Western Pacific country health information profiles : 2006 revision

WESTERN PACIFIC Country Health Information Profiles 2006 REVISION ii WHO Library Cataloguing in Publication Data Western Pacific country health information profiles : 2006 edition 1. Health status indicators 2. National health programs 3. Health priorities ISBN 92 9061 229 0 (NLM Classification: WA 900) © World Health Organization 2006 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 ……………………………………………………………………………………. 11 Brunei Darussalam ……………………………………………………………………... 24 Cambodia ………………………………………………………………………………….. 34 China ………………………………………………………………………………………… 46 Cook Islands ………………………………………………………………………………. 56 Fiji …………………………………………………………………………………………….. 67 French Polynesia ………………………………………………………………………… 79 Guam ………………………………………………………………………………………… 88 Hong Kong (China) ……………………………………………………………………… 97 Japan ………………………………………………………………………………………… 108 Kiribati ………………………………………………………………………………………. 119 Lao People’s Democratic Republic ………………………………………………... 129 Macao (China) ……………………………………………………………………………. 142 Malaysia …………………………………………………………………………………….. 151 Marshall Islands …………………………………………………………………………. 162 Micronesia, Federated States of …………………………………………………… 172 Mongolia ……………………………………………………………………………………. 182 Nauru ……………………………………………………………………………………….. 196 New Caledonia …………………………………………………………………………… 205 New Zealand ……………………………………………………………………………… 214 Niue ………………………………………………………………………………………….. 225 Northern Mariana Islands, Commonwealth of the …………………………… 234 Palau …………………………………………………………………………………………. 243 Papua New Guinea ……………………………………………………………………… 252 Philippines …………………………………………………………………………………. 264 Pitcairn Islands …………………………………………………………………………… 278 Republic of Korea ……………………………………………………………………….. 280 Samoa ………………………………………………………………………………………. 292 Singapore ………………………………………………………………………………….. 306 Solomon Islands …………………………………………………………………………. 318 Tokelau …………………………………………………………………………………….. 329 Tonga ……………………………………………………………………………………….. 337 Tuvalu ………………………………………………………………………………………. 353 Vanuatu …………………………………………………………………………………….. 362 Viet Nam ……………………………………………………………………………………. 373 Wallis and Futuna ………………………………………………………………………. 385 Statistical Tables ………………………………………………………………………… 393 Statistical Charts ………………………………………………………………………… 419 Appendix. Glossary of Terms ……………………………………………………….. 427 v Introduction Country health information profiles (CHIPS) were first published in 1974 by the WHO Regional Office for the Western Pacific. The first CHIPS were primarily a reference for WHO staff responsible for briefing other staff, writing reports, drafting plans of action and verifying statistical data. CHIPS then became a resource tool used by other United Nations agencies, international organizations and government agencies. In response to ever-growing demands for current data and information, every effort is made to update the figures and analysis in CHIPS annually, if possible. The 2006 edition of CHIPS comprises the country profiles and the health databanks for the countries and areas of the WHO Western Pacific Region. Prior to publication, clearance by the respective governments is sought. The data are either supplied by the health ministries/departments or compiled from national databases and reference libraries. However, data reliability and data coverage vary for each indicator and from country to country. The country profiles provide a general description of the sociodemographic and health conditions of each country, as well as the political and health care systems, as follows: • Demographics, gender and poverty – Highlights the main demographic factors and socioeconomic status, as well as gender and poverty conditions, that are determinants of health risks, health care-seeking behaviour, access to health services and health outcomes. • Political situation – Describes the political structure and situations that may have an impact on health, such as political stability, major government initiatives, and recent and forthcoming political events, such as elections. • Economic situation – Explains and quantifies the economic determinants of health, such as levels of poverty and unemployment, economic growth rates, regional economic disparities, employment and working conditions and government spending on health. • Health trends – Details the major communicable diseases (including outbreaks) in the country and their trends, rates of noncommunicable diseases and the health transition, and the leading causes of morbidity and mortality, and provides information about rates of maternal and infant mortality, childhood diseases, etc. • Health systems – Describes the organization and financing of the health sector, including the role of the private sector and any key problems/ limitations/ issues with funding, infrastructure, human resources, quality of services or inequalities in access to and use of services. Highlights new innovative or ‘pro-poor’ approaches to health care financing, such as social safety nets and social health insurance, and their impact. May also include a brief summary of Millennium Development Goals (MDG) achievements and monitoring, such as recent activities and progress, important developments over the previous year, key issues or challenges and partnerships for MDG achievement. vi • National health plan and priorities – Outlines the Government’s long- term objectives for the health sector, highlighting health plans, legislation passed recently or pending and health reform proposals. • List of major information sources • 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) The country health databank is annexed to each country profile and is more detailed in containing different sets of indicators to reflect the country’s: • sociodemographic and economic condition; • 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; and • health service coverage, such as immunization of infants. It also contains the indicators used to monitor progress in achieving the health- related MDGs. At the end of the publication is a statistical annex that summarizes most of the information in the health databanks to facilitate intercountry comparisons. The statistical annex also contains indicators on selected health conditions, such as HIV and obesity, smoking behaviour, and child care, 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 and 2005 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 AFP Acute flaccid paralysis AIDS Acquired immunodeficiency syndrome APEC Asian Pacific Economic Cooperation ARI Acute respiratory infection ART Antiretroviral treatment ASEAN Association of Southeast Asian Nations AusAID Australian Agency for International Development BCG Bacille-calmette guérin BHS Barangay health station BMI Body mass index CDHS Cambodia Demographic and Health Survey CEDAW Convention on the Elimination of all forms of Discrimination Against Women CHS Community health services CNS Central nervous system COPD Chronic obstructive pulmonary disease CPR Contraceptive prevalence rate CRC Convention of the Right of the Child CRS Congenital rubella syndrome CVD Cardiovascular diseases DALY Disability-adjusted life years DDHS Division Directors of Health Services DEPD Department of Economic Planning and Development DHF Dengue haemorrhagic fever DM Diabetes mellitus DMZ Demilitarized zone DOTS Directly observed treatment short-course DPHSS Department of Public Health and Social Services DTP Diptheria-tetanus-pertussis EEZ Exclusive Economic Zones ENT Ear, nose and throat EPI Expanded programme on immunization EU European Union FGP Family group practices FIES Family Income and Expenditures Survey FNRI Food and Nutrition Research Institute GAVI Global Alliance for Vaccine and Immunization GDP Gross domestic product GEPA Guam Environmental Protection Agency GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GNI Gross national income GNP Gross national product GTZ Deutsche Gessellschaft für Technische Zusammenarbeit HACCP Hazard analysis critical control point HBsAg Hepatitis B antigen HBV Hepatitis B virus HDI Human development index HIB Haemophilus influenzae type b HIES Household income and expenditure survey HIS Health information system HIV Human immunodeficiency virus HKSARG Hong Kong Special Administrative Region Government HPAI Highly pathogenic avian influenza HPN Hypertension HRD Human Resources Development viii HRDF Human Resources Development Fund ICD International classification of diseases IEC Information, education and communication IMCI Integrated management of childhood illness IMR Infant mortality rate JEMCO Joint Economic Management Committee JICA Japan International Cooperation Agency KIFHAD Korean International Foundation for Health and Development LDC Least developed countries LGU Local government unit LPRP Lao People’s Revolutionary Party MCH Maternal and child health MDA Mass drug administration MDG Millennium Development Goals MDP Mongolian Democratic Party MICS Multiple Indicator Cluster Survey MMR Measles-mumps-rubella MPRP Mongolian People’s Revolutionary Party MR Measles-rubella MTDS Medium-Term Development Strategy NCD Noncommunicable disease NCHP National Center for Health Development NDHS National Demographic and Health Survey NEDA National Economic and Development Authority NGO Non-governmental organization NGPES National Growth and Poverty Eradication Strategy NHA National health accounts NHEP National Health Emergency Plan NHG National Healthcare Group NHIP National Health Insurance Program NHIS National Health Insurance Scheme NHSS National Health Service Survey NPS National Pension Scheme NSCB National Statistics Coordinating Board NSEDP National Socioeconomic Development Plan NSO National Statistical Office NZAID New Zealand Agency for International Development NZDS New Zealand Disability Strategy NZHS New Zealand Health Strategy NZODA New Zealand Official Development Assistance ODA Official Development Assistance OECD Organisation for Economic Cooperation and Development OPV Oral polio vaccine PHC Primary health care PHO Primary health organizations PPP Purchasing power parity PRISM Pacific Regional Information System PRSP Poverty reduction strategy paper PSC Public Service Commission RAMSI Regional Assistance Mission to Solomon Islands RF/RHD Rheumatic fever/ rheumatic heart disease RHU Rural health unit SAR Special Administrative Region SARS Severe acute respiratory syndrome SCD Scientific Concept of Development SHS Singapore Health Services SOE State-owned enterprises ix SPC Secretariat of the Pacific Community STI Sexually transmitted infection TB Tuberculosis TCM Traditional and complementary medicine TFP Total factor productivity TFR Total fertility rate TT Tetanus toxoid UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Fund for Population Activities UNICEF United Nations Children’s Fund UNTAC UN Transitional Authority in Cambodia USAID United States Agency for International Development VCT Voluntary counselling and testing VWG Village welfare group WB World Bank WHO World Health Organization WID Women in Development WTO World Trade Organization COUNTRY HEALTH INFORMATION PROFILES | 1 AMERICAN SAMOA 1. DEMOGRAPHICS, GENDER AND POVERTY In 2005, American Samoa had an estimated population of 65 500, with 50% residing in urban areas. Based on 2004 population estimates, around 40% of the population is below 15 years of age, while almost 4% is above 65 years. The average age is estimated at 21.3 years. Life expectancy at birth for men is estimated to be 72 years, while for women it is 80 years. Based on 2004 estimates, there are 104 males for every 100 females. Table 1. Core population and health data (2005) [Total] 65 500 est [Both] 75.84 [0-14 years] 38.95% (2004 est) [Male] 72.27 Population [65+ years] 3.58% (2004 est) Life expectancy at birth (years) [Female] 79.62 Crude birth rate (per 1000 population) 26.70 Total fertility rate 3.25 [Total] 99.00 (2004) [Urban] 99.00 (2004) Crude death rate (per 1000 population) 4.50 % of population served with safe water [Rural] 99.00 (2004) [Total] 99.00 (2004) [Urban] 99.00 (2004) Infant mortality rate (per 1000 live births) 15.20 % of population with adequate sanitary facilities [Rural] 99.00 (2004) Maternal mortality ratio (per 100 000 live births) 123.00 (2002) est - Estimate 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation American Samoa was defined by a treaty in 1899 between the United States of America, the United Kingdom of Great Britain and Northern Ireland, and Germany, which gave the United States of America control of all Samoan islands east of 171ºW. In 1978, the first popularly elected Samoan governor was inaugurated. There is a bicameral legislature (Fono), consisting of a senate (18 members chosen by county councils) and a house of representatives (20 members elected by popular vote, plus one non-voting member from Swains Island, which is privately owned). There is also an independent judiciary. 2.2 Economic situation American Samoa is a small developing economy that depends on two main sources of income: the United States Government and tuna canning. Federal expenditures and the canning business together account for 93% of the economy. The remaining 7% results from a small tourism industry and a service sector. Transfers from the United States Government add substantially to American Samoa’s economy. Annual budget revenues of US$ 121 million comprise grants from the United States of America (63%) and local revenue (37%). The United States is the main trading partner. Gross domestic product (GDP) per capita (purchasing power parity) was estimated at US$ 8000 in 2000. AMERICAN SAMOA 2 | COUNTRY HEALTH INFORMATION PROFILES 3. HEALTH SITUATION 3.1 Health trends In 2005, the crude birth rate was 26.7 per 1000 population and the crude death rate 4.5 per 1000 population. The infant mortality rate was estimated at 15.2 per 1000 live births in the same year, and the under-five mortality rate at 4.90 per 1000 live births in 2002. The total fertility rate for women aged 15-49 years is 3.25, and the maternal mortality ratio was 123 per 100 000 live births in 2002. In 2000, 33% of women in the reproductive age group were using modern contraceptive methods. There has been considerable progress in primary health care in recent years. Water supplies and sanitation systems are well organized and maintained, and 99% of the population have access to safe water. Water is increasingly supplied from deep bores, with a smaller portion from reservoirs, and is chlorinated. 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 adequate space for solid waste landfill operations is very limited. The morbidity pattern has shifted significantly over the past three decades from infectious diseases to a predominance of noncommunicable diseases related to modernization and lifestyle changes. Enumerated data on the leading causes of morbidity are currently unavailable. However, based on the observations and the personal experiences of senior health officers, the following are assessed as the leading communicable diseases presently affecting the population: respiratory infectious diseases, filariasis, dengue, hepatitis, tuberculosis, leprosy and intestinal worm infestations. For noncommunicable diseases, obesity, diabetes and its complications (including hypertension, heart disease and stroke), chronic disabling conditions (including asthma, gout, osteoarthritis and osteoporosis), tobacco-related obstructive pulmonary disease, cancer and oral disease are the leading causes of morbidity. The most serious health issues are related to the increase in chronic diseases associated with lifestyle, with their roots in improper nutrition and physical inactivity. Significant increases in the prevalence of obesity, in both sexes and at increasingly younger ages, are associated with a number of these conditions. Hypertension, cardiovascular diseases, cerebrovascular diseases, type II diabetes mellitus and its complications, arthritis, gout and some forms of cancer are among these important chronic diseases. American Samoa reported one positive case of HIV in 2001. The Government is taking the issue of HIV/AIDS seriously and has developed a national policy and prevention programme. Filariasis is a major endemic problem. The mass drug administration (MDA) campaign in 2001 reported coverage of 52% for the target population. The reported coverage represents a 50% improvement compared with the 1999 MDA, which only had 19% coverage. In 2003, MDA coverage among the total population was 70%. Blood survey results for filariasis were 2.6% (microfilaria) and 11.5% (immunochromatographic test) in 2001. 3.2 Health systems The Department of Health and the National Hospital continue to co-exist as two separate systems. The Department of Health is responsible for public health issues, communicable disease control (including tuberculosis and HIV/AIDS) and health dispensaries at district and community levels. The National Hospital in Pago Pago is under the management of the Hospital Board, designated by the Governor, and is subject to the federal rules and regulation of the United States of America (i.e. the hospital does not have to report to the Department of Health). Nevertheless, coordination between the Department of Health and the National Hospital is generally well conducted at the technical level. Most public health programmes continue to be funded by federal grants. COUNTRY HEALTH INFORMATION PROFILES | 3 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 scope of general inpatient and outpatient services covering: medicine; surgery; obstetrics and gynaecology; ear, nose and throat (ENT); eye; paediatrics; mental health; and renal dialysis. 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, and severe government financial difficulties, make long-range health workforce planning uncertain and recruitment and retention problematic. Both the hospital and the Department of Health have inadequate resources for continuing education for their staff members. This leaves the Department of Health with a rapidly growing gap between evolving professional responsibilities and existing workforce competencies. The long-standing problem of health workforce deficiencies is one of the greatest challenges for health development. Therefore, human resource development for health has been identified as a priority area for national health development, particularly for WHO collaboration. Training of nurses takes place locally and through overseas education in the American system and, as recognition of qualifications requires certification and/or registration by American professional associations, much undergraduate and post-graduate training is undertaken in that system. Adequate numbers of licensed practical nurses are produced this way, but the supply of registered nurses is insufficient to meet the quality standards required for United States federal health care financing programmes. Specialized training courses and workshops sponsored by WHO and American sources are welcomed and add to the quality of services, particularly those related to public health. The newly acquired telecommunications capability at the LBJ Tropical Medical Center provides additional opportunities for distance learning through the telemedicine/telehealth system housed in that facility. Medical and dental officers are trained at the Fiji Schools of Medicine and Dentistry, and post- graduate training through short-term courses and attachments is arranged in Australia and New Zealand. A number of medical students are also in medical schools in the United States of America, although this practice does not provide any assurance that these individuals will return to the island as doctors after their training. Financial management of public health programmes is mainly grant-driven rather than programme-driven. The hospital generates financial resources from user fees, local government appropriations, and federal health care financing through the Medicaid and Medicare programmes. The total government health budget amounts to 14% of the territory’s total budget and the bulk goes towards curative care, with only about 10% going to public health. Total health expenditures are around US$ 32.3 million, which corresponds to per capita health expenditure of US$ 500. The United States health care financing administration provides about US$ 3 million a year to the LBJ Tropical Medical Center (16% of its funding), most of which is used to purchase medicine and medical supplies used at the centre. Pharmaceuticals and vaccines are purchased from the United States of America. United States Federal Drug Administration regulations prevent the territory from purchasing pharmaceuticals from foreign sources. There are frequent shortages due to problems with ordering logistics and financial shortfalls. A planned project to build a new acute care hospital to replace the LBJ Tropical Medical Center has been deferred due to cost. An alternative plan to renovate and expand the existing facility is being implemented. AMERICAN SAMOA 4 | COUNTRY HEALTH INFORMATION PROFILES 4. NATIONAL HEALTH PLAN AND PRIORITIES The territorial health priorities are as follows: (1) Increase the capacity of the health system to meet the health challenges of the 21st century through: - improving health policy development mechanisms, - developing the health workforce, - improving management processes at all levels, and - strengthening long-range health planning and programme planning. (2) Identify emerging and re-emerging diseases and implement effective interventions. (3) Implement effective interventions to decrease the burden of chronic diseases related to unhealthy lifestyles, especially cardiovascular disease, cancer and diabetes mellitus. (4) Actively implement the Healthy Islands concepts of health promotion, health protection and primary health care in priority settings, particularly through community health centres and school-linked programmes. (5) Increase the effectiveness of public investment in health through development of decision-oriented information systems, applied research, effective deployment of the health workforce, application of appropriate technology, and increased allocation of funding for health promotion, health protection and primary health care. 5. MAJOR INFORMATION SOURCES Department of Health Department of Commerce, Statistics Division (http://www.asdoc.info/statistics/statshp.htm) Pacific Island Populations 2005. Noumea, Secretariat of the Pacific Community (http://www.spc.int) Demographic Tables for the Western Pacific Region 2000-2005. Manila, WHO Regional Office for the Western Pacific, 2005. World Population 2002. New York, United Nations Population Division, Department of Economic and Social Affairs, 2002. 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Pago Pago, American Samoa 98799 Postal Address : Official Email Address : Telephone : (684) 633 4606 Fax : (684) 633 5379 Office Hours : Pago Pago, American Samoa 98799 Website : COUNTRY HEALTH INFORMATION PROFILES | 5 WHO REPRESENTATIVE IN SAMOA Office Address : Ioane Viliamu Building Beach Road, Apia, Western Samoa Postal Address : P.O. Box 77 Apia, Samoa Official Email Address : who@sma.wpro.who.int Telephone : (685) 23756 Fax : (685) 23765 Office Hours : Website : ORGANIZATIONAL CHART: DEPARTMENT OF HEALTH AMERICAN SAMOA 6 AMERICAN SAMOA WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 0.20 2004 1 2 Estimated population ('000s) 65.50 … … 2005 est 7 3 Annual population growth rate (%) 2.30 … … 2005 7 4 Percentage of population - 0–14 years 38.95 39.27 38.62 2004 est 3 - 65+ years 3.58 3.31 3.87 2004 est 3 5 Urban population (%) 54.00 … … 2003 4 6 Crude birth rate (per 1 000 population) 26.70 … … 2005 7 7 Crude death rate (per 1 000 population) 4.50 … … 2005 7 8 Rate of natural increase of population (% per annum) 1.98 … … 2005 8 9 Life expectancy (years) - at birth 75.84 72.27 79.62 2005 8 - Health-adjusted Life Expectancy (HALE) at age 60 … … … 10 Adult literacy rate (%) … … … 11 Neonatal mortality rate (per 1 000 live births) 9.90 … … 2005 7 12 Infant mortality rate (per 1 000 live births) 15.20 … … 2005 7 13 Under-five mortality rate (per 1 000 live births) 4.90 … … 2002 5 14 Total fertility rate (women aged 15–49 years) 3.25 2005 8 15 Maternal mortality ratio (per 100 000 live births) 123.00 2002 5 16 Percentage of newborn infants weighing at least 2500 g at birth 96.67 f … … 2004 2 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 32.00 2002 5 19 Immunization coverage for infants (%) - BCG NR NR NR 2003 6 - DTP3 94.00 … … 2003 6 - OPV3 93.00 … … 2003 6 - Measles 89.00 … … 2003 6 - Hepatitis B III 89.00 … … 2003 6 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 70.00 2002 5 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) 1.00 2002 5 - Percentage of deliveries in health facilities (as % of total deliveries) 99.00 2002 5 21 Percentage of women in the reproductive age group using modern contraceptive methods 33.00 2000 5 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … COUNTRY HEALTH INFORMATION PROFILE 7 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 99.00 99.00 99.00 2004 5 26 Proportion of population with access to improved sanitation 99.00 99.00 99.00 2004 5 27 Proportion of the population using solid fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index … … … 32 Per capita GDP at current market prices (US$) 8000.00 g … … 2000 est 5 33 Rate of growth of per capita GDP (%) … … … 34 Health expenditure Total health expenditure - amount (in million US$) 32.30 2003 7 - total health expenditure on health as % of GDP … - per capita total expenditure on health (in US$) 500.00 2003 7 Government expenditure on health - amount (in million US$) 31.80 2003 7 - general government expenditure on health as % of total expenditure on health 98.00 2003 7 - general government expenditure on health as % of total general government expenditure 14.00 2003 7 External source of government health expenditure - external resources for health as % of general government expenditure on health 70.00 2003 7 Private health expenditure - private expenditure on health as % of total expenditure on health 2.00 2003 7 Exchange rate in US$ of local currency is: 1 US$ = … 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population a,e 36 Health workforce - physicians 49 36 13 7.83 … … 2003 5 - dentists 15 8 7 2.40 … … 2003 5 - pharmacists 2 2 0 0.32 0.32 0.00 2003 5 - nurses 127 4 123 20.29 … … 2003 5 - midwives 1 0 1 0.16 0.00 0.16 2003 5 - other nursing / auxiliary staff 98 8 90 15.65 … … 2003 5 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 146 63 83 23.32 … … 2003 5 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 13 13 0 2.08 2.08 0.00 2003 5 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … AMERICAN SAMOA 8 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity b Number Rate per 100 000 population 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 40 Ten leading causes of mortality Number Rate per 100 000 population a 1. Heart diseases 38 … … 60.70 … … 2003 2 2. Neoplasm 36 … … 57.51 … … 2003 2 3. Diabetes 30 … … 47.92 … … 2003 2 4. Cerebrovascular 22 … … 35.14 … … 2003 2 5. Pneumonia and influenza 21 … … 33.55 … … 2003 2 6. Certain conditions originating in the perinatal period 15 … … 23.96 … … 2003 2 7. Accidents 13 … … 20.77 … … 2003 2 8. Nephritis and nephrosis 12 … … 19.17 … … 2003 2 9. Chronic obstructive pulmonary diseases 10 … … 15.97 … … 2003 2 10. Suicide 9 … … 14.38 … … 2003 2 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 6 - Pertussis (whooping cough) 0 0 0 0 0 0 2004 6 - Tetanus NR NR NR NR NR NR 2004 6 - Neonatal tetanus NR NR NR NR NR NR 2004 6 - Poliomyelitis 0 0 0 0 0 0 2004 6 - Hib meningitis 2 … … … … … 2004 6 - Measles 0 0 0 0 0 0 2004 6 - Mumps 0 0 0 0 0 0 2004 6 - Rubella 0 0 0 0 0 0 2004 6 - Congenital rubella syndrome 0 0 0 0 0 0 2004 6 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral - Type A < 5 … … 0 0 0 2003 5 - Type B < 5 … … 0 0 0 2003 5 - Type C < 5 … … 0 0 0 2003 5 - Type E … … … … … … - Unspecified 0 0 0 0 0 0 2003 5 Cholera 0 0 0 0 0 0 2003 5 Typhoid fever < 5 … … 0 0 0 2003 5 Encephalitis 0 0 0 0 0 0 2003 5 Plague 0 0 0 0 0 0 2003 5 Syphilis 3 1 2 0 0 0 2003 5 COUNTRY HEALTH INFORMATION PROFILE 9 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Cases and deaths for selected communicable diseases Number of cases aa Number of deaths Gonorrhoea 41 30 11 0 0 0 2003 5 Leprosy 3 … … … … … 2004 6 Malaria … … … … … … Dengue/DHF 1185 … … 0 0 0 2002 6 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 5 … … … … … 2004 6 - New pulmonary tuberculosis (smear-positive) 2 … … … … … 2004 6 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 49.00 … … 5.00 … … 2004 6 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 25.00 … … 100.00 (2003) … … 2004 6 Number of cases Number of deaths 45 Acute respiratory infections … … … 11 … … 2002 5 46 Diarrhoeal diseases … … … 0 0 0 2002 5 47 Cancers All cancers (malignant neoplasms only) 58 … … 37 … … 2002 5 - Trachea, bronchus, and lung 2 … … 7 … … 2002 5 - Stomach 7 … … 5 … … 2002 5 - Colon and rectum 7 … … 3 … … 2002 5 - Lip, oral cavity and pharynx 4 … … 0 … … 2002 5 - Liver 2 … … 6 … … 2002 5 - Cervix 7 4 2002 5 - Leukaemia 2 … … 2 … … 2002 5 48 Circulatory All circulatory system diseases … … … 88 ... … 2002 5 - Ischaemic heart disease … … … … … … - Acute myocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … 17 … … 2002 5 - Hypertension … … … 9 … … 2002 5 49 Maternal causes - Haemorrhage … … - Abortion … … - Eclampsia … … - Sepsis … … - Obstructed labour … … AMERICAN SAMOA 10 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 50 Diabetes mellitus 2417 1119 1298 29 … … 2002 5 51 Mental disorders 135 … … 0 0 0 2003 5 52 Injuries - All types 1500 … … 26 … … 2002 5 - Motor and other vehicle accidents 101 … … 5 … … 2002 5 - Suicide 35 … … 4 … … 2002 5 - Homicide and violence 130 … … 10 … … 2002 5 - Occupational injuries … … … 1 … … 2002 5 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 128 2003 5 - Specialized hospitals … … - District/first-level referral hospitals … … - Primary health care centres 5 0 2003 5 Private hospitals … … Notes: Red text Millennium Development Goals (MDG) indicators … Data not available p Provisional est Estimate NR Not relevant aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans to school attendance on non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b The leading indicators of morbidity in American Samoa for communicable infectious or parasitic diseases are: respiratory infectious diseases, filariasis, dengue, hepatitis, Hansen's disease, and intestinal worm infestations. For noncommunicable diseases, the morbidity patterns are: obesity, diabetes and complications (hypertension, heart disease and stroke), chronic disabling conditions (asthma, gout, osteoarthritis and osteoporosis), tobacco- related obstructive pulmonary diseases, cancer and oral health. American Samoa Department of Health, 2004. c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. e Revised data. f Figure refers to birth weight equal to 2501 grams and above. g Figure refers to per capita GDP at PPP (US$). Sources: 1 Pacific Island Populations 2004. Secretariat of the Pacific Community http://www.spc.int 2 Health Information System, ASG Department of Health, American Samoa http://www.spc.int/prism/country/as/stats/Vital%20&%20Health%20Statistics/vital.htm 3 Demographic Tables for the Western Pacific Region 2000-2005. Manila, WHO Regional Office for the Western Pacific. 4 World Population 2002. United Nations Population Division, Department of Economic and Social Affairs. 5 Department of Health, American Samoa. 6 WHO Regional Office for the Western Pacific, data received from technical units. 7 ASG Department of Commerce, Statistics Division, American Samoa http://www.asdoc.info/Statistic/statshp.htm 8 US Census Bureau http://www.census.gov COUNTRY HEALTH INFORMATION PROFILES | 11 AUSTRALIA 1. DEMOGRAPHICS, GENDER AND POVERTY Australia had a population of 20 328 609 in 2005, 76.0% Australian-born, 2.4% with indigenous status and 24.0% overseas-born. The average age of the population is 37.6 years, with a life expectancy at birth of 78.1 years for men and 83.0 years for women. In 2004, Australia's fertility rate was 1.77 live births per woman, slightly higher than in 2001 (1.73). It is one of the world’s most urbanized countries, with about 70% of the population living in the 10 largest cities. Most of the population is concentrated along the eastern seaboard and the south-eastern corner of the continent. Table 1. Core population and health data (2005) [Total] 20 328 609 [Both] … [0-14 years] 3 978 221 (19.60%) [Male] 78.10 (2002–2004) Population [65+ years] 2 668 001 (13.10%) Life expectancy at birth (years) [Female] 83.00 (2002–2004) Crude birth rate (per 1000 population) 12.70 (2004) Total fertility rate 1.77 (2004) [Total] 100.00 (2002) [Urban] 100.00 (2002) Crude death rate (per 1000 population) 6.60 (2004) % of population served with safe water [Rural] 100.00 (2002) [Total] 100.00 (2002) [Urban] 100.00 (2002) Infant mortality rate (per 1000 live births) 4.70 (2004) % of population with adequate sanitary facilities [Rural] 100.00 (2002) Maternal mortality ratio (per 100 000 live births) 8.20 (1997-1999) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Australia was created in 1901 when former British colonies (now the six states) agreed to federate. The Government is based on a popularly elected parliament with two chambers, the House of Representatives and the Senate. Ministers appointed from these chambers conduct executive government. Policy decisions are made in meetings of the Cabinet. Ministers are bound by the principle of Cabinet solidarity. Although Australia is an independent nation, Queen Elizabeth II of the United Kingdom of Great Britain and Northern Ireland is also formally Queen of Australia. The Queen appoints a Governor-General (on the advice of the elected Australian Government) to represent her. The Governor-General has wide powers, but by convention acts only on the advice of ministers on virtually all matters. Australia’s system of government is based on the liberal democratic tradition, which includes religious tolerance and freedom of speech and association. Its institutions and practices reflect British and North American models, but are uniquely Australian. Australia has a written constitution that defines the responsibilities of the Federal Government, which include foreign relations and trade, defence and immigration. Governments of states and territories are responsible for all matters not assigned to the Commonwealth. State parliaments are subject to the national constitution as well as their state constitutions. A federal law overrides any state law not consistent with it. AUSTRALIA 12 | COUNTRY HEALTH INFORMATION PROFILES A national general election must be held within three years of the first meeting of a new federal parliament. The average life of parliaments is about two-and-a-half years. The Australian colonies inherited an electoral tradition from the United Kingdom that included limited franchise and public and plural voting. Abuses, such as bribery and intimidation of voters, stimulated electoral reform. Australia pioneered reforms that underpin the electoral practices of modern democracies. 2.2 Economic situation Australia has had one of the strongest economies in the world over the past decade: more competitive, open and vibrant than ever before. Australia's high level of economic performance, resting on strong growth, low inflation and low interest rates, has been the result of effective economic management and ongoing structural reform, along with a competitive and dynamic private sector and a skilled, flexible workforce. With its abundant physical resources, Australia has enjoyed a high standard of living since the nineteenth century. It has made a comparatively large investment in social infrastructure, including education, training, health and transport. In recent decades, the shift from manufacturing to services has been rapid, with most new jobs created in the services sector, which accounted for 75% of total employment in Australia across all industries in 2002-2003. The new economy is characterized in part by the increasing pace of technological and social change, with innovation leading to higher productivity, and the development of information and knowledge in all industries. 3. HEALTH SITUATION 3.1 Health trends The twentieth century was a period of great social, economic and scientific development in Australia. In health, these developments brought better nutrition and living conditions from the start of the century, widespread immunization and improvements in medical treatment in the second half, and a growing awareness of the effects of lifestyle and socioeconomic factors on health in more recent times. Such advances have resulted in death rates that are now less than one-third of those in 1900, an improvement in life expectancy at birth of over 20 years, and a dramatic decline in perinatal mortality and deaths from infectious diseases. However, there has also been a greater prominence of chronic diseases (e.g. cardiovascular diseases and cancer) and the rise and partial fall of two epidemics, coronary heart disease and lung cancer. Although most Australians enjoy good health today, some groups in the population continue to suffer poor health, in particular Aboriginal and Torres Strait Islander peoples. The 2004 infant mortality rate was 4.7 deaths per 1000 live births, a 2% decrease from the previous year, and a decline from 5.9 in 1994 and 9.2 in 1984. In 2004, 39% of all infant deaths occurred within one day of birth. The current infant and child death rates are low by international standards. Although infant and child deaths form only a small proportion (less than 1%) of all deaths, they nevertheless have important public health policy significance. In the four years from 2000 to 2003, two major groups of causes accounted for 94% of neonatal deaths: conditions originating in the perinatal period (68%), and congenital malformations (26%). Conditions originating in the perinatal period include causes that relate to pregnancy, foetal growth, labour and delivery. Congenital malformations are conditions present at birth that are either hereditary or originating from pregnancy, including deformities and chromosomal abnormalities. Between 1987-1990 and 2000-2003, the neonatal death rate for congenital malformations halved, declining from 1.6 to 0.08 deaths per 1000 live births, partly due to improved screening methods to detect such conditions (including amniocentesis and ultrasound) and greater awareness of preventive measures during pregnancy. COUNTRY HEALTH INFORMATION PROFILES | 13 There has also been a dramatic decline in mortality rates for women during childbirth. Maternal death rates remained relatively high until a dramatic decline in 1937, when antibacterial drugs became available. Improved nutrition, better general health, the advent of medical interventions like antiseptic procedures, a decrease in pregnancies (due to contraception and family planning), use of blood transfusions and the professional training of those attending births have all contributed to a sustained decrease in deaths of women following childbirth. In the triennium 1997-1999, the maternal mortality ratio (MMR) was 8.2 deaths per 100 000 confinements. The risk of death was highest for women aged 40-44 years, who had an MMR of 23.2 deaths per 100 000 confinements, and lowest for women aged 20-24 years, who had an MMR of 4.0 deaths. The MMR for Aboriginal and Torres Strait Islander women continues to be higher than the rate for non-indigenous women, with an MMR of 23.5 deaths for 100 000 confinements, compared with 6.7 for non-indigenous women. There is justification for continuing concern about this disparity. Significant increases in life expectancy have occurred throughout the twentieth century, reductions in infant and child mortality being the most significant contributing factors. Life expectancy at birth continued to increase, reflecting the general decrease in death rates. A boy born in 2002–2004 could expect to live 78.1 years, while a girl could expect to live 83.0 years. Since 1984, life expectancy at birth has increased by 5.6 years for males and 4.1 years for females. In 2002–2004, life expectancy at birth for males and females varied across the regions of Australia by up to 10 years. Indigenous life expectancy at birth was almost 20 years less than for the total population, at 59.4 years for indigenous males and 64.8 years for indigenous females (1996–2001). There were 132 508 deaths registered in 2004, 68 395 male and 64 113 female, a rise of 0.2% on the corresponding figure for 2003 (132 292). There has been a corresponding decrease in the standardized death rate of 22%, from 8.1 deaths per 1000 population in 1994 to 6.3 deaths per 1000 population in 2004, which is consistent with continuing improvements in life expectancy. The leading underlying causes of death in 2004 were generally consistent with 2003 data with respect to standardized death rates and relative proportions. However, there have been some changes in these relative proportions since 1994. In 2004, malignant neoplasms (29%) and ischaemic heart diseases (18%) were responsible for 47% of all deaths, while in 1994 these two causes contributed almost equally (27% and 24%) and were responsible for 51% of all deaths. The most serious health issues are related to the increase in chronic diseases 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 a number of these conditions. Hypertension, cardiovascular diseases, cerebrovascular diseases, diabetes and its complications, arthritis and some forms of cancer are among these important chronic diseases. An estimated 14 840 people were living with HIV/AIDS in Australia in 2004. There was a reduction in the annual number of newly acquired HIV infections, adjusted for multiple reporting, from 281 cases in 2003 to 253 cases in 2004. However, there was an increase in the annual number of new HIV diagnoses, adjusted for multiple reporting, from 782 cases in 2003 to 820 cases in 2004. The rate of AIDS diagnosis among Australian-born people declined from 2.6 to 1.1 per 100 000 population from 1995-1999 to 2000-2004. The rate of AIDS diagnosis among overseas-born people declined from 3.2 to 1.2 per 100 000 population over the same period. The per capita rate of HIV and AIDS diagnosis among indigenous people was similar to that found among non-indigenous people, but a higher proportion of HIV diagnoses in indigenous people were among women (33% compared with 11%). Transmission of HIV infection in Australia continues to be mainly through sexual contact between men, as reported in 86% of cases of newly acquired HIV infections diagnosed in 2000–2004. However, an almost equal proportion of diagnoses among indigenous people are attributed to male homosexual contact as heterosexual contact. Survival following AIDS in Australia increased from 17 months for cases diagnosed prior to 1996 to 45 months for cases diagnosed in 2001. AUSTRALIA 14 | COUNTRY HEALTH INFORMATION PROFILES The Government’s domestic response to HIV/AIDS is guided by the principles and priorities outlined in the fifth National HIV/AIDS Strategy 2005–2008. Australia’s achievements in relation to HIV/AIDS have been largely attributed to the cooperative partnership between all levels of government; community organizations; the medical, health care and scientific communities; and people living with or affected by HIV/AIDS. The National HIV/AIDS Strategy 2005–2008 identifies five priority areas for action to be addressed over the life of the Strategy: development of a targeted prevention education and health promotion programme for HIV; improvement of the health of people living with HIV/AIDS; development of an effective response to the changing care and support needs of people living with HIV/AIDS; review of the National HIV Testing Policy; and provision of a clearer direction for HIV/AIDS research. 3.2 Health systems In 2003–2004, there were 1304 hospitals in Australia, 761 of them public hospitals and 543 private. The number of beds per 1000 population in health care institutions is a useful indicator of the comparative supply of health care services between public and private beds across the states and territories. In 2003–2004, there were 2.67 available hospital beds per 1000 population in public hospitals, and 1.33 available beds per 1000 population in private hospitals, providing a total of 4.00 beds per 1000 population. In 2005, approximately 440 000 people were employed in health occupations, comprising 4.4% of the total number of employed persons in Australia. The health occupation workforce grew by an annual average of 3.2% from 1998, higher than the rate of growth for total employment (2.2%). Registered nurses and registered midwives increased in number between 1999 and 2003, while the number of enrolled nurses remained steady, reflecting the structural changes in nursing occupations. More than one-third (38%) of the health workforce are employed on a part-time basis, compared with 27% for the total Australian workforce. In 2002–03, health expenditure was US$ 38 502 million, an average of US$ 1960 per person. Health expenditure represented 9.3% of gross domestic product (GDP) for the same period, approximately double the percentage in 1960–1961 (4.3%). 4. NATIONAL HEALTH PLAN AND PRIORITIES In view of the importance, high cost and complexity of maintaining health, it is necessary to coordinate activities, set priorities and monitor the performance of the health system. Priority areas and performance indicators are widely used and include those for Aboriginal and Torres Strait Islander health, hospital services, and the National Chronic Disease Health Strategy, covering the national health priority areas of: asthma; cancer; diabetes; heart, stroke and vascular disease; osteoarthritis, rheumatoid arthritis and osteoporosis. In 2006, health ministers established a new Australian Health Development Committee to coordinate the development and implementation of national strategies relating to primary and secondary prevention of chronic and noncommunicable disease. The type of evidence and information required to support informed priority setting in health depends on the societal goals for health. Improving the overall health of the population is a major goal of all societies. However, priority-setting based on the potential for health gain is not the only goal that Australians might value. Others might be: • to give priority to those most disadvantaged, so that inequalities in health are reduced; • to attach greater priority to large benefits than to the sum of many small ones, with lifesaving counting the most of all; • to attach greater importance to giving everyone some benefits as opposed to larger benefits for a few; and • to attach less importance to life extension past a normal lifespan, thus attaching greater moral weight to the quality of life. COUNTRY HEALTH INFORMATION PROFILES | 15 There are a number of issues that are currently influencing decisions on health priorities to some extent and are likely to take on greater significance in coming years. These include: demographic changes, such as population ageing; changes in service delivery models, including a move to greater emphasis on community care; and coordinated care. 5. MAJOR INFORMATION SOURCES Australian Bureau of Statistics. Year Book Australia, ABS Cat. No. 1301.0 Australian Bureau of Statistics. Australian demographic statistics, ABS Cat. No. 3101.0 Australian Bureau of Statistics. Births Australia, ABS Cat. No. 3301.0 Australian Bureau of Statistics. Deaths Australia, ABS Cat. No. 3302.0 Australian Bureau of Statistics. Causes of death, Australia, ABS Cat. No. 3303.0 Australian Bureau of Statistics. Australian social trends, ABS Cat. No. 4102.0 Australian Bureau of Statistics. National nutrition survey: nutrient intakes and physical measurements, Australia, ABS Cat. No. 4805.0 Australian Bureau of Statistics. National health survey Australia, ABS Cat. No. 4364.0 Australian Bureau of Statistics. National income, expenditure and product, ABS Cat. No. 5206.0 Australian Bureau of Statistics. Labour force survey, ABS Cat. No. 6291.0.55.001 Australian Bureau of Statistics. Employed Persons by Sex, Occupation, State, Status in Employment, ABS Cat No. 6291.0.55.003 Australian Institute of Health and Welfare . Australia’s health Australian Institute of Health and Welfare. Australian hospital statistics Australian Institute of Health and Welfare. The burden of disease and injury in Australia. Australian Institute of Health and Welfare, National Perinatal Statistics Unit. Australia's Mothers and Babies Australian Institute of Health and Welfare and Australian Association of Cancer Registries (AACR). Cancer in Australia Australian Government Department of Health and Ageing. Communicable diseases intelligence OECD health data:: a comparative analysis of 30 countries (CD-ROM). Paris, Organisation for Economic Co-operation and Development. Private Health Insurance Administration Council. Statistical trends United Nations Development Programme. Human development report United Nations. Millenium indicators database. World health report. Geneva, World Health Organization AUSTRALIA 16 | COUNTRY HEALTH INFORMATION PROFILES 6. ADDRESSES AUSTRALIAN DEPARTMENT OF HEALTH AND AGEING Office Address : Postal Address : The Secretary Australian Department of Health and Ageing Attention: Assistant Secretary International Strategies Branch G.P.O. Box 9848, MDP 85 Canberra, A.C.T. 2601 Australia Official Email Address : Telephone : (612) 6289 1555 Fax : (612) 6289 7087 Office Hours : Mon–Fri 0830-1700 Website : www.health.gov.au AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE Office Address : Australian Institute of Health and Welfare 6A Traeger Court, Fern Hill Park Bruce ACT 2617 Australia Postal Address : The Director Australian Institute of Health and Welfare GPO Box 570 Canberra ACT 2601 Australia Official Email Address : Telephone : (612) 6244 1000 Fax : (612) 6244 1299 Office Hours : Mon-Fri 0830-1700 Website : www.aihw.gov.au WHO REPRESENTATIVE There is no WHO Representative in Australia. Queries about WHO’s programme of collaboration with Australia should be directed to Director, Programme Management, WHO Regional Office for the Western Pacific. Office Address : Postal Address : Director, Programme Management World Health Organization Regional Office for the Western Pacific United Nations Avenue P.O. Box 2932, 1000 Manila, the Philippines Official Email Address : Telephone : Fax : Office Hours : 7:00-15.:30 Website : www.wpro.who.int COUNTRY HEALTH INFORMATION PROFILES | 17 ORGANIZATIONAL CHART: DEPARTMENT OF HEALTH AND AGEING AUSTRALIA 18 AUSTRALIA WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 7692.02 2006 1 2 Estimated population ('000s) 20 328.60 10 110.80 10 217.80 2005 2 3 Annual population growth rate (%) 1.18 … … 2004-2005 2 4 Percentage of population - 0–14 years 19.60 20.20 19.00 2005 2 - 65+ years 13.10 11.90 14.40 2005 2 5 Urban population (%) 86.50 … … 2001 1 6 Crude birth rate (per 1 000 population) 12.70 13.10 12.20 2004 3 7 Crude death rate (per 1 000 population) 6.60 6.80 6.30 2004 4 8 Rate of natural increase of population (% per annum) 0.63 … … 2004-2005 2 9 Life expectancy (years) - at birth … 78.10 83.00 2002-2004 2 - Health-adjusted Life Expectancy (HALE) at age 60 … 16.90 19.50 2002 5 10 Adult literacy rate (%) 88.20 a … … 2003 6 11 Neonatal mortality rate (per 1 000 live births) 3.20 3.60 2.80 2004 4 12 Infant mortality rate (per 1 000 live births) 4.70 5.20 4.10 2004 4 13 Under-five mortality rate (per 1 000 live births) 5.70 6.30 5.00 2004 4 14 Total fertility rate (women aged 15–49 years) 1.77 2004 3 15 Maternal mortality ratio (per 100 000 live births) 8.20 b 1997-1999 7 16 Percentage of newborn infants weighing at least 2500 g at birth 93.70 94.20 93.10 2003 8 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 6.90 d 2003 9 19 Immunization coverage for infants (%) - BCG NR NR NR 2005 10 - DPT3 92.30 … … 2005 10 - OPV3 92.20 … … 2005 10 - Measles 93.40 e … … 2005 10 - Hepatitis B III 94.60 … … 2005 10 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 99.00 2001 24 - Percentage of pregnant women immunized with tetanus toxoid (TT2) NR 2005 10 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) 0.20 2003 8 - Percentage of deliveries in health facilities (as % of total deliveries) 99.80 2003 8 21 Percentage of women in the reproductive age group using modern contraceptive methods 65.00 f 2001 11 22 Condom use rate of the contraceptive prevalence rate 36.00 … … 2001 11 23 HIV prevalence among 15–24 year-old pregnant women 0.01 2004 est 12 24 Number of children orphaned by HIV/AIDS ab … … … COUNTRY HEALTH INFORMATION PROFILE 19 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 100.00 100.00 g 2002 13 26 Proportion of population with access to improved sanitation 100.00 100.00 100.00 g 2002 13 27 Proportion of the population using solid fuels for cooking or heating (%) < 5.00 … … 2003 21 28 Proportion of households with access to secure tenure 99.50 h … … 2001 27 29 Proportion of vehicles using unleaded gasoline (%) 76.04 … … 2005 14 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.96 … … 2003 15 32 Per capita GDP at current market prices (US$) 33 241.00 … … 2004-05 16 33 Rate of growth of per capita GDP (%) 6.40 … … 2004-05 16 34 Health expenditure Total health expenditure - amount (in million US$) 38 502.00 2002-03 17 - total health expenditure on health as % of GDP 9.30 2002-03 17 - per capita total expenditure on health (in US$) 1960.00 2002-03 17 Government expenditure on health - amount (in million US$) 25 982.00 2002-03 17 - general government expenditure on health as % of total expenditure on health 67.50 2002-03 17 - general government expenditure on health as % of total general government expenditure 17.50 2002-03 17 External source of government health expenditure - external resources for health as % of general government expenditure on health NR Private health expenditure - private expenditure on health as % of total expenditure on health 32.50 2002-03 17 Exchange rate in US$ of local currency is: 1 US$ = AUD 1.28 2005 35 Health insurance coverage as % of total population 43.10 2005 18 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 54 800 36 500 18 300 27.20 36.50 18.10 Nov 2004 19 - dentists 9 400 6700 2700 4.70 6.70 2.70 Nov 2004 19 - pharmacists 18 600 6100 12 500 9.20 6.10 12.40 Nov 2004 19 - nurses 159 600 12 600 147 000 79.40 12.60 145.30 Nov 2004 19 - midwives 14 500 0 14 500 7.20 0.00 14.30 Nov 2004 19 - other nursing/ auxiliary staff 21 900 4100 17 800 10.90 4.10 17.60 Nov 2004 19 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 52 400 16 400 36 000 26.10 16.40 35.60 Nov 2004 19 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 11 400 2700 8700 5.70 2.70 8.60 Nov 2004 19 37 Yearly new graduates – physicians i 1385 711 674 2003 20 38 Yearly new graduates – nurses i 5306 578 4728 2003 20 AUSTRALIA 20 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Malignant neoplasms 37 980 21 376 16 604 189.00 214.00 164.40 2004 22 2. Ischaemic heart disease 24 502 13 099 11 403 122.00 131.10 112.90 2004 22 3. Cerebrovascular disease (stroke) 12 034 4 821 7 213 59.90 48.30 71.40 2004 22 4. Chronic lower respiratory diseases (inc asthma, emphysema, bronchitis) 5 777 3 182 2 595 28.80 31.90 25.70 2004 22 5. Accidents 5209 3245 1964 25.90 32.50 19.40 2004 22 6. Diabetes mellitus 3 592 1 865 1 727 17.90 18.70 17.10 2004 22 7. Influenza & pneumonia 3 362 1 486 1 876 16.70 14.90 18.60 2004 22 8. Organic (inc symptomatic) mental disorders 2 879 904 1 975 14.30 9.10 19.60 2004 22 9. Disease of arteries (inc atherosclerosis and aortic aneurism) 2 469 1 258 1 211 12.30 12.60 12.00 2004 22 10. Heart failure 2 276 881 1 395 11.30 8.80 13.80 2004 22 41 Selected diseases under the WHO- EPI Number of cases (C) Number of deaths (D) C: 2004 D: 2003 C: 21 D: 22 - Diphtheria 0 0 0 0 0 0 - Pertussis (whooping cough) 8676 … … 0 0 0 - Tetanus 5 … … 0 0 0 - Neonatal tetanus 0 0 0 0 0 0 - Poliomyelitis 0 0 0 0 0 0 - Hib meningitis … … … 0 0 0 - Measles 45 c … … 0 0 0 - Mumps 106 … … 0 0 0 - Rubella 44 … … 0 0 0 - Congenital rubella syndrome 1 … … 0 0 0 42 Selected communicable diseases Number of cases aa (C) Number of deaths (D) Hepatitis viral - Type A 418 … … 6 … … 2003 C:23, D:21 - Type B 6 170 … … 4 … … 2003 C:23, D:21 - Type C 14 629 … … 0 0 0 2003 C:23, D:21 - Type E … … … … … … - Unspecified 36 … … 3 1 2 2003 C:23, D:22 Cholera 0 0 0 0 0 0 2003 C:23, D:21 Typhoid fever 51 … … 0 0 0 2003 C:23, D:21 Encephalitis 0 0 0 28 16 12 2003 C:23, D:21 COUNTRY HEALTH INFORMATION PROFILE 21 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Syphilis 2 066 … … 5 2 3 2003 C:23, D:22 Plague 0 0 0 0 0 0 2003 C:23, D:21 Gonorrhoea 6 611 … … 0 0 0 2003 C:23, D:22 Leprosy 5 … … … … … 2004 21 Malaria 601 … … 3 2 1 2003 C:23, D:22 Dengue/DHF 352 … … 1 … … 2004 21 43 Malaria Prevalence rates (P) Death rates (D) - Rates associated with malaria (per 100 000 population) 3.00 … … 0.02 0.02 0.01 2003 P:23, D:22 - Proportion of population in malaria-risk areas using effective malaria prevention measures j NR - Proportion of population in malaria-risk areas using effective malaria treatment measures k NR 44 Tuberculosis Number of cases Number of deaths - All types 1059 … … … … … 2004 21 - New pulmonary tuberculosis (smear-positive) 285 … … … … … 2004 21 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 6.00 … … 1.00 … … 2004 21 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 33.00 … … 82.00 (2003) … … 2004 21 Number of cases Number of deaths 45 Acute respiratory infections … … … 3675 1605 2070 2003 22 46 Diarrhoeal diseases … … … 153 60 93 2003 22 47 Cancers All cancers (malignant neoplasms only) 88 398 47 820 40 578 37 980 21 376 16 604 C: 2001 D: 2004 C:25, D:22 - Trachea, bronchus, and lung 8275 5384 2891 7262 4731 2531 C: 2001 D: 2004 C:25, D:22 - Stomach 1902 1202 700 1093 772 321 C: 2001 D: 2004 C:25, D:22 - Colon and rectum 12 619 6859 5760 4391 2391 2000 C: 2001 D: 2003 C:25, D:22 - Lip, oral cavity and pharynx 2686 1878 808 693 473 220 C: 2001 D: 2003 C:25, D:22 - Liver 853 617 236 892 560 332 C: 2001 D: 2004 C:25, D:22 - Cervix 735 238 C: 2001 D: 2003 C:25, D:22 - Leukaemia 2516 1465 1051 1446 841 605 C: 2001 D: 2004 C:25, D:22 48 Circulatory All circulatory system diseases … … … 47 512 22 837 24 675 2004 22 - Ischaemic heart disease … … … 24 502 13 099 11 403 2004 22 - Acute myocardial infarction … … … 12 735 6 650 6 085 2004 22 - Rheumatic fever and rheumatic heart diseases … … … 256 83 173 2004 22 - Cerebrovascular diseases … … … 12 034 4821 7213 2004 22 - Hypertension … … … 1337 501 836 2004 22 AUSTRALIA 22 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 49 Maternal causes - Haemorrhage … 1 2003 22 - Abortion … 0 2003 22 - Eclampsia … 1 2003 22 - Sepsis … 0 2003 22 - Obstructed labour … 0 2003 22 50 Diabetes mellitus … … … 3592 1865 1727 2004 22 51 Mental disorders … … … 3382 1209 2173 2004 22 52 Injuries - All types … … … 7749 5273 2476 2003 22 - Motor and other vehicle accidents … … … 1811 1336 475 2003 22 - Suicide … … … 2213 1736 477 2003 22 - Homicide and violence … … … 278 196 82 2003 22 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis 100.00 2006p 28 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 741 50 915 2003-04 26 - Specialized hospitals 20 l 2413 l 2003-04 26 - District/first-level referral hospitals … … - Primary health care centres … … Private hospitals 543 26 580 2003-04 26 Notes: Red text Millennium Development Goals (MDG) indicators … Data not available NR Not relevant est Estimate p Provisional C Cases P Prevalence D Deaths aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 years. a Data for 15-year-old schoolchildren. Literacy defined as Levels 2-5 using OECD PISA (Programme for International Student Assessment) standards. b Direct and indirect maternal deaths per 100 000 live births over the triennium 1997-1999. c Revised data. d No national data available. South Australia only. e Measles as at age 2. f Percentage of women aged 18–49 (or their partners) reporting using contraceptive methods (including hysterectomy, tubal ligation and partner vasectomy). g A relatively small number of indigenous people, particularly in remote areas, do not always have access to water which passes quality testing or access to adequate sewerage systems. h Persons without secure tenure include those sleeping rough (primary homeless), in stop-gap housing (secondary homeless) and boarding house residents (tertiary homeless). i Course completions in medical field, and in nursing. j Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. COUNTRY HEALTH INFORMATION PROFILE 23 k Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. l Figure refers to psychiatric hospitals. Sources: 1 Year Book Australia 2006. Australian Bureau of Statistics (ABS) (Cat. No. 1301.0) 2 Australian Demographic Statistics, June Quarter 2005. ABS (Cat. No. 3101.0) 3 Births Australia 2004. ABS (Cat. No. 3301.0) 4 Deaths Australia 2004. ABS (Cat. No. 3302.0) 5 The World Health Report 2004. World Health Organization 6 Learning for Tomorrow’s World. First results from PISA 2003. Organisation for Economic Co-operation and Development (OECD) 7 Slaytor EK, Sullivan EA & King JF. Maternal deaths in Australia 1997-1999. Australian Institute of Health and Welfare (AIHW) (Cat. No. PER 24) 8 Australia's Mothers and Babies 2003. AIHW National Perinatal Statistics Unit 9 Pregnancy Outcome in South Australia 2003. Pregnancy Outcome Unit, Department of Human Services 10 Communicable Diseases Intelligence 29(3), September 2005. Australian Government Department of Health and Ageing 11 National Health Survey Australia 2001. ABS (Cat. No. 4364.0, and unpublished) 12 National Centre in HIV Epidemiology and Clinical Research, personal communication 13 United Nations Millennium Indicators Database 14 Motor vehicle census, Australia, 2005. ABS (Cat. No. 9309.0) 15 Human Development Report 2005. New York, United Nations Development Programme, 2005. 16 National Income, Expenditure and Product, June quarter 2005. ABS (Cat. No. 5206.0) 17 OECD Health Data 2005: a comparative analysis of 30 countries (CD-ROM). Paris, OECD 18 Statistical Trends, June 2005. Private Health Insurance Administration Council 19 Labour force survey, November 2004. ABS (Cat. No. 6291.0.55.001) 20 Australia’s Health 2006. AIHW 21 WHO Regional Office for the Western Pacific, data received from technical units 22 Causes of Death, Australia 2004. ABS (Cat. No. 3303.0) 23 Communicable Diseases Intelligence 29(1), March 2005. Australian Government Department of Health and Ageing 24 Reproductive Health Indicators, Australia 2002. AIHW 25 Cancer in Australia 2001. AIHW & Australian Association of Cancer Registries (AACR) 26 Australian hospital statistics 2003-04. AIHW 27 Australian social trends 2004. ABS (Cat. No. 4102.0) 28 Information furnished by the Australian Government of Health and Ageing, 21 April 2006. 24 | COUNTRY HEALTH INFORMATION PROFILES BRUNEI DARUSSALAM 1. DEMOGRAPHICS, GENDER AND POVERTY In 2004, Brunei Darussalam had an estimated population of 359 700, with around 32% below 15 years of age and 2.3% above 65 years of age. Population growth was 2.89% over the previous year. The total fertility rate dropped to 2.10 in 2004 from 2.40 in 1999, giving rise to a change in the age structure of the population. Table 1. Core population and health data (2004) [Total] 359 700 [Both] … [0-14 years] 116 000 (32.30%) [Male] 74.60 (2004p) Population [65+ years] 8400 (2.34%) Life expectancy at birth (years) [Female] 77.50 (2004p) Crude birth rate (per 1000 population) 19.91 Total fertility rate 2.10 (2004p) [Total] 99.00 [Urban] … Crude death rate (per 1000 population) 2.81 % of population served with safe water [Rural] … [Total] 80.00 (2002) [Urban] … Infant mortality rate (per 1000 live births) 8.80 % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 13.90 p – Provisional 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Brunei Darussalam is an independent sovereign Sultanate governed on the basis of a written constitution, achieving its 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 is also the Prime Minister, Minister of Defence and Minister of Finance. Brunei’s first written Constitution came into force in 1959 and, since that date, has been subject to two 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 three-year terms. COUNTRY HEALTH INFORMATION PROFILES | 25 2.2 Economic situation Following the announcement by the Ministry of Finance that the Government's financial year would run from 1 April to 31 March each year, the Council of Cabinet Ministers, with the consent of His Majesty the Sultan and Yang Di-Pertuan of Brunei Darussalam, approved a budget totalling US$ 4 990 322 402 for the financial year 1 April 2004 to 31 March 2005. The allocation to Public Utilities and Health amounted to US$ 208 108 000. Human resources development (HRD) is a crucial element in the implementation of the economy's five-year national development plan. As such, a sum of US$ 250 million, or 3.4% of the Eighth National Development Plan's total allocation, has been allocated to the HRD Fund (HRDF). Its main objective is to facilitate training, retraining and other HRD-related programmes and projects aimed at better career development of the economy's human resources. Among other things, the HRDF includes special schemes for undergraduate, post-graduate and specialized studies, and pre- and post-employment for local job seekers, as well as pre-retirement programmes. This small, wealthy economy encompasses a mixture of foreign and domestic entrepreneurship, government regulation, welfare measures and village tradition. Crude oil and natural gas production account for nearly half of gross domestic product (GDP). Per capita GDP is far above most other developing countries (US$ 15 241 in 2004), and substantial income from overseas investment supplements income from domestic production. The Government provides for all medical services and subsidizes rice and housing. 3. HEALTH SITUATION 3.1 Health trends Data on the main diseases affecting health status (morbidity) are derived from hospital discharge summaries, outpatient morbidity information 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 2004 were: abortions; asthma; diarrhoea and gastroenteritis of presumed infectious origin; acute lower respiratory infections; and non-inflammatory disorders of the female genital tract. The trend in the major causes of death has changed over the past 30 years from infectious diseases to chronic degenerative diseases related to a modern lifestyle. The leading causes of mortality in 2004 were: cancer; heart disease; diabetes mellitus; cerebrovascular disease; and bronchitis, chronic and unspecified emphysema and asthma. The most common type of heart disease is ischaemic heart disease, while the most common types of cancer are those of the trachea, lung and bronchus; colon and rectum; and stomach. Brunei Darussalam has an enviable record in being almost entirely free of major communicable diseases. Fifty-five communicable diseases are notifiabe 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. There is a comprehensive child immunization programme to protect against vaccine-preventable diseases. All vaccination services are provided free of charge. Medical advances in vaccines are widely available through the Expanded Programme on Immunization, which is in incorporated in the Child Health Services and School Health Services. Brunei Darussalam, together with several other countries in South-East Asia has been declared ‘poliomyelitis-free’. 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. Infant mortality has fallen as a result of higher standards of living, improved levels of education and literacy, the increasing empowerment of women, and rising standards of infant-care services. BRUNEI DARUSSALAM 26 | COUNTRY HEALTH INFORMATION PROFILES Maternal health has also improved dramatically and the rate has plunged to extremely low levels, although figures are deceptive: rates that appear substantial represent just one or two deaths. Maintaining such outcomes depends on the availability and practice of contraception, antenatal care, skilled care during childbirth and postnatal care, and the quality of health services. Almost all births are delivered in hospitals and almost all deliveries are attended by skilled health personnel. 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. 3.2 Health systems The people of Brunei Darussalam enjoy free medical and health care, provided through government hospitals, health centres and health clinics throughout the country. In remote areas that are not accessible or are difficult to access by land or water, primary health care is provided by the Flying Medical Services. In addition to government hospitals in each district, there are also two private hospitals and five medical centres operated by the Ministry of Defence. The main referral hospital in the country is Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital, which is situated on a 32-acre site about 0.8 km from the heart of the capital. The hospital was officially opened on 28 August 1984 and is equipped with modern, cutting-edge medical technology. However, patients who require very specialized treatment are sent abroad. All medical expenses incurred by citizens of Brunei Darussalam are borne by the Government. Public Health Services is the main division in the Ministry of Health responsible for providing community-based preventive and promotive primary health care services in the country. As a result of its monitoring and surveillance activities and preventive programmes, such as its immunization programme, the country is free from major communicable diseases. The decentralization programme, started in 2000, was a concerted and ongoing effort by the Ministry to provide access to primary health care for the general population throughout the country. Until 2004, a total of 16 primary health care centres operated in all four districts. The Ministry of Health has now categorized the respective health care services available in Brunei Darussalam into two main health services. The Directorate of Medical Services is responsible for hospital, nursing, laboratory, pharmaceutical and dental services, while the Directorate of Health Services oversees community health, environmental health and scientific services. 4. NATIONAL HEALTH PLAN AND PRIORITIES The Government is fully committed to continuously improving the health status of the people and considers government funding for health care a major public investment in human development. It is the aspiration of the Government that the Ministry of Health’s agenda for the 21st century be health improvement for people-centred development. In this regard, health policies and programmes will be constantly reviewed in the context of changing economic, social and technological environments and health situations. In looking ahead to the future, the following four principles will be observed in the provision of health services for all citizens: • ensuring universal access to better health care; • enabling equity of access to comprehensive health services; • promoting 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 COUNTRY HEALTH INFORMATION PROFILES | 27 strongly evidence-based. In this respect, the Ministry of Health intends to pursue the following set of goals or ‘policy objectives’ derived from a careful analysis of the strategic issues and themes. To facilitate understanding of these goals and their implementations, they are classified into two categories, strategic goals and instrumental goals, based on their logical relationships. The achievement of the strategic goals depends to a large extent on the prior achievement of the instrumental goals. Hence, an understanding of the relationship between these goals will provide a useful and pragmatic framework for future strategic actions. Strategic goals: • to promote primary health care; • to focus on the management of priority chronic diseases; • to pursue high quality in health care; • to achieve a more equitable allocation of funds for diverse health services and to venture into alternative sources of health care financing; and • to promote selected areas of excellence in health services. Instrumental goals: • to develop comprehensive health databases and information management systems 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 to deal with national health emergencies. With noncommunicable diseases now the dominating causes of morbidity and mortality, Brunei Darussalam has identified health promotion as a major initiative 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 aims to increase public awareness of these problems as well as come up with 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; healthy environments/settings; and women’s health. These priorities are promoted by special events, publicity on major health issues and appropriate measures for modifying lifestyles. BRUNEI DARUSSALAM 28 | COUNTRY HEALTH INFORMATION PROFILES 5. MAJOR INFORMATION SOURCES Department of Economic Planning and Development (DEPD), Prime Minister’s Office Statistics Unit, Research and Development Section, Ministry of Health Ledger Section – Expenditure, Ministry of Finance Budget and Tender Section – Budget, Ministry of Finance 2001 Preliminary Census Report. DEPD, Prime Minister’s Office SEAMIC Health Statistics 2002. Southeast Asian Medical Information Center, International Medical Foundation of Japan 6. ADDRESSES MINISTRY OF HEALTH Office Address : Jalan Menteri Besar Bandar Seri Begawan BB3910 Negara Brunei Darussalam Postal Address : Official Email Address : Telephone : (673) 238 1640 Fax : (673) 238 1440, 238 0128 Office Hours : Website : http://www.moh.gov.bn WHO REPRESENTATIVE IN MALAYSIA, BRUNEI DARUSSALAM AND SINGAPORE Office Address : 1st Floor, Wisma UN, Block C, Komplek Pejabat Damansara, Jalan Dungun, Damansara Heights 50490 Kuala Lumpur, Malaysia Postal Address : PO Box 12550 50782 Kuala Lumpur Malaysia Official Email Address : who@maa.wpro.who.int Telephone : (603) 209 39908 / 209 21184 Fax : (603) 209 37446 Office Hours : Website : ORGANIZATIONAL CHART: MINISTRY OF HEALTH DEPUTY MINISTER OF HEALTH GENERAL DIRECTOR Hospital Services Nursing Services Pharmaceutical Services Laboratory Services Dental Services DIRECTOR-GENERAL OF MEDICAL SERVICES Risk Management Centre Health Informatics Biomedical Engineering and Medical Physics Director of Health Care Technology Services International Affairs Research and Development Quality Improvement Biomedical Sciences Research and Training Centre Director of Policy and Planning Human Resource Management Human Resource Development Procurement and Supply Finance and Account Director of Administration and Finance Project Development Building and Transport Engineering Services Director of Estate Management Community Health Services Scientific Services Environmental Health Services DIRECTOR-GENERAL OF HEALTH SERVICES PERMANENT SECRETARY MINISTER OF HEALTH COUNTRY HEALTH INFORMATION PROFILE 29 BRUNEI DARUSSALAM WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 5.77 2004 1 2 Estimated population ('000s) 359.70 189.40 170.30 2004 1 3 Annual population growth rate (%) 2.89 3.78 1.92 2004 1 4 Percentage of population - 0–14 years 32.30 32.26 32.35 2004 1 - 65+ years 2.34 2.11 2.58 2004 1 5 Urban population (%) 76.20 … … 2003 5 6 Crude birth rate (per 1 000 population) 19.91 … … 2004 2 7 Crude death rate (per 1 000 population) 2.81 2.95 2.65 2004 2 8 Rate of natural increase of population (% per annum) 1.71 … … 2004 1 9 Life expectancy (years) - at birth … 74.60 77.50 2004p 1 - Health-adjusted Life Expectancy (HALE) at age 60 … 13.10 13.30 2002 6 10 Adult literacy rate (%) 93.90 96.30 91.40 2002 7 11 Neonatal mortality rate (per 1 000 live births) 6.00 … … 2004 2 12 Infant mortality rate (per 1 000 live births) 8.80 … … 2004 2 13 Under-five mortality rate (per 1 000 live births) 9.80 … … 2004 2 14 Total fertility rate (women aged 15–49 years) 2.10 2004p 1 15 Maternal mortality ratio (per 100 000 live births) 13.90 2004 2 16 Percentage of newborn infants weighing at least 2500 g at birth 93.00 … … 2003 2 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 99.40 … … 2004 9 - DTP3 91.70 … … 2004 9 - OPV3 92.20 … … 2004 9 - Measles 100.00 … … 2004 9 - Hepatitis B III 100.00 … … 2004 9 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 99.60 2004 2 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 47.40 d 2004 2 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) 0.18 2004 2 - Percentage of deliveries in health facilities (as % of total deliveries) 99.38 2004 2 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … BRUNEI DARUSSALAM 30 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 99.00 … … 2004 1 26 Proportion of population with access to improved sanitation 80.00 … … 2002 2 27 Proportion of the population using solid fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.87 … … 2003 7 32 Per capita GDP at current market prices (US$) 15 240.85 … … 2004p 1 33 Rate of growth of per capita GDP (%) 1.70 … … 2004p 1 34 Health expenditure Total health expenditure (National medical care expenditure) - amount (in million BS$) 262.93 2004 3 - total health expenditure (MOH) on health as % of GDP 2.84 2004 3 - per capita total expenditure on health (in US$) 443.03 2004 3 Government expenditure on health - amount (in million BS$) 233.32 2004 4 - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure … External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = … 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 463 293 170 12.87 15.47 9.98 2004 2 - dentists 68 36 32 1.89 1.90 1.88 2004 2 - pharmacists 41 12 29 1.14 0.63 1.70 2004 2 - nurses 1748 311 1437 48.60 16.42 84.38 2004 2 - midwives 527 0 527 14.65 0.00 30.95 2004 2 - other nursing/ auxiliary staff 6 0 6 0.17 0.00 0.35 2004 2 - other paramedical (e.g. medical assistants, laboratory technicians, X- ray technicians) 193 74 119 5.37 3.91 6.99 2004 2 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 253 154 99 7.03 8.13 5.81 2004 2 37 Yearly new graduate – physicians 15 6 9 2004 2 38 Yearly new graduate – nurses 169 33 136 2004 2 COUNTRY HEALTH INFORMATION PROFILE 31 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Pregnancy with abortive outcome 1009 1009 280.51 592.48 2004 2 2. Asthma 788 416 372 219.07 219.64 218.44 2004 2 3. Diarrhoea and gastroenteritis of presumed infectious origin 771 441 330 214.35 232.84 193.78 2004 2 4. Acute lower respiratory infections 743 427 316 206.56 225.45 185.55 2004 2 5. Non-inflammatory disorders of female genital tract 722 722 200.72 423.96 2004 2 6. Hypertensive diseases 695 350 345 193.22 184.79 202.58 2004 2 7. Acute upper respiratory infections 680 390 290 189.05 205.91 170.29 2004 2 8. Heart diseases 680 418 262 189.05 220.70 153.85 2004 2 9. Diabetes mellitus 606 289 317 168.47 152.59 186.14 2004 2 10. Maternal diseases classifiable but complicating pregnancy, childbirth and the puerperium (indirect obstetric causes) 604 604 167.92 354.67 2004 2 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Cancer 218 110 108 60.61 58.08 63.42 2004 2 2. Heart diseases (inc A.Rheumatic F) 185 109 76 51.43 57.55 44.63 2004 2 3. Diabetes mellitus 78 45 33 21.68 23.76 19.38 2004 2 4. Cerebrovascular diseases 72 34 38 20.02 17.95 22.31 2004 2 5. Bronchitis, chronic & unspecified emphysema & asthma 48 25 23 13.34 13.20 13.51 2004 2 6. Hypertensive diseases 42 23 19 11.68 12.14 11.16 2004 2 7. Certain conditions originating in the perinatal period 38 23 15 10.56 12.14 8.81 2004 2 8. Transport accidents 38 31 7 10.56 16.37 4.11 2004 2 9. Influenza and Pneumonia 22 20 2 6.12 10.56 1.17 2004 2 10. Congenital malformations, deformations & chromosomal abnormalities 17 7 10 4.73 3.70 5.87 2004 2 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diptheria 0 0 0 0 0 0 2004 9 - Pertussis (whooping cough) 2 d 1 1 … … … 2004 8 - Tetanus 1 0 1 … 0 … 2004 9 - Neonatal tetanus 0 0 0 0 0 0 2004 9 - Poliomyelitis 0 0 0 0 0 0 2004 9 - Hib Meningitis 0 0 0 0 0 0 2004 8, 9 - Measles 15 d 6 9 … … … 2004 8 - Mumps 24 d 14 10 … … … 2004 8 - Rubella 1 d 0 1 … 0 … 2004 8 - Congenital rubella syndrome 0 0 0 0 0 0 2004 8, 9 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral 10 … … 0 0 0 2004 9 - Type A 9 6 3 0 0 0 2004 9 - Type B 1 0 1 0 0 0 2004 9 - Type C 0 0 0 0 0 0 2004 9 - Type E … … … … … … BRUNEI DARUSSALAM 32 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths - Unspecified … … … … … … Cholera 0 0 0 0 0 0 2004 9 Typhoid fever (including paratyphoid fever) 4 … … 0 0 0 2004 9 Encephalitis 0 0 0 0 0 0 2004 9 Plague 0 0 0 0 0 0 2004 9 Syphilis (1 – unknown) 7 3 3 0 0 0 2004 8 Gonorrhoea (3 – unknown) 147 130 14 0 0 0 2004 8 Leprosy 4 4 0 0 0 0 2004 8 Malaria 13 10 3 0 0 0 2004 8 Dengue/DHF 36 22 14 0 0 0 2004 8 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 3.61 5.28 1.76 … … … 2004 8 - Proportion of population in malaria-risk areas using effective malaria prevention measures b … - Proportion of population in malaria-risk areas using effective malaria treatment measures c … 44 Tuberculosis Number of cases Number of deaths - All types 176 … … … … … 2004 9 - New pulmonary tuberculosis (smear-positive) 115 … … … … … Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 63.00 … … 5.00 … … 2004 9 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 129.00 … … 60.00 (2003) … … 2004 9 Number of cases Number of deaths 45 Acute respiratory infections 1423 817 606 91 54 37 2004 2 46 Diarrhoeal diseases 791 455 336 1 1 0 2004 2 47 Cancers All cancers (malignant neoplasms only) 814 264 550 218 110 108 2004 2 - Trachea, bronchus, and lung 52 33 19 36 22 14 2004 2 - Stomach 15 9 6 21 10 11 2004 2 - Colon and rectum 39 25 14 22 11 11 2004 2 - Lip, oral cavity and pharynx 22 11 11 11 8 3 2004 2 - Liver 23 17 6 19 14 5 2004 2 - Cervix 46 46 9 9 2004 2 - Leukaemia 9 2 7 6 1 5 2004 2 48 Circulatory All circulatory system diseases 1783 981 802 305 170 135 2004 2 - Ischaemic heart disease 304 210 94 105 72 33 2004 2 - Acute myocardial infarction 77 62 15 64 43 21 2004 2 - Rheumatic fever and rheumatic heart diseases 15 8 7 2 0 2 2004 2 - Cerebrovascular diseases 170 94 76 72 34 38 2004 2 COUNTRY HEALTH INFORMATION PROFILE 33 INDICATORS DATA Year Source Total Male Female Total Male Female 48 Circulatory Number of cases Number of deaths - Hypertension 695 350 345 42 23 19 2004 2 49 Maternal causes - Haemorrhage 464 … 2004 2 - Abortion 1009 … 2004 2 - Eclampsia … … - Sepsis … … - Obstructed labour 4 1 2004 2 50 Diabetes mellitus 606 289 317 78 45 33 2004 2 51 Mental disorders 56 24 32 0 0 0 2004 2 52 Injuries - All types 3413 2316 1097 78 45 33 2004 2 - Motor and other vehicle accidents 505 347 158 38 31 7 2004 2 - Suicide (X60 – X84) 50 12 38 3 2 1 2004 2 - Homicide and violence 83 48 35 14 9 5 2004 2 - Occupational injuries 88 … … … … … 2004 2 53 Proportion of population with access to affordable essential drugs on a sustainable basis 100.00 2003 2 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 598 2004 2 - Specialized hospitals 1 … 2004 2 - District/first-level referral hospitals 3 310 2004 2 - Primary health care centres 16 NR 2004 2 Private hospitals 1 148 2004 2 Notes: Red text Millennium Development Goals (MDG) indicators … Data not available p Preliminary / provisional NR Not relevant aa Figure refers to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. c Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. d Revised data. Sources: 1 Department of Economic Planning and Development (DEPD), Prime Minister’s Office 2 Statistics Unit, Research and Development Section, Ministry of Health 3 Ledger Section – Expenditure, Ministry of Finance 4 Budget and Tender Section – Budget, Ministry of Finance 5 Urban and Rural Areas 2003. New York, United Nations. Department of Economic and Social Affairs Population Division, 2004 6 Changing history. The World health report 2004. Geneva, World Health Organization, 2004 7 Human Development Report 2005. New York, United Nations Development Programme, 2005 8 Disease Control Division, Environmental Health Services, Ministry of Health 9 WHO Regional Office for the Western Pacific, data received from technical units 34 | COUNTRY HEALTH INFORMATION PROFILES CAMBODIA 1. DEMOGRAPHICS, GENDER AND POVERTY Cambodia’s latest population estimate, based on the 2004 intercensal survey, is 13 million. The median age is just under 20 years, with the proportion aged 0-24 being twice that of those aged 25-50. The total fertility rate is 3.3 (2004) and the annual population growth rate from 1998 to 2004 was 1.8%. Eighty-four per cent of the population lives in rural areas, but there is a significant urban drift, especially among young people. The Constitution guarantees women and men the same legal protection. However, women are disproportionately vulnerable in economic terms. While labour force participation for both is about 60%, over 60% of working women are in unpaid family work. More than 25% of households are headed by women. The adult literacy rate for Cambodian women is 64%, compared with 85% for men. During the 1990s, the maternal mortality rate declined; however, it is still high, at 437 per 100 000 lives births (2000). 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 2003 it had increased to 0.57, moving Cambodia from the low to the medium human development category. Despite that achievement, the country still has some of the worst human development indicators in South-East Asia. In 2003, per capita gross domestic product (GDP) was only US$ 306, 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%. Access to potable water has improved, but nearly two thirds of the rural population and one quarter of city dwellers still rely on unsafe sources. Less than one quarter of Cambodians have access to safe excreta disposal. Table 1. Core population and health data (2004) [Total] 13 091 000 [Both] … [0-14 years] 5 105 490 (39.00%) [Male] 56.40 (2001) Population [65+ years] 523 640 (4.00%) Life expectancy at birth (years) [Female] 60.30 (2001) Crude birth rate (per 1000 population) 25.00 Total fertility rate 3.34 [Total] 44.20 [Urban] 72.00 Crude death rate (per 1000 population) 6.70 % of population served with safe water [Rural] 39.60 [Total] 21.90 [Urban] 55.40 Infant mortality rate (per 1000 live births) 66.00 % of population with adequate sanitary facilities [Rural] 16.40 Maternal mortality ratio (per 100 000 live births) 437.00 (2000) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 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 COUNTRY HEALTH INFORMATION PROFILES | 35 stability has allowed for economic growth, improvements in human development indicators, and re-integration of Cambodia into the international community. Poverty alleviation and governance are increasingly important items on the Government’s agenda. Following the July 2003 general election, coalition negotiations delayed formation of a new Government for 12 months. In September 2004, the Royal Government issued its ‘Rectangular Strategy’, with reforms focusing on corruption, the judiciary, public administration and the military as core priorities for its current term. The National Strategic Development Plan 2006-10 specifies the prioritized goals, targets and actions. 2.2 Economic 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. This growth has reduced poverty by 10%-15%, but has, however, increased inequality. Over 85% of the labour force is in the informal sector, with employment in industry (mainly the garment industry) growing substantially during the period from 1998 to 2004, stimulated by preferential trade status with the United States of America. This status has now ended. Agriculture, mainly rice production, accounts for 40% of GDP and employs more than 70% of the workforce. Annual flooding and drought result in year-to-year fluctuations in agricultural production. 3. HEALTH SITUATION 3.1 Health trends Health indicators show a decline in infant and under-five mortality rates between 1990 and 2000, but there was a slowing down of this trend in the second half of the 1990s, possibly due to an increase in post-neonatal mortality. In 2000, the infant mortality rate was estimated to be 95 deaths per 1000 live births and the under-five mortality rate 124 per 1000 live births. The Inter- Censal Survey in 2004 suggests a decline in child mortality rates to 66 per 1000 live births for infant mortality and 82 for under-fives, confirmation of which is awaited through the Cambodia Demographic and Health Survey (CDHS) 2005. Post-neonatal mortality is estimated at 58 per 1000 live births. The leading causes of deaths are neonatal conditions, including tetanus; acute respiratory infections, mainly pneumonia; and diarrhoeal diseases. Malnutrition among women and children is a major health problem. Fifteen per cent of children less than six months of age have stunted growth, increasing to 53% of children aged three to five years. Twenty-one per cent of 15-49 year-old women are underweight. Widespread nutritional deficiencies among women represent the biggest risk factor for childhood mortality. Poor infant and child feeding practices, lack of access to health services and inappropriate health-seeking behaviour are other major contributing factors. Malaria and dengue fever pose a considerable burden of mortality and morbidity in certain remote geographical areas and during certain periods, with a malaria incidence rate (treated cases) of 752 per 100 000, with 404 malaria deaths, in 2004 (routine HIS 2004), and a dengue fever rate of 70.7 per 100 000 (2005). Cambodia is ranked among the 22 high tuberculosis burden countries in the world. The National TB Prevalence Survey 2002 estimated incidence of smear-positive cases at 229/100 000. The case detection rate under DOTS was 64% in 2004, with the cure rate exceeding 90%. DOTS coverage reached 100% in 2005. A HIV sero-prevalence survey in 2005 among TB patients found one in ten is HIV-positive. The prevalence of HIV infection among adults appears to have levelled off over the last few years to a rate of 1.9% in 2003. However this is still the highest reported prevalence in the Asia Pacific region. The Government has accelerated the decentralized implementation of continuum- of-care services, currently available in almost all operational districts, including more than 12 400 people living with HIV/AIDS receiving antiretroviral therapy, thus becoming one of the few countries worldwide to achieve the 3 x 5 target. CAMBODIA 36 | COUNTRY HEALTH INFORMATION PROFILES Limited access to skilled health workers is reported to be a significant factor in the high maternal mortality rate. The majority of deliveries are still attended by untrained birth attendants. Direct causes of maternal death include haemorrhage, eclampsia, sepsis and abortion; the indirect causes are related to poor access to emergency obstetric care. The proportion of women using modern birth spacing methods has increased significantly from 2000, when only 18.5% accessed contraception from all sources combined, to 21% of married women accessing modern spacing methods via the public sector and considerably more through social marketing systems and the private sector in 2004. Cambodia has the highest rate of amputation due to landmine injury in the world. Currently, there are about 40 000 people with amputations in the population. However, since 1995, road traffic injuries have started to exceed those due to landmines. In 2002, the Department of Transport reported a fatality rate of 13 per 10 000 vehicles, one of the highest rates in ASEAN countries. There are few data on the prevalence of mental illness in Cambodia. However, several small studies have shown high levels of depression among adults and behavioural problems among children and adolescents. There are no official data available on the incidence of noncommunicable diseases. However, a diabetes survey in 2004 unexpectedly found a prevalence of 5% in a rural and 11% in a semi- urban setting. Tobacco use is one of the leading causes of preventable death, disease and disability in the world today. The national prevalence of smoking among men of 20 years and over is 54%. On average, Cambodian families spend similar amounts on tobacco as they do on health, and significantly more than on education, housing and clothing. Cambodia ratified the WHO Framework Convention on Tobacco Control in 2005. Increasing use of illicit drugs, especially by young people, sex workers and those in labour-intensive activities, are putting such people at risk of HIV/AIDS and other health problems. 3.2 Health systems In the 1990s, the Government introduced health system reforms to improve and extend primary health care through the implementation of a district health system that focuses on the distribution of facilities in accordance with a health coverage plan and the allocation of financial resources to provinces. Operational districts are composed of 100 000 to 200 000 people, with a referral hospital providing a ‘comprehensive package of activities’ and health centres delivering primary health care to a target population of 10 000 through a ‘minimum package of activities’. Government health expenditure has been increasing in recent years. In 1999, the approximate total government expenditure on health was US$ 2.85 per capita; that figure increased to US$ 4.09 per capita in 2005. Overall, health sector financing absorbs approximately 10% of GDP, the highest percentage among developing countries in Asia. An estimated 70% of health sector financing is from out-of-pocket payments, representing approximately US$ 24 per capita, with donors paying approximately two-thirds of the remainder. 4. NATIONAL HEALTH PLAN AND PRIORITIES In 2002, the first national Health Sector Strategic Plan, a medium-term expenditure framework, and a monitoring and evaluation framework were developed and approved. The Health Sector Strategic Plan 2003-07 identifies a number of key challenges for the health sector: (1) Increasing the utilization of cost-effective health services: The overall utilization of public health facilities is around 0.4 visits per person per year. Except in a few areas where additional resources and semi-autonomous management have been provided, utilization rates are not increasing and, to date, the under-resourced publicly funded COUNTRY HEALTH INFORMATION PROFILES | 37 health services have had little to offer the rural poor. Most people choose to use legal or illegal pharmacies and traditional healers to access health care. (2) Improving the quality of care in both the public and private health sectors: Poor staff attitudes and practices in the public sector, uncertainty about user charges and lack of knowledge about available services are factors that contribute to the low utilization of health services. A number of initiatives have been introduced to promote a client-centred approach to service delivery in health staff training programmes, and the newly established Medical Council is introducing a code of medical ethics in an attempt to improve professionalism among medical practitioners. (3) Improving the distribution of staff, particularly midwives, in the health sector: Currently, many referral hospitals and health centres, particularly in rural areas, have insufficient midwives to provide safe coverage for emergency obstetric care. A functional analysis process, initiated in 2002, has focused attention on the need to develop policy to address the maldistribution of staff. There has been an increase in the number of midwifery trainees in recent years. (4) Improving reproductive and adolescent health services: The main focus of reproductive health services is fertility control and antenatal care. In remote rural areas, however, the fertility rate has increased. The Health Sector Strategic Plan sets out the Ministry of Health's strategic objectives for 2003– 2007. Its eight essential objectives (strategies) are: (1) to improve coverage and access to health services, especially for the poor and other vulnerable groups; (2) to strengthen the delivery of high quality basic health services; (3) to strengthen the quality of care, especially that of obstetric and paediatric care; (4) to improve the attitude of health providers to enable them to communicate with customer effectively; (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. CAMBODIA 38 | COUNTRY HEALTH INFORMATION PROFILES 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 Joint Annual Performance Review and directives for the next Annual Operational Plan are issued. 5. MAJOR INFORMATION SOURCES Cambodia Inter-Censal Population Survey 2004, General Report. Ministry of Planning, November 2004 National Institute of Statistics, Ministry of Planning Cambodia Demographic and Health Survey 2000 National Health Statistics Report of Cambodia 2004 Cambodia Integrated Fiduciary Assessment and Public Expenditure Review 2003. World Bank and Asian Development Bank. 6. ADDRESSES MINISTRY OF HEALTH Office Address : No. 151-153 Avenue Kampuchea Krom Phnom Penh, Cambodia Postal Address : Official Email Address : Telephone : (855-23) 722 933 Fax : (855 23) 426 034 / 426 841 Office Hours : 07:00 – 11:30 and 14:00 – 17:00 Website : WHO REPRESENTATIVE IN CAMBODIA Office Address : No. 177-179 corner Streets Pasteur (51) and 254 Postal Address : PO Box 1217 Sangkat Chak Tomok Khan Daun Penh Phnom Penh, Cambodia Official Email Address : who@cam.wpro.who.int Telephone : (855-23) 216 610 / 216 942 / 215 464 Fax : (855-23) 216 211 Office Hours : 07:30 – 12:00 and 14:00 – 17:30 Website : COUNTRY HEALTH INFORMATION PROFILES | 39 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 Administration & Finance Secretariat Secretariat Department of Administration Department of Personnel Department of Budget and Finance National Institutes a National Hospitals b 4 Regional Schools of Technical Medical Care Department of Planning and Health Information Department of Human Resources Development Department of Drugs, Food and Cosmetics Department of Hospital Services Department of Preventive Medicine Department of Communicable Disease Control Bureau of ASEAN Affairs Bureau of International Relations Secretariat Bureau of Inspection Bureau of Control 24 Provincial Health Departments 76 Operational Districts Health 942 Health Centres69 Referral Hospitals 67 Health Posts Pasteur Institute National Pharmaceutical Factory UNIVERSITY OF MEDICAL SCIENCES Faculty of Medicine Faculty of Odontostomatology Faculty of Pharmacy School of Technical Medical Care NB: a. NCHADS, NCTB/Lepr, NCMalaria, NCMCH, NIPH, NCTraMed, NCDrugQuaCon, NCBloodTran b. Excluding Hopitals in NCMCH and NCTB/Lepr c. Battambang, Kampot, Kg. Cham and Stung Treng CAMBODIA 40 CAMBODIA WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 181.04 3 2 Estimated population ('000s) 13 091.00 6.32 6.76 2004 1 3 Annual population growth rate (%) 1.81 … … 1998-2004 1 4 Percentage of population - 0–14 years 39.00 41.10 36.20 2004 1 - 65+ years 4.00 3.30 4.50 2004 1 5 Urban population (%) 16.00 … … 2004 1 6 Crude birth rate (per 1 000 population) 25.00 … … 2004 1 7 Crude death rate (per 1 000 population) 6.70 … … 2004 1 8 Rate of natural increase of population (% per annum) 1.83 a … … 2004 1 9 Life expectancy (years) - at birth … 56.40 60.30 2001 1 - Health-adjusted Life expectancy (HALE) at age 60 … 9.70 11.00 2002 15 10 Adult literacy rate (%) 73.60 f 84.70 f 64.10 f 2004 1 11 Neonatal mortality rate (per 1 000 live births) 37.30 … … 2000 4 12 Infant mortality rate (per 1 000 live births) 66.00 … … 2004 1 13 Under-five mortality rate (per 1 000 live births) 82.00 … … 2004 1 14 Total fertility rate (women aged 15–49 years) 3.34 2004 1 15 Maternal mortality ratio (per 100 000 live births) 437.00 2000 4 16 Percentage of newborn infants weighing at least 2500 g at birth 77.00 … … 2000 20 17 Prevalence of underweight children under five years of age 45.20 44.30 46.30 2000 4 18 Percentage of pregnant women with anaemia 66.40 2000 4 19 Immunization coverage for infants (%) - BCG 95.00 … … 2004 8 - DTP3 85.00 … … 2004 8 - OPV3 86.00 … … 2004 8 - Measles 80.00 … … 2004 8 - Hepatitis B III … … … 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 32.97 2004 5 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 51.00 2004 5 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) 16.51 2004 5 - Percentage of deliveries in health facilities (as % of total deliveries) 16.34 2004 5 21 Percentage of women in the reproductive age group using modern contraceptive methods 19.00 2000 4 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … COUNTRY HEALTH INFORMATION PROFILE 41 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 44.20 72.00 39.60 2004 1 26 Proportion of population with access to improved sanitation 21.90 55.40 16.40 2004 1 27 Proportion of the population using solid fuels for cooking or heating (%) >95.00 … … 2003 8 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.57 … … 2003 2 32 Per capita GDP at current market prices (US$) 306.00 … … 2003 13 33 Rate of growth of per capita GDP (%) 2.60 … … 2003 11 34 Health expenditure Total health expenditure - amount (in million US$) 469.43 2005 18 - total health expenditure on health as % of GDP 10.20 2005 18 - per capita total expenditure on health (in US$) 4.09 g 2005 19 Government expenditure on health - amount (in million US$) 56.45 2005 18 - general government expenditure on health as % of total expenditure on health 12.03 2005 18 - general government expenditure on health as % of total general government expenditure 7.14 2005 18 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health 70.00 2003 est 14 Exchange rate in US$ of local currency is: 1 US$ = 4090.14 Riels 2005 12 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population a 36 Health workforce - physicians 2122 … … 1.62 … … 2004 16 - dentists 241 … … 0.18 … … 2004 16 - pharmacists 577 … … 0.44 … … 2004 16 - nurses 4516 c … … 3.45 … … 2004 16 - midwives 1754 c … … 1.34 … … 2004 16 - other nursing / auxiliary staff 4449 … … 3.39 … … 2004 16 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 160 … … 0.12 … … 2004 16 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 1638 … … 1.25 … … 2004 5 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses 280 c … … 2002-2004 16 CAMBODIA 42 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population a 1. Acute respiratory infections 2 122 728 … … 16 215.17 … … 2004 5 2. Diarrhoeal diseases 383 118 … … 2926.58 … … 2004 5 3. Malaria (treated cases) 101 857 … … 778.07 … … 2004 9 4. Cough (of at least 21 days) 97 122 … … 741.90 … … 2004 5 5. Tuberculosis 31 105 … … 237.60 … … 2004 10 6. Road accidents 12 556 … … 95.91 … … 2004 5 7. Dengue haemorrhagic fever 9983 … … 76.26 … … 2004 8 8. Gyneco-obstetrics 8598 … … 65.68 … … 2004 5 9. Dysentery 3622 … … 27.67 … … 2004 5 10. Measles 1584 … … 12.10 … … 2004 5 40 Ten leading causes of mortality Number Rate per 100 000 population a 1. Tuberculosis 1301 … … 9.94 … … 2004 10 2. Acute respiratory infections 884 … … 6.75 … … 2004 5 3. Malaria 382 … … 2.92 … … 2004 9 4. Road accidents 337 … … 2.57 … … 2004 5 5. Meningitis 163 … … 1.24 … … 2004 5 6. Dengue haemorrhagic fever 90 … … 0.69 … … 2004 8 7. Diarrhoeal diseases 76 … … 0.58 … … 2004 5 8. Other tetanus 37 … … 0.28 … … 2004 5 9. Neonatal tetanus 23 … … 0.18 … … 2004 5 10. Gyneco-obstetrics 8 … … 0.06 … … 2004 5 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 4 … … … … … 2004 8 - Pertussis (whooping cough) 66 … … … … … 2004 8 - Tetanus 1041 … … … … … 2004 8 - Neonatal tetanus 146 … … … … … 2004 8 - Poliomyelitis 0 0 0 0 0 0 2004 8 - Hib meningitis … … … … … … - Measles 352 … … … … … 2004 8 - Mumps … … … … … … - Rubella NR NR NR NR NR NR 2004 8 - Congenital rubella syndrome … … … … … … 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral - Type A … … … … … … - Type B 1410 … … … … … 2000 5 - Type C 536 … … … … … 2000 5 - Type E … … … … … … - Unspecified … … … … … … Cholera … … … … … … Typhoid fever … … … … … … Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … Gonorrhoea … … … … … … Leprosy 461 … … … … … 2004 8, 10 COUNTRY HEALTH INFORMATION PROFILE 43 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Malaria 16 183 … … 105 … … 2004 8 Dengue/DHF 3075 … … 10 … … 2004 8 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 413.00 … … 2.64 … … 2004 8 - Proportion of population in malaria-risk areas using effective malaria prevention measures d … - Proportion of population in malaria-risk areas using effective malaria treatment measures e … 44 Tuberculosis Number of cases Number of deaths - All types 30 838 … … … … … 2004 8 - New pulmonary tuberculosis (smear-positive) 18 978 … … … … … 2004 8 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 709.00 … … 94.00 … … 2004 8 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 61.00 … … 93.00 (2003) … … 2004 8 Number of cases Number of deaths 45 Acute respiratory infections 2 122 728 … … 884 … … 2004 5 46 Diarrhoeal diseases 383 118 … … 76 … … 2004 5 47 Cancers All cancers (malignant neoplasms only) 810 … … 134 … … 2000 5 - Trachea, bronchus, and lung … … … … … … - Stomach … … … … … … - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … … … … - Liver 167 … … 32 … … 2000 5 - Cervix 75 0 75 4 0 4 2000 5 - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … … … … - Ischaemic heart disease … … … … … … - Acute myocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … … … … - Hypertension 2492 … … 213 … … 2000 5 49 Maternal causes - Haemorrhage 1390 1390 … … 2000 5 - Abortion 1983 1983 … … 2000 5 - Eclampsia … … … … - Sepsis … … … … - Obstructed labour … … … … 50 Diabetes mellitus 416 … … 29 … … 2000 5 51 Mental disorders 1237 … … 33 … … 2000 5 CAMBODIA 44 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 52 Injuries - All types … … … … … … - Motor and other vehicle accidents … … … 535 … … 2002 7 - Suicide … … … … … … - Homicide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals … … - Specialized hospitals 8 1770 2004 6 - District/first-level referral hospitals 68 5712 2004 6 - Primary health care centres 961 … 2004 6 Private hospitals … … Notes: Red text Millennium Development Goals (MDG) indicators … Data not available est Estimate NR Not relevant FY The financial year refers to the span from April 1 of respective year to March 31 next year. aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by the Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Unspecified whether delivered by a trained personnel. c Primary nurses and midwives included in other nursing/auxiliary staff graduated between 2002-2004 (Ministry of Health) d Prevention is measured by the percentage of children aged 0–59 months sleeping under insecticide-treated bednets. e Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. f Revised data g Figure refers to per capita government health expenditure. Sources: 1 Cambodia Inter-Censal Population Survey 2004, General Report. Ministry of Planning, Department of Demographic Statistics, Censuses and Survey, November 2004. 2 Human Development Report 2005. New York, United Nations Development Programme, 2005. 3 Information furnished by the WHO Representative for Cambodia, 09 March 2004 4 Cambodia Demographic and Health Survey 2000 5 National Health Statistics Report of Cambodia 2004 6 Ministry of Health Information – data for 2004, Cambodia. 7 Department of Transport 8 WHO Regional Office for the Western Pacific, data received from technical units 9 Annual report of the National Centre for Parasitology, Entomology and Malaria Control 10 Annual TB & Leprosy statistics 2004, furnished by the National Centre for Tuberculosis and Leprosy Control, Cambodia 11 IMF Cambodia Country Report 04/331. Phnom Penh, IMF, 2004 12 UN Rates: WHO Intranet 2005 13 GDP 2003 from IMF Country Report 04/331 14 Ministry of Health, Finance Department, 2003 COUNTRY HEALTH INFORMATION PROFILE 45 15 Changing history. The World Health Report 2004. Geneva, World Health Organization, 2004. 16 Human resources database, Ministry of Health, 2004 (civil service employees) 17 National TB Prevalence Survey (2002), Report published in 2005 18 Draft of Financial Management 2006, Ministry of Economics and Finance in 2005 19 Ministry of Health, Joint Annual Performance Review 2006 20 National Health Statistics Report of Cambodia, 2003. 46 | COUNTRY HEALTH INFORMATION PROFILES CHINA 1. DEMOGRAPHICS, GENDER AND POVERTY At the end of 2004, the total population of China was 1.3 billion. In the same year, there were 15.93 million births and the crude birth rate was 12.29 per thousand population. The crude death rate was 6.42 per thousand population (8.32 million deaths). The net population growth in 2004 was 7.61 million, representing a natural growth rate of 5.87 per thousand, down by 0.014 percentage points from the previous year. In 2004, the per capita annual net income of rural households was 2936 Yuan (US$ 356). The per capita disposable income of urban households was 9422 Yuan (US$ 1138), a real increase of 7.7%. The rural population living in absolute poverty (with an annual per capita net income below 668 Yuan or US$ 81) was 26.1 million at the end of 2004, a decline of 2.9 million from the previous year. The low-income population in rural areas (with annual per capita net income between 669 Yuan and 924 or US$ 114) was 49.77 million, a decline of 6.4 million. Table 1. Core population and health data (2004 preliminary) [Total] 1 299 880 000 [Both] 71.40 (2000) [0-14 years] 279 470 000 (21.50%) [Male] 69.60 (2000) Population [65+ years] 98 570 000 (7.58%) Life expectancy at birth (years) [Female] 73.30 (2000) Crude birth rate (per 1000 population) 12.29 Total fertility rate 1.90 (2001) [Total] 83.55 (2002) [Urban] 94.00 (2002) Crude death rate (per 1000 population) 6.42 % of population served with safe water [Rural] 73.00 (2002) [Total] 53.12 [Urban] … Infant mortality rate (per 1000 live births) 25.50 (2003) % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 51.30 (2003) In the past 20 years, China has made considerable progress in improving living standards, reducing poverty and maintaining strong economic growth. 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation In March 2003, President Hu Jintao and Premier Wen Jiabao became the political leaders of the country. In recent years, the Central Committee of the Communist Party of China (CCCPC) has issued three important political documents. First, The Decision on Completing Socialist Market Economic System was issued during the Third Session of the 16th Central Committee of the Party in October 2003. In this document, the Party calls for the implementation of a Scientific Concept of Development (SCD), which is “people-centred” and promotes “comprehensive, balanced and sustainable development”. The SCD will be a long-term guiding principle in the economic COUNTRY HEALTH INFORMATION PROFILES | 47 development in China. The Decision on Strengthening the Party’s Governing Capacity, issued during the Forth Session of the 16th Central Committee of the Party in September 2004, proposes the construction of a socialist harmonious Xiaokang society as the development goal in China. During the Fifth Session of the 16th Central Committee of the Party, held in October 2005, The Proposals for Formulating the 11th Five-Year Plan for National Economy and Social Development were adopted, providing the roadmap for the country's development in the next five years. 2.2 Economic situation In 2005, the economic situation showed a steady upward trend. According to the statistical indicators reported by the National Bureau of Statistics of China, gross domestic product (GDP) for the first three quarters of 2005 was 10 627.5 billion Yuan; the growth rate over the same period was 9.4%. The GDP of primary industry was 1351.0 billion Yuan, with a growth rate of 5.0%; the GDP of secondary industry was 6044.0 billion Yuan; and the GDP of tertiary industry was 3232.5 billion Yuan, with a growth rate of 8.1%. In 2005, the growth rate of investments in fixed assets (January to November) was 27.8%; total retail sales of consumer goods (January to November) amounted to 5683.6 billion Yuan, with a growth rate (January to November) of 12.5%. The total value of imports and exports (January to December) was US$1422.1; the growth rate was 23.2%. 3. HEALTH SITUATION 3.1 Health trends During the 1960s and 1970s, when publicly financed community and preventive health programmes provided access to basic care throughout the country, there were important improvements in health conditions, especially in rural areas of China. However, despite continued overall progress, the speed of improvement in health-related indicators during the 1990s was slower than in the 1970s and 1980s, and many health indicators appear to have reached a plateau. Overall, people in China are living longer and healthier lives. The disease profile resembles that of a developed country: 85% - 90% of deaths are due to noncommunicable diseases and injuries. National averages, however, mask considerable regional variations and disparities. For example, the under-five mortality rate is two to three times higher in the poorer western provinces than in the more developed eastern provinces. Similar regional inequities can be seen for most basic health indicators. Poor urban migrants with less access to subsidized social services, including health and education, are also disproportionately marginalized and affected. 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. Circulatory, endocrine, nutritious and kinetic system disorders continually rose over the same period. The following table provides more detailed information. CHINA 48 | COUNTRY HEALTH INFORMATION PROFILES Table 2. Two-week morbidity rate per 1000 population, by major disease, NHSS 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: A Health Situation Assessment of the People’s Republic of China July 2005 United Nations Health Partners Group in China 3.2 Health systems In 2005, China’s health sector experienced considerable changes in terms of the rural and urban service delivery systems, the regulation of illegal medical practice, the importance given to community health services (CHS) and the promotion of international cooperation. However, despite progress in these areas, the Chinese health system still faces some substantial challenges. The problems can be grouped as follows. First, the disease prevention and control system and emergency responsiveness system needs to be further improved, especially in rural areas. The spreading trend of some major diseases, such as HIV/AIDS, has not been effectively controlled, and the network for disease surveillance and reporting still needs further improvement. The capacity of supervision and enforcement teams is insufficient and requirements in this area cannot be met. Second, newly emerging diseases and diseases that can infect both humans and animals (such as avian influenza) are posing an increasing threat in China, whilst controlling existing epidemic and endemic diseases continues to be a severe problem in many parts of the country. At the same time, chronic noncommunicable diseases and injuries have become the main cause of death and disability. Third, most resources are deployed to big cities and large hospitals. Greater efforts need to be made to increase resources for the health sector and to ensure that the limited resources available are used efficiently to increase access to essential health services for the rural population and to support more effective community health services. Fourth, the system for financing operations and services at public sector health facilities needs to be improved. Providers at public sector facilities appear increasingly to be motivated solely by the need to cover costs through user fees. To solve these problems, at the beginning of 2006, the Ministry of Health proposed the following actions as the key priorities for the year: COUNTRY HEALTH INFORMATION PROFILES | 49 (1) developing the public health system and strengthening the prevention and control of major diseases; (2) accelerating the establishment of the New Rural Cooperative Medical System and improving the capacity of health service delivery in rural areas; (3) strongly promoting the development of community health services and supporting urban medical system reform; (4) strengthening the management of medical services; (5) further improving maternal and child health care services, health education and patriotic health work; (6) strengthening health legislation and improving health enforcement and supervision; (7) further improving health scientific research and pushing the development of health human resources; (8) further promoting the development of Traditional Chinese Medicine; (9) promoting international health cooperation and improving the cooperation with the areas of Hong Kong, Macao and Taiwan; and (10) developing a good 11th Five-Year Plan for health development. The effective implementation of the above tasks will contribute, not only to health development, but also to reaching the Millennium Development Goals in China. 4. NATIONAL HEALTH PLAN AND PRIORITIES As mentioned in Section 2.1, the major policies and the principles proposed by Central Committee and the Chinese Government have provided a good political and policy environment for health development in China. 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 and fostering a modern TCM industry. CHINA 50 | COUNTRY HEALTH INFORMATION PROFILES 5. MAJOR INFORMATION SOURCES The Decision on Completing Socialist Market Economic System. Issued during the Third Session of the 16th Central Committee of the Party in October 2003. The Decision on Strengthening the Party’s Governing Capacity. Issued during the Forth Session of the 16th Central Committee of the Communist Party in September 2004. The Proposals for Formulating the 11th Five-Year Plan for National Economy and Social Development. Issued during the Fifth Session of the 16th Central Committee of the Communist Party A Health Situation Assessment of the People’s Republic of China. United Nations Health Partners Group in China, July 2005. Documents of the National Health Work Conference in 2006, Ministry of Health Website 6. ADDRESSES MINISTRY OF HEALTH Office Address : 1, Xi Zhi Men Wai Nan Lu Beijing, PR China 100044 Postal Address : Official Email Address : Telephone : Fax : Office Hours : Website : http://www.moh.gov.cn WHO REPRESENTATIVE IN THE PEOPLE’S REPUBLIC OF CHINA Office Address : World Health Organization China Office 401 Dongwai Diplomatic Office Building No. 23 Dongzhimenwai Dajie Chaoyang District Beijing 100600, PR China Postal Address : Official Email Address : who@chn.wpro.who.int Telephone : (8610) 65327189 to 92 Fax : (8610) 65322359 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILE 51 CHINA WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 9600.00 2 2 Estimated population ('000s) 1 299 880.00 669 760.00 630 120.00 2004p 1 3 Annual population growth rate (%) 0.59 a … … 2004 1 4 Percentage of population - 0–14 years 21.50 … … 2004p 1 - 65+ years 7.58 … … 2004p 1 5 Urban population (%) 41.80 … … 2004 1 6 Crude birth rate (per 1 000 population) 12.29 … … 2004p 1 7 Crude death rate (per 1 000 population) 6.42 … … 2004p 1 8 Rate of natural increase of population (% per annum) 0.59 … … 2004 1 9 Life expectancy (years) - at birth 71.40 69.60 73.30 2000 3 - Heal th-adjusted Life Expectancy (H ALE) at age 60 … 13.10 14.70 2002 5 10 Adult literacy rate (%) 90.90 … … 2003 5 11 Neonatal mortality rate (per 1 000 live births) 18.00 … … 2003 9 12 Infant mortality rate (per 1 000 live births) 25.50 … … 2003 3 13 Under-five mortality rate (per 1 000 live births) 29.90 … … 2003 3 14 Total fertility rate (women aged 15–49 years) 1.90 2001 3 15 Maternal mortality ratio (per 100 000 live births) 51.30 2003 3 16 Percentage of newborn infants weighing at least 2500 g at birth 97.61 … … 2002 3 17 Prevalence of underweight children under five years of age 7.88 … … 2002 4 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 98.80 … … 2004 8 - DTP3 98.90 … … 2004 8 - OPV3 98.90 … … 2004 8 - Measles 98.50 … … 2004 8 - Hepati tis B III 98.70 … … 2004 8 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 90.14 2002 3 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in heal th facilities (as % of total deliveries) 82.80 2004 3 21 Percentage of women in the reproductive age group using modern contraceptive methods 84.60 2002 est 3 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … CHINA 52 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 83.55 94.00 73.00 2002 2 26 Proportion of population with access to improved sanitation 53.12 … … 2004p 2 27 Proportion of the population using solid fuels for cooking or heating (%) 80.00 … … 2003 7 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.76 … … 2003 5 32 Per capita GDP at current market prices (US$) 1268.91 a … … 2004p 1 33 Rate of growth of per capita GDP (%) 7.30 2001-2002 7 34 Health expenditure Total health expenditure - amount (in m illion US$) 79 546.94 2003 3 - total heal th expenditure as % of GDP 5.62 2003 3 - per capita total expendi ture on health (in US$) 61.56 2003 3 Government expenditure on health - amount (in million US$) 13 494.50 2003 3 - general government expenditure on health as % of total expenditure on health 16.96 2003 3 - general government expenditure on heal th as % of total general government expendi ture 4.53 2003 3 External source of government health expenditure - external resources for heal th as % of general government expendi ture on health … Private health expenditure - private expenditure on health as % of total expenditure on heal th 55.87 2003 3 Exchange rate in US$ of local currency is: 1 US$ = 8.28 2004 1 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 1 892 000 g … … 14.56 … … 2004p 1 - dentists 136 520 … … 1.10 … … 2001 10 - pharmacists 357 659 … … 27.84 … … 2002 2 - nurses 1 286 000 … … 9.89 … … 2004p 1 - m idwives 42 000 … … 0.30 … … 2001 10 - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 209 144 … … 16.28 … … 2002 2 - other heal th personnel (health inspec tors, assistant sani tarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … COUNTRY HEALTH INFORMATION PROFILE 53 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Five leading causes of morbidity among inpatients in city hospitals In City Hospitals (% of total cases) Rate per 100 000 population 1. Diseases of the respiratory system 11.20 … … … … … 2002 3 2. Diseases of the digestive system 11.00 … … … … … 2002 3 3. Pregnancy, childbirth and puerperium causes 10.68 … … … … … 2002 3 4. Injury and poisoning 9.13 … … … … … 2002 3 5. Malignant neoplasms 6.36 … … … … … 2002 3 40 Five leading causes of mortality in urban areas % of Total Deaths Rate per 100 000 population 1. Malignant tumours 23.75 … … 119.71 … … 2002 3 2. Cerebrovascular diseases 17.53 … … 88.37 … … 2002 3 3. Diseases of the respiratory system 15.49 … … 78.06 … … 2002 3 4. Heart diseases 14.71 … … 74.12 … … 2002 3 5. Injury and poisoning 8.62 … … 43.45 … … 2002 3 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 2 … … 0 0 0 2004 3 - Pertussis (whooping cough) 4705 … … 9 … … 2004 3 - T etanus … … … … … … - Neonatal tetanus 2954 … … 300 … … 2004 3 - Poliomyelitis 0 0 0 0 0 0 2004 3 - Hib meningitis … … … … … … - Measles 70 549 … … 26 … … 2004 3 - Mumps 226 819 … … … … … 2004 8 - Rubella 24 015 … … … … … 2004 8 - Congeni tal rubella syndrome … … … … … … 42 Selected communicable diseases Number of cases aa Number of deaths Hepati tis vi ral - T ype A 93 585 … … 40 … … 2004 8 - T ype B 916 396 … … 783 … … 2004 8 - T ype C 39 380 … … 82 … … 2004 8 - T ype E … … … … … … - Unspecified 87 035 … … 115 … … 2004 8 Cholera 973 … … 4 … … 2005 8 Typhoid fever 22 741 … … 9 … … 2005 8 Encephalitis 5097 … … 214 … … 2005 8 Plague 10 … … 3 … … 2005 8 Syphilis 62 549 … … 20 … … 2002 3 Gonorrhoea … … … … … … Leprosy 1499 … … … … … 2004 8 Malaria 27 201 … … 31 … … 2004 8 Dengue/DHF 247 … … 0 0 0 2004 8 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 2.00 … … 0.00 0.00 0.00 2004 8 - Proportion of population in malaria-risk areas using effective malaria prevention measures e … - Proportion of population in malaria-risk areas using effective malaria treatment measures f … CHINA 54 INDICATORS DATA Year Source Total Male Female Total Male Female 44 Tuberculosis Number of cases Number of deaths - All types 790 603 … … … … … 2004 8 - New pulmonary tuberculosis (smear-posi tive) 384 886 … … … … … 2004 8 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 221.00 … … 17.00 … … 2004 8 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOT S) 63.00 … … 94.00 (2003) … … 2004 8 Number of cases Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases … … … … … … Mortality Rate per 100 000 population Urban Rural 47 Cancers Total Male Female Total Male Female All cancers (malignant neoplasms only) 119.71 … … 105.83 … … 2002 3 - T rachea, bronchus and lung 29.34 … … 18.47 … … 2002 3 - Stomach 18.91 … … 21.89 … … 2002 3 - Colon and rectum 7.90 … … 5.69 … … 2002 3 - Lip, oral cavity and pharynx 9.13 … … 10.84 … … 2002 3 - Liver 21.86 … … 25.09 … … 2002 3 - Cervix 1.41 1.24 2002 3 - Leukaemia 3.54 … … 2.92 … … 2002 3 48 Circulatory All circulatory system diseases 190.22 … … 183.53 … … 2002 3 - Ischaemic heart disease … … … … … … - Acute m yocardial infarction 18.79 … … 12.00 … … 2002 3 - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases 97.46 … … 89.12 … … 2002 3 - H ypertension 14.19 … … 19.08 … … 2002 3 49 Maternal causes - Haemorrhage 0.06 0.25 2002 3 - Abortion 0.05 0.04 2002 3 - Eclampsia … … - Sepsis … … - Obstruc ted labour … … 50 Diabetes mellitus 11.36 … … 5.58 … … 2002 3 51 Mental disorders 3.16 … … 4.08 … … 2002 3 52 Injuries - All types 43.45 … … 52.16 … … 2002 3 - Motor and other vehicle accidents 6.39 … … 7.86 … … 2002 3 - Suicide 12.79 … … 15.32 … … 2002 3 - Hom icide and violence 1.15 … … 1.02 … … 2002 3 - Occupational injuries … … … … … … 2002 3 COUNTRY HEALTH INFORMATION PROFILE 55 INDICATORS DATA Year Source 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public heal th facilities - General hospitals 62 000 h … 2004 1 - Specialized hospi tals 4718 i … 2004 1 - District/first-level referral hospitals … … - Primary health care centres 44 000 b 674 000 b 2004 1 Private hospitals … … General hospitals and heal th care institutions 277 000 3 004 000 2004 1 Notes: Red text M illennium Development Goals (MDG) indicators … Data not available est Estimate p Preliminary aa Figures refer to number of new reported cases. ab Proxy indicator for MDG 20: Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 years a Computed by Health Information and Evidence for Policy Uni t of the WHO Regional Office for the Western Pacific . b Figure applies to rural heal th care institutions c Applies to hospitals only e Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. f Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. g Figure includes assistant doctors h Figure includes health care stations i Figure includes MCH institutions Sources: 1 Statistical Communique of the People’s Republic of China on the 2004 National Economic and Social Development. National Bureau of Statistics of China (http://www.stats.gov.cn/english/newrelease/index.htm ), 28 February 2005 2 Information provided by the WHO Representative for China, 20 April 2004 3 Information furnished by M inistry of Health, 2003, 2004 and 2005. 4 2002 National Nutri tion and Health Survey 5 Human development report 2005. New York, Uni ted Nations and Development Programme, 2005. 6 World health report 2004. Changing history. Geneva, World Health Organization, 2004. 7 2002 World development indicators. Washington, D.C., The World Bank, 2002. 8 WHO Regional Office for the Western Paci fic, data received from technical units. 9 Millennium Development Goals: China’s progress (An assessment by the UN Country Team in China). Beijing, Office of the United Nations Resident Coordinator in China, 2004. 10 World health report 2006. Working together for heal th. Geneva, World Health Organization, 2006. 56 | COUNTRY HEALTH INFORMATION PROFILES COOK ISLANDS 1. DEMOGRAPHICS, GENDER AND POVERTY The population of Cook Islands has been dropping steadily since 1996. In 2005, the midyear population was 20 200, and the midyear resident population 12 400. It was estimated in 2003 that around 35% of the population is below 15 years of age and about 6% is above 65 years. Table 1. Core population and health data (2005) [Total] 20 200 [Both] 72.00 (2004) [0-14 years] 34.71% (2003 est) [Male] 70.00 (2004) Population [65+ years] 5.79% (2003 est) Life expectancy at birth (years) [Female] 75.00 (2004) Crude birth rate (per 1000 population) 21.20 (2003) Total fertility rate 2.60 (2004) [Total] 100.00 (2003) [Urban] 100.00 (2003) Crude death rate (per 1000 population) 6.30 (2003) % of population served with safe water [Rural] 100.00 (2003) [Total] 100.00 (2003) [Urban] 100.00 (2003) Infant mortality rate (per 1000 live births) 28.60 % of population with adequate sanitary facilities [Rural] 100.00 (2003) Maternal mortality ratio (per 100 000 live births) 0.00 (2003) est - Estimate 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Cook Islands has a unicameral, democratic parliament with 25 elected members who serve parliamentary terms of five years. 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. 2.2 Economic situation The country went through some economic difficulties during the period from 1996 to 1997. Since then, there have been public sector reforms, the sale of state assets, and the stimulation of the private sector, all of which have led to the growth and strengthening of financial and economic management. Tourism is the main industry and accounts for around 40% of gross domestic product (GDP). GDP was estimated at almost 262 million New Zealand dollars (approximately US$ 1732 million) and 12 887 New Zealand dollars (approximately US$ 8534) per capita in 2004. The growth rate of per capita GDP was -3.4%. The Government’s total revenue for the financial year 2004/2005 was 91 761 000 New Zealand dollars (US$ 60 768 874) and current expenditure was estimated at 88 128 000 New Zealand dollars (US$ 62 606 000). The country’s focus on development has been affected by challenges such as the emigration of skilled workers to New Zealand, an unstable political situation and the insufficient and inequitable distribution of resources. Of central importance is the delivery of health services to all the islands. COUNTRY HEALTH INFORMATION PROFILES | 57 New Zealand remains the largest donor, while Australia and the Asian Development Bank (ADB) provide significant inflows geared towards capacity-building, outer island development and human 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. 3. HEALTH SITUATION 3.1 Health trends In 2004, life expectancy at birth was estimated at 70 years for men and 75 years for women. The infant mortality rate was 28.60 per 1000 live births in 2005. There has been no case of maternal mortality since 1993. The crude birth rate was 21.2 per 1000 population, and the crude death rate 6.3 per 1000 resident population in 2003. Almost 100% of the population has access to a clean safe water supply, adequate sewage sanitation disposal and primary health care. During the 2004- 2005 financial year, the country’s expanded programme on immunization (EPI) aimed to achieve 100% coverage. Infectious diseases are rarely seen and usually occur as imported cases. Parasitic intestinal worm disease has been greatly reduced by improved water and sanitation. A water supply and sanitation improvement programme, with the building of flush toilets in all schools and health centres on the outer islands, has enhanced the reduction in these diseases and probably also septic skin disease, rheumatic fever and obstructive airways disease. Leprosy is rarely seen. There was no case of tuberculosis reported in 2003. The incidence of sexually transmitted infections (STI) varies. Gonorrhoea and syphilis are rare, while trichomoniasis and chlamydial infection are relatively common. The prevalence of condom use is low. The mass drug administration (MDA) programme for elimination of filariasis continues as part of the WHO Filariasis Elimination Programme. A small-scale blood survey was conducted before 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. The only infectious disease outbreak since the dengue outbreaks in 1992-1993 and 1995 was the dengue outbreak of 2002 (2491 cases reported). Noncommunicable diseases, such as hypertension, diabetes, cancer, coronary heart disease, obesity, and injury and poisoning, 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, 66.8% of registered patients in 2003 were reported to have acquired hypertension disease, 15.3% having both hypertension and diabetes and 17.9% having diabetes only. 3.2 Health systems While the population on the main island, Rarotonga, has access to the best health care in the country, those on the outer islands, especially the northern islands, do not. There is an urgent need to address and rectify this disparity. It is therefore of vital importance that the delivery of health services to the outer islands be addressed, especially the availability of drugs, the deficiency in equipment and the provision of properly trained health staff to provide services. National health expenditure was 4 285 000 New Zealand dollars (US$ 2 702 549) in 2001. The health infrastructure is well developed. There is a general hospital with 80 beds in Rarotonga and seven primary health care centres. As of 2003, there were 27 doctors, 15 midwives, 60 nurses and 18 dentists and dental nurses. COOK ISLANDS 58 | COUNTRY HEALTH INFORMATION PROFILES Since August 2002, responsibility for the administration of health services for the outer islands, with the exception of Rakahanga and Palmerston, has been returned to the central administration in Rarotonga. This has solved several of the problems identified in the document A review of the health sector of Cook Islands 2000. During the past two years, the Ministry of Health has concentrated on providing sufficient general practitioners to provide health services in the outer islands. To date, there are only two islands, Palmerston and Rakahanga, without a resident doctor. However, there are health officers on these two islands. The Ministry of Health has also provided extra doctors at the Rarotonga Hospital so that 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 and equipment. The high “decayed, missing or filled (DMF)” result clearly shows the lack of diagnosis of dental caries and the absence of restorative treatment for tooth decay. There is also a need to review and improve the oral health safety procedures to maintain the provision of quality health care services. In 2001, the Ministry of Health opened a new hospital wing that provides ample room for laboratory services, maternal health care, and statistics. There is also a library and a conference room to assist in continuous medical education. A telehealth venture is also being established, which will provide distance-learning education for doctors, nurses and other health staff in Rarotonga and some of the outer islands to improve human 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. 4. NATIONAL HEALTH PLAN AND PRIORITIES Partnerships will be built nationally, regionally and internationally to achieve the vision of “accessible quality health for all Cook Islanders”. In order to achieve this vision, nine health issues are being targeted for priority action. (1) Expanded programme on immunization: The current immunization coverage rate is 90% or more for childhood diseases. The expanded programme on immunization continues to pursue 100% coverage with the following objectives: • to improve accessibility, particularly to outer islands and hard-to-reach communities; • to upgrade the skills of existing health personnel; • to upgrade equipment and facilities; • to improve management, supervision and coordination; and • to put in place protocols for quality. (2) Sexually transmitted infections, including HIV/AIDS: The prevalence of trichomoniasis and chlamydial infection is relatively high. The prevalence of condom use is low. The objective is to develop a strategy on STI control, COUNTRY HEALTH INFORMATION PROFILES | 59 intensify sexual health education and promotion of condom use, and explore the need for qualified counsellors. (3) 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. (4) Healthy settings and environment: 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: • evaluating the effectiveness of health education and promotion activities and strengthening the concepts approach; and • providing special training for health personnel and other stakeholder agencies in order to execute service deliveries satisfactorily. (5) Child and adolescent health and development: Child and adolescence health will be further strengthened through increasing awareness of risky behaviours, reducing teenage pregnancy, and reducing STI, with emphasis on: • conducting seminars that target adolescents to enhance knowledge of safer sex practices; and • increasing knowledge on risky behaviours through awareness programmes on television and radio and newspaper articles. (6) Reproductive health: There are insufficient trained and skilled personnel to provide quality reproductive health services at various levels of the health care system. At present, there is only one family planning nurse, assisted by a retired staff nurse. There is an immediate need to train younger nurses in technical and management skills. The responsibilities of husbands or male partners will be emphasized. Through training, their awareness and understanding of the reproductive health needs of women, care during pregnancy and childbirth and after delivery, and family planning will be enhanced. (7) Noncommunicable diseases and mental health: A more vigorous effort will be made to change the attitudes of people through health education and promotion. Technical training of health educators in healthy living (e.g. diet, exercise) is part and parcel of this programme. Monitoring and management of noncommunicable diseases will be strengthened. Properly trained dental personnel are required for each island to strengthen preventive dental care and the treatment of common dental diseases. There is also a need to upgrade facilities, including rooms and dental equipment. (8) Tobacco Free Initiative: The Global Youth Tobacco Survey, conducted in 2002, needs to be extended to examine smoking prevalence and consumption among adults. The results of the survey will determine and guide development of the tobacco control programme and strengthen the COOK ISLANDS 60 | COUNTRY HEALTH INFORMATION PROFILES nationwide promotion of healthy lifestyles, and will reduce the toll of tobacco-related mortality and associated diseases. (9) 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. 5. MAJOR INFORMATION SOURCES Statistics Division (http://www.stats.gov.ck/) 2002 Annual Statistical Bulletin. Ministry of Health Medical Records Unit, November 2004. 2002 Annual Statistical Bulletin. Ministry of Health Medical Records Unit, July 2003. Key Indicators 2003 of Developing Asian and Pacific Countries, vol. 34. Manila, Asian Development Bank. Pacific Human Development Report 1999 (Creating Opportunities). New York, United Nations Development Programme, June 1999. Politics of the Cook Islands (http://en.wikipedia.org/wiki/Cook_Island/Government) 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Postal Address : P.O. Box 109, Avarua, Rarotonga, Cook Islands Official Email Address : dcsl@health.gov.ck Telephone : (682) 22664 (Hospital), (682) 29664 (Admin) Fax : (682) 22670 (Hospital), (682) 23109 (Admin) Office Hours : Website : WHO REPRESENTATIVE IN SAMOA Office Address : Ioane Viliamu Building Beach Road, Apia, Western Samoa Postal Address : P.O. Box 77, Apia, Western Samoa Official Email Address : who@sma.wpro.who.int Telephone : (685) 23756/ 23757 Fax : (685) 23765 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILE 61 COOK ISLANDS WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 0.24 2004 1 2 Estimated population ('000s) 20.20 … … 2005 2 3 Annual population growth rate (%) 1.10 … … 2002 est 2 4 Percentage of population - 0–14 years 34.71 35.12 34.29 2003 est 3 - 65+ years 5.79 5.86 5.71 2003 est 3 5 Urban population (%) 62.23 … … 2003 4 6 Crude birth rate (per 1 000 population) 21.20 … … 2003 4 7 Crude death rate (per 1 000 population) 6.30 … … 2003 4 8 Rate of natural increase of population (% per annum) 1.49 a … … 2003 2 9 Life expectancy (years) - at birth 72.00 70.00 75.00 2004 5 - Health-adjusted Life Expectancy (HALE) at age 60 … 11.50 12.60 2002 6 10 Adult literacy rate (%) 100.00 … … 2003 4 11 Neonatal mortality rate (per 1 000 live births) 12.00 b … … 2000 7 12 Infant mortality rate (per 1 000 live births) 28.60 … … 2005 2 13 Under-five mortality rate (per 1 000 live births) 21.00 24.00 17.00 2004 5 14 Total fertility rate (women aged 15–49 years) 2.60 2004 5 15 Maternal mortality ratio (per 100 000 live births) 0.00 2003 4 16 Percentage of newborn infants weighing at least 2500 g at birth 97.60 … … 2003 4 17 Prevalence of underweight children under five years of age 10.00 … … 1997 8 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 100.00 … … 2004 7 - DTP3 100.00 … … 2004 7 - OPV3 100.00 … … 2004 7 - Measles 100.00 … … 2004 7 - Hepatitis B III 100.00 … … 2004 7 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 100.00 2000 10 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 100.00 2004 7 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods 40.85 a 2003 4 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … COOK ISLANDS 62 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 100.00 100.00 2003 4 26 Proportion of population with access to improved sanitation 100.00 100.00 100.00 2003 4 27 Proportion of the population using solid fuels for cooking or heating (%) 10.90 … … 2001 8 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.82 … … 1998 11 32 Per capita GDP at current market prices (NZD) 12 887.00 … … 2004 p 2 33 Rate of growth of per capita GDP (%) -3.40 … … 2004 p 2 34 Health expenditure Total health expenditure - amount (in million NZD) 4.28 2001 12 - total health expenditure on health as % of GDP 3.80 2003 5 - per capita total expenditure on health (in US$) 294.00 2003 5 Government expenditure on health - amount (in million US$) … - general government expenditure on health as % of total expenditure on health 87.90 2003 5 - general government expenditure on health as % of total general government expenditure 9.60 2003 5 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health 12.10 2003 5 Exchange rate in US$ of local currency is: 1 US$ = 1.51 NZD (average) 2003 9 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 27 … … 14.67 … … 2003 4 - dentists 18 f … … 9.78 … … 2003 4 - pharmacists 2 … … 1.09 … … 2003 4 - nurses 60 … … 32.60 … … 2003 4 - midwives 15 … … 8.15 … … 2003 4 - other nursing / auxiliary staff 55 … … 29.89 … … 2003 4 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 20 … … 10.87 … … 2003 4 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 14 … … 7.61 … … 2003 4 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … COUNTRY HEALTH INFORMATION PROFILE 63 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of (inpatients) morbidity in Rarotonga Number Rate per 100 000 population a 1. Injury, poisoning and certain other consequences of external causes 392 248 144 2130.43 … … 2003 4 2. Diseases of the circulatory system 311 167 144 1690.22 … … 2003 4 3. Diseases of the respiratory system 307 153 154 1668.48 … … 2003 4 4. External causes of morbidity and mortality 252 159 93 1369.57 … … 2003 4 5. Diseases of the digestive system 173 109 64 940.22 … … 2003 4 6. Diseases of the genitourinary system 144 37 107 782.61 … … 2003 4 7. Endocrine, nutritional and metabolic diseases 116 57 59 630.43 … … 2003 4 8. Symptoms, signs and abnormal clinical and laboratory findings 115 59 56 625.00 … … 2003 4 9. Diseases of the musculoskeletal system and connective tissue 107 68 39 581.52 … … 2003 4 10. Diseases of the skin and subcutaneous tissue 86 50 36 467.39 … … 2003 4 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Diseases of the circulatory system 19 … … 103.26 … … 2003 4 2. Endocrine, nutritional and metabolic diseases 19 … … 103.26 … … 2003 4 3. Neoplasms 15 … … 81.52 … … 2003 4 4. Symptoms, signs and ill-defined conditions 10 … … 54.35 … … 2003 4 5. Diseases of the respiratory system 8 … … 43.48 … … 2003 4 6. Injury and poisoning 4 … … 21.74 … … 2003 4 7. Diseases of the digestive system 4 … … 21.74 … … 2003 4 8. External causes of injury and poisoning 4 … … 21.74 … … 2003 4 9. Infectious and parasitic diseases 3 … … 16.30 … … 2003 4 10. Certain conditions originating in the perinatal period 3 … … 16.30 … … 2003 4 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 9 - Pertussis (whooping cough) 0 0 0 0 0 0 2004 9 - Tetanus 0 0 0 0 0 0 2004 9 - Neonatal tetanus 0 0 0 0 0 0 2004 9 - Poliomyelitis 0 0 0 0 0 0 2004 9 - Hib meningitis 0 0 0 0 0 0 2004 9 - Measles 0 0 0 0 0 0 2004 9 - Mumps 0 0 0 0 0 0 2004 9 - Rubella 0 0 0 0 0 0 2004 9 - Congenital rubella syndrome 0 0 0 0 0 0 2004 9 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral … … … 16 … … 2002 9 - Type A … … … … … … - Type B 23 … … … … … 2003 4 - Type C … … … … … ... - Type E ... ... … … … … COOK ISLANDS 64 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths - Unspecified ... ... … … … … Cholera 0 0 0 0 0 0 2002 9 Typhoid fever 1 … … … … … 2003 4 Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … Gonorrhoea 19 … … … … … 2003 4 Leprosy 0 0 0 0 0 0 2004 9 Malaria 1 … … … … … 2003 4 Dengue/DHF 4 … … 0 0 0 2004 9 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures d … - Proportion of population in malaria-risk areas using effective malaria treatment measures e … 44 Tuberculosis Number of cases Number of deaths - All types 1 … … … … … 2004 9 - New pulmonary tuberculosis (smear-positive) 1 … … … … … 2004 9 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 51.00 … … 5.00 … … 2004 9 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 43.00 … … 100.00 (2002) … … 2004 9 Number of cases Number of deaths 45 Acute respiratory infections 8131 … … … … … 2003 4 46 Diarrhoeal diseases 835 … … … … … 2003 4 47 Cancers All cancers (malignant neoplasms only) 36 19 17 15 … … 2003 4 - Trachea, bronchus, and lung … … … 4 … … 2003 4 - Stomach … … … … … … - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … … … … - Liver … … … 1 … … 2003 4 - Cervix … … - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases 311 167 144 19 … … 2003 4 - Ischaemic heart disease … … … … … … - Acute myocardial infarction … … … 6 … … 2003 4 - Rheumatic fever and rheumatic heart diseases 175 … … … … … 2003 4 - Cerebrovascular diseases … … … 4 … … 2003 4 - Hypertension 1745 … … 3 … … 2003 4 COUNTRY HEALTH INFORMATION PROFILE 65 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 49 Maternal causes - Haemorrhage 12 … 2002 13 - Abortion 36 … 2002 13 - Eclampsia 5 … 2002 13 - Sepsis 3 … 2002 13 - Obstructed labour 23 … 2002 13 50 Diabetes mellitus 469 … … 17 … … 2003 4 51 Mental disorders 114 85 29 3 3 0 2002 13 52 Injuries - All types 392 248 144 4 … … 2003 4 - Motor and other vehicle accidents 128 c … … 3 … … 2003 4 - Suicide … … … … … … - Homicide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 80 2004 12 - Specialized hospitals … … - District/first-level referral hospitals … … - Primary health care centres 7 … 2004 12 Private hospitals … … Notes: Red text Millennium Development Goals (MDG) indicators … Data not available est Estimate P Preliminary aa Figures refer to number of new reported cases. ab Proxy indicator of MDG indicator 20: Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Estimates derived by regression and similar estimation methods. c In Rarotonga hospital. d Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. e Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. f Figure includes six dental nurses. Sources: 1 Pacific Island Populations 2004. Secretariat of the Pacific Community <http://www.spc.int/> 2 Cooks Island Statistics Office < http://www.spc.int/prism/country/ck/stats/index.html> 3 Demographic Tables for the Western Pacific Region 2000-2005. Manila, WHO Regional Office for the Western Pacific, 2005. 4 2003 Annual Statistical Bulletin. Ministry of Health Medical Records Unit, November 2004. 5 Working Together for Health. The World Health Report 2006, World Health Organization. 6 Changing History. The World Health Report 2004, World Health Organization. 7 Make Every Mother and Child Count. The World Health Report 2005. World Health Organization. 8 Pacific Islands Regional Millennium Development Goals Report 2004. Secretariat of the Pacific Community and UN/CROP MDG Working Group, November 2004. COOK ISLANDS 66 9 WHO Regional Office for the Western Pacific, data received from the technical units. 10 2000 Annual Statistical Bulletin. Ministry of Health Medical Records Unit, October 2001. 11 Pacific Human Development Report 1999 (Creating Opportunities). New York, United Nations Development Programme, June 1999. 12 Information furnished by the WHO Representative in Samoa, 20 February 2004. 13 2002 Annual Statistical Bulletin. Ministry of Health Medical Records Unit, July 2003. COUNTRY HEALTH INFORMATION PROFILES | 67 FIJI 1. DEMOGRAPHICS, GENDER AND POVERTY Fiji has the largest population of the South Pacific island countries. The estimated multiethnic population for 2005 was 846 085 and it is growing slowly due to a moderately low level of fertility and a high level of emigration. The population occupies around two-thirds of the 322 Fiji islands and is concentrated on the two largest islands, Viti Levu (10 429 km2) and Vanua Levu (5556 km2), with the nation's capital of Suva located on Viti Levu. Life expectancy at birth is high for both women (72.1 years) and men (67.0 years). Infant, child and maternal mortality have been halved since the 1960s and are now low. There is a high level of adult literacy and almost universal primary school enrolment (98%), and around 40% of adolescents remain at school until the age of 18 years, up from a small minority a generation ago. In 2003, the ratio of girls to boys in primary education was 0.93, in secondary education 1.0 and in tertiary education 0.99. Of the adult population (all people over 15 years), the most disadvantaged group is Indo-Fijian female adults, of whom 14% in 1996 had no formal education, followed by Indo-Fijian male adults, of whom 8% had no formal education. The share of women in paid employment has grown considerably in Fiji over the past three decades. During the 1990s, female waged employment grew faster than male employment because more women were joining the labour force and the occupations where most women were employed were expanding. The latest urban National Household Income and Expenditure Surveys (HIES - 2002) found that women comprised 35.5% of the economically active population, but only 31% of people engaged in the cash economy. Of urban women who did work, 64% were engaged in the money economy; most others worked in non-monetary subsistence activities. Despite the prominence now given in national policy to reducing poverty, there are very few reliable or up-to-date data available. While HIES have been conducted, the most recent in 2003- 2004, the data have not yet been evaluated. The extent of poverty increased between 1977 and 1990-1991. In 1977, around 15% of Fiji households lived below the poverty line. By 1990-1991, that figure had risen to 25.5% (urban 27.6%, rural 22.4%), and the poverty gap ratio was 0.3% in 1990. Although there are as yet no firm data, there are signs that the extent of poverty has grown further during the 1990s and the 2000s. Table 1. Core population and health data (2005) [Total] 846 085 est [Both] 69.53 [0-14 years] 35.30% (2002 est) [Male] 67.05 Population [65+ years] 3.10% (2002 est) Life expectancy at birth (years) [Female] 72.14 Crude birth rate (per 1000 population) 24.60 (2005-2010) Total fertility rate 3.08 (2005-2010) [Total] 65.00 (2002) [Urban] 95.00 (2002) Crude death rate (per 1000 population) 5.50 (2005-2010) % of population served with safe water [Rural] 53.00 (2002) [Total] 60.00 (2002) [Urban] 90.00 (2002) Infant mortality rate (per 1000 live births) 16.00 (2005-2010) % of population with adequate sanitary facilities [Rural] 50.00 (2002) Maternal mortality ratio (per 100 000 live births) 35.29 (2002) est- Estimate FIJI 68 | COUNTRY HEALTH INFORMATION PROFILES 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The return to full political stability after the coup in May 2000 was hampered by unresolved power struggles within the indigenous Fijian community over land and other resources and by constitutional uncertainty over the composition of the Government. Prime Minister Laisenia Qarase and former Prime Minister Mahendra Chaudhry held a series of informal talks to resolve the situation. The Republic of Fiji Military Forces has indicated that it will not support any forces to de- stabilize the Government. Court cases against several members within the ruling Government for their involvement in the 2000 crisis produced a certain degree of anxiety and uncertainty during 2004. The large-scale emigration of skilled labour, particularly among Indo-Fijians, which began in the wake of the 2000 coup, continues. This has had an impact on health care service delivery. Ongoing disputes over communally owned resources and land leases have adversely affected thousands of indigenous landowners as well as Indo-Fijian tenant farmers, many of whom have lost their livelihoods after being evicted from leasehold land. 2.2 Economic situation According to the Fiji National MDG Report for 2004, the national economy is barely growing. It rests primarily on sugar production and tourism, but is becoming more diverse, with manufacturing now an important employment sector. In the next few years, the fate of the sugar industry will probably have the greatest effect on the national economy. Sugar provides around 30% of Fiji’s domestic export earnings and employs around 13% of the labour force. The deepening unemployment problem is also contributing to instability and poverty. The economy is generating far fewer jobs than needed each year just to provide for school-leavers. Emigration and skill loss is also having an impact on the economy. Fiji has long had a slow but steady exodus of professional and skilled workers, and emigration accelerated after the turbulent political events in 1987 and 2000. Since the 2000 coup, it has peaked at around 6300 persons in 2001 and 5800 in 2003 (Fiji Bureau of Statistics). Fiji still enjoys an abundance of forest, mineral and marine resources, and a well developed tourism sector provides substantial income and employment. With a population of 838 317 in 2004 and a gross domestic product (GDP) of about US$ 7.02 billion, GDP per capita is about US$ 8377. The shock to the economy delivered by the 2000 coup was minimized by the quick action of the central bank to maintain stability and sharply reduce aggregate demand. The Reserve Bank of Fiji protected the value of the currency during the crisis, and thus inflation was not a factor in 2000, coming in at about 1%. In 2001, the inflation rate spiked to 4.3%, but that increase was due to increases in VAT rates and was not the result of demand pressures. However, given the weak global economy and the desire of the new Government to ensure economic growth, monetary policy was more expansionist in 2002 and 2003 and an inflation rate of 3%-4% is anticipated. The unemployment rate, which shot up to 12% in 2000 from 7.6% in 1999, has remained high despite the recovery in growth, although it is expected to continue to decline due to economic expansion and continued emigration. The successful return to constitutional government considerably improved Fiji's economic situation in 2004, as it restored normal relations with major trade and aid partners and eased potential tourists' fears about travelling to the country. COUNTRY HEALTH INFORMATION PROFILES | 69 3. HEALTH SITUATION 3.1 Health trends Fiji faces a number of health challenges. In addition to the continuing incidence of communicable diseases, they include an increasing prevalence of noncommunicable diseases (NCD), such as diabetes and hypertension, due to lifestyle changes, poor diet, smoking and changing patterns of physical activity; and continuing nutritional problems, particularly in schoolchildren and women. NCD have become the principal cause of ill-health and death. The NCD survey in 2002 showed an 11.9% prevalence rate for diabetes, and 19.1% for hypertension. A third of all deaths and half of those in the 40–59 year-old age group are due to circulatory diseases. Traffic accidents also represent an ever-increasing burden. All the above provides testimony to the ongoing epidemiological transition in Fiji and constitute a typical example of a triple burden of diseases (communicable diseases, noncommunicable diseases and injuries) in a developing country. The leading causes of death and serious illness in young children are acute respiratory infections, diarrhoea, parasitic infections, meningitis and anaemia. Child mortality has remained fairly steady over the past decade. The under-five mortality rate dropped slightly from 27.8 in 1990 to 22.3 in 2002, as well as the infant mortality rate, from 16.8 in 1990 to 12.62 in 2005. The latest estimate of the maternal mortality ratio was 35 in 2002, representing around six pregnancy-related deaths in that year. There is a good network of maternal and child health services throughout Fiji, and the proportion of women giving birth in hospital has risen steadily, reaching 99% in 2002. A rapid increase has been recorded in HIV/AIDS cases (158 cases of confirmed HIV infection as of 31 December 2004) and sexually transmitted infections (STI). Despite the increasing burden of chronic and degenerative diseases, respiratory disease and infectious and parasitic diseases continue to represent the leading causes of admission to hospital. 3.2 Health systems The Fiji health sector was transformed in 2003 from a highly centralized system to one that is decentralized within the Ministry of Health. This transition has been taking place at a slower pace than originally conceived, and will continue to require substantial technical support and systems development to put it into place. Decentralization is taking place on two levels. The first is the delegation from the central agencies – the Ministry of Finance and the Public Service Commission (PSC) – to the Chief Executive Officer (former Permanent Secretary for Health). The second level is the delegation of powers by the Chief Executive Officer to the Divisional Directors of Health Services (DDHS) in the Western, Northern and Central-Eastern Divisions. Health care in Fiji is financed mainly by general taxation. The Government has been allocating about 8%-10% of total public expenditure for health care for the last 10 years. Total health expenditure is 3% of GDP, which is the lowest rate in the Pacific. Although the government budget for health care has been increasing each year, total health expenditure in terms of percentage of GDP has not increased. Of the appropriated allocation, 62%-67% is spent on personnel emoluments at divisional and subdivisional hospitals. Only about 7.5% of the total government budget for health care has been allocated to drug procurement in recent years, compared with the 10%-20% allocated by other member countries of the Organisation for Economic Co-operation and Development (OECD). The allocation for health care facility maintenance has been very limited. Out-of-pocket payments for health care are estimated at 35% of total health expenditure, mostly in the private health sector. The Ministry of Health is aware of the limitations of the current health financing mechanism and the necessity for health care financing reform. In his 2003 budget address to Parliament, Mr Solomoni Naivalu, Honourable Minister for Health said: “… the best option that seems to FIJI 70 | COUNTRY HEALTH INFORMATION PROFILES emanate from these discussions is the option of a social health insurance scheme for both the formal and informal sectors that will help supplement the existing government health budget.” The Fiji National Provident Fund, a compulsory social savings scheme for formal sector employees, has become a significant player in the Fiji financial system. The Fund has a well developed infrastructure, with a head office in Suva and two branch offices in Lautoka and Labasa, and is interested in a medical benefit scheme for its members. The Ministry of Health is considering developing a social health insurance system and will carry out a community-based social health insurance pilot project. The Fiji Blood Transfusion Services are in a transitional period. The Fiji Red Cross Society (FRSC) has transferred the responsibility of all blood-related public awareness activities, blood donor recruitment and collection of blood to the Ministry of Health, effective 1 January 2005. 4. NATIONAL HEALTH PLAN AND PRIORITIES The Fiji Government currently has two development plans: • The National Vision and Strategic Development Plan 2003-2005, and • “50/50 by 2020”: A 20-Year Development Plan for the Enhancement of Participation of Indigenous Fijians and Rotumans in the Socio-Economic Development of Fiji. These two planning documents are intended to be complementary. Both give a high priority to addressing issues of poverty and hardship throughout the various sections of society. Based on the above, the Fiji Ministry of Health developed the Strategic Plan for 2003 – 2005: Shaping Fiji’s Health, which provides the strategic framework for the development of the health sector. The Plan defines the goal of the Ministry of Health to provide quality health services for the citizens of Fiji. The vision is defined as: “an integrated and decentralized health system to foster good health and well-being.” A draft Ministry of Health Strategic Plan for 2005 – 2008 has been prepared and builds on the achievements of the previous period, outlining a series of priorities for the next four years. The strategic goals for the Ministry are the five Ps: Provision of health services Planning, integrated delivery and maintenance of appropriate, effective, efficient and quality health services (clinical, diagnostic, pharmaceutical, rehabilitative, preventative) to the people of Fiji. Protection of health Development and implementation of appropriate policies, legislation, regulations and standards to protect the health and well-being of the people of Fiji. Promotion of health Development and maintenance of effective partnerships that empower all stakeholders to reduce risk factors related to communicable and noncommunicable diseases. People in health Development and retention of a valued, skilled and high performance workforce to enhance the delivery of quality health services. Productivity in health Development and use of financial (FMIS), human resource (HRIS) and health information (HIS, PATIS) systems to maximize resources and promote continuous improvement at all levels of health service delivery. COUNTRY HEALTH INFORMATION PROFILES | 71 The ultimate goals for the collective work will be seven health outcomes. These health outcomes should be the end-result of health service activities (outputs), which are either internal business processes, such as staff development and retention (people) and resource management systems (productivity) or external business processes, such as provision, protection and promotion. The outcomes will also contribute to broader developmental goals, such the Millennium Development Goals. The seven health outcomes are as follows: Health outcome 1: Reduced burden of noncommunicable diseases Health outcome 2: Begun to reverse the spread of HIV/AIDS and preventing, controlling or eliminating other communicable diseases Health outcome 3: Improved maternal health and reduced maternal mortality Health outcome 4: Improved child health and reduced child mortality Health outcome 5: Improved adolescent health and reduced adolescent mortality Health outcome 6: Improved mental health and decreased disability due to mental illness Health outcome 7: Contributed to environmental sustainability At the operational level, the Ministry of Health’s Corporate Plan is an annual publication that articulates how the Ministry will meet the objectives of the Fiji National Plan for the Millennium (2001) and the Ministry of Health Strategic Plan. 5. MAJOR INFORMATION SOURCES Ministry of Health, data update, February 2005 Fiji National MDG Report,. July 2004 Corporate Plan 2004, 4/4/03-E, Ministry of Health Strategic Plan 2003 – 2005: Shaping Fiji’s Health, Ministry of Health Pacific Regional Millennium Development Goals Report, SPC/UNDP/UN-CROP MDG TWG, 2004, http://www.spc.int/mdgs/MDGReport/Reg_report.htm Pacific Regional Information System (PRISM), SPC http://www.spc.int/prism WHO mission reports on social health insurance in Fiji. WHO Western Pacific Regional Office, November 2003 and June 2004. Amnesty International Report 2003 Other United Nations agencies, http://www.un.org 6. ADDRESSES MINISTRY OF HEALTH Office Address : Dinem House, 88 Amy Street, Toorak, Suva Postal Address : P.O. Box 2223, Government Buildings Suva, Fiji Official Email Address : info@health.gov.fj Telephone : (679) 330 6177 Fax : (679) 330 6163 Office Hours : Website : FIJI 72 | COUNTRY HEALTH INFORMATION PROFILES WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4 Provident Plaza 1, Downtown Boulevard, 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@fij.wpro.who.int Telephone : (679) 330 4600 / 330 4631 Fax : (679) 330 0462 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILE 73 FIJI WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 18.27 1 2 Estimated population ('000s) 846.09 … … 2005 est 1 3 Annual population growth rate (%) 0.93 … … 2005 est 1 4 Percentage of population - 0–14 years 35.30 … … 2002 est 2 - 65+ years 3.10 … … 2002 est 2 5 Urban population (%) 52.00 … … 2001 1 6 Crude birth rate (per 1 000 population) 24.60 … … 2005-2010 3 7 Crude death rate (per 1 000 population) 5.50 … … 2005-2010 3 8 Rate of natural increase of population (% per annum) … … … 9 Life expectancy (years) - at birth 69.53 67.05 72.14 2005 4 - Health-adjusted Life Expectancy (HALE) at age 60 … 10.40 11.90 2002 5 10 Adult literacy rate (%) 92.90 e … … 2002 6 11 Neonatal mortality rate (per 1 000 live births) 9.00 … … 2000 7 12 Infant mortality rate (per 1 000 live births) 16.00 ... … 2005-2010 3 13 Under-five mortality rate (per 1 000 live births) 20.00 … … 2005-2010 3 14 Total fertility rate (women aged 15–49 years) 3.08 2005-2010 3 15 Maternal mortality ratio (per 100 000 live births) 35.29 2002 2 16 Percentage of newborn infants weighing at least 2500 g at birth 90.46 … … 1998 8 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 17.78 1998 8 19 Immunization coverage for infants (%) - BCG 93.10 … … 2004 9 - DTP3 71.30 … … 2004 9 - OPV3 76.40 … … 2004 9 - Measles 61.80 … … 2004 9 - Hepatitis B III 72.90 … … 2004 9 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 100.00 1998 8 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) 99.00 2002 10 21 Percentage of women in the reproductive age group using modern contraceptive methods 40.45 1998 8 22 Condom use rate of the contraceptive prevalence rate … … 14.80 2002 10 23 HIV prevalence among 15–24 year-old pregnant women < 0.01 2002 10 24 Number of children orphaned by HIV/AIDS ab … … … FIJI 74 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 65.00 95.00 53.00 2002 2 26 Proportion of population with access to improved sanitation 60.00 90.00 50.00 2002 2 27 Proportion of the population using solid fuels for cooking or heating (%) 40.00 b … … 2003 9 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.75 … … 2003 11 32 Per capita GDP at current market prices (US$) 8377.19 … … 2004 1 33 Rate of growth of per capita GDP (%) 6.16 a … … 2002 1 34 Health expenditure Total health expenditure - amount (in million US$) … - total health expenditure on health as % of GDP 3.00 2002 2 - per capita total expenditure on health (in US$) 60.61 a FY 2003/4 1 Government expenditure on health - amount (in million US$) 1117.13 2004 est 1 - general government expenditure on health as % of total expenditure on health 15.11 a 2004 est 1 - general government expenditure on health as % of total general government expenditure 8.32 a FY 2003/4 1 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 0.57 FJ$ 2004 1 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population a 36 Health workforce - physicians 339 … … 4.04 … … 2004 1 - dentists 30 … … 0.36 … … 2004 1 - pharmacists 87 … … 1.05 … … 2003 12 - nurses 1682 … … 19.88 … … 2004 1 - midwives … … … … … … - other nursing / auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 355 … … 4.27 … … 2003 12 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 963 … … 11.58 … … 2003 12 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … COUNTRY HEALTH INFORMATION PROFILE 75 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Five leading causes of morbidity Number Rate per 100 000 population 1. Respiratory disease … … … 614.05 … … 2001 2 2. Circulatory disease … … … 500.58 … … 2001 2 3. Injury and poisoning … … … 401.28 … … 2001 2 4. Infectious and parasitic disease … … … 364.34 … … 2001 2 5. Genitourinary disease … … … 321.60 … … 2001 2 40 Ten leading causes of mortality Number Rate per 100 000 population a 1. Disease of the Circulatory System 1009 … … 122.23 … … 2002 13 2. Signs, Symptoms and Ill-defined conditions 804 … … 97.40 … … 2002 13 3. Hypertensive Disease 417 … … 50.52 … … 2002 13 4. Ischaemic Heart Disease 268 … … 32.47 … … 2002 13 5. Acute Myocardial Infarction 256 … … 31.01 … … 2002 13 6. Diabetes Mellitus 345 … … 41.79 … … 2002 13 7. Cerebrovascular Disease 249 … … 30.16 … … 2002 13 8. Nephritis, Nephrotic Syndrome and Nephrosis 193 … … 23.38 … … 2002 13 9. Malignant Neoplasms 149 … … 18.05 … … 2002 13 10. Pneumonia 160 … … 19.38 … … 2002 13 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 9 - Pertussis (whooping cough) 3 … … … … … 2004 9 - Tetanus 0 0 0 0 0 0 2003 9 - Neonatal tetanus 0 0 0 0 0 0 2003 9 - Poliomyelitis 0 0 0 0 0 0 2004 9 - Hib meningitis 63 … … … … … 2004 9 - Measles 37 … … … … … 2004 9 - Mumps 20 … … … … … 2004 9 - Rubella 2 … … … … … 2004 9 - Congenital rubella syndrome 0 0 0 0 0 0 2003 9 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral - Type A … … … … … … - Type B … … … … … … - Type C … … … … … … - Type E … … … … … … - Unspecified … … … … … … Cholera 0 0 0 0 0 0 2002 9 Typhoid fever … … … … … … Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … Gonorrhoea … … … … … … Leprosy 3 … … … … … 2004 9 Malaria … … … … … … Dengue/DHF 2 … … 0 0 0 2004 9 FIJI 76 INDICATORS DATA Year Source Total Male Female Total Male Female 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 134 … … … … … 2004 9 - New pulmonary tuberculosis (smear-positive) 62 … … … … … 2004 9 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 41.00 … … 5.00 … … 2004 9 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 58.00 … … 86.00 (2003) … … 2004 9 Number of cases (C) Number of deaths (D) 45 Acute respiratory infections 17 115 … … 0 0 0 C: 1998 D: 1999 C: 8, D: 14 46 Diarrhoeal diseases 12 272 … … 0 0 0 C: 1998 D: 1999 C: 8, D: 14 47 Cancers All cancers (malignant neoplasms only) 695 … … 229 61 168 C: 1998, D: 1999 C: 8, D: 14 - Trachea, bronchus, and lung 6 … … 29 21 8 - Stomach 35 … … 23 13 10 - Colon and rectum 18 … … 23 7 16 - Lip, oral cavity and pharynx 8 … … 0 0 0 - Liver … … … 0 0 0 - Cervix 89 60 - Leukaemia … … … 35 20 15 48 Circulatory All circulatory system diseases 4682 … … 1052 659 393 C: 1998 D: 1999 C: 8, D: 14 - Ischaemic heart disease 1014 … … 421 341 80 - Acute myocardial infarction 530 … … 421 341 80 - Rheumatic fever and rheumatic heart diseases 185 … … 29 8 21 - Cerebrovascular diseases 715 … … 461 241 220 - Hypertension 764 … … 140 68 72 49 Maternal causes - Haemorrhage 366 0 C: 1998 D: 1999 C: 8, D: 14 - Abortion 53 1 - Eclampsia … … - Sepsis … … - Obstructed labour … … COUNTRY HEALTH INFORMATION PROFILE 77 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 50 Diabetes mellitus 783 … … 185 93 92 C: 1998 D: 1999 C: 8, D: 14 51 Mental disorders 123 … … 0 0 0 C: 1998 D: 1999 C: 8, D: 14 52 Injuries - All types 4146 … … 54 … … 1998 8 - Motor and other vehicle accidents 551 … … 13 … … 1998 8 - Suicide 156 … … 8 … … 1998 8 - Homicide and violence 359 … … 1 … … 1998 8 - Occupational injuries … … … … … … 1998 8 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 25 f 1819 2004 1 - Specialized hospitals … … - District/first-level referral hospitals … … - Primary health care centres 74 … 2004 1 Private hospitals … … Notes: Red text Millennium Development Goals (MDG) indicators … Data not available est Estimate FY The financial year refers to the span from April 1 of respective year to March 31 next year. C Cases D Deaths aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Modeled data c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. e Figure refers to 1999/2000 schoolyear and census data. f Figure does not specify the type of hospital Sources: 1 Fiji Islands Bureau of Statistics <http://www.statsfiji.gov.fj/> 2 Ministry of Health, April 2004. 3 Demographic Tables for the Western Pacific 2005-2010, World Health Organization, Regional Office for the Western Pacific. 4 Working Together for Health. The World Health Report 2006, World Health Organization. 5 Changing History. The World Health Report 2004, World Health Organization. 6 Human Development Report 2004. New York, United Nations Development Programme, 2005. 7 Make every Mother and Child Count. The World Health Report 2005, World Health Organization. 8 Annual Tabulation for 1998, Ministry of Health 9 WHO Regional Office for the Western Pacific, data received from technical units. 10 Ministry of Health, February 2005. 11 Human Development Report 2005. New York, United Nations Development Programme, 2005. FIJI 78 12 Draft Master Plan of Social Health Insurance Development in Fiji. 13 Ministry of Health <http://www.spc.int/PRISM/country/fj/stats/Social/health_cdeath.htm> 14 Fiji Mortality Statistics by Gender, furnished by the WHO Representative in the South Pacific, 21 June 2001. COUNTRY HEALTH INFORMATION PROFILES | 79 FRENCH POLYNESIA 1. DEMOGRAPHICS, GENDER AND POVERTY In 2005, French Polynesia had an estimated population of 254 600. It was estimated in 2002 that around 30% of the population were below 15 years of age and, in 2003, that almost 5% were above 65 years of age. Around 52% of the population are urban dwellers (2005 estimate). There were 106 males for every 100 females in 2003. Table 1. Core population and health data (2005 estimate) [Total] 254 600 [Both] 74.10 [0-14 years] 30.30% (2002) [Male] 71.70 Population [65+ years] 4.60% (2003) Life expectancy at birth (years) [Female] 76.80 Crude birth rate (per 1000 population) 17.60 Total fertility rate 2.30 (2005-2010) [Total] 100.00 (2002) [Urban] 100.00 (2002) Crude death rate (per 1000 population) 5.00 % of population served with safe water [Rural] 100.00 (2002) [Total] 98.00 (2002) [Urban] 99.00 (2002) Infant mortality rate (per 1000 live births) 6.30 % of population with adequate sanitary facilities [Rural] 97.00 (2002) Maternal mortality ratio (per 100 000 live births) 0.00 (2002) est - Estimate 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation French Polynesia was a French overseas territory from 1946 until 2003, when it became a French overseas collectivity. Elections for the Assembly of French Polynesia, the territorial assembly of French Polynesia, were held on 23 May 2004. President Oscar Temaru was elected in June 2004, replacing Gaston Flosse. However, an opposition party passed a censure motion against the Government which led to a political crisis in October 2004. By-elections for the Assembly were held in 13 February 2005. In March 2005, President Temaru was elected for the second time. 2.2 Economic situation French Polynesia has reached a high level of health and socioeconomic development, as shown by the principal indicators. About 10% (US$ 300 million) of the gross national product (GNP) is currently spent on health. This favourable situation may be attributed to significant socioeconomic development and to the gradual implementation of an efficient health care system. FRENCH POLYNESIA 80 | COUNTRY HEALTH INFORMATION PROFILES 3. HEALTH SITUATION 3.1 Health trends Like many other countries, French Polynesia is experiencing an epidemiological transition, where communicable diseases are decreasing while noncommunicable diseases are increasing. Nearly all of the population have ready access to quality health care, resulting in immunization coverage levels of over 90%, low infant mortality rates (6.30 infants deaths per 1000 live births), a low maternal morality ratio, and a high life expectancy at birth of 71.7 years for men and 76.8 years for women. While morbidity due to acute respiratory infections remains fairly high, especially in rural and poor urban districts, improvements in medical care have resulted in very low mortality for these conditions. The leading causes of mortality are noncommunicable diseases, especially cardiovascular diseases and cancers. 3.2 Health systems Collaboration with international and regional organizations, such as WHO and the Pacific Community (formerly the South Pacific Commission), has taken on particular significance in recent years. In order to strengthen health services, one or two nurses have been assigned to each island in French Polynesia and are responsible for local coordination of the various public health programmes. They are the liaison persons for the programme managers and are responsible for implementation and evaluation. These nurse coordinators are regularly recalled to share their experiences and be informed on the status of the different public health programmes and their outcomes. About 15 nurses work in isolated communities where there is no doctor. 4. NATIONAL HEALTH PLAN AND PRIORITIES Although “Health for all by the year 2000” was adopted as a general objective of the national health policy in the early 1980s, French Polynesia has not defined or implemented a health development strategy. Nevertheless, most primary health care services are delivered at the first- contact level. The Direction de la Santé (Directorate for Health) is mandated by the Ministry of Health to prepare, every five years, a master plan for health as a high priority. Emphasis is placed on planning and management processes, and on decentralization. The reorganization of the administrative structure of the Direction de la Santé has facilitated the process. 5. MAJOR INFORMATION SOURCES Bureau de la Veille Sanitaire, Direction de la Santé en Polynésie Française Institut de la Statistique de Polynésie Française Secretariat of the Pacific Community, Pacific Regional Information System (PRISM) (http://www.spc.int/prism) French Polynesian legislative election, 2004 (http://en.wikipedia.org/wiki/French_Polynesian_legislative_election%2C_2004) COUNTRY HEALTH INFORMATION PROFILES | 81 6. ADDRESSES MINISTRY OF HEALTH Office Address : Ministère de la Santé B.P. 611, 98713 Papeete TAHITI, Polynésie Française Postal Address : Official Email Address : Maheata.schyle@sante.gov.pf Telephone : (689) 46 00 56 Fax : (689) 46 00 59 Office Hours : Website : WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4 Provident Plaza One Downtown Boulevard 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@fij.wpro.who.int Telephone : (679) 3-304600 / 3-304631 / 3-300727 Fax : (679) 3-300462 Office Hours : Website : FRENCH POLYNESIA 82 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: MINISTRY OF HEALTH COUNTRY HEALTH INFORMATION PROFILE 83 FRENCH POLYNESIA WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 3.52 1 2 Estimated population ('000s) 254.60 … … 2005 est 2 3 Annual population growth rate (%) 1.39 … … 2005-2010 3 4 Percentage of population - 0–14 years 30.30 30.40 30.30 2002 2 - 65+ years 4.60 4.20 4.90 2003 2 5 Urban population (%) 51.90 … … 2005 est 3 6 Crude birth rate (per 1 000 population) 17.60 … … 2005 est 2 7 Crude death rate (per 1 000 population) 5.00 … … 2005 est 2 8 Rate of natural increase of population (% per annum) 1.26 … … 2005 est 2 9 Life expectancy (years) - at birth 74.10 71.70 76.80 2005 est 3 - Health-adjusted Life Expectancy (HALE) at age 60 … 15.10 18.70 1997-2001 2 10 Adult literacy rate (%) … … … 11 Neonatal mortality rate (per 1 000 live births) 4.00 … … 2002 4 12 Infant mortality rate (per 1 000 live births) 6.30 … … 2005 est 2 13 Under-five mortality rate (per 1 000 live births) 11.00 … … 2005-2010 3 14 Total fertility rate (women aged 15–49 years) 2.30 2005-2010 3 15 Maternal mortality ratio (per 100 000 live births) 0.00 2002 4 16 Percentage of newborn infants weighing at least 2500 g at birth 93.00 … … 2001 4 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 66.60 2002 3 19 Immunization coverage for infants (%) - BCG 99.00 … … 2003 5 - DTP3 99.00 … … 2003 5 - OPV3 99.00 … … 2003 5 - Measles 95.60 … … 2002 5 - Hepatitis B III 98.00 … … 2003 5 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 100.00 2000 6 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 100.00 2000 6 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … FRENCH POLYNESIA 84 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 100.00 100.00 2002 7 26 Proportion of population with access to improved sanitation 98.00 99.00 97.00 2002 7 27 Proportion of the population using solid fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index … … … 32 Per capita GDP at current market prices (US$) 15 063.30 a … … 2002 2 33 Rate of growth of per capita GDP (%) … … … 34 Health expenditure Total health expenditure - amount (in million US$) … - total health expenditure on health as % of GDP … - per capita total expenditure on health (in US$) … Government expenditure on health - amount (in million US$) … - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure … External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 96.10 F.CFP (average) 2004 2 35 Health insurance coverage as % of total population … INDICATORS DATA DATA Year Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 447 a … … 17.80 … … 2004 est 2 - dentists 113 a, f … … 4.10 … … 2004 est 2 - pharmacists b 100 a … … 4.00 … … 2004 est 2 - nurses 824 … … 35.90 … … 2000 4 - midwives 93 … … 15.80 … … 2000 4 - other nursing / auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) … … … … … … - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … COUNTRY HEALTH INFORMATION PROFILE 85 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Five leading causes of morbidity Number Rate per 100 000 population 1. Acute respiratory infections 27 259 … … 11 035.00 … … 2003 4 2. Influenza (flu-like syndrome) 18 357 … … 7431.00 … … 2003 4 3. Infections of the skin and subcutaneous tissues 16 085 … … 6511.00 … … 2003 4 4. Pharyngitis 7544 3054.00 … … 2003 4 5. Acute otitis media 6294 … … 2548.00 … … 2003 4 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Diseases of the circulatory system 260 139 121 105.30 … … 2003 4 2. Neoplasms 245 133 112 99.20 … … 2003 4 3. Injuries and external causes 122 100 22 49.40 … … 2003 4 4. Symptoms, signs and findings, not elsewhere classified 93 61 32 37.60 … … 2003 4 5. Diseases of the respiratory system 93 61 51 37.60 … … 2003 4 6. Diseases of the genitourinary system 47 29 18 19.00 … … 2003 4 7. Infectious and parasitic diseases 40 25 15 16.20 … … 2003 4 8. Endocrine diseases 38 20 18 15.40 … … 2003 4 9. Diseases of the digestive system 35 26 9 14.20 … … 2003 4 10. Diseases of the nervous system 23 15 8 9.30 … … 2003 4 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2003 4 - Pertussis (whooping cough) 1 … … 0 0 0 2003 4 - Tetanus 0 0 0 0 0 0 2003 4 - Neonatal tetanus 0 0 0 0 0 0 2003 4 - Poliomyelitis 0 0 0 0 0 0 2003 4 - Hib meningitis 0 0 0 2 1 1 2003 4 - Measles 0 0 0 0 0 0 2003 4 - Mumps 12 … … 0 0 0 2003 4 - Rubella 3 … … 0 0 0 2003 4 - Congenital rubella syndrome … … … 0 0 0 2003 4 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral - Type A 0 0 0 0 0 0 2003 4 - Type B 168 … … 0 0 0 2003 4 - Type C 43 … … 0 0 0 2003 4 - Type E … … … … … … - Unspecified 13 … … 0 0 0 2003 4 Cholera 0 0 0 0 0 0 2003 4 Typhoid fever 0 0 0 0 0 0 2003 4 Encephalitis … … … 0 0 0 2003 4 Plague 0 0 0 0 0 0 2003 4 Syphilis 0 0 0 0 0 0 2003 4 Gonorrhoea 94 … … 0 0 0 2003 4 Leprosy 11 … … … … … 2004 5 Malaria … … … 0 0 0 2003 4 Dengue/DHF 58 … … 0 0 0 2004 5 FRENCH POLYNESIA 86 INDICATORS DATA Year Source Total Male Female Total Male Female 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 60 … … … … … 2004 5 - New pulmonary tuberculosis (smear-positive) 30 … … … … … 2004 5 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 56.00 … … 5.00 … … 2004 5 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 93.00 … … 83.00 (2003) … … 2004 5 Number of cases (C) Number of deaths (D) 45 Acute respiratory infections 27 259 … … 0 0 0 2003 4 46 Diarrhoeal diseases 7 406 … … 9 5 4 2003 4 47 Cancers All cancers (malignant neoplasms only) 427 237 190 245 133 112 2003 4 - Trachea, bronchus, and lung 57 48 9 64 45 19 2003 4 - Stomach 11 8 3 8 4 4 2003 4 - Colon and rectum 20 13 7 9 6 3 2003 4 - Lip, oral cavity and pharynx 13 9 4 8 7 1 2003 4 - Liver 17 14 3 14 8 6 2003 4 - Cervix 12 0 2003 4 - Leukaemia 18 11 7 9 5 4 2003 4 48 Circulatory All circulatory system diseases … … … 260 139 121 C: 2001 D: 2003 4 - Ischaemic heart disease … … … 54 32 22 - Acute myocardial infarction … … … 28 15 13 - Rheumatic fever and rheumatic heart diseases … … … 3 1 2 - Cerebrovascular diseases … … … 54 31 23 - Hypertension … … … 31 15 16 49 Maternal causes - Haemorrhage … 0 2003 4 - Abortion … 0 2003 4 - Eclampsia … 0 2003 4 - Sepsis … 0 2003 4 - Obstructed labour … 0 2003 4 50 Diabetes mellitus … … … … … … 51 Mental disorders … … … … … … COUNTRY HEALTH INFORMATION PROFILE 87 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 52 Injuries - All types … … … 122 100 22 2003 4 - Motor and other vehicle accidents … … … 33 28 5 2003 4 - Suicide … … … 28 24 4 2003 4 - Homicide and violence … … … 0 0 0 2003 4 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 5 624 2003 4 - Specialized hospitals … … - District/first-level referral hospitals 13 62 e 2003 4 - Primary health care centres 86 … 2003 4 Private hospitals 4 285 2003 4 Notes: Red text Millennium Development Goals indicators … Data not available est Estimate C Cases D Deaths aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Reported as chemists. c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. e Figure refers to observation beds f Figure refers to dental surgeons only. Sources: 1 Pacific Island Populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 2 Institut de la Statistique de Polynésie Française <http://www.ispf.pf> 3 Demographic Tables for the Western Pacific 2005-2010. World Health Organization, Regional Office for the Western Pacific. 4 Bureau de la Veille Sanitaire, Direction de la Santé en Polynésie Française. 5 WHO Regional Office for the Western Pacific, data received from the technical units. 6 Information furnished by the Bureau of Epidemiology and Health Statistics, 3 May 2002. 7 Meeting the MDG drinking water and sanitation targets: A mid-term assessment of progress. WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2004. 88 | COUNTRY HEALTH INFORMATION PROFILES GUAM 1. DEMOGRAPHICS, GENDER AND POVERTY The population of Guam was estimated to be 168 564 in 2005, and it is estimated that there are 104 males for every 100 females. Population density is 311 per square kilometre. Total life expectancy for both sexes is 78.40 years. Men are expected to live up to 75.34 years and women up to 81.64 years. Table 1. Core population and health data (2005) [Total] 168 564 [Both] 78.40 [0-14 years] 49 532 (29.38%) [Male] 75.34 Population [65+ years] 10 982 (6.52%) Life expectancy at birth (years) [Female] 81.64 Crude birth rate (per 1000 population) 19.03 Total fertility rate 2.60 [Total] 100.00 (2003p) [Urban] … Crude death rate (per 1000 population) 4.41 % of population served with safe water [Rural] … [Total] 100.00 (2003p) [Urban] … Infant mortality rate (per 1000 live births) 11.22 (2003p) % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 0.00 (2003p) p - Provisional 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The political situation on Guam remains stable, with elections for the mayors of municipal civil districts (villages) and the unicameral legislature held in 2004. Cooperation between the Executive Branch and the Legislative Branch is growing. 2.2 Economic situation Guam has been in a financial crisis since the 1994 fiscal year. The economic decline is related to the Asian economic crisis and unforeseen events such as supertyphoons (which have destroyed much of Guam’s infrastructure and left much of the island with little or no potable water for weeks and no electricity for two to three months in some areas), the war in Iraq, and the outbreak of severe acute respiratory syndrome (SARS). Guam’s economy is heavily reliant on the tourism industry, with the majority of visitors originating from Japan and the Pacific rim. Tourist arrivals and expenditures have dwindled due to the aforementioned events, although there are indications of an upswing. 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. COUNTRY HEALTH INFORMATION PROFILES | 89 3. HEALTH SITUATION 3.1 Health trends The crude death rate in 2005 was 4.41 per 1000 population, a slight decrease from 4.35 in 2004. However, the provisional infant mortality rate in 2003 was 11.22 per 1000 live births, a significant increase from the 2002 rate of 6.21 per 1000 live births. Although the health status of Guam’s population continues to improve, the five leading causes of death in 2002 remain as follows: diseases of the heart (130.39 per 1000 population), malignant neoplasms (76.99), cerebrovascular diseases (32.29), accidents (14.28) and suicides (13.66). 3.2 Health systems Guam is faced with the challenge of maintaining a health care system that will adequately meet the needs of a predominantly young and growing population. At the same time, it is also faced with the added challenge of addressing the problems of the rapidly increasing number of older people, forecast to increase from 3.9% of the total population in 1990 to 7.5% in 2010. A reduction in human and financial resources has severely impacted the health system. An early retirement programme, instituted at the end of 1999, led many experienced health workers to retire. While the vacated positions have continued to be funded, there is not a large enough resource pool to fill all of them. Tightening government budgets have left some less critical positions vacant, and these vacancies have reduced the overall amount of services available to the uninsured and underinsured population. The vacancies have also affected progress in strengthening other health service priority areas, such as disposal of hazardous and toxic materials, environmental protection, vector control, and drug and alcohol abuse services. 4. NATIONAL HEALTH PLAN AND PRIORITIES Guam is dedicated to the attainment of health for all by the year 2010. In 1992, the Guam Health Planning and Development Agency identified 13 health service priority areas to be strengthened: • human 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. All public health services depend on having a basic infrastructure, especially in terms of personnel. Unfortunately, Guam is experiencing health workforce shortages due to the early retirement of its most experienced professionals. Human resources for health in critical areas are still lacking and must be developed locally to the greatest extent possible. The following training needs are priorities: environmental studies, with an emphasis in environmental law, policy, GUAM 90 | COUNTRY HEALTH INFORMATION PROFILES management, and planning and analysis; and short-term training in retail hazard analysis critical control point (HACCP), and in drugs, medical devices and controlled substances. The Guam Environmental Protection Agency (GEPA) relies heavily on its professional staff to provide technical expertise in all areas of environmental resource protection, management and policy. In addition, technical expertise in the areas of environmental protection, management and policy is needed for the young professionals within GEPA, as the fields of environmental protection and science are constantly changing. However, due to early retirement and voluntary separation, all personnel with over 10 years of professional and technical experience have left GEPA, leaving half (two out of four) of the remaining personnel with less than four years of professional GEPA experience. Combined with the local hiring freeze, it is anticipated that no new professionals will be hired within the next two to three years. The lack of well educated and technically trained personnel is severely undermining the professional credibility of GEPA. To further complicate matters, GEPA also serves as the primary regulatory agency for all environmental issues and policies on Guam, and takes the lead for most other islands in Micronesia. The Division of Environmental Health of the Department of Public Health and Social Services (DPHSS) is also greatly understaffed. Over half the Division's staff have fewer than five years experience, and staff generally lack specialized training. Training in retail HACCP is lacking. The United States Federal Drug Administration is urging all locales, states and territories to explore HACCP as a requirement in retail and food service establishments, and to develop a model food code that incorporates HACCP principles. All health care products, from toothbrushes to prescription medications, are regulated and enforced by the Drug and Medical Device Programme. Because of Guam's geographical location and the ethnic diversity of its people, various drugs and medical devices of foreign origin are imported, distributed and marketed. 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 Division of Environmental Health staff. Forged prescriptions, lack of accountability of controlled substances by businesses, and illegal dispensing of controlled substances are estimated to be significant problems. However, because of the lack of human resources, only urgent cases are pursued and investigated. 5. MAJOR INFORMATION SOURCES Office of Vital Statistics, Guam Department of Health and Social Services Department of Health and Social Services, Guam United States of America Bureau of the Census Secretariat of the Pacific Community http://www.spc.int/prism/ 6. ADDRESSES DEPARTMENT OF HEALTH AND SOCIAL SERVICES Office Address : Postal Address : P.O. Box 2816, Agana, Guam 96910 Official Email Address : Telephone : (671) 735-7102 Fax : (671) 734-5910 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILES | 91 WHO REPRESENTATIVE There is no WHO Representative in Guam. Queries about WHO’s programme of collaboration with Guam should be directed to the Director (Programme Management): Office Address : World Health Organization Regional Office for the Western Pacific, United Nations Avenue, Manila, Philippines 1000 Postal Address : P.O. Box 2932, Manila, Philippines 1000 Official Email Address : Telephone : (632) 528-8001 (trunk line) Fax : Office Hours : 0700H-1530H Website : http://www.wpro.who.int GUAM 92 GUAM WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 0.54 1 2 Estimated population ('000s) 168.56 85.92 82.65 2005 2 3 Annual population growth rate (%) 1.46 … … 2005 2 4 Percentage of population - 0–14 years 29.38 a 29.85 a 28.90 a 2005 2 - 65+ years 6.52 a 6.00 a 7.05 a 2005 2 5 Urban population (%) 94.00 … … 2005 est 3 6 Crude birth rate (per 1 000 population) 19.03 … … 2005 2 7 Crude death rate (per 1 000 population) 4.41 … … 2005 2 8 Rate of natural increase of population (% per annum) 1.46 … … 2005 2 9 Life expectancy (years) - at birth 78.40 75.34 81.64 2005 2 - Health-adjusted Life Expectancy (HALE) at age 60 … … … 10 Adult literacy rate (%) … … … 11 Neonatal mortality rate (per 1 000 live births) 3.41 … … 2002 4 12 Infant mortality rate (per 1 000 live births) 11.22 … … 2003 p 4 13 Under-five mortality rate (per 1 000 live births) 10.00 … … 2005 est 3 14 Total fertility rate (women aged 15–49 years) 2.60 2005 2 15 Maternal mortality ratio (per 100 000 live births) 0.00 2003 p 5 16 Percentage of newborn infants weighing at least 2500 g at birth 91.54 e … … 2004 4 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 1.20 2001 6 19 Immunization coverage for infants (%) - BCG NR NR NR. 2004 7 - DTP3 87.00 … … 2004 7 - OPV3 79.00 … … 2004 7 - Measles 82.00 … … 2004 7 - Hepatitis B III 85.00 … … 2004 7 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 92.05 2001 6 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … COUNTRY HEALTH INFORMATION PROFILE 93 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 … … 2003p 5 26 Proportion of population with access to improved sanitation 100.00 … … 2003p 5 27 Proportion of the population using solid fuels for cooking or heating (%) <5.00 … … 2003 7 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index … … … 32 Per capita GDP at current market prices (US$) 15 439.00 b … … 2002 8 33 Rate of growth of per capita GDP (%) … … … 34 Health expenditure Total health expenditure - amount (in million US$) 159. 81 2000 6 - total health expenditure on health as % of GDP … - per capita total expenditure on health (in US$) 1032.36 2000 6 Government expenditure on health - amount (in million US$) 34.35 FY2000 4 - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure 6.18 FY2000 4 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = NR 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 166 … … 11.10 … … 1999 6 - dentists 31 f … … 2.05 … … 1999 6 - pharmacists … … … … … … - nurses … … … … … … - midwives … … … … … … - other nursing / auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) … … … … … … - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … GUAM 94 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. … … … … … … 2. … … … … … … 3. … … … … … … 4. … … … … … … 5. … … … … … … 6. … … … … … … 7. … … … … … … 8. … … … … … … 9. … … … … … … 10. … … … … … … 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Diseases of the heart 210 … … 130.39 … … 2002 4 2. Malignant neoplasm 124 … … 76.99 … … 2002 4 3. Cerebrovascular disease 52 … … 32.29 … … 2002 4 4. All other accidents 23 … … 14.28 … … 2002 4 5. Suicide 22 … … 13.66 … … 2002 4 6. Pneumonia 22 … … 13.66 … … 2002 4 7. Chronic obstructive pulmonary diseases 20 … … 12.42 … … 2002 4 8. Bacterial diseases (septicaemia) 18 … … 11.18 … … 2002 4 9. Diabetes mellitus 18 … … 11.18 … … 2002 4 10. Motor vehicle accidents 13 … … 8.07 … … 2002 4 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 7 - Pertussis (whooping cough) 0 0 0 0 0 0 2004 7 - Tetanus 0 0 0 0 0 0 2004 7 - Neonatal tetanus 0 0 0 0 0 0 2004 7 - Poliomyelitis 0 0 0 0 0 0 2004 7 - Hib meningitis 0 0 0 0 0 0 2004 7 - Measles 2 … … … … … 2004 7 - Mumps 1 … … … … … 2004 7 - Rubella 1 … … … … … 2004 7 - Congenital rubella syndrome 0 0 0 0 0 0 2004 7 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral 17 … … 2 … … 2003 7 - Type A 2 … … 0 0 0 2003 7 - Type B 10 … … 1 … … 2003 7 - Type C 5 … … 1 … … 2003 7 - Type E … … … … … … - Unspecified … … … … … … Cholera 0 0 0 0 0 0 2003 7 Typhoid fever 0 0 0 0 0 0 2003 7 Encephalitis 2 … … 0 0 0 2003 7 Plague 0 0 0 0 0 0 2003 7 Syphilis … … … … … … Gonorrhoea … … … … … … COUNTRY HEALTH INFORMATION PROFILE 95 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Leprosy 1 … … … … … 2001 7 Malaria … … … … ... … Dengue/DHF … … … … … … 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 51 … … … … … 2004 7 - New pulmonary tuberculosis (smear-positive) 22 … … … … … 2004 7 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 91.00 … … 10.00 … … 2004 7 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 50.00 … … 96.00 (2003) … … 2004 7 Number of cases Number of deaths 45 Acute respiratory infections 137 … … 11 7 4 2000 6 46 Diarrhoeal diseases … … … 0 0 0 2000 6 47 Cancers All cancers (malignant neoplasms only) … … … 125 74 51 2000 6 - Trachea, bronchus, and lung … … … 36 22 14 2000 6 - Stomach … … … 7 3 4 2000 6 - Colon and rectum … … … 13 8 5 2000 6 - Lip, oral cavity and pharynx … … … 1 1 0 2000 6 - Liver … … … 7 6 1 2000 6 - Cervix … 2 2000 6 - Leukaemia … … … 4 1 3 2000 6 48 Circulatory All circulatory system diseases … … … 246 149 97 2000 6 - Ischaemic heart disease … … … 142 88 54 2000 6 - Acute myocardial infarction … … … 25 19 6 2000 6 - Rheumatic fever and rheumatic heart diseases … … … 2 2 0 2000 6 - Cerebrovascular diseases … … … 58 33 25 2000 6 - Hypertension … … … 15 10 5 2000 6 49 Maternal causes - Haemorrhage 57 0 2000 6 - Abortion 76 0 2000 6 - Eclampsia … … - Sepsis … … - Obstructed labour … … GUAM 96 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 50 Diabetes mellitus … … … 21 8 13 2000 6 51 Mental disorders … … … 0 0 0 2000 6 52 Injuries - All types … … … 82 69 13 2000 6 - Motor and other vehicle accidents … … … 23 18 5 2000 6 - Suicide … … … 29 27 2 2000 6 - Homicide and violence … … … 4 2 2 2000 6 - Occupational injuries … … … 5 4 1 2000 6 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 225 2000 6 - Specialized hospitals 0 0 2000 6 - District/first-level referral hospitals 0 0 2000 6 - Primary health care centres 2 0 2000 6 Private hospitals 0 0 2000 6 Notes: Red text Millennium Development Goals (MDG) indicators … Data not available est Estimate p Provisional NR Not relevant FY The financial year refers to the span from April 1 of respective year to March 31 next year. aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Figure reported as Gross Island Product. c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. e Figure refers to birth weight equal to 2501 grams and above. f Figure refers to dental surgeons only. Sources: 1 Pacific Island Populations 2004. Secretariat of the Pacific Community. 2 US Census Bureau (http://www.census.gov) 3 Demographic Tables for the Western Pacific 2005-2010. World Health Organization, Regional Office for the Western Pacific. 4 Guam Bureau of Statistics and Plans (http://www.spc.int/prism) 5 Information furnished by the Department of Health and Social Services, Guam, 21 June 2004. 6 Information furnished by the Department of Health and Social Services, Guam, 16 January 2003. 7 WHO Regional Office for the Western Pacific, data received from the technical units. 8 Asia Pacific in Figures 2004. United Nations Economic and Social Commission for Asia and the Pacific (http://www.unescap.org/stat/data/apif/index.asp) COUNTRY HEALTH INFORMATION PROFILES | 97 HONG KONG 1. DEMOGRAPHICS, GENDER AND POVERTY The population of Hong Kong (China) was 6 935 900 in mid-2005, comprising 3 325 100 men and 3 610 800 women. For more than three decades, life expectancy at birth has been rising steadily, reaching 78.82* years among males and 84.37* years among females in 2005. As a result of a decreasing birth rate and increasing life expectancy, Hong Kong's population has been ageing steadily. In 2005, 12.1% of the population were aged 65 and above (7.4% in 1985, 9.8% in 1995), while the elderly dependency ratio was 164 per 1000 population aged 15 to 64 (108 in 1985, 138 in 1995). Table 1. Core population and health data (2005) [Total] 6 935 900 [Both] … [0-14 years] 1 005 400 (14.50 %) [Male] 78.82* Population [65+ years] 836 400 (12.06 %) Life expectancy at birth (years) [Female] 84.37* Crude birth rate (per 1000 population) 8.24 Total fertility rate 0.97* [Total] 100.00 [Urban] 100.00 Crude death rate (per 1000 population) 5.58 % of population served with safe water [Rural] … [Total] 99.00 [Urban] … Infant mortality rate (per 1000 live births) 2.36* % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 1.75* Note: * Provisional figure 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Hong Kong is a Special Administrative Region (SAR) of the People’s Republic of China. Under the Basic Law, Hong Kong (China) enjoys a high degree of autonomy, except in defence, foreign affairs and other matters falling outside its autonomy. Hong Kong exercises executive, legislative and independent judicial power, including that of final adjudication. The Government introduced a new accountability system for principal officials on 1 July 2002. Under the new system, the politically appointed principal officials accept total responsibility relating to their respective portfolios. 2.2 Economic situation Hong Kong is one of the world’s most successful communities. Within the space of two generations, economic growth has transformed the living standards of its 6.9 million people. Gross domestic product (GDP) grew at an average annual rate of 3.9% in real terms during the 10 years to 2005. Per capita GDP increased by 1.0% in money terms over the same period, reaching US$ 25 625(HK$ 199 282) in 2005. For the financial year 2005-2006, public expenditure on health reached US$ 4.1 billion, representing 12.6% of total public expenditure. HONG KONG 98 | COUNTRY HEALTH INFORMATION PROFILES 3. HEALTH SITUATION 3.1 Health trends Hong Kong takes pride in having achieved health indices that rank among the best in the world. Infant and under-five mortality rates are consistently low, as is the maternal mortality ratio. Chronic degenerative diseases, among others, are the major causes of registered death. Preliminary figures in 2005 show the four major killers were malignant neoplasms (12 141 registered deaths), diseases of the heart (6031), pneumonia (4108) and cerebrovascular diseases (3 427); they represented approximately 66.5% of all registered deaths. Children are immunized against tuberculosis, diphtheria, pertussis, poliomyelitis, tetanus, hepatitis B, measles, mumps and rubella. Due to high immunization coverage, diseases such as diphtheria and poliomyelitis have been virtually eradicated, and the incidence of vaccine- preventable infectious diseases among children is relatively low. In 2005, the number of tuberculosis (TB) notifications was 6237*, representing an increase of 0.2*% compared with 2004 figures. The TB notification rate was 89.9* per 100 000 population, largely due to the ageing population and overcrowded living environment. By the end of 2005, a cumulative total of 2 825 cases of HIV infection and 782 AIDS patients had been reported. *provisional figures The Government has enhanced its capacity to manage disease outbreaks. The Centre for Health Protection was set up under the Department of Health on 1 June 2004 to achieve effective prevention and control of diseases, in collaboration with local and international stakeholders. 3.2 Health systems In 2005, there were 11 505 doctors, 1941 dentists, 1583 pharmacists, 35 465 registered and enrolled nurses, 4917 midwives, 5133 registered Chinese medicine practitioners, 2957 listed Chinese medicine practitioners and 86 chiropractors. There were 9204 other health care personnel under statutory registration, including medical laboratory technologists, physiotherapists, occupational therapists, optometrists and radiographers. 4. NATIONAL HEALTH PLAN AND PRIORITIES The Government’s health care policy is that no one should be denied adequate medical treatment due to lack of means. To this end, it provides a range of services and facilities through the Department of Health and the Hospital Authority to meet the needs of the public. These are complemented by health services provided in the private sector. The Department of Health is the Government’s health adviser and the agency charged with the responsibility of executing health care policies and statutory functions. It safeguards the community’s health through a range of promotional, preventive, curative and rehabilitative services. It is committed to providing quality client-oriented services. The Hospital Authority is a statutory body responsible for the management of all public hospitals. It provided medical treatment and rehabilitation services to patients through outreach services, specialist clinics and 38 public hospitals during 2005. The Government’s goal is to provide a health care system that is able to protect and promote health, and to provide quality health care services to citizens at reasonable prices. To meet the changing needs of the community, the Government will continue to improve the quality of patient care and review the health care system to ensure the continued delivery of quality care at reasonable cost. COUNTRY HEALTH INFORMATION PROFILES | 99 5. MAJOR INFORMATION SOURCES Department of Health, Hong Kong Special Administrative Region Government (HKSARG) Lands Department, HKSARG Census and Statistics Department, HKSARG Planning Department, HKSARG Immigration Department, HKSARG Water Supplies Department, HKSARG Drainage Services Department, HKSARG Financial Services and the Treasury Bureau, Government Secretariat, HKSARG Hospital Authority of the HKSARG 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : 21/F Wu Chung House, 213 Queen’s Road East, Wan Chai, Hong Kong Postal Address : 21/F Wu Chung House, 213 Queen’s Road East, Wan Chai, Hong Kong Official Email Address : enquiries@dh.gov.hk Telephone : 29618989 Fax : 28360071 Office Hours : Mon to Fri: 9am-5pm; Sat: 9am-1pm; Sun & Public Holidays off Website : http://www.info.gov.hk/dh/ WHO REPRESENTATIVE There is no WHO Representative in Hong Kong (China). Queries about WHO’s programme of collaboration with 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 United Nations Avenue, P.O. Box 2932, 1000 Manila, the Philippines Postal Address : Official Email Address : Telephone : +6325288001 Fax : +6325211036 Office Hours : Website : http://www.wpro.who.int/ HONG KONG 100 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: DEPARTMENT OF HEALTH COUNTRY HEALTH INFORMATION PROFILE 101 HONG KONG (CHINA) WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 1.10 2005 1 2 Estimated population ('000s) 6935.90 3325.10 3610.80 2005 2 3 Annual population growth rate (%) 0.77 0.29 1.23 2005 2 4 Percentage of population - 0–14 years 14.50 15.61 13.47 2005 2 - 65+ years 12.06 11.69 12.40 2005 2 5 Urban population (%) 94.56 … … 2004 3 6 Crude birth rate (per 1 000 m id-year population) 8.24 a 9.00 a 7.53 a 2005 2, 4, 5 7 Crude death rate (per 1 000 mid-year population) 5.58 a, b 6.49 a 4.74 a 2005 2, 4, 5 8 Rate of natural increase of population (% per annum) 0.27 c … … 2005 2 9 Life expectancy (years) - at birth … 78.82 c 84.37 c 2005 2 - Heal th-adjusted Life Expectancy (H ALE) at age 60 … 21.80 c 26.27 c 2005 2 10 Adult literacy rate (%) 93.56 d 96.88 d 90.58 d 2005 2 11 Neonatal mortality rate (per 1 000 live births) 1.51 a, c … … 2005 2, 4, 5 12 Infant mortality rate (per 1 000 live births) 2.36 a, c … … 2005 2, 4, 5 13 Under-five mortality rate (per 1 000 live births) 2.90 a, c 2.80 a, c 3.02 a, c 2004 2, 4, 5 14 Total fertility rate (women aged 15–49 years) 0.97 c 2005 2 15 Maternal mortality ratio (per 100 000 live births) 1.75 a, c 2005 2, 4, 5 16 Percentage of newborn infants weighing at least 2500 g at birth 94.42 e 95.01 e 93.78 e 2004 2, 4 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 1.91 f 2005 4 19 Immunization coverage for infants (%) - BCG 95.00 … … 2004 15 - DTP3 95.00 … … 2004 15 - OPV3 95.00 … … 2004 15 - Measles 95.00 … … 2004 15 - Hepati tis B III 95.00 … … 2004 15 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel About 100.00 2005 4 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) About 0.00 g 2005 4 - Percentage of deliveries in heal th facilities (as % of total deliveries) About 100.00 h 2005 4 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … HONG KONG (CHINA) 102 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 100.00 … 2005 6 26 Proportion of population with access to improved sanitation 99.00 … … 2005 7 27 Proportion of the population using solid fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) 72.10 i … … 2005 8 30 Health care waste generation (metric tons per year) 2 895.18 … … FY 2005/ 2006 est 9 31 Human development index 0.92 … … 2003 10 32 Per capita GDP at current market prices (US$) 25 624.53 c … … 2005 2, 4 33 Rate of growth of per capita GDP (%) 6.19 c … … 2005 2, 4 34 Health expenditure Total health expenditure - amount (in m illion US$) ... - total heal th expenditure on health as % of GDP … - per capita total expendi ture on health (in US$) … Government expenditure on health - amount (in million US$) 4 068.28 c, j FY 2005/06 2, 4, 11 - general government expendi ture on health as % of total expendi ture on health q ... - general government expendi ture on health as % of total general government expendi ture 12.64 c, k FY 2005/06 2, 4, 11 External source of government health expenditure - external resources for heal th as % of general government expendi ture on health … Private health expenditure - private expenditure on health as % of total expenditure on heal th … Exchange rate in US$ of local currency is: 1 US$ = 7.78HK$ 2005 2 35 Health insurance coverage as % of total population 26.40 l 2002 2 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 end-year population c 36 Health workforce i, m - physicians 11 505 n 8543 n 2962 n 16.50 12.26 4.25 2005 2, 4 - dentists 1941 n 1431 n 510 n 2.78 2.05 0.73 2005 2, 4 - pharmacists 1583 810 773 2.27 1.16 1.11 2005 2, 4 - nurses 35 465 o 3858 o 31 607 o 50.88 5.53 45.34 2005 2, 4 - m idwives 4917 0 4917 7.05 0.00 7.05 2005 2, 4 - registered Chinese medicine practi tioners 5133 3723 1410 7.36 5.34 2.02 2005 2, 4 - listed Chinese medicine practi tioners 2957 p 2262 p 695 p 4.24 3.24 1.00 2005 2, 4 - chiropractors 86 71 15 0.12 0.10 0.02 2005 2, 4 - other nursing / auxiliary staff … … … … … … COUNTRY HEALTH INFORMATION PROFILE 103 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 end-year population c 36 Health workforce i, m - other heal th care personnel under statutory registration including medical laboratory technologists, occupational therapists, radiographers, optometrists and physiotherapists 9204 4871 4333 13.20 6.99 6.22 2005 2, 4 - other heal th personnel staff (health inspec tors, assistant sani tarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates – physicians 415 q 200 q 215 q 2005 12 38 Yearly new graduates – nurses 417 q 68 q 349 q 2005 12 39 Ten leading causes of morbidity Number r Rate per 10 000 population 1. Diseases of the geni tourinary system (ICD10: N00-N99) 178 097 … … … … … 2004 4, 13 2. Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (ICD10: R00- R99) 133 626 … … … … … 2004 4, 13 3. Diseases of the respiratory system (ICD10: J00-J99) 125 400 2004 4, 13 4. Neoplasms (ICD10: C00-D48) 123 065 … … … … … 2004 4, 13 5. Diseases of the digestive system (ICD10: K00-K93) 117 686 2004 4, 13 6. Diseases of the circulatory system (ICD10: I00-I99) 116 510 … … … … … 2004 4, 13 7. Pregnanc y, childbirth and the puerperium (ICD10: O00-O99) 94 124 … … … … … 2004 4, 13 8. Factors influencing heal th status and contact with health services (ICD10: Z00-Z99) 89 013 … … … … … 2004 4, 13 9. Injury, poisoning and certain other consequences of external causes (ICD10: S00-T98) 73 495 … … … … … 2004 4, 13 10. Diseases of the musculoskeletal system and connective tissue (ICD10: M00-M99) 46 140 … … … … … 2004 4, 13 40 Ten leading causes of mortality a, c Number Rate per 10 000 population 1. Malignant neoplasms (ICD10: C00-C97) 12 141 … … 175.05 … … 2005 2, 4 2. Diseases of heart (ICD10: I00-I09, I11, I13, I20-I51): 6031 … … 86.95 … … 2005 2, 4 3. Pneumonia (ICD10: J12-J18) 4108 … … 59.23 … … 2005 2, 4 4. Cerebrovascular diseases (ICD10: I60-I69) 3427 … … 49.41 … … 2005 2, 4 5. Chronic lower respiratory diseases (ICD10: J40-J47) 2334 … … 33.65 … … 2005 2, 4 6. External causes of morbidi ty and mortality (ICD10: V01-Y89) 2013 … … 29.02 … … 2005 2, 4 7. Nephritis, nephrotic syndrome and nephrosis (ICD10: N00-N07, N17- N19, N25-N27) 1236 … … 17.82 … … 2005 2, 4 8. Diabetes mellitus (ICD10: E10- E14) 689 … … 9.93 … … 2005 2, 4 9. Septicaem ia (ICD10: A40-A41) 684 … … 9.86 … … 2005 2, 4 HONG KONG (CHINA) 104 INDICATORS DATA Year Source Total Male Female Total Male Female 40 Ten leading causes of mortality a, c Number Rate per 100 000 population 10. Tuberculosis and sequelae of tuberculosis (ICD10: A15-A19, B90) 368 … … 5.31 … … 2005 2, 4 41 Selected diseases under the WHO- EPI Number of cases c, t Number of deaths - Diphtheria (ICD10: A36) 0 0 0 0 0 0 2005 2, 4 - Pertussis (whooping cough) (ICD10: A37) 32 15 17 … … … 2005 2, 4 - T etanus (ICD10: A35) 0 0 0 0 0 0 2005 2, 4 - Neonatal tetanus (ICD10: A33) 0 0 0 0 0 0 2005 2, 4 - Acute poliomyelitis (ICD10: A80) 0 0 0 0 0 0 2005 2, 4 - Hib meningitis (ICD10: G00.0) 1 u 1 u 0 u … … 0 2005 2, 4 - Measles (ICD10: B05) 65 39 26 … … … 2005 2, 4 - Mumps (ICD10: B26) 145 100 45 … … … 2005 2, 4 - Rubella (ICD10: B06) 53 24 29 … … … 2005 2, 4 - Congeni tal rubella syndrome (ICD10: P35.0) 0 u 0 u 0 u 0 0 0 2005 2, 4 42 Selected communicable diseases Number of cases (C) c, t, aa Number of deaths (D) Hepati tis viral (ICD10: B15-B17, B19) 202 148 54 … … … 2005 2, 4 - T ype A (ICD10: B15) 63 39 24 … … … 2005 2, 4 - T ype B (ICD10: B16) 102 78 24 … … … 2005 2, 4 - T ype C (ICD10: B17.1) 1 0 1 … 0 … 2005 2, 4 - T ype E (ICD10: B17.2) 32 27 5 … … … 2005 2, 4 - Unspecified (ICD10: B19) 4 4 0 0 0 0 2005 C: 2, 4 D: 15 Cholera (ICD10: A00) 5 0 5 … 0 … 2005 2, 4 Typhoid fever (ICD10: A01.0) 36 20 16 0 0 0 2005 C: 2, 4 D: 15 Encephalitis (ICD10: G04) 2 … … 0 0 0 2005 15 Plague (ICD10: A20) 0 0 0 0 0 0 2005 C: 2, 4 D: 15 Syphilis (ICD10: A50-A53) 1088 v 635 v 453 v … … … 2005 2, 4 Gonorrhoea (ICD10: A54) 1748 v 1535 v 213 v … … … 2005 2, 4 Leprosy (ICD10: A30) 4 1 3 … … … 2005 2, 4 Malaria (ICD10: B50-B54) 32 19 13 … … … 2005 2, 4 Dengue/DHF (ICD10: A90, A91) 31 16 15 … … … 2005 2, 4 43 Malaria Prevalence rates c, t Death rates - Rates associated with malaria (per 100 000 population) 0.46 0.57 0.36 … … … 2005 2, 4 - Proportion of population in malaria-risk areas using effective malaria prevention measures w … - Proportion of population in malaria-risk areas using effective malaria treatment measures x … 44 Tuberculosis Number of cases Number of deaths - All types (ICD10: A15-A19, B90) 6143 … … … … … 2004 15 - New pulmonary tuberculosis (smear-posi tive) 1694 … … … … … 2004 15 COUNTRY HEALTH INFORMATION PROFILE 105 INDICATORS DATA Year Source Total Male Female Total Male Female 44 Tuberculosis Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 77.00 … … 6.00 … … 2004 15 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOT S) 55.00 … … 78.00 (2003) … … 2004 15 Number of cases Number of deaths a,c 45 Acute respiratory infections (ICD10: J00-J06, J20-J22) … … … 6 3 3 2004 2, 4 46 Diarrhoeal diseases (ICD10: A00- A09) … … … 11 8 3 2004 2, 4 47 Cancers All cancers (malignant neoplasms only) (ICD10: C00-C97) … … … 12 141 … … 2005 2, 4 - Trachea, bronchus, and lung (ICD10: C33-C34) … … … … … … - Stomach (ICD10: C16) … … … … … … - Colon and rectum (ICD10: C18- C21) … … … … … … - Lip, oral cavity and pharynx (ICD10: C00-C14) … … … … … … - Liver (ICD10: C22) … … … … … … - Cervix (ICD10: C53) … … - Leukaemia (ICD10: C91-C95) … … … … … … 48 Circulatory All circulatory system diseases (ICD10: I00-I99) … … … 10 312 … … 2005 2, 4 - Ischaemic heart disease (ICD10: I20-I25) … … … … … … - Acute myocardial infarction (ICD10: I21-I22) … … … … … … - Rheumatic fever and rheumatic heart diseases (ICD10: I00-I09) … … … … … … - Cerebrovascular diseases (ICD10: I60-I69) … … … … … … - H ypertension (ICD10: I10-I15) … … … … … … 49 Maternal causes - Haemorrhage (ICD10: O46, O67, O72) … 0 2004 2, 4 - Abortion (ICD10: O02.1, O03-O07) … 0 2004 2, 4 - Eclampsia (ICD10: O15) … 0 2004 2, 4 - Sepsis (ICD10: O85) … 0 2004 2, 4 - Obstructed labour (ICD10: O64- O66) … 0 2004 2, 4 - Other direct obstetric deaths (ICD10 : O10-O92 exclude O15, O46, O64-O67, O72, O85) … 2 2004 2, 4 50 Diabetes mellitus … … … 689 … … 2005 2, 4 51 Mental disorders … … … 293 … … 2005 2, 4 HONG KONG (CHINA) 106 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 52 Injuries - All types (ICD10: V01-Y89) … … … 2013 a, c … … 2005 2, 4 - Motor and other vehicle accidents (ICD10: V01-V89) … … … … … … - Suicide (ICD10 : X60-X84) … … … … … … - Homicide and violence (ICD10 : X85-Y09) … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure i Number Number of beds Public heal th facilities - General hospitals 38 27 765 2005 13 - Specialized hospi tals … … - District/first-level referral hospitals … … - Primary health care centres 284 y 729 c 2005 4, 13 Private hospitals 12 z 3 047 c 2005 4 Nursing homes 27 z 2 587 c 2005 4 Notes: Red text M illennium Development Goals (MDG) indicators … Data not available est Estimate FY The financial year refers to the span from April 1 of respective year to March 31 next year. aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 years. a The figures are compiled based on registered deaths and/or registered births. b The figure includes unknown sex. c The figure(s) is/are subject to revision later on (i .e. provisional figure(s)). d The figure refer to the percentage of population aged 15 and above with primary or above educational attainment. e The figures exclude those with unknown birth weight. f The figure refers to the cases who had Hb<10g/dl and attending the maternal and child heal th centres for ante-natal checkups. g Nearly all newborns were delivered in health facilities. h The figure refers to the cases known to the materni ty homes, public and private hospitals. i The figure(s) is/are at the posi tion of end year. j The figure refers to the public health expenditure. k The figure refers to public heal th expenditure as percentage of overall public expenditure. l The figure refers to the percentage of the population who were covered by medical insurance purchased by individuals. m The number of healthcare personnel regardless of whether they are ac tually working in the profession or not. n The number of doctors/dentists refers to the number of doctors/dentists wi th full registration on both the local and overseas lists. o The number of nurses refers to the number of registered nurses and enrolled nurses. p Listed Chinese medicine practitioners who can practise lawfully in Hong Kong under the transi tional arrangements for registration of Chinese medicine practi tioners until a date to be announced by the Secretary for Health, Welfare and Food in the Gazette. T hey may apply for registration under the requirements of transitional arrangement. COUNTRY HEALTH INFORMATION PROFILE 107 q The figures only cover graduates of full-time sub-degree and undergraduate programmes funded by the Universi ty Grants Committee in medicine, Chinese medicine, dental surgery and nursing at the end of the graduation year 2005. Graduates may not be engaged in work areas direc tly related to their discipline of study after graduation. r The figures refer to the number of in-patient discharges including deaths by disease from public hospi tals, private hospi tals and correctional institutions. s According to the ICD 10th revision, when the morbid condition is classifiable under Chapter XIX as “injury, poisoning and certain other consequences of external causes”, the codes under Chapter XX for “external causes of morbidi ty and mortali ty” should be used as the primary cause of death. t The figures refer to the cases reported to the Department of Heal th for the listed Statutory Noti fiable Infectious Diseases (except Hib meningi tis, Congeni tal rubella syndrome, Encephali tis, Syphilis and Gonorrhoea). u Number of cases refers to the cases reported to the Department of Health. v Number of cases refers to the number of new cases seen in public Sexually Transmitted Diseases clinics and those in prisons. w Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. x Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. y The figure covers the out-patient clinics under the Department of Heal th, general out-patient clinics under the Hospital Authori ty and the out-patient clinics in the correctional insti tutions. z The figure covers the insti tutions licensed under the Hospi tals, Nursing Homes and Materni ty Homes Registration Ordinance (Cap.165). Sources: 1 Lands Department, Hong Kong Special Administrative Region Government (HKSARG) 2 Census and Statistics Department, HKSARG 3 Planning Department, HKSARG 4 Department of Health, HKSARG 5 Immigration Department, HKSARG 6 Water Supplies Department, H KSARG 7 Drainage Services Department, HKSARG 8 Transport Department, HKSARG 9 Environmental Protection Department, HKSARG 10 Human Development Report 2005. New York, United Nations Development Programme, 2005. 11 Financial Services and the Treasury Bureau, Government Secretariat, HKSARG 12 Universi ty Grants Committee, HKSARG 13 Hospital Authority of the HKSARG 14 Labour Department, HKSARG 15 WHO Regional Office for the Western Paci fic, data received from technical units 108 | COUNTRY HEALTH INFORMATION PROFILES JAPAN 1. DEMOGRAPHICS, GENDER AND POVERTY As of 01 October 2005, the total population of Japan was estimated to be 127 757 000, comprising 62 341 000 males and 65 416 000 females, indicating a total population increase of 70 000 or 0.05% from the previous year. With regards to distribution by age group, 13.7% of the population are aged 0-14 years, 66.3% 15-64 years and 19.5% 65 years and over. Table 1. Core population and health data (2005 estimates) [Total] 127 757 000 [Both] … [0-14 years] (13.70%) [Male] 78.64 (2004) Population [65+ years] (19.50%) Life expectancy at birth (years) [Female] 85.59 (2004 Crude birth rate (per 1000 population) 8.80 (2004) Total fertility rate 1.29 (2004) [Total] 96.90 (2003) [Urban] ... Crude death rate (per 1000 population) 8.20 (2004) % of population served with safe water [Rural] … [Total] 77.70 (2003) [Urban] … Infant mortality rate (per 1000 live births) 2.80 (2004) % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 4.40 (2004) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The Japanese Government, a constitutional monarchy, is based on a parliamentary cabinet system. Executive power is vested in the Cabinet, which consists of the Prime Minister and not more than 17 Ministers of State, who are collectively responsible to the Diet (legislature). In April 2001, Junichiro Koizumi was designated by the Diet as Japan's eighty-seventh Prime Minister. The third Koizumi Cabinet was inaugurated in September 2005. Prime Minister Koizumi is a member of the Liberal Democratic Party, which currently holding the largest block of representation in both the House of Representatives and the House of Councillors, which together make up the Diet. 2.2 Economic situation Japan has the second largest economy in the world in terms of gross domestic product (GDP), after the United States of America. As of 2004, the GDP of Japan and the United States totalled 40.6% of the world’s GDP. Japan's GDP per capita in 2003 was US$ 33 727, one of the highest in the world. This economic scale was achieved largely due to high economic growth from 1955 to the late 1960s. Japan's long-term economic prospects are considered good. Prime Minister Koizumi’s administration is committed to addressing economic issues, such as non-performing loans and deflation, and to conducting regulatory and other structural reforms in order to revive the economy. COUNTRY HEALTH INFORMATION PROFILES | 109 3. HEALTH SITUATION The health situation in Japan remains one of the best in the Region. The majority of health- related statistics, such as life expectancy and the under-five mortality rate, continue to improve. The health disparities within the country are also relatively small compared with those in other industrialized nations. 3.1 Health trends The average life expectancy remains the highest in the world. In 2004, it was 85.59 years for women and 78.64 years for men. The infant mortality rate fell from 2.99 per 1000 live births in 2003 to 2.80 per 1000 live births in 2004. The crude death rate was 8.20 per 1000 persons in 2004. Malignant neoplasms have been the leading cause of death since 1981 and have continued to increase. They accounted for 31.1% of all deaths (253.90 per 100 000 population) in 2004. Other major causes of death are lifestyle- related diseases, such as diseases of the circulatory system (247.80 per 100 000 population), in which daily diet and behaviour play a significant role. Due to the increasingly complex social environment created by a high-tech and competition- oriented society, it is said that stress levels felt by all age groups are rising. There were 30 247 suicides in 2004; the number has remained stable at approximately 30 000 since 1998. The suicide rate is relatively high for men aged from their mid-twenties to forties. Tuberculosis, infectious and difficult-to-treat diseases, such as HIV infection, and new types of influenza are becoming serious threats to public health in Japan. 3.2 Health systems The basic principle governing the delivery of health care services is that all citizens should be able, at any time and place, to receive the care they require with an affordable personal contribution. The health insurance system in Japan maintains universal coverage and there is free access to all health institutions. While this system has ensured equitable health care delivery across different socioeconomic groups and different areas of the country, it has given rise to an inefficient supply of services. Under the free access system, patients have a tendency to skip the general practitioner and go directly to hospitals for even relatively common illnesses. At the same time, the current fee-for- service payment scheme tends to invite overtreatment. For example, the average length of a hospital stay in Japan is more than three weeks, more than double that in the majority of developed countries. With increasing financial constraints, the Government is planning to introduce structural reforms in its heath system to create a more efficient system while maintaining equity and quality of services. This reform is closely associated with the ongoing demographic transition – longer life expectancy and lower birth rate – which has resulted in a rapid increase in the percentage of elderly citizens. It is estimated that, by 2025, the elderly, defined as those aged 65 years and older, will constitute over 26% of the entire population. Currently, they make up 19.5%. The speed at which Japan’s population will age over the next few decades will be the fastest in human history. This ageing population will need to pay attention to lifestyle-related diseases. Maintaining healthy lifestyles and the early detection of disease could help reduce the incidence of the three major killer diseases: malignant neoplasms, cardiovascular diseases and cerebrovascular diseases. The new Health Promotion Law (2002) emphasizes the importance of establishing an environment conducive to healthier lifestyles as a key strategy for the ageing society. As of 2004, there were 270 371 doctors and 1 146 181 nurses, public health nurses and assistant nurses. Due to population ageing, along with the growing sophistication and specialization of JAPAN 110 | COUNTRY HEALTH INFORMATION PROFILES medical services among other factors, it is presumed that the demand for health, medical and welfare services personnel will increase in the future. National expenditure for medical care has been rising year after year. In the 2003 fiscal year, expenditure totalled about ¥ 31.5 trillion (US$ 272 039 000 000), about 8.55% of Japan’s national income. In the same fiscal year, expenditure on medical services for the aged was about ¥ 11.7 trillion, or about one-third of the total medical cost, and this proportion is increasing every year. The rapidly growing number of senior citizens has resulted in a sharp rise in medical costs for the elderly and is a major reason for the upwards trend in medical care expenditures. The annual cost of medical care per capita averaged ¥ 247 100 (US$ 2131) in the 2003 fiscal year. Per capita medical care costs for the elderly averaged ¥ 653 300 a year. 4. NATIONAL HEALTH PLAN AND PRIORITIES 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 2010, 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 a national nutrition survey every year since 1945. The recommended dietary allowances (Dietary Reference Intakes) are revised every five years. In 1999, they underwent their sixth revision. Dietary Guidelines for Japanese, the benchmark for dietary improvement, were established in 2000. • Promoting good exercise habits: There were 12 736 health and fitness instructors and 7892 health and fitness programmers as of April 2000. In recent years, it has been recognized that exercise and hot spring therapy are effective methods for the treatment of various noncommunicable diseases. Therefore, the fees to use exercise/hot spring facilities have been made deductible as medical expenses for income tax purposes when the therapies are supplied at the instruction of a physician at a health promotion facility that meets certain requirements and is approved by the Ministry of Health, Labour and Welfare. • Promoting appropriate relaxation: The need for relaxation and the part it plays in maintaining and improving health is well recognized. Therefore, “relaxation and health of mind” is one of the targets in “Healthy Japan 21”. In addition, in 1994, the Ministry of Health, Labour and Welfare devised relaxation guidelines for health promotion that encourage and promote appropriate relaxation in daily life. • Smoking and health: Since cigarettes have a number of negative health effects, not only on smokers but also on the people around them, the Ministry of Health, Labour and Welfare is engaged in efforts to provide accurate information to all citizens about the effects of smoking. 5. MAJOR INFORMATION SOURCES Ministry of Health Labour and Welfare (http://www.mhlw.go.jp/english/index.html) Statistics Bureau, Ministry of Public Management, Home Affairs, Posts and Telecommunications (http://www.stat.go.jp/english/index.htm) SEAMIC Health Statistics 2002. International Medical Foundation of Japan Abridged life table for Japan 2004. Ministry of Health, Labour and Welfare COUNTRY HEALTH INFORMATION PROFILES | 111 6. ADDRESSES MINISTRY OF HEALTH, LABOUR AND WELFARE Office Address : Postal Address : The Honourable Minister of Health, Labour and Welfare Ministry of Health, Labour and Welfare Japanese Government l-2-2, Kasumigaseki, Chiyoda-ku Tokyo 100-8916, Japan Official Email Address : Telephone : Fax : Office Hours : Website : http://www.mhlw.go.jp/english/index.html WHO REPRESENTATIVE There is no WHO Representative in Japan. Queries about the WHO programme of collaboration with Japan should be directed to Director, Programme Management, WHO Regional Office for the Western Pacific. Office Address : Postal Address : Director, Programme Management World Health Organization Regional Office for the Western Pacific United Nations Avenue, P.O. Box 2932, 1000 Manila, the Philippines Official Email Address : Telephone : Fax : Office Hours : 7:00-15:30 Website : http://www.wpro.who.int/ JAPAN 112 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: MINISTRY OF HEALTH, LABOUR AND WELFARE COUNTRY HEALTH INFORMATION PROFILE 113 JAPAN WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 377.89 2002 4, 10 2 Estimated population ('000s) 127 757.00 62 341.00 65 416.00 2005 est 1 3 Annual population growth rate (%) 0.05 0.07 0.37 2005 1 4 Percentage of population - 0–14 years 13.70 14.40 13.10 2005 est 1 - 65+ years 19.50 17.40 22.40 2005 est 1 5 Urban population (%) 78.70 … … 2002 1 6 Crude birth rate (per 1 000 population) 8.80 9.20 8.40 2004 3 7 Crude death rate (per 1 000 population) 8.20 9.00 7.30 2004 3 8 Rate of natural increase of population (% per annum) 0.06 e 0.02 e 0.11 e 2004 3 9 Life expectancy (years) - at birth … 78.64 85.59 2004 3 - Health-adjusted Life Expectancy (HALE) at age 60 … 17.50 21.70 2002 est 13 10 Adult literacy rate (%) 99.00 … … 2000 est 2 11 Neonatal mortality rate (per 1 000 live births) 1.50 1.60 1.30 2004 3 12 Infant mortality rate (per 1 000 live births) 2.80 3.00 2.60 2004 3 13 Under-five mortality rate (per 1 000 live births) 3.90 4.20 3.50 2004 3 14 Total fertility rate (women aged 15–49 years) 1.29 2004 3 15 Maternal mortality ratio (per 100 000 live births) 4.40 2004 3 16 Percentage of newborn infants weighing at least 2500 g at birth 90.60 91.60 89.50 2004 3 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG … … … - DTP3 100.00 … … 2004 12 - OPV3 97.00 … … 2004 12 - Measles 100.00 … … 2004 12 - Hepatitis B III … … … 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel … - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) 99.80 2004 3 21 Percentage of women in the reproductive age group using modern contraceptive methods 59.00 1995-2000 7 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … JAPAN 114 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 96.90 … … 2003 5 26 Proportion of population with access to improved sanitation 77.70 … … 2003 8, 9, 10 27 Proportion of the population using solid fuels for cooking or heating (%) <5.00 … … 2003 12 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) 260 000 … … 2002 8 31 Human development index 0.94 … … 2003 6 32 Per capita GDP at current market prices (US$) 33 727.00 … … 2003 11 33 Rate of growth of per capita GDP (%) … 34 Health expenditure Total health expenditure (National medical care expenditure) - amount (in million US$) 272 039.00 FY 2003 1 - total health expenditure on health as % of GDP 8.55 h FY 2003 1 - per capita total expenditure on health (in US$) 2131.46 FY 2003 1 Government expenditure on health - amount (in million US$) … - general government expenditure on health as % of total expenditure on health 5.77 FY 2003 1 - general government expenditure on health as % of total general government expenditure … External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 115.93 yen 2003 1 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 270 371 225 743 44 628 21.17 36.24 6.82 2004 1 - dentists 95 197 77 301 17 896 7.46 12.41 2.74 2004 1 - pharmacists 241 369 94 794 146 575 18.90 15.22 22.41 2004 1 - nurses 1 146 181 g … … 89.77 … … 2004 1 - midwives 25 257 … … 1.98 … … 2004 1 - other nursing / auxiliary staff 67 376 … … 5.31 … … 2000 2 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 284 968 … … 22.32 … … 2004 1 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 8499 … … 0.67 … … 2000 2 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … COUNTRY HEALTH INFORMATION PROFILE 115 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Influenza (grippe) 769 964 … … 604.88 … … 2000 2 2. Chickenpox 275 036 … … 216.07 … … 2000 2 3. Mumps (cases treated in large hospitals only) 132 877 … … 104.39 … … 2000 2 4. Other venereal diseases (cases treated in large hospitals only) 50 527 … … 39.69 … … 2000 2 5. Tuberculosis (all forms) 39 384 … … 30.94 … … 2000 2 6. Food poisoning (bacterial) 32 417 … … 25.47 … … 2000 2 7. Measles 22 978 … … 18.05 … … 2000 2 8. Gonococcal infections (cases treated in large hospitals only) 16 926 … … 13.30 … … 2000 2 9. Pertussis (whooping cough) 3804 … … 2.99 … … 2000 2 10. Rubella (cases treated in large hospitals only) 3123 … … 2.45 … … 2000 2 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Malignant neoplasms 320 358 193 096 127 262 253.90 313.50 197.10 2004 3 2. Heart disease 159 625 77 465 82 160 126.50 125.80 127.20 2004 3 3. Cerebrovascular diseases 129 055 61 547 67 508 102.30 99.90 104.50 2004 3 4. Pneumonia 95 534 51 306 44 228 75.70 83.30 68.50 2004 3 5. Accidents and adverse effects 38 193 23 667 14 526 30.30 38.40 22.50 2004 3 6. Suicide 30 247 21 955 8292 24.00 35.60 12.80 2004 3 7. Senility 24 126 6172 17 954 19.10 10.00 27.80 2004 3 8. Renal failure 19 117 8806 10 311 15.20 14.30 16.00 2004 3 9. Disease of liver 15 885 10 705 5180 12.60 17.40 8.00 2004 3 10. Chronic obstructive pulmonary disease 13 444 10 187 3257 10.70 16.50 5.00 2004 3 41 Selected diseases under the WHO- EPI Number of cases (C) Number of deaths (D) - Diphtheria 0 0 0 0 0 0 2004 C: 12, D: 3 - Pertussis (whooping cough) 1534 … … 0 0 0 2004 C: 12, D: 3 - Tetanus 69 … … 9 4 5 2004 C: 12, D: 3 - Neonatal tetanus … … … 0 0 0 2004 C: 12, D: 3 - Poliomyelitis 0 0 0 0 0 0 2004 C: 12, D: 3 - Hib meningitis … … … 1 1 0 2004 C: 12, D: 3 - Measles 8752 … … 3 1 2 2004 C: 12, D: 3 - Mumps 84 672 … … 0 0 0 2004 C: 12, D: 3 - Rubella 2794 … … 0 0 0 2004 C: 12, D: 3 - Congenital rubella syndrome 1 … … 0 0 0 2004 C: 12, D: 3 42 Selected communicable diseases Number of cases aa (C) Number of deaths (D) Hepatitis viral 650 … … 5888 3066 2822 2004 C: 12, D: 3 - Type A 12 … … 5 4 1 2004 C: 12, D: 3 - Type B … … … 836 534 302 2004 D: 3 - Type C … … … 4648 2307 2341 2004 D: 3 - Type E … … … … … … - Unspecified 636 … … 332 187 145 2004 C: 12, D: 3 Cholera 43 … … 0 0 0 2005 12 Typhoid fever 50 … … … … … 2005 12 Encephalitis 7 … … … … … 2005 12 JAPAN 116 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa (C) Number of deaths (D) Plague 0 0 0 0 0 0 2005 12 Syphilis 759 … … 14 12 2 C: 2000 D: 2004 C: 2, D: 3 Gonorrhoea 16 926 … … 0 0 0 C: 2000 D: 2004 C: 2, D: 3 Leprosy 11 … … 0 0 0 2004 C: 12, D: 3 Malaria … … … 1 1 0 2004 3 Dengue/DHF 0 0 0 0 0 0 2004 3, 12 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … 0.00 0.00 0.00 2004 3 - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases (C) Number of deaths (D) - All types 29 736 … … 2330 1555 775 2004 C: 12, D: 3 - New pulmonary tuberculosis (smear-positive) 10 471 … … 12 9 3 2004 C: 12, D: 3 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 39.00 … … 4.00 … … 2004 12 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 45.00 … … 76.00 (2003) … … 2004 12 Number of cases Number of deaths 45 Acute respiratory infections … … … 343 147 196 2004 3 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (malignant neoplasms only) … … … 320 358 193 096 127 262 2004 3 - Trachea, bronchus, and lung … … … 59 922 43 921 16 001 2004 3 - Stomach … … … 50 562 32 851 17 711 2004 3 - Colon and rectum … … … 40 042 21 835 18 207 2004 3 - Lip, oral cavity and pharynx … … … 5573 4034 1539 2004 3 - Liver … … … 34 510 23 421 11 089 2004 3 - Cervix … 2494 2004 3 - Leukaemia … … … 7048 4133 2915 2004 3 48 Circulatory All circulatory system diseases … … … 310 894 149 913 160 981 2004 3 - Ischaemic heart disease … … … 71 285 39 014 32 271 2004 3 - Acute myocardial infarction … … … 44 055 23 932 20 123 2004 3 - Rheumatic fever and rheumatic heart diseases … … … 2363 761 1602 2004 3 - Cerebrovascular diseases … … … 129 055 61 547 67 508 2004 3 - Hypertension … … … 5706 2066 3640 2004 3 COUNTRY HEALTH INFORMATION PROFILE 117 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 49 Maternal causes - Haemorrhage … 10 2004 3 - Abortion … 1 2004 3 - Eclampsia … … - Sepsis … … - Obstructed labour … … 50 Diabetes mellitus … … … 12 637 6694 5943 2004 3 51 Mental disorders … … … 4267 1585 2682 2004 3 52 Injuries - All types … … … 73 425 48 596 24 829 2004 3 - Motor and other vehicle accidents … … … 10 551 7355 3196 2004 3 - Suicide … … … 30 247 21 955 8292 2004 3 - Homicide and violence … … … 655 349 306 2004 3 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities 6420 488 022 2004 3 - General hospitals … … - Specialized hospitals … … - District/first-level referral hospitals … … - Primary health care centres … … Private hospitals 106 128 1 324 532 2004 3 Notes: Red text Millennium Development Goals (MDG) indicators … Data not available est Estimate NA Not applicable FY The financial year refers to the span from April 1 of respective year to March 31 next year. aa Figure refers to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 years. a The weight of all public and private solid and liquid waste generated by health care establishments in a fiscal year. b The method of calculation was changed in 2002. c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. e Revised data f Population figure excludes foreigners g Figure includes nurses, public health nurses and assistant nurses h As % of national income. Sources: 1 Statistics Bureau, Ministry of Public Management, Home Affairs, Posts and Telecommunications (http://www.stat.go.jp/english/index.htm) 2 SEAMIC Health Statistics 2002. International Medical foundation of Japan 3 Vital Statistics of Japan. Ministry of Health, Labour and Welfare 4 Geographical Survey Institute, Japan 5 Journal of Health and Welfare Statistics, Japan JAPAN 118 6 Cultural liberty in today’s diverse world. New York, United Nations Development Programme, 2004. 7 2000 Maternal and Child Health Statistics in Japan. Maternal and Child Health Division, Children’s and Families Bureau, Ministry of Health and Welfare 8 Ministry of the Environment 9 Ministry of Agriculture, Forestry and Fisheries 10 Ministry of Land, Infrastructure and Transport 11 Economic and Social Research Institute, Japan. 12 WHO Regional Office for the Western Pacific, data received from technical units 13 The World health report 2004: Changing history. Geneva, World Health Organization, 2004. COUNTRY HEALTH INFORMATION PROFILES | 119 KIRIBATI 1. DEMOGRAPHICS, GENDER AND POVERTY Speaking one national language and sharing a common simple lifestyle, the 93 100 people of Kiribati inhabit a country of 33 atolls and reef islands stretching 5000 kilometres across the central-western Pacific. The total land area of 810 square kilometres falls into three island groups lying within three exclusive economic zones that together cover 3.5 million square kilometres. The people of Kiribati are Micronesian in origin. A growing population and fixed amount of domestic resources dominate concerns about the future of Kiribati. During 2000-2003, the total population is estimated to have increased by 6000 persons, with two-thirds of that increase taking place in South Tarawa. According to estimates by the Secretariat of the Pacific Community (SPC) and the United Nations, the total population will double by 2025, and the population of South Tarawa (which has an annual growth rate of 5.2%) will double by 2015. About 41% of the population is below 15 years of age. This demographic structure ensures increasing pressure for services and jobs and serious and growing environmental problems (water quality, waste, sanitation, lagoon pollution), exacerbated by South Tarawa’s congestion. Crowded and unsanitary conditions contribute to the high incidence of diarrhoeal diseases and the high death rate for young children. Table 1. Core population and health data (2004 estimate) [Total] 93 100 [Both] … [0-14 years] 38 115 (40.94%) [Male] 59.00 (2003 est) Population [65+ years] 3193 (3.43%) Life expectancy at birth (years) [Female] 70.00 (2003 est) Crude birth rate (per 1000 population) 33.40 (2002 est) Total fertility rate 4.30 (2000) [Total] 64.00 (2002) [Urban] 77.00 (2002) Crude death rate (per 1000 population) 7.20 (2002) % of population served with safe water [Rural] 53.00 (2002) [Total] 39.00 (2002) [Urban] 59.00 (2002) Infant mortality rate (per 1000 live births) 43.00 (2000) % of population with adequate sanitary facilities [Rural] 22.00 (2002) Maternal mortality ratio (per 100 000 live births) 103.00 (2002) est- Estimate 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation A new government took office in July 2003 after a landslide victory for the Boutokaan te Koaua Party (BTK). The Government has formulated national development strategies for 2004-2007 with the catchphrase “enhancing growth and ensuring equitable distribution”. The Government's lack of an absolute majority led to delayed implementation of the 2003 budget. The six main policy areas are economic growth, fair distribution, public sector performance, equipping people to manage change, conservation of physical assets, and sustainable use of financial reserves. KIRIBATI 120 | COUNTRY HEALTH INFORMATION PROFILES 2.2 Economic situation Kiribati is categorized as a least-developed country (LDC) because of its low per capita gross domestic product (GDP), limited human resources and high vulnerability to external forces. Foreign reserves have grown steadily in recent years to the equivalent of seven years’ imports, and investment income is currently about one-third of GDP. GDP has grown by about 1.6% annually since independence in 1979, well below population growth. The economy is dominated by public services, with state-owned enterprises (SOEs) accounting for 80% of paid employment and 30% of GDP. However, delivery of social services has been inefficient, subsidies to SOEs reduce opportunities for private job creation (under 20% of the working-age population is formally employed) and nearly two-thirds of all formal jobs are in the capital, South Tarawa. The Kiribati economy suffered a recession from 2000 to 2003, partly due to falling financial markets and economic uncertainties associated with international terrorism and the war in Iraq and also to reduced Exclusive Economic Zone (EEZ) access fees because of the effect of the oceanic weather cycle on fish catches. The major sources of revenue are the EEZ access fee, the government reserve fund (RERF), and remittances from Kiribati seamen and fisheries on overseas ships. From 2000 to 2003, official grants and loans from abroad amounted to AUD 105 million (US$ 79 million), providing about 30% of the Government's annual budget expenditures. According to the 2000 Census, 9200 persons work in the cash economy. Two-thirds of them work in the public sector, and two-thirds live in South Tarawa. Gross national product (GNP) in 2002 is estimated to have been AUD 175 million or US$ 132 million (AUD 1987 or US$ 1502 per person). GDP is estimated to have been about AUD 98 million (US$ 74 million), and this is expected to decline due to the fall in EEZ access fees, which contribute 25% of total government revenue. The main exports are seaweed, aquarium fish and copra, which contribute 10%-20% of GDP. The Kiribati economy remains resilient, due in part to government reserve funds, which had a market value of AUD 576 million (US$ 435 million) at the end of 2002. There has been substantial progress on projects to improve the infrastructure and social services. A new 18 km pipeline has been laid for the water supply system in South Tarawa and 24 000 residential water tanks have been installed with funding from the Asian Development Bank. Japanese aid has funded a number of infrastructure projects. Two solid waste landfill sights have been developed for the sewerage system in South Tarawa. Two new 1.4 MW electricity generators and a new powerhouse have been installed. The power cable and transformers have been replaced at South Tarawa. A loan from the Bank of China will be used to install a digital radio concentrator system by the end of 2004, as well as satellite systems at five outer islands in Gilbert Islands. 3. HEALTH SITUATION 3.1 Health trends With an estimated life expectancy at birth of 59 years for males and 70 years for females in 2003, the I-Kiribati have a shorter life span than most other Pacific islanders. This is partly due to high child mortality from respiratory and diarrhoeal diseases. Nevertheless, continuous improvements in the standard of health care delivery over the last 10 years have led to a slow but steady improvement in health indicators (e.g. the morbidity rate of diarrhoeal diseases declined by 8.6% annually and lower respiratory infections by 7.7% annually during the period from 1992 to 2000). However, lifestyle-related diseases, such as diabetes and hypertension, have led to rapid increases in adult mortality compared with child mortality in the last ten years. If current trends continue, adult mortality may reach 50% of total mortality by 2008. In 2005, acute respiratory infections, diarrhoeal diseases, eye diseases, skin diseases (including wound and sores), food poisoning, sexually transmitted infections and tuberculosis were major COUNTRY HEALTH INFORMATION PROFILES | 121 public health problems. In addition, lifestyle-related diseases have become growing health concerns. 3.2 Health systems Government spending on health is about AUD 13 million or US$ 9.8 million (7.8%) of the government budget of AUD 167 million (US$ 126 million). Per capita total expenditure on health in 2003 was AUD 147 (US$ 94.8). Ten new clinics have been developed in the outer islands in Gilbert Islands. The nurse-to- population ratio has decreased from 1:450 to 1:375. A Traditional Medicine Research Centre has been approved by the Government. A Tobacco Control Bill has been drafted. Following growing concerns about HIV/AIDS, relevant legislation is being prepared. 4. NATIONAL HEALTH PLAN AND PRIORITIES In the National Health Plan for 2004-2007, 12 priority areas are identified: • reproductive health, including sexual health, adolescent health and women’s health; • population and family planning; • maternal and child health (safe motherhood); • health education, health promotion and community development in the context of Healthy Islands; • immunization and childhood preventable diseases; • control of acute respiratory infections and diarrhoeal diseases; • control of communicable diseases, including HIV/AIDS, tuberculosis, leprosy, lymphatic filariasis, and emerging health problems, including severe acute respiratory syndrome (SARS); • control of noncommunicable diseases, including hypertension, heart diseases, diabetes, cancer and tobacco and alcohol; • environmental health, including food safety, water and sanitation; • nutrition, including vitamin A deficiency and breast-feeding; • traditional medicine; and • information technology and evidence-based public health policies and legislation, including the Environment Act. In order to support these 12 priority areas, the "village welfare group" (VWG) will be strengthened as part of community development in outer islands during the period from 2004 to 2007. VWGs play a key role in providing health education and health data collection at the household level, under the supervision of a public health nurse. 5. MAJOR INFORMATION SOURCES National Health Plan 2004-2007. Ministry of Health and Medical Services Kiribati statistical yearbook 2002. Statistics Office Ministry of Finance National development strategies 2004-2007. Ministry of Finance and Economic Development Morbidity and mortality database. Health Information Centre, Ministry of Health and Medical Services KIRIBATI 122 | COUNTRY HEALTH INFORMATION PROFILES 6. ADDRESSES MINISTRY OF HEALTH AND MEDICAL SERVICES Office Address : P. O. Box 268, Bikenibeu, Tarawa, Republic of Kiribati Postal Address : Official Email Address : mhfp@tskl.net.ki Telephone : (686) 28100 Fax : (686) 28152 Office Hours : Website : WHO COUNTRY LIAISON OFFICER IN KIRIBATI Office Address : World Health Organization Bikenibeu, Tarawa, Kiribati Postal Address : World Health Organization P. O. Box 210 268, Bikenibeu, Tarawa, Kiribati Official Email Address : who@kir.wpro.who.int Telephone : (686) 28231 Fax : (686) 28188 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILES | 123 ORGANIZATIONAL CHART: MINISTRY OF HEALTH AND MEDICAL SERVICES KIRIBATI 124 KIRIBATI WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 0.81 2004 1 2 Estimated population ('000s) 93.10 … … 2004 est 1 3 Annual population growth rate (%) 1.70 … … 2000 1 4 Percentage of population - 0–14 years 40.94 42.24 39.66 2004 est 2 - 65+ years 3.43 2.87 3.99 2004 est 2 5 Urban population (%) 47.30 … … 2003 13 6 Crude birth rate (per 1000 population) 33.40 e 45.50 e 21.80 e 2002 est 3 7 Crude death rate (per 1000 population) 7.20 … … 2002 4 8 Rate of natural increase of population (% per annum) 2.62 a … … 2002 9 Life expectancy (years) - at birth … 59.00 e 70.00 e 2003 est 3 - Heal th-adjusted Life Expectancy (H ALE) at age 60 … 11.50 11.60 2002 14 10 Adult literacy rate (%) 95.00 g 93.00 g 95.00 g 2000 3 11 Neonatal mortality rate (per 1 000 live births) 27.00 b … … 2000 5 12 Infant mortality rate (per 1 000 live births) 43.00 55.00 31.00 2000 3 13 Under-five mortality rate (per 1 000 live births) 69.00 … … 2000 6 14 Total fertility rate (women aged 15–49 years) 4.30 2000 3 15 Maternal mortality ratio (per 100 000 live births) 103.00 2002 7 16 Percentage of newborn infants weighing at least 2500 g at birth 91.80 92.30 91.40 2002 7 17 Prevalence of underweight children under five years of age 13.00 … … 1999 6 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 94.50 … … 2004 8 - DTP3 63.40 … … 2004 8 - OPV3 60.70 … … 2004 8 - Measles 56.00 … … 2004 8 - Hepati tis B III 66.60 … … 2004 8 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel … - Percentage of pregnant women immunized with tetanus toxoid (TT2) 42.60 2002 7 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) 12.90 2002 7 - Percentage of deliveries in heal th facilities (as % of total deliveries) 76.00 2002 7 21 Percentage of women in the reproductive age group using modern contraceptive methods 22.00 2002 7 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … COUNTRY HEALTH INFORMATION PROFILE 125 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 64.00 77.00 53.00 2002 9 26 Proportion of population with access to improved sanitation 39.00 59.00 22.00 2002 9 27 Proportion of the population using solid fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.52 … … 1998 10 32 Per capita GDP at current market prices (US$) 789.78 … … 2004 est 11 33 Rate of growth of per capita GDP (%) … … … 34 Health expenditure Total health expenditure - amount (in m illion US$) 107. 79 2003 12 - total heal th expenditure on health as % of GDP … - per capita total expendi ture on health (in US$) 94.84 2003 12 Government expenditure on health - amount (in million US$) 9.80 2003 12 - general government expenditure on health as % of total expenditure on health … - general government expenditure on heal th as % of total general government expendi ture 7.80 2003 12 External source of government health expenditure - external resources for heal th as % of general government expendi ture on health … Private health expenditure - private expenditure on health as % of total expenditure on heal th … Exchange rate in US$ of local currency is: 1 US$ = 1.55 (average) 2003 8 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 20 16 4 2.20 … … 2004 7 - dentists 3 0 3 0.30 0.00 0.30 2004 7 - pharmacists 2 0 2 0.20 0.00 0.20 2004 7 - nurses 238 18 220 26.50 … … 2004 7 - m idwives 32 4 28 3.60 … … 2004 7 - other nursing/ auxiliary staff 12 1 11 1.30 … … 2004 7 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 16 8 8 1.80 … … 2004 7 - other heal th personnel (health inspec tors, assistant sani tarians, traditional workers, etc.) 10 8 2 1.10 … … 2004 7 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … KIRIBATI 126 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Eight leading causes of morbidity Number Rate per 100 000 population a,f 1. Ac ute respiratory infections 101 954 50 097 51 857 109 510.20 … … 2005 7 2. Diarrhoeal diseases 22 548 11 664 10 884 24 219.12 … … 2005 7 3. Eye diseases 10 239 4946 5293 10 997.85 … … 2005 7 4. Skin diseases 795 398 397 853.92 … … 2005 7 5. Communicable diseases 694 383 311 745.44 … … 2005 7 6. Non-communicable diseases 444 205 239 476.90 … … 2005 7 7. Nutrition and related diseases 317 160 157 340.50 … … 2005 7 8. Injury and poisoning 86 43 43 92.37 … … 2005 7 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Symptoms, signs and ill-defined conditions 117 60 57 133.76 … … 2002 7 2. Disease of the circulatory system 70 50 20 80.03 … … 2002 7 3. Disease of the digestive system 59 33 26 67.45 … … 2002 7 4. Infectious and parasi tic system 57 33 24 65.16 … … 2002 7 5. Certain conditions originating in the perinatal 54 26 28 61.73 … … 2002 7 6. Endocrine, nutri tional and metabolic 46 18 28 52.59 … … 2002 7 7. Disease of the respiratory system 35 18 17 40.01 … … 2002 7 8. Neoplasms 15 4 11 17.15 … … 2002 7 9. Factors influencing health status 11 7 4 12.58 … … 2002 7 10. Disease of the nervous system 10 7 3 11.43 … … 2002 7 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2005 7 - Pertussis (whooping cough) 0 0 0 0 0 0 2005 7 - T etanus … … … 1 0 1 2005 7 - Neonatal tetanus … … … … … … - Poliomyelitis … … … … … … - Hib meningitis 0 0 0 0 0 0 2005 7 - Measles 0 0 0 0 0 0 2005 7 - Mumps 0 0 0 0 0 0 2005 7 - Rubella 0 0 0 0 0 0 2005 7 - Congeni tal rubella syndrome 0 0 0 0 0 0 2005 7 42 Selected communicable diseases Number of cases aa Number of deaths Hepati tis vi ral - T ype A … … … … … … - T ype B … … … 3 … 3 2005 7 - T ype C … … … … … … - T ype E … … … … … … - Unspecified 51 25 26 … … 2005 7 Cholera 0 0 0 0 0 0 2005 7 Typhoid fever 0 0 0 0 0 0 2005 7 Encephalitis 0 0 0 0 0 0 2005 7 Plague … … … … … … Syphilis … … … … … … Gonorrhoea … … … … … … COUNTRY HEALTH INFORMATION PROFILE 127 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Leprosy 64 … … … … … 2004 8 Malaria … … … … … … Dengue/DHF 0 0 0 0 0 0 2004 8 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 310 … … … … … 2004 8 - New pulmonary tuberculosis (smear-posi tive) 142 … … … … … 2004 8 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 59.00 … … 4.00 … … 2004 8 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOT S) 550.00 … … 88.00 (2003) … … 2004 8 Number of cases Number of deaths 45 Acute respiratory infections 101 954 50 097 51 857 … … … 2005 7 46 Diarrhoeal diseases 22 548 11 664 10 884 41 24 17 2005 7 47 Cancers All cancers (malignant neoplasms only) … … … 27 … … 2005 7 - T rachea, bronchus and lung … … … 2 2 0 2005 7 - Stomach … … … 2 1 1 2005 7 - Colon and rectum … … … 1 0 1 2005 7 - Lip, oral cavity and pharynx … … … 1 0 1 2005 7 - Liver … … … … … … - Cervix … 7 2005 7 - Leukaemia … … … 3 2 1 2005 7 48 Circulatory All circulatory system diseases … … … 70 … … 2002 7 - Ischaemic heart disease … … … 2 2 0 2002 7 - Acute m yocardial infarction … … … 24 14 10 2002 7 - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … 40 31 9 2002 7 - H ypertension … … … 4 3 1 2002 7 49 Maternal causes - Haemorrhage … 2 2002 7 - Abortion … … - Eclampsia … … - Sepsis … … - Obstruc ted labour … … KIRIBATI 128 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 50 Diabetes mellitus 248 112 136 23 12 11 2005 7 51 Mental disorders 8 6 2 1 1 0 2005 7 52 Injuries - All types … … … … … … - Motor and other vehicle accidents … … … 3 2 1 2005 7 - Suicide … … … 21 17 4 2005 7 - Hom icide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public heal th facilities - General hospitals 1 140 2004 7 - Specialized hospi tals … … - District/first-level referral hospitals … … - Primary health care centres 94 … 2005 7 Private hospitals … … Notes: Red text M illennium Development Goals (MDG) indicators … Data not available est Estimate aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Uni t, WHO Regional Office for the Western Pacific b Estimates derived by regression and similar estimation methods c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. e Estimate based on 2000 Census. f Figures computed using the 2004 estimated population. g Figure refers to persons aged 15-24 years old. Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 2 Demographic Tables for the Western Pacific Region 2000-2005 . Manila, WHO Regional Office for the Western Pacific, 2005. 3 Report on the 2000 Census of Population. Statistics Office M inistry of Finance, 2000. 4 World development indicators 2003. Washington, D.C., World Bank, 2003. 5 Make every mother and child count. World heal th report 2005. Geneva, World Heal th Organization, 2004. 6 Pacific Island Regional Millennium Development Goals report 2004. Noumea, Secretariat of the Pacific Community, UN/ CROP MDG Working Group, November 2004. 7 Information furnished by the Heal th Information Centre, M inistry of Health and Medical Services, 2005. 8 WHO Regional Office for the Western Paci fic, data received from the technical units. 9 Meeting the MDG drinking water and sani tation target: A mid-term assessment of progress. WHO and UNICEF, 2004 10 Pacific human development report 1999 (Creating opportuni ties). New York, United Nations Development Programme, 1999. 11 Kiribati Statistics Office (http://www.spc.int/prism /) 12 Statistic s Office, Ministry of Finance, 2004. 13 Urban and rural areas 2003 . New York, Department of Economic and Social Affai rs Population Division, United Nations, 2004. 14 Changing history. World health report 2004. Geneva, World Health Organization, 2004. COUNTRY HEALTH INFORMATION PROFILES | 129 LAO PEOPLE'S DEMOCRATIC REPUBLIC 1. DEMOGRAPHICS, GENDER AND POVERTY In 2005, the Lao Peoples’ Democratic Republic had a population of 5.6 million, a population growth rate of 2.0%, a sparse population density (23.70 persons/km2) with large inter-provincial variations, and an average household size of 5.9. 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 their livelihoods. The population is young (44.10%< 15 years). The nation is largely rural (80%), with the beginnings of a rural-to- urban shift. The most recent census identified 47 distinct ethnic groups. The ethnic Lao comprise 52.5% of the total and predominate in the lowlands, while ethnic minorities predominate in the highlands, although mixing is common. The highlands have more poverty, worse health indicators and fewer services available for multiple reasons, including remoteness, lower education levels, land which is less agriculturally productive and increasing land pressure. Ethnic diversity presents linguistic problems in health care delivery and education. Women have lower literacy rates 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 by women when ill. Female life expectancy is slightly higher than that of males. The Lao People’s Democratic Republic ranks 133rd out of 177 nations on the Human Development Index (2003). The poverty rate fell from 39% in 1997 to 33.5% in 2002. Poverty is higher in remote and highland areas and poverty inversely correlates with road or river access. Seventy-one per cent of the population lives on less than US$ 2.00 a day and 23% live on less than US$ 1.00 a day. Inequalities remain important, with the shares of the national economy of the lowest and the highest quintile being 7.6% and 45.0% respectively. Table 1. Core population and health data (2005) [Total] 5 609 997 [Both] 59.00 (2000) [0-14 years] 44.10% (2000 est) [Male] 57.00 (2000) Population [65+ years] 3.80% (2000 est) Life expectancy at birth (years) [Female] 61.00 (2000) Crude birth rate (per 1000 population) 34.00 (2000 est) Total fertility rate 4.90 (2000) [Total] 63.80 (2004) [Urban] 75.00 (2004) Crude death rate (per 1000 population) 6.30 (2000 est) % of population served with safe water [Rural] 60.00 (2004) [Total] 44.30 (2004) [Urban] 70.00 (2004) Infant mortality rate (per 1000 live births) 82.20 (2000) % of population with adequate sanitary facilities [Rural] 35.70 (2004) Maternal mortality ratio (per 100 000 live births) 530.00 (2000) est- Estimate LAO PEOPLE'S DEMOCRATIC REPUBLIC 130 | COUNTRY HEALTH INFORMATION PROFILES 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 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 will be held in early 2006. A National Assembly election will be held in April 2006 with competition among a group of LPRP-approved candidates. Strengthening the rule of law has been emphasized recently, including several health sector laws in respect of public health, curative services, food safety, and drugs and medical devices. 2.2 Economic situation The World Bank estimated per capita gross domestic product (GDP) was US$ 390 in 2004, with a 6.3% economic growth rate. Agriculture makes up 48.5% of GDP, industry (mainly hydropower, mining and textiles) 25.5%, and services 26%. Revenue collection remains low at 13.2% of 2004 GDP, causing constraints on public expenditure. External debt is high at 103.4% of GDP. Health expenditure made up 4.4% of total government spending in 2004, with a plan for 5.7% in 2005. Donor spending is planned to make up 73.1% of total public sector health spending in 2005. The bulk of Lao revenue in the public health budget (75.3%) goes to salaries. 3. HEALTH SITUATION 3.1 Health trends 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 and a National Reproductive Health Survey were conducted in 2005 but final results were not available in early 2006. A Multiple Indicator Cluster Survey (MICS) will be conducted in early 2006. These three exercises will update many indicators. There is a general perception that there will be further improvements in many indicators. Maternal mortality fell from 656 to 530 deaths per 100 000 live births from 1995 to 2000, infant mortality from 104 to 82 deaths per 1000 live births, and under-five mortality from 170 to 106 deaths per 1000 live births. The National Health Survey showed children had a two-week fever incidence rate of 2.9%, an ARI incidence rate of 3%, and a diarrhoea incidence rate of 6.2%. The same survey revealed that 21% of deliveries were attended by a trained birth attendant, 12% were in a health facility, and 32% of 12-23-moth year-olds had completed their immunizations. The rate of modern contraceptive use is 28.9% (2000). Safe water is accessible to 63.8% of the population and improved sanitation access to 44.25% (2004). Malaria is considered the leading cause of morbidity and mortality, with 70% of the population at risk. Programme data showed 76.8% of those at risk using preventive measures in 2004, an increase from 55% in 2003. Malaria drug resistance is increasing and Artemesinen-based combination treatment is being introduced. Tuberculosis prevalence was estimated at 71 sputum-positive cases/100 000 in 2005. There were 2801 sputum-positive cases reported in 2005, an increase from 2230 in 2004. The DOTS programme reaches 100% of districts. The estimated sputum-positive case detection rate was 70.3% in 2005 and the treatment success rate was 85.8% in 2004. The Lao People’s Democratic Republic is a low HIV prevalence country, with an estimated adult seroprevalence of 0.08% and 1636 HIV-positive individuals detected since 1993. Preliminary results from a second round of second generation surveillance have shown the HIV-positive COUNTRY HEALTH INFORMATION PROFILES | 131 seroprevalence in female sex workers increasing from 0.9% in 2001 to 2% in 2005. Chlamydia and gonorrhoea are common in sex workers, with an estimated combined infection rate of 37.6%. A total of 375 patients are currently receiving antiretroviral treatment at a single treatment site. Outbreaks of dengue occurred again in 2005, with 5446 cases reported. Dengue appears to be moving peripherally, with cases recorded in smaller population centres. The most recent data show an intestinal helminth prevalence rate of 62% among schoolchildren. A project to scale up school deworming nationally will begin in 2005. There is evidence to show that schistosomiasis is re-emerging in southern parts of the country since control programmes have ended. The Lao People’s Democratic Republic has had no case of severe acute respiratory syndrome (SARS) and no human case of avian influenza. There was an outbreak of avian influenza in poultry in 2004, but none in 2005. Road accidents are of increasing concern as roads improve and vehicle numbers increase. Mental health issues, particularly drug abuse, are also a growing concern. Other mental health issues include management of seizure disorders and psychoses. Nutrition is a neglected area, with 40% of children stunted and 48.2% of children and 31.3% of females with haemoglobin levels below 11 g/dl. Universal salt iodinization misses at least 7% of children, and vitamin A supplementation is far from universal. The rate of exclusive breast- feeding at three months of age is only 28.1%. The rate of obesity, defined as a body mass index of 30 or greater, is only 1.2% nationally, although it is two to three times higher in urban areas. Reliable rates for hypertension and diabetes are not known, although anecdotal reports from urban areas suggest an increase. 3.2 Health systems The state health system is predominant, although a private alternative is growing. There are no private hospitals, but over 2000 private pharmacies and 484 private clinics, mainly in urban areas. The state system is underutilized, especially in the peripheral areas. An effort to increase access through village volunteers and village revolving drug funds has reached 5226 villages. There are about 18 000 public sector health workers, 70% in the Ministry of Health and 30% under the Ministries of Public Security and Defence. Low salaries and low levels of basic training inhibit health system efficiency. Estimated per capita health expenditure is US$ 12.00, about 60% from households, 30% from donors and 10% from the Government. Hospitals are highly dependent on user fees for recurrent expenditure. There are nascent health insurances systems for the formal and non- formal sectors and a civil service scheme is being reformed. Equity funds are under discussion and limited piloting has occurred. 4. NATIONAL HEALTH PLAN AND PRIORITIES The health priorities of the Lao People’s Democratic Republic are articulated in three documents. 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. LAO PEOPLE'S DEMOCRATIC REPUBLIC 132 | COUNTRY HEALTH INFORMATION PROFILES This then leads to six health development policies, which are: • 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, the 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 Ministry of Health with JICA support in 2001/02 conducted the Lao Health Master Planning Study. This study identified seven ‘precedent programmes’ to be implemented and 31 ‘very high priority’ programmes in the fields of planning and management, human resources development, health financing, health education, infectious disease control, primary health care, maternal and child health, nutrition, hospital services, medical laboratory technology, and essential drugs. The need for sectorwide coordination is emphasized. A third major policy document is the The National Growth and Poverty Eradication Strategy (NGPES). The NGPES focuses on poverty and the poorest districts; 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 where there are shortages; • maternal and child health (MCH) promotion; • immunization; • water supply and environmental health; • communicable disease control; • control of sexually transmitted infections, including HIV/AIDS; • village 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 of these documents will be superceded by the Sixth National SocioEconomic Development Plan (2006-10) (NSEDP), which will be considered and promulagated by the VIIIth Party Congress and the National Assembly in the first half of 2006. The NGPES has been fully integrated into the draft 6th NSEDP and serves as its core. The draft has been presented to and discussed widely with both internal and external partners, a first in the Lao People’s Democratic Republic. There is a large funding gap for implementation of the draft 6th NSEDP in all sectors, including health. As part of the policy framework with the Bretton-Woods institutions, the Government has also pledged to increase health spending. The health sector is extremely project- and donor-dependent, which has often led to competing and overlapping donor demands. The Minister of Health has called for more integrated approaches, particularly for MCH and immunization, decentralized service delivery methods, improved methods of health care financing, a unified and simplified health 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. COUNTRY HEALTH INFORMATION PROFILES | 133 A new Constitutional article (2004) obligates the Government to improve and extend the health network; to improve disease prevention; to create conditions so all people receive health care, especially mothers, children and the poor; and to legalize private investment in health services. 5. MAJOR INFORMATION SOURCES Preliminary report on the population and household census 2005. National Statistical Center, 2005. Sixth National Socio Economic Development Plan (2006-2010), Committee for Planning and Investment. Basic Statistics 2003. National Statistical Center, 2004. United Nations Development Assistance Framework for the Lao People’s Democratic Republic 2002-2006. New York, UNDP, July 2002. United Nations Common Country Assessment for the Lao People’s Democratic Republic 2005. Government of Lao People’s Democratic Republic and the United Nations System, September 2005 Lao Reproductive Health Survey 2000 . State Planning Committee/National Statistical Center United Nations Common Country Assessment for the Lao People’s Democratic Republic 2000. Government of Lao People’s Democratic Republic and the United Nations System, December 2000. The National Growth and Poverty Eradication Strategy. Committee for Planning and Investment, 2004. Millennium Development Goals Progress Report, Lao People’s Democratic Republic. January 2004. Results from the Population Census 1995. State Planning Committee/National Statistics Center, April 1997. Annual Report 2003. Bank of the Lao People’s Democratic Republic, 2004 Annual Report 2004. Bank of the Lao People’s Democratic Republic, 2005 Statistical Report 2000. Statistics Department, Ministry of Health, 2000. Health Status of the People in the Lao People’s Democratic Republic: Report on the National Health Survey. January 2001. TB Statistics. National TB Center, February 2004. HIV Surveillance Survey and Sexually Transmitted Infection Periodic Surveillance Survey . Lao People’s Democratic Republic, 2001. Mental Health Situation Analysis in the People’s Democratic Republic. Ministry of Health/WHO, December 2002. Survey data from Ministry of Health/WHO/Korean Association for Health Promotion. Lao People’s Democratic Republic, 2000-2003. The Study on Improvement of Health and Medical Services in the Lao People’s Democratic Republic – Progress Report I. Ministry of Health/JICA Study Team, September 2001. Hospital Costing Study. Ministry of Health Planning and Budgeting Department and WHO,January 2004. Lao Health Master Planning Study. Ministry of Health/JICA Study Team, November 2002. Health Strategy up to the Year 2020 – A Discussion Paper for the Donor Round Table Meeting. Ministry of Health, May 2000. Lao Expenditure and Consumptions Survey 2002/03. National Statistical Center, March 2004. Official Gazette, 11th Year. Ministry of Justice, July 2004. Official Gazette, 12th Year. Ministry of Justice, 2005. Lao People’s Democratic Republic public expenditure review 2005, intermediary draft reports. World Bank, 2005-06. Lao People’s Democratic Republic 2004 Article IV consultation staff report. International Monetary Fond, 2005. Lao People’s Democratic Republic Economic Monitor. World Bank, October 2005. LAO PEOPLE'S DEMOCRATIC REPUBLIC 134 | COUNTRY HEALTH INFORMATION PROFILES Grant Performance Report for Global Fund. CMPE, Ministry of Health, October 2004. Report on the Roundtable Process. National Round Table Process Steering Committee, November 2004. 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Simuang Road, Vientiane, Lao People’s Democratic Republic Postal Address : Official Email Address : pomdohp@laotel.com (for Department of Prevention and Hygiene) Telephone : 856 (0)21 217607 Fax : 856 (0)21 214003 Office Hours : Website : WHO REPRESENTATIVE IN LAO PEOPLE’S DEMOCRATIC REPUBLIC Office Address : That Luang Rd., Ban Phonxay, Vientiane, Lao People’s Democratic Republic Postal Address : P.O. Box 343, Vientiane, Lao People’s Democratic Republic Official Email Address : who.laos@lao.wpro.who.int Telephone : 856 (0)21 413431, 414264 Fax : 856 (0)21 413432 Office Hours : 7:30 a.m. – 4:00 p.m. Website : COUNTRY HEALTH INFORMATION PROFILES | 135 ORGANIZATIONAL CHART: DEPARTMENT OF HEALTH LAO PEOPLE’S DEMOCRATIC REPUBLIC 136 LAO PEOPLE’S DEMOCRATIC REPUBLIC WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 236.80 2005 21 2 Estimated population ('000s) 5609.90 2796.40 2813.60 2005 21 3 Annual population growth rate (%) 2.00 … … 2005 21 4 Percentage of population - 0–14 years 44.10 45.60 42.90 2000r 1 - 65+ years 3.80 3.70 3.90 2000r 1 5 Urban population (%) 20.70 … … 2000r 1 6 Crude birth rate (per 1 000 population) 34.00 … … 2000 est 2 7 Crude death rate (per 1 000 population) 6.30 … … 2000 est 2 8 Rate of natural increase of population (% per annum) 2.77 a … … 2000 2 9 Life expectancy (years) - at birth 59.00 57.00 61.00 2000 2 - Health-adjusted life expectancy (HALE) at age 60 … 9.60 10.10 2002 13 10 Adult literacy rate (%) 74.00 85.00 64.00 2003 16 11 Neonatal mortality rate (per 1 000 live births) 36.20 … … 2000 2 12 Infant mortality rate (per 1 000 live births) 82.20 … … 2000 2 13 Under-five mortality rate (per 1 000 live births) 106.90 h … … 2000 2 14 Total fertility rate (women aged 15–49 years) 4.90 2000 2 15 Maternal mortality ratio (per 100 000 live births) 530.00 2000 2 16 Percentage of newborn infants weighing at least 2500 g at birth 82.00 … … 1998 8 17 Prevalence of underweight children under five years of age 40.00 … … 2000 5 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 60.00 … … 2004 19 - DTP3 45.00 … … 2004 19 - OPV3 46.00 … … 2004 19 - Measles 36.00 … … 2004 19 - Hepatitis B III 45.00 … … 2004 19 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 23.00 2000 2 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 37.00 2003 19 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) 9.00 2004 17 - Percentage of deliveries in health facilities (as % of total deliveries) 12.00 2000 2 21 Percentage of women in the reproductive age group using modern contraceptive methods 28.90 h 2000 2 22 Condom use rate of the contraceptive prevalence rate … … 0.50 2000 2 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … COUNTRY HEALTH INFORMATION PROFILE 137 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 63.80 75.00 60.00 2004 14 26 Proportion of population with access to improved sanitation 44.30 70.00 35.70 2004 14 27 Proportion of the population using solid fuels for cooking or heating (%) 96.00 … … 2000 3 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.54 … … 2003 11 32 Per capita GDP at current market prices (US$) 390.00 h … … 2004 22 33 Rate of growth of per capita GDP (%) 6.40 h … … 2004 22 34 Health expenditure Total health expenditure - amount (in million US$) 63.25 k 2004 10 - total health expenditure on health as % of GDP 2.72 l 2004 15,23,24 - per capita total expenditure on health (in US$) 11.50 2004 est 10 Government expenditure on health - amount (in million US$) 17.00 2003-2004 15,24 - general government expenditure on health as % of total expenditure on health 26.90 2003-2004 15,24,10 - general government expenditure on health as % of total general government expenditure 4.40 2003-2004 15,24 External source of government health expenditure - external resources for health as % of general government expenditure on health 58.20 2003-2004 15,24 Private health expenditure - private expenditure on health as % of total expenditure on health 55.60 2002 9 Exchange rate in US$ of local currency is: 1 US$ = 10 585.5 kips 2004 24 35 Health insurance coverage as % of total population <2.00 2005 10 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce c, n - physicians 1283 … … 2.26 … … 2005 25 - dentists 83 … … 0.15 … … 2005 25 - pharmacists 276 … … 0.49 … … 2005 25 - nurses 5291 m … … 9.32 … … 2005 25 - midwives … … … … … … - other nursing/ auxiliary staff 8183 o … … 14.59 … … 2005 25 - other paramedical staff(e.g. medical assistants, laboratory technicians, X-ray technicians) 1722 … … 3.07 … … 2005 25 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 429 … … 0.76 … … 2005 25 37 Yearly new graduates – physicians 53 … … 2005 25 38 Yearly new graduates – nurses 30 g … … 2005 25 LAO PEOPLE’S DEMOCRATIC REPUBLIC 138 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Five leading causes of morbidity Number of cases Rate per 100 000 population b 1. Malaria 104 434 … … 4083.17 … … 2000 5 2. Pneumonia 18 096 … … 728.00 … … 2000 5 3. Gastritis 17 132 … … 690.00 … … 2000 5 4. Influenza 12 987 … … 523.00 … … 2000 5 5. Diarrhoea 12 334 … … 496.49 … … 2000 5 40 Five leading causes of mortality Number of cases Rate per 100 000 population b 1. Malaria 996 … … 40.09 … … 2000 5 2. Pneumonia 83 … … 3.34 … … 2000 5 3. Diarrhoea 34 … … 1.36 … … 2000 5 4. Heart failure 34 … … 1.36 … … 2000 5 5. Injury 33 … … 1.32 … … 2000 5 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 9 … … 2 … … 2005 18 - Pertussis (whooping cough) 120 … … 4 … … 2005 18 - Tetanus 21 … … 1 … … 2005 18 - Neonatal tetanus 14 … … 3 … … 2005 18 - Poliomyelitis 1 e … … … … … 2004 19 - Hib Meningitis 264 … … 4 … … 2005 18 - Measles 1491 … … … … … 2004 19 - Mumps … … … … … … - Rubella … … … … … … - Congenital rubella syndrome … … … … … … 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral 632 … … 0 0 0 2002 6 - Type A 10 … … 0 0 0 2002 6 - Type B 61 … … 0 0 0 2002 6 - Type C … … … … … … - Type E … … … … … … - Unspecified 495 … … 0 0 0 2005 18 Cholera 1272 … … 1 … … 2002 6 Typhoid fever 1573 … … 1 … … 2005 18 Encephalitis 16 … … 0 0 0 2005 18 Plague 0 0 0 0 0 0 2005 18 Syphilis … … … … … … Gonorrhoea … … … … … … Leprosy 156 … … … … … 2003 6 Malaria 16 183 … … 105 … … 2004 6 Dengue/DHF 3075 h … … 10 h … … 2004 6 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 280.00 … … 1.81 … … 2004 6 - Proportion of population in malaria-risk areas using effective malaria prevention measures f 76.80 2004 20 - Proportion of population in malaria-risk areas using effective malaria treatment measures p … COUNTRY HEALTH INFORMATION PROFILE 139 INDICATORS DATA Year Source Total Male Female Total Male Female 44 Tuberculosis Number of cases Number of deaths - All types 3173 … … … … … 2004 6 - New pulmonary tuberculosis (smear-positive) 2241 … … … … … 2004 6 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 318.00 … … 25.00 … … 2004 6 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 55.00 … … 79.00 (2003) … … 2004 6 Number of cases Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (malignant neoplasms only) … … … … … … - Trachea, bronchus, and lung … … … … … … - Stomach … … … … … … - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … … … … - Liver … … … … … … - Cervix … … - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … … … … - Ischaemic heart disease … … … … … … - Acute myocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … … … … - Hypertension … … … … … … 49 Maternal causes - Haemorrhage … … - Abortion … … - Eclampsia … … - Sepsis … … - Obstructed labour … … 50 Diabetes mellitus … … … … … … 51 Mental disorders … … … … … … 52 Injuries - All types … … … … … … - Motor and other vehicle accidents … … … … … … - Suicide … … … … … … - Homicide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … LAO PEOPLE’S DEMOCRATIC REPUBLIC 140 INDICATORS DATA Year Source 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 21 c 2555 2005 25 - Specialized hospitals 3 d 160 2005 21 - District/first level referral hospitals 127 2366 2005 21 - Primary health care centres 746 1658 2005 21 Private hospitals 0 0 2005 21 Notes: Red text Millennium Development Goals (MDG) indicators … Data not available est Estimate r Revised reference year aa Figure refers to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Calculated by Statistical Division of Ministry of Health. c Refers to all hospitals, ministries and health facilities at central, regional, provincial, and district level. d Refers to specialized hospitals at central level. e Vaccine-derived polio-virus. f Proportion of population in malaria risk areas protected by impregnated bed nets reflect the status of the distribution of impregnated bed nets in malaria risk areas. It is assumed, that 70% of the Lao population is living in malaria risk areas. g Includes only nurses trained at university, due to a reformulation of the curricula there has not been any graduation of staff at nursing schools since 2 years. The number of graduates in 2006 is estimated to rise up to 600. h Revised data i Proportion of households k Est. on an average 11.5 US$ expenditure per capita and a total 2004 population of 5,499,997 inhabitants (calculated on data of National Census 2005) l Est. Based on a GDP of Kip 24,621.2 , and an annual average exchange rate of 10,585.5 Kip per US$ m Including medical assistants n Includes medical staff of Ministries of Health, Public Security and Defence; Does not segregate between administrative (+/- 10%) and curative staff; Does not include non medical staff associated to the health system (maintenance, management, accounting, etc). o Corresponds to the technical auxiliary nurses (low level trained staff) p Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Statistical Yearbook 2005. National Statistical Centre, July 2005 2 Lao Reproductive Health Survey 2000. National Statistical Centre 3 Millennium Development Goals Progress Report. Lao People’s Democratic Republic, January 2004 4 National Statistics Centre, 2002 5 National Health Survey. National Statistical Centre and NIOPH, January 2001 6 WHO Regional Office for the Western Pacific, data received from technical units 7 Association of South-East Asia Nations – www.aseansec.org 8 United Nations Country Indicators – Lao People’s Democratic Republic. Last amendment, 14 February 2000 9 Lao Health Master Planning Study. Ministry of Health, November 2002 10 Information furnished by WHO Representative in the Lao People’s Democratic Republic, February 2006 11 Human development report 2005. New York, United Nations Development Programme, 2005 – www.undp.org 12 Urban and Rural Areas 2003. Department of Economic and Social Affairs Population Division, United Nations, 2004 13 The World health report 2004. Changing history. Geneva, World Health Organization, 2004. 14 Report 2004. Water and Sanitation Centre of the Lao People’s Democratic Republic. 15 Official gazette. State Budget Revenue-Expenditure Implementation of FY 2003-2004. Ministry of Justice, January 2006 16 Lao Expenditure and Consumption Survey 2002/03. National Statistical Centre, March 2004. 17 Report 2004. Mother and Child Centre of the Lao People’s Democratic Republic. 18 Weekly epidemiological surveillance report, National Center for Laboratory and Epidemiology, January 2006 COUNTRY HEALTH INFORMATION PROFILE 141 19 Report 2004. Expanded programme on immunization project of the Lao People’s Democratic Republic, WHO/UNICEF joint reporting, April 2005 20 National Center for Malariology, Parasitology and Entomology 21 Population and Housing Census Year 2005, Preliminary Report, National Statistics Centre, Lao PDR, September 2005 22 Lao PDR Economic Monitor, World bank, October 2005 23 Annual Report 2004, Bank of Lao PDR, October 2005 24 Comparative table of exchange rates, Statistic Institute of Quebec 2006 – http://www.stat.gouv.qc.ca/ 25 National Ministry of Health, Department of Personal and Organization 142 | COUNTRY HEALTH INFORMATION PROFILES MACAO (CHINA) 1. DEMOGRAPHICS, GENDER AND POVERTY Based on the results of the 2001 census and the data on population changes since then, the resident population of Macao (China) was estimated at 465 333 as of 31 December 2004, an increase of 16 838 since December 2003 and representing an annual growth rate of 3.8%. Among the resident population, 48.0% were males and 52.0% were females. As regards the distribution by age group, 17.1% of the population were aged 0-14 and 8.1% were 65 and above. Compared with 2003, the proportion of residents aged 0-14 dropped 1.5 percentage points, while those aged 65 and above went up 0.2 of a percentage point. The natural increase of the population is an important factor in population growth. In Macao, 3308 live births and 1533 deaths were recorded in 2004, up by 3.0% and 4.0% respectively compared with 2003. The natural growth rate was 0.4%. Population migration is another important factor in population growth. In 2004, there was an inflow of 16 548 persons, including legal and illegal immigrants from Mainland China, persons authorized to reside in Macao and non-resident workers. In the same year, the estimated number of emigrants was 1485 persons. Table 1. Core population and health data (2004) [Total] 465 333 [Both] 79.20 (2000-2003) [0-14 years] 79 681 (17.12%) [Male] 77.40 (2000-2003) Population [65+ years] 37 778 (8.12%) Life expectancy at birth (years) [Female] 82.00 (2000-2003) Crude birth rate (per 1000 population) 7.20 Total fertility rate 0.85 [Total] 100.00 (2003) [Urban] … Crude death rate (per 1000 population) 3.40 % of population served with safe water [Rural] … [Total] 99.85 (1996) [Urban] …. Infant mortality rate (per 1000 live births) 3.02 % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 0.00 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Macao became the Macao Special Administrative Region (SAR) of China on 20 December 1999, entering a new era in its development, with the return of its administration to China. Under its “one country, two systems” formula, China has promised Macao (China) a high degree of autonomy with its present political, judicial, social, cultural and economic systems for the next 50 years. The third election for the Legislative Assembly was held on 25 September 2005. The 29-member Legislative Council serves a four-year term. Twelve of the Council members are elected directly, ten are elected indirectly and seven are appointed by the Chief Executive. COUNTRY HEALTH INFORMATION PROFILES | 143 2.2 Economic situation Macao (China) has a history of more than four centuries of serving as an entrepot between China and the Western world. This fits in with the Government’s policy of establishing Macao as a regional service centre. Since China's accession to the World Trade Organization (WTO), Macao has been able to strengthen itself as a bridge that connects the business community on the mainland with their counterparts abroad. Improvements have been made in Macao's social, economic and public security environment over the past few years, while, at the same time, the Macao Government has intensified its public relations campaigns to introduce its policies to the public. As a result of opening up the gaming sector and constantly improving the investment environment, the economy has been developing rapidly in recent years. The gross domestic product (GDP) real growth rates for 2001, 2002 and 2003 were 2.9%, 10.1% and 14.2%, respectively. In 2004, the GDP growth rate reached 28.6%. Following its upgrade of Macao’s credit rating from Baa1 to A3 in February 2003, Moody’s Investors Service raised Macao’s rating again to A1 in October 2003. Recently, Macao was awarded “Best Economic Potential City of Asia” status by Foreign Direct Investment (fDi) magazine, reflecting a positive appraisal and recognition from the outside world in general. 3. HEALTH SITUATION 3.1 Health trends Having gone through the process of a demographic and epidemiological transition, the population of Macao enjoys a fairly low mortality rate and a long life expectancy. They also enjoy a high standard of health, as reflected in the general decline in the incidence of communicable diseases and the increase in life expectancy, as well as the improvement in health indices. Noncommunicable diseases are the main causes of morbidity and mortality. However, as in other developed areas, the threat from re-emerging and newly emerging infectious diseases continues. Neoplasms are the leading cause of death; a rate of 104 per 100 000 population (475 cases of neoplasm) was recorded in 2004. By rank, the most common neoplasms per 100 000 population were: malignant neoplasms of the trachea, bronchus and lung (27.9); malignant neoplasms of the liver and intrahepatic bile ducts (12.9); malignant neoplasms of the colon (9.7); malignant neoplasms of the nasopharynx (6.0); and malignant neoplasms of the stomach (5.8). Some 450 deaths due to diseases of the circulatory system occur each year. Tuberculosis is one of the top communicable diseases. Morbidity and mortality of most vaccine- preventable communicable diseases have remained very low for many years. Safe water is available to almost 100% of the population and the incidence of waterborne or foodborne infections remains low. There is no risk of malaria, but dengue fever occurs sometimes. The hepatitis B carrier rate among adults is around 11.5%, and is less than 1% among vaccinated children. HIV/AIDS prevalence remains low, at less than 0.1%. 3.2 Health systems In the 1980s, the Government built a two-level health system, supported by a government budget, to provide free, universally accessible primary health care for all citizens through its health centres and comprehensive specialized care through the central hospital. At the beginning of the new century, the Government defined “efficacious medical care, with privilege in prevention” as its guiding principle in health. In developing its work in the area of preventive medicine, the Government cited WHO policies and the promotion of healthy lifestyles as main strategies. MACAO (CHINA) 144 | COUNTRY HEALTH INFORMATION PROFILES In 2004, there were 1024 physicians, 262 traditional Chinese medicine doctors, 150 dentists and 1063 nurses. This gives a physician-to-population ratio of 1:446, a traditional Chinese medicine doctor-to-population ratio of 1:1744, a dentist-to-population ratio of 1:3046, and a nurse-to- population ratio of 1:430. For the 2004 financial year, the Government spent US$ 177 million, 10.5% of the total government budget, on health expenditure. The total expenditure on health per capita was around US$ 566. 4. NATIONAL HEALTH PLAN AND PRIORITIES The Government calls for “appropriate medical treatment based on adequate medical prevention”. The most crucial tasks to be achieved by the Government are to: • consolidate the disease prevention and control system; • accelerate the progress of the Healthy City Programme; • provide quality health care services; • raise the level of medical specialists; • upgrade medical facilities and equipment; • build a healthy population; • promote the application of technology in clinical practice; • encourage continuing education of personnel. 5. MAJOR INFORMATION SOURCES Statistics and Census Service Health Bureau Finance Services Bureau 6. ADDRESSES HEALTH BUREAU Office Address : Postal Address : Caixa Postal 3002 - Macau Official Email Address : seg@ssm.gov.mo Telephone : (853) 313731 Fax : (853) 716105 Office Hours : Website : www.ssm.gov.mo WHO REPRESENTATIVE There is no WHO Representative in Macao (China). Queries about the WHO programme of collaboration with Macao (China) should be directed to: Office Address : Postal Address : Director, Programme Management World Health Organization Regional Office for the Western Pacific United Nations Avenue, P.O. Box 2932, 1000 Manila, Philippines Official Email Address : Telephone : Fax : Office Hours : 7:00-15:30 Website : www.wpro.who.int COUNTRY HEALTH INFORMATION PROFILES | 145 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) 146 MACAO (CHINA) WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 0.03 2004 1 2 Estimated population ('000s) 465.33 223.23 242.10 2004 1 3 Annual population growth rate (%) 3.80 … … 2004 1 4 Percentage of population - 0–14 years 17.12 18.60 15.80 2004 1 - 65+ years 8.12 7.40 8.80 2004 1 5 Urban population (%) 100.00 … … 2004 1 6 Crude birth rate (per 1 000 population) 7.20 … … 2004 1 7 Crude death rate (per 1 000 population) 3.40 … … 2004 1 8 Rate of natural increase of population (% per annum) 0.40 … … 2004 1 9 Life expectancy (years) - at birth 79.20 77.40 82.00 2000-2003 1 - Health-adjusted Life Expectancy (HALE) at age 60 … … … 10 Adult literacy rate (%) 91.03 95.30 87.80 2001 1 11 Neonatal mortality rate (per 1 000 live births) 1.81 2.29 1.28 2004 1 12 Infant mortality rate (per 1 000 live births) 3.02 3.43 2.56 2004 1 13 Under-five mortality rate (per 1 000 live births) 3.93 4.58 3.21 2004 1 14 Total fertility rate (women aged 15–49 years) 0.85 2004 1 15 Maternal mortality ratio (per 100 000 live births) 0.00 2004 1 16 Percentage of newborn infants weighing at least 2500 g at birth 93.32 94.57 91.92 2004 1 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 96.20 … … 2004 4 - DTP3 90.20 … … 2004 4 - OPV3 90.20 … … 2004 4 - Measles 91.10 … … 2004 4 - Hepatitis B III 86.40 … … 2004 4 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 100.00 2004 1 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 68.00 2003 2 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) 0.00 2004 1 - Percentage of deliveries in health facilities (as % of total deliveries) 100.00 2004 1 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … COUNTRY HEALTH INFORMATION PROFILE 147 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 … … 2003 2 26 Proportion of population with access to improved sanitation 99.85 … … 1996r 1 27 Proportion of the population using solid fuels for cooking or heating (%) 1.35 … … 1991 1 28 Proportion of households with access to secure tenure 99.24 … … 2001 1 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) - Hospital: General solid waste (metric tons per year) - Hospital: Pathological solid waste (metric tons per year) 6164.65 198.53 … … … … 2004 2004 1 1 31 Human development index 0.90 … … 2002 1 32 Per capita GDP at current market prices (US$) 22 670.95 NA NA 2004 1 33 Rate of growth of per capita GDP (%) 27.30 … … 2004 1 34 Health expenditure Total health expenditure b - amount (in million US$) 258.54 2004 1 - total health expenditure on health as % of GDP 2.50 2004 1 - per capita total expenditure on health (in US$) 565.84 2004 1 Government expenditure on health - amount (in million US$) 177.12 2004 1 - general government expenditure on health as % of total expenditure on health 68.51 2004 1 - general government expenditure on health as % of total general government expenditure 10.46 2004 1 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure c - private expenditure on health as % of total expenditure on health 31.49 2004 1 Exchange rate in US$ of local currency is: 1 US$ = 8.02(MOP) 2004 1 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female 36 Health workforce Number Rate per 10 000 population - physicians 1286 g … … 28.15 ... … 2004 1 - dentists 150 … … 3.28 … … 2004 1 - pharmacists … … … … … … - nurses 1063 … … 23.26 … … 2004 1 - midwives … … … … … … - other nursing / auxiliary staff 676 … … 14.79 … … 2004 1 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 402 … … 8.79 … … 2004 1 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 701 … … 15.34 … … 2004 1 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … MACAO (CHINA) 148 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity (compulsory notifiable diseases) Number Rate per 100 000 population 1. Varicella (chickenpox) 1411 736 675 296.43 321.40 273.28 2005 2 2. Tuberculosis of lung 368 275 93 77.31 120.09 37.65 2005 2 3. Hand, foot and mouth disease 218 d 123 94 45.80 53.71 38.06 2005 2 4. Mumps 85 50 35 17.86 21.83 14.17 2005 2 5. Salmonella infection 75 27 48 15.76 11.79 19.43 2005 2 6. Bacterial food intoxication 62 d 32 29 13.03 13.97 11.74 2005 2 7. Acute hepatitis C 35 18 17 7.35 7.86 6.88 2005 2 8. Gonococcal infections 32 d 27 3 6.72 11.79 1.21 2005 2 9. Scarlet fever 32 16 16 6.72 6.99 6.48 2005 2 10. Asymptomatic HIV infection 23 17 6 4.83 7.42 2.43 2005 2 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Malignant neoplasms 475 283 192 103.96 128.98 80.84 2004 2 2. Heart disease 303 145 158 66.31 66.08 66.53 2004 2 3. Pneumonia & Influenza 122 72 50 26.70 32.81 21.05 2004 2 4. Cerebrovascular 119 52 67 26.04 23.70 28.21 2004 2 5. Suicide 73 45 28 15.98 20.51 11.79 2004 2 6. Bronchitis, emphysema, asthma 72 55 17 15.76 25.07 7.16 2004 2 7. Nephritis 42 19 23 9.19 8.66 9.68 2004 2 8. Unintentional injuries & adverse effects 35 28 7 7.66 12.76 2.95 2004 2 9. Septicaemia 27 15 12 5.91 6.84 5.05 2004 2 10. Liver disease 14 10 4 3.06 4.56 1.68 2004 2 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 4 - Pertussis (whooping cough) 0 0 0 0 0 0 2004 4 - Tetanus 0 0 0 0 0 0 2004 4 - Neonatal tetanus 0 0 0 0 0 0 2004 4 - Poliomyelitis 0 0 0 0 0 0 2004 4 - Hib meningitis 0 0 0 0 0 0 2004 4 - Measles 0 0 0 0 0 0 2004 4 - Mumps 67 40 27 … … … 2004 4 - Rubella 2 2 0 … … 0 2004 4 - Congenital rubella syndrome 0 0 0 0 0 0 2004 4 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral 71 43 28 … … … 2005 2 - Type A 4 4 0 ... ... ... 2005 2 - Type B 23 12 11 ... ... ... 2005 2 - Type C 35 18 17 … ... ... 2005 2 - Type E … … … … … … - Unspecified 9 9 0 … ... ... 2005 2 Cholera 0 0 0 0 0 0 2005 2 Typhoid fever 2 0 2 … … … 2005 2 Encephalitis 0 0 0 0 0 0 2005 2 Plague 0 0 0 0 0 0 2005 2 Syphilis 6 5 1 … … … 2005 2 COUNTRY HEALTH INFORMATION PROFILE 149 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Gonorrhoea (gonococcal infections) 32 d 27 3 … … … 2005 2 Leprosy 0 0 0 0 0 0 2005 2 Malaria 0 0 0 0 0 0 2005 2 Dengue/DHF 0 0 0 0 0 0 2005 2 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 0.00 0.00 0.00 0.00 0.00 0.00 2004 2 - Proportion of population in malaria-risk areas using effective malaria prevention measures e … - Proportion of population in malaria-risk areas using effective malaria treatment measures f … 44 Tuberculosis Number of cases Number of deaths - All types 323 … … … … … 2004 4 - New pulmonary tuberculosis (smear-positive) 128 … … … … … 2004 4 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 90.00 … … 10.00 … … 2004 4 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 76.00 … … 88.00 (2003) … … 2004 4 Number of cases Number of deaths 45 Acute respiratory infections (460- 466) … … … 1 1 0 2004 1 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (malignant neoplasms only) (140-208) … … … 475 283 192 2004 1 - Trachea, bronchus, and lung (162) … … … 130 83 47 2004 1 - Stomach (151) … … … 27 14 13 2004 1 - Colon and rectum (153-154) … … … 64 31 33 2004 1 - Lip, oral cavity and pharynx (149) … … … 1 1 0 2004 1 - Liver (155) … … … 70 58 12 2004 1 - Cervix (180) … 5 2004 1 - Leukaemia (204-208) … … … 7 4 3 2004 1 48 Circulatory All circulatory system diseases … … … 447 212 235 2004 1 - Ischaemic heart disease (410-414) … … … 115 59 56 2004 1 - Acute myocardial infarction (410) … … … 26 14 12 2004 1 - Rheumatic fever and rheumatic heart diseases (390-392, 393-398) … … … 6 5 1 2004 1 -Cerebrovascular diseases(430-438) … … … 119 52 67 2004 1 - Hypertension (401-405) … … … 57 26 31 2004 1 MACAO (CHINA) 150 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 49 Maternal causes - Haemorrhage (640-648) … 0 2004 1 - Abortion (630-639) … 0 2004 1 - Eclampsia … … - Sepsis … … - Obstructed labour (660) … 0 2004 1 50 Diabetes mellitus (250) … … … 9 5 4 2004 1 51 Mental disorders (290-319) … … … 1 1 0 2004 1 52 Injuries - All types (800-994) … … … 121 79 42 2004 1 - Motor and other vehicle accidents (E810-E819) … … … 15 11 4 2004 1 - Suicide (E950-E959) ... ... ... 73 45 28 2004 1 - Homicide and violence(E960-E969) ... ... ... 9 5 4 2004 1 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 556 2004 1 - Specialized hospitals NA NA 2004 1 - District/first-level referral hospitals NA NA 2004 1 - Primary health care centres 8 NA 2004 1 Private hospitals 1 607 2004 1 Notes: Red text Millennium Development Goals (MDG) indicators … Data not available est Estimate p Provisional figure r Revised reference year. NA Not applicable aa Figure refers to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance on non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Total health expenditure is sum of government and private expenditure on health. c Derived from gross domestic product of Statistics and Census Service. d Gender of some cases were not noted. e Prevention is measured by the percentage of children aged 0–59 months sleeping under insecticide-treated bednets. f Treatment is measured by the proportion of children aged 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. g Figure includes physicians and traditional Chinese medicine doctors. Sources: 1 Statistics and Census Service 2 Health Bureau 3 Finance Services Bureau 4 WHO Regional Office for the Western Pacific, data received from technical units COUNTRY HEALTH INFORMATION PROFILES | 151 MALAYSIA 1. DEMOGRAPHICS, GENDER AND POVERTY In 2005, the total population of Malaysia was 26 127 700, with about 42.3% below 20 years of age and 6.6% aged 60 years and above. The population density was around 76 persons per square kilometre in the same year. Women outnumbered men, with a ratio of 96 males for every 100 females. Table 1. Core population and health data (2005 provisional) [Total] 26 127 700 [Both] 73.50 [0-14 years] 8 525 000 (32.63%) [Male] 70.60 Population [65+ years] 1 119 400 (4.28%) Life expectancy at birth (years) [Female] 76.40 Crude birth rate (per 1000 population) 20.80 Total fertility rate 2.60 [Total] … [Urban] … Crude death rate (per 1000 population) 4.60 % of population served with safe water [Rural] 95.80 [Total] … [Urban] ... Infant mortality rate (per 1000 live births) 5.10 % of population with adequate sanitary facilities [Rural] 99.80 Maternal mortality ratio (per 100 000 live births) 30.00 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Malaysia practises parliamentary democracy based on the federal system, with a constitutional monarchy and three branches of government: the legislative, judicial and administrative or executive. Under the Federal Constitution, the states of Perlis, Kedah, Pulau Pinang, Perak, Selangor, Negeri Sembilan, Melaka, Johor, Pahang, Terengganu, Kelantan, Sarawak and Sabah have agreed to the concept of the formation of the country of Malaysia. The powers of state governments are limited by the Federal Constitution. The chief of state is the Paramount Ruler (Yang Di-Pertuan Agong), who is elected from and by the hereditary rulers of nine of the states for a five-year term. The Paramount Ruler has the power to safeguard the customs and traditions of the Malay people and the administration of the Islamic religion in each state. He is also the Highest Commander of the Armed Forces. Since December 2001, the Paramount Ruler has been Tuanku Syed Sirajuddin ibni Almarhum Tuanku Syed Putra Jamalullail, the Rajah of Perlis. The head of government is the Prime Minister, who appoints the Cabinet from among the members of Parliament with the consent of the Paramount Ruler. The current Prime Minister is Abdullah bin Ahmad Badawi (since October 2003). 2.2 Economic situation The Malaysian economy grew at an average rate of 6.2% per annum during the period from 1991 to 2005. The strong rate of growth was achieved despite the challenges faced from events such as the 1997-98 Asian financial crisis, the September 11 incident in 2001, wars in Afghanistan and Iraq, outbreaks of severe acute respiratory syndrome (SARS) and avian influenza, as well as MALAYSIA 152 | COUNTRY HEALTH INFORMATION PROFILES increases in world oil prices. Economic fundamentals remain strong. Growth was achieved, with inflation averaging a low 2.9% per annum and similarly low unemployment averaging 3.1% over the period. The current account of the balance of payments and the consolidated public sector account registered twin surpluses by the end of the period. The level of savings and external reserves rebounded to healthy levels after the Asian financial crisis. Gross domestic product (GDP) per capita grew at an average of 7.1% per annum to RM 18 489 or US$ 4904 in 2005. When adjusted for Malaysia’s cost of living, the Purchasing Power Parity (PPP)–adjusted GDP per capita in 2005 doubled to US$ 10 318. Compared with other Organisation for Economic Co-operation and Development (OECD) countries, Malaysia’s PPP- adjusted GDP per capita is above that of Mexico and that of Poland. The economy evolved from capital-led growth in 1991 to growth based more evenly on capital, labour and total factor productivity (TFP) in 2005. Malaysia’a economic structure continues to develop away from manufacturing services. Growth in knowledge-based service industries was expanded with the establishment of the Multimedia Super Corridor in 1996, followed by other initiatives such as the National Biotechnology Policy, launched in 2005. 3. HEALTH SITUATION 3.1 Health trends Life expectancy at birth for both males and females has increased over the years, rising from 56 years for males and 58 for females in 1957 to 70.6 years for males and 76.4 for females in 2005. Over the same period, the crude death rate fell from 12.4 per 1000 live births in 1957, to 5.0 in 1985 and 4.5 in 2005. There have been gradual improvements in the infant mortality rate, perinatal mortality rate and toddler mortality rate, with the infant mortality rate improving from 75.5 per 1000 live births in 1957 to 16.4 in 1985, and a further decrease to 5.1 per 1000 live births in 2005. Intensive immunization efforts and other related programmes carried out by both the public and private sectors contributed to this improvement. The perinatal mortality rate decreased from 19.3 per 1000 live births in 1985 to 7.3 in 2005, while the toddler mortality rate fell from 1.4 per 1000 live births in 1985 to 0.5 in 2005. The maternal mortality ratio (MMR) also showed a decrease from 160 in 1970 to 30 per 100 000 live births in 2000 and 2005. Both communicable and noncommunicable diseases remain a burden in Malaysia. The country has begun experiencing a changing pattern of both types of disease. The top five diseases are dominated by noncommunicable diseases, similar to the disease burden of a developed nation. However, the rise in the incidence of noncommunicable disease is accompanied by persistent incidence of some communicable diseases. Mental illness has also become an increasing problem. Faced with the above, the Ministry of Health, in collaboration with WHO, completed a study on the burden of disease using disability-adjusted life years (DALY) in 2004 (using 2000 data). The study, which took both mortality and morbidity into account, found that the five most common diseases in Malaysia were ischaemic heart disease, followed by mental illness, cerebrovascular disease/stroke, road traffic injuries and cancers. 3.2 Health systems Health care in Malaysia is presently provided by the public and private sectors, as well as by nongovernmental organizations. The major provider and financier of health services is the Ministry of Health, which is responsible for the health of the population, as stated in the Federal Constitution. The private health sector, whose role has been increasing over the past few decades, provides health services through private hospitals and clinics, which have been mushrooming throughout the country, especially in urban areas. COUNTRY HEALTH INFORMATION PROFILES | 153 Other health care providers include traditional and complementary medicine (TCM) practitioners and nongovernmental organizations. TCM in Malaysia comprises traditional Malay, Chinese and Ayuverdic medicines, among others, and is well accepted by both rural and urban communities. Some nongovernmental organizations also contribute to the provision of health care by complementing tasks undertaken by the Ministry of Health. The emergence and rapid growth of private health care insurance and managed care organizations over the past few years may be an indication that health care, especially in the private sector, is becoming less affordable and market-oriented. The challenge is to fulfill the need for health care services to be affordable, comprehensive, equitable and accessible in both the public and private sectors for people of all levels of socioeconomic status, via an acceptable national health care financing mechanism. 4. NATIONAL HEALTH PLAN AND PRIORITIES The objective of the health services is to raise and continuously improve the health status of individuals, families and communities. The essential services in the health system of the future will be information and education of individuals to support wellness, as well as consultations to maintain health or provide early treatment of illness. Thus, the health system of the future will be different from that of today, and will not only focus on care using the present health care delivery system. The vision for health empowers individuals, families and communities, and emphasizes wellness and care as well as achieving an enhanced quality of life. Maintaining wellness has been identified as the way forward for the Malaysian health system, and is one of the health services’ goals in designing and planning health care in the country. However, current health promotion and prevention services are still perceived to be disease-oriented rather than wellness-oriented, not only by health care providers, but also by the people at large. In achieving the Vision for Health and Mission of the Ministry of Health, the activities carried out by the health sector must be in line with the eight goals of the health services: wellness; person-focused; informed person; self-help; care provided at home or closer to home; seamless, continuous care; services tailored to individual or group needs; and effective, efficient and affordable services. 5. MAJOR INFORMATION SOURCES Ministry of Health (http://www.moh.gov.my/) National Statistics Department (http://www.statistics.gov.my/) Parliament (http://www.parlimen.gov.my) Treasury Department (http://www.treasury.gov.my) Ninth Malaysia Plan 2006-2010. Economic Planning Unit, Prime Ministers Department Malaysia: Achieving the Millennium Development Goals, successes and challenges Policy review: Developing the Malaysian health system to meet the challenges of the future. MALAYSIA 154 | COUNTRY HEALTH INFORMATION PROFILES 6. ADDRESSES MINISTRY OF HEALTH Office Address : Block E1, E6, E7 & E10, Parcel E Federal Government Complex Administrative Centre 62590 PUTRAJAYA, MALAYSIA Postal Address : Official Email Address : webmaster@moh.gov.my Telephone : 603-8883 3888 Fax : 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 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILES | 155 ORGANIZATIONAL CHART: MINISTRY OF HEALTH MALAYSIA 156 MALAYSIA WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 330.25 2005 2 2 Estimated population ('000s) 26 127.70 … … 2005p 2 3 Annual population growth rate (%) 2.10 ... ... 2005 2 4 Percentage of population - 0–14 years 32.63 … … 2005p 2 - 65+ years 4.28 … … 2005p 2 5 Urban population (%) 62.82 … … 2004 2 6 Crude birth rate (per 1 000 population) 20.80 … … 2005p 2 7 Crude death rate (per 1 000 population) 4.60 … … 2005p 2 8 Rate of natural increase of population (% per annum) 1.67 a … … 2004 2 9 Life expectancy (years) - at birth 73.50 70.60 76.40 2005p 2 - Heal th-adjusted Life Expectancy (H ALE) at age 60 … 10.90 12.00 2002 8 10 Adult literacy rate (%) 94.00 … … 2002 2 11 Neonatal mortality rate (per 1 000 live births) 2.10 … … 2005 2 12 Infant mortality rate (per 1 000 live births) 5.10 … … 2005p 2 13 Under-five mortality rate (per 1 000 live births) 8.60 … … 2002 4 14 Total fertility rate (women aged 15–49 years) 2.60 2005p 2 15 Maternal mortality ratio (per 100 000 live births) 30.00 2005p 2 16 Percentage of newborn infants weighing at least 2500 g at birth 90.40 … … 2004 6 17 Prevalence of underweight children under five years of age 12.00 … … 2002 4 18 Percentage of pregnant women with anaemia 2.40 h 2005 6 19 Immunization coverage for infants (%) - BCG 100.00 … … 2005 6 - DTP3 95.30 … … 2005 6 - OPV3 94.30 … … 2005 6 - Measles 95.40 … … 2005 6 - Hepati tis B III 95.00 … … 2005 6 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 78.80 2005 6 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 86.10 2005 6 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) 2.00 2005 6 - Percentage of deliveries in heal th facilities (as % of total deliveries) 98.00 2005 6 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab 5500 j … … 2001 4 COUNTRY HEALTH INFORMATION PROFILE 157 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source … … 95.80 2005p 6 26 Proportion of population with access to improved sanitation … … 99.80 2005p 11 27 Proportion of the population using solid fuels for cooking or heating (%) <5.00 … … 2003 5 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.80 …. … 2003 7 32 Per capita GDP at current market prices (US$) 4904.00 … … 2005 1 33 Rate of growth of per capita GDP 7.10 … … 2005 1 34 Health expenditure Total health expenditure - amount (in m illion US$) … - total heal th expenditure on health as % of GDP … - per capita total expendi ture on health (in US$) … Government expenditure on health - amount (in million US$) 3684.21 2002 9 - general government expenditure on health as % of total expenditure on health 3.80 i 2002 9 - general government expenditure on heal th as % of total general government expendi ture …. External source of government health expenditure - external resources for heal th as % of general government expendi ture on health … Private health expenditure - private expenditure on health as % of total expenditure on heal th 44.00 2002 9 Exchange rate in US$ of local currency is: 1 US$ = 3.80 (average) 2003 6 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population a 36 Health workforce - physicians 21 122 … … 8.08 … … 2005 6 - dentists 2751 … … 1.05 … … 2005 6 - pharmacists 2539 … … 0.97 … … 2005 6 - nurses 44 120 … … 16.88 … … 2005 6 - m idwives 15 618 … … 5.98 … … 2005 6 - other nursing / auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 11 167 … … 4.27 … … 2005 6 - other heal th personnel (health inspec tors, assistant sani tarians, traditional workers, etc.) 3593 … … 1.38 … … 2005 6 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … MALAYSIA 158 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of Hospitalisation in MOH hospitals Number Rate per 100 000 population 1. Normal delivery (single spontaneous delivery) 281 222 1076.24 2005 6 2. Complications of pregnancy, childbirth and the puerperium 222 900 853.04 2005 6 3. Accidents (accidental injury) 165 481 119 796 45 685 633.30 458.46 174.84 2005 6 4. Diseases of the circulatory system 130 948 72 395 58 553 501.14 277.06 224.08 2005 6 5. Diseases of the respiratory system 129 284 72 676 56 608 494.77 278.13 216.64 2005 6 6. Certain conditions originating in the perinatal period 115 809 62 081 53 728 443.20 237.59 205.62 2005 6 7. Diseases of the digestive system 94 731 55 984 38 747 362.54 214.25 148.29 2005 6 8. Diseases of the urinary system 69 047 34 985 34 062 264.24 133.89 130.36 2005 6 9. Ill-defined condi tions (symptoms and signs) 61 814 32 510 29 304 236.56 124.42 112.15 2005 6 10. Malignant neoplasms 55 642 25 894 29 748 212.94 99.10 113.85 2005 6 40 Ten leading causes of mortality in M inistry of Health hospitals Number Rate per 100 000 population 1. Septicaemia 6549 3709 2840 25.06 14.19 10.87 2005 6 2. Heart diseases and diseases of pulmonary circulation 5669 3381 2288 21.70 12.94 8.76 2005 6 3. Malignant neoplasms 4005 2210 1795 15.33 8.46 6.87 2005 6 4. Cerebrovascular diseases 3245 1800 1445 12.42 6.89 5.53 2005 6 5. Accident 2247 1776 471 8.60 6.80 1.80 2005 6 6. Pneumonia 2097 1284 813 8.03 4.91 3.11 2005 6 7. Certain conditions originating in the perinatal period 1762 1189 573 6.74 4.55 2.19 2005 6 8. Diseases of the digestive system 1729 939 790 6.62 3.59 3.02 2005 6 9. Nephritis, nephrotic syndrome and nephrosis 1541 882 659 5.90 3.38 2.52 2005 6 10. Ill defined conditions 1115 666 449 4.27 2.55 1.72 2005 6 41 Selected diseases under the WHO- EPI Number of cases (C) Number of deaths (D) - Diphtheria 3 … … 1 … … 2005 C: 5, D: 10 - Pertussis (whooping cough) 8 … … 0 0 0 2005 C: 5, D: 10 - T etanus (adul t) 27 … … 1 … … 2005 C: 5, D: 10 - Neonatal tetanus 6 … … 0 0 0 2005 C: 5, D: 10 - Poliomyelitis 0 0 0 0 0 0 2005 C: 5, D: 10 - Hib meningitis … … … … … … - Measles 1407 … … … … … 2005 5 - Mumps … … … … … … - Rubella … … … … … … - Congeni tal rubella syndrome … … … … … … 42 Selected communicable diseases Number of cases aa Number of deaths Hepati tis vi ral - T ype A 44 … … 0 0 0 2005 10 - T ype B 1490 … … 0 0 0 2005 10 - T ype C 995 … … 0 0 0 2005 10 - T ype E … … … … … … - Unspecified … … … … … … COUNTRY HEALTH INFORMATION PROFILE 159 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Cholera 386 … … 2 … … 2005 10 Typhoid fever 1072 … … 0 … … 2005 10 Encephalitis 32 … … 4 … … 2005 10 Plague 0 0 0 0 0 0 2005 10 Syphilis 900 … … 0 0 0 2005 10 Gonorrhoea 537 … … 0 0 0 2005 10 Leprosy 262 … … … … … 2005 10 Malaria 5569 … … 33 … … 2005 10 Dengue Fever/ DHF 16861 … … 107 … … 2005 10 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) …. … … 0.13 … … 2005 10 - Proportion of population in malaria-risk areas using effective malaria prevention measures b … - Proportion of population in malaria-risk areas using effective malaria treatment measures c … 44 Tuberculosis Number of cases (C) Number of deaths (D) - All types 15 875 … … 159 … … 2005 C: 5, D:10 - New pulmonary tuberculosis (smear-posi tive) …. … … … … … …. .. Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 133.00 … … 16.00 … … 2004 5 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOT S) 69.00 … … 72.00 (2003) … … 2004 5 Number of cases Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (malignant neoplasms only) 55 642 25 894 29 748 4005 2210 1795 2005 6 - T rachea, bronchus and lung 5702 4150 1552 835 598 237 2005 6 - Stomach 1529 989 540 191 135 56 2005 6 - Colon and rectum 8202 4775 3427 345 212 133 2005 6 - Lip, oral cavity and pharynx 3519 2417 1102 243 183 60 2005 6 - Liver 1729 1185 544 268 193 75 2005 6 - Cervix 2771 135 2005 6 - Leukaemia 4874 2926 1948 264 154 110 2005 6 48 Circulatory All circulatory system diseases 130 948 72 395 58 553 9143 5341 3802 2005 6 - Ischaemic heart disease 39 770 26 448 13322 3038 1955 1083 2005 6 - Acute m yocardial infarction 9351 6993 2358 1654 1099 555 2005 6 - Rheumatic fever and rheumatic heart diseases 3524 1795 1729 80 32 48 2005 6 - Cerebrovascular diseases 17 909 10 084 7825 3245 1800 1445 2005 6 - H ypertension 37 580 16 105 21 475 158 70 88 2005 6 MALAYSIA 160 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 49 Maternal causes - Haemorrhage 7312 1 2005 6 - Abortion 34 739 11 2005 6 - Eclampsia 472 5 2005 6 - Sepsis 140 3 2005 6 - Obstruc ted labour 1369 0 2005 6 50 Diabetes mellitus 41 375 19 066 22 309 361 167 194 2005 6 51 Mental disorders 28 470 18 831 9639 12 11 1 2005 6 52 Injuries - All types 149 205 111 568 37 637 2002 1618 384 2005 6 - Motor and other vehicle accidents 83 831 64 344 19 487 1584 1287 297 2005 6 - Intentional sel f harm (X60-84) 2562 901 1661 136 101 35 2005 6 - Hom icide and violence 5502 3873 1629 43 37 6 2005 6 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public heal th facilities - General hospitals 128 d 35 210 2005 1 - Specialized hospi tals … … - District/first-level referral hospitals … … - Primary health care centres 3148 e, g … 2004 6 Private hospitals 222 f 10 794 2005 3 Notes: Red text M illennium Development Goals (MDG) indicators … Data not available p Preliminary C Cases D Deaths aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Uni t of the WHO Regional Office for the Western Pacific b Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. c Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. d Figure includes insti tution. e Figure includes M inistry of Health clinics/ community polyclinics, Ministry of Health rural clinics, Ministry of Health maternal and child heal th clinics and M inistry of Health mobile clinics. f Figure includes materni ty/ nursing homes. g Revised data. h Figure refers to percentage of pregnant women with haemoglobin level <9.0 grams. i Figure refers to general government expendi ture on heal th as % of GDP. j Figure refers to cumulative number of children orphaned by HIV/AIDS under age 15. Sources: 1 Ninth Malaysia Plan 2006-2010 2 Department of Statistics (http://www.statistics.gov.my) COUNTRY HEALTH INFORMATION PROFILE 161 3 Medical Practice Division, Ministry of Health, Malaysia 4 Malaysia: Achieving the Millennium Development Goals, successes and challenges. United Nations Country T eam and UNDP January 2005. 5 WHO Regional Office for the Western Paci fic, data received from the technical units 6 Information and Documentation System Unit, Ministry of Heal th 7 Human Development Report 2005. New York, United Nations Development Programme, 2005. 8 The World health report 2004: Changing history. Geneva, World Heal th Organization, 2004. 9 Malaysia National Heal th Accounts Project 10 Disease control Division, M inistry of Health, Malaysia (preliminary data) 11 Rural Environment Sanitation Program, Ministry of Heal th, Malaysia 162 | COUNTRY HEALTH INFORMATION PROFILES MARSHALL ISLANDS 1. DEMOGRAPHICS, GENDER AND POVERTY 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 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 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 appropriate poverty reduction strategies and programmes. Table 1. Core population and health data (2004) [Total] 61 218 est [Both] 62.00 [0-14 years] 41.76% est [Male] 60.00 Population [65+ years] 2.07 % est Life expectancy at birth (years) [Female] 64.00 Crude birth rate (per 1000 population) 24.70 est Total fertility rate 5.71 (1999) [Total] 85.00 (2002) [Urban] 80.00 (2002) Crude death rate (per 1000 population) 4.05 est % of population served with safe water [Rural] 95.00 (2002) [Total] 82.00 (2002) [Urban] 93.00 (2002) Infant mortality rate (per 1000 live births) 29.00 (2002) % of population with adequate sanitary facilities [Rural] 59.00 (2002) Maternal mortality ratio (per 100 000 live births) 73.80 (2002) est -Estimate COUNTRY HEALTH INFORMATION PROFILES | 163 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The Marshall Islands practises parliamentary democracy, constitutionally in free association with the United States of America. During the last elections, conducted in November 2002, President, H.E. Kessai Note was elected, along with 10 ministers. The Minister for Health and Environment is the Honourable Alvin Jacklick. The legislative branch of government consists of the Nitijela (Parliament) with an advisory council of high chiefs. The Nitijela has 33 members from 24 districts, elected for concurrent four-year terms. Members are called senators. The President is elected by the Nitijela from among its members. Presidents pick cabinet members from the Nitijela. The Marshall Islands has four court systems: the Supreme Court, the High Court, district and community courts, and traditional rights courts. Trial is by jury or judge. The jurisdiction of the traditional rights courts is limited to cases involving titles or land rights or other disputes arising from customary law and traditional practices. The relatively new democratic political system is combined with a hierarchical traditional culture. The first two presidents were chiefs, while the current president is a commoner. The new Government, running on a reform platform, has publicly confirmed its commitment to an independent judiciary. 2.2 Economic situation Assistance from the United States of America is the mainstay of the economy. The Government is the largest employer, employing 30.6% of the workforce, a reduction of 3.4% since 1988. The gross domestic product (GDP) is derived mainly from payments made by the United States of America under the terms of the Compact of Free Association. Direct aid accounts for 60% of the Marshall Islands’ US$ 90 million budget. The Compact of Free Association II, as amended in 2002-2003, stipulates heavy emphasis on United States foreign aid to target education and health. The economy combines a small subsistence sector and a modern urban sector. There is a developing agrarian and service-oriented economy. Subsidies are designed to help reduce migration from outer atolls to densely populated Majuro and Ebeye. 3. HEALTH SITUATION 3.1 Health trends High population growth and crowded conditions in urban areas have caused the re-emergence and/or rise of certain communicable diseases, such as tuberculosis and leprosy. In addition, exposure to modern culture has brought about a rise in levels of adult obesity, noncommunicable diseases, teenage pregnancy, suicide, alcoholism and tobacco use. The Government focuses on training native Marshallese health professionals, strengthening community health care programmes, upgrading the quality of health care services, and improving the dissemination of health care information to its citizens. Other health-related issues include the need to reduce population growth and urban population density, reduce malnutrition and strengthen the capacity of the health sector. Recent initiatives have included training basketball players in reproductive health issues so they can lead advocacy programmes. 3.2 Health systems During the 2004 fiscal year, the Ministry of Health received an annual government budget of US$ 15 756 334, equivalent to 14% of the nation’s budget. In line with its mission statement, the Ministry continues to explore avenues to provide the best quality health care possible to the people despite its meagre funding and limited human and capital resources. The current health indicators reveal a much improved health status and steady progress in MARSHALL ISLANDS 164 | COUNTRY HEALTH INFORMATION PROFILES community participation in implementing the theme “Health is a Shared Responsibility.” However, there is still a need to reflect more on the changing lifestyles associated with epidemiological transition from infectious to noncommunicable diseases. A significant proportion of health services are funded under external aid or grant programmes, including the United States Federal Health Grants and grants under the Compact of Free Association between the Marshall Islands and the United States of America. The Planning and Vital Statistics Department of the Ministry of Health is responsible for registration of birth, deaths and causes of death. Vital statistics are compiled from returns received by the Department from Majuro and Ebeye hospitals and from outer islands health service centres. Underreporting of births and deaths is a common problem in developing countries, including the Marshall Islands, where the geographically scattered population creates logistical challenges for the registration process. More generally, health information systems remain weak. Even where data are adequate, they are seldom used to drive policy development. 4. NATIONAL HEALTH PLAN AND PRIORITIES In April 2000, the Ministry of Health and Environment (the title changed to the Ministry of Health in 2002), prepared a pivotal document to guide health policies: the Fifteen Year Strategic Plan 2001-2015. The document encompasses the Fifteen Year Plan 2001 to 2015, the Strategic Five Year Plan 2001 to 2005 and the Operational Plan 2001 to 2005. The overarching principle guiding activities of the Ministry of Health is stated in its mission statement as: “To provide high quality, effective, affordable, and efficient health services to all peoples of the Marshall Islands, through a primary health care programme to improve health status and build the capacity of each community, family and individual to care for their own health. To the maximum extent possible, the Ministry of Health pursues these goals using the national facilities, staff and resources of the Republic of the Marshall Islands.” The national health priorities remain the same as in 2004 and are to: • develop and strengthen the capabilities of indigenous personnel; • institutionalize primary health care strategies, decentralize health care, promote community-based health care and take steps to make community-based health care systems as self-reliant as possible; • strengthen and develop the health information system; • secure a sustainable financial base from the government, community and private sectors 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 the causes and effects of malnutrition; • address, prevent and manage the rising number of cases of diabetes and their health and social impacts; • coordinate and strengthen the provision of health education; and • coordinate all aspects of the health care delivery system through the National Health Services Board of the Ministry of Health. 5. MAJOR INFORMATION SOURCES Fifteen Year Strategic Plan 2001-2015. Ministry of Health and Environment, April 2000,. Ministry of Health Annual Report 2003– “Health is a Shared Responsibility”. Ministry of Health annual report 2004 – “Health is a Shared Responsibility”. COUNTRY HEALTH INFORMATION PROFILES | 165 Ministry of Health statistical abstract 1999-2001. Statistical yearbook 2003. Economic Policy Planning and Statistics Office, Office of the President, 16th Edition, Augtust 2004, Economic Policy, Planning and Statistics Office (EPPSO) (http://www.spc.int/prism) 6. ADDRESSES MINISTRY OF HEALTH Office Address : Postal Address : P.O. Box 16, Majuro, Marshall Islands Official Email Address : rmimohe@ntamar.com Telephone : + (692) 625 7246/5660/5661 Fax : + (692) 625 3432/4543/4372 Office Hours : 8:00 – 12:00 and 13:00 – 17:00 Website : WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4 Provident Plaza One Downtown Boulevard, 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@fij.wpro.who.int Telephone : (679) 3-304600/ 3-304631 Fax : (679) 3-300462 Office Hours : Website : ORGANIZATIONAL CHART: MINISTRY OF HEALTH MARSHALL ISLANDS 166 MARSHALL ISLANDS WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 0.18 1 2 Estimated population ('000s) 61.22 31.28 29.93 2004 est 2 3 Annual population growth rate (%) 1.18 … … 2005-2010 3 4 Percentage of population - 0–14 years 41.76 a 41.89 a 41.63 a 2004 est 2 - 65+ years 2.07 a 1.95 a 2.21 a 2004 est 2 5 Urban population (%) 66.70 … … 2005-2010 3 6 Crude birth rate (per 1 000 population) 24.70 a, b … … 2004 est 2, 11 7 Crude death rate (per 1 000 population) 4.05 a, b 5.56 a, b 4.04 a, b 2004 est 2, 11 8 Rate of natural increase of population (% per annum) 4.90 … … 1999 2 9 Life expectancy (years) - at birth 62.00 60.00 64.00 2004 4 - Health-adjusted Life Expectancy (HALE) at age 60 … 9.80 10.70 2002 5 10 Adult literacy rate (%) 97.00 96.80 97.20 1999 6 11 Neonatal mortality rate (per 1 000 live births) … … … 12 Infant mortality rate (per 1 000 live births) 29.00 … … 2002 7 13 Under-five mortality rate (per 1 000 live births) 48.00 … … 1999 7 14 Total fertility rate (women aged 15–49 years) 5.71 1999 2 15 Maternal mortality ratio (per 100 000 live births) 73.80 2002 7 16 Percentage of newborn infants weighing at least 2500 g at birth 88.00 … … 1999 6 17 Prevalence of underweight children under five years of age 27.00 … … 1999 7 18 Percentage of pregnant women with anaemia 8.00 1999 6 19 Immunization coverage for infants (%) - BCG 91.00 … … 2004 8 - DTP3 64.00 … … 2004 8 - OPV3 68.00 … … 2004 8 - Measles 70.00 … … 2004 8 - Hepatitis B III 72.00 … … 2004 8 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel … - Percentage of pregnant women immunized with tetanus toxoid (TT2) 50.00 2004 8 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods 34.00 c 2001 7 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … COUNTRY HEALTH INFORMATION PROFILE 167 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 85.00 80.00 95.00 2002 9 26 Proportion of population with access to improved sanitation 82.00 93.00 59.00 2002 9 27 Proportion of the population using solid fuels for cooking or heating (%) 29.90 … … 1999 7 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.56 … … 1998 10 32 Per capita GDP at current market prices (US$) 1817.00 … … 2001 2 33 Rate of growth of per capita GDP (%) … … … 34 Health expenditure Total health expenditure - amount (in million US$) 12.70 1999 6 - total health expenditure on health as % of GDP 4.00 1999 6 - per capita total expenditure on health (in US$) 248.00 1999 6 Government expenditure on health - amount (in million US$) 15.76 FY2004 12 - general government expenditure on health as % of total expenditure on health 96.70 2003 4 - general government expenditure on health as % of total general government expenditure 14.00 FY2004 12 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = NA 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 24 … … 4.63 … … 2000 6 - dentists 4 … … 0.77 … … 2000 6 - pharmacists 2 … … 0.39 … … 2000 6 - nurses 152 … … 29.34 … … 2000 6 - midwives … … … … … … - other nursing / auxiliary staff 7 … … 1.35 … … 2000 6 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 53 … … 10.23 … … 2000 6 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … MARSHALL ISLANDS 168 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Gastroenteritis 1010 … … 1614.22 … … 1998 2 2. Scabies 1003 … … 1603.03 … … 1998 2 3. Influenza 998 … … 1595.04 … … 1998 2 4. Conjunctivitis 890 … … 1422.43 … … 1998 2 5. Diarrhoea – adults 610 … … 974.92 … … 1998 2 6. Amoebiasis 340 … … 543.40 … … 1998 2 7. Diarrhoea – infantile 210 … … 335.63 … … 1998 2 8. Chickenpox 120 … … 191.79 … … 1998 2 9. Fish poisoning 99 … … 158.23 … … 1998 2 10. Typhoid and paratyphoid fever 32 … … 51.14 … … 1998 2 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Malnutrition 20 … … 31.96 … … 1998 2 2. Accidents (all types) 20 … … 31.96 … … 1998 2 3. Sepsis 17 … … 27.17 … … 1998 2 4. Pneumonia 12 … … 19.18 … … 1998 2 5. Cancer (all types) 12 … … 19.18 … … 1998 2 6. Prematurity 11 … … 17.58 … … 1998 2 7. Myocardial infarction 9 … … 14.38 … … 1998 2 8. End-stage renal disease 9 … … 14.38 … … 1998 2 9. Cerebrovascular accidents 9 … … 14.38 … … 1998 2 10. Septicaemia 8 … … 12.79 … … 1998 2 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 8 - Pertussis (whooping cough) 0 0 0 0 0 0 2003 8 - Tetanus 0 0 0 0 0 0 2004 8 - Neonatal tetanus 0 0 0 0 0 0 2004 8 - Poliomyelitis 0 0 0 0 0 0 2004 8 - Hib meningitis 0 0 0 0 0 0 2003 8 - Measles 0 0 0 0 0 0 2004 8 - Mumps 6 … … … … … 2003 8 - Rubella 0 0 0 0 0 0 2003 8 - Congenital rubella syndrome 0 0 0 0 0 0 2004 8 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral - Type A 12 … … … … … 2002 13 - Type B 31 … … … … … 2002 13 - Type C … … … … … … - Type E … … … … … … - Unspecified … … … … … … Cholera 0 0 0 0 0 0 2005 8 Typhoid fever 14 … … 0 0 0 2005 8 Encephalitis … … … … … … Plague … … … … … … Syphilis 77 … … … … … 2002 13 Gonorrhoea 230 … … … … … 2002 13 Leprosy 62 … … … … … 2004 8 COUNTRY HEALTH INFORMATION PROFILE 169 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Malaria … … … … … … Dengue/DHF 0 0 0 0 0 0 2004 8 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures d … - Proportion of population in malaria-risk areas using effective malaria treatment measures e … 44 Tuberculosis Number of cases Number of deaths - All types 119 … … … … … 2004 8 - New pulmonary tuberculosis (smear-positive) 39 … … … … … 2004 8 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 59.00 … … 4.00 … … 2004 8 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 246.00 … … 90.00 (2003) … … 2004 8 Number of cases Number of deaths 45 Acute respiratory infections 3703 … … … … … 2002 13 46 Diarrhoeal diseases 1954 … … … … … 2002 13 47 Cancers All cancers (malignant neoplasms only) … … … 12 … … 1998 2 - Trachea, bronchus, and lung … … … … … … - Stomach … … … … … … - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … … … … - Liver … … … … … … - Cervix … 4 1998 14 - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … … … … - Ischaemic heart disease … … … … … … - Acute myocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … … … … - Hypertension … … … … … … 49 Maternal causes - Haemorrhage … … - Abortion … … - Eclampsia … … - Sepsis … … - Obstructed labour … … MARSHALL ISLANDS 170 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 50 Diabetes mellitus 1612 … … … … … 1998 6 51 Mental disorders … … … … … … 52 Injuries - All types … … … … … … - Motor and other vehicle accidents … … … … … … - Suicide … … … … … … - Homicide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 80 1999 6 - Specialized hospitals … … - District/first-level referral hospitals 1 25 1999 6 - Primary health care centres 5 … 1999 6 Private hospitals … … Notes: Red text Millennium Development Goals (MDG) indicators … Data not available est Estimate NA Not applicable FY The financial year refers to the span from April 1 of respective year to March 31 next year. aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Figure based on projected population for 2004. c Contraceptive prevalence rate. d Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. e Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community http://www.spc.int 2 Economic Planning, Policy and Statistics Office, Marshall Islands http://spc.int/prism/country/mh/stats/Index.htm 3 Demographic Tables for the Western Pacific 2005-2010. World Health Organization, Regional Office for the Western Pacific. 4 Working Together for Health. The World Health Report 2006, World Health Organization. 5 Changing History. The World health report 2004, World Health Organization. 6 Information furnished by the Ministry of Health and Environment of the Marshall Islands through the WHO Representative for the South Pacific in a memo dated 6 April 2001. 7 Pacific Islands Regional Millennium Development Goals report 2004. Noumea, Secretariat of the Pacific Community/ Un/ CROP MDG Working Group, November 2004. 8 WHO Regional Office for the Western Pacific, data received from technical units. 9 Meeting the MDG drinking water and sanitation target: A mid-term assessment of progress. WHO/ UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2004. 10 Pacific human development report 1999 (Creating opportunities). New York, United Nations Development Programme, June 1999. 11 Vital Statistics Division, Ministry of Health, Marshall Islands. 12 Information furnished by the Ministry of Health and Environment of the Marshall Islands through the WHO Representative in the South Pacific in a memo dated 10 February 2005. COUNTRY HEALTH INFORMATION PROFILE 171 13 Ministry of Health Services, Marshall Islands. 14 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. 172 | COUNTRY HEALTH INFORMATION PROFILES FEDERATED STATES OF MICRONESIA 1. DEMOGRAPHICS, GENDER AND POVERTY In 2005, the estimated population of the Federated States of Micronesia was 114 100, 41.6% of which were below 15 years old while 3.5% were 65 years or over. For every 100 females, there are about 102 males. The average age of the population is estimated to be 18.9 years. Almost 30% of the population reside in urban areas. Table 1. Core population and health data (2005 estimate) [Total] 114 100 [Both] 70.00 (2003 est) [0-14 years] 41.62% (2004 est) [Male] 68.00 (2003 est) Population [65+ years] 3.54% (2004 est) Life expectancy at birth (years) [Female] 71.00 (2003 est) Crude birth rate (per 1000 population) 23.30 (2003) Total fertility rate 4.40 (2000) [Total] 59.00 (2003) [Urban] 87.00 (2003) Crude death rate (per 1000 population) 4.40 (2003) % of population served with safe water [Rural] 31.00 (2003) [Total] 48.00 (2003) [Urban] 84.00 (2003) Infant mortality rate (per 1000 live births) 21.00 (2003) % of population with adequate sanitary facilities [Rural] 12.00 (2003) Maternal mortality ratio (per 100 000 live births) 317.00*(2003) *Based on child-bearing age 15-44 years old 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The Constitution of the Federated States of Micronesia provides for three separate branches of government at the national level, executive, legislative and judicial. It contains a Declaration of Rights, similar to the Bill of Rights of the United States of America, specifying basic standards of human rights consistent with international norms. The Congress of the Federated States of Micronesia is unicameral and has 14 senators, one from each state, elected for a four-year term, and 10 who serve two-year terms, whose seats are apportioned by population. The President and Vice-President are elected to four-year terms by the Congress. 2.2 Economic situation Economic activity consists primarily of subsistence farming and fishing. The islands have few mineral deposits worth exploiting, except for high-grade phosphate. The potential for a tourist industry exists, but the remote location, lack of adequate facilities, and limited air connections hinder development. In November 2002, the country experienced a further reduction in future revenues from the Compact of Free Association, the agreement with the United States of America, by which Micronesia received US$ 1.3 billion in financial and technical assistance over a 15-year period until 2001. Under the new compact, the country received approximately US$92 million a year until 2023, including contributions to a jointly managed trust fund. A Joint COUNTRY HEALTH INFORMATION PROFILES | 173 Economic Management Committee (JEMCO) consisting of representatives of both countries has been established to manage this compact assistance. Additional funding from the U.S. totalled $57 million in 2004. The country’s medium-term economic outlook appears fragile due, not only to the reduction in assistance from the United States of America, but also to the slow growth of the private sector. Geographical isolation and a poorly developed infrastructure remain major impediments to long- term growth. 3. HEALTH SITUATION 3.1 Health trends The overall health situation remained unchanged between 2000 and 2005, with the population showing continuing susceptibility to both communicable and noncommunicable diseases. Citizens of the Federated States of Micronesia enjoy a level of health care which is high in comparison with the rest of the Pacific region. Micronesian doctors have taken the place of United States doctors in much of the health system through such programmes as the now defunct Pacific Basin Medical Officer Training Programme in Pohnpei. Prenatal care is slowly improving in the state centres and is being expanded to remote areas. Death and illness due to diarrhoea and acute respiratory infections still form a large proportion of infant mortality and morbidity. The number of vaccine-preventable diseases has declined considerably. However, 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 (84.1%) was in 1992 and was the result of heavy campaigning at that time due to outbreaks of measles and the hepatitis B immunization campaign. A strategic plan to continue improvement of health services, public health surveillance and information systems are needed. 3.2 Health systems The development of the health workforce remains a government priority. The need has been met partially through overseas fellowship training and by the several dozen graduates of the Pacific Basin Medical Officer Training Programme from 1991 to 1996, but serious constraints remain. These include the lack of a nursing school and gaps in speciality training for both nurses and physicians. Government health services also lack specialized allied health professional workers, particularly hospital administrators, epidemiologists, medical record administrators, pharmacists, laboratory technicians, radiologists and environmentalists. Due to limited resources, medical and nursing fellowships have been prioritized, based on the states' requests. 4. NATIONAL HEALTH PLAN AND PRIORITIES There are 10 key health system issues confronting the Federated States of Micronesia: • improving health status; • setting clear priorities to ensure the most efficient use of resources; • establishing clear lines of inter- and intra-government accountability; • establishing new health system funding and financial management approaches; • building managerial capacity; • testing innovative approaches in every aspect of the system to increase quality, including improving both access for, and responsiveness to, the community; • introducing cost-effective new technologies; • focusing on functions that constitute public goods; FEDERATED STATES OF MICRONESIA 174 | COUNTRY HEALTH INFORMATION PROFILES • establishing national policies, measurable outputs and standards to be met, including their monitoring and regulation; and • developing the private health sector. 5. MAJOR INFORMATION SOURCES National Health Statistics Office, Department of Health, Education and Social Affairs Federated States of Micronesia Statistics Division, Department of Economic Affairs (http://www.spc.int/prism/) 2000 Population and Housing Census report. Division of Statistics, Department of Economic Affairs 6. ADDRESSES DEPARTMENT OF HEALTH SERVICES Office Address : Postal Address : P.O. Box PS 70, Palikir, Pohnpei FM 96941, Federated States of Micronesia Official Email Address : fsmhesa@mail.fm Telephone : Fax : (691) 3205263 Office Hours : Website : WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4 Provident Plaza One Downtown Boulevard 33 Ellery Street, Suva, Fiji 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 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILES | 175 ORGANIZATIONAL CHART: DEPARTMENT OF HEALTH SERVICES FEDERATED STATES OF MICRONESIA 176 FEDERATED STATES OF MICRONESIA WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 0.70 1 2 Estimated population ('000s) 114.10 57.66 56.44 2005 est 4 3 Annual population growth rate (%) 0.26 … … 2000 11 4 Percentage of population - 0–14 years 41.62 42.19 41.02 2004 est 2 - 65+ years 3.54 3.15 3.95 2004 est 2 5 Urban population (%) 29.00 … … 2003 3 6 Crude birth rate (per 1 000 population) 23.30 … … 2003 4 7 Crude death rate (per 1 000 population) 4.40 … … 2003 4 8 Rate of natural increase of population (% per annum) 1.89 a … … 2003 9 Life expectancy (years) - at birth 70.00 68.00 71.00 2003 est 5 - Heal th-adjusted Life Expectancy (H ALE) at age 60 … 10.90 11.50 2002 est 12 10 Adult literacy rate (%) 92.40 92.90 91.90 2000 6 11 Neonatal mortality rate (per 1 000 live births) 12.00 b … … 2000 est 5 12 Infant mortality rate (per 1 000 live births) 21.00 … … 2003 4 13 Under-five mortality rate (per 1 000 live births) 23.00 … … 2003 est 5 14 Total fertility rate (women aged 15–49 years) 4.40 2000 4 15 Maternal mortality ratio (per 100 000 live births) 317.00 c 2003 4 16 Percentage of newborn infants weighing at least 2500 g at birth 82.00 … … 2000 8 17 Prevalence of underweight children under five years of age 15.00 … … 1997 7 18 Percentage of pregnant women with anaemia 51.00 2000 8 19 Immunization coverage for infants (%) - BCG 62.00 … … 2004 9 - DTP3 78.00 … … 2004 9 - OPV3 82.00 … … 2004 9 - Measles 85.00 … … 2004 9 - Hepati tis B III 80.00 … … 2004 9 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 80.00 2000 8 - Percentage of pregnant women immunized with tetanus toxoid (TT2) NR 2004 9 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in heal th facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods 70.00 2000 8 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … COUNTRY HEALTH INFORMATION PROFILE 177 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 59.00 87.00 31.00 2003 4 26 Proportion of population with access to improved sanitation 48.00 84.00 12.00 2003 4 27 Proportion of the population using solid fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.57 … … 1998 10 32 Per capita GDP at current market prices (US$) 2200.00 … … FY2005est 14 33 Rate of growth of per capita GDP (%) 0.60 a … … FY2002 est 11 34 Health expenditure Total health expenditure - amount (in m illion US$) 9.26 2000 8 - total heal th expenditure on health as % of GDP 6.50 2004 5 - per capita total expendi ture on health (in US$) 143.00 2005est 13 Government expenditure on health - amount (in million US$) … - general government expenditure on health as % of total expenditure on health 88.20 2004 5 - general government expenditure on heal th as % of total general government expendi ture 8.80 2004 5 External source of government health expenditure - external resources for heal th as % of general government expendi ture on health … Private health expenditure - private expenditure on health as % of total expenditure on heal th 11.80 2004 5 Exchange rate in US$ of local currency is: 1 US$ = … 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 62 … … 5.43 … … 2005 4 - dentists 13 … … 1.14 … … 2005 4 - pharmacists 16 g … … 1.40 … … 2005 4 - nurses 229 … … 20.07 … … 2005 4 - m idwives 20 … … 1.75 … … 2005 4 - other nursing/ auxiliary staff 86 … … 7.54 … … 2005 4 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 325 … … 28.48 … … 2005 4 - other heal th personnel (health inspec tors, assistant sani tarians, traditional workers, etc.) 183 … … 16.04 … … 2005 4 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses 115 … … 2001 11 FEDERATED STATES OF MICRONESIA 178 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Five leading causes of morbidity Number Rate per 100 000 population 1. Pregnancy, childbirth and diseases of the perperium … 2775.40 2003 4 2. Diseases of the respiratory system … … … 1625.00 … … 2003 4 3. Infectious and parasi tic diseases … … … 1167.00 … … 2003 4 4. Diseases of the circulatory system … … … 1129.00 … … 2003 4 5. Endocrine, nutri tional and metabolic diseases … … … 1113.20 … … 2003 4 40 Five leading causes of mortality Number Rate per 100 000 population 1. Diseases of the circulatory system … … … 116.10 … … 2003 4 2. Neoplasms … … … 57.10 … … 2003 4 3. Diseases of the respiratory system … … … 55.30 … … 2003 4 4. Endocrine, nutri tional and metabolic diseases … … … 54.40 … … 2003 4 5. Infectious and parasi tic diseases … … … 40.00 … … 2003 4 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 9 - Pertussis (whooping cough) 0 0 0 0 0 0 2004 9 - T etanus 0 0 0 0 0 0 2004 9 - Neonatal tetanus 0 0 0 0 0 0 2004 9 - Poliomyelitis 0 0 0 0 0 0 2004 9 - Hib meningitis 0 0 0 0 0 0 2004 9 - Measles 0 0 0 0 0 0 2004 9 - Mumps 0 0 0 0 0 0 2004 9 - Rubella 0 0 0 0 0 0 2004 9 - Congeni tal rubella syndrome 0 0 0 0 0 0 2004 9 42 Selected communicable diseases Number of cases aa Number of deaths Hepati tis vi ral - T ype A 17 … … 0 0 0 C: 2005 D: 2004 C: 15, D:9 - T ype B 92 … ... 5 … … C: 2005 D: 2004 C: 15, D: 9 - T ype C … … ... 0 0 0 2004 9 - T ype E … … … … … … - Unspecified … … ... 0 0 0 2004 9 Cholera 0 0 0 0 0 0 2005 9 Typhoid fever 0 0 0 0 0 0 2005 9 Encephalitis 0 0 0 0 0 0 2005 9 Plague … … ... 0 0 0 2004 9 Syphilis 293 … … … … … 2005 11 Gonorrhoea (gonococcal infections) 55 … … … … … 2005 11 Leprosy 153 … … … … … 2004 9 Malaria … … … … … … Dengue/DHF 658 … … 0 0 0 2004 9 COUNTRY HEALTH INFORMATION PROFILE 179 INDICATORS DATA Year Source Total Male Female Total Male Female 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures d … - Proportion of population in malaria-risk areas using effective malaria treatment measures e … 44 Tuberculosis Number of cases Number of deaths - All types 118 … … … … … 2004 9 - New pulmonary tuberculosis (smear-posi tive) 35 … … … … … 2004 9 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 59.00 … … 4.00 … … 2004 9 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOT S) 120.00 … … 92.00 (2003) … … 2004 9 Number of cases Number of deaths f 45 Acute respiratory infections 8146 … … … … … 2002 11 46 Diarrhoeal diseases 1856 … … … … … 2002 11 47 Cancers All cancers (malignant neoplasms only) … … … 51 … … 2000 11 - T rachea, bronchus, and lung … … … 8 … … 2000 11 - Stomach … … … 14 … … 2000 11 - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … 4 … … 2000 11 - Liver … … … … … … - Cervix … … - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … 84 … … 2000 11 - Ischaemic heart disease … … … 34 … … 2000 11 - Acute m yocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … 3 … … 2000 11 - Cerebrovascular diseases … … … … … … - H ypertension … … … 6 … … 2000 11 49 Maternal causes - Haemorrhage … 6 2000 11 - Abortion … 4 2000 11 - Eclampsia … … - Sepsis … … - Obstruc ted labour … … 50 Diabetes mellitus … … … 47 … … 2000 11 51 Mental disorders … … … 0 0 0 2000 11 FEDERATED STATES OF MICRONESIA 180 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 52 Injuries - All types … … … 21 … … 2000 11 - Motor and other vehicle accidents … … … 4 … … 2000 11 - Suicide … … … 11 … … 2000 11 - Hom icide and violence … … … 6 … … 2000 11 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public heal th facilities - General hospitals 0 0 2005 8 - Specialized hospi tals 0 0 2005 8 - District/first-level referral hospitals 4 h 303 h 2005 8 - Dispensary / aid posts 109 0 2005 8 - Primary health care centres 6 i 18 i 2005 8 Private clinics (medical services) 5 8 2005 8 Private hospitals 1 36 2005 8 Notes: Red text M illennium Development Goals (MDG) indicators … Data not available est Estimate NR Not relevant FY The financial year refers to the span from April 1 of respective year to March 31 next year. aa Figure refers to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Uni t of the WHO Regional Office for the Western Pacific . b Estimates derived by regression and similar estimation records. c Figure is based on child-bearing age 15-44 years old. d Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. e Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. f Deaths certi ficates based on underlying causes. g Figure refers only to pharmacy technicians. h Figure refers to state hospi tals. i Figure refers to community health centres. Sources: 1 Pacific islands populations 2004. Secretariat of the Pacific Community (http://www.spc.int/) 2 Demographic tables 2000-2005 for the Western Pacific Region. Manila, WHO Regional Office for the Western Pacific, 2005. 3 World population 2002. New York, United Nations Population Division Department of Economic and Social Affairs, 2002. 4 National Health Statistics Office, Department of Health, Education and Social Affai rs, 2005. 5 The world heal th report 2005. Geneva, World Heal th Organization, 2005. 6 2000 Population and Housing Census report. Division of Statistics, Department of Economic Affairs, May 2002. 7 Pacific islands Regional Millennium Development Goals report 2004. Secretariat of the Pacific Community and UN/CROP MDG Working Group, November 2004. 8 Department of Health, Education and Social Affai rs. 9 WHO Regional Office for the Western Paci fic, data received from technical units COUNTRY HEALTH INFORMATION PROFILE 181 10 Pacific human development report 1999 (creating opportuni ties). New York, Uni ted Nations Development Programme, June 1999. 11 The Federated States of M icronesia Statistics Division, Department of Economic Affairs http://www.spc.int/prism) 12 The World health report 2004: Changing history. Geneva, World Heal th Organization, 2004. 13 HNP ata Glance: Federated States of Micronesia, 2005. World Bank. Available at http://devdata.worldbank.org/hnpstats/HnpAtaGlance.asp?sC try=FSM,Micronesia,%20Fed.%20Sts 14 Background Note, Micronesia, 2005. U.S. Department of State, Bureau of East Asian and Pacific Affai rs. Available at http://www.state.gov/r/pa/ei /bgn/1839.htm 15 Information furnished by the Department of Heal th, Education and Social Affairs, FSM National Government, through the Office of the WHO Representative for South Pacific, 21 March 2006. 182 | COUNTRY HEALTH INFORMATION PROFILES MONGOLIA 1. DEMOGRAPHICS, GENDER AND POVERTY Landlocked between the Russian Federation and China, Mongolia is the fifth largest country in Asia, with a total area of 1565 million square kilometres. In 2004, the resident population was 2 533 100, an increase of 1.2% over that of the previous year. Of the total population, 49.6% are men, giving a ratio of 98.5 males for every 100 females. In 2004, about 59.1% of the total population were living in urban areas. The birth rate has declined by nearly 52% over the past ten years as a result of a 40% drop in the marriage rate, greater use of contraceptives, legalization of abortions, delayed marriages and a longer interval between births. In 2004, the population growth rate was 11.6 per 1000 live births and the average life expectancy at birth was 64.6 years, 61.6 years for males and 67.8 years for females. The total fertility rate decreased from 2.1 in 2002, to 2.00 in 2003 and 1.90 in 2004. According to the household income and expenditure sample surveys of the latest three years, total household income has increased in terms of current prices. According to the results of sample surveys carried out with the purpose of defining household living standards and poverty in 1995, 1998 and 2002-2003, rural areas experience much more poverty than urban areas. However there is a more unequal distribution of income among the populations in urban areas. Table 1. Core population and health data (2005) [Total] 2 533 100 (2004) [Both] 64.60 (2004) [0-14 years] 32.63% (2004) [Male] 61.60 (2004) Population [65+ years] 3.50% (2004) Life expectancy at birth (years) [Female] 67.80 (2004) Crude birth rate (per 1000 population) 18.10 (2004) Total fertility rate 1.90 (2004) [Total] 41.50 (2002) [Urban] 62.10 (2002) Crude death rate (per 1000 population) 6.50 (2004) % of population served with safe water [Rural] 17.30 (2002) [Total] 40.20 (2002) [Urban] 45.30 (2002) Infant mortality rate (per 1000 live births) 20.80 % of population with adequate sanitary facilities [Rural] 37.50 (2002) Maternal mortality ratio (per 100 000 live births) 93.80 The percentages of men and women among the economically active population are nearly the same, while women account for a greater share of the registered unemployed. The number of registered unemployed increased by 6.7% during 2004, with females accounting for 55.2%. The end of the preferential textile export provisions on 1 January 2004 resulted in some 40 000 additional unemployed, the majority of whom were female. Labour force participation rates are estimated at 64.4% for women and 67.6% for men. Educational enrolment rates at all levels continue to be higher for school-age girls than for school-age boys. Among the poor, female school enrolment rates greatly exceed those of boys while, for the non-poor, female enrolment only marginally exceeds that of boys. Using a low poverty line (approximately US$ 20.00 per month per person), some 36.1% of the population are classified as poor. In urban areas, the poor account for 30% of the population, while in rural areas they account for 43%. For all of Mongolia, the average consumption per person in 2003 was estimated at less than US$ 30.00 per month. With very harsh winters, poverty COUNTRY HEALTH INFORMATION PROFILES | 183 and homelessness are life-threatening issues in Mongolia. Gers accommodate 45% of the Mongolian population, with apartments accommodating 20%. Some 43.4% of the population living in gers are estimated to live on less than US$ 20.00 per month, with very limited access to safe water, sanitation and basic infrastructure services. The cost of heating a ger is not insignificant for the poor, as the lowest temperature measured in 2005 reached -50C. Inequality, as measured by the Gini coefficient, is 0.33. As noted in the Household Income and Expenditure Survey (HIES) 2002-2003, spending on health care represents 5% of the average household’s consumption, with the non-poor spending more than three times as much as the poor. Expenditure on self-prescribed medicines represents almost half total personal spending on health, and two-thirds of the poor’s total health expenditure. Although more females than males report health complaints (7.6%/5.2%), there is little difference in their treatment-seeking behaviour (72%/70%). The non-poor have more health complaints than the poor (7.4%/4.6%), while more of the non-poor seek treatment than the poor (74%/63%). 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation A new government was installed in Mongolia in August 2004, with an equal balance between the Mongolian People’s Revolutionary Party (MPRP) and a coalition of democratic parties. Subsequently, in December 2004, after agreeing on a joint action plan, the coalition dissolved, leaving the MPRP in essential control of Parliament. However, in January 2006 the resignation of the Joint Government was effected by the resignation of 10 MPRP ministers, who formed the majority in an 18-member cabinet, with the remaining ministers coming mainly from the Mongolian Democratic Party (MDP). Frequent changes of ministers and vice-ministers, along with subsequent and continuing changes in senior staff of the Ministry of Health, has not facilitated the implementation of health-related programmes. The Government approved the final Poverty Reduction Strategy Paper (PRSP) in 2003 and the first report to monitor Mongolia’s progress towards the Millennium Development Goals (MDGs) in January 2004. Linking the PRSP to support progress towards the MDGs will require additional government action. The Government’s new action plan does include limited financial support for the very poor. 2.2 Economic situation During the early years of economic transition, Mongolia experienced negative growth rates of 9.2% in 1991 and 9.5% in 1992. Since 1994, the country has been experiencing positive economic growth, despite recent natural disasters. Real gross domestic product (GDP) increased by 1% in 2001, 4% in 2002 and an estimated 10% in 2004, primarily as a result of growth in the mining sector. The inflation rate fell from 8% in 2000-2001 to 1.6% in 2002. However, inflation at the end of 2004 was reported to be 11%, based on the consumer price index for the end of 2003. Bank interest rates remain above 30%. By the end of 2004, the money supply had increased by 33.8% over that for 2003, and tax revenue by 37.5%. In 2002, GDP at constant prices was increased by 2.1 % against the 1989 data, the first time that GDP at constant prices had exceeded the 1989 level since the transition to a market economy was started. As a result of the rapid transition to a market economy, there has been significant change in property relations in the economy. The private sector’s share was only 3.3% of GDP in 1989, but in 2004 it reached 76.0 %. The private sector’s share of GDP is accordingly higher in the following sectors: the hotels and restaurant sector (100 %); the trade sector (99.9 %); the agriculture, hunting and forestry sector (95.9 %); and the construction sector. MONGOLIA 184 | COUNTRY HEALTH INFORMATION PROFILES In 1990, budget revenue constituted 50.9% of GDP; in 1991-1999 it dropped to 32.0%-28.8%, affected by the changes in tax policy and the legal environment in Mongolia. Since 2000, budget and fiscal policies have been directed towards macroeconomic stabilization. In November 2002, the Mongolian General Government Budget Law was approved, reflecting major changes in classification of budget revenues and expenditures. The Ministry of Health is now directly involved in the decision-making process for the allocation of public finances to health care institutions and programmes. There have been increasing total budget revenues and grants since 2000 compared with 2001; 2004 preliminary results show that revenues and grants increased by 1.6 times and expenditures by 1.5 times. The start of 2005 saw the implementation of the Government’s Financial Management Information System, with the support of the World Bank. The system will facilitate the adoption and use of national health accounts, which will be jointly supported by the World Bank and WHO. Mongolia also received a grant from the World Bank to assist the Ministry of Health in building local capacity to develop a national health accounts (NHA) system to track the sources and use of funds in the health system. The project commenced in March 2003 and ended on 27 May 2005. In November 2005, a Ministerial Order transferred the NHA project outputs to the newly established NHA Unit of the National Center for Health Development (NCHD). 3. HEALTH SITUATION 3.1 Health trends Since the beginning of the 1990s, the mortality pattern has shown a rapid epidemiological transition. Cardiovascular diseases, cancer and injuries and poisonings have increased, while deaths from communicable and respiratory diseases have declined. The end of the 1990s saw injuries and poisonings exceeding respiratory diseases as a cause of death. Excessive maternal mortality is a priority concern of the Ministry of Health. The maternal mortality ratio has been decreasing for the past five years and reached 93.8 per 100 000 live births in 2005 due to increased government attention, after being relatively stable at the level of 145-176 per 100 000 live births in the period from 1996 to 2001. Maternal mortality reduction is one of the main themes of the State Policy on Population Development (2004) and the Maternal Mortality Reduction Strategy (2000, 2005) approved by the National Reproductive Health Programme, as well as other national programmes. The State Public Health Policy (2001), approved by Parliament, puts special emphasis on improving reproductive health services for the vulnerable and those living in remote areas. Although antenatal care has reached almost universal levels, with no rich/poor divide, many rural women do not have easy physical access to prenatal care. Complications of pregnancy, delivery and puerperium, as well as extragenital diseases are responsible for 22.7%, 25.0%, 6.8% and 45.5% of maternal mortality, respectively. Latest figures also show that 38.6% of maternal deaths were among herders and 45.5% among urban housewives. The steady decline in infant and under-five mortality rates during the last decade is attributed to the implementation of such effective public health measures as the Expanded Immunization Programme, application of the integrated management of childhood illness(IMCI) strategy, and promotion of breast-feeding. There was a twofold decrease in the under-five mortality rate between 1990 and 2000, and in 2005 the rate was 25.6 per 1000 live births. The goal of under- five mortality reduction is reflected in several health and social welfare programmes and policy papers in Mongolia. The country ratified the United Nations Convention on the Rights of the Child in 1992, and has approved the National Programme on Child Development (1990-2000) and the National Programme on Improving Child Development and Protection (2002-2010). COUNTRY HEALTH INFORMATION PROFILES | 185 In 2005, 32 332 cases of infectious diseases were registered, with an incidence rate of 128.5 per 10 000 population. Sexually transmitted infections (47.4% of all), viral hepatitis (19.7%) and tuberculosis (13.6%) continue to be the top infections. Sexually transmitted infections (STIs) are common and increasing among both the general adult population and vulnerable groups. The first HIV case was reported in 1992, and four more cases were reported from 1997 to 2004. In 2005, 11 HIV cases were reported. Three of the reported cases have led to AIDS-related deaths. Although the HIV/AIDS prevalence rate is low, the country is at high risk of an epidemic due to the relatively young population (more than 50% below 23 years); the steady increase in STIs in recent years; increased population migration; growing HIV/AIDS epidemics in neighbouring countries, China and Russia; and the growing number of visiting tourists. In recent years, the number of tuberculosis cases has remained high, comprising 13.6% of all reported communicable diseases. In 2005, TB incidence was 17.5 per 10000 population. Within the framework of National Tuberculosis Programme, the directly observed treatment, short- course (DOTS) strategy was introduced in 1995, and has been implemented successfully since then. As a result, DOTS coverage increased from 6.5% in 1995 to 100% in 2004. Mongolia is experiencing high incidence rates of cardiovascular disease, cancer, injuries and mental health problems. Because these noncommunicable diseases (NCD) are accounting for a growing share of all deaths, the Ministry of Health started to plan integrated prevention and control programmes for NCDs in 2001, with WHO support. In addition, Parliament has ratified the Framework Convention on Tobacco Control. In 1999, tobacco consumption was excessive, with 56.8% of males aged 35 to 44 smoking cigarettes daily. Females were less frequent users, with 5.9% smoking daily in 1999. Injuries, poisonings and other external causes is the third leading cause of death (103.4 per 100 000 population in 2004) and the fifth leading cause of outpatient morbidity. It was the fifth leading cause of population mortality in 1990, moving to fourth place in 1994 and third place in 2000. In 2004, the majority of fatal accidents and injuries were associated with excessive alcohol consumption. Traffic accidents, suicides and homicides accounted for 20.4%, 17.1% and 14.1% of injury mortality, respectively. Self-medication, including self-injection, is a problem that mirrors the irrational use of drugs and injectables in health care settings. 3.2 Health systems Aggravating factors affecting the health system include a sparse population spread over huge areas, growing patient expectations, and an overprovided health system (26.17 physicians and 72.94 beds per 10 000 population in 2004), with problems in cost-effectiveness (a high hospital admission rate of 2203 per 10000 population and a average length of stay 9.7 days in 2004). From 2003 to 2004, the share of private hospital beds increased from 9.5% to 10% and private hospital admissions increased from 9.1% to 10.4%. The excessive admissions and long length of stay are thought to be related to the quality of diagnostic and care services as well as perverse incentives. Within the framework of the Health Sector Development Programme, family group practices (FGPs) have been established in Ulaanbaatar city and aimag centres. As of 2004, there were 230 FGPs. One family doctor provides health care to 1460 persons (on average), with an average of 3.6 outpatient visits per registered person. In an effort to provide tertiary-level health services on a regional basis, three provincial hospitals were upgraded in 2002 to regional diagnostic and treatment centres, with the objective of also providing specialized services for neighbouring provinces. In the last few years, new equipment has been provided and new specialists recruited for these regional centres to improve coverage of the population in remote rural areas and ensure access to quality services. MONGOLIA 186 | COUNTRY HEALTH INFORMATION PROFILES The structure and performance standards for inter-soum hospitals were approved in 2001. These hospitals have the mandate of providing higher levels of primary health care to the populations of two or more neighbouring districts (soums). However, the populations served by soum hospitals have inadequate access to essential medicines. Additionally, very few soum hospitals have running water or acceptable sanitation facilities, and very few have indoor sanitation facilities. Many collect water in containers from unimproved and unprotected water sources. Diagnostic support services in soum hospital are essentially nonexistent. At the end of 2004, Mongolia had 577 private hospitals and clinics. Most pharmacies are private. Despite the relatively high number of organizations, the private sector is not well developed due to low purchasing power, lack of managerial capacity and a traditionally large public sector. Most private health enterprises are located in the capital city. The number of Mongolians seeking health care in neighbouring countries is thought to be increasing as a result of the increased assets of the non-poor and because of poor maintenance and use of diagnostic equipment in Mongolia. In 2004, the total number of health workers was 33478, including 6590 doctors, 913 pharmacists and 7915 nurses. The continued overproduction of physicians has resulted in a high physician- nurse ratio of 1:1.2. A human resource development policy, approved in November 2003, is focused on planning, development, distribution and management of human resources in 2004- 2013. Despite 2003 being designated as the year of the soum hospital and significant financial support being given by the Asian Development Bank (ADB) to retain soum doctors, there was an almost 5% decrease in the number of doctors working in district, inter-soum and soum hospitals and family practices from 2002 to 2003. During the same period, there was a 10% increase in the number of doctors working in private institutions. The previous Directorate of Medical Services was reorganized into a National Center for Health Development in early 2005. The percentage of GDP spent on health has increased slightly in the last few years, reaching 4.7% in 2002, resulting in per capita health expenditure of US$ 23. The main financing sources are the state budget (68.9% in 2004), health insurance fund (27.4%) and out-of-pocket payments and other sources (3.7%). Donor aid has accounted for about 15%-20% of all health spending during recent years. In 2004, health accounted for 10.1% of total government expenditures. In 2002, the provincial and district hospitals and the tertiary level centres consumed 54% of health spending, 6% lower than in 1999. During the same period, funding to rural district (soum) hospitals and family practices increased by 6.7%, in line with government policies to strengthen primary health care. Despite this increase, serious spatial inequalities persist. Social health insurance (introduced in 1994) covered 80% of the population in 2002, with the state subsidizing the premiums for 73% of those insured. Over 90% of health insurance funds are spent on inpatient care, 7% on outpatient care, and about 2% on operational costs. Efforts to improve donor coordination and cooperation are under way, with the Ministry of Health and WHO co-chairing a donor coordination programme under the proctorship of the Ministry of Finance. The Ministry now has a website which lists all projects and donor contributions. Health sector donor meetings were conducted at the end of 2005 with WHO support. Donor organizations have been informed of the intention to introduce and implement a sectorwide approach in the health sector in order to improve donor coordination. With the adoption of a new maternal mortality reduction strategy in 2005, the Government is focusing new resources on this effort. Contributing and collaborating organizations include ADB, Gesellschaft fűr Technische Zusammenarbeit (GTZ), the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), World Vision and WHO. GTZ, UNICEF and WHO continue to support IMCI activities directed at reducing child COUNTRY HEALTH INFORMATION PROFILES | 187 mortality. The Global Fund and WHO support tuberculosis reduction efforts and ADB, UNICEF, World Bank and WHO support improved access to potable water. In April 2004, the Ministry of Health submitted a project proposal to the Global Alliance for Vaccine and Immunization (GAVI) for new vaccine introduction and safe immunization. The main objective of the project is to introduce the DTP-HepB-Hib combination vaccine and auto- disable (AD) syringes into the routine EPI programme in order to decrease childhood mortality and morbidity caused by Hib infections and reduce the operational costs of the EPI programme. This five-year project was approved in July 2004 with total funding of US$ 3 325 000. GAVI will provide 52 500 doses of pentavalent vaccine, 53 700 AD syringes, 29 200 reconstitution syringes and 925 safety boxes in 2005. The pentavalent vaccine was introduced in January 2005, initially in Ulaanbaatar city and two provinces (Gobi-Sumber and Dornogobi), following a three-dose schedule at two, three and four months. The Government has developed a plan for phased introduction of combination DTP-HepB-Hib vaccine over three years (2005-2007). Nationwide coverage will be achieved in 2008. In April 2005, the Ministry of Health submitted a proposal to the fifth round of the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM), requesting support for the HIV/AIDS programmes. It was approved, with a budget of US$ 4.2 million for the period from 2006 to 2011. The main objectives of the project are: (1) to reduce HIV transmission among vulnerable populations through reduction of high-risk behaviours by scaling up existing targeted prevention interventions; (2) to establish and scale up prevention programmes at workplaces vulnerable to HIV/AIDS/STI (mining, construction, transportation, trade, entertainment companies and uniformed services); (3) to strengthen the health system for improved prevention, care and support programmes regarding HIV/AIDS/STI, including the link between HIV and TB; and (4) to scale up HIV/AIDS advocacy, human rights protection and de-stigmatization. Recent indicators of Mongolia’s efforts to reach MDG targets present a mixed picture of achievements and problems. Clear advances have been made in reducing maternal and child mortality, which give an indication that the country can reach the MDG targets in these two areas with continued high-level government support. Additionally, with increased donor funding for tuberculosis control, the related target for Mongolia is clearly reachable. However, data from 2004 show that poverty is not decreasing and there is no evidence that the prevalence of underweight children is falling. Although significant donor resources are being directed towards improving the piped water supply to peri-urban ger communities, these communities are growing faster than new water transport systems are being installed. There are no significant developments for increased potable water supply systems outside Ulaanbaatar. Aside from some scattered projects promoting VIP latrines, the Government has not yet started any programme to increase access to improved sanitation facilities. Essentially all soum hospitals and soum boarding schools utilize unacceptable, outdoor basic sanitation facilities. 4. NATIONAL HEALTH PLAN AND PRIORITIES According to the Government's Plan of Action, the health priorities are to provide good quality primary health services, improve rural health care, develop the private health sector and expand health insurance coverage. In addition to the Plan of Action, the most important policy document is the State Public Health Policy, approved in November 2001. With the support of the Government of Japan (JICWELS), the Ministry of Health developed a Health Sector Master Plan for 2006-2015, representing the Ministry’s first comprehensive documentation of its future directions and incorporating the Government’s commitment to the MDGs. The “Maternal mortality reduction strategy” was revived and approved by Ministerial Order # 35 in 2005. The “Strategy on prevention of malnutrition among women and chidlren” was developed and approved by Ministerial Order #85 of April 15, 2005. This strategy is an important policy MONGOLIA 188 | COUNTRY HEALTH INFORMATION PROFILES document which serves as a coordination mechanism for many small programmes and projects on malnutrition prevention. By Government Resolution # 271 of December 24, 2005, the programme on “ Elderly health and social protection” will continue until 2008. The Government established a Gerontogy and Rehabilitation Centre in 2005. In 2005, the “Health management information system development strategy” was developed. The Joint Order of the Ministers of Education and Health #188/143 approved the 2003-2006 Plan of Action and mid-term strategy on implementation of the National Programme on Population Health Education and Development of Medicine. The national Programme on Noncommunicable Disease Prevention and Control was approved by the Government at the end of 2005. The National Programme on Environmental Health 2006-2010 was approved by the Government in 2005. The issue of environmental health has spread beyond one country, region and continent, having become one of the critical/crucial modern problems of the world. Effective solution of this problem will be a pillar condition in reaching the Millennium Development Goals. Health legislation and most national health programmes have been updated in the last few years. However, programme implementation depends on international support, as government health spending is mainly used for inpatient care. The following policies and programmes have been implemented to address the most pressing health issues: ▶ State policies: • State policy to develop Mongolian traditional medicine; • State public health policy; • National drug policy; • Reform and privatization in the social sector; • Human resource policy for the health sector; • State policy on population. ▶ Health-related laws: • Health law of Mongolia, revised in 2005 • Drug law of Mongolia; • Citizen's health insurance law of Mongolia; • Sanitation law of Mongolia; • Mental health law of Mongolia; • Immunization law of Mongolia; • Donor law of Mongolia; • Tobacco law of Mongolia; • Anti-alcohol law of Mongolia; • Law on salt iodization and prevention of iodine deficiency; • HIV/AIDS law of Mongolia, revised in 2004; • Law on welfare and services for the elderly; • Law on social welfare for the disabled; • Law on control of narcotic drugs and other psychotropic substances; • Spa resort law of Mongolia; COUNTRY HEALTH INFORMATION PROFILES | 189 ▶ National health programmes: • National programme to improve health and social welfare of the elderly, 1999- 2004; • National cancer programme, 1997–2005; (finished) • National programme on improving children's development and protection, 2002-2010; • National programme on population health education, 1998-2005; (finished) • Oral health programme, 2000-2005; ( to be continued) • National programme on outsourcing some of the health services, 2000- (has been discontinued with the approval of State policy on social sector reform and privatisation); • National reproductive health programme, 2002-2006; • National mental health programme, 2002-2007; • National programme against iodine deficiency disorder, 2002-2006; • Soum hospital development programme, 2002-2008; • National programme on population physical fitness, 2002-2008; • National programme to combat infectious diseases, 2002-2010; • National programme on injury prevention, 2002-2008; • Cardiovascular disease prevention programme, 2001-2020; • Blindness prevention programme, 2000-2010; • National programme to develop spa resorts, 2003-2010; • National programme on health technology improvement, 2003-2008; • National programme on food supply, safety and nutrition, 2001- 2005; • National programme to improve the lives of the disabled, 1998-2004; • Strategic plan to reduce maternal mortality, 2001-2004. 5. MAJOR INFORMATION SOURCES Mongolian statistical yearbook 2004. Ulaanbaatar, National Statistical Office, 2005 Mongolian population in XX century, Ulaanbaatar, National Statistical Office, 2003 ‘ Mongolia in a market system’ statistical yearbook, Ulaanbaatar, National Statistical Office, 2004 Health sector 2002: Reducing maternal mortality. Ulaanbaatar, Ministry of Health, 2003. Health sector of Mongolia: 80 years. 2nd edition. Ulaanbaatar, Ministry of Health, 2002. Health indicators 2004 Ulaanbaatar, Directorate of Medical Services, 2005. Mongolian statistical yearbook 2004. Ulaanbaatar, National Statistical Office, 2005 Human development report, Mongolia, 2003. Implementation of the Millennium Development goals in Mongolia – National report 2004 Main Report of the “Household income and expenditure survey/living standards”. New York, United Nations Development Programme, 2004. Mongolia public expenditure and financial management review, 2003-2004. World Bank, 2004 MONGOLIA 190 | COUNTRY HEALTH INFORMATION PROFILES 6. ADDRESSES MINISTRY OF HEALTH Office Address : Ministry of Health Government Building-8 Olympic Street-2 Ulaanbaatar – 210648, Mongolia Postal Address : Official Email Address : moh@moh.mng.net Telephone : (976) 11-321569 Fax : (976) 11-320916 Office Hours : 0900H-1800H Website : http://www.moh.mn WHO REPRESENTATIVE IN MONGOLIA Office Address : Ministry of Health Government Building-8 Ulaanbaatar, Mongolia Postal Address : WHO Representative Office P.O. Box 663 Ulaanbaatar-13, Mongolia Official Email Address : who@mog.wpro.who.int Telephone : (976) 11-327870, 11-322430 Fax : (976) 11-324683 Office Hours : 0830H-1700H Website : ORGANIZATIONAL CHART: MINISTRY OF HEALTH COUNTRY HEALTH INFORMATION PROFILE 191 MONGOLIA WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 1565.00 2004 1 2 Estimated population ('000s) 2533.10 1256.70 1276.40 2004 1 3 Annual population growth rate (%) 1.10 … … 2004 1 4 Percentage of population - 0–14 years 32.63 32.83 32.44 2004 1 - 65+ years 3.50 3.05 3.96 2004 1 5 Urban population (%) 59.10 … … 2004 1 6 Crude birth rate (per 1 000 population) 18.10 … … 2004 1 7 Crude death rate (per 1 000 population) 6.50 … … 2004 1 8 Rate of natural increase of population (% per annum) 1.16 … … 2004 1, 4 9 Life expectancy (years) - at birth 64.60 61.60 67.80 2004 1 - Health-adjusted Life Expectancy (HALE) at age 60 … 10.20 12.40 2002 3 10 Adult literacy rate (%) 97.80 98.00 97.50 2003 3 11 Neonatal mortality rate (per 1 000 live births) 13.00 … … 2004 2 12 Infant mortality rate (per 1 000 live births) 20.80 … … 2005 1 13 Under-five mortality rate (per 1 000 live births) 25.60 … … 2005 1 14 Total fertility rate (women aged 15–49 years) 1.90 2004 1 15 Maternal mortality ratio (per 100 000 live births) 93.80 2005 2 16 Percentage of newborn infants weighing at least 2500 g at birth 95.90 96.40 95.40 2004 2 17 Prevalence of underweight children under five years of age 12.50 … … 1999 3 18 Percentage of pregnant women with anaemia 14.40 2004 2 19 Immunization coverage for infants (%) - BCG 95.00 … … 2004 6 - DTP3 98.90 … … 2004 6 - OPV3 95.00 … … 2004 6 - Measles 96.00 … … 2004 6 - Hepatitis B III 95.00 … … 2004 6 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 98.00 2004 2 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) 99.70 2004 2 21 Percentage of women in the reproductive age group using modern contraceptive methods 51.28 2004 2 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab 0 0 0 2000 5 MONGOLIA 192 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 41.50 62.10 17.30 2002 2 26 Proportion of population with access to improved sanitation 40.20 45.30 37.50 2002 2 27 Proportion of the population using solid fuels for cooking or heating (%) 51.00 b … … 2003 6 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.68 … … 2003 7 32 Per capita GDP at current market prices (US$) 500.62 … … 2004 5 33 Rate of growth of per capita GDP (%) 10.60 … … 2004p 5 34 Health expenditure Total health expenditure - amount (in million US$) 79.81 2004 4 - total health expenditure on health as % of GDP 6.30 2004 4 - per capita total expenditure on health (in US$) 31.67 2004 4 Government expenditure on health - amount (in million US$) 45.73 2004 4 - general government expenditure on health as % of total expenditure on health 68.90 2004 4 - general government expenditure on health as % of total general government expenditure 8.22 2004 4 External source of government health expenditure - external resources for health as % of general government expenditure on health 22.19 2004 Private health expenditure - private expenditure on health as % of total expenditure on health 3.70 2004 4 Exchange rate in US$ of local currency is: 1 US$ = 1209.00 MNT (average) 2004 35 Health insurance coverage as % of total population 89.90 2004 4 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 6590 1424 5166 26.17 11.63 40.29 2004 2 - dentists 438 … … 1.74 … … 2004 2 - pharmacists 913 72 841 3.63 0.59 6.56 2004 2 - nurses 7915 154 7761 31.43 1.26 60.52 2004 2 - midwives 616 … … 2.45 … … 2004 2 - other nursing / auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 6480 … … 26.35 … … 2004 2 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … COUNTRY HEALTH INFORMATION PROFILE 193 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Diseases of the respiratory system 216 466 101 716 114 705 8594.79 8310.11 8948.54 2004 2 2. Diseases of the digestive system 186 655 81 665 104 990 7411.14 6671.96 8187.43 2004 2 3. Diseases of genitourinary system 172 453 42 065 130 388 6847.25 3436.67 10168.04 2004 2 4. Diseases of the circulatory system 127 032 51 339 75 693 5043.81 4194.35 5902.76 2004 2 5. Injuries, poisoning and other consequences of external causes 93 109 62 760 30 349 3696.90 5127.44 2366.70 2004 2 6. Diseases of the nervous system 52 165 23 255 28 910 2071.21 1899.91 2254.49 2004 2 7. Diseases of the skin and subcutaneous tissues 64 015 32 031 31 984 2541.71 2616.91 2494.21 2004 2 8. Infectious and parasitic diseases 34 679 15 361 19 318 1376.93 1254.98 1506.47 2004 2 9. Diseases of the eye and adnexa 23 327 16 701 6 626 926.20 1364.46 516.71 2004 2 10. Mental and behavioural disorders 28 658 15 457 13 201 1137.87 1262.82 1029.35 2004 2 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Diseases of the circulatory system 5808 3233 2575 230.61 264.13 200.81 2004 2 2. Tumours and neoplasms 3062 1700 1362 121.58 138.89 106.21 2004 2 3. Injuries, poisoning and other consequences of external causes 2603 2094 509 103.35 171.08 39.69 2004 2 4. Diseases of the digestive system 1213 679 534 48.16 55.47 41.64 2004 2 5. Diseases of the respiratory system 764 455 309 30.33 37.17 24.10 2004 2 6. Certain conditions originating in the perinatal period 472 272 200 18.74 22.22 15.60 2004 2 7. Diseases of genitourinary system 339 192 147 13.46 15.69 11.46 2004 2 8. Infectious and parasitic diseases 378 226 152 15.01 18.46 11.85 2004 2 9. Diseases of the nervous system 221 127 94 8.77 10.38 7.33 2004 2 10. Congenital malformations, deformations and chromosomal abnormalities 138 82 56 5.48 6.70 4.37 2004 2 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 6 - Pertussis (whooping cough) 0 0 0 0 0 0 2004 6 - Tetanus 0 0 0 0 0 0 2004 6 - Neonatal tetanus 0 0 0 0 0 0 2004 6 - Poliomyelitis 0 0 0 0 0 0 2004 6 - Hib meningitis 25 … … … … … 2004 6 - Measles 0 0 0 0 0 0 2004 6 - Mumps 417 … … 0 0 0 2004 6 - Rubella 36 … … 0 0 0 2004 6 - Congenital rubella syndrome 0 0 0 0 0 0 2004 6 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral 6372 3453 2919 39 19 20 2005 2 - Type A 5325 2851 2474 0 0 0 2005 2 - Type B 867 515 352 0 0 0 2005 2 - Type C 165 78 87 0 0 0 2005 2 - Type E - Unspecified 15 9 6 ... ... ... 2005 2 Cholera 0 0 0 0 0 0 2005 6 Typhoid fever 14 ... ... 0 0 0 2005 6 Japanese Encephalitis 0 0 0 0 0 0 2005 6 MONGOLIA 194 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Plague 0 0 0 0 0 0 2005 6 Syphilis 2387 837 1550 1 1 0 2005 2 Gonorrhoea 6371 2760 3611 0 0 0 2005 2 Leprosy 0 0 0 0 0 0 2004 6 Malaria 0 0 0 0 0 0 2005 2 Dengue 0 0 0 0 0 0 2004 6 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 4570 … … … … … 2004 6 - New pulmonary tuberculosis (smear-positive) 1808 … … … … … 2004 6 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 209.00 … … 24.00 … … 2004 6 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 80.00 … … 87.00 (2003) … … 2004 6 Number of cases Number of deaths 45 Acute respiratory infections 152 264 62 761 89 503 491 280 211 2004 2 46 Diarrhoeal diseases 16 107 8247 7860 115 62 53 2004 2 47 Cancers All cancers (malignant neoplasms only) 3381 1788 1593 2669 1537 1132 2004 2 - Trachea, bronchus, and lung 345 264 81 331 262 69 2004 2 - Stomach 469 311 158 394 253 141 2004 2 - Colon and rectum 76 43 33 55 20 35 2004 2 - Lip, oral cavity and pharynx 49 30 19 39 23 16 2004 2 - Liver 1312 756 556 1175 681 494 2004 2 - Cervix 264 82 2004 2 - Leukaemia 22 14 8 24 15 9 2004 2 48 Circulatory All circulatory system diseases 127 032 51 339 75 693 5808 3233 2575 2004 2 - Ischaemic heart disease 27 694 12 602 15 092 1106 590 516 2004 2 - Acute myocardial infarction 1453 745 708 682 494 188 2004 2 - Rheumatic fever and rheumatic heart diseases 19 025 5886 13 139 67 30 37 2004 2 - Cerebrovascular diseases 13 907 6635 7272 2478 1344 1134 2004 2 - Hypertension 49 822 18 700 31 122 444 237 207 2004 2 COUNTRY HEALTH INFORMATION PROFILE 195 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 49 Maternal causes - Haemorrhage 1365 7 2004 2 - Abortion 8919 0 2004 2 - Eclampsia 6782 6 2004 2 - Sepsis 61 0 2004 2 - Obstructed labour 10128 11 2004 2 50 Diabetes mellitus 1810 875 935 33 20 13 2004 2 51 Mental disorders 28 658 15 457 13 201 26 15 11 2004 2 52 Injuries - All types 93 109 62 760 30 349 2603 2094 509 2004 3 - Motor and other vehicle accidents … … … 531 413 118 2004 3 - Suicide … … … 451 381 70 2004 3 - Homicide and violence … … … 358 297 61 2004 3 - Occupational injuries … … … 20 17 3 2004 3 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 34 4644 2004 2 - Specialized hospitals 17 4180 2004 2 - District/first-level referral hospitals 12 / 327 4579 2004 2 - Primary health care centres 230 … 2004 2 Private hospitals (and clinics) 577 1839 2004 2 Notes: Red text Millennium Development Goals (MDG) indicators … Data not available p Preliminary aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Modeled data. c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 National Statistical Office of Mongolia 2 Annual Health Report 2004: Health indicators. Ulaanbaatar, Department for Health Statistics and Information, National Centre for Health Development. 3 Human development report Mongolia 2003. Ulaanbaatar, National Statistical Office, 2003. 4 Ministry of Health, Mongolia. 5 Mongolian statistical yearbook – 2004. Ulaanbaatar, National Statistical Office of Mongolia, 2005. 6 WHO Regional Office for the Western Pacific, data received from technical units 7 Human development report 2005. New York, United Nations Development Programme, 2005 – www.undp.org 196 | COUNTRY HEALTH INFORMATION PROFILES NAURU 1. DEMOGRAPHICS, GENDER AND POVERTY The projected population size of Nauru for 2005 was 13 839, 35.10% of which were below 15 years old, while around 4.91% were 65 and above. It is estimated that there are 107 men for every 100 women. In 2002, the crude birth rate was 31.20 and the crude death rate was 7.80 per 1000 population. The infant mortality rate was 12.7 per 1000 live births. Table 1. Core population and health data (2005 estimate) [Total] 13 839 [Both] 61.00 (2004) [0-14 years] 7150 (35.10%) [Male] 58.00 (2004) Population [65+ years] 6689 (4.91%) Life expectancy at birth (years) [Female] 61.00 (2004) Crude birth rate (per 1000 population) 31.20 (2002) Total fertility rate 3.80 (2004) [Total] 100.00 (2003) [Urban] 100.00 (2003) Crude death rate (per 1000 population) 7.80 (2002) % of population served with safe water [Rural] NA [Total] 100.00 (2003) [Urban] 100.00 (2003) Infant mortality rate (per 1000 live births) 12.70 (2002) % of population with adequate sanitary facilities [Rural] NA Maternal mortality ratio (per 100 000 live births) 300.00 (2002) NA- Not applicable 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The 18-member Parliament is elected every three years. The Parliament elects the President from among its members, who appoints the Cabinet of five to six people. The President is both head of state and head of government. There is a loose multi-party system; the two main parties are the Democratic Party and the Nauru Party. The period 1999-2003 was marked by considerable political instability. 2.2 Economic situation There are few comprehensive statistics on the Nauru economy, with estimates of Nauru’s per capita gross domestic product (GDP) varying widely. Traditionally, revenues of this tiny island have come from exports of phosphates, but reserves are expected to be exhausted within five to ten years. Phosphates are exported principally to Australia, Japan, New Zealand, the Philippines and the Republic of Korea. In anticipation of the exhaustion of the phosphate deposits, substantial amounts of phosphate income have been invested in trust funds to help cushion the transition to alternative sources of revenue and to provide for Nauru’s economic future. There are few other resources and most necessities are imported, including fresh water from Australia. There are frequent disruptions of supplies of food, fuel, equipment and materials. Air Nauru, the only airline servicing the country, faces repeated interruptions due to a shortage of funds for lease payments, fuel, maintenance and other running costs. COUNTRY HEALTH INFORMATION PROFILES | 197 The central plateau has limited agricultural value, but some 202-243 hectares, mainly around the coastal belt, are available for cultivation. Coconut, banana and papaya are the main fruit crops and small quantities of vegetables are also grown. However, cultivated crops are for home consumption only and, apart from fish, most food is imported from Australia and New Zealand. In 2001, a group of Afghani refugees rescued at sea were transferred to a camp in Nauru in exchange for a multi-million dollar aid package from Australia. 3. HEALTH SITUATION 3.1 Health trends As a result of an effective public health programme focused on safe water and sanitation, there were no outbreaks of infectious diseases in 2003. However, noncommunicable diseases, such as diabetes, hypertension, heart disease and cancer, have become leading causes of morbidity and mortality, together with respiratory diseases. Rates of obesity are very high. In 2003, the adult diabetes prevalence (30.2 %) was the highest in the world. 3.2 Health systems The Government plans to make available a balanced supply of health care providers, including physicians, nurses, other specialized staff and community health workers. Health care services will continue to be provided free of charge to all Nauruans. Nauru General Hospital (NGH) and the National Phosphate Corporation (NPC) Hospital amalgamated in July 1999 to become the Republic of Nauru Hospital. The hospital has five doctors. Specialist treatment is restricted and usually has to be sought in Australia. In the 1995-1996 budget, health expenditure amounted to AUD 8.9 million (US$ 6.8 million), and accounted for 8.9% of the total government budget, compared with 2.5% in 1991-1992. Currently, 50% of professional staff are expatriates on contract, although training of local staff is planned. 4. NATIONAL HEALTH PLAN AND PRIORITIES The primary health care approach to acute respiratory infections and diarrhoeal diseases was strengthened. The Expanded Programme on Immunization expanded the coverage of target diseases. A survey of noncommunicable diseases, using the WHO STEP-wise approach, was carried out. Health promotion and healthy lifestyles programmes was carried out. The following priority areas have been identified: • diabetes services; • service enhancement to reduce overseas referrals; • emergency services; • pharmacy services; • lifestyle diseases; • school health programme; • public health legislation and ordinances; • national strategy; • effective health promotion, media strategy; • healthy eating; and • health promotion as part of curative health. NAURU 198 | COUNTRY HEALTH INFORMATION PROFILES 5. MAJOR INFORMATION SOURCES Nauru Bureau of Statistics Nauru population profile: A guide for planners and policy makers. Noumea, Secretariat of the Pacific Community. Republic of Nauru Hospital data 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Yaren District, Nauru Postal Address : Official Email Address : Telephone : Fax : Office Hours : Website : WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4 Provident Plaza One Downtown Boulevard 33 Ellery Street, Suva Postal Address : PO Box 113, Suva, Fiji Official Email Address : who@fij.wpro.who.int Telephone : (679) 3-304600 / 3-304631 Fax : (679) 3-300462 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILE 199 NAURU WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 0.02 2004 1 2 Estimated population ('000s) 13.84 7.15 6.69 2005 est 2 3 Annual population growth rate (%) 0.15 … … 2002 1 4 Percentage of population - 0–14 years 35.10 34.87 35.34 2005 est 2 - 65+ years 4.91 4.57 5.26 2005 est 2 5 Urban population (%) 100.00 … … 2005 est 2 6 Crude birth rate (per 1 000 population) 31.20 … … 2002 4 7 Crude death rate (per 1 000 population) 7.80 … … 2002 4 8 Rate of natural increase of population (% per annum) 2.34 a ... … 2002 4 9 Life expectancy (years) - at birth 61.00 58.00 61.00 2004 13 - Health-adjusted Life Expectancy (HALE) at age 60 … 8.70 10.50 2002 9 10 Adult literacy rate (%) 95.00 95.00 95.00 1998 6 11 Neonatal mortality rate (per 1 000 live births) 6.30 … … 2002 4 12 Infant mortality rate (per 1 000 live births) 12.70 … … 2002 4 13 Under-five mortality rate (per 1 000 live births) 19.10 … … 2002 4 14 Total fertility rate (women aged 15–49 years) 3.80 2004 13 15 Maternal mortality ratio (per 100 000 live births) 300.00 2002 7 16 Percentage of newborn infants weighing at least 2500 g at birth … … … 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 90.00 … … 2004 8 - DTP3 80.00 … … 2004 8 - OPV3 75.00 … … 2004 8 - Measles 87.00 … … 2004 8 - Hepatitis B III 75.00 … … 2004 8 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 100.00 2003 est 3 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 100.00 2003 est 3 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … NAURU 200 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 100.00 NA 2003 3 26 Proportion of population with access to improved sanitation 100.00 100.00 NA 2003 3 27 Proportion of the population using solid fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.66 … … 1998 6 32 Per capita GDP at current market prices (US$) … … … 33 Rate of growth of per capita GDP (%) … … … 34 Health expenditure Total health expenditure - amount (in million US$) … - total health expenditure on health as % of GDP 12.30 2003 13 - per capita total expenditure on health (in US$) 798.00 2003 13 Government expenditure on health - amount (in million US$) … - general government expenditure on health as % of total expenditure on health 88.50 2003 13 - general government expenditure on health as % of total general government expenditure 8.80 2003 13 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health 11.50 2003 13 Exchange rate in US$ of local currency is: 1 US$ = … 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population a 36 Health workforce - physicians 5 5 0 4.95 4.95 0.00 2004 10 - dentists 1 1 0 0.99 0.99 0.00 2004 10 - pharmacists 4 e 0 4 e 3.96 0.00 3.96 2004 10 - nurses 48 6 42 47.52 … … 2004 10 - midwives 2 0 2 1.98 0.00 1.98 2004 10 - other nursing/ auxiliary staff 8 0 8 7.92 0.00 7.92 2004 10 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 13 9 4 12.87 … … 2004 10 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 156 … … 154.46 … … 2004 10 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … COUNTRY HEALTH INFORMATION PROFILE 201 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity (hospital admissions) Number (estimates) Rate per 100 000 population a 1. Symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified 252 132 120 2495.05 … … 2004 11 2. Confinement (post partum care) 156 156 1544.55 1544.55 2004 11 3. Newborn 144 60 84 1425.74 … … 2004 11 4. Diabetes 72 36 36 712.87 … … 2004 11 5. Hypertension 72 60 12 712.87 … … 2004 11 6. Abscess cutaneous 60 24 36 594.06 … … 2004 11 7. Disease of the genitourinary system 48 0 48 475.25 0.00 475.25 2004 11 8. Anaemia 36 24 12 356.44 … … 2004 11 9. Asthma 36 24 12 356.44 … … 2004 11 10. Carbuncle 24 24 0 237.62 237.62 0.00 2004 11 40 Ten leading causes of mortality Number Rate per 100 000 population b 1. Diabetes 16 8 8 158.97 155.76 162.30 2003 12 2. Diseases of respiratory system 15 8 7 149.03 155.76 142.02 2003 12 3. Diseases of the circulatory system (excluding hypertension –cardiovascular) 12 7 5 119.23 136.29 101.44 2003 12 4. Neoplasms 8 0 8 79.48 0.00 162.30 2003 12 5. Transport accident and drowning 8 6 2 79.48 116.82 40.58 2003 12 6. Hypertension 7 3 4 69.55 58.41 81.15 2003 12 7. Septicaemia unspecified 4 3 1 39.74 58.41 20.29 2003 12 8. Fibrosis and cirrhosis of liver 4 4 0 39.74 77.88 0.00 2003 12 9. Renal failure 2 0 2 19.87 0.00 40.58 2003 12 10. Certain conditions originating in the perinatal period 2 1 1 19.87 19.47 20.29 2003 12 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 8 - Pertussis (whooping cough) 0 0 0 0 0 0 2004 8 - Tetanus 1 … … … … … 2004 8 - Neonatal tetanus 0 0 0 0 0 0 2004 8 - Poliomyelitis 0 0 0 0 0 0 2004 8 - Hib meningitis 0 0 0 0 0 0 2004 8 - Measles 0 0 0 0 0 0 2004 8 - Mumps 0 0 0 0 0 0 2004 8 - Rubella 0 0 0 0 0 0 2004 8 - Congenital rubella syndrome 0 0 0 0 0 0 2004 8 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral - Type A 0 0 0 0 0 0 2002 4 - Type B 0 0 0 0 0 0 2002 4 - Type C 0 0 0 0 0 0 2002 4 - Type E … … … … … … - Unspecified 0 0 0 0 0 0 2002 4 Cholera 0 0 0 0 0 0 2002 4 Typhoid fever 0 0 0 0 0 0 2002 4 NAURU 202 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Encephalitis 0 0 0 0 0 0 2002 4 Plague 0 0 0 0 0 0 2002 4 Syphilis … … … 0 0 0 2002 4 Gonorrhoea … … … 0 0 0 2002 4 Leprosy 3 … … … … … 2002 8 Malaria … … … … … … Dengue/DHF … … … … … … 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 3 … … … … … 2003 8 - New pulmonary tuberculosis (smear-positive) 1 … … … … … 2003 8 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 35.00 … … 4.00 … … 2004 8 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 57.00 … … 50.00 (2002) … … 2003 8 Number of cases (estimates) Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (malignant neoplasms only) … … … 13 5 8 2002 4 - Trachea, bronchus and lung … … … 5 4 1 2002 4 - Stomach … … … 1 0 1 2002 4 - Colon and rectum … … … 0 0 0 2002 4 - Lip, oral cavity and pharynx … … … 0 0 0 2002 4 - Liver … … … 2 1 1 2002 4 - Cervix … 1 2002 4 - Leukaemia … … … 4 0 4 2002 4 48 Circulatory All circulatory system diseases … … … 14 12 2 2002 4 - Ischaemic heart disease … … … 2 1 1 2002 4 - Acute myocardial infarction … … … 9 9 0 2002 4 - Rheumatic fever and rheumatic heart diseases … … … 0 0 0 2002 4 - Cerebrovascular diseases … … … 2 1 1 2002 4 - Hypertension 72 60 12 1 1 0 2002 4 COUNTRY HEALTH INFORMATION PROFILE 203 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 49 Maternal causes - Haemorrhage 1 1 2002 4 - Abortion 12 0 2002 4 - Eclampsia 0 0 2002 4 - Sepsis 0 0 2002 4 - Obstructed labour 0 0 2002 4 50 Diabetes mellitus 72 36 36 8 1 7 2002 4 51 Mental disorders … … … 0 0 0 2002 4 52 Injuries - All types … … … 12 9 3 2002 4 - Motor and other vehicle accidents … … … 0 0 0 2002 4 - Suicide … … … 1 1 0 2002 4 - Homicide and violence … … … 2 2 0 2002 4 - Occupational injuries … … … 0 0 0 2002 4 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 60 2004 10 - Specialized hospitals 0 0 2004 10 - District/first-level referral hospitals 0 0 2004 10 - Primary health care centres 1 0 2004 10 Private hospitals 0 0 2004 10 Notes: Red text Millennium Development Goals (MDG) indicators … Data not available est Estimate NA Not applicable aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Unit, WHO Regional Office for the Western Pacific. b Estimated by Health Information and Evidence for Policy Unit, WHO Regional Office for the Western Pacific using 2002 census population. c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. e Figure refers to dispensers only. Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 2 Demographic Tables for the Western Pacific 2005-2010. World Health Organization, Regional Office for the Western Pacific. 3 Health Inspectors Report in the Public Health Office (NGH). 4 Birth and Death Documents from Director of Public Health 2002. 5 Nauru Bureau of Statistics Office. 6 Pacific human development report 1999 (Creating opportunities). New York, United Nations Development Programme, 1999. 7 Nauru population profile. A guide for planners and policy makers. Noumea, Secretariat of the Pacific Community. 8 WHO Regional Office for the Western Pacific, data received from technical units 9 Changing History. The World Health Report 2004, World Health Organization. 10 Republic of Nauru (RON) Hospital data (data from Health Planning Officer) NAURU 204 11 RON Hospital Inpatient Record Study up to March 24 (data from Health Planning Officer) 12 RON Hospital 2003 Mortality Data Analysis (Data from Chief Nursing Officer) 13 Working Together for Health. The World Health Report 2006, World Health Organization. COUNTRY HEALTH INFORMATION PROFILES | 205 NEW CALEDONIA 1. DEMOGRAPHICS, GENDER AND POVERTY The estimated multiethnic population of New Caledonia was 230 789 in 2004. Based on 2002 data, the population consists of 42.5% Melanesians, 37.1% Europeans, 8.4% Wallisians, 3.8% Polynesians, 3.6% Indonesians, 1.6% Vietnamese and 3% other nationalities. The population density is 11 persons per square kilometre. The natural per annum growth rate is 1.4% and life expectancy at birth is high for both women (77.6 years) and men (69.9 years). Infant, child and maternal mortality rates are low. In 2005, the infant mortality rate was 6.4 per 1000. The overall birth rate decreased from 28 per 1000 in 1981 to 17.2 per 1000 population in 2005. The fertility rate is 2.4 children per female. There is a high level of adult literacy, estimated to be 91% of the total population (male 92%, female 90%). Table 1. Core population and health data (2004) [Total] 230 789 [Both] 75.20 (2005p) [0-14 years] 28.17% (2002) [Male] … Population [65+ years] 6.05% (2002) Life expectancy at birth (years) [Female] … Crude birth rate (per 1000 population) 17.20 (2005p) Total fertility rate 2.40 (2002) [Total] … [Urban] … Crude death rate (per 1000 population) 4.90 (2005p) % of population served with safe water [Rural] … [Total] … [Urban] … Infant mortality rate (per 1000 live births) 6.40 (2005p) % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 31.56 (1991-2002) p- Provisional 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 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 became a self-governing French overseas country and was granted a new status, with more internal autonomy. New Caledonia consists of three provinces, Iles Loyaute, Nord, and Sud, and has a three-tiered system of administration: metropolitan France (represented by the High Commissioner), the territorial congress and the provincial assemblies. The Noumea Accords of 1998 diminished the hopes of those involved in the pro-independence movement, as the earliest date of possible independence for the country is now 2014. The President of France has been represented by High Commissioner Daniel Constantin since 3 July 2002. The President of the New Caledonian Government is elected by the members of The Territorial Congress. The last election was held on 29 June 2004, when Marie-Noelle Themerau was elected. NEW CALEDONIA 206 | COUNTRY HEALTH INFORMATION PROFILES 2.2 Economic situation New Caledonia has about 25% of the world’s known nickel resources. Only a small amount of the land is suitable for cultivation, and food accounts for about 20% of imports. In addition to nickel, substantial financial support from France (equal to more than 25% of GDP) and tourism are key to the economy. Substantial new investment in the nickel industry, combined with the recovery of the global nickel market, suggests a bright economic outlook for the next several years. The mainstays of the country’s booming economy are mining, cattle, shrimp farming, fishing, forestry agriculture and tourism. The main economic indicators in 2001 were: GDP 442 billion F.CFP (US$4.2 billion), and GDP per capita 2 034 000 F.CFP (US$19 190). 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 kilometres. 3. HEALTH SITUATION 3.1 Health trends New Caledonia enjoys a relatively high standard of living compared with most other Pacific island countries and areas, with a profile similar to that of fully industrialized countries. About 9.22% of GDP (1999) is spent on health. By and large, the health challenges being faced are similar to those across the Pacific region. For many years, emphasis has been placed on maternal and child health, immunization and communicable disease control. Today, the disease patterns traditionally associated with consumer societies are appearing; the prevalence of noncommunicable diseases is growing, while the burden of communicable diseases is still present, although reduced. Traffic accidents also represent a considerable burden, although the incidence rate has been relatively stable since 1993. All the above provides testimony to the ongoing epidemiological transition. The leading causes of death are neoplasms (26.5%) and cardiovascular disease (23.4%), followed by injuries and poisonings (15.1%). In 2002, the four major communicable diseases of concern were dengue fever (105 new cases), leptospirosis (49 new cases), tuberculosis (66 new cases), and HIV/AIDS (17 new cases). The incidence of dengue shows marked annual variations. There were 2211 cases in 1995, 2121 in 1996, 251 in 1997, 2612 in 1998, 354 in 1999, 12 in 2000, 34 in 2001, 105 in 2002, 5673 in 2003 and 792 in 2004. The incidence of leptospirosis decreased from 207 cases in 1997 to 132 in 1998, 200 in 1999, 28 in 2000, 23 in 2001 and 49 in 2002. 3.2 Health systems The significant improvement in the health status of the population in recent years can be attributed to the economic growth of New Caledonia as well as to the quality of health care coverage. The whole population has access to health services. Various public mechanisms fund social welfare programmes, including national insurance, family allowances, industrial programmes and a pension scheme. Consequently, all citizens are comprehensively covered for health and welfare needs. However, it requires a constant effort to balance the distribution of these resources equally among all the population. As of 31 December 2002, there were 476 practising medical doctors, 243 of whom were specialists and 233 of whom practised general medicine. There were also 1128 nurses, 126 dentists, 83 midwives and 97 pharmacists. COUNTRY HEALTH INFORMATION PROFILES | 207 4. NATIONAL HEALTH PLAN AND PRIORITIES The Government has endorsed ‘Health for All’ and primary health care is one of the priorities set by the health offices of all three provinces. The main elements of the health strategy are: • qualitative and quantitative improvements to health care; • prevention of communicable diseases through immunization; and • improvement of health status, housing and environment by means of health education 5. MAJOR INFORMATION SOURCES DASS – NC, 2005 update Situation sanitaire pour l’annee 2002. DASS-NC; http://www.dass.gouv.nc/publications/publication.jsp?PAGE=situation_sanitaire2002.htm DASS-NC, www.dass.gouv.nc Institut Territorial de la Statistique et des Etudes Economiques Secretariat of the Pacific Community, Pacific Regional Information System (PRISM), (http://www.spc.int/prism/country/NC/NC_index.html 6. ADDRESSES DIRECTION DES AFFAIRES SANITAIRES ET SOCIALES DE NOUVELLE-CALÉDONIE Office Address : DASS – NC, 5 rue Gallieni – Centre ville 98800 Noumea – Nlle- Caledonie Postal Address : BP N4 – 98851 Noumea – Nlle-Calédonie Official Email Address : dass@gouv.nc Telephone : (687) 24.37.00 Fax : (687) 24.37.02 Office Hours : 7h30-11h30 ; 12h15-16h00 Website : http://www.dass.gouv.nc WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4 Provident Plaza 1 Downtown Boulevard 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@sp.wpro.who.int Telephone : (679) 330 4600 / 330 4631/ 330 4635 / 331 7447 Fax : (679) 330 0462 / 331 1530 Office Hours : Website : NEW CALEDONIA 208 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: DIRECTION DES AFFAIRES SANITAIRE ET SOCIALES DE NOUVELLE-CALEDONIE COUNTRY HEALTH INFORMATION PROFILE 209 NEW CALEDONIA WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 18.58 f 1 2 Estimated population ('000s) 230.79 … … 2004 1 3 Annual population growth rate (%) 1.40 … … 2002 1 4 Percentage of population - 0–14 years 28.17 … … 2002 1 - 65+ years 6.05 … … 2002 1 5 Urban population (%) 60.30 … … 2001 1 6 Crude birth rate (per 1 000 population) 17.20 … … 2005p 1 7 Crude death rate (per 1 000 population) 4.90 6.30 3.90 2005p 1 8 Rate of natural increase of population (% per annum) 1.40 … … 2002 3 9 Life expectancy (years) - at birth 75.20 … … 2005p 1 - Health-adjusted Life Expectancy (HALE) at age 60 … … … 10 Adult literacy rate (%) 91.00 92.00 90.00 2002 est 1 11 Neonatal mortality rate (per 1 000 live births) 2.40 … … 2002 3 12 Infant mortality rate (per 1 000 live births) 6.40 … … 2005p 1 13 Under-five mortality rate (per 1 000 live births) 9.06 … … 2002 3 14 Total fertility rate (women aged 15–49 years) 2.40 2002 3 15 Maternal mortality ratio (per 100 000 live births) 31.56 1991-2002 3 16 Percentage of newborn infants weighing at least 2500 g at birth 93.00 … … 2002 3 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG … … … - DTP3 … … … - OPV3 … … … - Measles … … … - Hepatitis B III … … … 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel … - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … NEW CALEDONIA 210 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source … … … 26 Proportion of population with access to improved sanitation … … … 27 Proportion of the population using solid fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index … … … 32 Per capita GDP at current market prices (US$) 19 190.49 d … … 2001 1 33 Rate of growth of per capita GDP (%) 2.30 … … 1997 1 34 Health expenditure Total health expenditure - amount (in million US$) 382.00 2002 2 - total health expenditure on health as % of GDP 9.22 1999 2 - per capita total expenditure on health (in US$) 1558.40 g 2002 2 Government expenditure on health - amount (in million US$) … - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure … External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 96.27 fcfp 2005 1 35 Health insurance coverage as % of total population 99.90 2004 2 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 476 … … 22.04 … … 2002 2 - dentists 126 … … 5.84 … … 2002 2 - pharmacists 97 … … 4.49 … … 2002 2 - nurses 1128 … … 52.25 … … 2002 2 - midwives 83 … … 3.81 … … 2002 2 - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) … … … … … … - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … COUNTRY HEALTH INFORMATION PROFILE 211 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. … … … … … … 2. … … … … … … 3. … … … … … … 4. … … … … … … 5. … … … … … … 6. … … … … … … 7. … … … … … … 8. … … … … … … 9. … … … … … … 10. … … … … … … 40 Ten leading causes of mortality Number Rate per 100 000 population a 1. Malignant neoplasms 297 f 176 121 135.63 158.92 113.11 2002 2 2. Diseases of the circulatory system 261 158 103 119.19 142.66 96.27 2002 2 3. Injury, poisoning & certain other consequences of external causes 169 128 41 77.62 115.58 38.32 2002 2 4. Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified 110 57 53 50.23 51.47 49.54 2002 2 5. Diseases of the respiratory system 99 67 32 45.21 60.50 29.91 2002 2 6. Infectious and parasitic diseases 45 27 18 20.55 24.38 16.83 2002 2 7. Diseases of the digestive system 33 23 10 15.07 20.77 9.35 2002 2 8. Endocrine, nutritional and metabolic diseases 25 10 15 11.41 9.03 14.02 2002 2 9. Diseases of the nervous system 24 17 7 10.96 15.35 6.54 2002 2 10. Diseases of the genitourinary system 18 12 6 8.22 10.84 5.61 2002 2 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 4 - Pertussis (whooping cough) 1 … … … … … 2004 4 - Tetanus 0 0 0 0 0 0 2004 4 - Neonatal tetanus 0 0 0 0 0 0 2004 4 - Poliomyelitis 0 0 0 0 0 0 2004 4 - Hib Meningitis 0 0 0 0 0 0 2004 4 - Measles 0 0 0 0 0 0 2004 4 - Mumps 0 0 0 0 0 0 2004 4 - Rubella 0 0 0 0 0 0 2004 4 - Congenital rubella syndrome 0 0 0 0 0 0 2004 4 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral - Type A … … … … … … - Type B 31 … … … … … 2002 2 - Type C 0 0 0 0 0 0 2002 2 - Type E … … … … … … - Unspecified … … … … … … Cholera … … … … … … NEW CALEDONIA 212 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Typhoid fever 0 0 0 0 0 0 2002 2 Encephalitis … … … … … … Plague … … … … … … Syphilis 10 5 5 … … … 2003 2 Gonorrhoea (gonococcal infections) 31 15 16 … … … 2003 2 Leprosy 8 5 3 … … … 2004 2 Malaria … … … … … … Dengue/DHF (7 sex unknown) 792 401 384 2 1 1 2004 2 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures b … - Proportion of population in malaria-risk areas using effective malaria treatment measures c … 44 Tuberculosis Number of cases Number of deaths - All types 83 45 38 1 (2002) 1 (2002) 0 (2002) 2004 2 - New pulmonary tuberculosis (smear-positive) 17 … … … … … 2004 2 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 117.00 … … 12.00 … … 2004 4 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 24.00 … … 75.00 (2003) … … 2004 4 Number of cases Number of deaths 45 Acute respiratory infections 21 642 9729 11 913 … … … 2000 2 46 Diarrhoeal diseases 1858 923 935 … … … 2000 2 47 Cancers All cancers (malignant neoplasms only) … … … 297 f 176 121 2002 2 - Trachea, bronchus, and lung 79 57 22 85 65 20 2002 2 - Stomach 14 10 4 10 5 5 2002 2 - Colon and rectum 30 15 15 12 5 7 2002 2 - Lip, oral cavity and pharynx 18 13 5 5 0 5 2002 2 - Liver 13 8 5 31 27 4 2002 2 - Cervix 22 7 2002 2 - Leukaemia 3 3 0 7 3 4 2002 2 48 Circulatory All circulatory system diseases … … … 262 158 104 2002 2 - Ischaemic heart disease … … … 85 64 21 2002 2 - Acute myocardial infarction … … … 56 45 11 2002 2 - Rheumatic fever and rheumatic heart diseases 94 … … 1 0 1 2002 2 - Cerebrovascular diseases … … … 49 19 30 2002 2 - Hypertension 7059 … … 26 12 14 2002 2 COUNTRY HEALTH INFORMATION PROFILE 213 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 49 Maternal causes - Haemorrhage … 0 2000 2 - Abortion 612 0 2002 2 - Eclampsia … … - Sepsis … … - Obstructed labour … … 50 Diabetes mellitus 4 942 … … 12 4 8 2002 2 51 Mental disorders 2 159 … … 11 7 4 2002 2 52 Injuries - All types … … … 179 f 128 51 2002 2 - Motor and other vehicle accidents 662 … … 62 53 9 2002 2 - Suicide … … … 35 24 11 2002 2 - Homicide and violence … … … 13 10 3 2002 2 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 2 528 2002 2 - Specialized hospitals 1 184 e 2002 2 - District/first level referral hospitals … … - Primary health care centres … … Private hospitals 2 176 2002 2 Notes: Red text Millennium Development Goals (MDG) indicators … Data not available est Estimate p Provisional aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. c Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. d Converted to US$ using available exchange rates nearest to the period, i.e. 2003. e Figure refers to 108 beds for psychiatric cases and 76 beds for geriatric cases. f Revised data. g Figure is in Euros. Sources: 1 Institut Territorial de la Statistique et des Etudes Economiques (http://www.isee.nc/) 2 Department of Health and Social Affairs of New Caledonia. 3 Health situation in New Caledonia, 01 January 2002 to 31 December 2002. Department of Health and Social Affairs of New Caledonia. 4 WHO Regional Office for the Western Pacific, data received from technical units. 214 | COUNTRY HEALTH INFORMATION PROFILES NEW ZEALAND 1. DEMOGRAPHICS, GENDER AND POVERTY The resident population of New Zealand on 30 June 2005 was estimated at 4 098 900, representing an increase of 37 500 or 0.9% over the previous year. There were an estimated 2 017 000 male and 2 081 800 female residents – around 103 women for every 100 men. Women have outnumbered men since the late 1960s. New Zealand continues to give priority to ensuring that Official 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. Table 1. Core population and health data (2005 estimates) [Total] 4 098 900 (resident) [Both] … [0-14 years] 880 070 (21.47%) [Male] 68.05 est (2001) Population [65+ years] 497 610 (12.14%) Life expectancy at birth (years) [Female] 72.03 est (2001) Crude birth rate (per 1000 resident population) 14.30 est (2004) Total fertility rate 1.95 (2003) [Total] 90.00* (2002) [Urban] 97.00 (2002) Crude death rate (per 1000 resident population) 7.00 est (2004) % of population served with safe water [Rural] 81.00 (2002) [Total] 100.00 (2002) [Urban] 100.00 (2002) Infant mortality rate (per 1000 live births) 5.58 est (2004) % of population with adequate sanitary facilities [Rural] 100.00 (2002) Maternal mortality ratio (per 100 000 live births) 5.30 (2001) est – Estimate * - Revised data 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 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. 2.2 Economic situation Economic activity has been very strong over the past four years. Most recently, buoyancy due to immigration has outweighed the negative impulse from an appreciating exchange rate. This has left productive resources stretched. Rising housing prices are providing further impetus to domestic demand. However, the pace of activity has slowed in recent months. COUNTRY HEALTH INFORMATION PROFILES | 215 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 the past six years. Over the period 2003-2005, the domestic economy, employment and income growth and high international commodity prices have been the main drivers of growth. Annual growth for the 2002/03 and 2003/04 years was 4.2% and 4.7% respectively, growing to 4.8% in 2004/05. Annual average growth was 2.7% for the year ended September 2005. 3. HEALTH SITUATION 3.1 Health trends New Zealand has been successful in raising the average life expectancy of its population over the past century. A newborn girl can expect to live 72.03 years and a newborn boy 68.05 years. A temperate climate, low population density, lack of heavy industry and good nutrition gave New Zealand an early advantage over other nations in terms of health conditions. The infant mortality rate has fallen steadily in association with a major reduction in infectious diseases (and respiratory diseases), which were previously the main causes of death in the country. AIDS was first diagnosed in New Zealand in 1983 and 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. Malignant neoplasms, ischaemic heart disease and cerebrovascular disease were the leading causes of death in New Zealand from 1997 to 2002. In 2002, they collectively accounted for almost 60% of deaths (cancer 28%, ischaemic heart disease 22%, and cerebrovascular disease 10%). In terms of health risk factors influenced by individual behaviour, use of tobacco products declined significantly during the period from 1976 to 1992, levelling off from 1992 to 1996, but subsequently falling steadily. However, the rate of smoking is not even among all groups within the population. An estimated 50% of Mäori and 33% of Pacific island people smoke, compared with 23% of the New Zealand European population, a 30% decline since 1997. People are smoking fewer cigarettes per day. The Government is also concerned about reducing overconsumption of alcohol, especially by men and young people; reducing the average fat intake; and promoting physical exercise. Mean alcohol consumption in 2003 was 10.8 litres of pure alcohol for all drinkers. In 2003, 88.5% of men and 80.3% of women aged 15–64 years drank alcohol. In 2003, drinking and driving contributed to 141 deaths, 555 serious injuries and 1398 minor injuries, and 31% of all road deaths were caused by drinking-related crashes. New Zealand has low levels of air pollution compared with other similar countries, but a relatively high incidence of waterborne diseases, such as camphylobacteriosis, giardiasis and cryptosporidiosis compared with other developed countries. There is also evidence of pollution of recreational waters. It is estimated that 90.0% of the population have an improved drinking water source. 3.2 Health systems The New Zealand Health Strategy (NZHS) and the New Zealand Disability Strategy (NZDS) provide the framework for the health sector's overall direction. These strategies take a population approach to identify the areas where intervention will make a contribution to the goal of healthy and independent New Zealanders. The two strategies sit alongside each other and guide the development and implementation of more detailed service, specific health-issue and population-group strategies and action plans. NEW ZEALAND 216 | COUNTRY HEALTH INFORMATION PROFILES The Ministry of Health aims to ensure the health and disability support system works for New Zealanders. It is the Government's primary advisory on health policy and disability support services. District Health Boards (DHBs) have the responsibility for improving, promoting and protecting the health and independence of a geographically defined population. Twenty-one DHBs are in 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. By April 2005, more than 3.8 million New Zealanders (95% of the population) were enrolled in PHOs. The Minister of Health has overall responsibility for the health and disability support system. The Minister determines the content of the NZHS, works through the Ministry of Health to enter into accountability arrangements with DHBs and agrees with government colleagues how much public money will be spent on the delivery of public services. 4. NATIONAL HEALTH PLAN AND PRIORITIES The Government’s overall direction for the health and disability sector places particular emphasis on improving population health outcomes and reducing disparities among all New Zealanders, including Mäori and Pacific peoples. Thirteen population health objectives, set out in the New Zealand Health Strategy, aim to: • reduce smoking; • improve nutrition; • reduce obesity; • increase the level of physical activity; • reduce the rate of suicide and suicide attempts; • minimize harm caused by alcohol and illicit and other drug use to both individuals and the community; • reduce the incidence and impact of cancer; • reduce the incidence and impact of cardiovascular disease; • reduce the incidence and impact of diabetes; • improve oral health; • reduce violence in interpersonal relationships, families, schools and communities; • improve the health status of people with severe mental illness; and • ensure access to appropriate child health care services, including ‘well child’ and family health care and immunization. Toolkits identify appropriate actions to address the priority objectives, while DHB accountability documents contain specific targets to give effect to the Strategy. The New Zealand Disability Strategy guides action to promote a more inclusive society which values disabled people’s lives and enhances their full participation in society. Population- or illness-specific strategies include the Child Health Strategy, Achieving Health for All People (public health), the Health of Older People Strategy, the Korowai Oronga (the Mäori Health Strategy), the Pacific Health and Disability Action Plan, the National Mental Health Strategy and the Primary Health Care Strategy. COUNTRY HEALTH INFORMATION PROFILES | 217 The Ministry of Health is responsible for planning the national response to health service emergencies of all kinds. The Ministry is working on a number of projects that will collectively form the National Health Emergency Plan (NHEP), of which infectious diseases is one part. The NHEP describes the larger context within which the Ministry of Health and all New Zealand health services will function during any national health-related emergency, including New Zealand's responsibilities under international agreements and regulations. 5. MAJOR INFORMATION SOURCES New Zealand Ministry of Health New Zealand Health Information Service (http://www.nzhis.govt.nz) Statistics New Zealand (http://www.stats.govt.nz) 6. ADDRESSES MINISTRY OF HEALTH Office Address : 133 Molesworth St , P.O. Box 5013 , Wellington, New Zealand Postal Address : Official Email Address : Telephone : 04 - 496-2000 Fax : 04 - 496-2340 Office Hours : Website : 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 : Website : NEW ZEALAND 218 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: MINISTRY OF HEALTH COUNTRY HEALTH INFORMATION PROFILE 219 NEW ZEALAND WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 270.69 b 2005 1 2 Estimated population ('000s) 4098.90 i 2017.10 i 2081.80 i 2005 est 1 3 Annual population growth rate (%) 0.90 i ... ... 2005 est 1 4 Percentage of population - 0–14 years 21.47 i … … 2005 est 1 - 65+ years 12.14 i … … 2005 est 1 5 Urban population (%) 85.90 … … 2003 3 6 Crude birth rate (per 1 000 population) 14.30 i 14.89 i 13.73 i 2004 est 1 7 Crude death rate (per 1 000 population) 7.00 i 7.05 i 6.95 i 2004 est 1 8 Rate of natural increase of population (% per annum) 0.73 a … … 2004 9 Life expectancy (years) - at birth … 68.05 72.03 2001 est 4 - Health-adjusted Life Expectancy (HALE) at age 60 … 21.08 24.00 2001 est 4 10 Adult literacy rate (%) … … … 11 Neonatal mortality rate (per 1 000 live births) 3.10 … … 2004 est 1 12 Infant mortality rate (per 1 000 live births) 5.58 … … 2004 est 1 13 Under-five mortality rate (per 1 000 live births) 6.34 … … 2003 1 14 Total fertility rate (women aged 15–49 years) 1.95 2003 1 15 Maternal mortality ratio (per 100 000 live births) 5.30 2001 5 16 Percentage of newborn infants weighing at least 2500 g at birth 93.00 … … 2003 5 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 27.00 1998 4 19 Immunization coverage for infants (%) - BCG … … … - DTP3 … … … - OPV3 … … … - Measles … … … - Hepatitis B III … … … 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 100.00 2001 5 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) 96.60 2001 est 5 21 Percentage of women in the reproductive age group using modern contraceptive methods 72.00 2002 est 6 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … NEW ZEALAND 220 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 90.00 c 97.00 81.00 2002 2 26 Proportion of population with access to improved sanitation 100.00 100.00 100.00 2002 7 27 Proportion of the population using solid fuels for cooking or heating (%) <5.00 … … 2003 8 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.93 … … 2003 9 32 Per capita GDP at current market prices (US$) 23 200.00 … … 2003 1 33 Rate of growth of per capita GDP (%) 4.80 … … 2004 1 34 Health expenditure Total health expenditure (National medical care expenditure) - amount (in million US$) 7383.42 2005 2 - total health expenditure on health as % of GDP 7.27 2004 2 - per capita total expenditure on health (in US$) 1801.62 2005 2 Government expenditure on health - amount (in million US$) 5781.00 2005 2 - general government expenditure on health as % of total expenditure on health 78.30 2005 2 - general government expenditure on health as % of total general government expenditure 20.00 2005 2 External source of government health expenditure - external resources for health as % of general government expenditure on health 4.60 2002 2 Private health expenditure - private expenditure on health as % of total expenditure on health 21.70 2005 2 Exchange rate in US$ of local currency is: 1 US$ = 1.52 NZD 2006 2 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 resident population 36 Health workforce - physicians 8790 5754 3036 21.90 c 14.40 c 7.50 c 2003 5 - dentists 1582 1182 400 5.50 c 4.10 c 1.40 c 2003 5 - pharmacists 3808 … … 10.20 … … 2002 11 - nurses 34 660 g 2205 g 31 497 g 85.40 c … … 2004 5 - midwives 3780 h 11 h 3683 h 9.30 c … … 2004 5 - other nursing / auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) … … … … … … - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … COUNTRY HEALTH INFORMATION PROFILE 221 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 , age-standardized to Segi's world population 1. Malignant neoplasms 41 585 22 161 19 424 1054.98 1144.98 968.01 2002/ 2003 5 2. Ischaemic heart diseases 27 295 16 808 10 487 692.40 868.41 522.63 2002/ 2003 5 3. Complications of labour and delivery 28 306 NA 28 306 718.04 NA 1410.65 2002/ 2003 5 4. Other forms of heart disease 20 107 10 773 9334 510.06 556.60 465.17 2002/ 2003 5 5. Maternal care related to the fetus and amniotic cavity and possible delivery problems 18 901 NA 18 901 479.47 NA 941.94 2002/ 2003 5 6. Chronic lower respiratory diseases 18 450 8819 9631 468.02 455.64 479.97 2002/ 2003 5 7. Arthropathies 15 688 8216 7472 397.96 424.49 372.37 2002/ 2003 5 8. Symptoms and signs involving the circulatory and respiratory systems 18 201 9164 9037 461.71 473.47 450.36 2002/ 2003 5 9. Symptoms and signs involving the digestive system and abdomen 18 053 6179 11 874 457.95 319.25 591.75 2002/ 2003 5 10. Pregnancy with abortive outcome 13 917 NA 13 917 353.04 NA 693.56 2002/ 2003 5 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Malignant neoplasms 7800 4125 3675 197.86 213.12 183.15 2002 5 2. Ischaemic heart diseases 6287 3333 2954 159.48 172.20 147.21 2002 5 3. Cerebrovascular diseases 2829 1078 1751 71.76 55.70 87.26 2002 5 4. Chronic lower respiratory diseases 1748 943 805 44.34 48.72 40.11 2002 5 5. Other forms of heart disease 1293 579 714 32.80 29.91 35.58 2002 5 6. Diabetes mellitus 805 427 378 20.42 22.06 15.83 2002 5 7. Organic, including symptomatic, mental disorders 648 203 445 16.43 10.49 22.18 2002 5 8. Diseases of arteries, arterioles and capillaries 558 305 253 14.16 15.76 12.61 2002 5 9. Transport accidents 531 382 149 13.47 19.74 7.43 2002 5 10. Intentional self-harm 465 352 113 11.80 18.18 5.63 2002 5 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 8 - Pertussis (whooping cough) 3689 … … … … … 2004 8 - Tetanus 1 … … … … … 2004 8 - Neonatal tetanus 0 0 0 0 0 0 2004 8 - Poliomyelitis 0 0 0 0 0 0 2004 8 - Hib meningitis 1 … … … … … 2004 8 - Measles 33 … … … … … 2004 8 - Mumps 45 … … … … … 2004 8 - Rubella 25 … … … … … 2004 8 - Congenital rubella syndrome 0 0 0 0 0 0 2004 8 NEW ZEALAND 222 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral - Type A 49 18 31 0 0 0 2004 C: 8, D: 10 - Type B 39 23 16 16 12 4 2004 C: 8, D: 10 - Type C (one case with unspecified gender) 24 c 14 c 9 c 15 10 5 2004 C: 8, D: 10 - Type E … … … … … … - Unspecified 0 0 0 0 0 0 2004 10 Cholera 1 … … 0 0 0 2005 8 Typhoid fever 30 … … 0 0 0 2005 8 Encephalitis 0 0 0 0 0 0 2005 8 Plague 0 0 0 0 0 0 2004 8 Syphilis … … … 0 0 0 2004 10 Gonorrhoea … … … 0 0 0 2004 10 Leprosy 3 … … … … … 2004 8 Malaria (1 unspecified gender case) 33 d 26 d 6 d 0 0 0 2004 10 Dengue/DHF 8 5 3 0 0 0 2004 10 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures e … - Proportion of population in malaria-risk areas using effective malaria treatment measures f … 44 Tuberculosis Number of cases Number of deaths - All types 373 … … … … … 2004 8 - New pulmonary tuberculosis (smear-positive) 112 … … … … … 2004 8 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 11.00 … … 1.00 … … 2004 8 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 59.00 … … 36.00 (2003) … … 2004 8 Cases = publicly funded hospital discharges (2002/2003) Number of deaths (2002) 45 Acute respiratory infections 28 632 15 454 13 178 481 177 304 5 46 Diarrhoeal diseases 6509 3390 3119 17 3 14 5 47 Cancers Cases = Registrations Number of deaths All cancers (malignant neoplasms only) 17 943 9399 8544 7800 4125 3675 2002 5 - Trachea, bronchus and lung 1619 931 688 1471 866 605 2002 5 - Stomach 408 264 144 301 189 112 2002 5 - Colon and rectum 2588 1208 1380 1135 590 545 2002 5 - Lip, oral cavity and pharynx 262 164 98 122 83 39 2002 5 - Liver 167 111 56 153 94 59 2002 5 - Cervix 180 65 2002 5 - Leukaemia 695 392 303 236 128 108 2002 5 COUNTRY HEALTH INFORMATION PROFILE 223 INDICATORS DATA Year Source Total Male Female Total Male Female 48 Circulatory Cases = publicly funded hospital discharges (2002/2003) Number of deaths (2002) All circulatory system diseases 69 768 38 719 31 049 11 402 5449 5953 5 - Ischaemic heart disease 27 295 16 808 10 487 6287 3333 2954 5 - Acute myocardial infarction 11 582 7272 4310 3254 1699 1555 5 - Rheumatic fever and rheumatic heart diseases 703 329 374 150 55 95 5 - Cerebrovascular diseases 8681 4131 4550 2829 1078 1751 5 - Hypertension 857 335 522 219 74 145 5 49 Maternal causes Cases = publicly funded hospital discharges (2002/2003) Number of deaths (2002) - Haemorrhage 5521 0 5 - Abortion 15 123 1 5 - Eclampsia 71 0 5 - Sepsis 369 0 5 - Obstructed labour 2805 0 5 Cases = publicly funded hospital discharges (2002/2003) Number of deaths (2002) 50 Diabetes mellitus 7139 3825 3314 805 427 378 5 51 Mental disorders 21 999 10 391 11 608 725 252 473 5 52 Injuries Cases = publicly funded hospital discharges (2002/2003) Number of deaths (2002) - All types 135 489 72 170 63 319 1695 1124 571 5 - Motor and other vehicle accidents 12 603 7925 4678 531 382 149 5 - Suicide 5292 1682 3610 465 352 113 5 - Homicide and violence 4316 3252 1064 69 38 31 5 - Occupational injuries 229 489 170 448 59 041 85 80 5 7 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities 85 12 484 2002 5 - General hospitals … … - Specialized hospitals … … - District/first-level referral hospitals … … - Primary health care centres … … Private hospitals 360 11 341 2002 5 Notes: Red text Millennium Development Goals (MDG) indicators … Data not available est Estimate NA Not applicable C Cases D Deaths aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Unit, WHO Regional Office for the Western Pacific. b Excludes inland waters and oceanic areas. c Revised data. d Imported cases. NEW ZEALAND 224 e Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. f Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. g Figure refers to nurses (registered) and midwives. There were 958 registered nurses without reported gender. h Figure also included in the registered nurses. There were 86 midwives without registered gender. i Figure refers to resident population. Sources: 1 Demographic trends 2005. Statistics New Zealand (http://www.stats.govt.nz) 2 Information furnished by the Ministry of Health, New Zealand, February 2006 3 Urban and rural areas 2003. New York, United Nations Department of Economic and Social Affairs, Population Division, 2004 4 Information furnished by the Ministry of Health, New Zealand, 14 July 2005 5 New Zealand Health Information Service (http://www.nzhis.govt.nz) 6 2002 ESCAP population data sheet. Bangkok, Economic and Social Commission for Asia and the Pacific, 2002. 7 Information provided by WHO Representative in the South Pacific, 05 April 2004 8 WHO Regional Office for the Western Pacific, data received from technical units 9 Human development report 2005. New York, United Nations Development Programme, 2005. 10 Environmental science and research, New Zealand 11 New Zealand Pharmaceutical Society COUNTRY HEALTH INFORMATION PROFILES | 225 NIUE 1. DEMOGRAPHICS, GENDER AND POVERTY The population of Niue decreased from a peak of 5194 in 1966, to 2322 in 1991, 1788 in 2001 and an estimated 1600 in 2004. In 2005, the estimated population rose slightly to 1730. 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 34.0% living in urban areas. Children under the age of 15 years make up 25.1% of the population, and adults 65 years and older 11.2%. The crude birth rate is 17.9 per 1000 population and the crude death rate 8.0 per 1000. Table 1. Core population and health data (2005) [Total] 1730 est [Both] 70.10 (2001) [0-14 years] 25.14% est [Male] 69.80 (2001) Population [65+ years] 11.21% est Life expectancy at birth (years) [Female] 71.20 (2001) Crude birth rate (per 1000 population) 17.90 Total fertility rate 3.01 (2001) [Total] 100.00 (2003) [Urban] … Crude death rate (per 1000 population) 8.09 % of population served with safe water [Rural] … [Total] 100.00 (2003) [Urban] … Infant mortality rate (per 1000 live births) 0.00 % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 0.00 est - Estimate 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Niue is a self-governing nation in free association with New Zealand. The head of government is Premier Young Viviani of the Niue People's Party. The chief of state is Queen Elizabeth II of the United Kingdom of Great Britain and Northern Ireland. The Legislative Assembly is Niue’s supreme law-making body. It has 20 members, six elected from a common roll and 14 as village representatives. The Legislative Assembly is responsible for electing the Premier. Elections are held every three years by secret ballot under a system of universal suffrage. 2.2 Economic situation The economy is dependent on limited agricultural exports and the sale of fishing rights. The sale of postage stamps to foreign collectors is also an important source of revenue. The gap between domestic production and demand for goods and services is very wide. The resulting trade deficit makes the economy heavily dependent on foreign aid, most of which comes from New Zealand, and remittances from Niueans living abroad. NIUE 226 | COUNTRY HEALTH INFORMATION PROFILES In 2003, the gross domestic product (GDP) at current prices was NZD 17 252 000 (US$ 12 140 411); per capita GDP stood at NZD 10 048 (US$ 7070). The New Zealand High Commissioner’s Office, the only diplomatic mission in Niue, manages the projects of the New Zealand Official Development Assistance (NZODA). Niue also receives aid from the Australian Agency for International Development (AusAID), the Government of Japan and other international agencies. 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 small twin otter aircraft for passenger service three times a week between Nukualofa, Tonga and Niue. Polynesian Airlines has started a new service from Apia to Auckland via Niue twice a week. 3. HEALTH SITUATION 3.1 Health trends In general, health indicators are good, consistent with the country’s high literacy rate (100% in 2003) and its well educated population. Infant mortality is low and no maternal death was recorded from 1999 to 2005. Average life expectancy in 2001 was 70.1 years, 69.8 years for men and 71.2 years for women. The fertility rate is 3.01 (2001). The incidence of teenage pregnancy is relatively high (8%). Common childhood illnesses and traditional communicable diseases, such as tuberculosis and leprosy, have been substantially contained. The programme on elimination of filariasis is ongoing, with high coverage (>80% eligible population) of mass drug administration (MDA). Niue has a 0.2% antigenemia rate and is targeting filariasis elimination by 2005. No case of HIV/AIDS has been reported and sexually transmitted infections are rare. With support from WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS), the Department of Health has been active in working with communities, nongovernmental organizations and the private sector to increase public awareness on reproductive health and HIV/ AIDS. Although the prevalence of vectorborne parasitic diseases has been negligible in the 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 a 1997 census, 30.8% of males and 13.6% of females smoked cigarettes. Alcohol consumption is also reported to be high: casual drinking (43%) and heavy drinking (3.2%). The National Nutritional Survey in 1987 noted a concern about the high consumption of sugar snacks and the low intake of vegetables and fruits. In 2001, the major causes of morbidity were hypertension, diabetes mellitus, infections of the skin and subcutaneous tissue, upper respiratory tract infections and influenza. The five leading causes of mortality were injuries from gunshots, diabetes and hypertension complications (cardiovascular and cerebrovascular diseases), premature births, pneumonia (one case) and accidental drowning (one case). 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. COUNTRY HEALTH INFORMATION PROFILES | 227 The groundwater supply is safe and potable for human consumption and coverage of safe water sanitation facilities is 100% (2005). AusAID supported the development of the national waste management plan. The Government is committed to the Healthy Islands programme and the Tobacco Free Initiative, which are supported by WHO. The Moui Olaola Project (a Healthy Islands health promotion project) was started in 1996. 3.2 Health systems The only hospital, Lord Liverpool Hospital, was destroyed by Cyclone Heta in January 2004. Hospital services were set up subsequently in a youth centre in Fonuakula, Alofi, which is near the airport. 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 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. 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. 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. The government budget for non-trading expenditures for the fiscal year 2002-2003 was NZD 10 518 696 (US$ 7 403 525), down from NZD 11 850 683 (US$ 8341 037) for 2001-2002. The budget for health expenditures also dropped, from NZD 1 462 489 (US$ 1 029 289) for 2001-2002, to NZD 1 421 864 (US$ 1 000 364) (13.5% of non-trading expenditures) for 2002- 2003. Education gets more or less the same budget as health. Total government non-trading expenditures for personnel (364 employees) amounts to NZD 6 042 007 (US$ 4 251 106), and for health personnel (49 employees) NZD 830 264 (US$ 580 097). Health expenditures are distributed as follows: administration, NZD 339 742 (US$ 239 069); medical, NZD 535 332 (US$ 376 582); nursing, NZD 314 844 (US$ 221 540); public health, NZD 114 713 (US$ 80 718); and dental, NZD 117 233(US$ 82 491). The health revenue from administration is NZD 30 500 (US$ 21 455). 4. NATIONAL HEALTH PLAN AND PRIORITIES National health priorities are focused on public health prevention strategies 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. NIUE 228 | COUNTRY HEALTH INFORMATION PROFILES 5. MAJOR INFORMATION SOURCES Boladuadua A. Mission report on primary health care services development. Manila, WHO Western Pacific Regional Office, 2001. Estimates of expenditure and revenue for year 2002/2003. Government of Niue, 2003. Report on the Nationwide Health Survey, May 2002. Health Department, 2002. Health Department statistics Niue statistics, 2000-2001 Niue Sustainable Human Development Situation Analysis, 2002. New York, UNDP, 2002. 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Postal Address : Official Email Address : Telephone : Fax : Office Hours : Website : WHO REPRESENTATIVE IN SAMOA Office Address : Ioane Viliamu Building Beach Road, Apia, Western Samoa Postal Address : P.O. Box 77 Apia, Samoa Official Email Address : who@sma.wpro.who.int Telephone : (685) 23756 Fax : (685) 23765 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILE 229 NIUE WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 0.26 2004 1 2 Estimated population ('000s) 1.73 … … 2005 est 1 3 Annual population growth rate (%) -3.72 … … 2001 4 4 Percentage of population - 0–14 years 25.14 … … 2005 est 11 - 65+ years 11.21 … … 2005 est 11 5 Urban population (%) 34.00 … … 2001 2 6 Crude birth rate (per 1 000 population) 17.90 … … 2005 11 7 Crude death rate (per 1 000 population) 8.09 … … 2005 11 8 Rate of natural increase of population (% per annum) 1.10 … … 2001 1 9 Life expectancy (years) - at birth 70.10 69.80 71.20 2001 3 - Heal th-adjusted Life Expectancy (H ALE) at age 60 … 11.60 12.80 2002 7 10 Adult literacy rate (%) 100.00 … … 2003 1 11 Neonatal mortality rate (per 1 000 live births) 0.00 … … 2005 1 12 Infant mortality rate (per 1 000 live births) 0.00 … … 2005 11 13 Under-five mortality rate (per 1 000 live births) 0.00 0.00 0.00 2005 11 14 Total fertility rate (women aged 15–49 years) 3.01 2001 3 15 Maternal mortality ratio (per 100 000 live births) 0.00 2005 11 16 Percentage of newborn infants weighing at least 2500 g at birth 100.00 55.50 44.50 2005 11 17 Prevalence of underweight children under five years of age 0.00 0.00 0.00 2005 11 18 Percentage of pregnant women with anaemia 2.00 2005 11 19 Immunization coverage for infants (%) b - BCG 99.00 55.00 44.00 2005 11 - DTP3 98.00 … … 2005 11 - OPV3 98.00 … … 2005 11 - Measles 97.00 … … 2005 11 - Hepati tis B III 98.00 … … 2005 11 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 100.00 2005 11 - Percentage of pregnant women immunized with tetanus toxoid (TT2) NR 2005 11 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) 0.00 2005 11 - Percentage of deliveries in heal th facilities (as % of total deliveries) 100.00 2005 11 21 Percentage of women in the reproductive age group using modern contraceptive methods 22.00 2005 11 22 Condom use rate of the contraceptive prevalence rate (%) 5.00 … … 2005 11 23 HIV prevalence among 15–24 year-old pregnant women 0.00 2005 11 24 Number of children orphaned by HIV/AIDS ab … … 0 2005 11 NIUE 230 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 … … 2003 1 26 Proportion of population with access to improved sanitation 100.00 … … 2003 1 27 Proportion of the population using solid fuels for cooking or heating (%) 16.90 … … 2001 7 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.77 … … 1998 9 32 Per capita GDP at current market prices (NZ$) 10 048.00 … … 2003 10 33 Rate of growth of per capita GDP (%) 6.88 a … … 2003 10 34 Health expenditure Total health expenditure - amount (in m illion US$) … - total heal th expenditure on health as % of GDP … - per capita total expendi ture on health (in US$) 417.32 2001-2002 4 Government expenditure on health - amount (in million NZ$) 1.42 FY2002- 2003 4 - general government expenditure on health as % of total expenditure on health … - general government expenditure on heal th as % of total general government expendi ture 13.52 a FY2002- 2003 4 External source of government health expenditure - external resources for heal th as % of general government expendi ture on health … Private health expenditure - private expenditure on health as % of total expenditure on heal th … Exchange rate in US$ of local currency is: 1 US$ = 1.73 (average) 2003 6 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 4 1 3 23.12 … … 2006p 11 - dentists 3 3 0 17.34 … … 2006p 11 - pharmacists 1 1 0 5.78 … … 2006p 11 - nurses 13 1 12 75.14 … … 2006p 11 - m idwives 2 0 2 11.56 … … 2006p 11 - other nursing / auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 4 0 4 23.12 … … 2006p 11 - other heal th personnel (health inspec tors, assistant sani tarians, traditional workers, etc.) 4 4 0 23.12 … … 2006p 11 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses 0 0 0 2006p 11 COUNTRY HEALTH INFORMATION PROFILE 231 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Hypertension 343 … … 19 183.45 … … 2001 5 2. Diabetes mellitus 308 … … 17 225.95 … … 2001 5 3. Infection of the skin and subcutaneous tissue 271 … … 15 156.60 … … 2001 5 4. Upper respiratory tract infection, unspecified 270 … … 15 100.67 … … 2001 5 5. Influenza 156 … … 8724.83 … … 2001 5 6. Myalgia and m yositis 148 … … 8277.40 … … 2001 5 7. Other disease of the skin 110 … … 6152.13 … … 2001 5 8. Open wounds 97 … … 5425.06 … … 2001 5 9. Bronchitis 78 … … 4362.42 … … 2001 5 10. Sprains and strains of joints and adjacent muscles 72 … … 4026.85 … … 2001 5 40 Five leading causes of mortality Number Rate per 100 000 population 1. Injuries from gunshots … … … … … … 2001 4 2. Diabetes and hypertension complications … … … … … … 2001 4 3. Premature births … … … … … … 2001 4 4. Pneumonia 1 … … … … … 2001 4 5. Accidental drowning 1 … … … … … 2001 4 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2005 11 - Pertussis (whooping cough) 0 0 0 0 0 0 2005 11 - T etanus 0 0 0 0 0 0 2005 11 - Neonatal tetanus 0 0 0 0 0 0 2005 11 - Poliomyelitis 0 0 0 0 0 0 2005 11 - Hib meningitis 0 0 0 0 0 0 2005 11 - Measles 0 0 0 0 0 0 2005 11 - Mumps 0 0 0 0 0 0 2005 11 - Rubella 0 0 0 0 0 0 2004 6 - Congeni tal rubella syndrome 0 0 0 0 0 0 2005 11 42 Selected communicable diseases Number of cases aa Number of deaths Hepati tis vi ral 0 0 0 0 0 0 2005 11 - T ype A 0 0 0 0 0 0 2005 11 - T ype B 0 0 0 0 0 0 2005 11 - T ype C 0 0 0 0 0 0 2005 11 - T ype E … … … … … … - Unspecified … … … … … … Cholera 0 0 0 0 0 0 2005 11 Typhoid fever 0 0 0 0 0 0 2005 11 Encephalitis 0 0 0 0 0 0 2005 11 Plague 0 0 0 0 0 0 2005 11 Syphilis 0 0 0 0 0 0 2005 11 Gonorrhoea (gonococcal infections) 0 0 0 0 0 0 2005 11 Leprosy 0 0 0 0 0 0 2005 11 Malaria 0 0 0 0 0 0 2005 11 Dengue/DHF 0 0 0 0 0 0 2005 11 NIUE 232 INDICATORS DATA Year Source Total Male Female Total Male Female 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 0 0 0 0 0 0 2004 6 - New pulmonary tuberculosis (smear-posi tive) 0 0 0 0 0 0 2004 6 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 57.00 … … 6.00 … … 2004 6 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOT S) 469.00 b … … 100.00 … … 2002 6 Number of cases Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (malignant neoplasms only) … … … … … … - T rachea, bronchus, and lung … … … … … … - Stomach … … … … … … - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … … … … - Liver … … … … … … - Cervix … … - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … … … … - Ischaemic heart disease … … … … … … - Acute m yocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … … … … - H ypertension 343 … … … … … 2001 5 49 Maternal causes - Haemorrhage … … - Abortion … … - Eclampsia … … - Sepsis … … - Obstruc ted labour … … 50 Diabetes mellitus 308 … … … … … 2001 5 51 Mental disorders … … … … … … COUNTRY HEALTH INFORMATION PROFILE 233 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 52 Injuries - All types … … … … … … - Motor and other vehicle accidents … … … … … … - Suicide … … … … … … - Hom icide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public heal th facilities - General hospitals 1 8 2006 11 - Specialized hospi tals … … - District/first-level referral hospitals … … - Primary health care centres … … Private hospitals … … Notes: Red text M illennium Development Goals (MDG) indicators … Data not available FY The financial year refers to the span from July 1 of respective year to June 30 next year. aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Uni t of the WHO Regional Office for the Western Pacific . b Revised data. c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Pacific island populations 2004. Secretariat of the Pacific Community (http://www.spc.int/) 2 Demographic tables for the Western Paci fic Region 2000-2005. Manila, WHO Regional Office for the Western Pacific , 2005. 3 Statistics Niue (http://www.spc.int/prism) 4 Information furnished by WHO Representative in Samoa, 13 March 2004. 5 Niue sustainable human development situation analysis 2002 . New York, United Nations Development Programme, 2002. 6 WHO Regional Office for the Western Paci fic, data received from technical units. 7 The world heal th report 2004. Changing history. Geneva, World Health Organization, 2004. 8 Pacific islands Regional Millennium Development Goals report 2004. Secretariat of the Pacific Community and UN/CROP MDG Working Group, November 2004 9 1999 Paci fic human development report (creating opportuni ties). New York, Uni ted Nations Development Programme, 1999. 10 Statistics Nuie (http://www.gov.nu/statsniue/) 11 Niue Foou Hospital Data Sources, 2006 234 | COUNTRY HEALTH INFORMATION PROFILES NORTHERN MARIANA ISLANDS 1. DEMOGRAPHICS, GENDER AND POVERTY The estimated multi-ethnic population of the Northern Mariana Islands was 80 362 in 2005 and comprised Chamorros, Carolinians, Micronesians, Japanese, Chinese, Filipinos, Koreans and Caucasians. Even though the three official languages are English, Chamorro and Carolinian, 86% of the population speak a language other than English at home. Of the fourteen islands that make up the island nation, only three were inhabited in 2000: Saipan, Rota, and Tinian. The population has an estimated growth rate of 2.61% (2005 estimate). The median age is 31.4 for men and 28.2 for women (2004 estimate). The country has an estimated crude birth rate of 19.77 births per 1000 population and an estimated crude death rate of 2.30 deaths per 1000 population. Table 1. Core population and health data (2005 estimates) [Total] 80 362 [Both] 75.88 [0-14 years] 15 978 (19.88%) [Male] 73.31 Population [65+ years] 1281 (1.59%) Life expectancy at birth (years) [Female] 78.61 Crude birth rate (per 1000 population) 19.51 Total fertility rate 1.27 [Total] 98.00 (2002) [Urban] 98.00 (2002) Crude death rate (per 1000 population) 2.30 % of population served with safe water [Rural] 97.00 (2002) [Total] 94.00 (2002) [Urban] 94.00 (2002) Infant mortality rate (per 1000 live births) 7.11 % of population with adequate sanitary facilities [Rural] 96.00 (2002) Maternal mortality ratio (per 100 000 live births) 0.00 (2000) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The Northern Mariana Islands are under the administration of the United States of America as part of the US Trust Territory of the Pacific. Negotiations for territorial status began in 1972 and a covenant to establish a commonwealth in political union with the United States of America was approved in 1975. A new government and constitution went into effect in 1978. The Northern Mariana Islands elect a governor and a legislature. Governor Benigno R. Fitial was elected in November 2005. 2.2 Economic situation The economy benefits substantially from financial assistance from the United States of America, but funding has declined as locally generated government revenues have grown. The tourist industry employs about 50% of the workforce and accounts for roughly one-quarter of gross domestic product (GDP). Japanese tourists predominate and annual tourist entries have exceeded half a million in recent years, although the financial recession in Japan led to a slowdown. COUNTRY HEALTH INFORMATION PROFILES | 235 3. HEALTH SITUATION 3.1 Health trends The overall health status of the population is changing as the economy of the Commonwealth continues to grow and develop, and is moving away from the health profile of a developing nation towards that of a more industrialized one. Compared with the United States of America, the Northern Mariana Islands spends much less per capita on health care but enjoys a level of health that is comparable in terms of disease incidence and prevalence, with the exception of diabetes, certain cancers and some infectious diseases. Infectious diseases are once again emerging as a major public health concern. Of particular concern are tuberculosis, hepatitis B, hepatitis A, enteric foodborne illnesses, vaccine-preventable diseases, HIV infection and other sexually transmitted infections. The public health department has dealt with recent outbreaks of hepatitis A, measles and foodborne outbreaks involving salmonella, shigella and cholera. Obesity, diabetes, hypertension and atherosclerotic vascular disease are increasing concerns facing the ageing population. 3.2 Health systems In 1996, per capita health expenditure was US$ 1095. It dropped by more than half to US$ 519 in the 2000 fiscal year. To increase the effectiveness of available resources, the College of the Northern Mariana Islands has developed a nursing programme oriented towards public health nursing. In collaboration with the University of Hawaii, the School of Public Health is strengthening manpower training in public health. However, there have been difficulties in recruiting and retaining qualified personnel. The main obstacles include the small human resource pool from which to recruit, the ever-rising costs of maintaining the Commonwealth Health Centre and a lack of community participation in the health care system. Human resource development and upgrading of the knowledge and skills of primary health care personnel will be priorities for the coming years. There is a need for political commitment in the form of legislation to make primary health care services a priority, and the allocation of funds to primary health care services needs to increase. Future primary health care efforts must include strengthening of direct participation by the community and community-based agencies. 4. NATIONAL HEALTH PLAN AND PRIORITIES The Public Health Division has set nine immediate objectives targeted at all Northern Mariana Islands residents: • to provide appropriate preventive health care and services to all communities, with an emphasis on women and children; • to provide appropriate reproductive health and family planning services to all women of child-bearing age and their partners; • to provide appropriate and timely health education, promotion and nutrition information to all residents; • to provide an adequate surveillance and monitoring system, and timely prevention information on communicable and infectious diseases; • to provide timely and appropriate noncommunicable disease prevention information and outreach services to all residents; • to strengthen the availability of health information and health planning by developing surveillance systems that accurately monitor the health status of the community; NORTHERN MARIANA ISLANDS 236 | COUNTRY HEALTH INFORMATION PROFILES • to provide public health dental care and outreach dental health prevention services in schools; • to provide and improve the environmental health and sanitation services; and • to identify children who are developmentally delayed or ‘at risk’ in order to minimize their problems and enhance the quality of life for them and for their families. 5. MAJOR INFORMATION SOURCES Division of Public Health, Government of the Northern Mariana Islands Pacific Regional Information System (PRISM). Secretariat of the Pacific Community (http://www.spc.int/prism/) Politics of the Northern Mariana Islands (http://en.wikipedia.org/wiki/Politics_of_the_Northern_Mariana_Islands) 6. ADDRESSES DEPARTMENT OF PUBLIC HEALTH Office Address : Postal Address : P.O. Box 560409, Saipan MP 96950, Commonwealth of the Northern Mariana Islands Official Email Address : Telephone : Fax : Office Hours : Website : WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4 Provident Plaza 1, Downtown Boulevard, 33 Ellery Street, Suva, Fiji Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@fij.wpro.who.int Telephone : (679) 3-304600 / 3-304631/ 3-300727 Fax : (679) 3-300462 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILE 237 NORTHERN MARIANA ISLANDS WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 0.47 2004 1 2 Estimated population ('000s) 80.36 35.10 45.26 2005 est 2 3 Annual population growth rate (%) 2.61 … … 2005 est 2 4 Percentage of population - 0–14 years 19.88 23.74 16.89 2005 est 2 - 65+ years 1.59 1.84 1.40 2005 est 2 5 Urban population (%) 94.20 … … 2003 4 6 Crude birth rate (per 1 000 population) 19.51 … … 2005 est 2 7 Crude death rate (per 1 000 population) 2.30 … … 2005 est 2 8 Rate of natural increase of population (% per annum) 1.75 a … … 2005 est 2 9 Life expectancy (years) - at birth 75.88 73.31 78.61 2005 est 2 - Health-adjusted Life Expectancy (HALE) at age 60 … … … 10 Adult literacy rate (%) … … … 11 Neonatal mortality rate (per 1 000 live births) … … … 12 Infant mortality rate (per 1 000 live births) 7.11 7.05 7.17 2005 est 2 13 Under-five mortality rate (per 1 000 live births) 7.43 … … 1999 5 14 Total fertility rate (women aged 15–49 years) 1.27 2005 est 2 15 Maternal mortality ratio (per 100 000 live births) 0.00 2000 5 16 Percentage of newborn infants weighing at least 2500 g at birth 81.01 … … 2000 5 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 4.55 2000 5 19 Immunization coverage for infants (%) - BCG … … … - DTP3 87.00 … … 2004 6 - OPV3 87.00 … … 2004 6 - Measles 82.00 … … 2004 6 - Hepatitis B III 89.00 … … 2004 6 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 75.67 2000 5 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods 64.00 2000 7 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … NORTHERN MARIANA ISLANDS 238 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 98.00 98.00 97.00 2002 8 26 Proportion of population with access to improved sanitation 94.00 94.00 96.00 2002 8 27 Proportion of the population using solid fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index … … … 32 Per capita GDP at current market prices (US$) 28 734.49 … … 1998 9 33 Rate of growth of per capita GDP (%) 7.85 … … 1998 9 34 Health expenditure Total health expenditure - amount (in million US$) 42. 14 2000 10 - total health expenditure on health as % of GDP … - per capita total expenditure on health (in US$) 519.00 2000 10 Government expenditure on health - amount (in million US$) 52.40 2002 3 - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure 16.44 2002 3 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = … 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 31 … … 4.47 … … 1999 5 - dentists 3 … … 0.43 … … 1999 5 - pharmacists 4 … … 0.58 … … 1999 5 - nurses 123 … … 17.74 … … 1999 5 - midwives 14 … … 2.02 … … 1999 5 - other nursing/ auxiliary staff 25 … … 3.61 … … 1999 5 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 20 … … 2.88 … … 1999 5 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 14 … … 2.02 … … 1999 5 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … COUNTRY HEALTH INFORMATION PROFILE 239 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity (notifiable diseases) Number Rate per 100 000 population 1. Bacterial food poisoning 1219 … … 1758.00 … … 1999 11 2. Chlamydiosis 206 … … 297.00 … … 1999 11 3. Syphilis 97 … … 140.00 … … 1999 11 4. Hepatitis B 76 … … 110.00 … … 1999 11 5. Tuberculosis 58 … … 84.00 … … 1999 11 6. Salmonellosis 31 … … 45.00 … … 1999 11 7. Gonorrhoea 29 … … 42.00 … … 1999 11 8. Shigellosis 29 … … 42.00 … … 1999 11 9. Ciguatera 15 … … 22.00 … … 1999 11 10. HIV 4 … … 6.00 … … 1999 11 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Cardiovascular diseases 33 … … 54.08 … … 1998 5 2. Neoplasms 26 … … 39.06 … … 1998 5 3. Cerebrovascular diseases 14 … … 21.03 … … 1998 5 4. Perinatal conditions 13 … … 19.53 … … 1998 5 5. Motor vehicle accidents 7 … … 10.51 … … 1998 5 6. Pneumonia 6 … … 9.01 … … 1998 5 7. All other accidents 5 … … 7.51 … … 1998 5 8. Chronic liver diseases and cirrhosis 5 … … 7.51 … … 1998 5 9. Suicide 5 … … 7.51 … … 1998 5 10. Diabetes mellitus 4 … … 6.00 … … 1998 5 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 … … … 2004 6 - Pertussis (whooping cough) 0 0 0 … … … 2004 6 - Tetanus 0 0 0 … … … 2004 6 - Neonatal tetanus 0 0 0 … … … 2004 6 - Poliomyelitis 0 0 0 … … … 2004 6 - Hib meningitis 0 0 0 … … … 2004 6 - Measles 0 0 0 … … … 2004 6 - Mumps 0 0 0 … … … 2004 6 - Rubella 0 0 0 … … … 2004 6 - Congenital rubella syndrome 0 0 0 … … … 2004 6 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral - Type A … … … … … … - Type B … … … … … … - Type C … … … … … … - Type E … … … … … … - Unspecified … … … … … … Cholera … … … … … … Typhoid fever … … … … … … Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … Gonorrhoea … … … … … … NORTHERN MARIANA ISLANDS 240 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Leprosy 4 … … … … … 2003 6 Malaria … … … … … … Dengue/DHF … … … … … … 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures b … - Proportion of population in malaria-risk areas using effective malaria treatment measures c … 44 Tuberculosis Number of cases Number of deaths - All types 53 … … … … … 2004 6 - New pulmonary tuberculosis (smear-positive) 14 … … … … … 2004 6 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 68.00 … … 8.00 … … 2004 6 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 67.00 … … 75.00 (2003) … … 2004 6 Number of cases (C) Number of deaths (D) 45 Acute respiratory infections 4242 … … … … … 2000 5 46 Diarrhoeal diseases 10 … … 1 … … C: 2000 D: 1998 5 47 Cancers Number of cases (C) 2000 Number of deaths (D) 1998 All cancers (malignant neoplasms only) 437 … … 26 … … C: 2000 D: 1998 5 - Trachea, bronchus and lung 12 … … 10 … … 5 - Stomach 1 … … 2 … … 5 - Colon and rectum 0 0 0 1 … … 5 - Lip, oral cavity and pharynx 0 0 0 0 0 0 5 - Liver 0 0 0 0 0 0 5 - Cervix 11 3 5 - Leukaemia 0 0 0 5 … … 5 48 Circulatory All circulatory system diseases 2265 … … … … … C: 2000 D: 1998 5 - Ischaemic heart disease 28 … … 7 … … 5 - Acute myocardial infarction 16 … … 7 … … 4 - Rheumatic fever and rheumatic heart diseases 39 … … 0 0 0 5 - Cerebrovascular diseases 98 … … 14 … … 5 - Hypertension 1758 … … 2 … … 5 49 Maternal causes - Haemorrhage 0 0 2000 5 - Abortion 0 0 2000 5 - Eclampsia … … - Sepsis … … - Obstructed labour … … COUNTRY HEALTH INFORMATION PROFILE 241 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases (C) Number of deaths (D) 50 Diabetes mellitus 2490 … … 4 … … C: 2000 D: 1998 5 51 Mental disorders 1197 … … 2 … … C: 2000 D: 1998 5 52 Injuries - All types 5742 … … … … … 2000 5 - Motor and other vehicle accidents 555 … … 7 … … C: 2000 D: 1998 5 - Suicide 43 … … 5 … … C: 2000 D: 1998 5 - Homicide and violence 389 … … 3 … … C: 2000 D: 1998 5 - Occupational injuries 510 … … … … … FY1999 12 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals (Saipan) 1 74 2000 5 - Specialized hospitals 0 0 2000 5 - District/first-level referral hospitals (Rota and Tinian) 2 8 2000 5 - Primary health care centres 1 0 2000 5 Private hospitals 5 0 2000 5 Notes: Red text Millennium Development Goals (MDG) indicators … Data not available est Estimate C Cases D Deaths FY The financial year refers to the span from April 1 of respective year to March 31 next year. aa Figure refers to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. c Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community (http://www.spc.int) 2 United States Census Bureau, International Programs Center (http://www.spc.int/prism/) 3 CNMI Central Statistics Division, Department of Finance (http://www.spc.int/prism) 4 Urban and rural areas 2003. New York, United Nations Department of Economic and Social Affairs, 2004. 5 Data analyzed through the RPMS computerized system. Birth and Death Database Registry, Office of Health Planning and Statistics, Division of Public Health, Department of Public Health. 6 WHO Regional Office for the Western Pacific, data received from the technical units 7 Family Planning Programme, Division of Public Health, Department of Public Health. 8 Meeting the MDG drinking water and sanitation target: A mid-term assessment of progress. WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2004. 9 Census information from the Central Statistics Division, Department of Commerce. NORTHERN MARIANA ISLANDS 242 10 Hospital Division, Department of Public Health. 11 Annual report on notifiable diseases to the Epidemiology and Surveillance Unit, Division of Public Health. 12 Data from Worker's Compensation Commission, Northern Mariana Islands Retirement Fund. COUNTRY HEALTH INFORMATION PROFILES | 243 PALAU 1. DEMOGRAPHICS, GENDER AND POVERTY The estimated multi-ethnic population of Palau was 19 907 in 2005, with a natural per annum increase of 5.7%. The population consists of 70% Palauans (who are a conglomeration of Micronesian with Malayan and Melanesian admixtures), 28% Asians (mainly Filipinos, followed by Chinese, Taiwanese and Vietnamese) and 2% Caucasian (2000 est.). Since the 1990 census, life expectancy at birth has been higher for women than men; the 2004 estimate stood at 75.7 years for women and 67.8 years for men. In 2000, the ratio of girls to boys in primary school was 97.25 girls per 100 boys and the ratio of girls to boys in secondary school was 88 girls per 100 boys. Also in 2000, the share of women in employment in the non- agricultural sector (includes self-employed and unpaid) was 40.1%, and 3.7% of the seats in the national Parliament were held by women. Table 1. Core population and health data (2005) [Total] 19 907 [Both] 71.62 (2004) [0-14 years] 4798 (24.10%) [Male] 67.80 (2004) Population [65+ years] 1136 (5.70%) Life expectancy at birth (years) [Female] 75.68 (2004) Crude birth rate (per 1000 population) 12.60 (2004) Total fertility rate 1.54 (2004) [Total] 95.40 (2003) [Urban] 99.00 (2003) Crude death rate (per 1000 population) 6.90 (2004) % of population served with safe water [Rural] 89.00 (2003) [Total] 99.00 (2003) [Urban] 99.00 (2003) Infant mortality rate (per 1000 live births) 16.22 (2004) % of population with adequate sanitary facilities [Rural] 98.00 (2003) Maternal mortality ratio (per 100 000 live births) 11.58 (2004) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Palau is a democratic republic with directly elected executive and legislative branches. Presidential elections take place every four years to select the President and the Vice-President, who run on separate tickets. The Palau National Congress (Olbiil era Kelulau) has two houses. The Senate has nine members, elected nationwide. The House of Delegates has 16 members, one from each of Palau's 16 states. All of the legislators serve four-year terms. Each state also elects its own governor and legislature. The Council of Chiefs is an advisory body to the President that contains the highest traditional chiefs from each of the 16 states. The Council is consulted on matters concerning traditional laws and customs. The judicial system consists of the Supreme Court, the 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. The current head of state is President Tommy Esang Remengesau, Jr. The Vice-President is Elias Camsek Chin. PALAU 244 | COUNTRY HEALTH INFORMATION PROFILES 2.2 Economic situation Palau’s real per capita gross domestic product (GDP) of US$ 5678 makes it one of the wealthier Pacific island states. The economy consists primarily of tourism, subsistence agriculture and fishing. The Government is the major employer of the workforce, relying heavily on financial assistance from the United States of America. Business and tourist arrivals numbered 87 462 in 2004. Long-term prospects for the key tourist sector have been bolstered greatly by the expansion of air travel in the Pacific, the rising prosperity of leading East Asian countries, and the willingness of foreigners to finance infrastructure development. 3. HEALTH SITUATION 3.1 Health trends The health of Palauans seems to have improved a little, as manifested in improved health indicators such as increased life expectancy at birth and a decreased under-five mortality rate. Also, sanitation has improved, with the entire population now having access to excreta disposal facilities. Tuberculosis remains a problem, while the prevalence of leprosy has increased slightly. Modern lifestyle-related diseases (circulatory diseases and cancer) remain at the top of the list of major causes of death. It is expected that environmental problems will increase with more foreign investment and workers on the islands in coming years. Water pollution is a major concern due to the lack of sufficient land area for proper waste disposal. Progressive industrial development will continue to worsen both air and marine quality. Marine life and reefs will be affected by the pollution. 3.2 Health systems ‘Health for all’ remains a top priority in the socioeconomic development of Palau. The Government aims to provide enough trained and qualified staff to provide quality services in all outlying dispensaries, including the more remote areas and islands, as well as at the main hospital in Koror. Although health services are supported by grants and funds from the Federal Government of the United States of America, in addition to the provision of technical support from several United Nations agencies, resource requirements will still be dependent on successful economic development. A new hospital has been built, with United States funding, to accommodate more patients. More staff are needed as a result. Training of more local health workers is needed to replace the expensive expatriate staff. Subsequent to the enactment of a new mandatory retirement law, there is an urgent need to train younger people to replace older personnel who are close to retirement age. In 1998, Palau had a health workforce comprising 20 doctors, two dentists, a midwife, a pharmacist and 106 other health personnel. In 2003, the number of doctors increased to 25. In 2005, there were 111 nurses. Plans are being made to develop a nursing school at Palau Community College to provide essential training for health personnel in-country and thereby avoid losing health workers who are trained abroad. 4. NATIONAL HEALTH PLAN AND PRIORITIES The national health priorities are: • to deliver quality health care, including community-based health care, in order to improve the health of the population and contribute towards building a COUNTRY HEALTH INFORMATION PROFILES | 245 balanced economy; • to increase the accessibility of health services through the establishment of outlying dispensaries/health centres; • to train and certify health workers and allied health workers in proper training institutions; • to establish a nursing school at Palau Community College; • to control communicable and noncommunicable diseases; • to improve the nutritional status of community members through the implementation of a national action plan for food and nutrition; and • to protect environmental health 5. MAJOR INFORMATION SOURCES Palau Government Statistics(http://www.palaugov.net) Palau Statistics (http://www.spc.int/prism) Bureau of East Asian and Pacific Affairs, United States of America Department of State (http://www.state.gov/r/pa/ei/bgn/1840.htm ) Ministry of Health 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Postal Address : P.O.Box 6027, Koror, Republic of Palau 96940 Official Email Address : Telephone : (680) 488 2552 / 488 2553 Fax : (680) 488 5618 Office Hours : Website : WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4 Provident Plaza 1, Downtown Boulevard, 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@fij.wpro.who.int Telephone : (679) 3-304600 / 3-304631 / 3-300727 Fax : (679) 3-300462 Office Hours : 8:00 a.m. to 5:00 p.m., Monday to Friday Website : PALAU 246 PALAU WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 0.49 2004 4 2 Estimated population ('000s) 19.91 10.70 9.21 2005 5 3 Annual population growth rate (%) 1.64 a … … 2003 est 5 4 Percentage of population - 0–14 years 24.10 22.94 25.46 2005 5 - 65+ years 5.70 4.33 7.30 2005 5 5 Urban population (%) 77.35 … … 2005 5 6 Crude birth rate (per 1 000 population) 12.60 … … 2004 5 7 Crude death rate (per 1 000 population) 6.90 … … 2004 5 8 Rate of natural increase of population (% per annum) 5.70 … … 2004 5 9 Life expectancy (years) - at birth 71.62 67.80 75.68 2004 5 - Heal th-adjusted Life Expectancy (H ALE) at age 60 … 10.20 12.00 2002 9 10 Adult literacy rate (%) 99.90 b 99.90 b 99.80 b 2005 5 11 Neonatal mortality rate (per 1 000 live births) 14.00 c … … 2000 11 12 Infant mortality rate (per 1 000 live births) 16.22 19.02 13.24 2004 5 13 Under-five mortality rate (per 1 000 live births) 6.89 6.89 0.00 2004 5 14 Total fertility rate (women aged 15–49 years) 1.54 2004 5 15 Maternal mortality ratio (per 100 000 live births) 11.58 2004 5 16 Percentage of newborn infants weighing at least 2500 g at birth 91.00 … … 1998 7 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 1.20 1998 7 19 Immunization coverage for infants (%) - BCG … … … 2004 10 - DTP3 98.00 … … 2004 10 - OPV3 98.00 … … 2004 10 - Measles 100.00 … … 2004 10 - Hepati tis B III 98.00 … … 2004 10 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 99.64 1998 7 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 100.00 2004 10 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in heal th facilities (as % of total deliveries) 18.50 1998 7 21 Percentage of women in the reproductive age group using modern contraceptive methods 17.20 2000 8 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … COUNTRY HEALTH INFORMATION PROFILE 247 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 95.40 99.00 89.00 2003 1 26 Proportion of population with access to improved sanitation 99.00 99.00 98.00 2003 1 27 Proportion of the population using solid fuels for cooking or heating (%) 1.00 … … 2000 8 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.86 … … 1998 3 32 Per capita GDP at current market prices (US$) 5678.00 … … 2003 5 33 Rate of growth of per capita GDP (%) -1.73 a … … 2003 5 34 Health expenditure Total health expenditure - amount (in m illion US$) … - total heal th expenditure on health as % of GDP 9.70 2003 2 - per capita total expendi ture on health (in US$) 607.00 2003 2 Government expenditure on health - amount (in million US$) 11.87 FY2004/ 2005 5 - general government expenditure on health as % of total expenditure on health 86.70 2003 2 - general government expenditure on heal th as % of total general government expendi ture 16.39 FY2004/ 2005 5 External source of government health expenditure - external resources for heal th as % of general government expendi ture on health … Private health expenditure - private expenditure on health as % of total expenditure on heal th 13.30 2003 2 Exchange rate in US$ of local currency is: 1 US$ = … 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 25 … … 12.31 … … 2003 12 - dentists 2 … … 1.10 … … 1998 7 - pharmacists 1 … … 0.55 … … 1998 7 - nurses 111 f … … 55.76 … … 2005 13 - m idwives 1 … … 0.56 … … 1998 7 - other nursing/ auxiliary staff 87 … … 48.00 … … 1998 7 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 13 … … 7.20 … … 1998 7 - other heal th personnel (health inspec tors, assistant sani tarians, traditional workers, etc.) 6 … … 3.30 … … 1998 7 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … PALAU 248 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Injuries (all types) 2911 … … 16 073.99 … … 1998 7 2. Unspecified upper respiratory infection 1806 … … 9972.39 … … 1998 7 3. Unspecified oti tis media 1625 … … 8972.94 … … 1998 7 4. Colitis, enteri tis and gastroenteri tis 687 … … 3793.48 … … 1998 7 5. Ac ute tonsilitis 591 … … 3263.39 … … 1998 7 6. Ac ute pharyngitis 531 … … 2932.08 … … 1998 7 7. Unspecified allergy 496 … … 2738.82 … … 1998 7 8. Unspecified gastritis and duodenitis 343 … … 1893.98 … … 1998 7 9. Ac ute lymphadeni tis 343 … … 1893.98 … … 1998 7 10. Unspecified urinary trac t infection 338 … … 1866.37 … … 1998 7 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Cardiovascular diseases 18 … … 99.39 … … 1998 7 2. Unknown and other 18 … … 99.39 … … 1998 7 3. Other circulatory diseases 16 … … 88.34 … … 1998 7 4. Other injuries 14 … … 77.31 … … 1998 7 5. Cancer 13 … … 71.78 … … 1998 7 6. Respiratory diseases 6 … … 33.13 … … 1998 7 7. Digestive diseases 6 … … 33.13 … … 1998 7 8. Suicide 5 … … 27.61 … … 1998 7 9. Car accidents 4 … … 22.08 … … 1998 7 10. Coronary heart disease 4 … … 22.08 … … 1998 7 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 10 - Pertussis (whooping cough) 0 0 0 0 0 0 2004 10 - T etanus 0 0 0 0 0 0 2004 10 - Neonatal tetanus 0 0 0 0 0 0 2004 10 - Poliomyelitis 0 0 0 0 0 0 2004 10 - Hib meningitis 0 0 0 0 0 0 2004 10 - Measles 0 0 0 0 0 0 2004 10 - Mumps 0 0 0 0 0 0 2004 10 - Rubella 0 0 0 0 0 0 2004 10 - Congeni tal rubella syndrome 0 0 0 0 0 0 2004 10 42 Selected communicable diseases Number of cases aa Number of deaths Hepati tis vi ral (all forms) 5 3 2 … … … 2004 5 - T ype A … … … … … … - T ype B … … … … … … - T ype C … … … … … … - T ype E … … … … … … - Unspecified … … … … … … Cholera 0 0 0 0 0 0 2003 5 Typhoid fever … … … … … … Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … COUNTRY HEALTH INFORMATION PROFILE 249 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Gonorrhoea 38 17 21 … … … 2004 5 Leprosy 6 … … … … … 2004 10 Malaria 0 0 0 0 0 0 2003 5 Dengue/DHF 57 … … 0 0 0 2004 10 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures d … - Proportion of population in malaria-risk areas using effective malaria treatment measures e … 44 Tuberculosis Number of cases Number of deaths - All types 5 … … … … … 2004 10 - New pulmonary tuberculosis (smear-posi tive) 5 … … … … … 2004 10 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 91.00 … … 7.00 … … 2004 10 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOT S) 95.00 … … 80.00 (2003) … … 2004 10 Number of cases Number of deaths 45 Acute respiratory infections 2550 1176 1374 … … … 2004 5 46 Diarrhoeal diseases 69 41 28 … … … 2004 5 47 Cancers All cancers (malignant neoplasms only) 142 … … 13 … … 1998 7 - T rachea, bronchus and lung 6 … … 4 … … 1998 7 - Stomach 0 0 0 0 0 0 1998 7 - Colon and rectum 0 0 0 1 … … 1998 7 - Lip, oral cavity and pharynx 0 0 0 1 … … 1998 7 - Liver 2 … … 3 … … 1998 7 - Cervix 3 1 1998 7 - Leukaemia 0 0 0 0 0 0 1998 7 48 Circulatory All circulatory system diseases 738 … … 38 … … 1998 7 - Ischaemic heart disease 6 … … 2 … … 1998 7 - Acute m yocardial infarction 8 … … 1 … … 1998 7 - Rheumatic fever and rheumatic heart diseases 3 … … 0 0 0 1998 7 - Cerebrovascular diseases 53 … … 2 … … 1998 7 - H ypertension 375 … … 9 … … 1998 7 PALAU 250 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 49 Maternal causes - Haemorrhage 0 0 1998 7 - Abortion 28 0 1998 7 - Eclampsia … … - Sepsis … … - Obstruc ted labour … … 50 Diabetes mellitus 164 … … 3 … … 1998 7 51 Mental disorders … … … … … … 52 Injuries - All types 2911 … … 25 … … 1998 7 - Motor and other vehicle accidents 77 … … 4 … … 1998 7 - Suicide 3 … … … … … 1998 7 - Hom icide and violence 20 … … 2 … … 1998 7 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public heal th facilities - General hospitals 1 80 1998 7 - Specialized hospi tals 0 0 1998 7 - District/first-level referral hospitals 0 0 1998 7 - Primary health care centres 12 10 1998 7 Private hospitals … … Notes: Red text M illennium Development Goals (MDG) indicators … Data not available est Estimate FY The financial year refers to the span from April 1 of respective year to March 31 next year. aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Uni t of the WHO Regional Office for the Western Pacific . b Figure refers to 15-24 years old. c Estimates derived by regression and similar estimation methods. d Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. e Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. f Figure refers to registered nurses, licensed practical nurses and nursing assistants. Sources: 1 Information furnished by WHO Representative for the South Pacific, draft copy, 19 April 2004. 2 Working together for heal th. World heal th report 2006. Geneva, World Heal th Organization, 2006. 3 Pacific human development report 1999 (Creating opportuni ties). New York, United Nations Development Programme, 1999. 4 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 5 Palau Statistics (http://www.spc.int/prism) 6 Palau M inistry of Health Office of Nursing and Palau Board of Health Professionals Licensure (PBHPL). 7 Information furnished by M inistry of Health, Republic of Palau, 23 April 1999. 8 Pacific Island Regional Millennium Development Goals report 2004. Noumea, Secretariat of the Pacific Community, UN/ CROP MDG Working Group, November 2004. COUNTRY HEALTH INFORMATION PROFILE 251 9 Changing history. World health report 2004 . Geneva, World Health Organization, 2004. 10 WHO Regional Office for the Western Paci fic, data received from technical units. 11 Make every mother and child count. World heal th report 2005.Geneva, World Heal th Organization, 2005. 12 Information furnished by WHO Representative for the South Pacific, 11 April 2005. 13 Palau M inistry of Health, Office of Nursing; and Palau Board of Heal th Professional Licensures (PBHPL). 252 | COUNTRY HEALTH INFORMATION PROFILES PAPUA NEW GUINEA 1. DEMOGRAPHICS, GENDER AND POVERTY Papua New Guinea has an estimated population of approximately 5.9 million, with almost 87% living in rural areas. Around 800 languages are spoken and each language group has a distinct culture. There are large sociocultural differences between and within provinces. The official languages are English, Pidgin and Motu. Access to widely scattered rural communities is often difficult, slow and expensive. Only 3% of the country’s roads are paved. Many villages can only be reached on foot and most travel between provinces is by air. Papua New Guinea has made some progress in social development over the last 30 years, Literacy rates have risen from 32% to 56%. However, only half of all women aged 15 years and above and two-thirds of all men aged 15 years and older have ever attended school, and enrolment rates vary significantly across provinces. Life expectancy has risen from 49 to 53 years, and Papua New Guinea’s Human Development Index has risen from 0.43 to 0.54. However, in recent years, progress has slowed. Because of the country’s economic stagnation, 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 intended to give an added focus to poverty in the national Medium-Term Development Strategy (MTDS, 2003- 2007). The country is a signatory to the Millennium Development Declaration and the first MDG progress report was published in 2005. Table 1. Core population and health data (2005 estimates) [Total] 5 950 690 [Both] 53.00 (2000) [0-14 years] 41.68% (2004 est) [Male] 52.50 (2000) Population [65+ years] 2.54% (2004 est) Life expectancy at birth (years) [Female] 53.60 (2000) Crude birth rate (per 1000 population) 35.00 (2000) Total fertility rate 4.60 (2000) [Total] 39.00 (2002) [Urban] 88.00 (2002) Crude death rate (per 1000 population) 12.00 (2000) % of population served with safe water [Rural] 32.00 (2002) [Total] 45.00 (2002) [Urban] 67.00 (2002) Infant mortality rate (per 1000 live births) 64.00 (2000) % of population with adequate sanitary facilities [Rural] 41.00 (2002) Maternal mortality ratio (per 100 000 live births) 330.00 (2000) est - Estimate COUNTRY HEALTH INFORMATION PROFILES | 253 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Papua New Guinea is divided administratively into four regions: Southern Coastal (Papuan) Region, Northern Coastal (Momase) Region, Highlands Region 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 to the two tiers of government: national and local. Presently, there is only one women representative in the national Parliament. There is a decentralized system of government. At the subnational level, there are three levels of administration: provincial, district and local. 2.2 Economic situation During the 1990s, economic performance was mixed, although the economy benefited greatly from major mining and petroleum projects. While there was the potential for economic and social development, the period was largely characterized by negative economic growth and macroeconomic instability. As a result, the economy grew very little in real terms. Growth in the non-mining sector was more sluggish than that in the mining sector. The reasons for the economic stagnation are complex. External contributing factors include the worldwide economic depression, the negative development in commodity prices, and unfavourable trade conditions, among others, while internal factors include a series of inappropriate policy regimes and fiscal failures, the catastrophic civil war in Bougainville from 1989 to 1999, and a series of devastating national disasters. 3. HEALTH SITUATION 3.1 Health trends The health status of Papua New Guineans, the lowest in the Pacific region, steadily improved during the 1980s before declining in the 1990s. Life expectancy (2000) is estimated to be 52.5 years for men and 53.6 years for women, and 15% of a woman’s lifetime is estimated to be affected by some form of disability or morbidity. The infant mortality rate is estimated to be 64 per 1000 live births (2000 census) compared with 82 in 1991 and 72 from the 1981 National Census. The estimations of mortality and morbidity patterns in the population are very approximate, as data are almost entirely facility-based and laboratory confirmation of clinical diagnoses is rare. A proposed 2006 Demographic and Health Survey will, if completed, provide new data on health outcomes. Communicable diseases remain the major causes of morbidity and mortality in all age groups. However, significant progress has been made in some areas. In 2000, the country was declared poliomyelitis-free. In addition, the national leprosy elimination target of less than one case per 10 000 population was reached. However, around 50% of all mortality is still due to communicable diseases. Malaria is the leading cause of all outpatient visits and the third leading cause of hospital admissions and deaths, and is now endemic in every province, including those that were once malaria-free. Malaria mortality rates for 2004 were estimated to be 10.6 per 100 000. Together, malaria and pneumonia account for one-third of all recorded deaths. Tuberculosis incidence is also rising and the rate per 100 000 population is estimated to be 95.30. The number of measles cases decreased from 3863 in 2003 to 1385 in 2004. Diarrhoeal diseases remain common. PAPUA NEW GUINEA 254 | COUNTRY HEALTH INFORMATION PROFILES Papua New Guinea was declared to have a generalized HIV/AIDS epidemic in 2003, the main mode of transmission being heterosexual. HIV prevalence among women attending antenatal clinics is between 0.6% and 3.7% (2005). The incidence of other sexually transmitted infections is also rising. The high incidence of sexual assaults on women contributes to their risk of contracting an STI. Maternal and child morbidity and mortality are not improving. Maternal mortality estimates vary widely, but all are high. The 2000 figure was 330 per 100 000 live births. Causes of maternal mortality include postpartum haemorrhage, puerperal sepsis, antepartum haemorrhage, eclampsia and anaemia. Almost 40% of pregnant women are cared for by trained health personnel and about 39% of births are in health facilities. About 9% of women are using modern family planning methods. Perinatal conditions account for over 10% of all recorded deaths. Overall, 27% of children are considered moderately to severely malnourished and 43% of those aged 0–5 are stunted, while the wasting rate is comparatively low. Again, there are marked regional variations. The incidence of noncommunicable diseases is rising. Cases of tobacco- and alcohol-related illness appear to be increasing, while data from Port Moresby Hospital suggest that diabetes and hypertension are also on the rise. The three leading cancers in Papua New Guinea – oral, hepatic and cervical – have largely preventable causes. A major challenge to improving health in Papua New Guinea is related to perceptions of illness and health among the general population. There is a widespread lack of awareness about risk- related and health-promoting behaviour, and little involvement by local communities in health- promoting activities. Key risks include behaviour and environments that increase the risks of communicable disease; risks of noncommunicable disease, for example from tobacco consumption; and the risks associated with unsafe sexual behaviour. 3.2 Health systems Health services are provided by government and church providers (both of which are financed primarily from public sector funds); by enterprise-based services (e.g. the mines); by a small, modern private sector; and by traditional healers (undocumented amount). Within the public sector, management responsibility for hospitals and rural health services within provinces is divided. The National Department of Health manages the 19 provincial hospitals, while provincial and local governments are responsible for all other services (health centres and subcentres, rural hospitals and aid posts), known collectively as “rural health services”. Rural health services are poor and deteriorating. A Functional and Expenditure Review in 2001 described the health system in rural areas as being in a state of “slow breakdown and collapse, currently being saved from complete collapse by donors”. The review stated, “About 600 rural facilities are closed or not functioning effectively. Where services remain, the breadth and quality of services is diminishing.” At district level, there is either an absolute lack of services or limited use of services that do exist, limited clinical and managerial capacity among district health workers in a very decentralized health system, and limited and poorly coordinated efforts at training and other approaches to capacity-building. In addition, there is a lack of district supervision and support, the existence of parallel systems for provincial hospitals and district health services, a scarcity and misdistribution of financial and human resources, and a lack of timely and reliable information for decision- making. The nurse-to-population ratio is 55:100 000. An additional 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 the gap. The doctor-to-population ratio is 13 per 100 000, with the majority in Port Moresby. COUNTRY HEALTH INFORMATION PROFILES | 255 Churches are important providers of care, especially in rural areas, where they provide around 60% of health services. They share many of the problems of public facilities, but appear to perform better in a number of areas. Papua New Guinea trains most of its health workforce and the churches run five of the eight nursing schools and all of the community health worker training schools. Overall health spending is falling despite receiving a high share of government funds. Total health expenditure as a share of GDP rose steadily from 3.2% to 4.4% between 1997 and 2001. However, total health expenditure per capita fell from US$ 32 in 1997 to US$ 24 in 2001. About 70% of recurrent provincial health budgets were allocated to salaries in 2000. Papua New Guinea receives significant levels of official development assistance (ODA), estimated to have amounted to US$ 203 million, or 7.2% of GNP in 2001. The health sector receives around 15% of total ODA. Over the last five years, ODA for health has fluctuated, but has been around 24% (2004) of total health spending. Levels of aid have been falling in the last four years and are expected to fall further. Papua New Guinea has relatively few development partners. According to statistics provided by the Organisation of Economic Co-operation and Development (OECD), 96% of ODA for health in 1998-2000 was from Australia. Other major external agencies providing loans or grants are the Asian Development Bank (ADB), the Government of Japan and, until recently, the World Bank. The World Bank has not contributed to the health sector since 2001. There have been smaller contributions from New Zealand, the United States Agency for International Development (USAID), the European Union and United Nations agencies. A major new source of funds for health was assured in 2005 with the signing of an agreement for a US$ 30 million grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). In 2004, the Fund committed US$ 20 million over five years for malaria control. Although a further proposal of about US$ 6 million for tuberculosis control was rejected, the board encouraged Papua New Guinea to resubmit after making some changes to the proposal. 4. NATIONAL HEALTH PLAN AND PRIORITIES The National Health Plan 2001-2010 and the Medium-Term Expenditure Framework 2004-2006 have identified some explicit priorities. These include maternal and child health, immunization, malaria control, HIV/AIDS, and water and sanitation programmes. The Government is focusing its efforts on improving child health and reducing malaria, tuberculosis and AIDS through specific programmes. The malaria control strategy received a major injection of funds from GFATM in 2004. In the area of tuberculosis control, the DOTS programme is gradually expanding: it is currently operational in eight provinces. Reasons for the somewhat slower-than-planned expansion of DOTS include a number of system constraints common to other disease control programmes: central-level staffing; weak infrastructure and support services; and delays in access to funds, which limit training, supervision and other local- level support. Child health is being tackled through improved immunization and the integrated management of childhood illness (IMCI) approach. Both DOTS and IMCI are seen as entry points for strengthening district health services more generally. The National Health Conference 2001 supported a proposal to create a unified provincial health system. This will create a single provincial health authority responsible for both hospital and rural health services, and headed by a provincial director of health who will report to both the national and provincial governments. So far, this has only been implemented in two provinces. Strategies to ease managerial difficulties include: amendment of selected public finance and management procedures; quarantining (earmarking) of health funds in provincial grants; PAPUA NEW GUINEA 256 | COUNTRY HEALTH INFORMATION PROFILES delegation of powers over district health staff from the provincial administrator to the provincial health adviser; and alignment of treasury warrants to provincial budgets. In the last few years, there have been major government and partner efforts to ensure a more unified approach to health sector development. The 2001-2010 National Health Plan was developed with extensive consultation. There is now one annual activity plan for the National Department of Health and all donor partners. A Medium-Term Expenditure Framework has been developed for 2004–2006. There are formal annual reviews of achievements, most importantly by the National Health Conference, attended by the National Department of Health, donor partners, churches and provincial government staff. Stronger monitoring mechanisms are being developed. A review of functions has recommended that provincial health budgets should make provision for each rural health facility individually, which may have implications for the current budget structure if all resources going to facilities from several different programmes are to be captured comprehensively. 5. MAJOR INFORMATION SOURCES 2000 National Census. National Statistical Office (NSO) Papua New Guinea Demographic and Health Survey. National Statistical Office (NSO) Millennium Development Goals Progress Report for Papua New Guinea 2004. Government of Papua New Guinea and United Nations in Papua New Guinea, 2004. Papua New Guinea National Department of Health Information System, Monitoring and Research Branch Papua New Guinea National Health Plan 2001-2010 (volume II) Discharge Reports 2000, Monitoring and Research Branch Annual Health Sector Review, national report.: 2001 performance report. Department of Health, 2001. 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Postal Address : P.O. Box 807, Waigani, National Capital District, Papua New Guinea Official Email Address : Telephone : Fax : (675) 301-3604 Office Hours : Monday to Friday, 0745-1606 Website : WHO REPRESENTATIVE IN PAPUA NEW GUINEA Office Address : 4th Floor, AOPI CENTRE Waigani Drive, Papua New Guinea Postal Address : World Health Organization P.O. Box 5896 Boroko, National Capital District, Papua New Guinea Official Email Address : who@png.wpro.who.int Telephone : (675) 325-7827/ 301-3698 / 325-2035 Fax : (675) 325-0568 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILES | 257 ORGANIZATIONAL CHART: DEPARTMENT OF HEALTH PAPUA NEW GUINEA 258 PAPUA NEW GUINEA WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 462.84 2004 1 2 Estimated population ('000s) 5950.69 … … 2005 est 7 3 Annual population growth rate (%) 2.70 … … 2000 4 4 Percentage of population - 0–14 years 41.68 42.08 41.23 2004 est 2 - 65+ years 2.54 2.66 2.40 2004 est 2 5 Urban population (%) 13.20 … … 2003 3 6 Crude birth rate (per 1 000 population) 35.00 … … 2000 4 7 Crude death rate (per 1 000 population) 12.00 … … 2000 4 8 Rate of natural increase of population (% per annum) 2.30 … … 2000 4 9 Life expectancy (years) - at birth 53.00 52.50 53.60 2000 4 - Health-adjusted Life Expectancy (HALE) at age 60 … 10.10 10.60 2002 18 10 Adult literacy rate (%) 56.20 e 61.20 e 50.90 e 2000 4 11 Neonatal mortality rate (per 1 000 live births) 32.00 … … 2000 est 5 12 Infant mortality rate (per 1 000 live births) 64.00 67.00 61.00 2000 4 13 Under-five mortality rate (per 1 000 live births) 88.00 93.00 83.00 2000 6 14 Total fertility rate (women aged 15–49 years) 4.60 2000 4 15 Maternal mortality ratio (per 100 000 live births) 330.00 2000 6 16 Percentage of newborn infants weighing at least 2500 g at birth 90.00 … … 2002 7 17 Prevalence of underweight children under five years of age 24.90 … … 2000 8 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 74.00 d … … 2004 9 - DTP3 62.00 d … … 2004 9 - OPV3 49.00 d … … 2004 9 - Measles 50.00 d … … 2004 9 - Hepatitis B III 60.00 d … … 2004 9 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 39.90 2004 7 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 66.00 2004 7 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) 3.00 2004 7 - Percentage of deliveries in health facilities (as % of total deliveries) 39.00 2004 7 21 Percentage of women in the reproductive age group using modern contraceptive methods 8.98 2004 7 22 Condom use rate of the contraceptive prevalence rate (%) … … 1.00 2005 est 19 23 HIV prevalence among 15–24 year-old pregnant women (%) 1.70 2004 est 20 24 Number of children orphaned by HIV/AIDS ab … … 80 000 2005 est 21 COUNTRY HEALTH INFORMATION PROFILE 259 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 39.00 88.00 32.00 2002 10 26 Proportion of population with access to improved sanitation 45.00 67.00 41.00 2002 10 27 Proportion of the population using solid fuels for cooking or heating (%) 90.00 … … 2003 9 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.52 … … 2003 11 32 Per capita GDP at current market prices (US$) 846.74 … … 2004 12 33 Rate of growth of per capita GDP 0.68 … … 2004 12 34 Health expenditure Total health expenditure - amount (in million US$) … - total health expenditure on health as % of GDP 4.40 2001 16 - per capita total expenditure on health (in US$) 24.00 2001 16 Government expenditure on health - amount (in million US$) 166.38 2004 13 - general government expenditure on health as % of total expenditure on health … - general government expenditure on health as % of total general government expenditure 8.60 2004 13 External source of government health expenditure - external resources for health as % of general government expenditure on health 23.93 2004 13 Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 2.87 2005 22 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 750 … … 1.26 … … 2005 23 - dentists 182 … … 0.30 … … 2005 23 - pharmacists … … … … … … - nurses 8914 … … 14.98 … … 2005 23 - midwives 567 0 567 0.95 0 0.95 2005 23 - other nursing / auxiliary staff 3926 … … 6.60 … … 2005 23 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 385 … … 0.64 … … 2005 23 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 1065 … … 1.79 … … 2005 23 37 Yearly new graduates – physicians 50 … … 2005 23 38 Yearly new graduates – nurses 165 … … 2005 23 PAPUA NEW GUINEA 260 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population a 1. Normal deliveries (incl. BBA) 55 996 NA 55 996 1082.77 NA 2247.23 2000 15 2. Pneumonia 31 550 17 436 14 114 610.07 650.65 566.42 2000 15 3. Malaria 30 471 15 295 15 176 589.20 570.76 609.04 2000 15 4. Perinatal conditions 8508 4576 3932 164.52 170.76 157.80 2000 15 5. Direct obstetric causes 8284 NA 8284 160.18 NA 332.45 2000 15 6. Diarrhoea 7566 4210 3356 146.30 157.10 134.68 2000 15 7. Open wounds and injury to blood vessels 7085 4619 2466 137.00 172.37 98.97 2000 15 8. Diseases of the digestive system 7076 3476 3600 136.83 129.71 144.48 2000 15 9. Tuberculosis 5841 3082 2759 112.94 115.01 110.72 2000 15 10. Skin diseases 5700 3070 2630 110.22 114.56 105.55 2000 15 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Pneumonia 957 510 447 18.51 19.03 17.94 2000 15 2. Perinatal conditions 834 455 379 16.13 16.98 15.21 2000 15 3. Malaria 629 324 305 12.16 12.09 12.24 2000 15 4. Tuberculosis 502 305 197 9.71 11.38 7.91 2000 15 5. Meningitis 401 217 184 7.75 8.10 7.38 2000 15 6. Heart diseases 302 147 155 5.84 5.49 6.22 2000 15 7. Diseases of the digestive system 239 167 72 4.62 6.23 2.89 2000 15 8. Septicaemia 192 114 78 3.71 4.25 3.13 2000 15 9. Anaemia 180 82 98 3.48 3.06 3.93 2000 15 10. Diarrhoea 179 105 74 3.46 3.92 2.97 2000 15 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria … … … … … … - Pertussis (whooping cough) 2050 … … … … … 2004 9 - Tetanus 39 … … … … … 2004 9 - Neonatal tetanus 50 … … … … … 2004 9 - Poliomyelitis 0 0 0 0 0 0 2004 9 - Hib meningitis … … … … … … - Measles 1385 … … … … … 2004 9 - Mumps … … … … … … - Rubella … … … … … … - Congenital rubella syndrome … … … … … … 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral - Type A … … … … … … - Type B 392 575 … … … … … 2002 7 - Type C … … … … … … - Type E … … … … … … - Unspecified 81 55 26 2 2 0 2000 15 Cholera 0 0 0 0 0 0 2000 15 Typhoid fever 5145 2546 2599 164 95 69 2000 15 Encephalitis … … … … … … Plague … … … … … … Syphilis 184 66 118 8 3 5 2000 15 Gonorrhoea 34 14 20 0 0 0 2000 15 Leprosy 312 … … … … … 2004 9 COUNTRY HEALTH INFORMATION PROFILE 261 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Malaria 84 096 … … 619 … … 2004 7, 9 Dengue/DHF 22 … … … … … 2002 9 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 1441.00 … … 10.61 … … 2004 9 - Proportion of population in malaria-risk areas using effective malaria prevention measures b … - Proportion of population in malaria-risk areas using effective malaria treatment measures c … 44 Tuberculosis Number of cases Number of deaths - All types 12 743 … … … … … 2004 9 - New pulmonary tuberculosis (smear-positive) 1896 … … … … … 2004 9 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 448.00 … … 42.00 … … 2004 9 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 19.00 … … 58.00 (2003) … … 2004 9 Number of cases Number of deaths 45 Acute respiratory infections 300 160 140 3 1 2 2000 15 46 Diarrhoeal diseases 7566 4210 3356 179 105 74 2000 15 47 Cancers All cancers (malignant neoplasms only) 2694 1071 1623 268 137 131 2000 15 - Trachea, bronchus and lung 63 43 20 16 12 4 2000 15 - Stomach 31 12 19 4 2 2 2000 15 - Colon and rectum 36 16 20 9 6 3 2000 15 - Lip, oral cavity and pharynx 428 248 180 22 11 11 2000 15 - Liver 335 239 112 51 35 16 2000 15 - Cervix 656 29 2000 15 - Leukaemia 102 56 46 28 14 14 2000 15 48 Circulatory All circulatory system diseases - Ischaemic heart disease 123 67 54 8 3 5 2000 15 - Acute myocardial infarction 19 16 3 1 0 1 2000 15 - Rheumatic fever and rheumatic heart diseases 47 25 22 7 5 2 2000 15 - Cerebrovascular diseases 7 5 2 0 0 0 2000 15 - Hypertension 491 258 233 28 22 6 2000 15 49 Maternal causes - Haemorrhage 1698 36 2000 15 - Abortion 3371 6 2000 15 - Eclampsia 605 4 2000 15 - Sepsis 951 13 2000 15 - Obstructed labour 50 0 2000 15 PAPUA NEW GUINEA 262 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 50 Diabetes mellitus 323 183 140 43 27 16 2000 15 51 Mental disorders 520 274 246 6 5 1 2000 15 52 Injuries - All types 20 420 12 404 8016 230 147 83 2000 15 - Motor and other vehicle accidents 504 346 158 19 12 7 2000 15 - Suicide 60 11 49 1 0 1 2000 15 - Homicide and violence 446 102 346 4 2 2 2000 15 - Occupational injuries 0 0 0 0 0 0 2000 15 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 19 … 2000 14 - Specialized hospitals 4 … 2000 14 - District/first-level referral hospitals 201 … 2000 14 - Primary health care centres 2875 … 2000 17 Private hospitals … … Notes: Red text Millennium Development Goals (MDG) indicators … Data not available est. Estimate NA Not applicable aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. c Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. d Revised data. e Figure refers to population aged 10 years and over. Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 2 Demographic tables for the Western Pacific 2000-2005. Manila, WHO Regional Office for the Western Pacific, 2005. 3 Urban and rural areas 2003. New York, United Nations Department of Economic and Social Affairs, Population Division, 2004. 4 2000 National Census, National Statistical Office. 5 World health report 2005: Make every mother and child count. Geneva, World Health Organization, 2005. 6 Millennium Development Goals progress report for Papua New Guinea 2004. Government of Papua New Guinea and United Nations in Papua New Guinea, 2004. 7 Papua New Guinea National Department of Health Information System, Monitoring and Research Branch. 8 Pacific Island Regional Millennium Development Goals report 2004. Noumea, Secretariat of the Pacific Community/ UN/ CROP MDG Working Group, November 2004. 9 WHO Regional Office for the Western Pacific, data received from technical units. 10 Meeting the MDG drinking water and sanitation target: A mid-term assessment of progress. WHO/ UNICEF Joint Monitoring Programme for Water Supply and Sanitation 2004. COUNTRY HEALTH INFORMATION PROFILE 263 11 Human development report 2005. New York, United Nations Development Programme, 2005. 12 Papua New Guinea National Statistics Office http:///www.spc.int/prism/country/pg/stats 13 Papua New Guinea National Department of Health, Planning Division, Health Economist. 14 National Inventory of Health Facilities 2000. 15 Discharge Reports 2000, Monitoring and Research Branch. 16 Information furnished by WHO Representative for Papua New Guinea, 08 April 2004. 17 Annual Health Sector Review, National Report, 2001 Performance Report. National Department of Health, 2001. 18 World health report 2004: Changing history. Geneva, World Health Organization, 2004. 19 Port Moresby General Hospital report. 20 Consensus Workshop, November 2004. 21 UNICEF Estimate. 22 UN Exchange rate December 2005. 23 Medical Board & Nursing Council of PNG. 264 | COUNTRY HEALTH INFORMATION PROFILES PHILIPPINES 1. DEMOGRAPHICS, GENDER AND POVERTY With an estimated population growth rate of 2.36%, the Philippines had an estimated population of 85 236 913 in 2005 (NSCB), with almost equal numbers of males and females. The population is predominantly young, with the 0-14 years age group representing 34.8%. Those aged 65 years and above comprise 4.2% of the population. Despite institutional mechanisms like commissions, task forces, working groups and councils that have been created to address poverty and gender issues, problems and challenges remain and continue to influence health outcomes. Official government statistics show that 24.7% or one out of every four Filipino families is poor, based on the 2003 Family Income and Expenditures Survey (FIES). On a headcount basis, 30.4% of the population are poor. A family of five members should have an income of at least PhP5111 or around US$ 100 a month to be able to sustain their minimum basic needs, both food and non-food. Poverty remains a predominantly rural problem, accounting for nearly two-thirds of the poor in the country. The largest part of the poorest provinces in the Philippines, with the lowest literacy rate and life expectancy, are located in the Mindanao region. Recent scanning of gender issues in the health sector (National Commission on the Role of Filipino Women, 2004) revealed the persistence of several health-related concerns such as: a high fertility rate; a gap between the desired and actual number of children; declining nutritional status among young and adult women; and increasing health consequences of gender-based violence. According to a study by the Asian Development Bank (Country Gender Assessment), violence against women is widespread in the Philippines. This includes sexual harassment in schools and at work, as well as human trafficking, forced prostitution, domestic violence and marital rape. In 2003, some 8000 cases of violence against women were reported to the Philippine National Police. However, cases are often not reported. Violence against women causes severe health problems and affects earnings, job performance and job security. It is one of the factors that causes low productivity among women and makes them vulnerable to poverty. The Philippines continues to have one of the highest maternal mortality rates in Asia. Its MMR of 172 per 100 000 live births in 1998 was about four times that of Thailand and about twice that of Viet Nam. The country also has the second highest number of total births per year (1995- 2000), four times that of Malaysia and about twice that of Thailand. This is due to the lower contraceptive prevalence rate among women, who do not control or decide freely on matters relating to their fertility. This results in women being vulnerable to health risks due to complications in pregnancy and reduces their job opportunities. The persistently high annual population growth rate of 2.36% impacts heavily on the government's capacity to catch up with desired investments in human capital and physical infrastructure. Asian Development Bank analysts say that this is a major factor that reduces available financial resources. Furthermore, it lessens women's opportunities to participate fully in the job market. COUNTRY HEALTH INFORMATION PROFILES | 265 The infant mortality rate among households in the poorest quintile is 2.3 times higher than among the richest quintile. The under-five mortality rate, on the other hand, is 2.7 times higher among the poorest quintile than the richest. Such inequality is also evident in differences in the health-seeking behaviour of different income groups. Health improvements in poor provinces and regions further indicate inequities in health outcomes due to continuing differences in access to health care. Table 1. Core population and health data (2005) [Total] 85 236 913 [Both] 69.60 (2002) [0-14 years] (34.80 %) [Male] 66.90 (2002) Population [65+ years] (4.20 %) Life expectancy at birth (years) [Female] 72.20 (2002) Crude birth rate (per 1000 population) 24.09 Total fertility rate 3.50 (2000-2003) [Total] 80.00 (2004) [Urban] … Crude death rate (per 1000 population) 5.60 % of population served with safe water [Rural] … [Total] 86.00 (2004) [Urban] … Infant mortality rate (per 1000 live births) 29.00 (1998-2003) % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 172.00 (1998) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Although administrations since at least 1986 have been committed to the broad goals of economic and trade liberalization, poverty reduction, sustainable growth, people’s participation and good governance, the periodic change in political leadership has generally meant a lack of continuity in policies and programmes, as new leaders strive to leave their mark by downplaying what others before them have accomplished. The present Arroyo administration focuses on continuing the battle against poverty by directing social development and anti-poverty measures towards enhancing the capability of the poor to find gainful income and employment. Meeting the poor’s basic needs, including health, is one of its top priorities. President Gloria Macapagal-Arroyo emphasized in her 2005 State of the Nation Address that poverty alleviation will be advanced for the next years through specific targets, such as the creation of 10 million new jobs in six years; an increase in gross domestic product (GDP) to a sustainable 7% or more up to 2010; the reduction of poverty incidence from 34% to 17%; an increased investment rate from 19% to 28% of GDP in two years; increased exports from US$ 38 billion to US$ 50 billion in two years; development of 2 million hectares of agribusiness land; and development and support of 2 million entrepreneurs. 2.2 Economic situation The government’s budget deficit grew from Php134.2 billion in 2000 to Php210.7B in 2002 (NEDA). The share of both the economic and social sectors declined, while the size and share of the debt service fund rose significantly. The shrinking share of the economic sector negatively affects people’s employment and livelihoods as well as the social services being provided by the Government. Unemployment is currently running at an estimated 11.3%. In spite of the brief resurgence in agriculture, the Philippines continues to be more dependent on the services sector, both for employment and output growth, as the industrial sector has not demonstrated sustained growth since the financial crisis in 1997 and 1998. Domestic unemployment rose from 9.8% in 2001 to 11.3 % in 2004 (NSCB). Overseas employment remains an important response, not only to unemployment, but also to the need for foreign exchange. PHILIPPINES 266 | COUNTRY HEALTH INFORMATION PROFILES The Government increased its health spending by 28.2% from P36.3 billion in 2002 to P46.5 billion in 2003. Over the same period, social health insurance benefit payments grew from P10.6 billion to P12.9 billion, a 22.3% increase. This contributes to a meagre 9.5% as a source of health funds. Private sources continued to be the highest health spender at P74.7 billion. Health care is still mainly financed through out-of-pocket payments (59.8%), hence the financial burden of paying for services is a major obstacle to the poor accessing health care and can make them even poorer. The aim to depend less on out-of-pocket payments and more on social health insurance is still far from being realized, even although there have been slight improvements. 3. HEALTH SITUATION 3.1 Health trends The infant mortality rate (IMR), although declining, is still high compared with those of neighbouring countries, and varies throughout the country depending on socioeconomic and demographic factors. A high IMR is noted among infants of mothers with less or no education, those who receive no antenatal and delivery care, and mothers aged below 20 and above 40 years. The IMR is also lower in urban areas, at 245 infant deaths per 1000 live births compared with 36 in rural areas (NDHS, 2003). The maternal mortality rate from 1970 to 1995 barely improved and remains high. The maternal mortality rate was 190 per 100 000 live births in 1970, 179.70 in 1995 and was estimated at 172 as of 1998. Nutritional problems and parasitism are common among children and a national survey of under-5 year-olds revealed a prevalence of soil- transmitted Helminths ranging from 49% -93%. The prevalence of underweight preschool children (0–5 years old) is 27.6% (Food and Nutrition Research Institute, 2003), a slight decrease from 30.6% in 1998. The prevalence of stunted growth was 26.7% in 2002 (FNRI). Adolescents and youths account for 17% of the total morbidity from notifiable diseases and 6.7% of the total deaths. The Philippines is one of 42 countries that account for 90% of global deaths among children under five. Furthermore, the latest National Demographic and Health Survey (NDHS) shows that only 16.1% of babies are exclusively breast-fed up to four to five months of age. As in the past, most of the leading causes of morbidity are communicable diseases. The prevalence of communicable diseases is still very high, while that of noncommunicable diseases is increasing. The leading noncommunicable causes of morbidity are hypertension and diseases of the heart. Unlike the leading causes of morbidity, deaths are mainly due to noncommunicable diseases, the seven leading causes being diseases of the heart, stroke, cancer, accidents, chronic obstructive pulmonary disease (COPD), diabetes mellitus and kidney disease. The majority of these diseases are linked to common preventable lifestyle-related risk factors that include tobacco use, unhealthy diet and physical inactivity. The rates per 100 000 population for the ten leading causes of mortality increased from 2000 to 2002. In 2002, there were 70 138 deaths due to cardiovascular disease, compared with 60 417 in year 2000. Diabetes also increased from 10747 in 2000 to 13922 in 2002. Malaria control has advanced significantly through Global Fund support for enhanced diagnostic facilities and increased coverage of insecticide-treated nets, as well as through the AusAID- Department of Health-WHO Roll Back Malaria project in Mindanao. The Filariasis Elimination Program currently covers 11 million populations with a mass drug administration programme. In 2005, there were reported cholera outbreaks in several towns in Catanduanes and Palawan, causing deaths among children and adults. There were also outbreaks of non-cholera-related diarrhoea in some municipalities of Catanduanes, Zamboanga Sibugay and Sultan Kudarat. Cassava poisoning in Mabini, Bohol, killed 27 schoolchildren due to contamination of the COUNTRY HEALTH INFORMATION PROFILES | 267 cassava with an organophosphate insecticide while cooking. Health emergency management was again tested in the flash floods and landslides which affected several towns of Quezon and Aurora provinces and placed the area under water and mud for several days. Although there were no disaster-related outbreaks of diseases, the tragedy had a significant psychosocial impact on the residents. Tuberculosis remains among the 10 leading causes of morbidity and mortality, ranking number 6. However, significant progress has been made in its control, and data for 2004 show that the Philippines has exceeded global epidemiological targets, achieving 73% case detection of new smear-positives and an 88% treatment success rate. This has been possible through 100% DOTS implementation in the public sector and with the introduction of the Public-Private Mix DOTS strategy in 2003. The tuberculosis burden still remains high in the country, however, with a prevalence rate of 463 cases per 100 000 population. 3.2 Health systems The country’s public health care system has achieved significant milestones in the past 25 years: adoption of the primary health care approach in 1979, integration of public health and hospital services in 1983, reorganization of the Department of Health in 1987, devolution of health services to local government units (LGUs) in 1992, and the streamlining of its organization and functions in 1999–2000. With the devolution of health services to LGUs, the provincial government oversees provincial and district hospitals, while the municipal government manages rural health units (RHUs) and barangay health stations (BHSs). Issues such as geographic inequity, where people who live in the rural and isolated communities receive less and lower quality health services, and socioeconomic inequity, where the poor do not receive health services due to inaccessibility and/or unaffordability, continue to abound in the country. Equally disturbing is the mass migration of doctors and nurses, making rural areas (52% of the population) even more vulnerable to health human resource deficiencies. Hospitals, both public and private, all over the country are lamenting 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 300-500 of their 2000 nurse workforce every year. Midwives, the front-liners in providing health services, are also seeking jobs as caregivers in other countries. The latest (2003) national health accounts show that the most common source of funds for health in the country today are still out-of-pocket payments (around 60%). Spending for personal health care continues to lead the three categories of health care services, despite the slight drop from 77.3% in 2002 to 75.7% in 2003. On the other hand, public health care spending increased by 1.5 percentage points, largely due to rises in most sources of funds. Other health care services, supported mostly from loans on operations/policy research programmes, also went up. Factors contributing to the limited capacity of the country’s health care system to deliver better health outcomes may be summed up as follows: (1) poor health care financing; (2) the inappropriate health service delivery system, where there is excessive reliance on use of high-end hospital services rather than primary care, including ineffective mechanisms for providing public health programmes; (3) the ‘brain drain’ of health professionals; (4) the excessively high price of medicines, leading to costly out-of-pocket payments and inadequate and irrational use; (5) inadequate enforcement of regulatory mechanisms; and (6) insufficient effort being expended on prevention and control of new diseases, particularly noncommunicable diseases. Data adequacy, accuracy and timeliness are other important and perennial issues that have to be addressed. The unavailability of timely and accurate data/information makes it difficult to make appropriate decisions and actions on policies and programmes to improve health care. PHILIPPINES 268 | COUNTRY HEALTH INFORMATION PROFILES 4. NATIONAL HEALTH PLAN AND PRIORITIES The Department of Health has now embarked on an implementation framework for health sector reform, labeled 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 health system. FOURmula ONE for Health intends to implement critical interventions as a single package backed by effective management infrastructure and financing arrangements and following a sectorwide approach. This implies that the management perspective covers the entire health sector, and that financing portfolio management encompasses all sources. The four elements of the strategy are: (1) Health financing – The goal of this health reform area is to foster greater, better and sustained investments in health. The Philippine Health Insurance Corporation, through the NHIP, and the Department of Health, through sectorwide policy support, will lead this component jointly. (2) Health regulation – The goal is to ensure the quality and affordability of health goods and services. (3) Health service delivery – The goal is to improve and ensure the accessibility and availability of basic and essential health care in both public and private facilities and services. (4) Good governance – The goal is to enhance health system performance at the national and local levels. A key feature of the FOURmula ONE for Health implementation strategy is the engagement of the National Health Insurance Program (NHIP) as the main lever to effect desired changes and outcomes in each of the four implementation components. The NHIP supports each of the FOURmula ONE elements in terms of: • financing, as it reduces the financial burden placed on Filipinos by health care costs; • governance, as it is a prudent purchaser of health care, thereby influencing the health care market and related institutions; • regulation, as the NHIP’s role in accreditation and payments based on quality acts as a driver for improved performance in the health sector; and • service delivery, as the NHIP demands fair compensation for the costs of care directed at providing essential goods and services in health. The main functions of the NHIP, including enrolment, accreditation, benefit delivery, provider payment and investment, must be employed to leverage the attainment of the targets for each of the four components. The major strategies under the financing reform area include: (1) rationalization and mobilization of resources for health financing; (2) coordination of local and national health spending; (3) focusing on direct subsidies to priority programmes; and (4) adopting a performance-based financing system and expanding the national health insurance programme. Under the regulations reform area, the strategies are: (1) upgrading, harmonization and streamlining of the regulatory systems and processes; (2) ¯institutionalization of cost recovery / revenue enhancement mechanisms for health regulatory agencies; (3) development of a quality- seal system, taking into account ASEAN harmonization; and (4) ensuring the availability and access of the poor to low priced, quality essential health products. The third reform area, service delivery, encompasses: (1) making available a basic and essential health service packages by designated providers in strategic locations; (2) assuring the quality COUNTRY HEALTH INFORMATION PROFILES | 269 of both basic and specialized health services; and (3) intensifying current efforts to reduce public health threats by implementing intensified disease prevention and control strategies and enhancing health promotion and disease surveillance. There are six major components under this reform area, namely: (a) Public health development, which involves: • undertaking disease-free zone initiatives that aim to ‘mop up’ such diseases as leprosy, schistosomiasis, filariasis and malaria (This would include stratification of areas according to disease burden, validation of the status of potential disease-free areas, and identification of appropriate interventions based on the stratifications.); • implementing an intensified disease prevention control and strategy specifically for vaccine-preventable diseases, tuberculosis and HIV/AIDS; • activities to improve reproductive health outcomes, such as the maternal mortality rate (MMR), the infant mortality rate (IMR), the under-five mortality rate, the total fertility rate (TFR), and the contraceptive prevalence rate (CPR); and • intensifying the promotion of healthy lifestyles for the prevention of diabetes mellitus (DM), hypertension (HPN), cardiovascular diseases (CVD), and breast and cervical cancers, and the promotion of anti-smoking, safe water, sanitation, and other such campaigns. (b) Health facilities development, which pertains to rationalization of facilities and services (to cover public, both national and local, and private facilities), upgrading of facilities and integration of wellness services in hospitals. (c) Disease epidemiology and surveillance network, through the creation and strengthening of epidemiology and surveillance units at all government levels. (d) Intensification of health promotion. (e) Strengthening of the disaster response and preparedness system. Under governance, strategies are grouped into the following components: (1) implementation of a sectorwide development approach for health; (2) implementation of a national health human resource master plan; (3) establishment of F1 convergence sites; (4) establishment of an integrated health information system; and (5) an improved procurement and logistics system. With its sectorwide development approach to health, the Department of Health hopes to strengthen government leadership in the health sector through effective donor and LGU coordination and harmonization of procedures among donors and national government. 5. MAJOR INFORMATION SOURCES National Demographic and Health Survey 2003. National Statistics Office. Philippine Health Statistics 2002. National Epidemiology Center-Department of Health. Department of Health Administrative Order No. 0023 series of 2005 dated 30 August 2005. HIV/AIDS country report 2004. National Epidemiology Center – Department of Health. Philippine National Health Accounts 2003. National Statistical Coordinating Board (NSCB). 2nd Philippine Progress Report on the MDGs. National Economic and Development Authority (NEDA), 2005. Field Health Information Service Information System Annual Report 2002. Department of Health. PHILIPPINES 270 | COUNTRY HEALTH INFORMATION PROFILES 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : San Lazaro Compound, Tayuman, Sta. Cruz, Manila, Philippines 1003 Postal Address : Official Email Address : info@doh.gov.ph Telephone : (632) 743-8301 Fax : (632) 743-1829 Office Hours : Website : http://www.doh.gov.ph WHO REPRESENTATIVE IN THE PHILIPPINES Office Address : 2/f, bldg 9, Department of Health San Lazaro Compound, Tayuman, Sta. Cruz, Manila, Philippines Postal Address : Official Email Address : who@phl.wpro.who.int Telephone : (632) 338-7479/ 338-8605 Fax : (632) 731-3914 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILES | 271 ORGANIZATIONAL CHART: DEPARTMENT OF HEALTH PHILIPPINES 272 PHILIPPINES WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 300.00 2002 1 2 Estimated population ('000s) 85 236.91 42 874.77 42 362.15 2005 9 3 Annual population growth rate (%) 2.36 … … 2000 2 4 Percentage of population - 0–14 years 34.80 35.30 34.20 2005 4 - 65+ years 4.20 3.70 4.60 2005 4 5 Urban population (%) 48.05 … … 2000 3 6 Crude birth rate (per 1 000 population) 24.09 … … 2005 7 7 Crude death rate (per 1 000 population) 5.60 … … 2005 7 8 Rate of natural increase of population (% per annum) 1.90 … … 2004 7 9 Life expectancy (years) - at birth 69.60 66.90 72.20 2002 6 - Heal th-adjusted Life Expectancy (H ALE) at age 60 … 10.60 12.10 2002 20 10 Adult literacy rate (%) 92.60 92.50 92.70 2002 5 11 Neonatal mortality rate (per 1 000 live births) 17.00 21.00 13.00 1998-2003 11 12 Infant mortality rate (per 1 000 live births) 29.00 35.00 25.00 1998-2003 11 13 Under-five mortality rate (per 1 000 live births) 40.00 48.00 34.00 1998-2003 11 14 Total fertility rate (women aged 15–49 years) 3.50 2000-2003 11 15 Maternal mortality ratio (per 100 000 live births) 172.00 1998 18 16 Percentage of newborn infants weighing at least 2500 g at birth 54.80 … … 1998-2003 11 17 Prevalence of underweight children under five years of age 27.60 27.20 28.10 2003 10 18 Percentage of pregnant women with anaemia 43.90 2003 21 19 Immunization coverage for infants (%) - BCG 77.00 … … 2005 15 - DTP3 76.00 … … 2005 15 - OPV3 76.00 … … 2005 15 - Measles 78.00 … … 2005 15 - Hepati tis B III 43.00 … … 2004 16 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 87.60 1998-2003 11 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 37.30 1998-2003 11 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) 35.20 1998-2003 11 - Percentage of deliveries in heal th facilities (as % of total deliveries) 38.00 1998-2003 11 21 Percentage of women in the reproductive age group using modern contraceptive methods 21.60 f 2003 11 22 Condom use rate of the contraceptive prevalence rate … … 1.90 2003 4 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … COUNTRY HEALTH INFORMATION PROFILE 273 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 80.00 … … 2004 17 26 Proportion of population with access to improved sanitation 86.00 … … 2004 17 27 Proportion of the population using solid fuels for cooking or heating (%) 47.00 … … 2003 16 28 Proportion of households with access to secure tenure 66.50 … … 2002 17 29 Proportion of vehicles using unleaded gasoline (%) 30.20 … … 2003 19 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.76 2003 5 32 Per capita GDP at current market prices (US$) 963.80 … … 2003 est 4 33 Rate of growth of per capita GDP (%) 6.10 … … 2003 est 4 34 Health expenditure Total health expenditure - amount (in m illion PHP) 136 000.00 2003 4 - total heal th expenditure on health as % of GDP 3.20 2003 4 - per capita total expendi ture on health (in PHP) 1662.00 2003 4 Government expenditure on health - amount (in million PHP) 46 500.00 2003 4 - general government expenditure on health as % of total expenditure on health 36.20 2003 4 - general government expenditure on heal th as % of total general government expendi ture 7.40 2003 4 External source of government health expenditure - external resources for heal th as % of total expenditure on heal th 3.70 2003 4 Private health expenditure - private expenditure on health as % of total expenditure on heal th 54.50 2003 4 Exchange rate in US$ of local currency is: 1 US$ = 54.20 2003 4 35 Health insurance coverage as % of total population 64.00 2005 13 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population a 36 Health workforce - physicians 93 862 … … 11.35 … … 2004 12 - dentists 45 903 … … 5.55 … … 2004 12 - pharmacists 49 667 … … 6.01 … … 2004 12 - nurses 352 398 … … 42.63 … … 2004 12 - m idwives 136 036 … … 16.46 … … 2004 12 - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 58 145 … … 7.03 … … 2004 12 - other heal th personnel (health inspec tors, assistant sani tarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates – physicians 2000 … … 2005 10 38 Yearly new graduates – nurses 10 000 … … 2005 10 PHILIPPINES 274 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number e Rate per 100 000 population 1. Ac ute lower respiratory trac t infection & Pneumonia 776 562 373 607 360 409 971.60 897.80 877.90 2004 8 2. Bronchitis/bronchiolitis 719 982 274 019 339 291 900.80 658.80 826.50 2004 8 3. Ac ute watery diarrhea 577 118 281 007 270 509 722.00 675.30 659.00 2004 8 4. Influenza 379 910 168 447 184 613 475.30 404.80 449.70 2004 8 5. Hypertension 342 284 142 171 183 556 428.20 341.70 447.10 2004 8 6. Tuberculosis/ respiratory 103 214 57 897 39 986 129.10 139.10 97.40 2004 8 7. Chickenpox 46 779 21 637 23 343 58.50 52.00 56.90 2004 8 8. Diseases of the heart 37 092 16 214 18 740 46.40 39.00 45.70 2004 8 9. Malaria 19 894 10 104 8 307 24.90 24.30 20.20 2004 8 10. Dengue Fever 15 838 7 475 7 107 19.80 18.00 17.30 2004 8 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Diseases of the heart 70 138 39 502 30 636 88.20 98.70 77.60 2002 6 2. Diseases of vascular system 49 519 27 536 21 983 62.30 68.80 55.70 2002 6 3. Malignant neoplasms 38 821 20 440 18 381 48.80 51.10 46.60 2002 6 4. Pneumonia 34 218 16 729 17 489 43.00 41.80 44.30 2002 6 5. Accidents 33 617 27 448 6 169 42.30 68.60 15.60 2002 6 6. Tuberculosis, all forms 28 507 19 293 9 214 35.90 48.20 23.30 2002 6 7. Chronic obstruc tive pulmonary disease & allied conditions 19 320 13 007 6 313 24.30 32.50 16.00 2002 6 8. Certain conditions originating in the perinatal period 14 209 8 520 5 689 17.90 21.30 14.40 2002 6 9. Diabetes mellitus 13 922 6 524 7 398 17.50 16.30 18.70 2002 6 10. Nephritis, nephrotic syndrome and nephrosis 9 192 5 358 3 834 11.60 13.40 9.70 2002 6 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 89 … … … … … 2004 16 - Pertussis (whooping cough) 10 … … … … … 2004 16 - T etanus 1293 … … … … … 2004 16 - Neonatal tetanus 250 … … … … … 2004 16 - Poliomyelitis 0 0 0 0 0 0 2004 16 - Hib meningitis … … … … … … - Measles 3025 … … … … … 2004 16 - Mumps … … … … … … - Rubella 25 … … … … … 2004 16 - Congeni tal rubella syndrome … … … … … … 42 Selected communicable diseases Number of cases e, aa Number of deaths Hepati tis vi ral 4096 2260 1546 828 577 251 C: 2004 D: 2002 C:8, D:6 - T ype A … … … … … … - T ype B … … … … … … - T ype C … … … … … … - T ype E … … … … … … - Unspecified … … … … … … Cholera 351 238 104 23 13 10 C: 2004 D: 2002 C:8, D:6 Typhoid fever (and parathyroid fever) 12 535 6255 5556 1120 651 469 C : 2002 D : 1998 C:8, D:6 COUNTRY HEALTH INFORMATION PROFILE 275 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases e, aa Number of deaths (Meningitis) encephalitis 306 153 152 117 63 54 C: 2004 D: 2002 C:8, D:6 Plague 0 0 0 0 0 0 2005 16 Syphilis 35 14 21 6 4 2 C: 2004 D: 2002 C:8, D:6 Gonorrhoea 1483 505 967 2 1 1 C: 2004 D: 2002 C: 8, D:6 Leprosy 2254 … … … … … 2004 16 Malaria 43 736 … … 93 … … 2004 16 Dengue 23 040 … … 244 … … 2004 16 DHF 3229 1702 1527 … … … 2004 8 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 54.00 … … 0.11 … … 2004p 16 - Proportion of population in malaria-risk areas using effective malaria prevention measures c 15.40 2003p 18 - Proportion of population in malaria-risk areas using effective malaria treatment measures d 7.50 2003p 18 44 Tuberculosis Number of cases Number of deaths - All types 130 530 … … … … … 2004 16 - New pulmonary tuberculosis (smear-posi tive) 78 163 … … … … … 2004 16 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 463.00 … … 48.00 … … 2004 16 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOT S) 73.00 … … 88.00 (2003) … … 2004 16 Number of cases Number of deaths 45 Acute respiratory infections … … … 237 123 114 D: 2002 6 46 Diarrhoeal diseases 581 414 283 311 272 501 3684 2108 1576 C: 2004 D: 2002 C:8, D:6 47 Cancers All cancers (malignant neoplasms only) 38 821 20440 18 381 2002 6 - T rachea, bronchus and lung … … … 6890 5167 1723 2002 6 - Stomach … … … 1590 927 663 2002 6 - Colon and rectum … … … 2650 1430 1220 2002 6 - Lip, oral cavity and pharynx … … … 2017 1282 735 2002 6 - Liver … … … … … … - Cervix … 998 2002 6 - Leukaemia … … … 2406 1245 1161 2002 6 PHILIPPINES 276 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 48 Circulatory All circulatory system diseases … … … 119 742 67 085 52 657 2002 6 - Ischaemic heart disease … … … 14 762 7608 7154 2002 6 - Acute m yocardial infarction … … … 25 612 16 487 9125 2002 6 - Rheumatic fever and rheumatic heart diseases … … … 2609 1114 1495 2002 6 - Cerebrovascular diseases … … … 40 515 22 856 17 659 2002 6 - H ypertension 304 690 136 011 168 679 16 382 8860 7522 2002 6 49 Maternal causes - Haemorrhage … 328 2002 6 - Abortion … 161 2002 6 - Eclampsia … … - Sepsis … … - Obstruc ted labour … … 50 Diabetes mellitus … … … 13 922 6524 7398 2002 6 51 Mental disorders … … … 966 738 228 2002 6 52 Injuries - All types … … … 33 617 27 448 6169 2002 6 - Motor and other vehicle accidents … … … 6131 4630 1501 2002 6 - Suicide … … … 1301 999 302 2002 6 - Hom icide and violence … … … 13 267 12 222 1045 2002 6 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public heal th facilities - General hospitals 638 35 276 2002 14 - Specialized hospi tals 23 10 119 2002 14 - District/first-level referral hospitals 161 b 5834 2002 14 - Primary health care centres 2293 … 2002 6 Private hospitals 1077 39 771 2002 14 Notes: Red text M illennium Development Goals (MDG) indicators … Data not available est Estimate C Cases D Deaths p Provisional aa Figure refers to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Uni t of the WHO Regional Office for the Western Pacific . b District hospi tal can be general or special. c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d T reatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. e Totals may not tally due to some reported cases with no gender breakdown. f Revised data. COUNTRY HEALTH INFORMATION PROFILE 277 Sources: 1 2003 Philippine statistical yearbook. National Statistical Coordination Board (NSCB) 2 Population Commission, Department of Heal th – http://www.popcom.gov.ph 3 2000 Census of Population and Housing, National Statistics Office 4 National Statistical Coordination Board – http://www.nscb.gov.ph 5 Human development report 2005. New York, Uni ted Nations Development Programme, 2005. 6 2002 Philippine Heal th Statistics, National Epidemiology Center, Department of Heal th 7 National Statistics Office, Philippines (http://www.census.gov.ph) 8 2004 Field Health Service Information System (FHSIS) annual report. Department of Heal th 9 Department of Health (http://www.doh.gov.ph) 10 Insti tute of Health Polic y Development Studies, National Insti tute of Heal th, University of the Philippines 11 2003 National Demographic and Health Survey, Philippines 12 Professional Regulation Commission 13 2005 Philippine Heal th Insurance Corporation (PHIC) Stats and Charts 14 Bureau of Health Facilities and Services, Department of Health, Philippines 15 National Center for Disease Prevention & Control , Department of Heal th, Philippines 16 WHO Regional Office for the Western Paci fic, data received from technical units 17 2004 Annual Poverty Indicators Survey (Preliminary Results). National Statistics Office 18 WHO Representative in the Philippines office 19 Land transportation Office, Department of Transportation and Communication 20 World health report 2004. Changing history. Geneva, World Health Organization, 2004. 21 Food and Nutrition Research Institute, Department of Science and Technology – http://www.fnri.dost.gov.ph 278 | COUNTRY HEALTH INFORMATION PROFILES PITCAIRN ISLANDS 1. DEMOGRAPHICS, GENDER AND POVERTY An estimated 46 people live in Pitcairn Islands (2004). Two languages are spoken: English, the official language, and Pitkern, a mixture of an 18th century English dialect and a Tahitian dialect. Outmigration, primarily to New Zealand, has thinned the population from a peak of 233 in 1937 to less than 50 today. Table 1. Core population and health data (2004 estimate) [Total] 46 [Both] … [0-14 years] … [Male] … Population [65+ years] … Life expectancy at birth (years) [Female] … Crude birth rate (per 1000 population) … Total fertility rate … [Total] … [Urban] … Crude death rate (per 1000 population) … % of population served with safe water [Rural] … [Total] … [Urban] … Infant mortality rate (per 1000 live births) … % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) … 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Pitcairn Islands is an overseas territory of the United Kingdom of Great Britain and Nothern Ireland, one of the 14 scattered around the world. It is governed from the United Kingdom by an appointed Governor whose office is in Wellington, New Zealand. A Commissioner for the islands, 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. 2.2 Economic situation Pitcairn islanders exist on fishing, subsistence farming, handicrafts and postage stamps. The fertile soil of the valleys produces a wide variety of fruits and vegetables, including citrus, sugarcane, watermelons, bananas, yams and beans. Bartering is an important part of the economy. The major sources of revenue are the sale of postage stamps to collectors and the sale of handicrafts to passing ships. COUNTRY HEALTH INFORMATION PROFILES | 279 3. HEALTH SITUATION 3.1 Health trends No available information. 3.2 Health systems 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. 4. NATIONAL HEALTH PLAN AND PRIORITIES No available information. 5. MAJOR INFORMATION SOURCES Pitcairn Island http://www.government.pn or http://www.visitpitcairn.pn CIA The World Factbook http://www.cia.gov/cia/publications/factbook/geos/ Pitcairn Islands Study Center http://library.puc.edu/pitcairn/ 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Mrs. Susan E O'Malley Medical Officer Pitcairn Islands Postal Address : Official Email Address : co@pitcairn.gov.pn Telephone : Fax : (872) 7623 37767 Office Hours : Website : WHO REPRESENTATIVE IN THE SOUTH PACIFIC Office Address : Level 4, Provident Plaza 1, Downtown Boulevard, 33 Ellery Street, Suva, Fiji Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@sp.wpro.who.int Telephone : (679) 330 4600 / 330 4631/ 330 4635 / 331 7447 Fax : (679) 330 0462 / 331 1530 Office Hours : Website : 280 | COUNTRY HEALTH INFORMATION PROFILES REPUBLIC OF KOREA 1. DEMOGRAPHICS, GENDER AND POVERTY The population of the Republic of Korea was 48.2 million as of 2005. The population density of the country is 485 persons per square kilometre. The Republic of Korea has experienced rapid socioeconomic change during the past three decades. Rapid economic growth and industrialization have accelerated urbanization and, by 2003, about 80% of the population was urbanized. A notable trend in Korea's demographic situation is that the population is growing older with each passing year. Statistics show that, while 6.9% of the total population of Korea was 65 years or older in 1999, that percentage had risen to 10% by 2005. In the Human Development Index prepared by the United Nations Development Programme (Human Development Report 2005), the Republic of Korea ranks 28th out of 177 nations. The recent socioeconomic development has transformed the Republic of Korea from a recipient country into a donor country. As a result, WHO and other development partners have gradually changed their roles within the country, moving chiefly to liaison and resource mobilization. Table 1. Core population and health data (2005) [Total] 48 294 143 [Both] 77.46 (2003) [0-14 years] 9 240 017 (19.13%) [Male] 73.87 (2003) Population [65+ years] 4 811 631 (9.96%) Life expectancy at birth (years) [Female] 80.82 (2003) Crude birth rate (per 1000 population) 9.80 (2004) Total fertility rate 1.16 (2004) [Total] 90.10 (2004) [Urban] … Crude death rate (per 1000 population) 5.10 (2004) % of population served with safe water [Rural] … [Total] 81.40 (2004) [Urban] … Infant mortality rate (per 1000 live births) 5.30 (2003) % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 15.00 (2003) Socioeconomic factors, such as poverty and gender, have a decisive impact on national health status and are a major cause of health inequalities, but the Government has made consistent efforts to prevent those factors from undermining the quality of life of its citizens. In particular, efforts have been made to sever the link between low income and unequal access to health services. People in the low-income bracket receive state assistance when they suffer from intractable diseases. The Government is extending the coverage of this medical aid. Gender mainstreaming is another goal of Korean health policy, aiming to eliminate gender-based inequality in health services by reflecting the perspective of women in devising policy measures. To this end, initiatives have been put in place to guarantee a minimum standard of living for single mothers, women involved in the sex trade, and female victims of domestic and sexual violence. In addition, health-related legal provisions that are considered at odds with women’s rights are to be amended or removed. COUNTRY HEALTH INFORMATION PROFILES | 281 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The tension between the Republic of Korea and the Democratic People's Republic of Korea continues to play a major role in life and decision-making on the Korean peninsula. The summit meeting of both heads of state in 2001 symbolized improving relations and many activities have taken place since that historic meeting. Several rounds of family reunions have taken place, and the 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 current President of the Republic of Korea, Roh Moo-hyun, and the former president, Kim Dae-jung, have called for continued dialogue and further assistance to the Democratic People's Republic of Korea. The Republic of Korea National Security Council has officially designated WHO as the channel of support for the health sector in the Democratic People's Republic of Korea. Since 2001, the Government of the Republic of Korea has successfully donated a quantity of malaria control supplies to the Government of the 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. The total value of the materials provided in 2005 was approximately US$ 1 million. 2.2 Economic situation Since the beginning of the first Five-Year Economic Development Plan in 1962, the Republic of Korea's economy and quality of life have improved rapidly. An outward-oriented economic development strategy, which used exports as the engine of growth, contributed greatly to the country’s radical economic transformation. The Republic of Korea recently pulled through an economic storm that began in late 1997. The crisis, which affected markets all across Asia, had threatened Korea's remarkable economic achievements. However, thanks to the faithful implementation of an IMF agreement made by the Government, its strong resolve for reform, and successful negotiation of foreign debt restructuring with creditor banks, the nation is currently on track to resume economic growth. Since the onset of the crisis, Korea has been rapidly integrating itself into the world economy. The goal is to overcome problems rooted in the past by creating an economic structure suitable for an advanced economy. As a result, from 1962 to 2005, the gross national income (GNI) increased from US$2.3 billion to US$786.8 billion, with per capita GNI soaring from US $87.00 to about US$16 291.00. The establishment of the Korean International Foundation for Health and Development (KIFHAD) on 10 December 2003 reflects the Republic of Korea's interest in increasing its contribution to international health development. KIFHAD’s objectives are primarily medical relief and health system support for developing countries, emergency aid for disaster areas, and health care support for the Democratic People's Republic of Korea. 3. HEALTH SITUATION 3.1 Health trends In recent years, the health and quality of life of citizens in the Republic of Korea has improved steadily. There has been a significant rise in life expectancy, in part due to progress in medical services and increases in the number of medical facilities and medical staff. These improvements have also greatly contributed to reductions in the infant mortality rate and the maternal mortality ratio. Average life expectancy for males in the Republic of Korea rose from 51.1 years in the 1960s to 73.87 in 2003, and for females from 53.7 to 80.82 over the same period. However, the disparity REPUBLIC OF KOREA 282 | COUNTRY HEALTH INFORMATION PROFILES between males and females in part reflects a relatively high mortality rate for males in their forties and fifties. The infant mortality rate fell from 61.0 per 1000 live births in the 1960s to an estimated 5.30 in 2003, while the maternal mortality ratio stood at 15 per 100 000 live births in 2002. The country’s health policies have been guided by two strategic documents: • Health Vision 2010; and • Welfare Vision 2010. The Ministry of Health and Welfare has published a Health Care Development Plan for the 21st century, which focuses on the following four major areas: • establishing a lifetime health maintenance system; • establishing an efficient health care delivery system; • fostering the health care industry; and • revising the health care law and the administrative system to establish an advanced social welfare system. In order to maintain or reduce the incidence of chronic diseases, the Government has enlarged its focus to include external factors, such as pollution and health promotion, including eating habits, nutrition, exercise and use of leisure time. In addition, the Government also intends to establish a comprehensive health care system at the community level. The state of the health industry is directly linked to improvements in public health and quality of life, and is a highly value-added and knowledge-based industry. The Government is planning to establish a ‘Bio Health Technopolis’ at Osong in Chungcheongbuk-do Province, in the south- western part of the country, by 2006. Changes in socioeconomic structures and lifestyles, and improvements in health and medical care, have drastically changed the leading causes of death in the country. In the past, the main causes were acute and communicable diseases, but these have been replaced by chronic and noncommunicable diseases. As the population grows more elderly and the number of people suffering from chronic degenerative diseases increases, treatment-focused health care policies are being increasingly supplemented by prevention-focused and health-promotion policies. These changes have also contributed to decreasing infant and maternal mortality. The great majority of malaria cases are associated with activity along the demilitarized zone (DMZ) separating the Republic of Korea and the Democratic People's Republic of Korea and are most frequently found in military or former military personnel. The decrease in the number of cases is a reflection of the success, since 2001, of the malaria prevention and control programme in both countries, facilitated by the donation by the Government of Republic of Korea of malaria control supplies to the Democratic People's Republic of Korea. 3.2 Health systems Expenditures by the Government for health and social welfare have risen every year. The budget of the Ministry of Health and Welfare for 2005 amounted to approximately US$ 9.2 billion, 6.4% of the total government budget. There were 97 404 physicians, 21 344 dentists, 53 492 pharmacists and 202 012 nurses in the country in 2004. Demand for higher quality health services has increased greatly with improvements to living standards, greater consciousness of health and longer life expectancy. Moreover, the extension of health insurance to the whole population has led to greater demands for health care, which has resulted in the need for a larger health workforce and more facilities. Thanks to the wide coverage of its social security system, the Republic of Korea has been able to build a basic framework for social security institutions. However, the increasing demands of the COUNTRY HEALTH INFORMATION PROFILES | 283 Korean people will require improvements to both the quality and the content of the existing system, as well changes to the current supplier-focused orientation The existing social welfare system is divided into: • social insurance (National Health Insurance Scheme [NHIS], National Pension Scheme [NPS], Employment Insurance, Industrial Accident Compensation Insurance); • public assistance (livelihood protection, medical aid, veterans relief, disaster relief); and • social welfare services (for the disabled, seniors, children, women and the mentally handicapped). The Ministry of Health and Welfare is primarily responsible for administering social security schemes, such as the NPS, NHIS, Public Assistance and Social Welfare Services. There are 13 WHO collaborating centres in the Republic of Korea. 4. NATIONAL HEALTH PLAN AND PRIORITIES The Republic of Korea has passed through an epidemiological transition: during the past few decades, the incidence of infectious diseases has decreased while the incidence of chronic degenerative diseases has increased consistently. As most chronic degenerative diseases need to be treated, often with long-term care, the importance of prevention and health promotion has been stressed. The Government will strengthen health promotion programmes using the National Health Promotion Fund. These programmes consist of health education, disease prevention, improvements to nutrition, and encouragement of healthy lifestyles, as defined in the 1995 National Health Promotion Act. The objectives of health policy are to enhance the quality of life and the life span by encouraging healthy lifestyles, improving accessibility to preventive services and formulating a social environment that encourages healthy lifestyles. In order to achieve the above objectives, the strategies are: • encourage healthy lifestyles; • strengthen health education; • promote a nationwide movement for the practice of healthy lifestyles; • improve access to preventive services; • strengthen preventive services at health centres; • activate preventive programmes of nongovernmental organizations; • strengthen health examination programmes at schools and workplaces; • create a social environment that encourages healthy lifestyles; and • establish health promotion facilities such as exercise and recreation facilities, and • enforce legal regulations on tobacco and alcohol marketing and advertisements. 5. MAJOR INFORMATION SOURCES Korea National Statistical Office: Statistical Handbook of Korea 2002. Health Insurance and Review Agency: Health Insurance Review and Evaluation, December 2001 Human Development Report 2005, New York, UNDP, 2005 Health and Welfare Services 2003, Ministry of Health and Welfare, The Republic of Korea REPUBLIC OF KOREA 284 | COUNTRY HEALTH INFORMATION PROFILES Yearbook of health and welfare statistics 2005, Ministry of Health and Welfare Maternal and infant mortality survey report in 2002-2003, Ministry of Health and Welfare Economic statistics yearbook 2004, The Bank of Korea Population projections for Korea, National Statistical Office 6. ADDRESSES MINISTRY OF HEALTH AND WELFARE Office Address : Government Complex-Gwacheon, 1, Jungang-dong, Gwacheon-si 427- 721, Gyeonggi-do, Republic of Korea Postal Address : Official Email Address : Telephone : (822) 2110-6125~6134 Fax : (822) 504-6418 Office Hours : Website : http://www.mohw.go.kr COUNTRY LIAISON OFFICER IN REPUBLIC OF KOREA Office Address : Room 306, 2-dong, Government Complex-Gwacheon, 1 Chungang- dong, Kwachon City, 427-760, Kyonggido, Republic of Korea Postal Address : Central P.O. Box 540, Seoul, Republic of Korea Official Email Address : ChungNH@kor.wpro.who.int Telephone : (822) 503-7533, 2110-6473 Fax : (822) 502-7818 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILES | 285 ORGANIZATIONAL CHART: MINISTRY OF HEALTH AND WELFARE REPUBLIC OF KOREA 286 REPUBLIC OF KOREA WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 99.62 2004 1 2 Estimated population ('000s) 48 294.14 … … 2005 2 3 Annual population growth rate (%) 0.49 … … 2004 2 4 Percentage of population - 0–14 years 19.13 … … 2005 2 - 65+ years 9.96 … … 2005 2 5 Urban population (%) 80.30 … … 2003 3 6 Crude birth rate (per 1 000 population) 9.80 … … 2004 4 7 Crude death rate (per 1 000 population) 5.10 … … 2004 4 8 Rate of natural increase of population (% per annum) 0.47 … … 2004 4 9 Life expectancy (years) - at birth 77.46 73.87 80.82 2003 5 - Heal th-adjusted Life Expectancy (H ALE) at age 60 … 13.20 17.10 2002 15 10 Adult literacy rate (%) 97.90 99.20 96.60 2002 9 11 Neonatal mortality rate (per 1 000 live births) 3.30 3.50 3.10 2002 7 12 Infant mortality rate (per 1 000 live births) 5.30 5.70 5.00 2003 7 13 Under-five mortality rate (per 1 000 live births) 6.17 … … 2004 4 14 Total fertility rate (women aged 15–49 years) 1.16 2004 4 15 Maternal mortality ratio (per 100 000 live births) 15.00 2003 7 16 Percentage of newborn infants weighing at least 2500 g at birth 95.84 96.21 95.44 2004 4 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 92.70 … … 2004 16 - DTP3 87.50 … … 2004 16 - OPV3 89.80 … … 2004 16 - Measles 99.50 … … 2004 16 - Hepati tis B III 91.60 … … 2004 16 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 99.80 2003 6 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) 0.70 2003 6 - Percentage of deliveries in heal th facilities (as % of total deliveries) 99.30 2003 6 21 Percentage of women in the reproductive age group using modern contraceptive methods 84.50 2003 6 22 Condom use rate of the contraceptive prevalence rate 8.50 … … 2003 6 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … COUNTRY HEALTH INFORMATION PROFILE 287 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 90.10 … … 2004 8 26 Proportion of population with access to improved sanitation 81.40 … … 2004 8 27 Proportion of the population using solid fuels for cooking or heating (%) <5.00 … … 2003 16 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) 37.00 … … 2003 8 31 Human development index 0.90 … … 2003 9 32 Per capita GDP at current market prices (US$) 14 193.00 e … … 2004 10 33 Rate of growth of per capita GDP (%) 11.31 … … 2004 10 34 Health expenditure Total health expenditure - amount (in m illion US$) 33 736.00 2003 11 - total heal th expenditure on health as % of GDP 5.60 2003 11 - per capita total expendi ture on health (in US$) 705.00 2003 11 Government expenditure on health - amount (in million US$) 16 668.00 2003 11 - general government expenditure on health as % of total expenditure on health 49.40 2003 11 - general government expenditure on heal th as % of total general government expendi ture … External source of government health expenditure - external resources for heal th as % of general government expendi ture on health … Private health expenditure - private expenditure on health as % of total expenditure on heal th 50.06 e 2003 11 Exchange rate in US$ of local currency is: 1 US$ = 1191.61 Won 2003 11 35 Health insurance coverage as % of total population 98.09 f 2004 12 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 97 404 79 721 17 683 20.26 32.90 7.41 2004 12 - dentists 21 344 16 616 4728 4.44 6.86 1.98 2004 12 - pharmacists 53 492 19 344 34 148 11.13 7.98 14.32 2004 12 - nurses 202 012 … … 42.01 … … 2004 12 - m idwives 8628 … … 1.79 … … 2004 12 - other nursing / auxiliary staff 94 881 h … … 19.73 h … … 2004 12 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 134 780 c 45 522 c 89 258 c 28.03 c 18.79 c 37.42 c 2004 12 - other heal th personnel (health inspec tors, assistant sani tarians, traditional workers, etc.) 158 793 g 29 281 g 122 922 g 33.03 g 12.09 g 51.53 g 2004 12 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … REPUBLIC OF KOREA 288 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Diseases of the respiratory system 674 238 308 661 365 577 1415.30 1287.00 1545.40 2002 13 2. Diseases of the musculoskeletal system & connec tive tissues 307 048 106 836 200 212 644.50 445.40 846.40 2002 13 3. Diseases of the digestive system 301 691 140 763 160 928 633.30 586.90 680.30 2002 13 4. Injury, poisoning and certain other consequences of external causes 150 792 81 817 68 975 316.50 341.10 291.60 2002 13 5. Diseases of the circulatory system 105 467 44 736 60 731 221.40 186.50 256.70 2002 13 6. Diseases of the genitourinary system 84 626 22 219 62 407 177.60 92.60 263.80 2002 13 7. Diseases of the skin and subscutaneous tissue 83 950 39 215 44 735 176.20 163.50 189.10 2002 13 8. Diseases of the eye and adnexa 63 748 24 864 38 884 133.80 103.70 164.40 2002 13 9. Certain infectious and parasitic diseases 58 971 27 580 31 391 123.80 115.00 132.70 2002 13 10. Factors influencing heal th status and contact with heal th services 49 310 13 851 35 459 103.50 57.80 149.90 2002 13 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Malignant neoplasms 64 731 41 312 23 419 133.50 169.90 96.90 2004 14 2. Cerebrovascular diseases 34 091 16 219 17 872 70.30 66.70 73.90 2004 14 3. Heart diseases 17 915 9 443 8 472 36.90 38.80 35.00 2004 14 4. Intentional sel f-harm 11 523 7 903 3 620 25.20 34.50 15.80 2004 14 5. Diabetes mellitus 11 768 5 858 5 910 24.30 24.10 24.50 2004 14 6. Diseases of the liver 9 272 7 549 1 723 19.10 31.00 7.10 2004 14 7. Chronic lower respiratory diseases 8 378 5 228 3 150 17.30 21.50 13.00 2004 14 8. Transport accidents 8 333 6 125 2 208 17.20 25.20 9.10 2004 14 9. Hypertensive diseases 5 036 1 684 3 352 10.40 6.90 13.90 2004 14 10. Pneumonia 3 512 1 911 1 601 7.20 7.90 6.60 2004 14 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 17 - Pertussis (whooping cough) 6 2 4 … … … 2004 17 - T etanus 11 8 3 … … … 2004 17 - Neonatal tetanus NR NR NR … … … 2004 17 - Poliomyelitis 0 0 0 0 0 0 2004 17 - Hib meningitis NR NR NR … … … 2004 17 - Measles 16 6 10 … … … 2004 17 - Mumps 1744 1142 602 … … … 2004 17 - Rubella 15 9 6 … … … 2004 17 - Congeni tal rubella syndrome 0 0 0 0 0 0 2004 17 42 Selected communicable diseases Number of cases aa Number of deaths Hepati tis vi ral - T ype A 355 b, e 198 b 157 b … … … 2004 17 - T ype B 537 b, e 338 b 199 b … … … 2004 17 - T ype C 1657 b, e 909 b 748 b … … … 2004 17 - T ype E … … … … … … - Unspecified … … … … … … COUNTRY HEALTH INFORMATION PROFILE 289 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Cholera 10 6 4 0 0 0 2004 17 Typhoid fever 174 85 89 0 0 0 2004 17 Encephalitis 0 0 0 0 0 0 2004 17 Plague 0 0 0 0 0 0 2004 17 Syphilis 807 b ,e 410 b,e 397 b,e ... … … 2004 17 Gonorrhoea 10 845 b,e 7066 b,e 3779 b,e … … … 2004 17 Leprosy 17 … … … … … 2004 16 Malaria 827 … … 0 0 0 2004 16 Dengue/DHF 0 0 0 0 0 0 2004 16 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 2.00 … … 0.00 0.00 0.00 2004 16 - Proportion of population in malaria-risk areas using effective malaria prevention measures l … - Proportion of population in malaria-risk areas using effective malaria treatment measures m … 44 Tuberculosis Number of cases Number of deaths - All types 34 671 … … … … … 2004 16 - New pulmonary tuberculosis (smear-posi tive) 11 501 … … … … … 2004 16 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 125.00 … … 10.00 … … 2004 16 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOT S) 21.00 … … 82.00 (2003) … … 2004 16 Number of cases Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases … … … 90 d 44 d 46 d 2004 14 47 Cancers All cancers (malignant neoplasms only) … … … 64 731 41 312 23 419 2004 14 - T rachea, bronchus, and lung … … … 13 319 9869 3450 2004 14 - Stomach … … … 11 255 7320 3935 2004 14 - Colon and rectum … … … 5899 3271 2628 2004 14 - Lip, oral cavity and pharynx … … … 935 752 183 2004 14 - Liver … … … 10 962 8277 2685 2004 14 - Cervix … 1078 2004 14 - Leukaemia … … … 1483 859 624 2004 14 48 Circulatory All circulatory system diseases … … … 58 382 28 051 30 331 2004 14 - Ischaemic heart disease … … … 12 760 6809 5951 2004 14 - Acute m yocardial infarction … … … 9333 5176 4157 2004 14 - Rheumatic fever and rheumatic heart diseases … … … 291 114 177 2004 14 - Cerebrovascular diseases … … … 34 091 16 219 17 872 2004 14 - H ypertension … … … 5036 1684 3352 2004 14 REPUBLIC OF KOREA 290 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 49 Maternal causes - Haemorrhage … 26 2003 7 - Abortion … 1 2003 7 - Eclampsia … 2 2003 7 - Sepsis … 2 2003 7 - Obstruc ted labour … 0 2003 7 50 Diabetes mellitus … … … 11 768 5858 5910 2004 14 51 Mental disorders … … … 4796 1967 2829 2004 14 52 Injuries - All types … … … 30 567 21 114 9453 2004 14 - Motor and other vehicle accidents … … … 8 333 6125 2208 2004 14 - Suicide … … … 11 523 7903 3620 2004 14 - Hom icide and violence … … … 882 453 429 2004 14 - Occupational injuries 92 697 … … 2923 … … 2003 18 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public heal th facilities 3499 n 35 986 n - General hospitals 282 117 323 2004 12 - Specialized hospi tals 100 k 36 682 2004 12 - District/first-level referral hospitals … … - Primary health care centres 3420 j 434 2004 12 Private hospitals 1334 i 209 889 2004 12 Notes: Red text M illennium Development Goals (MDG) indicators … Data not available est Estimate NR Not relevant p Preliminary aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Uni t of the WHO Regional Office for the Western Pacific . b Data from a hospital survey, incidence case. c Including licensed medical technicians (clinical pathology technicians, radiological technicians, physical therapists, occupational therapists, dental technicians, dental hygienists, medical records officers). d Including ICD code A01-A09. e Revised data. f Not including medical aid. g Figures for licensed sani tary workers, licensed dietitians and opticians. 74 quasi-medical practi tioners (bone setters, acupuncturists, moxibustioners) and 6516 massuers/masseuses are excluded from these figures (gender not classified) h Only other nursing personnel in medical facilities, m idwifery clinics, health centres, sub-heal th centres and primary heal th care (PHC) posts i Only hospi tals, not including clinics j Including heal th centres, sub-heal th-centres and PHC posts k Including mental, tuberculosis and leprosy hospi tals COUNTRY HEALTH INFORMATION PROFILE 291 l Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. m Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. n Not including Primary heal th care centres. Sources: 1 Cadastral statistical annual report 2004. M inistry of Government Administration and Home Affai rs, 2004. 2 Population projections for Korea. National Statistical Office. 3 Urban and rural areas 2003 . New York, United Nations Department of Economic and Social Affairs, Population Division, 2004. 4 2004 annual report on live births and deaths statistics. National Statistical Office, 2004. 5 Statistical database. National Statistical Office (http://www.nso.go.kr). 6 National Fertili ty and Family Health Survey 2003. Korea Institute for Heal th and Social Affairs. 7 Maternal and infant mortality survey report in 2002-2003. Ministry of Health and Welfare. 8 Environmental statistics yearbook 2005 . M inistry of Environment. 9 Human development report 2005. New York, Uni ted Nations Development Programme, 2005. 10 Economic statistics yearbook 2004. The Bank of Korea. 11 OECD health data 2005 : How does Korea compare, OECD. 12 Yearbook of heal th and wel fare statistics 2005 . Ministry of Heal th and Welfare. 13 Patient survey report 2002 . Ministry of Health and Welfare. 14 Annual report on the cause of death statistics 2004 . National Statistical Office. 15 World heal th report 2004. Changing history. Geneva, World Health Organization, 2004. 16 WHO Regional Office for the Western Paci fic, data received from the technical units. 17 Communicable diseases statistical yearbook 2004. Korea Center for Disease Control and Prevention. 18 Yearbook of labor statistics 2004 . M inistry of Labor. 292 | COUNTRY HEALTH INFORMATION PROFILES SAMOA 1. DEMOGRAPHICS, GENDER AND POVERTY In 2004, estimates put Samoa’s population at 182 700, with around 39% composed of young people aged less than 15 years and only 4% of people aged 65 years and over. The country is divided into four major statistical regions: Apia Urban Area (AUA), North West Upolu, Rest of Upolu (including Manono and Apolima Islands) and Savaii. AUA represents the urban area, while the other three regions make up the rural population. Table 1. Core population and health data (2004) [Total] 182 700 est [Both] 72.80 (2001) [0-14 years] (39.17%) est [Male] 71.80 (2001) Population [65+ years] (4.03%) est Life expectancy at birth (years) [Female] 73.80 (2001) Crude birth rate (per 1000 population) 20.80 Total fertility rate 3.40 [Total] 88.00 (2002) [Urban] 91.00 (2002) Crude death rate (per 1000 population) 3.00 % of population served with safe water [Rural] 88.00 (2002) [Total] 100.00 (2002) [Urban] 100.00 (2002) Infant mortality rate (per 1000 live births) 13.00 % of population with adequate sanitary facilities [Rural] 100.00 (2002) Maternal mortality ratio (per 100 000 live births) 5.30 est - Estimate Gender issues, such as the promotion and protection of women's rights, gender equity and women and HIV/AIDS are of high importance in Samoan society. The level of women’s participation in the paid labour force is relatively high, and their access to education and achievement in the formal educational system is virtually equal to men. Women occupy a number of senior positions in the public sector. The church plays a key role in influencing public opinion and in education through the provision of schools at all levels. The UNDP Human Development Index (HDI) ranks Samoa 75th out of 177 countries. Based on the HDI, Samoa has one of the higher levels of social development rankings in the Pacific, showing higher overall educational and health standards than other Pacific islands. 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Democratic traditions and a strong social system based on village communities and extended family ties continue to play a major role in maintaining peace in Samoan society. The extended family, the aiga, is the foundation of the fa’a-samoa (traditional way of life). The head of each aiga is the matai (customary chief), who is elected by family members. Traditionally, the family matai is responsible for maintaining the family’s dignity and well-being by administrating family affairs. More than 80% of the population lives under the matai system. Particularly strong in the rural areas and at village level, it functions as a safety net in providing social and financial security. COUNTRY HEALTH INFORMATION PROFILES | 293 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 (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 2005–2007, which highlight the medium-term vision as follows: “For every Samoan to enjoy an improved quality of life premised on a competitive economy with sustained economic growth, improved education, enhanced health standards and strengthened cultural and traditional values”. 2.2 Economic situation The economy of Samoa has traditionally been dependent on development aid, family remittances from overseas, and agriculture and fishing. Agriculture still plays an important role in the economy. Village agriculture provides food security and support to the agro-based industries, such as coconut cream, oil and desiccated coconut, which have been major export products in the past. The manufacturing sector mainly processes agricultural products. Tourism is an expanding sector. The Government has called for deregulation of the financial sector, encouragement of investment, and continued fiscal discipline, while protecting the environment. Development efforts in the area of trade, at both national and international levels, are considered relatively advanced compared with other Pacific islands. However, Samoa is ecologically fragile and vulnerable to natural disasters, such as cyclones and disease infestations. Gross domestic product (GDP) per capita in 2001 was US$ 1442.67 US dollars. Economic growth in the same year was estimated at 6.5%, with an annual rate of inflation of 4% by the end of 2001. Manufacturing, transport and communications, and commerce contributed most to the growth. Agriculture production, on the other hand, dropped by 12% as a direct result of the limited market outlets for copra, cocoa, kava and coconut cream. Gross tourism receipts rose only marginally, by 0.7%. The sharp slowdown in growth was seen as a direct result of the 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. SAMOA 294 | COUNTRY HEALTH INFORMATION PROFILES 3. HEALTH SITUATION 3.1 Health trends The health status of the population has improved significantly, and Samoans now enjoy a relatively good health status. Life expectancy is 72.8 according to the 2001 census, compared with 66.4 years ten years previously. The infant mortality rate dropped from 19.3 per 1000 live births in 2001 to 13 in 2004, 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 5.3 in 2004. Poliomyelitis, tetanus and diphtheria have been virtually eradicated in Samoa, and the whole of the Pacific region is poliomyelitis-free. Remaining high mortality and high morbidity rates for communicable diseases call for a renewed control, management and surveillance commitment. Typhoid and dengue are both endemic and periodically reach epidemic levels. Lymphatic filariasis is also endemic, with a standardized antigen prevalence rate of 1.6% in 2003. As the Government has made a firm commitment to 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. An average of 33 cases of tuberculosis were diagnosed each year in the period from 1995 to 2004, an average of 13 being the most infectious form, sputum smear-positive pulmonary TB. WHO estimates of the likely numbers of smear-positive cases are somewhat higher, however, and so the calculated case-detection rate has been relatively low at around 50% for the past two years, ranging from 25%-79% in the past 10 years. The directly observed 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, 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 urgency of tackling 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 to Fight HIV/AIDS, Tuberculosis and Malaria, severely under resourced. 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: obesity 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. COUNTRY HEALTH INFORMATION PROFILES | 295 Diabetes: • 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. • Diabetes is more common in the urban area, (Apia 27%, Rural Upolu 19.7% and Savaii 20.3%). The trend is similar for males and females. • In general, for every known case of diabetes that is diagnosed, almost three cases remain undiagnosed. This ratio is 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. High blood pressure (hypertension): • The total prevalence of high blood pressure is 21.4%. It 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 the urban area (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 every known case there are 22 unknown cases). • Most people (more than 90%) with high blood pressure do not know that they have it. Obesity: • The total prevalence of obesity is 57.0%: 48.4% in males and 67.4% in females. These rates are similar to previous surveys. Prevalence increases with age. • Obesity is more common in the urban area. (For males, Apia 53.1%; Rural Upolu 48%; Savaii 40.2%. For females, Apia 69.3%, Rural Upolu 65.9%, Savaii 65.4%). Risk factors: • 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: Current levels of alcohol consumption place 37.6 % of males and 19.6 % of females at moderate to high risk of developing an NCD. 1 No fruit or less than one serving per day Obesity Prevalence 54.9 61.355.9 34.4 70.1 77.1 70.5 58.1 0 20 40 60 80 100 25-34 35-44 45-54 55-64 Age group Male Female 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 296 | COUNTRY HEALTH INFORMATION PROFILES • 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%). • 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. Suicide: Even although the number of suicide attempts is increasing, 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 um 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 less than 30. 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 um be r fy99/00 fy00/01 fy01/02 fy02/03 fy03/04 Source: Health Information System, Ministry of Health 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 two years. 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 na nc ia l y ea r Per cent Paraquat % Hanging % others % Source: Health Information System, Ministry of Health COUNTRY HEALTH INFORMATION PROFILES | 297 The current staffing of the Mental Health Unit consists of one part-time psychiatrist (nine hours a week), one full-time medical officer who is currently on leave without pay studying and working in New Zealand, and five nurse specialists working full-time. The current nurse-patient ratio is 29.8 to 1. As of April 2005, 149 patients were receiving regular visits by the Mental Health Unit, the majority between 14 and 40 years of age. No services are provided specifically for children and very few for youths or elderly people. Currently, the majority of patients have been diagnosed with schizophrenia or other psychotic disorders. In addition, the Mental Health Unit provides continuous assessment and consultation services to a wide range of other health programmes including the hospital, community nurses and general practitioners. Referrals are also received from families, police, NGOs and private lawyers. In 2005, 92 cases were received from families, 26 from Tupua Tamasese Meaole Hospital Outpatients and Emergency Department (TTM OPED), 14 were self-referrals and the rest were from NGOs and the Police. The Mental Health Legislation Review has been completed and has gone through Parliament, while the Mental Health Policy and Plan of Action is in the finalization stage. 3.2 Health systems 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. The Ministry of Health publishes National Health Accounts, providing information on who generates and manages resources for the health system, how health resources are allocated across different services and who benefits from health spending. The Total National Health Expenditure in Samoa amounted to ST$51 millions (US$ 16.4 million) in the 2002/2003 fiscal year, with per capita spending of ST$291 (US$ 94.00). In the same period, health spending as a share of gross domestic product (GDP) came to 5.6% (6% in 1998/1999), public expenditures for health comprised 60.7% of total health spending (62% in 1998/1999), private spending for health comprised 16.5% of total health spending (23% in 1998/1999), and donor spending made up the remaining 19% (15% in 1998/1999). More than 22% of total health expenditure was for Ministry of Health providers of curative care. Private providers of inpatient curative care accounted for 2% (Medcen Hospital and sleep clinics), pharmacies for 16%, overseas treatment for 10.3%, and providers of ambulatory and diagnostics services for more than 17%. 4. NATIONAL HEALTH PLAN AND PRIORITIES 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, SAMOA 298 | COUNTRY HEALTH INFORMATION PROFILES 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. Whilst 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 (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. 5. MAJOR INFORMATION SOURCES Strategy for the development of Samoa 2002-2004: Opportunities for all Strategy for the Development of Samoa 2005-2007: Enhancing People’s Choices Samoa National Health Service Planning Framework April 2002. Department of Health Review of the Rural Health Services Plan 2006 (Draft) COUNTRY HEALTH INFORMATION PROFILES | 299 Report of the PacELF 5th Annual Meeting 2003. Tuberculosis control in the WHO Western Pacific Region: 2002 report Review of the National Tuberculosis Control Programme in Samoa from the internal medicine perspective. Dr Viali Lameko et al., 20 June 2002. Review of the National Tuberculosis Control Programme in May 2001 (WHO mission report by Dr Pierre Yves Norval) Department of Health Annual Report 1999-2000 (leading cause of mortality) Department of Health Annual Report 2002/2003 & 2003/2004 Review of the Health Sector Plan 2006-2010 (Draft), MOH Collins V, Dowse GK, Toelupe et al. Increasing prevalence of NIDDM in Pacific Islands population. Hodge AM, Dowse GK, Toelupe et al. Dramatic increase in the prevalence of obesity in Western Samoa over the 13 years period of 1978-1991. International journal of obesity, 1994; 18:419-428. Samoa Suicide Prevention Strategy 2002-2006: An introduction ‘Faataua le Ola’ (FLO) Samoa National Health Account for FY 2000/2001. Executive summary. Ministry of Health and the World Bank Samoa National Health Accounts Report for FY 2002-2003, MOH & World Bank 6. 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 Office Hours : Website : WHO REPRESENTATIVE IN SAMOA Office Address : Ioane Viliamu Building Beach Road, Apia, Western Samoa Postal Address : P.O. Box 77 Apia, Western Samoa Official Email Address : who@sma.wpro.who.int Telephone : (685) 23756; (685) 24976 Fax : (685) 23765 Office Hours : Website : SAMOA 300 SAMOA WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 2.94 2004 1 2 Estimated population ('000s) 182.70 ... ... 2004 est 1 3 Annual population growth rate (%) 1.00 ... ... 2001 4 4 Percentage of population - 0–14 years 39.17 38.98 39.38 2004 est 2 - 65+ years 4.03 3.64 4.46 2004 est 2 5 Urban population (%) 22.30 … … 2003 3 6 Crude birth rate (per 1 000 population) 20.80 … … 2004 18 7 Crude death rate (per 1 000 population) 3.00 … … 2004 18 8 Rate of natural increase of population (% per annum) 2.75 a … … 2001 9 Life expectancy (years) - at birth 72.80 71.80 73.80 2001 4 - Heal th-adjusted Life Expectancy (H ALE) at age 60 … 10.90 11.60 2002 5 10 Adult literacy rate (%) 98.70 … … 2002 19 11 Neonatal mortality rate (per 1 000 live births) 4.20 … … 2002 7 12 Infant mortality rate (per 1 000 live births) 13.00 2004 18 13 Under-five mortality rate (per 1 000 live births) 13.70 8.90 4.70 2002 7 14 Total fertility rate (women aged 15–49 years) 3.40 2004 21 15 Maternal mortality ratio (per 100 000 live births) 5.30 2004 18 16 Percentage of newborn infants weighing at least 2500 g at birth 98.50 … … 2004 20 17 Prevalence of underweight children under five years of age 1.90 … … 1999 20 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 93.00 … … 2004 10 - DTP3 68.00 … … 2004 10 - OPV3 41.00 … … 2004 10 - Measles 55.00 … … 2005 13 - Hepati tis B III 70.00 … … 2004 10 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 100.00 2004 21 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 4.00 2004 10 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) 9.00 2004 21 - Percentage of deliveries in heal th facilities (as % of total deliveries) 91.00 2004 21 21 Percentage of women in the reproductive age group using modern contraceptive methods 53.90 2004 21 22 Condom use rate of the contraceptive prevalence rate 5.30 … … 2004 21 23 HIV prevalence among 15–24 year-old pregnant women 0.00 2004 22 24 Number of children orphaned by HIV/AIDS ab 0 0 0 2004 22 COUNTRY HEALTH INFORMATION PROFILE 301 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 88.00 91.00 88.00 2002 11 26 Proportion of population with access to improved sanitation 100.00 100.00 100.00 2002 11 27 Proportion of the population using solid fuels for cooking or heating (%) 62.90 … … 2001 9 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) 73.00 … … 2005 17 31 Human development index 0.78 … … 2003 12 32 Per capita GDP at current market prices (US$) 1442.67 … … 2001 4 33 Rate of growth of per capita GDP (%) … … … 34 Health expenditure Total health expenditure - amount (in m illion US$) 16.40 FY 2002- 2003 14 - total heal th expenditure on health as % of GDP 5.60 FY 2002- 2003 14 - per capita total expendi ture on health (in US$) 94.00 FY 2002- 2003 14 Government expenditure on health - amount (in million US$) 10.98 FY 2002- 2003 14 - general government expendi ture on health as % of total expendi ture on health (budget) 25.20 FY 2002- 2003 14 - general government expendi ture on health as % of total general government expendi ture (budget) 15.10 FY 2002- 2003 14 External source of government health expenditure - external resources for heal th as % of general government expendi ture on health 19.60 FY 2002- 2003 14 Private health expenditure - private expenditure on health as % of total expenditure on heal th 16.50 FY 2002- 2003 14 Exchange rate in US$ of local currency is: 1 US$ = ST 2.80 FY 2002- 2003 14 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce (M inistry of Health) - physicians 50 33 17 2.74 … … 2005 23 - dentists 6 3 3 0.33 … … 2005 24 - pharmacists 3 3 0 0.16 … … 2005 6 - nurses 136 … … 7.47 … … 2005 25 - m idwives 37 … … 2.03 … … 2005 25 - other nursing / auxiliary staff 73 … … 4.01 … … 2005 25 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 101 … … 5.53 a … … 2004 18 - other heal th personnel (health inspec tors, assistant sani tarians, traditional workers, etc.) 35 … … 2.90 a … … 2004 18 SAMOA 302 INDICATORS DATA Year Source Total Male Female Total Male Female 37 Yearly new graduates - physicians 5 … … 2005 23 38 Yearly new graduates – nurses 19 … … 2004 18 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Spontaneous vertex delivery 2408 2408 1326 2768 2004 18 2. Pneumonia, unspeci fied 1017 549 468 560 580 538 2004 18 3. First-degree perineal laceration during delivery 385 385 212 442 2004 18 4. Ac ute bronchiolitis, unspecified 342 204 138 188 216 159 2004 18 5. Diarrhoea 321 183 138 177 193 159 2004 18 6. T yphoid fever 254 151 103 140 160 118 2004 18 7. Cellulitis of other parts of limb 172 108 64 95 114 74 2004 18 8. Congestive heart failure 156 75 81 86 80 93 2004 18 9. Neonatal aspiration of meconium 154 85 69 85 90 79 2004 18 10. Second degree perineal laceration during delivery 135 135 74 155 2004 18 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Cerebrovascular diseases 43 26 17 24.30 28.20 20.10 2002 7 2. Septicaemia 34 24 10 19.20 26.10 11.80 2002 7 3. Congestive heart failure 28 11 17 15.80 12.00 20.10 2002 7 4. Pneumonia 28 10 18 15.80 10.90 21.30 2002 7 5. Myocardial infarction 24 6 18 13.60 6.50 21.30 2002 7 6. Renal failure 17 5 12 9.60 5.40 14.20 2002 7 7. Old age 10 4 6 5.70 4.30 7.10 2002 7 8. Leukaemia 9 3 6 5.10 3.30 7.10 2002 7 9. Cancer of the liver 6 4 2 3.40 4.30 2.40 2002 7 10. Cardiovascular accident 6 2 4 3.40 2.20 4.70 2002 7 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 10 - Pertussis (whooping cough) 0 0 0 0 0 0 2004 10 - T etanus 0 0 0 0 0 0 2004 10 - Neonatal tetanus 0 0 0 0 0 0 2004 10 - Poliomyelitis 0 0 0 0 0 0 2004 10 - Hib meningitis 4 … … … … … 2004 10 - Measles 0 0 0 0 0 0 2004 10 - Mumps 0 0 0 0 0 0 2004 10 - Rubella 0 0 0 0 0 0 2004 10 - Congeni tal rubella syndrome 1 … … … … … 2004 10 42 Selected communicable diseases Number of cases aa Number of deaths Hepati tis vi ral - T ype A 2 1 1 0 0 0 2002 7 - T ype B 10 4 6 0 0 0 2004 19 - T ype C 0 0 0 0 0 0 2002 7 - T ype E … … … … … … - Unspecified 34 13 21 0 0 0 2004 19 Cholera 0 0 0 0 0 0 2004 18 Typhoid fever 254 151 103 0 0 0 2004 18 Encephalitis 1 1 0 0 0 0 2004 18 COUNTRY HEALTH INFORMATION PROFILE 303 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Plague 0 0 0 0 0 0 2004 18 Syphilis 0 0 0 0 0 0 2004 18 Gonorrhoea (gonococcal infections) 0 0 0 0 0 0 2004 18 Leprosy 10 … … … … … 2004 10 Malaria … … … … … … Dengue/DHF 1 0 1 0 0 0 2004 18 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures b … - Proportion of population in malaria-risk areas using effective malaria treatment measures c … 44 Tuberculosis Number of cases Number of deaths - All types 85 … … … … … 2005 15 - New pulmonary tuberculosis (smear-posi tive) 12 … … … … … 2005 15 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 43.00 … … 5.00 … … 2004 10 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOT S) 49.00 d … … 84.00 (2002) … … 2003 10 Number of cases Number of deaths 45 Acute respiratory infections 349 206 143 0 0 0 2004 18 46 Diarrhoeal diseases 322 184 138 5 2 3 2004 18 47 Cancers All cancers (malignant neoplasms only) 73 43 30 12 8 4 2004 18 - T rachea, bronchus and lung 21 13 8 5 4 1 2004 18 - Stomach 8 6 2 0 0 0 2004 18 - Colon and rectum 6 5 1 3 2 1 2004 18 - Lip, oral cavity and pharynx 7 5 2 0 0 0 2004 18 - Liver 8 4 4 2 1 1 2004 18 - Cervix 6 0 2004 18 - Leukaemia 17 10 7 2 1 1 2004 18 48 Circulatory All circulatory system diseases 301 143 158 37 8 29 2004 18 - Ischaemic heart disease 72 52 20 3 2 1 2004 18 - Acute m yocardial infarction 39 15 24 1 0 1 2004 18 - Rheumatic fever and rheumatic heart diseases 113 50 63 27 5 22 2004 18 - Cerebrovascular diseases 77 26 51 6 1 5 2004 18 - H ypertension 45 206 143 0 0 0 2004 18 SAMOA 304 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 49 Maternal causes - Haemorrhage 15 0 2004 18 - Abortion 134 0 2004 18 - Eclampsia 7 0 2004 18 - Sepsis 23 1 2002 7 - Obstruc ted labour 7 0 2004 18 50 Diabetes mellitus 7195 e … … … … … 2004- 2005 16 51 Mental disorders 76 e … … … … … 2003 26 52 Injuries - All types 733 556 177 22 13 9 2002 7 - Motor and other vehicle accidents 129 103 26 4 3 1 2002 7 - Suicide 42 26 16 21 18 3 2003/ 2004 18 - Hom icide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public heal th facilities - General hospitals 2 177 f 2005 25 - Specialized hospi tals … … - District/first-level referral hospitals 6 55 2004 8 - Primary health care centres 19 0 2005 8 Private hospitals 1 21 2004 8 Notes: Red text M illennium Development Goals (MDG) indicators … Data not available Est Estimate FY The financial year refers to the span from April 1 of respective year to March 31 next year. aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Uni t of the WHO Regional Office for the Western Pacific b Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. c Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. d Revised data e Figure refers to registered patients f Figure includes 157 beds in T upua T amasese Meaole Hospi tal , and 20 beds in Malietoa Tanumafili II Hospi tal Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 2 Demographic tables for the Western Paci fic Region 2000-2005. Manila, WHO Regional Office for the Western Pacific, 2005. 3 Urban and rural areas 2003 . New York, United Nations Department of Economic and Social Affairs Population Division, 2004. 4 M inistry of Finance, Statistical Services Division (http://www.spc.int.prism) 5 World health report 2004. Changing history. Geneva, World Health Organization, 2004. 6 Assistant Chief Executive Officer, Pharmacy Services, Ministry of Heal th 7 Ministry of Health statistical bulletin 2002 – review 1999-2002 COUNTRY HEALTH INFORMATION PROFILE 305 8 Rural Heal th Services Plan Review 2006 (Draft) 9 Pacific Island Regional Millennium Development Goals report 2004. Noumea, Secretariat of the Pacific Community, UN/CROP MDG Working Group, November 2004. 10 WHO Regional Office for the Western Paci fic, data received from technical units 11 Meeting the MDG drinking water and sani tation target, A mid-term assessment of progress. WHO and UNICEF, 2004 12 Human development report 2005. New York, Uni ted Nations Development Programme, 2005. 13 Expanded Programme on Immunization (EPI) Report 2005, Ministry of Heal th, Samoa. 14 National Health Accounts Report 2002-2003 15 July-Dec 05 budget performance measures – review 2006 , T B & Leprosy Clinic 16 Diabetic Association Clinic Registry – 2004/2005 17 Health Care Waste Management Report 2005 18 M inistry of Health Annual Report 2002/2003 & 2003/2004 19 M illennium Development Goals Report for Samoa 2004 20 Nutrition Centre, Ministry of Health, Samoa 21 2004 Annual Report – Maternal & Child Heal th 22 STI Clinic, Ministry of Health, Samoa 23 Tupua Tamasese Meaole Hospi tal Management Report 2005 , ACEO Clinical Heal th Services 24 Assistant Chief Executive Officer, Dental Heal th Services, Ministry of Health 25 Assistant Chief Executive Officer, Nursing Services, M inistry of Health 26 Mental Heal th Policy Si tuational Analysis 2005 306 | COUNTRY HEALTH INFORMATION PROFILES SINGAPORE 1. DEMOGRAPHICS, GENDER AND POVERTY Singapore is a small country with a total land area of about 700 square kilometres. The total population is about 4.35 million, with a resident population of 3.55 million in 2005. While the population is relatively young, with only 8% of the resident population above 65 years of age, the percentage over 65 years of age is projected to increase to 27% by 2030. Table 1. Core population and health data (2005 provisional) [Total] 3 553 500 (resident) [Both] 79.70 [0-14 years] 699 000 (19.70%) [Male] 77.90 Population [65+ years] 296 900 (8.40%) Life expectancy at birth (years) [Female] 81.60 Crude birth rate (per 1000 resident population) 10.00 Total fertility rate 1.24 (2004) [Total] 100.00 [Urban] … Crude death rate (per 1000 resident population) 4.30 % of population served with safe water [Rural] … [Total] 100.00 [Urban] … Infant mortality rate (per 1000 resident live births) 2.10 % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 resident live births and still births) 11.00 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Singapore is a parliamentary republic that obtained independence from Malaysia on 9 August 1965. The Constitution was established on 3 June 1959 and amended in 1965 (based on the pre- independence State of Singapore Constitution). The legal system is based on English common law. The head of state is President Sellapan Rama Nathan (since 1 September 1999), the head of government is Prime Minister Lee Hsien Loong (since 12 August 2004), and the Deputy Prime Ministers are 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 Rama Nathan was re-elected for his second term in August 2005. The legislative branch is a 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. 2.2 Economic 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 3.7 times the size of gross domestic product (GDP), external demand is the main driver of the economy. COUNTRY HEALTH INFORMATION PROFILES | 307 The Singapore economy grew by a healthy 6.4% in 2005 after a strong 8.7% growth rate in 2004. Per capita gross national income amounted to US$ 26 700 in 2005. As Singapore looks to a future increasingly marked by globalization, the country is positioning itself as a leading global city and a hub of talent, enterprise and innovation. 3. HEALTH SITUATION 3.1 Health trends Health status in Singapore is good by international standards. The infant mortality rate in 2005 stood at 2.10 per 1000 resident live births, while the average life expectancy was 79.70 years. Rising standards of living, high standards of education, good housing, a safe water supply and sanitation, a high level of medical services and the active promotion of preventive medicine have all helped to significantly boost the health of Singaporeans. The leading causes of morbidity and mortality are currently the major noncommunicable diseases such as cancer, coronary heart diseases, pneumonia, strokes, accidents and injuries. 3.2 Health systems Health services for the country are provided primarily by the Ministry of Health, as well as two cooperating ministries, and by the private sector. The Ministry of Health is responsible for providing preventive, curative and rehabilitative health services. The Ministry formulates national health policies, coordinates the development and planning of the private and public health sectors, and regulates health standards. The Ministry of the Environment and Water Resources 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 regulations and policies concerning the health, safety and welfare of employed persons at workplaces. The Ministry enforces requirements on working conditions under the Employment Act and safeguards the health and safety of workers through provisions in the Workplace Safety and Health Act, as well as administering 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 reverse occurs, 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). This enabled more integrated and better quality health care services through greater cooperation and collaboration among public sector health care institutions. Patients are free to choose their health care providers within the dual health care delivery system, and can walk in for a consultation at any private clinic or any government polyclinic. For emergency services, patients can access the 24-hour accident and emergency departments located in government hospitals. The Singapore Civil Defence Force runs an emergency ambulance SINGAPORE 308 | COUNTRY HEALTH INFORMATION PROFILES service to transport accident and trauma cases and medical emergencies to the acute general hospitals. Primary health care involves the provision of primary medical treatment, preventive health care and health education. Primary health care is provided through an island network of 17 outpatient polyclinics and 2080 private medical practitioners’ clinics, run by 1900 practitioners. Each polyclinic serves as a one-stop health centre, providing outpatient medical care, follow-up of patients discharged from hospitals, immunization, health screening and education, investigative facilities and pharmacy services. The private clinics are located in close proximity to population centres in the city, housing estates and satellite towns. The average outpatient consultation fee (inclusive of medication) is between S$10 (US$ 6.00) and S$15 (US$ 9.00), well within the means of most Singaporeans. At the government polyclinics, Singapore citizens aged 65 and above, children up to 18 years of age and all schoolchildren are given a subsidy of up to a 75% on their consultation and treatment fees. Other Singapore citizens are given a 50% subsidy. 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. Seventy-four per cent of the beds are in the 13 public sector specialty centres and hospitals, each with between 185 and 2430 beds. The 16 private sector hospitals are smaller, with a capacity ranging from 16 to 505 beds. The Government’s role as the dominant health care provider allows it to manage the supply of hospital beds, the adoption of high-tech/high-cost medicine, and cost increases in the public sector, which serves as a price benchmark for the private sector. The seven public hospitals comprise five acute general hospitals and two specialized hospitals (obstetrics and gynaecology, and psychiatry). The general hospitals provide multidisciplinary acute inpatient and specialist outpatient services and a 24-hour accident and emergency service. In addition, there are six specialty centres for cardiology, neuroscience, ophthalmology, dermatology, oncology and dentistry. Tertiary specialist care in the areas of cardiology, renal medicine, haematology, neurology, oncology, radiotherapy, plastic and reconstructive surgery, paediatric surgery, neurosurgery, cardiothoracic surgery and transplant surgery is centralized in two of the larger general hospitals, the Singapore General Hospital and the National University Hospital. The private hospitals have similar specialist disciplines and comparable facilities. The Government has restructured all its 13 hospitals and speciality institutes into private companies wholly owned by the Government and managed like not-for-profit organizations. This has granted the public hospitals management autonomy and flexibility to respond more promptly to the needs of patients. In the process, greater financial discipline and accountability have been introduced. Unlike private hospitals, the restructured public hospitals receive an annual government subvention or subsidy for the provision of subsidized medical services to subsidized patients. Public hospitals are subject to broad government policy guidance through the Ministry of Health. The Government has also introduced low-cost community hospitals for intermediate health care for the convalescent sick and aged who do not require the more expensive care provided by the acute general hospitals. In 2005, Singapore had 6750 doctors in its health care delivery system (44% in the private sector), giving a doctor-to-population ratio of 1:640; 37% of the doctors were trained specialists with postgraduate medical degrees and advanced specialty training. In the same year, there were 1200 dentists (69% in private practice), giving a dentist-to-population ratio of 1:3400, and about 20 150 nurses (26% in the private sector), giving a nurse-to-population ratio of 1:220. The Singapore health care philosophy emphasizes the building of a healthy population through preventive health care programmes and the promotion of healthy living. The population is encouraged through the public health education programme to adopt a healthy lifestyle and be responsible for their health, and is made aware of the adverse consequences of harmful habits like smoking, alcohol consumption, bad diet and sedentary lifestyles. The child immunization programme, which targets infectious diseases like tuberculosis, poliomyelitis, diphtheria, whooping cough, tetanus, measles, mumps, rubella and hepatitis B, is offered at government COUNTRY HEALTH INFORMATION PROFILES | 309 polyclinics. Health screening programmes have been introduced for the early detection of common ailments such as cancer, heart disease, hypertension and diabetes mellitus. The Government ensures that good and affordable basic medical services are made available to all Singaporeans through heavily subsidized medical services at public hospitals and government clinics. The basic medical package reflects up-to-date medical practice that is of proven value, and is delivered in a cost-effective way by trained personnel using appropriate facilities. There is no guarantee of the latest and best of everything, and nonessential or cosmetic services, experimental drugs and procedures of unproven value are excluded. All private hospitals, medical clinics, clinical laboratories and nursing homes are required to maintain a good standard of medical services through licensing by the Ministry of Health. The health care delivery system is based on individual responsibility, coupled with government subsidies, to keep basic health care affordable. Patients are expected to pay part of the cost of the medical services they use, and pay more when they demand a higher level of service. The principle of co-payment applies even to the most heavily subsidized wards to avoid the pitfalls of providing completely “free” medical services. Patients who choose to be accommodated in the lower classes of wards in public hospitals have up to 80% of their hospitalization expenses subsidized by the Government. Individuals are encouraged to take responsibility for their own health by saving for medical expenses. Under the Medisave scheme, every working person is required by law to save 6%-8% of his or her income in a personal Medisave Account, which can be used to pay for hospitalization expenses incurred by the person or by immediate family members. MediShield, a catastrophic illness insurance scheme, is designed to help individuals meet medical expenses from major or prolonged illnesses. Medifund acts as a safety net of last resort for those who are truly indigent. Therefore, no Singaporean is denied access to the health care system or turned away by the public hospitals because of inability to pay. The median waiting time for elective surgery is one week. Patients requiring emergency or urgent surgery are admitted immediately. Support services for the hospital and primary health care programmes include forensic pathology, pharmaceutical services and the blood transfusion service. Except for forensic pathology and the blood transfusion service, which are centralized in the Ministry of Health, the other services can be found in both the public and private sectors. 4. NATIONAL HEALTH PLAN AND PRIORITIES The eight priorities of the Ministry of Health focus on the following key areas: (1) Building a healthy population: to promote healthy lifestyles in a sustained and comprehensive way. (2) Managing diseases in a holistic manner: to ensure long-term effectiveness and sustainability in managing diseases. (3) Exploiting IT to the maximum: to increase productivity, enhance patient care and manage costs. (4) Countering disease outbreaks: to enhance surveillance and enable effective responses. (5) Managing medical inflation: to spend within available means, manage limited resources and moderate patients’ expectations. (6) Ensuring long-term health care financing: to enhance the financing framework (Medisave, Medifund and Medishield). SINGAPORE 310 | COUNTRY HEALTH INFORMATION PROFILES (7) Safeguarding medical standards: to ensure quality, reliability and cost-effectiveness; develop manpower and facilities; and regulate appropriately. Establishing Singapore as a regional medical hub: to ensure the competitiveness of Singapore as a regional hub for medical services. 5. MAJOR INFORMATION SOURCES Ministry of Health (http://www.moh.gov.sg) Singapore Department of Statistics (http://www.singstat.gov.sg) The World Factbook 2004. CIA 6. ADDRESSES MINISTRY OF HEALTH Office Address : College of Medicine Building, 16 College Road, Singapore 169854 Postal Address : As above Official Email Address : moh_info@moh.gov.sg Telephone : (65) 6325 9220 Fax : (65) 6224 1677 Office Hours : 8.30am – 6.00pm (Mon to Thu) 8.30am – 5.30pm (Fri) Website : http://www.moh.gov.sg WHO REPRESENTATIVE IN MALAYSIA, BRUNEI DARUSSALAM AND SINGAPORE Office Address : 1st Floor, Wisma UN, Block C, Kompleks Pejabat Damansara, Jalan Dungun, Damansara Heights, 50490 Kuala Lumpur Postal Address : P.O. Box 12550, 50782 Kuala Lumpur, Malaysia Official Email Address : who@maa.wpro.who.int Telephone : (603) 2093-9908 Fax : (603) 2093 7446 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILES | 311 ORGANIZATIONAL CHART: MINISTRY OF HEALTH SINGAPORE 312 SINGAPORE WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1000 km2) 0.70 2005 1 2 Estimated population ('000s) 3553.50 g … … 2005 1 3 Annual population growth rate (%) 1.90 g … … 2005 1 4 Percentage of population - 0–14 years 19.70 g … … 2005p 1 - 65+ years 8.40 g … … 2005p 1 5 Urban population (%) 100.00 2005 1 6 Crude birth rate (per 1000 population) 10.00 g … … 2005p 2 7 Crude death rate (per 1000 population) 4.30 g … … 2005p 2 8 Rate of natural increase of population (per 100 population) 0.57 g … … 2005p 4 9 Life expectancy (years) - at birth 79.70 g 77.90 g 81.60 g 2005p 1 - Health-adjusted Life Expectancy (HALE) at age 65 18.20 17.00 19.30 2005p 1 10 Adult literacy rate (%) 95.00 h … … 2005 1 11 Neonatal mortality rate (per 1000 live births) 1.60 … … 2005 1, 4 12 Infant mortality rate (per 1000 live births) 2.10 g … … 2005p 4 13 Under-five mortality rate (per 1000 live births) 3.60 g … … 2005p 4 14 Total fertility rate (women aged 15–49 years) 1.24 2004 1 15 Maternal mortality ratio (per 100 000 live births and still births) 11.00 g 2005p 4 16 Percentage of newborn infants weighing at least 2500 g at birth 91.40 … … 2004 3 17 Prevalence of underweight children under five years of age 14.00 … … 1995-2003 12 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 97.00 … … 2005p 13 - DTP3 95.00 … … 2005p 13 - OPV3 95.00 … … 2005p 13 - Measles 93.00 … … 2005p 13 - Hepatitis B III 94.00 … … 2005p 13 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 100.00 2003 2 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of live births in health facilities (as % of total live births) 99.70 2004 3 21 Percentage of women in the reproductive age group using modern contraceptive methods 72.50 2003 5 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … COUNTRY HEALTH INFORMATION PROFILE 313 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 … … 2005 2 26 Proportion of population with access to improved sanitation 100.00 … … 2005 2 27 Proportion of the population using solid fuels for cooking or heating (%) <5.00 … … 2003 12 28 Proportion of households with access to secure tenure 99.00 … … 2005 14 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.91 … … 2003 11 32 Per capita GDP at current market prices (US$) 26 833.00 … … 2005 1 33 Rate of growth of per capita GDP (%) 5.84 … … 2005 1 34 Health expenditure Total health expenditure - amount (in million US$) 3628.69 FY2003 1, 2 - total health expenditure on health as % of GDP 3.81 FY2003 1, 2 - per capita total expenditure on health (in S$) 1510.54 FY2003 1, 2 Government expenditure on health b - amount (in million S$) 2006.99 FY2003 2 - general government expenditure on health as % of total expenditure on health 31.75 FY2003 1, 2 - general government expenditure on health as % of total general government expenditure 7.04 FY2003 2, 6 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health 68.52 FY2003 1, 2 Exchange rate in US$ of local currency is: 1 US$ = 1.66 2005 1 35 Health insurance coverage as % of total population c 76.40 End 2003 1, 2 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 6748 4596 2152 15.51 … ... 2005 7 - dentists 1277 … … 2.93 … ... 2005 8 - pharmacists 1330 … … 3.06 … ... 2005 9 - nurses 19 820 f … … 45.55 … ... 2005 10 - midwives 347 … … 0.80 … ... 2005 10 - other nursing / auxiliary staff … … … … … ... - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) … … … … … ... - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) … … … ... … ... 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … SINGAPORE 314 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 resident population 1. Accidents, poisoning and violence (E800-999) 33 253 … … 935.78 … … 2005p 2 2. Cancer (140-208) 21 029 … … 591.78 … … 2005p 2 3. Ischaemic heart diseases (410- 414) 14 399 … … 405.21 … … 2005p 2 4. Dengue (061) 12 748 … … 358.74 … … 2005p 2 5. Obstetric complications affecting fetus or newborn (761–763) 10 418 … … 293.18 … … 2005p 2 6. Pneumonia (480-486) 10 076 … … 283.55 … … 2005p 2 7. Chronic obstructive lung disease (490-493, 496) 8 977 … … 252.62 … … 2005p 2 8. Other heart diseases (393-398, 402,415-429) 8 663 … … 243.79 … … 2005p 2 9. Cerebrovascular disease (430- 438) 8 628 … … 242.80 … … 2005p 2 10. Complications related to pregnancy (640-648) 7 706 … … 216.86 … … 2005p 2 40 Ten leading causes of mortality Number Rate per 100 000 resident population 1. Cancer (140-208) 4276 2361 1915 120.33 … … 2005p 2 2. Ischaemic heart diseases (410- 414) 2939 1725 1214 82.71 … … 2005p 2 3. Pneumonia (480-486) 2414 1269 1145 67.93 … … 2005p 2 4. Cerebrovascular disease (430- 438) 1610 699 911 45.31 … … 2005p 2 5. Accidents, poisoning and violence (E800-999) 787 551 236 22.15 … … 2005p 2 6. Other heart diseases (393- 398,402,415-429) 643 371 272 18.09 … … 2005p 2 7. Chronic obstructive lung disease (490-493,496) 561 428 133 15.79 … … 2005p 2 8. Diabetes mellitus (250) 508 225 283 14.30 … … 2005p 2 9. Urinary tract infections (599.0) 330 112 218 9.29 … … 2005p 2 10. Nephritis, eٛaths iٛc syndrome and nephrosis (580-589) 266 130 136 7.49 … … 2005p 2 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2005p 2 - Pertussis (whooping cough) 1 0 1 … 0 … 2005p 2 - Tetanus 2 2 0 … … 0 2005p 2 - Neonatal tetanus 0 0 0 0 0 0 2005p 2 - Poliomyelitis 0 0 0 0 0 0 2005p 2 - Hib meningitis 5 3 2 … … … 2005p 2 - Measles 33 19 14 … … … 2005p 2 - Mumps 1003 558 445 … … … 2005p 2 - Rubella 139 74 65 … … … 2005p 2 - Congenital rubella syndrome 0 0 0 0 0 0 2005p 2 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral 250 198 52 … … … 2005p 2 - Type A 98 80 18 … … … 2005p 2 - Type B 83 67 16 … … … 2005p 2 - Type C 32 24 8 … … … 2005p 2 COUNTRY HEALTH INFORMATION PROFILE 315 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths - Type E 37 27 10 … … … 2005p 2 - Unspecified 0 0 0 0 0 0 2005p 2 Cholera 1 1 0 … … 0 2005p 2 Typhoid fever 69 45 24 … … … 2005p 2 (Viral) Encephalitis 36 21 15 … … … 2005p 2 Plague 0 0 0 0 0 0 2005p 2 Syphilis 1210 849 361 … … … 2005p 2 Gonorrhoea (gonococcal infections) 2589 2144 445 … … … 2005p 2 Leprosy 5 … … … … … 2004 12 Malaria 166 132 34 … … … 2005p 2 Dengue/DHF 14 209 8192 6017 … … … 2005p 2 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures d … - Proportion of population in malaria-risk areas using effective malaria treatment measures e … 44 Tuberculosis Number of cases Number of deaths - All types 1360 933 427 73 49 24 2004 2 - New pulmonary tuberculosis (smear-positive) 506 … … … … … 2004 2, 12 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 41.00 … … 4.00 … … 2004 12 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 67.00 … … 77.00 (2003) … … 2004 12 Number of cases Number of deaths 45 Acute respiratory infections 7593 … … … … … 2005p 2, 4 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (140 – 208) 21 029 … … 4276 2361 1915 2005p 2, 3 - Trachea, bronchus, and lung (162) 2297 … … 1027 711 316 2005p 2, 3 - Stomach (151) 939 … … 332 189 143 2005p 2, 3 - Colon and rectum (153,154) 2839 … … 640 332 308 2005p 2, 3 - Lip, oral cavity and pharynx (140- 149) 753 … … 301 155 146 2005p 2, 3 - Liver (155, 155.1, 155.2) 1702 … … 426 311 115 2005p 2, 3 - Cervix (180) 603 82 2005p 2, 3 - Leukaemia (204-208) 1410 … … 101 60 41 2005p 2, 3 48 Circulatory All circulatory system diseases (390- 398,401-405,410-417,420-438,440- 448,451-459) 40 217 … … 5350 2890 2460 2005p 2, 4 - Ischaemic heart disease (410-414) 14 463 … … 2939 1725 1214 2005p 2, 4 - Acute myocardial infarction (410) 4836 … … 1602 934 668 2005p 2, 4 - Rheumatic fever and rheumatic heart diseases (390-398) 182 … … 22 11 11 2005p 2, 4 SINGAPORE 316 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 48 Circulatory - Cerebrovascular diseases including stroke (430-438) 8662 … … 1610 699 911 2005p 2, 4 - Hypertension (401-405) 1594 … … 339 201 138 2005p 2, 4 49 Maternal causes - Haemorrhage (640, 641, 666) 1982 … 2005p 2, 4 - Abortion (630-639) 3931 2 2005p 2, 4 - Eclampsia … … 2005p 2, 4 - Sepsis … … 2005p 2, 4 - Obstructed labour (660) 275 … 2005p 2, 4 50 Diabetes mellitus (250) 3962 … … 508 225 283 2005p 2, 4 51 Mental disorders 9815 … … 0 0 0 2005p 2, 4 52 Injuries - All types … … … 787 551 236 2005p 2, 4 - Motor and other vehicle accidents (E810-819) … … … 154 121 33 2005p 2, 4 - Suicide (E950-959) … … … 334 216 118 2005p 2, 4 - Homicide and violence (E960-969) … … … 16 9 7 2005p 2, 4 - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities 13 8599 2005 2 - General hospitals 5 … 2005 2 - Specialized hospitals 2 … 2005 2 - District/first-level referral hospitals 6 i … 2005 2 - Primary health care centres 18 … 2005 2 Private hospitals 16 3231 2005 2 Notes: Red text Millennium Development Goals (MDG) indicators … Data not available est Estimate p Preliminary / provisional figures. NR Not relevant. FY The financial year refers to the span from April 1 of respective year to March 31 next year. aa Figure refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Excludes expenditure on environmental health. c Using the more relevant population. Excludes cash and employer-based plans. d Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. e Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. f Figure includes assistant nurses and excludes midwives. g Figure applies to resident population. h Figure applies to residents aged 15 yrs and over. COUNTRY HEALTH INFORMATION PROFILE 317 i Figure refers to Specialty Centres. Sources: 1 Statistics Singapore (http://www.singstat.gov.sg) 2 Ministry of Health (http://www.moh.gov.sg) 3 Report on Registration of Births and Deaths 2004. Registry of Births and Deaths, Immigration and Checkpoints Authority 4 Singapore Demographic Bulletin Jan 2006. Registry of Births and Deaths, Immigration and Checkpoints Authority 5 Study on Marriage and Procreation, Perception and Policies in Singapore, 2003. Ministry of Community Development and Sports 6 Ministry of Finance 7 Singapore Medical Council 8 Singapore Dental Council 9 Singapore Pharmacy Board 10 Singapore Nursing Board 11 Human Development Report 2005. New York, United Nations Development Programme, 2005. 12 WHO Regional Office for the Western Pacific, data received from technical units 13 Health Promotion Board, Singapore 14 Ministry of National Development, Singapore 318 | COUNTRY HEALTH INFORMATION PROFILES SOLOMON ISLANDS 1. DEMOGRAPHICS, GENDER AND POVERTY Solomon Islands is a double-chain archipelago of more than 900 coral atolls, located in the south-west Pacific about 1800 km north-east of Australia. Its total land area of 28 900 km2 is widely scattered over 1.3 million km2 (Exclusive Economic Zone) of the Pacific Ocean, with most of its smaller islands uninhabited. The population of Solomon Islands was estimated to be 478 000 in 2005. The growing population and the relatively young population structure dominate concerns about future development. In 2004, estimated life expectancy at birth was 61.9 years for males and 63.1 years for females. According to the 1999 national population census, 93% of the total population are Melanesians, 4% are Polynesians and 3% are of other ethnic groups. During 2000-2005, the total population is estimated to have increased by about 59 000 persons and about 40% 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. Table 1. Core population and health data (2005 estimates) [Total] 478 000 [Both] … [0-14 years] 194 132 (40.60%) [Male] 61.90 (2004 est) Population [65+ years] 11 472 (2.40%) Life expectancy at birth (years) [Female] 63.10 (2004 est) Crude birth rate (per 1000 population) 30.20 (2005-2010) Total fertility rate 3.79 (2005-2010) [Total] 70.00 (2002) [Urban] 94.00 (2002) Crude death rate (per 1000 population) 6.70 (2005-2010) % of population served with safe water [Rural] 65.00 (2002) [Total] 31.00 (2002) [Urban] 98.00 (2002) Infant mortality rate (per 1000 live births) 31.40 (2005-2010) % of population with adequate sanitary facilities [Rural] 18.00 (2002) Maternal mortality ratio (per 100 000 live births) 184.00 (2004) est - Estimate 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 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 New Zealand, Papua New Guinea, Fiji, Tonga, Samoa and Cook Islands, led by the Australian Army and Police. With the restoration of law and order, RAMSI has 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 in on 20 Dec 2005. A national election was held on 5 April 2006. 2.2 Economic 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$10 million) more than expected. Contributions COUNTRY HEALTH INFORMATION PROFILES | 319 to government revenue were derived mainly from export duties on timber and growth in both company and personal income taxation receipts. Overseas development assistance has also increased from US$ 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 recurrent budget will undoubtedly strengthen the provision of quality health care services and also enhance the implementation of the WHO programme of assistance for 2005. 3. HEALTH SITUATION 3.1 Health trends Solomon Islands is in an epidemiological transition phase. Having to face both the control of infectious diseases and the increasing incidence of noncommunicable diseases, with very limited resources, poses a major challenge for the Government. In 2005, cardiovascular diseases, neoplasms, malaria, respiratory diseases and neonatal causes were major public health problems in terms of mortality. 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. With the dissipation of ethnic conflict during 1999-2003 and with support from the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM), the Austrlaian Agency for International Development (AusAID), the World Bank and Rotary International in 2004, progress has been made in malaria control. Compared with 2003, 2004 saw a 3.5% reduction, and 2005 a 17.7% reduction, in 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 malaria 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 and continuous financial support and efforts. A total of 393 tuberculosis cases were reported in 2005 by the Central Registry (30% increase in detected cases compared with 2004). The National TB Programme is progressing well with its implementation at both provincial and national levels to achieve an 85% cure rate in the near future (seven out of nine provinces have achieved a more than 85% cure rate). Although infectious diseases are still the major causes of morbidity and mortality, there is some evidence that noncommunicable diseases like cancer (cervical and breast cancers are reported to be the most common, followed by lung cancer), diabetes mellitus, hypertension, tobacco-related diseases and mental illness are increasing noticeably. 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. SOLOMON ISLANDS 320 | COUNTRY HEALTH INFORMATION PROFILES 3.2 Health systems 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 in 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 620 nurses, including nurse aides, were employed by the Ministry of Health (130 nurses per 100 000 population). 4. NATIONAL HEALTH PLAN AND PRIORITIES 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; • 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. 5. MAJOR INFORMATION SOURCES Goals and Strategies, Corporate Plan 2006-2008. Honiara, Ministry of Health and Medical Services, 2006. Solomon Islands Health Status Assessment Report. Canberra, Australian Agency for International Development, 2005. IMCI Annual Report. Honiara, Ministry of Health and Medical Services, 2004. Reproductive Health Annual Report, Honiara, Ministry of Health and Medical Services, 2004. Tuberculosis Unit Annual Report. Honiara, Ministry of Health and Medical Services, 2005. EPI Annual Report. Honiara, Ministry of Health and Medical Services, 2004. National Vector Borne Disease Control Programme Annual Report. Honiara, Ministry of Health and Medical Services, 2005. Health Workforce for the Solomon Islands. Nursing School, 2005. COUNTRY HEALTH INFORMATION PROFILES | 321 Death records. Honiara, Heath Statistics Unit, Ministry of Health and Medical Services, 2005. Year 2006 Approved Recurrent Estimates. Honiara, Ministry of Finance, 2006. Press releases. Department of Prime Minister and Cabinet, 2005 (http://www.pmc.gov.sb/) Statistical Profiles of the Least Developed Countries. New York, United Nations, 2005. 6. 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 : COUNTRY LIAISON OFFICER IN THE 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 Website : SOLOMON ISLANDS 322 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: MINISTRY OF HEALTH COUNTRY HEALTH INFORMATION PROFILE 323 SOLOMON ISLANDS WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 28.90 2005 1 2 Estimated population ('000s) 478.00 247.00 231.00 2005 est 2 3 Annual population growth rate (%) 2.36 … … 2005 est 2 4 Percentage of population - 0–14 years 40.60 … … 2005 est 2 - 65+ years 2.40 … … 2005 est 2 5 Urban population (%) 17.10 … … 2005 est 2 6 Crude birth rate (per 1 000 population) 30.20 … … 2005-2010 2 7 Crude death rate (per 1 000 population) 6.70 … … 2005-2010 2 8 Rate of natural increase of population (% per annum) 2.60 a … … 2004 est 3 9 Life expectancy (years) - at birth … 61.90 63.10 2004 est 3 - Heal th-adjusted Life Expectancy (H ALE) at age 60 … 10.90 11.60 2002 4 10 Adult literacy rate (%) 77.00 84.00 67.00 1999 5 11 Neonatal mortality rate (per 1 000 live births) 12.00 c … … 2002 4 12 Infant mortality rate (per 1 000 live births) 31.40 33.10 29.60 2005-2010 2 13 Under-five mortality rate (per 1 000 live births) 52.00 55.00 49.00 2005 est 2 14 Total fertility rate (women aged 15–49 years) 3.79 2005-2010 2 15 Maternal mortality ratio (per 100 000 live births) 184.00 2004 6 16 Percentage of newborn infants weighing at least 2500 g at birth … … … 17 Prevalence of underweight children under five years of age 21.00 … … 1999 5 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 82.00 … … 2004 7 - DTP3 80.00 … … 2004 7 - OPV3 75.00 … … 2004 7 - Measles 72.00 … … 2004 7 - Hepati tis B III 72.00 … … 2004 7 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 76.00 g 2003 8 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 65.00 2004 7 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in heal th facilities (as % of total deliveries) 43.00 f 2003 8 21 Percentage of women in the reproductive age group using modern contraceptive methods 16.00 2004 10 22 Condom use rate of the contraceptive prevalence rate 2.40 … … 2001 11 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … SOLOMON ISLANDS 324 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 70.00 94.00 65.00 2002 12 26 Proportion of population with access to improved sanitation 31.00 98.00 18.00 2002 12 27 Proportion of the population using solid fuels for cooking or heating (%) 95.00 b … … 2003 7 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.59 … … 2003 13 32 Per capita GDP at current market prices (US$) 494.68 … … 2002 14 33 Rate of growth of per capita GDP (%) … … … 34 Health expenditure Total health expenditure - amount (in m illion US$) … - total heal th expenditure on health as % of GDP 4.80 2002 15 - per capita total expendi ture on health (in US$) 83.00 2002 15 Government expenditure on health - amount (in million US$) 12.13 2005 16 - general government expenditure on health as % of total expenditure on health 93.20 2002 15 - general government expenditure on heal th as % of total general government expendi ture 12.60 2005 16 External source of government health expenditure - external resources for heal th as % of general government expendi ture on health 34.00 2004 17 Private health expenditure - private expenditure on health as % of total expenditure on heal th … Exchange rate in US$ of local currency is: 1 US$ = 7.18 2005 18 35 Health insurance coverage as % of total population … INDICATORS DATA DATA Year Total Male Female Total Male Female Number Rate per 10 000 population a 36 Health workforce - physicians 89 87 2 1.86 3.52 0.09 2005 19 - dentists 52 29 23 1.09 1.17 1.00 2005 19 - pharmacists 53 40 13 1.10 1.62 0.56 2005 19 - nurses 620 … … 12.97 … … 2005 19 - m idwives 74 … … 1.55 … … 2005 19 - other nursing / auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 493 … … 10.31 … … 2005 19 - other heal th personnel (health inspec tors, assistant sani tarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses 43 … … 2005 19 COUNTRY HEALTH INFORMATION PROFILE 325 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Ac ute respiratory infections 178 327 … … 38 758.00 … … 2004 9 2. Fever (syndromic) 117 777 … … 25 598.00 … … 2004 9 3. Malaria 90 240 … … 19 613.00 … … 2004 21 4. Skin diseases (excluding yaws) 40 440 … … 8789.00 … … 2004 9 5. Ear infections 25 370 … … 5514.00 … … 2004 9 6. Yaws 20 090 … … 4366.00 … … 2004 9 7. Diarrhoeal diseases 14 565 … … 3166.00 … … 2004 9 8. Conjunctivi tis (red eye) 11 191 … … 2432.00 … … 2004 9 9. STI 2 631 … … 572.00 … … 2004 9 10. Tuberculosis 302 … … 66.00 … … 2004 22 40 Five leading causes of mortality Number Rate per 100 000 population 1. Cardiovascular diseases (cerebrovascular accident or CVA as the leading causes) … … … … … … 2005 23 2. Neoplasm … … … … … … 2005 23 3. Malaria … … … … … … 2005 23 4. Respiratory diseases (pneumonia as the leading causes) … … … … … … 2005 23 5. Neonatal causes … … … … … … 2005 23 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 7 - Pertussis (whooping cough) 0 0 0 0 0 0 2004 7 - T etanus 0 0 0 0 0 0 2004 7 - Neonatal tetanus 0 0 0 0 0 0 2004 7 - Poliomyelitis 0 0 0 0 0 0 2004 7 - Hib meningitis … … … … … … - Measles 0 0 0 0 0 0 2004 7 - Mumps … … … … … … - Rubella … … … … … … - Congeni tal rubella syndrome … … … … … … 42 Selected communicable diseases Number of cases aa Number of deaths Hepati tis vi ral - T ype A … … … … … … - T ype B … … … … … … - T ype C … … … … … … - T ype E … … … … … … - Unspecified … … … … … … Cholera … … … … … … Typhoid fever … … … … … … Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … Gonorrhoea … … … … … … Leprosy 26 … … … … … 2005 22 Malaria 90 240 … … 51 … … 2004 7 Dengue/DHF 0 0 0 0 0 0 2004 7 SOLOMON ISLANDS 326 INDICATORS DATA Year Source Total Male Female Total Male Female 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 18 379.00 … … 10.39 … …. 2004 7 - Proportion of population in malaria-risk areas using effective malaria prevention measures d … - Proportion of population in malaria-risk areas using effective malaria treatment measures e … 44 Tuberculosis Number of cases Number of deaths - All types 340 … … … … … 2004 7 - New pulmonary tuberculosis (smear-posi tive) 152 … … … … … 2004 7 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 59.00 … … 4.00 … … 2004 7 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOT S) 123.00 … … 87.00 (2003) … … 2004 7 Number of cases Number of deaths 45 Acute respiratory infections 178 327 … … … … … 2004 9 46 Diarrhoeal diseases 14 565 … … … … … 2004 9 47 Cancers All cancers (malignant neoplasms only) … … … … … … - T rachea, bronchus, and lung … … … … … … - Stomach … … … … … … - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … … … … - Liver … … … … … … - Cervix … … - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … … … … - Ischaemic heart disease … … … … … … - Acute m yocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … … … … - H ypertension … … … … … … 49 Maternal causes - Haemorrhage … … - Abortion … … - Eclampsia … … - Sepsis … … - Obstruc ted labour … … 50 Diabetes mellitus … … … … … … 51 Mental disorders … … … … … … COUNTRY HEALTH INFORMATION PROFILE 327 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 52 Injuries - All types … … … … … … - Motor and other vehicle accidents … … … … … … - Suicide … … … … … … - Hom icide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public heal th facilities 157 691 2005 20 - General hospitals 12 … 2005 20 - Specialized hospi tals … … - District/first-level referral hospitals 29 … 2005 20 - Primary health care centres 116 … 2005 20 Private hospitals 3 … 2005 20 Notes: Red text M illennium Development Goals (MDG) indicators … Data not available Est Estimate aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Uni t of the WHO Regional Office for the Western Pacific . b Modelled data. c Estimates derived by regression and similar estimation methods. d Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. e Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. f Applies to clinics only. g Figure reported as the antenatal coverage. Sources: 1 Statistical Profiles of the least developed countries, United Nations, 2005. 2 World Population Prospec ts: The 2004 Revision Population Database (Medium Variant), United Nations Department of Economic and Social Affairs, (http://esa.un.org/unpp/p2k0data.asp). 3 Solomon Islands Statistics (http://www.spc.int/prism). 4 World health report 2005: Make every mother and child count. Geneva, World Heal th Organization, 2005. 5 Population and Housing Census, Solomon Islands, 1999. 6 National Health Report, MOHMS, Solomon Islands, 2004. 7 WHO Regional Office for the Western Paci fic, data received from technical units. 8 Solomon Islands Millennium Development Goals report 2004: Scoring fundamental goals (Draft). Department of National Reform and Planning, United Nations Country Team for Solomon Islands 9 Health Information System, Heal th Statistic Unit, MOHMS, 2004. 10 Annual Report of Reproduc tive Heal th, MOHMS, 2004. 11 Pacific Island Regional Millennium Development Goals report 2004. Noumea, Secretariat of the Pacific Community, UN/CROP MDG Working Group, November 2004. 12 Meeting the MDG drinking water and sani tation target: A mid-term assessment of progress, WHO and UNICEF, 2004. 13 Human development report 2004. New York, Uni ted Nations Development Programme, 2004. 14 National Accounts, Central Bank of Solomon Islands, 2005. 15 Country Profile, WHO Statistical Information System, 2005 (http://www.who.int/countries/slb/en/). SOLOMON ISLANDS 328 16 Year 2006 Approved Recurrent Estimates, Ministry of Finance and Treasury, Solomon Islands Government, 2006. 17 M inistry of Finance and Treasury, 2005. 18 UN Exchange rate average in 2005. 19 Registry Department, Nursing School and Registry of Reproduc tive Heal th Unit, 2005. 20 List of Clinic, Ministry of Health, 2005. 21 Annual Report, National Vector Borne Disease Control Programme, 2004. 22 Database of National T B and Leprosy Uni t, MOHMS, 2005. 23 Information provided by Country Liaison Officer for Solomon Islands, 04 April 2006. COUNTRY HEALTH INFORMATION PROFILES | 329 TOKELAU 1. DEMOGRAPHICS, GENDER AND POVERTY The last census, conducted in October 2001, recorded a population of Tokelau as 1515, a slight increase from the 1996 census of 1500. The estimated population in 2005 is 1530, 34% below 15 years of age and almost 5% above 65 years of age. Life expectancy at birth is 68 years for males and 71 years for females (1997-2000). The crude birth rate is 31.0 per 1000 population (1997- 2001), the crude death rate is 7.0 per 1000 population (1997-2001), and the total fertility rate is 4.9 (1997-2001). The infant mortality rate is 33.0 per 1000 live births (1997-2000), the under-five mortality rate is 0 per 1000 live births (1999), and the maternal mortality ratio is 0 per 100 000 live births (2001-2002). Table 1. Core population and health data (2005 estimate) [Total] 1530 [Both] ... [0-14 years] 520 (33.99%) [Male] 68.40 (1997-2000) Population [65+ years] 75 (4.90%) Life expectancy at birth (years) [Female] 71.30 (1997-2000) Crude birth rate (per 1000 population) 31.00 (1997-2001) Total fertility rate 4.90 (1997-2001) [Total] 89.00 (2002) [Urban] NA Crude death rate (per 1000 population) 7.00 (1997-2001) % of population served with safe water [Rural] 89.00 (2002) [Total] 74.00 (2002) [Urban] NA Infant mortality rate (per 1000 live births) 33.00 (1997-2000) % of population with adequate sanitary facilities [Rural] 74.00 (2002) Maternal mortality ratio (per 100 000 live births) 0.00 (2001-2002) NA- Not applicable 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation The constraints of atoll life and limited opportunities have led some 6000 Tokelauans to settle in New Zealand and a few hundred more in Samoa. Tokelauans have linguistic, family and cultural links with other Pacific islands, notably Samoa and Tuvalu. The family and extended family constitute the core of social organization, with the village (nuku) being the foundation of Tokelauan society. Community welfare is paramount in what has been traditionally a subsistence environment. 2.2 Economic situation Per capita gross national product (GNP) is US$ 612.50 or about NZ$ 1000 (2003). The economy is basically subsistence, although cash is now becoming an important part of everyday life. The country’s resource base is fragile as very little land is available for any agricultural endeavour without substantial preparation and support. 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. TOKELAU 330 | COUNTRY HEALTH INFORMATION PROFILES 3. HEALTH SITUATION 3.1 Health trends The overall health status is reasonably good, but changes have been observed in the last few years. There has been an increase in noncommunicable diseases, with cerebrovascular disease seen as the leading cause of death. The mortality rate due to cardiovascular diseases increased from 31.0% of the total in 1981 to 37.8% in 2003. Blood pressure recordings of 90 mm Hg diastolic and greater are seen in 36% of women and 23% of men of 30 years of age and over. Random blood sugar levels of 7 mmol/litre and above for the same group appear in 18% of men and 28% of women. Tobacco and alcohol consumption is relatively high among the adult population, but is more prominent in males. Obesity is common and is attributed to diet and physical inactivity, with prevalence rates of 70% for men and 83% for women between 30 and 39 years of age. There is an observable diet shift from local to imported foods. 3.2 Health systems The Health Department has its main office in Atafu. Each of the three atolls has a 12-bed hospital, manned by a medical officer, four to five staff nurses, one dental nurse, four to five nurse’s aides and a handyman. There is ongoing renovation of the three hospitals and the bed capacity has been reduced to six 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 is available in the Nukunonu hospital. The Department also has an office in the Tokelau Apia Liaison Office (TALO) in Samoa. Its main purpose is to facilitate referral of patients in Samoa and to New Zealand. The TALO Health Office also serves as the storage and distribution point for medical supplies. For the financial year 2003/04, the Tokelau GNP forecast was NZ$ 11 381 770 (US$ 8 115 604). Health was allocated 12.5%, about NZ$ 1 424 502 (US$ 1 015 452). For the previous financial year, health was allocated 8.2%. The national budget is made up of locally generated resources and a grant from the New Zealand Government as part of its constitutional responsibility for Tokelau. Other assistance comes from international partner agencies including WHO, 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). 4. NATIONAL HEALTH PLAN AND PRIORITIES (1) Healthy islands and communities: Support existing community groups and structures that will enhance the ability to provide a healthy environment for the people. (2) Promotion of healthy lifestyles: Support community members and health workers to lead healthy and improved diverse lifestyles. (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. COUNTRY HEALTH INFORMATION PROFILES | 331 (4) Development of accessible primary health care services: Develop and improve primary health care services that are effective and relevant to communities. (5) Successful community participation: Develop a successful participative strategy for an effective, combined approach to service delivery by community groups and health service providers. (6) Development and improvement of health service system: Improve the accessibility and quality of health services, which will increase people’s confidence and participation in the total health system and add value to existing services. 5. MAJOR INFORMATION SOURCES Tokelau Census Tokelau Department of Health World Factbook. CIA, 2003 (http://www.cia.gov/cia/publications/factbook/index.html) 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Nukunonu, Tokelau Postal Address : Official Email Address : tokelau.health@clear.net.nz , talo.health@clear.net.nz Telephone : (690) 4132 Fax : (690) 4290 Office Hours : Website : WHO REPRESENTATIVE IN SAMOA Office Address : Ioane Viliamu Building Beach Road, Apia, Western Samoa Postal Address : P.O. Box 77, Apia, Western Samoa Official Email Address : who@sma.wpro.who.int Telephone : (685) 23756; (685) 24976 Fax : (685) 23765 Office Hours : Website : TOKELAU 332 TOKELAU WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 0.01 2004 1 2 Estimated population ('000s) 1.53 0.79 0.74 2005 est 2 3 Annual population growth rate (%) 0.40 ... ... 2001 1 4 Percentage of population - 0–14 years 33.99 33.97 34.01 2005 est 2 - 65+ years 4.90 4.18 5.67 2005 est 2 5 Urban population (%) 0.00 … … 2005 2 6 Crude birth rate (per 1 000 population) 31.00 … … 1997-2001 1 7 Crude death rate (per 1 000 population) 7.00 … … 1997-2001 1 8 Rate of natural increase of population (% per annum) 2.4 … … 1997-2001 1 9 Life expectancy (years) - at birth … 68.40 71.30 1997-2000 1 - Heal th-adjusted Life Expectancy (H ALE) at age 60 … … … 10 Adult literacy rate (%) 86.50 … … 2003 6 11 Neonatal mortality rate (per 1 000 live births) 40.00 a … … 2003 5 12 Infant mortality rate (per 1 000 live births) 33.00 … … 1997-2000 1 13 Under-five mortality rate (per 1 000 live births) 0.00 … … 1999 7 14 Total fertility rate (women aged 15–49 years) 4.90 1997-2001 1 15 Maternal mortality ratio (per 100 000 live births) 0.00 2001-2002 8 16 Percentage of newborn infants weighing at least 2500 g at birth 100.00 … … 2003 5 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 0.00 1999 7 19 Immunization coverage for infants (%) - BCG 100.00 … … 2004 9 - DTP3 99.00 … … 2004 9 - OPV3 99.00 … … 2004 9 - Measles 82.00 … … 2004 9 - Hepati tis B III 99.00 … … 2004 9 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 100.00 1999 3 - Percentage of pregnant women immunized with tetanus toxoid (TT2) … - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in heal th facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods 13.40 1999 3 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … COUNTRY HEALTH INFORMATION PROFILE 333 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 89.00 NA 89.00 2002 4 26 Proportion of population with access to improved sanitation 74.00 NA 74.00 2002 4 27 Proportion of the population using solid fuels for cooking or heating (%) 14.50 NA 14.50 2001 6 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index … … … 32 Per capita GDP at current market prices (US$) 612.50 e … … 2003 8 33 Rate of growth of per capita GDP (%) 3.20 … … 1999 7 34 Health expenditure Total health expenditure - amount (in m illion NZ$) 0.51 1999-2000 7 - total heal th expenditure on health as % of GDP … - per capita total expendi ture on health (in NZ$) 341.07 1999-2000 7 Government expenditure on health - amount (in million NZ$) 1.42 FY2003- 2004 8 - general government expenditure on health as % of total expenditure on health … - general government expenditure on heal th as % of total general government expendi ture 12.50 FY2003- 2004 8 External source of government health expenditure - external resources for heal th as % of general government expendi ture on health … Private health expenditure - private expenditure on health as % of total expenditure on heal th … Exchange rate in US$ of local currency is: 1 US$ = … 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 3 … … 20.00 … … 2003 8 - dentists 3 … … 20.00 … … 2003 8 - pharmacists 0 0 0 0.00 0.00 0.00 2000 7 - nurses 10 … … 66.67 … … 2003 8 - m idwives 3 … … 20.00 … … 2000 7 - other nursing/ auxiliary staff 7 … … 46.67 … … 2003 7 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 1 … … 6.67 … … 2000 7 - other heal th personnel (health inspec tors, assistant sani tarians, traditional workers, etc.) 1 … … 6.67 … … 2000 7 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … TOKELAU 334 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Five leading causes of health clinic morbidity Number of cases reported Rate per 100 000 population a 1. Upper and lower respiratory diseases 1000 … … 65 061.81 … … 2003 5 2. Diseases of the skin and subcutaneous tissues 439 … … 28 562.13 … … 2003 5 3. Diseases of the digestive system 400 … … 26 024.72 … … 2003 5 4. Diseases of the musculoskeletal system 151 … … 9824.33 … … 2003 5 5. Diseases of the circulatory system 73 … … 4749.51 … … 2003 5 40 Five leading causes of mortality Deaths reported (%) Rate per 100 000 population 1. Diseases of the circulatory system 37.80 … … … … … 2003 5 2. Diseases of the respiratory system 20.70 … … … … … 2003 5 3. Neoplastic diseases 15.90 … … … … … 2003 5 4. Ill-defined and undiagnosed conditions 11.00 … … … … … 2003 5 5. Congeni tal anomalies 4.90 … … … … … 2003 5 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 9 - Pertussis (whooping cough) 0 0 0 0 0 0 2004 9 - T etanus 0 0 0 0 0 0 2004 9 - Neonatal tetanus 0 0 0 0 0 0 2004 9 - Poliomyelitis 0 0 0 0 0 0 2004 9 - Hib meningitis 0 0 0 0 0 0 2004 9 - Measles 0 0 0 0 0 0 2004 9 - Mumps 0 0 0 0 0 0 2004 9 - Rubella 0 0 0 0 0 0 2004 9 - Congeni tal rubella syndrome 0 0 0 0 0 0 2004 9 42 Selected communicable diseases Number of cases aa Number of deaths Hepati tis vi ral - T ype A … … … … … … - T ype B … … … … … … - T ype C … … … … … … - T ype E … … … … … … - Unspecified … … … … … … Cholera … … … … … … Typhoid fever … … … … … … Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … Gonorrhoea (gonococcal infections) … … … … … … Leprosy 0 0 0 0 0 0 2003 9 Malaria … … … … … … Dengue/DHF … … … … … … COUNTRY HEALTH INFORMATION PROFILE 335 INDICATORS DATA Year Source Total Male Female Total Male Female 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 0 0 0 0 0 0 2003 9 - New pulmonary tuberculosis (smear-posi tive) 0 0 0 0 0 0 2003 9 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 57.00 … … 6.00 … … 2004 9 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOT S) … … … … … … Number of cases Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (malignant neoplasms only) … … … … … … - T rachea, bronchus and lung … … … … … … - Stomach … … … … … … - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … … … … - Liver … … … … … … - Cervix … … - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … … … … - Ischaemic heart disease … … … … … … - Acute m yocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … … … … - H ypertension … … … … … … 49 Maternal causes - Haemorrhage … … - Abortion … … - Eclampsia … … - Sepsis … … - Obstruc ted labour … … 50 Diabetes mellitus … … … … … … 51 Mental disorders … … … … … … TOKELAU 336 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 52 Injuries - All types … … … … … … - Motor and other vehicle accidents … … … … … … - Suicide … … … … … … - Hom icide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public heal th facilities 3 18 2003 8 - General hospitals … … - Specialized hospi tals … … - District/first-level referral hospitals … … - Primary health care centres … … Private hospitals … … Notes: Red text M illennium Development Goals (MDG) indicators … Data not available est Estimate FY The financial year refers to the span from April 1 of respective year to March 31 next year. NA Not applicable aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Uni t of the WHO Regional Office for the Western Pacific . b Revised data. c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. e Figure refers to per capi ta GNP at current market prices (US$) Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 2 Demographic tables for the Western Paci fic Region 2005-2010. Manila, WHO Regional Office for the Western Pacific, 2005. 3 Hospital records 4 Meeting the MDG drinking water and sanitation target: A mid-term assessment of progress. WHO/ UNICEF Joint Monitoring Programme for Water Supply and Sanitation 2004. 5 Tokelau Statistics Unit http://www.spc.int/prism/country/tk/ 6 Pacific Island Regional Millennium Development Goals Report 2004. Noumea, Secretariat of the Paci fic Community, UN/ CROP MDG Working Group, November 2004. 7 Information furnished by the T okelau Department of Heal th, 17 May 2001 8 Information furnished by WHO Representative in Samoa, 25 February 2004 9 WHO Regional Office for the Western Paci fic, data received from technical units COUNTRY HEALTH INFORMATION PROFILES | 337 TONGA 1. DEMOGRAPHICS, GENDER AND POVERTY Tonga’s projected population for 2005, based on the 1996 census, was 102 371, giving a population density of 156.7 per square kilometre, with 68% residing on the largest main island of Tongatapu. About 33% of the population live in urban settings. The population is young, with 38% 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 3.8 in 2004. 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 among Pacific island states. 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. The literacy rate is very high (98.8%) and most children complete compulsory primary school classes. A decision has been made to extend primary education from six to eight years in 2007. 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 Right of the Child (CRC) but has failed to fulfil the reporting requirements. It has yet to sign the Convention on 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 in Tonga over the last 50 years and there is now little absolute poverty. The country is placed 54th 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 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. TONGA 338 | COUNTRY HEALTH INFORMATION PROFILES Table 1. Core population and health data (2005 estimates) [Total] 102 371 [Both] 70.00 (2003) [0-14 years] 37.91% (2004 est) [Male] 70.00 (2003) Population [65+ years] 5.29% (2004 est) Life expectancy at birth (years) [Female] 72.00 (2003) Crude birth rate (per 1000 population) 24.80 (2004) Total fertility rate 3.80 (2004) [Total] 94.00 (2004) [Urban] … Crude death rate (per 1000 population) 6.10 (2004) % of population served with safe water [Rural] … [Total] 78.20 (2002) [Urban] … Infant mortality rate (per 1000 live births) 14.60 (2004) % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) 83.30 (2004) est - Estimate 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Tonga is a constitutional monarchy with almost absolute power given to the head of state, King Taufa’ahau Tupou IV, who has reigned since 1965. 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’ipelekahe 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. 2.2 Economic 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 GDP, which was estimated at TOP 361 million (US$ 189.6 million). The Government is heavily dependent on development support for capital investments and, with the sharp increase in recurrent costs as a result of the strike, it will have even fewer internal resources for infrastructure. 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- COUNTRY HEALTH INFORMATION PROFILES | 339 2005, giving an average GDP growth per year for 1998-2005 of 2.9% per year. The 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 will compensate 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). 3. HEALTH SITUATION 3.1 Health trends Tonga has gone through an epidemiological transition since the 1950s, with increasing life expectancy and falling fertility rates, childhood mortality rates and maternal mortality. 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 ICD10 coding, particularly for communicable diseases. Noncommunicable diseases: The steep increase in the burden of noncommunicable disease is worrying and 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 noncommunicable diseases in 2003. There are multiple reasons for the rapidly growing burden of noncommunicable diseases, of which the most important include increasing rates of overweight and obesity, reduced physical activity, smoking, and, to some extent, the ageing 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 in 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 develop overweight and obesity 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 TONGA 340 | COUNTRY HEALTH INFORMATION PROFILES 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 are 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 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 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 and marijuana. All 24 deaths in 2003 were caused directly or indirectly by intoxication. The section on alcohol in the current Traffic Act is antiquated and, in practice, not enforceable, 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. COUNTRY HEALTH INFORMATION PROFILES | 341 Maternal and child health: More than 99% of pregnant women attend antenatal clinics, 98% deliver in a health facility and 99% of deliveries are attended by trained staff. The maternal mortality ratio (MMR) was 83.3 per 100 000 live births in 2004, which translates to two 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 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. A review of developments in child health is planned for 2006 and is expected to help in identifying the way forward. Currently, 67% of under-five mortality is in the 0-1 age group and investments in perinatal and neonatal care are likely to be important in reducing infant mortality. Mortality from Haemophilus Influenzae type B (Hib) infection lies almost entirely in the 0-1 age group and the introduction, in 2005, of routine childhood immunizations against Hib is a good example of an affordable new intervention to improve child health. Of the 17 hospital-certified deaths in the 1-4 age group in 2003, eight were from infectious causes, one from dehydration, two from malignancies and two from road trauma. Of the eight children who died as a result of infection, six were from septicaemia and CNS infection, one from dengue fever and one from pneumonia. The picture resembles more the situation in an industrialized country than a poor developing 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. Communicable diseases: 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. The country experienced a large outbreak of dengue fever (serotype 1) in 2003, causing six deaths in children, and transmission has continued into 2005. The outbreak was confined to the main island of Tongatapu in the first year, but transmission has now spread to all TONGA 342 | COUNTRY HEALTH INFORMATION PROFILES 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 and it is expected that the current outbreak of type 1 dengue virus will run its course in 2006. However, vector control and vector surveillance is poor and the measures introduced to prevent fatalities and control transmission have been suboptimal during the current epidemic. It looks inevitable that the introduction of another serotype will cause a new outbreak of dengue fever with fatalities. 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. Is 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 paediatric department is documenting the impact of Hib vaccine on admissions for meningitis and pneumonia. 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 sero-survey will be conducted in 2006 in order 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 about to enter reproductive life. A serosurvey of 211 preschool children in 1998 found a 3.8% 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 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 should be in the position to eliminate typhoid fever altogether if adequate coordinated resources were allocated to treat carriers, improve sanitary practices and ensure the supply of safe water in all villages. 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 and, for the first time, Rota virus was confirmed in a sample sent to the Pasteur Institute in New Caledonia. COUNTRY HEALTH INFORMATION PROFILES | 343 Twelve new cases of tuberculosis (all types) were reported in 2004. All tuberculosis treatment follows the DOTS strategy and there is active contact tracing. The cure rate for patients diagnosed between 2000 and 2003 was 87%. 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 is 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 being carried out annually as part of screening of blood donors, government employees and visa applicants, and an estimated 45 000 HIV tests have been done since the start in the 1980s. A pilot trial with voluntary counselling and testing (VCT) at the antenatal clinic at the referral hospital showed that the uptake was very high, 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 treatment guidelines for 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 in appropriate services for women. A serosurvey in pregnant women in 2005 found a high overall prevalence of Chlamydia 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. 3.2 Health systems 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. 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 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. A major refurbishment of Vaiola Hospital, supported by a grant from the Government of Japan and a World Bank loan, commenced in 2005 and will result in a leaner hospital when it is completed in 2007. Primary curative care and preventive services are delivered through a system of 14 health centres and 34 maternal health clinics. There are large variations in equipment, staffing and catchment populations depending on location but, on average, a health centre serves 7200 people and is typically staffed by a health officer and one to three nurses. There were 32 filled medical officer posts in 2003 (3.9 doctors per 10 000 population) to which should be added 18 filled health officer posts. In the same year, there were 342 filled nursing posts (33.7 nurses per 10 000 population). There are 13 dental officers and 10 dental therapists. The number of private providers is increasing, but the majority of private doctors remain government employees and run part-time private clinics, many out of their homes. TONGA 344 | COUNTRY HEALTH INFORMATION PROFILES 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 regularly visit Tonga. 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. It had a total of 945 established posts in 2002, with an overall vacancy rate of 25%, making it one of the biggest employers in the country. Doctors normally train in Australia, Fiji or New Zealand, often on bilateral scholarships or WHO fellowships. Three-year health officer training courses are organized by the Ministry of Health when required. Nurses train at the Queen Salote School of Nursing in Tonga. On average, 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 post-graduate certificate training programme in collaboration with the nursing department at the Auckland University of Technology, New Zealand. The first training programme in intensive care nursing started in 2005 and there are plans to conduct post-graduate training programmes in midwifery, internal medicine, surgery and public health in 2006-2007. A 2003 household survey on health care expenditure showed that 89% of all health services were delivered by public hospitals and only 6.2% by health centres. The Government covers 45% of total expenditure on health, households 23% and donors 32%. However, when expenditure on traditional healers and international referrals is excluded, it becomes obvious that the Government covers the absolute majority of both curative and preventive care and that ‘out-of- pocket’ payments on health care are low. About 12% of the population have some kind of health insurance. The private sector is still small and consists mainly of traditional healers and after- hours practising government-employed doctors. About 14% of total expenditure on health is for traditional healers, although they are mostly paid in kind. Expenditure on drugs accounts for approximately 7.8% of total expenditure on health. There is a health insurance system, but it covers only government employees. 4. NATIONAL HEALTH PLAN AND PRIORITIES The most critical question for the health system today is how to increase the resources available for health. Government health expenditure is about US$ 50 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%-12% 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 with the current health financing system. At the same time, the pressure on the health system will increase with the increasing burden of noncommunicable diseases and the ageing population. Identifying alternative sources for health care financing is thus one of the top priorities of the Ministry of Health. In December 2005, Cabinet approved the introduction of user fees and work is now in progress on solutions to protect disadvantaged groups. The first fees are expected to be introduced in 2006. 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 the 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 (NCDs) has now reached epidemic proportions. In addition to human suffering, NCDs can have a negative impact on family economies. The loss of income due to disease and the cost of treating chronic conditions can put enormous strain on COUNTRY HEALTH INFORMATION PROFILES | 345 families and destroy years of work to improve a family’s situation. Ultimately there will be a negative impact on the country’s economic development as more resources have to be used for health care and productive and experienced middle-aged people in the workforce are lost to death and chronic illness. Identifying and implementing effective population-targeted preventive measures that can slow the increase of disease and, in the future, reverse the trend, are of the highest priority. The national multisectoral strategy for the control and prevention of noncommunicable diseases, developed in 2003, is a sign that the Government takes the issue very seriously. There are plans to establish a Health Promotion Foundation with funding from dedicated taxation on tobacco and alcohol. Such a mechanism could provide crucial resources for health promotion, 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 noncommunicable diseases, in view of the increasing burden of an 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 noncommunicable disease must be able to be evaluated so that strategies can be modified when needed. The information must be easily available, cheap and reliable, and should therefore be based on ongoing surveillance rather than repeated and costly surveys. A first step towards such a system is the strengthening of vital statistics 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. 5. MAJOR INFORMATION SOURCES Annual Reports of the Minister of Health 1995 to 2004 Ministry of Health Corporate Plan 2001-2004 Ministry of Health Corporate Plan 2005-2008 National Health Accounts report of July 2004 Tonga’s health 2000 Health Sector Support Project (HSSP/WB) Project Implementation Plan (PIP) EPI and Reproductive Health Services annual reports 2000-2003 WHO/UNICEF joint reporting form on immunization for Tonga 2004 Tonga’s report on progress towards the Millennium Development Goals (MDGs) Annual report of the National Reserve Bank 2003-2004 Government of Tonga statistics, http://www.spc.int/prism/country/to/stats Social and Economic Update and Pro-Poor Policy Formulation, Tonga. Pacific Island Economic Report series. Manila, Asian Development Bank TA6245 (reg) Tonga Population Census 1996: Demographic Analysis: Summary and Population Projections. Government Statistics Department, 1999. TONGA 346 | COUNTRY HEALTH INFORMATION PROFILES 6. 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 Website : COUNTRY LIAISON OFFICER IN TONGA Office Address : Ministry of Health Nuku’alofa, Tonga Postal Address : P.O. Box 70, Nuku’alofa, Tonga Official Email Address : who@ton.wpro.who.int Telephone : (676) 23217 / 25522 Fax : (676) 23 938 Office Hours : 08.30 – 16.30 Time zone Manila +5 hrs, CET + 12 hrs Website : COUNTRY HEALTH INFORMATION PROFILES | 347 ORGANIZATIONAL CHART: MINISTRY OF HEALTH TONGA 348 TONGA WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 0.65 2004 1 2 Estimated population ('000s) 102.37 … … 2005 est 16 3 Annual population growth rate (%) 0.30 2001 7 4 Percentage of population - 0–14 years 37.91 39.11 36.69 2004 est 15 - 65+ years 5.29 5.04 5.55 2004 est 15 5 Urban population (%) 33.40 … … 2003 13 6 Crude birth rate (per 1 000 population) 24.80 … … 2004 4 7 Crude death rate (per 1 000 population) 6.10 … … 2004 4 8 Rate of natural increase of population (% per annum) 1.84 … … 2002 10 9 Life expectancy (years) - at birth 70.00 70.00 72.00 2004 19 - Health-adjusted Life Expectancy (HALE) at age 60 … 11.90 12.00 2002 12 10 Adult literacy rate (%) 98.80 … … 2000 6 11 Neonatal mortality rate (per 1 000 live births) 10.00 c … … 2000 11 12 Infant mortality rate (per 1 000 live births) 14.60 … … 2004 4 13 Under-five mortality rate (per 1 000 live births) 16.59 … … 2001 2 14 Total fertility rate (women aged 15–49 years) 3.80 2004 4 15 Maternal mortality ratio (per 100 000 live births) 83.30 2004 4 16 Percentage of newborn infants weighing at least 2500 g at birth 97.50 … … 2002 10 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 19 Immunization coverage for infants (%) - BCG 99.60 … … 2004 14 - DTP3 99.30 … … 2004 14 - OPV3 99.30 … … 2004 14 - Measles 99.60 … … 2004 14 - Hepatitis B III 99.20 … … 2004 14 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 98.00 2004 4 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 93.00 2003 9 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in health facilities (as % of total deliveries) 98.00 2004 4 21 Percentage of women in the reproductive age group using modern contraceptive methods 23.10 2002 10 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … COUNTRY HEALTH INFORMATION PROFILE 349 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 94.00 … … 2004 4 26 Proportion of population with access to improved sanitation 78.20 … … 2002 10 27 Proportion of the population using solid fuels for cooking or heating (%) 56.00 b … … 2003 14 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.81 … … 2003 8 32 Per capita GDP at current market prices (US$) 1780.00 … … 2003-2004 17 33 Rate of growth of per capita GDP (%) … … … 34 Health expenditure Total health expenditure - amount (in million US$) … - total health expenditure on health as % of GDP … - per capita total expenditure on health (in US$) 49.00 FY2002- 2003 4 Government expenditure on health - amount (in million US$) 4.95 FY2002- 2003 4 - general government expenditure on health as % of total expenditure on health 45.00 FY2002- 2003 4 - general government expenditure on health as % of total general government expenditure 10.00 FY2002- 2003 4 External source of government health expenditure - external resources for health as % of general government expenditure on health … Private health expenditure - private expenditure on health as % of total expenditure on health … Exchange rate in US$ of local currency is: 1 US$ = 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female 36 Health workforce Number Rate per 10 000 population - physicians 32 g … … 3.90 … … 2003 4 - dentists 23 h … … 2.27 … … 2003 4 - pharmacists 4 3 1 0.40 0.58 0.20 2002 10 - nurses 342 … … 33.70 … … 2003 4 - midwives 21 0 21 2.08 0 2.08 2002 10 - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 26 18 8 2.57 3.50 1.60 2002 10 - other health personnel (health inspectors, assistant sanitarians, traditional workers, etc.) 22 18 4 2.18 … … 2002 10 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses 30 … … 2004 18 TONGA 350 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Five leading causes of morbidity Number Rate per 100 000 population a 1. Acute respiratory infections 20 819 … … 20 437.83 … … 2004 4 2. Influenza 20 057 … … 19 689.79 … … 2004 4 3. Bronchiopneumonia 1947 … … 1911.35 … … 2004 4 4. Diarrhoea (adult) 1011 … … 992.49 … … 2004 4 5. Diarrhoea (children) 671 … … 658.71 … … 2004 4 40 Five leading causes of mortality Number Rate per 100 000 population 1. Diseases of the circulatory system 146 … … 190.10 … … 2002 4 2. Neoplasms 67 … … 77.23 … … 2002 4 3. Symptoms, signs and ill-defined conditions 51 … … 53.47 … … 2002 4 4. Diseases of the respiratory system 37 … … 49.50 … … 2002 4 5. Endocrine, nutritional and metabolic conditions 33 … … 43.56 … … 2002 4 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 14 - Pertussis (whooping cough) 0 0 0 0 0 0 2004 14 - Tetanus 0 0 0 0 0 0 2004 14 - Neonatal tetanus 0 0 0 0 0 0 2004 14 - Poliomyelitis 0 0 0 0 0 0 2004 14 - Hib meningitis 16 … … … … … 2004 14 - Measles 0 0 0 0 0 0 2004 14 - Mumps 0 0 0 0 0 0 2004 14 - Rubella 0 0 0 0 0 0 2004 14 - Congenital rubella syndrome 0 0 0 0 0 0 2004 14 42 Selected communicable diseases Number of cases aa Number of deaths Hepatitis viral 7 4 3 0 0 0 2002 3 - Type A 2 0 2 0 0 0 2002 3 - Type B 5 4 1 5 3 2 2002 3 - Type C 0 0 0 0 0 0 2002 3 - Unspecified 0 0 0 0 0 0 2002 3 Cholera 0 0 0 0 0 0 2002 3 Typhoid fever 23 … … … … … 2003 4 Encephalitis 2 … … … … … 2003 2 Plague 0 0 0 0 0 0 2002 3 Syphilis 0 0 0 0 0 0 2002 3 Gonorrhoea 42 … … … … … 2003 2 Leprosy 1 … … … … … 2004 14 Malaria … … … … … … Dengue/DHF 3 … … 0 0 0 2004 14 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … 1.00 … … 2000 est 12 - Proportion of population in malaria-risk areas using effective malaria prevention measures d … - Proportion of population in malaria-risk areas using effective malaria treatment measures e … COUNTRY HEALTH INFORMATION PROFILE 351 INDICATORS DATA Year Source Total Male Female Total Male Female 44 Tuberculosis Number of cases Number of deaths - All types 16 … … … … … 2003 14 - New pulmonary tuberculosis (smear-positive) 11 … … … … … 2003 14 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 42.00 … … 5.00 … … 2004 14 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOTS) 81.00 f … … 83.00 (2002) … … 2003 14 Number of cases Number of deaths 45 Acute respiratory infections 16 038 … … … … … 2003 3 46 Diarrhoeal diseases 2320 … … … … … 2003 3 47 Cancers All cancers (malignant neoplasms only) 101 46 55 76 42 34 2002 10 - Trachea, bronchus and lung 7 7 0 13 11 2 2002 10 - Stomach 8 6 2 5 4 1 2002 10 - Colon and rectum 3 3 0 0 0 0 2002 10 - Lip, oral cavity and pharynx 6 3 3 3 0 3 2002 10 - Liver 6 3 3 8 6 2 2002 10 - Cervix 7 3 2002 10 - Leukaemia 1 0 1 1 0 1 2002 10 48 Circulatory All circulatory system diseases … … … 192 121 71 2002 10 - Ischaemic heart disease 34 18 16 7 7 0 2002 10 - Acute myocardial infarction 34 26 8 28 19 9 2002 10 - Rheumatic fever and rheumatic heart diseases 21 9 12 1 1 0 2002 10 - Cerebrovascular diseases 41 15 26 21 9 12 2002 10 - Hypertension 1154 634 520 7 4 3 2002 10 49 Maternal causes - Haemorrhage 0 1 2002 10 - Abortion 114 0 2002 10 - Eclampsia … … - Sepsis … … - Obstructed labour … … 50 Diabetes mellitus 2035 787 1248 35 14 21 2002 10 51 Mental disorders 199 130 69 0 0 0 2002 10 52 Injuries - All types … … … … … … - Motor and other vehicle accidents 109 80 29 0 0 0 2002 10 - Suicide 0 0 0 1 1 0 2002 10 - Homicide and violence 0 0 0 1 1 0 2002 10 - Occupational injuries 0 0 0 0 0 0 2002 10 TONGA 352 INDICATORS DATA Year Source 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public health facilities - General hospitals 1 191 2004 5 - Specialized hospitals … … - District/first-level referral hospitals 3 105 2004 5 - Primary health care centres … … Private hospitals … … Notes: Red text Millennium Development Goals (MDG) indicators … Data not available est Estimate FY The financial year refers to the span from July 1 of representative year to June 20 next year. aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. b Modelled data. c Estimates derived by regression and similar estimation methods. d Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. e Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. f Revised data. g Figure refers to government doctors. h Figure refers to dental officers and dental therapists. Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 2 Tonga Statistics Department (http://www.spc.in/prism) 3 Information Unit, Ministry of Health. 4 Information provided by Country Liaison Officer for Tonga, 10 May 2005. 5 Information provided by Country Liaison Officer for Tonga, 05 March 2004. 6 Report of the Minister of Education – Year 2000. 7 Report of the Minister of Health – Year 2001. 8 Human development report 2005. New York, United Nations Development Programme, 2005. 9 Report of the Minister of Health for the year 2003. 10 Report of the Minister of Health for the year 2002. 11 World health report 2005: Make every mother and child count. Geneva, World Health Organization, 2005. 12 World health report 2004: Changing history. Geneva, World Health Organization, 2004. 13 Urban and rural areas 2003. New York, United Nations Department of Economic and Social Affairs, Population Division, 2004. 14 WHO Regional Office for the Western Pacific, data received from technical units. 15 Demographic tables for the Western Pacific Region 2000-2005. Manila, WHO Regional Office for the Western Pacific, 2005. 16 Tonga Population Census 1996; Demographic Analysis: Summary and Population Projections (Government Statistics Department 1999). 17 Social and Economic Update and Pro-Poor Policy Formulation, Tonga. Pacific Island Economic Report series, ADB TA6245 (reg). 18 Personal communication with the Principal, Queen Salote School of Nursing. 19 Information provided by Country Liaison Officer for Tonga, 21 April 2006. COUNTRY HEALTH INFORMATION PROFILES | 353 TUVALU 1. DEMOGRAPHICS, GENDER AND POVERTY Tuvalu is one of the smallest independent countries in the world, comprising nine low-lying atolls with a total land area of only 25.63 square kilometres. With an estimated population of 10 885 in 2005, the country has a very high population density. About 57% of the population reside in urban areas. Gender equality has been achieved in primary and secondary school enrolment. Tuvalu’s main resource is considered to be its ocean, but the country will need vast financial resources, technology and manpower to fully tap its potential. The poor sandy soil requires intensive agricultural input so that vegetable and fruit can be grown. There is very little industry, although there are small government and family-owned businesses that cater for tourists, and a new fishing industry is being developed. In 2002, (39%) of the population were employed. Of these, the majority (54%) owned their businesses, 9% were selling fish, handicrafts and other local items, 2% were in other forms of employment, and 6.2% earned no income. Table 1. Core population and health data (2005 estimate) [Total] 10 885 [Both] 65.00 (2002) [0-14 years] 3700 (33.99%) [Male] 64.00 (2002) Population [65+ years] 531 (4.88%) Life expectancy at birth (years) [Female] 67.00 (2002) Crude birth rate (per 1000 population) 27.10 (2002) Total fertility rate 3.70 (2002) [Total] 100.00 (2002) [Urban] 100.00 (2002) Crude death rate (per 1000 population) 9.90 (2002) % of population served with safe water [Rural] 100.00 (2002) [Total] 100.00 (2002) [Urban] 100.00 (2002) Infant mortality rate (per 1000 live births) 21.60 (2003) % of population with adequate sanitary facilities [Rural] 100.00 (2002) Maternal mortality ratio (per 100 000 live births) 0.00 (2002) 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Tuvalu is a member of the Pacific Islands' Forum and is associated with the European Union as a member of the African Caribbean Pacific Group. In 2000, the country acceded to full membership of both the United Nations and the Commonwealth. Tuvalu has a high Commissioner in Suva, Fiji; Consuls-General in Australia and New Zealand; and Honorary Consuls in Germany, Belgium, Japan and the Vatican. There has been a Tuvalu mission to the United Nations in New York since 2002. A national election took place in July 2002 and new cabinet members were appointed in October 2003. TUVALU 354 | COUNTRY HEALTH INFORMATION PROFILES 2.2 Economic situation Foreign fishing licence fees support the Tuvalu economy to a substantial degree, in addition to interest from the Tuvalu Trust Fund established by donors and the Government of Tuvalu in 1987. Remittances from Tuvaluans working abroad in the phosphate industry on Nauru or as seamen on overseas ships provide a further source of foreign exchange. Windfall gains from commercial marketing of its “.tv” Internet country domain name have boosted Tuvalu’s finances considerably in recent years. The major sources of income for the people of Tuvalu are the sale of copra and fishing rights, wages paid for employment, remittance from relatives living overseas and seamen's wages sent home to their families. Per capita gross domestic product (GDP) was 2872 Australian dollars (approximately US$ 2096) in 2002. The country has bilateral fishing agreements with the United States of America, the Republic of Korea, Japan and Taiwan (China). Australia presented Tuvalu with a patrol boat and support team in late 1993, which improved enforcement of the Tuvalu fisheries zone. The Government and the population are conscious of the potential long-term negative impact of global warming on the country’s landmass, although scientific evidence at this stage remains controversial. At present, the biggest fear is a tidal wave or hurricane. The last hurricane occurred in 1972. Tuvalu has also inquired about buying land in Fiji for resettlement of some of its people, both to ease pressure on the country’s limited land and as a long-term hedge against a possible rise in the sea level. An appeal to New Zealand for assistance resulted in a migratory scheme that permits 70 Tuvaluans to migrate to New Zealand each year. However, this migratory scheme continues to fall behind the targeted number each year. It is assumed that the problem will have to be examined over the long term and other countries like Australia will be approached. 3. HEALTH SITUATION 3.1 Health trends Communicable diseases are the major cause of morbidity, with alarming numbers of skin infections, acute respiratory infections and eye infections reported. An increase in tuberculosis prevalence has resulted in strengthening of the tuberculosis programme and a filariasis mass drug programme is in place. Vector control is an ongoing activity. Lifestyle diseases are also evident. 3.2 Health systems Health services are working to meet the new demands of the changing lifestyles (especially regarding diet) of the population. Few economies of scale exist in terms of human resources. While health workers have most of the key skills, they have little depth in their human resources. Therefore, there is often no one to take over core responsibilities if someone goes on sabbatical or fellowship, changes jobs due to a promotion or transfer, or acquires additional responsibilities. This situation applies in remote communities as well as in urban areas. Such a situation requires that development efforts be designed differently from those for large economies, where economies of scale are possible. Rainwater is the main source of fresh water in Tuvalu. Thus, any period of drought poses very serious consequences for the health and well-being of the population. COUNTRY HEALTH INFORMATION PROFILES | 355 4. NATIONAL HEALTH PLAN AND PRIORITIES The national health policy goals for Tuvalu are: • to prevent diseases, promote healthy lifestyles, and raise the standard of living; • to provide high quality primary, secondary and tertiary health services; • to continually improve the effectiveness and efficiency of 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 given to diabetes mellitus and hypertension). 5. MAJOR INFORMATION SOURCES 2002 Tuvalu annual report Tuvalu Central Statistics Division (http://www.spc.int/prism) 6. ADDRESSES MINISTRY OF HEALTH Office Address : Postal Address : P.O. Box 36, Funafuti, Tuvalu Official Email Address : Telephone : Health Division: (688) 20765 Fax : Health Division: (688) 20481 Office Hours : 0800-1600 Website : WHO REPRESENTATIVE IN SOUTH PACIFIC Office Address : Level 4, Provident Plaza 1, Downtown Boulevard, 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@fij.wpro.who.int Telephone : (679) 3-304600 / 3-304631 Fax : (679) 3-300462 Office Hours : 0800H-1700H Website : TUVALU 356 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: MINISTRY OF HEALTH COUNTRY HEALTH INFORMATION PROFILE 357 TUVALU WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 0.03 2004 1 2 Estimated population ('000s) 10.88 5.61 5.27 2005 est 2 3 Annual population growth rate (%) 0.60 … … 2002 4 4 Percentage of population - 0–14 years 33.99 34.02 33.96 2005 est 2 - 65+ years 4.88 4.13 5.67 2005 est 2 5 Urban population (%) 57.00 … … 2005 2 6 Crude birth rate (per 1 000 population) 27.10 … … 2002 4 7 Crude death rate (per 1 000 population) 9.90 … … 2002 4 8 Rate of natural increase of population (% per annum) 1.60 … … 2002 1 9 Life expectancy (years) - at birth 65.00 64.00 67.00 2002 5 - Heal th-adjusted Life Expectancy (H ALE) at age 60 … 9.70 10.30 2002 11 10 Adult literacy rate (%) 95.00 95.00 95.00 1998 7 11 Neonatal mortality rate (per 1 000 live births) … … … 12 Infant mortality rate (per 1 000 live births) 21.60 … … 2003 6 13 Under-five mortality rate (per 1 000 live births) 32.40 … … 2003 6 14 Total fertility rate (women aged 15–49 years) 3.70 2002 4 15 Maternal mortality ratio (per 100 000 live births) 0.00 2002 8 16 Percentage of newborn infants weighing at least 2500 g at birth 95.00 … … 2000 9 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 100.00 … … 2004 10 - DTP3 98.00 … … 2004 10 - OPV3 98.00 … … 2004 10 - Measles 98.00 … … 2004 10 - Hepati tis B III 98.00 … … 2004 10 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 99.00 2001 9 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 96.00 2004 10 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in heal th facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods 28.50 2001 9 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … TUVALU 358 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 100.00 100.00 100.00 2002 5 26 Proportion of population with access to improved sanitation 100.00 100.00 100.00 2002 5 27 Proportion of the population using solid fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.58 … … 1998 7 32 Per capita GDP at current market prices (US$) 2096.35 … … 2002 4 33 Rate of growth of per capita GDP (%) … … … 34 Health expenditure Total health expenditure - amount (in m illion US$) 0.18 2002 9 - total heal th expenditure on health as % of GDP 6.10 2003 12 - per capita total expendi ture on health (in US$) 142.00 2003 12 Government expenditure on health - amount (in million US$) … - general government expenditure on health as % of total expenditure on health 83.30 2003 12 - general government expenditure on heal th as % of total general government expendi ture 6.00 2003 12 External source of government health expenditure … - external resources for heal th as % of general government expendi ture on health … Private health expenditure - private expenditure on health as % of total expenditure on heal th 16.70 2003 12 Exchange rate in US$ of local currency is: 1 US$ = 1.37 2002 4 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 4 … … 4.18 … … 2003 5 - dentists 2 … … 2.09 … … 2003 5 - pharmacists 2 … … 2.09 … … 2003 5 - nurses 30 d … … 31.38 … … 2003 5 - m idwives 10 … … 10.46 … … 2003 5 - other nursing/ auxiliary staff 12 … … 12.55 … … 2003 5 - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 5 … … 5.23 … … 2003 5 - other heal th personnel (health inspec tors, assistant sani tarians, traditional workers, etc.) 23 … … 24.06 … … 2003 5 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … COUNTRY HEALTH INFORMATION PROFILE 359 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Five leading causes of morbidity Number Rate per 100 000 population a 1. Septic sores/ wounds 4758 … … 49 764.67 … … 2003 3 2. Influenza 3663 … … 38 311.89 … … 2003 3 3. Ac ute respiratory infection 2950 … … 30 854.51 … … 2003 3 4. Headache 2303 … … 24 087.44 … … 2003 3 5. Cough 1890 … … 19 767.80 … … 2003 3 40 Five leading causes of mortality Number Rate per 100 000 population a 1. Heart problem 21 … … 219.64 … … 2003 3 2. Senili ty 11 … … 115.05 … … 2003 3 3. Undiagnosed 10 … … 104.59 … … 2003 3 4. Diabetes 5 … … 52.30 … … 2003 3 5. Hypoglycaemia 5 … … 52.30 … … 2003 3 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 10 - Pertussis (whooping cough) 0 0 0 0 0 0 2004 10 - T etanus 0 0 0 0 0 0 2004 10 - Neonatal tetanus 0 0 0 0 0 0 2004 10 - Poliomyelitis 0 0 0 0 0 0 2004 10 - Hib meningitis 0 0 0 0 0 0 2004 10 - Measles 0 0 0 0 0 0 2004 10 - Mumps 0 0 0 0 0 0 2004 10 - Rubella 0 0 0 0 0 0 2004 10 - Congeni tal rubella syndrome 0 0 0 0 0 0 2004 10 42 Selected communicable diseases Number of cases aa Number of deaths Hepati tis vi ral - T ype A 0 0 0 0 0 0 2001 10 - T ype B 0 0 0 0 0 0 2001 10 - T ype C 0 0 0 0 0 0 2001 10 - T ype E … … … … … … - Unspecified 23 … … 0 0 0 2001 10 Cholera 0 0 0 0 0 0 2005 10 Typhoid fever 0 0 0 0 0 0 2005 10 Encephalitis 0 0 0 0 0 0 2005 10 Plague 0 0 0 0 0 0 2001 10 Syphilis … … … … … … Gonorrhoea (gonococcal infections) … … … … … … Leprosy 0 0 0 0 0 0 2004 10 Malaria … … … … … … Dengue/DHF 0 0 0 0 0 0 2004 10 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures b … - Proportion of population in malaria-risk areas using effective malaria treatment measures c … TUVALU 360 INDICATORS DATA Year Source Total Male Female Total Male Female 44 Tuberculosis Number of cases Number of deaths - All types 30 … … … … … 2003 10 - New pulmonary tuberculosis (smear-posi tive) 0 0 0 0 0 0 2003 10 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 57.00 … … 5.00 … … 2004 10 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOT S) … … … … … … Number of cases Number of deaths 45 Acute respiratory infections 2950 … … … … … 2003 8 46 Diarrhoeal diseases 967 … … 1 … … 2002 8 47 Cancers All cancers (malignant neoplasms only) 1 … … 0 0 0 2001 9 - T rachea, bronchus and lung … … … … … … - Stomach … … … … … … - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … … … … - Liver … … … … … … - Cervix … … - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … … … … - Ischaemic heart disease … … … … … … - Acute m yocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … … … … - H ypertension 344 … … … … … 2002 8 49 Maternal causes - Haemorrhage … … - Abortion … … - Eclampsia … … - Sepsis … … - Obstruc ted labour … … 50 Diabetes mellitus 281 … … … … … 2002 8 51 Mental disorders … … … … … … 52 Injuries - All types … … … … … … - Motor and other vehicle accidents 1 … … 0 0 0 2001 9 - Suicide … … … … … … - Hom icide and violence … … … … … … - Occupational injuries 32 … … … … … 2002 8 53 Proportion of population with access to affordable essential drugs on a sustainable basis … COUNTRY HEALTH INFORMATION PROFILE 361 INDICATORS DATA Year Source 54 Health infrastructure Number Number of beds Public heal th facilities - General hospitals 1 40 2001 9 - Specialized hospi tals … … - District/first-level referral hospitals … … - Primary health care centres 8 16 2001 9 Private hospitals 0 0 2001 9 Notes: Red text M illennium Development Goals (MDG) indicators … Data not available est Estimate aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Uni t of the WHO Regional Office for the Western Pacific b Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. c Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. d Figure refers to bachelor and diploma graduate nurses. Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community (http://www.spc.int) 2 Demographic tables for the Western Paci fic 2005-2010. Manila, WHO Regional Office for the Western Pacific, 2005. 3 Information furnished by the WHO Representative for the South Pacific, 24 February 2005 4 Tuvalu Central Statistics Division (http://www.spc.int/prism) 5 Information furnished by the Heal th Department through the WHO Representative for the South Pacific, 02 April 2004 6 Pacific Island Regional Millennium Development Goals report 2004. Noumea, Secretariat of the Pacific Community UN/ CROP MDG Working Group, November 2004. 7 Pacific human development report 1999 (Creating opportuni ties). New York, United Nations Development Programme, 1999. 8 PMH health report 2002 . M inistry of Heal th 9 Information furnished by the Heal th Department, Government of Tuvalu, 18 March 2003 10 WHO Regional Office for the Western Paci fic, data received from technical units 11 Changing history. World health report 2004 . Geneva, World Health Organization, 2004. 12 Working together for heal th . World heal th report 2006. Geneva, World Health Organization, 2006. 362 | COUNTRY HEALTH INFORMATION PROFILES VANUATU 1. DEMOGRAPHICS, GENDER AND POVERTY According to the national census in 1999, the population of Vanuatu was 186 678; the 2005 estimated population is 221 852, with around 41% below 15 years of age. The crude birth rate, at the time of the 1999 census, was 28.2 per 1000 population, the total fertility rate was 4.8, and the infant mortality rate was 27 per 1000 live births. Most of the population are employed in subsistence agriculture; the rest are employed in government posts, service industries and light industry. Table 1. Core population and health data (2005 estimates) [Total] 221 852 [Both] 68.60 (2002 est) [0-14 years] 91 503 (41.24%) [Male] 67.40 (2002 est) Population [65+ years] 7139 (3.22%) Life expectancy at birth (years) [Female] 70.40 (2002 est) Crude birth rate (per 1000 population) 28.20 (1999) Total fertility rate 4.80 (1999) [Total] 60.00 (2002) [Urban] 85.00 (2002) Crude death rate (per 1000 population) 6.00 (1999) % of population served with safe water [Rural] 52.00 (2002) [Total] 50.00 (2002) [Urban] 78.00 (2002) Infant mortality rate (per 1000 live births) 27.00 (1999) % of population with adequate sanitary facilities [Rural] 42.00 (2002) Maternal mortality ratio (per 100 000 live births) 96.30 (1998) est- Estimate 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Vanuatu has had a relatively prolonged period of political stability. The current Government is a coalition, formed on 23 July 2004, comprising the National United Party, with Prime Minister Ham Lini Vanuaroroa and Minister of Health Morking Stevens Iatika; the People’s Progressive Party; the Melanesian Progressive Party; the Vanua’aku Party; the Vanuatu Republican Party; and the Green Alliance. 2.2 Economic situation For a number of years, economic growth has been stagnant or recessive. Employment has also stagnated or declined. Local industries (ice cream and tinned meat) are threatened by cheaper imports, which, under Melanesian Spear Head Group trade agreements, have increased because of reduced or eliminated tariffs between member countries. Recent revisions to the agreements reintroduced tariffs in Vanuatu for ice cream, tinned meat and other products, but the effects on the local economy will be minimal. The economy is moving towards complete dependence on the tourism industry, which will not be sustainable for economic development. Very few new jobs are created annually in all sectors of the economy, especially for returned trainees and graduates. COUNTRY HEALTH INFORMATION PROFILES | 363 In spite of the poor economic reports and forecasts, there appears to be a growing middle class with economic power. There are more new vehicles on the roads, new public transportation vehicles, mobile telephones and more people eating lunch at restaurants. This could be the result of increased activity in the construction industry, at least in Port Vila. In any event, it is not clear whether the perceived local economic upturn has substance in fact. The traditional economic staples, copra and kava, are not likely to sustain economic growth into the future. Copra is currently subsidized by the Government and demand is not increasing to meet production. Kava (Rhizoma Piperis Methystici) has been the victim of investigations into its possible detrimental effect on health, specifically liver toxicity. Cocoa could be an important export if sufficient quantities can be produced. 3. HEALTH SITUATION 3.1 Health trends Two natural disasters affected Vanuatu in 2005: a series of earthquakes hit Port Vila on 26 September; and Mount Manaro on Ambae Island, Penama Province erupted in November. There was no loss of life caused by the earthquakes, but the Pompidou complex, which accommodated the Ministry of Health and the WHO country office, was badly damaged. An assessment of its structure estimated that it was no longer safe for occupancy. On Ambae, about 4000 were relocated to safer areas as the result of the volcanic eruption, and were allowed to return home after two months. The Ministry of Health's major health concerns remain malaria, tuberculosis and noncommunicable diseases, such as diabetes. The Directorate of Public Health, which has managed an extensive vectorborne disease programme for over 20 years, is implementing the directly observed treatment, short-course (DOTS) strategy in tuberculosis control and is initiating more focus on noncommunicable diseases. With the recent introduction of long-lasting nets through funding from the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM), the global incidence of malaria has been decreasing. However, this fragile success will require more effort to make it sustainable. Concurrently, malaria has been rising in certain areas, requiring further investigation and targeted activities. Malaria baseline surveys during the dry and the wet seasons are currently being carried out with technical support from WHO and the University of California, San Francisco (UCSF) and financial support from the Bill and Melinda Gates Foundation. The Rotary Against Malaria three-year project has reached its last phase and will end in June 2006. It involves 50 aid posts in Sanma and Malampa provinces and focuses on the development of a revolving fund at community level using re-treatment of bednets. The project is co-funded by Rotary and the Bill and Melinda Gates Foundation. Tuberculosis is still a serious national concern in both urban and rural areas. Despite a number of GFATM-supported activities, the expected improvements in programme performance indicators are not yet visible. However, 100% DOTS coverage was achieved recently. The programme is now directing its efforts towards quality, consistency and sustainability. The implementation of the GFATM-funded initiative provides good support in terms of procurement and training opportunities, as well as promoting a culture of planning and reporting. Noncommunicable diseases, especially diabetes and hypertension, have come to the attention of the Ministry of Health in the last few years. The number of new outpatient cases of hypertension increased from 636 in 1995, to 770 in 1996 and 1000 in 1997. Outpatient cases of diabetes grew from 112 in 1995, to 163 in 1996 and 247 in 1997. Lifestyle changes and a growing urban population appear to be the main culprits. Sexually transmitted infections (STI) have always been suspected of being highly prevalent, and data from health facilities indicate high prevalence and incidence rates. In 2000, a survey of VANUATU 364 | COUNTRY HEALTH INFORMATION PROFILES 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. Pap smear screening and an STI survey on the island of Ambae in February 2002 showed incidence rates of 5.2% for Trichomonal vaginalis and 1.5% for Chlamydia trachomatis in a sample population of 406 women aged over 15 years. It is of concern that the results showed 8.2% of the women tested positive for HBs antigen as an azythromycin-based presumptive treatment of pregnant women has been ongoing at Vila Central Hospital since January 2001. Preliminary results of an STI survey carried out in 2005 in the same population of antenatal clinic women seem to be encouraging, but will need further investigation for a better understanding of the successful strategies. Vanuatu officially reported its first HIV-positive case on 25 September 2002. There was considerable public interest, 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 AIDS tests. Mass drug administration (MDA) against filariasis has been included in the vectorborne disease programme. The fifth and last round of MDA was conducted in 2005. The next steps for this programme will be further discussed and decided in 2006. Voluntary and non-remunerated blood donor recruitment has made good progress with the support of an Australian Youth Ambassador assigned to the WHO country office for a ten- month period, working closely with Vila Central Hospital laboratory staff. 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 of advanced cases of ARI and diarrhoeal diseases. 3.2 Health systems In 2003, the country spent about 3.9% of gross domestic product (GDP) on health, and in 2004, 10.8% of total government expenditure. Health services are mainly funded by the Government and external support. However, user fees have been introduced and are practised in various forms. The WHO NHA estimation in 2001 indicated that 36% was funded by out-of-pocket payments. The share of out-of-pocket payment in health expenditure increased from 30% to 36% from 1998 to 2001, with newly emerged private clinics and overseas referrals contributing to the rise. There is, as yet, no social health insurance based on the principles of mandatory contribution, risk sharing and fund pooling, but serious consideration is now being given to this option. As a requirement of the Ministry of Finance and Economic Management, the Ministry of Health produces corporate and business plans, which are universally regarded as the blueprint for development of the health sector. While the health system and services cover the country adequately in terms of facilities and access, the quality of services delivered will be improved through planned multitasking of health workers and integration of programmes for greater efficiency. There have been developments in the management of human resources in the Ministry of Health towards rationalizing salary levels and looking at career options for health workers. Currently there are no career structures in the Ministry of Health. Salary and career advancement will be tied to the new performance appraisal system. The Ministry of Health is in the process of a long and difficult reorganization process under the leadership of the Director General of Health. The current structure, with three directorates, is a temporary one as the Ministry moves step-by-step from four directorates to two. The whole process is expected to be completed by the end of 2006. COUNTRY HEALTH INFORMATION PROFILES | 365 4. NATIONAL HEALTH PLAN AND PRIORITIES There is a continuing need to consolidate rather than expand health services. Available resources for programme implementation are scarce and unreliable. More emphasis will be placed on creating added value in programmes through amalgamation of resources. Objectives include: • improving case management for communicable and noncommunicable diseases; • improving management of service delivery nationally; • improving communication between all levels of the health system; • improving the rationale for staffing and distribution; • improving community participation; and • integrating clinical health services. The overall goal for the Ministry of Health is the implementation of health service delivery from two autonomous areas of health: the Northern Health Care Group and the Southern Health Care Group. This strategy will meet the objectives and priorities of the Ministry of Health, in keeping with national primary health care policy. 5. MAJOR INFORMATION SOURCES Health Workforce Plan, 2003. Development of the Health Workforce Plan, 2003. Budget and expenditure planning for the Ministry of Health 2004-2006. 2003. Country health profile, 2005. Analysis of the function and structure of the Ministry of Health. 2003 Further options for the overall management of the Ministry of Health. 2001 Health seeking practices in rural Vanuatu. 2000 6. ADDRESSES MINISTRY OF HEALTH Office Address : Lolam House, level 2 and 3 Postal Address : Private Mail Bag 009, Port Vila, Vanuatu Official Email Address : Telephone : (678) 22512 Fax : (678) 26 204 Office Hours : 7.30 am to 12.00 pm and 1.30pm to 5.00pm Website : COUNTRY LIAISON OFFICER IN VANUATU Office Address : Lolam House, Level 2, Port Vila, Vanuatu Postal Address : World Health Organization PO Box 177 Port Vila, Vanuatu, South Pacific Official Email Address : who@van.wpro.who.int Telephone : (678) 27 683 Fax : (678) 22691 Office Hours : 7.30 am to 12.00 pm and 1.30pm to 5.00pm Website : VANUATU 366 | COUNTRY HEALTH INFORMATION PROFILES ORGANIZATIONAL CHART: MINISTRY OF HEALTH Ministry of Health Organizational Chart 2005 Vanuatu Political Advisors (3) Northern District Hospital Lolowai Hospital Norsup Hospital TORBA Health Services SANMA Health Services MALAMPA Health Services PENAMA Health Services Director of Northern Health Care Group Vila Central Hospital Lenakel Hospital SHEFA Health Services TAFEA Health Services Director of Southern Health Care Group Family Health Services Health Promotion Malaria and Vectorborne Diseases Control Environmental Health Health Information System Director of Public Health Director General of Health Minister of Health COUNTRY HEALTH INFORMATION PROFILE 367 VANUATU WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 12.19 2004 1 2 Estimated population ('000s) 221.85 … … 2005 est 2 3 Annual population growth rate (%) 2.75 … … 2004 est 3 4 Percentage of population - 0–14 years 41.24 41.70 40.77 2005 est 2 - 65+ years 3.22 3.31 3.13 2005 est 2 5 Urban population (%) 22.80 … … 2003 14 6 Crude birth rate (per 1 000 population) 28.20 … … 1999 3 7 Crude death rate (per 1 000 population) 6.00 … … 1999 3 8 Rate of natural increase of population (% per annum) 2.22a … … 1999 9 Life expectancy (years) - at birth 68.60 67.40 70.40 2002 est 4 - Heal th-adjusted Life Expectancy (H ALE) at age 60 … 11.10 11.70 2002 13 10 Adult literacy rate (%) … 50.10 f 49.90 f 2002 2 11 Neonatal mortality rate (per 1 000 live births) 19.00 b … … 2000 est 5 12 Infant mortality rate (per 1 000 live births) 27.00 27.00 26.00 1999 3 13 Under-five mortality rate (per 1 000 live births) 33.00 33.00 31.00 1999 3 14 Total fertility rate (women aged 15–49 years) 4.80 1999 3 15 Maternal mortality ratio (per 100 000 live births) 96.30 1998 6 16 Percentage of newborn infants weighing at least 2500 g at birth 97.00 … … 2003 7 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia 7.00 2003 7 19 Immunization coverage for infants (%) - BCG 63.00 … … 2003 8 - DTP3 49.00 … … 2003 8 - OPV3 53.00 … … 2003 8 - Measles 48.00 … … 2003 8 - Hepati tis B III 56.00 … … 2003 8 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 91.00 2003 7 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 22.00 2003 7 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) 3.00 2003 7 - Percentage of deliveries in heal th facilities (as % of total deliveries) 84.00 2003 7 21 Percentage of women in the reproductive age group using modern contraceptive methods 15.00 2001 9 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … VANUATU 368 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 60.00 85.00 52.00 2002 10 26 Proportion of population with access to improved sanitation 50.00 78.00 42.00 2002 10 27 Proportion of the population using solid fuels for cooking or heating (%) 79.00c … … 2003 8 28 Proportion of households with access to secure tenure 90.00 … … 1998 2 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index 0.66 … … 2003 4 32 Per capita GDP at current market prices (US$) 1331.26 a … … 2003 2 33 Rate of growth of per capita GDP (%) … … … 34 Health expenditure Total health expenditure - amount (in m illion US$) 6.60 2001 9 - total heal th expenditure on health as % of GDP 3.90 2003 15 - per capita total expendi ture on health (in US$) 76.22 2001 9 Government expenditure on health - amount (in million US$) … - general government expenditure on health as % of total expenditure on health … - general government expenditure on heal th as % of total general government expendi ture 10.80 2004 2 External source of government health expenditure - external resources for heal th as % of general government expendi ture on health … Private health expenditure - private expenditure on health as % of total expenditure on heal th … Exchange rate in US$ of local currency is: 1 US$ = 111.86 (average) 2004 2 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 29 … … 1.35 … … 2004 est 11 - dentists … … … … … … - pharmacists … … … … … … - nurses 312 … … 14.48 … … 2004 est 11 - m idwives 50 … … 2.32 … … 2004 est 11 - other nursing / auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) … … … … … … - other heal th personnel (health inspec tors, assistant sani tarians, traditional workers, etc.) 51 … … 2.37 … … 2004 est 11 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … COUNTRY HEALTH INFORMATION PROFILE 369 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. Ac ute respiratory infections - all ages 42 802 …. …. 20 227.00 …. …. 2003 7 2. Malaria 22 037 …. …. 10 414.00 …. …. 2003 7 3. Scabies and skin diseases 7900 …. …. 3733.00 …. …. 2003 7 4. Worms 4496 …. …. 2125.00 …. …. 2003 7 5. Diarrhoea 3187 …. …. 1506.00 …. …. 2003 7 6. Tooth / gum diseases 2979 …. …. 1408.00 …. …. 2003 7 7. Eye infection 1853 …. …. 1558.00 …. …. 2003 7 8. Arthri tis 2535 1216 1319 1198.00 1121.00 1279.00 2003 7 9. Injuries 1746 …. …. 825.00 …. …. 2003 7 10. Conjunctivi tis 1646 …. …. 778.00 …. …. 2003 7 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Ashtma 24 12 12 11.00 11.00 12.00 2003 7 2. Stroke 18 9 9 9.00 8.00 9.00 2003 7 3. Heart failure 18 12 6 9.00 11.00 6.00 2003 7 4. Diabete mellitus 18 6 12 9.00 6.00 12.00 2003 7 5. Malaria 15 10 5 7.00 9.00 5.00 2003 7 6. Pneumonia 12 6 6 6.00 6.00 6.00 2003 7 7. Cardiac arrest 11 7 4 5.00 6.00 4.00 2003 7 8. Tuberculosis 7 4 3 3.00 4.00 3.00 2003 7 9. Septicaemia 6 2 4 3.00 2.00 4.00 2003 7 10. Malignant neoplasm - bronchus and lung 4 4 0 2.00 4.00 0.00 2003 7 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria … … ... … … … - Pertussis (whooping cough) … … ... … … … - T etanus 0 0 0 0 0 0 2003 8 - Neonatal tetanus 3 … ... … … … 2003 8 - Poliomyelitis 0 0 0 0 0 0 2003 8 - Hib meningitis 20 … ... … … … 2003 8 - Measles 165 … ... … … … 2003 8 - Mumps NR … ... … … … 2003 8 - Rubella NR … ... … … … 2003 8 - Congeni tal rubella syndrome NR … ... … … … 2003 8 42 Selected communicable diseases Number of cases aa Number of deaths Hepati tis vi ral - T ype A 26 … … 1 … … 2004 8 - T ype B 18 … … 2 … … 2004 8 - T ype C 1 … … 0 0 0 2004 8 - T ype E … … … … … … - Unspecified 17 … … 1 … … 2004 8 Cholera 0 0 0 0 0 0 2005 8 Typhoid fever 0 0 0 0 0 0 2005 8 Encephalitis 0 0 0 0 0 0 2005 8 Plague 0 0 0 0 0 0 2005 8 Syphilis … … … … … … VANUATU 370 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Gonorrhoea … … … … … … Leprosy 3 … … … … … 2004 8 Malaria 14 653 … … 1 … … 2004 8 Dengue/DHF … … … … … … 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 6 753.00 … … 0.46 … … 2004 8 - Proportion of population in malaria-risk areas using effective malaria prevention measures d … - Proportion of population in malaria-risk areas using effective malaria treatment measures e … 44 Tuberculosis Number of cases Number of deaths - All types 115 … … … … … 2004 8 - New pulmonary tuberculosis (smear-posi tive) 59 … … … … … 2004 8 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 64.00 … … 5.00 … … 2004 8 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOT S) 107.00 … … 75.00 (2003) … … 2004 8 Number of cases Number of deaths 45 Acute respiratory infections 42 802 …. …. 41 19 22 2003 7 46 Diarrhoeal diseases 3187 …. …. … … … 2003 7 47 Cancers All cancers (malignant neoplasms only) 151 52 99 38 … … 2003 7 - T rachea, bronchus, and lung 22 9 13 4 4 0 2003 7 - Stomach 3 3 0 1 1 0 2003 7 - Colon and rectum 7 4 3 1 1 0 2003 7 - Lip, oral cavity and pharynx …. …. …. … … … - Liver 15 10 5 3 1 2 2003 7 - Cervix 21 3 2003 7 - Leukaemia 8 3 5 5 2 3 2003 7 48 Circulatory All circulatory system diseases 402 229 173 46 …. …. 2003 12 - Ischaemic heart disease 19 14 5 3 … … 2003 12 - Acute m yocardial infarction 7 7 0 3 3 0 2003 12 - Rheumatic fever and rheumatic heart diseases 30 18 12 2 1 1 2003 12 - Cerebrovascular diseases … … … … … … - H ypertension 225 100 125 3 2 1 2003 7 49 Maternal causes - Haemorrhage 72 … 2003 7 - Abortion 123 … 2003 12 - Eclampsia 8 … 2003 7 - Sepsis … … - Obstruc ted labour 25 … 2003 12 COUNTRY HEALTH INFORMATION PROFILE 371 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 50 Diabetes mellitus 48 13 35 18 6 12 2003 7 51 Mental disorders 133 …. …. …. …. …. 2003 7 52 Injuries g - All types 1746 …. …. 7 …. …. 2003 7 - Motor and other vehicle accidents 30 …. …. … … … 2003 7 - Suicide 29 6 23 1 0 1 2003 12 - Hom icide and violence 223 73 150 …. …. …. 2003 7 - Occupational injuries 1192 …. …. 1 …. …. 2003 7 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public heal th facilities - General hospitals 1 135 2003 7 - Specialized hospi tals … … - District/first-level referral hospitals 4 262 2003 7 - Primary health care centres 25 …. 2003 7 Private hospitals … … Notes: Red text M illennium Development Goals (MDG) indicators … Data not available est Estimate NR Not relevant aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Uni t, WHO Regional Office for the Western Pacific. b Estimates derived by regression and similar estimation methods. c Modeled data. d Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. e Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. f Figure refers to those aged 15-24 years. g Deaths are underreported. Also, deaths caused by injuries represent only hospi tal data. Information represents only 43% of the annual monthly returns (710 monthly reports out of 1644), Information has not been received for Norsup Hospital since July 2003. Sources: 1 Pacific island populations 2004. Noumea, Secretariat of the Pacific Community, 2004. 2 Vanuatu Statistics Office (http://www.spc.int/prism) 3 1999 Census. 4 Human development report 2005. New York, Uni ted Nations Development programme, 2005. 5 World health report 2005. Make every mother and child count. Geneva, World Heal th Organization, 2004. 6 Pacific Island Millennium Development Goals report 2004 . Noumea, Secretariat of the Pacific Community, UN/CROP MDG Working Group, November 2004. 7 Health Information System Ministry of Health. 8 WHO Regional Office for the Western Paci fic, data received from technical units. 9 National Health Statistics Office. 10 Meeting the MDG drinking water and sani tation target: A mid-term assessment of progress. WHO and UNICEF, 2004. 11 Information furnished by the Country Liaison Officer for Vanuatu, 11 February 2004. 12 Inpatients data. M inistry of Health. VANUATU 372 13 Changing history. World Health report 2004. Geneva, World Health Organization, 2004. 14 Urban and rural areas 2003 . New York. United Nations Department of Economic and Social Affairs, Population Division, 2004. 15 Working together for heal th . World Health report 2006. Geneva, World Health Organization, 2006. COU NTR Y HE ALTH INFOR MA TION PR OFILES | 373 VIET NAM 1. DEMOGRAPHICS, GENDER AND POVERTY The population of Viet Nam rose to 82 032 400 people in 2004, with 73.7% living in rural areas. Migration to urban areas continues at an ever-increasing rate. The percentage of the population aged below 15 years has decreased, especially in the 0-4 and 5-9 year-old age groups, while that of those over 64 years has increased, as in previous years. This is placing pressure on the health care system to deal with problems arising from an ageing population. The population growth rate in 2004 was 1.38%, about a 6.1% decrease compared with the rate in 2003. The total fertility rate was estimated to be 2.23 in 2004, an increase of 6.2% compared with the rate in 2003, and contrary to the declining trend of previous years. Also in 2004, the crude birth rate increased by 9.7% while the crude death rate decreased by 6.9%. Table 1. Core population and health data (2004 estimates) [T otal] 82 032 400 [Both] 71.30 (2002) [0-14 years] 22 977 300 (28.01%) [Male] 70.00 (2002) Population [65+ years] 5 463 400 (6.66%) Life expectancy at birth (years) [Female] 73.00 (2002) Crude birth rate (per 1000 population) 19.20 Total fertility rate 2.23 [Total] 70.10 (2003 est) [Urban] ... Crude death rate (per 1000 population) 5.40 % of population served with safe water [Rural ] 54.00 (2003 est) [Total] 25.30 (2002) [Urban] 68.30 (2002) Infant mortali ty rate (per 1000 live bi rths) 18.00 % of population with adequate sanitary facilities [Rural ] 11.50 (2002) Maternal mortali ty ratio (per 100 000 live bi rths) 85.00 est - Estimate According to the United Nations Development Programme (UNDP) classification, Viet Nam ranked 89 in the gender development index among 162 countries in 2001. Gender inequity in the country is less serious than in many other countries in the Region or in other low-income countries around the world. However, it varies across regions, particularly in the North West and the Central Highlands. The incidence of ill-health, both in general and by age group, ethnicity, educational level, poverty status, disability, residence and seasons, is generally higher in females than in males. Women are more likely to buy drugs for self-treatment and to use private health facilities and traditional medicine, but less likely to access preventive services and health facilities at higher levels, to remain in hospital for longer periods, to refer to higher levels for consultation and treatment or to visit village health workers. Per capita health expenditure among females is lower than among males. Similarly, coverage of health insurance for females is lower than for males, except for the poor, who are provided with free health insurance. Poverty reduction is one of the greatest successes of economic development in Viet Nam. The poverty rate nationwide has decreased from two-thirds to one-third in the last decade, a faster rate than in other countries at a similar level of development, but with considerable variation across regions. The Central Highlands ranks as the poorest, followed by the Northern Uplands and the Northern Central Coast. Ethnic minorities show widespread poverty and will remain poor for longer. VIET NAM 374 | COUNTRY HEALTH INFORMATION PROFILES The disparities in poverty coverage and reduction are consistent with those in health status and access to health services. Although the general health status of the Vietnamese people has improved in the last decade, as indicated by continuing improvements in the infant mortality rate, the maternal mortality ratio and other basic health indicators, the gaps between the poor and the non-poor in terms of health status, as well as access to health services, have widened. Improvements have resulted mostly among the non-poor. Significant progress has been made in developing water and sanitation infrastructure in the last decade. Improved water and sanitation facilities are less widespread in rural than in urban areas, but are developing at a higher rate. There is also a wide gap between the poor and the non-poor in terms of access to clean water and hygienic sanitation facilities. 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Viet Nam is a socialist republic and one-party state governed by the Communist Party of Viet Nam. The National Assembly is designated the highest representative body of the people and is the only organ with constitutional and legislative power. Beyond central government, People’s Committees are responsible for daily administration at local levels. Mass organizations, such as the Women’s Union, Farmers’ Union and Youth Union, accommodate the interests of the people and serve as links between the people and the Party. Although the political system is stable, the country’s senior leaders have raised concerns on a number of occasions about the lack of transparency, administrative inefficiency and corruption. Steps have been taken to strengthen open public debate and effective rule of law from the central to local level. 2.2 Economic situation Vietnamese authorities have moved to implement a free-market economy with socialist orientation, to modernize the economy and to produce more competitive, export-driven industries. This led to a strong gross domestic product (GDP) growth rate, averaging around 9% per year from 1993 to 1997. Following the 1997 Asian financial crisis, the annual GDP growth rate fell to 5% in 1999, and then rose to 7.7% in 2004, at an average rate of 7.04% per year. The unemployment rate in the whole country, after increasing from 5.88% to 6.85% during the period from 1996 to 1998, gradually decreased to 5.60% in 2004. It has remained highest in the Red Delta Region of the country for many years. The rate of working time, used in rural areas, increased from 72.28% in 1996 to 79.10% in 2004. Unemployment is a greater problem for young urban males than for any other group. 3. HEALTH SITUATION 3.1 Health trends Good progress has been made in child survival. From 1993 to 2004, the infant mortality and under-five mortality rates decreased rapidly by 59.3% and 48.6% (approximately 2.2-2.4 per 1000 live births per year) to the current rates of 18.0 and 28.5, respectively, and the country’s IMR is half that of South-East Asia as a whole. Viet Nam, however, remains among the 42 countries accounting for 90% of under-five deaths in the world, and neonatal deaths represent more than 75% of infant deaths and more than 50% of under-five deaths. Despite a gradual decrease, maternal mortality remains relatively high, mainly among ethnic minorities and in remote areas. Child nutrition has improved dramatically, with rapid annual reductions of around 2% in both the underweight and stunting rates among children under five between 1993 and 2004. COUNTRY HEALTH INFORMATION PROFILES | 375 However, the rates are still high, at about 26.6% and 30.7%, respectively, and micronutrient deficiencies are a significant problem. Large disparities in health status exist between different geographical regions and population groups. Health indicators in the Central Highlands, the Northern Uplands, and the Northern Central Coast are considerably worse than in the rest of the country. Health status in rural areas is poorer than urban areas, with ethnic minorities and people in mountainous areas lowest on the scale. Maternal and infant mortality among ethnic minority groups can be as much as four times higher than the national average. In remote and mountainous areas, maternal and infant mortality rates are increasing among the poorest 20% of the population. The incidence of communicable diseases has fallen in recent decades, represented in a decrease in total morbidity and mortality rates from 55.5% and 53.05% in 1976 to 26.13% and 17.00% in 2004, respectively. Urolithiasis and diseases of the appendix are no longer among the ten leading causes of morbidity, and acute pharyngitis and acute tonsillitis, and intracranical injury have fallen in ranking. The ten leading causes of mortality remained the same in 2004 as in the previous year, with acute respiratory infection (ARI), diarrhoea and parasitic infections the most common childhood diseases. New or re-emerging diseases, such as tuberculosis (TB), HIV/AIDS, dengue fever and Japanese encephalitis, are increasing. On average, there are more than 58 389 new TB patients every year. The proportion of HIV infections among persons under 30 years of age has been increasing in recent years. In 2004, HIV/AIDS, with a 44.2% increase in mortality compared with 2003, became the second most common cause of hospital deaths. Severe acute respiratory syndrome (SARS) was detected in its early stages in Viet Nam. Fatality remained relatively low, with five deaths out of 63 cases. The situation contributed to the reinforcement of infection control measures in the country and sensitized health workers and the population to ‘universal precautions’. Highly pathogenic avian influenza (HPAI) was first recognized in late 2003 and has subsequently caused waves of extensive outbreaks. The influenza A/H5N1 virus had led to the death of 42 out of 93 reported cases of infected persons by February 2006. Noncommunicable diseases have shown a tendency to increase in the last two decades, with total morbidity rising from 39% in 1986 to 60.81% in 2004, and mortality from 41.08% to 57.91%. Cardiovascular diseases, cancer and diabetes are significant contributing factors. Intracerebral haemorrhage has an extremely high prevalence in emergency/intensive care units and has been among the leading causes of death in recent years. Heart disease is one of the most common causes of death in hospitals. The number of cancer cases is rising, with an estimated 150 000 newly reported cases annually. There is no national cancer control programme as yet and diagnosis tends to be made in the late stages. Lifestyle-related health problems are becoming increasingly important, particularly tobacco use, alcohol and drug abuse, injuries due to road accidents, violence, suicide and mental health. Accidents, injuries and poisoning are set to overtake infectious diseases as the most common causes of mortality, accounting for 25.09% of total deaths in 2004. Drug abuse is a growing concern and the vast majority of the 97 000 registered drug users are under the age of 30. Viet Nam is witnessing the emergence of high drug resistance to common antibiotics and has yet to formulate a strategy to tackle the problem. 3.2 Health systems The health system in Viet Nam is a mixed public-private provider system in which the public system still plays a key role in health care, especially in prevention, research and training. The private sector has grown steadily since the ‘reform’ of the health sector in 1989, but is mainly active in outpatient care; inpatient care is provided essentially through the public sector. Only 26% of private health facilities participate in primary health care activities. In treatment areas, VIET NAM 376 | COUNTRY HEALTH INFORMATION PROFILES specialized hospitals and clinics account for only 11.36% of health facilities and are therefore often overloaded. The ratio of nurses to doctors is still very low. Health care is strengthened by national health programmes, especially those for important public health problems. The tuberculosis control programme is now considered to be one of the best, with treatment success rates of more than 90%. However, coverage in poor communities and mountainous areas is limited, usually only 50%-60%. The extended immunization programme is also considered a successful child health intervention, resulting in high reduction rates in vaccine-preventable diseases, the elimination of polio, and the gradual elimination of newborn tetanus. However, current conditions for vaccine maintenance, vaccination timing and safety, as well as high staff turnover, are among the current challenges to ensuring the continued quality of child immunization. Total health expenditure in 2003 was 5.22% of GDP and government expenditure accounted for only 42.17% of the total health expenditure for 2004. The majority of the government expenditure was allocated to treatment, with increasing rates from 71.29% in 1991 to 85.02% in 2000. Budget allocation for prevention remains low and continues to decrease. Generally speaking, health insurance policies have not been implemented in the private sector. Pro-poor policies, such as providing health insurance cards for the poor, direct exemption from hospitalization fees, and the establishment of health care funds, are being actively implemented, but with limited coverage because of budget shortages. The current, most pressing issues are improving the quality of care, rationalizing and training health staff, and increasing public funding for health care through extension of health insurance coverage. Inequity is highest in outpatient and rehabilitation services. A large disparity in access to health care facilities exists across regions and population groups, particularly in mountainous areas and among minority ethnic groups and the poor. Access to blood transfusion services is also variable throughout the country and paid blood donors are still the main source of blood. The volume of blood collected, however, does not meet the needs of patients. 4. NATIONAL HEALTH PLAN AND PRIORITIES The Law on People’s Health Protection, issued by the National Assembly in 1989, sets out the responsibilities and rights of citizens, the Government, social organizations and enterprises in the protection and improvement of the population’s health, and provides the legal basis for all health activities in Viet Nam. In January 1993, the Executive Committee of the Central Communist Party released Central Resolution No. 4, which set out three key issues for the health sector: • the need to increase the government budget for health; • the need to consolidate and develop the basic health care network, with a special focus on poor and disadvantaged areas; and • the role of the Government, Party authorities and social organizations in the leadership and supervision of health care. The Government has set out ambitious goals and targets in the Ten-Year Socio-Economic Development Strategy, the Comprehensive Poverty Reduction and Growth Strategy and the National Strategy for People’s Health Care 2001–2010. These include substantially improving the human development index of the country and providing prevention and treatment services to all citizens. Recently, in order to catch up with the new context, the Minister of Health promulgated the five- year plan for the health sector, setting the following new targets for 2010: • to increase the average life expectancy to 72 years; • to reduce the maternal mortality ratio to below 70 per 100 000 live births; • to reduce the infant mortality rate to below 16 per 1000 live births; • to reduce the under-five mortality rate to below 25 per 1000 live births; COUNTRY HEALTH INFORMATION PROFILES | 377 • to reduce the percentage of low-birth-weight infants to below 6%; • to reduce the percentage of malnourished under-five children to below 20%; • to increase the average height of young people to at least 160 cm; • to increase the ratio of medical doctors per population to 4.5/10 000; and • to increase the ratio of college-trained pharmacists to 1/10 000 population. 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 among the entire population (ethnic minority groups, women, children, the 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 medicine and implementing the national drug policy in order to promote the rational and effective use of modern and traditional drugs; • developing new technology to catch up with other countries in the Region; and • improving planning and management capacity in all areas within the health sector. As it stands today, the National Strategy provides a broad basis for further planning and can be seen as an orientation document for the development of the health sector. However, it does not provide specific solutions on how to: (1) ensure equal access to health care; (2) improve the performance of the health system and the quality of care; (3) rationalize the use of and expenditure on drugs; and (4) respond to new public health problems, including noncommunicable diseases. Some recent policies have begun to address those issues. For example, in October 2002, the Prime Minister signed Decree 139 to establish the Health Care Fund for the Poor, which aims to provide free health services for 14.6 million people. As of December 2003, 11 million people had received health care through this financing mechanism. Earlier, in January 2002, the Ministry of Health published the Directive on Consolidating and Strengthening the Basic Health Care Network (06- CT/TW). However, Viet Nam still faces a number of key challenges, such as: • achieving adequate recognition that improved health outcomes are central to poverty reduction and economic growth and that health improvements require an intersectoral approach to address broad health determinants; • developing a clear consensus among policy-makers on the road to developing an efficient equity-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 VIET NAM 378 | COUNTRY HEALTH INFORMATION PROFILES and the lack of responsiveness of health services to the needs of the poor; • strengthening the public health agenda to address the incomplete agenda of infectious diseases and the problems brought about by urbanization, changing lifestyles and an ageing population; • strengthening capacities at district and provincial levels to prioritize and implement successful interventions within an increasingly decentralized health system; and • improving the enforcement of regulations and speeding up the implementation of public administration reform. 5. MAJOR INFORMATION SOURCES Health Statistical Year Books, 1998-2004. Hanoi, Ministry of Health, 1999-2005. Statistical Year Book 2003. Hanoi, General Statistics Office, 2004. Vietnam Development Report: Poverty. Joint Donor Report to the Vietnam Consultative Group Meeting. Hanoi, 2003. Reports on National Health Survey 2001-2002. Hanoi, Ministry of Health and General Statistics Office, 2003. Millennium Development Goals: Closing to the Millennium Gaps. Hanoi, United Nations, 2003. Health Policies and Guidelines. Hanoi, Health Policy Unit, Ministry of Health, 2002. http://www.moh.gov.vn/tinbyt/ http://www.gso.gov.vn/ 6. ADDRESSES MINISTRY OF HEALTH Office Address : 138A Giang Vo, Hanoi, Viet Nam Postal Address : Official Email Address : Telephone : (84 4) 846 1325 Fax : (84 4) 846 4051 Office Hours : Website : http://www.moh.gov.vn/tinbyt/ WHO REPRESENTATIVE IN VIET NAM Office Address : 63 Tran Hung Dao Street, Hoan Kiem District Ha Noi, Socialist Republic of Viet Nam Postal Address : P.O. Box 52, Ha Noi, Socialist Republic of Vietnam Official Email Address : who@vtn.wpro.who.int Telephone : (84 4) 943 3734 Fax : (84 4) 943 3740 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILES | 379 ORGANIZATIONAL CHART: MINISTRY OF HEALTH VIET NAM 380 VIET NAM WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 332.60 2003 1 2 Estimated population ('000s) 82 032.40 40 317.90 41 714.50 2004 est 1 3 Annual population growth rate (%) 1.38 … … 2004 est 1 4 Percentage of population - 0–14 years 28.01 29.48 26.53 2004 est 1 - 65+ years 6.66 5.42 7.85 2004 est 1 5 Urban population (%) 26.30 49.00 51.00 2004 1 6 Crude birth rate (per 1 000 population) 19.20 … … 2004 est 1 7 Crude death rate (per 1 000 population) 5.40 … … 2004 est 1 8 Rate of natural increase of population (% per annum) 1.50 … … 2003 1 9 Life expectancy (years) - at birth 71.30 70.00 73.00 2002 1 - Heal th-adjusted Life Expectancy (H ALE) at age 60 … 11.40 13.10 2002 7 10 Adult literacy rate (%) 92.70 94.50 90.90 2002 2 11 Neonatal mortality rate (per 1 000 live births) … … … 12 Infant mortality rate (per 1 000 live births) 18.00 … … 2004 est 1 13 Under-five mortality rate (per 1 000 live births) 28.50 … … 2004 est 1 14 Total fertility rate (women aged 15–49 years) 2.23 2004 est 1 15 Maternal mortality ratio (per 100 000 live births) 85.00 2004 est 1 16 Percentage of newborn infants weighing at least 2500 g at birth 94.20 … … 2004 1 17 Prevalence of underweight children under five years of age 26.60 … … 2004 1 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 95.60 … … 2004 10 - DTP3 96.20 … … 2004 10 - OPV3 96.30 … … 2004 10 - Measles 97.10 … … 2004 10 - Hepati tis B III 94.20 … … 2004 10 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel 95.80 2004 1 - Percentage of pregnant women immunized with tetanus toxoid (TT2) 91.00 2004 1 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in heal th facilities (as % of total deliveries) 82.00 2004 1 21 Percentage of women in the reproductive age group using modern contraceptive methods 75.70 2004 1 22 Condom use rate of the contraceptive prevalence rate 9.31 … … 2004 1 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … COUNTRY HEALTH INFORMATION PROFILE 381 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 70.10 … 54.00 2003 est 1 26 Proportion of population with access to improved sanitation 25.30 68.30 11.50 2002 4 27 Proportion of the population using solid fuels for cooking or heating (%) 70.00 ... ... 2003 3 28 Proportion of households with access to secure tenure ... ... ... 29 Proportion of vehicles using unleaded gasoline (%) ... ... ... 30 Health care waste generation (metric tons per year) ... ... ... 31 Human development index 0.70 ... ... 2003 2 32 Per capita GDP at current market prices (VND) 8 692 910.00 ... ... 2004 est 1 33 Rate of growth of per capita GDP (%) 16.15 ... ... 2004 1 34 Health expenditure Total health expenditure - amount (in m illion US$) 2 072.16 d 2003 6 - total heal th expenditure on health as % of GDP 5.22 d 2003 6 - per capita total expendi ture on health (in US$) 25.60 d 2003 6 Government expenditure on health - amount (in million US$) 874.00 2004 est 1 - general government expenditure on health as % of total expenditure on health 42.17 2004 est 6 - general government expenditure on heal th as % of total general government expendi ture 7.34 2004 est 1 External source of government health expenditure - external resources for heal th as % of general government expendi ture on health 1.13 2004 est 1 Private health expenditure - private expenditure on health as % of total expenditure on heal th 70.03 2003 6 Exchange rate in US$ of local currency is: 1 US$ = 15 500.00 (average) 2003 8 35 Health insurance coverage as % of total population 16.00 2002 5 INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 48 215 … … 5.88 … … 2004 1 - dentists … … … … … … - pharmacists 25 165 … … 3.06 … … 2004 1 - nurses 49 534 … … 6.02 … … 2004 1 - m idwives 17 610 … … 2.14 … … 2004 1 - other nursing / auxiliary staff … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 57 822 … … 7.02 … … 2004 1 - other heal th personnel (health inspec tors, assistant sani tarians, traditional workers, etc.) 46 724 … … 5.68 … … 2004 1 37 Yearly new graduates – physicians … … … 38 Yearly new graduates – nurses … … … VIET NAM 382 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population a 1. Pneumonia 254 528 … … 310.28 … … 2004 1 2. Acute pharyngitis and acute tonsillitis 238 780 … … 291.08 … … 2004 1 3. Acute bronchitis and acute bronchioli tis 206 641 … … 251.90 … … 2004 1 4. Diarrhoea and gastroenteritis of presumed infectious origin. 161 174 … … 196.48 … … 2004 1 5. Transport accident 147 850 … … 180.23 … … 2004 1 6. Essential (primary) hypertension 132 173 … … 161.12 … … 2004 1 7. Gastri tis and duodeni tis 106 298 … … 129.58 … … 2004 1 8. Influenza 92 685 … … 112.99 … … 2004 1 9. Respiratory tuberculosis 58 911 … … 71.81 … … 2004 1 10. Intracranial injury 55 860 … … 68.10 … … 2004 1 40 Ten leading causes of mortality Number Rate per 100 000 population 1. Intracranial injury 2521 … … 3.07 … … 2004 1 2. Human immunodeficienc y virus disease 1754 … … 2.14 … … 2004 1 3. Transport accident 1609 … … 1.96 … … 2004 1 4. Pneumonia 1224 … … 1.49 … … 2004 1 5. Intracerebral haemorrhage 1070 … … 1.30 … … 2004 1 6. Acute myocardial infarction 775 … … 0.94 … … 2004 1 7. Stroke, not specified as haemorrhage or infarction 771 … … 0.94 … … 2004 1 8. Respiratory tuberculosis 770 … … 0.94 … … 2004 1 9. Heart failure 627 … … 0.76 … … 2004 1 10. Septicemia 507 … … 0.62 … … 2004 1 41 Selected diseases under the WHO- EPI Number of cases (C) Number of deaths (D) - Diphtheria 49 … … 1 … … 2004 C: 3, D: 1 - Pertussis (whooping cough) 328 … … 1 … … 2004 C: 3, D: 1 - T etanus 72 … … 14 … … 2004 C: 3, D: 1 - Neonatal tetanus 46 … … 32 … … 2004 C: 3, D: 1 - Poliomyelitis 0 0 0 0 0 0 2004 3 - Hib meningitis … … … 12 … … 2004 C: 3, D: 1 - Measles 217 … … 0 0 0 2004 C: 3, D: 1 - Mumps … … … … … … - Rubella … … … … … … - Congeni tal rubella syndrome … … … … … … 42 Selected communicable diseases Number of cases aa Number of deaths Hepati tis vi ral 8022 … … 8 … … 2004 1 - T ype A … … … … … … - T ype B … … … … … … - T ype C … … … … … … - T ype E … … … … … … - Unspecified … … … … … … Cholera 67 … … 1 … … 2004 1 Typhoid fever 4 257 … … 1 … … 2004 1 Encephalitis 2257 … … 74 … … 2004 1 COUNTRY HEALTH INFORMATION PROFILE 383 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Plague 0 … … 0 0 0 2004 1 Syphilis 2543 … … 0 0 0 2004 1 Gonorrhoea 6409 … … 0 0 0 2004 1 Leprosy 858 … … … … … 2004 3 Malaria (confirmed) 24 909 … … 34 … … 2004 3 Dengue/DHF 78 669 … … 114 … … 2004 3 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) 30.00 ... ... 0.04 ... ... 2004 3 - Proportion of population in malaria-risk areas using effective malaria prevention measures b … - Proportion of population in malaria-risk areas using effective malaria treatment measures c … 44 Tuberculosis Number of cases Number of deaths - All types 98 389 … … … … … 2004 3 - New pulmonary tuberculosis (smear-posi tive) 58 389 … … … … … 2004 3 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 232.00 ... ... 22.00 ... ... 2004 3 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOT S) 89.00 ... ... 92.00 (2003) ... ... 2004 3 Number of cases Number of deaths 45 Acute respiratory infections 351 645 … … 100 … … 2004 1 46 Diarrhoeal diseases 280 733 … … 263 … … 2004 1 47 Cancers All cancers (malignant neoplasms only) 123 183 … … 768 … … 2004 1 - T rachea, bronchus, and lung 6614 … … 155 … … 2004 1 - Stomach 5458 … … 104 … … 2004 1 - Colon and rectum 4714 … … 53 … … 2004 1 - Lip, oral cavity and pharynx 2481 … … 19 … … 2004 1 - Liver 5235 … … 146 … … 2004 1 - Cervix 2831 10 2004 1 - Leukaemia 2764 … … 79 … … 2004 1 48 Circulatory All circulatory system diseases 288 786 … … 2499 … … 2004 1 - Ischaemic heart disease 23 766 … … 101 … … 2004 1 - Acute m yocardial infarction 7723 … … 775 … … 2004 1 - Rheumatic fever and rheumatic heart diseases 18 668 … … 93 … … 2004 1 - Cerebrovascular diseases 78 854 … … 2080 … … 2004 1 - H ypertension 170 766 … … 331 … … 2004 1 VIET NAM 384 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 49 Maternal causes - Haemorrhage 2 133 80 2004 1 - Abortion 28 537 … 2004 1 - Eclampsia 438 8 2004 1 - Sepsis 329 5 2004 1 - Obstruc ted labour … … 50 Diabetes mellitus 20 474 … … 135 … … 2004 1 51 Mental disorders 42 497 … … 25 … … 2004 1 52 Injuries - All types 394 871 … … 2588 … … 2004 1 - Motor and other vehicle accidents 147 850 … … 609 … … 2004 1 - Suicide 20 223 … … 431 … … 2004 1 - Hom icide and violence 16 948 … … 99 … … 2004 - Occupational injuries 1 407 … … 62 … … 2002 1 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public heal th facilities 13 366 188 906 2004 1 - General hospitals 730 e 98 092 2004 1 - Specialized hospi tals 101 f 20 780 2004 1 - District/first-level referral hospitals 946 10 310 2004 1 - Primary health care centres 11 357 42 966 2004 1 Private hospitals … … Notes: Red text M illennium Development Goals (MDG) indicators … Data not available Est Estimate aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphans age 10-14 years. a Computed by Health Information and Evidence for Policy Uni t of the WHO Regional Office for the Western Pacific . b Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. c Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. d Revised data e Figure excludes district hospi tals f Figure refers to polyclinic, maternity homes, etc. Sources: 1 Health Statistics Yearbook 2004: HSID . Planning and Finance Department, Ministry of Health. 2 Human Development Report 2005. New York, United Nations Development Programme, 2005. 3 WHO Regional Office for the Western Paci fic, data received from technical units 4 Health Statistics Yearbook 2002: HSID . Planning and Finance Department, Ministry of Health. 5 Viet Nam Social Securi ty (VSS) Statistics Yearbook 2002 6 National Health Account: The process of implementation and development in Vietnam. Hanoi, Ministry of Health, 2004. 7 The World health report 2004: Changing history. Geneva, World Heal th Organization, 2004. 8 Information furnished by the WHO Representative for Viet Nam, 28 April 2006. COUNTRY HEALTH INFORMATION PROFILES | 385 WALLIS AND FUTUNA 1. DEMOGRAPHICS, GENDER AND POVERTY The estimated population of Wallis and Futuna in 2005 was 15 016, comprising 7741 males and 7275 females. Overall, the life expectancy was 74.3 years, 73.1 for males and 75.5 for females. The average age of the population was 23.9 years. Table 1. Core population and health data (2005 estimates) [Total] 15 016 [Both] 74.30 (2003 est) [0-14 years] 5105 (34.00%) [Male] 73.10 (2003 est) Population [65+ years] 733 (4.88% ) Life expectancy at birth (years) [Female] 75.50 (2003 est) Crude birth rate (per 1000 population) 19.40 (2003) Total fertility rate 3.10 (2003 est) [Total] 80.90 (2003) [Urban] … Crude death rate (per 1000 population) 5.90 (2003) % of population served with safe water [Rural] … [Total] 68.50 (2003) [Urban] … Infant mortality rate (per 1000 live births) 5.90 (2003 est) % of population with adequate sanitary facilities [Rural] … Maternal mortality ratio (per 100 000 live births) … est - Estimate 2. POLITICAL AND SOCIOECONOMIC SITUATION 2.1 Political situation Wallis and Futuna is a French overseas territory. The Chief of State is President Jacques Chirac of France, and the head of government is the President of the Territorial Assembly, Patalione Kanimoa. There are three traditional kings with limited powers; the kingdoms are Uvea, Alo and Sigave. 2.2 Economic situation The economy of Wallis and Futuna is limited to traditional subsistence agriculture, with about 80% of labour force earnings from agriculture (coconut and vegetables), livestock (mostly pigs) and fishing. About 4% of the population is employed by the Government. Revenues come from French Government subsidies, licensing of fishing rights to Japan and the Republic of Korea, import taxes, and remittances from expatriate workers in New Caledonia. 3. HEALTH SITUATION 3.1 Health trends Dengue outbreaks in Wallis and Futuna were reported in 1976 (Type I), 1988 (Type II) and 1989 (Type II and III). The last outbreak started in September 2002. In 2004, 41 dengue cases were reported. Other data for health indicators are not available. WALLIS AND FUTUNA 386 | COUNTRY HEALTH INFORMATION PROFILES 3.2 Health systems As of 2003, there were one hospital and three dispensaries in Wallis, and one hospital and two dispensaries in Futuna. As for the health workforce, there were five physicians in Wallis and three in Futuna, two midwives in Wallis and one in Futuna, and three dentists in Wallis and one in Futuna. Only Wallis has a chemist, biologist, gynaecologist, surgeon, anaesthetist and internist. Wallis and Futuna each have a physical therapist. 4. NATIONAL HEALTH PLAN AND PRIORITIES There is no information available. 5. MAJOR INFORMATION SOURCES Secretariat of the Pacific Community (http://www.spc.int/prism/wf/) Draft of WHO mission report by Dr K.Ichimori to Wallis and Futuna from 9-13 May 2003. WHO Western Pacific Regional Office, MR/2003/0439 Pacific Magazine, January 2004 http://www.pacificislands.cc World Factbook , CIA (http://www.cia.gov/cia/publications/factbook/geos/wf.html) 6. ADDRESSES MINISTRY OF HEALTH Office Address : Postal Address : B.P. 4G Mata’utu, 98600 Uvea Official Email Address : sante.wf@wallis.co.nc Telephone : Fax : (681) 72-23-99 Office Hours : Website : WHO REPRESENTATIVE IN SOUTH PACIFIC Office Address : Level 4, Provident Plaza 1, Downtown Boulevard, 33 Ellery Street, Suva Postal Address : P.O. Box 113, Suva, Fiji Official Email Address : who@sp.wpro.who.int Telephone : (679) 330 4600 / 330 4631 / 330 4635 / 331 7447 Fax : (679) 330 0462 / 331 1530 Office Hours : Website : COUNTRY HEALTH INFORMATION PROFILE 387 WALLIS AND FUTUNA WESTERN PACIFIC REGION HEALTH DATABANK, 2006 Revision INDICATORS DATA Year Source Total Male Female 1 Area (1 000 km2) 0.14 2003 1 2 Estimated population ('000s) 15.02 7.74 7.28 2005 est 2 3 Annual population growth rate (%) 1.00 a … … 2003 est 1 4 Percentage of population - 0–14 years 34.00 34.03 33.97 2005 est 2 - 65+ years 4.88 4.15 5.66 2005 est 2 5 Urban population (%) 0.00 … … 2005 2 6 Crude birth rate (per 1 000 population) 19.40 … … 2003 5 7 Crude death rate (per 1 000 population) 5.90 … … 2003 5 8 Rate of natural increase of population (% per annum) 1.63 … … 2003 1 9 Life expectancy (years) - at birth 74.30 73.10 75.50 2003 est 5 - Heal th-adjusted Life Expectancy (H ALE) at age 60 … … … 10 Adult literacy rate (%) 78.80 g 78.20 g 78.20 g 2003 5 11 Neonatal mortality rate (per 1000 live births) … … … 12 Infant mortality rate (per 1000 live births) 5.90 … … 2003 est 5 13 Under-five mortality rate (per 1000 live births) … … … 14 Total fertility rate 3.10 2003 est 5 15 Maternal mortality ratio (per 100 000 live births) … 16 Percentage of newborn infants weighing at least 2500 g at birth … … … 17 Prevalence of underweight children under five years of age … … … 18 Percentage of pregnant women with anaemia … 19 Immunization coverage for infants (%) - BCG 73.50 … … 2002 3 - DTP3 100.00 … … 2002 3 - OPV3 100.00 … … 2002 3 - Measles 100.00 … ... 2002 3 - Hepati tis B III 100.00 … … 2002 3 20 MCH coverage (pregnancies, deliveries, infant care) - Percentage of pregnant women cared for by skilled health personnel … - Percentage of pregnant women immunized with tetanus toxoid (TT2) 69.50 2002 3 - Percentage of deliveries at home by skilled health personnel (as % of total deliveries) … - Percentage of deliveries in heal th facilities (as % of total deliveries) … 21 Percentage of women in the reproductive age group using modern contraceptive methods … 22 Condom use rate of the contraceptive prevalence rate … … … 23 HIV prevalence among 15–24 year-old pregnant women … 24 Number of children orphaned by HIV/AIDS ab … … … WALLIS AND FUTUNA 388 INDICATORS DATA Year Source Total Urban Rural 25 Proportion of population with sustainable access to an improved water source 80.90 … … 2003 5 26 Proportion of population with access to improved sanitation 68.50 … … 2003 5 27 Proportion of the population using solid fuels for cooking or heating (%) … … … 28 Proportion of households with access to secure tenure … … … 29 Proportion of vehicles using unleaded gasoline (%) … … … 30 Health care waste generation (metric tons per year) … … … 31 Human development index … … … 32 Per capita GDP at current market prices (US$) … … … 33 Rate of growth of per capita GDP (%) … … … 34 Health expenditure Total health expenditure - amount (in m illion US$) … - total heal th expenditure on health as % of GDP … - per capita total expendi ture on health (in US$) … Government expenditure on health - amount (in million US$) 4.79 2003 est 5 - general government expenditure on health as % of total expenditure on health … - general government expenditure on heal th as % of total general government expendi ture 7.58 a 2003 5 External source of government health expenditure - external resources for heal th as % of general government expendi ture on health … Private health expenditure - private expenditure on health as % of total expenditure on heal th … Exchange rate in US$ of local currency is: 1 US$ = 95.42 CFP (average) 2005 5 35 Health insurance coverage as % of total population … INDICATORS DATA Year Source Total Male Female Total Male Female Number Rate per 10 000 population 36 Health workforce - physicians 11e … … 7.36 b … … 2003 4 - dentists 4 … … 2.70 … … 2003 4 - pharmacists … … … … … … - nurses … … … … … … - m idwives 5 … … 3.38 … … 2003 4 - other nursing/ auxiliary staff … … … … … … - other paramedical staff (e.g. medical assistants, laboratory technicians, X-ray technicians) 2 … … 1.34 … … 2003 4 - other heal th personnel (health inspec tors, assistant sani tarians, traditional workers, etc.) … … … … … … 37 Yearly new graduates –- physicians … … … 38 Yearly new graduates – nurses … … … COUNTRY HEALTH INFORMATION PROFILE 389 INDICATORS DATA Year Source Total Male Female Total Male Female 39 Ten leading causes of morbidity Number Rate per 100 000 population 1. … … … … … … 2. … … … … … … 3. … … … … … … 4. … … … … … … 5. … … … … … … 6. … … … … … … 7. … … … … … … 8. … … … … … … 9. … … … … … … 10. … … … … … … 40 Ten leading causes of mortality Number Rate per 100 000 population 1. … … … … … … 2. … … … … … … 3. … … … … … … 4. … … … … … … 5. … … … … … … 6. … … … … … … 7. … … … … … … 8. … … … … … … 9. … … … … … … 10. 41 Selected diseases under the WHO- EPI Number of cases Number of deaths - Diphtheria 0 0 0 0 0 0 2004 3 - Pertussis (whooping cough) 0 0 0 0 0 0 2004 3 - T etanus 0 0 0 0 0 0 2004 3 - Neonatal tetanus 0 0 0 0 0 0 2004 3 - Poliomyelitis 0 0 0 0 0 0 2004 3 - Hib meningitis 0 0 0 0 0 0 2004 3 - Measles 0 0 0 0 0 0 2004 3 - Mumps 0 0 0 0 0 0 2004 3 - Rubella 1 … … … … … 2004 3 - Congeni tal rubella syndrome 0 0 0 0 0 0 2004 3 42 Selected communicable diseases Number of cases aa Number of deaths Hepati tis vi ral - T ype A … … … … … … - T ype B … … … … … … - T ype C … … … … … … - T ype E … … … … … … - Unspecified … … … … … … Cholera … … … … … … Typhoid fever … … … … … … Encephalitis … … … … … … Plague … … … … … … Syphilis … … … … … … Gonorrhoea (gonococcal infections) … … … … … … Leprosy 0 0 0 0 0 0 2003 3 WALLIS AND FUTUNA 390 INDICATORS DATA Year Source Total Male Female Total Male Female 42 Selected communicable diseases Number of cases aa Number of deaths Malaria … … … … … … Dengue/DHF 41 … … 0 0 0 2004 3 43 Malaria Prevalence rates Death rates - Rates associated with malaria (per 100 000 population) … … … … … … - Proportion of population in malaria-risk areas using effective malaria prevention measures c … - Proportion of population in malaria-risk areas using effective malaria treatment measures d … 44 Tuberculosis Number of cases Number of deaths - All types 15 … … … … … 2003 3 - New pulmonary tuberculosis (smear-posi tive) 7 … … … … … 2003 3 Prevalence rates Death rates - Rates associated with tuberculosis (per 100 000 population) 28.00 … … 2.00 … … 2004 3 Detection rates Success rates - Proportion of tuberculosis cases detected and cured under directly observed treatment, short-course (DOT S) 344.00 b … … 100.00 (2002) … … 2003 3 Number of cases Number of deaths 45 Acute respiratory infections … … … … … … 46 Diarrhoeal diseases … … … … … … 47 Cancers All cancers (malignant neoplasms only) … … … … … … - T rachea, bronchus and lung … … … … … … - Stomach … … … … … … - Colon and rectum … … … … … … - Lip, oral cavity and pharynx … … … … … … - Liver … … … … … … - Cervix … … - Leukaemia … … … … … … 48 Circulatory All circulatory system diseases … … … … … … - Ischaemic heart disease … … … … … … - Acute m yocardial infarction … … … … … … - Rheumatic fever and rheumatic heart diseases … … … … … … - Cerebrovascular diseases … … … … … … - H ypertension … … … … … … 49 Maternal causes - Haemorrhage … … - Abortion … … - Eclampsia … … - Sepsis … … - Obstruc ted labour … … COUNTRY HEALTH INFORMATION PROFILE 391 INDICATORS DATA Year Source Total Male Female Total Male Female Number of cases Number of deaths 50 Diabetes mellitus … … … … … 51 Mental disorders … … … … … … 52 Injuries - All types … … … … … … - Motor and other vehicle accidents … … … … … … - Suicide … … … … … … - Hom icide and violence … … … … … … - Occupational injuries … … … … … … 53 Proportion of population with access to affordable essential drugs on a sustainable basis … 54 Health infrastructure Number Number of beds Public heal th facilities - General hospitals 2 74 2003 4 - Specialized hospi tals … … - District/first -level referral hospitals … … - Primary health care centres 5 f … 2003 4 Private hospitals … … Notes: Red text M illennium Development Goals (MDG) indicators … Data not available est Estimate aa Figures refer to number of new reported cases. ab Proxy indicator for MDG indicator 20: Ratio of school attendance of orphans and school attendance of non-orphan age 10-14 years. a Computed by Health Information and Evidence for Policy Uni t of the WHO Regional Office for the Western Pacific . b Revised data. c Prevention is measured by the percentage of children ages 0–59 months sleeping under insecticide-treated bednets. d Treatment is measured by the proportion of children ages 0–59 months who were ill with the fever in the two weeks before the survey and who received appropriate antimalarial drugs. e Figure refers to physicians and specialists. f Figure includes dispensaries. g Figure refers to aged 19 years and above. Sources: 1 Pacific island populations 2004. Secretariat of the Pacific Community (http://www.spc.int) 2 Demographic tables for the Western Paci fic Region 2005-2010. Manila, WHO Regional Office for the Western Pacific, 2005. 3 WHO Regional Office for the Western Paci fic, data received from technical units 4 Information furnished by the WHO Representative to the South Paci fic, 30 March 2004 5 Service terri torial de la statistique (http://www.spc.int/prism /wf/) Statistical Tables STATISTICAL TABLES 394 American Samoa 2005 est 65.50 0.20 327.50 Australia 2005 20 328.60 7692.02 2.64 Brunei Darussalam 2004 359.70 5.77 62.34 Cambodia 2004 13 091.00 181.04 72.31 China 2004p 1 299 880.00 9600.00 135.40 Cook Islands 2005 20.20 0.24 84.17 Fiji 2005 est 846.09 18.27 46.31 French Polynesia 2005 est 254.60 3.52 72.33 Guam 2005 168.56 0.54 312.15 Hong Kong (China) 2005 6935.90 1.10 6305.36 Japan 2005 est 127 757.00 377.89 338.08 Kiribati 2004 est 93.10 0.81 114.94 Lao People's Democratic Republic 2005 5609.90 236.80 23.69 Macao (China) 2004 465.33 0.03 15 511.00 Malaysia 2005p 26 127.70 330.25 79.12 Marshall Islands 2004 est 61.22 0.18 340.11 Micronesia, Federated States of 2005 est 114.10 0.70 163.00 Mongolia 2004 2533.10 1565.00 1.62 Nauru 2005 est 13.84 0.02 692.00 New Caledonia 2004 230.79 18.58 c 12.42 New Zealand 2005 est 4098.90 a 270.69 d 15.14 Niue 2005 est 1.73 0.26 6.65 Northern Mariana Islands 2005 est 80.36 0.47 170.98 Palau 2005 19.91 0.49 40.63 Papua New Guinea 2005 est 5950.69 462.84 12.86 Philippines 2005 85 236.91 300.00 284.12 Pitcairn Islands 2004 est 0.05 0.04 1.25 Republic of Korea 2005 48 294.14 99.62 484.78 Samoa 2004 est 182.70 2.94 62.14 Singapore 2005 3553.50 a 0.70 5076.43 Solomon Islands 2005 est 478.00 28.90 16.54 Tokelau 2005 est 1.53 0.01 153.00 Tonga 2005 est 102.37 0.65 157.49 Tuvalu 2005 est 10.88 0.03 362.67 Vanuatu 2005 est 221.85 12.19 18.20 Viet Nam 2004 est 82 032.40 332.60 246.64 Wallis and Futuna 2005 est 15.02 0.14 107.29 WESTERN PACIFIC REGION 2005 est 1 745 620.00 b . . . . . . Table 1 Demographic indicators ... Data not available est Estimate p Preliminary a Figure applies to resident population. b Interpolated based on 2000 and 2005 population estimates in World Population Prospects: The 2002 Revision, UN Economic and Social Affairs. c Revised data. d Figure excludes inland waters and oceanic areas. Country/area Year Total Population Surface Area Population Density (‘000s) (in 1000 sq km) (per sq km) STATISTICAL TABLES 395 Year Urban Year Growth Year < 15 years 65+ years Aged 60 years or older by (%) Rate (%) (%) gender (2005) (%) Male Female Percent Distribution of PopulationPopulation 2003 54.00 2005 2.30 2004 est 38.95 3.58 6.51 8.18 2001 86.50 2004-2005 1.18 2005 19.60 13.10 16.16 18.73 2003 76.20 2004 2.89 2004 32.30 2.34 5.13 4.44 2004 16.00 1998-2004 1.81 2004 39.00 4.00 3.59 5.94 2004 41.80 2004 0.59 f 2004p 21.50 7.58 10.13 11.78 2003 62.23 2002 est 1.10 2003 est 34.71 5.79 6.50 8.18 2001 52.00 2005 est 0.93 2002 est 35.30 3.10 5.69 6.90 2005 est 51.90 2005-2010 1.39 2002 30.30 (2003) 4.60 7.69 8.13 2005 est 94.00 2005 1.46 2005 29.38 f 6.52 f 8.80 9.32 2004 94.56 2005 0.77 2005 14.50 12.06 14.65 15.11 2002 78.70 2005 0.05 2005 est 13.70 19.50 23.58 29.01 2003 47.30 2000 1.70 2004 est 40.94 3.43 6.69 7.52 2000 r 20.70 2005 2.00 2000 r 44.10 3.80 4.79 5.71 2004 100.00 2004 3.80 2004 17.12 8.12 9.73 11.02 2004 62.82 2005 2.10 2005p 32.63 4.28 6.52 7.39 2005-2010 66.70 2005-2010 1.18 2004 est 41.76 f 2.07 f 6.69 7.52 2003 29.00 2000 0.26 2004 est 41.62 3.54 4.41 5.49 2004 59.10 2004 1.10 2004 32.63 3.50 5.10 6.32 2005 est 100.00 2002 0.15 2005 est 35.10 4.91 6.69 7.52 2001 60.30 2002 1.40 2002 28.17 6.05 9.02 9.57 2003 85.90 2005 est 0.90 a 2005 est 21.47 a 12.14 a 15.40 17.77 2001 34.00 2001 -3.72 2005 est 25.14 11.21 6.47 8.16 2003 94.20 2005 est 2.61 2005 est 19.88 1.59 6.69 7.52 2005 77.35 2003 est 1.64 f 2005 24.10 5.70 6.69 7.51 2003 13.20 2000 2.70 2004 est 41.68 2.54 4.07 3.91 2000 48.05 2000 2.36 2005 34.80 4.20 5.49 6.56 .. . . . . . . . . . . 39.13 43.48 2003 80.30 2004 0.49 2005 19.13 9.96 11.02 14.67 2003 22.30 2001 1.00 2004 est 39.17 4.03 5.23 7.59 2005 100.00 2005 1.90 a 2005p 19.70 a 8.40 a 11.38 13.09 2005 est 17.10 2005 est 2.36 2005 est 40.60 2.40 4.18 4.03 2005 0.00 2001 0.40 2005 est 33.99 4.90 6.59 8.10 2003 33.40 2001 0.30 2004 est 37.91 5.29 7.21 8.89 2005 57.00 2002 0.60 2005 est 33.99 4.88 6.51 8.17 2003 22.80 2004 est 2.75 2005 est 41.24 3.22 4.89 4.97 2004 26.30 2004 est 1.38 2004 est 28.01 6.66 6.61 8.98 2005 0.00 2003 est 1.00 f 2005 est 34.00 4.88 6.51 8.18 2005 est 45.01 e 2000-2005 0.78 g 2005 21.99 b 8.20 b . . . . . . ... Data not available est Estimate p Preliminary r Revised reference year a Figure applies to resident population. e Figure based on all WPR countries and areas except Pitcairn Islands, Tokelau and Wallis and Futuna. f Computed by the Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. g Interpolated based on 2000 and 2005 population estimates in World Population Prospects: The 2000 Revision, UN Economic and Social Affairs. STATISTICAL TABLES 396 ... Data not available est Estimate p Preliminary a Figure applies to resident population. f Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. h Figures are compiled based on registered deaths and/ or registered births. i Estimate based on 2000 census. j Figure based on projected population for 2004. k Figure includes unknown sex. Table 1 Demographic indicators (continued) Year Crude Birth Rate Crude Death Rate Dependency Ratio Year Total Fertility Rate Country/area (per 1000 popn) (per 1000 popn) 2005 (women 15-49 yrs) (%) American Samoa 2005 26.70 4.50 (2004 est) 74.02 2005 3.25 Australia 2004 12.70 6.60 48.59 2004 1.77 Brunei Darussalam 2004 19.91 2.81 (2004) 53.00 2004p 2.10 Cambodia 2004 25.00 6.70 (2004) 75.44 2004 3.34 China 2004p 12.29 6.42 (2004p) 41.00p 2001 1.90 Cook Islands 2003 21.20 6.30 (2003 est) 68.07 2004 2.60 Fiji 2005-2010 24.60 5.50 (2002 est) 62.34 2005-2010 3.08 French Polynesia 2005 est 17.60 5.00 (2002) 53.61 2005-2010 2.30 Guam 2005 19.03 4.41 56.01 2005 2.60 Hong Kong (China) 2005 8.24 h 5.58 h, k 36.17 2005p 0.97 Japan 2004 8.80 8.20 49.70 2004 1.29 Kiribati 2002 33.4 est i 7.20 (2004 est) 79.76 2000 4.30 Lao People's Democratic Republic 2000 est 34.00 6.30 (2000r) 91.94 2000 4.90 Macao (China) 2004 7.20 3.40 (2004) 33.76 2004 0.85 Malaysia 2005p 20.80 4.60 58.50 2005p 2.60 Marshall Islands 2004 est 24.70 f, j 4.05 f, j (2004 est) 78.03 1999 5.71 Micronesia, Federated States of 2003 23.30 4.40 (2004 est) 82.35 2000 4.40 Mongolia 2004 18.10 6.50 (2004) 56.57 2004 1.90 Nauru 2002 31.20 7.80 66.69 est 2004 3.80 New Caledonia 2005p 17.20 4.90 (2002) 52.02 2002 2.40 New Zealand 2004 est 14.30 a 7.00 a 50.63 est 2003 1.95 Niue 2005 17.90 8.09 57.11 est 2001 3.01 Northern Mariana Islands 2005 est 19.51 2.30 27.34 est 2005 est 1.27 Palau 2004 12.60 6.90 42.45 2004 1.54 Papua New Guinea 2000 35.00 12.00 (2004 est) 79.28 2000 4.60 Philippines 2005 24.09 5.60 63.93 2000-2003 3.50 Pitcairn Islands .. . . . . . . . . . . Republic of Korea 2004 9.80 5.10 41.02 2004 1.16 Samoa 2004 20.80 3.00 (2004 est) 76.06 2004 3.40 Singapore 2005p 10.00 a 4.30 a 39.08p 2004 1.24 Solomon Islands 2005-2010 30.20 6.70 75.44 est 2005-2010 3.79 Tokelau 1997-2001 31.00 7.00 63.64 est 1997-2001 4.90 Tonga 2002 24.80 6.10 (2004 est) 76.06 2004 3.80 Tuvalu 2002 27.10 9.90 63.59 est 2002 3.70 Vanuatu 1999 28.20 6.00 80.05 est 1999 4.80 Viet Nam 2004 est 19.20 5.40 (2004 est) 53.07 2004 est 2.23 Wallis and Futuna 2003 19.40 5.90 63.61 est 2003 est 3.10 WESTERN PACIFIC REGION 2000-2005 14.90 g 7.00 g . . . 1995-2000 2.00 STATISTICAL TABLES 397 FY Fiscal year f Figure refers to population aged 10 years and above. p Provisional g Figure applies to residents aged 15 years and above. a Data for 15 year old schoolchildren. Literacy defined as levels 2-5 using h Figure refers to aged 19 years and above. OECD PISA (Programme for International Student Assessment) standards. i Per capita Gross Domestic Product at PPP. b Revised data. j Computed by Health Information and Evidence of Policy Unit c Figure refers to 1999/2000 schoolyear and census data. of the WHO Regional Office for the Western Pacific. d Figure refers to the percentage of population aged 15 years and above k Figure reported as Gross Island Product. with primary or above educational attainment. l Coverted to US$ using available exchange rates nearest to the period e Figure refers to persons aged 15-24 years old. m Figure refers to per capita GNP at current market prices (US$) Table 2 Socioeconomic indicators Country/area Year Total Male Female Year Per capita GDP (%) (%) (%) (in US$ ) Adult literacy rate American Samoa .. . . . . . . . 2000 est 8000 i Australia 2003 88.20 a . . . . . . 2004-2005 33 241 Brunei Darussalam 2002 93.90 96.30 91.40 2004p 15 241 Cambodia 2004 73.60 b 84.70 b 64.10 b 2003 306 China 2003 90.90 .. . . . . 2004p 1269 j Cook Islands 2003 100.00 .. . . . . 2004p 12 887 nzd Fiji 2002 92.90 c . . . . . . 2004 8377 French Polynesia .. . . . . . . . 2002 15 063 j Guam ... . . . . . . 2002 15 439 k Hong Kong (China) 2005 93.56 d 96.88 d 90.58 d 2005p 25 624 Japan 2000 est 99.00 .. . . . . 2003 33 727 Kiribati 2000 95.00 e 93.00 e 95.00 e 2004 est 790 Lao People's Democratic Republic 2003 74.00 85.00 64.00 2004 390 b Macao (China) 2001 91.30 95.30 87.80 2004 22 671 Malaysia 2002 94.00 .. . . . . 2005 4904 Marshall Islands 1999 97.00 96.80 97.20 2001 1817 Micronesia, Federated States of 2000 92.40 92.90 91.90 FY2005 est 2200 Mongolia 2003 97.80 98.00 97.50 2004 501 Nauru 1998 95.00 95.00 95.00 .. . New Caledonia 2002 est 91.00 92.00 90.00 2001 19 190 l New Zealand .. . . . . . . . 2003 23 200 Niue 2003 100.00 .. . . . . 2003 10 048 nzd Northern Mariana Islands .. . . . . . . . 1998 28 734 Palau 2005 99.90 e 99.90 e 99.80 e 2003 5678 Papua New Guinea 2000 56.20 f 61.20 f 50.90 f 2004 846.74 Philippines 2002 92.60 92.50 92.70 2003 est 964 Pitcairn Islands .. . . . . . . . . . . Republic of Korea 2002 97.90 99.20 96.60 2004 14 193 b Samoa 2002 98.70 .. . . . . 2001 1443 Singapore 2005 95.00 g . . . . . . 2005 26 833 Solomon Islands 1999 77.00 84.00 67.00 2002 495 Tokelau 2003 86.50 .. . . . . 2003 612 m Tonga 2000 98.80 .. . . . . FY2003-2004 1780 Tuvalu 1998 95.00 95.00 95.00 2002 2096 Vanuatu 2002 .. . 50.10 e 49.90 e 2003 1331 j Viet Nam 2002 92.70 94.50 90.90 2004 est 8 692 910 vnd Wallis and Futuna 2003 78.80 h 78.20 h 78.20 h . . . WESTERN PACIFIC REGION 1994-1996 85.80 .. . . . . . . . STATISTICAL TABLES 398 Year Per capita As % of Year Country/area (US$/Local Currency) GDP Human Development Index (HDI) 2003 Health Expenditure American Samoa 2003 US$ 500 .. . 2003 14.00 .. . Australia 2002-2003 US$ 1960 9.30 2002-2003 17.50 0.96 Brunei Darussalam 2004 US$ 443 2.84 .. . 0.87 Cambodia 2005 US$ 4 n 10.20 2005 7.14 0.57 China 2003 US$ 62 5.62 2003 4.53 0.76 Cook Islands 2003 US$ 294 3.80 2003 9.60 (1998) 0.82 Fiji FY2003-2004 US$ 61 j (2002) 3.00 FY2003-20004 8.32 j 0.75 French Polynesia .. . . . . . . . . . . Guam 2000 US$ 1032 .. . FY2000 6.18 .. . Hong Kong (China) . . . . . . FY2005-2006p 12.64 q 0.92 Japan FY2003 US$ 2131 8.55 o . . . 0.94 Kiribati 2003 US$ 95 .. . 2003 7.80 (1998) 0.52 Lao People's Democratic Republic 2004 US$ 12 est 2.72 p 2003-2004 4.40 0.54 Macao (China) 2004 US$ 566 2.50 2004 10.46 (2002) 0.90 Malaysia .. . . . . . . . 0.80 Marshall Islands 1999 US$ 248 4.00 FY2004 14.00 (1998) 0.56 Micronesia, Federated States of 2005 est US$ 143 (2004) 6.50 2004 8.80 (1998) 0.57 Mongolia 2004 US$ 32 6.30 2004 8.22 0.68 Nauru 2003 US$ 798 12.30 2003 8.80 (1998) 0.66 New Caledonia 2002 EUR$ 1558 (1999) 9.22 .. . . . . New Zealand 2005 US$ 1802 (2004) 7.27 2005 20.00 0.93 Niue 2001-2002 US$ 417 .. . FY2002-2003 13.52 j (1998) 0.77 Northern Mariana Islands 2000 US$ 519 .. . 2002 16.44 .. . Palau 2003 US$ 607 9.70 FY2004-2005 16.39 (1998) 0.86 Papua New Guinea 2001 US$ 24 4.40 2004 8.60 0.52 Philippines 2003 PHP 1662 3.20 2003 7.40 0.76 Pitcairn Islands .. . . . . . . . . . . Republic of Korea 2003 US$ 705 5.60 .. . 0.90 Samoa FY2002-2003 US$ 94 5.60 FY2002-2003 15.10 0.78 Singapore FY2003 S$ 1511 3.81 FY2003 7.04 r 0.91 Solomon Islands 2002 US$ 83 4.80 2005 12.60 0.59 Tokelau 1999-2000 NZ$ 341 .. . FY2003-2004 12.50 .. . Tonga FY2002-2003 US$ 49 .. . FY2002-2003 10.00 0.81 Tuvalu 2003 US$ 142 6.10 2003 6.00 (1998) 0.58 Vanuatu 2001 US$ 76 (2003) 3.90 2004 10.80 0.66 Viet Nam 2003 US$ 26 b 5.22 b 2004 est 7.34 0.70 Wallis and Futuna .. . . . . 2003 7.58 j . . . WESTERN PACIFIC REGION . . . . . . . . . . . . . . . Table 2 Socioeconomic indicators ... Data not available est Estimate FY Fiscal year b Revised data. j Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. n Figure refers to per capita government health expenditure. o As percentage of national income. p Estimate based on a GDP of Kip 24 621.2 and an annual average exchange rate of 10 585.5 kip per US$. q Figure refers to the public health expenditure as percentage of overall public expenditure. r Figure excludes expneditures on environmental health. General Government Expenditure on Health as % of Total General Government Expenditure STATISTICAL TABLES 399 Year Total Male Female Year Neonatal Infant Under-5 Year Maternal mortality (years) (years) (years) (per 1000 (per 1000 (per 1000 ratio (per livebirths) (livebirths) livebirths) 100 000 livebirths) Life Expectancy at Birth Table 3 Health status indicators 2005 75.84 72.27 79.62 2005 9.90 15.20 (2002) 4.90 2002 123.00 2002-2004 .. . 78.10 83.00 2004 3.20 4.70 5.70 1997-1999 8.20 h 2004p .. . 74.60 77.50 2004 6.00 8.80 9.80 2004 13.90 2001 .. . 56.40 60.30 2004 (2000) 37.30 66.00 82.00 2000 437.00 2000 71.40 69.60 73.30 2003 18.00 25.50 29.90 2003 51.30 2004 72.00 70.00 75.00 2000 12.00 d (2005) 28.60 (2004) 21.00 2003 0.00 2005 69.53 67.05 72.14 2005-2010 (2000) 9.00 16.00 20.00 2002 35.29 2005 est 74.10 71.70 76.80 2002 4.00 (2005 est) 6.30 (2005-2010) 11.00 2002 0.00 2005 78.40 75.34 81.64 2002 3.41 (2003p) 11.22 (2005 est) 10.00 2003p 0.00 2005p .. . 78.82 84.37 2005p 1.51 e 2.36 e (2004) 2.90 e 2005p 1.75 e 2004 .. . 78.64 85.59 2004 1.50 2.80 3.90 2004 4.40 2003 est . . . 59.00 a 70.00 a 2000 27.00 d 43.00 69.00 2002 103.00 2000 59.00 57.00 61.00 2000 36.20 82.20 106.90 f 2000 530.00 2000-2003 79.20 77.40 82.00 2004 1.81 3.02 3.93 2004 0.00 2005p 73.50 70.60 76.40 2005 2.10 5.10p (2002) 8.60 2005p 30.00 2004 62.00 60.00 64.00 2002 .. . 29.00 (1999) 48.00 2002 73.80 2003 est 70.00 68.00 71.00 2000 est 12.00 d (2003) 21.00 (2003 est) 23.00 2003 317.00 i 2004 64.60 61.60 67.80 2005 (2004) 13.00 20.80 25.60 2005 93.80 2004 61.00 58.00 61.00 2002 6.30 12.70 19.10 2002 300.00 2005p 75.20 .. . . . . 2002 2.40 (2005p) 6.40 9.06 1991-2002 31.56 2001 est . . . 68.05 72.03 2004 est 3.10 5.58 (2003) 6.34 2001 5.30 2001 70.10 69.80 71.20 2005 0.00 0.00 0.00 2005 0.00 2005 est 75.88 73.31 78.61 2005 est . . . 7.11 (1999) 7.43 2000 0.00 2004 71.62 67.80 75.68 2004 (2000) 14.00 d 16.22 6.89 2004 11.58 2000 53.00 52.50 53.60 2000 32.00 est 64.00 88.00 2000 330.00 2002 69.60 66.90 72.20 1998-2003 17.00 29.00 40.00 1998 172.00 .. . . . . . . . . . . . . . . . . . . . 2003 77.46 73.87 80.82 2002 3.30 (2003) 5.30 (2004) 6.17 2003 15.00 2001 72.80 71.80 73.80 2002 4.20 (2004) 13.00 13.70 2004 5.30 2005p 79.70 b 77.90 b 81.60 b 2005 1.60 2.10p b 3.60p g 2005p 11.00 b 2004 est . . . 61.90 63.10 2002 12.00 d (2005-2010) 31.40 (2005 est) 52.00 2004 184.00 1997-2000 .. . 68.40 71.30 2003 40.00 g (1997-2000) 33.0 (1999) 0.00 2001-2002 0.00 2004 70.00 70.00 72.00 2000 10.00 d (2004) 14.60 (2001) 16.59 2004 83.30 2002 65.00 64.00 67.00 2003 .. . 21.60 32.40 2002 0.00 2002 est 68.60 67.40 70.40 2000 est 19.00 d (1999) 27.00 (1999) 33.00 1998 96.30 2002 71.30 70.00 73.00 2004 est . . . 18.00 28.50 2004 est 85.00 2003 est 74.30 73.10 75.50 2003 est . . . 5.90 .. . . . . 2000 c A:80.90 A:77.30 A:84.20 2000-2005 .. . 33.80 39.50 2000 est 81.00 B:70.40 B:68.20 B:72.70 a Estimate based on 2000 census. Samoa, Solomon Islands, Tonga, Tuvalu, Vanuatu, and Viet Nam. b Figure applies to resident population. d Estimates derived by regression and similar estimation methods. c To aid in demographic analysis, the 192 Member States of WHO have been e Figures are compiled based on registered deaths and/or registered divided into mortality strata on the basis of their level of child (5q0) and adult births. mortality (45q15). For the Western Pacific Region, the division is as follows: f Revised data. A=Very low child, very low adult; B=Low child, low adult. Countries belonging to g Computed by Health Information and Evidence for Policy Unit of WHO strata A are Australia, Brunei Darussalam, Japan, New Zealand and Singapore. Regional Office for the Western Pacific. Countries belonging to strata B are Cambodia, China, Cooks Islands, Fiji, h Direct and indirect maternal deaths per 100 000 live births over the Kiribati, Lao PDR, Malaysia, Marshall Islands, Federated States of Micronesia, triennium 1997-1999. Mongolia, Nauru, Niue, Palau, Papua New Guinea, Philippines, Republic of Korea, i Figure is based on childbearing age 15-44 years old. Mortality Rates STATISTICAL TABLES 400 Table 4 Maternal, child care and nutritional indicators % of women of reproductive age % of delivery at home Country/area Year (15-49 yrs) using modern Year % of deliveries in Year assisted by skilled contraceptive methods health facilities health personnel (%) (%) (%) Maternal and Child Care American Samoa 2000 33.00 2002 99.00 2002 1.00 Australia 2001 65.00 a 2003 99.80 2003 0.20 Brunei Darussalam ... 2004 99.38 2004 0.18 Cambodia 2000 19.00 2004 16.34 2004 16.51 China 2002 est 84.60 2004 82.80 .. . Cook Islands 2003 40.85 b . . . . . . Fiji 1998 40.45 2002 99.00 .. . French Polynesia .. . . . . . . . Guam ... . . . . . . Hong Kong (China) . . . 2005 About 100.00 e 2005 About 0.00 g Japan 1995-2000 59.00 2004 99.80 .. . Kiribati 2002 22.00 2002 76.00 2002 12.90 Lao People's Democratic Republic 2000 28.90 c 2000 12.00 2004 9.00 Macao (China) . . . 2004 100.00 2004 0.00 Malaysia .. . 2005 98.00 2005 2.00 Marshall Islands 2001 34.00 d . . . . . . Micronesia, Federated States of 2000 70.00 .. . . . . Mongolia 2004 51.28 2004 99.70 .. . Nauru .. . . . . . . . New Caledonia .. . . . . . . . New Zealand 2002 est 72.00 2001 est 96.60 .. . Niue 2005 22.00 2005 100.00 2005 0.00 Northern Mariana Islands 2000 64.00 .. . . . . Palau 2000 17.20 1998 18.50 .. . Papua New Guinea 2004 8.98 2004 39.00 2004 3.00 Philippines 2003 21.60 c 1998-2003 38.00 1998-2003 35.20 Pitcairn Islands .. . . . . . . . Republic of Korea 2003 84.50 2003 99.30 2003 0.70 Samoa 2004 53.90 2004 91.00 2004 9.00 Singapore 2003 72.50 2004 99.70 .. . Solomon Islands 2004 16.00 2003 43.00 f . . . Tokelau 1999 13.40 .. . . . . Tonga 2002 23.10 2004 98.00 .. . Tuvalu 2001 28.50 .. . . . . Vanuatu 2001 15.00 2003 84.00 2003 3.00 Viet Nam 2004 75.70 2004 82.00 .. . Wallis and Futuna .. . . . . . . . WESTERN PACIFIC REGION . . . . . . . . . ... Data not available d Contraceptive prevalence rate. est Estimate e The figure refers to cases known to the maternity homes, public and a Percentage of women aged 18-49 (or their partners) reporting private hospitals. using contraceptive methods (including hysterectomy, tubal ligation f Figure applies to clinics only. and partner vasectomy). g Nearly all newborns were delivered in health facilities. b Computed by Health Information and Evidence for Policy Unit of the WHO Regional Office for the Western Pacific. c Revised data. STATISTICAL TABLES 401 Maternal and Child Care % of women given % of newborn babies weighing at least 2 doses of Year of < 2 SD < 2 SD < 2 SD Year at least 2500 grams at birth Year tetanus toxoid TT2+ survey weight/age height/age weight/height 2004 96.67 h . . . . . . . . . . . . . . . . . . 2003 93.70 94.20 93.10 2005 N R 1995-1996 0.00 j 0.00 j 0.00 j 2003 93.00 .. . . . . 2004 47.40 c 1995-1996 14.00 13.00 3.60 2000 77.00 .. . . . . 2004 51.00 2000 45.20 44.60 15.00 2002 97.61 .. . . . . . . . 2002 7.88 14.30 .. . 2003 97.60 .. . . . . 2004 100.00 .. . . . . . . . 1998 90.46 .. . . . . . . . 1993 7.90 2.70 8.20 2001 93.00 .. . . . . 2000 100.00 .. . . . . . . . 2004 91.54 h . . . . . . . . . . . . . . . . . . 2004 94.42 i 95.01 i 93.78 i . . . . . . . . . . . . 2004 90.60 91.60 89.50 .. . . . . . . . . . . 2002 91.80 92.30 91.40 2002 42.60 1985 12.90 28.30 10.80 1998 82.00 .. . . . . 2003 37.00 2000 40.00 40.70 15.40 2004 93.32 94.57 91.92 2003 68.00 .. . . . . . . . 2004 90.40 .. . . . . 2005 86.10 2002 11.30 .. . . . . 1999 88.00 .. . . . . 2004 50.00 1998 22.0 (M)/33.0 (F) 32.0 (M)/40.0 (F) 5.8 (M)/7.0 (F) 2000 82.00 .. . . . . 2004 N R ... . . . . . . 2004 95.90 96.40 95.40 .. . 1999 12.50 24.60 3.60 .. . . . . . . . 2003 est 100.00 .. . . . . . . . 2002 93.00 .. . . . . . . . 1996 1.60/ 4.40 k . . . . . . 2003 93.00 .. . . . . . . . . . . . . . . . . 2005 100.00 55.50 44.50 2005 N R ... . . . . . . 2000 81.01 .. . . . . . . . . . . . . . . . . 1998 91.00 .. . . . . 2004 100.00 1997 1.40 .. . . . . 2002 90.00 .. . . . . 2004 66.00 1982-1983 29.90 l 43.20 l 5.50 l 1998-2003 54.80 .. . . . . 1998-2003 37.30 2003 27.60 30.00 5.30 .. . . . . . . . . . . . . . . . . . . . 2004 95.84 96.21 95.44 .. . 1997 3.00 m .. . . . . 2004 98.50 .. . . . . 2004 4.00 1999 1.90 4.20 0.90 2004 91.40 .. . . . . . . . 2000 .. . 2.20 2.40 .. . . . . . . . 2004 65.00 1989 21.30 27.30 6.60 2003 100.00 .. . . . . . . . . . . . . . . . . 2002 97.50 .. . . . . 2003 93.00 1986 .. . 1.30 0.90 2000 95.00 .. . . . . 2004 96.00 .. . . . . . . . 2003 97.00 .. . . . . 2003 22.00 1996 12.00 20.00 6.00 2004 94.20 .. . . . . 2004 91.00 2004 26.60 30.70 (2003) 7.20 .. . . . . . . . 2002 69.50 .. . . . . . . . Total Male Female (%) (%) (%) (%) National underweight, stunting and wasting prevalence (age 0-59 months) NR Not relevant m Data from a subnational survey. M Male n This is a weighted average based on births. Coverage data from F Female the 2005 WHO/ UNICEF Joint Reporting Form. h Figure refers to birthweight equal to 2501 grams and above. o Based on available data received from 23 countries. i The figure excludes those with unknown birthweight . j Figure applies to age group 24-95 months. k 1.60% in the southern province; 4.40% in the northern province. l Figure applies to national rural (covering >85% of total population). . . . . . . . . . 2005 66.71 n, o . . . . . . . . . STATISTICAL TABLES 402 Table 4 Maternal, child care and nutritional indicators (continued) Proportion of babies Vitamin A Proportion of babies aged 6-9 months supplementation Year of exclusively breastfed receiving breastmilk to children Country/area survey for the first 6 months and semi-solid food 6-59 months old (%) (%) (%) American Samoa 1997 20.00 (at 4 months) . . . . . . Australia 2001 46.00 .. . . . . Brunei Darussalam 2003 14.60 .. . . . . Cambodia 2000 11.00 p 71.00 29.00 China 2000 48.70 (urban); 60.40 (rural) (<4 months) . . . . . . Cook Islands 1998 19.00 45.00 .. . Fiji 1995 53.00 52.00 .. . French Polynesia 2001 19.00 .. . . . . Guam ... . . . . . . Hong Kong (China) . . . . . . . . . Japan 2000 41.00 (<4 months) 97.90 .. . Kiribati 1995-2003 80.00 (<4 months) . . . (2003) 45.00 Lao People's Democratic Republic 2000 16.90 p (4-5 months) 9.90 28.80 Macao (China) . . . . . . . . . Malaysia 1995-2003 29.00 (<4 months) . . . . . . Marshall Islands 1995-2003 63.00 (<4 months) . . . (2003) 23.00 Micronesia, Federated States of 1995-2003 60.00 (<4 months) . . . (2003) 95.00 q Mongolia 2001 88.00 (<4 months) 55.00 (2003) 87.00 q Nauru .. . . . . . . . New Caledonia .. . . . . . . New Zealand .. . . . . . . . Niue .. . . . . . . . Northern Mariana Islands .. . . . . . . . Palau 1995-2003 59.00 (<4 months) . . . . . . Papua New Guinea 2004 21.00-86.00 60.00 (2003) 1.00 Philippines 2003 33.50 57.90 76.60 p Pitcairn Islands .. . . . . . . . Republic of Korea 1998 14.00 (at 4 months) 92.00 .. . Samoa 1999 58.30 (at 4 months) . . . . . . Singapore .. . . . . . . . Solomon Islands 1995-2003 65.00 (<4 months) . . . . . . Tokelau .. . . . . . . . Tonga 1999 61.00 (<4 months) 37.00 .. . Tuvalu .. . . . . . . . Vanuatu 1996 73.00 (at 4 months) . . . . . . Viet Nam 2002 7.70 (4-5 months) 89.30 94.00-97.00 p Wallis and Futuna .. . . . . . . . WESTERN PACIFIC REGION . . . . . . . . . ... Data not available p Revised data. q Identifies countries that have achieved a second round of Vitamin A coverage greater than one or equal to 70 percent. STATISTICAL TABLES 403 Year of Year of survey BMI > 25 survey BMI > 30 Age group Total Male Female Age group Total Male Female (yrs) (yrs) Percentage prevalence overweight Percentage prevalence obese . . . . . . . . . . . . . . . . . . 2001 18+ 46.20 54.50 38.20 2001 18+ 15.10 14.80 15.30 .. . . . . . . . . . . . . . . . . 2000 15-49 .. . . . . 6.40 2000 15-49 .. . . . . 0.70 2002 18+ 22.80 r . . . . . . 2002 18+ 7.10 s . . . . . . 2003 25-64 89.20 90.10 88.30 2003 25-64 62.40 58.60 66.30 2002 25-64 56.70 46.40 68.40 2002 25-64 22.80 13.20 33.70 1995 16+ 73.70 75.20 72.50 1995 16+ 40.90 36.30 44.30 .. . . . . . . . . . . . . . . . . 1995/1996 25-74 .. . 38.00 34.00 1995/1996 25-74 .. . 5.00 7.00 2002 20+ 25.50 28.80 22.70 1991-1995 20+ 2.37 1.86 2.79 .. . . . . . . . . . . . . . . . . 2000 15+ 8.50 5.90 10.80 2000 15+ 1.20 0.70 1.60 .. . . . . . . . . . . . . . . . . 1996 20+ 26.50 24.10 29.00 1996 20+ 5.80 4.00 7.60 2002 25-64 80.60 78.00 83.50 2002 25-64 45.20 38.50 52.70 2002 25-64 73.90 65.40 83.10 2002 25-64 43.50 30.50 57.30 1999 35+ 52.00 44.00 57.00 .. . . . . . . . 2004 25-64 93.30 92.80 93.80 2004 25-64 74.70 72.10 77.30 1992-1994 30-59 .. . . . . 70.40 .. . . . . . . . 2002-2003 15+ 57.00 63.00 51.10 2002-2003 15+ 22.50 21.90 23.20 .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1998 20+ 20.20 17.00 23.30 1998 20+ 3.30 2.10 4.40 .. . . . . . . . . . . . . . . . . 1998 19+ 26.30 26.00 26.50 1998 19+ 2.40 1.70 3.00 2002 25-64 86.10 82.20 90.80 2002 25-64 57.30 48.40 67.90 1998 18-69 30.40 33.90 27.00 1998 18-69 6.00 5.30 6.70 .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1998-2000 15-70 56.00 .. . . . . . . . . . . . . . 1983 .. . . . . 75.00 50.00 1998 20+ 48.90 45.90 51.90 1998 20+ 15.90 12.20 19.60 .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Data not available r The recommended cut-off point for overweight for Chinese people is BMI at 24. s The recommended cut-off point for obesity for Chinese people is BMI at 28. STATISTICAL TABLES 404 Year of Country/area survey Age group Total Male Female (yrs) Table 4 Maternal, child care and nutritional indicators (continued) American Samoa .. . . . . . . . Australia . . . . . . . . . Brunei Darussalam ... . . . . . . Cambodia 2000 15-49 .. . . . . 17.80-23.40 China .. . . . . . . . Cook Islands 2003 25-64 32.90 32.50 33.40 Fiji 2002 25-64 26.60 25.20 28.10 French Polynesia 1995 16+ 29.40 23.10-34.50 22.60-37.00 Guam ... . . . . . . Hong Kong (China) . . . . . . . . . Japan .. . . . . . . . Kiribati . . . . . . . . . Lao People's Democratic Republic . . . . . . . . . Macao (China) . . . . . . . . . Malaysia 1996 20+ 22.90 22.70 23.10 Marshall Islands 2002 25-64 29.90 28.90 31.00 Micronesia, Federated States of 2002 25-64 29.50 27.70 31.40 Mongolia 1999 35+ 26.00 25.00 26.60 Nauru 2004 25-64 35.10 34.60 35.60 New Caledonia 1992-1994 30-59 22.80-33.20 22.50-31.70 23.10-34.50 New Zealand 2002-2003 15+ 26.60 26.90 26.40 Niue 1981 20+ 27.00 26.10 27.80 Northern Mariana Islands .. . . . . . . . Palau .. . . . . . . . Papua New Guinea .. . . . . . . . Philippines 1998 20+ 22.50 22.40 22.60 Pitcairn Islands .. . . . . . . . Republic of Korea .. . . . . . . . Samoa 2002 25-64 31.70 30.00 33.40 Singapore .. . . . . . . . Solomon Islands .. . . . . . . . Tokelau .. . . . . . . . Tonga 1998-2000 15-70 32.30 30.20 33.80 Tuvalu .. . . . . . . . Vanuatu 1998 20+ 25.60 21.20-29.20 20.90-31.10 Viet Nam 1987-1989 15+ 17.00-21.20 16.90-21.30 17.00-21.20 Wallis and Futuna .. . . . . . . . WESTERN PACIFIC REGION ... . . . . . . Mean BMI ... Data not available STATISTICAL TABLES 405 Youth prevalence on tobacco use Table 5 Environmental health and tobacco use prevalence indicators Estimated smoking prevalence among adults Year of Total Male Female Year of Male Female Access to Adequate excreta survey a (%) (%) (%) survey (%) (%) Year safe water Year disposal facilities (%) (%) Percentage of population with . . . . . . . . . 1985 41.00 16.20 2004 99.00 2004 99.00 2001 15.10 14.10 16.20 2001 21.10 b 18.00 b 2002 100.00 2002 100.00 .. . . . . . . . 1997 36.10 6.40 2004 99.00 2002 80.00 2003 8.80 11.40 3.20 1999 66.70 b 10.00 b 2004 44.20 2004 21.90 1999 8.60 11.10 6.40 1998 53.40 4.00 2002 83.55 2004p 53.12 2003 43.60 39.90 46.70 1998 34.40 71.10 2003 100.00 2003 100.00 1999 15.10 24.10 13.40 1999 52.30 23.00 2002 65.00 2002 60.00 .. . . . . . . . 1995 36.00 36.00 2002 100.00 2002 98.00 .. . . . . . . . 1999 37.70 26.90 2003p 100.00 2003p 100.00 1999 .. . 17.00 13.00 1998 27.10 2.90 2005 100.00 2005 99.00 .. . . . . . . . 2000 47.40 11.50 2003 96.90 2003 77.70 1981 .. . 95.00 63.00 1999 56.50 32.30 2002 64.00 2002 39.00 .. . . . . . . . 1995 41.00 15.00 2004 63.80 2004 44.30 2001 8.00 9.40 6.20 1997 31.58 4.18 2003 100.00 1996 r 99.85 .. . . . . . . . 1986 41.00 4.00 2005p 95.80 c 2005p 99.80 c . . . . . . . . . . . . . . . 2002 85.00 2002 82.00 .. . . . . . . . 1994 42.00 0.60 2003 59.00 2003 48.00 2001 .. . 18.80 8.20 2001 67.80 25.50 2002 41.50 2002 40.20 .. . . . . . . . 1994 49.80 59.00 2003 100.00 2003 100.00 .. . . . . . . . 1992 28.00 34.00 .. . . . . 2001 .. . 16.30 22.00 2001 25.10 24.80 2002 90.00 b 2002 100.00 1980 .. . 43.00 15.00 1980 58.00 17.00 2003 100.00 2003 100.00 2000 62.40 68.40 57.10 .. . . . . 2002 98.00 2002 94.00 2001 71.00 .. . . . . 1998 14.00 4.00 2003 95.40 2003 99.00 1996 13.40 13.50 13.30 1990 76.00 80.00 2002 39.00 2002 45.00 2000 23.30 b 37.30 18.40 2001 50.60 8.00 2004 80.00 2004 86.00 .. . . . . . . . . . . . . . . . . . . . 1998 .. . 29.00 13.00 1997 65.00 4.40 2004 90.10 2004 81.40 .. . . . . . . . 1995 58.00 24.00 2002 88.00 2002 100.00 2000 9.10 13.40 8.80 2001 24.20 3.50 2005 100.00 2005 100.00 1989 .. . . . . 10.00 1989 .. . 33.00 b 2002 70.00 2002 31.00 1994 .. . 50.50 47.40 1991 67.60 42.00 2002 89.00 2002 74.00 1994 .. . 14.30 0.00 1991 62.40 14.20 2004 94.00 2002 78.20 1975 .. . 37.00 17.00 1976 51.00 31.00 2002 100.00 2002 100.00 1998 .. . 58.20 17.70 1998 49.00 5.00 2002 60.00 2002 50.00 1995 .. . 20.00 .. . 1997 50.70 b 3.50 b 2003 est 70.10 2002 25.30 .. . . . . . . . 1996 42.00 18.00 2003 80.90 2003 68.50 . . . . . . . . . . . . . . . 2002 78.00 d 2002 45.00 d ... Data not available est Estimate p Preliminary r Revised reference year a Smoked cigarettes or used other tobacco products within 30 days preceeding the survey. b Revised data. c Figure applies to rural areas. d Estimate for Eastern Asia taken from Meeting the MDG Drinkign Water and Sanitation Target: A Mid-Term Assessment of Progress, WHO/UNICEF 2004. STATISTICAL TABLES 406 American Samoa 2003 49 7.83 2003 15 2.40 Australia 2004 54 800 27.20 2004 9400 4.70 Brunei Darussalam 2004 463 12.87 2004 68 1.89 Cambodia 2004 2122 1.62 2004 241 0.18 China 2004p 1 892 000 a 14.56 2001 136 520 1.10 Cook Islands 2003 27 14.67 2003 18 h 9.78 Fiji 2004 339 4.04 2004 30 0.36 French Polynesia 2004 est 447 b 17.80 2004 est 113 b, i 4.10 Guam 1999 166 11.10 1999 31 i 2.05 Hong Kong (China) 2005 11 505 c 16.50 2005 1941 c 2.78 Japan 2004 270 371 21.17 2004 95 197 7.46 Kiribati 2004 20 2.20 2004 3 0.30 Lao People's Democratic Republic 2005 1283 2.26 2005 83 0.15 Macao (China) 2004 1286 d 28.15 2004 150 3.28 Malaysia 2005 21 122 8.08 2005 2751 1.05 Marshall Islands 2000 24 4.63 2000 4 0.77 Micronesia, Federated States of 2005 62 5.43 2005 13 1.14 Mongolia 2004 6590 26.17 2004 438 1.74 Nauru 2004 5 4.95 2004 1 0.99 New Caledonia 2002 476 22.04 2002 126 5.84 New Zealand 2003 8790 21.90 e 2003 1582 5.50 e Niue 2006p 4 23.12 2006p 3 17.34 Northern Mariana Islands 1999 31 4.47 1999 3 0.43 Palau 2003 25 12.31 1998 2 1.10 Papua New Guinea 2005 750 1.26 2005 182 0.30 Philippines 2004 93 862 11.35 2004 45 903 5.55 Pitcairn Islands .. . . . . . . . . . . Republic of Korea 2004 97 404 20.26 2004 21 344 4.44 Samoa 2005 50 2.74 2005 6 0.33 Singapore 2005 6748 15.51 2005 1277 2.93 Solomon Islands 2005 89 1.86 2005 52 1.09 Tokelau 2003 3 20.00 2003 3 20.00 Tonga 2003 32 f 3.90 2003 23 j 2.27 Tuvalu 2003 4 4.18 2003 2 2.09 Vanuatu 2004 est 29 1.35 .. . . . . Viet Nam 2004 48 215 5.88 .. . . . . Wallis and Futuna 2003 11 g 7.36 e 2003 4 2.70 WESTERN PACIFIC REGION . . . . . . . . . . . . Table 6 Health workforce and infrastructure indicators ... Data not available f Figure refers to government doctors. est Estimate g Figure refers to physicians and specialists. p Preliminary h Figure includes six dental nurses. a Figure includes assistant doctors. i Figure refers to dental surgeons only. b Computed by Health Information and Evidence for Policy Unit j Figure refers to dental officers and dental therapists. of the WHO Regional Office for the Western Pacific. c The number of doctors/ dentists refers to the number of doctors/ dentists with full registration on both the local and overseas lists. d Figure includes physicans and traditional Chinese medicine doctors. e Revised data. Country/area Physicians Health workforce Year Number Rate per 10 000 Year Number Rate per 10 000 Dentists STATISTICAL TABLES 407 ... Data not available p Figure refers to registered nurses, licensed practical nurses est Estimate and nursing assistants. k Primary nurses and midwives included in other nursing/ auxiliary staff q Figure includes asisstant nurses and excludes midwives. graduated between 2002-2004(MOH). r Figure refers to bachelor and diploma graduate nurses. l Figure refers to the number of registered nurses and enrolled nurses. s Figure includes beds in psychiatric hospital. m Figure includes nurses, public health nurses and assistant nurses. t Figure includes beds in state hospitals and community health centres. n Figure includes medical assistants. u Figure includes beds for psychiatric and geriatric cases. o Figure refers to nurses (registered) and midwives. Health workforce (continued) Year Number Rate per 10 000 Year No. of hospital beds Rate per 1000 population Nurses Health Infrastructure 2003 127 20.29 2003 128 1.95 2004 159 600 79.40 2003-2004 79 908 s 3.93 2004 1748 48.60 2004 1056 2.94 2004 4516 k 3.45 2004 7482 0.57 2004p 1 286 000 9.89 2004 3 004 000 2.31 2003 60 32.60 2004 80 3.96 2004 1682 19.88 2004 1819 2.15 2000 824 35.90 2003 909 3.57 .. . . . . 2000 225 1.33 2005 35 465 l 50.88 2005p 34 128 4.92 2004 1 146 181 m 89.77 2004 1 812 554 14.19 2004 238 26.50 2004 140 1.50 2005 5291 n 9.32 2005 6739 1.20 2004 1063 23.26 2004 1163 2.50 2005 44 120 16.88 2005 46 004 1.76 2000 152 29.34 1999 105 1.72 2005 229 20.07 2005 365 t 3.20 2004 7915 31.43 2004 15 242 6.02 2004 48 47.52 2004 60 4.34 2002 1128 52.25 2002 888 u 3.85 2004 34 660 o 85.40 e 2002 23 825 5.81 2006p 13 75.14 2006 8 4.62 1999 123 17.74 2000 82 1.02 2005 111 p 55.76 1998 90 4.52 2005 8914 14.98 .. . . . . 2004 352 398 42.63 2002 91 000 1.07 .. . . . . . . . . . . 2004 202 012 42.01 2004 364 328 7.54 2005 136 7.47 2005 253 1.38 2005 19 820 q 45.55 2005 11 830 3.33 2005 620 12.97 2005 691 1.45 2003 10 66.67 2003 18 11.76 2003 342 33.70 2004 296 2.89 2003 30 r 31.38 2001 56 5.15 2004 est 312 14.48 2003 397 1.79 2004 49 534 6.02 2004 188 906 2.30 .. . . . . 2003 74 4.93 .. . . . . . . . . . . STATISTICAL TABLES 408 ... Data not available p Preliminary a Figure refers to new cases. b Imported cases. c Confirmed. d Inclusive of imported cases and deaths. e Figure refers to microscopically diagnosed malaria cases in10 endemic countries namely, Cambodia, China, Lao People’s Democractic Republic, Malaysia, Papua New Guinea, Philippines, Republic of Korea, Solomon Islands, Vanuatu and Viet Nam. Table 7 Mortality and morbidity indicators Country/area Year Cases a Deaths Year Cases a Deaths Cholera Malaria Communicable Diseases American Samoa 2003 0 0 .. . . . . Australia 2003 0 0 2003 601 3 Brunei Darussalam 2004 0 0 2004 13 0 Cambodia .. . . . . 2004 16 183 105 China 2005 973 4 2004 27 201 31 Cook Islands 2002 0 0 2003 1 .. . Fiji 2002 0 0 .. . . . . French Polynesia 2003 0 0 2003 .. . 0 Guam 2003 0 0 .. . . . . Hong Kong (China) 2005 5 .. . 2005 32 .. . Japan 2005 43 0 2004 .. . 1 Kiribati 2005 0 0 .. . . . . Lao People's Democratic Republic 2002 1272 1 2004 16 183 105 Macao (China) 2005 0 0 2005 0 0 Malaysia 2005 386 2 2005 5569 33 Marshall Islands 2005 0 0 .. . . . . Micronesia, Federated States of 2005 0 0 .. . . . . Mongolia 2005 0 0 2005 0 0 Nauru 2002 0 0 .. . . . . New Caledonia .. . . . . . . . . . . New Zealand 2005 1 0 2004 33 b 0 Niue 2005 0 0 2005 0 0 Northern Mariana Islands .. . . . . . . . . . . Palau 2003 0 0 2003 0 0 Papua New Guinea 2000 0 0 2004 84 096 619 Philippines 2004 351 (2002) 23 2004 43 736 93 Pitcairn Islands .. . . . . . . . . . . Republic of Korea 2004 10 0 2004 827 0 Samoa 2004 0 0 .. . . . . Singapore 2005p 1 .. . 2005p 166 .. . Solomon Islands .. . . . . 2004 90 240 51 Tokelau .. . . . . . . . . . . Tonga 2002 0 0 .. . . . . Tuvalu 2005 0 0 .. . . . . Vanuatu 2005 0 0 2004 14 653 1 Viet Nam 2004 67 1 2004 24 909 c 34 c Wallis and Futuna .. . . . . . . . . . . WESTERN PACIFIC REGION 2005 1165 d 5 2004 367 744 e 135 e STATISTICAL TABLES 409 Year Cases a Deaths Year Cases a Dengue fever/ Dengue Hemorrhagic Fever Communicable Diseases Leprosy 2002 1185 0 2004 3 2004 352 1 2004 5 2004 36 0 2004 4 2004 3075 10 2004 461 2004 247 0 2004 1499 2004 4 0 2004 0 2004 2 0 2004 3 2004 58 0 2004 11 .. . . . . 2001 1 2005 31 .. . 2005 4 2004 0 0 2004 11 2004 0 0 2004 64 2004 3075 f 10 f 2003 156 2005 0 0 2005 0 2005 16 861 107 2005 262 2004 0 0 2004 62 2004 658 0 2004 153 2004 0 0 2004 0 .. . . . . 2002 3 2004 792 2 2004 8 2004 8 0 2004 3 2005 0 0 2005 0 .. . . . . 2003 4 2004 57 0 2004 6 2002 22 .. . 2004 312 2004 26 269 g 244 h 2004 2254 .. . . . . . . . 2004 0 0 2004 17 2004 1 0 2004 10 2005p 14 209 .. . 2004 5 2004 0 0 2005 26 .. . . . . 2003 0 2004 3 0 2004 1 2004 0 0 2004 0 .. . . . . 2004 3 2004 78 669 114 2004 858 2004 41 0 2003 0 2004 160 372 571 2004 10 000 g a Figure refers to new cases. f Revised data. g Figure is composed of 23 040 dengue fever cases and 3229 dengue hemorrhagic fever cases. h Figure refers to dengue fever cases only. i Registered prevalence/ cases. STATISTICAL TABLES 410 Table 7 Mortality and morbidity indicators (continued) American Samoa (2004) 0 (2004) 0 (2004) NR (2004) NR (2004) 0 (2004) 0 Australia (2004) 0 (2004) 45 a (2004) 0 (2004) 5 (2004) 8676 (2004) 0 Brunei Darussalam (2004) 0 (2004) 15 a (2004) 0 (2004) 1 (2004) 2 a (2004) 0 Cambodia (2004) 4 (2004) 352 (2004) 146 (2004) 1041 (2004) 66 (2004) 0 China (2004) 2 (2004) 70 549 (2004) 2954 .. . (2004) 4705 (2004) 0 Cook Islands (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 Fiji (2004) 0 (2004) 37 (2003) 0 (2003) 0 (2004) 3 (2004) 0 French Polynesia (2003) 0 (2003) 0 (2003) 0 (2003) 0 (2003) 1 (2003) 0 Guam (2004) 0 (2004) 2 (2004) 0 (2004) 0 (2004) 0 (2004) 0 Hong Kong (China) 0 65 0 0 32 0 Japan (2004) 0 (2004) 8752 .. . (2004) 69 (2004) 1534 (2004) 0 Kiribati 0 0 .. . . . . 0 . . . Lao People's Democratic Republic 9 (2004) 1491 14 21 120 (2004) 1 c Macao (China) (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 Malaysia 3 1407 6 27 b 8 0 Marshall Islands (2004) 0 (2004) 0 (2004) 0 (2003) 0 (2003) 0 (2004) 0 Micronesia, Federated States of (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 Mongolia (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 Nauru (2004) 0 (2004) 0 (2004) 0 (2004) 1 (2004) 0 (2004) 0 New Caledonia (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 1 (2004) 0 New Zealand (2004) 0 (2004) 33 (2004) 0 (2004) 1 (2004) 3689 (2004) 0 Niue 0 0 0 0 0 0 Northern Mariana Islands (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 Palau (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 Papua New Guinea .. . (2004) 1385 (2004) 50 (2004) 39 (2004) 2050 (2004) 0 Philippines (2004) 89 (2004) 3025 (2004) 250 (2004) 1293 (2004) 10 (2004) 0 Pitcairn Islands .. . . . . . . . . . . . . . . . . Republic of Korea (2004) 0 (2004) 16 (2004) NR (2004) 11 (2004) 6 (2004) 0 Samoa (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 Singapore 0p 33p 0p 2p 1p 0p Solomon Islands (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 Tokelau (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 Tonga (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 Tuvalu (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 Vanuatu .. . (2003) 165 (2003) 3 (2003) 0 .. . (2003) 0 Viet Nam (2004) 49 (2004) 217 (2004) 46 (2004) 72 (2004) 328 (2004) 0 Wallis and Futuna (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 WESTERN PACIFIC REGION ... 128 059 .. . . . . . . . . . . Neonatal Total Country/area Diphtheria Measles tetanus tetanus Pertussis Poliomyelitis 2005 2005 2005 2005 2005 2005 Vaccine Preventable Diseases - Number of Reported Cases ... Data not available NR Not relevant p Preliminary a Revised data. b Figure refers to adults. c Vaccine-derived poliovirus. STATISTICAL TABLES 411 Congenital Yellow fever Hib meningitis Mumps Rubella rubella AFP 2004 2005 2005 2005 2005 2005 Vaccine Preventable Diseases - Number of Reported Cases N R (2004) 2 (2004) 0 (2004) 0 (2004) 0 0 0 .. . (2004) 106 (2004) 44 (2004) 1 26 0 (2004) 0 (2004) 24 a (2004) 1 a (2004) 0 2 .. . . . . . . . (2004) NR ... 111 0 .. . (2004) 226 819 (2004) 24 015 .. . 5448 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 0 0 (2004) 63 (2004) 20 (2004) 2 (2003) 0 1 .. . (2003) 0 (2003) 12 (2003) 3 .. . 0 0 (2004) 0 (2004) 1 (2004) 1 (2004) 0 0 0 1 145 53 0 22 .. . . . . (2004) 84 672 (2004) 2794 (2004) 1 0 .. . 0 0 0 0 0 .. . 264 .. . . . . . . . 59 0 (2004) 0 (2004) 67 (2004) 2 (2004) 0 1 0 .. . . . . . . . . . . 140 0 (2003) 0 (2003) 6 (2003) 0 (2004) 0 0 N R (2004) 0 (2004) 0 (2004) 0 (2004) 0 0 0 (2004) 25 (2004) 417 (2004) 36 (2004) 0 8 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 0 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 0 0 (2004) 1 (2004) 45 (2004) 25 (2004) 0 9 0 0 0 (2004) 0 0 0 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 0 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 0 .. . . . . . . . . . . . . . 18 .. . . . . . . . (2004) 25 .. . 352 .. . . . . . . . . . . . . . . . . . . . (2004) NR (2004) 1744 (2004) 15 (2004) 0 17 0 (2004) 4 (2004) 0 (2004) 0 (2004) 1 0 0 5p 1003p 139p 0p 10 0 .. . . . . . . . . . . 2 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 0 N R (2004) 16 (2004) 0 (2004) 0 (2004) 0 1 0 (2004) 0 (2004) 0 (2004) 0 (2004) 0 0 .. . (2003) 20 (2003) NR (2003) NR (2003) NR 0 N R ... . . . . . . . . . 469 0 (2004) 0 (2004) 0 (2004) 1 (2004) 0 1 . . . . . . . . . . . . . . . 6697 ... Data not available NR Not relevant p Preliminary a Revised data. STATISTICAL TABLES 412 Table 7 Morbidity and mortality indicators (continued) American Samoa (2003) NR (2003) 99.00 (2003) 98.00 (2003) 94.00 (2003) 93.00 (2003) 89.00 Australia N R ... . . . 92.30 92.20 (2005) 94.60 Brunei Darussalam (2004) 99.40 99.20 100.00 (2004) 91.70 (2004) 92.20 100.00 Cambodia (2004) 95.00 .. . 92.00 (2004) 85.00 (2004) 86.00 .. . China (2004) 98.80 98.90 98.80 (2004) 98.90 (2004) 98.90 98.70 Cook Islands (2004) 100.00 100.00 100.00 (2004) 100.00 (2004) 100.00 100.00 Fiji (2004) 93.10 85.90 75.20 (2004) 71.30 (2004) 76.40 72.90 French Polynesia (2003) 99.00 (2003) 99.00 (2003) 99.50 (2003) 99.00 (2003) 99.00 (2003) 98.00 Guam (2004) NR 99.00 .. . (2004) 87.00 (2004) 79.00 85.00 Hong Kong (China) (2004) 95.00 100.00 95.00 (2004) 95.00 (2004) 95.00 95.00 Japan .. . . . . 100.00 (2004) 100.00 (2004) 97.00 .. . Kiribati (2004) 94.50 .. . 75.10 (2004) 63.40 (2004) 60.70 66.60 Lao People's Democratic Republic (2004) 60.00 2.00 66.00 (2004) 45.00 (2004) 46.00 45.00 Macao (China) (2004) 96.20 99.70 94.60 (2004) 90.20 (2004) 90.20 86.40 Malaysia 100.00 95.00 95.50 95.30 94.30 95.00 Marshall Islands (2004) 91.00 91.00 71.00 (2004) 64.00 (2004) 68.00 72.00 Micronesia, Federated States of (2004) 62.00 83.00 83.00 (2004) 78.00 (2004) 82.00 80.00 Mongolia (2004) 95.00 97.70 99.00 (2004) 98.90 (2004) 95.00 95.00 Nauru (2004) 90.00 90.00 90.00 (2004) 80.00 (2004) 75.00 75.00 New Caledonia .. . . . . . . . . . . . . . . . . New Zealand .. . . . . . . . . . . . . . . . . Niue 99.00 20.80 100.00 98.00 98.00 98.00 Northern Mariana Islands .. . 98.70 96.00 (2004) 87.00 (2004) 87.00 89.00 Palau .. . 100.00 100.00 (2004) 98.00 (2004) 98.00 98.00 Papua New Guinea (2004) 74.00 a (2003) 21.00 81.00 (2004) 62.00 a (2004) 49.00 a 60.00 a Philippines 77.00 (2003) NR 81.00 76.00 76.00 43.00 Pitcairn Islands .. . . . . . . . . . . . . . . . . Republic of Korea (2004) 92.70 96.20 95.20 (2004) 87.50 (2004) 89.80 91.60 Samoa (2004) 93.00 58.00 90.00 (2004) 68.00 (2004) 41.00 70.00 Singapore 97.00p 99.00 95.00 95.00p 95.00p (2005p) 94.00 Solomon Islands (2004) 82.00 (2003) 76.00 84.00 (2004) 80.00 (2004) 75.00 72.00 Tokelau (2004) 100.00 99.00 99.00 (2004) 99.00 (2004) 99.00 99.00 Tonga (2004) 99.60 100.00 99.90 (2004) 99.30 (2004) 99.30 99.20 Tuvalu (2004) 100.00 91.00 100.00 (2004) 98.00 (2004) 98.00 98.00 Vanuatu (2003) 63.00 .. . . . . (2003) 49.00 (2003) 53.00 (2003) 56.00 Viet Nam (2004) 95.60 59.50 91.60 (2004) 96.20 (2004) 96.30 94.20 Wallis and Futuna (2002) 73.50 .. . . . . (2002) 100.00 (2002) 100.00 (2002) 100.00 WESTERN PACIFIC REGION 96.37 b,c . . . . . . 95.56 b,d 95.61 b, d 92.37 b,e HepB birth Hepatitis Country/area BCG dose DTP1 DTP3 OPV3 B3 2005 2004 2004 2005 2005 2004 Immunization Coverage (%) ... Data not available NR Not relevant a Revised data b This is a weighted average based on births. Coverage data from the 2005 WHO/UNICEF Joint Reporting Form. c Based on available data received from 19 countries. d Based on available data received from 24 countries. e Based on available data received from 23 countries. STATISTICAL TABLES 413 Hib3 MCV1 MCV2 Vitamin A1 2004 2005 2004 2004 Immunization Coverage (%) (2003) 90.00 (2003) 89.00 (2003) 76.00 (2003) NR 95.00 93.40 f 84.80 N R 91.70 (2004) 100.00 96.60 N R ... (2004) 80.00 (2003) NR 75.00 .. . (2004) 98.50 96.20 (2003) NR N R (2004) 100.00 86.00 .. . 71.30 (2004) 61.80 .. . . . . (2003) 98.00 (2002) 95.60 .. . . . . 83.00 (2004) 82.00 .. . N R ... (2004) 95.00 95.00 (2003) NR ... (2004) 100.00 .. . . . . . . . (2004) 56.00 56.00 58.30 .. . (2004) 36.00 29.00 42.00 N R (2004) 91.10 83.80 N R 71.00 95.40 (2003) NR (2003) NR 46.00 (2004) 70.00 (2003) 90.00 46.00 65.00 (2004) 85.00 74.00 N R ... (2004) 96.00 97.80 .. . . . . (2004) 87.00 60.00 .. . . . . . . . . . . . . . . . . . . . . . . . . . 100.00 97.00 (2003) 85.70 .. . 70.00 (2004) 82.00 82.00 .. . 98.00 (2004) 100.00 98.00 .. . . . . (2004) 50.00 a 37.00 .. . . . . 78.00 (2003) NR 89.00 .. . . . . . . . . . . . . . (2004) 99.50 99.50 .. . . . . 55.00 .. . . . . N R 93.00p 95.00 .. . N R (2004) 72.00 N R ... 99.00 (2004) 82.00 (2003) NR (2003) NR ... (2004) 99.60 98.60 .. . . . . (2004) 98.00 .. . . . . . . . (2003) 48.00 N R (2003) NR N R (2004) 97.10 N R 82.60 .. . (2002) 100.00 72.00 .. . . . . 95.72 b, d . . . . . . ... Data not available NR Not relevant a Revised data b This is a weighted average based on births. Coverage data from the 2005 WHO/UNICEF Joint Reporting Form. d Based on available data received from 24 countries. f Measles at age 2. STATISTICAL TABLES 414 Table 7 Morbidity and mortality indicators (continued) American Samoa .. . . . . Australia 2003 0.10 .. . Brunei Darussalam 2003 <0.01 .. . Cambodia 2004 1.90 a (2003) 20.80 a (direct SW) China 2005 0.10 b <5 - >50 (IDU) Cook Islands .. . . . . Fiji 2003 0.10 .. . French Polynesia .. . . . . Guam ... . . . Hong Kong (China) . . . . . . Japan 2003 <0.10 .. . Kiribati . . . . . . Lao People's Democratic Republic 2003 0.10 (2001) 1.10 (SW) Macao (China) . . . . . . Malaysia 2003 0.40 b . . . Marshall Islands .. . . . . Micronesia, Federated States of . . . . . . Mongolia 2003 <0.10 .. . Nauru .. . . . . New Caledonia .. . . . . New Zealand 2003 0.10 .. . Niue .. . . . . Northern Mariana Islands .. . . . . Palau .. . . . . Papua New Guinea 2005 2.00 a (2004) 19.90 a, c Philippines 2005 <0.10 0.16 (SW) Pitcairn Islands .. . . . . Republic of Korea 2003 <0.10 .. . Samoa .. . . . . Singapore 0.20 .. . Solomon Islands .. . . . . Tokelau .. . . . . Tonga .. . . . . Tuvalu .. . . . . Vanuatu .. . . . . Viet Nam 2003 0.40 b (2005) 34.00 b (IDU); 16.00 b (SW) Wallis and Futuna .. . . . . WESTERN PACIFIC REGION . . . . . . Percentage in general population based Percentage in a high risk group based Country/area Year on HIV estimates in adults on sentinel surveillance HIV Prevalence Rate HIV / AIDS ... Data not available b Concentrated epidemic (<1% in general population but p Preliminary >5% in specific vulnerable groups such as sex workers (SW), NR Not relevant. injecting drug users (IDU), etc. IDU Injecting drug users c Among STI patients in Port Moresby SW Sex workers STI Sexually-transmitted infection M Male F Female a Generalized epidemic (>1% in general population) STATISTICAL TABLES 415 % of people with HIV/AIDS in need of and receiving Year % of condom use Year adequate treatment including antiretroviral therapy (ART) HIV / AIDS . . . . . . . . . . . . . . . . . . 2005 93.00 d (direct SW) 2005 56.20 .. . 2005 27.20 .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2001 60.00 e (SW) .. . . . . . . . 2003p 51.00 e (SW) .. . . . . . . . . . . . . . 2003 66.00 f (SW) .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2004 22.00 g =M (STI); 56.00 g =F (STI) 2005 < 5.00 2005 57.00 d (SW) .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2005 72.50 h (15-49 y.o men) 2005 8.90 .. . . . . . . . . . . . . . Data not available d Consistent condom use in the past week. e Consistent condom use in the last month. f Consistent condom use in the last year. g Consistent condom use in the last three months with non-regular partners. h Condom use at last high risk sex. STATISTICAL TABLES 416 Table 7 Morbidity and mortality indicators (continued) Country/area All Smear positive 2003 2003 2004 cases cases Prevalence rate (all cases per 100 000 population) Incidence rate (per 100 000 population) 2004 American Samoa 70.00 3 49 28 13 Australia . . . . . . 6 6 3 Brunei Darussalam ... . . . 63 54 24 Cambodia .. . 0 709 510 226 China .. . . . . 221 101 46 Cook Islands 88.00 4 51 28 13 Fiji 62.00 2 41 28 13 French Polynesia 90.00 4 56 28 13 Guam ... . . . 91 59 26 Hong Kong (China) . . . . . . 77 75 34 Japan .. . . . . 39 30 13 Kiribati 49.00 3 59 59 27 Lao People's Democratic Republic . . . . . . 318 156 70 Macao (China) . . . . . . 90 82 37 Malaysia .. . 0 133 103 46 Marshall Islands 68.00 2 59 59 27 Micronesia, Federated States of 100.00 1 59 59 27 Mongolia . . . . . . 209 192 86 Nauru .. . . . . 35 28 13 New Caledonia .. . 0 117 59 26 New Zealand .. . . . . 11 11 5 Niue 78.00 4 57 28 13 Northern Mariana Islands .. . . . . 68 59 27 Palau .. . . . . 91 59 27 Papua New Guinea .. . 0 448 233 104 Philippines 74.00 3 463 293 132 Pitcairn Islands .. . . . . . . . . . . . . . Republic of Korea .. . . . . 125 90 41 Samoa 80.00 5 43 28 13 Singapore .. . . . . 41 40 18 Solomon Islands .. . . . . 59 59 27 Tokelau .. . . . . 57 28 13 Tonga 91.00 3 42 28 13 Tuvalu 83.00 3 57 28 13 Vanuatu 87.00 4 64 59 27 Viet Nam 87.00 1 232 176 79 Wallis and Futuna 65.00 2 28 28 13 WESTERN PACIFIC REGION ... . . . 216 111 50 Tuberculosis ... Data not available Reported MDA coverage among Number of total population (%) MDA rounds Lymphatic Filariasis STATISTICAL TABLES 417 Cure rate Case detection rate of TB notification rate Mortality rate (smear-positive cases) smear positive cases DOTS (per 100 000 population) (All cases per in DOTS areas) 2004 coverage 2004 100 000 population) 2003 2004DOTS Total Tuberculosis 5 100 25 25 100 8 3 1 82 33 56 63 5 1 5 60 129 129 100 48 31 94 93 61 61 100 223 138 17 94 63 65 96 60 29 5 (2002) 100 43 43 98 6 6 5 86 58 58 100 16 7 5 83 93 93 100 24 12 10 96 50 50 100 31 13 6 78 55 72 100 88 24 4 76 45 62 71 23 8 4 88 550 550 100 318 146 25 79 55 55 98 55 39 10 88 76 76 100 71 28 16 72 69 69 100 60 32 4 90 246 246 100 199 65 4 92 120 120 90 108 32 24 87 80 80 100 175 69 4 (2002) 50 (2003) 57 (2003) 57 (2003) 100 (2003) 23 (2003) 8 12 75 24 24 100 26 6 1 36 59 59 100 9 3 6 (2002) 100 (2002) 469 a 0 100 0 0 8 75 67 67 100 67 18 7 80 95 95 95 25 25 42 58 19 31 47 221 33 48 88 73 73 100 160 96 .. . . . . . . . . . . . . . . . . . . . 10 82 21 59 100 73 24 5 (2002) 84 (2003) 49 a (2003) 51 (2003) 100 (2003) 15 (2003) 7 4 77 67 67 100 35 12 4 87 123 123 100 73 33 6 .. . . . . (2003) 0 (2003) 0 (2003) 0 (2003) 0 5 (2002) 83 (2003) 81 a (2003) 80 (2003) 100 (2003) 16 (2003) 11 5 .. . . . . (2003) 0 (2003) 0 (2003) 290 (2003) 0 5 75 107 107 100 55 28 22 92 89 89 100 118 70 2 (2002) 100 (2003) 344 a (2003) 356 (2003) 90 (2003) 98 (2003) 46 18 91 65 67 94 67 33 ... Data not available a Revised data. All cases Smear-positive cases2004 STATISTICAL TABLES 418 Table 7 Morbidity and mortality indicators (continued) Motor and other Diseases of the Suicide vehicle accidents Cancer circulatory system (per 100 000 population) Non-communicable diseases American Samoa 2002 101 5 2002 37 2002 88 .. . . . . Australia 2003 .. . 1811 2004 37 980 2004 47 512 2003 17.59 4.77 Brunei Darussalam 2004 505 38 2004 218 2004 305 2004 1.06 0.59 Cambodia 2002 .. . 535 2000 134 .. . . . . . . . China 2002 .. . b 2002 c 2002 d 1999 13.00 f 14.80 f Cook Islands 2003 128 e 3 2003 15 2003 19 .. . . . . Fiji 1998 551 13 1999 229 1999 1052 .. . . . . French Polynesia 2003 .. . 33 2003 245 2003 260 .. . . . . Guam 2000 .. . 23 2000 125 2000 246 2000 34.10 2.64 Hong Kong (China) . . . . . . 2005 12 141 2005 10 312 2003p 22.28 10.52 Japan 2004 .. . 10 551 2004 320 358 2004 310 894 2004 35.24 12.68 Kiribati 2005 .. . 3 2005 27 2002 70 .. . . . . Lao People's Democratic Republic . . . . . . . . . . . . . . . . . . Macao (China) 2004 .. . 15 2004 475 2004 447 2004 20.16 11.57 Malaysia 2005 83 831 1584 2005 4005 2005 9143 2003 0.77 0.37 Marshall Islands .. . . . . 1998 12 .. . . . . . . . Micronesia, Federated States of 2000 .. . 4 2000 51 2000 84 .. . . . . Mongolia 2004 .. . 531 2004 2669 2004 5808 2004 30.32 5.48 Nauru 2002 .. . 0 2002 13 2002 14 2002 19.46 0.00 New Caledonia 2002 662 62 2002 297 f 2002 262 2002 21.67 10.28 New Zealand 2002/2003 12 603 (2002) 531 2002 7800 2002 11 402 2002 18.02 5.59 Niue .. . . . . . . . . . . . . . . . . Northern Mariana Islands 2000 555 (1998) 7 1998 26 .. . . . . . . . Palau 1998 77 4 1998 13 1998 38 .. . . . . Papua New Guinea 2000 504 19 2000 268 .. . 2000 0.00 0.04 Philippines 2002 .. . 6131 2002 38 821 2002 119 742 2002 2.50 0.77 Pitcairn Islands .. . . . . . . . . . . . . . . . . Republic of Korea 2004 .. . 8333 2004 64 731 2004 58 382 2004 32.62 15.18 Samoa 2002 129 4 2004 12 2004 37 2002 11.95 g 5.91 g Singapore 2005p .. . 154 2005p 4276 2005p 5350 2004p 6.69 a 4.62 a Solomon Islands .. . . . . . . . . . . . . . . . . Tokelau .. . . . . . . . . . . . . . . . . Tonga 2002 109 0 2002 76 2002 192 .. . . . . Tuvalu 2001 1 0 2001 0 .. . . . . . . . Vanuatu 2003 30 .. . 2003 38 2003 46 .. . . . . Viet Nam 2004 147 850 609 2004 768 2004 2499 .. . . . . Wallis and Futuna .. . . . . . . . . . . . . . . . . WESTERN PACIFIC REGION ... . . . . . . . . . . . . . . . ... Data not available d Mortality rate (per 100 000 population) for diseases of the p Preliminary circulatory system in urban areas =190.22 and in NR Not relevant. rural areas = 183.53. a Resident population. e In Rarotonga hospital. b Mortality rate (per 100 000 population) of motor and other vehicle f Refers to selected urban and rural areas in mainland China. accidents in urban areas=6.39 and in rural areas=7.86 g Suicide rate for Samoa was derived based on the latest c Mortality rate (per 100 000 population) for cancer in population size available (by gender). urban areas = 119.71 and in rural areas= 105.83. Country/area Year Cases Deaths Year Deaths Year Deaths Year Male Female Statistical Charts ANNEX CHARTS 420 Figure 1 Annual Incidence Rate of Confirmed Malaria Cases per 1000 population, 1992-2004. ANNEX CHARTS 421 Figure 2 Annual Mortality rate of Malaria per 1000 population, 1992-2004. ANNEX CHARTS 422 Figure 3 Reported number of dengue cases and case fatality rate (CFR) of dengue in the Western Pacific Region, 1991-2004. ANNEX CHARTS 423 Figure 4 Tuberculosis Case Notification Rates in the Western Pacific Region, All forms and Smear positive cases, 1995-2004. ANNEX CHARTS 424 Figure 5 Trend of DOTS New Smear positive Case Detection Rate, 1995-2004. ANNEX CHARTS 425 Figure 6 Major Emergencies in the Western Pacific Region, 2005-2006. 427 Acute respiratory infections, cases and deaths. The number of cases and deaths recorded or estimated from respiratory infections during the most recent year for which valid statistics are available. Admission. Formal acceptance, by a health facility, of a patient who is to receive medical or paramedical care while occupying a health facility bed. Healthy babies born in hospital should not be counted if they do not require special care. Adult literacy rate. The percentage of persons (male or female, or both sexes) aged 15 years and over who can, with understanding, both read and write a short simple statement on their everyday lives. Notes are made when a country has a different definition. Annual population growth rate. (See Population growth rate) Area. The total surface area comprising land area and all inland waters. Presented in 1000 square kilometres or actual value. Bed. A bed regularly maintained and staffed for the accommodation and full-time care of a succession of inpatients and which is situated in wards or a part of the hospital where continuous medical care for inpatients is provided. The total of such beds constitutes the normally available bed complement of the hospital. Cribs and bassinets maintained for use by healthy newborn babies who do not require special care 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 cases and deaths due to all types and specific types of cancer during the most recent year for which valid statistics are available. Causes of morbidity. (See Leading causes of morbidity) Causes of mortality. (See Leading causes of mortality). Circulatory system diseases, number and cases. The number of cases and deaths resulting from any form of circulatory disease. Condom use rate of the contraceptive prevalence rate. The number of women aged 15-49 in marital or consensual unions who are practising contraception by using condoms as a proportion of all women of the same age group in consensual unions who are practising, or whose sexual partners are practising, any form of contraception. Crude birth rate. The number of live births for every 1000 population in a given year or period of time. Crude death rate. The number of deaths for every 1000 population in a given year or period of time. Dependency ratio. The ratio of persons in the "dependent" ages (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 year for which valid statistics are available. Diarrhoeal diseases, cases and deaths. The number of cases of and/or recorded or estimated deaths from all types of diarrhoeal diseases during the most recent year for which valid statistics are available. Discharges (including deaths). The number of persons, living or dead, whose stay in a health care facility has terminated 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.); Appendix: Glossary of Terms 428 (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) 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 % of general government expenditure on health. The percentage share of external resources for health to the total general government expenditure on health. GDP per capita annual growth rate (%). Least squares annual growth rate, calculated from constant price GDP in local currency units. 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 external funds. (See also External source of government health expenditure.) (1) Amount. Government expenditure on health expressed in US dollars or another indicated currency. (2) Government expenditure on health as % of total expenditure on health. The percentage share of the government expenditure on health to the total expenditure on health. (3) Government expenditure on health as % of total general government expenditure. The percentage share of the government expenditure on health to the total government expenditure. Growth rate. (See also Population growth rate) Gross domestic product (GDP). 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. Health-adjusted 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. 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. Health expenditure per capita. (See Total health expenditure - Per capita total expenditure on health) Health facilities. (See Health infrastructure) Health infrastructure. • General hospital. A hospital which provides a range of different services for patients of various age groups and with varying disease conditions. • Specialized hospital. A hospital admitting primarily patients suffering from a specific disease or affection of one system, or reserved for the diagnosis and treatment of conditions affecting a specific age group or of a long-term nature. • District/first-level referral hospital. A hospital at the first referral level that is responsible for a district or a defined geographical area 429 containing a defined population and governed by a politico-administrative organization such as a district health management team. The role of district hospitals in primary health care has been expanded beyond being dominantly curative and rehabilitative to include promotional, preventive and educational roles as part of a primary health care approach. The district hospital has the following functions: (1) It is an important support for other health services and for health care in general in the district. (2) It provides wide-ranging technical and administrative support and education and training for primary health care. (3) It provides an effective, affordable health care service for a defined population, with their full participation, in cooperation with agencies in the district that have similar concerns. • Primary health care centre. A centre that provides services which are usually the first point of contact with a health professional. They include services provided by general practitioners, dentists, community nurses, pharmacists and midwives, among others. Health insurance coverage as % of total population. The percentage of the population covered by health insurance. Health workforce. • Physicians. All graduates of any faculty or school of medicine, actually working in the country in any medical field (practice, teaching, administration, research, laboratory, etc.) • Dentists. All graduates of any faculty or school of dentistry, odontology or stomatology, actually working in the country in any dental field. • Pharmacists. All graduates of any faculty or school of pharmacy, actually working in the country in pharmacies, hospitals, laboratories, industry, etc. • Nurses. All persons who have completed a programme of basic nursing education and are qualified and registered or authorized to provide responsible and competent service for the promotion of health, prevention of illness, care of the sick, and rehabilitation, and are actually working in the country. • Midwives. All persons who have completed a programme of midwifery education, and have acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery, and are actually working in the country. The person may or may not have prior nursing education. • Other paramedical staff. This includes medical assistants, laboratory technicians and X-ray technicians, among others. • Other health care providers (including community health workers). Other health care providers include all workers who respond to the national definition of health care providers and are not physicians, midwives, nurses, dentists or pharmacists. HIV prevalence among 15–24 year-old pregnant women. Percentage of pregnant women aged 15–24 whose blood samples test positive for HIV. HIV percentage in general population based on HIV estimates in adults. Proportion of the general population positive for HIV. Notes are made if a special population was surveyed e.g. sex workers or injecting drug users. HIV percentage in a high-risk group based on sentinel surveillance. Proportion of population in the high-risk group (sex workers, men who have sex with men or injecting drug users, or as indicated) infected with HIV based on sentinel surveillance. Notes are made if a special population was surveyed e.g. patients with sexually-transmitted infections. Hospital bed. (See Bed) Human Development Index (HDI). The HDI measures the average achievements in a country in three basic dimensions of human development – longevity, knowledge and a decent standard of living. A composite index, the HDI thus contains three variables: life expectancy, educational attainment (adult literacy and combined primary, secondary and tertiary enrolment) and real GDP per capita (in purchasing power parity or PPP$). Immunization coverage for infants. (See Percentage of infants fully immunized with BCG, DPT3, OPV3, measles and hepatitis B3). 430 Infant mortality rate. The number of deaths among infants (below one year of age) per 1000 live births in a given year or period of time. Injuries, all types. The number of recorded or estimated number of diseases/injuries and deaths related to motor and other vehicle accidents; suicide; homicide and violence; and work accidents. • 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 total number of deaths refers only to the fatal injuries. • 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. • Homicide and violence, cases and deaths. Total number of cases and deaths from injuries resulting from homicides and other forms of violence. • Occupational injuries, cases and deaths. Total number of cases and deaths due to injuries arising out of or in the course of work. 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) for which the greatest number of cases have been reported during a given year. Morbidity can be described in terms of the incidence and/or prevalence of certain diseases. The morbidity rate is usually expressed as the number of cases of disease per 100 000 population for a given year. (1) persons who were ill; (2) the illnesses (periods or spells of illness) that those persons experienced; and (3) the duration (days, weeks, etc.) of those illnesses. Leading causes of mortality. The most frequently occurring causes of mortality (usually 10) under which the greatest number of deaths have been reported during a given year. Causes of mortality are all those diseases, morbid conditions, or injuries which either resulted in or contributed to death, and the circumstances of the accident or violence which produced any such injuries. The mortality rate is usually expressed as the number of deaths from a specific cause per 100 000 population for a given year. 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. 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. Malaria prevalence rate. The number of cases of malaria per 100 000 population. Maternal causes, number and deaths. The number of cases and deaths due to haemorrhage, abortion, eclampsia, sepsis obstructed labour 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 deaths, resulting from obstetric complications of the pregnant state (pregnancy, labour and the puerperium), from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above; and (2) indirect obstetric deaths, resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but was aggravated by the physiological effects of pregnancy. Maternal mortality ratio. The number of 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. 431 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. 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 total number of deaths refers only to the fatal injuries. National underweight, stunting and wasting prevalence. • Underweight. Low weight for age or weight for age more than a standard deviation of 2 below the median value of the reference (healthy) population. • Stunting. Low height for age or height for age more than a standard deviation of 2 below the median value of the reference (healthy) population. • Wasting. Low weight for height or weight or weight for height more than a standard deviation of 2 below the median value of the reference (healthy) population. 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. Neonatal mortality rate. Number of deaths in the neonatal period per 1000 live births in a given year or period of time. Neonatal period. Commences at birth and ends 28 completed days after birth. Number of children orphaned by HIV/AIDS. The estimated number of children who have lost one or both parents to AIDS before age 15. Used as a proxy to the MDG indicator ratio of orphans to non- orphans who are in school through the ratio of school attendance of orphans to school attendance of non-orphans aged 0- 14. 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 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. Per capita gross domestic product (GDP). Gross domestic product divided by mid-year population (or population size if mid-year population is not available). Per capita gross national income (GNI). Gross national income divided by mid-year population (or population size if mid-year population is not available). 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. 432 Percentage distribution of population aged 60 years or older by gender. The percentage of the male and the female population 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 condom use. Proportion of sex workers who reported having consistently used a condom in the past week (or month, three months or year, as indicated). Notes are made if the estimate was derived using a different population e.g. patients with sexually-transmitted infections. Percentage of infants fully immunized with BCG, DPT3, OPV3, measles, and hepatitis B3. Percentage of children under one year of age who have received immunization against tuberculosis (BCG), diphtheria, pertussis, tetanus (DPT3), poliomyelitis (OPV3), measles (at least one dose) and hepatitis B3. Percentage of newborn babies weighing at least 2500 grams at birth. The percentage of newborn babies 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. Notes are made when a country has a different definition. Percentage of people with HIV/AIDS in need of and receiving adequate treatment, including antiretroviral therapy (ART). The proportion of those with HIV/AIDS and still living who are in need of ART (i.e. people with advanced HIV infection) and receiving adequate treatment, including ART. Percentage of the population below 15 years of age or above 65 years of age. The percentage of the total population below 15 years of age or above 65 years of age in a given period of time. Percentage of pregnant women cared for by skilled health personnel. The percentage of pregnant women who have had at least one consultation with skilled health personnel during pregnancy. Expressed as a percentage of all live births since the number of pregnant women is generally not available. Percentage of the population with access to safe water. (See Proportion of the population with sustainable access to an improved water source) Percentage of the population with access to excreta disposal facilities. (See also Proportion of the population with access to improved sanitation) 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 e.g. married women only. Person with midwifery skills. A person who has successfully completed the prescribed course in midwifery and is able to give the necessary supervision, care and advice to women during pregnancy, labour and the postpartum period, to conduct deliveries alone, to provide lifesaving obstetric care, and to care for the newborn and the infant. Population. All the inhabitants of a given country or area considered together. Estimates are based on a recent census, 433 official national data or United Nations projections. Presented in thousands or actual value. 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. Private health expenditure. The sum of total outlays on health by private entities, notably commercial insurance, non-profit institutions, households acting as complementary funders to the previously cited institutions or disbursing unilaterally on health commodities. This would include out-of-pocket health expenditure, patient co-payments, private health insurance premiums, and health expenditures by nongovernmental organizations. Private expenditure on health as % of total expenditure on health. The percentage share of the private expenditure on health to the total expenditure on health. 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 manufactured or locally prepared, or a commercial or home-modified replacement food or breast milk substitute. Proportion of births 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 the newborn. 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 the newborn. 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. Proportion of households with access to secure tenure is 1 minus the percentage of the urban population that lives in slums. In the absence of data on the number of slum dwellers, the United Nations Human Settlements Programme (UN-HABITAT) produces estimates based on a definition of slums as agreed by the Expert Group Meeting on Urban Indicators in 2002. Proportion of 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 the fever in the two weeks before the survey and who received appropriate antimalarial drugs. Proportion of the population using solid fuels. The proportion of the population that relies on biomass (wood, charcoal, crop residues and dung) and coal as the primary source of domestic energy for cooking and heating. Proportion of the population with access to affordable, essential drugs on a sustainable basis. The percentage of the population that has access to a minimum of 20 of the most essential drugs. Access is defined as having drugs continuously available and affordable at public or private health facilities or drug outlets that are within one hour’s walk of the population. Essential drugs are drugs that satisfy the health care needs of the majority of the population. Proportion of the population with access to improved sanitation. Percentage of the population with access to facilities that hygienically separate human excreta from human, animal and insect contact. Facilities such as sewers or septic tanks, pour-flush latrines and simple pit or ventilated improved pit latrines are assumed to be adequate, provided that they are not public, according to the World Health Organization (WHO) and United 434 Nations Children’s Fund (UNICEF) Global Water Supply and Sanitation Assessment 2000 Report. To be effective, facilities must be correctly constructed and properly maintained. Proportion of the population with sustainable access to an improved water source. The percentage of the population who use any of the following types of water supply for drinking: piped water, public tap, borehole or pump, protected well, protected spring or rainwater. Improved water sources do not include vendor-provided waters, bottled water, tanker trucks or unprotected wells and springs. Proportion of vehicles using unleaded gasoline (%). The proportion of motor vehicles that use unleaded gasoline as their primary fuel. Expressed as a percentage of the total number of motor vehicles. 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. 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. 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. Reported mass drug administration (MDA) coverage for lymphatic filariasis among total population. Proportion of the population in identified filaria-endemic areas covered by MDA. Secure tenure refers to households that own or are purchasing their homes, are renting privately, are in social housing or are subtenants. Households without secure tenure are defined as squatters (whether or not they pay rent), the homeless and households with no formal agreement. Selected communicable diseases, cases and deaths. The number of new cases and deaths due to hepatitis viral types A, B and C and unspecified, cholera, typhoid fever, encephalitis, plague, syphilis, gonorrhoea, leprosy, malaria and dengue/DHF in a given year. Selected diseases under the WHO expanded programme on immunization (EPI), cases and deaths. The number of cases and deaths due to a specific disease among selected preventable diseases (diphtheria, pertussis, tetanus, neonatal tetanus, poliomyelitis, hib meningitis, measles, mumps, rubella and congenital rubella syndrome) in a specific country or area over a given year. Skilled health personnel or skilled birth attendants. Doctors (specialist or non- specialist), and/or persons with midwifery skills who can diagnose and manage obstetrical complications as well as normal deliveries. Excludes traditional birth attendants, even if they have received a short training course. Slum. A slum household is defined by UN- HABITAT as a group of individuals living under the same roof who lack one or more (in some cities, two or more) of the following conditions: security of tenure, structural quality and durability of dwellings, access to safe water, access to sanitation facilities and sufficient living area. Smoking prevalence among adults. The proportion of the adult population (15 years and over) who are smokers (both daily and occasional) at a point in time. Stunting. (See National underweight, stunting and wasting prevalence) Surface area. (See Area) Total fertility rate. The number of children who would be born per woman if the woman was to live to the end of her child- bearing years and bear children at each age in accordance with prevailing age- specific fertility rates. Total 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) 435 (1) Amount. Total health expenditure expressed in US dollars or another indicated currency. (2) Total health expenditure on health as % 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). Trained traditional birth attendant. A traditional birth attendant (TBA) who initially acquired her ability by delivering babies herself or through apprenticeship to other TBAs and who has undergone subsequent extensive training and is now integrated into the formal health care system. Tuberculosis case. A patient in whom tuberculosis has been bacteriologically confirmed or diagnosed by a clinician. • All types, cases and deaths. The total number of new pulmonary smear- positive pulmonary, relapse, new pulmonary smear-negative, and extrapulmonary tuberculosis cases and deaths. • New pulmonary tuberculosis (smear-positive), cases and death. The total number of patients and deaths among those who have never received treatment for tuberculosis or have taken anti-tuberculosis drugs for less than four weeks 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 treating medical officer; 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 cases. Estimated number of tuberculosis cases arising in a given period of time. Includes all forms of TB, as are cases of people with HIV. Expressed as per capita rate. Tuberculosis prevalence, all cases. The number of cases of tuberculosis in a population in a year or given period of time. Includes all forms of TB, as are cases of TB in people with HIV. Expressed as number of cases per 100 000 population in a given year. Tuberculosis prevalence, sputum smear- positive. The number of sputum-smear positive cases of tuberculosis in a population in a year or given period of time. Expressed as 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 bacteriologic 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. 436 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. Underweight. (See National underweight, stunting and wasting prevalence) Urban population. The percentage of the total population living in areas termed as “urban” by that country. Typically, the population living in towns of 2000 or more or in national and provincial capitals is classified as “urban”. Expressed as a percentage. 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. Youth prevalence of tobacco use. Proportion of youths (aged 15-24 years) who smoked or used other tobacco products within 30 days preceding the survey. Notes are made for instances where only cigarette use was considered.