USAPI Region

PIHOA is lead by and represents the collective interests of the Ministers, Directors and Secretaries of Health of the U.S. Affiliated Pacific Islands (USAPIs).  The USAPIs include the three U.S. Flag Territories of Guam, the Commonwealth of the Northern Mariana Islands, and American Samoa, and the three Freely Associated States (independent nations in a special compact relationship with the United States) of the Republic of Palau, the Republic of the Marshall Islands, and the Federated States of Micronesian (Pohnpei, Kosrae, Chuuk, and Yap).

The USAPIs are populated by more than 500,000 people who live on hundreds of islands and atolls spanning millions of square miles of ocean and crossing five Pacific time zones, including the international dateline.  The islands are culturally and linguistically diverse with more than a dozen spoken languages. While the indigenous peoples of the USAPI are rich in culture they are small in population.  The islands are fragile but in the past they have been plentiful with rich eco-systems.  Multiple complex factors contribute to the severe health disparities in the islands. Colonization and rapid westernization have adversely affected many of the social, cultural, and environmental structures and practices that traditionally supported and protected the health of the islands, their waters and their people.

American Samoa

American Samoa is an unincorporated territory of the U.S. located in the South Pacific Ocean. There are five main islands, and two coral atolls.  The population is 55,519 (2010 Census), and the majority of the population lives on Tutuila.

American Samoa has some of the highest rates of obesity in the world, which greatly contribute to their high burden of NCDs.  These alarmingly high rates of obesity have been attributed to modernization and its associated nutritional transition, in people consume more calorie-rich foods and expend less energy. Although these behavioral factors are linked to obesity and  obesity related disease, genetic factors have also been shown to play an important role in Samoan obesity and obesity related risk factors.

In American Samoa, the delivery of healthcare services is mixed.  Health care is subsidized and all American Samoans have Medicaid with small copays for services.

There are three main providers of health care services in American Samoa.  The LBJ Tropical Medical Center, which is the only hospital in American Samoa. There are also four Federally Qualified Health Centers (community health clinic sites).    Additionally, the Department of Human and Social Services houses substance programs related to alcohol and tobacco as well as the WIC program. There is only one pharmacy for all of American Samoa, so getting drugs to outer islands can be a challenge.

Other public health needs are led by the American Samoa Department of Health (AS DOH).



Commonwealth of the Northern Mariana Islands

  • The Commonwealth of Northern Mariana Islands (CNMI) is a trust territory of the United States; however, it is self-governed by an elected governor and has an independent constitution.CNMI is located in the North Pacific Ocean, 1,842 miles east of Hong Kong and 3,226 miles west of Hawaii.CNMI consists of 14 volcanic islands encompassing approximately 180 square miles of land. The official languages are English, Chamorro, and Carolinian. The climate is tropical throughout the year, with an average temperature of 83° Fahrenheit.

    In 2010, CNMI had a total population 53,883 living on Saipan (the capital), Tinian and Rota (2010 Census). The population on each of the inhabited islands was as follows: Saipan 48,220; Tinian 3,136 and Rota 2,527 (2010 Census). Pagan and Alamangan islands have a transitory population with less than 10 inhabitants.

    In 2010, the dominant ethnic groups included Filipino (40%), Chamorro (27%), Chinese (except Taiwanese) (8%), other Native Hawaiian and Pacific Islanders (7%), Carolinian (5%), Korean (5%), other Asian (4%), other ethnicities (3%). Thirteen percent of the population is identified to have two or more ethnic origins. Seventeen percent of the CNMI population spoke English only. Of the 83% that spoke languages other than English, the most commonly spoken languages were Filipino languages (40%) and Chamorro language (29%) (2010 Census).

    In 2010, the age distribution of the CNMI population was as follows:  27% of the population was aged 15 years and below, 68% was aged between 15 to 59 years and 6% were aged 60 years and above. The male and female population was approximately equal (51% male and 49% female). The average household size was 3.26 and the average family size was 3.80 (2010 Census).

    The Commonwealth Healthcare Corporation (CHCC) is the public provider of healthcare services and includes one hospital, one medical laboratory, Kagman Community Health Center, Rota Health Center, Tinian Health Center, Community Guidance Center (mental health and substance abuse information) and the Division of Public Health. Information on the CHCC budget could not be obtained and is not publicly available.

    The CHCC hospital has 86 beds. It is a Medicare-certified hospital that opened in 1986 and was expanded in 2007. The hospital’s scope of services includes emergency medicine, obstetrics, post-partum care, nursery, adult and neonatal intensive care, surgery, general medicine, pediatrics, nursing, physical therapy, respiratory care, radiology, medical social services, dietetic and food services, medical laboratory, pharmacy, hemodialysis, mental health and various outpatient services.  

    The Division of Public Health includes the following departments: Noncommunicable Disease Bureau, Maternal and Child Health Program, Women’s Infants and Children’s program, Tuberculosis and Hansen’s disease program, HIV and STD program, Health and Vital Statistics Program, Immunization program, and Bureau of Environmental Health program.

    In the CNMI, there are five private healthcare clinics, FHP Health Center, Marianas Medical Center, Medical Associates of the Pacific, Pacific Medical Center, Saipan Health Clinic. There are three private laboratories, Diagnostic Laboratory Services, Pacific laboratories and Precision Medical Imagining. There are two dialysis clinics, CHCC Hospital dialysis clinic (27 stations) and Saipan Health Clinic (27 stations).


Federated States of Micronesia

The Federated States of Micronesia (FSM) is a sovereign nation located in the North Pacific Ocean about three-quarters of the way from Hawaii to Indonesia.  It is officially a constitutional government in free association with the U.S. which provides funding under a Compact of Free Association (COFA) that is administered by the Department of the Interior’s Office of Insular Affairs.  FSM consists of 607 islands occupying over 1,000,000 square miles of ocean with a total land area of 436 square miles of mountains, coral atolls or volcanic outcroppings.  The islands are grouped into four states; Chuuk, Kosrae, Pohnpei and Yap.  Yap, Chuuk and Pohnpei have outlyigng atolls in addition to their main islands.  Kosrae has only a main island.  The nation is located in two time zones; Yap and Chuuk are 18 hours ahead of Pacific Standard Time and Pohnpei and Kosrae are 19 hours ahead of Pacific Standard Time.

As of 2012. the population of FSM was approximately 107,500; 53,500 in Chuuk, 7,800 in Kosrae, 35,000 in Pohnpei and 11,2000 in Yap.  The median age is 22.7 years and life expectancy at birth is 71.8 years.  The majority of (63.4%) of Micronesias are between the ages of 15 and 64 years.  English is the official and most common language spoken and functions as a linguistic bridge in the FSM.  Fifteen indigenous languages are spoken and they are grouped into five major categories, Chuukese, Kosraen, Pohnpeian, Yapese and Kapinga-Nukuoro.  Only 23% of the population lives in an urban settings. Eighty-nine percent of the population is literate.

In FSM, the delivery of healthcare services is mixed.  A great deal of the population relies on a public health care system that is controlled and regulated by the states governments.  The public health care system consists of the overarching, FSM National Department of Health and Social Affairs and the four state governments; Chuuk State Department of Health Services, Kosrae State Department of Health Services, Pohnpei State Department of Health Services and Yap State Department of Health Services.  The present health care system in the FSM has three levels; the community dispensaries, the state hospitals and referral to hospitals outside of the FSM.  



 Guam  is an Unincorporated Organized Territory of the United States. The population of Guam is approximately 159,358 (2010 Census). Guam is ethnically quite diverse; the most prevalent ethnicities are: Native Chamorro (37.3%), Filipino (26.3%), White (7.1%), and Chuukese (7.0%).  The remainder of the population is comprised mostly of other Asian and Pacific Islander etnicities. Guam is made up of a single island that is 209 square miles, with 29% of Guam’s total land area occupied by U.S. military bases. There are approximately 12,000 military personnel and dependents living on Guam. The central region of Guam is the most populated, with approximately 44,943 people residing in Dededo.

In Guam, the delivery of healthcare services is mixed. Services are provided by the Department of Public Health and Social Services (DPHSS) and the Guam Behavioral Health and Wellness Center (GBHWC), formerly known as the Department of Mental Health and Substance Abuse (DMHSA). The Guam DPHSS is organized under five divisions, the Division of General Administration, the Division of public Health, the Division of Environmental Health, the Division of Public Welfare and the Division of Senior Citizens.

There are two civilian hospitals on Guam, the Guam Memorial Hospital Authority (GMHA) located in Tamuning and the Guam Regional Medical City (GRMC) located in Dededo. There is a U.S. Naval hospital for the military and their dependents located on the Guam Naval Base. There are also a number of private clinics located on Guam, including many specialty clinics.

Medicaid and Medicare programs are available on Guam. There is also a locally-funded Medically Indigent Program (MIP) designed to pay for medical expenses of low-income families without other health insurance. Those who don’t qualify for assistance may opt for private insurance.  There are several health insurance providers on Guam. Approximately 75% of Guam residents have health insurance (2013 BRFSS). Although Guam has many more medical services available than the other USAPIs, patients still need to go off-island for certain specialty care.


The Republic of the Marshall Islands

The Republic of the Marshall Islands (RMI) has been a soverign nation since 1986 with a Compact of Free Association (COFA) with the United States of America. The nation consists of 24 coral atolls, with a total of 1,156 individual islands and islets. The population is 52,158 (2011 Census).  74% of the population resides on Majuro and Kwajalein atolls.  The poulation density on these two atolls is quite high.  Majuro has a total land mass of 3.75 square miles with a population of 27,797 (7,413 people/m2).  Ebeye island on Kwajalein atoll has 9,614 people on 0.12 square miles (80,117 people/m2).  Although the fertility rate is quite high, the population is decreasing due to out migration.

In the RMI, the delivery of healthcare services is mixed.  Basic public healthcare is available for all residents of RMI. A small copay ($5) is required for all services.  Supplemental insurance is also offered for residents which offers better options for off-island care.  There are private clinics available, though the majority of the population uses the public system.  Generally only foreigners living in RMI have private insurance.

There are two hospitals in RMI, one in Majuro and one in Ebeye.  There are 56 outer island health centers managed by the hospital in Majuro by the Office of Outer Islands. These clinics are staffed by local health assistants, and much information is communicated to Majuro Hospital via radio.  There are 5 outer island health centers that are managed by the 177 healthcare program (victims of nuclear fallout). This is a U.S. federal grant in which U.S. doctors manage these health centers.

90-120 off-island referrals occur per year- mostly cancer, congenital issues, and orthopedic surgeries.  These are determined using a ranked waitlist.


The Republic of Palau

The Republic of Palau has been a soverign nation since 1994 with a Compact of Free Association (COFA) with the United States of America. The nation consists of over 340 islands, but only 12 are permanantly inhabited. The population is 17,501 (2012 Mini Census). The majority of the population has always resided in the state of Koror, Palau’s most urban area. In 2012, 66.7% of the population resided in Koror, with the second highest populated state being that of Airai (14.5%), located just north of Koror. Airai can be considered the “suburb” of Koror, whereas the remaining sparsely populated states are quite rural. The population of Palau has decreased since 2005 due to a low fertility rate and emigration.  There is however a lot of immigration into Palau.  As of 2012, 73.5% of the population is native Palauan, with the second largest group being Filipino at 16%. The majority of the remaining foreign residents are of other Asian ethnicities.

In Palau, the delivery of healthcare services is mixed.  There is one government hospital in Koror and 8 Community Health Centers (CHCs).  Five of these CHCs are on the main islands of Koror and Babeldaob, and there are CHCs in the outer islands of Peleliu, Kayangel, and Angaur.  There are also two private clinics in Koror.  Additionally, the small military Civil Action Team with one medic provides limited free services.

There has been National Health Insurance since 2010 and some private insurance is available.  Over 90% of the population has health insurance. Off-island referrals are primarily to Manila, Taiwan, or Hawaii.  These referrals are prioritized and there is a waitlist.