II.A. OVERVIEW OF THE STATE

Geography & Demography

The FSM is an island nation consisting of approximately 607 islands in the Western Pacific Ocean. Although the total area encompassing the FSM is very expansive, the total land area is only 271 square miles with an additional 2,776 square miles of lagoon area. The 607 islands vary from large, high mountainous islands of volcanic origin to small flat uninhabited atolls. The FSM consists of four geographically and politically separate states: Chuuk, Kosrae, Pohnpei, and Yap. 

The State of Chuuk consists of 15 high volcanic islands in the Chuuk Lagoon and a series of 14 outlying atolls and low islands. There are three geographic aspects to Chuuk, the administrative center of the state on the island of Weno, the islands of the Chuuk Lagoon, and the islands of the outlying atolls - a total of approximately 290 islands in all. The 15 islands of the Chuuk Lagoon have a total land area of 39 square miles; and the lagoon itself has a total surface area of 822 square miles and is surrounded by 140 miles of coral reef. Because of the vast expanse of water between islands, travel within the State of Chuuk is difficult. Within the lagoon, travel by boat from Weno to any of the other islands will take from 1.5 hours to 2 hours. Access to the outer islands is even more difficult with travel times on a cargo ship taking from four hours up to two days. The provision of health care, including MCH program and family planning services, to the population of Chuuk is made difficult by the lack of transportation and communication with widely dispersed, small clusters of the populations on outer and lagoon islands.

The State of Kosrae is the only single-island state in the FSM and the furthest southeastern point of the four FSM states. Because of the steep rugged mountain peaks, all of the local villages and communities are coastal communities connected by paved roads. Travel around Kosrae island is not difficult and it is possible to drive from one end of the island to the other end in approximately two hours of easy driving. The state is divided into the four municipalities of: Lelu, Malem, Utwe, and Tafunsak. However, the community of Walung (approximate population of 200) is part of Tafunsak municipality, is isolated and only accessible by a ½ hour boat ride at high tide.

The State of Pohnpei consists of the main island of Pohnpei and eight smaller outer islands. The island of Pohnpei, the largest island in the FSM, is approximately 13 miles long with a land mass of 129 square miles. It is subdivided into five municipalities of Madolenihmw, U, Nett, Sokehs, Kitti, and the town of Kolonia where the majority of the government buildings and offices, and the Pohnpei State Hospital are located. Of the outer islands of Pohnpei, to the south lies Kapingamarangi (410miles from Pohnpei proper), Nukuoro (308 miles), Sapwuahfik (100 miles), Oroluk (190 miles), Pakin (28 miles), and Ant (21 miles). To the east lie the islands of Mwoakilloa (95 miles) and Pingelap (155 miles). These outer islands together comprise a land mass of approximately 133 square miles and 331 square miles of lagoons. Travel on the island of Pohnpei proper is increasingly easier to outlying communities with the completion of pavement of the road around the island. However, because of scattered housing along feeder unpaved dirt roads, there are still many residents who have difficulties in accessing health care including MCH program. The outer islands are the most difficult to reach because of the infrequent and undependable ships to bring supplies and health personnel to deliver goods and services.

The State of Yap lies in the western most part of the Federated States of Micronesia. Yap proper is the primary area in Yap state and is a cluster of four islands (Yap, Gagil-Tomil, Maap, and Rumung) connected by roads, waterways, and channels. The town of Colonia on Yap proper is the capital. Yap has a total of 78 outer islands stretching nearly 600 miles east of Yap Proper. Island of which 22 islands are inhabited. Although these islands encompass approximately 500,000 square miles of area in the Western Caroline Island chain, Yap state consists of only 45.8 square miles of land area. Most of the outer islands are coral atolls and are sparsely populated. Transportation on Yap Proper is easier because of the development of paved roads; however, there are clusters of villages that are still inaccessible to health and MCH program services because of unpaved dirt roads. The outer islands are also difficult to reach because of infrequent ships to bring supplies and health personnel to deliver goods and services.

Population distribution

Based on the 2021 Census projection, the total population of the FSM is 104,832 residents. Kosrae, with the smallest population, has 6,744 residents (6.4%); then Yap with 11,597 persons (11%); then Pohnpei state with 36,896 (35.2%). Chuuk has the largest population with 49,595 residents (47.3%). There are 23,533 women of child-bearing years of 15-44, which is 22.4% of the total population. The population structure continues to show that 49,627 (47.3%) of the residents are under 20 years and children under five-years comprise 12,306 or 11.7%.

About 35.7% of the total population were aged 0-14 years, 58.7% were aged 15-59 years, and 5.6% were aged 60 years and above. The median age is 21.5 years, an increase of about 3 years since 2000, indicating the FSM population is ageing. The sex ratio 102.7, indicating the FSM population is dominantly male.

Age structures of all the states, including many of the outer islands, are undergoing dramatic changes, associated with international and rural-urban migration combined with an on- going transition to lower rates of fertility and mortality. Overall, the population is contracting in the 0-9 age group while increasing in the 10-19 age group as a result of previous fertility levels. In Yap and Kosrae the 20-44 age group shows the effects of age-selective out-migration.

Dramatic age-structure changes are also evident in the outer islands of Pohnpei, Chuuk and some municipalities of Kosrae. Such age distributions have major consequences for local production as well as social welfare and health care, particularly of older women and children who are often "left behind".

System of Care Population Served

The 2020 FSM population projection estimates showed that there were 22,693 women of reproductive age (defined as women 15-44 years old). It was reported that about 1,700 of the women who are pregnant had received direct services from the MCH programs in 2021.

The number of infants (less than one year old) in the 2020 FSM population projection was 2,140. The 2020 population estimates show that there were 44,215 of children ages (0-19 years old) including the CSHCN population.  About two third of this age group was served by the MCH programs services.

Government

The President and the Vice President of the Federated States of Micronesia are the highest Chief Executives of the FSM. They are elected from among fourteen members of the National Legislative branch, which is the national Congress. Four of them represent each of the four states for four-year terms, and the other ten members apportioned based on the population. They only serve their terms for two years. Currently, Chuuk has six seats in the Congress, Pohnpei has four, and the remaining four are two seats for Yap and two seats for Kosrae. All members of the Congress get elected by their respective state eligible, registered voters. Although there is the FSM National Constitution that holds the four FSM states together, each of the four states has its own state Constitution. Each of them replicates that of the national government with three branches of separate powers. Each of the FSM states has considerable autonomy and each one of them is equally unique in its own geography, ecology, language and cultures. Each state has unique cultural characteristics which are as important as the others.

The four FSM states are united and regulated under the FSM National Constitution. The Constitution provides separation of power of the three branches of government, the Executive, Legislative and Judiciary. Unlike the USA, most of the government functions are carried out at the state levels, except foreign policy and national defense are carried out at the national level.

One of the strengths that impact the health status of the FSM MCH population is the existing governmental structure.  Although the FSM National Constitution holds the four FSM states together, each of the four states has its own state Constitution. Each of them replicates that of the national government with three branches of separate powers. Each of the FSM states has considerable autonomy and each one of them is equally unique in its own geography, ecology, language and cultures. Each state has unique cultural characteristics which are as important as the others. One of the known challenges that the four MCH programs encountered is the cultural diversity which in itself is challenging and typified by the existence of eight major indigenous languages. However, with the existence of English language as the official language throughout the islands in the governments, schools, and commercial businesses, it lessens the burden of not understanding one another when languages become the barrier.

Economy

The FSM's economy remains dominated by the public sector. Over 50% of the labor force is employed in public administration or state-owned enterprises and the government sector generates 40% of gross domestic product (GDP). Despite the combined efforts of the FSM Government, the U.S. Government and various development partners, little new private sector investment has occurred.

According to the latest Household and Income Expenditure Survey (HIES) in 2013/14, the FSM per capita income was $2,112. The average household size was 6.2 persons. The average household income for the FSM household was $16,950. Pohnpei had a much higher household income at $22,293. Chuuk has the lowest household income at $11,398. Kosrae and Yap household income lies in the middle at $18,461 and $17,768 respectively. The median individual and household incomes for Yap, Pohnpei and Chuuk main islands were higher than the median incomes of the outer islands creating even further disparities. Thus, the need for MCH services among the poor remains high.

Insurance status

The majority of the FSM population does not have health insurance. Health care is provided at a minimal cost by the government. MCH funding for services and Family Planning commodities are provided with no cost given they have been donated by US HHS & UNFPA, who prohibit their resale.

In the FSM are designed and delivered at the State level. At the State level, the Department of Health Services is headed by the Director of Health, who is appointed by the Governor of the State and is responsible for all medical and health services in the state. Each state has a central State Hospital with medical, nursing, and support personnel that provide all of the acute inpatient and outpatient medical services for the residents of the state. Each State now has a 330-funded Community Health Center. There are very few private health care providers in FSM, but Pohnpei State has several that add extra service delivery for the population in Pohnpei.

Organizational Structure

There are two levels of government in the FSM, the National Government level and the State Government level. The FSM is self-governing with locally elected President, Vice President and Legislature at the National level. Each State also elects a Governor, Lieutenant Governor, and Legislature. For the purposes of receiving US Federal Domestic Assistance, the National Government is designated as the "State Agency". However, all funds approved by the US Federal Government to support Title V and allocated to the FSM Government are further allotted to each State MCH Program by way of Advice of Allotments issued by the National Budget Office, under the FSM national Finance administration.

At the National level, the Secretary of the Department of Health and Social Affairs (H&SA) manages health affairs for the nation. There are several divisions under H&SA, including the Division of Health Services which houses the Family Health Services Section. The Title V Maternal Child Health (MCH) Program is one of the Five programs under the Family Health Services Section along with Title X Family Planning program, UNFPA Family Health Project, HRSA funded Early Hearing Detection and Intervention (EHDI) Programs, and State System Development Initiative (SSDI).

Title V Program Structure

The administration and management of the Title V Program is under the direct supervision of the National MCH Program Manager at the FSM Department of Health and Social Affairs, who provides guidance and works closely with each of the four State MCH Coordinators. Within each of the four States, under the direction of the State Director of Health, the Public Health Division administers the Title V Program. The MCH Programs provide primary care and preventive services to adolescents and women of childbearing age, education in the communities and schools, and counseling services to mothers during antenatal and postpartum clinics. The Title V Program will also prioritize and continue to strengthen its partnerships with relevant programs and stakeholders such as the National Immunization program, National Non-Communicable Disease (NCD) program, State Women Councils and other National, State and Non-Governmental Organizations (NGO’s).  

Youth Suicide

As mentioned in the “Adolescent Suicide in the Federated States of Micronesia: A Literature Review” by Paulette M. Coulter Youth suicides and suicidal ideation are currently increasing in the U.S. and other developed and developing countries. Because the family is the initial core of culture in individual lives, the family must be the place to start. The research done by Francis X. Hezel and Donald H. Rubinstein had shown that conflict with someone in the family or with family expectations is often a precipitating event of suicide, and these conflicts may differ by island culture as well as by individual. Highest rate of Micronesian suicides occurs among males aged 15 to 24, and the preferred method is hanging, with death by anoxia. Anger and alcohol use may precede the suicide. For nearly fifty years Hezel and Rubinstein have collected data on more than a thousand suicides in Micronesia through records searches and through psychological autopsy.

Financial Management

The FSM Title V Program is managed by the FSM National Government, Department of Health and Social Affairs (DHSA), which is located at Palikir on the island of Pohnpei.  For the purposes of receiving U. S. Federal Domestic Assistance, the National Government is designated as the "State Agency".  However, all funds approved by the U. S. Federal Government to support Title V program and allocated to the FSM Government are further allotted to each State Title V Program by way of Advice of Allotments issued by the National Division of Budget, under the administration of the Department of Finance and Administration.  The Title V program employs a Program manager at the National level, and the State Title V programs employ all clinical and non-clinical staffs who are taking care of the management of the Title V programs in their respective States. All MCH clients seeking Title V services in the four FSM States have reported either low incomes or no income at all. The Public Health Department provides all of the preventive and primary health care services at no cost to the clients. 

Emergency Preparedness

There is a National Disaster Response Plan established in 2016 for the FSM which is called “Federated States of Micronesia National Disaster Response Plan 2016”.  This plan provides for the establishment of national institutional arrangements for the Federated States of Micronesia (FSM) government for responding to emergency and disaster events within the country. It includes arrangements for preparedness, monitoring for potential events and response at the national level to manage national level events and support state level events. It also outlines arrangements to guide state disaster response plans and their connection to the national level arrangements. It includes provisions for accessing international support.

Other Issues

The FSM, like many Pacific island countries and territories, face a triple burden including communicable disease, noncommunicable disease, and the health impacts of climate change. Adverse effects of climate change and highly vulnerable nature disaster are areas that the nation is still focusing on for the country and its partners. These natural disasters tore through the islands of the FSM causing fatalities, damaging houses, crops, and public infrastructure, and causing millions of dollars in damage.

As usual, other barriers and challenges that all the MCH programs in the four FSM States do encountered are shared and exist in the MCH population domain.  Demographic Setting of the islands is always a challenge, and it has been a major barrier in the healthcare services delivery to the in-need population.  Transportation issues either by land or air is very expensive and most families could not afford in the long run.  Data collection from hard to reach areas and the Outer Islands is an ongoing issue that the MCH programs are still tackling.  All of these existing issues in the MCH programs had been discussed and deliberated upon for better solutions. 

The FSM Department of Health & Social Affairs (FSMDHSA) had convened a National Health Summit from April 22-26, 2024. The Health Summit was attended by the leaderships from the National and State Governments as well as key stakeholders. Technical and resource experts are presented to the leadership recommendations as to how the FSM will achieve better health for all beyond 2033.  The objective of the Summit was:

1. Understand the challenges impacting health development in the FSM;

2. Have general understanding of the current capacity of the healthcare delivery system;

3. Better appreciate the concept of Universal Health Coverage and its application to the FSM; and

4. Reach a common understanding of what the next steps should be to improve the overall health services in the FSM.

The FSM MCH program did a presentation on the trend of the MCH activities for the decade, and also had breakout sessions on the MCH topics.

Japan International Cooperation Agency (JICA) introduces Project for Pacific Co-Learning Towards Resilient Health System was introduced as pilot project in the States of Pohnpei and Chuuk currently this year.  The purpose of this project is the capacity of continuum of essential health service provision of MCH in health emergencies is strengthened in the FSM.  Expected Outcomes from this initiative:

Policies/guidelines integrating the provision of MCH essential health services in health emergencies are established.  Human resources development to provide essential health services to mothers and children continuously under health emergencies are enhanced. Capacity to utilize digital technology is strengthened to provide essential health services in the digital technology (DT) pilot area. Networking among the Pacific Island Countries (PICs) is strengthened to share experiences and practices regarding the continued provision of essential health services, such as MCH in health emergencies.