Republic of the Marshall Islands assessment for a continuing health care professional development program.

Abstract

In 2003, the University of Hawai'i Department of Family Medicine and Community Health entered a 4-year cooperative agreement with the U.S. Health Resources and Services Administration to establish the "Pacific Association for Clinical Training" (PACT). PACT's goal is to develop effective distance education methods to improve the education and skills of healthcare professionals in the U.S.-Affiliated Pacific Island nations. To determine the situation existing in 2004, one of PACT's first projects was to perform site visits to each jurisdiction, conducting needs assessments through interviews with key health care professionals, hospital administrators, and government officials. This article highlights findings of PACT's assessment of Republic of the Marshall Islands. Meant to establish a baseline for future reference, all data are those collected in 2004/2005 and have not been updated.

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Introduction
A preliminary written needs assessment survey was
distributed in November 2003 and completed by key
informants in the Republic of the Marshall Islands (RMI)
Ministry of Health and Environment (MOHE) and at
Majuro and Ebeye Hospitals. Drs. Sheldon Riklon and
Lee Buenconsejo-Lum interviewed additional partici-
pants in person and through written communications.
Cherie Shehata (University of Hawai‘i Family Practice
Resident) conducted the key informant interview for
the laboratory staff during a clinical rotation in the RMI.
The draft was reviewed and discussed at the November
2004 Advisory Board meeting and with the Secretary of
Health for the RMI (fist author, Justina Langidrik).
Republic of the Marshall Islands Assessment for a
Continuing Health Care Professional Development Program
Justina R. Langidrik, MPH*
Sheldon Riklon, MD**
Salome Lanwi, RN†
Kamal Gunawardane, MBBS‡
Tin Soe, MD§
Tom Jack, MD‡
Grace Ann Balaoing, MD§
Lee Buenconsejo-Lum, MD
¶
*Secretary of Health, Ministry of Health, Republic of the Marshall Islands (RMI); ¶Department of Family Medicine and
Community Health, John A. Burns School of Medicine, University of Hawai‘i at Manoa; **Department of Energy Clinic, Majuro,
RMI; †Majuro Hospital, Ministry of Health, Majuro, RMI; ‡Kwajalein Atoll Health Care Bureau, Ministry of Health, RMI;
§Ebeye Hospital, Ministry of Health, RMI. Address correspondence and reprint requests to: Lee E. Buenconsejo-Lum, MD,
Department of Family Medicine and Community Health, John A. Burns School of Medicine, University of Hawai‘i at Manoa,
95-390 Kuahelani Avenue, Mililani, Hawai‘i 96789-1192; lbuencon@hawaii.edu.
Abstract
In 2003, the University of Hawai‘i Department of Family Medicine and Community Health entered a 4-year cooperative agreement
with the U.S. Health Resources and Services Administration to establish the “Pacific Association for Clinical Training” (PACT).
PACT’s goal is to develop effective distance education methods to improve the education and skills of healthcare professionals
in the U.S.-Affiliated Pacific Island nations. To determine the situation existing in 2004, one of PACT’s first projects was to
perform site visits to each jurisdiction, conducting needs assessments through interviews with key health care professionals,
hospital administrators, and government officials. This article highlights findings of PACT’s assessment of Republic of the
Marshall Islands. Meant to establish a baseline for future reference, all data are those collected in 2004/2005 and have not been
updated.
Key words: Republic of the Marshall Islands; Clinical Training; Workforce Development; Distance Education.
(PHD 2007 Vol 14 No 1 pp 81-88)
The RMI is an island nation located in the central Pacific.
The country consists of 29 coral atolls, including the
world’s largest, Kwajalein, and five coral islands (1,225
islands in total) running in two parallel chains. Total land
area is 70 square miles, but the Exclusive Economic
zone covers 750,000 square miles. The RMI is divided
into 33 municipalities, with Majuro, Ebeye, Wotje and
Jaluit as major district centers. Majuro and Kwajalein
are served by international airlines and by Air Marshall
Islands that offers flights between Majuro, Kwajalein
and the outer islands, 23 of which have airstrips. Travel
between many outer islands is by small boat. Most outer
islands do not have electricity or running water. Supplies
for some of the outer islands are transported by ship.1
The RMI is a self-governing democracy in free
association with the U.S. and has been independent
since 1986, and a member of the United Nations since
1991. During the period 1946-1958, the U.S. detonated
total of 67 nuclear weapons in the atolls of Bikini and
Enewetak and the total yield during the 12-year testing
period equaled 108 megatons (equivalent to over 7,000
Hiroshima bombs). Radioactive material was absorbed
from the contaminated food and water and increases

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in leukemia, breast cancer and thyroid2 cancer after
radiation exposure have been established,3 especially
for those with childhood exposure.
Between 1986 and 2003, a targeted health care
program (the 177 Health Care Plan) provided more
comprehensive care for approximately 10,000 persons,
including radiation-affected and displaced Marshallese
and their descendants from the atolls of Rongelap,
Utrik, Bikini and Enewetak. Funding for the 177
program, along with all other sector grants, is scheduled
for incremental reduction per the Amended Compact of
Free Association with the U.S.,4 so it exists on a smaller
scale. A U.S. Department of Energy-sponsored program
(Ejmour Mokta)5 provides screening and treatment for
207 Marshallese citizens considered
by the U.S. to have been most directly
exposed to radiation from nuclear
weapons testing.
The total RIM population, based on a
July 2004 estimate, is reported at 57,738
with a growth rate of 2.3%, a birth rate
of 33.88 per 1,000 and a death rate of
4.94. Infant mortality is 30.5 per 1,000
live births, in comparison to the U.S.
infant mortality rate of 6.63. Overall life expectancy is
69.7 years, compared to 77.4 years in the U.S. Over
62% of the population are 15 years of age or older.6
A 1999 World Health Organization (WHO) report
estimated that the population growth has outpaced the
facilities for the provision of safe water and sanitation.7
The overwhelming majority of the population is ethnic
Marshallese or part-Marshallese. Major languages
spoken include two major dialects of Marshallese and
English; Japanese is also spoken by some. Ninety
percent of the population is defined as literate (percent
of the population >14 years of age who can read), based
on a 1999 estimate from the RMI census. Approximately
half of the population lives on Majuro Atoll. Another
13,000 citizens reside in densely populated Ebeye Atoll,
which is a 78-acre (0.14 square miles) island 3 miles
north of Kwajalein atoll. There are some homes and
rural villages on all inhabited islands that do not have
electricity or running water.
The RIM Gross Domestic Product (GDP) per capita
is $1,194,7 in comparison with the Hawai‘i GDP of
$37,986. Per capita income in urban areas is $1,379
and in rural areas, $520. Thirty percent of the country’s
revenue is from local sources (small-scale agriculture
and handicrafts); 70% are from U.S. grants. The
unemployment rate is approximately 31%. In 2002, the
RMI spent $248 per capita on health care expenditures
compared to $4,499 for the U.S.8
Health Workforce Demographics
There are two MOHE hospitals in the RMI, Majuro
Hospital and Ebeye Hospital. Majuro is the main referral
center. Basic health services are provided at the two
hospitals and 49 dispensaries and health centers (most
on the outer atolls). The majority of health care workers
in both hospitals, including MDs, registered nurses
(RNs) and laboratory staff are expatriate contract
workers, while outer atoll health centers are staffed by
medical officers, health assistants and local support
staff. Majuro Hospital has a radiologist and pathologist
(Table 1 details the number of health workers in various
fields in the RMI).
There is an additional hospital at the U.S.
military base on the island of Kwajalein,
close to Ebeye, which is staffed by U.S.-
trained health workers; workers there
have good access to health information
resources. Entrance to the military base
is restricted for most Marshallese and the
hospital on Kwajalein does not typically
provide care for Marshallese patients.
Included in the count of nurses in the
RMI are Marshallese-licensed RNs, licensed practical
nurses (LPNs) and certified nurse aides (CNAs). Nurses
hold a variety of degrees, including Associates of Arts
(AA), Bachelor of Science in Nursing (BSN) and Master
of science in Nursing (MSN). The majority of nurses
are practical nurses without formal degrees; most of the
others hold Associate-level degrees.
The RMI Public Health Council employs approximately 16
nurses and eight health educators, and most participate
in all prevention and education activities, ranging from
immunizations, sexually transmitted disease prevention,
Tuberculosis (TB) prevention, to high school education
sessions. Additional public health services are provided
by the Department of Reproductive Health and the Outer
Island Health Care Services.
Health Workforce Training
Of the 32 physicians, one (author, Dr. Sheldon Riklon,
who is Marshallese) received and completed his training
in a U.S. allopathic medical school and is licensed to
practice in the U.S. Some physicians are graduates of
the now defunct Pacific Basin Medical Officer Training
Program. The remaining physicians are expatriate
physicians from the Philippines, Burma (Myanmar), Sri
Lanka, and elsewhere.
Many of the graduate nursing staff received their
education (Associate’s degree) at the College of
the Marshall Islands (CMI) nursing program or at
Northern Marianas Community College in Saipan,
A 1999 World Health
Organization (WHO)
report estimated
that the population
growth has outpaced
the facilities for the
provision of safe
water and sanitation.

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Commonwealth of the Northern Mariana Islands. The
CMI is an autonomous community college offering 2-
year Associate degree programs, including nursing and
allied health. The CMI is accredited by the Accrediting
Commission for Community and Junior Colleges of
the Western Association of Schools and Colleges.
The Department of Nursing and Allied Health currently
offers an Associate of Science (AS) degree in Nursing
and is planning to offer an AS in Medical Laboratory
Technology. There are few graduate nurses.
LPNs receive 9-12-month on-the-job nurse aide training.
Many of them have difficulty succeeding in the nursing
program at the CMI, according to key nursing personnel
at MOHE.
Dentists,
assistants receive their training outside
of RMI, typically at the Fiji School of
Dentistry or in the United Kingdom.
None of the seven dental assistants
are formally certified. Dr. Ohnmar Tut,
Preventive Service Dentist with RMI’s
Ministry of Health, with the assistance
of Dr. Peter Milgrom from the University
of Washington, School of Dentistry
and others, has started a local dental
assistant training pilot program that also
incorporates training in health education and community
outreach skills. Other U.S.-Affiliated Pacific Island
(USAPI) jurisdictions have expressed great interest in
sending potential candidates to the RMI for training and
certification in such a program.
dental hygienists and
A WHO-funded consultant has been conducting
formal health assistant training. Participants are high
school graduates who receive an intensive 18-month
core curriculum, covering English, basic anatomy and
pathophysiology, and basic pharmacology. Once the
health assistants return to their outer island dispensary,
ongoing case-based education is conducted via
shortwave radio. Currently, the health assistant training
program is only open to Marshallese.
One radiologist was recently hired, so mammograms
are now performed with increasing frequency. Few
of the radiology technicians are certified. Until
recently, radiology services were limited to x-rays and
mammograms. However, a new computed tomography
scanner is now in place. There is no fluoroscopic unit
or magnetic resonance imaging scanner. Most of the
technicians in Majuro and all of the technicians in Ebeye
do not hold college certificates.
A pathologist was recently hired, so pap smears can
now be read in Majuro. Technicians are also trained
primarily on-the-job, and in Ebeye, none of the staff are
certified medical technologists. Pharmacy technicians
are also trained primarily on-the-job.
Continuing Professional
Development Activities
Continuing Professional Development
as a Health Priority
The RMI has recently endorsed a
national strategic plan, Vision 2018, to
guide the development of the country.
The plan strongly emphasizes the need
to develop human resource potential
through improved education and other
specific initiatives. The plan proposes to
“establish a knowledge-based economy
by equipping Marshallese citizens with internationally
competitive skills, qualities and positive attitudes
towards work and society.” Priorities include improving
the education system in order to develop a local health
care workforce (educational “pipeline” programs), create
or expand on opportunities for maintenance of skills of
the existing workforce locally, through capacity building
and addressing the many systemic issues that affect
development of a sustainable health care workforce and
a continuing professional development (CPD) program.
Most of the health care workforce and supervisors
are eager for CPD opportunities, especially for those
professionals trained primarily on-the-job. MOHE and
hospital administrators have strongly supported this
effort. A new Health Professions Licensing Board was
PHD13.2-00815
Table 1: RMI Health Workforce Demographics
Physicians
(MD, MO,
MBBS,
DCHMS,
other)
Nurses
(RN,
LPN,
CNA or
Graduate
nurse,
practical
nurse)
Nurse
Mid-
wives
DDS
/ DO
Dental
Asst,
nurse,
tech
Extend-
ers
(Health
Asst,
Medex,
comm
health
worker)
Lab
Pharm-
acist
or
pharm
tech
Radiol
techs
Other:
SW,
diet,
hlth
inspec-
tor,
rehab,
mental
hlth
RMI--Ebeye
1027023104222
RMI-Majuro
211501144513468
A new Health
Professions
Licensing Board was
recently appointed
and members are
beginning the process
of creating formal and
standardized policies
and procedures.

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recently appointed and members are beginning the
process of creating formal and standardized policies
and procedures. Assistance with this process is a high
priority area of need. Nurses who are members of the
American Pacific Nurse Leaders Council (APNLC) and
the Marshall Islands Nursing Association have a CPD
requirement in order to maintain an active membership.
Nurses are regulated by the RMI Board of Nursing. For
the large remainder of the health professionals, there
are no requirements or incentives for CPD activities.
Currently, CPD activities are not considered criteria for
job retention and promotion and many system barriers
need to be addressed to change these policies. Leaders
of the Pacific Basin Medical Association (PBMA), the
regional professional organization for physicians, are
also considering instituting a CPD requirement for
active membership in order to establish and standardize
continuing education requirements across the region.
Continuing Professional Development
Infrastructure and Program
A small group of dedicated physicians
and nurses at both Majuro and Ebeye
Hospitals have been at the forefront
of developing and improving CPD
efforts over several years. However,
there is still insufficient administrative
or financial support despite their
efforts.
At Majuro Hospital, one or two physicians lead a
fledgling group CPD program, mostly centered on
interesting cases where medical care is discussed
similar to “morbidity and mortality” rounds. Monthly
speaker assignments are made a year in advance and
the presenters often review hospital statistics for the
previous month, summarize most of the cases they
cared for and then discuss one case in more detail.
Some of the discussions are evidence-based, while
others describe the clinical course and ask for input
on management or advice on improving care for future
cases.
There is a regular continuing education time established,
so at least half the physicians are able to attend. Although
there is no dedicated administrative support person for
CPD activities, fliers are posted and announcements
are made overhead, which does improve attendance.
Health professionals feel this method of communication,
as well as the monthly assigned schedule, are very
effective. Tracking of participation in group CPD
activities is mainly the responsibility of the Chief of
Nursing (for nurses) and one physician. There is no
formal CPD committee structure, nor is there a written
assessment of learning needs; potential topics for CPD
discussion are also discussed at department meetings.
When University of Hawai‘i Family Medicine residents
were rotating in the RMI, they were required to make at
least one educational presentation for health staff. The
residents’ topic selection were independently selected
or guided by the rotation supervisor, Dr. Riklon.
With the recent expansion of video-teleconference
(VTC) capability to Majuro Hospital and the hiring of a
dedicated support staff to coordinate distance-education
opportunities, more hospital staff members have been
able to participate in routine educational conferences
held at the Queen’s Medical Center and Shriners Hospital
in Honolulu, Hawai‘i. Access to a WHO Pacific Open
Health Learning Network (POHLN) computer laboratory
at Majuro Hospital also provides opportunities for some
individual CPD and basic training opportunities. Please
refer to the in-depth assessment of e-learning capacity
by Higa, also published in this special issue (pp 89-
97). The information technology (IT) staffer at Majuro
Hospital helps to coordinate VTC and online learning
opportunities, but she does not track
nor is she responsible for tracking
participation and completion of the
online courses.
preferentially allow native
Marshallese health staff
(rather than expatriates)
to participate in off-island
travel opportunities.
Nurses at Majuro have regular
training and update sessions, and the
need for this training is mostly based
on quality improvement or training
to support new services offered at
Majuro Hospital. Nurses also try to take advantage of
VTC opportunities, but with the timing of their shifts and
the time difference between Hawai‘i and the RMI, many
are unable to participate. Recently imposed access
restrictions to the WHO computer lab present further
barriers to nurses and allied health personnel working
in the evening or night shifts.
The continuing medical education programs borrow a
computer and VGA projector from the Department of
Energy Ejmour Mokta programs in Majuro and Ebeye.
The RMI received selected core texts from the University
of Washington’s Pacific Islands Continuing Clinical
Education Program to augment their hospital libraries in
the early 2000s. Other text resources are at least five
to15 years old.
There are no coordinated CPD opportunities for dental
health professionals, radiology staff, laboratory or
pharmacy staff or other allied health providers in the
RMI. Occasionally a funding agency will offer on-site
continuing education opportunities, but those are usually
limited to personnel in particular funded public health
programs only, even though the topics may be relevant
to a broader audience. Some staff rely on web-based
CPD for individual learning, but most do not participate
In the RMI, there was
a recent emphasis to

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in regular CPD opportunities. Many of the allied health
providers who participate in online courses do so under
the direction of their supervisors.
In Ebeye, no formal CPD program exists for any of the
health providers. Several staff members are interested
in CPD, but administrative barriers and lack of incentives
prevail. The University of Hawai‘i Family Medicine
residents conducted at least one continuing medical
education session while rotating at Ebeye Hospital.
In the RMI, there was a recent emphasis to
preferentially allow native Marshallese health staff
(rather than expatriates) to participate in off-island
travel opportunities. However, many of the off-island
trips are associated with administrative meetings and
do not include opportunities for continuing education.
The restriction on travel by expatriate physician staff,
that provide much of the health care to
the population, has been eased in large
part after Marshallese physician leaders
advocated on behalf of their expatriate
colleagues. At the June 2004 PBMA
meeting in Pohnpei, FSM, the majority
of physician participants from the RMI
were expatriates.
Barriers to Accessing Currently
Available Continuing Professional
Development Opportunities
In Majuro, historically there has been
little administrative infrastructure to help
formalize CPD programs or to provide support services
for presenters. Even when programs are relevant and
presented effectively, providers are often not able to
implement the new knowledge or skills because of
resource and infrastructure limitations or other systemic
barriers. A prevalent concern among key informants
was that many health providers are not familiar with
online CPD opportunities and might not be comfortable
using this technology. Those that are comfortable with
or enthusiastic about utilizing online resources face
slow and costly internet connections, as well as limited
access at work. In general, there are insufficient CPD
opportunities for providers. No group activities exist for
dental or allied health providers and limited opportunities
exist for nursing staff.
CPD opportunities on Ebeye are even more limited
due to lack of incentives, limited administrative support,
limited staffing and other infrastructure restrictions.
Priority Continuing Professional
Development Needs
Key informant and hospital data sources point toward
diabetes mellitus and associated non-communicable
illnesses (coronary artery disease, heart failure,
hypertension, renal failure, metabolic syndrome and
obesity) as the most common diseases in the RMI. A
majority of the hospital and off-island referral budgets
are for these chronic illness and their complications. In
2001, diabetes (including complications) was the leading
cause of death, followed by heart disease, cancer,
neonatal deaths and accidents. A high and increasing
rate of sexually transmitted diseases (syphilis and
chlamydia, in particular) and other infectious diseases,
as well as a high teen pregnancy rate, are of concern;
these contribute to one of the highest infant mortality
rates in the USAPI.
All providers interviewed agreed that more emphasis
on preventive health and preventive oral health is needed.
Otitis media and pneumonia were also consistently
identified as priorities, based on the high prevalence of
these two conditions. Nursing staff at
Majuro Hospital also identified issues
surrounding rape, especially unreported
childhood rape, as a priority. Nursing
staff in each department also identified
content and skill areas needed to
improve the quality of care provided at
the hospital and public health clinics.
Physician, nursing and pharmacy staff
indicated a great desire to develop
local capacity for advanced cardiac life
support training and certification.
pregnancy rate are of
concern.
For dental providers (including
dentists, hygienists and technicians), there is a need
for education of all providers regarding preventive
and curative aspects of bottle caries, caries in general
and periodontal disease. Because dental caries, gum
disease and nutrition-related disease are so common,
nutrition and dental health education is also a high
priority area for all who perform direct patient care.
In general, there is a great need for basic, foundational
training in addition to continuing education for the
technicians in the laboratory, pharmacy and radiology.
Many technicians are trained on-the-job without
prior formal training. Pharmacists would like to see
pharmacy and other staff, including nurses and doctors,
receive training aimed at reducing medication errors,
appropriately selecting antibiotics and properly using
medications in emergency situations.
The laboratory has an acute need for training technicians
in all areas of operation, from understanding what tests
are used for, to developing policies surrounding blood
transfusions, to skills building in histopathology and
microbiology, to interpreting and analyzing laboratory
statistics. The recently hired pathologist actively seeks
A high and
increasing rate of
sexually transmitted
diseases (syphilis
and chlamydia, in
particular) and other
infectious diseases,
as well as a high teen