D
Assessments of Individual Jurisdictions' Health Care Services

Although the six jurisdictions of the U.S.-Associated Pacific Basin are often grouped together into one geographic category, as demonstrated in Chapter 2, such groupings tend to downplay the very different situations that exist in each unique jurisdiction. This appendix assesses the health care delivery system in each jurisdiction. Each assessment is organized into four parts:

  1. an overview of the jurisdiction's government, economy, population, and infrastructure;
  2. the organization of its health care delivery system;
  3. the available health care resources (financial, health care workforce and technology, supplies, and equipment); and
  4. future health care issues.


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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 95 D Assessments of Individual Jurisdictions' Health Care Services Although the six jurisdictions of the U.S.-Associated Pacific Basin are often grouped together into one geographic category, as demonstrated in Chapter 2, such groupings tend to downplay the very different situations that exist in each unique jurisdiction. This appendix assesses the health care delivery system in each jurisdiction. Each assessment is organized into four parts: 1. an overview of the jurisdiction's government, economy, population, and infrastructure; 2. the organization of its health care delivery system; 3. the available health care resources (financial, health care workforce and technology, supplies, and equipment); and 4. future health care issues.

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 96 AMERICAN SAMOA Total Population 58,070 Number of Inhabited Islands and Atolls 7 Access to Major Health Facility (percentage of population requiring 50% more than 1 hour of travel) Total Health Budget $21,403,500 Per Capita Health Budget $369 SOURCE: PIHOA (1997). NOTES: Total population is the official estimate from the 1990 U.S. census; the health care budget is from Fiscal Year 1995. Overview American Samoa is the only U.S. territory south of the equator. U.S. involvement with the islands began more than 120 years ago when U.S. businesses began using the port at Pago Pago. The United States officially annexed the islands in 1900 and placed the U.S. Navy in charge of their administration. In 1951 control was turned over to the U.S. Department of the Interior (DOI). Today, although many aspects of Samoan life have been westernized, the traditional culture—Fa'a Samoa—with its emphasis on

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 97 extended families headed by a matai, or chief, and communal life remains strongly rooted. The health care system is almost entirely administered and subsidized by the government. On the committee's site visit, the committee heard many expressions of dissatisfaction and frustration with the current state of the health care system from practically every person interviewed—from physicians and nurses to politicians to people waiting at a bus stop. Complaints ranged from concerns about the competence of health care providers and the lack of supplies and equipment to the high cost of sending patients off-island for care. Government American Samoans elect a governor and a bicameral legislature (the Fono). They also send a nonvoting delegate to represent their concerns in the U.S. House of Representatives. Economy The American Samoan economy is heavily dependent on two industries: government and tuna canneries. DOI estimates that 93 percent of the American Samoan economy is based directly or indirectly on U.S. federal expenditures and the canning industry (DOI, 1996b). In 1993, the American Samoa Government (ASG) employed about 32 percent of the workforce and the canneries employed almost 30 percent (Bank of Hawaii, 1997).1 The remaining economic activity is based on tourism and small-scale service businesses. Population American Samoa's population is increasing rapidly. With an annual growth rate of 3.7 percent, it has one of the highest growth rates in the Pacific (PIHOA, 1997). This growth is fueled by increased immigration and high birth rates. The majority of immigration is from the neighboring islands of Western Samoa and Tonga; additional immigrants have come from the Philippines and other Asian countries. Despite this, traditionally, a considerable amount of emigration has also occurred. Seventy thousand American Samoans now live in the United States (primarily in Hawaii and California); this means that more American Samoans live in the United States than in American Samoa itself (Bank of Hawaii, 1997). The native Samoan population is ethnically Polynesian (rather than Micronesian, as is the case in the other U.S.-Associated Pacific Basin 1 The majority of cannery workers are resident aliens, not American Samoans.

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 98 jurisdictions) and represents 90 percent of the island's total population (PIHOA, 1997). Infrastructure In general, water, waste disposal, and power systems in American Samoa have improved significantly in the last decade. For example, in 1995, 74 percent of housing units were connected to a public water system, up from 63 percent in 1990. The quality of the water is considered good. Even with these improvements, however, only a little more than half of households have complete indoor plumbing. Electrical power, once highly unpredictable and poorly managed, is provided by new, fuel-efficient electrical plants. Unfortunately, the operations of the privatized American Samoa Power Authority—which is responsible for many of the improvements—are currently threatened by ASG's inability to pay its obligatory subsidies (DOI, 1996b). Roads, telephones, and distance communications systems (which are responsibilities of ASG) are somewhat in a state of disrepair. According to DOI (1996b), roadways are in poor condition as a result of hurricanes, poor maintenance, and heavy traffic loads. Telephones reach only about 68 percent of households. With expensive long-distance rates, the Internet is currently limited to a privileged few and the community college that uses PEACESAT (although this may change rapidly as a result of new U.S. federal telecommunication regulations). Health Care Delivery System Organization Administration All health care services are administered through the Department of Health, which is headed by a director of health. The director, who reports directly to the governor, is responsible for overseeing the hospital, public health and dental services, and health planning. Almost all health services are actually provided at the LBJ Tropical Medical Center in Pago Pago, the island's main health care facility and hospital. The administration of the hospital has changed within recent years. Several years ago, the former governor created a quasi-independent Hospital Authority to oversee the hospital's management and finances. A similar authority had been created for the public utilities a few years earlier with marked improvements in service; it was hoped the Hospital Authority would achieve similar results. The Hospital Authority proved an unpopular, if misunderstood, idea with residents. It was eliminated in January 1997 by the newly elected governor who had run on a platform of getting rid of it. He reinstituted the current administrative structure of having a director of health in charge of all health care services.

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 99 Since 1993, an independent consulting team from Mercy International Health Services has also been involved with hospital administration. Originally brought in to co-manage the hospital, their involvement and the scope of the work have changed considerably in recent years. Mercy now acts in a training and advisory role; one of its most important assignments is to find ways to increase reimbursement from Medicare. Health Care Facilities The only hospital in American Samoa, the LBJ Tropical Medical Center, is located on the island of Tutuila in Pago Pago. The structure was built in 1968 and has been repeatedly cited by Health Care Financing Administration (HCFA) licensing officials as having major safety problems that could result in life- threatening situations. These problems include serious fire code violations and lack of routine or preventive maintenance. Although plans to correct these deficiencies have been developed, the majority have not been implemented. The situation is serious enough that HCFA has threatened to decertify (and hence stop payments to) the facility on numerous occasions.2 Some improvements have been made. For example, the Emergency Department was recently updated and remodeled. For the most part, however, over the course of several years few earnest attempts to address the concerns of the HCFA surveyors appear to have been made. Additionally, DOI is currently withholding $2 million dollars in capital improvement funds earmarked for the hospital until an independent authority is established to manage the hospital. Some community health centers, or dispensaries, exist in outlying villages of American Samoa, although most care is still provided through the hospital (which is relatively accessible by bus and car to most people on the main island). It is unclear exactly how many centers are currently operating; it could be as many as eight. At the time of the committee's site visit, several were reported to have been under construction after being damaged during a hurricane 2 years previously. Immunizations and well-baby care are being provided at these satellite health care centers. A few private clinics exist. These are staffed by doctors who also work for the government. American Samoa also has three private drug stores and these are owned by the hospital's pharmacist. These arrangements are viewed by many people as presenting potential conflicts of interest. Health-Related Community Organizations The American Red Cross is active on the island, helps prepare for emergencies, and provides disaster assistance. Many church groups also provide health-related services such as counseling. 2 As this report was being written, HCFA had begun the process of decertification.

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 100 Off-Island Care Off-island tertiary care referrals consume almost 30 percent of the total health budget and serve less than 1 percent of the total population (PIHOA, 1997). Most patients are referred to Honolulu (private hospitals as well as Tripler Army Medical Center). A patient coordinator in Hawaii helps to coordinate a referred patient's care and to attend to the logistics of lodging for escorts. Consideration is being given to referring more people to New Zealand and Australia as a cost-saving measure. A Medical Referral Committee (MRC) is supposed to review all cases for off-island referral. The governor must also approve off-island tertiary care referrals. The referrals must be medically necessary and must be for services unavailable on-island. It is reported that the current director of health, however, has stopped referring his patients to MRC and is deciding himself if patients can go off-island. Many problems have been linked to off-island care. One study found that in 1991 a conservatively estimated 16 percent of all medical referrals were inappropriate with, for example, referrals being granted to family members and friends as political favors (Larin et al., 1994). An increase in the number and cost of off-island referrals was pointed to as one of the major reasons for the government going deeply into debt in the early 1990s (GAO, 1992). Health Care Resources Financial Resources ASG—and hence the Department of Health—faces grave financial problems. It is several million dollars in arrears with many suppliers and organizations. As of March 1997, it owed Tripler Army Medical Center $1.5 million (P. Barcia, personal communication, March 20, 1997). The U.S. Department of Health and Human Services' discount pharmaceutical supplier, Perry Point, has refused to accept any more requests from American Samoa until it pays its current debts. Most vendors require cash in advance for any new purchase. The Department of Health annually receives about $2.4 million from Medicaid and $2 million from Medicare, which represents approximately one- fifth of the health budget. Patients are required to make copayments of about $2 for each outpatient visit and $7 a day to stay as an inpatient in the hospital. Collection of fees is rarely pursued. Government employees and cannery workers typically have health insurance and make use of the government health care facilities. Government employees can opt for government health insurance coverage. Virtually no private insurance market exists at this time.

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 101 Workforce3 Physicians Four M.D.s and nine medical officers work in American Samoa. Most of the physicians are U.S.-trained expatriates working on short-term contracts (usually for 2 years). The pay scale for health care workers is reported to be one of the highest in the South Pacific region, although many consider it too low to consistently attract high-quality personnel. Additionally, individuals with expertise in some vital areas are lacking. For example, no one on-island is able to surgically repair a blocked shunt for dialysis patients, who must then be sent off- island for this relatively straightforward procedure. Administrative delays are often encountered in the hiring of health care professionals. Doctors from the U.S. Department of Veterans Affairs are sent to American Samoa on a quarterly basis, although they typically conduct eligibility assessments rather than provide medical treatment (GAO, 1993). Nine medical officers trained at the Pacific Basin Medical Officers Training Program (PBMOTP) are working in American Samoa (two are currently on educational leave at the Fiji School of Medicine). All of them work in the hospital, with occasional duty at the dispensaries. In the future, one or two of the medical officers may be assigned to work full-time for the Public Health Department. Individuals have expressed concerns that the medical officers did not receive enough training in hospital care. In part, this training was to have been provided during the medical officers' required 2-year internship after graduation. The necessary training and supervision for the medical officers within the hospital in American Samoa, however, appear not to have been provided. The lack of appropriate on-island training is one reason given for American Samoa's decision to send its medical officers to the Fiji School of Medicine for further training. Although all PBMOTP graduates can go on to postgraduate training immediately after completing their internship, American Samoan medical officers are being required to repeat 1 or 2 years of undergraduate coursework to earn an M.B.B.S. (the British equivalent of the M.D.). At that point, they can go home to practice or go on to further formal postgraduate education. Nurses There are 31 registered nurses, 97 licensed practical nurses, 23 graduate nurses, and 12 nurse's aides currently working in American Samoa. Licensed practical nurses and registered nurses must meet U.S. national certification standards. Many nurses are reported to be unmotivated to take the certification test, particularly because they will still receive pay increases and benefits regardless of whether they have passed the test. Nonetheless, several remedial 3 Workforce numbers are from the 1997 PIHOA Data Matrix (PIHOA, 1997).

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 102 programs have been established to help prepare nurses who are planning on taking the national examinations. In 1996, to counter the shortage of practical nurses, the hospital held a successful 15-month training program designed to provide hands-on clinical experience. The American Samoa Community College (ASCC) has a career ladder nursing program, offering certificates for practical nurses and an associate degree for registered nurses. It also offers an emergency medical technician certificate course through the hospital. This year the nursing program experienced problems recruiting and retaining instructors, primarily as a result of budget cuts at ASCC. Retention of nursing students is also problematic; only 5 nursing students from an original class of 20 students were likely to graduate in 1997. The reasons cited for this poor student retention rate include students' problem with basic English skills and the limited amount of actual clinical experience. Consideration is being given to revitalizing the ASCC program by having it more closely linked to the hospital. Basic academic courses would be provided at ASCC and clinical work would be done in the hospital and dispensaries. Other Health Care Personnel Only two of the eight dentists in American Samoa are Samoan, the other six are expatriates on contract (PIHOA, 1997). This may change because nine Samoan students are currently studying at the Fiji School of Dentistry and appear likely to return to American Samoa to practice dentistry. Traditional health practitioners, fao faos, are still regularly used by many Samoans. The fao faos use herbal remedies and vigorous massage to help their clients. Workforce Quality Assurance As mentioned earlier, HCFA is responsible for monitoring quality in the hospital, and its surveyors have repeatedly determined that quality and safety are seriously lacking. Although a few attempts to establish a quality assurance program in the hospital have been made, no comprehensive program is in place. No continuing education is required for any health care provider. A Health Services Regulatory Board was created to license all health professionals (except nurses) and to ensure that certain minimum educational and professional criteria are met. However, the board has not met in many months and is considered to be defunct. Several of the PBMOTP graduates do meet on their own to stay abreast of the literature and discuss research. Nurses have advocated for legislation to implement a Nurse Practice Act, but this has not been passed by the Fono.

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 103 Technology, Supplies, and Equipment Shortages of even the most ordinary supplies such as X-ray film and pain medication are a chronic and recurring situation at the hospital. Shortages of supplies have forced the dialysis unit to be closed for up to a week, imperiling patients' lives. Staff have sometimes been creative in improvising ways to deal with shortages. For example, when supplies of oxygen ran out, staff arranged for a federal surplus oxygen generator to be installed. Although the gauge showing the actual quality of the oxygen is broken, the new equipment has the potential to save thousands of dollars each year. A mammogram machine was donated to the hospital several years ago, but it is not being used because it is broken and no one is trained to operate it. A computed tomography (CT) scanner has been requested as a way of reducing the costs related to sending people off-island for diagnosis. There would need to be a person trained in the machine's operation and maintenance as well as the clinical skills needed to interpret the images. The LBJ Tropical Medical Center has several dialysis machines and hopes to add more machines in the near future to meet increased demands. PEACESAT provides an opportunity for limited telemedicine applications, but to date this has been used mostly for in-service training of physicians. During the committee's site visit, however, the equipment was broken and a scheduled session was canceled indefinitely. Future Health Care Issues The most pressing issue confronting the American Samoan health care system is getting its financial house back in order. The hospital's physical plant must be brought up to minimum safety requirements. Vendors need to be paid so that shortages of vital equipment and supplies no longer imperil patients' lives. Residents of American Samoa are not receiving the quality health care they so strongly desire.

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 104 COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS Total Population 58,846 Number of Inhabited Islands and Atolls 3 Access to Major Health Facility (percentage of population requiring 90% more than 1 hour of travel) Total Health Budget $36,161,007 Per Capita Health Budget $614 SOURCE: PIHOA, 1997. NOTES: Total population is the official estimate from the CNMI 1995 mid-decade census; health care budget is from Fiscal Year 1996. Overview The Commonwealth of the Northern Mariana Islands (CNMI) has witnessed tremendous economic and social changes since 1978, when it began the process of becoming an official commonwealth of the United States. The tourism, garment, and construction industries expanded rapidly, creating a labor shortage. Tens of thousands of workers from neighboring countries moved to CNMI to get jobs. Although incomes soared, the rapid and largely unplanned

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 105 economic development and resulting influx of foreigners have put stress on health care and other basic services. Development has also been cited as a factor in the breakdown in traditional family arrangements and an increase in the use of alcohol and drugs. Government Although they do not vote in U.S. elections, CNMI residents are U.S. citizens and elect their own governor, lieutenant governor, and a legislature with nine senators and 15 representatives. Although they have a representative in Washington, D.C., that person is a not an official congressional delegate like those from American Samoa and Guam. Because CNMI is a U.S. commonwealth, its government has control over many policies such as immigration, tax, and labor. Economy CNMI's economy is based largely on tourism and the garment industry. In 1995, almost 655,000 tourists—primarily from Japan—visited CNMI and spent roughly $522 million (DOI, 1996b). That same year, the garment industry exported over $419 million in goods, primarily to the United States. Concerns about possible labor abuses and poor working conditions in both the public and private sectors have brought increased attention from the United States and several foreign governments. Although once used by the Central Intelligence Agency as a training base, CNMI currently has no U.S. military bases and hence no income from the U.S. military, unlike other U.S.-Associated Pacific Basin jurisdictions. Population Within the past decade and a half, the CNMI population has exploded—from 16,890 in 1980 to 58,846 by 1995 (U.S. Bureau of the Census, 1997b; PIHOA, 1997). Almost all of the growth results from immigration–workers for the booming tourism and garment industries—primarily from the Philippines and China. In fact, today for every native CNMI resident there are approximately two non-resident aliens. Of the native population that does exist, 75 percent is Chamorro and the rest is Carolinian. Infrastructure Water, wastewater, and sewage systems operate at the limit of their capacity on Saipan, the main island. Although millions of dollars in improvements have

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 144 agency. Within MOH, the secretary of health oversees four major departments: Primary Health Care, Kwajalein Atoll Health Care, Majuro Hospital, and Administration and Finance. In addition, MOH administers a special program known as the 177 Health Care Program, which provides health care to individuals adversely affected by nuclear testing. The U.S. Department of Energy (DOE) administers yet another program, the Marshall Islands Medical Program, specifically for people who were directly exposed to nuclear fallout. Both of these programs are explained in more detail below. Marshall Islands Medical Care Program As mandated through the Compacts of Free Association, the Marshall Islands Medical Care Program provides medical care and treatment for potentially radiogenic diseases for the remaining exposed victims15 of the 1954 Bravo test on Rongelap and Utrik plus screening and acute care for a comparison group of 109 people. This special medical care and surveillance have been provided by the Brookhaven National Laboratory via a contract with DOE. The program receives annual funding from the U.S. Congress at about $2 million (Bell, 1997). Under the current structure of the Marshall Islands Medical Care Program, teams of doctors are sent to RMI for 1-month missions two times per year. The mission teams provide full medical examinations, including thyroid and endocrine examinations, gynecological examinations, various urine and blood examinations, and diagnostic tests that can include mammograms, thyroid ultrasound, and X-rays. Patients with conditions potentially radiogenic in origin are referred to off-island facilities (primarily Hawaii) when diagnoses and treatments for those conditions are not available in RMI. Patients requiring care for other conditions and between missions (and patients in the comparison group who need medical attention) are referred to the 177 Health Care Program. The structure of the Marshall Islands Medical Care Program is in the process of being changed to place a greater emphasis on providing more holistic and community- based care to the individuals served by this program (Bell, 1997). Section 177 Health Care Program The Compact of Free Association also provided money for a ''Four Atoll Health Care Program" to provide health care services to people of the four atolls affected by U.S. nuclear testing (Bikini, Enewetok, Rongelap, and Utrik), as well as to their descendants. Named for the section of the Compact that speaks to nuclear testing effects, the 177 Health Care Program provides care for 15 A total of 253 people were directly exposed to fallout from the Bravo tests in 1954. However, only 131 are still alive.

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 145 approximately 11,470 Marshallese people. The U.S. Department of the Interior annually provides about $2 million to the Marshallese government for the program, and RMI government contracts administration of the program to a private health care organization (Bell, 1997).16 To be eligible for the program a person must be Marshallese and must have been residing on one of the four atolls during 1946–1958 or be a direct descendant of a resident. Health-Care-Related Community Organizations The Youth to Youth in Health Program is a nongovernmental organization that promotes youth and community involvement with primary health care. The program trains young people to be peer educators and to serve as role models. It sponsors health outreach programs and produces radio and television programs promoting health and cultural awareness on such topics as nutrition, family planning, substance abuse, and mental illness. In 1995, a health clinic for adolescents opened in Majuro. Another aspect of the project is to promote and supervise income-generating projects for outer islanders. The program operates on 20 islands and receives some support from MOH (Youth to Youth in Health, 1996). Off-Island Care RMI spent approximately 33 percent of its total health care budget serving 148 patients in 1996 (PIHOA, 1997). An off-island referral committee is chosen by the secretary of health. However, during the committee's site visit it was reported that about 60 people are on the waiting list to be sent off-island for medical care, with the government able to afford sending only 1 or 2 each month. Consequently, there are also reports that decisions of who is sent off-island are based largely on political favors and social status, with no internal consistency in the criteria or decisionmaking used to refer people off-island. Added to the problem is the higher level of attention and financial support given to radiation- related health problems; those patients are often referred to hospitals in Hawaii (a preferred location) or the Philippines. Health Care Facilities RMI has two major hospitals, located in the major urban centers of Majuro and Ebeye. Built in 1986, the Majuro Hospital has 103 inpatient beds, an emergency room, and a dental clinic. The structure itself is largely constructed 16 Until the fall of 1997, Mercy International Health Services administered the Section 177 Health Care Program.

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 146 with specially coated cardboard paneling. MOH estimates the hospital can only last another 5 years and would like to replace it as soon as possible. The Ebeye Hospital has 25 inpatient beds and is in serious disrepair. A new hospital facility has been built with funds from the Department of the Interior but it remains unoccupied because there are no funds to purchase and install the equipment necessary to make it operational. The U.S. Army hospital on the USAKA base, which serves military personnel, their dependents and, very occasionally, some Marshallese individuals who work at the base, is in close proximity but is not available to the general Marshallese population. A Health Resources and Services Administration (HRSA)-funded Section 330 community health center operates in Ebeye. The Youth-to-Youth in Health Program also operates a health clinic for adolescents in Majuro as well. Among the outer islands and atolls are 58 dispensaries. Currently, each is run by a health assistant and is linked to the Majuro Hospital through shortwave radio. Many of the health assistants are nearing retirement. However, the government recently implemented a health careers opportunity program (see below) to train a new set of health assistants at the Majuro Hospital. Health Care Resources Financial The total health care budget for RMI for Fiscal Year 1996 was $7.6 million (PIHOA, 1997). Funding for operations comes from Compact money, the general fund, U.S. funds for primary health care and public health, and other grants. The universal health care system (the Marshall Islands Health Plan) provides for and insures every Marshallese resident. User fees are charged for health services, but the fee amount itself is low (e.g., $2 per outpatient visit) and the collection effort is minimal. Radiation-exposed victims, their descendants, and current residents of the four atolls exposed to radiation are insured separately under the Marshall Islands Program and the Section 177 Health Care Program, funded by Compact money. Workforce17 Physicians The RMI relies heavily on expatriate physicians; 13 of the 19 M.D.s working in RMI are expatriates (9 are from the Philippines and 1 each from the United States, Australia, Burma, and Sri Lanka). There is also one expatriate M.B.B.S. One of the hospital doctors has reportedly opened a private practice. 17 Workforce data are from the 1997 PIHOA Data Matrix (PIHOA, 1997).

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 147 Currently, six graduates of the Pacific Basin Medical Officers Training Program (PBMOTP) are working in RMI (five are indigenous, one is from the Federated States of Micronesia; one more is on maternity leave, but she plans to practice in RMI). These medical officers provide staffing for the two hospitals' inpatient and outpatient units and emergency room. With only one Marshallese student known to be enrolled in medical school, RMI will remain dependent on expatriates for the foreseeable future. Dentists All four dentists in RMI are expatriates (two are from Burma, one each is from the United States and the Philippines), three are located on Majuro, and one is located on Ebeye. They are assisted by four dental nurses and eight aides. At least two Marshallese students are enrolled in the school of dentistry in Fiji. Mid-Level Practitioners Nine medexes and 56 health assistants staff the dispensaries. However, the average age of the health assistants is 56, and many plan to retire in the near future. MOH has recently begun to offer a health care opportunities program to train new health assistants. The program, funded by a HRSA grant, enrolls high school graduates in a special 18-month training program that includes 4 months of formal classes at MOH and 5 months of work in the Majuro Hospital before they are sent out to staff the dispensaries. Nurses The College of the Marshall Islands (CMI) is an accredited 2-year college and offers an associate degree in nursing. Nurses from CMI staff the hospitals not only in RMI, but also throughout the region. However, with a relatively low current enrollment, concerns are mounting that the hospitals will soon experience a shortage of nursing personnel. CMI is actively seeking to expand its nursing program to offer a 4-year bachelor's degree program. Accordingly, although the island has only 1 registered nurse, 79 graduate nurses (96 percent of whom are indigenous) and 44 nursing aides are in practice. Traditional Health Care Practitioners In the Marshall Islands there has been no tangible carryover of pre-Western traditional healers, as is the case with the suruhanos in Guam, for example. However, particular cultural beliefs about family, gender roles, privacy, and

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 148 religion do influence health behavior, and at times, these beliefs place people at odds with the Western medicine that so dominates the system. Technology, Supplies, and Equipment A chronic lack of critical supplies and equipment exists. In recent years, the Army Hospital on Kwajalein has taken some referrals and has used telecommunications technology to send images to doctors at Tripler Army Medical Center in Hawaii for diagnoses, although it has primarily been for dermatological patients (Bice et al., 1996). Future Health Care Issues With rapid population growth, child malnutrition, and increases in the occurrence of diseases resulting from lifestyle factors, such as diabetes, RMI is recognizing the need for restructuring its health care system to focus on primary care. In 1987, the RMI government launched a national campaign to focus on primary health care and to involve the community in planning services. To this end the government is in the process of building 21 community health stations that will be operated and maintained by community health councils (which will include community leaders, church leaders, and residents), staffed by health assistants, and regularly visited and assisted by primary health care teams consisting of doctors, nurses, dentists, and social services staff. The primary health care team has already begun its work on Ebeye with 10 community health councils. At the time of the committee's site visit, the team had completed the process of collecting data such as household characteristics, and level of access to public water, power, and sewage systems to establish community profiles. This primary health care team appears to be highly motivated about its work, communicated effectively, and was knowledgeable about residents' needs. It is hoped that this primary health care approach, with an emphasis on education, will empower people to better care for their own health and the health of the people in their community.

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 149 PALAU (BELAU) Total Population 17,225 Number of Inhabited Islands and Atolls 8 Access to Major Health Facility (percentage of population requiring 70% more than 1 hour of travel) Total Health Budget $10,912,500 Per Capita Health Budget $633 SOURCE: PIHOA (1997). NOTE: Total population is the official estimate from the 1990 U.S. census; health care budget is from Fiscal Year 1997. Overview Palau became an independent country in 1994 after years of negotiations with the United States and several national plebiscites. Like Guam and the Commonwealth of the Northern Mariana Islands (CNMI), Palau is currently experiencing somewhat of an economic boom, with marked increases in tourism, new construction, and development and, relatedly, an increase in foreign workers—primarily from the Philippines. At the same time new emphasis has been placed on the promotion of primary health care and

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 150 preventive services. A new hospital has been constructed, and several superdispensaries have been established. Much of the primary care is being provided by newly graduated medical officers from the Pacific Basin Medical Officers Training Program (PBMOTP). Government Palau has several layers of government. At the national level, there is a president, vice president, and a national congress with 14 senators and 16 delegates. The national government also receives advice from a council of chiefs, formed of one traditional chief from each state. At the state level, each of the 16 states has a governor and a state legislature. Population Although it is estimated that the Palauan Islands may have been home to as many as 45,000 people in 1783 when westerners first landed and more than 30,000 people during the height of Japanese administration in the 1930s, Palau's current population is only about 17,225 (PIHOA, 1997). Only 8 of Palau's more than 200 islands are inhabited, and 70 percent of the people live on the island of Koror. More than 80 percent of the total population is native Palauan; the ethnicity of the rest of the population is mostly Filipino. Fewer than 100 people live in Palau's Southwest Islands; ethnically, they are considered Southwestern Islanders rather than Palauan. Economy Palau's economy is based primarily on tourism and government expenditures. In 1995 approximately 65 percent of the labor force worked in the private sector, whereas the remaining 35 percent was employed by the government (DOI, 1996b). Palau's economic future appears bright, with confident forecasts of increased tourism and resulting development in the coming years (Bank of Hawaii, 1994). In addition, unlike the Compacts of Free Association with the Federated States of Micronesia and the Republic of the Marshall Islands, Palau's Compact with the United States provides for a trust fund for long-term capital investments. Infrastructure Although nearly all housing units in Palau (92 percent in 1995) have access to a public water source, the water remains unsafe. According to the U.S. Department of the Interior (1996b), the water treatment plant that serves the

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 151 majority of the population on Koror does not meet U.S. Public Health Service standards for public water systems. In the outlying areas and islands, people must rely primarily on rain water catchment systems, surface water sources, or shallow wells to meet their needs (DOI, 1996b). Inadequate sewage and waste disposal systems present another hazard. Only about 41 percent of households in 1995 (up from 30 percent in 1990) were connected to a public sewer system. The only waste treatment plant has reached capacity, and trash collection has been infrequent, causing a buildup of garbage in and around residences. Coastal waters and harbors are beginning to show signs of contamination (DOI, 1996b). Health Care Delivery System Organization Administration The minister of health, a cabinet-level appointee, administers the overall health care system. Under the minister are a director of the Bureau of Public Health and Primary Health who manages all outpatient activities, dispensaries, and superdispensary services as well as all other federally funded health services and programs and a director of the Bureau of Clinical Services who manages medical inpatient activities with the Belau National Hospital. Although most health care is provided through the government, a small and growing private medical practice has been established. Off-Island Care A team of senior physicians must make a majority decision about any recommendation for off-island tertiary care referral. Most of the patient referrals (75 percent) are to the Philippines because the facilities and services there are closer and less costly than those in Hawaii. Most of the remaining patients are referred to the Tripler Army Medical Center in Hawaii (20 cases of a total 103 patients [or 20 percent] in 1995). The cost for each off-island tertiary care referral is capped at $30,000 per year (although the committee heard reports that some patients' bills were much higher). Referrals accounted for 15 percent of the total health care budget in 1995 (PIHOA, 1997). Health Care Facilities An 80-bed hospital in Koror opened in December 1992 and is managed by a health services administrator who reports to the minister of health. Although the physical plant appears to be in good condition and relatively well maintained, it does lack some basic equipment. Recently, more than 110 pieces

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 152 of major medical equipment were purchased under a special grant made available through the U.S. Congress. A room in the hospital was recently designated as the medical library and the telemedicine and telecommunications center. Funding for books and equipment is being requested but is unavailable. The new hospital provides the anchor for a health care system that also includes four superdispensaries, nine smaller state dispensaries, an ambulatory care center, and a community health center (the old hospital). Each dispensary is staffed with a nurse or a health assistant, whereas the superdispensaries are staffed with a doctor and a nurse, with telephone linkage to the hospital if needed for consultation. Providing care to the outer islands continues to pose challenges. In addition to the main airport near Koror, two small airports in Peleliu and Anguar are available for patients going to Koror. Some concern was expressed about reaching islands farther out. Although they keep in touch via radio or a ship making an occasional field trip, the islands have no airports and can be reached only by ship. Health-Related Community Organizations Palau has several community-based organizations that relate to health care: the American Red Cross, high school group mentors such as Pride, Shalom, Karui el Make er Ngii, the Committee on Population and Children, and the Alcohol and Substance Abuse Prevention Program (ASAP). Health Care Resources Financial Funding for the health care budget comes from a variety of sources including Compact monies. In 1997 U.S. federal grants and aid from other international donors accounted for $2,350,500—or roughly 20 percent of the total health care budget. Proposed legislation levying taxes on such things as diving, cigarettes, beer, wine, liquor, and canned meats and to provide funding for health care is pending in the national congress. Some private insurance is also available. The Palauan government is, however, considering passage of a Palau National Health Care Plan (NHCP), which would set up a nationwide public health insurance system. Under NHCP, hospital care and preventive care services would be provided to all citizens and would require only a small copayment for outpatient services, emergency room visits, and prescriptions. All resident aliens would be required to enroll in the plan with premiums paid by their employer if they earn less than $10,000 per year and by themselves if they earn more than $10,000 per year. Monthly premiums would range from $25 to $70, depending on the number of dependents.

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 153 Workforce18 Physicians Twelve graduates of the PBMOTP are currently working in Palau (one is on educational leave taking postgraduate courses in obstetrics in Fiji). Eighty percent of the physician workforce is native Palauan. Most of the native physicians provide primary care, whereas expatriate contract workers provide specialty care. Palau now has four surgeons: two Palauans who returned after training abroad, one South Korean (supported by the South Korean government), and one contract surgeon from Burma. One Palauan doctor who trained in the United States and returned to Palau has opened a private health clinic and is doing extremely well; patients have been known to come from as far away as Yap for treatment. Dentists The supply of dentists and dental assistants is critical. Two of the three dentists are expatriates under contract. Nurses Many nurses have left Palau where they make between $6.40 and $8.40 an hour, to work in Saipan and Guam, where the entry pay scale is considerably higher. The Palau Community College helps coordinate continuing education courses for nurses. Since 1992 several classes of Palauan nurses have participated in a distance education course offered from the University of Guam (Fochtman et al., 1997). An on-the-job training program is also offered to nurse's aides and practical nurses at the hospital. They receive a subsidy of $50 per week and are guaranteed a job after completion of the training program. Other Health Care Personnel Officials reported a shortage of nurses, pharmacists, medical laboratory technicians, and radiologists. A psychiatrist and a clinical psychologist are also needed. Traditional Health Practices The usefulness of herbal medicines and acupuncture is recognized and the Ministry of Health desires their use, but protocols or procedures for 18 Workforce data are from the 1997 PIHOA Data Matrix (PIHOA, 1997).

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ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 154 incorporating them into the local health care system have not worked out yet. Palau participates in the Western Pacific Region of the World Health Organization's current effort to address this issue seriously. Quality Assurance The nurses in Palau have established a nurse's association, which helped to create a Nurse Practice Act and a nursing licensing committee, which requires continuing education before recertification. In 1996 doctors began requiring continuing education for themselves, and recently the Belau Medical Society has been restarted as a professional organization for physicians and medical officers. Comprehensive medical licensure legislation for various health professionals is pending in the national congress. Future Health Care Issues Palau plans to continue to improve its primary health care system. This will include better equipment at the facilities and more trained staff. Although expatriates will continue to be used for specialty care such as oncology, cardiology, and urology, the government also plans on sponsoring some of the new medical officers so that they can go to Fiji to obtain additional experience in these and other specialties. Careful planning will be needed to ensure the adequate provision of health care services when the capital makes the planned move from Koror to Babeldaob.