2.1 Communicable and noncommunicable diseases, health risk factors and transition

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1 1. CONTEXT 1.1 Demographics The estimated population of Tokelau in 2006 was 1466, 35% below 15 years of age and 7.4% above 65 years. Life expectancy at birth is 67.8 years for males and 70.4 years for females (2008). The crude birth rate is 15 per 1000 population (2009) and the crude death rate is five per 1000 population (2009). 1.2 Political situation The constraints of atoll life and limited opportunities have led some 6000 Tokelauans to settle in New Zealand and a few hundred more in Samoa. Tokelauans have linguistic, family and cultural links with other Pacific islands, notably Samoa and Tuvalu. The family and extended family constitute the core of social organization, with the village (nuku) being the foundation of Tokelauan society. Community welfare is paramount in what has been traditionally a subsistence environment. 1.3 Socioeconomic situation Per capita gross national product (GNP) was NZ$ 1000 in 2003, or about US$ The economy is basically subsistence, although cash is now becoming an important part of everyday life. The 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 lifestylerelated diseases. 1.4 Risks, vulnerabilities and hazards The effects of climate change, where sea levels are likely to cause increased flooding in the form of storm surges and other coastal hazards in small islands and low-lying states, pose risks to Tokelau. Furthermore, the deterioration of coastal environments through beach erosion, coastal deforestation and coral bleaching has the potential to adversely affect food security. In addition, ocean acidification due to the increase of carbon dioxide in the sea and increase in temperature with little precipitation will also affect the diversity and availability of marine food resources and marine systems. The most significant climate change impacts in Tokelau will be on water resources. There is no surface water and, in a typical atoll, the aquifer s potential as a source of fresh water is limited. Consequently, dry spells and droughts have adverse impacts on fresh water sources, subsistence agriculture (impacting food security), and reef and lagoon ecology. Other risks are related to the need for urgent access to medical care in the event of an emergency where the only vessel currently available is the MV Tokelau and, in extreme emergencies, the Samoa Government Police Patrol Boat, Nafanua. 2. HEALTH SITUATION AND TREND 2.1 Communicable and noncommunicable diseases, health risk factors and transition While overall health status is reasonably good, changes have been observed in the last few years. There has been an increase in noncommunicable diseases, with cerebrovascular disease the leading cause of death. The mortality rate due to cardiovascular diseases increased from 31.0% of the total in 1981 to 37.8% in Blood pressure recordings of 90 mm Hg diastolic and greater are seen in 36% of women COUNTRY HEALTH INFORMATION PROFILES 437

2 and 23% of men aged 30 years and over. Random blood sugar levels of 7 mmol/litre and above for the same group appear in 18% of men and 28% of women. Tobacco and alcohol consumption is relatively high among the adult population, but is more prominent in males. Obesity is common and is attributed to diet and physical inactivity, with prevalence rates of 70% for men and 83% for women between the ages of 30 and 39. There is an observable diet shift from local to imported foods. 2.2 Outbreaks of communicable diseases There was an outbreak of an influenza-like illness in March/April 2008, which affected a significant number of children across the nation. It was managed with no deaths and field surveillance was carried out by WHO, the Capital and Coast District Health Board (CCDHB) (Wellington, New Zealand) and local health staff. 2.3 Leading causes of mortality and morbidity In 2003, the top three leading causes of death in Tokelau were diseases of the circulatory system; diseases of the respiratory system; and neoplastic diseases. The 2009 leading causes of morbidity were upper and lower respiratory diseases; diseases of the digestive system; and diseases of the skin and subcutaneous tissue. 2.4 Maternal, child and infant diseases The infant mortality rate in 2009 was 0 per 1000 live births. The maternal mortality ratio is 0 per live births ( ) and the total fertility rate is 4.5 (2008). 2.5 Burden of disease The main burden of disease is from NCDs. A chronic disease management approach, together with nuku-(village) and family-driven programmes, is the only way that change can occur and the Taupulega (Village Council) realize this. 3. HEALTH SYSTEM 3.1 Ministry of Health's mission, vision and objectives The Vision for the Ministry of Health is: Promotion, Prevention, Preservation and Sustainability The objectives are to: 1. Protect our population. 2. Ensure efficiency and effectiveness. 3. Promote public health. 4. Protect our environment. 3.2 Organization of health services and delivery systems Each of the three atolls has a 12-bed hospital that provides primary health care to the community. The three hospitals are similarly equipped. There are no X-ray facilities due to the short life of this type of machinery in Tokelau. Ongoing renovation of the three hospitals has meant that bed capacity has been reduced to six in each. Preventive health services are also provided by the Health Department. Water and sanitation programmes are ongoing, as well as maternal and child health programmes that are supported by women's committees. 3.3 Health policy, planning and regulatory framework Tokelau's national health plan priorities are the following: 438 COUNTRY HEALTH INFORMATION PROFILES

3 (1) Healthy islands and communities: Support existing community groups and structures that will enhance the ability to provide a healthy environment for the people. (2) Promotion of healthy lifestyles: Support community members and health workers to lead healthy and improved diverse lifestyles. (3) Development of health partnerships: Establish long-term strategic relationships with key partners in government, external donors, other relevant institutions and community groups in health development. (4) Development of accessible primary health care services: Develop and improve primary health care services that are effective and relevant to communities. (5) Successful community participation: Develop a successful participative strategy for an effective, combined approach to service delivery by community groups and health service providers. (6) Development and improvement of health service system: Improve the accessibility and quality of health services, which will increase people s confidence and participation in the total health system and add value to existing services. Tokelau s National Women's Policy 2010 ensures that women s health concerns are addressed and are integrated within the Health Department ss National Health Strategic Plan Health care financing For the financial years , the Tokelau GNP forecast was NZ$ or US$ Health was allocated 10.5% (NZ$ or US$ ) health expenditure for was NZ$ 7 million or US$ 4.3 million, while per capita expenditure was US$ The national budget is made up of locally generated resources and a grant from the New Zealand Government as part of its constitutional responsibility for Tokelau. Other assistance comes from international partner agencies including WHO, the United Nations Development Programme (UNDP), the United Nations Children s Fund (UNICEF), the United Nations Population Fund (UNFPA), and the Australian Agency for International Development (AusAID). 3.5 Human resources for health Each of the three atoll hospitals is manned by a medical officer, four to five staff nurses, one dental nurse, four to five nurse s aides and a handyman. There is one dentist employed nationally with another employed on a contractual basis. The doctor-to-population ratio is 1:389, the dentist-to-population ratio 1:1167, the nurse-to-population ratio 1:106, and midwife-to-population ratio 1:389. Tokelau still relies on the locum scheme in recruiting doctors. It was envisioned that this would go on for the next year, by which time new graduates would fill vacancies. However, there is only one graduate completing a Trainee Intern, who will commence in Tokelau in Partnerships Tokelau has informal partnerships with the National Hospital in Samoa, two district health boards in New Zealand. For more specialist interventions, Tokelau has access to various doctors in Samoa. 3.7 Challenges to health system strengthening Devolution has impacted on health system strengthening, with all health staff on the atolls being employed by the taupulegas (village councils). All programmes and projects have to be presented to each taupulega and the Department is working very closely with each community to develop a community model of care with a focus on the family. COUNTRY HEALTH INFORMATION PROFILES 439

4 The Department has also adopted a whole-village, whole-of-government approach, with a view to creating a sense of nationhood and consistency in approach, especially in addressing NCDs. 4. PROGRESS TOWARDS THE HEALTH MDGs No available information. 5. LISTING OF MAJOR INFORMATION SOURCES AND BASES Title 1 : 2006 Tokelau Census of Population and Dwellings: 2006 Census Tabular Report. Web address : [ News/TK/2006%20Census%20Tabular%20Report%20-%20Final.pdf] Title 2 : Tokelau Department of Health 6. ADDRESSES DEPARTMENT OF HEALTH Office Address : Tokelau Affairs Liaison Office (TALO), Savalalo, Apia Official Address : doh@lesamoa.net Telephone : ( /20822 Fax : (+685) WHO REPRESENTATIVE IN SAMOA Office Address : Office of the WHO Representative 4 th Ioane Viliamu Building Beach Road, Tamaligi, Apia, Western Samoa Postal Address : P.O. Box 77, Apia, Western Samoa Official Address : who@sma.wpro.who.int Telephone : (685) 23756; (685) Fax : (685) COUNTRY HEALTH INFORMATION PROFILES

5 COUNTRY HEALTH INFORMATION PROFILE TOKELAU WESTERN PACIFIC REGION HEALTH BANK, 2010 Revision Demographics 1 Area (1 000 km2) Estimated population ('000s) Annual population growth rate (%) 4 Percentage of population years years - 65 years and above Urban population (%) est 3 6 Crude birth rate (per 1000 population) Crude death rate (per 1000 population) Rate of natural increase of population (% per annum) 1.00 a Life expectancy (years) - at birth - Healthy Life Expectancy (HALE) at age fertility rate (women aged years) Socioeconomic indicators 11 Adult literacy rate (%) Per capita GDP at current market prices (US$) b Rate of growth of per capita GDP (%) 14 Human development index Environmental indicators Urban Rural 15 Health care waste generation (metric tons per year) Communicable and noncommunicable diseases Number of new cases Number of deaths 16 Selected communicable diseases Hepatitis viral - Type A - Type B - Type C - Type E - Unspecified Cholera Dengue/DHF Encephalitis Gonorrhoea Leprosy Malaria Plague Syphilis Typhoid fever Acute respiratory infections Among children under 5 years COUNTRY HEALTH INFORMATION PROFILES 441

6 Communicable and noncommunicable diseases Number of new cases Number of deaths 18 Diarrhoeal diseases Among children under 5 years 19 Tuberculosis - All forms - New pulmonary tuberculosis (smear-positive) Cancers All cancers (malignant neoplasms only) - Breast - Colon and rectum - Cervix - Leukaemia - Lip, oral cavity and pharynx - Liver - Oesophagus - Stomach - Trachea, bronchus, and lung Circulatory All circulatory system diseases - Acute myocardial infarction - Cerebrovascular diseases - Hypertension - Ischaemic heart disease - Rheumatic fever and rheumatic heart diseases Diabetes mellitus Mental disorders 24 Injuries All types - Drowning - Homicide and violence - Occupational injuries - Road traffic accidents - Suicide Leading causes of mortality and morbidity Number of cases Rate per population 25 Leading causes of morbidity (inpatient care) 1. Upper and lower respiratory diseases 2. Diseases of the digestive system 3. Diseases of the circulatory system 4. Diseases of the musculoskeletal system 5. Diseases of the skin and subcutaneous tissues a a a a a a a a 0.00 a a a 0.00 a a 0.00 a a COUNTRY HEALTH INFORMATION PROFILES

7 Number of deaths Rate per population 26 Leading causes of mortality 1. Diseases of the circulatory system 2. Diseases of the respiratory system 3. Neoplastic diseases 4. Ill-defined and undiagnosed conditions 5. Congenital anomalies c c c c c Maternal, child and infant diseases 27 Percentage of women in the reproductive age group using modern contraceptive methods 28 Percentage of pregnant women immunized with tetanus toxoid (TT2) Percentage of pregnant women with anaemia 30 Neonatal mortality rate (per 1000 live births) Percentage of newborn infants weighing less than 2500 g at birth Immunization coverage for infants (%) - BCG - DTP3 - Hepatitis B III - MCV2 - POL Number of cases Number of deaths 33 Maternal causes - Abortion - Eclampsia - Haemorrhage - Obstructed labour - Sepsis 34 Selected diseases under the WHO-EPI - Congenital rubella syndrome - Diphtheria - Measles - Mumps - Neonatal tetanus - Pertussis (whooping cough) - Poliomyelitis - Rubella - Tetanus Health facilities 35 Facilities with HIV testing and counseling services COUNTRY HEALTH INFORMATION PROFILES 443

8 Health facilities Number Number of beds 36 Health infrastructure Public health facilities - General hospitals Specialized hospitals - District/first-level referral hospitals - Primary health care centres Private health facilities - Hospitals - Outpatient clinics Health care financing 37 health expenditure - amount (in million US$) - total expenditure on health as % of GDP - per capita total expenditure on health (in US$) 4.32 d FY d Government expenditure on health - amount (in million US$) - general government expenditure on health as % of total expenditure on health - general government expenditure on health as % of total general government expenditure External source of government health expenditure - external resources for health as % of general government expenditure on health Private health expenditure - private expenditure on health as % of total expenditure on health 4.32 d FY FY out-of-pocket expenditure on health as % of total expenditure on health Exchange rate in US$ of local currency is: 1 US$ = Health insurance coverage as % of total population 39 Human resources for health Urban Rural Public Private Physicians - Number Ratio per 1000 population 2.57 a Dentists - Number Ratio per 1000 population 0.86 a Pharmacists - Number Ratio per 1000 population Nurses - Number Ratio per 1000 population 9.43 a Midwives - Number Ratio per 1000 population 2.57 a Paramedical staff - Number - Ratio per 1000 population Community health workers - Number 40 Annual number of graduates - Ratio per 1000 population Physicians 1 Dentists Pharmacists 444 COUNTRY HEALTH INFORMATION PROFILES

9 Urban Rural Public Private 40 Annual number of graduates Nurses Midwives Paramedical staff 41 Community health workers Workforce losses/ Attrition Physicians Dentists Pharmacists Nurses Midwives Paramedical staff Community health workers Health-related Millennium Development Goals (MDGs) 42 Prevalence of underweight children under five years of age 43 Infant mortality rate (per 1000 live births) Under-five mortality rate (per 1000 live births) 45 Proportion of 1 year-old children immunised against measles Maternal mortality ratio (per live births) Proportion of births attended by skilled health personnel Contraceptive prevalence rate 49 Adolescent birth rate Antenatal care coverage - At least one visit - At least four visits 51 Unmet need for family planning 52 HIV prevalence among population aged years 53 Estimated HIV prevalence in adults 54 Percentage of people with advanced HIV infection receiving ART 55 Malaria incidence rate per population 56 Malaria death rate per population 57 Proportion of population in malaria-risk areas using effective malaria prevention measures 58 Proportion of population in malaria-risk areas using effective malaria treatment measures 59 Tuberculosis prevalence rate per population Tuberculosis death rate per population Proportion of tuberculosis cases detected under directly observed treatment short-course (DOTS) 62 Proportion of tuberculosis cases cured under directly observed treatment short-course (DOTS) 63 Proportion of population using an improved drinking water source NA Proportion of population using an improved sanitation facility NA Percentage of deliveries at home by skilled health personnel (as % of total deliveries) - Percentage of deliveries in health facilities (as % of total deliveries) Proportion of population with access to affordable essential drugs on a sustainable basis Urban Rural NA COUNTRY HEALTH INFORMATION PROFILES 445

10 Notes: est a b c d s: Data not available Estimate Computed by Information, Evidence and Research Unit of the WHO Regional Office for the Western Pacific Figure refers to per capita GNP at current market prices (US$) Figure refers to percentage of deaths reported Converted to USD using average UN exchange rates for Pocket Statistical Summary (PSS) Secretariat of the Pacific Community, Statistics and Demography. Accessed on 12 May 2009 from Tokelau Census of Population and Dwellings: 2006 Census Tabular Report. [ Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2008 Revision and World Urbanization Prospects: The 2009 Revision. [ Accessed on June Information furnished by the Tokelau Department of Health, 22 July Information furnished by WHO Representative in Samoa, 25 February WHO Regional Office for the Western Pacific, data received from technical units. Tokelau Statistics Unit [ Progress on Sanitation and Drinking Water: 2010 Update. World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). UNICEF, New York and WHO, Geneva, [ 446 COUNTRY HEALTH INFORMATION PROFILES