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).

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