About

The total population of all six jurisdictions is approximately 500,000. This population is spread across 107 inhabited islands covering an expanse of ocean larger than the continental United States. If one were to superimpose the continental US over these Pacific Island jurisdictions, Hawai‘i would be located where Maine is, American Samoa would lie further south than Florida, and the Republic of Palau, the westernmost jurisdiction, would lie off the coast of southern California.

The Pacific Islands Primary Care Association serves community health centers spread over the largest geographic region of all the primary care associations. According to the Department of the Interior (based on the US federal standard), more than 50% of the population of American Samoa, Palau and FSM live below the federal poverty level.

About 25% of Guam’s people were living below the poverty level, and 33% in the CNMI. If one includes those who live partly on subsistence, which is not considered in poverty determinations, the levels are much higher – about 63% of the people in Palau were below poverty, 68% in American Samoa, and more than 91% in the Federated States of Micronesia.

Health care financing in the six jurisdictions differs significantly from the US. Citizens of the Marshall Islands, Palau and FSM are unable to participate in the US Medicaid or Medicare programs and, with some very minor exceptions, do not have access to other forms of health insurance. American Samoa, Guam, and CNMI do receive US Medicaid funds, but as a block grant that primarily underwrites the tertiary care system. Health insurance is somewhat more common in these three jurisdictions but participation is negligible: Most people have access to existing (and limited) healthcare systems by virtue of citizenship.

Almost all health indicators for the Pacific Islanders, and particularly in the freely-associated jurisdictions, are worse than those in the United States.

• Life expectancy in the jurisdictions is 69.1 years compared with 76.0 years in the U.S.
• Infant mortality (deaths per 1,000 births) is very high in the freely-associated jurisdictions, ranging from 37.0 in the Republic of the Marshall Islands (RMI) to 16.7 in Palau compared with 6.8 in the U.S.
• Serious health problems include the noncommunicable diseases such as diabetes, cancer, and heart disease, but the Pacific Islands are also challenged by infectious diseases including tuberculosis, Hansen’s Disease (leprosy), dengue fever, cholera, and sexually transmitted diseases. Tobacco use, alcohol abuse, vitamin deficiencies and suicide are also serious health issues.
• RMI and the FSM are among the highest scoring, i.e., 25, Health Professional Shortage Areas (HPSA) within the United States.

Numerous challenges exist in the delivery of health care services. These include the current health care structure that emphasizes acute hospital-based care, the long distances involved in providing care to people living on multiple and remote islands, and poorly maintained and equipped health care facilities. Over 20% of the jurisdictions’ residents must travel over one hour to a health facility. Except for Guam, each jurisdiction consists of multiple islands, thus necessitating travel by boat or plane, which adds to the cost and time.

All the jurisdictions are very supportive of primary and preventive care, but the reality is it has been challenging and difficult to move away from hospital-based acute care delivery of services. Keeping clinics and dispensaries that are located outside of the main population areas adequately staffed and supplied is a significant challenge. Even in the main hospitals, equipment and supplies for radiology, laboratory, and surgery are often unavailable in most of the jurisdictions.

In all the US-affiliated Pacific Island jurisdictions, tertiary care patients must be referred out of the region for treatment. Tertiary care creates a serious drain on the jurisdictions’ health budgets and shrinks the dollar amount remaining for basic public health and social services for Pacific Island communities.

Less than 1% of the Pacific population accesses tertiary care, but 10 to 30% of the jurisdictions’ total health budget is spent on tertiary care and associated costs. In some years, American Samoa, RMI, and FSM have spent between 20% and 30% of their health care budgets on off-island referrals. As just one example of the costs involved, a round-trip plane fare for a stretcher case, which must book 6 seats, can cost from $4,700 to $9,200.

None of the jurisdictions have enough health professionals to adequately serve their populations. While there has been difficulty in keeping the Health Personnel Shortage Areas (HPSA) scores for the jurisdictions up to date, all, except for Guam, have had HPSA scores scores of more than 20, with the Marshall Islands and the Federated States of Micronesia at the highest HPSA score of 25. The Pacific jurisdictions have a tremendous difficulty recruiting and retaining health care providers in such isolated areas. With the exception of Palau, 60% to 100% of the medical doctors with MD or MBBS degrees in the jurisdictions are expatriate physicians, and are often hired on two-year contracts. There is great turnover with these types of physicians. There is an extreme shortage and uneven distribution of dentists in the jurisdictions. Excluding Guam, which has half the dentists in the region, ratios of dentists to people range from 1 per 4,306 in Palau to 1 per 14,811 in the Marshall Islands. In the US, the ratio is 1 dentist per 1,785 people.

Institutions of higher learning in the Pacific remain extremely rare. The only four-year college-level educational institution in the northern Pacific is the University of Guam. Although it does have a Baccalaureate of Science in Nursing; it has no programs for the remaining allied health sector workforce.

While efforts are underway to improve the situation, telecommunications for training and education is generally weak and unreliable. Long-distance phone rates are expensive, and phone or Internet service is often unavailable, unreliable, or low quality due to bandwidth limitations. Many outer islands do not have access to phones and rely on single band radios to communicate to the main islands. Since the freely-associated jurisdictions (the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau) are not considered Insular Areas by the Federal Communications Commission, they are ineligible for the health and education Universal Service Fund. This results in increased costs, limits development, and impedes low-cost communication for education and health. Complicating the digital divide problem is the problem of extreme distances among these 107 inhabited Pacific Islands. Palau is one complete day, 13 times zones, and 22 hours flight time from Washington, DC by jet. In some Jurisdictions, there are only 2 airline flights a week.

Divergent Cultures and Systems – The Pacific jurisdictions consist of, at a minimum, nine completely different cultures and many more languages, spread out over many hundreds of atolls and islands that span a distance larger than the continental United to States. Add to this mix a tenth culture (Hawai‘i), an eleventh culture (HRSA) and the communications environment becomes complicated, to say the least. Each jurisdiction has different health infrastructures, available resources, and even priorities. Developing productive consensus across these nine cultures requires substantially more effort, resources, and time than what might be considered normal in the US. PIPCA’s work plan and budget reflect this fact.

Communications – Telecommunications in many of the jurisdictions is tenuous: Computers and e-mail frequently go down and phone lines are limited in number and easily disrupted by weather. In addition, the time differences (most the jurisdictions are across the international date line), the limited human resources, and the discomfort that many Pacific Islanders feel toward phone and e-mail communications—can make information sharing and decision making across such vast distances very, very challenging. As a result, things can take a long time to happen in the Pacific, and when they do happen, they often require a substantial travel budget. This fact is among the hardest for many US representatives to grasp: Travel budgets appear excessive—yet they reflect the substantial geographic isolation and the high cost of travel facing health staff in the area.

A changing management culture in the Pacific-Basin. The management structure of Pacific Basin health care has been undergoing a transformation in several of the jurisdictions, from centralized systems guided almost exclusively by politically appointed policy makers, to a more decentralized, participatory system that delegates greater responsibility to middle management and front-line staff. The community-based approach of the US CHC program is consistent with this movement and is even seen as an important catalyst for this continued and—according to Pacific health leadership—necessary transformation. PIPCA, whose membership consists of hands-on health administrators and clinicians, rather than health ministers and policymakers, is seen as a key step in this process.

The fostering of local expertise – The Pacific has a history of representatives and consultants from outside entities imposing their agendas, advocating for inappropriate development, and doing little to build local capacity and decrease dependence. Such entities were often well-paid for work that left few if any positive results. Pacific leaders are understandably sensitive to any assumption that local professionals are not equipped to lead primary care development. As result, PIPCA’s work plan places a high priority on developing local capacity, through networking, mentoring, and fostering local expertise.

A ticking clock – Three of the six Pacific Jurisdiction (Palau, FSM, and the Marshall Islands) fall under Compacts of Free Associations with the United States—time-limited agreements for limited federal aid, including cash payments and participation in some federal domestic programs, such as 330e. These Compacts were recently renegotiated and, until they expire in roughly twenty years, will focus on weaning these countries from US assistance. PIPCA members from these countries emphasize the importance of shifting their health care systems, within a relatively short time, from expensive tertiary programs to more sustainable preventive, primary care and community-based programs. Again, PIPCA is seen as eventually playing a key role in this process.

Human resources limitations – Most if not all health leadership in the Pacific—including administrators and clinicians—wear multiple hats and cannot easily be taken from their jobs without harming the local health care system. Balancing immediate, local health care needs with the demands of developing an effective collaborative network across the Pacific will be an ongoing challenge. PIPCA addresses this by relying heavily on telecommunications, limiting face-to-face meetings to once or twice annually, and improving mentoring and training for the next generation of leadership.

A more central role for environmental health. The Pacific jurisdictions are developing countries and a significant amount of illness in these areas stems from contaminated water, inadequate sewage disposal, insect-borne diseases, and other environmental conditions, such as rats and spoiled food. A PIHOA epidemiologist stationed in Pohnpei reported that 100% of the children recently tested for water-born parasites tested positive. In Palau, environmental health workers are part of the primary health care team. As a result of this prominent role, environmental health is included in PIPCA’s strategic plan, as a key training need, and the Northern Pacific Environmental Health Association is included as a member of the PIPCA board.