The Republic of Palau is situated 814 miles southwest of Guam on the western rim of what was once known as The Caroline Islands, which later became the U.S. Trust Territory of the Pacific Islands under the U.N. Trusteeship Agreement.  Palau maintains a close relationship with the United States under the Compact of Free Association.  The Island is an archipelago consisting of high volcanic islands, raised limestone island, classic atolls and barrier reefs extending nearly 700 miles on a northeast to southwest axis.  Palau has a total land mass of 188 square miles, which is roughly equivalent to the island of Guam or 2.5 times the size of Washing D.C.  The main island group, which lies 7 degrees above the equator consists of 14 of the States of Palau.  The island of Koror and Babeldaob are connected via roadways and bridges, while the island-states of Kayangel, Peleliu and Angaur are accessible by boat or plane (Peleliu and Angaur only).  A small group of island 200-380 miles southwest of the main islands of Palau make up the states of Sonsorol and Hatohobei and are only accessible by larger ships.  The grouping extends from Kayangel, the northern most atoll, to Babeldaob, Koror, and over a hundred uninhabited island enclosed in a barrier reef, and ends with the small islands of Peleliu and Angaur to the South and Sonsorol and Hatohobei to the Southwest.

The 7.1 square mile island of Koror is the island’s administrative and economic capital, with 70% of the population residing either there or the neighboring state of Airai, located on the island of Babeldaob.  Babeldaob itself is the single largest island, second in Micronesia only to Guam, and it is connected to Koror via a bridge.  Five states (Kayangel, Angaur, Peleliu, Sonsorol and Tobi) are accessible by either boat or a small plane (Angaur and Peleliu only) or via ship only (Sonsorol and Tobi).

Traditionally, Palau was comprised of several competing chiefdoms.  The society was characterized by a system of strong, ascribed hierarchical social ranking where the matrilineal descent determined social position, inheritance, kinship structure, residence, and land tenure.  Since western contact, dramatic societal changes have occurred, perhaps the great contributing factor being depopulation due to the introduction of western diseases.  Only a tenth of the estimated original pre-contact population of 40,000 remained at the turn of the century.  Regardless, traditional society continues to play an important function in the daily lives throughout the entire strata of the contemporary Palauan society.  While Palauan and English are the official languages, many persons 70 years and older still speak Japanese, having been educated during the Japanese administration of these islands from 1914 to 1945.

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Given the geographic nature of the island, several significant geographic barriers to health care access exist in Palau.  With the main island (babeldaob) having a paved road that provides motorized access to residents the high cost of fuel is a factor that prevents people from visiting the main Community Health Center.  Most travel in Palau is by automobile and there are still a few states that do not have fully paved roads.  The states within babeldaob are all connected by roads that have either partial completed roads or currently in progress for completion (contingent on the ability of the states to secure funding for completion), some of which are impassable during rainy seasons.  Palau receives nearly 200 inches of rainfall a year.  This emphasizes that while almost 80% of the population has reasonable access to health care, the remainder must undertake lengthy and expensive automobile or boat trips to reach services.

The economic and population capital is Koror, home to 66% of Palau’s residents.  Koror is also the location of Palau’s only hospital (Belau National Hospital), the Central Community Health Center (Central CHC) and three private medical clinics (and one dental clinic).  The neighboring state of Airai, with 14% of the population, is also home to Airai CHC.

Table 1: Population, Distance from Main Health Facility by State, Republic of Palau, 2015.  Source: 2015 Census Data; Office of Planning and Statistics, ROP

The geographic isolation noted earlier as a barrier to health care is compounded by the relatively high cost of transportation.  There is no public transportation in Palau and private taxi rates are standardized at a level which is quite excessive particularly in relation to the income level of those forced to use them.  The low socio-economic status and rural living conditions have other effects on standards of living.  Even though 92% of the people in Koror have access to public water, it frequently requires boiling to ensure complete safety from parasitic and bacterial contamination.  The sanitation and hygienic conditions are below US standards, with only 71% of the houses having adequate sewage disposal, 81% lacking complete plumbing (32% utilize outdoor privies and 2% have no toilet facilities at all).  Nearly three fourths (73.6%) have only cold water available and 6% have no piped water.

Socio Economic Characteristic

Palauan culture is centered on our connection to the land and sea.  Traditionally, men develop skills and understanding of our waters and phases of the moon to be able to provide for household consumption and for supplemental income.  The women tend to the land for subsistence farming and for some it is also to supplement household income.  Familial obligations and traditions are still practiced in matters of birth and death.  A woman that has her first born child goes through a ritual of a ‘hot bath’ where it is believed to help heal and strengthen a woman’s body from the effects of childbirth.  It is through this belief that some feel that there is no need to seek appropriate women’s health services, especially during pregnancy.  During pregnancy, family members provide the expectant mother with healthy meals, take on roles that she plays, to help reduce undue stress and put in extra effort to eliminate opportunities of illness as well.  A death in the family requires the collaboration of an entire clan to plan and take care of all costs associated with the funeral, financial obligations for the family of the deceased, including medical costs if any.  This places an extra burden on families, because now they also have to plan on contributions to care for those that are in their clan.  In the face of modernism, residents are increasingly seeking employment opportunities that take them out of our traditional practices and into opportunities where income can be guaranteed rather than being dependent on the seasons and the climate to provide for their families.

During the economic downturn in Palau in years 2008 and 2009, Palau’s GDP fell by 3% and 12%, respectively, reflecting the world financial recession. In 2010, the economy grew by 1.3% and gathered momentum in 2011 and 2012 with a surge in tourist arrivals.  In 2013, the economy contracted by 1.6%, with a significant drop-off in construction activity and declining tourist arrivals.  The economy’s estimated growth for 2014 was 5.4%, reflecting strong growth in tourism and related activities.  However, the current level of economic activity is below that attained in the mid-2000s when large infrastructure projects and a vibrant tourism industry led to a record GDP.  The estimated real GDP per capita grew by USD 1,028 since the 2006 HIES, from USD 9,500 to USD 10,528 between 2006 and 2014, respectively.  (2014, ROP Household Income and Expenditure survey).

Socio-economic characteristics play an important role in determining the quality and accessibility of preventive screening and medical services.  Since gaining independence in 1994, Palau’s economy has grown steadily fueled by steady growth in tourism and aid-funded infrastructure development.

Despite economic growth, inflation has undermined the well-being of many families.  Sharply escalating fuel prices triggered a 200% increase in consumer prices and a 300% increase in food prices.  Given the high level of dependence of Palauan families, especially lower income families, on imported foods, this highly inflationary period undermined the well-being of everyone, but especially the most economically vulnerable.

Over the past 15 years, employment has nearly doubled for both men and women, however, women only account for approximately 40% of the workforce.  This is likely due to a higher proportion of foreign male workers, coming to Palau to fill labor positions.  These foreign workers also have a lower minimum wage than native Palauans, likely contributing to higher unemployment among Palauans.

The 2006 Household Income & Expenditures Survey (two weeks of field work) estimated the Basic Needs Poverty Line (BNPL) for Palau to be US $244.67 per household per week.  With this index, it was estimated that approximately 24.9% of the nation was living at or below the BNPL with a slightly higher proportion of rural-dwellers living in poverty than urban-dwellers.  Subsistence living, defined as producing goods for one’s own family’s use and needs (e.g. growing or gathering food; fishing; cutting copra for home use; raising livestock; making handicrafts for home use), is still commonly practiced especially in the rural areas of Palau and not counted as ‘Employed’.  According to the 2014 HIES survey (took place over 12 months) revealed that real household income had not changed since 2006 and only had slightly increased by 0.1% increase per year.

The highest proportions of poor households were Kayangel, Angaur, and West Babeldoab.  For Kayangel and Angaur, their remoteness from Koror is likely a major factor in their relative level of disadvantage.  For those in West Babeldoab the situation is more complex; it appears that there is considerably more movement to and from Koror with many families living in the urban center during the week and returning to their villages on the weekends.  According to the HIES report, there is anecdotal evidence to suggest that many working couples may leave children in West Babeldoab villages to be looked after by grandparents and that unrecorded gifts of food and other essentials mitigate the low expenditure recorded by these households in the survey.

HEALTH CARE AND EDUCATION SYSTEMS

Health services in the Republic of Palau continue to be heavily subsidized by the Government. However, a great proportion of this budget goes into funding of secondary and tertiary medical services.  Almost all funding that goes into supporting MCH basic services are derived from U.S. Federal and other bi-lateral and multi-lateral sources.  Preventive health care is mandated by the Constitution of Palau to be provided “free or subsidized by the Government”.  Health care services in the Republic of Palau are provided primarily through the government’s Ministry of Health that manages the Belau National Hospital, the only hospital facility in Palau.  The ministry provides comprehensive primary, secondary and limited tertiary services, including both preventive and curative care through a 80-bed hospital and Community Health Center/Public Health Clinic located in the most populated state.  Community Health Centers are located in most of the outlying states and islands.  The dispensaries are staffed by medical personnel trained in primary health care, while the Public Health clinics and the Palau Community Health Center and Belau National Hospital (BNH) are staffed by physicians, medical officers, registered nurses, graduate nurses, laboratory technicians, and health assistants.

Primary and preventive services are provided through the Bureau of Public Health. Family Health Unit and the Community Health Center Programs are two service delivery systems for primary and preventive services.

The Family Health Unit/MCH Program receives majority of its funding from HRSA.  Because of our government’s inability to fund indicated improvement from year to year, other funding streams from HRSA and other external agencies are used to initiate improvement directed at MCH Program.  Through these changes in the program we are now able to develop more evidence-based program strategies and activities that are effective in addressing needs of the Palau MCH population.  Government of Palau’s funds are usually used to pay staff salaries, fringe benefits and other costs related to direct patient care. It is also used to fund secondary and tertiary care rather than public health related services.  Palau FHU/MCH Program has traditionally been funded through bi-lateral and multi-lateral funding sources.  Some examples of these funding sources are UNFPA, UNICEF, Title V MCH Program, and from time to time, direct in-kind assistance from other sources such as Japan, Korea, Taiwan and other countries. Palau is considered a developing island nation with limited financial resources and therefore at this stage of its development, relies mainly on these funding sources for preventive, promotional and primary health care.

Palau remains a medically underserved area with limited medical capabilities. A majority of Palau’s population fall below the 100% federal poverty guideline.  By USA standards, the entire nation of Palau is a rural area.

As a part of the Compact agreement, Palau is eligible to receive funding and support from various federal programs.  For instance, under the Department of Education, Palau is eligible for funding under the Special Education program, but not for funding for the Early Intervention Program for Infants and Toddlers with Disabilities (Part C).  Under the Department of Agriculture, Palau is not eligible for WIC or SNAP (Supplemental Nutrition Assistance Program).  Most notably, Palau is not eligible for the Maternal, Infant, and Early Childhood Home Visiting Grant (MIECHV) and Medicaid. Palau however is eligible for and has been the recipient of the MCH Title V Block Grant and other MCH funding streams including the UNHSI funding.  The MCH Block grant and UNHSI are the two primary funding streams within the Bureau of Public Health, Ministry of Health supporting services and activities relating to early childhood care.

Although there are existing services in Palau that provide care/services to newborn and young children, challenges continues to exist that must be addressed in order to assure timely and appropriate screening and interventions within the area of newborn hearing services.  Currently the newborn hearing program in Palau is faced with the following challenges (1) No single entity that addresses the needs of 0-3 year old age group, except the Maternal and Child Health Program of the Ministry of Health; (2) the lack of cohesive agency collaboration and fragmented services makes sharing of resources difficult, (3) lack of culturally appropriate materials that are relevant to Pacific populations, (4) lack of audiologist and trained early intervention providers on island; (5) limited trained personnel to do screening and equipment maintenance, (6) the concept of medical home must be developed with “families” in mind and therefore, parental education should be the focal point of creating the change necessary for this concept.

Palau’s early childhood system of care needs enhanced services and capacity support and a stronger infrastructure to coordinate and uphold its role in early childhood care.  Although Palau has a number of multi-system efforts currently taking place, there has been fragmentation of these efforts, and no single point at which these efforts for early childhood merge.  Early childhood programs for young children are found in a variety of state departments and divisions, and private service organizations.

Programming follows funding stream requirements which do not always consider the benefits of integrated, comprehensive services.  The categorical funding which targets specialized services to specific populations may have even created obstacles to improved services through partnerships and collaboration.  Since Palau is not eligible for Part C of IDEA and lacks Medicaid and SCHIP and does not have early head start, services geared toward the 0-3 age group are almost nonexistent.  Family Health Unit/MCH program have developed strong partnerships to bring together health care providers, early care and learning programs, family support services and others to plan for and provide services for children, but no comprehensive system exists to connect state, federal, community and private providers.

Lack of an audiologist on island pose significant barriers to providing the necessary services for newborns and children at risk for hearing disorder.  Palau is limited in its medical capabilities to provide specialized care for children identified to have hearing losses.  This is further compounded by other geographic and economic issues that pose challenges for families in the rural Babeldaob to receive the needed services.

The Maternal and Child Health Program is the only program in the Republic of Palau that provides promotive, primary and tertiary health care services for children 0-5 years of age. These services are primarily clinic based.  MCH Program also provides mass education program through public radios, television, community education, school talks or interest group discussions. It is also a key stakeholder in the CSN/High Risk Collaborative Clinic (with membership of Head Start and Special Education’s 0-3 program) and the Palau Child Care Program, located at the Palau Community College Campus.  MCH has always been active in creating community partnership in delivering specially targeted health issues.

Palau began newborn hearing screening in 2006.  Since the inception of newborn hearing screening, one (1) child in 2008 was identified with congenital hearing loss.  This re-screening is done within the first month in Family Health Unit at the 2- weeks routine well-baby check-up.  It also indicates a great proportion of newborns are screened prior to hospital discharge.  Some health risk factors of the population that makes Palau a high risk for congenital hearing loss and hearing loss that happens during the developmental years of children is the infant mortality rate. Prematurity and congenital anomalies are the major causes of infant mortality in Palau.

Organizational Information

The Title V MCH Block Grant implemented by the Family Health Unit.  The direction of the Program is under Sherilynn Madraisau who is the Director of the Bureau of Public Health and Edolem Ikerdeu, Chief of the Division of Primary & Preventive Health.  This is seen as a viable administrative structure for the Project as it crosses public health into the hospital. Kliu Basilius, Acting Program Manager for the Family Health Unit works with Sherilynn Madraisau and Edolem Ikerdeu to assure that the project attains what it was set out to do, but also to assure that these screening activities are integrated as routine services in the on-going neonatal and well-baby services that we offer in Palau.

At present, the Family Health Unit is a service component of the Division of Primary Health Care, one of four divisions within the Bureau of Public Health.  The Family Health Unit Acting Program Manager oversees all managerial activities of the Unit including grant writing, data analysis and reporting of important factors influencing the health of the MCH population.  Within the Unit, a Clinic Nurse Supervisor oversees all clinic activities.  An OB/GYN and a Pediatrician are on schedule to the Unit to provide services to the Unit’s clients.  Other specialists also provide services to clients through referral process.  The unit manager is also charged with coordination and implementation of the Palau Interagency Project

The FHU Acting Program Manager works closely with the FHU Clinic Nurse Supervisor and the Primary Health Care Division to ensure that activities undertaken are in conjunction with the planned Goals and Objectives set forth by the Maternal & Child Health Program and the Primary Health Care Division.