The discussion was not about whether doctors and nurses needed more training, why the hospitals never seem to have enough medicine, and what new equipment is needed to provide better health care. The topic of the discussion was on health care systems–that it, the way in which health care delivery is organized in FSM. This is a little removed from the concrete concerns that most people have, but it is a critical issue, nonetheless, because it is at the bottom of all those other concerns people have.
The present health care system in the FSM has three levels: the community dispensaries, the state hospitals, and referral to outside institutions. In our discussion we hoped to look at the strengths and weaknesses of each of these elements so as to improve the total system.
The history of the present health care system has its roots in the early US naval administration after World War II, according to the Director of FSM Health Services. In those early years, the US military selected a handful of Micronesians educated under the Japanese and sent them away to Guam for training as medical and nurse's assistants. No Micronesians except for a few Marshallese had received medical training before the war. Medical services in Japanese times consisted of a public hospital (and in some cases a private hospital) in each district, staffed by Japanese doctors and nurses. The US set up dispensaries on the outer islands and in remote villages that were staffed by the earliest crop of trainees. Thus began the dispensary system that continues up to the present.
The local dispensaries in these early days, like the village schools, were built by the local communities they served. The island medics who staffed them received a salary that was paltry by today's standards–as little as seven cents an hour at first. Yet, the men and women who served in them took a pride in their work and the rather high status they enjoyed in the eyes of the local community. Meanwhile, a hospital was established in each district to handle the more severe health problems. Neither budget nor air transportation would permit referral abroad in those days.
The system changed radically during the early 1960s when the US became impatient with the progress being made in its Trust Territory. Lean budgets were expanded to several times what they had been. Where it had once relied on the local communities to provide basic health care, the US administration now took over responsibility for building and maintaining the new dispensaries it set up. Responsibility shifted from the community to the government for providing local health care. The central government now paid all the bills; it hired and supervised the local medics, while the community, now relieved of this burden, could stand by and watch. The government rebuilt the old hospitals on a larger and more modern scale, and it began funding a medical referral system.
By the early 1980s, when Micronesia had become self-governing, it became clear that the young nations could no longer afford such a costly health care system. Influenced by the new concept of "primary health care" that was being advanced by the World Health Organization, the FSM tried to trim its expensive structure. Yap streamlined its system quite effectively with outside assistance, while Chuuk failed in its attempt to do the same. Pohnpei and Kosrae closed dispensaries at that time to save money. Pohnpei, while keeping its five outer island dispensaries, reduced the number on the main island from 20 to three. Kosrae shut down all three of its dispensaries. The supposition was that those needing health care in the villages could either make it to the hospital or would be reached by a mobile team. While the hospitals remained much as they were, the states tried to work out a reasonable way to limit the rapidly expanding costs of medical referrals abroad.
Our Health Services program was created in an era of expanding budgets, but we now live in an age of contraction due to the step-down in Compact funds and the uncertainty of the post-Compact years. Do we expect too much of our financially strapped government today? Should the local communities and the individuals who receive health services bear a larger share of the cost?
There is no doubt that the local communities have gotten used to having health services provided free or for a nominal charge. Villages that once bore the major share of dispensary costs now expect the state or national government to pay the cost of maintaining their dispensaries. Even though some of the state governments distribute 30 percent of their development funds to the municipalities, the latter never seem to use these funds for projects like infirmaries. Land leases for the island or village dispensaries in some places are still paid by the state government rather than the community. Although this tendency has been reversed in some places, notably Yap, it is still strong in states like Chuuk. Some forty years ago a fee of ten cents was set for a visit to the dispensary, the Director of Health Services reported. It remains the same today, inflation notwithstanding.
People in FSM have not yet become habituated to paying for the medical services they receive from the government. Fees collected for visits to the hospital and dispensaries bring in no more than ten percent of the total health costs. Yet, as some discussants pointed out, people seem ready enough to pay for quality private health care. Yapese will pay for the airfare to Palau in order to see Dr. Victor Yano, a well respected private practitioner. Word of his reputation has spread among the Yapese, and perhaps a dozen people a week visit him. Someone else noted that sick people on Pohnpei will spend the equivalent of thousands of dollars in goods for treatment from a local healer. The lesson in this may be that when people regard something as truly important, they will find the money to pay for it.
They even find the money to spend "on ways to destroy themselves," one person remarked. Somehow they manage to come up with the money to buy a six-pack of beer or a bottle of 151-proof rum or a carton of cigarettes, to say nothing of turkey tails and other high-fat foods. Why shouldn't they be expected to bear a larger share of legitimate health costs? Especially since so many of their health problems are alcohol-related or due to a bad diet.
Modern health care with its sophisticated and costly techniques is becoming more expensive by the day, too expensive for the government to provide for all its people. The alternative, in the eyes of many participants, seems to be medical insurance. The FSM plan now in effect provides three options with increasing coverage at premiums between $10 and $25 biweekly. The FSM is now offering medical insurance to all government employees, but this leaves the majority of the population uncovered. Those working in the private sector cannot buy into the government insurance package, although they have the option of finding their own program. Someone suggested that the time has come to find an insurance provider for the private sector. Naturally, those without any steady income would remain financially unprotected.
In 1982, WHO introduced the revolutionary concept of "primary health care" to Micronesia. The mission behind the concept was to help new nations strike a realistic note in their health planning goals. Countries like FSM were spared the frustration of trying to reach for the moon with the limited resources they had. Primary health care, as WHO preached it, should reach every citizen but without offering him or her everything. Health care should utilize appropriate technology, making use of local resources to the greatest extent possible and avoiding overly sophisticated machines. The community should also bear part of the responsibility for improving the health of its people by improving sanitation and providing clean water sources, among other things. All this requires intersectoral collaboration: between education, health services, and resources and development, as well as between the private sector and government.
In the same year, the Congress of FSM passed a resolution adopting this concept. This was a summons to communities to get seriously involved and take a leading role in the improvement of health. Communities were to help define what they needed and to start the momentum in that direction. Yap made its move first, and it did so with such success, according to the Director of FSM Health Services, that it became a model health care system in the area. Yap first strengthened its dispensaries, provided additional training for health aides caring for these dispensaries, and set up good radio link between the hospital and dispensaries. It also improved its logistics so as to insure the delivery of drugs and other medical supplies in a reasonable time. All persons requiring medical assistance were screened in dispensaries before they were referred to the hospital. The procedures of the medical referral system overseas were tightened, the number of referrals was limited, and patients were required to pay all or part of their own airfare.
If Yap's experiment in restructuring its system along the lines suggested in the primary health care concept was so successful, why don't other states do the same? In fact, other states have achieved part of what Yap set out to do. Pohnpei's dispensaries, although fewer, seem to have improved. Both Pohnpei and Kosrae have revised their referral policies, even though they are not always well enforced. Overall, the number of referrals abroad has dropped, and the referrals are generally more carefully chosen than they were in an earlier day. A medical doctor who spent three months in Hawaii registering all patients referred from FSM found that over 90 percent were fully justified cases.
This is not to deny that referrals still present a serious problem. Despite the attempt to curtail the number of medical referrals, they are still very much in demand. Patients with terminal illnesses will be sent to Hawaii or Manila, only to be told that nothing can be done for them. Growing numbers of FSM citizens today are going out of the country for a medical checkup. Someone suggested that perhaps this was because Micronesians would prefer to have their body examined by an anonymous doctor rather than a person from their community whom they knew well. But others thought the reason was simply their desire for quality health care.
Money. Because of the leaner budgets in the years ahead, the FSM government is being forced to curtail its expenditures on health services. The relatively lavish system enjoyed during the pre-self-government days of the 1970s is no longer a realistic possibility. In order to reduce its own financial commitment, the government will have to enlist much greater support from local communities and individuals in the future. It will have to seek ways to reduce the expenses of referral abroad, a move that has already begun with the introduction of health insurance. Yet, the question remains of what the government can afford to do for those unemployed citizens who have no way of paying for health insurance.
Quality of Service. Public confidence in the public health system seems to be sagging, at least if the growing rush to secure referrals abroad is any measure. Some people interpret this as a sign of despair of obtaining quality health care in Micronesia?
How can the government restore public confidence in its health system at the very time that it is cutting down its financial investment? What can be done to make the present government health delivery system more cost efficient with sacrificing quality? Should health planners encourage private clinics, as some persons suggest, arguing that they will relieve the pressure on public facilities while also forcing the government to rise to the challenge of improving its own system so as to compete? (The opening of a large private clinic in Palau some years ago evidently led to the improvement of services in the government hospital.)
Health Care at the Community Level. A basic level of health care was offered at the village/island level from the earliest years of US administration. The definition of "primary health care" that has become accepted since the early 1980s emphasizes the importance of health care at this level, even though some of the states have been shutting down local dispensaries due to shortage of funds. Should the dispensaries be restored, as they have in Yap, even on islands like Pohnpei and Kosrae with road access to the hospital? Can the dispensaries be made effective once again at a reasonable cost?
Shared Responsibility for Health Care. If anything is clear, it is that the government is unable to assume the entire burden of providing total womb-to-tomb health care for its citizens. Good health care will require the collaboration of local communities and individuals. It will also mean that people's expectations must be radically changed. The days when people could run to the government for everything they needed may be over. The community must provide support, financial and otherwise, for the health care of its members. A striking example of such support was when the Palau community contributed $200,000 towards the opening of Dr. Yano's new private clinic some years ago. What are the forms this collaboration should take in the FSM? How are people to be educated to think in this new way?
Improvement of the present health care system demands changes in the public's way of thinking, but it also requires improvements in the present public system. One of our participants remarked that during this recent campaign for FSM Congress not a single one of the candidates has addressed the issue of health care. Voters should voice their concerns, she urged, or else they have no one to blame but themselves for the quality of health care they're now receiving.