State Description

 

Geography & Demography

The Federated States of Micronesia (FSM) — made up of the four states of Yap, Chuuk, Pohnpei and Kosrae — has a population of approximately 113,815 people and shares maritime borders with the Republic of the Marshall Islands, Palau, Guam and Papua New Guinea. The capital, Palikir, is located on the island of Pohnpei.

 

FSM 2025 HIES Report

 

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 (Kapingamarangi, Nukuoro, Sapwuahfik, Oroluk, Pakin, Mwoakillo and Pingelap) 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. These outer islands together comprise a land mass of approximately 133 square miles and 331 square miles of lagoons. Scattered housing along unpaved dirt roads is still a major challenge for many residents who have difficulties in accessing health care including the MCH population. 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 current FSM HIES report, the total population of the FSM is 113,428.

 

 

 

 

 

                 2025 Household Income and Expenditure Survey (HIES)-population projection

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The 2020 FSM Census is yet to be released, so 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%.

 

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 because 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".

 

Government

FSM is an independent country in a Compact of Free Association with the United States. FSM has an American-style constitution that came into effect in 1979 and provides for a government composed of an executive branch, a legislative branch and a judicial branch.

 

The National Congress is unicameral and consists of 14 members. Four senators, each known as "senators-at-large" (one from each state) serve four-year terms. The remaining 10 members represent single member districts based on population and serve two-year terms. Both the President and the Vice-President are elected by the Congress from among its four-year members and serve a four-year term. The senator-at-large seats vacated by the President and Vice-President are filled by a representative from their state. An appointed cabinet supports the President and Vice President. Each of the four states has its own constitution, an elected governor and a lieutenant governor. The President of FSM, H.E. Mr. Wesley W. Simina, is both Head of State and Head of Government. President Simina took office in May 2023.

 

The four 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 government functions are carried out at the state level, 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 differences which 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.

 

FSM's Compact of Free Association with the United States was first agreed in 1986 and came into effect in 1994. The compact terms are indefinite, while the economic elements have a 20-year term, with reviews throughout the course of the term. In exchange for exclusive military operating rights, the United States provides FSM with economic assistance (including sector grants and trust fund contributions), access to federal services and programs (for instance postal and meteorological services), permission for citizens to enter, work/study and reside in US states and territories and assumes responsibility for FSM's defense and security.

 

The current Compact agreement between FSM and the United States was signed into law in March 2024 and is valued at USD 3.3 billion for FY2024-FY2043.  This phase of Compact assistance includes greater support for the environment, climate change adaptation, health care, education, and infrastructure.  The US Department of the Interior is responsible for oversight and coordination of funding under the Compact of Free Association.

 

Economy

FSM's economy is dominated by government services and external grants, with relatively limited private sector activity. FSM's small, remote and dispersed population, narrow range of natural resources, and vulnerability to external shocks present challenges to growth. The fisheries sector is regarded as having the greatest development potential. With an EEZ of 2.7 million square kilometers, FSM has access to major equatorial tuna migratory paths, and the fishing industry has been boosted by the introduction of the Vessel Day Scheme under the Parties to the Nauru Agreement. Fishery licensing fees account for nearly half of domestic budget revenue. The tourism industry is another area of potential for FSM, particularly diving and eco‑tourism. Some 21,000 tourists visit the islands each year. Tourism development is, however, constrained by limited airline links, limited infrastructure, including roads, power and water, and by the country's geographical isolation. 

 

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 products (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 2024/25, the FSM per capita income was $3,836. There is no readily available data on average households in 2024 and average household income for the FSM household. The median individual and household incomes in 2013/2014 for the main islands were higher than the median incomes of the outer islands creating further disproportion. Thus, the need for MCH services among the poor and hard-to-reach areas 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. Most of the Public health programs including MCH and Family Planning programs provided services to individuals with no cost, given that these programs are federally funded by the US government or other UN partners free of charge.

 

At the State level, the Department of Health Services is headed by the Director of Health, who has been 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 the acute inpatient and outpatient medical services for the residents of the state. Each State has their own funded Community Health Centers. There are few private health care providers in FSM, and some of the clinics that provide health services to people don’t accept government health insurance.  FSM government has only one health insurance called Micare.  All government employees are mandated to enroll under this insurance and pay an extra amount if they want to enroll family members.

 

Organizational Structure

There are two dominant levels of government in the FSM, the National Government level and the State Government level, while the municipal government is the third level of government. 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 through advice of allotment issued by the National Budget Office.

 

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).

Health service delivery is the responsibility of the Department of Health Services (DHS) at state level which manages the states´ hospitals to provide curative care, and a network of state-run dispensaries and community health centers (CHCs) to provide preventive and public services across the states. For example, the CHCs do not follow the essential service package for the primary care level.  Furthermore, different service delivery models co-exist at primary care level according to the state’s context and resources. For example, Chuuk state is expanding the CHC model building state run super-dispensaries in the maritime areas; Kosrae and Yap are relying on non-state CHCs in the main island and Yap OI are covered by the state dispensaries; Pohnpei state is consolidating a mobile team model, where dispensary services are expanded on certain days per month or per year depending on the dispensary location. Kosrae state relies on a network of CHC to decentralize certain public health services while other essential services remain centralized at the state hospital. Multi-program outreach services are regularly available and operational across all four states; however, limited community profiling and weak mobilization around outreach services in certain states, diminish their effectiveness.

 

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 women of childbearing age, children, adolescents and CSHCN. Community outreaches are conducted through education and awareness in the communities and schools, and counseling services to mothers during antenatal and postpartum clinics. The Title V Program also prioritize and continue to strengthen its partnerships with relevant health programs, stakeholders, National and State Non-Governmental Organizations (NGO’s), and affiliated UN partners – WHO, UNFPA, UNICEF, JICA etc.

 

The FSM Title V Program is managed by the FSM National Government, Department of Health and Social Affairs (DHSA).  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 program employs all clinical and non-clinical staff 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 the preventive and primary health care services at no cost to the clients. 

 

Youth Suicide and Youth Mental Health in the FSM

The FSM's commitment to mental health is evident in its efforts to improve access to clean water, enhance public health services, and support the mental health of its population through various programs and research initiatives.  Youth with Physical and Mental Health concerns - those who are under physical, mental and emotional stress, and those who are at risk of getting non-communicable diseases.  In agreement with the provisions of various Sections of Article IV of the FSM Constitution and other International Conventions, a policy was proposed that young people of the FSM be entitled to: Fundamental freedoms in accordance with the governing laws of the FSM; Have access to appropriate services and benefits that ensures their physical, mental, spiritual, moral and social development; A healthy and secure social and physical environment that promotes healthy lifestyles; Receive an education from early childhood to the highest level possible; Proper care and guidance from parents and care givers who have the responsibilities for their upbringing at home and in the community; Participate in decision-making processes on issues affecting them; and be free of unfair treatment, violence and abuse of any form.  This is the fundamental belief that the youths in the FSM should get all the good things in life.  Despite all the effort the government dictated, the youths in the FSM still tackle suicide and mental health issues in daily life. 

 

As mentioned in the “Adolescent Suicide in the Federated States of Micronesia: A Literature Review” that 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 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.

 

The “2021 U.S. Pacific Asia Inquiry”, Volume 13, Number 1, Fall 2022 115 DHHS report offers, as assessment, major reasons for committing suicide in the FSM:

1.Alterations in the family relationships and structures following the colonization periods and moving on into a new era where change is inevitable. 2. A reduction in dependence on subsistence production and more reliance on cash economy may have affected the importance of clan activities and lineage. 3. Undermining of the social supports structures for adolescents caused by unaccustomed reliance on the nuclear family leading to a rise in parent-adolescent conflicts. 4. Suicide has somewhat been accepted/expected (to some extent) and become more familiar among youths in the resolution of conflicts/social problems faced in society. 5. The Micronesian belief system that pertains to communication in spirit may also be another factor for influence from one suicide to another. 6. Despite the findings that suicides were a result of impulsive behavior, there is a trend involving long-term intolerable situations and the preference to withdraw and handle matters indirectly rather than confrontation.

 

Emergency Preparedness

The coronavirus disease 2019 (COVID-19), which spread globally since the early 2020s, has also reached to countries in the Pacific Region including the FSM. The outbreak highlighted the challenges for hesitation of the population to receive health services due to concerns on infection, in addition to the centralization of human and material resources to COVID-19 responses. In response to the situation, in the Pacific Region, the World Health Organization (WHO), the Secretariat of the Pacific Community (SPC), and other development partners, as well as the Joint Inter-Ministerial Team (JIMT) formed by the national health ministries, provided financial, technical, logistical, information, and monitoring support for the COVID-19 response. The JIMT provided financial and technical support for COVID-19 measures, as well as logistical, informational, and monitoring support. In this context, guidelines for maintaining the continuous provision of essential health services were also developed and introduced.

 

The FSM DHSA in collaboration with Japan International Cooperation Agency (JICA) embarked on The Project for Pacific Co-Learning Towards Resilient Health System.  The overall goal is to respond to health emergencies in the FSM and the capacity of continuum of essential health service provision of MCH in health emergencies is strengthened. The guidelines describe the content of essential services to be provided in health emergencies by health program, as well as the system and methods of provision. The media involvement and utilization, including social media and digital technology.

 

There are a few standard guidelines used in all the four states. According to DHSA, Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) and Digital/eHealth, policies/guidelines are planned to be developed, but not drafted yet. In addition to these strategies/guidelines, “the Health Dispensary Standard” was published in 2018, including monitoring tools, a list of essential supplies, and essential medicines, a budget needed for annual monitoring of dispensary standards, a list of monitoring indicators, and a list of essential health services. Available strategies/guidelines at the national are stated are: National Immunization Strategy, Family Planning Guideline, Vaccine Cold Chain Management Guideline and The Health Dispensary Standard.

 

FSM's PREPAREDNESS AND RESPONSE

In the current FSM Health Sector Development Plan, it aims to enhance population access to comprehensive family health and life-course cross-cutting programs, including behavioral health, eye health, and oral health. These programs will define the key promotion, prevention, and screening activities to be included in the outline patient pathways for secondary and tertiary care.

The HSDP will adopt a life-cycle approach, guided by evidence-based policies and best international practices tailored to the FSM context. National programs will focus on updating SOPs for each level of care, including community education and awareness efforts, while also strengthening monitoring and supervision processes. In its commitment to data-driven decision-making, national programs and state program coordinators will collaborate on conduct regular situation analyses and assess program performance to guide the work plan priorities. Involvement and collaboration from the community stakeholders to update the community profiles and improving data quality and accuracy will guide informed decisions. Standardizing data collection and indicator calculation across the states according to the SDG and international best practices in similar context will be prioritized.

To reduce maternal, infant, and child mortality, the HSDP will promote healthy pregnancies enhancing the ability of both community members and healthcare staff to identify risk factors and warning signs early on. In alignment with the commitment to leave no one behind, child health services, including support for children with special needs and behavioral disorders, will be strengthened. Specialized care will be made more accessible, and customized educational materials and educational Apps will be made available for the use of the families. As an important entry point for violence prevention, healthcare staff will receive training on how to take appropriate action and activate referral mechanisms.

The HSDP plans to revitalize the national medical dental association and establish both a national oral health program and a comprehensive national policy for oral health. The program will also support in-country training efforts and work to standardize monitoring and reporting processes. Collaborating with the education and youth sectors will be essential to raise awareness and promote oral health across communities. The Behavioral Health and Wellness program will be decentralized and will work with community partners to establish a family support system at community level. Specialized medical support will be explored via telemedicine consultations in-country and overseas

 

Other Issues

FSM, like many Pacific Island countries and territories, faces 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 encounter 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 are 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.  These existing issues in the MCH programs have been discussed and deliberated for better solutions. 

 

The FSM Department of Health & Social Affairs collaborated with the FSM Department of Transportation Communication & Infrastructure and several government agencies undertook an initiative on the FSM Digital Gender Project funded by the World Bank.  At its core, the initiative seeks to empower underprivileged youth, especially women and girls, by strengthening the capacities of the Gender Development Unit within the FSM Division of Social Affairs to lead targeted digital progress. Through innovative digital initiatives, the project endeavors to create a more inclusive digital economy where equal access to technology is a facilitator for economic empowerment and societal growth. Through strategic digital literacy programs, safety awareness campaigns, and targeted interventions, the project seeks to bridge existing gaps in technology access, especially for women and underserved youth in rural areas. A survey was conducted among students in five high schools in Pohnpei, highlighting the digital tools and persistent concerns regarding online safety, data security, and infrastructural inaccessibility. These insights emphasize the urgent need for tailored, culturally sensitive strategies to enhance digital literacy, promote safe internet use, and ensure equal development powered by digital transformation. Despite notable progress in digital access, especially through smartphones, significant barriers remain, including economic constraints and technological literacy gaps. Overall, the findings advocate for a multi-sectoral approach, combining education, infrastructure development, and community engagement, to utilize digital technology as a transformative tool for societal resilience and sustainable development in FSM. It's about learning from adversity to adapt and become stronger in the face of future challenges. This includes maintaining essential functions, preserving identity, and ensuring long-term well-being.  These interventions are designed not only to expand digital opportunities but also to address the unique needs of adolescents and women. Ultimately, the FSM Digital Gender Project aspires to unlock the transformative power of digital involvement, propelling women and young people towards full participation in the digital economy.