Program Overview

The Title V Maternal and Child Health block grant is administered by the Family Health Unit (FHU) under the Division of Primary and Preventive Health, encompassing the MCH and Children and Youth with Special Health Care Needs (CYSHCN) Program. Other federally funded programs under the FHU include the SSDI, Title X Family Planning and the UNHSI/EHDI. The Title V Maternal and Child Health Block Grant provides essential financial and technical support to the state to deliver programs that improve the well-being of mothers, infants, children, and youth, including children and youth with special health care needs (CYSHCN), and their families. In 2021, the new government administration revised its organizational chart based on legislation to separate the one government-operated Belau National Hospital from the Ministry of Health and Human Services (MHHS), to allow resources to focus more on disease prevention and health promotion. Under this new organization, there are only two bureaus: Bureau of Hospital Services (which will be separated once a board authority becomes functional) and the Bureau of Public Health and Human Services, in which is the Division of Primary and Preventive Health is under. The Maternal and Child Health Program is the only program in the Republic of Palau that provides promotive, primary and preventive services through the community health center program (FQHC). Some secondary and all tertiary care for children 0-5 years of age are referred to visiting specialist physicians and off island medical centers.

MCH Population

Based on the 2020 Palau Census, approximately 42% are within the reproductive age group (15-44), while children and infants 0 through 17 comprise about 24%.  About 4% of children and adolescents (0-17 years old) have special health care needs. A majority of Palau’s population fall below the 100% federal poverty guideline and by US standards, the entire nation of Palau is a rural area.

Framework for Needs Assessment, Program Planning, and Performance Reporting

Palau’s MCH priorities are identified in statewide needs assessment that is conducted every five years, and continual assessment during interim years. The program completes mini assessments on program activities that provides direction on activities that are developed for the following year. Institution-based data from various sources including medical charts, WEBIZ, disease registries, and other databases are collected and analyzed. The annual school health screening report also serves as the main source of children and adolescent information. The program identifies opportunities to present the data to partners and stakeholders for feedback, which is then incorporated into plan revisions.

Key Findings:

In early 2022, Palau experienced its first and highest surge of COVID-19, and from January to early April, all services (except for emergencies) were suspended to focus all resources on COVID response activities. The impact of the pandemic, compounded by unmet needs of the community, and disease trends in the last two decades can be seen in the past year and Palau expects to see more of it in the upcoming years.

We saw more women and pregnant mothers with co-morbidities in our clinics. Over 30% of these women were overweight or obese, over 10% with gestational diabetes and depression, and over half using tobacco. Palau also continues to see high rates of infant mortality and C-sections for such a small population.

Less than half of children received a developmental screening in our clinics. Obesity remains a public health concern in this population, along with oral and behavioral health concerns. Over half of children ages 5 to 10 report being made fun of at school, 30% reported inflicted with violence, and 11% bullied in other ways. Our data also shows an increase in chlamydia rates among adolescents and concerning number (7%) of sexual activity, with the mean age of first sexual intercourse at 11. Furthermore, 1.3% report multiple sex partners, 17% do not use contraceptives, and about 80% do not use condoms. Other risky behaviors in our youth population include high rates of alcohol consumption at 22% and about 20% using tobacco. Self-harming behavior in the 11 and older age group is an alarming public health concern in Palau.  The increase was observed from late 2019 to 2022 for both male and female adolescents.  However, self-harming behaviors were more common among female students and may be related to higher rates of depression. 

One out of five children with special health care needs in Palau have ongoing physical/medical conditions lasting more than 12 months.  Approximately 46% are reported with moderate to severe conditions, and about 54% have needs that usually remain the same.  About 42% live in families with less than $10,000 annual household income, and 30% spend more than $100 on monthly medical care.  Additionally, 78% of parents of children with special health care needs utilize their medical savings account to cover for prescription cost.  In 2020, 15% of families of CSHCN said they did not have enough money to pay for care.  Access to care remains a challenge with limited specialty services on the island.  The program works with the medical referral office to prioritize required specialty services for CSHCN when a request is made through Tripler Medical Center and Shriners Hospital in Hawaii.

The Palau MCH program continues to build upon its strengths in efforts to address these various public health concerns. The MCH population is a priority for Palau, and this was highlighted during the pandemic. Our clinics were the first to reopen after the surge, and infection control measures were put in place to ensure that women and children felt safe and confident to access our services. Because of this, there was only a 10% decrease in the number of patients accessing MCH services. We maintained the percentage of women accessing pre-natal care at 60%.

With maintained and established collaborative relationships, our breast feeding campaigns continued so than more than half of women reported breastfeeding exclusively for 3 months in 2022. Almost 90% reported resting their infants on their backs (safe sleep).

Although there was a slight decrease in the number, we were still able to implement school health screening to all the schools in Palau. 53% of adolescents between the ages of 11 to 19 participated in the screening.  In 2022, the program identified and referred 63% of the participating students for further assessment, counseling and treatment.  Collaborations and partnerships are also the program’s strengths, and they also allow the program to provide guidance in strategies that promote the health of children and adolescents. And because of this, the Ministry of Education, over the years, have implemented more and effective strategies to increase physical activity and nutrition in the schools. Our non-federal partners (i.e., Coalition for a Tobacco Free Palau and SAFE Committee) advocate for us and in the past year alone, legislation was passed to implement the Seat Belt Safety Act and a ban on the sale and use of vapes or electronic cigarettes.

Palau has taken steps to address issues of care, especially in light of the delayed and pronounced health needs of the community due to the pandemic and our local capacity for primary, secondary and tertiary care. A notable change in the past year has been the passage of a legislation to separate the Belau National Hospital from the Public Health department, to allow more investment of resources where is it much needed, in disease prevention and health promotion. This was especially pronounced during the pandemic and in early 2022 when Palau experienced its first and highest surge of COVID-19, all resources were redirected to the response. Lessons learned from the response include the leveraging of resources to ensure successful achievement of objectives.

Finally, Palau learned the value of telehealth and its potential in not only allowing for workforce education and training, but for provider – provider consultations and delivery of much needed services to patients in remote areas, or who cannot come into the clinics for other reasons. At this time, the Ministry of Health is working with regional partners to establish a formal telehealth program in Palau. 

Palau MCH Priorities:

Most of Palau’s priorities remain the same except for a couple of revisions to ensure inclusivity.

• Well woman
• Child and adolescent immunization
• Substance use among youth
• Mental health among pregnant women, children, and adolescents
• Systems improvement for MCH and CSHCN
• Youth sexual health
• Childhood obesity
• Improved birth outcomes and child/adolescent health
• Oral health for pregnant women and children

Women/Maternal Health

Palau will focus on the health of the woman before, during and after pregnancy, and will open an additional clinic to offer women of reproductive age, affordable and accessible preventive medical visits in a community health center. Furthermore, efforts will be taken to increase the number of women who access early prenatal care, by working with partners and taking the time to educate the woman and the community on the importance of the healthy women, mother, child and family. The program will work with the health center and other partners to ensure that these medical preventive visits are comprehensive (medical, dental, mental) based on guidelines, and that women are provided or referred to needed interventions as necessary.

Perinatal/Infant Health

The program recognizes that the health of the infant is essentially dependent of the mother during pregnancy. Unplanned and complicated pregnancies often result in pre-term or low birth weight. With this the team determines prenatal care during the first trimester as an objective to focus on this year. Revisions were made to the Priority Need to accommodate the comprehensive approach strategy the team is planning to pilot in women’s health. Breastfeeding and safe sleep are helpful factors to healthy infants and reducing infant/fetal mortality and therefore these will remain as strategies/activities for the year as well.

Child Health

Palau Title V program recognizes that child population in Palau are a vulnerable and dependent group needing extra efforts in accessing healthcare services. Oral health, obesity, and mental health have been determined as priority need areas for this group. Revisions were made to some strategies in order to assure effective implementation of activities. Program will work closely with oral health to ensure delivery of services in the clinics and in school outreach. Established partnerships in the community will allow the program to support activities that will also promote more and innovative ways for physical activity among the youth. The program also will work with the health center and partners to ensure that developmental screening is implemented and work to enhance EHR system to include this screening tool.

Adolescent Health

Palau Title V program identifies this domain with the most risk factors that call for action. Based on MCH and partner data, sexual behaviors, alcohol and tobacco use, obesity, oral health and HPV immunization are considered priority needs for this domain. Revisions were made in order to align with selected priority needs, although continued changes to improve performance measurement framework is still necessary. Our school counselor will work with partners to adopt a school-based intervention to decrease alcohol and drug use in adolescents, and implement educational sessions on sexual and reproductive health. The program will also work with immunization and cancer programs to revise and implement a parental consent form that will educate parents on the importance of the HPV vaccine. The program will continue to work with oral and behavioral health divisions to implement activities in the schools to address oral health and psychosocial issues.

Children with Special Health Care Needs

Palau Title V program identifies this domain as the most vulnerable. This upcoming year, FHU wants to raise awareness about the needs and voices of this population group. Revisions were made in order to align with selected objectives, although continued changes to improve performance measurement framework is still necessary. 

Cross cutting

Workforce capacity is such an integral part of the MCH program; however, workforce development is a huge endeavor with so many parts that it can become overwhelming. For this year, the program will draft a simple training plan, that outlines program staff and select partners (i.e., MCH physicians and nurses), and the type of training needed and attainable for the particular year. The program will coordinate and support the training for the year.

Evaluation Efforts:

The program conducts a few surveys every 1-2 years. These include client satisfaction surveys and an assessment on the quality of services that we provide.

The program epidemiologist/evaluator has also started working on evaluation plans to assess the effectiveness of the interventions that we implement as well as the process. For this upcoming year, the program will have an evaluation plan attached to the action plan.