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Pacific Partnerships for Health: Charting a New Course (1998)

Chapter: Appendix DD Assessments of Individual Jurisdictions' Health Care Services

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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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Suggested Citation:"Appendix DD Assessments of Individual Jurisdictions' Health Care Services." Institute of Medicine. 1998. Pacific Partnerships for Health: Charting a New Course. Washington, DC: The National Academies Press. doi: 10.17226/5941.
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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.

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

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.

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.

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.

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.

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).

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.

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.

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

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

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 106 been made to the public water system since 1990, both the World Health Organization (WHO) and the Health Care Financing Administration (HCFA) have deemed the water supply unsafe (HRSA, 1996). With no rivers and few springs, rainfall provides most of the fresh water. In addition, excessive well- drilling and cracked pipes in the distribution system have produced salty, unhealthy water in the groundwater lens (DOI, 1996b). Heavy rainfall often floods the wastewater collection system on Saipan, causing waste to rise and dissipate with the rain. In addition, Saipan's only waste disposal site, the Puerto Rico dump, has frequent fires that release toxic gases, threatening residents in surrounding areas. Plans are underway, however, to close the dump and to open a new landfill, for which $16 million in Covenant and local funding has been earmarked (DOI, 1996b). Transportation on the island of Saipan is also troublesome. Many of the 362 kilometers (225 miles) of roads throughout CNMI were paved during World War II and are now being rebuilt. Primary highways are increasingly overburdened with heavy traffic. Traffic lights have been added, and plans to reconstruct and pave more roadways are underway. Even so, the major road on Saipan, Beach Road, is often inundated with traffic jams, and motor vehicle accidents are one of the leading causes of death (DOI, 1996b). Health Care Delivery System Organization Administration Health care services are administered by the Department of Public Health. The department operates the Commonwealth Health Center (CHC), the hospital and main outpatient center, and administers all public health, mental health, and related social service programs. In recent years it has actively begun to privatize some of its services, such as outpatient pharmacy, linen and laundry, yard and grounds maintenance, security, and nurse recruitment. The private sector, in general, is expanding rapidly in CNMI. Several private health clinics operate on the islands, some in conjunction with private health maintenance and insurance organizations. Health Care Facilities CHC serves as the main hospital for CNMI. Built in 1986, the 76-bed facility provides both acute inpatient and outpatient services. CHC has 13 hemodialysis machines and a computed tomography (CT) scanner. As a recipient of Medicare funds, CHC is subject to the licensing and certification of HCFA. The facility has fared well on past surveys and has followed through in implementing its plans of corrections. CHC is also the only health care facility in the region to be fully accredited by HCFA.

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 107 Government-run health centers have been established on the islands of Rota and Tinian, and a new clinic operates in the southern village of San Antonio on Saipan. The emphasis in these health centers and clinic is to provide preventive services such as immunizations, prenatal care, and other primary health care services. Three private health clinics and one dental clinic have also been opened in recent years. Health-Related Community Organizations The CHC Volunteers is a volunteer group dedicated to raising funds for CHC. Money is raised through the hospital gift shop, raffles, and other special fundraising activities. In the past 10 years, CHC Volunteers has raised more than $750,000. The money has been used not only to buy needed equipment in the hospital, but also to sponsor a television series on health education and other community health information efforts. Other community organizations include youth drug prevention groups, the CNMI National Food and Nutrition Advisory Council, and a variety of school health education programs in several schools in CNMI. Off-Island Care CNMI recently enacted legislation that requires decisions about off-island tertiary care referrals to be made by a Medical Referral Committee (MRC) comprising six physicians. This has helped to depoliticize the process; on the site visit the committee was told that a senator's mother's request to have a gallstone operation off-island had been turned down by the MRC which felt that the operation could be appropriately handled on-island (it was, and with a good result). Typical reasons for off-island referrals include receiving services not available on-island, such as open-heart surgery or chemotherapy. People who do go off-island for medical treatment at government expense must now contribute toward the cost on a sliding fee scale and are subject to a $50,000 cap for expenses. The CNMI government budgeted $7 million in 1996 for the off-island referral program and included the incentive that if any money for the referral program remains at the end of the year it would be turned over directly to the health department (rather than the government's general fund). Health Care Resources Financial Resources The total health care budget in 1996 was $43 million, which represents 15 percent of the CNMI government's total budget. This includes funds from local taxes ($28 million), a CNMI government legislative appropriation ($10 million),

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 108 Medicare and Medicaid ($1.7 million), U.S. federal grants ($2.4 million), and WHO ($100,000) (I. Abraham, personal communi-cation, August 21, 1997). By law, health services must be provided to all regardless of their ability to pay. However, private health insurance is available through a number of companies and health maintenance organizations. It is estimated that roughly 60 to 70 percent of the population has some form of private health coverage. Employers of foreign workers are required to provide insurance to their employees (PIHOA, 1997). Compact Impact Under the provisions of the Compacts of Free Association, residents of the freely associated states may enter CNMI of their own accord. Many have done so in search of economic opportunities. In 1990, an estimated 3,327 people born in the freely associated states resided in CNMI, a little over half of whom immigrated after the Compacts were signed in 1986 (Levin, 1996). Although many are employed and have health insurance or sufficient income to cover the cost of their own health care, the CNMI Department of Public Health estimated that in 1996 it provided health care costing $1,480,000 to citizens of the freely associated states. This represents 11 percent of all the encounters at government- operated health facilities (CNMI Department of Public Health, 1997).4 Workforce Physicians The physician workforce in the CNMI is largely expatriate, with more than 90 percent of doctors coming from outside the region. Recruitment on the international market has been difficult in the past, but the pay scale and the benefits now being offered (government-sponsored housing, transportation and moving allowances, etc.) are believed to be competitive. Government-employed physicians are covered for malpractice, but private physicians are not. The CNMI government chose not to participate in the Pacific Basin Medical Officers Training Program (PBMOTP) because of concerns about meeting HCFA licensing requirements and local laws of the CNMI Medical Profession Licensing Board. An informal program to encourage local students interested in becoming doctors and practicing medicine in CNMI has recently been undertaken. Students study in the United States, are offered summer jobs in CHC to gain experience, and are given a mentor in CNMI who stays in contact with the student while he or she is studying on the U.S. Mainland. 4 For a more complete discussion of ''Compact Impact" and references to relevant literature, the reader is referred to Levin, 1996.

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 109 Nurses Recruitment and retention of nurses are problematic. Currently, the overwhelming majority of the nurses and assistants are foreign contract workers (primarily from the Philippines) hired through employment agencies. Many of these workers only stay long enough to complete a 2-year contract, get training, and pass the U.S. licensing examination (NCLEX), before moving to the United States or elsewhere. The Northern Marianas College has an accredited 2-year nurse degree program. Nursing students receive clinical experience at the CHC. The CHC itself provides training for nurses challenging the NCLEX, as well as a variety of continuing education courses. Nonetheless, with a limited pool of nurses being trained on-island, nurses continue to be actively recruited from Palau, the Philippines, and other neighboring islands. Workforce Quality Assurance Both physicians and nurses must meet certain quality standards to be licensed by the CNMI Medical Profession Licensing Board. As mentioned earlier, HCFA also accredits the hospital. Technology, Supplies, and Equipment CNMI will soon have fiberoptic capability for telecommunications. CHC is ready to hook up with Hawaiian and U.S. mainland hospitals for clinical telemedicine consultations as soon as the fiberoptic connection is completed (I. Abraham, personal communication, April 18, 1997). The Northern Marianas College already uses a microwave system to provide interactive distance education courses from Saipan to students in Tinian. Future Health Care Issues CNMI plans to continue finding innovative ways to provide health care for its rapidly growing population. It also plans on continuing to promote and develop the private health care sector. At the same time, it remains committed to providing quality health care to everyone, regardless of the ability to pay a commitment backed by the CNMI government. Finally, in the words of Secretary Abraham, "The most important vision we have for the future is a community whose members understand they must take responsibility for their health and health care" (Abraham, 1997).

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 110 FEDERATED STATES OF MICRONESIA Total Population 105,506 Number of Inhabited Islands and Atolls 62 Access to Major Health Facility (See below under descriptions of (percentage of population requiring individual states) more than 1 hour of travel) Total Health Budget $13,962,807 • National Health Budget 1,177,441 • State Health Budgets 12,785,366 Per Capita Health Budget $132 SOURCE: PIHOA (1997). NOTES: Total population is the official estimate from the FSM 1994 National Census; the health care budget is from Fiscal Year 1994. Overview An independent country since 1986, the Federated States of Micronesia (FSM) consists of four states: Chuuk, Kosrae, Pohnpei, and Yap. With the exception of Kosrae state, which consists of only one island, all the other states have many islands scattered across vast stretches of the Pacific Ocean. Almost all health care services are provided by the federal and state governments of FSM, although the quality of the health care system varies markedly from one state to another. The FSM economy—including its health sector—is extremely dependent on U.S. aid and, as funding from the Compact of Free Association winds down, uncertainty prevails across many aspects of island life.

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 111 Government The government structure is very similar to that of the United States with federal, state, and local governments. Both the federal and state governments of FSM have separate executive, legislative, and judicial branches. Traditional leaders continue to play key roles in the decisionmaking process. Economy The FSM economy depends heavily on its public sector. The government, largely supported by U.S. funds, provides most of the highest paying employment opportunities, especially in the more urban areas. Roughly 25 percent of the population works for the national or state governments of FSM (FSM, 1991). A more traditional subsistence economy based on farming and fishing dominates the more remote outer islands and villages. Serious planning for the country's economic future has begun in earnest as the Compacts wind down. The Asian Development Bank is working with the federal and state governments; each state has held a summit to develop economic plans and priorities, including plans and priorities for the health sector. Emphasis is being placed on developing FSM's fishing, tourism, and agriculture industries. In the short term, however, the federal and state governments have begun to change their personnel policies in anticipation of further decreases in funds from the United States. For instance, many government employees, including health care workers, are now on a 4-day work week, and salaries for government workers have been reduced by 20 percent. In light of the limited economic opportunities, it is assumed that many FSM residents will emigrate to Guam, the Commonwealth of the Northern Mariana Islands, Hawaii, and the U.S. mainland —a trend that has been on the rise since the Compacts first went into effect and presumably will still be allowed when the Compacts are renegotiated (DOI, 1996a). Population The native FSM population is primarily Micronesian and includes the major ethnic groups of the individual states: Chuukese; Kosraean; Pohnpeian; Yapese. Overall, the population is very young with 44 percent of the population under 15 years of age. The population growth rate has decreased to 2 percent in recent years. The crude birth and fertility rates are high compared with the rates in more developed countries; on average, women in FSM have 4.7 children (PIHOA, 1997). This rate is much lower than the 8.2 children women averaged in 1973, however (FSM, 1996). The decline in the population growth rate is most directly attributable to high infant mortality rates (46 per 1,000 births) and

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 112 emigration from FSM (PIHOA, 1997; Hezel et al., 1997). Family planning, and the education and employment of women are other important factors typically associated with such a change (Marshall and Marshall, 1983). Infrastructure Considered a private-sector success model, FSM has turned over road maintenance, telecommunications, and power to private companies. Water, sewage, and waste disposal remain the responsibility of the Department of Public Works. The level of access to sanitation facilities on FSM is extremely low, and this is particularly a problem in the crowded urban centers of Chuuk and Pohnpei. According to the U.S. Department of the Interior, in 1995 only about 34 percent of households in FSM had flush toilets, about 18 percent were connected to a public water system, and 11 percent were connected to a public sewer. Electrical power is available to only about half of the households (or 51 percent), the lowest number among the six jurisdictions of the U.S.-Associated Pacific Basin (DOI, 1996b). (See also the descriptions in the assessments of the individual states given below.) Health Care Delivery System Organization Administration FSM has a national Department of Health located in the capital, Palikir, which is responsible for overall health planning and technical assistance. Each state has its own state department of health, which provides actual health care services through a central hospital and a variety of primary care delivery sites (dispensaries), which can range from a building with several rooms to a medicine cabinet in a person's home. Typically, these state departments of health administer an inpatient ward, an outpatient department, a dental department, and a public health department. The public health departments conduct all of the current preventive activities (well-baby care, prenatal care, family planning, sexually transmitted disease treatment and follow-up of contacts, tuberculosis and leprosy treatment and follow-up of contacts, and any activities—admittedly sparse—devoted to the follow-up of chronic diseases like hypertension and diabetes). In some jurisdictions, within this public health department is a separate entity that specifically oversees the peripheral clinics or dispensaries. Only a handful of practitioners are in private practice; the rest work for the federal or state government. Further development of private practices has been hampered by the need to use government facilities for laboratory work or

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 113 inpatient hospital care. Legislation regarding liability and malpractice is also needed before more privatization can occur. Health Care Facilities (See descriptions in the assessments of the individual states given below.) Health-Related Community Organizations Each jurisdiction has a number of community organizations that are involved with some aspects of health care. Some churches and women's and youth groups offer such services as supportive counseling and a mechanism for health promotion activities (Hezel et al., 1997). The Red Cross is active in Chuuk. Off-Island Care All four states have protocols and medical review committees to review requests for off-island tertiary care referrals. Many states employ staff in the major referral centers (such as Honolulu and Manila) to coordinate care. In the past these referrals have drained significant portions of the total health care budgets to serve a very small percentage of the overall population. For example, in 1992 Chuuk spent $472,000 and overran its budget for such referrals by $30,000 (PIHOA, 1997). Reportedly, the decisions of the medical review committee are often overruled by members of the legislature. In Kosrae, both the number of cases and the total amount spent on off-island referrals has decreased in recent years, going from 34 cases accounting for 12 percent of the total health care budget in 1990 to 20 cases and 10 percent of the total health care budget in 1996 (Kosrae Department of Health Services, 1996). Nonetheless, on the site visits committee members were told by FSM health officials that a recent study from an outside reviewer reportedly found that 92 percent of all referrals were medically justified [need to get cite from Dr. Pretrick]. The remaining 8 percent still represents a significant and inappropriate drain of health care dollars away from the jurisdictions, even though the overall trend appears to be a steady albeit slow and difficult movement away from the abuses and cost overruns of the past. In April 1997, the FSM government revised its off-island medical referral program for government employees. Members of the National Government Employee Health Insurance Plan (NGEHIP), which is the government-subsidized health insurance, must now use accredited providers or hospitals in the Philippines and Hawaii (a private medical group and the Tripler Army Medical Center). Referral patients who choose not to go to these facilities and providers are responsible for paying all their medical bills up front. Reimbursement for such billings is then based on the same regulated fee

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 114 schedule being followed by all other off-island accredited facilities; the difference is the individual's responsibility. So, for example, if a person needs a procedure that costs $1,000 at Tripler Army Medical Center, but decides that he wants to have it done in San Diego, where the same procedure costs $4,000, he will have to cover his own airfare and pay the $3,000 difference. Health Care Resources Financial Underscoring its heavy dependence on U.S. aid, the FSM Department of Health estimates that if Compact funding ends as scheduled and no more U.S. aid is provided, funds for health services would decline by as much as 75 percent of the 1996 health budget (FSM, 1996). It is also estimated that FSM will receive little aid from other foreign countries; in 1997, it received $748,822 (or approximately five percent of its total health care budget) in non-U.S. foreign aid for health (Samo, 1997). FSM laws require that no person be denied health care because of an inability to pay. Although each jurisdiction has established some cost-sharing requirements, the amounts are very low and collection is not vigorously pursued. In Chuuk, for example, the average amount collected from the primary care delivery sites (dispensaries) is only $0.70 a month. The fees that are collected for health care services go to the state's general account. Government employees can voluntarily decide to participate in NGEHIP. Virtually no private health insurance market exists at present. Workforce (See descriptions of health care workforces in the assessments of the individual states given below.) Quality Assurance The Micronesian Medical Council provides for the nominal licensure of health professionals in the region, although no one is required to become licensed. Continuing education and training courses for physicians and medical officers are offered through the regionwide Pacific Basin Medical Association, as well as the newly organized medical associations in each FSM state. Technology, Supplies, and Equipment Computers are available in the hospitals of FSM, but they are not often used. The cost of access to the Internet used to be prohibitive, but in recent

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 115 months it has decreased considerably (in some places as little as $20 a month). Several hospitals are equipped with donated Picasso telephones that use a still- image, store-and-retrieve method of telemedicine. However, at $3/minute the cost of transmitting these still images has proven too costly for at least one jurisdiction (Kosrae) (WPHealthnet Infoline, 1997). It is unclear the extent to which the Picasso phones are currently being used. Other forms of telemedicine are virtually nonexistent, although there have been efforts recently to use the PEACESAT satellite for monthly conference calls for information sharing among health professionals throughout the region. Supply, equipment, and drug shortages are chronic. Sophisticated laboratory equipment is available in the hospitals, but it is often unusable because the necessary reagents and other supplies are unavailable. Some reasons for this include the inefficiency of the procurement process and personnel, unreliable air transportation, reprogramming of funds, and use of high-priced third-party vendors and emergency orders. The lack of maintenance of equipment is also an area causing grave concern. For example, on the committee's site visit committee members were told that the majority of X-ray machines (i.e., those that are still working) in FSM have not been properly calibrated in years. The quality of the lead lining in some hospitals is unknown. Yet radiology staff in some of the jurisdictions do not routinely wear badges indicating how much radiation they have been exposed to or turn their badges in for analysis. Future Health Care Issues The FSM Department of Health identifies the following issues as its priorities over the next 5 years (FSM, 1996): • Health care financing: develop a secure financial base for health services and a capacity for improved cost accounting. • Primary health care systems: move the focus from curative to preventive health services, which emphasize the health needs of women and children, limit population growth, and promote healthy lifestyles. • Epidemiological surveillance and data collection: improve the methods of and capability for measuring and assessing the population's health needs and conditions. • Quality assurance: develop minimum facility and workforce standards and regulations to ensure a basic level of competent and safe care. • Environmental, food, and drug safety: improve all of these to protect the nation's health. • Off-island tertiary care referrals and diagnostic services: develop means of controlling the spiraling costs associated with this type of care.

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 116 Chuuk Total Population 53,319 Number of Inhabited Islands and Atolls 40 Access to Major Health Facility (percentage of population requiring 62% more than 1 hour of travel) Total Health Budget $4,884,786 Per Capita Health Budget $92 SOURCE: PIHOA (1997). NOTES: Total population is the official estimate from the 1994 FSM National Census; health care budget is from Fiscal Year 1994. Infrastructure Like other FSM states, Chuuk has benefited from some of FSM's improvements to island infrastructure and privatization of its utilities. As the most populated and poorest state, however, Chuuk continues to suffer from poor sanitation, water shortages, and unreliable power. Drinking water, for example, is generally accessed through wells to an underground lens, and overdrilling in the past has damaged the water supply (FSM, 1991), and there are concerns about the future availability of underground water (Bank of Hawaii, 1995a). At the same time, on the site visit committee members were told that an estimated 40 percent of the municipal water supply in Weno is lost through water leaks. In addition, Chuuk's geographic location and low-lying atolls make it particularly

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 117 vulnerable to typhoons and severe weather conditions that can easily damage homes, power, and facilities. Lack of roadways and poor telecommunications make it difficult to expand a potentially lucrative tourist market (Bank of Hawaii, 1995a). Health Care Facilities The Chuuk State Hospital, a 125-bed facility built in 1969, is located in Weno. It is in serious disrepair. The wooden structure is also considered to be a fire risk and has a major termite infestation. Fire alarms do not work, and the water pressure throughout the hospital is extremely low. Broken equipment is scattered throughout the facility. Electricity is unreliable throughout the island, although the situation at the hospital has been aided since Queens Hospital in Hawaii donated a backup generator. Not all wards, including the pediatric ward, are hooked up to the backup generator, however; people must resort to using candles for light, increasing the risk of fire. Supply shortages are commonplace and chronic; during the site visit there were no supplies in the laboratory or X-ray departments. In the month before the committee's site visit a ventilator-dependent patient had died because oxygen supplies ran out. Renovation and expansion of the pediatric ward has started, but is on hold until the Chuukese government can find more funds to compete the work. Once the work is completed, U.S. Department of Interior has agreed to reimburse the expenses. In the meantime, the demolished ward continues to provide a hazardous pass-through to other hospital wards. Although there is no money and no master plan to do so, officials hope to build a new hospital rather than refurbish the current structure. Although the government lists 67 dispensaries (PIHOA, 1997), according to a recent report, only about half appear to be in operation (Medical Graduate Support Program, 1997). Even those that are reported to be in operation often have no supplies—even of the most basic medications like aspirin—because most supplies come from the Chuuk State Hospital, which itself is almost always out of supplies. Some health assistants resort to paying for supplies themselves to meet the needs of the community. According to the report, 21 dispensaries are run out of the health assistants' homes, a situation described as "the same as none" (Medical Graduate Support Program, 1997, p. 10). Health assistants are paid a salary whether they work or not and are also paid rent if they work out of their homes. Most of Chuuk's dispensaries have been built on private land and must be leased. This causes problems when the government does not pay its bill or when the title to the land is not clear. Remote outer islands have access to radios in government offices to contact the hospital in the event of an emergency. Residents on islands closer in can transport people to the hospital via boat.

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 118 Workforce5 Physicians Chuuk has five M.D.s (all expatriates from the Philippines and Burma) stationed at the hospital. They also have 19 medical officers (14 who trained at the Pacific Basin Medical Officers Training Program [PBMOTP] who also work in the hospital. One PBMOTP graduate is at Fiji doing postgraduate work in obstetrics. Dentists The dental workforce comprises five expatriate dentists, one indigenous dental officer nearing retirement, one dental therapist, three dental nurses, and 11 dental aides. Mid-Level Practitioners Eighty-four health assistants (including five medexes) staff the primary care delivery sites (dispensaries). Most have less than a high school education and have not received ongoing training and education. Supervision of the health assistants appears to be minimal. Nurses With 55 registered nurses and 99 licensed practical nurses, Chuukese officials believe there is a nursing shortage. The inability to recruit trained nurses and the loss of Chuukese nurses to other islands where the pay is better is a problem. Poor supervision of nurses and high absenteeism also contribute to the perceived shortage of nurses. 5 Workforce data are from the 1997 PIHOA Data Matrix (PIHOA, 1997).

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 119 Kosrae Total Population 7,317 Number of Inhabited Islands and Atolls 1 Access to Major Health Facility (percentage of population requiring 100% more than 1 hour of travel) Total Health Budget $1,104,444 Per Capita Health Budget $151 SOURCE: PIHOA (1997). NOTES: Total population is the official estimate from the 1994 FSM National Census; health budget is from Fiscal Year 1994. Infrastructure As the least populated and the only single-island state in FSM, Kosrae enjoys comparatively stronger infrastructure systems. Fresh water from perennial streams provides much of the drinking water (Hezel et al., 1997). Most households have access to electricity, and new roads that circumnavigate the island, improvements to ports, and expansion of the airport in the late 1980s

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 120 have helped Kosrae to attract some foreign trade and small-scale tourism (FSM, 1991). Health Care Facilities A 40-bed facility built in the mid-1970s is located in the main village of Tofol. It is in the process of being renovated. Two health centers in outer villages have recently started operations, and two other such health centers are planned. The health centers are designed to provide preventive services and basic medical care and are staffed by medical officers. The responsibility for managing the centers is planned to be turned over gradually from the state government to the villages. At this time, however, only very limited services are being provided at the health centers, and these are provided only on an infrequent basis. Workforce Almost all of the health care workforce (96 percent) in Kosrae is indigenous (Kosrae Department of Health Services, 1996).6 Recently, the work week for all state employees was reduced to 3 and one-half days. Physicians The only M.D. on Kosrae is a surgeon from the Philippines. One native Kosrean with an M.B.B.S. is also practicing. Seven graduates of PBMOTP are now working in Kosrae, and two of them have received postgraduate education at the Fiji School of Medicine (one in children's health and one in anesthesiology). Dentists Only one dentist serves the needs of the island. He is aided by one dental therapist, three dental nurses, and one dental aide. Mid-Level Practitioners Currently, the only mid-level health care workers are three health assistants. 6 Workforce data are from the 1997 PIHOA Data Matrix (PIHOA, 1997).

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 121 Nurses All the nurses are Kosrean and are graduates of the College of the Marshall Islands School of Nursing. There are 34 graduate nurses, 3 licensed practical nurses, and 1 registered nurse.

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 122 Pohnpei Total Population 33,692 Number of Inhabited Islands and Atolls 6 Access to Major Health Facility (percentage of population requiring 77% more than 1 hour of travel) Total Health Budget $4,808,691 Per Capita Health Budget $143 SOURCE: PIHOA (1997). NOTES: Total population is the official estimate from the 1994 FSM National Census; health budget is for Fiscal Year 1994. Infrastructure Pohnpei, as with Chuuk, contends with public health concerns like infectious, diarrheal, and skin diseases that occur in crowded conditions, lack of potable water, and poor sanitation. Outside the main center, most of Pohnpei's households still do not have access to public water or sewage systems. One recent study that sampled households in six of Pohnpei Island's villages reported that a majority of homes did not have access to waste disposal systems; most contained open-air pit latrines. Sixty-four percent of homes gathered their water

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 123 from rivers, others through various catchment systems (Yaingeluo, 1997). Sewage disposal systems are another problem: in Kolonia, Pohnpei's main landfill is leaking into an adjacent lagoon near the Kolonia airport (Hezel et al., 1997). One notable improvement in Pohnpei has been its telecommunications system, noted as one of the best in the Pacific region (DOI, 1996b). Health Care Facilities This 91-bed facility was built in the mid-1980s and, although a group of volunteers has painted it recently, it suffers greatly from a lack of routine facility maintenance. Reorganized in 1996, the Division of Primary Health Care operates a network of six primary care delivery sites (dispensaries) on Pohnpei and five on outer islands. One of these, a Section 330 community health center, operates at two locations on Pohnpei. All these sites receive regular visits from the medical officers and are staffed by health assistants and nurses. Although relatively new and extremely susceptible to budget cuts, the move towards greater decentralization reverses the trend in the 1980s to do away with dispensaries and move medical staff to the main island and hospital. Workforce7 Physicians Six expatriate M.D.s, one indigenous M.D., and two indigenous M.B.B.S.s are currently in practice. Fourteen medical officers are also practicing, thirteen of whom are PBMOTP graduates. One PBMOTP medical officer is completing postgraduate training in anesthesiology at the Fiji School of Medicine. One private practitioner works in Pohnpei, as well as one ophthamologist. Dentists Four expatriate dentists (from Burma and the Philippines) and two indigenous dental officers work on Pohnpei. They are assisted by ten dental nurses and nine dental aides. Mid-Level Practitioners Four medexes and 15 health assistants round out the health care workforce. 7 Workforce data are from the 1997 PIHOA Data Matrix (PIHOA, 1997).

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 124 Nurses There are 63 registered nurses and 49 licensed practical nurses, almost all of whom are indigenous. Pre-nursing coursework is offered through the College of Micronesia.

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 125 Yap Total Population 11,178 Number of Inhabited Islands and Atolls 15 Access to Major Health Facility (percentage of population requiring 65% more than 1 hour of travel) Total Health Budget $1,987,445 Per Capita Health Budget $178 SOURCE: PIHOA (1997). NOTES: Total population is the official estimate from the 1994 FSM National Census; health budget is for Fiscal Year 1994. Infrastructure Most people within the capital center of Colonia have access to a public water system. However, while on the site visit committee members were encouraged not to drink the tap water. A recent report noted that the Yap landfill, which sits atop a hill, lies in close proximity to the only water reservoir (Hezel et al., 1997). The telecommunications infrastructure has improved on the main island; some government workers were even connected to the Internet and were using it to track an approaching typhoon while the committee visited the island. It was also evident, however, that access to telephones was not common, and long- distance connections often failed or were of poor quality. Communication with outer islands is done through solar-powered shortwave radio. A PEACESAT station is located at the Department of Education (PIHOA, 1997).

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 126 Health Care Facilities Yap State Hospital is a 43-bed hospital facility located in Colonia. The Primary Care Program in the Public Health Division oversees a network of 30 primary care delivery sites (dispensaries), considered at one time by many observers to be a model of primary health care delivery. Community involvement with some of the dispensaries is quite high—from villagers assisting with building and maintaining the facilities to a community board providing guidance on the day-to-day operations. All dispensaries had been equipped with solar- powered shortwave radios so that they can communicate with a primary care team located at the hospital. The primary care team also makes occasional field trips to the outer islands. However, a recent report states that only 3 or 4 of an original 13 primary care sites are still in operation in Yap proper (in Makiy, Thol, Rumung, and possibly Gilman) (Medical Graduate Support Program, 1997). The reasons for this decline include improved access to the hospital, availability of other dispensaries nearby, decrease in funding from international sources, lack of community support for them as a priority, and a lack of trained personnel and medical support. The other 17 sites, located on the outer islands, appear to still be in operation—although the number of field trips with the primary care team has decreased. (J. Gilmatam, personal communication, September 16, 1997). Workforce8 Physicians Yap's physician workforce consists of 17 physicians: 1 expatriate M.D. (a National Health Corps Service doctor, board-certified in family practice), 4 indigenous M.B.B.S.s and 1 expatriate M.B.B.S., and 11 medical officers, 7 of whom are PBMOTP graduates. Dentists Yap has only one dental officer and he is about to retire; he is aided by 10 dental nurses. Nurses Although only one registered nurse is currently practicing in Yap, there are 12 graduate nurses, 12 licensed practical nurses, and 3 nurses aides. The University of Guam hopes to extend its distance education courses for nurses (currently being offered in Palau) to Yap within the next year. 8 Workforce data are from the 1997 PIHOA Data Matrix (PIHOP. 1997).

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 127 Health Assistants Yap has approximately 30 health assistants, most of whom staff the outer- island primary health centers (dispensaries). Some of these health assistants may have been trained as medexes (Medical Graduate Support Program, 1997).

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 128 GUAM (GUAHAN) Total Population 155,225 Number of Inhabited Islands and Atolls 1 Access to Major Health Facility (percentage of population requiring 90% more than 1 hour of travel) Total Health Budget $81,000,000 Per Capita Health Budget $510 SOURCE: PIHOA (1997). NOTES: Total population is the official estimate from the 1990 U.S. census; health budget is for Fiscal Year 1998. Overview The U.S. Territory of Guam is the largest and southernmost of the Mariana Islands. It straddles the western Pacific as at once a leader and an island caught in transition. By comparison with the other U.S.-Associated Pacific Basin jurisdictions, Guam ranks above the other island states in overall wealth and health. However, the island still lags behind U.S. mainland states, Alaska, and Hawaii in many of these indicators. This duality presents one of the greatest challenges to Guam as it strives to improve the health and well-being of its people.

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 129 Guam's relationship with the United States dates back nearly 100 years. Along with the islands of Puerto Rico, Cuba, and the Philippines, Guam was acquired as a U.S. possession following the Spanish-American War in 1898. Until 1949, and with the exception of 30 months of Japanese occupation during World War II, Guam remained under U.S. military administration. In 1949 administrative control moved to the U.S. Department of the Interior. In 1950 the United States and Guam passed the Organic Act that established a local government on Guam. However, the U.S. military has maintained a strong presence on the island, retaining about one-third of Guam's land for its use. Government Much like its Pacific neighbors, Guam's political and social structures are rooted in years of U.S. administration. Guam is an organized, unincorporated territory of the United States. The executive branch consists of a governor and a lieutenant governor. The legislative branch is unicameral and consists of 21 senators, each popularly elected. Guam also has a judiciary branch. Two local courts (a Superior Court and a Supreme Court) and one U.S. District Court serve the island. Local judges are appointed by the governor and are confirmed by voters every 6 years (DOI, 1996b). Economy Compared with the other U.S.-Associated Pacific Basin jurisdictions, Guam enjoys a healthy economy. The gross island product (GIP) for 1994 was $3.011 billion, a per capita GIP of $20,640, the highest of the U.S.-Associated Pacific Basin jurisdictions (Bank of Hawaii, 1995b). Primary sources of revenue are U.S. federal expenditures and tourism. In total, U.S. federal expenditures (military, grant assistance, and other payments) account for about one-third of Guam's revenue. Employment Guam's largest single employer is the government of Guam (GovGuam). On average GovGuam pays almost twice as much as the private sector (Guam Bureau of Planning, 1996). GovGuam employed 20.2 percent of the workforce (13,430 individuals); the U.S. federal government employed 10.4 percent of the workforce (6,390 individuals). The private sector—primarily the services and tourism industry—employed most of the remaining 46,100, or 69.4 percent (Bank of Hawaii, 1995b).

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 130 Federal Expenditures Federal Grant Assistance Total federal grant assistance to Guam in Fiscal Year 1996 was $134 million, most of which came from the U.S. Department of the Interior (44.6 million) and the Department of Health and Human Services ($19.8 million) (Bureau of the Census, 1997). GovGuam also directly receives federal income taxes paid by residents; this money goes directly into the local budget. Military Spending Total annual spending for the military in Guam in 1994 was $750 million. The U.S. military on Guam operates Navy and Air Force bases and employs about 7,000 civilians (Bank of Hawaii, 1995b). Average salaries for these civilians are double those in the civilian economy, making the jobs much more attractive. Some downsizing of the military has begun, and the military projects the loss of 1,100 to 1,200 jobs between 1996 and 2001. Even so, military spending is not expected to drop dramatically between 1996 and 2001 (Bank of Hawaii, 1995b). Tourism Guam is a desirable destination for travelers from Japan and East Asia. In the mid-1980s it experienced a tremendous growth in visitors to the island, from 368,620 visitors in 1984 to 780,404 visitors in 1990. Well-known for its good infrastructure and services, Guam has responded well to increasing numbers of visitors by upgrading its facilities, including a new airport terminal and new hotels and plans to upgrade some of its basic infrastructure, like roads, power, and water services. Tourism will likely continue to grow and emerge as the primary source of income (Bank of Hawaii, 1995b). Population The first settlers of Guam and the Mariana Islands, Chamorros, are believed to have originated in Southeast Asia. Today's Chamorros are a mix of Chamorro and Filipino. While the numbers of Chamorros in Guam have increased, they represent a lesser proportion of the total population than in the past. Prior to WWII, Chamorros represented about 90 percent of the civilian population, but today they represent less than half (43 percent) of the civilian population (GHPDA, 1996; PIHOA, 1997). The remainder are Filipino (23 percent), Caucasian (14 percent), other Asian (14 percent), and other Micronesian (6 percent) (GHPDA, 1996; PIHOA, 1997). About 145,000 (80 percent) are local

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 131 residents and about 20,000 (20 percent) are military personnel, dependents, and retirees (of which about 7,000 are active-duty personnel) (Bank of Hawaii, 1995b). Guam's annual population growth rate of 2.6 percent is the lowest growth rate in the region (PIHOA, 1997). Nonetheless, if this growth rate continues, Guam's population will almost double by 2050 (U.S. Bureau of the Census, International Database, 1997b). In the last decade, Guam's tourism boom has attracted immigrants from Southeast Asia (primarily the Philippines) and the Pacific in search of job opportunities (Bank of Hawaii, 1995b; East-West Center, 1996). Some of the migration has been from the freely associated states, particularly after the Compacts of Free Association granted citizens from the freely associated states unlimited access to the United States and its territories. The number of immigrants from the freely associated states has increased steadily since the implementation of the Compacts, and in 1994 there were about 6,630 FSM-born, and a few hundred RMI-and Palau-born, residents (Levin, 1996).9 Infrastructure In general, Guam's has the most stable infrastructure of the U.S.-Associated Pacific Basin jurisdictions. GovGuam owns and operates all public utilities: telephone, power, water, and sewer systems (Bank of Hawaii, 1995b). Some concerns remain, however. One of the biggest safety concerns is the frequent failures of the power system, operated by the Guam Power Authority (GPA). During site visits, several people reported that the agency has been plagued with mismanagement and that in the past brownouts occurred on a frequent basis. Some of the problems have been explained by the rapid increase in demand, especially during the spurt of tourism in the late 1980s, and increases in residential power demands. Brown tree snakes, which frequently climb electrical lines, have also been held responsible for outages. GPA has hired an off-island management firm to overhaul the electrical system, and reportedly outages are less frequent. Although the water is considered potable, the Power and Utilities Authority of Guam (PUAG) has also had difficulty with the water system; about 30 to 40 percent of the water goes unaccounted for each day. Persistent leakage and unmetered use are primarily responsible (DOI, 1996b). In addition, it was reported during the site visits that many of Guam's public water wells have greatly reduced fluoride levels, raising a concern for dental health. It was further 9 Data were compiled from several sources by the Department of the Interior, Office of Insular Affairs for its report to Congress, The Impact of the Compacts of Free Association on the United States Territories and Commonwealths and on the State of Hawaii, September 1996. Please note data are estimates only; they were compiled from different surveys and are not current. Therefore, the numbers may reflect a phenomenon that may or may not still be true today.

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 132 reported that water on Guam has high levels of lead and other minerals, such as manganese, which is another public health concern. Health Care Delivery System Organization Administration Government health care services on Guam are organized into four independent agencies of GovGuam: Guam Memorial Hospital Authority (GMHA), Department of Public Health and Social Services (DPHSS), Department of Mental Health and Substance Abuse (DMHSA), and the Department of Vocational and Rehabilitative Services. In addition, Guam has several private health clinics. Health Care Facilities Hospitals Guam has two hospitals. The Guam Memorial Hospital (GMH) serves civilians, and the Naval Hospital serves active-duty military personnel, their dependents, and retirees. Guam's two hospitals, two federally licensed health maintenance organizations (GMHP and FHP, see below), and DPH&SS all must adhere to federal quality guidelines to receive payment (GHPDA, 1996). Guam Memorial Hospital Authority GMHA operates GMH. With final expansion and construction completed in 1991, the hospital has 192 beds, comprising 159 acute-care beds and 33 long-term-care beds in the skilled nursing facility (GHPDA, 1996). All hospital services are provided at one campus. GMH is run by a board of directors and an administrator, all of whom are appointed by the governor and confirmed by the legislature. The following are some of the issues of concern to GMHA: Financial In the past GMH has been plagued with an inadequate billing system and a poor ability to collect fees. It was reported during the committee's site visits that although the hospital implemented a new computerized billing system, many staff have not been thoroughly trained, the error rate is high, and there is only one computer system support staff. In addition, the billing format does not conform to Medicaid specifications, which results in delayed payments. Other reasons cited for low rates of fee collection are the number of self-payers who do not pay their bills. In 1994 the hospital collected 72.2 percent of the money that it was owed. The rate is only slightly increased from that in 1990 (GHPDA, 1996).

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 133 Privatization The governor is pursuing a plan to privatize GMH, transferring partial ownership to community members willing to invest capital in the hospital. The governing board would consist of government representatives and investors. The increase in revenue would be used to upgrade the facility. Accreditation In 1990 the Health Care Financing Administration (HCFA) cited GMH for numerous deficiencies (113 altogether), including the use of unlicensed personnel, lack of accountability for quality of care and the safety of patients and staff, building maintenance, shortages of staff, and the lack of complete records. GMH has since corrected many of the problems, and in 1995 it received only 22 citations (HCFA, 1997). Nevertheless, GMH is still pursuing, although it has not re-attained the Joint Commission on the Accreditation of Healthcare Organizations accreditation that it lost in 1983 (GHPDA, 1996). U.S. Naval Medical Regional Center (USNMRC) The military health system on Guam consists of the Naval Hospital and several smaller dispensaries for general acute care. USNMRC provides outpatient services and runs one small dental clinic. The center is self-contained and is staffed and equipped to serve primarily active duty military, their dependents, and retirees. Limited coordination between the Naval Hospital and GMH exists, however. The Naval Hospital accepts emergency cases to stabilize patients and serves as a backup to GMH during natural disasters and other island emergencies, such as the recent crash of a South Korean passenger jet. Provisions in the Compacts direct the Defense Secretary to make all U.S. Department of Defense medical facilities available to citizens of the freely associated states, who are ''properly referred to such facilities by government authorities responsible for the provision of medical services" (P.L. 99-239), although this does not appear to occur very often. Public Clinics Department of Public Health and Social Services DPHSS operates four regional health centers. One is funded through a federal Community Health Center Grant; the others are funded by DPHSS local and other grant monies (GHPDA, 1996). The following programs and services are available at the regional health centers: • maternal and child health, • family planning, • nutrition and health program (Women, Infants, and Children, or WIC), • limited medical support services, • services for children with special health care needs, • communicable disease control, and • dental services.

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 134 Department of Mental Health and Substance Abuse DMHSA has a 48-bed inpatient facility with both a medical services division and a clinical services division (16 beds for residential treatment for drug and alcohol abuse, 16 beds for adults, and 16 beds for children). There is some concern that with increases in cases of substance abuse, especially ones that involve drug combinations (e.g., alcohol and methamphetamines), and violence, the facility may not be big enough to handle the demand for services and will need staff better trained to cope with the situation (GHPDA, 1996). Department of Education Each of Guam's 24 elementary, 6 middle, and 5 public high schools has a nurse's station staffed by one full-time registered nurse (some also have a licensed practical nurse) to provide health services to students and to refer children to maternal and child health services when needed. Private Clinics Guam has a total of 22 private health clinics (PIHOA, 1997), including multispecialty Seventh Day Adventist and FHP clinics (nonprofit), The Doctors' Clinic (multispecialty and for profit), and various other for-profit private practice clinics and auxiliary services. There are currently three home care agencies on- island: Guam Nursing Services (HCFA-approved); TropiCare (serving primarily the FHP/CHOICE PLUS health plan enrollees); and Micronesian Home Health Care (serving mainly GMHP health plan clients). There is also one non-profit, Catholic long-term care facility, Saint Dominic's Senior Care Home. Health-Related Community Organizations Guam has a rich variety of health-related community organizations including the American Red Cross, American Cancer Society, Lytico-Bodig Association, Hemophilia Association, and Guam Diabetes Association. Hospice Guam is another non-profit community organization that supports terminally ill persons and their families. Further, Guam is in the process of organizing a chapter of the Arthritis Foundation. Guam, like its neighbors, sends patients off-island for diagnoses and for treatments that are not available locally. Unlike the other islands, however, the decision to refer a patient for off-island tertiary care is left mostly to the doctor in charge of the patient's care and does not rest with a political entity. Some of the private health plans have agreements with hospitals in Hawaii and southern California for referrals. Lack of equipment and specialty services for diagnosis and treatment are the most likely reasons that people are referred off-island. Typical services for which patients are referred include cardiac procedures (e.g., bypass surgeries),

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 135 neonatal treatment, and radiation treatment for cancer (although there is a new Cancer Institute of Guam, complete with a radiation center, that should help to lessen the need to seek chemotherapy treatments off-island). Because malpractice insurance for providers does not exist on Guam, some speculate that doctors are more likely to send people off-island for diagnoses that they would otherwise make if they were insured against lawsuits (GHPDA, 1996). Because a number of off-island tertiary care referrals are self-initiated or are paid for through private health insurance, costs attributed to off-island referrals are difficult to estimate. GovGuam, through the Medically Indigent Program (MIP) and Medicaid spent about $4.9 million on off-island tertiary care referrals for 163 people in 1996 (T. Fejeran, personal communication, October 20, 1997). Unfortunately, no uniform system of data collection or mandated reporting exists among the private providers, so accurate data in the numbers of people referred and the costs incurred are not available (GHPDA, 1996). Health Care Resources Financial Similar to their neighbors, Guamanians believe in and practice the right of health care for all, regardless of the ability to pay. Unlike the other Pacific jurisdictions, however, the private insurance market is well established, with growing numbers of group health entities and HMOs, similar to the situation in small markets in the United States. Although these private insurers cover much of Guam's health care costs, including off-island referrals, the health care costs for many who cannot afford private insurance (about 10 to 15 percent of the population) are the government's obligations (see below). Compact Impact Guam has become increasingly concerned over the impact that the Compacts have had on migration citizens of the freely associated states to Guam (called "Compact impact"). Estimates indicate that between 1988 and 1992 (2 years after the Compacts became effective), the numbers of residents born in the FSM and residing in Guam increased almost three-fold: from 1,700 in 1988 to 4,954 in 1992 (Levin, 1996).10 The Guam Department of Public Health and 10 Data were compiled from several sources by the U.S. Department of the Interior, Office of Insular Affairs for its report to Congress, The Impact of the Compacts of Free Association on the United States Territories and Commonwealths and on the State of Hawaii (DOI, 1996). Note that data are estimates only; they were compiled from different surveys and are not current. Therefore, the numbers may reflect a phenomenon that may or may not still be true today.

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 136 Social Services estimates it spent $3.7 million between 1989 and 1992 for health services provided to citizens of the freely associated states (Government of Guam, 1993). In 1995, Guam received $2.5 million for impact costs, plus technical assistance and other grants aimed at measuring those costs (DOI, 1996b). Many citizens of the freely associated states, however, find jobs on Guam, have health insurance, or can pay for the costs of their own care, and pay taxes which offset local government expenditures.11 Public Health Insurance Public health insurance on Guam includes federal Medicare and Medicaid programs, but it also includes an entirely locally funded safety net program that covers the under- and uninsured (MIP). The Comprehensive Health and Medical Plan for the U.S. Armed Forces (CHAMPUS) also provides insurance for active- duty military personnel, their dependents, and retirees. Medicare enrolls about 2,000 seniors and about 8,000 people receive Medicaid (GHPDA, 1996). Guam receives federal funding for its Medicaid program at a 50–50 matching rate, but with a cap on federal assistance of $4.06 million (Guam Legislature, 1997). With growing numbers of enrollees and increasing costs, GovGuam has had to pay as much as 85 percent of its Medicaid costs (GHPDA, 1996). The Medicaid program is administered through DPHSS. For the approximately 16,000 to 21,000 (or about 10 to 15 percent) of Guam's population who are uninsured and who are not eligible for Medicare or Medicaid, GovGuam provides coverage through MIP (Guam Task Force, 1995). Administered by DPHSS and funded entirely through local money, MIP covers the costs for treatment and services for people whose incomes do not meet federal criteria, but who cannot afford health insurance premiums and people who have used up all of their available private health insurance benefits. MIP also acts as a supplement for the underinsured and Medicare recipients. Current concerns are that MIP cannot continue to function unless it is given more resources or reduces its expenditures. The average cost per recipient increased from $1,492 in 1991 to $3,663 in 1995, a 26 percent average increase per year (Guam Legislature, 1997). Recently, legislation was introduced in the Guam Legislature to contract HMOs to provide services both for MIP participants and Medicaid enrollees. This move would presumably not only cut expenses, but would also allow Guam to apply for a Medicaid Section 1115 waiver, potentially allowing it to garner more federal money to supplement the program (Guam Legislature, 1997). 11 For a more complete discussion of "Compact impact" and references to relevant literature, the reader is referred to Levin, 1996, "Micronesian Migrants to Guam and the Commonwealth of the Northern Mariana Islands: A Study of the Impact of the Compact of Free Association."

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 137 Private Health Insurance Most of the people in Guam receive their health insurance through their employers. Eighty-two percent of Guam's population is covered by some form of health insurance: for about three-quarters of the people employers provide coverage through 1 of the 22 private health plans; the remainder are covered through one of the public programs (PIHOA, 1997). Another small percentage of the population can and does pay out of pocket for services. GMHP, which was once owned by the government, is a private HMO and, together with FHP/ CHOICE PLUS HMO, covers about one-half of the privately insured population (GHPDA, 1996). Other plans include Staywell, HML, and Multicover. In addition, some of Guam's private health insurers have expanded services to the Commonwealth of the Northern Mariana Islands (CNMI), broadening the insurance market. Workforce12 Guam, like most islands or rural locations, suffers from isolation and the difficulties with the recruitment and training of a local workforce this incurs. To deal with such a shortage of trained personnel, Guam has flown in physician specialists for temporary work and has employed workers from other countries (many of whom are from the Philippines and work at GMH). Guam has also used international recruiting methods, such as advertising through the Internet and U.S. professional journals. Physicians Guam has a total of 311 civilian M.D.s, or 1 physician for every 500 people (PIHOA, 1997). Many of these physicians are contract workers, primarily from the Philippines, as is the case for CNMI. Nurses Currently, Guam has 648 registered nurses and 164 licensed practical nurses on-island, according to licensing records (PIHOA, 1997). In 1995, there were no nurse's assistants, 166 at GMH, and the remainder with the DPHSS (GHPDA, 1996). Although Guam may have a reasonable supply of registered nurses and licensed practical nurses, serious problems with recruitment and retention have led to shortages of nurses at GMH and public health clinics. At 12 Workforce data are from the 1997 PIHOA Data Matrix (PIHOA, 1997).

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 138 GMH, long work hours, shortages of other staff, and little continuing education and support have been cited as reasons that nurses are leaving. Because GMH is unable to recruit staff on-island, it has hired many non- U.S.-trained medical staff (many are Filipino) and has traditionally allowed them to work as mid-level practitioners until they passed the U.S. board examination. In 1990 HCFA cited GMH for using unlicensed personnel (HCFA, 1997). The committee learned at the site visits that after the citation many staff were let go. The committee was also told that the hospital fired 37 Filipino M.D.s and that as many as 90 percent of the Filipino-trained registered nurses were reclassified as nurse's assistants. Other Health Care Personnel A variety of allied health care personnel provide support and auxiliary health care services on Guam. Seventy dentists, 21 dental hygienists, and 221 dental aides serve the island, and most of these work in private practices. DPHSS has 26 dentists (one is a National Health Service Corps dentist) who work in the three regional health centers. Other personnel include 57 pharmacists and 13 laboratory technicians. Guam is lacking trained technicians such as radiologists, laboratory technicians, and assistants. However, Guam Community College is in the process of resurrecting its allied health program to develop a supply of technicians and other auxiliary personnel. Traditional Health Practitioners Traditional forms of medicine include the use of massage, herbs, coconut oil, and prayer and are administered by suruhanus, traditional Chamorro healers. Although their practices are well known in communities in Guam, they are not integrated into the health care system, and sometimes they are referred to as "witch doctors."13 However, many people turn to traditional medicines when Western medicine offers no hope of cure or relief from pain. People consult suruhanus for conditions such as infertility and stomach ailments. Suruhanas work with the medical establishment insofar as they ask patients to see a doctor first and to inform them of any medications they are taking. In addition, during the site visits the committee was told that patients at GMH are permitted to call in suruhanus. 13 Witch doctors, or kakahna, were believed to have supernatural powers to create and cure illnesses, but they are different from suruhanus, whose practice is limited to using various herbs and massage to treat illnesses.

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 139 Workforce Quality Assurance There are two licensing boards on Guam for physicians and nurses. The Guam Medical Association and Guam Nurses Association are both very active. HCFA accredits the hospital, skilled nursing facility, and home health agency. Technology, Supplies, and Equipment On Guam, there is some debate about whether more money should be used to purchase or upgrade needed equipment so that some diagnosis and treatment services can be provided on-island. For example, Guam had no magnetic resonance imager (MRI) on-island at the time of the site visit (although it reportedly does have one now), and no radiation treatment is provided. In addition, with the island's high numbers of dialysis patients and only one dialysis unit at GMH, and only one smaller private dialysis treatment center, there is a demand for increased numbers of dialysis machines. In July 1995 GMH's dialysis unit was providing treatments to 102 patients (GHPDA, 1996). Some have argued that efforts should focus on providing funding for kidney transplants, which would eliminate the need for a lifetime of dialysis and would thus save much more money in the long run. On the computer technology front, Internet service providers have begun to enter Guam's market. All public libraries, schools, and many homes now have access to the Internet. Since Guam was connected to the U.S. telephone network in July 1997, the cost of long-distance service has been dramatically reduced, making Internet access much more feasible. During the site visit, however, few trained computer services personnel were available to maintain the equipment. The committee visited one public library with three computers, all with Internet access, but only one machine was working, and therefore, access was limited to 1 hour per person. GMH has one computer located in a small library for use by hospital staff. Although hospital staff have expressed a desire to have Internet services, at the time of the committee's visit such services were not available. Future Health Care Issues With a private health care system already well established, Guam's attention and hopes for its future rest with public–private partnerships. The current governor has initiated the Vision 2000 Campaign for Guam. The aim of this campaign is to establish priorities in all areas of the island's government, social services, infrastructure, and environment. In health care, the governor has particularly emphasized promoting Guam as a regional health center for the western Pacific (Government of Guam, 1997). Toward that end, some of the following are top health service priorities:

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 140 • privatize GMH; • focus efforts on disease prevention, especially diabetes and cardiovascular diseases; • increase the numbers of physicians, and increase the amount of available specialty care services, equipment, and technology so that more can be provided on-island and so that Guam can be more widely used for regional referrals; and • make health care accessible and affordable by controlling costs (e.g., contracting out Medicaid and MIP to private managed care) and enhancing public health programs and services that can reduce the need for acute care.

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 141 REPUBLIC OF THE MARSHALL ISLANDS Total Population 59,246 Number of Inhabited Islands and Atolls 23 Access to Major Health Facility (percentage of population requiring 53% more than 1 hour of travel) Total Health Budget $7,600,000 Per Capita Health Budget $128 SOURCE: PIHOA (1997). NOTES: Total population is the official estimate from the RMI 1996 census. The total health budget excludes money for people exposed to radiation. Overview The people of the Republic of the Marshall Islands (RMI) live among 23 islands and coral atolls, tips of ocean volcanoes that have long since receded beneath the water. Although it is now an independent and sovereign republic, RMI remains closely involved with the United States. This involvement began after World War II when the United States took control over the islands from the Japanese. Beginning in 1946 and continuing until 1958, the U.S. Navy conducted nuclear tests in the region. As a result, hundreds of Marshallese people were relocated from their ancestral homes, and 253 Marshallese are known to have been directly exposed to radioactive fallout. Concerns about the

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 142 effects of the nuclear testing are ever present in RMI, even today, nearly 40 years after the last nuclear test. Government RMI has a unicameral government, a combination of U.S. democratic and British parliamentary systems. The Nitijela, or parliament, is the legislative body and comprises many committees. The Council of Iroij (chiefs) may provide opinions to the Nitijela on any matters concerning the nation, and they may also ask for reconsideration of any proposed bill. Any Marshallese citizen older than 18 years of age may run for a seat on the Nitijela, whereas seats on the Council of Iroij are passed down through families. There are two courts: a Supreme Court, with judges appointed by the RMI President's cabinet, and a High Court. Marshallese are a matrilineal society, with very organized land holding structures, and so there is also a Traditional Rights Court that deals with legal questions surrounding land and traditional practice (DOI, 1996b). Economy The Marshallese economy is almost entirely dependent on foreign aid, the vast majority of which is from the United States, either in the form of money from the Compact of Free Association or in the form of rent paid for the use of a missile testing facility on the atoll of Kwajalein known as USAKA (United States Army-Kwajalein Atoll). A very small amount of tourism and trading in copra (dried coconut meat) provide some local revenue. As with other jurisdictions, the local government employs the greatest number of people, about 34 percent of the labor force (Department of State, 1994). USAKA is another important employer, providing jobs to roughly 1,500 Ebeye residents (Bank of Hawaii, 1996). Aside from local government and U.S. military civilian jobs, there is little private industry. Overall, there are a very limited number of jobs to absorb the growing numbers of people entering the labor force each year. Population RMI had one of the world's highest population growth rates: 4.1 percent annually between 1980 and 1988 (Bank of Hawaii, 1996). Although it decreased somewhat in 1997 to 3.9 percent, the population is still expected to double in the next 20 years (U.S. Bureau of the Census, 1997a). The total fertility rate for a Marshallese woman is 7.2 children (World Bank, 1994). Population growth is one of the primary social concerns in the Marshall Islands and an issue that has been given top priority in government planning (Republic of the Marshall Islands, 1990).

ASSESSMENTS OF INDIVIDUAL JURISDICTIONS' HEALTH CARE SERVICES 143 In addition to high growth rates, the RMI population is also a young one and is the youngest of the six jurisdictions of the U.S.-Associated Pacific Basin. Half of the RMI population is under the age of 15 (PIHOA, 1997). About 20 percent of the births in 1994 were to teens under the age of 15 (HRSA, 1996). Population density is concentrated in two atolls: Majuro and Kwajalein. About half of the total population lives on Majuro Atoll; most of these people live in the 0.51 square mile of the Djarrit-Uliga-Dalap (D.U.D.) area, which has a density of 28,724 persons per square mile. Even more densely populated is Kwajalein's Ebeye Island: with a population of 8,324 persons in 1988 and a land area of only 0.14 square miles, it had a density of 59,457 persons per square mile—one of the highest densities in the world (Republic of the Marshall Islands, 1990). With such extreme population densities in its urban centers, the ensuing environmental and health problems are of great and urgent concern. Infrastructure One of the most significant public health risks to RMI is the lack of potable water and a very poor sewage system. Rapid population growth, notably in Majuro and Ebeye, poses serious threats to public health. In 1995, less than a quarter of the households in RMI were connected to a public water system, and according to the World Bank, between 1983 and 198514 only about 31 percent of the population had access to safe drinking water (World Bank, 1994). At the time of the committee's site visit, water had been cut off in Ebeye for almost a week. Communications within and among the atolls pose challenges. Most people outside Majuro and Ebeye do not have telephones or electricity. Although more people are obtaining Internet access, this is primarily limited to the College of the Marshall Islands (CMI) through PEACESAT, and a few others who have obtained access through private providers. Only a little more than half (54 percent) of the households had electricity in 1995 (DOI, 1996b), and power reliability is a problem. For example, during the site visit, electricity on Ebeye was available on a rotating basis with some areas receiving service during the evening and others receiving service during the day. Health Care Delivery System Organization Administration The health care system is administered and subsidized by the Marshallese government through the Ministry of Health and Environment (MOH), a cabinet- level 14 Although there may have been some improvement since this time, these estimates remain fairly close to what exists today.

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.

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.

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).

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

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.

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

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

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

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.

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).

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.

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The U.S.-Associated Pacific Basin consists of six island jurisdictions: American Samoa, the Commonwealth of the Northern Mariana Islands, Guam, the Federated States of Micronesia, Republic of the Marshall Islands, and the Republic of Palau. This book examines one aspect of the ties and U.S. involvement with this part of the world—its role in the region's health care delivery system. Although the health status of the islanders and the challenges faced by the health care systems naturally vary within and among the jurisdictions, in general, almost all health indicators for the islanders are worse than those of mainland Americans. The health systems in the area must deal with conditions normally seen in developing countries (e.g., malnutrition, tuberculosis, dengue fever, and cholera) and in developed countries alike (e.g., diabetes, heart disease, and cancer). In examining the strengths and weaknesses of the area's systems, the volume provides a regional health overview and assessments of health care in individual jurisdictions, evaluates the Pacific Basin Medical Officers Training Program, and lays out a strategic plan for future health services in the U.S.-Associated Pacific Basin.

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