Program Overview

American Samoa is a territory of the United States of America, classified more specifically as an unincorporated, unorganized territory of the United States. Simply, American Samoa is afforded diplomatic and military protection from the US, but not all of the provisions of the US Constitution apply to its people.  An example would be American Samoa citizens classified as US Nationals, not US citizens. All American Samoa born citizens are considered US Nationals. American Samoa includes five volcanic islands (Tutuila, Aunu'u, and the Manu'a islands of Ofu, Olosega, and Ta'u) and two coral atolls (Rose and Swains atolls). This US affiliated group of islands shares maritime borders with another set of Samoan Islands (9 altogether) that operate under an independent type of government.  Despite this difference, all of these Samoan island groups share the same ancestor lineage, language, and culture. 

The geographical location of some of these islands compared to the main Tutuila island can, at times, cause difficulty in accessing care. For example, people residing in the Manu’a Islands and Aunu’u will have to travel by air or by boat to the mainland Tutuila to receive comprehensive care such as an x-ray, refill prescriptions, or surgical needs.  Although there are healthcare centers in the Manu’a Islands, the available services are but a few.

The total population of American Samoa is 55,519 (2010 census). Over half (53%) of the population of American Samoa is less than 20 years of age. According to the 2010 census, there were 28,170 males (50.7%) and 27,349 (49.3%) females. A majority of the population resides in the Western District with 31,329 residents (56.4%). This is followed by the Eastern district with 23,030 residents (41.5%), then the Manu’a district with 1,143 residents (2.1%). The total fertility rate in American Samoa is 2.7 children born/woman. However, the population is decreasing due to out migration. About half of the people living in American Samoa were born there, with most immigrants coming from the Independent States of Samoa in search for jobs and to visit relatives. Many of them remain and establish families. There is no welfare system in American Samoa, however, a federally funded food stamp program is available for the elderly and children with special needs, as well as the Women, Infants, Children (WIC) Nutrition Program.

The territory experienced modest economic growth in 2014 and 2015, which was spurred, in part, by a large capital investment by Tri Marine International on the purchase and construction of facilities for processing and packaging locally harvested tuna. The cannery opened early in 2016, under the name Samoa Tuna Processors (STP). Competition from Asian-based canneries immediately put the company in a precarious position and processing operations permanently halted in late-2016. STP laid off at least 400 employees during the closure, which led to hundreds of additional job losses in related and support industries over the following year. Starkist Samoa Co., American Samoa’s last remaining tuna processor, also faced setbacks in 2017. Availability of landed fish, along with a number of federally-mandated equipment upgrades, forced the company to temporarily halt operations for five weeks in the fourth quarter of 2017. The shutdown left thousands of employees without salaries to cover basic expenses and cost the local government more than half-a-million dollars in income tax revenues. The combined impact of the cannery closures contributed to a spike in the unemployment rate in the territory in 2017, from 10.5% in 2016 to 14.3%.

The recession may have extended into the following year, if not for a devastating storm that impacted much of American Samoa in February of 2018. By some estimates, Tropical Storm Gita caused as much as $125 million in direct and indirect damages across the territory. At least 50% of all individuals in the territory were faced with significant damage to real and/or personal property during the storm. Food, water, and other basic necessities were in high demand throughout the days and weeks that followed. During that time, automated teller machines were persistently low on cash supplies as the people of the territory scrambled to draw enough to cover immediate repair and replacement costs. Additionally, international relief agencies distributed pre-loaded gift cards to families and individuals that were most affected by the storm. Disaster relief funding is expected to contribute to consumer and government spending in 2018. Once the immediate effects of the tropical storm have diminished, so will many of the economic stimulus benefits.

Non-communicable diseases (NCDs) continue to be the leading causes of morbidity and mortality for adults in American Samoa, similar to other US Affiliated Pacific Islands Jurisdictions.  Recently released was the American Samoa 2018 Adult Hybrid Survey, a population-based household survey, combined NCD and associated risk factor indicators and substance use conducted between 2017-2018.  From 2004 to 2018, cigarette smoking and alcohol consumption prevalence decreased, although binge drinking prevalence and remained about the same. Overweight/obesity (94.7%) and diabetes (45.4%) prevalence remains high in American Samoa.

The healthcare system in American Samoa is comprised of one local hospital; one federally funded community health center and 5 satellite health clinics throughout the island of Tutuila and Manu’a, as well as an outpatient veteran’s clinic. There are a few private clinics ranging from optometry to general health available for public access.  There is no health insurance program for the whole of the territory, except for those in the armed forces and some private companies.  Most people will have pay out of pocket for healthcare; however, most people are unable to afford healthcare costs, so these folks seek health services only on necessary conditions. 

There are limitations on specialty care availability on the island.  Most healthcare providers are general practitioners with limited training or exposure in special areas of medicine.  If specialty care is available, they are likely contracted for a specific brief period of time.  Many of the students who leave the island to seek further education to become a healthcare provider don’t return because the earnings are not sufficient.  Due to shortages of physicians, nurses, and other healthcare professionals, at times clinics are left with only an administrator or an assistant and the public is referred to clinics that may be of further distance where a provider is available. 

The local health department envisions Healthy FAMILIES, Healthy COMMUNITIES, and Healthy AMERICAN SAMOA.  Its mission statement states “To effectively and efficiently deploy available public health, human and material resources: to PROMOTE physical and mental health; to PREVENT disease, injury, and disability; and to PROTECT individual rights to access quality and affordable health care services for all residents of American Samoa”.  In support of women and children, the local health department partners with the federal government to ensure healthcare services for the MCH population is continually addressed and improved. 

The American Samoa Maternal and Child Health (ASMCH) Program under the Department of Health receives federal funding, from the federal Health Resources and Services Administration Title V Block Grant, towards improving the health and overall lives of women and children, including children and youth with special health care needs. ASMCH is currently under the leadership of the Nursing Director, who reports directly to the Director of Public Health. An organizational chart is displayed in Figure 1.

Figure 1: American Samoa MCH Program Organizational Chart:

Majority of the MCH direct services occur in the community health centers (Prenatal and Well Child Clinics). With Title V funds, nurse practitioners, dental assistant, health educators and special needs client navigators, are fully funded by the MCH Program to provide services at these centers. The local health agency influences and supports Title V priorities by integrating existing programs to work with each other, creating bigger outcomes and more successful results.  An example would be having a family access both well child and prenatal services at the community health center.  These services are supported by not only MCH, but also with Tobacco/Diabetes Program, Breast & Cervical Cancer Program, NCD program and of course CHC overall.  Each program targeting their own agenda and task while the family is able to access comprehensive care, a win-win situation for everyone involved.

There are only a handful of pediatric trained providers on the island.  The health care centers employ 3 pediatric trained physicians, however, only one provides services directly for children through the well child clinics, the other two are assigned administrative roles and serve the general public.  So, all children, with and without special needs are primarily cared for at the local hospital, which is   Supporting services such as behavioral, mental, and social aspects are offered through the Department of Human and Social Services.  Non-profit organizations also play a significant role in the care of children in the territory, providing necessities and support through groups and pertinent information.

Specialty care is dependent upon traveling consultants and recruitment.  When specialty care is not available, children and their families are often recommended for off-island referral.  Air travel is covered by the local hospital; however, all other associated costs are imposed on the family to cover.  Some families never return home due to continuous need of care and lack of available resources on the island. 

According to the Medicaid Title XIX program, all children and pregnant mothers are eligible for Medicaid coverage.  However, women, children including children with special needs are still required to pay out of pocket for their medical expenses, particularly if services are accessed through the local hospital.  This is a complication that the Title V and Title XIX are currently working on to resolve, as there are incongruities in the law that needs modifications.  The health department overall provides oversight and guidance so that these efforts are integrated into the system of care, which will expect to increase access for all pregnant women and children in American Samoa. 

The ASDOH receives approximately $485,500.00 in Title V dollars annually to assure access to preventive and primary health care services for the required population groups of: (1) preventive and primary care services for pregnant women, mothers and infants; (2) preventive and primary care services for children; and (3) services for children with special health care needs (CSHCN). Federal law requires each state to allocate a minimum of 30 percent of available funds to services for children with special health care needs, and a minimum of 30 percent of available funds to services for children and adolescents.

In the table below, it lists all the domain related priority needs and American Samoa’s selection is based on the 2015 Needs Assessment listed in Table 1 below.

Table 1: American Samoa MCH Title V Priority Needs

American Samoa MCH Title V’s five-year State Action Plan was developed to assist in aligning program strategies and activities with identified needs and performance measures. Each year the American Samoa Title V updates on progress toward the identified measures and implement changes to strategies and activities as appropriate.

Together with local funds and other additional federal funds, the Title V MCH block grant is used to address American Samoa’s MCH priority needs, improve performance related to targeted MCH outcomes, and expand systems of care for the MCH and CSHCN populations. American Samoa’s Title V Leadership Team—which includes the Title V MCH director, Title V CSHCN director, and key Title V administrative staff—meets on a regular basis to discuss all aspects of Title V, including the budget and how federal and non-federal funds are used to address the state’s MCH needs.

The key accomplishments for FY 2018 and plans for FY 2020 are summarized below.