3
Charting a Course for the 21st Century: A Strategic Plan for Future Health Initiatives in the U.S.-Associated Pacific Basin

The committee strongly recommends continued U.S. involvement and investment in the region's health care. The nature and scope of this involvement and investment, however, must change. Beyond merely providing health care—a great challenge in its own right—the United States and the island communities must work together with a renewed sense of partnership to produce improved health of Pacific Islanders.

To achieve this goal of improved health the committee recommends a four-pronged approach:

  • 1.  

    Adopt a viable system of community-based primary care and preventive services.

  • 2.  

    Improve coordination within and between the jurisdictions and the United States.

  • 3.  

    Increase community involvement and investment in health care.

  • 4.  

    Promote the education and training of the health care workforce.

The committee believes that priority should be given to the first two goals—adopting a viable system of community-based primary care and preventive services and improving coordination within the between the jurisdictions and the United States. To a certain extent the other two goals of increasing community involvement and strengthening the health care workforce flow naturally from these first two priorities. The committee cautions, however, that if the two main priorities are not given serious attention by all parties involved, the desired goal of improving the health care systems in the region and ultimately the health of the island populations will not be achieved—even if the full set of other recommendations are fully implemented.



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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 55 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN 3 Charting a Course for the 21st Century: A Strategic Plan for Future Health Initiatives in the U.S.-Associated Pacific Basin The committee strongly recommends continued U.S. involvement and investment in the region's health care. The nature and scope of this involvement and investment, however, must change. Beyond merely providing health care—a great challenge in its own right—the United States and the island communities must work together with a renewed sense of partnership to produce improved health of Pacific Islanders. To achieve this goal of improved health the committee recommends a four- pronged approach: 1. Adopt a viable system of community-based primary care and preventive services. 2. Improve coordination within and between the jurisdictions and the United States. 3. Increase community involvement and investment in health care. 4. Promote the education and training of the health care workforce. The committee believes that priority should be given to the first two goals —adopting a viable system of community-based primary care and preventive services and improving coordination within the between the jurisdictions and the United States. To a certain extent the other two goals of increasing community involvement and strengthening the health care workforce flow naturally from these first two priorities. The committee cautions, however, that if the two main priorities are not given serious attention by all parties involved, the desired goal of improving the health care systems in the region and ultimately the health of the island populations will not be achieved—even if the full set of other recommendations are fully implemented.

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 56 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN Implementation of some of the approaches recommended below has already begun in the jurisdictions. At times these new approaches have met with success, other times they have failed. The committee underscores the importance of working on several approaches at the same time. Taken individually the approaches will not have the same impact as the collective efforts and opportunities for potential synergy will be lost. Although it was beyond the charge, expertise, and capability of the committee to make detailed estimations of the costs of implementing these recommendations, the committee believes most of the costs can be covered through the reallocation of current levels of health care funding—especially as a more locally sustainable and viable system of community-based primary care and preventive services is adopted. In the 1993 landmark report, Investing in Health, the World Bank calculated the cost of providing a minimum package of public health and essential clinical services in low- and middle-income countries (World Bank, 1993). All the U.S.-Associated Pacific Basin jurisdictions are considered middle-income countries. In 1990, the cost of such a package for middle-income countries was $22 per capita. All the jurisdictions currently have considerably higher health budgets per capita as shown in Table 3.1 (PIHOA, 1997). TABLE 3.1 Total Health Budget Per Capita, U.S.-Associated Pacific Basin Jurisdictions Jurisdiction Total Health Budget Per Capita American Samoa $369 CNMI 614 FSM 132 Chuuk 92 Kosrae 151 Pohnpei 143 Yap 178 Guam 510 RMI 128 Palau 320 SOURCE: (PIHOA, 1997). ADOPT A VIABLE SYSTEM OF COMMUNITY-BASED PRIMARY CARE AND PREVENTIVE SERVICES Fundamental reform of the ways in which health care services are provided is occurring throughout the world. Reasons for this reform movement include the urgent need to decrease overall costs and increase cost-effectiveness, the desire to improve service delivery, and ultimately, the will to achieve better health

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 57 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN outcomes. This wave of reform has also hit the U.S.-Associated Pacific Basin. All the jurisdictions are struggling to design and implement health care delivery systems that are more locally sustainable, that provide more consistent and higher-quality services, and that more effectively improve the health of their residents. Improve the Island's Physical Infrastructure Basic sanitation, access to potable water, and other essential preconditions to good public health remain of great concern, particularly in the freely associated states. Power outages occur fairly regularly in the Federated States of Micronesia (FSM) and the Republic of the Marshall Islands (RMI). Poorly maintained and overcrowded roads contribute to accidents and injuries. Continued inattention to infrastructure development by the local governments is viewed as a barrier to health and a factor contributing to disease and illness. The committee believes that investment in infrastructure development is critical to the health and well- being of the people in the region. Assurance of potable water supplies, adequate sanitation, and reliable electricity throughout the jurisdictions must be a clear priority for both the aid-giving agencies of the U.S. federal government and the communities that strive to create healthy islands. Invest in Preventive and Primary Care and Public Health The committee underscores the vital importance of investment in preventive and primary care and in population-based public health care in the region. This investment does not necessarily require a great deal of new funding. Currently almost all of these activities are funded entirely by the U.S. federal government. The committee believes that it is important to have local governments adequately fund these functions and provide more funds through local sources. What it will require, therefore, is the reallocation of existing funds—a difficult process in any health care system. In some jurisdictions, it will also require the reorganization of delivery systems to better integrate the acute care, primary care, preventive care, and public health sectors. To combat the inappropriate and discretionary use of funds for health care services, the committee recommends that each jurisdiction place the funds reserved for this purpose in a separate cost center within the overall health budget. This is another difficult change because most jurisdictions' governments are reluctant to give up their control and access to these funding streams. One approach may be to limit the amount of money spent on tertiary care (both for care on-island and for referrals for off-island care). In Papua New Guinea, for example, public spending on hospitals has been successfully limited to 40 percent of the Ministry of Health's recurrent budget (World Bank, 1993).

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 58 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN Maintain or Establish Basic Health Care Standards U.S. licensing regulations for health care facilities, providers, and services in Guam, the Commonwealth of the Northern Mariana Islands (CNMI), and American Samoa should generally be maintained. These jurisdictions receive U.S. federal funding to provide Medicare and Medicaid services. The quality of these services should be roughly the same—no matter where a person receives them. Adherence to U.S. standards is necessary to ensure consistency of quality and accountability of U.S. taxpayer funds. Modification can be considered when a jurisdiction provides appropriate justification, stating its rationale and the fiscal implications. Such modification should apply only to a particular facility and should be subject to review by the Health Care Financing Administration (HCFA). HCFA staff should provide on-site assistance to those jurisdictions that demonstrate a willingness to make corrections. HCFA oversight of facilities that continue to be in noncompliance should be done on a quarterly basis. Target dates for decertification must be adhered to strictly. If a jurisdiction believes that adherence to U.S. standards, even with modifications, is too costly or culturally inappropriate, then perhaps it should fundamentally reconsider its participation in these U.S. federal health care programs. Each of the three freely associated states is strongly urged to establish its own standards for available resources and appropriate technology, including provisions for the licensure of health care providers and legislative practice acts. HCFA should be responsive in assisting these jurisdictions with developing such standards. This may require new legislative authority for HCFA. Develop a Regional Health Information System Accurate and informative data are critical for health care reform. The lack of good data hampers policymakers' and administrators' ability to analyze the current situation, set priorities, and plan for the future. The committee encourages each of the jurisdictions to participate in the development of a standard regional health information system. This system would be the repository of information needed to analyze the health care system and to make assessments of how best to proceed with reforms. The system should be able to track health outcomes and progress toward Healthy People 2010 goals that the jurisdiction has revised to more appropriately capture its unique circumstances and disease burdens (U.S. Department of Health and Human Services, 1997). However, the importance and practicality of developing compatible data systems that use the same defined terms, age groupings, and sampling frequencies across the jurisdictions cannot be underscored enough if regional data analysis is to be made possible. The Pacific Island Health Officers Association (PIHOA) is the logical candidate to provide the leadership for such an undertaking, with appropriate technical assistance provided by various U.S. federal health agencies. Such

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 59 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN efforts should be coordinated with similar data improvement efforts and other requirements of the World Health Organization (WHO), South Pacific Commission (SPC), and other users of regional health data. Reform Health Care Facility Management Health care facilities throughout the region are generally in poorly maintained buildings, experience chronic and commonplace shortages of vital supplies and equipment, and have outdated and broken equipment. To improve this situation, the committee recommends that each jurisdiction's government provide officials at the hospitals and other health care facilities with greater control over finances. For example, give the hospital administration the freedom to use hospital fees to purchase drugs and other supplies and to reorganize the ordering system and payment schedules to ensure that critically needed supplies are readily accessible on-island. Each of the jurisdictional governments must also be required to establish an annual budget with separate cost centers for health services facility maintenance and repair, equipment and supplies, salaries, and in-service training. This budget should be tied to an item-by-item work plan on an annual basis. Without the annual work plan it is difficult to determine if the budgeted figure is reasonably close to actual performance requirements. Financial assistance from U.S. funding sources for facility and equipment repair should be tied to the preparation and completion of these annual work programs, and to the inclusion of partial financing with local funds. The chief health administrator in each jurisdiction should receive advanced training through a certificate or degree program in health administration and health systems management. The training should include coursework taken at institutions of higher education that offer high-quality programs in this subject area combined with practical applications and fieldwork within the administrator's own jurisdiction. A ''buddy system" model of having the administrators who have received their training go to another jurisdiction in the region to provide on-site technical assistance should also be used. Finally, training and technical assistance will also be needed to assist other administrative and clinical staff transition to these new management approaches and practices. Promote Prudent Privatization Many of the jurisdictions have begun or are considering contracting out and privatizing many of their health care services in an effort to reduce costs and increase health care options for residents. Several physicians have entered private practice and some independent pharmacies and clinics have opened in recent years. Although the committee is generally supportive of such efforts, it also cautions that such arrangements should be carefully considered. Previous attempts at privatization in other economic sectors have not always been

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 60 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN successful. Reasons for failures include poor or inadequate collection of fees and the low productivity of some personnel. Additionally, in most jurisdictions privatization will require new legislation dealing with issues such as malpractice and the private use of public facilities. Technical assistance should be provided (through local institutions of higher education and cooperating professional societies) to the prospective private businesses. These businesses should be required to submit proposed business plans that include realistic fee collection goals and carefully considered policies regarding supervision and other personnel matters. Rethink and Restrict Off-Island Tertiary Care Referrals Each jurisdiction has begun to address the issue of off-island referral for tertiary care, but many difficult choices and changes still need to be made. The committee believes each jurisdiction must fundamentally rethink its government's financial support of off-island referrals. Clearly, there will always be a legitimate need for such referrals; the issue is who should pay for them. The committee recognizes the important steps that several jurisdictions have taken to reduce the costs of these referrals such as instituting co-payments; requiring greater cost sharing; creating referral committees of health care practitioners who use specific criteria and protocols to determine when referrals for off-island tertiary care should be made; and using competitive bidding. However, the committee also encourages each jurisdictional government to move away rapidly from providing financial support for such referrals altogether and to consider the development of insurance systems, possibly private-market insurance, or other funding mechanisms to cover such catastrophic health care costs. Planning assistance should be provided to each jurisdiction willing to reduce off-island tertiary care referrals to assist with developing locally acceptable and sustainable methods and timetables for reducing the health care funding being spent on off-island referrals. Ideally, the money formally used on off-island tertiary care can be used for primary health care, wellness and health promotion, health education, and on-island acute care to help reduce the need for such referrals in the first place. IMPROVE COORDINATION WITHIN AND BETWEEN THE JURISDICTIONS AND THE UNITED STATES To maximize scarce resources and minimize wasteful duplication of efforts, the committee calls for greater coordination and collaboration as well as improved management on both sides of the Pacific. Such coordination has begun, but it must be more focused and more consistently pursued and supported. Figure 3.1 provides an overview of the committee's recommendations for achieving this goal.

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 61 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN FIGURE 3.1 Overview of recommended organizational arrangements to improve coordination between the U.S.-Associated Pacific Basin jurisdictions and the United States. ROLE OF THE UNITED STATES Use of Block Grants That Require Meaningful Measures of Accountability U.S. federal agencies are encouraged to use block grants or to consolidate grants whenever feasible. The committee particularly encourages the use of common grant applications and consolidated reports to sponsors. The emphasis should be on achieving greater flexibility and efficiency with well-defined measures of accountability and common data systems. One possible approach is to have an agency set broad goals that it would like to see achieved in the region and then allow the individual jurisdictions to decide how they will go about achieving those goals. Outcome measures for assessing success would be developed jointly with the federal funding agency and the jurisdictions. This emphasis on results-oriented management and accountability is increasingly becoming a focus for all government programs. It is also well-suited to the region because in practical terms federal officials often cannot monitor Pacific Basin jurisdictions closely because of the prohibitive travel time and travel costs involved. An example of such an effort would be to allow all the funds from the Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration (HRSA) aimed at preventive services (i.e., immunizations, screening, health education, etc.) to be consolidated into one block grant. Jurisdictions would then submit one application and report their progress back to both agencies on an annual basis using agreed-upon outcomes- based indicators and one reporting form. Consideration of Multiple Uses of Military Facilities The committee recommends that officials from all U.S. military health facilities in the region enter into dialogue with the jurisdictions to determine the

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 62 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN optimal means of sharing regional resources and training opportunities to serve local populations. Continuation of Funding of Research Projects in the Region In the past the United States has funded scientific studies in the Pacific, such as studies of Lytico-Bodig on Guam (funded by the National Institutes of Health), and several studies on the health effects of radiation exposure in RMI. These studies have helped scientists make important new discoveries and gain greater understanding of subjects ranging from the biological basis of Alzheimer's disease to the effect of nuclear radiation exposure on the thyroid. The studies have not been universally viewed as successful in the islands, however, and many islanders are rightfully skeptical and disillusioned with U.S. research. In Guam, for example, epidemiological surveys in 1953 and 1987 caused considerable dissatisfaction among many Guamanians who felt they were not fully informed about the study, not given the opportunity to give proper consent, and had their confidentiality violated (Workman and Quintana, 1996). One of the most contentious issues in RMI relates to the effects of radiation exposure on its people (Simon, 1997). Although in the Compact of Free Association with RMI the United States accepted responsibility for the effects of radiation exposure during the period of U.S. nuclear weapons testing, and accordingly set aside trust funds and other monies as compensation, there is still uncertainty about the degree to which those tests affected the health of those directly exposed and among the people living outside the limited four-atoll region specified in the Compact. Documents that were declassified by the U.S. Department of Energy in 1993 indicated a much higher level of contamination of the islands than was previously recorded. It should be noted that workers who cleaned up test sites came from throughout the region and not just RMI. Additionally, recent reports linking health effects from nuclear weapons testing in Nevada to places as far away as New York have raised concerns from other island jurisdictions about possible radiation exposure (National Cancer Institute, 1997). Despite these problems and obstacles, the committee believes research in the region needs to continue. Changes must be made, however, in the topics being studied and the way research is conducted. Lytico-Bodig and thyroid cancer affect only a few hundred individuals. Research is needed to examine the major causes of morbidity and mortality in the region such as diabetes, substance abuse, tuberculosis, nutritional deficiencies, women's health issues, and other topics identified by Pacific Islanders as important to improving their overall health. Studies on health systems development that take into account the unique social and cultural belief systems in the U.S.-Associated Pacific Basin jurisdictions are also strongly encouraged. Finally, the committee also encourages greater interagency coordination to support existing research and monitoring such as studies of the health effects from radiation exposure

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 63 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN throughout the Pacific Basin jurisdictions, albeit with continued specific attention to the Marshall Islands. Research should be carried out using accepted ethical methodologies for participatory research, and should be cleared through an institutional research board in the appropriate jurisdiction. Efforts should be undertaken to appropriately involve islanders in the planning of any research. The committee further recommends that research be conducted not only by clinicians, but also by such researchers as public health workers, medical anthropologists, and epidemiologists. Taken together, such research would not only help health care workers, decisionmakers, and policymakers in the Pacific, but also U.S. funders, to better match health programs with the unique needs of the region. Establishment of an Interagency Governmental Committee on Pacific Health The committee believes that coordination of U.S. funding for all health- related activities in the Pacific Basin is needed to increase the coherent and consistent application of rules, regulations, and accountability requirements for expenditures, which should be based on the previously discussed outcomes measures. The development of the HRSA intragency work group has shown that improvement is possible. As the Compacts begin to be renegotiated, such collaboration at the federal level will be critical. In its deliberations, the committee considered several possible organizational arrangements to address this need for improved coordination of federal programs. These deliberations were informed by the IOM's Board on International Health recent report, America's Vital Interest in Global Health (IOM, 1997a), which also noted that "fragmentation of governmental responsibilities, divisions of authority between domestic and international health activities, and lack of coordination among U.S. governmental agencies and with the nongovernmental sector impede progress toward global health" (p. 7). Consolidation of all programs and funds into one agency, for example, was determined not be practical given the very different and complex roles each agency performs and the special expertise available from each. However, the board recommended that, because of its unique scientific and health expertise, the U.S. Department of Health and Human Services (DHHS) should act as lead agency to coordinate global health strategy and priority setting across the federal agencies. The committee therefore recommends the establishment of an Interagency Governmental Committee on Pacific Health (IGCOPH). This committee should be headed by the Secretary of Health and Human Services and should include representation from all federal agencies that fund health-related activities in the region, including DOI, DHHS, and the Departments of Agriculture, Education, Energy, State, and Defense. The goal of the committee will be to ensure coordination of health programs, administrative oversight, and technical

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 64 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN assistance to the region. IGCOPH should submit an annual report to the President and to Congress detailing the progress it made in achieving its goals. IGCOPH Composition The committee should be chaired by the Secretary of Health and Human Services or his or her designee. The committee believes it is important to have senior representation not only from DHHS, but from DOI, especially given the considerable resources DOI provides that directly affect the health of the populations and health care systems in the region. The committee should also include representation from each of the federal agencies that fund health-related activities in the region, including, but not limited to the following: • U.S. Department of Health and Human Services (Administration of Children, Youth, and Families; HCFA; HRSA; CDC; and the Substance Abuse and Mental Health Services Administration), • U.S. Department of the Interior (Office of Insular Affairs), • U.S. Department of Agriculture, • U.S. Department of Commerce, • U.S. Department of Defense, • U.S. Department of Education, • U.S. Department of Energy, and • U.S. Department of State. IGCOHP Tasks The specific responsibilities of the committee should include: • ensure coordination of health programs, administrative oversight, research and technical assistance to the region; • propose and support the rationale for any future federal health initiative for the Pacific Basin jurisdictions before its implementation and be explicit about the goals and objectives of such initiatives; • coordinate coherent and consistent rules and regulations on federal health expenditures in the region; • review agency grant reporting requirements and emphasize consistency on performance measures among agencies; • identify resources throughout the federal agencies that could provide technical assistance with health sector reform; and • report annually to the President and to Congress on the committee's progress.

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 65 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN ROLE OF THE ISLAND JURISDICTIONS Recognizing PIHOA's contribution to regional public health coordination, PIHOA is encouraged to continue its significant public health focus and its mission to promote interregional sharing of resources. PIHOA is further encouraged to (1) develop a regional health information system to promote a shared version with standard nomenclature, (2) review purchasing practices and encourage shared purchasing and volume buying to decrease costs and share resources in emergencies, and (3) identify technical assistance and consulting strategies that promote the prudent use of the expertise available within the region. INTERFACE BETWEEN THE UNITED STATES AND THE ISLAND JURISDICTIONS Establishment of a Pacific Basin Health Coordinating Council Finally, the committee recommends that the governments of the United States and the six island jurisdictions establish or designate a nongovernmental organization in the region to coordinate health affairs and facilitate collaboration between the United States and jurisdiction governments. This Pacific Basin Health Coordinating Council (PBHCC), would meet quarterly and would report annually on the progress of health sector reform in the U.S.-Associated Pacific Basin to the President of the United States, the U.S. Congress, the chief executive officer and legislature of the island jurisdictions, IGCOPH, and PIHOA. PBHCC should have a small permanent staff. The establishment of such a council is not meant to create yet another layer of bureaucracy; rather, it is envisioned as the catalyst for pragmatic health reforms and the watchdog for greater accountability of all parties—in the United States and the region. PBHCC Composition The 14-member council should have representation from three different groups: 4 representatives of the U.S. government and IGCOPH, a representative of each of the six island jurisdictions' governments, and a total of 4 private citizens, 2 each from the United States and the island jurisdictions. PBHCC Tasks What projects are undertaken by the PBHCC will need to be determined cooperatively with all the parties involved. The committee recognizes the differences in budgets, health care services, personnel, and program directions

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 66 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN between the U.S. flag territories (American Samoa, CNMI, and Guam) and the freely associated states (FSM, RMI, and Palau). Therefore, as it undertakes the following tasks, PBHCC should consider grouping jurisdictions accordingly. The PBHCC could: • help to develop health care priorities in the six jurisdictions that take into account burden of disease and cost-efficiency criteria, as well as priorities developed by the community. • ensure coordination of U.S. health programs, activities, and funding streams within the U.S. flag territories and the freely associated states. • review each jurisdiction's progress toward meeting specific health outcomes objectives as required under various U.S. grants. • assist with the simplification of filing and reporting formats and forms for various U.S. grants. • facilitate training in health administration for ministers or directors of health and for members of jurisdictional health authorities or boards; and • identify and establish working relationships with U.S. federal agencies and international organizations and other aid donors (e.g., the World Health Organization, Asian Development Bank, and South Pacific Commission) that could provide technical assistance resources for health care reform. PBHCC Funding Funding for this nongovernmental organization must come from a variety of sources. As described in Chapter 1, the U.S. federal government has several vital interests in investing in the region's health and ensuring that the money it provides is spent wisely. In keeping with several of its other recommendations, the committee underscores its belief in the vital importance of having the local jurisdictions provide financial support to this endeavor. The committee also sees a role for private organizations and foundations—both inside and outside the region—to play in funding the PBHCC. All these funding partners must believe that they have a stake in the PBHCC's work and will benefit from the results that work produces. Several possible funding mechanisms exist. The committee suggests a few options here, but ultimately the various funding partners must collectively determine exactly how each will pay. The U.S. federal government might consider contributing a fixed percentage of all funds it provides to the region. Similarly, each of the island jurisdictions may decide to base its funding on a fixed percentage of its total health care budget or on a fixed percentage of the total funds it receives from the U.S. federal government and international sources.

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 67 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN INCREASE COMMUNITY INVOLVEMENT AND INVESTMENT IN HEALTH CARE The committee believes that any attempt to improve the health care in the islands of the Pacific Basin must tap into the strengths and resources of the community—if the improvements are to be meaningful and sustained. Fostering an environment that enables households to improve the health of their members, particularly by promoting the rights and status of women, is seen as one of the best ways to improve global health (World Bank, 1993). This focus on women is particularly apt in the Pacific, given the central roles of women and girls in many of the island societies. For example, women are the primary caregivers for both young and old. This is especially important in the jurisdictions with high rates of fertility and infant mortality, where health education about health promotion and disease prevention can lead to vast improvements in health status. Women are also usually responsible for meal preparation and therefore can have a huge influence on the entire population's diets. The committee acknowledges the differences in the institutional capacities of each of the jurisdictions and in the cultural norms and functioning of individual communities. No one paradigm of community involvement applies to all island cultures equally or necessarily appropriately. Health services must be aligned to each community's needs and congruent with each unique culture, with special attention given to the most vulnerable groups. Each community will have to determine how best to achieve a level of involvement and investment that is needed to truly make a difference in its health. Island communities should consider taking some fundamental steps, including the following: establish a jurisdictional health authority or board, develop a health improvement benchmarking process, use nongovernmental community organizations to provide health services, and increase community involvement with primary care sites. These steps are described in more detail below. Establish Jurisdictional Health Authorities Jurisdictions should create, through local legislation and community input, an independent authority or board to oversee the administration of the health care system, plan and prioritize health initiatives, and provide accountability. Such an authority or board would oversee the budgets of all the health services, agencies, hospitals, primary care sites (dispensaries), and programs under its direction through the development and utilization of sound annual budget practices, monitoring systems, and timely annual audits. Such enforcement and monitoring powers should help to depoliticize health policy decisions. These authorities or boards should be independent of the government. Funds for all health care programs should be kept separately from the government's general fund. Nominations for membership on these authorities or

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 68 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN boards should come from the jurisdictional government and local communities. The health authority or board should include both men and women, and community volunteers such as businesspeople, clergy, educators, and health care professionals. The secretary or director of health would report directly to the health authority or board, although the president or governor of the jurisdiction would retain the right to veto decisions. Regular training in health administration should be provided to health authority members. This should include training to help Health Authority members understand and interpret the methods and findings of health research in the science of epidemiology and public health; conduct focus groups and analyze focus group information; improve their community organizing skills; and communicate information to the public. Develop Health Improvement Benchmarking Process Health improvement benchmarking is a method of comprehensive, long-term health planning. It involves determining how well a community is doing in a certain area of health and then deciding what should be done to improve that area to a desired level. One of the committee's charges was to develop assumptions about benchmarks established by earlier studies of the region's health care systems conducted by the University of Hawaii (1984, 1989) for their adequacy in assessing the needs and health status of the populations of the U.S.-Associated Pacific Basin. The committee was then to modify or re-create these benchmarks as necessary to assess the accomplishments, adequacy, and shortcomings of the health services programs and related health interventions in each jurisdiction. During the site visits committee members were told that health planning and goal setting are often empty exercises done only to satisfy grant requirements. People throughout the region reported that using such activities as a means of identifying, prioritizing, and ultimately improving community health rarely occurs. Therefore, rather than actually going through yet another empty exercise, the committee decided to recommend the development of methods to more actively and meaningfully involve the community in health planning and the implementation of new goals and objectives to achieve improvement. The committee recommends that individual jurisdictions and communities establish a process for determining which health issues are of greatest concern and how they will monitor their progress in addressing those issues. Health services must be tailored to the unmet needs in the region, especially those of women and vulnerable populations such as children and those with substance abuse or mental health problems. Similar processes are being established in many communities all over the world based on the principles of the healthy community movement (IOM, 1997b). Impressive improvements in health have been achieved when the entire community rallies behind a cause and focuses its collective efforts on making a positive change.

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 69 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN Each jurisdiction should also ensure that certain basic services are provided to all residents regardless of their ability to pay. The process used in each jurisdiction to determine these basic services should be coordinated by the jurisdictional health authority and should involve traditional leaders as well as residents of the broader community. The committee does not recommend any particular health improvement benchmarking process. Each community and jurisdiction will need to determine what works best, given its unique circumstances and culture. U.S. federal agencies, particularly the Department of Health and Human Services, are encouraged to provide technical assistance to all communities that undertake such a process. Once Pacific communities have gained experience (good or bad) with health improvement benchmarking, they should be supported to act as sources of technical assistance to other communities. Naturally, this process could prove to be politically problematic, especially when making decisions about appropriate referrals for off-island tertiary care or the continuation or expansion of a jurisdiction's hemodialysis program, for example. The committee encourages the jurisdictions to be clear about the process and the criteria to be used in making decisions. For example, Kosrae, in its Healthy Kosrae 2000 report (Kosrae Department of Health Services, 1996), recognizes that its health care budget will decrease in the coming years and has begun to develop a list of what it considers to be essential services. In Kosrae, the following criteria are to be used to determine whether a service is essential: the effect of a service in decreasing morbidity and mortality and producing improved functional health, the bona fide needs of the Kosraen people and health providers (rather than the dictates of foreign donors), the availability of personnel resources and medical equipment, and the cost-effectiveness of the service. Beyond its desire to have the communities themselves decide how well their health care systems are doing and what they will do to make improvements, the committee chose not to re-create or modify the benchmarks used in the University of Hawaii studies for a number of other practical and pragmatic reasons. The earlier studies involved months of on-site field work. The Institute of Medicine (IOM) contract with HRSA only called for very limited site visits lasting—at most—several days in each jurisdiction. This would mean that the jurisdictions would have to go to considerable effort to supply most of the needed information—a costly and time-consuming effort with limited direct utility. Once the committee decided not to make use of the benchmarks, it did not evaluate them in any greater detail. However, the committee raises the following points for the jurisdictions to consider if they decide to re-create a similar set of benchmarks. • An individual's decision about what is ''adequate" would not constitute a reliable benchmark. As much as possible, groups should define and agree on common definitions, including what is "adequate" and "acceptable."

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 70 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN • The University of Hawaii benchmarks were used only to conduct a structural assessment of the health care system. As such, they do not provide procedural or outcomes information, such as health status. • The criteria were designed to discern whether each Pacific Basin jurisdiction met minimally acceptable levels of health services and systems that might be expected of any health care system in rural America. This comparison does not seem entirely appropriate given the differences in social history, culture, finances, and the nature of the geographical isolation between rural America and the Pacific Basin. The committee believes that the benchmarks should be used to gauge how effectively health care services in the individual jurisdictions meet the needs of residents and that it should not develop comparisons that are not apt. • Some aspects of the health care system are not adequately captured by the benchmarks. For example, no criterion or indicator covers the use of telemedicine or presence of private-sector health care services. • The benchmarks are not weighted or prioritized in any way. The result is a "laundry list" of concerns, with equal importance given to having in place, for example, a geriatric program and a childhood immunization program. Use Nongovernmental Community Organizations to Provide Health Services Nongovernmental community organizations are often better situated to perform many activities not easily done by the government. They are often the best and sometimes the only effective means of outreach to the rural communities. However, they remain a potent and much underutilized force, particularly in the freely associated states. The committee believes that nongovernmental community organizations should be enlisted to provide a variety of health-related activities not currently being provided by the jurisdiction's government, including health education and peer counseling, whenever possible. In some cases the organizations will need to receive initial financial support from the government to anchor themselves in the community and to fund training and volunteer development, but for the most part these organizations should be voluntary and charitable. The committee sees the creation and support of these nongovernmental organizations as a vehicle that can be used to harness the diverse energies of the community. Such organizations will strengthen and support the islands' civil societies on a scale and in a manner that is appropriate to the jurisdictions and their cultures. The sharing of information about successful community-based programs and the creation of policies for replicating such programs in other jurisdictions are strongly encouraged.

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 71 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN Increase Community Involvement with Primary Care Sites For all jurisdictions, when U.S. funds are involved, the committee recommends requiring community commitment and involvement in the delivery of care and the maintenance of primary care sites (dispensaries). Minimal requirements would be (1) donation of land from the community or some of its members, with a clear deed attesting to the donation; (2) contribution to the construction of the facility either in the form of materials or labor; (3) commitment of the community to maintaining the facilities; and (4) contribution to the salary of the person(s) serving as (a) community health aide(s). More responsibility for nontechnical maintenance should be shifted to local communities. Communities should be required to enter into contracts with the government. In these contracts the communities should agree to meet certain initial and ongoing conditions in order for the government to continue to provide health services in the community. In-kind donations should consist of time and labor as well as or in place of monetary contributions. For example, the CNMI health department recently opened a satellite outreach center in the community of San Antonio near a teen center. Efforts to involve the community with the operation of the center should be actively pursued. These efforts could range from recruiting local teens to help staff the center to starting an advisory council that includes representation from nearby residents who could perform outreach to the growing immigrant population that lives near the center. PROMOTE THE EDUCATION AND TRAINING OF THE HEALTH CARE WORKFORCE The committee is gravely concerned about maintaining the skills and knowledge of the current health care workforce and strengthening the region's local human capacity. Crises similar to those that necessitated the establishment of the PBMOTP are destined to repeat themselves over and over again unless strategies to address the need for an adequate and well-trained workforce are not proactively developed and implemented. The committee therefore recommends several educational activities to address the present lack of adequate training opportunities available to the health care workforce in the U.S.-Associated Pacific Basin. These individual activities should be based on a comprehensive workforce development and training plan established by each jurisdiction. The plan should consider not only how to enhance and improve the skills of current health care providers but also how to train new providers, particularly women, to address shortages and natural loss through retirement and attrition. In general, the committee believes that education and training are best

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 72 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN accomplished in settings close to the local population. This allows for greater cultural competence and acceptance of the health care practitioner and means that vital health care services will be provided in the region. Activities should include but not be limited to the following: (1) improve and support basic education; (2) use distance-based learning, telemedicine, and electronic data libraries; (3) provide postgraduate continuing medical education programs; (4) sponsor training for dentists; (5) sponsor training for nurses; and (6) provide health administration and systems management training to the chief health administrator in each jurisdiction. Improve and Support Basic Education Currently, the primary and secondary educational systems throughout the region do not adequately provide students with the skills that they need to participate in the health care workforce. Fundamental educational reform is vitally needed. In the short-term, existing successful educational programs that prepare students to deal with the demands of higher education and that increase the applicability of coursework in secondary schools with regional health care institutions of higher education need to be replicated and nurtured. Programs aimed at increasing the education of women are particularly encouraged because of the likely improvements in health status that will result (Marshall and Marshall, 1983). Alternative ways of financing education also need to be developed and supported. The committee encourages private organizations to provide scholarships and other financial support to students in the region who are interested in pursuing careers in health care. Use Distance-Based Learning, Telemedicine, and Electronic Data Libraries The use of telecommunications for clinical consultation—whether through existing technologies such as shortwave radios, telephones, and the Internet or through more advanced technologies—is to be encouraged and supported. Ways to network or combine health telecommunications networks with other markets, such as education and private business, to decrease costs should be explored. Whenever possible common hardware and software standards should be used to avoid compatibility problems between and among sites. The use of existing instructional materials in an interactive CD-ROM format and the adaptation of such materials to the unique aspects of the region should be explored. The development of such instructional materials by institutions of higher education in the region should be supported by the U.S. federal government.

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 73 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN In view of the serious practical limitations of the PEACESAT satellite system reported during the committee's site visits and workshop in Saipan, Pacific Basin jurisdictions and the institutions of higher education in the region should continue to explore more reliable means of communication. The establishment of educational links within the region and with other areas of the world should be seriously explored. Provide Postgraduate and Continuing Medical Education Programs Continuing medical education (CME) must be required and incorporated into the health care workforce training plan for the entire region. The committee is particularly concerned that the graduates of the Pacific Basin Medical Officers Training Program (PBMOTP) receive CME to improve and maintain their clinical skills and knowledge. Several means of providing ongoing CME exist. Courses can be provided through the Pacific Basin Medical Association and, where available, through an individual jurisdiction's medical or professional associations. Whenever possible, training should be done within the jurisdiction, perhaps through periodic visits by other physicians and health care professionals who can provide personal support while offering consultative clinics and other training opportunities. The Archstone Foundation provides funding for the Medical Graduate Support Program, which allows a former PBMOTP faculty member to travel throughout the region to provide in-service training. Some additional in-service training has been provided though the Regional Training and Research Centre in Reproductive Health based at the Fiji School of Medicine, the John A. Burns School of Medicine (JABSOM) at the University of Hawaii, and teams of practitioners from the Tripler Army Medical Center (the missions of both JABSOM and Tripler, in fact, call for sending health care providers to the region). The departments of health of the various jurisdictions should work together to better plan and coordinate visits from such consultants and voluntary medical teams. The committee foresees the continued need for U.S. Public Health Service and National Health Service Corps personnel in the region, particularly in providing training to the existing workforce. Their assignment should reflect the needs identified by each jurisdiction in its health care workforce development plan. Each jurisdiction should also develop a description of the assignment that accurately describes the context in which the volunteer will be working and exactly what the volunteer's role will be. Volunteers should also be allowed and encouraged to provide on-site training and quality assurance evaluations in lieu of clinical care. The committee draws particular attention to the opportunity of recruiting and tailoring the education of National Health Service Corp-sponsored medical students, nurse practitioners, and nurse anesthetists at the Uniformed Services University of the Health Sciences. These students have

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 74 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN already made a commitment of service to the country and several have completed training programs in the region. Pacific Basin educational institutions and other organizations serving the region, such as WHO and the SPC, should collaboratively develop additional training programs and CME courses for all types of health care providers. The training should be appropriate for the region but should emphasize primary care and community health. Formal postgraduate education should be conducted at a regional training center, preferably an existing one. The availability of such programs should be open to all practitioners in the region. The role of the U.S. federal government should be directed toward capacity building and financial assistance. Sponsor Training for Dentists The committee is greatly concerned about the dearth of dentists currently practicing in the region. Many of the current dental practitioners are expatriates or are nearing retirement. The committee therefore strongly recommends that the U.S. federal government and local jurisdictions sponsor dental training immediately. A dental officer program based on the PBMOTP model was developed by PIHOA in consultation with the University of Kentucky School of Dentistry in the early 1990s (University of Kentucky, 1993). Although it was never funded, the committee believes that the basic model, which provides a graduated career ladder approach to training with substantial clinical work, is a sound one. Fortunately, the dental program at the Fiji School of Medicine has recently been reorganized using a similar model and would provide a good base for some of this much needed dental training to occur. In recent years improvements in distance-based education have also made it possible for the current and potential dental workforce to be trained in their own jurisdictions. This has the benefit of allowing dental practitioners to continue to provide their much needed services on-island and should be seriously explored and supported. Sponsor Training for Nurses Nurses play an important role in the region's health care delivery system. Yet in nearly every jurisdiction, officials reported having a nursing shortage. To address this situation, the committee recommends the following steps be taken. Training for nurses and for individuals in various allied health fields should continue to take place, as it does now, in several institutions of higher education located throughout the region. The committee is particularly concerned, however, about the high dropout and low graduation rates among individuals in every nursing program in the region. Regional nursing programs are encouraged

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 75 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN to work together to evaluate the reasons for these problems and design new approaches to address them. One approach that has been successfully implemented in some jurisdictions and that could be pursued further is the inclusion of clinical experience in community settings and the use of curricula that emphasize culturally appropriate primary care. Other approaches include the sharing of faculty members, the use of cooperative efforts to provide distance-based education, upgrading curriculum to the bachelor's level, and development of continuing nursing education programs for existing nurse personnel at all levels, which is viewed as essential to strengthen inpatient, outpatient, and community health care services. Some of these efforts have already begun, but they need to be sustained. HRSA's Bureau of Health Professions and its Division of Nursing should provide funds for nurse traineeships and other special training programs identified by the regional nursing programs. Provide Health Administration and Systems Management Training to the Chief Health Administrator (See earlier recommendation on reforming health care facility management.)

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CHARTING A COURSE FOR THE 21ST CENTURY: A STRATEGIC PLAN FOR FUTURE 76 HEALTH INITIATIVES IN THE U.S.-ASSOCIATED PACIFIC BASIN