The U.S.-Associated Pacific Basin consists of six island jurisdictions. Three—American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), and Guam—are considered U.S. flag territories. The other three—Federated States of Micronesia (FSM), Republic of the Marshall Islands (RMI), and Republic of Palau (Palau)—are independent countries, but are freely associated with the United States. The total population of all these jurisdictions is 454,118, roughly the same population as Portland, Oregon, but that population is scattered across 104 inhabited islands covering an expanse of ocean larger than the continental United States. The ties that bind these Pacific islands to the United States have been forged largely within the past century—from ties through trade and religious missions to ties as a result of the United States being the United Nations-approved trust administrator and the preeminent funder of most of the region's economic, social, and health services. The U.S. Department of Health and Human Services provided approximately $70 million in funding for health care in 1996.

The health care delivery systems of the different jurisdictions in the region reflect the challenges and strengths unique to the islands. The health status of the islanders naturally varies within and among the jurisdictions. In general, however, almost all health indicators for islanders are worse than those for mainland Americans. This is most notably so in the freely associated states. The systems must deal with health conditions typical of those of both developing countries (e.g., malnutrition, tuberculosis, dengue fever, and cholera) and developed countries (e.g., diabetes, heart disease, and cancer).

In the delivery of health care services numerous challenges must be overcome. These include: administrative structures that emphasize hospital-based acute care; the long distances that must be covered to provide care to people in remote areas; dependence on foreign aid; inadequate fiscal and

personnel management systems; poorly maintained and equipped health care facilities; the enormous costs involved with sending patients off-island for tertiary or specialized care; and shortages of adequately trained health care personnel. In many cases, the island jurisdictions are also contending with significant social change brought about by incredible population growth, rapid economic development, and a shift away from a way of life based on communal farming and fishing to one that is market and consumer oriented. Attempts to address these health conditions and challenges come at a time when U.S. federal government aid to the region has begun to decrease, a trend that is likely to continue.

These challenges are also embedded in the islands' many strengths and resources: cultures that remain vibrant even after years of foreign occupation and influence, strong familial ties and roles for women, highly developed and organized communities, traditional health practices, and powerful religious beliefs.

The Institute of Medicine (IOM) was asked by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), to examine these issues and suggest possible approaches to improve the situation. Specifically, IOM was to:

1. collect and examine all readily available information on the status of health service programs in the Pacific Basin, including the recently concluded Pacific Basin Medical Officers' Training Program (described in Chapter 2 and Appendix D);
2. develop assumptions about benchmarks to be used to assess needs and services in those jurisdictions (discussed in Chapter 3);
3. assess the accomplishments, adequacy, and shortcomings of health services programs and related health interventions compared to the baseline assumptions (described in Chapter 2 and Appendix D); and
4. develop a strategic plan to address the problems and inadequacies, and reinforce the successes, in health services (described in Chapter 3).

The status of the health care delivery systems varies markedly from island to island. The following is a brief overview of the current situation in each jurisdiction (more complete assessments are provided in Appendix D).

American Samoa: Government management and financial difficulties caused by unpaid debts threaten the functioning of the health care system. Critical

supplies have fallen short, the Health Care Financing Administration (HCFA) has threatened decertification of the only hospital, and some basic public health needs are being neglected.

Commonwealth of the Northern Mariana Islands: With a strong legislature and good leadership in the health sector, the CNMI has made significant strides in its health care system. Private insurance markets are beginning to be established, government financing of off-island referrals has been restricted, and the residents are proud of their hospital. However, rapid economic development and the resulting increase in the number of immigrants, primarily from Southeast Asia, brought in for contract work have placed significant strains on the infrastructure and health services.

Federated States of Micronesia: Although the quality of the health care system varies markedly from one state to another among the states of the FSM almost all health care services are extremely dependent on U.S. aid. As the Compacts of Free Association wind down, the resulting economic uncertainty has already begun to restrict some health services.

• Chuuk: The most populated and poorest of the four states, Chuuk suffers from a poorly developed infrastructure, crowded conditions, and a seriously inadequate hospital.
• Kosrae: Kosrae consists of only one island and has the smallest population of the four states of FSM. It has a relatively good health care system, with positive improvements in public health being seen and acute-care services being provided by a largely indigenous health care workforce. Limited supplies and outdated equipment at health care facilities have been a concern.
• Pohnpei: Pohnpei is the home of the former Pacific Basin Medical Officers Training Program and capital of the FSM. It has witnessed significant improvements in its health care systems, especially with the reinvigoration of its primary care system. However, Pohnpei does contend with environmental health concerns associated with poor sanitation and a poorly maintained acute-care facility.
• Yap: In general, Yapese are considered the healthiest among the populations of the four FSM states. Even the most populated island of Yap does not have the crowded conditions of the other capital state centers. With strong traditional leadership and community involvement, the Yapese built what was considered a model integrated primary health care system through a network of 30 dispensaries. Today, however, there are concerns that the lack of community support and the lack of government attention to the system are causing it to wither away.

Guam: By comparison with the other U.S.-Associated Pacific Basin jurisdictions, Guam ranks above the other island states in overall wealth and health. It has a well-integrated private insurance market, and a well-developed

infrastructure. However, the island still lags behind U.S. mainland states, Alaska, and Hawaii on most health indicators, and is experiencing population growth from neighboring freely associated states that is beginning to strain public health services.

Republic of the Marshall Islands: The RMI has one of the world's highest population densities in its two main urban areas and the youngest population of the six jurisdictions (half of the population is under 16 years of age). Crowded conditions, underdeveloped infrastructure, and poor hospital facilities are just some of the pressures on the health care system. Underlying these conditions is a deep mistrust of the United States, rooted in years of nuclear weapons testing in the area and subsequent research to study the health effects of radiation exposure.

Republic of Palau: With Compact money well secured until 2009 and beyond and a mini-economic boom, Palau is in a financially secure position. A new hospital, a newly trained cadre of Palauan medical officers, and a commitment to improve primary care have boosted the health care system of Palau.

The committee strongly recommends continued U.S. involvement and investment in the region's health care systems. The nature and scope of this involvement and investment, however, must change. Beyond merely providing health care—a great challenge in its own right—the United States and the island communities must work together with a renewed sense of partnership to produce improved health of Pacific Islanders. Implementation of some of the approaches recommended below has already begun in the jurisdictions. The committee underscores the importance of working on several approaches at the same time. Taken individually the approaches will not have the same impact as the collective efforts and opportunities for potential synergy will be lost.

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

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

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

• 3.	Increase community involvement and investment in health care.

• 4.	Promote the education and training of the health care workforce.

The committee believes that priority should be given to the first two goals—adopting a viable system of community-based primary care and preventive services and improving coordination within and between the

jurisdictions and the United States. To a certain extent the other two goals of increasing community involvement and strengthening the health care workforce flow naturally from these first two priorities. The committee cautions, however, that if the two main priorities are not given serious attention by all parties involved, the desired goal of improving the health care systems in the region and ultimately the health of the island populations will not be achieved—even if the other recommendations are fully implemented.

Although it was beyond the charge, expertise, and capability of the committee to make detailed estimations of the costs of implementing these recommendations, the committee believes most of the costs can be covered through the reallocation of current levels of health care funding—especially as a more locally sustainable and viable system of community-based primary care and preventive services is adopted. In the 1993 landmark report, Investing in Health, the World Bank calculated the cost of providing a minimum package of public health and essential clinical services in middle-income countries (which all the U.S.-Associated Pacific Basin jurisdictions are considered) in 1990 was $22 per capita. All the jurisdictions currently have considerably higher health budgets per capita—ranging from a high of $614 per capita in the CNMI to a low of $92 per capita in Chuuk (PIHOA, 1997).

Ensuring potable water supplies, adequate sanitation, and reliable electricity throughout the jurisdictions must be a clear priority for both the agencies of the U.S. federal government providing aid and the communities striving to create healthy islands.

The committee underscores the vital importance of investment in preventive and primary care and in population-based public health care in the region. Currently, almost all of these activities are funded entirely by the U.S. government. The committee believes it is important to have local governments adequately fund these functions and to provide more funds through local sources. This investment does not necessarily require a great deal of new funding. What it will require, however, is the reallocation of existing funds and the reorganization of delivery systems to more closely integrate acute and primary care systems—a difficult process in any health care system. To combat the inappropriate and discretionary use of funds for health care services, the

committee recommends that each jurisdiction place the funds reserved for these purposes in a separate cost center within the overall health care budget.

The flag territories should maintain HCFA standards. Modification of standards can be considered when a jurisdiction provides appropriate justification. Each freely associated state is strongly urged to establish its own health care standards, including provisions for the licensure of health care providers and legislative practice acts.

Each of the jurisdictions is encouraged to participate in the development of a standard regional health information system. This system would be the repository of information needed to analyze the health care system and to make assessments of how best to proceed. The system should be able to track outcomes and progress toward Healthy People 2010 goals that the jurisdictions have revised to capture more appropriately the unique circumstances and disease burdens of their populations.

Officials at the hospitals and other health care facilities should be given greater control over finances. Each of the jurisdictional governments must also be required to establish an annual budget with separate cost centers for health services facility maintenance and repair, equipment and supplies, salaries, and in-service training. This budget should be tied to an itemized annual work plan. Financial assistance from U.S. sources for facility and equipment repair should be tied to preparation and completion of these annual work plans, to the inclusion of partial financing with local funds.

As many of the jurisdictions have begun or are considering contracting out and privatizing many of their health care services, the committee cautions that technical assistance should be provided to the prospective private businesses. Business plans for these businesses should be developed that include realistic fee collection goals and carefully considered policies regarding supervision and other personnel matters.

While recognizing the significant attempts to reduce the enormous costs of such referrals, each jurisdictional government is encouraged to move away rapidly from providing financial support for such referrals altogether and to consider the development of insurance systems, possibly private-market insurance, or other funding mechanisms to cover such catastrophic health care costs.

To maximize scarce resources and minimize wasteful duplication of efforts, the committee calls for greater coordination and collaboration as well as improved management on both sides of the Pacific. Such coordination has begun, but it must be more focused and more consistently pursued and supported.

Use of Block Grants That Require Meaningful Measures of Accountability Federal agencies are encouraged to use block grants or to consolidate grants whenever feasible. The committee particularly encourages the use of common grant applications and consolidated reporting formats. The emphasis should be on achieving greater flexibility and efficiency with well-defined measures of accountability and common data systems.

Consider Multiple Uses of Military Facilities The committee recommends that officials from all U.S. military health care facilities in the region enter into dialogue with the jurisdictions to determine the optimal ways of sharing regional resources and providing training opportunities to serve local populations.

Continue to Fund Research Projects in the Region The committee encourages greater interagency coordination to support research and monitoring in the jurisdictions of (1) major causes of morbidity and mortality (e.g., diabetes, substance abuse, tuberculosis, and nutritional deficiencies); (2) health systems development; and (3) health effects from radiation exposure throughout the Pacific Basin jurisdictions, albeit with continued specific attention to the Marshall Islands. The conduct of the research must be in accordance with accepted ethical principles and with the full cooperation of the island communities being studied.

Establish an Interagency Governmental Committee on Pacific Health The committee believes that coordination of U.S. funding for all health-related

activities in the Pacific is needed to increase the coherent and consistent application of rules, regulations, and accountability requirements for expenditures, which should be based on the previously discussed outcomes measures. The committee therefore recommends the establishment of an Interagency Governmental Committee on Pacific Health (IGCOPH) to ensure coordination of health programs, health program administration, and technical assistance to the region. The committee should be chaired by the Secretary of the U.S. Department of Health and Human Services or his or her designee and include representation from each of the federal agencies that fund health-related activities in the region, including, but not limited to the following:

• U.S. Department of Health and Human Services (Administration on Children, Youth, and Families; HCFA; HRSA; Centers for Disease Control and Prevention; and the Substance Abuse and Mental Health Services Administration);
• U.S. Department of the Interior (Office of Insular Affairs),
• U.S. Department of Agriculture,
• U.S. Department of Commerce,
• U.S. Department of Education,
• U.S. Department of Energy,
• U.S. Department of Defense, and
• U.S. Department of State.

The island jurisdictions are also encouraged to continue their commitment to and collaboration in the Pacific Island Health Officers' Association (PIHOA). PIHOA is further encouraged to: (1) develop a regional health information system to promote a shared version with standard nomenclature, (2) continue to review purchasing practices and encourage shared purchasing and volume buying to decrease costs and to be able to share resources in emergencies, and (3) continue to identify technical assistance and consulting strategies that promote the prudent use of the expertise available within the region.

Establish a Pacific Basin Health Coordinating Council. Finally, the committee recommends that the governments of the United States and the six island jurisdictions establish or designate a nongovernmental organization in the region to coordinate health affairs and facilitate collaboration between the U.S. and jurisdiction governments. This ''Pacific Basin Health Coordinating Council," or PBHCC, would meet quarterly and report annually on the progress of health sector reform in the U.S.-Associated Pacific Basin to the President of the United

States, U.S. Congress, the chief executive officers and legislatures of each island jurisdiction, IGCOPH, and PIHOA. The PBHCC should have a small permanent staff. The establishment of such a Council is not meant to create yet another layer of bureaucracy; rather, it is envisioned as the catalyst for pragmatic health reforms and the watchdog for greater accountability of all parties—in the United States and the region.

PBHCC Composition. The 14-member Council should have representation from three different groups: 4 representatives of the U.S. government and the IGCOPH; a representative of each island jurisdiction's government; and a total of 4 private citizens, 2 each from the United States and the island jurisdictions.

PBHCC Tasks. What projects are undertaken by the PBHCC will need to be determined cooperatively with all the parties involved. The committee notes the differences in budgets, health care services, personnel, and program directions between the U.S. flag territories (American Samoa, CNMI, and Guam) and the freely associated states (FSM, RMI, and Palau). Therefore, as it undertakes the following potential tasks, the PBHCC should consider grouping jurisdictions accordingly. Specific PBHCC tasks could include:

• help develop health care priorities in the six jurisdictions that take into account burden of disease and cost-efficiency criteria, as well as community-developed priorities;
• ensure coordination of U.S. health programs, activities, and funding streams within the U.S. flag territories and the freely associated states;
• review each jurisdiction's progress toward meeting specific health outcome objectives as required under various U.S. grants;
• assist with the simplification of filing and reporting formats and forms for various U.S. grants;
• facilitate the provision of technical assistance and training in such areas as health administration for all Ministers and/or Directors of Health and for members of jurisdictional Health Authorities or Boards; and
• identify and establish working relationships with U.S. federal agencies and international organizations and other aid donors (e.g., the World Health Organization, the Asian Development Bank, the South Pacific Commission, and others) who could provide technical assistance resources for health care reform.

PBHCC Funding. Funding for this nongovernmental organization must come from a variety of sources. As described in Chapter 1, the U.S. federal government has several vital interests in investing in the region's health and ensuring that the money it provides is spent wisely. In keeping with several of its other recommendations, the committee underscores its belief in the vital importance of having the local jurisdictions provide financial support to this endeavor. The committee also sees a role for private organizations and foundations—both inside and outside the region—to play in funding the

PBHCC. All these funding partners must believe that they have a stake in the PBHCC's work and will benefit from the results that work produces.

Several possible funding mechanisms exist; the committee suggests a few options here, but ultimately the various funders must collectively determine exactly how each will pay. The U.S. federal government might consider contributing a fixed percentage of all funds it provides to the region. Similarly, each of the island jurisdictions may decide to base its funding on a fixed percentage of its total health care budget or on a fixed percentage of the total funds it receives from the U.S. government and other international sources.

The committee believes that any attempt to improve health care in the Pacific Basin must tap into the strengths and resources of the community—if the improvements are to be meaningful and sustained. Fostering an environment that enables households to improve the health of their members, particularly by promoting the rights and status of women, is viewed as an essential precondition for improving global health. This focus on women is particularly apt in the Pacific, given the central roles of women and girls in many of the island societies.

The committee acknowledges the differences in institutional capacities of each of the jurisdictions and in the cultural norms and functioning of individual communities. No one paradigm of community involvement applies to all island cultures equally or necessarily appropriately. Health services must be aligned to each community's needs and must be congruent with its unique culture, with special attention given to the most vulnerable groups. Each community will have to determine how best to achieve the levels of involvement and investment needed to truly make a difference in the health of its population.

The following are some fundamental steps that island communities should consider.

Where appropriate, individual jurisdictions should create, through local legislation and community input, an independent authority or board to oversee the administration of the health care system, plan and prioritize health initiatives, and provide accountability. Such an authority or board would oversee the budgets of all the health services, agencies, hospitals, primary care sites (dispensaries), and programs under its direction through the development of sound annual budget development practices, the use of monitoring systems, and timely annual audits. The Health Authority or Board should have both men and women, and include community volunteers such as business people, clergy, educators, and health care professionals.

Individual jurisdictions and communities should establish a process for determining what health issues are of greatest concern, how best to address those concerns, and how they will monitor their progress. This belief in the power of community involvement and decisionmaking, rather than outside consultants evaluating the current situation, lead the committee to decide not to revise or modify the existing benchmarks used by the University of Hawaii in two evaluations conducted during the 1980s.

Nongovernmental community organizations—particularly women's, church, and youth groups—represent a potent and much underutilized force. Such groups should be enlisted to provide a variety of health-related activities, including health education and treatment (e.g., drug counseling), whenever possible.

For all jurisdictions, when U.S. funds are involved, community commitment and involvement in the delivery of care and the maintenance of primary care sites (dispensaries) should be required. Minimal requirements would be (1) donation of land from the community or some of its members, with a clear deed attesting to the donation; (2) contributions to the construction of the facility in the form of either materials or labor; (3) commitment of the community to maintaining the facilities; and (4) contribution to the salary of the person(s) serving as community health aide(s). In-kind donations should consist of time and labor as well as or in place of monetary contributions.

The committee is gravely concerned about maintaining the skills and knowledge of the current health care workforce and strengthening the region's local human capacity. The committee therefore recommends several education activities for health professionals to address the present lack of adequate training opportunities available to the health care workforce in the U.S.-Associated Pacific Basin. The exact nature of these activities, however, should be based on a workforce development and training plan established by each jurisdiction. The plan should consider not only how to enhance and improve the skills of

current health care providers but also how to train new providers, particularly women, to address shortages and natural loss through retirement and attrition.

Activities should include, but should not be limited to the following.

Currently, the primary and secondary educational systems throughout the region do not adequately provide students the skills that they need to participate in the health care workforce. In the short term, targeting special programs to students interested in and academically able to pursue careers in health care should be considered. Public and private scholarships for health care education should also be promoted.

Given the remoteness of the islands, strategies that maximize the efficient and affordable use of these technologies need to be supported.

Continuing medical education (CME) is currently provided in a rather haphazard fashion, if at all. CME must be required for all levels of practitioners and incorporated into each jurisdiction's health care workforce training plan. The committee is particularly concerned about the graduates of PBMOTP and recommends that they receive continuing medical education to improve and maintain their clinical skills and knowledge. Advanced training should be conducted at a regional training center, preferably an existing one. The role of the U.S. government should be directed toward capacity-building and financial assistance.

The committee is greatly concerned by the dearth of dentists currently practicing in the region. Compounding this problem is the fact that many of the current dental practitioners are expatriates or are nearing retirement. The U.S. federal government and local jurisdictions should sponsor dental training immediately.

Nurse training in the region also needs to be reinvigorated. The committee believes it should continue to take place, as it does now, in several institutions of higher education located throughout the region. The nurse training programs throughout the region are encouraged to work together. This could include the sharing of faculty members, using cooperative efforts to provide distance-based education, upgrading of the curriculum to the bachelor's level, and the development of continuing nursing education programs for existing nurse personnel of all levels.

Advanced training for the jurisdiction's chief health administrator should be provided through a certificate or degree program. The training should include coursework taken at institutions of higher education that offer high-quality programs in this subject area combined with practical applications and fieldwork within the administrator's own jurisdiction.