Geography

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 islands 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).

History/Culture

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.

Demographics

Palau has experienced a tremendous decline in population over the past ten years.  Palau’s population, based on the 2020 census, is 17,614.  Gender difference indicates more males than females in all age groups except those 65 and above.  Approximately 42% are within the reproductive age group (15-44), while children and infants 0 through 17 comprise about 24% (Table 1).  Population growth continues to decline by high levels of Palauans moving to the United States and other neighboring countries and territories in search of better education and job opportunities.  The population growth rate in Palau is at 1% annually.

Although Palau’s racial and ethnic minority populations are growing, a large majority are Palauans. Therefore, population distribution by race and ethnicity was estimated as follows: Pacific Islander (72%); Asian (26%); all other races (2%).  Children and youth with special health care needs is 4% of the 0 to 18 years population.

Palau’s commonly spoken language is Palauan, and it is the official language spoken in most of the islands. The second most widespread language spoken in Palau is English. Most young adults and children of all ages speak fluent English at home and in the community. In addition, 96.6% of the population are literate (15 and over who can read and write).

Another important reproductive health indicator is the age specific fertility rate and the total fertility rate.  The total fertility rate in 2022 was 1.5 or a woman in reproductive age would have 1.5 children at average in her lifetime.  Reviewing the 5-year trend, it indicates a declining trend overtime.  Furthermore, the annual crude birth rate in 10 years indicates a similar trend at 11.2 per 1,000 live births.

Healthcare

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 64% of Palau’s residents. Koror is also the location of Palau’s only hospital (Belau National Hospital), the Central Community Health Center (Central CHC), three private medical clinics, and two private dental clinics. The neighboring state of Airai, with 14% of the population, is also home to Airai CHC.

Primary and Preventive services are provided through the Bureau of Public Health.  Under the most recent organizational structure of the Ministry of Health and Human Services, the Bureau of Public Health, Maternal and Child Health Program is under the direct management of the Chief of the Division of Primary and Preventive Health Services.  The Central Community Health Center in Koror is where most services are available for the MCH population. MCH provides services for children with special health care needs, high risk prenatal mothers, population services such as prenatal/postnatal care, childhood immunization, family planning, gynecological and cancer screening services, well-child services, male health services, school health screening and intervention services. Funding is directed toward services that are designed to improve performance measures and address state priorities. The Title V MCH Block Grant is 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 Human Services; and Edolem Ikerdeu, Chief of the Division of Primary & Preventive Health.  This is seen as a practical administrative structure for the project as it crosses public health into the hospital. Other Divisions under the direction of the Public Health are the Division of Behavioral Health, Division of Environmental Health and the Division of Oral Health.  These divisions work collaboratively to ensure that general public health initiatives work together to improve the lives of those that live in Palau

The Ministry of Health and Human Services receives its annual budget from congressional appropriations. Per traditional usage of the health budget, population services such as those provided by the Bureau of Public Health receive the least revenue.  At least three-fourths of the Bureau’s budget for implementing preventive and primary health care programs and services comes from external sources through the US Federal Grants, WHO funding, and other multi and bilateral sources.  With this analogy, most local revenue goes directly to hospitals and tertiary medical services. MCH direct services often compete for local resources that fund primary health care.

CSHCN in Palau often finds their healthcare needs unmet for various reasons, such as provider shortages, lack of access to specialists, lack of transportation, healthcare infrastructure, and long-term financial support. With limited specialty services, most children requiring further evaluation and treatment are sent off-island placing unprecedented stress on state budgets across the nation, threatening programs supporting the needs of CSHCN, and further exacerbating service gaps.

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 Babeldaob.  For Kayangel and Angaur, their remoteness from Koror is likely a major factor in their relative level of disadvantage. For those in West Babeldaob 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 Babeldaob 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.

In 2020, the impact of the pandemic affected Palau’s economy, education and health services and overall health and wellness of every man, woman and child.  The closure of our borders occurred in April and followed through the end of the year and through very strict guidelines, planes were allowed entry to bring in stranded residents and emergency supplies. Shipments of goods via air and sea had many delays as many international ports were working on their own procedures to ensure human safety. Palau being heavily reliant on tourism dollars as a driving force for commerce, the economy saw a sharp reduction in earned income, sales of commodities and eventual job loss.  This job loss extended outwards to include small businesses, fishing/farming to market business, hospitality industry and general merchandise sales.

Palau women and children experience disproportionate health outcomes in several domains. The causes of these disparities include long history of colonization and loss of traditional lifestyles. As Palau population adopts to western lifestyle and diet, the incidence of chronic diseases such as diabetes, heart diseases, and cancer become an increasing concern.

With the islands geographically isolated by water with less work opportunities, low income and higher cost for food, fuel, and supplies, as well as barriers to accessing health care services are among the contributing factors.

Geographic isolation means significant challenges in assuring all MCH populations have access to routine preventive care, and acute medical and specialty care. The Community Health Centers have no facilities equipped for childbirth, so pregnant women must leave their homes before their due date and travel to Koror for birth. Even well-child check-ups, prenatal exams and regular dental exams are difficult to provide. Recruiting and retaining physicians and primary health care providers for the centers is an ongoing barrier to providing health care services.