19 16.40 2006 19 13.28 d 2006p 19 7.50 2006p 19 1.00 2006p 19 39 … Year Source 40 Physicians - Number 26 … … … … … … 2006 21 - Rate per 1000 population 13.06 … … … … … … 2006 21 Dentists - Number 5 2 3 5 0 5 0 2007 10 - Rate per 1000 population 0.25 0.10 0.15 0.25 0.00 0.25 0.00 2007 10 Pharmacists - Number 1 1 0 1 0 1 0 2007 10 - Rate per 1000 population 0.05 0.05 0.00 0.05 0.00 0.05 0.00 2007 10 Nurses - Number 117 … … … … … … 2006 21 - Rate per 1000 population 5.88 … … … … … … 2006 21 Midwives - Number 1 … … … … … … 2006 21 - Rate per 1000 population 0.05 … … … … … … 2006 21 Paramedical staff - Number …. … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number …. … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians 0 0 0 0 0 0 0 2007 11 Dentists 0 0 0 0 0 0 0 2007 11 Annual number of graduates Number of bedsNumber DATA Exchange rate in US$ of local currency is: 1 US$ = R u ra l P u b lic DATA U rb an P ri va te M al e F em al e - general government expenditure on health as % of total expenditure on health Government expenditure on health Total health expenditure - total expenditure on health as % of GDP Human resources for health Health insurance coverage as % of total population T o ta l INDICATOR - private expenditure on health as % of total expenditure on health External source of government health expenditure Private health expenditure Health facilities INDICATORS - Primary health care centres - amount (in million US$) Health care financing Health infrastructure - Hospitals - Outpatient clinics - external resources for health as % of general government expenditure on health - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals - per capita total expenditure on health (in US$) Facilities with HIV testing and counseling services COUNTRY HEALTH INFORMATION PROFILES | 335 PALAU Year Source 41 Pharmacists 0 0 0 0 0 0 0 2007 11 Nurses 2 … … … … … … 2007 20 Midwives 0 0 0 0 0 0 0 2007 11 Paramedical staff 0 0 0 0 0 0 0 2007 11 Community health workers 0 0 0 0 0 0 0 2007 11 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 7.17 6.13 8.62 2007 2, 3 45 7.17 6.13 8.62 2007 2, 3 46 91.00 … … 2007 18 47 0.00 2007 2 48 100.00 2007 13 0.00 2007 13 100.00 2007 13 49 12.08 … … 2007 2 50 18.40 2007 2 51 Antenatal care coverage - At least one visit 95.00 2006 2 - At least four visits 79.00 2006 2 52 … … …. 53 0.00 0.00 0.00 2007 8 54 0.15 … … 2007 8 55 0.15 o … … 2007 7, 8 56 NR NR NR 2007 5 57 NR NR NR 2007 5 58 NR NR NR 2007 5 59 NR NR NR 2007 5 60 51.00 … … 2006 18 61 4.00 … … 2006 18 62 129.00 … … 2006 18 63 100.00 … … 2005 18 64 89.00 79.00 94.00 2006 15 65 67.00 96.00 52.00 2006 15 66 … … … Annual number of graduates Workforce losses/ Attrition INDICATORS DATA Female T o ta l M al e F em al e U rb an R u ra l P u b lic P ri va te HIV prevalence among population aged 15-24 years Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures INDICATORS DATA Total Male Adolescent birth rate Health-related Millennium Development Goals (MDGs) Tuberculosis death rate per 100 000 population Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Malaria incidence rate per 100 000 population Unmet need for family planning Estimated HIV prevalence in adults n Tuberculosis prevalence rate per 100 000 population Percentage of people with advanced HIV infection receiving ART Proportion of population with access to affordable essential drugs on a sustainable basis Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Contraceptive prevalence rate Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Proportion of population in malaria-risk areas using effective malaria treatment measures Maternal mortality ratio (per 100 000 live births) Infant mortality rate (per 1000 live births) Total Urban Rural 336 | COUNTRY HEALTH INFORMATION PROFILES PALAU … p est NR a b c d e f g h i j k l m n o p 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Information furnished by WHO Representative in the South Pacific, 2 April 2008 World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf] This is not part of the routine immunization Not included in the official list of MDG indicators Information furnished by Ministry of Health, Republic of Palau, 23 July 2007 Public Health Data and Statistics, Epidemiology, Bureau of Public Health, Ministry of Health, Palau Maintenance Office, Belau National Hospital, Ministry of Health, Palau Reportable Disease Surveillance System, Epidemiology, Bureau of Public Health, Ministry of Health, Palau Cancer Prevention and Control Program, Bureau of Public Health, Ministry of Health, Palau Communicable Disease Unit, Bureau of Public Health, Ministry of Health, Palau Sources: Immunization Program, Bureau of Public Health, Ministry fo Health, Palau Not relevant Family Health Unit Statistics, Bureau of Public Health, Ministry of Health, Palau HIV/STD Program, Bureau of Public Health, Ministry fo Health, Palau Office of Planning and Statistics, Ministry of Finance, Palau Total of 3 cases Figure refers to 15-24 year old Provisional Estimate Notes: Data not available HIS, Hospital Infromation System, Belau National Hospital, Ministry fo Health, Palau Diabetes was an underlying condition in these deaths, not the direct cause of death. Totals may not tally due to some reported cases with no gender breakdown Figure refers to age15-24 years Estimates derived by regression and similar estimation methods Revised data Computed by Health Information and Evidence for Policy Unit of WHO Regional Office for the Western Pacific COUNTRY HEALTH INFORMATION PROFILES | 337 WHO Regional Office for the Western Pacific, data received from the technical units Pharmacy, Belau National Hospital, Belau National Hospital, Ministry of Health, Palau Data refers to leading causes of hospitalization but no actual figures given Reported leading causes of mortality but no actual figures given Palau Community College produces minimum of 2 nursing graduates a year Figure refers to private clinics. There is no private hospital in Palau Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] Finance and HR Office, Belau National Hospital, Ministry of Health, Palau Palau Community College, Koror, Republic of Palau Palau Statistics (http://www.spc.int/prism) Figure refers to hospital waste only and excludes dispensaries Figure refers to confirmed cases only Figure refers to number of hospital encounters OB/GYN Ward, Belau National Hospital, Ministry of Health, Palau World health report 2004. Changing history. Geneva, World Health Organization, 2004. World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: 338 | COUNTRY HEALTH INFORMATION PROFILES PAPUA NEW GUINEA 1. CONTEXT 1.1 Demographics Papua New Guinea has an estimated population of around 6.5 million, 40% under the age of 15. Around 800 languages are spoken, each language group having a distinct culture, and there are large sociocultural differences between and within provinces. The official languages are English, Pidgin and Motu. Access to widely scattered rural communities (86% of the country’s population is living in rural areas) is often difficult, slow and expensive. Only 3% of the roads are paved and many villages can only be reached on foot. Most travel between provinces is by air. The capital, Port Moresby, is not linked by road with the rest of the country. 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. Women have a very high fertility rate of 4.6 births per woman. Life expectancy has risen from 49 to 53 years and, in 2000, the crude death rate was 12 per 1000 population. Papua New Guinea’s Human Development Index has risen from 0.43 to 0.53. However, progress has slowed in recent years. 1.2 Political situation Papua New Guinea is divided administratively into four regions: Southern Coastal (Papuan) Region, Northern Coastal (MoMaSe = Morobe, Madang and Sepik provinces) Region, Highlands Region, and New Guinea Islands Region. 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 woman 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 (including several communes with their villages). 1.3 Socioeconomic 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, with growth in the non-mining sector 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 COUNTRY HEALTH INFORMATION PROFILES | 339 inappropriate policy regimes and fiscal failures, the catastrophic civil war in Bougainville from 1989 to 1999, and a series of devastating national disasters. In recent years, the economic parameters have shown a more stable situation and a slightly more positive trend. However, this was caused by the rising prices of mining products on the international markets rather than by improved internal performance. Because of the economic situation as well as the widespread evidence of deterioration in public services, especially in 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 the 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. In 2003 Papua New Guinea developed a poverty-reduction strategy that is intended to give an added focus to poverty in the existing national Medium-Term Development Strategy (MTDS, 2003–2007). The country is a signatory to the Millennium Development Declaration. The first MDG progress report was published in 2005. 1.4 Vulnerabilities and hazards Papua New Guinea is prone to numerous chronic natural hazards as well as the occasional acute disaster situation, on a scale greater than any of its Pacific neighbours. The repertoire of hazards that continually hamper the development process in urban and rural remote locations of the country include volcanic eruptions, earthquakes, tsunamis, tropical cyclones, large-scale landslides, flooding, sporadic droughts, frosts in highland areas, the impact of climate change and variability and rising sea levels. There is also a high risk of technical and human-made disasters, such as oil spills, industrial pollution and unregulated and destructive land-use practices. Papua New Guinea is situated on the boundary between the Pacific and the Australian tectonic plates. The country has eight active volcanoes and is subject to regular earthquakes every year, secondary effects of this activity including tsunamis and landslides. The most recent disasters have included: • November 2004 Volcanic activity on Manam Island, displacing about 10 000 people. • July 2006: Bialla (West New Britain Province) seismo-volanic event, which displaced about 2000 people; no deaths were reported. • October 2006: Tavurvur (East New Britain Province) volcanic eruption, which displaced about 1200 people; no deaths were directly attributable to the eruption. • December 2007: Cyclone Guba, with torrential rains, affected 10 000 people through flooding in Oro Province. A major challenge to improving health is related to perceptions of illness and health among the general population. There is a widespread lack of awareness regarding 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, such as chewing Betel and smoking tobacco; and the risks associated with unsafe sexual behaviour. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition 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. Malaria is the leading cause of all outpatient visits and the third leading cause of hospital admissions and deaths. The disease is now endemic in every province, including those that were PAPUA NEW GUINEA 340 | COUNTRY HEALTH INFORMATION PROFILES once malaria-free. An average of 1.5-1.8 million suspected cases of malaria are seen at health care facilities annually. Malaria mortality rates for 2006 were estimated to be 10.8 per 100 000. Together, malaria and pneumonia account for one-third of all recorded deaths. According to WHO estimates (WHO Report 2007, Global Tuberculosis Control), in 2006, Papua New Guinea has an estimated tuberculosis prevalence rate of 513/100 000 and a TB death rate of 48/100 000 per year, and a total 12620 cases per year for all types of TB. However, it is very likely that these are underestimates because the prevalence and incidence rates are based on case notifications, which are generally underreported. According to the same WHO report, it is estimated that the incidence rate for new smear-positive cases was 111/100,000 per year in 2006. Thus TB remains a major public health problem in, particularly in view of the current HIV epidemic. The directly observed treatment, short-course (DOTS) programme is gradually expanding and 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. Papua New Guinea was declared to have a generalized HIV/AIDS epidemic in 2003. It is estimated that there are 23 000 to 91 000 HIV-positive individuals in the sexually active population of 15-49 years, estimated in a consensus workshop of February 2006. HIV prevalence among women attending antenatal clinics is between 0.6% and 3.7% (2005) and AIDS is the leading cause of death in adult inpatients at the Port Moresby Hospital. The main mode of transmission is heterosexual. The incidence of other sexually transmitted infections (STI) is also rising. The high incidence of sexual assaults on women is contributing to their risk of contracting an STI. Filariasis is endemic in Papua New Guinea, although the size of the problem is unknown. Mass drug administration through the Elimination of Lymphatic Filariasis (ELF) programme is ongoing. The incidence of noncommunicable diseases is rising, creating the double burden observed in most developing countries. Cases of tobacco-related 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. An ongoing health concern is related to injuries caused by road traffic accidents and all forms of violence (domestic, criminal and tribal). 2.2 Outbreaks of communicable diseases Outbreaks of vaccine-preventable diseases, such as measles, pertussis and diphtheria, continue to occur due to the low vaccination coverage and poor cold chain system for vaccine storage and transportation. There were an estimated 17 620 measles cases in 2002, but the number decreased to 3863 cases in 2003 and to 1222 in 2005. Diarrhoeal diseases remain common. Intestinal infectious diseases, including diarrhoeal diseases and typhoid, are major causes of morbidity, with an estimated combined incidence of 434/100 000 year. Contaminated food and water are the major contributing factors, with only 30% of the population having access to safe water, and poor hygienic conditions resulting in unsafe food handling practices. Malaria outbreaks in different parts of the country are yearly events. Papua New Guinea still seems to be free of Avian Influenza. COUNTRY HEALTH INFORMATION PROFILES | 341 2.3 Leading causes of mortality and morbidity Communicable diseases, including pneumonia, malaria, tuberculosis, diarrhoeal diseases, meningitis and, increasingly, HIV/AIDS, remain the leading cause of morbidity and account for around 50% of mortality Information on the true impact of HIV on mortality and morbidity in Papua New Guinea is lacking, but AIDS is now the leading cause of death in adult inpatients at the Port Moresby General Hospital. Perinatal conditions account for over 10% of all recorded deaths and maternal mortality estimates are high and have increased in past years, indicating a decrease in access to quality health services. The noncommunicable diseases epidemic in Papua New Guinea is firmly established and increasing, but remains largely unrecognized in reported data. Tobacco-related and alcohol related illnesses, diabetes and hypertension are on the increase, as are the three leading cancers (oral, hepatic and cervical) along with breast and lung cancers. 2.4 Maternal, child and infant diseases Maternal and child morbidity and mortality are not improving. Maternal mortality estimates vary widely, but all are high. The 2006 DHS established a maternal mortality ratio of 870 per 100 000 live births. The causes of maternal mortality include postpartum haemorrhage, puerperal sepsis, ante-partum haemorrhage, eclampsia and anaemia. Almost 58% of pregnant women are cared for by trained health personnel and about 39% of births are in health facilities. About 26% of women are using modern family planning methods (2006). Perinatal conditions account for over 10% of all recorded deaths. The infant mortality rate is estimated to be 49 per 1000 live births (2006) compared with 82 in 1991 and 72 from the 1981 National Census. Overall, 30% of children are considered to be moderately to severely malnourished and 31% of children aged 0–5 are stunted, while wasting is comparatively low. Again, there are marked regional variations. Child health problems are being addressed through improved immunization and the joint United Nations Children’s Fund (UNICEF)/WHO child survival strategy, with a focus on the integrated management of childhood illness (IMCI) approach. 2.5 Burden of disease 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 53.7 years for men and 54.8 years for women, and 15% of a woman’s lifetime is estimated to be affected by some form of disability or morbidity. 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. 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 the many socioeconomic, cultural, political and other constraints. Furthermore, disparities in most MDG-related indices at the provincial and subprovincial levels are very large by any standard. In some cases, the gaps between the provinces have widened further. The most obvious, cost-effective and easiest way of making progress towards achieving the MDGs, and in the process closing the gaps within the country, would be to concentrate on the low-achieving provinces. PAPUA NEW GUINEA 342 | COUNTRY HEALTH INFORMATION PROFILES 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The overall mission of the Papua New Guinea National Department of Health is to promote the physical social and mental wellbeing of people in their communities, and to promote and encourage the maintenance of community health at an acceptable level by planning and delivering preventive and curative medical and other health services. With this overall mission, the vision of the National Department of Health is a nation of healthy individuals, families and communities where self-reliance prepares all for healthy living in a healthy island environment, with the ultimate goal of improving the health of all Papua New Guineans through the development of a health system that is responsive, effective, affordable, acceptable and accessible to the majority of people. The Government is focusing its efforts on improving child health and reducing malaria, tuberculosis and AIDS through specific programmes. To be a nation of healthy individuals, families and communities and in the spirit of the National Goals and Directive Principles as enshrined in the National Constitution, Papua New Guineans strive for a future in which: • fewer infants and children die before they have had a chance to experience life; • fewer mothers die in childbirth from preventable causes; • all Papua New Guineans have access to basic health care and good nutrition; • fewer Papua New Guineans die from preventable and treatable diseases including malaria, pneumonia, tuberculosis, diarrhoea and HIV/AIDS; • women and men live healthier, longer, productive lives and age with dignity; • villages have safe drinking water and a clean environment; and • individuals make informed choice of health behaviour. 3.2 Organization of health services and delivery systems Health services are provided by both 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 sub- centres, rural hospitals and aid posts), known collectively as “rural health services”. The National Health Conference 2001 supported a proposal to create a unified provincial health system. The proposal envisages 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. Thus far this has only been implemented in four provinces. 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. 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 captured comprehensively. This too still needs to be actually put in place. 3.3 Health policy, planning and regulatory framework The National Health Plan 2001-2010 and the Medium-Term Expenditure Framework 2005 – 2007, with its 2007–2009 update, identify some explicit priorities. These include maternal and COUNTRY HEALTH INFORMATION PROFILES | 343 child health, immunization, malaria control, TB DOTS, HIV/AIDS, and water and sanitation programmes. 3.4 Health care financing 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. In 2006, however, it decreased back to 3.2% and total health expenditure per capita fell to US$ 28.8 (from US$ 32 US dollars in 1997). Over 80% of recurrent provincial health budgets were allocated to salaries in 2006. Increased income from the mining sector in the same year provided for an additional US$ 60 million for the health sector, which allowed the undertaking of long-awaited renovation work in hospitals and the addressing of human resource issues, such as staff housing. 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. Over recent years, ODA for health has fluctuated, but has been around 24% (2004) of total health spending. A major new source of funds for health in 2005 was the signing for a US$ 30 million grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) for the country’s HIV/AIDS programme. In 2004, the Global Fund committed US$ 20 million for malaria over five years. A further proposal of about US$ 21 million for TB was accepted in 2006. Papua New Guinea does not have any form of private health insurance, although there is an initiative to have mandatory staff health insurance introduced in the formal sector. In principle, health services are free. In most provinces, however, a small fee is charged for outpatient visits. It is not clear in how much this acts as a deterrent to people accessing health services. 3.5 Human resources for health The nurse-to-population ratio is estimated to be 15.0/10 000. An additional 600 nurses, 600 community health workers and 100 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 estimated to be 1.26 per 10 000, the majority being in Port Moresby. Churches are important providers of care, especially in rural areas, where they provide up to 80% 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 seven nursing schools and all of the community health worker training schools. 3.6 Partnerships 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. Since then, other major external agencies providing loans or grants have included: the Asian Development Bank (ADB); the United Nations agencies, including WHO; and the governments of Japan (JICA) and New Zealand (NZAID). Smaller contributions have been made by the United States Agency for International Development (USAID), the European Union and the World Bank. 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 after extensive consultation. There is now one annual activity plan for the National Department of Health and all donor partners. A Medium-Term Expenditure Framework was developed for 2004–2006, and further refined to become a rolling plan. 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. In 2004, two bilateral (AusAID, NZAID) and three multilateral partners (UNICEF, UNFPA and PAPUA NEW GUINEA 344 | COUNTRY HEALTH INFORMATION PROFILES WHO) signed a “Partnership Arrangement” with the National Department of Health, formally entering into a sector-wide approach called the “Health Services Improvement Programme” (HSIP), which ADB joined in 2006. This SWAp arrangement, through its management structure, has clearly strengthened day-to-day operations and coordination among development partners and with the National Department of Health. A jointly managed and financed Independent Monitoring and Review Group, which spends a couple of weeks in-country twice a year, is a key instrument in assessing the performance of the health sector in general and interactions between development partners and the Government, mainly the National Department of Health. This group provides recommendations on lessons learnt and best practices and guides the discussion on strategy development for the health sector. The Country Coordination Mechanism (CCM), a requirement of the Global Fund to execute programme activities, has had a further impact on overall cooperation between the different stakeholders in Papua New Guinea’s health sector.. In 2006 under the leadership of the Resident Representative of the United Nation to Papua New Guinea and the excom agencies (UNDP, UNICEF and UNFPA), as well as the other in-country and non-resident United Nations agencies (WHO, UNHCR, OCHA, UNIFEM, UNESCO and FAO) agreed to pilot a “Delivering as One UN” approach in the country. Although Papua New Guinea has not formally been included in the first eight pilot countries, there are indications that the Papua New Guinea common United Nations Country Programme is more advanced in the process. The bearing of this on the health sector remains to be seen. 3.7 Challenges to health system strengthening Under the Organic Law on Provincial Governments and Local Level Governments, district and local governments are given responsibility to manage and support their health services. Each level of government has different powers and functions in relation to health. The National Department of Health is responsible for policy, standards, training, medical supplies, specialist services, public hospitals and monitoring, while the provincial and local governments are responsible for implementation of health policies, standards and funding programmes. However, due to other district and local government priorities, almost all rural health services in the country are underfunded. Nurses and community health workers form the backbone of primary health care services in rural areas, and both are considered to be in short supply and dramatically reduced. These shortages constitute a serious constraint in implementing the National Health Plan, including the priority programmes. Some provinces and many districts have no doctor. The passing of the Organic Law exacerbated existing problems in health staff supervision and support. Provincial health advisers lost much of their authority to supervise and discipline district health staff. Central Department of Health oversight of provincial staff is also limited. Reasons include the limited capacity of programme units at the central level; the lack of funds for travel; the lack of economies of scale through joint training and supervision across programmes; and delayed disbursement of funds. As a result rural health services are poor and deteriorating. A function 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 the services are diminishing.” This dire situation has worsened since then, and more facilities have closed down. In spite of this being acknowledged for some time, little has been done yet to seek redress. The scarcity and maldistribution of human resources for health has not been addressed effectively, and there have only been limited and not very coordinated efforts in training and other approaches to capacity-building. No plan for development of human resources exists. There has been no proper assessment of the National Health Information and Surveillance System for many years, resulting in a lack of timely and reliable information for decision-making. COUNTRY HEALTH INFORMATION PROFILES | 345 The surveillance system is weak and there is a lack of capacity for conducting proper surveillance. Most information on communicable disease outbreaks come from the media, rather than the National Health Information and Surveillance System. At all levels in the country there are very limited capacities for outbreak response. Current central government policy of putting a ceiling on staff numbers does not allow for recruitment of more staff for the health system, especially in the peripheral areas. The National Department of Health is making an effort to strengthen communicable disease surveillance and to build outbreak response capacities by re-establishing its Disease Control Branch and recruiting staff for communicable disease surveillance and outbreak response, but the process is still ongoing. There is some laboratory capacity and a laboratory network in Papua New Guinea, but laboratory services are generally weak. The Central Public Health Laboratory (CPHL) in Port Moresby is responsible for overall coordination of operations for communicable disease diagnosis. The regional and provincial hospital laboratories form the backbone of the country’s laboratory network. Some health centres also have some limited laboratory diagnosis capacities. Medical supply and drug procurement and distribution face many challenges and ‘stock-outs’ are common occurrences. The distribution system is often dependent on ad hoc solutions. A 2006 survey showed a high level of susceptibility to corruption in the pharmaceutical sector. Although the necessary regulations are in place, these are not enforced and there seems to be collusion between the approving and procuring authorities. There is anecdotal evidence that the prices paid for drugs may be up to several times higher than those available on international markets. Recently, a push to outsource all or part of drug procurement and distribution system has emerged. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : 2000 National Census Operator : National Statistical Office (NSO) Title 2 : Papua New Guinea Demographic and Health Survey, 2006 (not yet published) Operator : National Statistical Office Features : Includes information on health outcomes, family planning etc. Title 3 : Millennium Development Goals Progress Report for Papua New Guinea 2004. Operator : Government of Papua New Guinea, United Nations in Papua New Guinea Features : Tables, graphs and maps on MDG indicators by province Title 4 : Papua New Guinea National Department of Health Information System, Operator : Monitoring and Research Branch Features : Yearly compiled tables of all collected and compiled data by province Title 5 : Papua New Guinea National Health Plan 2001-2010 (volume III) Features : Tables, graphs and maps of major health indicators by districts 1995 – 1999 Title 6 : Discharge Reports 2004 Operator : Monitoring and Research Branch National Department of Health Features : Survey of compiled data drawn from health facility discharge reports Title 7 : Annual Health Sector Review Operator : National Department of Health, Monitoring and Research Branch Specification : Compiled Provincial Reports with tables and graphs on regularly collected indicators Title 8 : National Inventory of Health Facilities 2003 Operator : National Department of Health Features : Tables (& graphs) on staff and equipment of all health facilities as foreseen by the health coverage plan (gazetteer) PAPUA NEW GUINEA 346 | COUNTRY HEALTH INFORMATION PROFILES Title 9 : Medium Term Development Strategy 2005 - 2010, (November 2004) Operator : Department of National Planning and Rural development Features : Financial information of all sectors, including health (Annex 1) Title 10 : Report of the 2004 National Consensus Workshop of Papua New Guinea Operator : National AIDS Council / National Department of Health Features : Tables and graphs on the HIV/AIDS situation in PNG Title 11 : Strategic Plan 2006 – 2008, (formerly Medium Term Expenditure Framework) Operator : National Department of Health Features : Outlines current situation and the way forward in priority areas in health Title 12 : Reports of the Independent Review Group, reports (Nov. 2005, May 2006 & Nov. 2006, May 2007 & November 2007) Operator : National Department of Health with all Development Partners united under the Sector Wide Approach (Health Service Improvement Programme) Features : Narratives on Health Sector Situation 5. ADDRESSES NATIONAL DEPARTMENT OF HEALTH Office Address : AOPI CENTRE (South), Waigani Drive, Waigani, Nat. Capital District Postal Address : P.O. Box 807, Waigani, National Capital District, Papua New Guinea Fax : (675) 301-3604 Office Hours : Monday to Friday, 07h45 – 16h06 (six past four!) WHO REPRESENTATIVE IN PAPUA NEW GUINEA Office Address : 4th Floor, AOPI CENTRE, Waigani Drive, Waigani, NCD, PNG 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 : Monday to Friday, 7h45 – 16h15 COUNTRY HEALTH INFORMATION PROFILES | 347 6. ORGANIZATIONAL CHART: National Department of Health Minister for Health Provincial Governor Provincial Health Board National Health Board Public Hospital Board Nursing Council Medical Board Pharmacy Board Institute of Medical Research National AIDS Council Secretary for Health Deputy Secretary National Health Planning & Corporate Services Deputy Secretary National Health Services & Standards Strategic Policy Div. Executive Manager Public Health Division Executive Manager Corporate Service Division Executive Manager Medical Standards Division Executive Manager Plans Policy Industrial Relations Legal Corporate Performance Finance Human Resources Infrastructure & Major Systms Commercial Support (outsourcing) Logistics Clinical Standards Health Facilities Standards Rural Health Service Standards Medical Supply Standards Health Sector Workforce Standards Family Health Programs Emergency Preparedness & Response Central Public Health Health Protection & Promotion Disease Control Year Source Demographics 1 462.84 2004 1 2 6.50 … … 2007 est 4 3 2.70 … … 2006 est 4 4 14.00 … … 2007 est 4 26.00 … … 2007 est 4 2.30 2.30 2.30 2007 est 4 5 14.00 … … 2007 est 3 6 35.00 … … 2000 4 7 12.00 … … 2000 4 8 2.30 … … 2000 4 9 53.00 52.50 53.60 2000 4 … 10.10 10.60 2002 18 10 4.60 2000 4 11 56.20 a 61.20 a 50.90 a 2000 4 12 909.00 2006 12 13 0.68 2004 12 14 0.53 2005 11 15 100.00 … … 2006 9 16 … … … 17 … … … … … … 392 575 … … … … … 2002 7 … … … … … … … … … … … … 81 55 26 2 2 0 2000 15 0 0 0 0 0 0 2000 15 22 … … … … … 2002 9 … … … … … … 34 14 20 0 0 0 2000 15 152 … … … … … 2006 9 81 303 … … 668 … … 2006 9 … … … … … … 184 66 118 8 3 5 2000 15 5 145 2 546 2 599 164 95 69 2000 15 348 | COUNTRY HEALTH INFORMATION PROFILES Urban Typhoid fever Encephalitis Leprosy Malaria Plague Syphilis COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male PAPUA NEW GUINEA Rate of natural increase of population (% per annum) Urban population (%) Estimated population ('000s) Annual population growth rate (%) Percentage of population - 0–4 years - 5–14 years Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Per capita GDP at current market prices (US$) Number of new cases Total Number of deaths Rural Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Environmental indicators Total Rate of growth of per capita GDP (%) Selected communicable diseases Human development index Communicable and noncommunicable diseases - Type E Hepatitis viral - Type A - Type B - Type C - Unspecified Cholera Dengue/DHF Gonorrhoea Male FemaleMaleTotal Female PAPUA NEW GUINEA Year Source 18 307 153 154 5 4 1 2000 15 19 7 009 3 932 3 077 185 122 63 2000 15 20 12 620 … … … … … 2006 9 1 948 … … … … … 2006 9 21 2 213 889 1 324 225 130 95 2004 15 184 0 184 7 0 7 2000 15 20 14 6 4 3 1 2004 15 518 22 2004 15 51 37 14 7 5 2 2000 15 82 46 36 24 14 10 2004 15 324 189 135 16 9 7 2004 15 306 207 99 70 54 16 2004 15 34 19 15 8 3 5 2004 15 45 32 13 15 13 2 2004 15 22 590 283 307 54 31 23 2004 15 32 27 5 4 1 3 2004 15 4 0 4 0 0 0 2004 15 430 223 207 27 19 8 2004 15 87 63 24 5 2 3 2004 15 137 70 67 18 9 9 2004 15 23 312 161 151 30 19 11 2004 15 24 600 347 253 2 1 1 2004 15 25 18 114 11 024 7 090 171 119 52 2004 15 326 72 254 1 0 1 2004 15 349 220 129 13 8 5 2004 15 0 0 0 0 0 0 2004 15 46 7 39 2 1 1 2004 15 26 49 423 49 423 867.79 1796.04 2004 15 27 357 15 247 12 110 480.34 517.98 440.08 2004 15 27 13 787 13 569 480.33 468.38 493.10 2004 15 8 148 4 348 3 800 143.07 147.71 138.09 2004 15 7 330 7 330 128.70 266.37 2004 15 6 827 3 811 3 016 119.87 129.47 109.60 2004 15 6 291 4 053 2 238 110.46 137.69 81.33 2004 15 6 082 2 992 3 900 106.79 101.65 141.73 2004 15 6 004 3 133 2 871 105.42 106.44 104.33 2004 15 3 947 1 623 2 342 69.30 55.14 85.11 2004 15 All types COUNTRY HEALTH INFORMATION PROFILES | 349 - Homicide and violence - Motor and other vehicular accidents - Occupational injuries - Suicide 1. Normal deliveries (incl. BBA) 2. Pneumonia 10. Anaemia - Liver - Cervix TotalTotal DATA - Leukaemia - Lip, oral cavity and pharynx - Hypertension All circulatory system diseases - Acute myocardial infarction Circulatory - Cerebrovascular diseases - Stomach - Trachea, bronchus, and lung - Breast 3. Malaria Total - Oesophagus Cancers All cancers (malignant neoplasms only) - Colon and rectum - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders Diabetes mellitus Leading causes of mortality and morbidity Female Rate per 100 000 population Male FemaleMale Number of cases Number of new cases Male Female Total Male Number of deaths Female 6. Diarrhoea 4. Perinatal conditions 5. Direct obstetric causes 7. Open wounds and injury to blood vessels 8. Diseases of the digestive system 9. Tuberculosis - All forms Leading causes of morbidity (inpatient care) - New pulmonary tuberculosis (smear-positive) Tuberculosis - Ischaemic heart disease Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections INDICATORS PAPUA NEW GUINEA Year Source 27 693 402 291 11.97 13.39 10.44 2004 15 648 354 294 11.19 11.79 10.55 2004 15 487 257 230 8.41 8.56 8.25 2004 15 486 282 204 8.39 9.39 7.32 2004 15 293 161 132 5.06 5.36 4.74 2004 15 213 109 104 3.68 3.63 3.73 2004 15 192 133 59 3.32 4.43 2.12 2004 15 186 123 63 3.21 4.1 2.26 2004 15 171 78 93 2.95 2.6 3.34 2004 15 161 90 71 2.78 3 2.55 2004 15 28 26.00 2006 2 29 43.00 2007 9 30 40.30 2005 5 31 26.00 … … 2006 2 32 90.70 … … 2006 7 33 67.00 … … 2007 9 60.00 … … 2007 9 61.00 … … 2007 9 59.00 … … 2007 9 34 3 320 11 2004 15 477 4 2004 15 1 698 33 2004 15 66 3 2004 15 729 17 2004 15 35 NR NR NR NR NR NR 2007 9 0 0 0 … … … 2007 9 … … … … … … 0 0 0 … … … 2007 9 … … … … … … … … … … … … … … … … … … 0 0 0 … … … 2007 9 4 … … … … … 2007 9 0 0 0 … … … 2007 9 350 | COUNTRY HEALTH INFORMATION PROFILES INDICATORS DATA FemaleTotal Total FemaleTotal MaleFemale Number of deaths Total 5. Meningitis Female Number of cases Male - Diphtheria Female - BCG - DTP3 - Total Tetanus Total - Rubella - Congenital rubella syndrome - Sepsis - Poliomyelitis - Pertussis (whooping cough) - Mumps - Neonatal tetanus - Measles - POL3 Maternal causes - Obstructed labour - Eclampsia - Haemorrhage - Hepatitis B III - Abortion Male Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth 9. Anaemia Percentage of pregnant women with anaemia 10. Diseases of the respiratory system 6. Heart diseases Immunization coverage for infants (%) 3. Malaria Male 1. Pneumonia Number of deaths Leading causes of mortality Rate per 100 000 population Maternal, child and infant diseases Male 7. Diseases of the digestive system 8. Diarrhoea 4. Tuberculosis 2. Perinatal conditions Percentage of women in the reproductive age group using modern contraceptive methods Percentage of pregnant women immunized with tetanus toxoid (TT2) Selected diseases under the WHO-EPI - Hib meningitis PAPUA NEW GUINEA Year Source 36 99 2007 17 37 Public health facilities 19 … 2003 14 4 … 2003 14 201 … 2003 14 2 875 … 2003 14 Private health facilities … … … … 38 178.43 2006p 13 3.20 2006p 13 28.77 2006p 13 147.71 2006p 13 82.70 2006p 13 7.30 2006p 13 13.65 b 2006p 13 17.30 2006p 13 3.06 2006p 13 39 … Year Source 40 Physicians - Number 750 … … … … … … 2005 19 - Rate per 1000 population 0.13 … … … … … … 2005 19 Dentists - Number 182 … … … … … … 2005 19 - Rate per 1000 population 0.03 … … … … … … 2005 19 Pharmacists - Number … … … … … … … - Rate per 1000 population … … … … … … … Nurses - Number 8 914 … … … … … … 2005 19 - Rate per 1000 population 1.50 … … … … … … 2005 19 Midwives - Number 567 0 567 … … … … 2005 19 - Rate per 1000 population 0.10 0.00 0.10 … … … … 2005 19 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians 50 … … … … … … 2008 8 Dentists … … … … … … … COUNTRY HEALTH INFORMATION PROFILES | 351 Number of beds P ri va te External source of government health expenditure Exchange rate in US$ of local currency is: 1 US$ = DATA U rb an T o ta l Private health expenditure - private expenditure on health as % of total expenditure on health Human resources for health Health insurance coverage as % of total population INDICATOR - external resources for health as % of general government expenditure on health M al e F em al e P u b lic Number DATA R u ra l - Primary health care centres Health facilities INDICATORS - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals Health care financing - general government expenditure on health as % of total expenditure on health - per capita total expenditure on health (in US$) Government expenditure on health Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) Facilities with HIV testing and counseling services Health infrastructure - Hospitals - Outpatient clinics Annual number of graduates PAPUA NEW GUINEA Year Source 41 Pharmacists … … … … … … … Nurses 140 … … … … … … 2008 8 Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 30.50 … … 2006 7 44 49.00 … … 2006 2 45 64.00 … … 2006 2 46 58.00 … … 2007 9 47 870.00 2006 2 48 … … 39.00 2006 7 49 26.00 … … 2004 7 50 13-15 2002 16 51 Antenatal care coverage - At least one visit 58.00 2006 7 - At least four visits … 52 … … … 53 59.54 … … 2007 17 54 1.61 … … 2007 17 55 35.00 … … 2007 17 56 1 311.00 … … 2006 9 57 10.77 … … 2006 9 58 50.00 … … 2007 7 59 60.00 … … 2007 7 60 513.00 … … 2006 9 61 48.00 … … 2006 9 62 21.00 … … 2006 9 63 57.00 … … 2005 9 64 40.00 88.00 32.00 2006 10 65 45.00 67.00 41.00 2006 10 66 … … … Annual number of graduates INDICATORS DATA 352 | COUNTRY HEALTH INFORMATION PROFILES Tuberculosis death rate per 100 000 population Female T o ta l M al e F em al e U rb an R u ra l HIV prevalence among population aged 15-24 years Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures Malaria incidence rate per 100 000 population Unmet need for family planning Total DATA Male P u b lic P ri va te Proportion of population in malaria-risk areas using effective malaria treatment measures Tuberculosis prevalence rate per 100 000 population Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Percentage of people with advanced HIV infection receiving ART Estimated HIV prevalence in adults b INDICATORS Maternal mortality ratio (per 100 000 live births) Adolescent birth rate Health-related Millennium Development Goals (MDGs) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Proportion of population with access to affordable essential drugs on a sustainable basis Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Contraceptive prevalence rate Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Under-five mortality rate (per 1000 live births) Infant mortality rate (per 1000 live births) Workforce losses/ Attrition Total Urban Rural Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source PAPUA NEW GUINEA … p est NR a b c 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 COUNTRY HEALTH INFORMATION PROFILES | 353 [http://hdr.undp.org/en/reports/global/hdr2007-2008/] Discharge Reports 2000-2004, Monitoring and Research Branch. Pacific island populations 2004 . Noumea, Secretariat of the Pacific Community, 2004. Demographic Health Survey 2006 , Papua New Guinea National Statistical Office United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). 2000 National Census, National Statistical Office. Papua New Guinea National Nutrition Survey, PNG National Department of Health Papua New Guinea National Statistical Office, Demographic Health Survey 1996 National Inventory of Health Facilities 2003 Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world . United Nations Development Programme, New York USA 2007. World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf] World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: Provisional Estimate Notes: Data not available World Health Report 2004: Changing history. Geneva, World Health Organization, 2004.B244:S262 Not relevant Not included in the official list of MDG indicators Human Resources Branch, National Department of Health, Papua New Guinea Medical Board and Nursing Council of Papua New Guiunea. Figure refers to population aged 10 years and over Computed by Health Information and Evidence for Policy Unit of WHO Regional Office for the Western Pacific Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] WHO Regional Office for the Western Pacific, data received from technical units. Papua New Guinea National Statistical Office [http://www.spc.int/prism/country/pg/stats] Honjupari et al Incidence of Teenage Pregancy in the National Capital district in PNG, unpublished 2002 Technical Unit National Department of Health, Disease Control Branch Sources: Information System, Monitoring and Research Branch, Papua New Guinea National Department of Health 354 | COUNTRY HEALTH INFORMATION PROFILES PHILIPPINES 1. CONTEXT 1.1 Demographics The Philippines consists of 7107 islands, with a land area of 300 000 square kilometers. Its population, as of 1 August 2007, was placed at 88 574 614, giving a population density of 295 per square kilometre Among the 14 regions of the country, Calabarzon (Region IV-A) had the largest population, with 11.7 million, followed by National Capital Region (NCR), with 11.6 million and Central Luzon (Region III), with 9.7 million. These three regions comprised more than one-third (37.3%) of the Philippine population. Based on the 2000 census figure of 76.5 million, the average annual population growth rate of 2% for the period from 2000 to 2007 is the lowest recorded for the Philippines since the 1960s. The country's population is predominantly young, with the 0-14 year age group representing 33.8% and those aged 65 years and above comprising 4.4%. There is an almost equal number of males and females. The crude birth rate stands at 20.5 per 1000 population and the crude death rate at 4.8 per 1000 population. Overall life expectancy is 67 years, 64 years for males and 70 years for females. 1.2 Political situation The Philippines is a democratic and republican state subscribing to the presidential form of government, with three branches: the executive, legislative and judicial branches. The country has a unitary form of government and a multiparty political system. Executive power is vested in the President, who is the head of state and commander-in-chief of the armed forces. The Cabinet members are the heads of agencies and assist the President in drafting executive laws, policies and programmes of government. The Constitution ensures direct election by the people for all elective positions from the President down to the members of the barangay councils. In 1991, the Local Government Code transferred some of the powers of the national Government to local government officials. The code devolved basic services, including health, giving responsibility to local government units. The country is made up of political local government units (LGUs) of provinces, cities, municipalities and barangays. A local chief executive heads each LGU. Administrative autonomy enables the LGUs to raise local revenues, to borrow and to determine types of local expenditure, including expenditures on health care. 1.3 Socioeconomic situation The Philippine economy in 2007 was at its strongest, with the gross domestic product (GDP) real growth rate for the year averaging 7.3%, the highest in 31 years. The economy continued to keep pace with population growth in the fourth quarter of 2007, as per capita GDP grew from 3.4% to 5.3%. The challenge for the Government is to enable these economic gains to be felt by the poorer sectors of society. The 2006 official poverty statistics revealed an increase of 2.5 percentage points to 26.9% from 24.45 in 2003, meaning a total of 4.7 million poor families in 2006 compared with the 4.0 million estimated in 2003. In terms of population, the number of poor Filipinos reached 27.6 million in 2006, 16% more than the 23.8 million estimated in 2003, while food-poor individuals increased to 12.2 million, 14% more than in 2003. In the presence of the country’s gains in economic growth, the Government's move to realign the national budget towards social services is a good opportunity to focus on the education and health needs of the population in tandem with an effective population management programme. COUNTRY HEALTH INFORMATION PROFILES | 355 The gender gap appears to be in favour of girls as far as participation in basic education, technical-vocational education and training and higher education are concerned. There is a need for the Government and other education stakeholders to look more seriously at the low completion and retention rates among boys in the school system. Although indicators to reflect gender equality, such as the country' Gender Development Index (GDI) and Gender Empowerment Measure (GEM) reflect gains, these do not necessarily translate into positive measurable changes in the roles of and status of women, given the continuing incidence of violence against women, the predominance of female child-abuse victims, the trafficking of women and children for sexual exploitation and female forced labour, among others. The slow decline in maternal mortality means that the country is unlikely to meet the Millennium Development Goal maternal mortality target or 80% access to reproductive health services by 2015. The reasons include the inadequate access to integrated reproductive health services, such as contraceptives, family planning and responsible-parenthood education, by women, including poor adolescents, and men. 1.4 Vulnerabilities and hazards There is constant concern about the Philippines' high population growth rate and it being a limiting factor for broad-based growth and reduction of poverty. There is a hidden threat from HIV and AIDS; although prevalence is still below 0.1% of the population, there was a 20% increase in the number of reported cases from 2004 to 2006. Due to its geographical location, the country faces various natural disasters, such as typhoons, landslides, volcanic eruptions and earthquakes. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition Tuberculosis continues to affect a sizeable segment of the population, although, in recent years, effective case-finding, disease management using the directly observed treatment short-course (DOTS) strategy, and partnership with the private sector have made inroads into the prevention and control of the disease. Mosquito-borne diseases, such as malaria, dengue and filariasis, are an ever-present danger in endemic areas. Although malaria is no longer a leading cause of death, it remains among the leading causes of morbidity in the country, particularly in rural areas. High-risk groups include upland subsistence farmers, forest-related workers, indigenous peoples and settlers in frontier areas and migrant agricultural workers. Dengue fever also remains a threat, with cyclical outbreaks every three to five years. Early in 2008, there was a resurgence in the number of cases. The increase in life expectancy, rapid urbanization and lifestyle trends have resulted in changes in the health profile. Four of the most prominent noncommunicable diseases are linked by common preventable risk factors related to lifestyle. These are cardiovascular diseases, cancer, chronic obstructive pulmonary diseases and diabetes. In a study conducted by the Food and Nutrition Research Institute in 2003, it was found that 90% of Filipinos have one or more of these risk factors: smoking, obesity, hypertension, high blood sugar and abnormal blood cholesterol levels. Among the risk factors found, smoking was the most common risk factor, with 12.1% of women and 56.3% of men smokers. Obesity based on waist-hip ratio is more common than obesity measured by BMI. Prevalence of obesity and overweight using the hip-to- weight ratio is 12.1% for men and 54.8% for women. PHILIPPINES 356 | COUNTRY HEALTH INFORMATION PROFILES 2.2 Outbreaks of communicable diseases A total of 7880 dengue cases were admitted to various sentinel hospitals nationwide from January 1 to March 29, 2008, 20.6% higher than during the same time period in 2007 (6532). Cases had exceeded and reached the alert threshold in weeks 1, 8 and 9 and went above the epidemic threshold on the 2nd to 7th week. Ages of cases ranged from <1 month to 87 years (median 12 years), the majority being male (53%). The age group with a case-fatality ratio greater than 1 is the 1-10 years age group. 2.3 Leading causes of mortality and morbidity Eight of the ten leading causes of morbidity in the country are caused by infections. They are: acute lower respiratory tract infection and pneumonia; acute watery diarrhoea; bronchitis/bronchiolitis; influenza; tuberculosis; malaria, acute febrile illness; and dengue fever. Among these communicable diseases, pneumonia and tuberculosis continue to be among the 10 leading causes of mortality, causing a significant number of deaths across the country. At the same time as deaths due to preventable diseases have been in a decline, life-style diseases have begun to dominate in the leading causes of death, particularly heart diseases; vascular system diseases; malignant neoplasm; diabetes mellitus; chronic lower respiratory diseases. However, certain conditions originating in the perinatal period are also among the 10 leading causes of mortality, further illustrating the vulnerability of the newborn child. Accidents and injuries, other leading causes of death, and are also among the neglected disease conditions of public health importance. The mortality rate from accidents gradually increased from 18.7 deaths per 100 000 populations in 1980 to 23 per 100 000 in 1996. An abrupt increase has been observed since then, reaching a level of 41.3 per 100 000 in 2004, almost double the 1996 rate. Among the causes, 36% are assaults, followed by deaths from transport accidents, at 25%. 2.4 Maternal, child and infant diseases The Philippines is one of 55 countries accounting for 94% of all maternal deaths in the world and is statistically off-track for achievement of MDG 5 by 2015. Maternal deaths are closely linked with neonatal deaths. Nearly half of all pregnancies every year are unintended, resulting in women having one-third more children than they desire, one-third being born less than two years apart, and 15% ending in abortion. For completed pregnancies, the majority (60%) of deliveries are home-based, two- thirds of them attended by an unskilled attendant. The vast majority of maternal deaths are due to haemorrhage, hypertensive diseases, sepsis, obstructed labour and problems related to abortion. These conditions are treatable if deliveries are attended by skilled health workers able to identify and treat them. They would also be less prevalent; if mothers had only their desired number of children, spaced by at least two years. For every maternal death, there are 20 neonatal, infant and child deaths. While the probability of reducing the under-five mortality by two thirds by 2015 has been adjudged highly probable, it may not be realized unless deaths during the first 28 days (neonatal period) are dealt with, as 40% of deaths among the under-fives (17 per 1000 live births) occur within 28 days of delivery. In fact, half of neonatal deaths occur during the first two days of life. Progress to curtail neonatal deaths is dismal, with death rates among this age group showing only the barest decline over the past 20 years. As mentioned, conditions originating in the perinatal period is among the leading cause of mortality; the top cause of death being pneumonia, followed by bacterial sepsis. Other causes of mortality are related to pregnancy, events during delivery and congenital malformations. COUNTRY HEALTH INFORMATION PROFILES | 357 Undernutrition remains a challenge in the country. Only 68% of children under five have the normal weight for age using the National Center for Health Statistics/WHO Standards. In 2005, the prevalence of underweight pre-school children (0-5 years) was 24.6%, 26.3% were stunted, 4.8% were wasted and 2.0% were overweight. In its State of the world’s children 2004. The United Nations Children’s Fund (UNICEF) reported that 20% of infants have a low birth weight, while according to the 2003 NDHS, 13% are babies of low birth weight. Exclusive breast-feeding is on the decline, with only 33.5% of children exclusively breast-fed up to the age of six months. Other nutritional challenges faced by the Filipino child include: • anaemia—with prevalence rates among children aged 6-12 months and 6-11 years of age still increasing, and presently at the high levels of 66% and 37.4%, respectively; • vitamin A deficiency—the level among children aged six months to five years increased from 35% in 1993 to 40% in 2003; • iodine deficiency—there are an estimated 1.5 million schoolchildren aged 6-12 years who are at risk of mental retardation due to iodine deficiency. 2.5 Burden of disease Tuberculosis is still among the leading causes of morbidity and mortality in the Philippines; the country as has the 8th highest TB incidence in the world and the 3rd highest in the Western Pacific Region. The burden of disease of TB is disproportionately high for the poor, elderly and male population, although death is highest among older persons. Since TB principally affects the productive age group, it is estimated that the country loses some Php 26 billion (US$ 540 million annually due to premature deaths from TB. Environmental-related health risks have been cited as a significant problem, with air pollution, water pollution, sanitation and unhygienic practices contributing to an estimated 22% of the reported disease cases and nearly 6% of reported deaths, costing Php 14.3 billion (US$ 287 million) per year in lost income and medical expenses. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The Department of Health's vision is to be "The leader of health for all in the Philippines". Its mission is to "guarantee equitable, sustainable and quality health for all Filipinos, especially the poor, and to lead the quest for excellence in health". The goals of the health department align with the WHO health systems framework. Better health for the entire population is the primary goal. This means making the health status of the people as good as possible over the entire life cycle. The second goal is related to how the health system performs in meeting people’s expectations and satisfaction with the services it provides. Equitable health care financing is the third goal because health and illness involves large and unexpected costs that may result in poverty for many people. The strategic thrusts to achieve the three primary health goals mentioned above are anchored in the current programme of health reforms, labelled ‘Fourmula One for Health’. It is designed to undertake critical reforms with speed, precision and effective coordination, with the end goal of improving the efficiency, effectiveness and equity of the Philippine health system. Vital reforms are organized into four major implementation components: health financing; health regulation; health service delivery; and good governance in health. Implementation will focus on four general objectives: (1) health financing, the general objective of which is to secure increased, PHILIPPINES 358 | COUNTRY HEALTH INFORMATION PROFILES better and sustained investments in health to provide equity and improve health outcomes, especially for the poor; (2) health regulation, which aims to assure access to quality and affordable health products, devices, facilities and services, especially those commonly used by the poor; (3) health service delivery, where health interventions are aimed at improving the accessibility and availability of social and essential health care for all, particularly the poor; and (4) good governance in health, aimed at improving health systems performance at the national and local levels. 3.2 Organization of health services and delivery systems With the devolution of health services to LGUs under the Local Government Code of 1991, fragmentation of services became evident. Service provision is regarded as ‘dual’, consisting of both the public and private sector. The public sector has three largely independent segments or sets of providers: (1) national government providers, which include, among others, hospitals run by national government agencies (e.g., hospitals of the Department of Health and the Department of National Defense), central and regional offices of the Department of Health; (2) provincial government providers, which include provincial hospitals, provincial blood banks and the Provincial Health Office; and (3) local (municipal or city) government providers, including rural health units or RHUs, city health centres and barangay health stations or BHSs. Each BHSs is staffed by a midwife, and each RHU by a doctor, a nurse and midwives. The Department of Health's role now focuses on regulation, technical guidelines/orientation, planning, evaluation, and inspection, while the provincial government is responsible for provincial and municipal hospitals, health centres and health posts, although funding flows do not exactly match responsibility. The municipal government-level role is not well defined and capacity is reportedly weak. With the decentralization of service delivery, local chief executives became core players in the health sector. The number of actors involved multiplied and hence the need for coordination and policy monitoring. On health financing, for instance, the Department of Health and the Central Government are no longer in control of resource allocation. The need for better coordination and a better working relationship with the local government units and other stakeholders is well recognized. Private providers are predominantly located in highly urbanized areas. The private sector consists of a wide range of privately operated facilities, such as pharmacies, physicians in solo or group practices, small hospitals and maternity centres, diagnostic centres, employer-based outpatient facilities, secondary and tertiary hospitals, traditional birth attendants and indigenous healers. Ongoing reforms in health service delivery are aimed at improving the accessibility and availability of basic and essential health care for all, particularly the poor. Public primary health facilities are perceived as being low quality, hence they are frequently bypassed. Clients are dissatisfied due to long waiting times; perceived inferior medicines and supplies; poor diagnosis, resulting in repeated visits; and the perceived lack of medical and people skills of the personnel available, especially in rural areas. The result is that secondary and tertiary facilities are inundated with patients needing primary health care. Since public primary facilities are more accessible to households and are mostly visited by the poor, improving the quality of those services particularly demanded by the poor would improve their health. Furthermore, referral mechanisms among different health facilities across local government units need to be strengthened. Pharmaceutical challenges remain due to asymmetric information, income distribution and the inadequacy of the regulatory system. This stems from various factors such as massive campaigns and lucrative incentives from multinational drug firms, prolonged patent rights cases and a lack of appropriate public understanding regarding generics. COUNTRY HEALTH INFORMATION PROFILES | 359 3.3 Health policy, planning and regulatory framework The Government's policy to achieve improvements in health includes a perspective on the integral value of health for any nation, the coordination of resources from all sectors, the right to access quality care, and the presence of socioeconomic fundamentals. While the Government provides the leadership and stewardship to ensure that all efforts in the health sector lead to a common goal, greater support to local health systems development and emphasis on strong management and administrative support systems at all levels of governance is critical. Better coordination between national policies and external development partner priorities would also play a major role in fostering the harmonization of resources for health. The Department of Health remains inadequate in regulating the quality of health services in the country. This is attributed to the immense gaps in health regulations caused by the lack of specific legal mandates, inadequate expertise, an inadequate number of health regulation officers, a lack of expertise and infrastructure in specialized services and laboratory facilities, and weak health regulatory systems and processes. 3.4 Health care financing The financial burden on individual families remains high. The latest (2005) national health accounts show that the most common source of funds for health in the country today is still out- of-pocket payments (around 49%). Paying for health care is an issue because of its poverty impacts. Under the current health care financing arrangements, low-income families are pushed into poverty due to payments for health care. Almost 80% of total health expenditure is spent on personal health care services. In contrast, only 11% is used for public health care services. About 10% is used for the administrative spending needed to run the entire health system. These are signs that the Philippines is not spending enough or effectively for health. Health care financing resources are spent largely on hospital-based curative services and not enough on preventive and promotive health services, and subsidies for health services are poorly targeted. The large hospitals in Metropolitan Manila and other urban areas get the biggest share of spending, while non-hospital health services face difficulties in getting adequate funding. Meanwhile, the national health insurance programme has seen only a relatively slow and cautious increase in its share of total health expenditure. Possible reasons for this include its low benefit package and the fact that coverage of the informal economy has not increased. The limited financial protection of the national health insurance programme, PhilHealth, is closely related to its benefit coverage and provider payment system. As physicians provide more services and raise prices under the current fee-for-service system, medical care expenses increase rapidly. However, PhilHealth pays only up to the rather low benefit ceiling and patients pay the rest of the expenses. At the same time, physicians’ have the freedom to bill without fee regulation. Discussions are now ongoing to explore the feasibility of extending benefit coverage by raising the benefit ceiling. Public health facilities are funded through a mix of public subsidies, such as Philhealth reimbursements, user fees and, to a limited extent, private health insurers. At the primary care level, public subsidies and Philhealth capitation allocations are funding services for both insured and non-insured members and for both public health and personal care. At the hospital level, the mix of funding is not well understood by regulators. Moreover, several schemes may be working at the same time, depending of local priorities and management styles. Drugs are mainly purchased out-of-pocket from private for-profit retailers. The Government has recently introduced thousands of non-profit community outlets, but their impact on access and the costs supported by patients remains to be seen. In response to these issues, the Government is finalizing its health care financing strategy to improve health care financing polices that would realistically enhance access, equity and effectiveness in resource mobilization and allocation, as well as the use of health services. PHILIPPINES 360 | COUNTRY HEALTH INFORMATION PROFILES 3.5 Human resources for health In 2004, there was one physician for every 880 people, one nurse for every 235, one dentist for every 1800, and one pharmacist for every 1664. However, these ratios have most likely changed, especially with the exodus of nurses in the past five years. The country is purportedly the leading exporter of nurses to the world and the second major exporter of physicians. Prevailing challenges include unmanaged immigration of Filipino health workers; a weak and inadequate human resources for health (HRH) information system; and an existing distribution imbalance, among others. Responses to HRH issues in the past have often been stopgap measures. In addition, the interventions of the agencies concerned have not always been well coordinated. In order to address such complex and multi-faceted issues, a comprehensive approach is needed. A master plan for human resources for health has been developed and implementation of activities is underway. A high-level coordinating body and multisectoral working group was established in 2006 to mobilize political commitment, donor/partner support and the funding needed to accomplish the priority activities of the master plan. Called the Human Resources for Health (HRH) Network, this group was able to successfully convene a policy forum to advocate their policy agenda, which aims to resolve issues related to production, entry and retention of health professionals, as well as their exit and re-entry. Strategic thrusts for 2005-2010 include development of HRH policies and strategies to address out-migration; sustaining incentive mechanisms for HRH distribution and complementation in underserved areas; and making education, training and skills development more appropriate to local needs. The strategies that are being undertaken include, among others, the institutionalization of the health human resource management and development system; improvement of the technical competence and relevant skills of health professionals through education and training; provision of targeted and performance-linked compensation benefits; strengthening of the coordination mechanism between the education sector, regulatory agencies and HRH users; and installation of and HRH information system. 3.6 Partnerships The attainment of national health goals has significantly progressed given the well-defined, commonly-shared vision and framework for health (now called ‘FOURmula ONE’). Department of Health experience has shown that better harmonization of efforts among the various stakeholders at all levels is critical. Currently, assistance for the health sector comes mainly in the form of grants, loans and technical assistance. A sectorwide development approach for health (SDAH) between government and partners is being initiated to maximize investments, minimize duplication of initiatives and generate the necessary resources for the health sector. The Department of Health is also working closely with international organizations and global initiatives to strengthen implementation of priority health programmes. 3.7 Challenges to health system strengthening The publicly funded health system has been undergoing a major reform programme since 1999. At the broadest level, this has included a review of the Department of Health’s primary functions, roles and responsibilities and the suitability of the existing organizational structure to support these at both the strategic and service-delivery level. Introducing and pilot-testing the different concepts and strategies of heath sector reform in selected provinces has showcased some gains in health systems development. However, one of the gaps then was the absence of a comprehensive operational framework to implement the reform strategies. Thus, the FOURmula ONE framework was launched in August 2005 to set the direction and implementation arrangements for strengthening the way health care is delivered, governed, regulated and financed. FOURmula ONE is now on its third year of implementation and both the Department of Health and the LGUs are being challenged with operational issues, such as procurement. In addition, the health care delivery system has yet to address some major issues and challenges including, COUNTRY HEALTH INFORMATION PROFILES | 361 among others: the absence of data disaggregated at provincial/municipal level (for baseline and monitoring); the absence of a workable means of identification of the poor for targeted health interventions; the minimal involvement of the private sector in the delivery of public health programmes; the still excessive reliance on the use of high-end hospital services rather than primary care; the slow improvement in maternal mortality reduction; and population growth. Issues such as geographic 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. More specific issues like out-migration of skilled health workers, low salaries/wages and lack of incentives and poor work environments, including shortages of basic medical equipment and supplies, continue to contribute to the worsening shortage of workers in rural areas, where health needs are greatest. Hospitals, both public and private, all over the country lament the loss of senior experienced nurses and doctors. The University of the Philippines-Philippine General Hospital (UP-PGH), the largest hospital in the country, loses 300 to 500 nurses of their 2000 nurse workforce every year. Midwives, the front liners in providing health services, are also seeking jobs as caregivers in other countries in need. There is a lack of reliable, disaggregated and integrated health and health-related data, evidence and information, and inability to use health information to ensure knowledge-based policies and programmes remains a major challenge. There is also low investment in health research and development systems, as well as in information management systems. In the area of health care financing, the following challenges remain: high out-of pocket spending; inadequate government spending on health; low spending for cost-effective public health interventions; low social health insurance benefit spending; and identification of the ‘true’ poor for social health insurance (sponsored programme). The high cost of drugs and medicines also remains a major challenge, as prices range from two times to as much as 30 times higher than in other neighbouring Asian countries. To date, the ‘Cheaper Medicines’ Bill, which aims to effectively reduce the cost of medicines in the country, is yet to be signed by the President of the Philippines. The devolution of health services created new challenges for the Government in overseeing that local actions are in accordance with national policies and goals. Good governance in health at the local levels, particularly in improving transparency and accountability in finance and procurement, and logistics management remains a big challenge. With FOURmula ONE, systems of accountability and transparency are being established to minimize unscrupulous behaviour, thereby ensuring efficient use of available resources for health. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : National Statistics Office. Web address : http://www.nso.gov.ph/ Title 2 : 2007 Government of the Philippines year-end report Web address : http://www.gov.ph/faqs/yearend_reports.asp Title 3 : Philippine environment monitor 2006. The World Bank Group. June 2007 Web address : http://www.worldbank.org.ph/pem Title 4 : National Epidemiology Center Operator Department of Health, Philippines Web address : http://www2.doh.gov.ph/nec/ Title 5 : 2007 Philippines Development Forum 8-9 March 2007, Cebu City, Philippines. PHILIPPINES 362 | COUNTRY HEALTH INFORMATION PROFILES Title 6 : 2005-2010 National Objectives for Health Operator : Department of Health, Philippines Web address : http://www2.doh.gov.ph/nec/ Title 7 : National Nutrition and Health Survey (NNHeS): Atherosclerosis-related disease and risk factors Authors : Antonio Dans, Dante Morales, Felicidad Velandria, Teresa Abola, Artemio Roxas Jr., Felix Eduardo Punzalan, Rosa Allyn Gy, Elizabeth Paz-Pacheco, Lourdes Amarillo and Maria Vanessa Villaruz Specification : Philippine Journal of Internal Medicine, 43:103-115, May-June 2005. Title 8 : Philippine nutrition facts and figures 2005 Operator : Food and Nutrition Research Institute. Department of Science and Technology Taguig, Metro Manila 5. ADDRESSES DEPARTMENT OF HEALTH Office Address : San Lazaro Compound, Tayuman, Sta. Cruz, Manila Official Email Address : info@doh.gov.ph Telephone : (632) 743-8301 Fax : (632) 743-1829 Website : http://www.doh.gov.ph WHO REPRESENTATIVE IN THE PHILIPPINES Office Address : 2nd Floor, Bldg 9, Department of Health San Lazaro Compound, Tayuman, Sta. Cruz, Manila Postal Address : P.O. Box 2932, Manila Official Email Address : who@phl.wpro.who.int Telephone : (632) 338-7479/ 338-8605 Fax : (632) 731-3914 COUNTRY HEALTH INFORMATION PROFILES | 363 6. ORGANIZATIONAL CHART: Department of Health Year Source Demographics 1 300.00 2006 1 2 88 574.61 … … 2007 2 3 2.04 … … 2000-07 2 4 11.47 a 11.64 a 11.29 a 2005 3 22.28 a 22.70 a 21.87 a 2005 3 4.40 a 4.02 a 4.78 a 2005 3 5 64.00 … … 2007 est 4 6 20.50 … … 2004 7 7 4.80 … … 2004 7 8 1.73 … … 2005 6 9 67.00 64.00 a 70.00 a 2004 7 … 10.60 12.10 2002 11 10 3.18 2005-15 6 11 92.60 … … 1995-2005 8 12 1 461.33 2007 9 13 8.10 2007 9 14 0.77 2005 8 15 30.20 … … 2003 10 16 … … … 17 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 36 24 12 2004 7 45 350 … … 416 … … 2007 17 34 22 12 … … … 2006 5 2 218 b 84 1 374 … … … 2006 5 2 517 … … … … … 2006 16 35 405 … … 122 … … 2006 22 … … … … … … 63 41 22 … … … 2006 5 11 374 c 5 869 c 5 505 c … … … 2006 5 Leprosy Malaria Plague 364 | COUNTRY HEALTH INFORMATION PROFILES - 5–14 years - 65 years and above COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km 2 ) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male Estimated population ('000s) Annual population growth rate (%) Percentage of population - 0–4 years Rate of natural increase of population (% per annum) Urban population (%) Crude birth rate (per 1000 population) Crude death rate (per 1000 population) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Typhoid fever Selected communicable diseases Per capita GDP at current market prices (US$) Environmental indicators - Type B - Type C Female Total Urban Human development index Rate of growth of per capita GDP (%) Dengue/DHF Gonorrhoea - Unspecified Cholera Encephalitis Rural Number of deaths FemaleMaleTotal Number of new cases Total Male Syphilis Communicable and noncommunicable diseases Hepatitis viral - Type E - Type A PHILIPPINES PHILIPPINES Year Source 18 690 566 b 348 992 328 956 … … … 2006 5 19 … … … 3 538 2 069 1 469 2004 7 20 147 305 … … … … … 2006 16 85 740 … … … … ... 2006 16 21 106 884 d 51 980 d 54 864 d 42 686 22 551 20 135 C: 2005 D: 2004 12, 7 14 043 d … 14 043 d 4 254 55 4 199 C: 2005 D: 2004 12, 7 8 585 d 4 737 d 3 848 d 2 230 1 234 996 C: 2005 D: 2004 12, 7 7 277 d 7 277 d 1 111 1 111 C: 2005 D: 2004 12, 7 992 d 647 d 345 d 452 307 145 C: 2005 D: 2004 12, 7 4 202 d 2 243 d 1 959 d 2 460 1 234 1 226 C: 2005 D: 2004 12, 7 4 113 d 2 140 d 1 973 d 1 927 1 201 726 C: 2005 D: 2004 12, 7 7 629 d 5 660 d 1 969 d …. …. …. C: 2005 D: 2004 12, 7 3 932 d 2 368 d 1 564 d 1 439 811 628 C: 2005 D: 2004 12, 7 17 238 d 13 273 d 3 965 d 7 240 5 446 1 794 C: 2005 D: 2004 12, 7 22 … … … 54 045 30 598 23 447 2004 7 … … … 28 663 18 571 10 092 2004 7 … … … 43 077 24 322 18 755 2004 7 … … … 15 617 8 614 7 003 2004 7 … … … 13 915 7 065 6 850 2004 7 … … … 2 183 930 1 253 2004 7 23 … … … 16 552 7 970 8 582 2004 7 24 … … … 1 104 799 305 2004 7 25 … … … … … … … … … 12 646 11 613 1 033 2004 7 … … … 6 976 5 312 1 664 2004 7 … … … … … … … … … 1 818 1 400 418 2004 7 26 670 231 342 989 327 242 828.80 794.50 767.20 2006 5 572 259 295 827 276 432 707.70 685.30 648.10 2006 5 537 100 265 320 271 780 689.90 614.60 637.20 2006 5 404 141 177 059 227 082 522.80 410.20 532.40 2006 5 337 275 161 446 175 829 435.00 374.00 412.20 2006 5 130 608 82 969 47 639 169.90 192.20 111.70 2006 5 38 482 17 946 20 536 49.30 41.60 48.10 2006 5 25 400 12 675 12 725 32.50 29.40 29.80 2006 5 22 284 12 128 10 156 27.60 28.10 23.80 2006 5 15 279 8 076 7 203 19.60 18.70 17.00 2006 5 1. ALRI and Pneumonia Circulatory - Cerebrovascular diseases - Liver - All forms - Leukaemia - Lip, oral cavity and pharynx - Trachea, bronchus, and lung 7. Diseases of the Heart INDICATORS DATA Tuberculosis Mental disorders Male Female - New pulmonary tuberculosis (smear-positive) Cancers All cancers (malignant neoplasms only) - Hypertension All circulatory system diseases - Acute myocardial infarction Number of deaths Male All types - Homicide and violence - Motor and other vehicular accidents Female Number of cases Male - Occupational injuries - Suicide COUNTRY HEALTH INFORMATION PROFILES | 365 3. Bronchitis/Bronciolitis 2. Acute Watery Diarrhea 10. Dengue Fever Female 6. TB Respiratory 8. Acute Febrile Illness 9. Malaria Rate per 100 000 population Total 4. Hypertension 5. Influenza - Ischaemic heart disease Number of new cases Leading causes of mortality and morbidity Total Male - Stomach - Breast Female TotalTotal Leading causes of morbidity (inpatient care) Injuries - Rheumatic fever and rheumatic heart diseases Diabetes mellitus - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections PHILIPPINES Year Source 27 70 861 40 361 30 500 85.72 96.99 74.30 2004 7 51 680 28 930 22 750 62.52 69.52 55.42 2004 7 40 524 21 395 19 129 49.02 51.42 46.60 2004 7 34 483 28 041 6 442 41.30 67.39 15.69 2004 7 32 098 15 822 16 276 38.83 38.02 39.65 2004 7 25 870 17 841 8 029 31.30 42.87 19.56 2004 7 21 278 10 916 10 362 25.74 26.23 25.24 2004 7 18 975 13 084 5 891 22.95 31.44 14.35 2004 7 16 552 7 970 8 582 20.02 19.15 20.91 2004 7 13 180 7 809 5 371 15.94 18.77 13.08 2004 7 28 35.90 2006 13 29 36.00 2007 16 30 43.90 2003 14 31 12.00 … … 2006 13 32 54.80 … … 2003 15 33 90.00 … … 2007 16 87.00 … … 2007 16 87.00 … … 2007 16 88.00 … … 2007 16 34 … 152 2004 7 … … … 317 2004 7 … … … … 35 172 … … … … … 2007 16 39 … … … … … 2007 16 … … … … … … 530 … … … … … 2007 16 ….. … … … … … 121 … … … … … 2007 16 17 … … … … … 2007 16 0 0 0 … … … 2007 16 … … … … … … 1 261 … … … … … 2007 16 3. Malignant Neoplasm Leading causes of mortality Total 366 | COUNTRY HEALTH INFORMATION PROFILES Total Male 2. Vascular System Diseases Number of deathsNumber of cases Female Total DATA Number of deaths Rate per 100 000 population Male Female Male Maternal, child and infant diseases 1. Heart Diseases 6. Tuberculosis, all form INDICATORS Male FemaleTotal Male Female Total Female - Pertussis (whooping cough) - Rubella - Congenital rubella syndrome - Sepsis - Mumps - Hib meningitis - Poliomyelitis - Eclampsia - Haemorrhage - Abortion Selected diseases under the WHO-EPI - Obstructed labour - Measles Percentage of pregnant women with anaemia Percentage of pregnant women immunized with tetanus toxoid (TT2) 8. Chronic lower respiratory diseasesw 9. Diabetes Mellitus Immunization coverage for infants (%) - POL3 - BCG - DTP3 - Diphtheria Percentage of newborn infants weighing at least 2500 g at birth 4. Accidents 10. Certain conditions originating in the perinatal period Percentage of women in the reproductive age group using modern contraceptive methods 7. Ill-defined and unknown causes of mortality 5. Pneumonia Neonatal mortality rate (per 1000 live births) Maternal causes - Hepatitis B III - Total Tetanus - Neonatal tetanus PHILIPPINES Year Source 36 … 37 Public health facilities 682 37 400 2006 19 21 10 374 2006 19 713 e 22 023 2006 19 2 293 … 2006 17 Private health facilities 1 068 36 519 2006 19 … … 38 3 911.61 2006p 20 3.30 2006p 20 45.34 2006p 20 1 549.17 2006p 20 39.60 2006p 20 6.40 2006p 20 8.33 2006p 20 60.40 2006p 20 51.31 2006p 20 39 … Year Source 40 Physicians - Number 93 862 … … … … … … 2004 21 - Rate per 1000 population 1.14 … … … … … … 2004 21 Dentists - Number 45 903 … … … … … … 2004 21 - Rate per 1000 population 0.55 … … … … … … 2004 21 Pharmacists - Number 49 667 … … … … … … 2004 21 - Rate per 1000 population 0.60 … … … … … … 2004 21 Nurses - Number 352 398 … … … … … … 2004 21 - Rate per 1000 population 4.26 … … … … … … 2004 21 Midwives - Number 136 036 … … … … … … 2004 21 - Rate per 1000 population 1.65 … … … … … … 2004 21 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … Exchange rate in US$ of local currency is: 1 US$ = - external resources for health as % of general government expenditure on health Number of beds COUNTRY HEALTH INFORMATION PROFILES | 367 R u ra l P u b lic DATA U rb an Number DATA Human resources for health Health insurance coverage as % of total population P ri va te M al e F em al e T o ta l INDICATOR Private health expenditure - private expenditure on health as % of total expenditure on health External source of government health expenditure Health facilities INDICATORS - general government expenditure on health as % of total expenditure on health Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals - Primary health care centres - per capita total expenditure on health (in US$) Government expenditure on health Health care financing - Outpatient clinics Facilities with HIV testing and counseling services Health infrastructure - Hospitals Annual number of graduates PHILIPPINES Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 27.60 … … 2003 14 44 24.00 … … 2006 13 45 32.00 … … 2006 13 46 92.00 … … 2007 16 47 162.00 2006 13 48 63.70 2006 13 20.30 2006 13 42.40 2006 13 49 50.60 … … 2006 13 50 4.80 2006 13 51 Antenatal care coverage - At least one visit … - At least four visits 59.00 2006 5 52 15.70 … … 2006 5 53 … … … 54 0.02 … … 2007 18 55 … … … 56 410.00 … … 2006 16 57 0.14 … … 2006 16 58 17.00 … … 2006 22 59 85.00 … … 2006 22 60 432.00 … … 2006 16 61 45.00 … … 2006 16 62 77.00 … … 2006 16 63 82.00 … … 2005 16 64 93.00 96.00 88.00 2006 23 65 78.00 81.00 72.00 2006 23 66 … … … DATA Proportion of population in malaria-risk areas using effective malaria prevention measures Health-related Millennium Development Goals (MDGs) Female Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) 368 | COUNTRY HEALTH INFORMATION PROFILES Tuberculosis death rate per 100 000 population T o ta l M al e HIV prevalence among population aged 15-24 years Estimated HIV prevalence in adults f Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source Malaria death rate per 100 000 population Unmet need for family planning INDICATORS INDICATORS Total DATA P ri va te Male U rb an R u ra l P u b lic F em al e Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Infant mortality rate (per 1000 live births) Annual number of graduates Workforce losses/ Attrition Adolescent birth rate Total Urban Rural Proportion of population with access to affordable essential drugs on a sustainable basis Contraceptive prevalence rate Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Proportion of population in malaria-risk areas using effective malaria treatment measures Tuberculosis prevalence rate per 100 000 population Maternal mortality ratio (per 100 000 live births) Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Malaria incidence rate per 100 000 population Percentage of people with advanced HIV infection receiving ART PHILIPPINES … p est NR a b c d e f 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 COUNTRY HEALTH INFORMATION PROFILES | 369 World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] WHO Regional Office for the Western Pacific, data received from technical units. National Epidemiology Center, Department of Health, Philippines. 2007 Estimation Workshop and Concensus Meeting, National Epidemiology Unit, Department of Health, Philippines. National Malaria Control Program, Department of Health, Philippipnes. Professional Regulation Commission. Philippines Official Website of the Republic of the Philippines [http://www.gov.ph/] 2007 Census of Pouplation, National Statistics Office Presss Release. [http://www.census.gov.ph/data/pressrelease/2008/pr0830tx.html] Projected Population by Five-Year Age Group and by Sex, by Five Yr. Interval, Medium Assumption.National Statistics Office. [http://www.census.gov.ph/data/sectordata/poproj07.txt] United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). Field Health Service Information System. Department of Health, Philippines. <http://www.doh.gov.ph/research_statistics> NSO Quick Stat Index Page. National Statistics Office, Philippines. Feb. 2008. <http://www.census.gov.ph/data/quickstat/index.html> National Statistical Coordination Boardm, Philippines. <http://www.nscb.gov.ph/stats/statwatch.asp> Bureau of Health Facilities and Services, Department of Health World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf] Sources: Not relevant Not included in the official list of MDG indicators Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world . United Nations Development Programme, New York USA 2007. Provisional Estimate 2004 Philippine Health Statistics, National Statistics Office. Philippines, 2004. Estimated figure Notes: Data not available [http://hdr.undp.org/en/reports/global/hdr2007-2008/] District hospital can be general or special Revised data Totals may not tally due to some reported cases with no gender breakdown Figure includes paratyphoid fever 2006 Family Planning Survey, National Statistics Office, Philippines. 2003 National Demographic Health Survey, National Statistics Office, Philippines. Land Transportation Office. Department of Transportation and Communication, Philippines. World health report 2004. Changing history . Geneva, World Health Organization, 2004. 2005 Philippine Cancer Facts and Figures, by the Philippine Cancer Society, Rizal Medical center and Department of Health. Sixth National Nutrition Survey, National Nutrition Council, Department of Health, Philippines, 2003. 370 | COUNTRY HEALTH INFORMATION PROFILES PITCAIRN ISLANDS 1. CONTEXT 1.1 Demographics The Pitcairn Islands, officially named the Pitcairn, Henderson, Ducie and Oeno Islands, constitute a group of islands in the southern Pacific Ocean. The only permanently inhabited island, Pitcairn, is only accessible by boat through Bounty Bay. A total of 54 people live on Pitcairn (2007), with about 20 additional outside persons working as teachers, prison staff, health staff, etc. Two languages are spoken: English, the official language, and Pitcairnese, a mixture of an 18th century English dialect and a Tahitian dialect. Pitcairnese is spoken as a first language by the population and is taught alongside standard English at the island's only school. It is closely related to the Creole language, Norfuk, spoken on Norfolk Island, because Norfolk was repopulated in the mid-nineteenth century by Pitcairners. Out-migration, primarily to New Zealand, has thinned the population from a peak of 233 in 1937. In September 2003, the first baby was born on the islands in 17 years. Another child, Adrianna Tracey Christian, was born on Pitcairn on 3 March 2007, increasing the island's population to 54. 1.2 Political situation Pitcairn Islands 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 Islands 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 Islands. Pitcairn Islands is also notable for being the least populated jurisdiction in the world (although it is not a sovereign nation). The United Nations Committee on Decolonization includes the Pitcairn Islands on the United Nations list of Non-Self-Governing Territories. 1.3 Socioeconomic situation Pitcairn islanders exist on fishing, subsistence farming, handicrafts and sales of 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. COUNTRY HEALTH INFORMATION PROFILES | 371 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. Trade is restricted by the jagged geography of the island, which lacks a harbour or airstrip, forcing all trade to be made by longboat to visiting ships. Occasionally, passengers from expedition-type cruise ships come ashore for a day, weather permitting. In 2004, the island had a labour force of 15 men and women. 1.4 Vulnerabilities and hazards While no specific data are available in the information sources listed, the vulnerabilities and hazards for Pitcairn Islands are similar to those of other tiny and remote Pacific island countries and areas. Remoteness from each other and from trading/supply partners, with resulting high transportation costs, raises the cost of social and protection services, as well as the cost of business. 2. HEALTH SITUATION AND TREND No specific information is available. However, the outcomes of the biennial Ministers of Health Meetings in the Pacific, especially the 2005 Samoa Commitment – Achieving Healthy Islands, apply by and large to most Pacific island countries and areas. Three themes have emerged at all seven biennial meetings of the Ministers of Health (1995 – 2007): • the predominant and growing burden of noncommunicable diseases; • the lingering burden of infectious diseases and the danger of their re-emergence; and • the need to support health systems so that they can cope with this double burden of communicable and noncommunicable disease. 2.1 Communicable and noncommunicable diseases, health risk factors and transition In March 2002, a blood survey was carried out by the Pacific Elimination of Lymphatic Filariasis Programme (PacELF) to detect lymphatic filariasis. The survey did not detect anyone with antigenemia and confirmed the Pitcairn Islands to be non-endemic for filariasis. 2.2 Outbreaks of communicable diseases No available information. 2.3 Leading causes of mortality and morbidity No available information. 2.4 Maternal, child and infant diseases No available information. 2.5 Burden of disease No available information. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives There is a subsidized national health system on Pitcairn and a fully-equipped Grade 2 medical centre staffed by a New Zealand general practitioner on a three- or six-month rotational basis. PITCAIRN ISLANDS 372 | COUNTRY HEALTH INFORMATION PROFILES 3.2 Organization of health services and delivery systems See Section 3.1. 3.3 Health policy, planning and regulatory framework No available information. 3.4 Health care financing See Section 3.1. 3.5 Human resources for health See Section 3.1. 3.6 Partnerships No available information. 3.7 Challenges to health system strengthening No available information. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Pitcairn Islands Office website Operator : Pitcairn Islands Office Comments : No information on health aspects Web address : http://government.pn/ Title 2 : Pacific Programme to Eliminate Lymphatic Filariasis – PacELF Operator : PacELF and WHO Web address : http://www.pacelf.org/regions/pitcairn.html Title 3 : Samoa Commitment – achieving healthy islands Web address : http://www.wpro.who.int/NR/rdonlyres/CE800376-BC67-45D6- A3B9-01EDDE4FCB7B/0/Samoa_Commitment_2005.pdf 5. ADDRESSES MINISTRY OF HEALTH Office Address : Dr. Alastair McDonald Medical Officer, Pitcairn Islands Official Email Address : mcdoc@pitcair.pn, co@pitcairn.gov.pn Fax : (872) 7623 37767 COMMISSIONER FOR PITCAIRN ISLANDS Office Address : Mr Leslie Jaques c/o The Pitcairn Islands Administration, Level 10, Reserve Bank Building, 67 Customs Street, Auckland, New Zealand Official Email Address : leslie@pitcairn.gov.pn Fax : (649) 366 0187 WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4, Provident Plaza 1, Downtown Boulevard, 33 Ellery Street, Suva, Fiji 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 COUNTRY HEALTH INFORMATION PROFILES | 373 REPUBLIC OF KOREA 1. CONTEXT 1.1 Demographics The population of the Republic of Korea, as of 2008, was 48 606 790, with a population density of 494 persons per square kilometre. The Republic saw its population grow by an annual rate of 3% during the 1960s, but growth slowed to 2% over the next decade. In 2008, the rate stood at 0.33% and is expected to further decline to 0.02% by 2020. A notable trend in the population structure is that it is getting increasingly older. The 2008 population estimate revealed that 10.3% of the total population was 65 years or older, while those aged 15 to 64 years of age accounted for 72.1%. In the 1960s, the country's population distribution formed a pyramid shape, with a high fertility rate and relatively short life expectancy. However, age-group distribution is now shaped more like a bell because of the low fertility rate and extended life expectancy. Youths (15 and younger) will make up a decreasing portion of the total, while senior citizens (65 and older) will account for some 15.6% of the total by 2020. In recent years, a low fertility rate has emerged as a serious social challenge. The total fertility rate dropped from 4.53 in the 1970s to 1.26 in 2006, among the lowest in member countries of the Organisation for Economic Co-operation and Development (OECD). The Government is working to tackle the issue by establishing comprehensive plans to create family-friendly workplace environments and bolster childcare policies. 1.2 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 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 family reunion centre has been established at Mt. Kumgang. Construction is complete on the two rail and road links between south and north—Gyeongui in the west and Donghae on the eastern coast. The Republic of Korea’s National Security Council has officially designated WHO as the channel of support for the health sector in the Democratic People's Republic of Korea. Since 2001, the Government of the Republic of Korea has successfully donated malaria control supplies to the Government of Democratic People's Republic of Korea through the WHO offices in each country. In 2006, WHO and the Republic of Korea launched a new programme to improve the health of women and children in the Democratic People’s Republic of Korea. 1.3 Socioeconomic situation The Republic of Korea, once one of the world's poorest agrarian societies, has undertaken economic development in earnest since 1962, fuelled by high savings and investment rates, and a strong emphasis on education. In less than four decades, it has achieved what has become known as the "Miracle on the Hangang River", an incredible process that dramatically transformed the economy while marking a turning point in the country's history. An outward- oriented economic development strategy, which used exports as the engine of growth, contributed greatly to the radical economic transformation. Based on such a strategy, many successful development programmes were implemented. As a result, from 1962 to 2007, gross domestic product (GDP) increased from US$ 2.3 billion to US$ 969.9 billion, with its per capita gross national income (GNI) soaring from US$ 87 to about US$ 20 045. These impressive figures REPUBLIC OF KOREA 374 | COUNTRY HEALTH INFORMATION PROFILES clearly indicate the magnitude of success that these economic programmes have brought about. The nation became the 29th member country of OECD in 1996. In the wake of the 1997 financial crisis, the country suffered serious economic instability but proved its underlying strength by recovering in a short period of time. However, the financial crisis had a huge impact on society, especially as regards employment insecurity, as well as social awareness. Imports have increased steadily thanks to the nation's liberalization policy and increasing per capita income levels. As one of the largest import markets in the world, the volume of the Republic of Korea's imports exceeds those of other Asian countries. Major imports include industrial raw materials, such as crude oil and natural minerals, general consumer products, foodstuffs and goods such as machinery, electronic equipment and transportation equipment. With a history as one of the fastest growing economies in the world, the Republic of Korea is working to become the focal point of a powerful Asian economic bloc during the 21st century. The Northeast Asian region commands a superior pool of essential resources that are the necessary ingredients for economic development. These include a population of 1.5 billion people, abundant natural resources and large-scale consumer markets. 1.4 Vulnerabilities and hazards With one of the world’s lowest fertility rates and fastest ageing populations, the Republic of Korea saw its total fertility rate drop to 1.13 in 2006, about a half of the replacement rate. The country became an ageing society (7% of the population old) in 2000 as a result of low fertility and prolonged life expectancy and is expected to become an aged society (14% of the population old) by 2018 and a super-aged society (20% of the population old) by 2026. It has taken France 115 years to move from an ageing to an aged society and 40 years to move from an aged to a super-aged society. It took 72 and 16 years, respectively in the United States of America, and 24 and 14 years in Japan. Considering such examples, 18 and 8 years for the Republic of Korea would be the world’s shortest transition. This rapid population ageing is causing concern regarding sustainable development as it will reduce the economically active population, hold back economic growth, narrow the tax base, and lead to tensions between generations. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition Changes in socioeconomic structures and lifestyles, as well as improvements in health and medical care, have drastically changed the leading causes of death in the Republic of Korea. In the past, the main causes of mortality were acute and communicable diseases, but these have been replaced with chronic and noncommunicable diseases. Beginning in the 1980s, the incidence of noncommunicable disease began to rise. Among the top 10 causes of death in 2006, seven were chronic diseases: cancer, cerebrovascular disease, diabetes, liver disorders, chronic lower respiratory disease, and high blood pressure. In addition, the proportion of deaths from noncommunicable diseases out of total deaths increased to over 60 % from 12% during the past two decades. The incidence of major noncommunicable diseases is also high. For example, the incidence rates for high blood pressure and diabetes stood at 27.9% and 8.1%, respectively, in 2005. The growing incidence of noncommunicable diseases is considered to be largely attributable to rapid COUNTRY HEALTH INFORMATION PROFILES | 375 population ageing, increases in obesity and overweight, a decrease in physical activity, and an increased smoking population. According to a 2005 study, a high proportion of adults were obese (BMI ≥ 25), 35.2% of males and 28.3% of females, and childhood obesity almost doubled from 6.8% in 1998 to 12% in 2005. Lack of physical activity was found to be a serious problem, with only 38% of adults aged 19 and older engaging in moderate levels of physical activity regularly. Thanks to strong smoking-control policies, the male smoking population dropped drastically from 67.4% to 52.3% in 2005, but it is still among the world’s highest. Youth smoking stood at a high level of 14.1% in 2006 and the age of starting smoking fell from 15 in 1998 to 12 in 2006, indicating a serious smoking problem among the country’s young people. While, in 2003, the Republic of Korea ranked 19th among 29 OECD members in term of per capita alcohol consumption, a trend towards heavy drinking and a high death rate due to alcohol are troubling the nation. Per capita alcohol consumption is on a steady increase, and among those aged between 18 and 64, 6.8% or 2.21 million suffered from alcohol-use disorders in 2001. 2.2 Outbreaks of communicable diseases With vaccination and improved hygiene, the incidence of acute communicable diseases has been decreasing steadily since the 1960s. However, global climate change and increasing overseas travel have increased the incidence of imported tropical diseases. In addition, the growing distribution of food materials, an increase in dining out, and contamination of water resources have the potential to trigger massive outbreaks of waterborne and foodborne infectious diseases. Avian influenza, which has been reported annually in the country since 2006, is also a concern. A total of 14 670 cases of acute communicable disease (excluding chicken pox) were notified in 2007, giving an incidence rate of 29.7 per 100 000 population, an increase of 27% from 25.3 in the previous year. Among these diseases, measles increased 592% year on year, while the increase was 118% for mumps and 177% for dengue fever. In particular, the incidence of chicken pox rose 1.8 times from 2006 to over 20 000, accounting for 58.4% of total acute communicable disease cases in 2007. 2.3 Leading causes of mortality and morbidity The number one cause of death in the Republic of Korea is cancer, accounting for 27% in 2006, followed by cerebrovascular disease at 12.3% and heart disease at 8.3%. The number of people dying from cancer rose steadily from 111.9 per 100 000 in 1996 to 134.8 in 2006. Among the major cancers, the number of deaths from stomach cancer has been decreasing, while those from lung and colon cancer have increased. The number of deaths from cerebrovascular diseases has dropped from 10 years ago. However, the incidence and prevalence rates for the diseases jumped from 1.60 and 6.15 per 1000 in 1998 to 2.3 and 10, respectively, in 2003. The hike means an increase in disabilities related to stroke, adding to the burden of disease. Cardiovascular diseases are not as prevalent in the Republic of Korea as in many Western countries, but have been showing an upward trend. The number of deaths from ischaemic heart disease more than doubled between 1996 and 2006, from 13.0 to 29.2 per 100 000. The recent increase in the number of suicides is notable. In 1996, 14.1 persons out of 100 000 killed themselves, making suicide the ninth most common cause of death. In 2006, however, suicide became the fifth largest cause of death, with 23 out of every 100 000 persons committing suicide. Among the major noncommunicable diseases, high blood pressure, arthritis and dental caries have the highest morbidity rates. The prevalence rate for hypertension was 27.9% in 2005, REPUBLIC OF KOREA 376 | COUNTRY HEALTH INFORMATION PROFILES showing that one third of all adults in the country were suffering high blood pressure. Furthermore, out of every 1000, 703.9 were suffering from dental caries and 102.5 from osteoarthritis, according to a study of prevalence rates among adults aged 19 and older. 2.4 Maternal, child and infant diseases The mortality risk for infants and young children, as well as for pregnant women, has decreased dramatically. The infant mortality rate fell from 61.0 per 1000 live births in the 1960s to an estimated 5.3 in 2003, while the maternal mortality ratio stood at 15 per 100 000 live births in 2003. The focus of public health programmes in this area is now not just on reducing mortality rates, 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, and 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. 2.5 Burden of disease According to a study of the disease burden in the country carried out using disability adjusted life years (DALYs), an indicator developed by WHO and the Global Burden of Disease Study Group, years of life lost (YLL) is highest for cancer, followed by injuries and cardio/cerebrovascular diseases, while years lost due to disability (YLD) is highest for gastrointestinal diseases, followed by respiratory diseases and diabetes. Out of the major diseases, excluding injuries, the DALY (YLL+YLD) for cancer per 100 000 was the highest, at 1525 or 17.1% of the total, followed by cardio/cerebrovascular diseases, with 1492 or 16.7%; gastrointestinal diseases, with 1 140 or 12.8%; diabetes, with 970 or 10.9%; and respiratory diseases, with 951 or 10.6%. Looking at individual diseases rather than disease groups, diabetes was found to have the highest DALY, followed by stroke, asthma, peptic ulcer, and ischaemic heart disease. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The mission of the Ministry for Health, Welfare and Family Affairs is to contribute to the quality of life of the public and to national development by protecting the public from social hazards, promoting social integration, investing in people, and offering social services. The Ministry envisions healthy and happy lives for all citizens. To carry out its mission and realize its vision, the Ministry for Health, Welfare and Family Affairs of Korea has set the following objectives: (1) Expand the social safety net by: • reforming the National Pension; • stabilizing the National Health Insurance fund; • improving the benefit system of the National Basic Livelihood Security; and • enhancing the quality of life for people with disabilities. (2) Strengthen economic growth hand in hand with health and welfare by: • fostering the health care industry; • creating the market for welfare services; • pursuing welfare through work ; and • operating the National Pension Fund strategically. COUNTRY HEALTH INFORMATION PROFILES | 377 (3) Pursue forward-looking family policies by: • strengthening comprehensive family policies; • restructuring child care policies; • fostering healthy children and youth; and • introducing long-term care insurance for the elderly. (4) Protect public health and safety by: • establishing a public health safety net; • implementing preventive health care; and • strengthening food-safety management. 3.2 Organization of health services and delivery systems Public health in the Republic of Korea has improved dramatically, especially in terms of life expectancy and infant mortality. The strengthened health care system, as well as increased income and improved living conditions have played a significant role. As regards health care resources, the number of doctors increased from 22 183 in 1975 to 108 054 in 2007 (including 16 661 traditional medicine doctors). The number of hospital-level institutions (hospitals and traditional hospitals with 30 or more beds, as well as dental hospitals) rose from 178 in 1975 to 2240 in 2007. The Government's health expenditure was 6.5% of GDP in 2006. Although this is a relatively low rate of health expenditure compared with other developed countries, the Government is able to offer comparatively good quality health care services. However, health expenditure is growing continuously because of increased use of health care services driven by greater public desire for healthy lives and implementation of the National Health Insurance scheme. To respond effectively to the fast-changing health care environment, it is necessary to comprehensively examine the existing health care system and set a new policy direction to advance it. 3.3 Health policy, planning and regulatory framework The Ministry for Health, Welfare and Family Affairs focuses on the following areas in its health policy, planning and regulatory framework: • establishing a lifetime health maintenance system; • establishing an efficient health care delivery system; • enhancing National Health Insurance coverage and strengthening the role of the Government in health care; and • fostering the health care industry. 3.4 Health care financing Since 1 July 1989, every citizen of the Republic of Korea has received health care benefits through either National Health Insurance (NHI) or the Medical Aid programme. As of the end of 2007, 96.3% of the total population or 47.82 million people were covered by the NHI, while the rest, 1.85 million people, including beneficiaries of the National Basic Livelihood Security System and patriots and veterans, were benefiting from the Medical Aid programme. The NHI is divided into employee insurance and self-employed insurance. Employee insurance covers employees, employers, public servants and teachers. All residents in rural areas, and the self- employed in cities, except those covered by employee insurance and their dependents, are covered by self-employed insurance. REPUBLIC OF KOREA 378 | COUNTRY HEALTH INFORMATION PROFILES The National Health Insurance system is operated by the Ministry for Health, Welfare and Family Affairs, the National Health Insurance Corporation (NHIC), and the Health Insurance Review Agency (HIRA). The Ministry for Health, Welfare and Family Affairs is in charge of supervision and management of the overall operation of the NHI. The NHIC oversees everyday tasks, such as determining the eligibility of the insured and their dependents, assessing and collecting insurance premiums and other fees, and making benefit payments. The HIRA reviews health care benefits and evaluates health care performance, independent of insurers, providers, and other involved parties. The finances of the NHI are mainly composed of contributions from the insured and their employers, along with government subsidies, including the National Health Promotion Fund. For an insured employee, the contribution is determined by the level of the standard monthly wage, the calculation of which is based on the wages earned by the employee over a specific period of time. Fifty percent of the contribution is paid by the employee and 50% by his/her employer. For the self-employed, contributions are calculated per household unit, and the amount is determined by considering the insured person’s assets, income and other factors. Since the introduction of the self-employed insurance scheme in 1998, the Government has subsidized health care benefits and the operation of the insurance programmes for the self- employed, to relieve their financial burden. The Government annually supports 14% of the expected insurance premium for the year out of government money, and 6% out of the National Health Promotion Fund. 3.5 Human resources for health The qualifications for health workers are strictly stipulated by law, and only those licensed by the Government can provide medical treatment and public health services. The Medical Service Act stipulates that the Ministry for Health, Welfare and Family Affairs licenses doctors, dentists, traditional medicine doctors, midwives and nurses. The Act prescribes nurses’ aides, bonesetters, acupuncturists, moxibustionists and masseurs as quasi-medical persons. There were 91 393 physicians, 23 114 dentists, 57 174 pharmacists and 235 682 nurses in the country as of 2007. 3.6 Partnerships The Ministry for Health, Welfare and Family Affairs is making an effort to contribute to improved health and quality of life for the public by responding to the new challenges of low fertility and population ageing. The Ministry works with the public, nongovernmental groups, local governments and expert groups and includes all of them in its policy formation, implementation, and assessment procedures. The partnership helps the Ministry to fulfil the real needs of the public. At the same time, the Ministry also works in close partnership with international organizations, including WHO and OECD, to resolve pending global health issues. The Republic of Korea strives to play a leadership role in making people of the world healthy and sound by exchanging knowledge, experience and technology, and sharing human, physical and intellectual resources with international partners, as well as by signing Memorandums of Understanding in the field of health care with foreign governments. 3.7 Challenges to health system strengthening Challenges to health system strebgthening in the Republic of Korea include: • the increase in chronic disease; • the ageing population and low fertility rate; and • the inequity in income distribution. COUNTRY HEALTH INFORMATION PROFILES | 379 Each challenge suggests health policy issues: • The growing incidence of chronic disease highlights the need to put a stronger emphasis on such diseases in the current health system. • The ageing population may mean an increase in the number of elderly people with health problems and higher health-related expenditure. • Income disparities may lead to inequity in health status. To respond to these issues, the Government is making an effort to prevent disease, enhance National Health Insurance coverage, strengthen its own role in health care, and establish a financially sustainable health care delivery system. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Cadastral statistical annual report, 2007 Operator : Ministry of Public Administration and Security, 2008 Web address : www.mopas.go.kr Title 2 : Population projections for Korea Operator : National Statistical Office Web address : www.nso.go.kr Title 3 : Annual report on the cause of death statistics, 2005 Operator : National Statistical Office Web address : www.nso.go.kr Title 4 : In-depth analysis of the 3rd Korea Health and Nutrition Examination Survey Operator : Korea Centre for Disease Control and Prevention, Korea Health Industry Development Institute Web address : www.cdc.go.kr, www.khidi..or.kr Title 5 : Annual report of the Ministry of Health and Welfare, 2006 Operator : Ministry of Health & Welfare Web address : www.mw.go.kr Title 6 : 2005 Population and Housing Census report Operator : Korea National Statistical Office, 2006 Web address : www.nso.go.kr 5. ADDRESSES MINISTRY OF HEALTH, WELFARE AND FAMILY AFFAIRS Office Address : Hyundai Bldg.,75 Yulgong-ro, Jongno-gu, Seoul, Republic of Korea Telephone : (822) 2023-7223~7233 Fax : (822) 2023-7234 Website : http://www.mw.go.kr WHO COUNTRY LIAISON OFFICER IN THE REPUBLIC OF KOREA Office Address : Hyundai Bldg.,75 Yulgong-ro, Jongno-gu, Seoul, Republic of Korea Postal Address : Central P.O. Box 540, Seoul, Republic of Korea Official Email Address : ChungN@wpro.who.int Telephone : (822) 2023- 7855 Fax : (822) 2023- 7858 REPUBLIC OF KOREA 380 | COUNTRY HEALTH INFORMATION PROFILES 6. ORGANIZATIONAL CHART: Ministry of Health, Welfare and Family Affairs Year Source Demographics 1 99.70 2006 1 2 48 606.79 24 415.88 24 190.90 2008 2 3 0.33 … … … 2008 2 4 4.64 4.79 4.49 2008 2 12.76 13.35 12.17 2008 2 10.32 8.32 12.33 2008 2 5 81.00 … … 2007 est 10 6 9.20 9.50 9.00 2006 4 7 5.00 5.50 4.50 2006 4 8 0.42 0.4 0.45 2006 4 9 79.18 75.74 82.36 2006 5 15.74 14.86 16.41 2005 3 10 1.13 2006 4 11 97.90 99.20 96.60 2002 15 12 20 045.00 a 2007 9 13 8.90 2007 9 14 0.92 2005 17 15 … … … 16 … … … 17 2 081 1 229 852 … … … 2006 1 8 214 789 7 425 … … … 2006 1 4 401 2 397 2 004 … … … 2006 1 … … … … … … … … … … … … 5 2 3 0 0 0 2006 1 35 20 15 … … … 2006 1 … … … … … … 4 219 3 468 751 … … … 2006 1 15 … … … … … 2006 16 2 021 … … 0 0 0 2006 16 0 0 0 0 0 0 2006 1 1 179 498 681 … … … 2006 1 200 100 100 0 0 0 2006 1 Typhoid fever Rural Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) MaleTotal Male COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male REPUBLIC OF KOREA - 0–4 years - 5–14 years - 65 years and above Estimated population ('000s) Annual population growth rate (%) Percentage of population Rate of natural increase of population (% per annum) Urban population (%) Crude birth rate (per 1000 population) Crude death rate (per 1000 population) Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Number of deaths Total Number of new cases Female Female Selected communicable diseases - Type A Syphilis - Type B - Type C Dengue/DHF Gonorrhoea Per capita GDP at current market prices (US$) Environmental indicators Total Urban Human development index Rate of growth of per capita GDP (%) - Unspecified Communicable and noncommunicable diseases COUNTRY HEALTH INFORMATION PROFILES | 381 Hepatitis viral Cholera - Type E Encephalitis Leprosy Malaria Plague REPUBLIC OF KOREA Year Source 18 … … … 4 603 2 376 2 227 2006 14 19 … … … 11 802 5 968 5 834 2006 14 20 21 … … … 65 909 42 080 23 829 2006 14 … … … 1 626 17 1 609 2006 14 … … … 6 277 3 453 2 824 2006 14 … 1 005 2006 14 … … … 1 486 1 357 129 2006 14 … … … 1 418 848 570 2006 14 … … … 894 695 199 2006 14 … … … 9 273 7 276 1 997 2006 14 … … … 10 779 7 094 3 685 2006 14 … … … 14 094 10 490 3 604 2006 14 22 … … … 56 388 27 174 29 214 2006 14 … … … 10 614 5 745 4 869 2006 14 … … … 30 036 14 510 15 526 2006 14 … … … 4 623 1 603 3 020 2006 14 … … … 14 276 7 466 6 810 2006 14 … … … 270 106 164 2006 14 23 … … … 11 600 5 823 5 777 2006 14 24 … … … 4 378 1 952 2 426 2006 14 25 … … … 29 615 20 045 9 570 2006 14 … … … 790 400 390 2006 14 … … … 7 822 5 716 2 106 2006 14 … … … 2 493 … … 2005 11 … … … 10 688 7 249 3 439 2006 14 26 575 192 260 791 314 401 1 194.80 1 077.70 1 313.00 2005 13 397 384 137 803 259 581 825.40 569.50 1 083.90 2005 13 340 475 160 360 180 115 708.50 664.30 753.10 2005 13 185 052 98 502 86 550 384.60 407.50 361.40 2005 13 162 604 69 632 92 972 337.80 287.90 388.20 2005 13 95 814 46 968 48 846 199.00 194.10 203.90 2005 13 91 938 26 472 65 466 191.00 109.50 273.30 2005 13 80 898 31 703 49 195 168.10 131.00 205.50 2005 13 67 857 28 793 39 064 141.00 119.00 163.10 2005 13 57 248 27 072 30 176 118.90 111.80 126.00 2005 13 1. Diseases of the respiratory system 2. Diseases of the musculoskeletal system & connective tissues 10. Certain infectious and parasitic diseases 3. Diseases of the digestive system - Suicide All types - Homicide and violence - Motor and other vehicular accidents - Occupational injuries Tuberculosis - All forms - New pulmonary tuberculosis (smear-positive) Cancers All cancers (malignant neoplasms only) - Hypertension All circulatory system diseases - Acute myocardial infarction Number of new cases Male Number of deaths INDICATORS Total DATA Female - Leukaemia - Lip, oral cavity and pharynx Male Female Total Total Male Number of cases - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders Diabetes mellitus Female 6. Diseases of the skin and subscutaneous tissue 8. Diseases of the eye and adnexa 9. Endocrine nutritional and metabolic diseases Total Rate per 100 000 population Male Female 4. Injury , poisoning and certain other consequences of external causes 5. Diseases of the circulatory system 382 | COUNTRY HEALTH INFORMATION PROFILES 7. Diseases of the genitourinary system Leading causes of mortality and morbidity - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections - Breast Leading causes of morbidity (inpatient care) - Ischaemic heart disease Circulatory - Cerebrovascular diseases - Liver - Stomach - Trachea, bronchus, and lung REPUBLIC OF KOREA Year Source 27 65 909 42 080 23 829 134.80 171.70 97.70 2006 14 30 036 14 510 15 526 61.40 59.20 63.70 2006 14 20 282 10 299 9 983 41.50 42.00 40.90 2006 14 11 600 5 823 5 777 23.70 23.80 23.70 2006 14 10 688 7 249 3 439 23.00 31.10 14.80 2006 14 7 822 5 716 2 106 16.00 23.30 8.60 2006 14 7 624 6 156 1 468 15.60 25.10 6.00 2006 14 7 070 4 470 2 600 14.50 18.20 10.70 2006 14 4 623 … 3 020 9.50 … 12.40 2006 14 4 603 2 376 2 227 9.40 9.70 9.10 2006 14 28 79.90 2006 6 29 … 30 … 31 3.30 3.50 3.10 2002 7 32 95.63 96.10 95.12 2006 4 33 96.00 … … 2007 16 91.00 … … 2007 16 91.00 … … 2007 16 91.00 … … 2007 16 34 … 1 2003 7 … 2 2003 7 … 26 2003 7 … 0 2003 7 … 2 2003 7 35 … … … … … … … … … … … … … … … … … … 180 … … … … … 2007 16 4 569 … … … … … 2007 16 … … … … … … 14 … … … … … 2007 16 0 0 0 … … … 2007 16 35 … … … … … 2007 16 … … … … … … Leading causes of mortality Number of deaths Total FemaleTotal Male Total Number of deaths Rate per 100 000 population 2. Cerebrovascular diseases DATA Maternal, child and infant diseases 9. Hypertensive diseases - Diphtheria Female Female - Rubella - Congenital rubella syndrome - Sepsis Male - Hib meningitis - Total Tetanus - Poliomyelitis - Pertussis (whooping cough) - Abortion Selected diseases under the WHO-EPI - Eclampsia - Haemorrhage 5. Intentional self-harm 8. Chronic lower respiratory disease 4. Diabetes mellitus INDICATORS 3. Heart diseases Male 7. Diseases of the liver Number of cases Percentage of pregnant women with anaemia 10. Pneumonia Percentage of women in the reproductive age group using modern contraceptive methods Percentage of pregnant women immunized with tetanus toxoid (TT2) - Hepatitis B III Immunization coverage for infants (%) - POL3 - BCG - DTP3 - Measles - Obstructed labour COUNTRY HEALTH INFORMATION PROFILES | 383 Maternal causes - Neonatal tetanus FemaleTotal Male Female Total Male - Mumps 1. Malignant neoplasms Neonatal mortality rate (per 1000 live births) 6. Transport accidents Percentage of newborn infants weighing at least 2500 g at birth REPUBLIC OF KOREA Year Source 36 … 37 Public health facilities 295 124 090 2006 20 111 39 802 2006 20 … … 3 442 0 2006 20 Private health facilities 1 676 253 495 2006 20 … … 38 57 526.26 2006p 18 6.50 2006p 18 1 186.70 2006p 18 31 674.20 2006p 18 55.10 2006p 18 11.90 2006p 18 0.00 2006p 18 44.90 2006p 18 954.85 2006p 18 39 96.30 2007 11 Year Source 40 Physicians - Number 91 393 72 140 19 253 … … … … 2007 8 - Rate per 1000 population 1.90 1.50 0.40 … … … … 2007 8 Dentists - Number 23 114 17 552 5 562 … … … … 2007 8 - Rate per 1000 population 0.50 0.40 0.10 … … … … 2007 8 Pharmacists - Number 57 174 20 404 36 770 … … … … 2007 8 - Rate per 1000 population 1.20 0.40 0.70 … … … … 2007 8 Nurses - Number 235 682 1 690 233 992 … … … … 2007 8 - Rate per 1000 population 4.80 0.00 4.70 … … … … 2007 8 Midwives - Number 8 587 4 8 583 … … … … 2007 8 - Rate per 1000 population 0.20 0.00 0.20 … … … … 2007 8 Paramedical staff - Number 195 332 72 963 122 369 … … … … 2007 8 - Rate per 1000 population 4.00 1.50 2.50 … … … … 2007 8 Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians 4 354 … … … … … … 2007 12 Dentists 909 … … … … … … 2007 12 384 | COUNTRY HEALTH INFORMATION PROFILES External source of government health expenditure Private health expenditure DATA R u ra l - general government expenditure on health as % of total expenditure on health - private expenditure on health as % of total expenditure on health Number Number of beds - external resources for health as % of general government expenditure on health - Outpatient clinics Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) P u b lic DATA U rb an Health insurance coverage as % of total population P ri va te M al e F em al e T o ta l INDICATOR Human resources for health Exchange rate in US$ of local currency is: 1 US$ = - Hospitals Health facilities INDICATORS - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals Health care financing - Primary health care centres Facilities with HIV testing and counseling services Annual number of graduates Health infrastructure - per capita total expenditure on health (in US$) Government expenditure on health REPUBLIC OF KOREA Year Source 41 Pharmacists … … … … … … … Nurses 14 572 … … … … … … 2007 12 Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 5.30 5.70 5.00 2003 7 45 5.70 6.10 5.30 2006 5 46 92.00 … … 2007 16 47 15.00 2003 7 48 100.00 2006 6 0.10 2006 6 99.90 2006 6 49 79.60 38.90 40.70 2006 6 50 … 51 Antenatal care coverage - At least one visit 99.90 b 2006 6 - At least four visits 98.60 2006 6 52 … 53 … … … 54 … … … 55 … … … 56 4.00 … … 2006 16 57 0.00 … … 2006 16 58 … … … 59 … … … 60 123.00 … … 2006 16 61 10.00 … … 2006 16 62 18.00 … … 2006 16 63 81.00 … … 2005 16 64 … 97.00 … 2006 21 65 83.50 … … 2005 19 66 … .. … Female T o ta l M al e F em al e U rb an R u ra l P u b lic P ri va te Health-related Millennium Development Goals (MDGs) HIV prevalence among population aged 15-24 years Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source Malaria incidence rate per 100 000 population Estimated HIV prevalence in adults a Tuberculosis death rate per 100 000 population Unmet need for family planning Adolescent birth rate Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Contraceptive prevalence rate Under-five mortality rate (per 1000 live births) INDICATORS INDICATORS DATA Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) DATA Tuberculosis prevalence rate per 100 000 population Percentage of people with advanced HIV infection receiving ART - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Proportion of population in malaria-risk areas using effective malaria treatment measures Maternal mortality ratio (per 100 000 live births) Infant mortality rate (per 1000 live births) Total Male Total Urban Rural Proportion of population with access to affordable essential drugs on a sustainable basis Annual number of graduates Workforce losses/ Attrition COUNTRY HEALTH INFORMATION PROFILES | 385 REPUBLIC OF KOREA … p est NR a b c 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Human development report 2004. New York, United Nations Development Programme, 2004. Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] Cadastral statistical Annual Report, Ministry of Government Administration and Home Affairs, Republic of Korea Population Projections for Korea, National Statistical Office, Republic of Korea 2005 National Health and Nutrition Survey, Ministry of Health and welfare, Republic of Korea 2006 Annual Report on Live Births and Deaths Statistics, National Statistical Office, Republic of Korea Life Tables for Korea, National Statistical Office, Republic of Korea National Fertility and Family Health Survey 2006, Korea Institute for Health and Social Affairs, Republic of Korea Maternal & Infant Mortality Survey Report in2002-2003, Ministry of Health and welfare, Republic of Korea Patient Survey Report 2005, Ministry of Health and welfare, Republic of Korea Economic Statistics Yearbook, The Bank of Korea, Republic of Korea Not relevant Figure refers to per capita GNI Not included in the official list of MDG indicators Unpublished Data, Health Insurance Review & Assessment Service Sources: WHO Regional Office for the Western Pacific, data received from the technical units United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). Yearbook of Health and Welfare Statistics 2007, Ministry of Health and Welfare, Republic of Korea 2006 Statistical Yearbook on the Education, Ministry of Education & Human Resources Development, Republic of Korea Annual Report on the Cause of Death Statistics 2006, National Statistical Office, Republic of Korea Revised figure Estimate Notes: 386 | COUNTRY HEALTH INFORMATION PROFILES Medical and paramedical institution data by city/province: 2006, Ministry of Health and Welfare, Healthcare Resources Team World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: [http://hdr.undp.org/en/reports/global/hdr2007-2008/] World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf] Environmental Statistics Yearbook 2006. Ministry of Environment. Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world. United Nations Development Programme, New York USA 2007. Provisional Data not available COUNTRY HEALTH INFORMATION PROFILES | 387 SAMOA 1. CONTEXT 1.1 Demographics In 2007, estimates put Samoa’s population at 186 650, with around 39.8% composed of young people aged less than 15 years and only 4% aged 65 years and over. The country is divided into four major statistical regions: Apia Urban Area (AUA), North West Upolu, 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. The health status of the population has improved significantly, and Samoans now enjoy relatively good health. Life expectancy is 72.8 according to the 2001 census, compared with 66.4 years ten years previously. 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 United Nations Development Programme (UNDP) Human Development Index (HDI) ranks Samoa 77th 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. 1.2 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 families 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 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 almost 20 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 SAMOA 388 | COUNTRY HEALTH INFORMATION PROFILES (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 annual statements of economic strategy (SES), currently the Strategy for the development of Samoa 2008–2012, which highlight the vision ”improved quality of life for all”. 1.3 Socioeconomic 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 2006 was US$ 2543.00. Economic growth in 2001 was estimated at 6.5%, with an annual rate of inflation of 4% by the end of the year. 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 11 September 2001 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. Remittance 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. 1.4 Vulnerabilities and hazards No available information. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition Persistent 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 eliminate 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. There were 25 tuberculosis cases (all forms) diagnosed in 2006, 13 with sputum-smear-positive pulmonary TB. The calculated case-detection rate was 80% in 2006. The directly observed COUNTRY HEALTH INFORMATION PROFILES | 389 treatment, short-course (DOTS) strategy has been established throughout the country and functions well. The incidence of HIV/AIDS is low, with a cumulative total of 12 known cases since 1990. Other sexually transmitted infections (STI), however, are present at extremely high rates, with 38% of women attending antenatal clinics being found to have at least one STI in a study carried out in Apia in 1999-2000. Women aged less than 25 years were significantly more likely to have an STI. The surprising results of this study indicate the potential for rapid spread of HIV, but also the urgent need to tackle the STI epidemic in its own right. Given the high prevalence and death rates caused by noncommunicable diseases, such as diabetes and suicide, resources for HIV/AIDS programmes are often limited. Whilst the supportive policy and national structures are in place for the coordination and management of HIV/AIDS activities nationally, this infrastructure has been until recently, with the release of funding from the Global Fund, severely underresourced. Noncommunicable diseases (NCDs), including obesity, diabetes, heart diseases, high blood pressure, strokes and cancer, are a top health priority in Samoa, with high and increasing prevalence rates: the obesity rate is currently 57.0%, diabetes 23.1% and high blood pressure 21.4%. NCDs are now appearing in younger age groups and complications are more common. NCDs are very costly, accounting for 43.3% of total health care expenditure in 2000. If their prevalence continues to increase, the Government will be unable to continue financing the rising health care costs; hence prevention must remain the mainstay of national NCD management and control. The four main risk factors are smoking (tobacco), poor nutrition, excess alcohol consumption and physical inactivity (SNAP). To reduce these risk factors changes in the lifestyles and behaviour of individuals, families and communities are necessary, requiring a coordinated, multisectoral, national response. The total prevalence of diabetes is 23.1%: 22.9% in males and 23.3% in females. Prevalence increases with age and overall has doubled since a previous survey in 1991. The disease is more common in urban areas, (Apia 27%, Rural Upolu 19.7% and Savaii 20.3%), and the trend is similar for males and females. In general, for every known case of diabetes that is diagnosed, almost three cases remain undiagnosed, with the ratio a lot higher in the younger age groups, (in males, for every known case there are 12 unknown cases). Of those with a known history of diabetes, 56.8% of males and 68.5% of females are taking tablets, and only 4% of males and 5.3% of females are taking insulin. The total prevalence of hypertension is 21.4%, and is higher in males (24.2%) than females (18.2%) and increases with age in both males and females. High blood pressure is more common in urban areas (Apia 23.5%; Rural Upolu 18.6%; Savaii 21.2%). In general, for every known case of high blood pressure that is diagnosed, another four remain undiagnosed. This ratio is higher in the younger age group, (for Hypertension Prevalence 42.8 32.2 19.511.3 0 20 40 60 80 100 25-34 35-44 45-54 55-64 Age group Pr ev al en ce (% ) Diabetes Prevalence 42.232.3 22.9 12.7 0 20 40 60 80 100 25-34 35-44 45-54 55-64 Age group Pr ev al en ce (% ) Source: Samoa STEPS Survey; 2002 SAMOA 390 | COUNTRY HEALTH INFORMATION PROFILES every known case there are 22 unknown cases). Most people (more than 90%) with high blood pressure do not know that they have it. The total prevalence of obesity is 57.0% (48.4% in males and 67.4% in females) and increases with age. It is more common in urban areas. (For males, Apia 53.1%; Rural Upolu 48%; Savaii 40.2%. For females, Apia 69.3%, Rural Upolu 65.9%, Savaii 65.4%). Many risk factors for noncommunicable disease are present among the Samoan population, including: smoking (40% of the total population are smokers: 56.3% of males and 21.8% of females.); poor nutrition: (35.6% of the population eat virtually no fruit1.); alcohol consumption (current levels of alcohol consumption place 37.6 % of males and 19.6 % of females at moderate to high risk of developing an NCD); lack of physical activity (21% of the population do very little or no physical activity). People in Apia are more likely to be inactive (28%) than people in rural areas (15%) and women (27.3%) are more likely to be inactive than men (14.8%).). There is a lack of regular health checks (In the last 12 months, only 35% of the population had a blood sugar check and only 44.9% had a blood pressure check. Males and younger people are less likely to have checks.). The number of suicide attempts is increasing. However, the proportion resulting in death was only 47.6% in 2003/2004, compared with 60.5% in 1999/2000. Suicide Attempts and Suicide Deaths for FY1999/2000 - FY2003/2004 42 28 24 26 43 20 12 7 11 26 0 5 10 15 20 25 30 35 40 45 50 fy99/00 fy00/01 fy01/02 fy02/03 fy03/04 Financial Years N u m be r Suicide Attempts Suicide Deaths Source: Health Information System, Ministry of Health The ages of those attempting suicide cases ranged from 10 to 76 years during the period from 1999 to 2004, with most aged below 30. Paraquat ingestion is the most common mode of suicide. Its use decreased in 2000/2002 then increased to more than 60% in 2001/2002 before exhibiting a slow deceleration in the last few years. Suicide attempts by age from FY 1999/2000 - fy 2003/04 0 2 4 6 8 10 12 14 <20 20-24 25-29 30-34 35-39 40-44 45-49 50+ Age group N u m be r fy99/00 fy00/01 fy01/02 fy02/03 fy03/04 Source: Health Information System, Ministry of Health 1 No fruit or less than one serving per day Obesity Prevalence 54.9 61.355.9 34.4 70.177.170.5 58.1 0 20 40 60 80 100 25-34 35-44 45-54 55-64 Age group Male Female COUNTRY HEALTH INFORMATION PROFILES | 391 Method of Suicide throughout FY1999/2000 - FY2003/2004 44 38 63 54 45 30 19 13 18 17 26 42 25 29 38 0% 20% 40% 60% 80% 100% 1999/2000 2000/2001 2001/2002 2002/2003 2003/2004 Fi n a n c ia l y e a r Per cent Paraquat % Hanging % others % Source: Health Information System, Ministry of Health 2.2 Outbreaks of communicable diseases No available information. 2.3 Leading causes of mortality and morbidity See Section 2.1. 2.4 Maternal, child and infant diseases The infant mortality rate dropped from 19.3 per 1000 live births in 2001 to 13.7 in 2005-2006, and the under-five mortality rate from 17.8 per 1000 live births in 2000 to 13.7 in 2002. The maternal mortality ratio also dropped from 19.6 per 100 000 live births in 2002, to 10.7 in 2003 and 3.0 in 2005-2006. Poliomyelitis, tetanus and diphtheria have been virtually eradicated in Samoa, and the whole Pacific region is poliomyelitis-free. 2.5 Burden of disease No available information. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The Ministry of Health, as the principal agent of government in the area of health, takes the lead role in working with government agencies, NGOs, the private and traditional health sectors and consumers of health services to promote a high quality, comprehensive, sustainable, integrated national health system founded on the Samoan lifestyle. The Ministry is specifically charged with implementing health legislation pertaining to public health issues and advising the Government on issues related to health care delivery, health funding and health status. It is the major provider of publicly funded health services and is responsible for the management of the publicly funded health sector. More specialized care not available in Samoa is provided to some patients through overseas treatment, either through programmes funded by the Samoan and New Zealand Governments or at personal expense. 3.2 Organization of health services and delivery systems See Section 3.1. SAMOA 392 | COUNTRY HEALTH INFORMATION PROFILES 3.3 Health policy, planning and regulatory framework National priorities in health, which are identified in the Strategy for the development of Samoa 2005- 2007 ‘enhancing people’s choices’ include improved health standards primarily through a focus on: • strengthening health prevention programmes; • developing skilled human resources; • improving health facilities and equipment; • financing health services; and • strengthening the Ministry of Health. The publicly funded health system has been undergoing a major reform programme since 1996. At the broadest level this has included a review of the Ministry of Health’s primary functions, roles and responsibilities and the suitability of the existing organizational structure to support these at both the strategic and service delivery levels. The themes of this reform have been: (1) Function before form; and (2) Client-based development. The reform process indicated a need for a more defined separation of the governance role from the service delivery role. This has culminated in the formal separation of the existing Ministry of Health into two new bodies, the revised Ministry of Health as a governance and regulatory body and the newly established National Health Service (NHS) to take responsibility for service delivery. The Government’s reform agenda is not only about organizational reform, but is also focused on reorienting the sector towards a population-health approach. The introduction of the Integrated Community Health Services (ICHS) model is a major step forward in that approach, the objective being to provide services closer to home, strengthen primary health care services and improve health services for the most vulnerable groups. Greater emphasis is also being placed on health promotion, protection and prevention services. It is acknowledged that this will be most effectively realized through partnering with other groups in the health sector, other sectors, private enterprise and communities. While increasing the focus on a population-health approach, there is a need to sustain, integrate and enhance the delivery of primary care services to the community. The Ministry of Health has developed a services planning model that is documented in the National Health Services Planning Framework. This is currently under review to consider how the private and community sector can contribute to the provision of primary services as close as possible to the people. The current review of the Health Sector Strategic Plan for the period 2006-2010 highlights some of the specific objectives and strategies that the Ministry is promoting to improve health services and health outcomes in partnership with other members of the sector. The vision of creating a healthy Samoa can only be effectively realized through all members of the health sector working in partnership. Partnership is thus the major theme of the health sector plan and is pertinent given the changes occurring within the sector. Government-funded health services are undergoing major reforms and there are rapid developments in the private health care industry. There is also a need to continue developing and strengthening collaboration with traditional health practitioners, as well as community-based and nongovernmental organizations. The Health Sector Strategic Plan review also stresses the need to continue to implement the three priority areas of the Health Reform Programme: (1) institutional strengthening; (2) primary health care and health promotion services; and (3) quality improvement. Major refurbishments to the Tupua Tamasese Meaole Hospital (TTMH) have been completed, while refurbishments to some rural health facilities are under way. The Health Care Waste Management System is also in place and running. The National Non-Communicable Diseases COUNTRY HEALTH INFORMATION PROFILES | 393 (NCD) Strategy and Plan of Action have been completed and are in the implementation stage, while the NCD Policy is under review and about to be finalized. 3.4 Health care financing Total national health expenditure in Samoa amounted to US$ 22.3 million in 2006, with per capita spending of US$ 120.60. In the same period, health spending as a share of gross domestic product (GDP) came to 4.9% (6% in 1998/1999), public expenditures for health comprised 81.0% of total health spending (62% in 1998/1999), private spending for health comprised 19.0% of total health spending (23% in 1998/1999), and donor spending made up the remaining 19% (15% in 1998/1999). 3.5 Human resources for health In 2005, Samoa's health workforce comprised 50 physicians, 6 dentists, 3 pharmacists, 136 nurses, 37 midwives, 73 other nursing/ auxiliary staff and 146 paramedical and other health personnel. 3.6 Partnerships No available information. 3.7 Challenges to health system strengthening No available information. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Samoa National Health Service Planning Framework April 2002; Department of Health Annual Report 1999-2000 (leading cause of mortality); Department of Health Annual Report 2002/2003 & 2003/2004; Review of the Health Sector Plan 2006-2010 (Draft) Operator : Department of Health Title 2 : Samoa National Health Accounts Report for FY 2002-2003; Samoa National Health Account for FY 2000/2001 (Executive summary) Operator : Ministry of Health and the World Bank Title 3 : Strategy for the Development of Samoa 2005-2007: Enhancing People’s Choices Title 4 : Strategy for the development of Samoa 2002-2004: Opportunities for all Title 5 : Review of the Rural Health Services Plan 2006 (Draft) Title 6 : Report of the PacELF 5th Annual Meeting 2003 Title 7 : Samoa Suicide Prevention Strategy 2002-2006: An introduction ‘Faataua le Ola’ (FLO) Title 8 : Collins V, Dowse GK, Toelupe et al. Increasing prevalence of NIDDM in Pacific Islands population Title 9 : 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 Title 10 : Dr Viali Lameko et al. Review of the National Tuberculosis Control Programme in Samoa from the internal medicine perspective, 20 June 2002. Title 11 : Review of the National Tuberculosis Control Programme in May 2001 (WHO mission report by Dr Pierre Yves Norval). SAMOA 394 | COUNTRY HEALTH INFORMATION PROFILES 5. ADDRESSES MINISTRY OF HEALTH Office Address : Motootua Postal Address : P.O Box 2268, Apia, Samoa Official Email Address : ceo@health.gov.ws Telephone : (685) 23330 or 21212 ext 502 Fax : (685) 26553 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 Year Source Demographics 1 2.94 2004 1 2 186.65 97.23 89.42 2007 est 2 3 1.00 … … 2001 3 4 14.40 14.20 14.60 2007 est 4 25.40 25.10 25.70 2007 est 4 4.40 3.40 5.50 2007 est 4 5 23.00 … … 2007 est 5 6 20.80 … … 2004 6 7 3.00 … … 2004 6 8 1.78 a … … 2004 6 9 72.80 71.80 73.80 2001 3 … 10.90 11.60 2002 7 10 3.40 2004 8 11 98.70 … … … 2002 9 12 2 543.00 2006 10 13 … 14 0.79 2005 11 15 … … … 16 73.00 … … 2005 12 17 2 1 1 0 0 0 2002 13 10 4 6 0 0 0 2004 9 0 0 0 0 0 0 2002 13 … … … … … … 34 13 21 0 0 0 2004 9 0 0 0 0 0 0 2004 6 28 … … 0 0 0 2005 14 1 1 0 0 0 0 2004 6 0 0 0 0 0 0 2004 6 5 … … … … … 2006 14 … … … … … … 0 0 0 0 0 0 2004 6 0 0 0 0 0 0 2004 6 254 151 103 0 0 0 2004 6 Syphilis - Type B - Type C Dengue/DHF Gonorrhoea - Unspecified Leprosy - Type E Cholera MaleTotal Female - Type A Human development index Rate of growth of per capita GDP (%) Per capita GDP at current market prices (US$) Environmental indicators Selected communicable diseases Communicable and noncommunicable diseases Total Male Female COUNTRY HEALTH INFORMATION PROFILES | 395 Encephalitis Hepatitis viral Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Rate of natural increase of population (% per annum) Urban population (%) Total fertility rate (women aged 15–49 years) Estimated population ('000s) Annual population growth rate (%) Percentage of population - 0–4 years - 5–14 years Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male SAMOA Rural Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Malaria Plague Number of deathsNumber of new cases Total Urban Typhoid fever SAMOA Year Source 18 349 206 143 0 0 0 2004 6 19 322 184 138 5 2 3 2004 6 20 25 … … … … … 2006 14 13 … … … … … 2006 14 21 73 43 30 12 8 4 2004 6 … … … … … … 6 5 1 3 2 1 2004 6 6 0 2004 6 … … … … … … 17 10 7 2 1 1 2004 6 7 5 2 0 0 0 2004 6 8 4 4 2 1 1 2004 6 8 6 2 0 0 0 2004 6 21 13 8 5 4 1 2004 6 22 301 143 158 37 8 29 2004 6 39 15 24 1 0 1 2004 6 77 26 51 6 1 5 2004 6 45 206 143 0 0 0 2004 6 72 52 20 3 2 1 2004 6 113 50 63 27 5 22 2004 6 23 7 195 b … … … … … 2004-05 15 24 76 b … … … … … 2003 16 25 733 556 177 22 13 9 2002 13 … … … … … … 129 103 26 4 3 1 2002 13 … … … … … … 45 26 19 21 … … 2004-05 2 26 789 … … 427.29 … … FY2005-06 6 648 648 350.93 … FY2005-06 6 531 … … 287.57 … … FY2005-06 6 319 … … 172.76 … … FY2005-06 6 264 … … 142.97 … … FY2005-06 6 237 … … 128.35 … … FY2005-06 6 235 … … 127.27 … … FY2005-06 6 232 … … 125.64 … … FY2005-06 6 197 … … 106.69 … … FY2005-06 6 182 … … 98.56 … … FY2005-06 6 Number of new cases Male FemaleTotal - All forms - New pulmonary tuberculosis (smear-positive) Cancers Leading causes of morbidity (inpatient care) Leading causes of mortality and morbidity - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections Tuberculosis 4. Infections of the skin and subcutaneous tissue 5. Diabetes mellitus Total Male Female Female Male Female 7. Intestinal infectious diseases - Trachea, bronchus, and lung Number of cases All types - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders Diabetes mellitus Total Rate per 100 000 population 6. Other acute lower respiratory infections - Cerebrovascular diseases - Liver - Stomach 1. Influenza and pneumonia 2. Complications of labour and delilvery 3. Injury, wounds, poisoning and certain other consequences of external causes 8. Respiratory & cardiovascular disorders specific to the perinatal period 9. Chronic lower respiratory diseases Number of deaths DATAINDICATORS 10. Malignant neoplasms - Suicide - Homicide and violence - Motor and other vehicular accidents Total Male 396 | COUNTRY HEALTH INFORMATION PROFILES - Occupational injuries All cancers (malignant neoplasms only) - Hypertension All circulatory system diseases - Acute myocardial infarction Circulatory - Leukaemia - Lip, oral cavity and pharynx - Breast - Ischaemic heart disease SAMOA Year Source 27 46 16 20 24.91 … … FY2005-06 6 41 18 23 22.20 … … FY2005-06 6 40 31 9 21.66 … … FY2005-06 6 39 19 20 21.12 … … FY2005-06 6 23 12 11 12.46 … … FY2005-06 6 23 16 7 12.46 … … FY2005-06 6 20 10 10 10.83 … … FY2005-06 6 16 9 7 8.67 … … FY2005-06 6 13 8 5 7.04 … … FY2005-06 6 9 6 3 4.87 … … FY2005-06 6 28 53.90 2004 8 29 1.00 2006 14 30 … 31 4.20 … … 2002 13 32 98.80 … … 2004 17 33 84.00 … … 2006 14 56.00 … … 2006 14 57.00 … … 2006 14 56.00 … … 2006 14 34 134 0 2004 6 7 0 2004 6 15 0 2004 6 7 0 2004 6 23 1 2002 9 35 0 0 0 0 0 0 2006 14 0 0 0 0 0 0 2006 14 1 … … … … … 2005 14 0 0 0 0 0 0 2006 14 0 0 0 0 0 0 2006 14 1 … … … … … 2006 14 24 … … … … … 2006 14 0 0 0 0 0 0 2006 14 0 0 0 0 0 0 2006 14 4 … … … … … 2006 14 Percentage of newborn infants weighing at least 2500 g at birth Male 7. Other forms of heart disease 6. Cerebrovascular diseases 4. Hypertensive diseases Maternal causes - Mumps - POL3 - Measles - BCG - DTP3 - Total Tetanus - Neonatal tetanus - Hepatitis B III - Hib meningitis Percentage of pregnant women with anaemia 10. Septicaemia Percentage of women in the reproductive age group using modern contraceptive methods 8. Chronic lower respiratory diseases 9. Ischaemic heart diseases Percentage of pregnant women immunized with tetanus toxoid (TT2) Maternal, child and infant diseases Number of cases - Obstructed labour - Diphtheria - Eclampsia - Haemorrhage - Abortion Selected diseases under the WHO-EPI Male - Sepsis - Congenital rubella syndrome - Pertussis (whooping cough) Total Male Female Total Female Female Neonatal mortality rate (per 1000 live births) - Poliomyelitis Number of deaths - Rubella DATA Male Female Number of deaths Rate per 100 000 population 1. Diabetes 5. Pneumonia 2. Cancer all sites FemaleTotal MaleTotal Immunization coverage for infants (%) INDICATORS 3. Injuries and wounds Leading causes of mortality Total COUNTRY HEALTH INFORMATION PROFILES | 397 SAMOA Year Source 36 … 37 Public health facilities 2 177 c 2005 18 … … 6 55 2004 19 19 0 2005 19 Private health facilities 1 21 2004 19 … … 38 22.30 2006p 20 4.90 2006p 20 120.55 2006p 20 17.99 2006p 20 81.00 2006p 20 10.50 2006p 20 5.20 2006p 20 19.00 2006p 20 2.78 2006p 20 39 … Year Source 40 Physicians - Number 50 33 17 … … … … 2005 21 - Rate per 1000 population 2.74 … … … … … … 2005 21 Dentists - Number 6 3 3 2005 22 - Rate per 1000 population 0.33 … … … … … … 2005 22 Pharmacists - Number 3 3 0 … … … … 2005 23 - Rate per 1000 population 0.16 0.16 0.00 … … … … 2005 23 Nurses - Number 136 … … … … … … 2005 24 - Rate per 1000 population 7.47 … … … … … … 2005 18 Midwives - Number 37 … … … … … … 2005 18 - Rate per 1000 population 2.03 … … … … … … 2005 18 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … Annual number of graduates Health infrastructure - Hospitals - Outpatient clinics - Primary health care centres Facilities with HIV testing and counseling services - per capita total expenditure on health (in US$) Government expenditure on health Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) INDICATORS - external resources for health as % of general government expenditure on health - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals Health care financing Health facilities External source of government health expenditure Private health expenditure - private expenditure on health as % of total expenditure on health - general government expenditure on health as % of total expenditure on health U rb an Human resources for health Health insurance coverage as % of total population INDICATOR DATA Exchange rate in US$ of local currency is: 1 US$ = P ri va te M al e F em al e T o ta l R u ra l P u b lic Number DATA Number of beds 398 | COUNTRY HEALTH INFORMATION PROFILES SAMOA Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 13.70 d … … 2005-06 6 45 13.70 8.90 4.70 2002 13 46 54.00 … … 2006 14 47 3.00 e 2005-06 6 48 100.00 2004 8 9.00 2004 8 91.00 2004 8 49 … … … 50 … 51 Antenatal care coverage - At least one visit 100.00 2004 8 - At least four visits … 52 … … … 53 … … … 54 … … … 55 … … … 56 … … … 57 … … … 58 … … … 59 … … … 60 25.00 … … 2006 14 61 3.00 … … 2006 14 62 80.00 … … 2006 14 63 91.00 … … 2005 14 64 88.00 90.00 87.00 2006 24 65 100.00 100.00 100.00 2006 24 66 … … … Total Urban Rural Maternal mortality ratio (per 100 000 live births) Infant mortality rate (per 1000 live births) Proportion of population with access to affordable essential drugs on a sustainable basis Contraceptive prevalence rate Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Proportion of population in malaria-risk areas using effective malaria treatment measures Adolescent birth rate Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source HIV prevalence among population aged 15-24 years Malaria death rate per 100 000 population Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Health-related Millennium Development Goals (MDGs) Total Male DATAINDICATORS P ri va te Annual number of graduates Malaria incidence rate per 100 000 population Percentage of people with advanced HIV infection receiving ART Unmet need for family planning Workforce losses/ Attrition P u b lic Proportion of population in malaria-risk areas using effective malaria prevention measures Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Tuberculosis prevalence rate per 100 000 population Estimated HIV prevalence in adults f COUNTRY HEALTH INFORMATION PROFILES | 399 Tuberculosis death rate per 100 000 population Female T o ta l M al e R u ra l INDICATORS DATA F em al e U rb an SAMOA … p est NR a b c d e f 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Figure refers to registered patients Not included in the official list of MDG indicators Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. Figure includes 157 beds in Tupua Tamasese Meaole Hospital, and 20 beds in Maliettoa Tanumafili II Hospital Figure refers to hospital reported IMR Figure refer to hospital reported MMR Provisional Estimate Notes: Data not available Assistant Chief Executive Officer, Dental Health Services, Ministry of Health. Health Care Waste Management Report 2005. Ministry of Health statistical bulletin 2002 – review 1999-2002. Assistant Chief Executive Officer, Nursing Services, Ministry of Health. Rural Health Services Plan Review 2006 (Draft). Mental Health Policy Situational Analysis 2005. Nutrition Centre, Ministry of Health, Samoa. Tupua Tamasese Meaole Hospital Management Report 2005, ACEO Clinical Health Services. WHO Regional Office for the Western Pacific, data received from the technical units. Diabetic Association Clinic Registry – 2004/2005. Not relevant Sources: [http://www.spc.int/prism/wstest/Products&Services/Reports/PDF/Abstract/ANNUAL%20ABSTRACT%202005.pdf] Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world. United Nations Development Programme, New York USA 2007. Annual Statistical Abstract 2005, 37th issue. Ministry of Finance Statistical Department, Government of Samoa, November 2006. Demographic Tables for the Western Pacific 2005-2010. Manila, World Health Organization Regional Office for the Western Pacific, 2005. United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). Ministry of Health Annual Report 2002/2003 & 2003/2004 & 2005/2006. Ministry of Finance, Statistical Services Division (http://www.spc.int.prism). Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific [http://hdr.undp.org/en/reports/global/hdr2007-2008/] World health report 2004. Changing history. Geneva, World Health Organization, 2004. 2004 Annual Report – Maternal & Child Health. Millennium Development Goals Report for Samoa 2004. Strategy for the Development of Samoa 2008-2012: Ensuring Sustainable Economic and Social Progress [http://www.mof.gov.ws/uploads/sds_2008_-_2012_-_english.pdf] Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: Assistant Chief Executive Officer, Pharmacy Services, Ministry of Health. World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf]. 400 | COUNTRY HEALTH INFORMATION PROFILES COUNTRY HEALTH INFORMATION PROFILES | 401 SINGAPORE 1. CONTEXT 1.1 Demographics Singapore is a small country with a total land area of 704 square kilometres. The total population is about 4.5 million, with a resident population of 3.6 million in 2007. While the population is relatively young, with only 8.5% of the resident population aged 65 and over, the proportion of residents aged 65 and over is projected to increase to 19% by 2030. In 2007, life expectancy at birth for males was 78.2 years and 82.9 years for females. The crude birth rate for the same year was 10.3 per 1000 resident population and the crude death rate was 4.5 per 1000 resident population. The total fertility rate per resident female is 1.3. The infant mortality rate is very low, at 2.1 per 1000 resident live births. 1.2 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 head of state is President S R 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 S Jayakumar (since 12 August 2004), and Wong Kan Seng (since 1 September 2005). 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. President Sellapan Ramanathan was re-elected for his second term in August 2005. The legislative branch is unicameral parliament (84 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. 1.3 Socioeconomic situation Singapore is characterized by a highly developed and successful free-market economy. It has a very open and corruption-free business environment. With trade 3.9 times the size of gross domestic product (GDP), external demand is the main driver of the economy. The Singapore economy grew by 7.7% in 2007. Per capita gross domestic product amounted to US$ 35 163 in 2007. Singapore continues to position itself as a vibrant global city and a hub of talent, enterprise and innovation in order to succeed in a globalized world. 1.4 Vulnerabilities and hazards Singapore suffers from few physical hazards. The island city-state is protected from typhoons and monsoons by neighbouring landmasses. Being a small country of only approximately 700 square kilometres, Singapore’s key challenge arises from its size and limited natural resources. As such, human resources are its key strength and great emphasis is given to the development of its population. Singapore is one of the world’s most open economies, highly dependent on the foreign investment, trade and health of other economies. This openness, coupled with a high SINGAPORE 402 | COUNTRY HEALTH INFORMATION PROFILES population density, makes Singapore particularly vulnerable to infectious disease outbreaks, such as sever acute respiratory syndrome (SARS). 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition Over previous decades, national efforts to combat traditional and vaccine-preventable communicable diseases have achieved great success. However, the SARS and Nipah virus outbreaks highlighted the regional vulnerability to new and emerging infectious diseases; the lessons learnt from the global SARS epidemic have been applied to enhance surveillance and outbreak response for endemics, as well as emerging and re-emerging infectious diseases. The effective implementation of the childhood immunisation programme against major vaccine- preventable diseases has contributed a significant reduction in incidence of these diseases. The incidence of acute hepatitis B showed a rapid decline from 9.5 per 100 000 in 1985 to 1.7 per 100 000 population in 2007. No acute hepatitis B cases have been reported in children below 15 years of age since 1998. Similarly, the incidence of measles was 0.3 per 100 000 in 2007, which has declined from 2.3 per 100 000 population in 2004. Despite being in a region endemic for malaria, Singapore has maintained its malaria free status accorded by the World Health Organisation since 1982. The incidence of malaria was 3.4 per 100 000 population in 2007 with majority of cases imported from endemic countries. Chronic infectious diseases such as tuberculosis and HIV/AIDS are still considered public health problems in Singapore. The morbidity rate for HIV/AIDS steadily increased from 0.8 per million in 1985 to 117.8 per million in 2007. After a rapid decline in TB incidence during the period from 1960 to 1987, the incidence rate has been stable at a low level. The TB incidence rate (all types) was 26 per 100 000 in 2006, a decline from 40 per 100 000 in 2004. National representative population-based health surveys showed that the prevalence of chronic diseases, such as diabetes mellitus and hypertension, and health risk factors, such as smoking, physical inactivity, obesity and high blood cholesterol, declined between 1992 and 2004. The age- standardized prevalence of diabetes mellitus fell from 10% to 8%, and the percentage of the population smoking declined from 18% to 13%. The age-standardized prevalence of high blood cholesterol also dropped, from 21% to 18%, and the proportion of Singaporeans engaging in regular physical activity rose from 14% to 25%. The age-standardized prevalence of hypertension stabilized at 24%, but that of obesity rose from 5% to 7%. Table 1 shows the trends in the prevalence of diabetes mellitus, hypertension and health risk factors between 1992 and 2004. Table 1: Prevalence of risk factors for cardiovascular diseases, 1992, 1998 and 2004 Risk factor# Prevalence 1992 1998 2004 Diabetes mellitus [plasma glucose 2 hours post-OGTT ≥ 11.1 mmol/l] Crude Age-standardized 8.6% 10.0% 9.0% 9.5% 8.2% 7.8% Hypertension [systolic pressure ≥ 140 mmHg or diastolic pressure ≥ 90 mmHg] Crude Age-standardized 22.2% 24.0% 27.3% 28.0% 24.9% 24.0% High blood cholesterol [Total cholesterol ≥ 6.2 mmol/l] Crude Age-standardized 19.4% 21.4% 25.4% 26.0% 18.7% 18.1% Obesity [BMI ≥ 30 kg/m2] Crude Age-standardized 5.1% 5.3% 6.0% 6.2% 6.9% 6.8% COUNTRY HEALTH INFORMATION PROFILES | 403 Risk factor# Prevalence 1992 1998 2004 Cigarette smoking [smoked cigarettes at least once a day] Crude Age-standardized 18.3% 17.8% 15.2% 15.0% 12.6% 12.5% Physical activity [exercised ≥ 20 minutes for ≥ 3 days per week] Crude Age-standardized 13.6% 13.5% 16.8% 17.0% 24.9% 25.0% # Risk factor for age group 18-69, except for hypertension, which is for age group 30-69 Sources: National Health Survey 1992, 1998 and 2004 2.2 Outbreaks of communicable diseases To prevent the introduction and spread of infectious diseases with outbreak potential, the Ministry of Health maintains a comprehensive and well-established system of disease surveillance and control involving the epidemiological investigation of specific notifiable diseases under the Infectious Diseases Act, as well as some emerging infectious diseases of public health importance. In the control of vector-borne diseases, such as dengue and malaria, the Ministry works closely with the National Environment Agency, which is responsible for eliminating the vector through larval-source-reduction activities, environmental controls, public education and community mobilization. 2.3 Leading causes of mortality and morbidity Cancer has been the leading cause of death in Singapore since 1991. In 2005, it accounted for 27% of all deaths. Men have a much higher death rate relative to women, but death rates for both genders have been slowly declining since 1995. In 2005, the age-standardized death rates in men and women were 127 and 87 per 100 000 resident population, respectively. The incidence rate in men has slowly declined since the early 1980s, due mainly to declines in lung, stomach, liver, nasopharyngeal and oesophageal cancer. Of note is the fact that colorectal and prostate cancers are increasing in men. The cancer incidence rate in women has increased, due mainly to increases in breast and colorectal cancer, despite declines in cervical, stomach, liver and oesophageal cancer. In the five-year period from 1998 to 2002, the five most common cancers were lung, colorectal, liver, stomach and prostate in men, and breast, colorectal, lung, ovarian and cervical in women. Heart diseases constitute the second most common cause of death among Singaporeans. Coronary heart disease death rates have shown consistent declines over the past 15 years. Men have almost twice the death rates of women and the difference in rates has remained constant over the years. In 2005, the age-standardized death rate in men was 92 per 100 000 resident population, compared with 55 in women. The incidence of acute myocardial infarction events among adults aged 35-64 has generally decreased since 1990. The incidence rate in men is about six times that of women; in 2004, the age-standardized incidence rate in men was 173 per 100 000 resident population, compared with 29 in women. Stroke has been among the leading causes of mortality since 1970. In 2005, it was fourth leading cause of death, accounting for 13% of all deaths. Nonetheless, death rates for both genders have fallen noticeably over the years. In 2005, the age-standardized death rates from stroke in men and women, about the same at 40 per 100 000 resident population, were half their respective levels in 1989. Figure 1 juxtaposes the leading causes of deaths of Singaporeans in 1950 with those in 2005. SINGAPORE 404 | COUNTRY HEALTH INFORMATION PROFILES Figure 1: Top 10 causes of deaths in Singapore, 1950 and 2005 2.4 Maternal, child and infant diseases The number of maternal deaths declined sharply from 86 deaths in 1950 to 12 deaths in 1975, and has dropped further to less than eight deaths per year since. There were five deaths in 2005. The corresponding maternal mortality ratio fell in tandem from 1.8 per 100 000 live births and stillbirths in 1950 to 0.3 in 1975, and has remained at a low of between 0.1 and 0.2 since then. The ratio was 7.6 per 100 000 live births in 2007. The infant mortality rate also fell sharply from 82.2 per 1000 live births in 1950 to 6.6 in 1990, and has continued to drop steadily since. The rate was 2.1 in 2007. The main causes of infant death are perinatal conditions, congenital anomalies and pneumonia. 2.5 Burden of disease No available information. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The vision of the Ministry of Health is to develop the world's most cost-effective health care system to keep Singaporeans in good health. Its mission is to promote good health and reduce illness, ensure access to good and affordable health care, and pursue medical excellence. This is to be achieved through three strategies: o Promote good health and reduce illness o Ensure access to good and affordable health care o Pursue medical excellence 1950 % of Deaths Tuberculosis 12.0 Infantile convulsions 11.1 Pneumonia 10.9 Gastroenteritis 8.9 Diseases of early infancy 6.6 Heart diseases 4.6 Injuries 4.0 2005 % of Deaths Cancer 26.5 Heart diseases 20.6 Pneumonia 15.9 Cerebrovascular diseases 12.6 Injuries 4.0 Diabetes mellitus 3.9 Urinary tract infections 3.1 Source: Registry of Births and Deaths, ICA, MHA COUNTRY HEALTH INFORMATION PROFILES | 405 3.2 Organization of health services and delivery systems Health services are provided through three cooperating ministries, as well as 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 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 employment conditions under the Employment Act, has provisions in the Workplace Safety and Health 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 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 ratios are reversed, with 80% provided by the public sector and the remainder by the private sector. 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). These two integrated networks enable comprehensive, yet affordable quality health care services through cooperation and collaboration between public health care establishments. The clustering of the health care delivery system encourages cooperation amongst the institutions within the cluster, fosters vertical integration of services and enhances synergy and economies of scale. The friendly competition between the two clusters encourages them to innovate and improve the quality of their care while ensuring that medical costs remain affordable. 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 over 1400 private medical practitioners’ clinics. Each polyclinic is an affordable, subsidized one-stop health centre, providing outpatient medical care, follow-up of patients discharged from hospital, immunization, health screening and education, investigative facilities and pharmacy services. The needy elderly receive further help through the Primary Care Partnership Scheme (PCPS). PCPS is most helpful for those who cannot travel to polyclinics. The private clinics are located in close proximity to population centres in the city, housing estates and satellite towns. The average outpatient consultation fee is between S$ 10 (US$ 6.00) and S$15 (US$ 9.00), well within the means of Singaporeans. At government polyclinics, Singapore citizens aged 65 and above, children up to 18 years of age and all schoolchildren are given a discount of SINGAPORE 406 | COUNTRY HEALTH INFORMATION PROFILES up to 57% on their consultation and treatment fees. Other Singapore citizens are given a 50% discount. There are about 11 830 hospital beds in the 29 public and private hospitals and speciality centres, giving a ratio of 3.3 beds per 1000 population; 74% 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 of between 16 and 505 beds. The Government’s role as the dominant provider of secondary and tertiary care 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 general hospitals, a women's and children's hospital and a psychiatric hospital. The general hospitals provide inpatient and specialist outpatient services, and a 24-hour emergency department. Seventy-five per cent of public hospital beds are heavily subsidized. There are also six national specialty centres for oncology, cardiology, ophthalmology, dermatology, neuroscience 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 specialty institutes into private companies wholly owned by the Government and managed as not-for-profit organizations. This has granted the public hospitals management autonomy and flexibility to respond more promptly to the needs of their patients. In the process, greater financial discipline and accountability have been introduced. Unlike private hospitals, the restructured public hospitals receive an annual government subsidy for the provision of subsidized patient care, and 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. 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, most of the other services can be found in both the public and private sectors. Dental care begins with preventive dentistry promoted through the Health Promotion Board. The Board targets students through a network of 200 static clinics located in schools, as well as 30 mobile dental clinics. This, plus fluoridation of potable water and availability of fluoridated toothpaste, has greatly diminished dental decay and tooth loss. Public dental services are available in some polyclinics and hospitals, and in the National Dental Centre. 3.3 Health policy, planning and regulatory framework The Singapore health care philosophy emphasizes the building of a healthy population through preventive health care programmes and the promotion of healthy living. Singaporeans are encouraged, through the public health education programme, to adopt healthy lifestyles and be responsible for their health, and are 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, as well as private primary health care clinics. Health screening programmes have been introduced for the early dietection of common ailments, such as cancer, heart disease, hypertension and diabetes mellitus. These are available in both primary and secondary care settings. COUNTRY HEALTH INFORMATION PROFILES | 407 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 includes evidence-based medical practices, and is delivered cost-effectively by trained personnel. Experimental, non-evidence-based treatments, as well as cosmetic and aesthetic treatments may be excluded. Singapore's health care regulatory framework consists mainly of two parties; the regulator (comprising the Ministry of Health along with its statutory boards) and the regulated (comprising public and private providers). All hospitals, clinics, clinical laboratories and nursing homes are required to maintain a good standard of medical services through licensing by the Ministry. Health care professionals are self-regulated by their relevant professional bodies: • Singapore Medical Council, • Singapore Dental Council, • Singapore Nursing Board, and the • Singapore Pharmacy Board, and the • Traditional Chinese Medicine Practitioners Board • Optometrists and Opticians Board In addition, health-related products such as medicines and medical devices are regulated by the Health Sciences Authority. 3.4 Health care financing In 2006, Singapore spent about S$ 7.2 billion (US$ 4.5 billion) or 3.4% of GDP on health care. Out of this, the Government expended S$2.4 billion (US$ 1.5 billion) or 1.2% of GDP on health services. The philosophy of Singapore's public health care delivery system is one of strong government support combined with individual responsibility and community support. The Government heavily subsidizes public health care for Singaporeans. At the same time, patients are expected to co-pay their medical expenses. The level of co-payment varies according to the level of non- medical service delivered to the customer, for example the availability of air-conditioning and the physical ward accommodation. To help Singaporeans to pay for their medical expenses, the Government has put in place a financing framework, which consists of Medisave, MediShield, ElderShield and Medifund. Individuals are encouraged to take responsibility for their own health by saving for their medical expenses. Medisave is the national savings scheme which helps individuals put aside part of their income into Medisave accounts to meet their personal or immediate family's hospitalization expenses. Under the Medisave scheme, every working person is required by law to save 6.5%-9% of his or her income in a personal Medisave account. MediShield is a low-cost, catastrophic illness insurance scheme designed to help members meet the medical expenses from major or prolonged illnesses, for which their Medisave balance would not be sufficient. Annual premiums for MediShield can be paid from the individual's Medisave account. There are also private supplementary insurance products offering additional coverage. These are integrated with MediShield to provide a national risk pool for basic coverage. Medifund is an endowment fund set up by the Government as a safety net to help poor Singaporeans pay for their medical care. Medifund is meant to be an avenue of last resort for patients who, despite heavy Government subsidies, are unable to pay for their medical expenses. Therefore, no Singaporean is denied access into the health care system or turned away by the SINGAPORE 408 | COUNTRY HEALTH INFORMATION PROFILES public hospitals because of their inability to pay. In 2007, part of Medifund was specifically set aside to be dedicated to needy, elderly patients (65 yrs and above). ElderShield is an affordable, severe-disability insurance scheme, designed to provide Singaporeans with basic financial protection against expenses required in the event of severe disability, especially in old age. Introduced in June 2002, it was further reformed in 2007 to improve its benefits, and private insurers are now allowed to provide supplementary products with higher coverage. Public sector health services are provided to cater to the lower income groups who cannot afford the private sector charges, and also to set the benchmark for the private sector on professional standards and charges. To support the latter objective, the Government requires public hospitals to publish basic consultation and ward charges for greater price transparency. The Ministry of Health also publishes hospital pricing data and bill sizes for common conditions on its website. 3.5 Human resources for health In 2007, Singapore had 7384 doctors in its health care delivery system, giving a doctor-to- population ratio of 1:620. Thirty-eight per cent of the doctors were trained specialists with postgraduate medical degrees and advanced specialty training. There are currently 35 medical specialties in Singapore. There were 1354 dentists, giving a dentist-to-total population ratio of 1:3247 in 2007. The Singapore Dental Council also expanded its list of registerable basic dental degrees in 2008 to enable more overseas-trained dentists to practise. Singapore had 1483 registered pharmacists in 2007, giving a pharmacist-to-population ratio of 1:3095. The number of pharmacists is expected to increase to meet demand due to growing health care needs and anticipated growth in the biomedical and pharmaceutical sectors. In 2007, Singapore had 16 504 registered nurses, 5604 enrolled nurses and 224 registered midwives, giving a nurse-to-population ratio of 1:214 or 4.7 nurses per 1000 population. To meet growing health care demands, the Singapore Nursing Board implemented an Advanced Practice Nurse Register in 2006 and the pioneer batch of eight Advanced Practice Nurses were registered in 2007. As the population grows and patient expectations rise, there is a need for greater investment in human resources for health. Besides increasing the numbers, the skills of the workforce must also change as chronic diseases become more prevalent with the ageing of the population. To help increase the number of health care professionals, efforts are being made to increase local training capacity and to facilitate mid-career conversions as well as the movement of overseas- trained health care professionals to Singapore. For example, • The intake of medical students was recently increased from 230 to 250, while the number of overseas medical schools recognized by the Singapore Medical Council is increasing steadily. • The Duke-NUS Graduate Medical School, which offers a postgraduate Doctoral Medicine (MD) programme, began their inaugural academic year in 2007 with a batch of 26 students, and will gradually increase their intake over the next few years. • The intake of nursing students has also expanded over the years with the introduction of a second polytechnic offering the Diploma in Nursing in 2005. In 2006, the National University of Singapore introduced the Bachelor of Science (Nursing) programme, a full- time undergraduate degree programme. COUNTRY HEALTH INFORMATION PROFILES | 409 • In 2007, the Professional Conversion Programme was also expanded to help mid-career entrants pursue a career in allied health. To prepare the workforce for the changing skills required to look after an ageing population, efforts have also been made to enhance their capabilities. For example, • The Singapore Nursing Board implemented an Advanced Practice Nurse Register in 2006. • Qualifying examinations were also implemented in the same year to ensure that foreign allied health professionals in physiotherapy, occupational therapy, diagnostic radiography and radiation therapy have the required knowledge and skills to provide good care to patients. • The Ministry also offers post-graduate scholarships for health care professionals to further their training locally or overseas. Policy efforts will continue to be geared towards ensuring adequate health care manpower to meet the evolving health care demands of the growing, and rapidly ageing population. 3.6 Partnerships Harnessing and forging strong partnerships is important for the attainment of national health goals. The Ministry of Health maintains strong partnerships and strategic alliances with voluntary welfare organizations and charities involved in health to ensure that their activities are aligned with the national health care framework. The Ministry of Health continues to work with health care institutions, organizations, professional associations, private general practitioners and other partners to develop health services in an integrated manner throughout the continuum of primary, intermediate and long-term care services. 3.7 Challenges to health system strengthening Singapore is facing a ageing population. It is projected that the number of residents aged 65 years or older will increase from the current 8.5% to 19% by year 2030, and careful planning is needed to ensure that this population is provided for. To this end, the Government has set up a Ministerial Committee on Aging to spearhead a whole-of-Government response to the opportunities and challenges presented by the ageing population. The Government aims to achieve its vision of successful ageing for Singapore by creating an environment where Singaporeans can look forward to leading healthy, active and productive lives as they grow old. The health workforce also faces the challenges of an ageing population, as well as new technologies, lifestyle medicine and higher demands for good medical care. There are shortages of professional staff that will have to be filled. At the same time, the growth of the private sector may lead to higher attrition from the public sector. High quality care will be delivered by health care professionals who are trained in an holistic way to meet the standards of care in a changing, more sophisticated population. The challenge is to ensure adequate numbers of such health care professionals trained in different disciplines, especially in those health care disciplines that are currently undersubscribed. Chronic diseases are another area of concern. An estimated one million Singaporeans suffer from four major chronic diseases: diabetes, hypertension, lipid disorder and stroke, and the numbers are expected to rise with the ageing population base. In 2006, the Ministry of Health initiated the Medisave for Chronic Disease Management Programme, a coordinated, nationwide effort to transform care for the four most common chronic illnesses. Participating medical institutions include all public hospitals and polyclinics, as well as about half of the 1400 private primary care clinics in the country. In 2007, the programme was further extended to cover asthma and chronic obstructive pulmonary disease (COPD). SINGAPORE 410 | COUNTRY HEALTH INFORMATION PROFILES The programme seeks to improve chronic disease care through two chief avenues,: (1) enhancing access and (2) improving care. By liberalizing the use of Medisave to cover outpatient treatments for the four diseases (enhancing access) and implementing evidence-based disease management programmes, together with clinical quality improvement efforts (improving care), complications arising from these chronic diseases can be better prevented. Correspondingly, patients will be healthier and the risks of expensive hospitalization and potential disabilities will be reduced. The programme is supported by the participation of medical and allied health professionals in the public and private sectors, enhancements to IT systems to improve sharing of essential medical data, and education tools to improve patients’ ability to manage their conditions. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Ministry of Health website Operator : Ministry of Health Features : Information on health policies, facilities and statistics Web address : www.moh.gov.sg Title 2 : Singapore Department of Statistics website Operator : Singapore Department of Statistics Features : Information on general Singapore statistics Web address : www.singstat.gov.sg 5. ADDRESSES MINISTRY OF HEALTH Office Address : Ministry of Health, College of Medicine Building, 16 College Road, Singapore 169854 Official Email Address : moh_info@moh.gov.sg Telephone : (65) 6325 9220 Fax : (65) 6224 1677 Office Hours : 8.30am – 5.30pm Website : http://www.moh.gov.sg 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) 2093 9908 / 2092 1184 Fax : (603) 2093 7446 COUNTRY HEALTH INFORMATION PROFILES | 411 6. ORGANIZATIONAL CHART: Ministry of Health Year Source Demographics 1 0.71 2007 1 2 3 583.10 a 1 775.50 1 807.60 2007 1 3 1.60 a 2007 1 4 5.40 a … … 2007 1 13.50 a … … 2007 1 8.50 a … … 2007 1 5 100.00 … … 2007 1 6 10.30 a … … 2007 4 7 4.50 a … … 2007 4 8 0.58 a … … 2007 4 9 80.60 a 78.20 a 82.90 a 2007 1 19.10 b 17.30 b 20.60 b 2007 1 10 1.29 c 2007 1 11 95.70 d … … 2007 1 12 35 163.00 2007 1 13 13.30 2007 1 14 0.92 2005 5 15 … … … 16 … … … 17 88 63 25 0 0 0 2007 2 79 67 12 0 0 0 2007 2 17 13 4 0 0 0 2007 2 35 27 8 0 0 0 2007 2 0 0 0 0 0 0 2007 2 7 3 4 0 0 0 2007 2 8 826 5 238 3588 24 13 11 2007 2 61 36 25 0 0 0 2007 2 2 571 2 099 472 0 0 0 2007 2 12 10 2 0 0 0 2007 2 155 121 34 1 1 0 2007 2 0 0 0 0 0 0 2007 2 1 013 726 287 0 0 0 2007 2 67 39 28 0 0 0 2007 2 Hepatitis viral Cholera Typhoid fever Encephalitis Malaria - Unspecified Dengue/DHF Total - Type E 412 | COUNTRY HEALTH INFORMATION PROFILES Plague Urban population (%) Environmental indicators - Type A Syphilis - Type B - Type C Selected communicable diseases Communicable and noncommunicable diseases Human development index Leprosy Total fertility rate (women aged 15–49 years) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 - 0–4 years - 5–14 years - 65 years and above Estimated population ('000s) Annual population growth rate (%) Percentage of population COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male SINGAPORE Rural Number of deaths Female Total Male Female Number of new cases Total Urban Male Crude birth rate (per 1000 population) Health care waste generation (metric tons per year) Gonorrhoea Proportion of vehicles using unleaded gasoline (%) Rate of growth of per capita GDP (%) Crude death rate (per 1000 population) Adult literacy rate (%) Socioeconomic indicators Per capita GDP at current market prices (US$) Rate of natural increase of population (% per annum) SINGAPORE Year Source 18 8 665 e,h 4 710 e 3 954 e 3 2 1 2007p 2, 3 19 … … … … … … 20 1 394 j 968 j 426 j 80 j 65 j 15 j 2007 2 507 380 127 NA NA NA 2007 2 21 23 610 e,h 11 857 e 11 750 e 4 745 2 622 2 123 2007p 2, 3 2 675 e,h 2 e 2 673 e 359 1 358 2007p 2, 3 3 112 e,h 1 727 e 1 384 e 718 376 342 2007p 2, 3 667 e 83 2007p 2, 3 293 e 246 e 47 e 91 75 16 2007p 2, 3 1 554 e,h 860 e 693 e 126 64 62 2007p 2, 3 769 e 576 e 193 e 238 193 45 2007p 2, 3 1 899 e,h 1 489 e 409 e 440 337 103 2007p 2, 3 1 051 e 635 e 416 e 334 194 140 2007p 2, 3 2 460 e 1 606 e 854 e 1 071 715 356 2007p 2, 3 22 43 942 e,h 26 618 e 17 319 e 5 835 3 239 2 596 2007p 2, 3 5 599 e 3 820 e 1 779 e 1 574 907 667 2007p 2, 3 9 494 e,h 5 292 e 4 200 e 1 490 686 804 2007p 2, 3 1 706 e,h 704 e 1 001 e 435 245 190 2007p 2, 3 16 194 e,h 11 565 e 4 628 e 3 394 2 022 1 372 2007p 2, 3 190 e 81 e 109 e 22 9 13 2007p 2, 3 23 4 225 e,h 2 163 e 2 061 e 609 262 347 2007p 2, 3 24 12 466 e 6 671 e 5 795 e 4 1 3 2007p 2, 3 25 … … … 1 036 h 712 321 2007p 3 … … … 20 15 5 2007p 3 … … … 228 181 47 2007p 3 … … … … … … … … … 374 215 159 2007p 3 26 39 910 e,h 23 583 e 16 323 e 892.66 a … … 2007p 2 23 610 e,h 11 857 e 11 750 e 516.93 a … … 2007p 2 16 194 e,h 11 565 e 4 628 e 385.62 a … … 2007p 2 10 934 e 5 996 e 4 938 e 281.96 a … … 2007p 2 10 256 e 5 252 e 5 004 e 260.19 a … … 2007p 2 10 203 e,h 6 318 e 3 883 e 271.83 a … … 2007p 2 9 771 e,h 5 246 e 4 524 e 251.57 a … … 2007p 2 9 494 e,h 5 292 e 4 200 e 241.66 a … … 2007p 2 8 575 e 4 221 e 4 354 e 214.00 a … … 2007p 2 8 313 e 8 313 e 210.26 a … 2007p 2 - Ischaemic heart disease Female 6. Chronic obstructive lung disease (ICD9: 490 - 493, 496) 8. Cerebrovascular disease (ICD9: 430 - 438) - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders Diabetes mellitus - Breast - Stomach Acute respiratory infections Male INDICATORS Communicable and noncommunicable diseases Male Female Total Number of new cases TotalFemale MaleMale Number of cases Female Number of deaths - Leukaemia - Lip, oral cavity and pharynx Diarrhoeal diseases All circulatory system diseases - Trachea, bronchus, and lung DATA Total Cancers All cancers (malignant neoplasms only) - Liver - Colon and rectum - Cervix - Oesophagus Rate per 100 000 population COUNTRY HEALTH INFORMATION PROFILES | 413 4. Pneumonia (ICD9: 480 - 486) 5. Obstetric complications affecting fetus or newborn (ICD9: 761 - 763) Leading causes of morbidity (inpatient care) Leading causes of mortality and morbidity Total 3. Ischemic heart disease (ICD9: 410 - 414) - Homicide and violence - Motor and other vehicular accidents - Acute myocardial infarction 9. Intestinal infectious infections (ICD9: 001 - 009) - Hypertension 2. Cancer (ICD9: 140-208) 10. Complications related to pregnancy (ICD9: 640 - 648) 7. Other heart diseases (ICD9: 393 - 398, 402, 415 - 429) Tuberculosis - All forms - New pulmonary tuberculosis (smear-positive) - Occupational injuries - Suicide All types Circulatory - Cerebrovascular diseases 1. Accidents, poisioning & violence (ICD9: 800-999) SINGAPORE Year Source 27 4 745 e 2 622 e 2 123 e 125.73 a … … 2007p 3 3 394 e 2 022 e 1 372 e 89.20 a … … 2007p 3 2 375 e 1 248 e 1 127 e 63.46 a … … 2007p 3 1 490 e 686 e 804 e 39.24 a … … 2007p 3 1 036 e,h 712 e 321 e 22.75 a … … 2007p 3 740 e 417 e 323 e 18.89 a … … 2007p 3 609 e 262 e 347 e 16.49 a … … 2007p 3 449 e 350 e 99 e 12.25 a … … 2007p 3 376 e 134 e 242 e 10.44 a … … 2007p 3 342 e 162 e 180 e 9.10 a … … 2007p 3 28 72.50 2003 15 29 … 30 … 31 1.30 … … 2007 4 32 90.70 … … 2007 3 33 95.00 … … 2007 16 92.00 … … 2007 16 92.00 … … 2007 16 91.00 … … 2007 16 34 4 266 b 1 2007p 2, 3 12 b 0 2007p 2, 3 2 113 b 1 2007p 2, 3 214 b 0 2007p 2, 3 6 b 0 2007p 2, 3 35 0 0 0 … … … 2007 2, 6 0 0 0 … … … 2007 2, 6 1 1 0 … … … 2007 2 15 11 4 … … … 2007 2, 6 781 457 324 … … … 2007 2 0 0 0 … … … 2007 6 38 21 17 … … … 2007 2, 6 0 0 0 … … … 2007 6 83 40 43 … … … 2007 2, 6 0 0 0 … … … 2007 6 Male 7. Diabetes mellitus (ICD9: 250) 6. Other heart disease(ICD9: 393 - 398, 402, 415 - 429) 4. Cerebrovascular disease (ICD9: 430 - 438) Number of deaths Rate per 100 000 population - Hib meningitis Percentage of pregnant women with anaemia 10. Nephritis, nephrotic syndrome & nephrosis (ICD9: 580 - 589) - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) 1. Cancer (ICD9: 140-208) Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth - Hepatitis B III 414 | COUNTRY HEALTH INFORMATION PROFILES Number of cases - Obstructed labour Male - POL3 - Eclampsia - Haemorrhage - Abortion Female Maternal causes - Rubella - Congenital rubella syndrome - Sepsis 8. Chronic obstructive lung disease (ICD9: 490 - 493, 496) 9. Urinary tract infections (ICD9: 599.0) - BCG Percentage of women in the reproductive age group using modern contraceptive methods Female Male Female DATA Total Total Total MaleTotal Selected diseases under the WHO-EPI - Total Tetanus - Neonatal tetanus Female Male Female Total - Pertussis (whooping cough) Maternal, child and infant diseases 2. Ischemic heart disease (ICD9: 410 - 414) Leading causes of mortality - DTP3 5. Accidents, poisioning & violence (ICD9: E800-E999) - Diphtheria Immunization coverage for infants (%) - Measles - Poliomyelitis 3. Pneumonia (ICD9: 480 - 486) INDICATORS Number of deaths SINGAPORE Year Source 36 … 37 Public health facilities 5 5 292 2007 2 2 2 891 2007 2 6 185 2007 2 19 0 2007 2 Private health facilities 16 3 179 2007 2 … … 38 5 096.73 FY2006 1, 2 3.70 FY2006 1, 2 1 446.00 FY2006 1, 2 1 215.94 FY2006 2 23.86 FY2006 1, 2 6.30 FY2006 2, 17 0.00 2006p 11 76.10 FY2004 1,2 1.59 2006p 11 39 … Year Source 40 Physicians - Number 7 384 … … … … … … 2007 7 - Rate per 1000 population 1.61 … … … … … … 2007 7 Dentists - Number 1 354 … … … … … … 2007 8 - Rate per 1000 population 0.30 … … … … … … 2007 8 Pharmacists - Number 1 483 … … … … … … 2007 9 - Rate per 1000 population 0.32 … … … … … … 2007 9 Nurses - Number 22 108 … … … … … … 2007 10 - Rate per 1000 population 4.82 … … … … … … 2007 10 Midwives - Number 224 … … … … … … 2007 10 - Rate per 1000 population 0.05 … … … … … … 2007 10 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians 227 … … … … … … 2007 12 Dentists 36 … … … … … … 2007 12 Annual number of graduates - Hospitals - Outpatient clinics - Primary health care centres - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals - per capita total expenditure on health (in US$) Government expenditure on health Total health expenditure Health care financing - total expenditure on health as % of GDP Health facilities INDICATORS T o ta l INDICATOR - external resources for health as % of general government expenditure on health Private health expenditure Exchange rate in US$ of local currency is: 1 US$ = DATA U rb an R u ra l P u b lic External source of government health expenditure Human resources for health Health insurance coverage as % of total population P ri va te M al e F em al e - general government expenditure on health as % of total expenditure on health - amount (in million US$) Facilities with HIV testing and counseling services Health infrastructure DATA Number Number of beds - private expenditure on health as % of total expenditure on health COUNTRY HEALTH INFORMATION PROFILES | 415 SINGAPORE Year Source 41 Pharmacists 86 … … … … … … 2007 12 Nurses 1 524 … … … … … … 2007 13, 14 Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 14.00 … … 1995-2003 15 44 2.10 a … … 2007 4 45 3.00 … … 2007 4 46 95.00 … … 2007 6 47 7.60 … … 2007 3 48 … … 99.68 f 2007 4 49 … … … 50 … 51 Antenatal care coverage - At least one visit 100.00 2006 2 - At least four visits … 52 … … … 53 … … … 54 0.08 0.14 0.02 2007 2 55 … … … 56 3.40 … … 2007 2 57 … … … 58 … … … 59 … … … 60 25.00 … … 2006 6 61 2.20 3.70 0.80 2006 2, 6 62 100.00 100.00 100.00 2006 2, 6 63 94.50 i 93.90 i 96.30 i 2007 2 64 100.00 … … 2007 2 65 100.00 … … 2007 2 66 … … … Maternal mortality ratio (per 100 000 live births) Annual number of graduates Infant mortality rate (per 1000 live births) Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Total Urban Rural Proportion of population with access to affordable essential drugs on a sustainable basis Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source Contraceptive prevalence rate Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Tuberculosis death rate per 100 000 population Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Proportion of population in malaria-risk areas using effective malaria treatment measures Tuberculosis prevalence rate per 100 000 population Percentage of people with advanced HIV infection receiving ART Estimated HIV prevalence in adults g Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures Malaria incidence rate per 100 000 population Unmet need for family planning F em al e U rb an R u ra l P u b lic P ri va te Adolescent birth rate DATA Health-related Millennium Development Goals (MDGs) Total Workforce losses/ Attrition INDICATORS DATA Male INDICATORS HIV prevalence among population aged 15-24 years 416 | COUNTRY HEALTH INFORMATION PROFILES Female T o ta l M al e SINGAPORE … p est NR a b c d e f g h i j 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Health Promotion Board Study on Marriage and Procreation, Perception and Policies in Singapore, 2003. Ministry of Community Development and Sports. Totals may not tally due to some reported cases with no gender breakdown Institute of Technical Education Singapore Nursing Board World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf] National University of Singapore Singapore Dental Council Sources: Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world . United Nations Development Programme, New York USA 2007. Provisional Estimate Notes: Data not available Not relevant Figure applies or refers to resident population WHO Regional Office for the Western Pacific, data received from the technical units Singapore Medical Council Figure refers to life expectancy at age 65 among the resident population Figure refers to number of inpatient discharges Figure refers to livebirths [http://hdr.undp.org/en/reports/global/hdr2007-2008/] Figure refers to resident women aged 15-49 years Figure applies to residents aged 15 years and over Statistics Singapore- Key Annual Indicators, Department of Statistics [http://www.singstat.gov.sg/stats/keyind.html#demoind] Ministry of Health Singapore [http://www.moh.gov.sg/mohcorp/default.aspx]. Report on Registration of Births and Deaths. Registry of Births and Deaths, Immigration and Checkpoints Authority Figure refers to new + relapsed cases Figure refers to DOTS completion rate in 2007 Not included in the official list of MDG indicators COUNTRY HEALTH INFORMATION PROFILES | 417 Ministry of Finance Nanyang Polytechnic Singapore Pharmacy Board Singapore Demographic Bulletin, December 2007. Registry of Births and Deaths, Immigration and Checkpoints Authority 418 | COUNTRY HEALTH INFORMATION PROFILES SOLOMON ISLANDS 1. CONTEXT 1.1 Demographics Solomon Islands is a double-chain archipelago of more than 900 coral atolls located in the south- west Pacific about 1 800 kilometres north-east of Australia. Its total land area of 28 900 square kilometres is widely scattered over 1.3 million square kilometres (Exclusive Economic Zone) of the Pacific Ocean, with most of its smaller islands uninhabited. The population of Solomon Islands was estimated to be 495 026 in 2007. The growing population and the relatively young population structure dominate concerns about future development. In 2005, estimated life expectancy at birth was 63.4 years (62.6 years for males and 64.3 years for females). According to the 1999 national population census, 93% of the total population are Melanesians, 4% are Polynesians and 3% are from other ethnic groups. During 2000-2005, the total population is estimated to have increased by about 59 000 persons and about 42% of the population is below 15 years of age according to United Nations population projections. This demographic trend is creating increasing pressure on infrastructures and jobs, as well as raising growing environmental issues. 1.2 Political situation The country has continued its peaceful development since 2003 with the help of the Regional Assistance Mission to Solomon Islands (RAMSI). RAMSI comprises soldiers and policemen from Cook Islands, Fiji, New Zealand, Papua New Guinea, Samoa and Tonga, led by the Australian Army and Police. With the restoration of law and order, RAMSI has been scaled back to 302 police officers and 120 soldiers, in addition to civilian technical advisors, since the end of 2004. The Government, led by Prime Minister Sir Allan Kemakeza since 17 December 2001, was dissolved on 20 December 2005. A national election was held on 5 April 2006. 1.3 Socioeconomic situation Since 2004, the country’s economy has shown a positive recovery along with the restoration of law and order. Total government revenue collection was SBD 625 million (around US$ 86 million) during 2005, SBD 75 million (US$ 10 million) more than expected. Contributions to government revenue were derived mainly from export duties on timber and growth in both company and personal income taxation receipts. 1.4 Vulnerabilities and hazards No available information. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition Solomon Islands is in a phase of epidemiological transition. Having to deal with both the control of infectious diseases and an increasing incidence of noncommunicable diseases, with very limited resources, poses a major challenge for the Government. COUNTRY HEALTH INFORMATION PROFILES | 419 With the dissipation of ethnic conflict during 1999-2003 and with support in 2004 from the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), the Australian Agency for International Development (AusAID), the World Bank and Rotary International, progress has been made in malaria control. Compared with 2003, 2004 saw a 3.5% reduction and 2005 a 17.7% reduction, in national malaria incidence. Impressive progress was seen in Isabel Province (49% reduction), Choiseul Province (45% reduction) and Western Province (34% reduction) in 2005 compared with 2004. The national malaria goal is to reduce the annual incidence rate to below 80 cases per 1000 population and malaria mortality to less than 25 cases by 2010. The achievement of these targets is dependent on maintenance of efforts and continuous financial support. A total of 371 tuberculosis cases were reported by the Central Registry in 2006. The National TB Programme is progressing well with its implementation at both provincial and national levels and is set to achieve an 85% cure rate in the near future (seven out of nine provinces have achieved a more than 85% cure rate). 2.2 Outbreaks of communicable diseases There was no major disease outbreak in 2004/2005. However, the worldwide threat of avian influenza and HIV/AIDS have resulted in the development of new policies and strategies to strengthen and revitalize disease prevention, control and surveillance, as well as preparedness for action. 2.3 Leading causes of mortality and morbidity 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. In 2005, cardiovascular diseases, neoplasms, malaria, respiratory diseases and neonatal causes were major public health problems in terms of mortality. 2.4 Maternal, child and infant diseases A reduction in childhood mortality and morbidity from diarrhoeal diseases is attributed to the improved status of sanitation, water supply, personal hygiene and breast-feeding. A reduction in 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. 2.5 Burden of disease No available information. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The Ministry of Health and Medical Services’ Corporate Plan for 2006-2008, based on the gains made during 2004 and 2005, has the following eight priority areas: • improvement of management and supervision of services; • improvement of access to quality care; • management and development of human resources for health care; • mortality and morbidity reduction; • maintenance of healthy environments; • promotion of healthy living and lifestyles; • improvement of reproductive health and family planning and; SOLOMON ISLANDS 420 | COUNTRY HEALTH INFORMATION PROFILES • forging of partnerships in health development. The Plan details future directions in terms of strategies and plans for the next three years, demonstrating the Government's commitment to meeting the Millennium Development Goals and those set by the International Conference on Population and Development (Cairo, Egypt, 1994). 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 priorities. 3.2 Organization of health services and delivery systems See Section 3.5. 3.3 Health policy, planning and regulatory framework See Section 3.1 3.4 Health care financing In 2006, the total expenditure on health in Solomon Islands amounted to US$ 16.2 million, with per capita spending of US$ 33.4. In the same period, health spending as a share of gross domestic product (GDP) came to 4.7%. Government expenditure on health was US$ 15.1 million, or 12.6% of total government expenditure. 3.5 Human resources for health Seven of the nine provinces have a public hospital: Guadalcanal Province is serviced 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. This gives a total of eight public and three private hospitals throughout the country. The public hospital in Choiseul has recently upgraded from health centre status, while the Central Province Hospital is still without a doctor. All provincial hospitals were at full operational capacity during 2005, although the total number of available hospital beds is yet to be confirmed. Infrastructure and refurbishment work is in progress. The area and rural health centres and nurse aide posts are well distributed throughout the provinces, based on the size and geographical distribution of their populations. At end of 2005, a total of 89 doctors (19 doctors per 100 000 population), 52 dentists (11 dentists per 100 000 population) and 53 pharmacists (11 pharmacists per 100 000 population) were employed by the Government and were working in the country. In terms of nurses, a total of 620 nurses, including nurse aides, were employed by the Ministry of Health (130 nurses per 100 000 population). 3.6 Partnerships Overseas development assistance increased from US$ 60 million in 2003 to US$ 122 million in 2004, with key contributions from Australia (US$ 85.6 million), New Zealand (US$ 8.9 million), the European Union (US$ 4.1 million) and Japan (US$ 2.3 million). Although the Government is the major source of funding for health services at both the central and provincial levels, there is still heavy reliance on external financial assistance. In 2005, expenditure by the Ministry of Health and Medical Services amounted to SBD 87 087 310 (around US$ 12 million), representing a 73% increase compared with 2004. An increase in the recurrent budget would undoubtedly strengthen the provision of quality health care services and also enhance the implementation of the WHO programme of assistance. 3.7 Challenges to health system strengthening No available information. COUNTRY HEALTH INFORMATION PROFILES | 421 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Goals and Strategies, Corporate Plan 2006-2008; IMCI Annual Report 2004; Reproductive Health Annual Report 2004; Tuberculosis Unit Annual Report 2005; EPI Annual Report 2004; National Vector Borne Disease Control Programme Annual Report 2005; Year 2006 Approved Recurrent Estimates Operator : Honiara, Ministry of Health and Medical Services Title 2 : Solomon Islands Health Status Assessment Report. Operator : Australian Agency for International Development, Canberra, 2005. Title 3 : Health Workforce for the Solomon Islands, 2005 Operator : Nursing School Title 4 : Death records 2005 Operator : Heath Statistics Unit, Ministry of Health and Medical Services Title 5 : Press releases 2005 Operator : Department of Prime Minister and Cabinet Web address : http://www.pmc.gov.sb/ Title 6 : Statistical Profiles of the Least Developed Countries Operator : United Nations, New York 2005 5. ADDRESSES MINISTRY OF HEALTH Office Address : Ministry of Health and Medical Services, Chinatown Postal Address : P.O. Box 349, Honiara, Solomon Islands Official Email Address : malefoasi@solomon.com.sb / pshealth@pmc.gov.sb Telephone : +677 20830 Fax : +677 20085 Office Hours : 8:00 – 16:30 Website : WHO COUNTRY LIAISON OFFICER IN SOLOMON ISLANDS Office Address : Ministry of Health and Medical Services, Chinatown Postal Address : P.O. Box 22, Honiara, Solomon Islands Official Email Address : who@sol.wpro.who.int Telephone : +677 23 406 Fax : +677 21 344 Office Hours : 8:00 – 16:30 SOLOMON ISLANDS 422 | COUNTRY HEALTH INFORMATION PROFILES 6. ORGANIZATIONAL CHART: Ministry of Health Year Source Demographics 1 28.90 2005 1 2 495.03 255.06 239.96 2007 est 2 3 2.36 … … 2005 est 3 4 15.70 15.90 15.60 2007 est 4 26.00 26.20 25.80 2007 est 4 2.50 2.40 2.70 2007 est 4 5 18.00 … … 2007 est 5 6 30.50 … … 2005-10 3 7 7.20 … … 2005-10 3 8 2.33 a … … 2005-10 3 9 63.40 62.20 64.30 2005 6 … 10.90 11.60 2002 7 10 3.80 2005 6 11 … … … 12 494.68 2002 8 13 … 14 0.60 2005 9 15 … … … 16 … … … 17 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 0 0 0 0 0 0 2004 10 … … … … … … … … … … … … 20 … … … … … 2006 10 75 337 … … 12 … … 2006 10 … … … … … … … … … … … … … … … … … … Rural Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Estimated population ('000s) Annual population growth rate (%) Percentage of population Rate of natural increase of population (% per annum) Urban population (%) Crude death rate (per 1000 population) - 0–4 years COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total SOLOMON ISLANDS Male - 5–14 years Crude birth rate (per 1000 population) - 65 years and above Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Encephalitis Leprosy Malaria Plague Per capita GDP at current market prices (US$) Environmental indicators Selected communicable diseases - Type A FemaleMaleTotal Typhoid fever COUNTRY HEALTH INFORMATION PROFILES | 423 Rate of growth of per capita GDP (%) Total Urban Human development index Number of new cases Communicable and noncommunicable diseases Total Number of deaths Male Female Syphilis - Type B - Type C Dengue/DHF Gonorrhoea - Unspecified - Type E Hepatitis viral Cholera SOLOMON ISLANDS Year Source 18 178 327 … … … … … 2004 11 19 14 565 … … … … … 2004 11 20 371 … … … … … 2006 10 124 … … … … … 2006 10 21 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 22 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 23 … … … … … … 24 … … … … … … 25 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 26 314 665 b … … 35 136.80 b … … 2006 11 243 600 b … … 50 426.10 b … … 2006 11 47 329 b … … 9 797.30 b … … 2006 11 31 378 b … … 6495.40 b … … 2006 11 22 828 b … … 4725.50 b … … 2006 11 20 371 b … … 4217.80 b … … 2006 11 … … … … … … … … … … … … … … … … … … … … … … … … All types - Homicide and violence - Motor and other vehicular accidents - Occupational injuries - Suicide 424 | COUNTRY HEALTH INFORMATION PROFILES 3. Skin disease Tuberculosis - Liver - Stomach Circulatory - Lip, oral cavity and pharynx - New pulmonary tuberculosis (smear-positive) Cancers All cancers (malignant neoplasms only) - All forms - Leukaemia Female Total Number of new cases INDICATORS Number of cases Total Male DATA FemaleMale 4. Ear infection 5. Red eye MaleTotal Number of deaths 1. Clinical and presumptive malaria 2. Acute respiratory infection 6. Yaws 8. 9. 7. 10. Rate per 100 000 population Male FemaleFemale Total - Trachea, bronchus, and lung Diabetes mellitus - Hypertension All circulatory system diseases - Cerebrovascular diseases - Acute myocardial infarction Diarrhoeal diseases Acute respiratory infections Leading causes of morbidity (inpatient care) Leading causes of mortality and morbidity - Breast - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases - Ischaemic heart disease SOLOMON ISLANDS Year Source 27 … … … … … … 2005 12 … … … … … … 2005 12 … … … … … … 2005 12 … … … … … … 2005 12 … … … … … … 2005 12 28 25.00 2005 13 29 71.00 2007 10 30 … 31 12.00 c … … 2002 7 32 … … … 33 84.00 … … 2007 10 79.00 … … 2007 10 78.00 … … 2007 10 79.00 … … 2007 10 34 … … … … … … … … … … 35 0 0 0 … … … 2007 10 0 0 0 … … … 2007 10 … … … … … … 0 0 0 … … … 2007 10 0 0 0 … … … 2007 10 0 0 0 … … … 2007 10 35 … … … … … 2007 10 0 0 0 … … … 2007 10 0 0 0 … … … 2007 10 0 0 0 … … … 2007 10 - Hepatitis B III - Sepsis - Hib meningitis COUNTRY HEALTH INFORMATION PROFILES | 425 3. Malaria Immunization coverage for infants (%) Total FemaleTotal MaleMale FemaleTotal Number of deaths - Eclampsia Maternal, child and infant diseases 2. Neoplasm Leading causes of mortality INDICATORS - Congenital rubella syndrome Female Number of cases DATA 5. Neonatal causes Percentage of pregnant women with anaemia 10. Percentage of women in the reproductive age group using modern contraceptive methods 8. 9. - Haemorrhage - Rubella - Mumps - Measles - Diphtheria - DTP3 - Poliomyelitis - Pertussis (whooping cough) - Abortion Selected diseases under the WHO-EPI - Total Tetanus - Neonatal tetanus Maternal causes Percentage of pregnant women immunized with tetanus toxoid (TT2) - Obstructed labour Male 1. Cardiovascular diseases Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth - POL3 - BCG FemaleTotal Male Female Total 4. Respiratory diseases (pneumonia as the leading causes) 6. Number of deaths Male 7. Rate per 100 000 population SOLOMON ISLANDS Year Source 36 … 37 Public health facilities 8 691 e 2005 14 … … … … 145 d … 2005 14 Private health facilities 3 … 2005 14 … … 38 16.16 2006p 15 4.70 2006p 15 33.39 2006p 15 15.11 2006p 15 93.00 2006p 15 12.60 2006p 15 26.52 2006p 15 7.00 2006p 15 7.61 2006p 15 39 … Year Source 40 Physicians - Number 89 87 2 … … … … 2005 16 - Rate per 1000 population 0.19 0.35 0.01 … … … … 2005 16 Dentists - Number 52 29 23 … … … … 2005 16 - Rate per 1000 population 0.11 0.12 0.10 … … … … 2005 16 Pharmacists - Number 53 40 13 … … … … 2005 16 - Rate per 1000 population 0.11 0.16 0.06 … … … … 2005 16 Nurses - Number 620 … … … … … … 2005 16 - Rate per 1000 population 1.30 … … … … … … 2005 16 Midwives - Number 74 … … … … … … 2005 16 - Rate per 1000 population 0.16 … … … … … … 2005 16 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … T o ta l - external resources for health as % of general government expenditure on health DATA Health insurance coverage as % of total population Private health expenditure - private expenditure on health as % of total expenditure on health INDICATORS 426 | COUNTRY HEALTH INFORMATION PROFILES Exchange rate in US$ of local currency is: 1 US$ = Number of beds DATA External source of government health expenditure P ri va te M al e F em al e U rb an P u b lic R u ra l Number Government expenditure on health - Primary health care centres - per capita total expenditure on health (in US$) - Hospitals - Outpatient clinics Health facilities - District/first-level referral hospitals Health care financing - General hospitals - Specialized hospitals Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) - general government expenditure on health as % of total general government expenditure - amount (in million US$) Annual number of graduates Human resources for health - general government expenditure on health as % of total expenditure on health INDICATOR Facilities with HIV testing and counseling services Health infrastructure SOLOMON ISLANDS Year Source 41 Pharmacists … … … … … … … Nurses 43 … … … … … … 2005 16 Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 31.40 33.10 29.60 2005-10 3 45 52.00 55.00 49.00 2005 est 3 46 78.00 … … 2007 10 47 236.00 2005 6 48 … … 43.00 f 2003 17 49 … … … 50 … 51 Antenatal care coverage - At least one visit 76.00 g 2003 17 - At least four visits … 52 … … … 53 … … … 54 … … .. 55 … … … 56 15 565.00 … … 2006 10 57 2.48 … … 2006 10 58 … … … 59 … … … 60 194.00 … … 2006 10 61 23.00 … … 2006 10 62 42.00 … … 2006 10 63 56.00 … … 2005 10 64 70.00 94.00 65.00 2006 18 65 32.00 98.00 18.00 2006 18 66 … … … M al e Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures Female Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Infant mortality rate (per 1000 live births) INDICATORS DATA F em al e U rb an R u ra l Health-related Millennium Development Goals (MDGs) DATA Total Male Workforce losses/ Attrition P u b lic P ri va te Tuberculosis death rate per 100 000 population COUNTRY HEALTH INFORMATION PROFILES | 427 Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source INDICATORS T o ta l HIV prevalence among population aged 15-24 years - Percentage of deliveries in health facilities (as % of total deliveries) Unmet need for family planning Estimated HIV prevalence in adults h Prevalence of underweight children under five years of age Annual number of graduates Malaria incidence rate per 100 000 population Adolescent birth rate Rural Proportion of population with access to affordable essential drugs on a sustainable basis Contraceptive prevalence rate Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Proportion of population in malaria-risk areas using effective malaria treatment measures Tuberculosis prevalence rate per 100 000 population Percentage of people with advanced HIV infection receiving ART Maternal mortality ratio (per 100 000 live births) Total Urban SOLOMON ISLANDS … p est NR a b c d e f g h 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Information provided by Country Liaison Officer for Solomon Islands, 04 April 2006. Reproductive Health, MOHMS. Health Information System Annual Report 2006, Health Statistic Unit, MOHMS. 428 | COUNTRY HEALTH INFORMATION PROFILES List of Clinic, Ministry of Health, 2005. World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf]. Registry Department, Nursing School and Registry of Reproductive Health Unit, 2005. Solomon Islands Millennium Development Goals report 2004: Scoring fundamental goals (Draft). Department of National Reform and Planning, World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: Special focus on Sanitation. UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] United Nations Country Team for Solomon Islands. National Accounts, Central Bank of Solomon Islands, 2005. Figure refers to 29 primary health care centres and 116 dispensaries Figure refers to primary health care data National Health Report 2005, MOHMS, Solomon Islands. Figure reported as the antenatal coverage Computed by Health Information and Evidence for Policy Unit of WHO Regional Office for the Western Pacific Estimates derived by regression and similar estimation methods Figure applies to clinics only [http://hdr.undp.org/en/reports/global/hdr2007-2008/] World health report 2004. Changing history. Geneva, World Health Organization, 2004. WHO Regional Office for the Western Pacific, data received from the technical units. Sources: Statistical Profiles of the least developed countries, United Nations, 2005 Solomon Islands Statistics (http://www.spc.int/prism) World Population Prospects: The 2006 Revision Population Database (Medium Variant), United Nations Department of Economic and Social Affairs, (http://esa.un.org/unpp/p2k0data.asp). Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world. United Nations Development Programme, New York USA 2007. Figure refers to total beds in public health facilities Not relevant Not included in the official list of MDG indicators Demographic Tables for the Western Pacific 2005-2010. Manila, World Health Organization Regional Office for the Western Pacific, 2005 United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). Data not available Provisional Estimate Notes: COUNTRY HEALTH INFORMATION PROFILES | 429 TOKELAU 1. CONTEXT 1.1 Demographics The estimated resident population of Tokelau in 2006 was 1466, 35% below 15 years of age and 7.4% were above 65 years. 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) and the crude death rate is 7.0 per 1000 population (1997-2001). 1.2 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. 1.3 Socioeconomic 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. 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 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. 1.4 Vulnerabilities and hazards No available information. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition 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 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 aged 30 years 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 the ages of 30 and 39. There is an observable diet shift from local to imported foods. TOKELAU 430 | COUNTRY HEALTH INFORMATION PROFILES 2.2 Outbreaks of communicable diseases No available information. 2.3 Leading causes of mortality and morbidity See Section 2.1. 2.4 Maternal, child and infant diseases The infant mortality rate is 33.0 per 1000 live births (1997-2000). Maternal mortality ratio is 0 per 100 000 live births (2001-2002) and the total fertility rate is 4.9 (1997-2001). 2.5 Burden of disease No available information. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The Health Department of the public service operates the health care system. Its main office is located in Atafu. The Department also has an office in the Tokelau Apia Liaison Office (TALO) in Samoa. Its main purpose is to facilitate referral of patients to Samoa and New Zealand. The TALO Health Office also serves as the storage and distribution point for medical supplies. 3.2 Organization of health services and delivery systems Hospitals in each of the three atolls provide primary health care to their communities. Preventive health services are also provided by the Health Department. Water and sanitation programmes are ongoing, as well as maternal and child health programmes that are supported by women's committees. 3.3 Health policy, planning and regulatory framework Tokelau's national health plan and priorities are the following: (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. (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. COUNTRY HEALTH INFORMATION PROFILES | 431 3.4 Health care financing For the financial year 2003/2004, the Tokelau GNP forecast was NZ$ 11 381 770 (US$ 8 115 604). Health was allocated 12.5%, or 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, the United Nations Development Programme (UNDP), the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), and the Australian Agency for International Development (AusAID). 3.5 Human resources for health 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 in 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 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 available is in the Nukunonu Hospital. 3.6 Partnerships No available information. 3.7 Challenges to health system strengthening No available information. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : 2006 Tokelau Census of Population and Dwellings: 2006 Census Tabular Report. Web address : [http://www.spc.int/prism/NSO- News/TK/2006%20Census%20Tabular%20Report%20-%20Final.pdf] Title 2 : Tokelau Department of Health 5. ADDRESSES DEPARTMENT OF HEALTH Office Address : Nukunonu, Tokelau Official Email Address : tokelau.health@clear.net.nz , talo.health@clear.net.nz Telephone : (690) 4132 Fax : (690) 4290 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 Year Source Demographics 1 0.01 2004 1 2 1.53 0.79 0.74 2006 est 2 3 0.40 … … 2001 1 4 12.70 12.80 12.70 2006 est 2 21.60 21.60 21.60 2006 est 2 5.00 4.30 5.60 2006 est 2 5 0.00 … … 2007 est 3 6 31.00 … … 1997-2001 1 7 7.00 … … 1997-2001 1 8 2.40 … … 1997-2001 1 9 … 68.40 71.30 1997-2000 1 … … … 10 4.90 1997-2001 1 11 86.50 … … 2003 4 12 612.50 c 2003 5 13 … 14 … 15 16 17 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 0 0 0 0 0 0 2005 6 … … … … … … … … … … … … … … … … … … … … … … … … Communicable and noncommunicable diseases - Type B - Type C Dengue/DHF - Unspecified Total - Type E Hepatitis viral Cholera - Type A Syphilis Male Total Per capita GDP at current market prices (US$) Environmental indicators Total Urban Human development index Rate of growth of per capita GDP (%) Leprosy Malaria Plague 432 | COUNTRY HEALTH INFORMATION PROFILES Male Number of deaths Female Number of new cases Female Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Typhoid fever Encephalitis Gonorrhoea Selected communicable diseases Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Estimated population ('000s) Annual population growth rate (%) Percentage of population Rate of natural increase of population (% per annum) Urban population (%) - 0–4 years - 5–14 years Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male TOKELAU Rural Proportion of vehicles using unleaded gasoline (%) … … Health care waste generation (metric tons per year) … … … … TOKELAU Year Source 18 … … … … … … 19 … … … … … … 20 0 0 0 … … … 2006 6 0 0 0 … … … 2006 6 21 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 22 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 23 … … … … … … 24 … … … … … … 25 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 26 1 000 … … 65 061.81 d … … 2003 7 439 … … 28 562.13 d … … 2003 7 400 … … 26 024.72 d … … 2003 7 151 … … 9824.33 d … … 2003 7 73 … … 4749.51 d … … 2003 7 - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections Number of cases COUNTRY HEALTH INFORMATION PROFILES | 433 3. Diseases of the digestive system All types - Homicide and violence Leading causes of morbidity (inpatient care) Leading causes of mortality and morbidity Female - Rheumatic fever and rheumatic heart diseases 1. Upper and lower respiratory diseases - Ischaemic heart disease Male Female Number of deaths DATA Total Male - Breast INDICATORS Injuries Rate per 100 000 population Male Female - Leukaemia - Lip, oral cavity and pharynx MaleTotal Mental disorders Diabetes mellitus 6. 8. Total Number of new cases Female Tuberculosis All cancers (malignant neoplasms only) - Hypertension All circulatory system diseases - Acute myocardial infarction Circulatory - Cerebrovascular diseases - Liver - Stomach - Trachea, bronchus, and lung - All forms - New pulmonary tuberculosis (smear-positive) Cancers - Motor and other vehicular accidents - Occupational injuries - Suicide 9. 4. Diseases of the musculoskeletal system 5. Diseases of the circulatory system 2. Diseases of the skin and subcutaneous tissues 10. Total 7. TOKELAU Year Source 27 … … … 38 e … … 2003 7 … … … 21 e … … 2003 7 … … … 16 e … … 2003 7 … … … 11 e … … 2003 7 … … … 5 e … … 2003 7 28 … 29 100.00 2007 6 30 … 31 40.00 d … … 2003 7 32 100.00 … … 2003 7 33 100.00 100.00 100.00 2007 6 100.00 100.00 100.00 2007 6 100.00 100.00 100.00 2007 6 100.00 100.00 100.00 2007 6 34 … … … … … … … … … … 35 0 0 0 … … … 2006 6 0 0 0 … … … 2006 6 0 0 0 … … … 2005 6 0 0 0 … … … 2006 6 0 0 0 … … … 2006 6 0 0 0 … … … 2006 6 0 0 0 … … … 2006 6 0 0 0 … … … 2007 6 0 0 0 … … … 2006 6 0 0 0 … … … 2006 6 - Congenital rubella syndrome - Sepsis 434 | COUNTRY HEALTH INFORMATION PROFILES - Total Tetanus - Neonatal tetanus - Measles - Pertussis (whooping cough) - Rubella - Poliomyelitis Maternal causes - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth - Hepatitis B III - Diphtheria - Hib meningitis Male Female Percentage of pregnant women with anaemia 10. Percentage of women in the reproductive age group using modern contraceptive methods - BCG - DTP3 - POL3 - Obstructed labour - Eclampsia - Haemorrhage - Abortion 9. 7. 6. DATA Male FemaleMale Female Total Number of deaths Rate per 100 000 population Selected diseases under the WHO-EPI 5. Congenital anomalies FemaleTotal Immunization coverage for infants (%) Maternal, child and infant diseases FemaleMale Number of cases 8. Total Number of deaths Total 1. Diseases of the circulatory system 4. Ill-defined and undiagnosed conditions 2. Diseases of the respiratory system INDICATORS 3. Neoplastic diseases Male Total Leading causes of mortality TOKELAU Year Source 36 … 37 Public health facilities 3 18 2003 5 … … … … … … Private health facilities … … … … 38 0.51 f 1999-2000 9 … 341.07 f 1999-2000 9 1.42 f FY2003- 2004 5 … 12.50 FY2003- 2004 5 … … … 39 … Year Source 40 Physicians - Number 3 … … … … … … 2003 5 - Rate per 1000 population 20.00 … … … … … … 2003 5 Dentists - Number 3 … … … … … … 2003 5 - Rate per 1000 population 20.00 … … … … … … 2003 5 Pharmacists - Number 0 0 0 0 0 0 0 2000 9 - Rate per 1000 population 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2000 9 Nurses - Number 10 … … … … … … 2003 5 - Rate per 1000 population 66.67 … … … … … … 2003 5 Midwives - Number 3 … … … … … … 2000 9 - Rate per 1000 population 20.00 … … … … … … 2000 9 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians …. … … … … … … Dentists … … … … … … … Annual number of graduates Facilities with HIV testing and counseling services Health infrastructure - Hospitals - Outpatient clinics - Primary health care centres External source of government health expenditure Private health expenditure - private expenditure on health as % of total expenditure on health - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals Government expenditure on health - amount (in million US$) - general government expenditure on health as % of total expenditure on health - per capita total expenditure on health (in US$) INDICATORS Health care financing Human resources for health Health insurance coverage as % of total population P ri va te M al e F em al e T o ta l INDICATOR R u ra l DATA P u b lic Number Number of beds Health facilities - external resources for health as % of general government expenditure on health COUNTRY HEALTH INFORMATION PROFILES | 435 Total health expenditure - total expenditure on health as % of GDP Exchange rate in US$ of local currency is: 1 US$ = DATA U rb an TOKELAU Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 33.00 … … 1997-2000 1 45 … … … 46 100.00 100.00 100.00 2007 6 47 0.00 2001-02 5 48 … … … 49 … … … 50 … 51 Antenatal care coverage - At least one visit … - At least four visits … 52 … … … 53 … … … 54 … … … 55 … … … 56 … … … 57 … … … 58 … … … 59 … … … 60 112.00 … … 2006 6 61 12.00 … … 2006 6 62 … … … 63 … … … 64 … … 88.00 2006 8 65 … … 78.00 2006 8 66 … … … Annual number of graduates Total Urban Rural Contraceptive prevalence rate Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Under-five mortality rate (per 1000 live births) Proportion of population with access to affordable essential drugs on a sustainable basis Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Proportion of population in malaria-risk areas using effective malaria treatment measures Tuberculosis prevalence rate per 100 000 population Percentage of people with advanced HIV infection receiving ART Tuberculosis death rate per 100 000 population P ri va te HIV prevalence among population aged 15-24 years Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Female T o ta l M al e F em al e U rb an R u ra l P u b lic INDICATORS DATA Unmet need for family planning Estimated HIV prevalence in adults g Adolescent birth rate Health-related Millennium Development Goals (MDGs) Total Male Maternal mortality ratio (per 100 000 live births) Infant mortality rate (per 1000 live births) 436 | COUNTRY HEALTH INFORMATION PROFILES Workforce losses/ Attrition INDICATORS DATA Malaria incidence rate per 100 000 population TOKELAU … p est NR FY a b c d e f g 1 2 3 4 5 6 7 8 United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). [http://www.spc.int/prism/NSO-News/TK/2006%20Census%20Tabular%20Report%20-%20Final.pdf] Information furnished by WHO Representative in Samoa, 25 February 2004. WHO Regional Office for the Western Pacific, data received from technical units. Special focus on Sanitation. UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] Pacific Island Regional Millennium Development Goals Report 2004 . Noumea, Secretariat of the Pacific Community, UN/ CROP MDG Working Group, November 2004. Tokelau Statistics Unit http://www.spc.int/prism/country/tk/. Figure refers to percentage of deaths reported Figure is in New Zealand dollars Provisional Estimate Notes: Data not available Not relevant Figure refers/applies to usually resident population Not included in the official list of MDG indicators World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: Sources: Fiscal year Computed by Health Information and Evidence for Policy Unit of WHO Regional Office for the Western Pacific Revised figure Figure refers to per capita GNP at current market prices (US$) Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 2006 Tokelau Census of Population and Dwellings: 2006 Census Tabular Report . COUNTRY HEALTH INFORMATION PROFILES | 437 438 | COUNTRY HEALTH INFORMATION PROFILES TONGA 1. CONTEXT 1.1 Demographics Tonga’s estimated population for 2007 was 109 000, giving a population density of 145.3 per square kilometre, with 68% residing on the largest main island of Tongatapu. About 24% of the population live in urban settings. The population is young, with 36.2% in the 0-14 year-old age group. The fertility rate remains high, although it has been falling slowly, decreasing from 4.1 in 1986 to 3.4 in 2005. The population growth rate is around 0.3%, a low figure taking into consideration a crude birth rate of about 25 per 1000 and the fact that child mortality rates are the lowest in the Pacific. The explanation is found in the high net emigration rate, which averaged 19.8% between 1986 and 1996. It is estimated that as many as 100 000 Tongans live overseas, most of them in Australia, New Zealand and the United States of America. The Tongan community in New Zealand alone accounts some 50 000 people. 1.2 Political situation Tonga is a constitutional monarchy with almost absolute power given to the head of state, King Siaosi Tupou V, who succeeded his father in 2006. The King’s Cabinet consists of the Prime Minister, the ministers of the Crown and the governors of Vava’au and Ha’apai, all directly appointed by the King. The unicameral Parliament consists of the cabinet members, the Speaker of the House (appointed by the King), nine nobles elected by the peers from among Tonga’s 33 hereditary title holders, and nine democratically elected peoples’ representatives. The political situation remains stable and peaceful overall despite growing discontent with the undemocratic system of rule; the, in some aspects, feudal structure of society; and the mounting pressure for constitutional reform. The introduction of civil service salary reforms in July 2005 sparked a six-week general strike, ending with a settlement on 3 September 2005 that gave civil servants pay increases of 60%-80%. The strike quickly developed into widespread demands for political reform. A Constitutional Review Committee, headed by Prince Tu’i pelehake and financially supported by the Commonwealth Secretariat, was set up in response to the protests and is expected to deliver its recommendation for political reform by mid-2006. Tonga has been a member of the United Nations since 1999. The churches are influential in Tonga and religion, traditional customs and hierarchy play important roles in policy development and the government decision-making process. 1.3 Socioeconomic situation Agriculture forms the backbone of the economy, and the export of pumpkins for the Japanese market plays a particularly important role as a foreign exchange earner. The second biggest industry, fishing, is in recession due to decreasing catches over several years. Tourism is slowly increasing in importance, although the prospects of Tonga developing a mass-tourism industry are limited. Remittances from relatives living abroad play an increasingly 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 gross domestic product (GDP), which was estimated at TOP 361 million (US$ 189.6 million). The Government is heavily dependent on development support for capital investments. Economic development has been sluggish in recent years and real growth in GDP fell from 2.3% in 1998-1999 and 5.4% in 1999-2000 to only 1.4% in 2003-2004. The figure was 2.5% in 2004-2005, giving an average GDP growth per year for 1998-2005 of 2.9% per year. The COUNTRY HEALTH INFORMATION PROFILES | 439 Government has liberalized the economy in recent years and has abolished government monopolies and allowed competition in several areas, including telecommunications, power supply and civil aviation. Tonga joined the World Trade Organization in December 2005 in an agreement that will see Tonga reduce its import tariffs for most goods to 15% and open its domestic markets, including health care provision and education, to foreign investors. A 15% consumption tax was introduced on goods and services in April 2005 and compensates for the loss of income from import duties. The tax base is small, with only about 4000 people having a taxable income, and income tax is low (10%) and non-progressive, resulting in a revenue from income taxation of less than TOP 2 million (US$ 1.05 million) per year. Property taxation is negligible and land ownership is concentrated among the royal family, churches and nobles. The labour force participation rate in 2003 (Labour Force Survey 2003) was 64% (75% for men and 53% for women). The literacy rate is very high (98.8%) and most children complete compulsory primary school classes. Education absorbed 14% of the national budget in 2004. While most primary schools teach in Tongan, secondary education is mainly conducted in English. The education rate is similar for both genders, with some advantages for girls at the secondary level. Despite equal opportunities in education, the number of women in leading positions remains limited. An important step was taken in 2005 when the first female Member of Parliament was elected. Tonga has ratified the Convention of the Rights of the Child (CRC), but has failed to fulfil the reporting requirements. It has yet to sign the Convention on the Elimination of all forms of Discrimination Against Women (CEDAW). Women continue to be discriminated against in legislation, including land ownership rights, child support rights and inheritance laws. The standard of living has improved dramatically over the last 50 years and there is now little absolute poverty. The country is placed 55th in the United Nations Development Programme’s Human Development Index ranking (HDI), the highest ranking of any Pacific island state, reflecting the comparatively high gross domestic product (GDP) per capita of US$ 1780 (2003- 2004 estimate), high life expectancy and near-universal literacy. Disposable income per capita, at approximately US$ 2308, is considerably higher than GDP per capita as a result of remittances from Tongans working abroad. The value of those remittances is also increasing much faster than the domestic economy and official development assistance, and the strong performance in the HDI is partly explained by the high disposable income. However, many families are dependent for food security on what they can produce on their farmland, and limited access to such land is an increasing problem. An estimated 4% of the population live on less than US$ 1.00 per day and about 6.7% of households live below the food poverty line. The Government uses the term ‘hardship’ to describe economically disadvantaged groups in Tonga and 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 an estimated 23% of the population falls into that category. People who live on the outer islands, where access to education and health care is poor, transport costs are high and income opportunities few, have higher rates of hardship. 1.4 Vulnerabilities and hazards No available information. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition Tonga has gone through an epidemiological transition since the 1950s, with increasing life expectancy and falling fertility rates, childhood mortality rates and maternal mortality. TONGA 440 | COUNTRY HEALTH INFORMATION PROFILES 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. However, there is likely to be considerable underreporting for many noncommunicable diseases. Post-mortem examinations are limited to criminal cases and death certificates are, at best, based on clinical findings and frequently on reports from relatives. More importantly, as many as 18% of deceased 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 consistent over time for those who die in hospital, there are clearly distortions in morbidity reporting caused by misclassification and inconsistent ICD-10 coding, particularly for communicable diseases. The steep increase in the burden of noncommunicable disease (NCD) is worrying and is the most important current health problem. Obesity, diabetes and cardiovascular diseases have increased to levels of epidemic proportion and prevalence rates now surpass those of most industrialized countries. Tonga developed a multisectoral national strategy to prevent and control NCD in 2003. There are multiple reasons for the rapidly growing NCD burden, of which the most important include increasing rates of overweight and obesity, reduced physical activity, smoking, and, to some extent, the ageing of the population. Economic development, motorization, improved access to processed imported food and the adoption of ‘western’ dishes with high fat and high sugar contents have had a strong negative impact on people’s health. 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. Figures from 2004 show that the average weight for a Tongan male increased over 30 years by 17.4 kg to 95.7 kg, while the average weight for a woman increased by 21.1 kg to 95.0 kg, a rise in body weight with few comparisons in the world. There are indications that people are becoming overweight and obese earlier in life; girls and young women in particular tend to gain weight during adolescence and pregnancy. The overall adult obesity rate (BMI>30) was 60% in the 2004 survey. Women have higher obesity rates than men over all age groups and they are more obese (mean BMI 34.5 compared with 31.0 for men). As a consequence, they have higher rates of diabetes than men, with 19.1% of women and 16.5% of men meeting the definition of diabetic. Most people continue to perceive fatty food as something desirable, a taste that may be explained partly 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 its composition. Studies have shown that the average Tongan male consumes double the quantity of food and amount of calories consumed by the average Australian male. Women are more overweight than men, while men have a higher prevalence of other risk factors, including hypertension, elevated blood lipids and smoking. The overall adult prevalence of diabetes type II has increased from 7% to 18% over the last 30 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 those 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 also 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 increasing rapidly. The increasing number of cars on the roads, together with outdated COUNTRY HEALTH INFORMATION PROFILES | 441 traffic safety measures, contributed to the record 24 traffic-related deaths in 2003, a figure that puts Tonga ahead of the United States of America in the 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 or 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 not enforceable in practice, and neither the health services nor the police have the equipment to measure blood alcohol or to ‘breathalize’ motorists. 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 controls in the future. The incidence of cancer is perceived to be increasing, 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 was started in 2005. Mammography is not available. Liver cancer, which is closely related to hepatitis B virus infection (HBV), is common in Tonga, where HBV infection 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 incidence. 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. 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. This picture resembles the situation in an industrialized country more than that of a poor developing one. 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. Infectious diseases have, to a large extent, been brought under control in the last 30-40 years, with some important exceptions. Tonga does not have the vector for malaria, but a few imported cases are diagnosed each year in people returning from visits to areas with malaria transmission. A fifth and final round of mass drug administration (MDA) for the eradication of lymphatic filariasis took place in 2005, with 100% geographical coverage and an estimated population coverage of >90%. A nationwide post MDA campaign serosurvey was conducted in 2006 to evaluate the results. Leprosy has, in practice, been eradicated, although the latest infection was diagnosed in 2004. This was an imported case in a Tongan adult who returned after having lived his entire life in American Samoa. The last case of indigenous transmission was in 1998 and today there are a handful of well documented people living with complications of leprosy. Hepatitis B is highly endemic in Tonga and screening of blood donors, government employees and visa applicants shows that more than 10% of the adult population 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 now entering reproductive life. A serosurvey of 211 preschool children in 1998 found a 3.8% TONGA 442 | COUNTRY HEALTH INFORMATION PROFILES prevalence of chronic hepatitis B infection, indicating a lower-than-expected efficacy for hepatitis B immunization. Increasing efforts are now being made to improve particularly the timeliness of hepatitis B vaccine delivery. A study using convenience testing for HbsAg in children admitted to Vaiola Hospital started in 2005 for surveillance purposes; of more than 100 children tested so far, none has been positive for HbsAg. Poor household hygiene and sanitation, as well as contamination of drinking water sources, are thought to contribute to the average 10-20 cases of typhoid fever recorded annually (22 confirmed cases in 2003). The Ministry of Health places a high importance on finding and treating asymptomatic chronic typhoid carriers through contact tracing and stool sampling, and this limits the spread of typhoid. However, it can be argued that Tonga is in the position to eliminate typhoid fever altogether if adequate coordinated resources were to be allocated to treat carriers, improve sanitary practices and ensure the supply of safe water in all villages. Eighteen new cases of tuberculosis (all types) were reported in 2006. All tuberculosis treatment follows the directly observed treatment, short-course (DOTS) strategy and there is active contact tracing. The cure rate for patients diagnosed in 2005 was 73%. HIV prevalence remains very low in Tonga. Fourteen people have been diagnosed with HIV infection over the last 16 years and, as of January 2006, there was only one person known to be living with HIV infection. 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, and an estimated 45 000 HIV tests have been carried out since the start in the 1980s. A pilot trial of voluntary counselling and testing (VCT) at the antenatal clinic at the referral hospital reported a very high uptake, but no decision has been taken to continue to offer antenatal screening. Risk behaviour surveillance and high-risk group serosurveillance started in 2005 and will provide valuable information on the risk of transmission. Antiretroviral treatment (ART) is not available through the public health system and there are no officially endorsed guidelines for treatment of HIV infection or prevention of mother-to-child transmission. The diagnostic capacity for sexually transmitted infections (STIs) is limited to gonorrhoea and syphilis (with the exception of HIV). The number of cases is thought to be much higher than revealed by the statistics, as many patients are treated by private practitioners who do not notify the Ministry of Health. The ratio of men to women receiving treatment for gonorrhoea is 10:1, indicating weak contact tracing and a lack of appropriate services for women. A serosurvey in pregnant women in 2005 found a high overall prevalence of chlamydial infection of 14.5%. The rate was 27.5% in women <25 years of age, an indication that transmission may be increasing in younger women. The RPR-positive rate for syphilis was 3.2%, which is alarming considering that the Ministry of Health took the controversial decision to discontinue syphilis screening in pregnancy a few years ago. The same study also asked questions about sexual risk behaviour, which showed that the condom use rate is very low and that condoms are primarily seen as a method of contraception to be used within marriage and not to protect against STIs. 2.2 Outbreaks of communicable diseases The country experienced a large outbreak of dengue fever (serotype 1) in 2003, causing six deaths in children, and transmission continued into 2005. The outbreak was confined to the main island of Tongatapu in the first year, but transmission then spread to all island groups except the Niuas. Two adult deaths due to dengue were recorded in 2005. It is unlikely that dengue will become endemic in Tonga because the population is not large enough to sustain transmission over time. However, vector control and vector surveillance is poor and the measures introduced to prevent fatalities and control transmission during outbreaks are suboptimal. It looks inevitable that the introduction of another serotype will cause a new outbreak of dengue fever, with fatalities. Tonga experienced an outbreak of watery diarrhoea from December 2005 to February 2006, with altogether six fatalities in children below one year of age. This was an unusually large outbreak COUNTRY HEALTH INFORMATION PROFILES | 443 and, for the first time, Rota virus was confirmed in a sample sent to the Pasteur Institute in New Caledonia. 2.3 Leading causes of mortality and morbidity See Section 2.1. 2.4 Maternal, child and infant diseases 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 227.8 per 100 000 live births in 2005, which translates to seven fatalities. Indicators that are based on relatively uncommon events, such as MMR and IMR, will show large variations between years due to chance and it can be more informative to either compare absolute numbers or to examine 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, which translates to one death per year. It is of concern that the MMR has been stable over the last two decades and that it has proven very difficult to reduce it further. The absolute majority of maternal deaths took place in hospital, which is an indication that patient monitoring and emergency services, such as availability of blood for transfusion, needs strengthening. Tonga is the best performing country in the Pacific in terms of infant and child mortality. The unusually low infant mortality rate of 9.1 deaths per 1000 live births at the 1990 baseline for the Millennium Development Goals (MDGs), together with the fact that the IMR has remained unchanged for the last decade, makes it unrealistic for the country to achieve the MDG for infant mortality. There are several 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. The result shows that it is possible to provide high coverage of essential services in an island state with isolated populations, and that it pays off. There is little absolute poverty in Tonga, no chronic undernutrition (stunting), no important micronutrient deficiencies and no malaria, all factors that contribute to well nourished and healthy mothers and children. The comparatively low teenage (<20 years) pregnancy rate (4.1% in the 2000-2003 period) is another protective factor. Breast-feeding promotion is receiving increasing attention as an important public health intervention. The goal of establishing Vaiola Hospital as a baby-friendly hospital in 2005 was, unfortunately, not achieved. This would have meant 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 Breast-milk Substitutes into national law and regulations. The challenge for child health lies in protecting the impressive gains made so far while at the same time identifying and implementing affordable and sustainable interventions that will reduce mortality rates further. 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. Mortality from Haemophilus influenzae type B (Hib) infection lies almost entirely in the 0-1 age group and the introduction of routine childhood immunizations against Hib in 2005 is a good example of an affordable new intervention to improve child health. Immunization rates are higher than in many industrialized countries, and neonatal tetanus and poliomyelitis have been eliminated. Rubella vaccine (measles-rubella [MR] vaccine) was added to the immunization schedule in 2002 in response to a large outbreak of the disease. There have been no detected cases of congenital rubella syndrome (CRS) following the outbreak. The immunization campaign with MR vaccine to break the epidemic included all children of 0-15 yrs and all women up to 45 years of age, with a coverage rate of above 80%, meaning that population immunity against measles can be expected to be high. The last confirmed measles infection was in 1998 and Tonga has set 2007 as a target for measles elimination. Immunization against Hib was introduced in April 2005, with a catch-up immunization campaign for children below two years of age. It has been estimated that Hib vaccine will prevent one to two infant deaths and several more cases of severe sequelae per year caused by Hib meningitis. The hospital paediatric TONGA 444 | COUNTRY HEALTH INFORMATION PROFILES departments are documenting the impact of Hib vaccine on admissions for meningitis and pneumonia. 2.5 Burden of disease See Section 2.1. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives No available information. 3.2 Organization of health services and delivery systems The Ministry of Health works in four programme areas: (1) policy formulation and administration; (2) preventive health services; (3) curative health services; and (4) dental health services. Government health services are provided free of charge and physical access to care is good for the majority of people, with the exception of small populations living on isolated islands. Primary curative care and preventive services are delivered through a system of 14 health centres and 34 maternal health clinics. 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 is low, 34% in 2003, an indication that the hospital system is oversized and has not adapted to the changes in the disease pattern and to improvements in physical access. However, transportation between islands remains difficult and acute referrals to the tertiary hospital are uncommon, making centralization of services problematic. The four hospitals also serve the populations on their respective islands with primary health care and they all run busy outpatient and emergency departments. 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 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 visit Tonga regularly. 3.3 Health policy, planning and regulatory framework See Section 3.2 3.4 Health care financing 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 costs 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 only covers government employees. COUNTRY HEALTH INFORMATION PROFILES | 445 3.5 Human resources for health 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 were 32 filled medical officer posts in 2003 (0.39 doctors per 1 000 population) to which should be added 18 filled health officer posts. In the same year, there were 342 filled nursing posts (3.4 nurses per 1 000 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, many out of their homes. The Ministry of Health 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, 30 nurses graduate each year from 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 postgraduate 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 postgraduate training programmes in midwifery, internal medicine, surgery and public health were offered in 2006-2007. 3.6 Partnerships No available information. 3.7 Challenges to health system strengthening The most critical question for the health system today is how to increase the resources available for health. Government health expenditure is about US$ 100 per capita per year and, given that this pays for free medical treatment and free drugs, it is fair to say that Tongans get a lot of value for their money. Around 10%-15% of the Government’s total budget has been spent on health for the last two decades and it is unlikely that share 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 within 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 of health care financing is thus one of the top priorities of the Ministry of Health. In December 2005, Cabinet approved the introduction of user fees. A decision has also been made to introduce social health insurance within the next three to five years. Initially it will cover civil servants, but the intention is to gradually include larger sections of the population. Tonga has achieved many of the health goals within its reach given its existing health spending level and the challenge now is to increase the resources for health promotion and health care without jeopardizing the health of poor and disadvantaged groups in the population. The increase in noncommunicable diseases (NCD) has now reached epidemic proportions. In addition to human suffering, NCD 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 chronic disease or death. 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 TONGA 446 | COUNTRY HEALTH INFORMATION PROFILES dedicated taxation on tobacco and alcohol. Such a mechanism could provide crucial resources for health promotion, an area of health that is currently heavily dependent on external support. There is a recognized need to improve both the quality of and access to health care, particularly for NCD, in view of the increasing burden of the ageing population. A large proportion of patients with diabetes and cardiovascular diseases remain undiagnosed and untreated. It is therefore a priority to both increase access to care and 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 their responsibility for care. Active participation in treatment and patient empowerment are essential for successful treatment of chronic conditions. 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 NCD 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 on 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 gathered. 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. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Annual reports 1995 to 2004; Ministry of Health Corporate Plan 2001-2004; Ministry of Health Corporate Plan 2005-2008; EPI and Reproductive Health Services annual reports 2000-2003 Operator : Ministry of Health Title 2 : Tonga Department of Statistics Web address : http://www.spc.int/prism/country/to/stats Title 3 : Social and economic update and pro-poor policy formulation, Tonga. Pacific Island Economic Report series Operator : Asian Development Bank TA6245 (reg) Title 4 : Tonga’s report on progress towards the Millennium Development Goals (MDGs) Title 5 : Annual report of the National Reserve Bank 2003-2004 Title 6 : Health Sector Support Project (HSSP/WB) Project Implementation Plan (PIP) Title 7 : National Health Accounts report of July 2004 Title 8 : Tonga’s health 2000 5. ADDRESSES MINISTRY OF HEALTH Office Address : Ministry of Health, Vaiola hospital 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 : 08.30 – 16.30 COUNTRY HEALTH INFORMATION PROFILES | 447 WHO 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 6. ORGANIZATIONAL CHART: Ministry of Health Year Source Demographics 1 0.75 1 2 109.00 56.00 54.00 2007 est 2 3 0.30 … … 2001 3 4 13.00 13.10 12.80 2007 est 2 23.20 23.80 22.70 2007 est 2 5.60 5.00 6.50 2007 est 2 5 24.00 … … 2007 est 4 6 24.80 … … 2004 5 7 6.10 … … 2004 5 8 1.87 a … … 2004 5 9 … 70.00 72.00 2005 7 … 11.90 12.00 2002 8 10 3.40 2005 7 11 98.80 … … 2000 9 12 1 780.00 2003-04 11 13 … 14 0.82 2005 13 15 … … … 16 … … … 17 2 0 2 0 0 0 2002 17 5 4 1 5 3 2 2002 17 0 0 0 0 0 0 2002 17 … … … … … … 0 0 0 0 0 0 2002 17 0 0 0 0 0 0 2002 17 62 … … … … … 2007 12 2 … … … … … 2003 17 42 … … … … … 2003 7 0 0 0 0 0 0 2006 12 … … … … … … 0 0 0 0 0 0 2002 17 0 0 0 0 0 0 2002 17 23 … … … … … 2003 5 TONGA Syphilis Hepatitis viral Cholera Leprosy Per capita GDP at current market prices (US$) Environmental indicators Dengue/DHF Gonorrhoea - Unspecified Health care waste generation (metric tons per year) Typhoid fever Number of deaths Male FemaleMale Selected communicable diseases Urban Total Number of new cases Female Rural Encephalitis - Type E - Type A Total - Type B - Type C Total Communicable and noncommunicable diseases Adult literacy rate (%) Proportion of vehicles using unleaded gasoline (%) Human development index Rate of growth of per capita GDP (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Total fertility rate (women aged 15–49 years) Rate of natural increase of population (% per annum) Urban population (%) Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 0–4 years - 5–14 years - 65 years and above Estimated population ('000s) Annual population growth rate (%) Percentage of population COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male Malaria Plague 448 | COUNTRY HEALTH INFORMATION PROFILES TONGA Year Source 18 20 891 … … … … … 2004 5 19 1 682 … … … … … 2004 5 20 18 … … … … … 2006 12 14 … … … … … 2006 12 21 101 46 55 76 42 34 2002 6 … … … … … … 3 3 0 0 0 0 2002 6 7 3 2002 6 … … … … … … 1 0 1 1 0 1 2002 6 6 3 3 3 0 3 2002 6 6 3 3 8 6 2 2002 6 8 6 2 5 4 1 2002 6 7 7 0 13 11 2 2002 6 22 … … … 192 121 71 2002 6 34 26 8 28 19 9 2002 6 41 15 26 21 9 12 2002 6 1 154 634 520 7 4 3 2002 6 34 18 16 7 7 0 2002 6 21 9 12 1 1 0 2002 6 23 2 035 787 1 248 35 14 21 2002 6 24 199 130 69 0 0 0 2002 6 25 … … … … … … 0 0 0 1 1 0 2002 6 109 80 29 0 0 0 2002 6 0 0 0 0 0 0 2002 6 0 0 0 1 1 0 2002 6 26 20 819 … … 20 437.83 a … … 2004 5 20 057 … … 19 689.79 a … … 2004 5 1 947 … … 1 911.35 a … … 2004 5 1 011 … … 992.49 a … … 2004 5 671 … … 658.71 a … … 2004 5 Leading causes of morbidity (inpatient care) Leading causes of mortality and morbidity 4. Diarrhoea (adult) 5. Diarrhoea (children) COUNTRY HEALTH INFORMATION PROFILES | 449 - Ischaemic heart disease - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases Rate per 100 000 population Male Female Number of cases Female Total Male TotalFemaleTotal Male - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders Diabetes mellitus 6. 10. 8. 9. - Breast All cancers (malignant neoplasms only) - Hypertension All circulatory system diseases - Acute myocardial infarction Circulatory - Cerebrovascular diseases - Liver - Stomach - Trachea, bronchus, and lung - Leukaemia - Lip, oral cavity and pharynx Total Number of new cases - All forms Number of deaths Female DATA Male All types - Homicide and violence - Motor and other vehicular accidents - Occupational injuries 1. Acute respiratory infections 2. Influenza 7. 3. Bronchiopneumonia INDICATORS - Suicide Tuberculosis - New pulmonary tuberculosis (smear-positive) Cancers Acute respiratory infections TONGA Year Source 27 146 … … 190.10 … … 2002 5 67 … … 77.23 … … 2002 5 51 … … 53.47 … … 2002 5 37 … … 49.50 … … 2002 5 33 … … 43.56 … … 2002 5 28 23.10 2002 6 29 98.30 2007 12 30 … 31 10.00 b … … 2000 10 32 97.50 … … 2002 6 33 99.80 … … 2007 12 100.00 … … 2007 12 100.00 … … 2007 12 100.00 … … 2007 12 34 114 0 2002 6 … … 0 1 2002 6 … … 35 0 0 0 … … … 2007 12 0 0 0 … … … 2007 12 0 0 0 … … … 2005 12 0 0 0 … … … 2007 12 0 0 0 … … … 2007 12 0 0 0 … … … 2007 12 0 0 0 … … … 2007 12 0 0 0 … … … 2007 12 0 0 0 … … … 2007 12 0 0 0 … … … 2007 12 - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) - Haemorrhage - Abortion Male Rate per 100 000 population - Measles 1. Diseases of the circulatory system Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth Maternal causes 5. Endocrine, nutritional and metabolic conditions Percentage of women in the reproductive age group using modern contraceptive methods - POL3 - BCG - DTP3 Percentage of pregnant women with anaemia Immunization coverage for infants (%) FemaleTotal Male Female Total - Pertussis (whooping cough) - Diphtheria Selected diseases under the WHO-EPI - Total Tetanus - Neonatal tetanus - Poliomyelitis 450 | COUNTRY HEALTH INFORMATION PROFILES - Rubella - Congenital rubella syndrome FemaleTotalFemale Male Number of cases - Hepatitis B III - Hib meningitis - Eclampsia - Sepsis - Obstructed labour Total FemaleTotal Male DATA Number of deaths Male Maternal, child and infant diseases 2. Neoplasms 7. 6. 4. Diseases of the respiratory system 10. 8. 9. 3. Symptoms, signs and ill-defined conditions INDICATORS Leading causes of mortality Number of deaths TONGA Year Source 36 … 37 Public health facilities 1 191 2004 18 … … 3 105 2004 18 14 … 2005 5 Private health facilities … … … … 38 11.82 2006p 15 5.40 2006p 15 118.20 2006p 15 8.87 2006p 15 75.30 2006p 15 11.10 2006p 15 43.84 2006p 15 24.70 2006p 15 2.03 2006p 15 39 12.00 FY 2002- 2003 5 Year Source 40 Physicians - Number 32 c … … … … … … 2003 5 - Rate per 1000 population 0.39 … … … … … … 2003 5 Dentists - Number 23 d … … … … … … 2003 5 - Rate per 1000 population 0.23 … … … … … … 2003 5 Pharmacists - Number 4 3 1 … … … … 2002 6 - Rate per 1000 population 0.04 0.06 0.02 … … … … 2002 6 Nurses - Number 342 … … … … … … 2003 5 - Rate per 1000 population 3.37 … … … … … … 2003 5 Midwives - Number 21 0 21 … … … … 2002 6 - Rate per 1000 population 0.21 0.00 0.21 … … … … 2002 6 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … COUNTRY HEALTH INFORMATION PROFILES | 451 - Hospitals - Outpatient clinics - Primary health care centres - total expenditure on health as % of GDP - amount (in million US$) INDICATORS DATA Exchange rate in US$ of local currency is: 1 US$ = R u ra l Health care financing - external resources for health as % of general government expenditure on health - general government expenditure on health as % of total general government expenditure - amount (in million US$) - per capita total expenditure on health (in US$) Government expenditure on health Total health expenditure Human resources for health Health insurance coverage as % of total population P ri va te M al e F em al e T o ta l INDICATOR P u b lic DATA U rb an Number Number of beds - general government expenditure on health as % of total expenditure on health - General hospitals - Specialized hospitals - District/first-level referral hospitals Facilities with HIV testing and counseling services Health infrastructure Health facilities - private expenditure on health as % of total expenditure on health External source of government health expenditure Private health expenditure Annual number of graduates TONGA Year Source 41 Pharmacists … … … … … … … Nurses 30 … … … … … … 2004 16 Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 11.80 … … 2005 7 45 16.59 … … 2001 7 46 99.50 … … 2007 12 47 227.80 2005 7 48 99.00 2004 5 1.00 2004 5 98.00 2004 5 49 … … … 50 … 51 Antenatal care coverage - At least one visit 99.00 2004 5 - At least four visits … 52 … … … 53 … … … 54 … … … 55 … … … 56 … … … 57 1 … … 2000 est 8 58 … … … 59 … … … 60 34.00 … … 2006 12 61 3.00 … … 2006 12 62 127.00 … … 2006 12 63 73.00 … … 2005 12 64 100.00 100.00 100.00 2006 14 65 96.00 98.00 96.00 2006 14 66 … … … 452 | COUNTRY HEALTH INFORMATION PROFILES Total Urban Rural Proportion of population using an improved sanitation facility Maternal mortality ratio (per 100 000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Infant mortality rate (per 1000 live births) Under-five mortality rate (per 1000 live births) Proportion of population in malaria-risk areas using effective malaria treatment measures Adolescent birth rate Estimated HIV prevalence in adults e Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures Percentage of people with advanced HIV infection receiving ART Unmet need for family planning HIV prevalence among population aged 15-24 years Malaria incidence rate per 100 000 population Proportion of population with access to affordable essential drugs on a sustainable basis Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Contraceptive prevalence rate Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Total Male P ri va te DATA P u b lic Annual number of graduates INDICATORS Workforce losses/ Attrition INDICATORS DATA Tuberculosis prevalence rate per 100 000 population Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Proportion of population using an improved drinking water source Tuberculosis death rate per 100 000 population Female T o ta l M al e F em al e U rb an R u ra l Health-related Millennium Development Goals (MDGs) TONGA … p est NR a b c d e 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 COUNTRY HEALTH INFORMATION PROFILES | 453 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. Computed by Health Information and Evidence for Policy Unit of WHO Regional Office for the Western Pacific [http://hdr.undp.org/en/reports/global/hdr2007-2008/] Report of the Minister of Education – Year 2000. Sources: United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). Information provided by Country Liaison Officer for Tonga, 10 May 2005. Report of the Minister of Health for the year 2002. Information Unit, Ministry of Health. Information provided by Country Liaison Officer for Tonga, 05 March 2004. WHO Regional Office for the Western Pacific, data received from the technical units. World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world . United Nations Development Programme, New York USA 2007. Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] Personal communication with the Principal, Queen Salote School of Nursing. World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf]. World health report 2005: Make every mother and child count . Geneva, World Health Organization, 2005. Social and Economic Update and Pro-Poor Policy Formulation, Tonga. Pacific Island Economic Report series, ADB TA6245 (reg). Figure refers to government doctors Figure refers to dental officers and dental therapists Not included in the official list of MDG indicators Provisional Notes: Data not available Not relevant Estimates derived by regression and similar estimation methods World health report 2004: Changing history . Geneva, World Health Organization, 2004. Tonga Statistics Department (http://www.spc.in/prism). Official Kingdom of Tonga Website- Key facts about Kingdom of Tonga [http://www.pmo.gov.to/index.php?option=com_content&task=view&id=27&Itemid=27] Demographic Tables for the Western Pacific 2005-2010. Manila, World Health Organization Regional Office for the Western Pacific, 2005. Report of the Minister of Health – Year 2001. Estimate 454 | COUNTRY HEALTH INFORMATION PROFILES TUVALU 1. CONTEXT 1.1 Demographics By population, Tuvalu is the smallest member of the United Nations. The population has more than doubled since 1980 and was estimated to reach 9652 in 2006. About 33.9% are in the 0-14 year age group, 57.3% in the 15-64 year age group and 8.5% are 60 years or older. The median age is 24 years. The population growth rate is estimated at 0.1% (2006-2010), and the crude birth rate was 27.1 per 1000 population in 2002. The population is primarily of Polynesian ethnicity, with about 4% Micronesian. Life expectancy at birth is 65 years for both sexes: 64 years for males and 67 years for female in 2002. The Tuvaluan language is spoken by virtually everyone, while a language very similar to Gilbertese is spoken on Nui. English is also an official language, but is not spoken in daily use. Parliamentary and official functions are conducted in Tuvaluan. 1.2 Political situation The islands came under Britain's sphere of influence in the late 19th century. In 1974, the Ellice Islanders voted for separate British dependency status as Tuvalu, separating from the Gilbert Islands, which became Kiribati upon independence. Tuvalu became fully independent within the Commonwealth in 1978. Tuvalu is a constitutional monarchy and Commonwealth Realm, with Queen Elizabeth II recognized as Queen of Tuvalu. She is represented in Tuvalu by a Governor General, who is appointed upon the advice of the Prime Minister. The local unicameral parliament, or Fale I Fono, has 15 members and is elected every four years. The members elect a Prime Minister, who is the head of government. The Cabinet is appointed by the Governor General on the advice of the Prime Minister. Some elders also exercise informal authority on a local level. There are no formal political parties and election campaigns are largely on the basis of personal/family ties and reputation. The highest court in Tuvalu is the High Court. There are also eight Island Courts with limited jurisdiction. Rulings from the High Court can be appealed to the Court of Appeal in Fiji. Tuvalu has no regular military force and spends no money on defense. The police force includes the Maritime Surveillance Unit for search and rescue missions and surveillance operations. The police have a Pacific-class patrol boat (Te Mataili), provided by Australia under the Pacific Patrol Boat Program, for use in maritime surveillance and fishery patrol. 1.3 Socioeconomic situation Tuvalu has almost no natural resources, its main source of income being foreign aid. Virtually the only jobs in the islands that pay a steady wage or salary are with the Government. Subsistence farming and fishing remain the primary economic activities, particularly off the capital island of Funafuti. Government revenues largely come from the sale of stamps and coins, issuing of fishing licenses and worker remittances. The traditional community system still survives to a large extent. Each family has its own task, or salanga, to perform for the community, such as fishing, house-building or defense. The skills of a family are passed on from father to son. COUNTRY HEALTH INFORMATION PROFILES | 455 About 800 Tuvaluans previously worked in Nauru in the phosphate mining industry or aboard foreign ships as sailors. When phosphate mining ceased in Nauru, 378 Tuvaluans were stranded in the country until they were repatriated in 2006 by a joint programme in which Australia, New Zealand and the European Union paid most of the cost of their return passage, and Taiwan (China) paid the back wages they were owed. Substantial income is received annually from an international trust fund established in 1987 by Australia, New Zealand and the United Kingdom and also supported by Japan and the Republic of Korea. This fund grew from an initial US$ 17 million to over US$ 35 million in 1999. The United States Government is also a major revenue source for Tuvalu, with 1999 payments from a 1988 treaty on fisheries valued at about US$ 9 million, a total that is expected to rise annually. In an effort to reduce the country’s dependence on foreign aid, the Government is pursuing public sector reforms, including privatization of some government functions and personnel cuts of up to 7%. In 1998, Tuvalu began deriving revenue from use of its area code for ‘900’ lines and from the sale of its ‘.tv’ Internet domain name. In 2000, Tuvalu negotiated a contract leasing its Internet domain name ‘.tv’ for US$ 50 million in royalties. However, the Canadian entrepreneur who negotiated the deal was unable to raise the US$ 50 million in the contracted time period, and the contract eventually fell into other hands. Due to its remoteness, tourism does not provide much income, with only a handful of tourists visiting the country annually. Almost all visitors are government officials, aid workers, officials of nongovernmental organizations or consultants. 1.4 Vulnerabilities and hazards In terms of physical land size, Tuvalu is the fourth smallest country in the world. The land is very low-lying, with narrow coral atolls, and the highest elevation is only five metres (16 ft) above sea level. Because of this low elevation, the islands that make up this nation may be threatened by any future rise in sea levels due to global warming. Under such circumstances, the population may evacuate to New Zealand, Niue or the Fijian island of Kioa. Tuvalu has very poor land and the soil is hardly usable for agriculture. There is almost no reliable supply of drinking water. The country has westerly gales and heavy rain from November to March and tropical temperatures moderated by easterly winds from March to November. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition Communicable diseases are reported as 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 TB programme and a filariasis mass drug administration programme is in place. Vector control is an ongoing activity. A new communicable disease surveillance system was implemented in 2003, which is appropriately simple and sustainable and addresses the right priority diseases. However, not all cases of infectious disease are reported. As in other Pacific island countries, diseases such as dengue and typhoid fever occur from time to time. One problem is the limited microbiological testing capability on the island; many specimens need to be shipped to overseas laboratories for confirmation and this limits the sensitivity and timeliness of surveillance. The high number of domesticated pigs suggests that there may a risk of leptospirosis, although this disease has not been reported on the island for several years. This low reporting may also be linked to the lack of microbiological testing available on the main island. TUVALU 456 | COUNTRY HEALTH INFORMATION PROFILES There is a limited supply of fresh (rain) water on these atoll islands, which means that there is a risk of spread of communicable diseases through drinking water. Groundwater is brackish and is not generally considered safe for consumption. Lifestyle diseases are also evident, with the leading causes of mortality including heart disease and diabetes. 2.2 Outbreaks of communicable diseases No outbreaks of infectious diseases have been reported in recent years. 2.3 Leading causes of mortality and morbidity The leading causes of morbidity and mortality are communicable diseases. However, noncommunicable diseases, such as obesity, heart disease and diabetes, are a growing concern. 2.4 Maternal, child and infant diseases The infant mortality rate is high, at 21.6 per 1000 live births. The total fertility rate was 3.7 in 2002. 2.5 Burden of disease No available information. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives No available information. 3.2 Organization of health services and delivery systems Health services are working to meet the new demands of the changing lifestyles (especially regarding diet) of the population. There is one hospital, located on the main island of Funafuti. The outer islands have clinics staffed by trained nurses. 3.3 Health policy, planning and regulatory framework 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 the health care delivery system; • to develop all health services to be customer-focused; and • to produce and retain high quality personnel for the health services. Along these lines, major activities of the Ministry of Health are geared towards: • strengthening the existing communicable diseases programmes (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 programmes (particular attention is to be given to diabetes mellitus and hypertension). 3.4 Health care financing As in other developing countries, health care financing remains a problem in Tuvalu. However, the Government is working towards improving it. COUNTRY HEALTH INFORMATION PROFILES | 457 3.5 Human resources for health Human resources are a major weak spot for the Tuvalu health care system. The workforce, consisting of four physicians and approximately 30 trained nurses, provides for limited surge capacity and is very sensitive to brain drain to countries such as Australia and New Zealand. 3.6 Partnerships No available information. 3.7 Challenges to health system strengthening Human resources are the main challenge. There needs to be an ongoing effort to strengthen the knowledge and expertise of the existing staff. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Central Statistics Department Operator : Government of Tuvalu Web address : http://www.spc.int/prism/country/tv/stats/ Title 2 : Secretariat of the Pacific Community – Prism. Web address : http://www.spc.int/prism/country/tv/tv_index.html Title 3 : 2006-2015 Population data Operator : SPC Demography/ Population Division Web address : http://www.spc.int/demog/en/stats/2006/Pacific%20Island%20Populations%202006- 2015%20-%2030% Title 4 : Household Income and Expenditure Survey (HIES) 2004/2005. Government of Tuvalu Central Statistics Division. Web address : http://www.spc.int/prism/Country/TV/Stats/Publictn/Tuvalu%20HIES%20Report.pdf 5. ADDRESSES MINISTRY OF HEALTH Office Address : Vaiaku, Funafuti, Tuvalu Postal Address : P.O. Box 36, Funafuti, Tuvalu Official Email Address : soh@tuvalu.tv Telephone : Health Division: (688) 20416/20480 Fax : Health Division: (688) 20481 Office Hours : 0800-1600 Website : http://www.gov.tv 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) 323 4100 Fax : (679) 323 4177 Office Hours : 0800 – 1700 TUVALU 458 | COUNTRY HEALTH INFORMATION PROFILES 6. ORGANIZATIONAL CHART: Ministry of Health Year Source Demographics 1 0.03 2006 1 2 9.65 4.79 4.87 2006 est 1 3 0.10 … … 2006-10 1 4 12.20 12.20 12.10 2006 est 2 21.70 21.60 21.70 2006 est 2 5.00 4.20 5.70 2006 est 2 5 49.00 … … 2007 est 3 6 27.10 … … 2002 4 7 9.90 … … 2002 4 8 1.72 … … 2002 4 9 63.60 61.70 65.10 2002 4 … 9.70 10.30 2002 5 10 3.70 2002 4 11 … … … 12 1139.32 2002 4 13 … 14 … 15 … … … 16 … … … 17 0 0 0 0 0 0 2001 6 0 0 0 0 0 0 2001 6 0 0 0 0 0 0 2001 6 … … … … … … 23 … … 0 0 0 2001 6 0 0 0 0 0 0 2005 6 0 0 0 0 0 0 2004 6 0 0 0 0 0 0 2005 6 … … … … … … 2 … … … … … 2006 6 … … … … … … 0 0 0 0 0 0 2001 6 … … … … … … 0 0 0 0 0 0 2005 6 Typhoid fever Leprosy Malaria Plague Syphilis Rural Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male - 0–4 years - 5–14 years Crude birth rate (per 1000 population) - 65 years and above Estimated population ('000s) Annual population growth rate (%) Percentage of population Rate of natural increase of population (% per annum) Urban population (%) Crude death rate (per 1000 population) Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Number of deaths Female Total Number of new cases Male Selected communicable diseases - Type A Per capita GDP at current market prices (US$) Environmental indicators Total Urban Human development index Rate of growth of per capita GDP (%) - Type B - Type C Dengue/DHF Gonorrhoea - Unspecified Encephalitis FemaleMaleTotal Communicable and noncommunicable diseases - Type E Hepatitis viral Cholera TUVALU COUNTRY HEALTH INFORMATION PROFILES | 459 TUVALU Year Source 18 2 950 … … … … … 2003 7 19 967 … … 1 … … 2002 7 20 9 … … … … … 2006 6 4 … … … … … 2006 6 21 1 … … 0 0 0 2004 7 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 22 … … … … … … … … … … … … … … … … … … 344 … … … … … 2002 7 … … … … … … … … … … … … 23 281 … … … … … 2002 7 24 … … … … … … 25 … … … … … … … … … … … … 1 … … 0 0 0 2001 8 32 … … … … … 2002 7 … … … … … … 26 1 667 … … 17 274.61 a … … 2007 4 1 504 … … 15 585.49 a … … 2007 4 1 298 … … 13 450.78 a … … 2007 4 1 186 … … 12 290.16 a … … 2007 4 1 067 … … 11 056.99 a … … 2007 4 992 … … 10 279.79 a … … 2007 4 732 … … 7 585.49 a … … 2007 4 553 … … 5 730.57 a … … 2007 4 536 … … 5 554.40 a … … 2007 4 - Occupational injuries - Suicide Total Male All types - Homicide and violence - Motor and other vehicular accidents 3. Acute respiratory infection 1. Septic sores 2. Headache 10. 7. Ringworm Tuberculosis - All forms - New pulmonary tuberculosis (smear-positive) Cancers All cancers (malignant neoplasms only) - Hypertension All circulatory system diseases - Leukaemia - Lip, oral cavity and pharynx - Trachea, bronchus, and lung - Breast INDICATORS Total Number of cases Number of deaths DATA Female FemaleTotal Male Total Rate per 100 000 population Male - Acute myocardial infarction Circulatory - Cerebrovascular diseases - Liver - Stomach - Rheumatic fever and rheumatic heart diseases Injuries Mental disorders Diabetes mellitus Number of new cases Male Female - Ischaemic heart disease 4. Body ache 5. Cough 460 | COUNTRY HEALTH INFORMATION PROFILES - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections Leading causes of morbidity (inpatient care) Leading causes of mortality and morbidity Female 6. Abdominal pain 8. Conjunctivitis 9. Tooth decay TUVALU Year Source 27 14 … … 145.08 a … … 2007 4 8 … … 82.90 a … … 2007 4 5 … … 51.81 a … … 2007 4 4 … … 41.45 a … … 2007 4 3 … … 31.09 a … … 2007 4 3 … … 31.09 a … … 2007 4 2 … … 20.73 a … … 2007 4 2 … … 20.73 a … … 2007 4 2 … … 20.73 a … … 2007 4 2 … … 20.73 a … … 2007 4 28 28.50 2001 8 29 100.00 2007 6 30 … 31 … … … 32 95.00 … … 2000 8 33 100.00 … … 2007 6 97.00 … … 2007 6 97.00 … … 2007 6 97.00 … … 2007 6 34 … … … … … … … … … … 35 0 0 0 … … … 2007 6 0 0 0 … … … 2007 6 … … … … … … 0 0 0 … … … 2007 6 0 0 0 … … … 2007 6 0 0 0 … … … 2007 6 0 0 0 … … … 2007 6 0 0 0 … … … 2007 6 0 0 0 … … … 2007 6 0 0 0 … … … 2007 6 Total Number of deaths Total Immunization coverage for infants (%) - Pertussis (whooping cough) INDICATORS 3. Diabetes Leading causes of mortality FemaleTotal Male Total - Poliomyelitis 1. Senility FemaleTotal Male Female - POL3 - BCG - Rubella - Congenital rubella syndrome - Sepsis 8. Stillbirth 9. Pulmonary tuberculosis Number of cases - Obstructed labour Male Maternal causes Female - Haemorrhage - Abortion - Eclampsia - Hepatitis B III - Hib meningitis Selected diseases under the WHO-EPI - Diphtheria - Total Tetanus - Neonatal tetanus - Measles - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) 10. Tuberculosis & others 6. Congestive heart failure 4. Pneumonia Female DATA Male COUNTRY HEALTH INFORMATION PROFILES | 461 Number of deaths Rate per 100 000 population - DTP3 5. Hypertension Percentage of pregnant women with anaemia Percentage of women in the reproductive age group using modern contraceptive methods Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth Male 7. Cerebral vascular accident Maternal, child and infant diseases 2. Cardiac arrest TUVALU Year Source 36 … 37 Public health facilities 1 40 2001 8 … … … … 8 16 2001 8 Private health facilities 0 0 2001 8 … … 38 2.93 2006p 10 11.40 2006p 10 279.27 2006p 10 2.71 2006p 10 92.30 2006p 10 16.10 2006p 10 4.33 2006p 10 7.70 2006p 10 1.33 2006p 10 39 … Year Source 40 Physicians - Number 4 … … … … … … 2003 11 - Rate per 1000 population 0.42 … … … … … … 2003 11 Dentists - Number 2 … … … … … … 2003 11 - Rate per 1000 population 0.21 … … … … … … 2003 11 Pharmacists - Number 2 … … … … … … 2003 11 - Rate per 1000 population 0.21 … … … … … … 2003 11 Nurses - Number 30 b … … … … … … 2003 11 - Rate per 1000 population 3.14 … … … … … … 2003 11 Midwives - Number 10 … … … … … … 2003 11 - Rate per 1000 population 1.05 … … … … … … 2003 11 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … Number of bedsNumber Exchange rate in US$ of local currency is: 1 US$ = R u ra l P u b lic DATA - general government expenditure on health as % of total expenditure on health Health care financing DATA Human resources for health External source of government health expenditure Private health expenditure - private expenditure on health as % of total expenditure on health Health insurance coverage as % of total population INDICATOR - external resources for health as % of general government expenditure on health - per capita total expenditure on health (in US$) Government expenditure on health Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) P ri va te M al e F em al e T o ta l U rb an Health facilities INDICATORS - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals - Hospitals - Outpatient clinics - Primary health care centres Facilities with HIV testing and counseling services Health infrastructure Annual number of graduates 462 | COUNTRY HEALTH INFORMATION PROFILES TUVALU Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 21.60 … … 2003 12 45 32.40 … … 2003 12 46 95.00 … … 2007 6 47 0.00 c 2003 13 48 100.00 2002 13 … … 49 32.00 … … 2002 13 50 … 51 Antenatal care coverage - At least one visit 99.00 2001 8 - At least four visits … 52 … … … 53 … … … 54 … … … 55 … … … 56 … … … 57 … … … 58 … … … 59 … … … 60 504.00 … … 2006 6 61 55.00 … … 2006 6 62 29.00 … … 2006 6 63 100.00 … … 2005 6 64 93.00 94.00 92.00 2006 14 65 89.00 93.00 84.00 2006 14 66 … … … Workforce losses/ Attrition INDICATORS DATA Tuberculosis death rate per 100 000 population Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures Unmet need for family planning Female T o ta l M al e F em al e U rb an R u ra l P u b lic DATA Health-related Millennium Development Goals (MDGs) Malaria incidence rate per 100 000 population Estimated HIV prevalence in adults d INDICATORS P ri va te Total Male Contraceptive prevalence rate Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Proportion of population in malaria-risk areas using effective malaria treatment measures Adolescent birth rate HIV prevalence among population aged 15-24 years Tuberculosis prevalence rate per 100 000 population Percentage of people with advanced HIV infection receiving ART Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Infant mortality rate (per 1000 live births) Maternal mortality ratio (per 100 000 live births) Total Urban Rural Proportion of population with access to affordable essential drugs on a sustainable basis Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source COUNTRY HEALTH INFORMATION PROFILES | 463 Annual number of graduates TUVALU … p est NR a b c d 1 2 3 4 5 6 7 8 9 10 11 12 13 14 World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: Information furnished by the Ministry of Health through the WHO Representative for the South Pacific, 02 April 2004. Tuvalu Millennium Development Goals Report 2006 . Government of Tuvalu, and United Nations Development Programme, 2006. There is only one maternal death in the last 5 years Demographic Tables for the Western Pacific 2005-2010. Manila, World Health Organization Regional Office for the Western Pacific, 2005. World health report 2004. Changing history . Geneva, World Health Organization, 2004. WHO Regional Office for the Western Pacific, data received from technical units. November 2004. Information furnished by the WHO Representative for the South Pacific, 24 February 2005. World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf] Tuvalu Central Statistics Division (http://www.spc.int/prism). PMH health report 2002. Ministry of Health. Notes: Data not available Figure refers to bachelor and diploma graduate nurses Pacific Island Populations - Estimates and projections 2005-2015, Secretariat of the Pacific Community, Noumea, 2006. http://www.spc.int/demog/en/index.html. Estimate 464 | COUNTRY HEALTH INFORMATION PROFILES Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] Information furnished by the Health Department, Government of Tuvalu, 18 March 2003. Provisional United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006. Wallchart (United Nations publication, Sales No. E.08.XIII.3). Not relevant Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific using the 2006 estimated population Not included in the official list of MDG indicators Pacific Island Regional Millennium Development Goals report 2004 . Noumea, Secretariat of the Pacific Community UN/ CROP MDG Working Group, Sources: COUNTRY HEALTH INFORMATION PROFILES | 465 VANUATU 1. CONTEXT 1.1 Demographics According to the last national census in 1999, the population of Vanuatu was 186 678; the 2008 mid-year estimated population is 233 000. Vanuatu has a young population, with nearly 50% below 15 years of age. Life expectancy at birth is 67 for males and 70 for females and 3% of the population is over 65 years of age. The median age is 19.4 years, with a dependency ratio of 80. The 2008 estimated crude birth rate is 31.1 per 1000 population and the crude death rate is 5.5. The infant mortality rate was 30 per 1000 live births in 2006. The annual growth rate is 2.6% a year and the population is expected to double by 2030. The urban population was estimated to make up 23% of the total population by 2005 and urban migration is very severe, particularly from rural islands to Port Vila and other main cities, as people seek employment or education. Most of the population are employed in subsistence agriculture the rest being in government posts, service industries and light industry. 1.2 Political situation Vanuatu has a republican political system, currently headed by a President who has primarily ceremonial powers and who is elected for a five-year term by a two-thirds majority in the Electoral College, consisting of Members of Parliament and the presidents of Regional Councils. The Prime Minister, who is the head of the Government, is elected by a majority vote by a three- fourths quorum of Parliament. The Prime Minister appoints the Council of Ministers, whose number may not exceed one-fourth of parliamentary representatives. The Prime Minister and the Council of Ministers constitute the Executive Government. The Parliament has 52 members who are elected every four years by popular vote. The legal system of the country is based on British common law. Vanuatu has had a relatively prolonged period of political stability. The current Government is a coalition, formed on 23 July 2004, comprising the National United Party (NUP) with Prime Minister Ham Lini Vanuaroroa and Minister of Health Morking Stevens Iatika; the People’s Progressive Party (PPP); the Melanesian Progressive Party (MPP); the Vanua’aku Party (VP); the Vanuatu Republican Party (VRP) and the Green Alliance (GA). The next election is due in September 2008. 1.3 Socioeconomic situation The economy is based primarily on subsistence or small-scale agriculture, which provides a living for 65% of the population. Fishing, offshore financial services and tourism are other mainstays of the economy. A small light industry sector caters to the local market. Economic development is hindered by dependence on relatively few commodity exports, vulnerability to natural disasters and the long distances from main markets. The average gross domestic product (GDP) growth rate has been about 3% over the last decade. As part of plans to improve the economic status of the country, the Government has introduced a priority action agenda: a long-term investment plan to expand the economy and improve the living standards of the people of Vanuatu. The agenda relies mainly on foreign aid for investment, with Australia, China, the European Union, Japan, Malaysia and New Zealand being the main donors. VANUATU 466 | COUNTRY HEALTH INFORMATION PROFILES The traditional economic staples, such as copra and kava, are not likely to sustain economic growth into the future. The Government currently subsidizes copra and demand is not increasing to meet production. Kava (Rhizoma Piperis Methystici) has been subjected to investigations into its possible detrimental effect on health, specifically liver toxicity. Cocoa could be an important export if sufficient quantities could be produced. 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. 1.4 Vulnerabilities and hazards Vanuatu is highly vulnerable to natural disasters as the country is in an earthquake zone. Volcanic eruptions, earthquakes, tsunamis and cyclones are the main culprits damaging the country. Most of the islands of Vanuatu are mountainous and of volcanic origin and have tropical or subtropical climates. There are several active volcanoes in Vanuatu, including several under water. Volcanic activity is common, with the ever-present danger of a major eruption. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition Malaria is the major public health problem in the country, other communicable disease concerns being tuberculosis; sexually transmitted infections; acute respiratory tract infections, including pneumonia; diarrhoeal diseases; viral hepatitis; typhoid fever; and measles. In 2008, the rapid diagnostic test for malaria will be progressively introduced in all health facilities. Annual parasite incidence decreased from a baseline of 73.9 positive cases per 1000 inhabitants to 23.3 per 1000 in 2007. This remarkable decline has opened up the prospect of further reduction and eventual elimination of malaria from Vanuatu. The Ministry of Health has introduced long-lasting, insecticide-treated nets, using funding from the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, to combat malaria. The use of bednets now seems to be widespread, with 65.3% of children sleeping under nets and 69.3% of households having at least one long-lasting, treated net. Nevertheless, concentrated efforts are still needed to achieve the elimination target. Tuberculosis (TB) is a national concern in both urban and rural settings. From 2000 to 2007 the average yearly prevalence rate was six cases per 10 000 inhabitants, which corresponds to 120 TB cases a year. The Ministry of Health has implemented the directly observed treatment, short- course (DOTS) strategy, and the case detection rate is 73%. The programme is now concentrating on quality, consistency and sustainability issues. Dengue fever, dengue haemorrhagic fever and filariasis are also very significant communicable diseases, and the Directorate of Public Health has implemented an extensive vectorborne disease control programme over the past 20 years. The five rounds of mass drug administration against filariasis have been completed and the programme is now in an evaluation and surveillance phase. Sexually transmitted infections (STI) have always been suspected of being highly prevalent, and data from health facilities indicate high prevalence and incidence rates. Azythromycin-based presumptive treatment for pregnant women has been ongoing at Vila Central Hospital since January 2001. In 2000, a survey of women visiting the antenatal clinic at the Vila Central Hospital showed incidence rates of 27.5% for Trichomonal vaginalis and 21.5% for Chlamydia trachomatis. However, the results of a cervical cancer screening project carried out in 2007 in 500 women in Efate found Chlamydia in only 2% of the sample. On the other hand, the survey revealed that 9% of the sample had cervical pre-cancer or cancer lesions. A number of STI were also identified, such as syphilis in 4% of the sample. COUNTRY HEALTH INFORMATION PROFILES | 467 Vanuatu officially reported its first HIV-positive case on 25 September 2002. Three confirmed HIV cases have been reported to date, with one AIDS-related death in 2006 and one in 2007. There was considerable public interest in the case, giving impetus to health service improvements in the areas of counselling, blood safety and testing. There has been an increase in the number of people requesting HIV tests. 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 and the support for integrated health services may reduce the burden on the health system caused by advanced cases of ARI and diarrhoeal disease. Noncommunicable diseases, especially diabetes and hypertension, have come to the attention of the Ministry of Health in the last few years; in 2006, diabetes was the 8th leading cause of morbidity (inpatient care) and hypertension the 10th leading cause. Lifestyle changes and the growing urban population appear to be the main causes. 2.2 Outbreaks of communicable diseases The country needs to develop a good disease surveillance system for early reporting of disease incidence in order to respond to outbreaks properly. During 2006, there was an outbreak of typhoid fever on the island of Tanna, which was successfully controlled by the Southern Health Care Directorate. There were also sporadic outbreaks of diarrhoeal diseases. In June 2008, a workshop on the International Health Regulations (IHR 2005) will be organized and a national surveillance action plan will be developed. 2.3 Leading causes of mortality and morbidity The 10 leading causes of morbidity (inpatient) during 2006 were: acute respiratory infection, including pneumonia (566); cutaneous abscess (251); malaria (249); asthma (241); diarrhoea (214); injuries (181); food poisoning (88); diabetes (85); chronic obstructive pulmonary disease (75); and hypertension (62). The quality of diagnosis is often hampered by inadequate laboratory investigation facilities and is mainly based on clinical judgement. The leading causes of mortality reported in 2006 were: heart disease (112), cancer (48), asthma (42), stroke (30), pneumonia (24), liver diseases (20), neonatal death (11), diabetes mellitus (8), septicaemia (8), and hypertension (8). The mortality pattern over the years shows a clearly increasing trend towards noncommunicable diseases becoming the leading cause of mortality in the country. 2.4 Maternal, child and infant diseases The Maternal and Child Health (MCH) Programme conducts clinics for antenatal mothers, child immunizations and birth spacing. In addition to care, it offers support, information and advice regarding parenting, child health and development, maternal health and well-being, child safety, immunization, breast-feeding, nutrition and birth spacing. During 2006, the five hospitals in the country treated 168 maternity cases: 109 for abortions, 7 for eclampsia, 11 for haemorrhage, 33 for obstructed labour and 8 for sepsis. There were six maternal deaths reported during the year. A total of 8567 births were reported for 2006: 2507 (29%) were delivered in hospitals; 5296 (61%) were delivered in health centres; 156 (2%) were delivered outside health facilities, assisted by skilled health personnel; and 608 (7%) were delivered by traditional birth attendants (TBA). Of the total births reported, 92.9% were attended by skilled health personnel and 95.49% of the newborn babies weighed more than 2500g. Only 48% of pregnant women receive a second dose of tetanus toxoid (TT2). In 2007, BCG coverage was 82.0%, DTP3 was 76.0%, POL3 was 76.0%, and hepatitis B III was 76.3%. VANUATU 468 | COUNTRY HEALTH INFORMATION PROFILES 2.5 Burden of disease Given that nearly 50% of the population is under 15 years of age and the annual population growth rate is 2.56%, the population is expected to continue to grow, with higher numbers of births every year. At the same time, life expectancy at birth is also increasing. This will lead to a double burden of disease: childhood diseases will continue in importance while, at the same time, diseases of the elderly will continue to rise. Hypertension and its complications, heart disease, cancer, diabetes and injuries are the diseases that will place a serious burden on the health services in coming years. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The vision of the Ministry of Health is to protect and promote the health of all people living in Vanuatu. The Ministry’s mission is to establish an integrated and decentralized health system to promote effective, efficient and equitable development and services for the well-being of all people across Vanuatu, based on the following values: Customer focus: Customers are the first priority and concern in the provision of quality care and access, while respecting their geographic situation, economic circumstances, and social and cultural beliefs and values. Equity: In cultural, ethnic, religious and political diversity, and irrespective of disability, gender and age, fairness, respect and honesty must prevail in all dealings. Quality: Pursuing high quality outcomes using safe and affordable interventions and the application of science and technology to maximize benefits, while minimizing risks in all facets of activities. Integrity: Striving for improvement and committing to the highest ethical standards in all that is done in providing quality care in Vanuatu. The objectives are: • to restructure the Ministry to ensure effective, efficient and responsive service delivery; • to strengthen health partnerships to ensure effective, efficient and coordinated service delivery; • to plan and provide equitable service delivery for the people of Vanuatu; • to further develop a range of public health programmes and initiatives, including programmes for tuberculosis, leprosy, malaria and HIV/AIDS; • to provide and promote effective and efficient reproductive health services; • to improve and strengthen the drug and medical supply system; • to plan new primary health care facilities based on population numbers; • to review and develop the patient referral system; • to develop hospital service standards, policy and regulations to assure quality and customer- focused services; • to strengthen the national health information system to support planning, management and effective service delivery to patients and customers; and • to further develop human resource management and development to achieve a well- managed and well-trained workforce. 3.2 Organization of health services and delivery systems The Ministry of Health is responsible for the provision of curative and preventive health services. The Ministry formulates national health policies, coordinates the development and planning of public health sectors, and regulates health standards. COUNTRY HEALTH INFORMATION PROFILES | 469 The six public and one private hospital provide inpatient and specialist outpatient services. Of the six hospitals, there is one tertiary referral public hospital located in both Port Vila and Luganville. Specialized tertiary services are not available in Vanuatu and are referred for overseas treatment, mainly to Australia and New Zealand. There are 32 health centres (referred to as district/first-level referral hospitals in the databank), about six in each province. They provide outpatient and inpatient services (mostly deliveries), health promotion and preventive health services, such as immunization. Each of these health centres is staffed by a nurse practitioner, who is also the manager, a midwife and a general nurse. The health centres are the referral centres for dispensaries (referred to as PHC centres in the health databank) and aid posts. There are 89 active dispensaries providing primary care. All the islands have at least one dispensary, which is usually staffed by a general nurse. Aid posts have been established in most villages and are funded by the community, while the Ministry of Health provides basic medicine and training for the staff. There are about 180 aid posts in the country, each staffed by a village health worker. The support services for hospitals and primary health care programmes include pharmaceutical, blood-transfusion and laboratory services. The six public hospitals in the country have a total of 480 beds and the health centres have 376 beds; this results in 2.10 hospital beds per 1000 population. In 2006, 14 856 inpatients and 356 236 outpatients attended clinics. Thus, the bed occupancy rate was 2.1 per 1000 population and 1.5 outpatient visits per person. 3.3 Health policy, planning and regulatory framework Based on an overarching primary health care philosophy, the policy objectives for the health sector are: • to improve the health status of the people; • to improve access to services; • to improve the quality of the services delivered; and • to make more effective use of resources The strategies to achieve these objectives are as follows: • Base health services delivery on a primary health care approach to ensure access to sustainable provincial services, including strong links with provincial governments. • Improve the health status of the people by: o reducing illness and death in children under five years of age; o promoting birth spacing and reducing teenage pregnancies; and o reducing disability and deaths amongst productive adults. • Improve access to services through: o adoption of the role delineation tool to distribute resources more fairly based on community health needs; o implementation of mechanisms to evaluate tertiary services and provide guidance for their access both within Vanuatu and beyond; o development of an integrated primary health care strategy and public health care strategy for Vanuatu; and o giving a higher priority to improving transportation and communication to (1) improve access for patients, (2) reduce the isolation of health workers, and (3) improve and strengthen partnerships for and ownership of health programmes through the coordination of donors, NGOs, other sectors of Government, chiefs, churches, etc. • Improve the quality of services delivered through: o implementation of a comprehensive hospital and health service quality and safety standards programme; and VANUATU 470 | COUNTRY HEALTH INFORMATION PROFILES o recognition of the potential for a key role to be played by health professionals in providing leadership and ensuring there is continued skills-base development and retention in the workforce. • Make more effective use of resources by: o improving the collection of data to enable monitoring of health status and support health planning and management; and o adopting only those health initiatives that are cost-effective and proven in the South Pacific, and continuing to roll out the planning process to include high- priority services and new programmes. The Ministry of Health’s Master Services Plan contains strategies, targets and performance indicators to measure progress in the priority areas. Performance indicators to reflect overall progress in the sector include those on: o infant and child mortality; o maternal mortality; o births attended by trained health personnel; o immunization coverage; o contraceptive prevalence; o malaria, TB and noncommunicable disease incidence; and o availability of timely and accurate health statistics. 3.4 Health care financing Until 2005, Vanuatu had one financing scheme represented by national health services operated and funded by the Government and under the supervision of the Ministry of Health. The major sources of funding sources for the health sector were the government budget and donor contributions. Household contributions consisted of in-kind payment to traditional healers and fees-for-services at the government facilities. The fees-for-service scheme, a Ministry of Health cost-recovery scheme, realized the reasonable amount of 10 to 12 million Vatu (US$ 95 000 to US$ 114 000) between 2002 and 2005, representing 1% to 2% of the Ministry’s executed budget. Unfortunately, these funds are not added to the Ministry of Health budget, but are treated as state revenue and go into the Ministry of Finance account. National Health Account (NHA 2007) results found that, in 2005, almost 100% of inpatient and 60% of outpatient services were provided by Ministry of Health facilities. Recently, private sector health services have started up in Vanuatu. New polyclinics have been established in the capital city of Port Vila and the major city of Luganville, and a private hospital (Vila Bay Hospital) established in Port Vila in 2006. The private insurance market in the country is utilized mainly by the large number of expatriates residing in the two major cities of Vanuatu. Private insurance companies represented 3% of total health expenditure in 2005. National health expenditure in 2006 totalled Vatu 1 568 million (US$ 14.9 million), representing 4.2% of GDP. Almost 61% of the total budget was from public sources, 23% from private funds and the remaining 16% from international donors’ contributions. Household out-of-pocket expenditure represented almost 17.4% of health expenditure, with about 13% of that being spent on traditional healers. Traditional healers and traditional birth attendants form the informal private sector. It is estimated that there are 200 traditional healers across the country, which averages two in every village. To date, there has been no social health insurance scheme based on the principles of mandatory contribution, risk-sharing and fund-pooling, but such a scheme is now being seriously considered. COUNTRY HEALTH INFORMATION PROFILES | 471 3.5 Human resources for health The Ministry of Health is responsible for development of the human resources required to provide health services in the country. A comprehensive Human Resource Development Plan has been prepared by the Ministry and is being implemented with the assistance of WHO and other donors. There have been developments in the management of human resources in the Ministry of Health towards rationalization of salary levels and a review of career options for health workers. Currently, only clinicians have an established career path, but the Ministry is working towards establishing career paths for technical categories. Salary and career advancement will be tied to the new performance appraisal system. The major challenge facing Vanuatu in the development and employment of its human resources for health is a health staff shortage. Currently, there are 1152 established posts, but only 620 are filled. Almost 90% of the Vanuatu health workforce is based on nursing staff that perform both clinical and community health roles, as well as most management roles. The Vanuatu Centre for Nursing Education (VCNE) graduated 21 nurses in 2007 and an intake of 25 nurses will graduate in 2010. However, these graduates will hardly compensate for the 40 or 50 nurses who are due to retire in the next few years. 3.6 Partnerships The Government and the Ministry of Health work very closely with partners. While WHO is the Ministry’s main technical assistance partner, the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), the United Nations Population Fund (UNFPA), the Japan International Cooperation Agency (JICA), the Australian Agency for International Development (AusAID), the New Zealand Agency for International Development (NZAID), the Asian Development Bank (ADB) and the Global Fund are the main development partners in the health sector. The Secretariat of the Pacific Community (SPC) and the Pacific Island Forum also assist the country in health sector development programmes. 3.7 Challenges to health system strengthening Vanuatu faces major challenges in the development and delivery of health services. Its population of about 233 000 people is spread over 80 islands and it is a huge task for the Ministry of Health to provide health services to such a dispersed population. The Government also has to face challenges due to the rapid growth of the population. The population will have doubled by 2030 and the population base will keep expanding, resulting in a very young population. As a result, health services will have to provide more and more services in the areas of antenatal, natal and postnatal care, as well as neonatal care. Diseases of childhood will continue and more and more paediatric and obstetric care services will be required. At the same time, the elderly population will also keep increasing due to longer life expectancy, and the diseases of the elderly will be another serious problem. With urbanization and changing lifestyles, the incidence of chronic diseases, such as diabetes, hypertension and stroke, are increasing. To address these issues properly, the health services need human resources trained in both the clinical and preventive health fields that are adequate in terms of both numbers and quality. Production of human resources for health will be the major challenge to be addressed in the near future. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : 1999 Vanuatu national population and housing census Operator : National Statistics Office Specification : Include information on population structure & dynamics, social profile, educational characteristic, household characteristic and economic activity VANUATU 472 | COUNTRY HEALTH INFORMATION PROFILES Title 2 : Vanuatu health situation report 2006 Operator : HIS Unit/ Ministry of Health Specification : Nationwide data compilation, as reported by health centres, dispensaries and hospitals Comments : 20 to 30% of health facilities don’t send in their monthly report, hence total are not accurate but gives the general trend. Title 3 : Statistical summary 2008 Operator : Secretariat of the Pacific Community , Noumea, New Caledonia Web address : http://wwv.spc.int/prisim/demog/ Title 4 : Multiple cluster sampling survey (MIC) 2007, Vanuatu Operator : UNICEF Web address : www.unicef.org/pacificislands/ Title 5 : Vanuatu national health accounts 2005 Operator : Vanuatu NHA team, Finance unit/ Ministry of Health Web address : www.who.int/nha/country/vut/en/ Title 6 : Republic of Vanuatu Master Health Service Plan (2004-2009) Operator : Ministry of Health Title 7 : World health statistics 2008 Web address : http://www.who.int/statistics 5. ADDRESSES MINISTRY OF HEALTH Office Address : Iatika Complex Postal Address : Private Mail Bag 009, Port Vila, Vanuatu Official Email Address : mabel@Vanuatu.gov.vu Telephone : (678) 22512 Fax : (678) 26 204 Office Hours : 7.30 am to 11.30 am and 1.15pm to 4.30pm WHO COUNTRY LIAISON OFFICER IN VANUATU Office Address : Lolam House, Level 2, Port Vila, Vanuatu Postal Address : PO Box 177, Port Vila, Vanuatu, South Pacific Official Email Address : WHO@wpro.who.int Telephone : (678) 27 683 Fax : (678) 22691 Office Hours : 7.30 am to 12.00 am and 1.30pm to 5.00pm COUNTRY HEALTH INFORMATION PROFILES | 473 6. ORGANIZATIONAL CHART: Ministry of Health VANUATU Year Source Demographics 1 12.19 2005 1 2 233.03 118.86 114.17 2008 est 2 3 2.56 … … 2005 2 4 14.00 7.20 6.82 2008 est 2 36.00 18.43 17.28 2008 est 2 3.00 1.81 1.65 2008 est 2 5 23.00 b … … 2005 3 6 31.10 … … 2008 est 2 7 5.50 … … 2008 est 2 8 2.56 … … 2008 est 2 9 69.00 67.00 70.00 2006 9 … 11.10 11.70 2002 4 10 4.80 2005 2 11 50.00 c 50.10 c 49.90 c 2002 1 12 1 642.00 2005 11 13 5.00 2007 est 13 14 0.67 2005 11 15 16 17 … … … … … … 2 d … … … … … 2006 5 … … … … … … … … … … … … 8 d … … … … … 2006 5 1 d 0 d 1 d … … … 2006 5 … … … … … … … … … … … … 910 910 0 0 0 0 2006 5 3 … … … … … 2006 5 8 055 … … 6 … … 2006 5 … … … … … … 192 93 99 0 0 0 2006 5 … … … … … … Leprosy - Type E Cholera Encephalitis - Unspecified Male FemaleMaleTotal 474 | COUNTRY HEALTH INFORMATION PROFILES Communicable and noncommunicable diseases Rate of growth of per capita GDP (%) - Type A Syphilis - Type B - Type C Dengue/DHF Gonorrhoea Malaria Plague Hepatitis viral Number of deaths Urban Number of new cases TotalFemale Selected communicable diseases Typhoid fever - 65 years and above Socioeconomic indicators Adult literacy rate (%) Rate of natural increase of population (% per annum) Urban population (%) Total fertility rate (women aged 15–49 years) Life expectancy (years) - at birth - 5–14 years Male Annual population growth rate (%) Percentage of population - 0–4 years Crude death rate (per 1000 population) Crude birth rate (per 1000 population) Estimated population ('000s) COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total … … … - Healthy Life Expectancy (HALE) at age 60 Per capita GDP at current market prices (US$) Environmental indicators Total Human development index Rural Proportion of vehicles using unleaded gasoline (%) … … Health care waste generation (metric tons per year) … VANUATU Year Source 18 25 411 … … 14 … … 2006 5 19 5 657 … … 2 … … 2006 5 20 128 … … … … … 2006 7 58 … … … … … 2006 7 21 96 d 37 d 59 d 58 d 36 d 22 d 2006 5 6 d 0 6 d 2 d 0 d 2 d 2006 5 0 d 0 d 0 d 0 d 0 d 0 d 2006 5 15 d 5 d 2006 5 2 d 1 d 1 d 1 d 0 d 1 d 2006 5 2 d 2 d 0 d 3 d 2 d 1 d 2006 5 7 d 6 d 1 d 6 d 4 d 2 d 2006 5 1 d 1 d 0 d 0 d 0 d 0 d 2006 5 15 d 11 d 4 d 8 d 7 d 1 d 2006 5 9 d 5 d 4 d 7 d 5 d 2 d 2006 5 22 414 d 216 d 198 d 53 d 35 d 18 d 2006 5 10 d 8 d 2 d 6 d 5 d 1 d 2006 5 48 d 26 d 22 d 13 d 6 d 7 d 2006 5 137 d 65 d 72 d 4 d 3 d 1 d 2006 5 34 d 26 d 8 d 10 d 8 d 2 d 2006 5 22 d 8 d 14 d 1 d 0 d 1 d 2006 5 23 120 d 58 d 62 d 8 d 5 d 3 d 2006 5 24 26 d 12 d 14 d … … … 2006 5 25 5 166 d … … 3 d … … 2006 5 122 d 66 d 56 d … … … 2006 5 101 … … … … … 2006 5 3 708 … … … … … 2006 5 19 d 3 d 16 d … … … 2006 5 26 566 d 409 d 157 d 252.63 d 182.56 d 70.08 d 2006 5 251 d 167 d 84 d 112.03 d 74.54 d 37.49 d 2006 5 3. Malaria 249 d 137 d 112 d 111.14 d 61.15 d 49.99 d 2006 5 241 d 149 d 92 d 107.57 d 66.51 d 41.06 d 2006 5 214 d 110 d 104 d 95.52 d 49.10 d 46.42 d 2006 5 181 d 125 d 56 d 80.79 d 55.79 d 25.00 d 2006 5 88 d 55 d 33 d 39.28 d 24.79 d 14.73 d 2006 5 85 d 37 d 48 d 37.94 d 16.51 d 21.42 d 2006 5 75 d 52 d 23 d 33.48 d 23.21 d 10.27 d 2006 5 62 d 27 d 35 d 27.67 d 12.05 d 15.62 d 2006 5 Acute respiratory infections Diabetes mellitus 9. Chronic obstructive pulmonary disease - Stomach INDICATORS Communicable and noncommunicable diseases Total Male TotalFemale 4. Asthma 5. Diarrhoea Female Leading causes of morbidity (inpatient care) Number of new cases Rate per 100 000 population Male Total MaleFemale Number of deaths Total FemaleMale - Suicide All types - Homicide and violence DATA Number of cases Injuries Mental disorders - Leukaemia - Lip, oral cavity and pharynx - Liver Leading causes of mortality and morbidity 8. Non-Insulin-dependent diabetes mellitus - Cerebrovascular diseases - Trachea, bronchus, and lung - Ischaemic heart disease - Rheumatic fever and rheumatic heart diseases - Breast Circulatory - Acute myocardial infarction - Colon and rectum - Cervix - Oesophagus Tuberculosis - All forms Diarrhoeal diseases 10. Hypertension 7. Food poisoning - New pulmonary tuberculosis (smear-positive) Cancers All cancers (malignant neoplasms only) - Hypertension All circulatory system diseases 6. Injuries COUNTRY HEALTH INFORMATION PROFILES | 475 1. Acute respiratory infection including Pneumonia 2. Cutaneous Abscess - Motor and other vehicular accidents - Occupational injuries VANUATU Year Source 27 112 56 56 49.99 25.00 25.00 2006 5 48 24 24 21.42 10.71 10.71 2006 5 42 21 21 18.75 9.37 9.37 2006 5 30 15 15 13.39 6.70 6.70 2006 5 24 10 14 10.71 4.46 6.25 2006 5 20 10 10 8.93 4.46 4.46 2006 5 11 8 3 4.91 3.57 1.34 2006 5 8 6 2 3.57 2.68 0.89 2006 5 8 4 4 3.57 1.79 1.79 2006 5 8 4 4 3.57 1.79 1.79 2006 5 28 37.00 2007 10 29 38.00 2007 16 30 3.00 2006 5 31 30.00 30.00 28.00 2006 5 32 98.00 … … 2006 5 33 82.00 … … 2007 7 76.00 … … 2007 7 76.00 … … 2007 7 76.30 … … 2007 7 34 109 d … 2006 5 7 d … 2006 5 11 d … 2006 5 33 d … 2006 5 8 d … 2006 5 35 NR NR NR NR NR NR 2007 7 0 0 0 … … … 2007 7 … … … … … … 0 0 0 … … … 2007 7 NR NR NR NR NR NR 2007 7 0 0 0 … … … 2007 7 0 0 0 … … … 2007 7 0 0 0 … … … 2007 7 NR NR NR NR NR NR 2007 7 0 0 0 … … … 2007 7 - Congenital rubella syndrome 10. Hypertension Percentage of pregnant women with anaemia 6. Liver diseases 7. Neonatal death 8. Diabetes mellitus - Diphtheria - Hib meningitis - Abortion Selected diseases under the WHO-EPI Percentage of newborn infants weighing at least 2500 g at birth - Hepatitis B III - Obstructed labour - Sepsis Rate per 100 000 population 4. Stroke 5. Pneumonia 3. Asthma Number of deaths Leading causes of mortality - Eclampsia - Haemorrhage - Total Tetanus - Rubella - Neonatal tetanus Immunization coverage for infants (%) Male Total Total Female FemaleTotal Male Female FemaleMaleFemale Number of cases Male Maternal, child and infant diseases 1. Heart disease 2. Cancer 9. Septicaemia Male Total - Mumps Percentage of women in the reproductive age group using modern contraceptive methods - POL3 - BCG - DTP3 - Measles Percentage of pregnant women immunized with tetanus toxoid (TT2) Neonatal mortality rate (per 1000 live births) Maternal causes Total Number of deaths DATAINDICATORS - Pertussis (whooping cough) - Poliomyelitis 476 | COUNTRY HEALTH INFORMATION PROFILES VANUATU Year Source 36 … 37 Public health facilities 5 334 2008 8 1 146 2008 8 32 376 2008 8 89 0 2008 8 Private health facilities 1 3 2008 8 4 … 2008 8 38 14.96 2006p 12 4.20 2006p 12 67.68 2006p 12 9.68 2006p 12 64.70 2006p 12 10.90 2006p 12 13.59 e 2006p 12 35.30 2006p 12 110.64 2006p 12 39 … Year Source 40 Physicians - Number 26 20 6 26 0 22 4 2008 8 - Rate per 1000 population 0.11 0.09 0.03 0.11 0.09 0.01 0.02 2008 8 Dentists - Number 3 2 1 3 0 2 … 2008 8 - Rate per 1000 population 0.01 0.01 0.00 0.01 0 0.01 … 2008 8 Pharmacists - Number 2 0 2 2 0 2 … 2008 8 - Rate per 1000 population 0.01 0.00 0.01 0.01 0.00 0.01 … 2008 8 Nurses - Number 332 115 217 110 222 332 … 2008 8 - Rate per 1000 population 1.42 0.49 0.93 0.47 0.95 1.42 … 2008 8 Midwives - Number 48 2 46 18 30 48 … 2008 8 - Rate per 1000 population 0.21 0.01 0.20 0.08 0.13 0.21 … 2008 8 Paramedical staff - Number 58 37 21 47 30 58 … 2008 8 - Rate per 1000 population 0.25 0.16 0.09 0.20 0.13 0.25 … 2008 8 Community health workers - Number 212 112 100 0 212 212 … 2008 8 - Rate per 1000 population 0.91 0.48 0.43 0.00 0.91 0.91 … 2008 8 41 Physicians 3 … … … … … … 2008 15 Dentists 1 … … … … … … 2007 15 INDICATORS - external resources for health as % of general government expenditure on health - per capita total expenditure on health (in US$) - total expenditure on health as % of GDP - amount (in million US$) - Outpatient clinics - General hospitals - Specialized hospitals - District/first-level referral hospitals - Primary health care centres Total health expenditure Health facilities Facilities with HIV testing and counseling services Health infrastructure - Hospitals U rb an Number Number of beds Health care financing - general government expenditure on health as % of total expenditure on health Government expenditure on health Private health expenditure External source of government health expenditure - general government expenditure on health as % of total general government expenditure - amount (in million US$) DATA Health insurance coverage as % of total population P ri va te M al e F em al e T o ta l INDICATOR R u ra l P u b lic Exchange rate in US$ of local currency is: 1 US$ = - private expenditure on health as % of total expenditure on health Human resources for health DATA Annual number of graduates COUNTRY HEALTH INFORMATION PROFILES | 477 VANUATU Year Source 41 Pharmacists 1 … … … … … … 2008 15 Nurses 21 … … … … … … 2007 15 Midwives 9 … … … … … … 2008 15 Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 19.50 17.80 1.70 2007 10 44 30.00 30.00 28.00 2006 9 45 36.00 36.00 34.00 2006 9 46 65.00 … … 2007 7 47 70.04 2006 5 48 92.90 2006 5 1.82 2006 5 91.08 2006 5 49 37.00 … … 2007 10 50 21.00 2003 14 51 Antenatal care coverage - At least one visit 67.00 2006 5 - At least four visits … 52 … … … 53 0.00 0.00 0.00 2007 16 54 0.00 0.00 0.00 2007 16 55 100.00 0.00 100.00 2007 16 56 3 645.00 … … 2006 7 57 2.71 … … 2006 7 58 65.30 … … 2007 10 59 … … … 60 65.00 … … 2006 7 61 8.00 … … 2006 7 62 73.00 … … 2006 7 63 64.00 … … 2005 7 64 60.00 86.00 52.00 2004 6 65 50.00 78.00 42.00 2004 6 66 … … … Proportion of population with access to affordable essential drugs on a sustainable basis Contraceptive prevalence rate Rural Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Total Urban Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source Adolescent birth rate HIV prevalence among population aged 15-24 years Tuberculosis death rate per 100 000 population Prevalence of underweight children under five years of age Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Infant mortality rate (per 1000 live births) Maternal mortality ratio (per 100 000 live births) DATA INDICATORS Health-related Millennium Development Goals (MDGs) INDICATORS Annual number of graduates Workforce losses/ Attrition Unmet need for family planning Male T o ta l Female M al e F em al e Total Percentage of people with advanced HIV infection receiving ART Tuberculosis prevalence rate per 100 000 population Malaria incidence rate per 100 000 population Estimated HIV prevalence in adults a Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria treatment measures P u b lic P ri va te Proportion of population in malaria-risk areas using effective malaria prevention measures Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) U rb an R u ra l Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) DATA 478 | COUNTRY HEALTH INFORMATION PROFILES VANUATU … p est NR a b c d e 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 HIV unit, Ministry of Health, Vanuatu Provisional Estimate Notes: Data not available Not included in the official list of MDG indicators Computed by Health Information and Evidence for Policy Unit of WHO Regional Office for the Western Pacific Human Resources for Health (HRH) Unit, Ministry of Health, Vanuatu. Health Information System (HIS) Unit, Ministry of Health. Meeting the MDG drinking water and sanitation target: The urban and rural challenge of the decade . Joint Monitoring Programme for water supply and sanitation. WHO Regional Office for the Western Pacific, data received from the technical units Vanuatu National Statistics Office Statistical Summary 2008. Secretariat of the Pacific Community, Noumea, New Caledonia. Urban and rural areas 2005 . Population Division Department of Economic and Social Affairs, UN New York 2006. [http:///www.unpopulation.org] WHO Global Burden of Disease (GBD) 2002 estimate. World Health Organization. [http://www.who.int/healthinfo/statistics/gbdwhr2004hale.xls] Sources: Not relevant Republic of Vanuatu Millennium Development Goals Report 2005, United Nations Development Programme. [http://hdr.undp.org/en/reports/global/hdr2007-2008/] WHO and UNICEF, 2006. [http://www.wssinfo.org/en/40_mdg2006]. Multiple Iindicator Cluster (MIC) Survey 2007, UNICEF, Vanuatu. Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world . United Nations Development Programme, New York USA 2007. World Health Organization. National health accounts [http://www.who.int/entity/nha/country/MYS.pdf]. 2008 World factbook. [https://www.cia.gov/library/publications/the-world-factbook/geos/nh.html#Econ] World Health Statistics 2008 . World Health Organization, 2008. [http://www.who.int/statistics] COUNTRY HEALTH INFORMATION PROFILES | 479 Report on First human resource national conference on health (September 2007) Figure refers to hospital data only Revised data Figure refers to those aged 15-24 years old 480 | COUNTRY HEALTH INFORMATION PROFILES VIET NAM 1. CONTEXT 1.1 Demographics The estimated population of Viet Nam rose to 84 155 800 people in 2006, 49.1% of them males. The population density is 252 persons per square kilometres, with most (73%) of the population living in rural areas. Over the past few years, Viet Nam has witnessed a gradual change in its population structure. In 2006, the percentage of the population aged 0-14 was 26.4%, a decrease of 8.6% in comparison with 1999. However, the proportion of those over 64 years increased rapidly (by 11%) over the same six-year period. The ageing trend in the population is remarkable. Viet Nam has 54 different ethnic groups, with the Kinh representing 87% of the total population. The rest are ethnic minorities scattered all over the country, mostly in mountainous and remote areas. Population migration is an important factor in rural-urban population growth differentials. The General Statistics Office survey on migration and family planning indicates that substantial spontaneous migration has been taking place and that migrants from rural to urban areas are numerous. In 2006, life expectancy at birth was 69 for males and 74 for females. In the same year, the population growth rate was 1.25% per annum, while the total fertility rate decreased from 2.33 in 1999 to 2.1 in 2006, reaching the replacement level fertility. In 2006, the crude birth rate was 17.4 per 1000 population and the crude death rate was 5.3 per 1000 population. Population migration is another important factor in population growth. The maternal mortality ratio was 130 per 100 000 live births in 1990. By 2006 the ratio had fallen to 75.1 per 100 000 live births. However, the MDG target of 32.5 maternal deaths per 100 000 live births by the year 2015 is a real challenge and will require drastic efforts. The under-five mortality rate was 55.4% in 1990 but fell by more than half to 26.0% by 2006. In order to achieve the MDG goal of 18.4% by 2015, however, progress must be accelerated. 1.2 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 at different levels are responsible for daily administration at the local level. Mass organizations, such as the Women’s Union, the Farmers’ Union and the Youth Union, exist to serve the interests of the population and to act 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 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. 1.3 Socioeconomic 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 COUNTRY HEALTH INFORMATION PROFILES | 481 industries. This has led to a strong gross domestic product (GDP) growth rate. Major economic achievements in the period 2001-2005 included, among others, a high level of economic growth, averaging 7.2% per year; comprehensive development; the solution of many social problems, especially hunger eradication and poverty reduction; and the improvement of people’s living standards. In 2000, the GDP per capita was only about US$ 400. It then increased to US$ 562 in 2004, higher than the mean for the lower-income-country group (US$ 530 per capita). By 2006, it stood at US$ 722, representing an 80% increase in comparison with 2000. It is expected that, by 2010, GDP will be 2.1 times higher, equivalent to US$ 1050-1100 in real terms. The General Statistics Office defines the poverty line in terms of average expenditure per capita per month. Using this definition, the poverty rate fell from 37.4% in 1998 to 16% in 2006. Poverty is concentrated in rural areas (20.4%). During 2001-2005, the economy created jobs for about 7.5 million workers. In 2005, 43 million people, about 52% of the population, were employed. The proportion of unemployed working - age people declined from 6.4% in 2001 to 5.3 % in 2005. It is planned that, by 2010, 8 million workers will be employed, reducing unemployment to 5%, and that farming will only involve 50% of the labour force. Access to safe water and sanitation has also improved. In 2006, 92% of the population had access to an improved water source and 65% had access to improved sanitation. About 21 000 tons of solid hospital waste is discharged each year from hospitals, sanatoriums and other health facilities. In the period from 1998 to 2002, there was considerable government investment in hospital waste treatment and disposal, mostly in the form of incinerators. Air pollution sources include industry, traffic, construction, traditional handicrafts, forest fires, and households. Of the facilities that pollute severely, 13% are cement factories, traditional handicraft villages using coal and wood, and waste collection facilities. In urban areas, traffic is the main cause of air pollution (70%). 1.4 Vulnerabilities and hazards In 2005, Viet Nam was affected by five major floods and four typhoons or tropical storms. A number of other rare natural disasters, such as a tornado, droughts, landslides and a forest fire also occurred. During the period from 2000 to 2005, between 128 and 591 deaths were caused by natural disasters annually, with a cumulative total of 1815 deaths over the six years. There were 594 recorded injuries from such disasters, although the actual figure might be higher. In total, those affected by disasters numbered from 403 000 to 5 million. The need to provide epidemic prevention and first aid as well as maintain basic health services when natural disasters occur poses a very great challenge. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition During the outbreak of severe acute respiratory syndrome (SARS), the preventive health system developed control measures to prevent the spread of the disease and was the first nation to effectively control SARS. Since 2003, no new case of SARS has been detected in the country. The first cases of avian flu in humans in Viet Nam were detected in the south of the country at the beginning of 2003. By 2005, there were 93 cases of confirmed A/H5N1 infection in humans, VIET NAM 482 | COUNTRY HEALTH INFORMATION PROFILES 42 of whom had died. It is predicted that avian influenza in humans will continue to be a complex issue in the future. In 2006, no new case of H5N1 was detected in Viet Nam. According to the Ministry of Health’s Department of Preventive Medicine, the incidence of dengue fever fell from 103 per 100 000 population in 1999 to 64 per 100 000 population in 2006. However, dengue incidence in children and adults has been increasing in recent years. Grade III and IV severe cases make up about 10%-13% of the total number of patients. In 2006, pneumonia was among the leading causes of morbidity, with 1179 cases, according to hospital statistics. HIV/AIDS cases are found in all provinces and cities of the country, with the majority concentrated in large cities and border provinces. In the period from 2003 to 2005, it is estimated that there were on average 23 000 new cases per year for the whole country. In 2006, there were 26 467 new HIV infections, 11 757 new cases of AIDS and 1731 reported deaths due to HIV/AIDS. In 2006, about 97 363 new cases of tuberculosis (all types) were detected, of whom 56 437 were pulmonary AFB-positive cases, 16 645 were cases of pulmonary tuberculosis with negative AFB and 17 711 were cases of non-pulmonary tuberculosis. Most tuberculosis patients in Viet Nam receive treatment under the directly observed, short-course (DOTS) strategy. With a high detection rate (85.0%) and a high cure rate (90.0%), the country has reached the WHO target for TB control. However, the tuberculosis control programme is facing new challenges, including drug-resistant bacillus (it is estimated that about 30% of new cases are drug-resistant to one drug and 2.3% to more than one) and tuberculosis among HIV/AIDS patients. Diarrhoea is also one of the leading causes of morbidity. Cholera, typhoid fever and dysentery still exist in some areas where the safe water supply and sanitary facilities remain inadequate. The mortality and morbidity rates for leprosy are not high. As of 2006, 666 new cases were reported, of which 37 were children under 15 years of age and 115 (17.3%) had established disabilities because of late detection. Viet Nam has reached the WHO leprosy elimination target on the national scale (the incidence rate is less than 1/10 000 people). Noncommunicable diseases have shown a tendency to increase in the last two decades, with total morbidity rising from 39.0% in 1986 to 62.4% in 2006, and mortality from 41.1% to 61.62%. Economic growth, the ageing population and lifestyle changes are the causes of an increasing burden of noncommunicable disease. Some noncommunicable diseases are common among children, such as nutritional disorders, asthma, vision disorders, dental caries, congenital malformations, and disability due to accident or illness. These diseases are also found among adults. Diseases commonly found among the elderly include cardiovascular disease, diabetes and cancer. Protein-calorific malnutrition and micronutrient deficiencies among children under five years of age have fallen significantly. However, a new trend towards overweight and obesity in children in cities and more economically developed areas has developed and needs to be controlled in to prevent the negative consequences that may result, such as diabetes and cardiovascular disease. The cancer incidence rate has been increasing, with about 77 282 new cases per year. The case fatality rate is very high, and cancer accounts for around 12% of total deaths each year. Lifestyle-related health problems are becoming increasingly important, particularly tobacco use, alcohol and drug abuse, injuries due to road accidents, violence, suicide and mental disorders. However, non-users, particularly women and children, may also suffer from external effects like passive or second-hand smoking, domestic violence, traffic accidents and exposure to HIV/AIDS. Unsafe sexual practices may lead to severe consequences for the health of other individuals, spouse or lover. In 2002, the adult male smoking prevalence rate was 56% (compared with 50% in 1998). Males aged 15 years and over consume an average of 12.5 cigarettes per day COUNTRY HEALTH INFORMATION PROFILES | 483 and a female of the same age 8.1 cigarettes per day. The VNHS 2001-2002 showed that 45.7% of males and 1.9% of females aged 15 and over drink once a week or more and each drinks 100 ml of spirits/wine or 1 can/bottle of beer or more each time. Injuries and accidents are causing serious concern in Viet Nam. In the period from 2002 to 2006, morbidity due to accidents, injuries and poisonings increased from 9.2% of all hospital admissions to 12.7 %, and hospital deaths related to accidents increased from 18.5% of all deaths in hospitals to 25.2%. Traffic accident is the third leading cause of mortality and the fifth leading cause of morbidity. 2.2 Outbreaks of communicable diseases In 2004, dengue fever was widespread in the Mekong delta, accounting for 84% of all infected cases, 9% in the South Central Coast, 5% in the Central Highlands and 2% in the North. There is not yet a vaccine to prevent dengue fever and treatment currently consists of analgesic and antipyretic drugs, such as acetaminophen. The prevention methods being applied include activities to reduce vectors in the community and to monitor when there is an outbreak. The health sector has made great efforts to reduce the incidence of dengue fever and, in 2006, no death due to dengue was detected. However, the sustainability of these achievements and the potential reduction of morbidity and mortality are still in question. The disease made a comeback in 2007. 2.3 Leading causes of mortality and morbidity In the past, communicable diseases were the leading causes of morbidity. In 2006, however, pneumonia, acute bronchitis, influenza and some noncommunicable diseases were also among the leading causes of morbidity (reported by public hospitals), particularly hypertension. Currently the vital registration system in Viet Nam does not operate effectively and cannot provide accurate data on the number of deaths, cause of death, age, sex and socioeconomic status of those who died. Therefore, it is still necessary to rely on mortality data collected in public hospitals for assessment of mortality patterns and trends. According to 2006 data from hospitals, injuries, pneumonia, accidents, AIDS and some NCDs are the leading causes of mortality. 2.4 Maternal, child and infant diseases More than 96.1% of pregnant women were cared for by skilled health personnel in 2006, with 84.4% of them delivered in health facilities. The maternal mortality ratio (MMR) fell from 200 per 100 000 live birth in the 1980s to 75.1 per 100 000 in 2006. There are huge differentials in MMR across regions, with the highest ratio in the Northern mountainous region and the Central Highlands. The infant mortality rate (IMR) has fallen rapidly in the past two decades; from 55.0 per 1000 live births in 1983 it declined to 31.2 in 2001 and 16.0 in 2006. Between 2001 and 2006 it declined by more than one half, with an average reduction of 3.28% per year. The MMR and IMR in Viet Nam are lower than in other Asia countries at the same level of economic development. The under-five mortality rate fell from 42% in 1999 to 26% in 2006, with an average decline of 2.3% per year. A recent study indicated that deaths among children under five years of age are concentrated in the perinatal period and are mainly due to premature births, asphyxia at birth and multiple birth defects. For children beyond the perinatal period, mortality is mainly due to drowning, respiratory infection and encephalitis. Child malnutrition is measured using two basic indicators: the proportion of children born with low birth weight and the proportion of children under five who are malnourished. The proportion of babies born with a low birth weight (under 2500g) declined from 7.3% in 2000 to 5.3% in 2006, and the under-five malnutrition rate fell from 33.8% to 25.2% in 2005. The VIET NAM 484 | COUNTRY HEALTH INFORMATION PROFILES problem of overweight children is beginning to appear, although still at an early stage, accounting for about 1.3% of children in the under-five age group and 0.8% in the 5-10 years age group. 2.5 Burden of disease No available information, with the exception of a few specific diseases noted previously. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The Ministry of Health is the government agency exercising state management in the field of people’s health care, including preventive medicine, consultation and treatment, rehabilitation, traditional medicine, pharmaceuticals including vaccine production, hazardous effects of cosmetics on human health, food hygiene and safety, medical equipment, health facilities, and health system development and management. 3.2 Organization of health services and delivery systems The health system in Viet Nam is a mixed public-private provider system in which the public system plays a key role in health care, especially in policy, 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. The health care network is organized under state administrative units: central, provincial, district, commune and village level, with the Ministry of Health at the central level. In the public sector, there are 727 general hospitals, 127 specialized hospitals and 11 458 primary health centres. The establishment of the grassroots health care network (including commune and district levels) as the foundation for people’s health care has yielded many benefits, contributing towards attainment of national health care goals for the entire population. Health stations in communes provide primary health services, including consultation, outbreak prevention and surveillance, treatment for common diseases, maternal and child health care, family planning, and hygiene and health promotion. The total number of private facilities rose from 56 000 in 2001 to 65 000 facilities in 2004. A total of 62 private hospitals account for 6.86 % of the total number of hospitals nationwide, with their 4456 beds accounting for 3.4% of the total number of hospital beds. Health care is further strengthened by the implementation of national health programmes to deal with diseases and health issues that are important public health concerns. For example, the tuberculosis control programme has made every effort, over many years, to maintain a high implementation rate, with DOTS covering 100% of the affected population. WHO has highly commended the programme and has ranked it as being on par with the best in the world. The expanded immunization programme is also considered a successful child health care intervention, with a marked reduction in vaccine-preventable diseases, including eradication of polio and elimination of neonatal tetanus and leprosy, according to WHO definitions. However, current challenges facing the programme in ensuring the continued quality of child immunization include vaccine maintenance, vaccination timeliness and safety, and the insufficient supply of newly developed vaccines to meet demand. The HIV/AIDS control programme is a National Target Health Programme for the period 2001-2005. Through its implementation, more than 90% of state officials, members of popular organizations, servicemen and students, more than 80% of urban populations, and 70% of rural and mountainous populations have gained a good knowledge about HIV/AIDS and have participated actively in HIV/AIDS interventions. COUNTRY HEALTH INFORMATION PROFILES | 485 3.3 Health policy, planning and regulatory framework 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. The current five-year plan for the health sector sets the following targets for 2010: • an increase in average life expectancy to 72 years; • a reduction in the maternal mortality ratio to below 70 per 100 000 live births; • a reduction in the infant mortality rate to below 16 per 1000 live births; • a reduction in the under-five mortality rate to below 25 per 1000 live births; • a reduction in the percentage of low-birth-weight infants to below 6%; • a reduction in the percentage of malnourished under-five children to below 20%; • an increase in the average height of young people to at least 160 cm; • an increase in the ratio of medical doctors per population to 4.5/10 000 people; and • an increase in 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: • the 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 care 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 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 medicines and implementing the national drug policy in order to promote rational and effective use of modern and traditional drugs; • developing new technologies 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 prescription and use of drugs and expenditure on medicines; and (4) respond to new public health problems, including non-communicable diseases. Some recent policies have begun to address those issues. In October 2002, the Prime Minister signed Decree 139 to establish the Health Care Fund for the Poor, which aims to provide free VIET NAM 486 | COUNTRY HEALTH INFORMATION PROFILES health care 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). 3.4 Health care financing Since 2000, the State has continued building and adjusting health financing policies with greater concern for efficiency and development than in the past. The broad orientation of health financing was decided upon in the 1990s through development of a health insurance scheme, the partial user-fee policy and the Government resolution on ‘social mobilization’ in the areas of education, health and culture. Health financing underwent further major changes in the 1990s as the State began to strongly promote decentralization of public finance, with major implications for the health sector. These orientations led to the creation of a health financing system that combines partially subsidized state health services with health services that collect user fees from patients. Nevertheless, the partial user fees created some contradictions and led to inequalities. As a consequence, the Government began to focus more on financial assistance for certain social groups, especially the poor. Total health expenditure in 2006 was 6.6% of GDP, with government expenditure accounting for only 32.4% of total health expenditure. Most health finance is used for curative and preventive care (98%): 84%-86% for curative care and 14%-16% for preventive care. There is little expenditure on scientific research and training (less than 2%). By 2006, about 36 million people (43.81% of the population) were enrolled in the public health insurance system, which includes compulsory insurance, voluntary insurance and insurance for the poor. 3.5 Human resources for health Currently, the number of health workers per bed for the whole country is 1.37 (including contract workers). The number of medical doctors per bed is about 2.6 per 10 beds on average, while the number of nurses is about 3 per 10 beds. The number of doctors per 1000 population is 0.6, the number of nurses is 0.7, and the number of pharmacists is 0.1 (not including the private sector). According to data from the Ministry of Health, of all health workers at the provincial level in the whole country, 81.8% are working in curative care, 13.0% in preventive medicine and 4% in management. Health staff are deployed at all levels (central provincial, district and communal) and in all provinces. In 2004, 24% were working at the commune level, participating directly in primary health care for the population. In the same year, 31% of health workers were employed at the district level and 45% at the provincial level. 3.6 Partnerships The external relations line of the Party and the State is one of multilateralism, diversification and expansion of health cooperation with international NGOs and foreign partners to gain financial, specific, technical and technological support. In implementation of this, international cooperation in health has created positive changes in terms of both quantity and quality. Since the 1990s, the number of donors/partners in health has increased considerably, together with the number of projects and the total value of aid. Aid to the health sector over past years has substantially helped to fill the gap created by the lack of funds from the State budget. ODA funds have come in diverse forms and have included grant aid from governments, international organizations, intergovernmental organizations and NGOs, and soft loans from international monetary institutions. COUNTRY HEALTH INFORMATION PROFILES | 487 3.7 Challenges to health system strengthening Despite the important achievements recorded in health care, the country is still beset with many problems. The Party Politburo’s Resolution No. 46 - NQ/TW on Health Care, Protection and Improvement for People in the new situation points out irrationalities in the health sector as follows: • The health system is slow to renew itself and has not adapted to the development of a socialist-oriented market economy and changes in disease patterns. • The quality of health services has not met the increasingly diversified needs of the people. • The health care conditions for the poor and those in remote areas and areas inhabited by ethnic groups remain very difficult. • Pharmaceutical production and supply capacity remains weak, and the price of pharmaceuticals remains high in comparison with people’s incomes. • The organization and operation of preventive medicine remains insufficient. A portion of the population lacks awareness about self-protection, self-care and health promotion. Environmental health and food safety have not been put under tight control. Therefore, 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 develop an efficient equity-oriented 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 health service responsiveness 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. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Health statistical year books, 1998-2004. Operator : Ministry of Health, 1999-2005. Title 2 : Statistical year book 2003 Operator : General Statistics Office, 2004. Title 3 : Vietnam development report: poverty. Features : Joint Donor Report to the Vietnam Consultative Group Meeting. Title 4 : Reports on National Health Survey 2001-2002. Operator : Ministry of Health and General Statistics Office, 2003. Web address : http://www.moh.gov.vn/tinbyt/ and http://www.gso.gov.vn/ VIET NAM 488 | COUNTRY HEALTH INFORMATION PROFILES Title 5 : Millennium Development Goals: closing the Millennium gaps. Features : Hanoi, United Nations, 2003. Title 6 : Health Policies and Guidelines Operator : Health Policy Unit, Ministry of Health, 2002. Web address : http://www.moh.gov.vn/tinbyt/ Title 7 : World health statistics 2007 Operator : World Health Organization 5. ADDRESSES MINISTRY OF HEALTH Office Address : 138A Giang Vo, Hanoi, Viet Nam Telephone : (84 4) 846 1325 Fax : (84 4) 846 4051 Website : http://www.moh.gov.vn 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 COUNTRY HEALTH INFORMATION PROFILES | 489 6. ORGANIZATIONAL CHART: Ministry of Health Year Source Demographics 1 331.21 2007 1 2 84 155.80 41 354.70 42 801.10 2006 est 1 3 1.25 … … 2006 est 1 4 7.50 7.80 7.10 2006 est 1 18.90 19.70 18.00 2006 est 1 7.00 5.80 8.30 2006 est 1 5 27.10 … … 2007 est 2 6 17.40 … … 2006 1 7 5.30 … … 2006 est 1 8 1..21 … … 2006 1 9 … 69.00 74.00 2006 3 … 60.00 63.00 2002 6 10 2.11 2006 est 1 11 92.70 94.50 90.90 2002 1 12 722.00 2006 1 13 12.99 2006 1 14 0.73 2005 7 15 … … … 16 21.00 … … 2005 3 17 628 … … 2 … … 2005 4 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 0 0 0 0 0 0 2006 3 68 532 … … 53 … … 2006 3 1 600 … … 74 … … 2006 3 5 526 … … 0 0 0 2006 3 666 … … … … … 2006 3, 8 22 637 … … 41 … … 2006 8 0 0 0 0 0 0 2006 3 2 070 … … 0 0 0 2006 3 3 021 … … 0 0 0 2006 3 Male Hepatitis viral Cholera Communicable and noncommunicable diseases - Type E - Type A - Unspecified Total Number of new cases Male Syphilis Typhoid fever 490 | COUNTRY HEALTH INFORMATION PROFILES Encephalitis Per capita GDP at current market prices (US$) Environmental indicators Total Human development index Rate of growth of per capita GDP (%) - Type B - Type C Adult literacy rate (%) Urban Number of deaths FemaleTotal Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Total fertility rate (women aged 15–49 years) Rate of natural increase of population (% per annum) Urban population (%) Estimated population ('000s) Annual population growth rate (%) Percentage of population - 0–4 years - 5–14 years Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male VIET NAM Rural Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Plague Leprosy Malaria Female Selected communicable diseases Dengue/DHF Gonorrhoea VIET NAM Year Source 18 182 018 … … 73 … … 2006 3 19 261 217 … … 186 … … 2006 3 20 97 363 … … … … … 2006 8 56 437 … … … … … 2006 8 21 77 282 … … 667 … … 2006 3 8 394 … … 14 … … 2006 3 6 285 … … 77 … … 2006 3 6 765 8 2006 3 727 … … 3 … … 2006 3 3 341 … … 62 … … 2006 3 1 868 … … 11 … … 2006 3 5 707 … … 99 … … 2006 3 5 860 … … 119 … … 2006 3 5 802 … … 143 … … 2006 3 22 139 515 … … 2 550 … … 2006 3 7 601 … … 628 … … 2006 3 70 003 … … 1 553 … … 2006 3 167 733 … … 253 … … 2006 3 29 100 … … 108 … … 2006 3 15 345 … … 54 … … 2006 3 23 22 262 … … 84 2006 3 24 35 514 … … 29 2006 3 25 196 294 … … 1 393 … … 2006 3 14 155 … … 50 … … 2006 3 103 814 … … 844 … … 2006 3 3 935 … … 38 … … 2006 3 15 417 … … 247 … … 2006 3 26 309 749 a … … 417.70 a … … 2006 3 271 173 a … … 365.68 a … … 2006 3 217 751 a … … 293.64 a … … 2006 3 164 863 a … … 222.32 a … … 2006 3 124 196 a … … 167.48 a … … 2006 3 117 737 a … … 158.77 a … … 2006 3 99 940 a … … 134.77 a … … 2006 3 79 933 a … … 107.79 a … … 2006 3 64 478 a … … 86.95 a … … 2006 3 58 902 a … … 79.43 a … … 2006 3 Male Female Total Female Leading causes of morbidity (inpatient care) - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections 5. Transport accident - Ischaemic heart disease 7. Influenza - Suicide - Breast - Rheumatic fever and rheumatic heart diseases Rate per 100 000 population Male Total COUNTRY HEALTH INFORMATION PROFILES | 491 4. Essential (primary) hypertension Number of cases 3. Acute bronchitis and acute bronchiolitis TotalFemale Circulatory - Cerebrovascular diseases - Liver - Stomach Tuberculosis - All forms - New pulmonary tuberculosis (smear-positive) Injuries Mental disorders - Trachea, bronchus, and lung All types - Homicide and violence 6. Gastritis and duodenitis 8. Diseases of appendix 9. Intracranial injury Diabetes mellitus Leading causes of mortality and morbidity - Motor and other vehicular accidents - Occupational injuries Female Number of deathsNumber of new cases Male INDICATORS DATA Total Male Cancers All cancers (malignant neoplasms only) - Hypertension All circulatory system diseases - Acute myocardial infarction - Leukaemia - Lip, oral cavity and pharynx 1. Pneumonia 2. Acute pharyngitis and acute tonsillitis 10. Urolithiasis VIET NAM Year Source 27 2 521 a … … 3.40 a … … 2006 3 1 179 a … … 1.59 a … … 2006 3 1 009 a … … 1.36 a … … 2006 3 964 a … … 1.30 a … … 2006 3 749 a … … 1.01 a … … 2006 3 653 a … … 0.88 a … … 2006 3 630 a … … 0.85 a … … 2006 3 601 a … … 0.81 a … … 2006 3 586 a … … 0.79 a … … 2006 3 519 a … … 0.70 a … … 2006 3 28 67.10 2006 1 29 90.50 2007 8 30 … 31 … … … 32 94.70 … … 2006 3 33 93.70 … … 2007 8 92.10 … … 2007 8 92.00 … … 2007 8 66.80 … … 2007 8 34 22 669 … 2006 3 445 15 2006 3 2 941 69 2006 3 … … 427 17 2006 3 35 NR … … … … … 2007 8 32 … … … … … 2007 8 … … … … … … 17 … … … … … 2007 8 NR … … … … … 2007 8 36 … … … … … 2007 8 183 … … … … … 2007 8 0 0 0 … … … 2007 8 3 530 … … … … … 2007 8 116 … … … … … 2007 8 Total FemaleMale Number of deaths Rate per 100 000 population DATA Total Male FemaleMale - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) - Pertussis (whooping cough) 7. Heart failure 6. HIV/AIDS 4. Intracerebral haemorrhage Leading causes of mortality 3. Transport accident 1. Intracranial injury - Congenital rubella syndrome - Poliomyelitis - Total Tetanus 10. Meningococcal infection Immunization coverage for infants (%) Percentage of women in the reproductive age group using modern contraceptive methods - Abortion Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth - Rubella - Sepsis - Eclampsia - Haemorrhage - Hepatitis B III - Hib meningitis - Diphtheria - Obstructed labour - POL3 Maternal causes - BCG - DTP3 5. Acute myocardial infarction 8. Stroke, not specified as haemorrhage or infarction Female Number of cases Female 9. Transient cerebral ischaemic attacks and related syndromes Percentage of pregnant women with anaemia Female 2. Pneumonia Total Male Number of deaths Total MaleTotal Maternal, child and infant diseases 492 | COUNTRY HEALTH INFORMATION PROFILES INDICATORS - Neonatal tetanus - Measles Selected diseases under the WHO-EPI VIET NAM Year Source 36 210 2007 10 37 Public health facilities 727 99 719 2006 3 127 27 102 2006 3 576 46 961 2006 3 11 458 46 013 2006 3 Private health facilities 62 4 456 2006 3 … … 38 3 987.53 2006p 5 6.60 2006p 5 46.26 2006p 5 1 290.84 2006p 5 6.80 2006p 5 67.60 2006p 5 15 994.30 2006p 5 39 45.00 2007 11 Year Source 40 Physicians - Number … … … … … 52 413 … 2006 3 - Rate per 1000 population … … … … … 0.62 … 2006 3 Dentists - Number … … … … … … … - Rate per 1000 population … … … … … … … Pharmacists - Number … … … … … 31 025 … 2006 3 - Rate per 1000 population … … … … … 0.37 … 2006 3 Nurses - Number … … … … … 57 003 … 2006 3 - Rate per 1000 population … … … … … 0.68 … 2006 3 Midwives - Number … … … … … 19 242 … 2006 3 - Rate per 1000 population … … … … … 0.23 … 2006 3 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians 4 545 b … … … … … … 2006 3 Dentists … … … … … … … Facilities with HIV testing and counseling services Health infrastructure INDICATORS - total expenditure on health as % of GDP - amount (in million US$) - Primary health care centres - external resources for health as % of general government expenditure on health - general government expenditure on health as % of total general government expenditure - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals Health facilities - Hospitals Number Number of beds Exchange rate in US$ of local currency is: 1 US$ = DATA R u ra l P u b lic DATA U rb an P ri va te M al e F em al e T o ta l External source of government health expenditure Human resources for health Health insurance coverage as % of total population INDICATOR - Outpatient clinics - per capita total expenditure on health (in US$) Private health expenditure - general government expenditure on health as % of total expenditure on health Health care financing Government expenditure on health Total health expenditure - private expenditure on health as % of total expenditure on health Annual number of graduates COUNTRY HEALTH INFORMATION PROFILES | 493 VIET NAM Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 26.00 … … 2006 3 44 16.00 … … 2006 est 1 45 26.00 … … 2006 est 3 46 82.80 … … 2007 8 47 75.10 2006 3 48 97.00 c 2006 3 … 84.40 2006 3 49 78.50 … … 2002 est 12 50 … 51 Antenatal care coverage - At least one visit 96.10 2005 3 - At least four visits … 52 4.80 … … 2002 est 12 53 0.30 … … 2005 13 54 0.54 … … 2007 14 55 30.00 … … 2007 15 56 26.00 … … 2006 8 57 0.05 … … 2006 8 58 … … … 59 … … … 60 225.00 … … 2006 8 61 23.00 … … 2006 8 62 85.00 … … 2006 8 63 90.00 … … 2005 8 64 92.00 98.00 90.00 2006 9 65 65.00 88.00 56.00 2006 9 66 … … … RuralTotal Urban Proportion of population in malaria-risk areas using effective malaria treatment measures Infant mortality rate (per 1000 live births) Under-five mortality rate (per 1000 live births) Proportion of 1 year-old children immunised against measles - Percentage of deliveries in health facilities (as % of total deliveries) Contraceptive prevalence rate - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Unmet need for family planning Health-related Millennium Development Goals (MDGs) Prevalence of underweight children under five years of age P ri va te INDICATORS DATA Total Male Tuberculosis death rate per 100 000 population Malaria death rate per 100 000 population Proportion of population in malaria-risk areas using effective malaria prevention measures Proportion of population with access to affordable essential drugs on a sustainable basis Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source Tuberculosis prevalence rate per 100 000 population Percentage of people with advanced HIV infection receiving ART M al e U rb an R u ra l P u b lic 494 | COUNTRY HEALTH INFORMATION PROFILES INDICATORS DATA Malaria incidence rate per 100 000 population Female Adolescent birth rate Proportion of births attended by skilled health personnel Maternal mortality ratio (per 100 000 live births) Annual number of graduates Workforce losses/ Attrition T o ta l F em al e HIV prevalence among population aged 15-24 years Estimated HIV prevalence in adults d VIET NAM … p est NR a b c d 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Viet Nam Ppopulation and AIDS indicator Survey 2005 Vietnam Social Security, 28/5/2008 Report No. 1516/BHXH.GDYT General Statistics Office of Viet Nam [http://www.gso.gov.vn] United Nations, Department of Economic and Social Affairs, Population Division (2007). World Population 2006 . Wallchart (United Nations publication, Sales No. E.08.XIII.3). HIV estimates and projections, Ministry of Health, Viet Nam. The World health report 2005: Changing history . Geneva, World Health Organization, 2005. Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world . United Nations Development Programme, WHO Regional Office for the Western Pacific, data received from the technical units World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: Sales No. E.08.XIII.6). United Nations, Department of Economic and Social Affairs, Population Division (2007). World Contraceptive Use 2007 . Wallchart (United Nations publication, Figure refers to physicians and pharmacists Figure applies to public health facilities Provisional Estimate Notes: Not relevant Figure applies to public hospitals Data not available Not included in the official list of MDG indicators Universal Access Health Sector Response Report , Ministry of Health, Viet Nam, January 2008. Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] New York USA 2007. [http://hdr.undp.org/en/reports/global/hdr2007-2008/] National Expanded Program of Immunization, Ministry of Health, Viet Nam Sources: Health Statistics Yearbook 2006: HSID. Planning and Finance Department, Ministry of Health, Viet Nam World Health Organization - National health accounts series [http://www.who.int/entity/nha/country/MYS.pdf] COUNTRY HEALTH INFORMATION PROFILES | 495 UNGASS Country Progress Report, 2008. 496 | COUNTRY HEALTH INFORMATION PROFILES WALLIS AND FUTUNA 1. CONTEXT 1.1 Demographics The Futuna and Wallis Islands are located in the Oceania Islands in the South Pacific Ocean, about two-thirds of the way from Hawaii to New Zealand. The total area is 274 square kilometres and includes Ile Uvea (Wallis Island), Ile Futuna , Ile Alofia 20 islets. The estimated population was 15 260 in 2006. About 30.4% were 0-14 years old and 9.8% were aged 60 years and older. 1.2 Political situation The Wallis and Futuna island group has been a French overseas territory since 1959. The Chief of State is President Nicolas Sarkozy of France (since 16 May 2007), represented by the High Administrator appointed by the French President on the advice of the French Ministry of the Interior. The High Administrator has been Richard Didier since 19 July 2006. The head of the government is the President of the Territorial Assembly, currently Patlione Kanimoa. The Council of the Territory consists of three kings with limited powers, appointed by the High Administrator on the advice of the Territorial Assembly. The presidents of the Territorial Government and the Territorial Assembly are elected by the members of the Assembly. 1.3 Socioeconomic situation The economy is limited to traditional subsistence agriculture, with about 80% of the labour force involved in agriculture (coconuts 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. 1.4 Vulnerabilities and hazards No available information. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition The leading noncommunicable diseases are: diabetes, obesity, rheumatism/gout and dental disease. For communicable diseases, they are leptospirosis, brucellosis, dengue, filariasis, tuberculosis, leprosy, hepatitis B, shigellosis and salmonellas. 2.2 Outbreaks of communicable diseases Wallis and Futuna has suffered the following dengue outbreaks: • 1971 – 500 cases reported (Type II) • 1976 – 500 cases reported (Type I) COUNTRY HEALTH INFORMATION PROFILES | 497 • 1979 – 300 cases reported (Type 4) • 1989/1990 – 2361 cases reported (Type IV) • 1998/1999 – 395 cases were reported (Type 2) • 2002/2003 – 2045 cases reported, including 1535 suspected cases, 166 confirmed cases, 280 hospitalized cases and two cases resulting in death. 2.3 Leading causes of mortality and morbidity No available information. 2.4 Maternal, child and infant diseases The estimated infant mortality rate was 5.9 per 1000 live births in 2003. In 2007, immunization coverage for infants was 88% for DTP3 and POL3, 91% for hepatitis B III and 100% for BCG. Only 86% of infants received measles immunization. In 2002, about 70% of pregnant women were immunized with tetanus toxoid. 2.5 Burden of disease No available information. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives No available information. 3.2 Organization of health services and delivery systems As for 2004, there were one hospital and three dispensaries in Wallis, and one hospital and two dispensaries in Futuna. Hospitalization and treatment are free of charge. Wallis hospital comprises an emergency ward, one medical ward with 21 beds, one surgical ward with 16 beds and two operation rooms, one delivery ward with two delivery rooms, one laboratory, one X-ray unit, two ultrasound rooms, one outpatient ward, one education room, and one pharmacy. Futuna hospital comprises one emergency ward, one internal medicine ward with 15 beds, one post- delivery ward with seven beds, one labour ward, one laboratory, one X-ray and ultrasound unit, one pharmacy, one dental unit, and one medical evacuation unit. 3.3 Health policy, planning and regulatory framework No available information. 3.4 Health care financing The French Government provides funding to support the health services. In 2003, the Government spent an estimated US$ 4.79 million on health, 7.6% of total government expenditure. 3.5 Human resources for health In Wallis, there are 62 medical staff, including one general surgeon, one anaesthesiologist, one gynaecologist, one polyvalent medical practitioner, one emergency doctor, five general doctors, three dental surgeons, one pharmacist, one anaesthesiology nurse, seven midwives, two physical therapists and 38 nurses. WALLIS AND FUTUNA 498 | COUNTRY HEALTH INFORMATION PROFILES In Futuna, there are 17 medical staff, including three general doctors, four midwives (three authorized), one dental surgeon, one physical therapist and eight nurses (only four authorized). 3.6 Partnerships No available information. 3.7 Challenges to health system strengthening No available information. 4. LISTING OF MAJOR INFORMATION SOURCES AND DATABASES Title 1 : Pacific Regional Information System (PRISM) Operator : Secretariat of the Pacific Community Web address : http://www.spc.int/prism/ Title 2 : SPC Statistics and Demographic Programme Web address : http://www.spc.int/demog/en/stats/2006/Pacific%20Island%20Populations%202006- 2015%20-%2030% Title 3 : Service territorial de la statistique Web address : http://www.spc.int/prism/wf/ 5. ADDRESSES MINISTRY OF HEALTH Postal Address : B.P. 4G Matautu 98600 Uvea Official Email Address : Sante.wf@wallis.co.nc Fax : (681) 72 2399 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/ (679) 330 4631/ (679)330 4635/ (679) 3317447 Fax : (679) 330 0462/ (679) 331 1530 Office Hours : 8 am to 5 pm Year Source Demographics 1 0.14 2006 1 2 15.26 7.66 7.60 2006 est 1 3 0.60 … … 2006-10 1 4 12.10 12.20 12.10 2006 est 2 21.70 21.60 21.80 2006 est 2 5.00 1.50 5.70 2006 est 2 5 0.00 … … 2005 est 2 6 19.40 … … 2003 5 7 5.90 … … 2003 5 8 1.63 … … 2003 1 9 74.30 73.10 75.50 2003 est 5 … … … 10 3.10 2003 est 5 11 78.80 a 78.20 a 78.20 a 2003 5 12 … 13 … 14 … 15 … … … 16 … … … 17 … … … … … … … … … …. … … … … … … … … … … … … … … … … … … … … … … … … … … 41 … … 0 0 0 2004 3 … … … … … … … … … … … … 0 0 0 … … … 2003 3 … … … … … … … … … … … … … … … … … … … … … … … … Communicable and noncommunicable diseases - Type E Hepatitis viral Cholera MaleTotal COUNTRY HEALTH INFORMATION PROFILES | 499 Dengue/DHF Gonorrhoea - Unspecified Per capita GDP at current market prices (US$) Environmental indicators Human development index Rate of growth of per capita GDP (%) Selected communicable diseases - Type A Number of deaths Rural Number of new cases Male FemaleTotal Total Urban Female - Type B - Type C Encephalitis Leprosy - Healthy Life Expectancy (HALE) at age 60 Socioeconomic indicators Total fertility rate (women aged 15–49 years) Adult literacy rate (%) Proportion of vehicles using unleaded gasoline (%) Health care waste generation (metric tons per year) Rate of natural increase of population (% per annum) Urban population (%) Life expectancy (years) - at birth Estimated population ('000s) Annual population growth rate (%) Percentage of population - 0–4 years - 5–14 years Crude birth rate (per 1000 population) Crude death rate (per 1000 population) - 65 years and above COUNTRY HEALTH INFORMATION PROFILE INDICATORS DATA Area (1 000 km2) Female WESTERN PACIFIC REGION HEALTH DATABANK, 2008 Revision Total Male WALLIS AND FUTUNA Malaria Plague Syphilis Typhoid fever WALLIS AND FUTUNA Year Source 18 … … … … … … 19 … … … … … … 20 7 … … … … … 2005 3 1 … … … … … 2005 3 21 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 22 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 23 … … … … … … 24 … … … … … … 25 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 26 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … - Colon and rectum - Cervix - Oesophagus Communicable and noncommunicable diseases Diarrhoeal diseases Acute respiratory infections - Ischaemic heart disease 500 | COUNTRY HEALTH INFORMATION PROFILES Male 4. 5. Leading causes of morbidity (inpatient care) 2. 10. Rate per 100 000 population Male FemaleTotalFemale Number of new cases FemaleMale Female Total Male Total Diabetes mellitus Leading causes of mortality and morbidity 6. 8. 9. Cancers All cancers (malignant neoplasms only) Total - New pulmonary tuberculosis (smear-positive) - Hypertension - Trachea, bronchus, and lung - Breast - Rheumatic fever and rheumatic heart diseases Injuries - Cerebrovascular diseases DATA Number of cases - Leukaemia - Lip, oral cavity and pharynx - Suicide All types - Homicide and violence - Motor and other vehicular accidents - Occupational injuries 1. Number of deaths Mental disorders All circulatory system diseases - Acute myocardial infarction Circulatory INDICATORS - Liver - Stomach Tuberculosis - All forms 7. 3. WALLIS AND FUTUNA Year Source 27 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 28 … 29 69.50 2002 3 30 … 31 … … … 32 … … … 33 100.00 … … 2007 3 88.00 … … 2007 3 88.00 … … 2007 3 91.00 … … 2007 3 34 … … … … … … … … … … 35 0 0 0 … … … 2007 3 0 0 0 … … … 2007 3 0 0 0 … … … 2007 3 0 0 0 … … … 2007 3 0 0 0 … … … 2007 3 0 0 0 … … … 2007 3 0 0 0 … … … 2007 3 0 0 0 … … … 2007 3 0 0 0 … … … 2007 3 0 0 0 … … … 2007 3 COUNTRY HEALTH INFORMATION PROFILES | 501 Male 7. 6. 4. Number of deaths Rate per 100 000 population - Mumps Percentage of pregnant women immunized with tetanus toxoid (TT2) - Measles 1. Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing at least 2500 g at birth Maternal causes Immunization coverage for infants (%) - POL3 - BCG - DTP3 5. Percentage of pregnant women with anaemia 10. Percentage of women in the reproductive age group using modern contraceptive methods 8. 9. INDICATORS Number of cases - Obstructed labour - Eclampsia - Haemorrhage - Abortion MaleTotal - Hepatitis B III - Rubella - Congenital rubella syndrome - Sepsis - Diphtheria Selected diseases under the WHO-EPI - Hib meningitis - Total Tetanus - Neonatal tetanus Total Total Female Female FemaleTotal MaleFemale Male FemaleTotal Male Maternal, child and infant diseases - Pertussis (whooping cough) - Poliomyelitis Number of deaths DATA 2. 3. Leading causes of mortality WALLIS AND FUTUNA Year Source 36 … 37 Public health facilities 2 59 2004 4 0 0 2006 4 0 0 2006 4 5 b 0 2006 4 Private health facilities … … … … 38 … … … 4.79 2003 est 5 … 7.58 c 2003 5 … … 95.42 2005 5 39 … Year Source 40 Physicians - Number 13 d … … … … … … 2004 4 - Rate per 1000 population 0.87 … … … … … … 2004 4 Dentists - Number 4 … … … … … … 2004 4 - Rate per 1000 population 0.27 … … … … … … 2004 4 Pharmacists - Number 1 … … … … … … 2004 4 - Rate per 1000 population 0.07 … … … … … … 2004 4 Nurses - Number 47 e … … … … … … 2004 4 - Rate per 1000 population 3.15 … … … … … … 2004 4 Midwives - Number 11 f … … … … … … 2004 4 - Rate per 1000 population 0.74 … … … … … … 2004 4 Paramedical staff - Number … … … … … … … - Rate per 1000 population … … … … … … … Community health workers - Number … … … … … … … - Rate per 1000 population … … … … … … … 41 Physicians … … … … … … … Dentists … … … … … … … 502 | COUNTRY HEALTH INFORMATION PROFILES Facilities with HIV testing and counseling services Health infrastructure - Hospitals - Outpatient clinics - amount (in million US$) - General hospitals - Specialized hospitals - District/first-level referral hospitals - Primary health care centres - per capita total expenditure on health (in US$) Government expenditure on health Total health expenditure - total expenditure on health as % of GDP - amount (in million US$) Health facilities INDICATORS Health care financing Human resources for health Health insurance coverage as % of total population P ri va te M al e F em al e T o ta l INDICATOR - external resources for health as % of general government expenditure on health External source of government health expenditure Private health expenditure - private expenditure on health as % of total expenditure on health - general government expenditure on health as % of total expenditure on health - general government expenditure on health as % of total general government expenditure Exchange rate in US$ of local currency is: 1 US$ = R u ra l P u b lic DATA U rb an Number DATA Number of beds Annual number of graduates WALLIS AND FUTUNA Year Source 41 Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … 42 Physicians … … … … … … … Dentists … … … … … … … Pharmacists … … … … … … … Nurses … … … … … … … Midwives … … … … … … … Paramedical staff … … … … … … … Community health workers … … … … … … … Year Source 43 … … … 44 5.90 … … 2003 est 5 45 … … … 46 86.00 … … 2007 3 47 … 48 … … … 49 … … … 50 … 51 Antenatal care coverage - At least one visit … - At least four visits … 52 … … … 53 … … … 54 … … … 55 … … … 56 … … … 57 … … … 58 … … … 59 … … … 60 60.00 … … 2006 3 61 7.00 … … 2006 3 62 … … … 63 … … … 64 … … 100.00 2006 6 65 … … … 66 … … … COUNTRY HEALTH INFORMATION PROFILES | 503 Infant mortality rate (per 1000 live births) Maternal mortality ratio (per 100 000 live births) Total Urban Rural Under-five mortality rate (per 1000 live births) - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) Proportion of population in malaria-risk areas using effective malaria treatment measures Unmet need for family planning Estimated HIV prevalence in adults g Adolescent birth rate Tuberculosis prevalence rate per 100 000 population Health-related Millennium Development Goals (MDGs) INDICATORS Tuberculosis death rate per 100 000 population Proportion of population using an improved sanitation facility Proportion of population using an improved drinking water source Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) Proportion of population with access to affordable essential drugs on a sustainable basis Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) Proportion of population in malaria-risk areas using effective malaria prevention measures Female T o ta l M al e F em al e DATA Male Percentage of people with advanced HIV infection receiving ART Prevalence of underweight children under five years of age Total P ri va te HIV prevalence among population aged 15-24 years Malaria death rate per 100 000 population Proportion of 1 year-old children immunised against measles Proportion of births attended by skilled health personnel - Percentage of deliveries in health facilities (as % of total deliveries) Contraceptive prevalence rate Malaria incidence rate per 100 000 population Workforce losses/ Attrition Annual number of graduates DATA U rb an R u ra l P u b lic INDICATORS WALLIS AND FUTUNA … p est NA a b c d e f g 1 2 3 4 5 6 504 | COUNTRY HEALTH INFORMATION PROFILES Figure includes dispensaries Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific Figure refers to physicians and specialists Figure includes 1 nurse anaesthesia and 4 unauthorized nurses Provisional Estimate Notes: Data not available Pacific Island Populations - Estimates and projections 2005-2015, Secretariat of the South Pacific, Noumea, 2006. http://www.spc.int/demog/en/index.html Not applicable Not included in the official list of MDG indicators Figure includes 1 unauthorized midwife Figure refers to aged 19 years and above World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: Special focus on Sanitation . UNICEF, New York and WHO, Geneva, 2008. [http://www.wssinfo.org/en/40_mdg2008.html] Sources: Demographic tables for the Western Pacific Region 2005-2010 . WHO Regional Office for the Western Pacific, Manila, 2005. WHO Regional Office for the Western Pacific, data received from technical units Information furnished by the WHO Representative to the South Pacific, 26 July 2007. Service territorial de la statistique (http://www.spc.int/prism/wf/). Statistical Tables STATISTICAL TABLES Table 1. Demographic Indicators Year Year Year 1 American Samoa 2007 est 68.20 0.20 341.00 2007 est 92.00 2007 est 2.00 2 Australia 2007 21 097.10 a 7 692.02 2.74 2007 est 89.00 a 2006–07 1.53 3 Brunei Darussalam 2006 383.00 5.77 66.38 2007 est 74.00 2006 3.50 4 Cambodia 2007 14 331.27 181.04 79.16 2007 est 21.00 2005 1.90 5 China 2007 1 321 290.00 9 600.00 137.63 2007 44.90 … 6 Cook Islands 2007p 21.10 0.24 87.92 2007 est 72.00 … 7 Fiji 2007p 860.74 18.33 46.96 2007 est 52.00 2006p 0.83 8 French Polynesia 2007 259.80 3.52 73.81 2007 est 52.00 2006 1.40 9 Guam 2006 est 167.37 0.54 309.94 2007 est 94.00 2006-10 1.10 10 Hong Kong (China) 2007 6 925.90 1.10 6 296.27 2007 95.02 2007 1.00 11 Japan 2007 est 127 775.00 377.91 d 338.11 2007 est 66.00 … 12 Kiribati 2006 est 93.71 0.81 115.69 2007 est 49.00 2006-10 1.90 13 Lao People's Democratic Republic 2005 5 621.00 236.80 23.74 2005 27.10 1995-2005 2.10 14 Macao (China) 2007 538.10 b 0.03 17 936.67 2007 100.00 2007 4.70 15 Malaysia 2007 27 173.60 329 876.00 0.08 2007 63.40 2006 1.90 16 Marshall Islands 2006 est 55.98 0.18 311.00 2007 est 67.00 2006-10 1.00 17 Micronesia, Federated States of 2007 est 108.03 0.70 154.33 2007 est 22.00 2006-10 0.50 18 Mongolia 2007 2 635.20 1 567.00 1.68 2007 60.70 2007 1.55 19 Nauru 2007 est 14.54 0.02 727.00 2007 est 100.00 2006-10 0.30 20 New Caledonia 2007p 244.60 19 100.00 0.01 2007 est 64.00 2006 2.50 21 New Zealand 2006 4 027.95 c 270.69 e 14.88 2007 est 86.00 2006 1.00 22 Niue 2006 est 1.54 b 0.26 5.92 2007 est 38.00 2001-06 - 2.40 23 Northern Mariana Islands 2006 est 84.49 0.47 179.77 2005 est 94.50 2006-10 3.20 24 Palau 2007 est 20.23 0.46 43.98 2007 est 77.00 2007 est 0.01 25 Papua New Guinea 2007 est 6.50 462.84 0.01 2007 est 14.00 2006 est 2.70 26 Philippines 2007 88 574.61 300.00 295.25 2007 est 64.00 2000-07 2.04 27 Pitcairn Islands 2007 0.05 0.04 1.25 … … 28 Republic of Korea 2008 48 606.79 99.70 487.53 2007 est 81.00 2008 0.33 29 Samoa 2007 est 186.65 2.94 63.49 2007 est 23.00 2001 1.00 30 Singapore 2007 3 583.10 b 0.71 5 046.62 2007 100.00 2007 1.60 b 31 Solomon Islands 2007 est 495.03 28.90 17.13 2007 est 18.00 2005 est 2.36 32 Tokelau 2006 est 1.53 0.01 153.00 2007 est 0.00 2001 0.40 33 Tonga 2007 est 109.00 0.75 145.33 2007 est 24.00 2001 0.30 34 Tuvalu 2006 est 9.65 0.03 321.67 2007 est 49.00 2006-10 0.10 35 Vanuatu 2008 est 233.03 12.19 19.12 2005 23.00 f 2005 2.56 36 Viet Nam 2006 est 84 155.80 331.21 254.09 2007 est 27.10 2006 est 1.25 37 Wallis and Futuna 2006 est 15.26 0.14 109.00 2005 est 0.00 2006-10 0.60 Total Population [1] Growth Rate [1] (%) Urban [1] (%) Density n 506 | COUNTRY HEALTH INFORMATION PROFILES Country/ area Population (per sq. km.)(1000 km 2 )('000s) Area [1] STATISTICAL TABLES Year 0-4 years 5-14 years 65+ years Male Female 2007 est 12.00 21.60 5.10 6.70 8.20 2007 21.60 4.00 2007 est 63.13 2005 3.25 2007 6.30 13.10 13.10 16.90 19.40 2006 12.80 6.50 2007 48.15 2006 1.81 2006 12.80 18.80 2.70 5.40 4.70 2006p 17.10 2.90 2006 52.21 2006p 2.20 2005 11.50 27.40 4.60 3.70 6.10 2004 25.00 6.70 2005 76.99 2005 3.40 2007 … 19.40 g 8.10 10.60 12.20 2006 12.09 6.81 2007 37.93 2001 1.90 2007 est 12.20 21.50 5.00 6.70 8.20 2007p 23.00 j 6.60 j 2007 est 63.13 2005 2.80 2007 est 11.60 20.40 4.10 6.10 7.50 2005 20.99 7.02 2007 est 56.49 2003 2.60 2006 … 43.10 h 6.10 7.90 7.90 2006 17.80 4.40 2006 96.85 2006 2.20 2006 est 10.50 19.90 6.20 9.30 9.80 2005 19.03 4.41 2006 est 57.73 2005 2.60 2007 3.10 10.20 12.58 15.50 15.60 2007 10.16 k 5.77 l 2007 34.92 2007p 1.00 2007 est 4.25 9.28 21.49 25.20 30.50 2006 8.70 8.60 2007 est 53.89 2006 1.32 2006 est 12.40 22.50 5.00 7.20 7.90 2005 26.80 8.70 2006 est 66.39 2005 3.50 2005 12.45 26.56 4.00 4.80 5.80 2005 34.30 9.80 2005 75.47 2002-05 4.07 2007 3.40 10.10 7.10 10.70 11.60 2007 8.60 2.90 2007 25.94 2007 1.00 2007 11.45 20.72 4.36 6.70 7.70 2007p 17.50 4.50 2007 57.55 2006 2.40 2007 est 12.30 22.30 5.10 7.20 7.90 2004 est 24.70 m 4.05 m 2007 est 65.84 … 2007 est 13.20 24.10 3.40 4.70 5.50 2003 23.30 4.40 2007 est 68.63 2000 4.40 2007 8.90 19.69 4.12 5.10 6.30 2007 21.70 6.20 2007 48.61 2007 2.30 2007 est 12.30 22.30 5.10 7.20 7.90 2002 31.20 7.80 2007 est 65.84 2007 3.40 2007 est 8.70 18.80 5.90 9.50 10.00 2007p 17.50 4.70 2008 est 50.15 2005 2.20 2006 6.83 c 14.70 c 12.32 c 16.10 18.50 2005 14.10 6.60 2006 51.17 2005 2.00 2006 est 9.17 i 17.56 i 10.73 i 6.80 8.20 2001-06 15.80 9.30 2006 est 59.90 2001-06 2.60 2006 est 12.30 22.50 5.00 7.20 7.90 2005 est 19.27 2.30 2006 est 66.11 2005 est 1.27 2007 est 6.84 17.25 5.70 7.20 7.90 2007 13.80 7.50 2007 est 42.43 2007 2.00 2007 est 14.00 26.00 2.30 4.10 4.00 2000 35.00 12.00 2007 est 73.31 2000 4.60 2005 11.47 f 22.28 f 4.40 f 5.60 6.80 2004 20.50 4.80 2005 61.68 2005-15 3.18 … … … 36.00 42.50 … … … … 2008 4.64 12.76 10.32 11.70 15.30 2006 9.20 5.00 2008 38.35 2006 1.13 2007 est 14.40 25.40 4.40 5.00 7.50 2004 20.80 3.00 2007 est 79.21 2004 3.40 2007 5.40 b 13.50 b 8.50 b 12.50 14.30 2007 10.30 b 4.50 b 2007 37.74 2007 1.29 b 2007 est 15.70 26.00 2.50 4.20 4.40 2005-10 30.50 7.20 2007 est 79.21 2005 3.80 2006 est 12.70 21.60 5.00 6.50 8.10 1997-2001 31.00 7.00 2006 est 64.74 1997-2001 4.90 2007 est 13.00 23.20 5.60 7.00 9.10 2004 24.80 6.10 2007 est 71.82 2005 3.40 2006 est 12.20 21.70 5.00 6.70 8.10 2002 27.10 9.90 2006 est 63.67 2002 3.70 2008 est 14.00 36.00 3.00 5.10 5.10 2008 est 31.10 5.50 2008 est 112.77 2005 4.80 2006 est 7.50 18.90 7.00 6.70 9.00 2006 17.40 5.30 est 2006 est 50.15 2006 est 2.11 2006 est 12.10 21.70 5.00 6.80 8.20 2003 19.40 5.90 2006 est 63.40 2003 est 3.10 Dependency Ratio o Aged 60 years or older by gender (2007) [2] (%)(%)(%) % Distribution of Population [1] (%) COUNTRY HEALTH INFORMATION PROFILES | 507 Total Fertility Rate (women 15-49 years) [1] Crude Death Rate [1] Crude Birth Rate [1] (per 1000 popn) (per 1000 popn) Year YearYear STATISTICAL TABLES Table 2. Socioeconomic Indicators Year Total Male Female Year Per capita (%) (%) (%) (in US$) (US$) Year 1 American Samoa … … … 2003 est 8052.00 x 2003 500.00 … 2003 14.00 2 Australia 2003 88.20 p … … 2007 44 700.00 y 2006p 3 180.61 8.77 2006p 16.98 3 Brunei Darussalam 2004 92.70 95.20 90.20 2006p 30 490.30 2006p 543.30 1.80 2006p 5.10 4 Cambodia 2004 73.60 84.70 64.10 2006 419.00 2006p 34.00 6.80 2006p 10.70 5 China 2005 88.96 94.14 83.85 2006 2 018.07 z 2006 93.94 4.67 2006p 1.00 6 Cook Islands 2005 100.00 100.00 100.00 2006 9 299.62 2006p 444.21 4.50 2006p 12.40 7 Fiji 2002 92.90 q … … 2006p 3 164.16 2006p 149.19 4.00 2006p 9.10 8 French Polynesia … … … 2003 17 000.00 … … … 9 Guam … … … 2002 15 439.00 aa 2000 1 032.36 … 2005 8.71 ak 10 Hong Kong (China) 2007 94.47 r 97.35 r 91.92 r 2007p 29 846.94 FY2004/05 1 283.00 ah 5.20 aj FY 2004/05 14.50 al 11 Japan 2000 est 99.00 … … 2006 34 181.00 2006p 2 690.43 7.90 2006p 17.70 12 Kiribati 2005 91.00 … … 2004 est 789.78 2006p 111.98 12.70 2006p 13.00 13 Lao People's Democratic Republic 2005 73.00 … … 2007 580.00 ab 2006 18.86 3.90 2006 3.30 14 Macao (China) 2007 95.00 97.70 92.40 2007 36 357.00 2006 648.70 2.20 2006 10.30 15 Malaysia 2004 95.10 … … 2007 5 937.00 2006 est 254.88 i 4.30 2006 est 7.00 16 Marshall Islands … … … FY2004 2 426.00 2006p 301.59 15.30 2006p 15.10 17 Micronesia, Federated States of 2000 92.40 92.90 91.90 FY2006 est 2 254.00 2005 281.00 12.80 2005 14.70 18 Mongolia 2007 97.80 98.00 97.50 2006 1 042.89 ac 2006p 52.69 5.10 2006p 11.00 19 Nauru … … … 2005-06 2 671.00 2006p 601.50 10.80 2006p 25.00 20 New Caledonia 2007 91.00 92.00 90.00 2001 19 190.49 ad 2003 1 941.48 8.70 … 21 New Zealand 2006 89.00 s … … 2005 24 996.00 ae 2006p 2 420.05 9.40 2006p 18.60 22 Niue 2003 100.00 100.00 100.00 2003 5 841.86 2006p 974.03 13.60 2006p 10.80 23 Northern Mariana Islands … … … … 2000 519.00 … … 24 Palau 2005 99.90 t 99.90 t 99.80 t 2003 est 5 678.00 2006 850.00 10.70 2006 16.40 25 Papua New Guinea 2000 56.20 v 61.20 v 50.90 v 2006 909.00 2006p 28.77 3.20 2006p 7.30 26 Philippines 1995-2005 92.60 … … 2007 1 461.33 2006p 45.34 3.30 2006p 6.40 27 Pitcairn Islands … … … … … … … 28 Republic of Korea 2002 97.90 99.20 96.60 2007 20 045.00 af 2006p 1 186.70 6.50 2006p 11.90 29 Samoa 2002 98.70 … … 2006 2 543.00 2006p 120.55 4.90 2006p 10.50 30 Singapore 2007 95.70 v … … 2007 35 163.00 FY2006 1 446.00 3.70 FY2006 6.30 31 Solomon Islands … … … 2002 494.68 2006p 33.39 4.70 2006p 12.60 32 Tokelau 2003 86.50 … … 2003 612.50 ag 1999-2000 341.07 ai … FY2003-04 12.50 33 Tonga 2000 98.80 … … 2003-04 1 780.00 2006p 118.20 5.40 2006p 11.10 34 Tuvalu … … … 2002 1 139.32 2006p 279.27 11.40 2006p 16.10 35 Vanuatu 2002 50.00 t 50.10 t 49.90 t 2005 1 642.00 2006p 67.68 4.20 2006p 10.90 36 Viet Nam 2002 92.70 94.50 90.90 2006 722.00 2006p 46.26 6.60 2006p 6.80 37 Wallis and Futuna 2003 78.80 w 78.20 w 78.20 w … … … 2003 7.58 i (%) General Government Expenditure on Health as % of Total General Government Expenditure [1] 508 | COUNTRY HEALTH INFORMATION PROFILES Country/ area Adult Literacy Rate [1] Year Per capita GDP [1] Health Expenditure [1] As % of GDP STATISTICAL TABLES Table 3. Health and Human Rights Instruments 1 American Samoa … … … … … … 2 Australia 1990 2003 1983 2004 1975 2007 3 Brunei Darussalam 1995 ef 2001 2006 ef … … … 4 Cambodia 1992 ef 1997 1992 ef 2004 1992 ef … 5 China 1992 2003 1980 2004 2001 2004 6 Cook Islands 1997 ef … 2006 ef 2006 … … 7 Fiji 1993 1996 1995 ef 2000 … … 8 French Polynesia … … … … … … 9 Guam … … … … … … 10 Hong Kong (China) … … … … … … 11 Japan 1994 2001 1985 2002 1979 1999 12 Kiribati 1995 ef 2005 2004 ef … … … 13 Lao People's Democratic Republic 1991 ef 1996 1981 2003 2007 … 14 Macao (China) … … … … … … 15 Malaysia 1995 ef 2006 1995 ef 2004 … … 16 Marshall Islands 1993 2004 2006 ah … … … 17 Micronesia, Federated States of 1993 ef 1996 2004 ah … … … 18 Mongolia 1990 2003 1981 2007 1974 1998 19 Nauru 1994 ef … … … … … 20 New Caledonia … … … … … … 21 New Zealand 1993 2001 1985 2006 1978 2001 22 Niue 1995 ef … … … … … 23 Northern Mariana Islands … … … … … … 24 Palau 1995 1998 … … … … 25 Papua New Guinea 1993 2002 1995 ef … 2008 … 26 Philippines 1990 2003 1981 2004 1974 2006 27 Pitcairn Islands … … … … … … 28 Republic of Korea 1991 2000 1984 2006 1990 ef 2007 29 Samoa 1994 2005 1992 ef 2003 … … 30 Singapore 1995 2002 1995 ef 2004 … … 31 Solomon Islands 1995 2001 2002 ef … 1982 eg 2001 32 Tokelau … … … … … … 33 Tonga 1995 … … … … … 34 Tuvalu 1995 … 1999 ef … … … 35 Vanuatu 1993 1997 1995 ef 2005 … … 36 Viet Nam 1990 2002 1982 2005 1982 ef 1992 37 Wallis and Futuna … … … … … … COUNTRY HEALTH INFORMATION PROFILES | 509 Year of ratification Year of ratification (as of March 2008) International covenant on economic, social and cultural rights [3,4] Latest submission of report (as of March 2008) Country/ area Convention on the rights of the child [3,4] Convention on the elimination of all forms of discrimination against women [3,4,5] Latest submission of report Latest submission of report (as of March 2008) Year of ratification STATISTICAL TABLES Table 4. Poverty- and Gender-related Development Indicators $1 a day National poverty line 1990-2005 am 1990-2003 am 2005 2005-07 ap 2005 as 1 American Samoa … … … … … … … 2 Australia 0.96 … 12.20 an 0.96 0.85 28.30 0.70 3 Brunei Darussalam 0.89 … … 0.89 … … aq 0.42 4 Cambodia 0.60 34.10 35.00 0.59 0.38 11.40 0.74 5 China 0.77 9.90 4.60 0.78 0.53 20.30 0.64 6 Cook Islands … … … … … … … 7 Fiji 0.76 … … 0.76 … … ar 0.48 8 French Polynesia … … … … … … … 9 Guam … … … … … … … 10 Hong Kong (China) 0.94 … … 0.93 … … 0.56 11 Japan 0.95 … 11.80 an 0.94 0.56 11.10 0.45 12 Kiribati … … … … … … … 13 Lao People's Democratic Republic 0.60 27.00 38.60 0.59 … 25.20 0.51 14 Macao (China) 0.93 … … … … … … 15 Malaysia 0.81 <2.00 15.50 ao 0.80 0.50 13.10 0.36 16 Marshall Islands … … … … … … … 17 Micronesia, Federated States of … … … … … … … 18 Mongolia 0.70 10.80 36.10 0.70 0.43 6.60 0.50 19 Nauru … … … … … … … 20 New Caledonia … … … … … … … 21 New Zealand 0.94 … … 0.93 0.81 32.20 0.70 22 Niue … … … … … … … 23 Northern Mariana Islands … … … … … … … 24 Palau … … … … … … … 25 Papua New Guinea 0.53 … 37.50 0.53 … 0.90 0.72 26 Philippines 0.77 14.80 36.80 0.77 0.59 22.10 0.61 27 Pitcairn Islands … … … … … … … 28 Republic of Korea 0.92 <2.00 … 0.91 0.51 13.40 0.40 29 Samoa 0.79 … … 0.78 … 6.10 0.38 30 Singapore 0.92 … … … 0.76 24.50 0.51 31 Solomon Islands 0.60 … … … … 0.00 0.50 32 Tokelau … … … … … … … 33 Tonga 0.82 … … 0.81 … 3.30 0.48 34 Tuvalu … … … … … … … 35 Vanuatu 0.67 … … … … 3.80 0.68 36 Viet Nam 0.73 … 28.90 0.73 0.56 25.80 0.70 37 Wallis and Futuna … … … … … … … Ratio of estimated female to male earned income [6] Seats in parliament held by women [6] (% of total) 510 | COUNTRY HEALTH INFORMATION PROFILES Country/ area Human Development Index (HDI) value [6] Population below income poverty line (%) [6] 2005 Gender- empowerment measure (GEM) value [6] Gender-related development index (GDI) value [6] STATISTICAL TABLES Table 5. Health Status Indicators Year Total Male Female Year Neonatal Infant Under-five (years) (years) (years) (per 1000 live births) (per 1000 live births) (per 1000 live births) Year (per 100 000 live births) 1 American Samoa 2005 75.84 72.27 79.62 2007 6.20 11.80 (2002) 4.90 2002 123.00 2 Australia 2004-06 … 78.70 83.50 2006 3.20 4.70 5.57 2000-02 11.00 ax 3 Brunei Darussalam 2006 … 74.10 77.70 2006p 4.70 6.60 9.20 2006p 15.30 4 Cambodia 2003 … 60.00 65.00 2005 28.00 66.00 83.00 2005 472.00 5 China 2000 71.40 69.60 73.70 2006 12.00 17.20 20.60 2006 41.10 6 Cook Islands 2005 69.00 65.00 73.00 2005 9.90 (2007p) 10.50 11.00 2005 0.00 7 Fiji 2007 … 68.00 72.00 2005 15.37 (2007) 18.40 25.81 2005 50.49 8 French Polynesia 2006 … 73.00 76.90 2005 3.80 5.30 14.70 2005 0.38 9 Guam 2005 78.40 75.34 81.64 2003 5.20 (2004) 12.30 (2005 est) 10.00 2003 0.00 10 Hong Kong (China) 2007p … 79.27 85.37 2007p 1.08 l 1.72 l 2.15 l 2007p 1.42 k 11 Japan 2006 … 79.00 85.81 2006 1.30 2.60 3.60 2006 4.90 12 Kiribati 2005 61.00 58.90 63.10 2000 (2005) 27.00 au (2005) 52.00 69.00 2005 158.00 13 Lao People's Democratic Republic 2005 61.00 59.10 63.00 2005 26.00 56.00 68.00 2005 405.00 14 Macao (China) 2003-06 81.50 79.00 83.80 2007 1.50 2.40 3.50 2007 0.00 15 Malaysia 2006 est 74.05 71.90 76.40 2007p (2006p) 3.90 6.30 8.10 2006 30.00 16 Marshall Islands 2004 … 67.00 70.60 FY2004 12.27 23.00 … FY 2004 0.00 17 Micronesia, Federated States of 2006 est 69.00 67.00 70.00 2006est (2004)11.00 est 33.00 41.00 2003 317.00 ay 18 Mongolia 2007 66.54 63.13 70.23 2007 8.80 17.80 22.10 2007 89.60 19 Nauru 2006 est 61.00 59.00 64.00 2006 est (2002) 6.30 25.00 30.00 2002 300.00 20 New Caledonia 2006 75.20 71.90 78.60 2005 2.50 (2007p) 6.60 (2002) 9.06 2006 29.60 21 New Zealand 2003-05 78.81 77.50 81.70 2006 5.76 est 4.80 (2003) 6.34 2004 6.81 22 Niue 2001-06 … 67.00 at 76.00 2006 (2005) 0.00 0.00 av 0.00 2006 0.00 23 Northern Mariana Islands 2005 est 75.88 93.31 78.61 2005est … 7.11 … 2000 0.00 24 Palau 2007 est … 67.80 75.70 2007 7.17 7.17 7.17 2007 0.00 25 Papua New Guinea 2000 53.00 52.50 53.60 2006 26.00 49.00 64.00 2006 870.00 26 Philippines 2004 67.00 64.00 f 70.00 f 2006 12.00 24.00 32.00 2006 162.00 27 Pitcairn Islands … … … … … … … 28 Republic of Korea 2006 79.18 75.74 82.36 2002 3.30 (2003) 5.30 (2006) 5.70 2003 15.00 29 Samoa 2001 72.80 71.80 73.80 2002 4.20 (2005-06) 13.70 aw (2002) 13.70 2005-06 3.00 30 Singapore 2007 80.60 m 78.20 m 82.90 m 2007 1.30 2.10 m 3.00 2007 7.60 31 Solomon Islands 2005 63.40 62.20 64.30 2002 12.00 au (2005-10) 31.40 (2005 est) 52.00 2005 236.00 32 Tokelau 1997-2000 … 68.40 71.30 2003 40.00 i (1997-2000) 33.00 … 2001-02 0.00 33 Tonga 2005 … 70.00 72.00 2000 10.00 au (2005) 11.80 (2001) 16.59 2005 227.80 34 Tuvalu 2002 63.60 61.70 65.10 2003 … 21.60 32.40 2003 0.00 az 35 Vanuatu 2006 69.00 67.00 70.00 2006 30.00 30.00 36.00 2006 70.04 36 Viet Nam 2006 … 69.00 74.00 2006est … 16.00 26.00 2006 75.10 37 Wallis and Futuna 2003 est 74.30 73.10 75.50 2003est … 5.90 … … COUNTRY HEALTH INFORMATION PROFILES | 511 Country/ area Life expectancy at birth [1] Mortality rates [1] Maternal mortality ratio STATISTICAL TABLES Table 6. Maternal, Child Care and Nutritional Indicators Year Year Year Year 1 American Samoa 2000 33.00 2002 100.00 2002 99.00 2002 1.00 2 Australia 2001 65.00 ba 2005 99.60 2005 99.40 2005 0.20 3 Brunei Darussalam … 2006 99.73 2006 99.63 2006 0.10 4 Cambodia 2005 27.20 2005 44.00 2005 22.00 2005 22.00 5 China 2002 est 84.60 2006 97.80 2006 88.40 … 6 Cook Islands 2005 39.87 2005 100.00 2005 99.63 2005 37.00 7 Fiji 2005 42.29 2007 98.50 … … 8 French Polynesia … 2004 99.97 2004 99.01 f 2004 0.96 9 Guam … … 2004 87.22 … 10 Hong Kong (China) … 2007 100.00 2007 100.00 bd 2007 0.00 bh 11 Japan 2004 est 43.90 2006 99.90 2006 99.76 2006 0.19 12 Kiribati 2005 18.46 2005 89.65 i 2005 85.00 be 2005 4.65 be 13 Lao People's Democratic Republic 2005 36.60 2005 18.50 2005 11.00 2005 7.50 14 Macao (China) … 2007 100.00 2007 100.00 2007 0.00 15 Malaysia 2006 4.30 2006 100.00 2006 97.40 2006 2.60 16 Marshall Islands 2001 34.00 bb … … … 17 Micronesia, Federated States of 2000 70.00 … … … 18 Mongolia 2007 52.84 2007 99.70 2007 99.60 2007 0.10 19 Nauru … 2007 97.00 2007 96.00 2007 1.00 20 New Caledonia 2005 33.00 2005 91.97 2005 87.60 2005 4.37 21 New Zealand 2002 est 72.00 2001 100.00 2004 est 95.30 … 22 Niue 2005 22.00 2006 100.00 2006 100.00 2006 0.00 23 Northern Mariana Islands 2000 64.00 … … … 24 Palau 2006 22.83 2007 100.00 2007 100.00 2007 0.00 25 Papua New Guinea 2006 26.00 … 2006 39.00 … 26 Philippines 2006 35.90 2006 63.70 2006 42.40 2006 20.30 27 Pitcairn Islands … … … … 28 Republic of Korea 2006 79.90 2006 100.00 2006 99.90 2006 0.10 29 Samoa 2004 53.90 2004 100.00 2004 91.00 2004 9.00 30 Singapore 2003 72.50 … 2007 99.68 bf … 31 Solomon Islands 2005 25.00 … 2003 43.00 bg … 32 Tokelau … … … … 33 Tonga 2002 23.10 2004 99.00 2004 98.00 2004 1.00 34 Tuvalu 2001 28.50 2002 100.00 … … 35 Vanuatu 2007 37.00 2006 92.90 2006 91.08 2006 1.82 36 Viet Nam 2006 67.10 2006 97.00 bc 2006 84.40 … 37 Wallis and Futuna … … … … (%) 512 | COUNTRY HEALTH INFORMATION PROFILES Country/ area (%)(%) Maternal and Child Care (%) % deliveries at home attended by skilled health personnel [1] % of women in reproductive age group using modern contraceptive methods [1] % deliveries attended by skilled health personnel [1] % of deliveries in health facilities [1] STATISTICAL TABLES Year % Year Total Male Female Year … 2006 97.15 bf … … … … 2005 93.60 94.10 93.10 … 2006 79.00 2005 90.60 … … … 2007 50.00 2005 90.00 bj … … 2005 69.00 … 2006 97.78 … … … 2007 67.00 2005 97.70 … … 2007 67.00 … 2005 91.00 … … … 2006 NR 2004 93.08 … … … 2006 NR 2004 91.54 bi … … … … 2006 94.89 bk 95.54 bl 94.17 bl … 2007 42.90 2006 90.40 91.50 89.30 … 2007 42.90 2005 91.80 92.30 91.40 … 2007 26.00 … … … … … 2007 93.10 94.20 91.90 … 2006 90.00 2006p 89.90 … … … 2007 90.00 FY2004 87.63 … … … 2007 NR 2000 82.00 … … … bm … 2007 96.20 … … … … … … … … … 2006 91.50 … … … 2006 NR 2006 94.18 … … … 2007 NR 2005 100.00 100.00 100.00 … 2006 NR 2000 81.01 … … … 2007 20.00 2007 91.00 91.40 90.52 … 2007 43.00 2006 90.70 … … … 2007 36.00 2003 54.80 … … 2006 69.00 9 … … … … … … 2006 95.63 96.10 95.12 … 2006 1.00 2004 98.80 … … … … 2007 90.70 … … … 2007 71.00 … … … … 2007 100.00 2003 100.00 … … … 2007 98.30 2002 97.50 … … … 2007 100.00 2000 95.00 … … 2007 100.00 2007 38.00 2006 98.00 … … … 2007 90.50 2006 94.70 … … 2006 80.30 2002 69.50 … … … … COUNTRY HEALTH INFORMATION PROFILES | 513 Maternal and Child Care % of women given at least 2 doses of tetanus toxoid TT2+ [1] % of newborn babies weighing at least 2500 grams at birth [1] Proportion of 1-year old children protected against neonatal tetanus through immunization of their mothers [7,8] STATISTICAL TABLES Table 6. Maternal, Child Care and Nutritional Indicators Year (%) (%) (%) (%) 1 American Samoa 1997 … 20.00 bn … … 2 Australia 2001 … 46.00 … … 3 Brunei Darussalam 2003 … 14.60 … … 4 Cambodia 2005 35.00 60.00 82.00 35.0 5 China 2000 … 48.70 (urban) 60.40 (rural) bo … … 6 Cook Islands 1998 … 19.00 45.00 … 7 Fiji 1995 … 53.00 52.00 … 8 French Polynesia 2001 … 19.00 … … 9 Guam … … … … 10 Hong Kong (China) 2006 … 13.00 [1] bp … … 11 Japan 2000 … 41.00 bo 97.90 … 12 Kiribati 1995-2003 … 80.00 bo … (2003) 45.00 13 Lao People's Democratic Republic 2000 … 16.90 bp 9.90 28.80 14 Macao (China) … … … … 15 Malaysia 1995-2003 … 29.00 bo … … 16 Marshall Islands 1995-2003 … 63.00 bo … (2003) 23.00 17 Micronesia, Federated States of 1995-2003 … 60.00 bo … (2003) 95.00 bq 18 Mongolia 2005 77.50 38.30 8 30.50 8 64.60 8 19 Nauru … … … … 20 New Caledonia … … … … 21 New Zealand … … … … 22 Niue … … … … 23 Northern Mariana Islands … … … … 24 Palau 1995-2003 … 59.00 bo … … 25 Papua New Guinea 2004 … 21.00-86.00 60.00 (2003) 1.00 26 Philippines 2003 54.00 33.50 57.90 76.60 27 Pitcairn Islands … … … … 28 Republic of Korea 1998 … 14.00 bn 92.00 … 29 Samoa 1999 … 58.30 bn … … 30 Singapore … … … … 31 Solomon Islands 1995-2003 … 65.00 bo … … 32 Tokelau … … … … 33 Tonga 1999 … 61.00 bo 37.00 … 34 Tuvalu … … … … 35 Vanuatu 1996 … 73.00 bn … … 36 Viet Nam 2006 57.80 16.90 8 70.40 8 53.10 br 37 Wallis and Futuna … … … … 514 | COUNTRY HEALTH INFORMATION PROFILES Country/ area Maternal and Child Care Vitamin A supplementation to children aged 6-59 months old [10] Proportion of babies exclusively breastfed for the first six months [10] Proportion of babies aged 6-9 months receiving breastmilk and complementary food [10] Proportion of babies <12 months of age with breastfeeding initiated within one hour of birth [7,8] STATISTICAL TABLES Year Year Year ≤2 SD weight/ age [1] ≤2 SD height/ age [10] ≤2 SD weight/ height [10] (%) (%) (%) (%) … … … … … … ... 1995-96 0.00 10, bs 0.00 bs 0.00 bs … … 1995-96 14.00 10 13.00 3.60 2005 58.40 2005 48.30 f 2005 35.55 43.70 11 8.30 11 … … 2002 7.80 14.30 (2000) 2.20 … … … … … … … 1993 7.90 10 2.70 8.20 … … 2004 3.10 … … … … … … … … … … … … … … … … … … … 1999 13.00 10 (1985) 28.30 (1985) 10.80 2000 95.50 2000 36.00 2000 40.00 40.70 15.40 … … … … … … … 2006 10.10 … … … … 1999 27.00 10 … bv … bx … … … … … 2005 63.00 2005 85.60 2007 6.30 (2004) 26.20 11 (2004) 0.00 11 … … … … … … … 1996 … 10, bt … … … … … … … … … 2005 0.00 … … … … … … … … … 1997 1.40 10 … … … … 2006 30.50 (1982-83) 43.20 bw (1982-83) 5.50 bw 2003 58.90 2003 46.30 f 2003 27.60 30.00 5.30 … … … … … … … 1997 3.00 10, bu … … … … 1999 1.90 10 4.20 0.90 … … 1995-2003 14.00 (2000) 2.20 (2000) 2.40 … … 1999 21.00 10 (1989) 27.30 (1989) 6.60 … … … … … … … 1986 … 1.30 0.90 … … … … … … … 2007 19.50 (1996) 20.00 (1996) 6.00 2006 94.70 2006 82.70 2006 26.00 (2004) 30.70 (2003) 7.20 … … … … … COUNTRY HEALTH INFORMATION PROFILES | 515 Maternal and Child Care National underweight, stunting and wasting prevalence (age 0-59 months) Proportion of children aged 0-59 months who had diarrhoea in the past 2 weeks and were treated with ORT [7,8] Proportion of children aged 0-59 months who had suspected pneumonia in the past 2 weeks and were taken to an appropriate health care provider [7,8] (%) STATISTICAL TABLES Table 7. Environmental Health and Prevalence of Tobacco Use Indicators Year Total Male Female Year of survey Total Male Year (%) Year (%) (%) (%) (%) (%) (%) (%) 1 American Samoa 2004 99.00 2004 99.00 2006 29.90 38.10 21.60 2005 16.70 18.30 15.10 2 Australia 2006 100.00 2006 100.00 2001 … 21.00 18.00 … … … 3 Brunei Darussalam 2005 99.00 2002 80.00 1997 … 36.10 6.40 … … … 4 Cambodia 2006 65.00 2006 28.00 1999 … 66.70 10.00 2003 2.50 f 4.60 f 0.20 f 5 China 2006 88.00 2006 65.00 1998 … 53.40 4.00 2005 1.70 ce 2.70 ce 0.80 ce 6 Cook Islands 2006 95.00 2006 100.00 2006 33.30 37.50 28.90 2003 45.10 f 39.90 49.60 f 7 Fiji 2006 47.00 2006 71.00 2006 14.30 cd 28.10 cd 4.40 cd 2005 5.00 6.70 3.10 8 French Polynesia 2006 100.00 2006 98.00 1995 … 36.00 36.00 … … … 9 Guam 2006 100.00 2006 99.00 1999 … 37.70 26.90 2002 22.60 25.30 19.70 10 Hong Kong (China) 2007 100.00 2007 99.00 1998 … 27.10 2.90 … … … 11 Japan 2006 100.00 2006 100.00 2000 … 47.40 11.50 … … … 12 Kiribati 2006 65.00 2006 33.00 1999 … 56.50 32.30 … … … 13 Lao People's Democratic Republic 2006 60.00 2006 48.00 1995 … 41.00 15.00 2003 5.50 cf 10.20 cf 0.70 cf 14 Macao (China) 2007 100.00 2007 100.00 1997 … 31.58 4.18 2005 10.40 11.00 9.80 15 Malaysia 2006 99.00 2006 94.00 1986 … 41.00 4.00 2003 20.20 36.30 4.20 16 Marshall Islands 2004 87.00 2004 82.00 2006 16.50 34.10 5.20 … … … 17 Micronesia, Federated States of 2006 94.00 2006 25.00 1994 … 42.00 0.60 2007 28.30 36.90 19.80 18 Mongolia 2006 72.00 2006 50.00 2006 24.20 43.10 4.10 2003 8.50 14.40 4.00 19 Nauru 2007 100.00 2007 100.00 2006 48.20 45.50 50.80 … … … 20 New Caledonia … … 1992 … 28.00 34.00 … … … 21 New Zealand 2006 100.00 cb … 2001 … 25.10 24.80 2007 18.00 13.00 23.90 22 Niue 2006 100.00 2006 100.00 1980 … 58.00 17.00 … … … 23 Northern Mariana Islands 2006 98.00 2006 94.00 … … … 2004 29.10 26.60 31.50 24 Palau 2006 89.00 2006 67.00 1998 … 14.00 4.00 2005 26.70 31.00 22.60 25 Papua New Guinea 2006 40.00 2006 45.00 1990 … 76.00 80.00 2007 43.80 52.10 35.80 26 Philippines 2006 93.00 2006 78.00 2001 … 50.60 8.00 2007 17.30 23.40 11.80 27 Pitcairn Islands … … … … … … … … 28 Republic of Korea 2006 97.00 cb 2005 83.50 1997 … 65.00 4.40 2005 6.80 7.90 5.30 29 Samoa 2006 88.00 2006 100.00 2006 34.60 49.40 18.00 2007 15.20 16.00 12.70 30 Singapore 2007 100.00 2007 100.00 2001 … 24.20 3.50 2000 9.10 10.50 f 7.50 f 31 Solomon Islands 2006 70.00 2006 32.00 1989 … … 33.00 … … … 32 Tokelau 2006 80.00 cc 2006 78.00 cc 2006 46.40 47.30 45.60 … … … 33 Tonga 2006 100.00 2006 96.00 1991 … 62.40 14.20 … … … 34 Tuvalu 2006 93.00 2006 89.00 1976 … 51.00 31.00 2007 26.60 33.20 22.10 35 Vanuatu 2004 60.00 2004 50.00 2006 12.60 23.50 4.60 2007 18.20 28.20 11.40 36 Viet Nam 2006 92.00 2006 65.00 1997 … 50.70 3.50 2003 1.20 cg 1.50 cg 0.80 cg 37 Wallis and Futuna 2006 100.00 cc … 1996 … 42.00 18.00 … … … 516 | COUNTRY HEALTH INFORMATION PROFILES Smoking prevalence among youth (student aged13-15 years) [12] Country/ area Estimated smoking prevalence among adults [10] Percentage of population using Female Improved drinking water source [1] Improved sanitation facility [1] STATISTICAL TABLES Table 8. Health Workforce and Infrastructure Indicators Year Number Number 1 American Samoa 2003 49 7.83 127 20.29 2 Australia 2007 57 000 2.77 182 200 8.84 3 Brunei Darussalam 2006 399 1.04 1 783 4.66 4 Cambodia 2004 2 122 0.16 4 516 0.35 5 China 2006 1 994 854 1.55 1 426 339 1.11 6 Cook Islands 2004 22 12.20 52 28.85 7 Fiji 2006 315 0.37 i 1 673 1.96 i 8 French Polynesia 2005 676 2.60 1 141 4.39 9 Guam 2005 244 cd 1.41 … … 10 Hong Kong (China) 2007 11 961 ce 1.72 ce 36 965 ci 5.31 ci 11 Japan 2006 277 927 2.18 1 234 312 cj 9.66 12 Kiribati 2006 30 0.32 ( 2004) 238 26.50 13 Lao People's Democratic Republic 2005 1 283 0.23 5 291 ck 0.93 14 Macao (China) 2007 1 666 cf 3.10 1 335 2.48 15 Malaysia 2007p 23 738 0.87 48 196 1.77 16 Marshall Islands 2004 31 0.51 115 1.88 17 Micronesia, Federated States of 2005 62 0.54 229 2.01 18 Mongolia 2007 7 336 2.78 8 633 3.27 19 Nauru 2004 5 4.95 48 47.52 20 New Caledonia 2007 536 2.19 1 082 4.42 21 New Zealand 2006 9 547 2.30 40 212 9.60 22 Niue 2006p 4 23.12 13 75.14 23 Northern Mariana Islands … … … … 24 Palau 2006 26 13.06 117 5.88 25 Papua New Guinea 2005 750 0.13 8 914 1.50 26 Philippines 2004 93 862 1.14 352 398 4.26 27 Pitcairn Islands … … … … 28 Republic of Korea 2007 91 393 1.90 235 682 4.80 29 Samoa 2005 50 2.74 136 7.47 30 Singapore 2007 7 384 1.61 22 108 4.82 31 Solomon Islands 2005 89 0.19 620 1.30 32 Tokelau 2003 3 20.00 10 66.67 33 Tonga 2003 32 df 0.39 342 3.37 34 Tuvalu 2003 4 0.42 30 cl 3.14 35 Vanuatu 2008 2 0.11 332 1.42 36 Viet Nam 2006 52 413 cg 0.62 cg 57 003 cg 0.68 cg 37 Wallis and Futuna 2004 13 ch 0.87 ch 47 cm 3.15 cm COUNTRY HEALTH INFORMATION PROFILES | 517 Health workforce [1] NursesCountry/ area Physicians Rate per 1000 Rate per 1000 STATISTICAL TABLES Table 8. Health Workforce and Infrastructure Indicators Number Year Number 1 American Samoa 1 0.16 177 2.83 di 2003 128 cp 2.04 2 Australia 16 800 0.82 256 000 12.13 2005-06 81 819 cq 3.97 3 Brunei Darussalam 429 1.12 2 611 6.82 2006 1 069 cr 2.79 4 Cambodia 1 754 0.13 8 392 0.64 … … 5 China 42 000 0.03 3 463 193 2.63 2006 2 933 705 cs 2.23 6 Cook Islands 11 6.10 85 4.21 di 2005 1 270 ct 6.29 7 Fiji … … … dg … 2005 1 768 cu 2.09 8 French Polynesia 131 0.50 1 948 7.65 2005 906 cu 3.56 9 Guam … … … dg … 2005 187 1.11 10 Hong Kong (China) 4 693 cn 0.67 53 619 7.74 2007 34 928 cv 5.04 11 Japan 25 775 0.20 1 538 014 12.04 2006 1 786 487 cw 13.98 12 Kiribati (2004) 32 3.60 … dh … 2005 140 cx 1.51 13 Lao People's Democratic Republic … … … dg … 2005 6 739 cu 1.20 14 Macao (China) … … … dg … 2007 1 155 cy 2.15 15 Malaysia 16 883 0.62 88 817 3.27 2007 47 784 cu 1.76 16 Marshall Islands … … … dg … … … 17 Micronesia, Federated States of 20 0.18 311 2.73 2006 365 3.31 18 Mongolia 649 0.25 16 618 6.31 2007 16 105 cz 6.11 19 Nauru 2 1.98 55 5.45 2007 51 ct 3.51 20 New Caledonia 88 0.36 1 706 6.97 2005 184 da 0.80 di 21 New Zealand 2 511 0.60 52 270 12.98 2002 23 825 db 6.18 di 22 Niue 2 11.56 19 12.34 2006 8 cx 5.19 23 Northern Mariana Islands … … … … 2000 82 cu 1.15 di 24 Palau 1 0.05 144 7.19 2007 100 4.99 25 Papua New Guinea 567 0.10 10 231 1.72 … … 26 Philippines 136 036 1.65 582 296 7.04 2006 106 316 cz 1.25 di 27 Pitcairn Islands … … … … … … 28 Republic of Korea 8 587 0.20 335 662 6.95 di 2006 417 387 dc 8.64 29 Samoa 37 2.03 223 1.22 di 2005 177 cp 0.97 di 30 Singapore 224 0.05 29 716 8.29 2007 11 547 cu 3.22 31 Solomon Islands 74 0.16 783 1.64 2005 691 cx 1.45 32 Tokelau 3 20.00 16 10.67 di 2003 18 cx 12.00 di 33 Tonga (2002) 21 0.21 … dh 0.00 2004 296 dd 2.91 34 Tuvalu 10 1.05 44 4.58 di 2001 56 de 5.56 35 Vanuatu 48 0.21 382 1.64 2008 859 cu 3.69 36 Viet Nam 19 242 cg 0.23 cg 128 658 1.53 2006 224 251 cu 2.66 37 Wallis and Futuna 11 co 0.74 co 71 4.75 di 2004 59 cx 3.95 Midwives Health workforce [1] 518 | COUNTRY HEALTH INFORMATION PROFILES Rate per 1000 population i Country/ area Health infrastructure [1] Hospital beds (per 1000 population) (physicians, nurses, midwives) Total Rate per 1000 Density i STATISTICAL TABLES Table 9. Morbidity and Mortality Indicators Year Year Year Year 1 American Samoa 2003 0 0 2003 0 0 2006 6 … … 2 Australia 2007 3 (2005) 0 2007 324 (2005) 0 2007 12 2005 580 (2005) 1 3 Brunei Darussalam 2006 0 0 2006 68 0 2006 2 2006 6 0 4 Cambodia … … 2007 39 851 407 2005 429 2006 78 696 396 5 China 2006 159 2 2007 362 0 2006 1506 2006 60 193 34 6 Cook Islands 2005 0 0 2007 362 0 2006 0 2005 0 0 7 Fiji 2005 0 0 2007 100 … 2006 4 2005 0 0 8 French Polynesia 2005 0 dj 0 2007 1 897 … 2006 8 2005 0 0 9 Guam 2006 0 0 2007 1 … 2006 3 2006 3 do … 10 Hong Kong (China) 2007p 3 dk 0 2007p 59 dm 0 2007p 2 dk 2007p 33 dk 0 11 Japan 2006 56 … 2006 74 … 2006 7 2006 67 1 12 Kiribati 2005 0 0 2005 0 0 2006 41 … … 13 Lao People's Democratic Republic 2002 1 272 … 2007 4 943 4 2006 150 2006 18 058 … 14 Macao (China) 2007 0 0 2007 8 0 2006 0 2007 0 0 15 Malaysia 2007p 133 2 2007p 22 980 64 2006 237 2006 5 294 22 16 Marshall Islands 2005 0 0 2005 0 0 2006 42 … … 17 Micronesia, Federated States of 2006 0 0 2007 6 … 2006 151 … … 18 Mongolia 2007 0 0 … … 2006 0 … … 19 Nauru 2002 0 0 2002 0 0 2006 1 … … 20 New Caledonia … … 2007 47 0 2006 7 2006 0 … 21 New Zealand 2005 1 0 2004 8 0 2005 2 2004 33 dp 0 22 Niue 2005 0 0 2005 0 … 2006 0 2005 0 0 23 Northern Mariana Islands … … … … 2006 7 … … 24 Palau 2007 0 0 2007 80 dn 1 2007 2 2007 0 0 25 Papua New Guinea 2000 0 0 2002 22 … 2006 152 2006 81 303 668 26 Philippines 2004 … 36 2007 45 350 416 2006 2517 2006 35 405 122 27 Pitcairn Islands … … … … … … … 28 Republic of Korea 2006 5 0 2006 35 … 2006 15 2006 2 021 0 29 Samoa 2004 0 0 2005 28 0 2006 5 … … 30 Singapore 2007 7 0 2007 8 826 24 2007 12 2007 155 1 31 Solomon Islands … … 2004 0 0 2006 20 2006 75 337 12 32 Tokelau … … … … 2005 0 … … 33 Tonga 2002 0 0 2007 62 … 2006 0 … … 34 Tuvalu 2005 0 0 2004 0 0 2006 2 … … 35 Vanuatu 2006 1 dl … … … 2006 3 2006 8 055 6 36 Viet Nam 2006 0 0 2006 68 532 53 2006 666 2006 22 637 41 37 Wallis and Futuna … … 2004 41 0 2003 0 … … Communicable Diseases [1] Country/ area Cholera Dengue fever/ DHF Cases CasesCases COUNTRY HEALTH INFORMATION PROFILES | 519 Leprosy Deaths DeathsCases Deaths Malaria STATISTICAL TABLES Table 9. Morbidity and Mortality Indicators 2007 1 American Samoa 0 (2006) 0 (2006) 0 (2006) 0 (2006) 0 (2006) 0 (2006) 0 2 Australia 27 1 0 17 11 584 0 3 Brunei Darussalam 4 0 0 (2006) 0 (2006) 13 (2006) 35 (2006) 0 4 Cambodia 94 NR 2 NR 394 NR 50 5 China 4 985 … 0 … 109 023 252 701 2 112 6 Cook Islands 0 0 0 … 1 420 0 7 Fiji 1 0 0 … 0 827 0 8 French Polynesia 1 … 0 … 0 9 0 9 Guam 0 0 0 … 0 0 0 10 Hong Kong (China) 14 0 0 3 88 181 0 11 Japan … 0 0 … 520 200 614 … 12 Kiribati 0 0 0 … 0 0 0 13 Lao People's Democratic Republic 19 NR 2 … 1 678 NR 15 14 Macao (China) 0 0 0 0 0 54 0 15 Malaysia 106 … 2 … 972p … 14p 16 Marshall Islands 0 0 0 … 0 0 0 17 Micronesia, Federated States of 0 0 0 … 0 0 0 18 Mongolia 8 0 0 … 12 965 0 19 Nauru 0 0 0 … 0 0 0 20 New Caledonia 1 0 0 13 0 … 0 21 New Zealand 4 0 0 … 25 75 0 22 Niue 0 0 0 … 0 0 0 23 Northern Mariana Islands 0 0 … … 0 0 0 24 Palau 0 0 0 0 0 0 0 25 Papua New Guinea 25 NR 0 … 0 … … 26 Philippines 502 172 39 … 530 … 121 27 Pitcairn Islands … … … … … … … 28 Republic of Korea 26 … … … 180 4 569 … 29 Samoa 1 0 0 1 0 0 1 30 Singapore 12 0 0 1 15 780 0 31 Solomon Islands 3 0 0 … 0 0 0 32 Tokelau 0 (2006) 0 (2006) 0 (2005) 0 (2006) 0 (2006) 0 (2006) 0 33 Tonga 0 0 0 (2005) 0 0 0 0 34 Tuvalu 0 0 0 … 0 0 0 35 Vanuatu 0 NR 0 … 0 NR 0 36 Viet Nam 391 NR 32 … 17 NR 36 37 Wallis and Futuna 0 0 0 0 0 0 0 Neonatal tetanus 2007 Measles 2007 Mumps 2007 520 | COUNTRY HEALTH INFORMATION PROFILES Vaccine preventable diseases --- Number of reported cases [1,10] Country/ area AFP 2007 Hib meningitis Congenital rubella 2007 Diptheria 2007 STATISTICAL TABLES 2007 (2006) 0 (2006) 0 (2006) 0 (2006) 0 … (2005) NR … (2006) 87.00 5 462 1 35 3 … … … 92.10 (2006) 0 (2006) 0 (2006) 0 (2006) 0 … (2006) 99.90 … (2006) 100.00 561 0 174 dq 242 NR 90.00 87.00 82.00 … 0 74 746 … … 94.00 94.00 93.00 0 0 0 0 NR 100.00 0.00 100.00 0 0 0 0 0 89.90 82.50 83.40 6 0 NR 0 0 99.00 98.00 98.00 0 0 0 0 0 … … (2006) 89.00 31 0 38 1 0 95.00 95.00 95.00 1 504 0 509 117 0 94.00 100.00 98.20 0 0 0 0 0 90.10 98.60 93.90 13 0 1 17 NR 56.00 59.00 50.00 0 0 4 0 0 99.70 92.60 90.20 15p 0p … 36p … 95.00 f … 90.00 f 1 0 0 0 0 92.00 100.00 93.00 47 0 0 0 0 82.00 0.00 79.00 0 0 6363 2 0 99.00 98.00 97.80 0 0 0 0 0 100.00 100.00 100.00 1 0 … 0 0 98.00 80.50 100.00 331 0 10 1 0 … 91.00 87.00 0 0 0 0 0 99.00 99.00 99.00 … 0 0 0 0 NR 94.00 78.00 0 0 0 0 0 NR 100.00 94.00 … 0 4 0 … 67.00 76.00 60.00 17 0 … 1261 … 90.00 90.00 87.00 … … … … … … … … 14 0 35 … 0 96.00 95.00 91.00 24 0 0 4 … (2006) 84.00 … (2006) 56.00 38 0 83 0 0 95.00 97.00 92.00 35 0 0 0 0 84.00 83.00 79.00 (2006) 0 0 (2006) 0 (2006) 0 … 100.00 100.00 100.00 0 0 0 0 NR 99.80 99.90 100.00 0 0 0 0 0 100.00 100.00 97.00 0 0 NR 0 NR 82.00 79.00 76.00 183 0 3530 116 NR 93.70 92.10 92.10 0 0 0 0 0 100.00 91.00 88.00 Immunization coverage (%) [1, 10] Pertussis 2007 Total tetanus 2007 DTP3 2007 Yellow fever COUNTRY HEALTH INFORMATION PROFILES | 521 Vaccine preventable diseases --- Number of reported cases [1, 10] BCG 2007 DTP1 2007 Rubella 2007 Poliomyelitis 2007 STATISTICAL TABLES Table 9. Morbidity and Mortality Indicators MCV2 VitA1 1 American Samoa … (2006) 74.00 … … … (2006) 87.00 ds … 2 Australia … 94.40 … 94.20 dr … 92.10 … 3 Brunei Darussalam … (2006) 100.00 … (2006) 100.00 … (2006) 100.00 … 4 Cambodia 25.00 82.00 … 79.00 … 82.00 99.50 5 China 86.00 (2006) 92.00 … 94.00 92.00 (2006) 94.00 … 6 Cook Islands 100.00 100.00 … 98.00 98.00 100.00 … 7 Fiji … 83.90 83.40 (2006) 100.00 … 83.50 … 8 French Polynesia 100.00 99.00 98.00 (2006) 96.00 84.00 98.00 … 9 Guam 100.00 (2006) 91.00 … (2006) 85.00 … (2006) 85.00 ds … 10 Hong Kong (China) 95.00 95.00 … 95.00 95.00 95.00 … 11 Japan … … … 97.80 … 95.20 … 12 Kiribati 58.20 95.50 … (2006) 61.00 92.60 92.60 … 13 Lao People's Democratic Republic 6.00 50.00 … 40.00 … 46.00 82.00 14 Macao (China) 99.90 90.00 … 89.90 87.20 90.00 … 15 Malaysia … 90.00 f … (2006) 90.00 f … 90.00 f … 16 Marshall Islands 90.00 93.00 83.00 91.00 94.00 91.00 51.00 17 Micronesia, Federated States of 86.00 90.00 79.00 92.00 86.00 79.00 0.00 18 Mongolia 96.80 98.00 98.60 98.40 96.80 98.70 … 19 Nauru 100.00 100.00 … 100.00 100.00 100.00 … 20 New Caledonia 98.60 97.80 100.00 98.60 78.20 100.00 … 21 New Zealand … 88.00 68.00 98.00 … 87.00 33.00 22 Niue 99.00 99.00 99.00 99.00 99.00 99.00 0.00 23 Northern Mariana Islands 97.00 80.00 60.00 71.00 77.00 79.00 0.00 24 Palau 100.00 91.00 95.00 91.00 83.00 94.00 … 25 Papua New Guinea 29.00 59.00 0.00 58.00 47.00 61.00 58.00 26 Philippines 9.00 88.00 … 92.00 … 87.00 85.00 27 Pitcairn Islands … … … … … … … 28 Republic of Korea 94.00 91.00 … 92.00 99.90 91.00 … 29 Samoa … (2006) 56.00 … (2006) 54.00 … (2006) 57.00 … 30 Singapore 99.00 91.00 … 95.00 96.00 92.00 … 31 Solomon Islands 83.00 79.00 0.00 78.00 0.00 78.00 0.00 32 Tokelau 100.00 100.00 100.00 100.00 100.00 100.00 … 33 Tonga 99.90 100.00 100.00 99.50 99.00 100.00 … 34 Tuvalu 100.00 97.00 … 95.00 74.00 97.00 … 35 Vanuatu 79.40 76.30 0.00 65.00 0.00 76.00 0.00 36 Viet Nam 26.90 66.80 … 82.80 18.20 92.00 88.00 37 Wallis and Futuna 100.00 91.00 88.00 86.00 98.00 88.00 0.00 522 | COUNTRY HEALTH INFORMATION PROFILES Hib3 2007 2007 2007 Country/ area Immunization coverage (%) [1, 10] HepB birth dose 2006 HepB3 2006 MCV1 2007 POL3 2007 STATISTICAL TABLES Year Data 2006 … … … … 69.53 6 … 0.20 … (2005) 70.00 est 1 … … … (2005) <0.10 … … … … 2006 0.41 0.80 67.00 82.60 1,ca 78.50 2 NA <0.10 1 19.00 41.00 bz … … … … … … 94.33 6 … 0.10 … … 63.94 5 … … … … 106.96 7 … … … … … … … <0.10 1 … 86.00 1,ec … … … <0.10 … … … … … … … … (2005) 86.00 5 … 0.20 >95.00 100.00 1 … .. … <0.10 1 … … … … 2006-07 0.10 0.30 35.00 … … 3 … … … … … … … … … … … 1--3 2007 <0.10 1 <0.10 1 … 11.50 1,dy … … … … … … … … … … … … … 0 … 0.10 … … … … … … … … (2004) 85.20 5 … … … … … … 2007 0.00 1 0.15 1 … 0.15 1,ed … … 2007 59.54 1 1.61 1 38.00 35.00 … 2 NA 0.02 31.00 56.00 68.00 3--4--5 … … … … … … … … … … … … … … … … 75.67 6 … <0.10 1 … … … … … … … … … .. … … … … … … … … … … 97.00 … … … … … (2005) 80.80 5 2007 <0.10 1 <0.10 1 … 100.00 1 (2004) 85.00 5 2005 0.30 1 0.54 1 26.00 35.00 bz 88.85 3--4 … … … … 52.37 5 Lymphatic filariasis Reported MDA coverage among total population at risk (%) [10] 2006 Number of MDA rounds [10] HIV prevalence among population aged 15-24 years [13] HIV/AIDS % of people with advanced HIV infection receiving ART (2007) Estimated HIV prevalence in adults (%) [14] COUNTRY HEALTH INFORMATION PROFILES | 523 Data [15] dh Data [16] di 2007 STATISTICAL TABLES Table 9. Morbidity and Mortality Indicators 2005 1 American Samoa 12.00 9.00 4.00 1.00 75.00 2 Australia 7.00 6.00 3.00 1.00 12.00 3 Brunei Darussalam 99.00 83.00 37.00 11.00 66.00 4 Cambodia 665.00 500.00 220.00 92.00 89.00 5 China 201.00 99.00 45.00 15.00 92.00 6 Cook Islands 24.00 16.00 7.00 3.00 100.00 7 Fiji 30.00 22.00 10.00 3.00 71.00 8 French Polynesia 29.00 26.00 12.00 3.00 89.00 9 Guam 49.00 37.00 17.00 6.00 85.00 10 Hong Kong (China) 64.00 62.00 28.00 5.00 74.00 11 Japan 29.00 22.00 10.00 3.00 38.00 12 Kiribati 402.00 372.00 168.00 45.00 62.00 13 Lao People's Democratic Republic 292.00 152.00 68.00 24.00 85.00 14 Macao (China) 59.00 59.00 27.00 4.00 93.00 15 Malaysia 125.00 103.00 45.00 17.00 69.00 16 Marshall Islands 241.00 220.00 99.00 28.00 85.00 17 Micronesia, Federated States of 109.00 101.00 45.00 12.00 75.00 18 Mongolia 191.00 188.00 85.00 15.00 82.00 19 Nauru 134.00 106.00 48.00 15.00 0.00 20 New Caledonia 35.00 27.00 12.00 4.00 88.00 21 New Zealand 9.00 9.00 4.00 1.00 0.00 22 Niue 85.00 43.00 19.00 9.00 … 23 Northern Mariana Islands 90.00 75.00 34.00 10.00 73.00 24 Palau 51.00 51.00 23.00 4.00 100.00 25 Papua New Guinea 513.00 250.00 111.00 48.00 57.00 26 Philippines 432.00 287.00 129.00 45.00 82.00 27 Pitcairn Islands … … … … … 28 Republic of Korea 123.00 88.00 40.00 10.00 81.00 29 Samoa 25.00 19.00 9.00 3.00 91.00 30 Singapore 25.00 26.00 12.00 2.20 85.00 31 Solomon Islands 194.00 135.00 61.00 23.00 56.00 32 Tokelau 112.00 56.00 25.00 12.00 … 33 Tonga 34.00 25.00 11.00 3.00 73.00 34 Tuvalu 504.00 295.00 133.00 55.00 100.00 35 Vanuatu 65.00 58.00 26.00 8.00 64.00 36 Viet Nam 225.00 173.00 77.00 23.00 90.00 37 Wallis and Futuna 60.00 46.00 21.00 7.00 … Cure rate (smear positive cases in DOTS areas) [1] Smear-positive Incidence rate (per 100 000 population) 2006 [10] Country/ area 524 | COUNTRY HEALTH INFORMATION PROFILES Tuberculosis Prevalence rate (per 100 000 population) 2006 [1] All forms Mortality rate (all cases per 100 000 population) [1] 2006All forms STATISTICAL TABLES Year Total Smear-positive 2006 115.00 115.00 100 6 5 … … … 40.00 45.00 97 6 1 2.50 … … 91.00 91.00 100 53 34 8.90 … … 62.00 62.00 100 244 136 10.00 2001 0.00 3.10 79.00 79.00 100 71 35 0.30 77.00 0.00 80 7 0 … … … 88.00 88.00 100 14 9 0.30 … … 78.00 78.00 100 27 9 … … … 73.00 73.00 100 26 12 … … … 56.00 78.00 100 75 22 … 2005 0.90 8.00 79.00 80.00 99 20 8 0.40 2002 0.70 9.80 82.00 82.00 100 404 138 … … … 77.00 77.00 100 69 53 1.80 … … 113.00 113.00 100 78 30 … 2005 2.30 15.80 80.00 80.00 100 61 36 11.00 … … 79.00 79.00 100 238 78 … … … 82.00 82.00 98 94 37 … … … 97.00 97.00 100 194 82 0.10 1999 1.00 … 42.00 42.00 100 118 20 … … … 32.00 32.00 100 20 4 … … … 61.00 61.00 100 8 2 1.30 2006 0.60 0.00 … 0.00 100 0 0 … … … 54.00 54.00 100 62 18 … 2006 11.10 … 129.00 129.00 100 59 30 … … … 21.00 28.00 40 203 31 4.00 … … 77.00 77.00 100 171 99 0.10 2004 4.00 20.90 … … … … … … … … 18.00 60.00 100 79 24 1.70 2004 2.70 14.00 80.00 80.00 100 13 7 … … … 100.00 107.00 100 30 12 2.70 2005 0.20 1.00 42.00 42.00 100 77 26 … … … … 0.00 0 0 0 … … … 127.00 127.00 100 18 14 … … … 29.00 29.00 100 86 38 … … … 73.00 73.00 100 57 19 … 2006 0.00 … 85.00 85.00 100 113 65 5.00 2006 2.70 19.30 … … … … … … … … Estimated HIV prevalence among TB cases (%) TB Notification rate (per 100 000 population) 2006 DOTS coverage (%) All cases2006 Proportion of MDR in new cases (%) COUNTRY HEALTH INFORMATION PROFILES | 525 DOTS Case detection rate of smear-positive cases (2006) [1] Tuberculosis [10] Anti-tuberculosis drug resistance [10] Proportion of MDR in re-treatment cases (%) STATISTICAL TABLES Table 9. Morbidity and Mortality Indicators Cancer Year Deaths Year Deaths Year Cases Deaths Year Male Female 1 American Samoa 2002 37 2002 88 2002 101 5 … … 2 Australia 2005 38 380 2005 46 134 2003 25 381 (2005) 1 638 2005 16.39 4.35 3 Brunei Darussalam 2006 220 2006 352 2006 415 39 2006 2.95 1.04 4 Cambodia … … … … … … 5 China … … … … … … 6 Cook Islands 2005 7 2005 31 2005 105 6 2005 … dx … dx 7 Fiji 2005 … 2005 … 2005p 745 76 … … 8 French Polynesia 2005 293 2005 319 2005 … 37 2005 … dx … dx 9 Guam 2000 125 2000 246 2000 … 23 2000 … dx … dx 10 Hong Kong (China) 2006 12 093 2006 9 680 2006 … 157 2006 … dx … dx 11 Japan 2006 329 314 2006 324 786 2006 … 9 048 2006 34.36 6.65 12 Kiribati 2005 27 2005 84 2005 … 3 2005 37.27 4.32 13 Lao People's Democratic Republic … … … … … … 14 Macao (China) 2006 538 2007 369 2007 … 18 2007 13.93 2.23 15 Malaysia 2006 4 229 2006 9 977 2006 85 109 1 675 2006 0.39 0.24 16 Marshall Islands … … … … … … 17 Micronesia, Federated States of 2000 51 dt … 2000 … 4 dt … … 18 Mongolia 2007 2 933 2007 5 677 2007 … 550 2007 33.71 4.74 19 Nauru 2007 5 2002 12 2002 … 1 … … 20 New Caledonia … … 2007 667 … … … 21 New Zealand 2004 8 023 2004 11 293 2003-04 13 125 du (2004) 520 2004 18.97 5.28 22 Niue … … … … … … 23 Northern Mariana Islands … 2000 … 2000 555 … … … 24 Palau 2007 22 … 2007 95 dv 2 2007 46.00 10.68 25 Papua New Guinea 2004 225 2004 54 2004 349 13 2004 … dx … dx 26 Philippines 2004 42 686 2004 54 045 2004 … 6 976 2004 3.36 1.02 27 Pitcairn Islands … … … … … … 28 Republic of Korea 2006 65 909 2006 56 388 2006 … 7 822 2006 29.87 14.31 29 Samoa 2004 12 2004 37 2002 129 4 … … 30 Singapore 2007p 4 745 2007p 5 835 2007p … 228 2007p 12.11 8.80 31 Solomon Islands … … … … … … 32 Tokelau … … … … … … 33 Tonga 2002 76 2002 192 2002 109 0 2002 1.95 di 0.00 di 34 Tuvalu 2004 … 2001 1 0 … … 35 Vanuatu 2006 58 dl 2006 53 dl 2006 101 … … … 36 Viet Nam 2006 667 2006 2 550 2006 103 814 844 … … 37 Wallis and Futuna … … … … … … 526 | COUNTRY HEALTH INFORMATION PROFILES Motor and other vehicular accidents [1]Country/ area Noncommunicable diseases [1] Suicide rate (per 100 000 population) [1] i Diseases of the circulatory system STATISTICAL TABLES Table 10. Noncommunicable Risk Factors Year Age group (%) Year Age group (%) Year Age group (%) 1 American Samoa … … … 2 Australia 2004 14+ 17.00 … … 3 Brunei Darussalam … … … 4 Cambodia 2004 15+ 21.70 … … 5 China 2002 15-69 31.40 21,eh … … 6 Cook Islands … … … 7 Fiji 2002 15-64 M=26.00, F=3.90 26 2002 15-64 23.80 26 … 8 French Polynesia … … … 9 Guam … … … 10 Hong Kong (China) 2007 18-64 15.90 1 … 2007 18-64 8.90 1 11 Japan 2000 20+ M=47.40, F=11.50 20 … 2003 20+ 6.40 ek 12 Kiribati … … … 13 Lao People's Democratic Republic … … 2003 18+ 3.00 ej 14 Macao (China) … … 15 Malaysia 2006 25-64 21.20 … 2003 18+ 0.30 ej 16 Marshall Islands … … … 17 Micronesia, Federated States of … … … 18 Mongolia 2005 15-64 24.20 2005 15-64 66.50 27 2005 15-64 M=27.30, F=10.30 27 19 Nauru 2004 15-64 48.20 2004 15-64 46.20 2004 15-64 M=18.10, F=8.20 20 New Caledonia … … 21 New Zealand 2006 15+ 20.70 … … 22 Niue … … … 23 Northern Mariana Islands … … … 24 Palau … … … 25 Papua New Guinea … … … 26 Philippines 2003 18+ 23.60 … 2003 18+ 1.20 ej 27 Pitcairn Islands … … 28 Republic of Korea 2005 20+ 29.10 eh … … 29 Samoa … … … 30 Singapore 2004 18-69 12.50 1 … … 31 Solomon Islands … … … 32 Tokelau … … … 33 Tonga … 2000 15+ M=25.80,F=3.60 … 34 Tuvalu … … … 35 Vanuatu … … … 36 Viet Nam 2003 18+ 17.50 … 2003 18+ 1.00 ej 37 Wallis and Futuna … … … COUNTRY HEALTH INFORMATION PROFILES | 527 Country/ area Behavioural measures Daily smokers [17] Current drinkers [18] Binge drinkers [18] STATISTICAL TABLES Table 10. Noncommunicable Risk Factors Year Age group (%) Year Age group (<5 servings/day) Year Age group % 1 American Samoa … … 2 Australia 2005 18+ M=33.60,F=34.40 ei 2005 12+ Fruit=46.10, Vegetable=86.10 eq 2005 18+ 14.00 er 3 Brunei Darussalam … … … 4 Cambodia … … … 5 China 2002 18-69 10.60 el … 2002 18+ 18.80 6 Cook Islands … … … 7 Fiji 2002 15-85 Work=41.00, Transport=14.80, Leisure=76.10 26, em 2002 15-64 Fruit: M=98.80, F=99.40, Vegetable: M=97.10, F=97.80 26 2002 15-64 19.10 26 8 French Polynesia … … … 9 Guam … … … 10 Hong Kong (China) 2007 18-64 18.90 1,db 2007 18-64 81.10 1 … 11 Japan 2004 15+ 79.40 en … 2000 30+ M=56.20, F=39.70 12 Kiribati … … 13 Lao People's Democratic Republic 2003 18-69 14.60 el 2003 18+ 80.90 14 Macao (China) … … 15 Malaysia 2005 25-64 60.10 1 2005 25-64 72.80 1 2005 25-64 25.70 1 16 Marshall Islands … … … 17 Micronesia, Federated States of … … … 18 Mongolia 2005 15-64 23.10 27 2005 15-64 Fruit=46.30, Vegetable=91.80 27 2005 15-64 22.20 27 19 Nauru 2004 15-64 16.50 2004 15-64 96.90 2004 15-64 17.20 20 New Caledonia … … … 21 New Zealand 2004 15+ 13.10 … 2004 15+ 20.80 dd 22 Niue … … … 23 Northern Mariana Islands … … … 24 Palau … … … 25 Papua New Guinea … … … 26 Philippines 2003 18-69 7.50 el 2003 18+ 76.50 … 27 Pitcairn Islands … … … 28 Republic of Korea 2005 20+ 78.20 eo … 2005 30+ 27.90 29 Samoa … … 30 Singapore 2004 18-69 48.10 dc … 2004 30-69 24.90 1 31 Solomon Islands … … … 32 Tokelau … … … 33 Tonga … … … 34 Tuvalu … … … 35 Vanuatu … … … 36 Viet Nam 2003 18-69 8.20 el 2003 18+ 84.0 2001 15+ 23.80 37 Wallis and Futuna … … … 528 | COUNTRY HEALTH INFORMATION PROFILES Raised blood pressure [23] Physical measures Country/ area Physically inactive [19] Behavioural measures Low fruit and vegetable consumption [22] STATISTICAL TABLES Year Total Male Female Total Male Female Male Female … … … … … … … … 2001 18+ … … … 46.20 54.50 38.20 23.80 24.90 … … … … … … 15.20 27.40 2000 15-49 … … 17.80-23.40 … … 6.40 0.20 0.10 2002 18+ … … … 22.80 by … … 1.60 1.90 2003 25-64 32.90 32.50 33.40 89.20 90.10 88.30 69.50 70.80 2002 15-64 … 24.20 26 26.70 26 … 27.50 26 31.50 26 9.80 26 26.40 26 … … … … … … … … … … … … … … … … … … … … … … … … 2002 20+ … … … 25.50 28.80 22.70 1.80 1.50 … … … … … … 29.80 41.00 2000 15+ … … … 8.50 5.90 10.80 2.60 10.40 … … … … … … … … 2005 25-64 … … … 31.60 1 … … 1.60 8.20 2002 25-64 29.90 28.90 31.00 80.60 78.00 83.50 … 2002 25-64 29.50 27.70 31.40 73.90 65.40 83.10 66.20 72.90 2005 15-64 … 23.30 27 24.50 27 … 18.20 27 25.50 27 7.20 27 12.50 27 2004 15-64 32.10 28 31.70 28 32.50 28 24.10 26.50 28 21.80 28 55.70 28 60.50 28 … … … … … … … … 2002-03 15+ 26.60 26.90 26.40 57.00 63.00 51.10 23.00 31.50 … … … … … … 36.00 61.00 … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … 4.10 10.10 2002 25-64 31.70 30.00 33.40 86.10 82.20 90.80 38.40 57.30 … … … … … … … … … … … … … … 5.40 14.70 … … … … … … … … 1998-2000 15-70 32.30 30.20 33.80 … … … … … … … … … … … … … … … … … … … 13.40 26.30 … … … … … … … … … … … … … … … … COUNTRY HEALTH INFORMATION PROFILES | 529 Physical measures Obese among 15+ years (2005) [23]Overweight [10]Mean BMI [10] Age group STATISTICAL TABLES Table 10. Noncommunicable Risk Factors Year Age group (%) Year Age group (%) 1 American Samoa … … 2 Australia 2005 18+ 8.90 es 2000 35+ M=7.80, F=6.80 eu 3 Brunei Darussalam … … 4 Cambodia … 2004 25+ 11.40 ev 5 China … 2002 18+ 2.60 ew 6 Cook Islands … … 7 Fiji 2002 25-64 M=49.10, F=37.80 26 2002 25-64 M=12.90, F=15.20 26 8 French Polynesia … … 9 Guam … … 10 Hong Kong (China) … … 11 Japan 2000 30+ M=25.70, F=34.10 et 2000 30+ M=2.70, F=1.70 ex 12 Kiribati … … 13 Lao People's Democratic Republic … … 14 Macao (China) … … 15 Malaysia 2005 25-64 53.50 1 2005 25-64 11.00 1 16 Marshall Islands … … 17 Micronesia, Federated States of … … 18 Mongolia 2005 15-64 7.00 2005 15-64 8.20 27,df 19 Nauru 2004 15-64 17.90 2004 15-64 16.20 da 20 New Caledonia … … 21 New Zealand 2004 15+ 15.50 dd … 22 Niue … … 23 Northern Mariana Islands … … 24 Palau … … 25 Papua New Guinea … … 26 Philippines … 2002 20-65 4.80 ev 27 Pitcairn Islands … … 28 Republic of Korea 2005 30+ 8.20 de 2005 30+ 96.30 ez 29 Samoa … 30 Singapore 2004 18-69 18.70 1, de 2004 18-69 8.20 1,ev 31 Solomon Islands … … 32 Tokelau … … 33 Tonga … 2000 15+ M=9.50, F=11.00 ev 34 Tuvalu … 2001 10-80 9.00 ev 35 Vanuatu … … 36 Viet Nam … 2001 15+ 6.60 dg 37 Wallis and Futuna … … WESTERN PACIFIC REGION 530 | COUNTRY HEALTH INFORMATION PROFILES Country/ area Biochemical measures Raised blood cholesterol / lipids [24] Raised blood glucose [25] STATISTICAL TABLES Table 11. Millennium Development Goals Indicators Year Year Year Year 1 American Samoa … 2002 4.90 2007 11.80 … 2 Australia 1995-96 0.00 10, bs 2006 5.57 2006 4.70 2007 94.20 dr 3 Brunei Darussalam 1995-96 14.00 10 2006p 9.20 2006p 6.60 2006 100.00 4 Cambodia 2005 35.55 2005 83.00 2005 66.00 2007 79.00 5 China 2002 7.80 2006 20.60 2006 17.20 2007 94.00 6 Cook Islands … 2005 11.00 2007p 10.50 2007 98.00 7 Fiji 1993 7.90 10 2005 25.81 2007 18.40 2006 100.00 8 French Polynesia 2004 3.10 2005 14.70 2005 5.30 2006 96.00 9 Guam … 2005 est 10.00 2004 12.30 2006 85.00 10 Hong Kong (China) … 2007p 2.15 l 2007p 1.72 l 2007 95.00 11 Japan … 2006 3.60 2006 2.60 2007 97.80 12 Kiribati 1999 13.00 10 2005 69.00 2005 52.00 2006 61.00 13 Lao People's Democratic Republic 2000 40.00 2005 68.00 2005 56.00 2007 40.00 14 Macao (China) … 2007 3.50 2007 2.40 2007 89.90 15 Malaysia 2006 10.10 2007p 8.10 2007p 6.30 2006 90.00 f 16 Marshall Islands 1999 27.00 10 … FY2004 23.00 2007 91.00 17 Micronesia, Federated States of … 2006 est 41.00 2006 est 33.00 2007 92.00 18 Mongolia 2007 6.30 2007 22.10 2007 17.80 2007 98.40 19 Nauru … 2006 est 30.00 2006 est 25.00 2007 100.00 20 New Caledonia 1996 … bt, 10 2002 9.06 2007p 6.60 2007 98.60 21 New Zealand … 2003 6.34 2006 4.80 2007 98.00 22 Niue 2005 0.00 2006 0.00 2006 0.00 av 2007 99.00 23 Northern Mariana Islands … … 2005 est 7.11 2007 71.00 24 Palau 1997 1.40 10 2007 7.17 2007 7.17 2007 91.00 25 Papua New Guinea 2006 30.50 2006 64.00 2006 49.00 2007 58.00 26 Philippines 2003 27.60 2006 32.00 2006 24.00 2007 92.00 27 Pitcairn Islands … … … … 28 Republic of Korea 1997 3.00 10, bu 2006 5.70 2003 5.30 2007 92.00 29 Samoa 1999 1.90 10 2002 13.70 2005-06 13.70 aw 2006 54.00 30 Singapore 1995-2003 14.00 2007 3.00 2007 2.10 m 2007 95.00 31 Solomon Islands 1999 21.00 10 2005 est 52.00 2005-10 31.40 2007 78.00 32 Tokelau … … 1997-2000 33.00 2007 100.00 33 Tonga … 2001 16.59 2005 11.80 2007 99.50 34 Tuvalu … 2003 32.40 2003 21.60 2007 95.00 35 Vanuatu 2007 19.50 2006 36.00 2006 30.00 2007 65.00 36 Viet Nam 2006 26.00 2006 est 26.00 2006 est 16.00 2007 82.80 37 Wallis and Futuna … … 2003 est 5.90 2007 86.00 COUNTRY HEALTH INFORMATION PROFILES | 531 Under-five mortality rate [1] Infant mortality rate [1] Country/ area Goal 4: Reduce child mortality Target 4A: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate Prevalence of underweight children under five years of age [1] Proportion of 1 year-old children immunised against measles [1,10] Target 1C: Halve, between 1990 and 2015, the proportion of people who suffer from hunger Goal 1: Eradicate extreme poverty and hunger STATISTICAL TABLES Table 11. Millennium Development Goals Indicators Year Year 1 American Samoa 2002 123.00 2002 100.00 1.00 99.00 2 Australia 2000-02 11.00 ax 2005 99.60 0.20 99.40 3 Brunei Darussalam 2006p 15.30 2006 99.73 0.10 99.63 4 Cambodia 2005 472.00 2005 44.00 22.00 22.00 5 China 2006 41.10 2006 97.80 … 88.40 6 Cook Islands 2005 0.00 2005 100.00 37.00 99.63 7 Fiji 2005 50.49 2007 98.50 … … 8 French Polynesia 2005 0.38 2004 99.97 0.96 99.01 f 9 Guam 2003 0.00 2004 … … 87.22 10 Hong Kong (China) 2007p 1.42 k 2007 100.00 0.00 bh 100.00 bd 11 Japan 2006 4.90 2006 99.90 0.19 99.76 12 Kiribati 2005 158.00 2005 89.65 i 4.65 be 85.00 be 13 Lao People's Democratic Republic 2005 405.00 2005 18.50 7.50 11.00 14 Macao (China) 2007 0.00 2007 100.00 0.00 100.00 15 Malaysia 2006 30.00 2006 100.00 2.60 97.40 16 Marshall Islands FY 2004 0.00 … … … 17 Micronesia, Federated States of 2003 317.00 ay … … … 18 Mongolia 2007 89.60 2007 99.70 0.10 99.60 19 Nauru 2002 300.00 2007 97.00 1.00 96.00 20 New Caledonia 2006 29.60 2005 91.97 4.37 87.60 21 New Zealand 2004 6.81 2001 100.00 … (2004 est) 95.30 22 Niue 2006 0.00 2006 100.00 0.00 100.00 23 Northern Mariana Islands 2000 0.00 … … … 24 Palau 2007 0.00 2007 100.00 0.00 100.00 25 Papua New Guinea 2006 870.00 2006 … … 39.00 26 Philippines 2006 162.00 2006 63.70 20.30 42.40 27 Pitcairn Islands … … … … 28 Republic of Korea 2003 15.00 2006 100.00 0.10 99.90 29 Samoa 2005-06 3.00 2004 100.00 9.00 91.00 30 Singapore 2007 7.60 2007 … … 99.68 bf 31 Solomon Islands 2005 236.00 2003 … … 43.00 bg 32 Tokelau 2001-02 0.00 … … … 33 Tonga 2005 227.80 2004 99.00 1.00 98.00 34 Tuvalu 2003 0.00 az 2002 100.00 … … 35 Vanuatu 2006 70.04 2006 92.90 1.82 91.08 36 Viet Nam 2006 75.10 2006 97.00 bc … 84.40 37 Wallis and Futuna … … … … 532 | COUNTRY HEALTH INFORMATION PROFILES Country/ area Maternal mortality ratio [1] Proportion of births attended by skilled health personnel [1] Goal 5: Improve maternal health % of deliveries at home by skilled health personnel (as % of total deliveries) [1] % of deliveries in health facilities (as % of total deliveries)[1] Target 5A: Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio STATISTICAL TABLES Year At least 1 visit At least 4 visits Year … … 2002 70.00 … … 2001 65.00 dy 2005 8.49 dz 2001 99.00 … … … … 2004 99.60 … … 2005 24.10 2005 5.20 2005 44.40 27.00 2005 25.00 … … 2002 90.14 … … … … 2005 100.00 … … 2007 43.00 … 2005 100.00 … … … … 2004 99.10 … … … … 2001 92.05 … … … 2006 4.14 2006 100.00 … … … … … … … … … 2005 100.00 … … 2005 38.40 … 2005 28.50 … … … 2007 3.40 2007 89.20 ea … … 2006 4.30 … 2006 60.20 … … 2001 34.00 … … … … … … 2000 80.00 … … 2007 52.84 2007 6.30 2007 … 83.70 eb … … … 2007 94.50 … … … … … … … … … 2005 100.00 … … 2001 22.60 … 2005 10.00 … … 2000 64.00 … 2000 75.67 … … 2007 12.08 2007 18.40 2006 95.00 79.00 … 2004 26.00 2002 13-15 2006 58.00 … … 2006 50.60 2006 4.80 2006 … 59.00 2006 15.70 … … … … … 2006 79.60 … 2006 99.90 f 98.60 … … … 2004 100.00 … … … … 2006 100.00 … … … … 2003 76.00 … … … … … … … … … 2004 99.00 … … 2002 32.00 … 2001 99.00 … … 2007 37.00 2003 21.00 2006 67.00 … … 2002 est 78.50 … 2005 96.10 … 2002 est 4.80 … … … … … COUNTRY HEALTH INFORMATION PROFILES | 533 Goal 5: Improve maternal health Target 5B: Achieve, by 2015, universal access to reproductive health Contraceptive prevalence rate [1] Adolescent birth rate [1]YearYear Antenatal care coverage [1] Unmet need for family planning [1] STATISTICAL TABLES Table 11. Millennium Development Goals Indicators Year Year Year Data [15] dh Data [16] di 1 American Samoa … … … 2 Australia … 2007 0.20 2005 est … 70.00 1 3 Brunei Darussalam … 2005 <0.10 … 4 Cambodia 2006 0.41 2007 0.80 2007 67.00 82.60 1,ca 5 China NA 2007 <0.10 1 2007 19.00 41.00 bz 6 Cook Islands … … … … 7 Fiji … 2007 0.10 … … 8 French Polynesia … … … … 9 Guam … … … … 10 Hong Kong (China) … 2007 <0.10 1 2007 … 86.00 1,ec 11 Japan … 2007 <0.10 … … 12 Kiribati … … … … 13 Lao People's Democratic Republic … 2007 0.20 2007 >95.00 100.00 1 14 Macao (China) … 2007 <0.10 1 … … 15 Malaysia 2006-07 0.10 2007 0.30 2005 35.00 … 16 Marshall Islands … … … … 17 Micronesia, Federated States of … … … … 18 Mongolia 2007 <0.10 1 2007 <0.10 1 2007 … 11.50 dy 19 Nauru … … … … 20 New Caledonia … … … … 21 New Zealand … 2007 0.10 … … 22 Niue … … … … 23 Northern Mariana Islands … … … … 24 Palau 2007 0.00 1 2007 0.15 1 2007 … 0.15 1,ed 25 Papua New Guinea 2007 59.54 1 2007 1.61 1 2007 38.00 35.00 26 Philippines NA 2007 0.02 2007 31.00 56.00 27 Pitcairn Islands … … … … 28 Republic of Korea … … … … 29 Samoa … … … … 30 Singapore … 2007 <0.10 1 … … 31 Solomon Islands … … … … 32 Tokelau … … … … 33 Tonga … … … … 34 Tuvalu … … … … 35 Vanuatu 2007 <0.10 1 2007 <0.10 1 2007 … 100.00 1 36 Viet Nam 2005 0.30 1 2007 0.54 1 2007 26.00 30.00 bz 37 Wallis and Futuna … … … … 534 | COUNTRY HEALTH INFORMATION PROFILES Country/ area Data Data Goal 6: Combat HIV/AIDS, malaria and other diseases % of people with advanced HIV infection receiving (ART) Estimated HIV prevalence in adults [14] HIV prevalence among population aged 15-24 years [13] Target 6A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS Target 6B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it STATISTICAL TABLES Year Year Year Year … … … … 2007 0.40 2005 0.01 2007 NR 2007 NR 2006 0.00 2006 0.00 … … 2006 554.00 2006 2.79 … … 2006 4.60 2006 0.00 … … … … … … … … … … … 2005 0.00 … … … … … … 2007p 0.48 dk 2007p 0.00 … … 2006 0.05 2006 0.00 … … … … … … 2006 319.00 2006 0.36 2006 75.50 … 2007 0.00 2007 0.00 … … 2006 20.00 2006 0.80 … … … … … … … … … … … … … … … … … … 2006 0.00 2006 0.00 2006 0.00 2006 0.00 … … … … … … … … … … … … 2007 NR 2007 NR 2007 NR 2007 NR 2006 1311.00 2006 10.77 2007 50.00 2007 60.00 2006 410.00 2006 0.14 2006 17.00 2006 85.00 … … … … 2006 4.00 2006 0.00 … … … … … … 2007 3.40 … … … 2006 15 565.00 2006 2.48 … … … … … … … 2000 est 1.00 … … … … … … 2006 3645.00 2006 2.71 2007 65.30 … 2006 26.00 2006 0.05 … … … … … … COUNTRY HEALTH INFORMATION PROFILES | 535 Goal 6: Combat HIV/AIDS, malaria and other diseases Target 6C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases Malaria death rate per 100 000 population [1] Malaria incidence rate per 100 000 population [1] Proportion of children under 5 sleeping under insecticide-treated bednets [1] Proportion of children under 5 with fever who are treated with appropriate anti-malarial drugs [1] STATISTICAL TABLES Table 11. Millennium Development Goals Indicators Year Year Year 1 American Samoa 2006 9.00 2006 12.00 2006 1.00 115.00 75.00 2 Australia 2006 6.00 2006 7.00 2006 1.00 40.00 12.00 3 Brunei Darussalam 2006 83.00 2006 99.00 2006 11.00 91.00 66.00 4 Cambodia 2006 500.00 2006 665.00 2006 92.00 62.00 89.00 5 China 2006 99.00 2006 201.00 2006 15.00 79.00 92.00 6 Cook Islands 2006 16.00 2006 24.00 2006 3.00 (2005) 77.00 100.00 7 Fiji 2006 22.00 2006 30.00 2006 3.00 88.00 71.00 8 French Polynesia 2006 26.00 2006 29.00 2006 3.00 78.00 89.00 9 Guam 2006 37.00 2006 49.00 2006 6.00 73.00 85.00 10 Hong Kong (China) 2006 62.00 2006 64.00 2006 5.00 56.00 74.00 11 Japan 2006 22.00 2006 29.00 2006 3.00 79.00 38.00 12 Kiribati 2006 372.00 2006 402.00 2006 45.00 82.00 62.00 13 Lao People's Democratic Republic 2006 152.00 2006 292.00 2006 24.00 77.00 85.00 14 Macao (China) 2006 59.00 2006 59.00 2006 4.00 113.00 93.00 15 Malaysia 2006 103.00 2006 125.00 2006 17.00 80.00 69.00 16 Marshall Islands 2006 220.00 2006 241.00 2006 28.00 79.00 85.00 17 Micronesia, Federated States of 2006 101.00 2006 109.00 2006 12.00 82.00 75.00 18 Mongolia 2006 188.00 2006 191.00 2006 15.00 97.00 82.00 19 Nauru 2006 106.00 2006 134.00 2006 15.00 42.00 0.00 20 New Caledonia 2006 27.00 2006 35.00 2006 4.00 32.00 88.00 21 New Zealand 2006 9.00 2006 9.00 2006 1.00 61.00 0.00 22 Niue 2006 43.00 2006 85.00 2006 9.00 … … 23 Northern Mariana Islands 2006 75.00 2006 90.00 2006 10.00 54.00 73.00 24 Palau 2006 51.00 2006 51.00 2006 4.00 129.00 100.00 25 Papua New Guinea 2006 250.00 2006 513.00 2006 48.00 21.00 57.00 26 Philippines 2006 287.00 2006 432.00 2006 45.00 77.00 82.00 27 Pitcairn Islands … … … … … 28 Republic of Korea 2006 88.00 2006 123.00 2006 10.00 18.00 81.00 29 Samoa 2006 19.00 2006 25.00 2006 3.00 80.00 91.00 30 Singapore 2006 26.00 2006 25.00 2006 2.20 100.00 85.00 31 Solomon Islands 2006 135.00 2006 194.00 2006 23.00 42.00 56.00 32 Tokelau 2006 56.00 2006 112.00 2006 12.00 … … 33 Tonga 2006 25.00 2006 34.00 2006 3.00 127.00 73.00 34 Tuvalu 2006 295.00 2006 504.00 2006 55.00 29.00 100.00 35 Vanuatu 2006 58.00 2006 65.00 2006 8.00 73.00 64.00 36 Viet Nam 2006 173.00 2006 225.00 2006 23.00 85.00 90.00 37 Wallis and Futuna 2006 46.00 2006 60.00 2006 7.00 … … 536 | COUNTRY HEALTH INFORMATION PROFILES Proportion of TB cases detected under directly observed treatment short course (DOTS) (2006) [1] Proportion of TB cases cured under directly observed treatment short course (DOTS) (2005) [1] Country/ area Goal 6: Combat HIV/AIDS, malaria and other diseases Target 6C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases TB death rate per 100 000 [1] TB incidence rate per 100 000 [10] TB prevalence rate per 100 000 [1] STATISTICAL TABLES Year Urban Rural Year Urban Rural Year 2004 99.00 99.00 2004 99.00 99.00 … 2006 100.00 100.00 2006 100.00 100.00 … 2005 … ee … ee 2002 … ee … ee 2003 100.00 2006 80.00 61.00 2006 62.00 19.00 … 2006 98.00 81.00 2006 74.00 59.00 … 2006 98.00 88.00 2006 100.00 100.00 … 2006 43.00 51.00 2006 87.00 55.00 … 2006 100.00 100.00 2006 99.00 97.00 … 2006 100.00 100.00 2006 99.00 98.00 … 2007 … ee … ee 2007 … ee … ee … 2006 100.00 100.00 2006 100.00 100.00 … 2006 77.00 53.00 2006 46.00 20.00 … 2006 86.00 53.00 2006 87.00 38.00 … 2007 100.00 NR 2007 100.00 NR … 2006 100.00 96.00 2006 95.00 93.00 … 2004 82.00 96.00 2004 93.00 58.00 … 2006 95.00 94.00 2006 61.00 14.00 … 2006 90.00 48.00 2006 64.00 31.00 2005 70.00 2007 100.00 NR 2007 100.00 NR … … … … … … 2006 100.00 … … … … 2006 100.00 100.00 2006 100.00 100.00 … 2006 98.00 97.00 2006 94.00 96.00 … 2006 79.00 94.00 2006 96.00 52.00 … 2006 88.00 32.00 2006 67.00 41.00 … 2006 96.00 88.00 2006 81.00 72.00 … … … … … … 2006 97.00 … 2005 … ee … ee … 2006 90.00 87.00 2006 100.00 100.00 … 2007 … ee … ee 2007 … ee … ee … 2006 94.00 65.00 2006 98.00 18.00 … 2006 … 88.00 2006 … 78.00 … 2006 100.00 100.00 2006 98.00 96.00 … 2006 94.00 92.00 2006 93.00 84.00 … 2004 86.00 52.00 2004 78.00 42.00 … 2006 98.00 90.00 2006 88.00 56.00 … 2006 … 100.00 … … … Target 8E: In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries Proportion of population using an improved drinking water source [1] Target 7C: Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation Proportion of population using an improved sanitation facility [1] COUNTRY HEALTH INFORMATION PROFILES | 537 Proportion of population with access to affordable essential drugs on a sustainable basis [1] Goal 7: Ensure environmental sustainability Goal 8. Develop a global partnership for development STATISTICAL TABLES Notes a Estimated figure includes Other Territories comprising Jervis Bay territory, Christmas Island and the Cocos (Keeling) Islands. b Figure refers to resident population. c Figure refers to usual resident population. Usual resident population includes those residents who are present and those who are temporarily elsewhere in New Zealand. Residents who are temporariliy overseas were not counted. d Figure excludes some areas of which boundaries are not yet fixed. e Figure includes inland waters and oceanic areas. f Revised data. g Figure refers to 0-14 years old. h Figure refers to 0-19 years old. i Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. j Figure is computed per thousand resident population as of 1992. k Figure is compiled based on registered deaths and/or registered births. l Figure is compiled based on registered deaths and/or registered births and includes those with unknown sex. m Revised figure refers/ applies to resident population. n Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific using data in columns 1 & 2 of this table. o Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific using data in columns 10-12 of this table. p Data for 15 years old schoolchildren. Literacy defined as Levels 2-5 using OECD PISA (Programme for International Student Assessment) standards. q Figure refers to 1999/2000 schoolyear and census data. r Figure refers to the percentage of population aged 15 years and above with primary or above education attainment. s Literacy defined as Levels 2-5 using OECD PISA (Programme for International Student Achievement) standards. t Figure refers to 15-24 years old. u Figure refers to population aged 10 years and over. v Figure applies to residents aged 15 years and over. w Figure refers to aged 19 years and above. x Figure refers to per capita GDP (goods and services). y Using exchange rate as of 7 April 2008. z Figure RMB 16 084 was converted to US$ using the exchange rate US$1=RMB 7.97. aa Figure reported as Gross Island Product. ab Figure refers to Atlas method. ac Figure was converted using 2006 exchange rate=1179.7 tugriks/US$. ad Figure was converted to US$ using available exchange rate nearest to the period i.e. 2003. ae Figure refers to GNP per capita (PPP US$). af Figure refers to per capita GNI. ag Figure refers to per capita GNP at current market prices (US$). ah Figure is complied based on the summation of public health expenditure and private health expenditure in the fiscal year 2004/2005 per mid-2004 population . ai Figure is in New Zealand dollars. aj Figure is complied based on the summation of public health expenditure and private health expenditure in the fiscal year 2004/2005 as percentage of GDP in the fiscal year 2004/2005. ak Figure refers to percentage total expenditure on public health as to total government expenditure. al Figure refers to public health expenditure as percentage of overall public expenditures. am Data refers to the most recent year available during the period specified. an Figure refers to those below 50% of median income. ao Data refers to a year or period other than that specified, differ from the standard definition or refer to only part of a country. ap Data as of 31 May 2007, unless otherwise specified. Where there are lowe and upper houses, data refer to the weighted average of women's shares of seats in both houses. aq Brunei Darussalam does not currently have a parliament. 538 | COUNTRY HEALTH INFORMATION PROFILES STATISTICAL TABLES Notes ar Parliament has been dissolved or suspended for an indefinite period. as Estimates are based on data for the most recent year available between 1996 and 2005. Following the methodology implemented in the calculation of the GDI, the income component of the GEM has been scaled downward for countries whose income exceeds the maximum goalpost GDP per capita value of 40,000 (PPP US$). at Much care is advised in interpreting these data, as these are based only on 76 reported deaths in Niue between 2001 and 2006. au Esimates derived by regression and similar estimation methods. av There is only 1 infant death in 2006. aw Figure refers to hospital reported IMR. ax Figure refers to the latest data for both direct and indirect maternal deaths. More recent data for direct maternal deaths is available. ay Figure is based on child-bearing age 15-44 years old. az There is only 1 maternal death in the last 5 years. ba Percentage of women aged 18-49 (or their partners) reported using contraceptive methods (including hysterectomy, tubal ligation and partner vasectomy). bb Figure refers to the contraceptive prevalence rate. bc Figure applies to public health facilities. bd The figure refers to the cases known to the maternity homes, public and private hospitals. be Best estimated figure. bf Figure refers to live births. bg Figure applies to clinics only. bh Nearly all newborns were delivered in health facilities. bi Figure refers to birthweight equal to 2501 grams and above. bj Figure refers to children with normal birthweight among approximately 40% of children in Cambodia with reported birthweight. bk Figure includes those with unknown sex and birthweight. bl Figure includes those with unknown birthweight. bm Neonatal tetanus eliminated. bn Figure applies to babies at 4 months old bo Figure applies to babies <4 months. bp Figure applies to babies at 4-5 months. bq Identifies countries that have achieved a second round of Vitamin A coverage greater than 1 or equal to 70%. br Figure includes only children less than 3 years old. bs Figure applies to agegroup 24-95 months. bt Figure 1.60 in the southern province and 4.40 in the northern province. bu Data from a subnational survey. bv Figure for 1998 are 32 for males and 40 for females. bw Figure applies to national rural (covering >85% of total population). bx Figure for 1998 are 5.8 for males and 7.0 for females. by The recommended BMI cutoff point for overweight among Chinese is 24. bz Based on country reports as of end of December 2007. ca Figure applies to adults only. cb Figure applies to urban areas only cc Figure applies to rural areas only. cd Figure refers to physicians in Guam Memorial Hospital and includes licensed military physicians working on part-time basis. ce Figure refers to the number of doctors with full registration on both the local and overseas lists, excluding Chinese medicince practitioners, and regardless of whether they are actually working in the profession or not. cf Figure refers to general practitioners and practitioners of Chinese medicine. cg Figure refers to healthcare personnel in public sector. ch Figure refers to physicians and specialists. COUNTRY HEALTH INFORMATION PROFILES | 539 STATISTICAL TABLES Notes ci Figure refers to the number of registered nurses and enrolled nurses regardless of whether they are actually working in the profession or not. cj Figure includes nurses, public nurses and assistant nurses. ck Figure includes medical assistants. cl Figure refers to bachelor and diploma graduate nurses. cm Figure includes 1 nurse anaesthesia and 4 unauthorized nurses. cn Figure refers to the number of healthcare personnel regardless of whether they are actually working in the profession or not. co Figure includes 1 unauthorized midwife. cp Figure refers to beds in general hospitals and primary health care centres only. cq Figure refers to beds in general hospitals, specialized hospitals and private hospitals. cr Figure refers to beds in general hospitals, district/ first-level referral hospitals, primary health care centres and private hospitals. cs Figure refers to beds in general hospitals, specialized hospitals, and primary health care centres. ct Figure refers to beds in general hospitals, specialized hospitals, district/ first level referral hospitals, and primary health care centres. cu Figure refers to beds in general hospitals, specialized hospitals, district/ first level referral hospitals, primary health care centres, and private hospitals. cv Figure refers to beds in general hospitals, primary health care centres, private hospitals and nursing homes. cw Figure includes beds in general hospitals, private hospitals and outpatient clinics. cx Figure refers to beds in general hospitals. cy Figure refers to beds in general hospitals, specialized hospitals, primary health care centres, and private hospitals. cz Figure refers to beds in general hospitals, specialized hospitals, district/ first level referral hospitals, and private hospitals. da Figure refers to beds in specialized hospitals. db Figure refers to beds in general and private hospitals. dc Figure refers to beds in general hospitals, specialized hospitals, primary health care centres and private hospitals. dd Figure refers to beds in general hospitals and district/ first level referral hospitals. de Figure refers to beds in general hospitals, primary health care centres and private hospitals. df Figure refers to government doctors. dg Incomplete data. dh Data have different reference years. di Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific using available population data nearest the reference year needed. dj Figure provided by dispensaries and isolated aid posts only. It does not represent the whole public and private data. dk The figure refers to the cases reported ot the Department of Health for the listed Statutory Notifiable Infectious diseases. dl Figure refers to hospital data only. dm Figure refers to the cases reported to the Department of Health for the listed Statutory Notifiable Infectious diseases and includes 58 dengue fever cases (27 males and 31 females). dn Figure refers to confirmed cases only. do Disease contracted "off island". dp Imported cases. dq Laboratory confirmed cases. dr At 24-27 months. ds Given as inactivated polio vaccine (IPV). dt Death certificates based on underlying causes. du Figure refers to hospitalization - first reported e-code. dv Figure refers to number of hospital encounters. dw Figure refers to selected urban and rural areas in mainland China. dx No available population size by gender. dy Figure applies to females only. dz Births to girls under 20. 540 | COUNTRY HEALTH INFORMATION PROFILES STATISTICAL TABLES Notes ea Figure refers to services provided by public health facilities. eb Figure refers to pregnant woment with antenatal care for at least six times during pregnancy. ec Figure reflects those attending Department of Health's specialist clinic. ed Total of 3 cases. ee No available data by urban and rural areas. ef Accession eg Succession eh Figure refers to current smokers. ei Figure refers to 100 MET-minutes/2 weeks. ej Figure refers to heavy drinker which is defined as drinking alcohol amounting to ≥20g/day for females and ≥40g/day for males. ek Figure refers to female binge drinkers defined as drinking alcohol amounting to ≥5 standard drinks. el Figure refers to IPAQ inactive which is defined as not meeting any of the following criteria: (1) 3 or more days of vigorous activity of at least 20 minutes per day . OR, (2) 5 or more days of moderate-intensity activity or walking of at least 30 minutes per day OR, (3) 5 or more days of any combination of walking, moderate-intensity or vigorous intensity activities achieving a minimum of at least 600 MET-min/week em Figure refers to insufficient physical activity. Definition for insufficient physical activity, refer to cited source. en Figure refers to those walking <10 000 steps a day. eo Figure refers to moderate intensity. ep Figure refers to current cigarette use. eq Figure refers to fruit intake of 1 serving or less, and vegetable intake of 4 servings or less. er Figure refers to those previously diagnosed or on hypertensive medication. es FiguFigure refers to those previously diagnosed. et Figure refers to those with total cholesterol ≥ 5.7 mmol/l (220 mg/dl). eu Figure refers to results of fasting glucose blood sample and oral glucose tolerance test performed according to WHO specifications. ev Figure refers to results of oral glucose tolerance test with blood value ≥11.10 mmol/l. ew Figure refers to results of fasting glucose blood sample and oral glucose tolerance test performed according to WHO specifications and diagnosed by doctors and is being treated. ex Figure refers to results of fasting glucose blood sample wherein subject had not eaten 3 hours prior to exam using criteria plasma value (mg/dl) of ≥200. ey Figure refers to result of fasting glucose blood sample. ez Figure refers to mean blood glucose level detected through fasting glucose blood sample. da Figure refers to fasting glucose blood test ≥ 7mmol/l in venous blood sample or currently being treated. db Figure refers to low level of physical activity. dc Figure refers to inactive level of physical activity for leisure time. dd Figure refers to those previously diagnosed by a physician. de Figure refers to those with total cholesterol ≥ 6.2 mmol/l (240 mg/dl). df Figure refers to total prevalence of diabetes in the surveyed population determined by questionnaire and laboratory test methods. dg Figure refers to those detected by finger prick and qualifiers returned on different day for fasting plasma glucose. Refer to cited source for the cut-off of blood glucose. dh Figure based on UNAIDS/WHO computation methods. di The number of people in need of ART used as denominator in the computation of estimates was based on country estimates in country reports. Sources 1 Western Pacific Region Health Databank and country profile, 2008 Revision. 2 Demographic Tables for the Western Pacific 2005-2010 . Manila, World Health Organization Regional Office for the Western Pacific, 2005. 3 The United Nations Human Rights Treaties [http://www.bayefsky.com/bystate.php/alist/af]. 4 Office of the United Nations High Commissioner for Human Rights [http://tb.ohchr.org/default.aspx]. COUNTRY HEALTH INFORMATION PROFILES | 541 STATISTICAL TABLES Sources 5 Convention on the Elimination of all Forms of Discrimination against Women. Division for the Advancement of Women, Department of Economic and Social Affairs. [http://www.un.org/womenwatch/daw/cedaw/reports.htm]. 6 Human Development Report 2007/2008: Fighting climate change: Human solidarity in a divided world. United Nations Development Programme, New York USA 2007. [http://hdr.undp.org/en/reports/global/hdr2007-2008/]. 7 Demographic Health Surveys (DHS). 8 Multiple Indicator Cluster Survey (MICS). 9 Family Planning Survey (FPS) 2006. 10 WHO Regional Office for the Western Pacific, data received from the technical units. 11 WHO Global Database on Child Growth and Malnutrition [http://www.who.int/nutgrowthdb/database/countries/en/index.html/p-child_pdf/]. 12 Global Youth Tobacco Survey 13 UNGASS Country Progress report 2008. 14 2008 Report on the Global Aids Epidemic, UNAIDS. 15 Towards Universal Access: Scaling up Priority HIV/AIDS interventions in the health sector, Progress Report 2008. WHO, UNAIDS, UNICEF. 16 Country reports on HIV/AIDS. 17 WHO Global Infobase, Tobacco [http://www.who.int/infobase/report.aspx?rid=112&ind=TOB]. 18 WHO Global Infobase, Alcohol [http://www.who.int/infobase/report.aspx?rid=116&dm=15&filterButton=Filter+Countries]. 19 WHO Global Infobase, Physical Inactivity [http://www.who.int/infobase/report.aspx?rid=116&dm=22&filterButton=Filter+Countries]. 20 Shafey O, Dolwick S, Guindon GE (eds). Tobacco Control Country Profile 2nd edition. 2003 [http://www.who.int/tobacco/global_data/country_profiles/en/index.html, accessed 28 Nov 2005]. 21 WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER Package. [http://www.who.int/entity/tobacco/mpower/mpower_report_full_2008.pdf]. 22 WHO Global Infobase, Fruit and vegetable consumption [http://www.who.int/infobase/report.aspx?rid=116&dm=16&filterButton=Filter+Countries&iso=ZZZ]. 23 WHO Global Infobase, BMI/Overweight/Obesity [http://www.who.int/infobase/comparestart.aspx]. 24 WHO Global Infobase, Cholesterol raised [http://www.who.int/infobase/report.aspx?rid=116&dm=24&filterButton=Filter+Countries&iso=ZZZ]. 25 WHO Global Infobase, Diabetes [http://www.who.int/infobase/report.aspx?rid=116&dm=2&filterButton=Filter+Countries&iso=ZZZ]. 26 Fiji Non-Communicable Diseases (NCD) STEPS Survey 2002. [http://www.who.int/entity/chp/steps/FijiSTEPSReport.pdf] 27 Mongolian STEPS Survey on the Prevalence of Noncommunicable Disease Risk Factors 2006. [http://www.who.int/chp/steps/27%20December%202006%20Mongolia%20STEPS%20Survey.pdf] 28 Nauru NCD Risk Factors STEPS Report 2004. [http://www.spc.int/prism/country/nr/stats/Publication/Surveys/Nauru_NCD_rpt.pdf] 542 | COUNTRY HEALTH INFORMATION PROFILES Annex Charts ANNEX CHARTS 544 ANNEX CHARTS 545 ANNEX CHARTS 546 ANNEX CHARTS 547 ANNEX CHARTS 548 549 Acute respiratory infections, cases and deaths. The number of new cases and deaths recorded or estimated from respiratory infections during the most recent year for which valid statistics are available. Disaggregated by gender. 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. Adolescent birth rate. Annual number of live births to girls aged 15-19 years, per 1000 girls aged 15-19 years. Adult literacy rate. The percentage of the total population aged 15 years and over who can, with understanding, both read and write a short simple statement on their everyday lives. Disaggregated by gender. Notes are made when a country has a different definition. Annual number of graduates. Includes all students in the health education sector duly conferred of an academic degree or diploma signifying advancement to a new level of skill, achievement or activity. Annual population growth rate. (See Population growth rate) Antenatal care. Includes recording medical history, assessment of individual needs, advice and guidance on pregnancy and delivery, screening tests, education on self- care during pregnancy, identification of conditions detrimental to health during pregnancy, first-line management and referral if necessary. Antenatal care coverage. • At least one visit. Percentage of women who utilized antenatal care provided by skilled birth attendance for reasons related to pregnancy at least once during pregnancy as a percentage of live births in a given time period. • At least four visits. Percentage of women who utilized antenatal care provided by skilled birth attendants for reasons related to pregnancy at least four times during pregnancy as a percentage of live births in a given time period. Area. The total surface area comprising land area and all inland waters. Presented in 1000 square kilometres or actual value. Beds. The number of beds regularly maintained and staffed for the accommodation and full-time care of a succession of inpatients and which are situated in wards or a part of the hospital where continuous medical care for inpatients is provided. The total number 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 are not included. Body mass index (BMI). Calculated as weight in kilograms (kg) divided by height in square metres (m2). Cancers, cases and deaths. The number of new cases or deaths detected due to all types and specific types of cancer during the most recent year for which valid data are available. The number of deaths due to all types and specific types of cancer that occurred during the most recent year for which valid data are available. Disaggregated by gender. Causes of morbidity. (See Leading causes of morbidity) Causes of mortality. (See Leading causes of mortality). Circulatory system diseases, cases and deaths. The number of cases and deaths resulting from any form of circulatory disease. Disaggregated by gender. Contraceptive prevalence rate. Percentage of women between 15-49 years who are practising, or whose sexual partners are practising, any form of contraception. Crude birth rate. The registered number of live births for every 1000 population in a given year or period of time. Disaggregated by gender. Crude death rate. The registered number of deaths for every 1000 population in a given year or period of time. Disaggregated by gender. Dependency ratio. The ratio of persons in the ‘dependent’ age groups (under 15 years plus 65 years and above) to those in the ‘economically productive’ age group (15-64 years), expressed as a percentage. Diabetes mellitus, cases and deaths. The number of existing cases and deaths due to diabetes mellitus during the most recent Appendix: Definition of Terms 550 year for which valid statistics are available. Disaggregated by gender. Diarrhoeal diseases, cases and deaths. The number of new cases of and/or recorded or estimated deaths from all types of diarrhoeal disease during the most recent year for which valid statistics are available. Disaggregated by gender. Discharges (including deaths). The number of persons, living or dead, whose stay in a health care facility has terminated and whose departure has been officially recorded. Diseases of the circulatory system. (See Circulatory system diseases) 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 DOTS 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) Estimated HIV prevalence in adults. Percentage of persons with HIV infection among persons aged 15-49 years. Estimated HIV prevalence among TB cases. Estimated percentage of HIV- positive cases among TB cases. External source of government health expenditure. Pertains to government expenditure on health coming from external sources, mainly in the form of grants passing through the Government or loans channelled through the national budget. External resources for health as a percentage of general government expenditure on health. The ratio of external resources for health to total general government expenditure on health, expressed as a percentage. Facilities with HIV testing and counselling services. Number of facilities where HIV testing and counselling is available, including both health and non- health facilities. GDP per capita annual growth rate (%). Least squares annual growth rate, calculated from constant price GDP in local currency units. Gender empowerment measure (GEM) value. A composite index measuring gender inequality in three basic dimensions of empowerment— economic participation and decision-making, political participation, and decision-making, and power over economic resources. Gender-related development index (GDI) value. A composite index measuring average achievement in the three basic dimensions captured in the human development index—a long and healthy life, knowledge and a decent standard of living— adjusted to account for inequalities between men and women. General government expenditure on health (excluding social security). 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. Government expenditure on health. The sum of outlays by government entities to purchase health care services and goods, notably by ministries of health and social security agencies. The revenue base may comprise multiple sources, including 551 external funds. (See also External source of government health expenditure) (1) Amount. Government expenditure on health expressed in million US dollars or another indicated currency. (2) General government expenditure on health as a percentage of total expenditure on health. The ratio of government expenditure on health to total expenditure on health, expressed as a percentage. (3) General government expenditure on health as a percentage of total general government expenditure. The ratio of government expenditure on health to total government expenditure, expressed as a percentage. Growth rate. (See also Population growth rate) Growth rate of per capita GDP (%). Least squares annual growth rate, calculated from constant price GDP ion local currency units. Gross domestic product (GDP). 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. Gross national income (GNI). 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. Gross national product (GNP). Comprises the gross domestic product (GDP), plus 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. Healthy life expectancy (HALE). The average number of years in full health a person (usually at age 60) can expect to live based on current rates of ill-health and mortality. Disaggregated by gender. 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. Expressed as metric tons per year. Disaggregated by location, i.e. urban or rural. Health expenditure per capita. (See Total health expenditure - Per capita total expenditure on health) Health facilities. (See Health infrastructure) Health infrastructure. Public (state/ government) health facilities • General hospital. Hospital providing a range of different services for patients of various age groups and with varying disease conditions. • Specialized hospital. 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. Hospital at the first referral level 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 a district hospital 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. • Primary health care centre. Centre that serve as first point of contact with a health professional and provides outpatient medical and nursing care. Services are provided by general practitioners, dentists, community nurses, pharmacists and midwives, among others. Health infrastructure. Private facilities. • Hospital. Hospital not owned by government or parastatal organizations (includes both private not-for profit, e.g. owned by religious organizations, and private-for-profit). • Outpatient clinic. Clinic not owned by government or parastatal organizations (includes both private-not-for-profit, 552 e.g. owned by religious organizations, and private-for-profit). Health insurance coverage as a percentage of total population. The percentage of the population covered by health insurance, both private and public health insurance schemes. Health workforce. • Physicians. Graduates of any faculty or school of medicine, licensed or registered to work in the country as medical doctors who apply preventive or curative measures and/or conduct research. Also expressed as number of physicians per 1000 population. Disaggregated by gender, area and sector. • Dentists. Graduates of any faculty or school of dentistry, odontology or stomatology, duly licensed or registered to practise dentistry, and actually working in the country in any dental field to apply medical knowledge in the field of dentistry and/or conduct research. Also expressed as number of dentists per 1000 population. Disaggregated by gender, area and sector. • Pharmacists. Graduates of any faculty or school of pharmacy, duly licensed or registered to practise pharmacy and actually working in the country in pharmacies, hospitals, laboratories, industry, etc. applying pharmaceutical concepts and theories by preparing and dispensing or selling medicaments and drugs. Also expressed as number of pharmacists per 1000 population. Disaggregated by gender, area and sector. • Nurses. 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. Also expressed as number of nurses per 1000 population. Disaggregated by gender, area and sector. • Midwives. 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 persons may or may not have prior nursing education. Also expressed as number of midwives per 1000 population. Disaggregated by sex, gendera and sector. • Paramedical staff. Health care assistants, laboratory technicians, technologists, therapists, nutritionists, sanitarians, among others, who are actually working in the country and are graduates of 2- to 5-year health courses in recognized health training institutions. Also expressed as number of paramedical staff per 1000 population. Disaggregated by gender, area and sector. • Community health workers. Lay members of communities who have a period of on-the-job training, sometimes formalized in apprenticeships, who work either for pay or as volunteers in association with the local health care system in both urban and rural environments and usually share ethnicity, language, socioeconomic status and life experiences with the community members they serve. Also expressed as number of community health workers per 1000 population. Disaggregated by gender, area and sector. Area. • Urban. Those working in urban areas or in planned metropolitan communities in developed areas designed to be self-sufficient, with their own housing, education, commerce and recreation. • Rural. Those working rural areas or in areas outside cities and metropolitan areas generally regarded as underdeveloped in terms of infrastructure and specialized services. Sector. • Public. Those who are employed in the public sector, which is the portion of society controlled by national, state or provincial and local governments. • Private. Those who are employed in the private sector, which comprises private corporations, households and non-profit institutions serving households. HIV prevalence among population aged 15–24 years. The percentage of the population aged 15–24 whose blood samples tested positive for HIV. 553 Hospital beds. (See Beds) 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 registered deaths among infants (below one year of age) per 1000 live births in a given year or period of time. Disaggregated by gender. Injuries, all types. Recorded or estimated number of diseases/injuries and deaths related to homicide and violence; motor and other vehicular accidents; work accidents; and suicide. Disaggregated by gender. • Homicide and violence, cases and deaths. Total number of cases and deaths from injuries resulting from homicides and other forms of violence. Disaggregated by gender. • Motor and other vehicular accidents, cases and deaths. The total number of cases refers to injuries (non-fatal and fatal) from motor and other vehicular accidents, while the total number of deaths refers only to the fatal injuries. Disaggregated by gender. • Occupational injuries, cases and deaths. Total number of cases and deaths due to injuries arising out of or in the course of work. Disaggregated by gender. • Suicide, cases and deaths. Total number of cases and deaths from self- inflicted injuries with the intention of taking one’s life. Also expressed as a proportion to the general population. Disaggregated by gender. Inpatient. A person admitted to a health care facility and who usually occupies a bed in that health care facility. Leading causes of morbidity. The most frequently occurring causes of morbidity (usually 10) among inpatients for which the greatest number of cases have been reported during a given year. The crude morbidity rate is usually expressed as the number of cases of disease per 100 000 population for a given year, disaggregated by gender. 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 that produced any such injuries. The crude mortality rate is usually expressed as the number of deaths from a specific cause per 100 000 population for a given year. Disaggregated by gender. Life expectancy at birth. The average number of years a newborn baby is expected to live if mortality patterns at the time of its birth were to prevail throughout the child’s life. Disaggregated by gender. 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 death rate. The number of malaria deaths per 100 000 population. Disaggregated by gender. Malaria incidence rate. The number of cases of malaria per 100 000 population. Disaggregated by gender. Maternal causes, cases and deaths. The number of cases and deaths due to abortion, eclampsia, haemorrhage, obstructed labour and sepsis among women while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy. Maternal causes of death may be subdivided into two groups: (1) direct obstetric death, resulting from obstetric complications of the 554 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 death, resulting from previous existing disease or disease that developed during pregnancy and that was not due to direct obstetric causes, but was aggravated by the physiological effects of pregnancy. Maternal mortality ratio. The number of registered deaths among women, from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy, childbirth or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy, for every 100 000 live births in a given year or period of time. Mental disorders, cases and deaths. The number of cases and deaths from any form of mental disorder, i.e. clinical, behavioural or psychological syndrome, characterized by the presence of distressing symptoms or significant impairment of functioning. Disaggregated by gender. 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 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. Motor and other vehicular accidents. The total number of cases refers to injuries (non-fatal and fatal) from motor and other vehicular accidents, while the total number of deaths refers only to the fatal injuries. Multidrug-resistant tuberculosis (MDR- TB). Describes strains of tuberculosis that are resistant to at least the two main first- line TB drugs— isoniazid and rifampicin. National poverty line. The percentage of the population living below the poverty line deemed appropriate for a country by its authorities. National estimates are based on population-weighted subgroup estimates from household surveys. 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 for height more than a standard deviation of 2 below the median value of the reference (healthy) population. Natural rate of increase. A measure of population growth (in the absence of migration) comprising addition of newborn infants to the population and subtraction of deaths. Expressed as a percentage per annum. Disaggregated by gender. Neonatal mortality rate. The number of registered deaths in the neonatal period per 1000 live births in a given year or period of time. Disaggregated by gender. Neonatal period. Commences at birth and ends 28 completed days after birth. Noncommunicable risk factors. • Behavioural measures. (1) Daily smokers. Those who smoke any tobacco product every day. (2) Current drinkers. Those who have consumed a drink containing alcohol in the last 12 months. (3) Binge drinkers. Consuming ≥5 (males) or ≥4 (females) standard drinks in a sitting. Standard drinks defined as: beer (285 ml), spirits (30 ml), wine (120 ml), aperitif (60 ml). (4) Physically inactive. Less 600 MET minutes/ week. MET is defined as the Activity Metabolic Rate divided by the Resting Metabolic Rate (=1 MET) across 3 domains (work, leisure and transport) and 2 levels (moderate and vigorous). (5) Low fruit and vegetable consumption. Total number of fruit and vegetable servings consumed each day per person. • Physical measures. (1) Raised blood-pressure. Systolic BP≥140 mmHg and/or diastolic BP≥90 mmHG or receiving treatment. 555 (2) Overweight. BMI≥25 to <30 (3) Obese. BMI≥30 • Biochemical measures. (1) Raised blood-cholesterol/ lipids. Total cholesterol≥5.2 mmol/Lor 200 mg/dl whole blood. (2) Raised blood glucose. BG≥110 mg/dl or 6.1 mmol/L of whole blood without having known diabetes or being on treatment. Diabetes as diagnosed by medical doctor. Number of mass drug administration (MDA) rounds for lymphatic filariasis. Number of rounds of mass drug administration of diethylcarbamazine or ivermectin in combination with albendazole conducted for prevention of lymphatic filariasis. Obese. A person whose 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 consultation, is not admitted to the facility and does not occupy a hospital bed for any length of time. Overweight. A person whose calculated body mass index (BMI) is greater than or equal to 25 kg/m2 but less than 30 kg/m2. Per capita gross domestic product (GDP) at current market prices. 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). Per capita gross national product (GNP). The per capita GNP is obtained by dividing the total gross national product by the total population. (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 distribution of population aged 60 years or older by gender. The percentage of the male and the female populations aged 60 years or older in a given period of time. Percentage distribution of population less than 15 years. (See Percentage of the population below 15 years of age or above 65 years of age.) Percentage distribution of population above 65 years. (See Percentage of the population below 15 years of age or above 65 years of age.) Percentage of deliveries attended by skilled health personnel. The percentage of deliveries attended by personnel trained: to give the necessary supervision, care and advice to women during pregnancy, labour and the postpartum period; to conduct deliveries on their own; and to care for newborn infants. Estimated in this CHIPS publication using two indicators: (1) Percentage of deliveries at home attended by skilled health personnel. Percentage of deliveries that take place at home and are attended by personnel trained: to give the necessary supervision, care and advice to women during pregnancy, labour and the postpartum period; to conduct deliveries on their own; and to care for newborn infants. Expressed as a percentage of total deliveries. (2) Percentage of deliveries in health facilities. Percentage of total deliveries 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, DTP3, POL3, measles (MCV1 and MCV2), hepatitis B3, Hib3, and DTP1, HepB birth dose, and VitA1. Percentage of children under one year of age who have received immunization against tuberculosis (BCG), diphtheria, pertussis, tetanus (DTP3 and DTP1), poliomyelitis (POL3), measles (at least one 556 dose and two doses) and hepatitis B3 and HepB birth dose. Also includes coverage with vitamin A1. Percentage of newborn infants weighing at least 2500 grams at birth. The percentage of newborn infants 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. Disaggregated by gender. Notes are made when a country has a different definition. Percentage of people with advanced HIV infection receiving ART. Percentage of people with advanced HIV infection who are receiving antiretroviral therapy (ART) according to a nationally approved treatment protocol (or WHO/Joint UN Programme on HIV and AIDS standards) among the estimated number of people with advanced HIV infection. Percentage of the population: 0- 4 years of age; 5-14 years old; or 65 years and older. The percentage of the total population aged 0 to 4 years, 5 to 14 years, or 65 years and above in a given period of time. Disaggregated by gender. Percentage of the population with access to safe water. (See Proportion of the population using improved drinking water source.) Percentage of the population with access to excreta disposal facilities. (See also Proportion of the population using improved sanitation facilities.) Percentage of pregnant women immunized with tetanus toxoid (TT2). The percentage of pregnant women adequately immunized against tetanus, having received at least two doses of tetanus toxoid during pregnancy. Expressed as a percentage of all live births since the number of pregnant women is generally not available. Percentage of pregnant women with anaemia. Percentage of pregnant women aged 15 to 49 years with a blood concentration of haemoglobin below 110 grams per litre (or 6.83 millimoles per litre) or haematocrit below 33%. Percentage of women given at least 2 doses of TT2+. (See also Percentage of women immunized with tetanus toxoid (TT2) during pregnancy.) Percentage of women in the reproductive age group using modern contraceptive methods. The percentage of women aged 15-49 in marital or consensual unions who are practising, or whose male partners are practising, any form of modern contraception, including female and male sterilization, oral contraceptives, injectables or implants, intrauterine devices, condoms, spermicidal foams, jelly, cream, sponges, among others. Notes are made when specific female populations are pertained to, such as only married 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 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. Presented in thousands or actual value. Disaggregated by gender. Population density. Population per square kilometre. Population growth rate. The average exponential population growth of the population in a given period of time. Expressed as a percentage. Disaggregated by gender. Prevalence of underweight children under five years of age. Percentage of children under five years of age whose weight for age is less than a standard deviation of 2 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. Disaggregated by gender. Prevalence rate. The proportion of the population with the health condition or disease in a given time. Expressed in 100, 1000, 10 000 or 100 000 population. Private health expenditure. The sum of total outlays on health by private entities, notably commercial insurance, non-profit institutions and households acting as complementary funders to the previously cited institutions or disbursing unilaterally on health commodities. This includes out- 557 of-pocket health expenditure, patient co- payments, private health insurance premiums, and health expenditures by nongovernmental organizations. Private expenditure on health as a percentage of total expenditure on health. Ratio of private expenditure on health to total expenditure on health, expressed as a percentage. Proportion of babies exclusively breast- fed for the first six months. Proportion of babies exclusively breast-fed for the first six months, i.e. given only breast milk except for drops or syrups consisting of vitamins, minerals or medicines. Proportion of babies aged 6-9 months receiving breast milk and complementary food. Proportion of babies aged 6-9 months receiving breast milk and complementary food, i.e. any food, whether home prepared or industrially processed, suitable as a complement to breast milk to satisfy the nutritional requirements of the infant. Proportion of babies less than 12 months of age with breast-feeding initiated within one hour of birth. Proportion of infants less than 12 months of age who were breast-fed by their mothers within one hour after birth, based on mother's recall. Proportion of children 0-59 months who had diarrhoea in the past two weeks and were treated with ORT. Proportion of children ages 0-59 months with diarrhoea in the two weeks preceding the survey who received oral rehydration therapy (oral rehydration therapy solutions or recommended homemade fluids) or increased fluids and continued feeding. Proportion of children 0-59 months of age who had suspected pneumonia in the past two weeks and were taken to an appropriate health care provider. Proportion of children ages 0-59 months with suspected pneumonia in the two weeks preceding the survey taken to an appropriate health care provider. Proportion of 1-year old children immunized against measles. Percentage of children under one year of age who have received at least one dose of measles vaccine. Proportion of 1-year old children protected against neonatal tetanus through immunization of their mothers. Proportion of infants whose mothers had two Tetanus Toxoid doses during the last pregnancy or had received at least TT2 (3 years protection), TT3 (5 years protection), TT4 (10 years protection) or TT5 (lifetime protection). Proportion of population in malaria-risk areas using effective malaria prevention measures. Percentage of children aged 0–59 months sleeping under insecticide-treated bednets. Proportion of population in malaria-risk areas using effective malaria treatment measures. Proportion of children aged 0–59 months who were ill with fever in the two weeks before the survey and who received appropriate antimalarial drugs. Proportion of 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 population using an improved sanitation facility. 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. Disaggregated by location: urban or rural. Proportion of population using an improved drinking 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. Disaggregated by location: urban or rural. 558 Proportion of tuberculosis cured under directly observed treatment short- course (DOTS). The proportion of new smear-positive tuberculosis cases registered under DOTS in a given year that successfully completed treatment, whether with bacteriological evidence of success (‘cured’) or without (‘treatment completed’). Expressed as a percentage. Proportion of tuberculosis detected under directly observed treatment short-course (DOTS). The percentage of estimated new infectious tuberculosis cases under the DOTS strategy. Expressed as a ratio of the number of DOTS-detected cases to the estimated number of new cases. Proportion of vehicles using unleaded gasoline (%). The percentage of total motor vehicles that use unleaded gasoline as their primary fuel. Disaggregated by location: urban or rural. Public expenditure on health. (See Government expenditure on health.) 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 GDP (%) (See Growth rate of per capita GDP.) Rate of natural increase of population. (See Natural rate of increase.) Reported mass drug administration (MDA) coverage for lymphatic filariasis among total population. Proportion of the population in identified filaria-endemic areas covered by MDA. Selected communicable diseases, cases and deaths. The number of new cases and deaths due to hepatitis (types A, B and C, E and unspecified), cholera, dengue fever/dengue haemorrhagic fever (DHF), encephalitis, gonorrhoea, leprosy, malaria, plague, syphilis and typhoid fever in a given year. Disaggregated by gender. Selected diseases under the WHO expanded programme on immunization (EPI), cases and deaths. The number of reported cases and deaths due to a specific disease among selected preventable diseases (AFP, congenital rubella syndrome, diphtheria, hib meningitis, measles, mumps, neonatal tetanus, pertussis [whooping cough], poliomyelitis, rubella, total tetanus and yellow fever) in a specific country or area over a given year. Skilled health personnel or skilled birth attendants. Those who are properly trained and who have appropriate equipment and drugs. Excludes traditional birth attendants, even if they have received a short training course. Smoking prevalence among adults. Proportion of the adult population (15 years and over) who are smokers (both daily and occasional) at a point in time. Smoking prevalence among youth. Proportion of young people (aged 13-15 years) who smoked during one or more of the 30 days preceding the survey (regardless of amount used). 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 health expenditure. The sum of general government expenditure on health (commonly called public expenditure on health) and private expenditure on health. (See also Government expenditure on health and Private health expenditure.) (1) Amount. Total health expenditure expressed in million US dollars or another indicated currency. (2) Total expenditure on health as a percentage of GDP (or GNP). The percentage share of total expenditure on health with respect to a country’s GDP (or GNP). (3) Per capita total expenditure on health. Total expenditure on health divided by the mid-year population (or population size if mid-year population is not available). 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 559 training and is now integrated into the formal health care system. Tuberculosis case. A patient in whom tuberculosis has been bacteriologically confirmed or has been diagnosed by a clinician. • All forms, cases and deaths. The sum of new smear-positive pulmonary, relapse, new pulmonary smear- negative pulmonary, and extrapulmonary tuberculosis cases and deaths. • New pulmonary tuberculosis (smear-positive), cases. Patients who have never received treatment for tuberculosis or have taken antituberculosis drugs for less than 30 days and who have 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 clinician; or (3) one sputum specimen positive for AFB and at least one sputum specimen that is culture-positive for AFB. Tuberculosis case detection. Tuberculosis is diagnosed in a patient and is reported within the national surveillance system, and then to WHO. Tuberculosis case detection rate, total. The ratio of new smear-positive cases notified to the estimated number of new smear-positive cases for a given year. Tuberculosis case detection rate under directly observed treatment, short- course (DOTS). The percentage of estimated new infectious tuberculosis cases detected under the DOTS strategy. Expressed as a ratio of the number of DOTS-detected cases to the estimated number of new cases. (See also Tuberculosis case detection.) Tuberculosis cure rate. (See Tuberculosis success rate.) Tuberculosis death rate. Estimated number of deaths due to TB for a given year. Includes deaths from all forms of TB and deaths from TB in people with HIV. Expressed as deaths per 100 000 population per year. Tuberculosis DOTS coverage. The percentage of the national population living in areas where health services have adopted the DOTS strategy. Tuberculosis incidence rate, all forms. Estimated number of tuberculosis cases arising in a given period of time. Includes all forms of TB, including cases of people co-infected with HIV. Expressed as a per capita rate. Tuberculosis prevalence, all forms. Estimated number of cases of tuberculosis in a population in a year or given period of time. Includes all forms of TB, including cases co-infected with HIV. Expressed as number of cases per 100 000 population in a given year. Tuberculosis prevalence, sputum-smear- positive. Estimated number of sputum-smear- positive cases of tuberculosis in a population in a year or given period of time. Expressed as the number of sputum-smear-positive cases per 100 000 population in a given year. Tuberculosis success rate under directly observed treatment, short-course (DOTS). The proportion of new smear- positive tuberculosis cases registered under DOTS in a given year that successfully completed treatment, whether with bacteriological evidence of success (‘cured’) or without (‘treatment completed’). Expressed as a percentage. Tuberculosis case notification rate, all cases. The number of tuberculosis cases reported per 100 000 population in a given year. Includes all forms of TB. Tuberculosis case notification rate, sputum smear-positive. The number of new smear-positive pulmonary tuberculosis cases reported per 100 000 population in a given year. 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. Disaggregated by gender. Underweight. (See National underweight, stunting and wasting prevalence.) Urban population. 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’. Expressed as a percentage. Disaggregated by gender. 560 Unmet need for family planning. Percentage of currently married women aged 15-49 who want to stop having children or to postpone the next pregnancy for at least two years, but who are not using contraception. 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. Workforce losses/ attrition. Number of persons who have left the local health workforce due to retirement, death, outmigration or resignation in a given period of time. Disaggregated by gender, area and sector.
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Western Pacific country health information profiles : 2008 revision
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