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Bringing Health Care to the People: A Look at Dispensaries in the FSM

By Eugenia A. Samuel and Marcus H. Samo

January 2000 (MC #24) Health

A Health worker was sent on an assignment to a dispensary on a nearby island. Just as he was about to make his way to the recently completed two-story building on which the municipal government invested a significant amount of its capital improvement funds, some old classmates greeted him and asked what brought him to their island. The health worker explained that he had been sent to their island to work with the health assistant in providing health care to the people, and to follow up on the current status of their dispensary.

Surprised and embarrassed, the old classmates looked at each other and politely said, "Don't you know we have not had a dispensary for almost a year now, ever since our building was taken over by the land owners?" They went on to explain to him that it had been closed after the former mayor went out of office. The mayor had negotiated an outright purchase of the land on which the municipal office and the dispensary had been located. Years later, the island decided to put up a two-story building on this piece of land. By the time the building was completed, the mayor had finished his two terms in office and was replaced. Soon after, the original owners decided to reclaim the piece of land that they had sold to the municipal government. They demanded that the land be leased for a higher price than the original sale price, even though technically the land had already been purchased outright.

New in office, the current mayor was in a quandary. Should he side with his political allies, the original landowners, who wanted to reclaim the land on which the dispensary was located? Or should he uphold the island's ordinance by doing everything necessary to oppose and prevent the takeover of the land?

Thinking it would alleviate the dilemma, the mayor compromised with the family by paying them from the island's capital improvement project fund. Years later, the family demanded a still higher price. When the mayor refused, the landlord and his relatives broke into the dispensary, smashed the windows and anything they could put their hands on, removed any supplies and appliances that could be of any personal use to them, and defecated in the building. The family was asking the mayor to pay another $40,000, money that the family considered reasonable annual rent on the piece of land. They barred the building from the health assistant so that he could not use it anymore and was forced to work out of his home.

"Then what do you do for health care?" asked the health worker. He replied that most of the people on the island no longer receive the basic health care they used to. Those who have boats now have to travel to the main island for care at the hospitals. Some of the people were upset by the new mayor's unwillingness to stand against his political allies for the well-being of the entire island. People are beginning to wonder what happened to the good old days when people were happy and the chief always looked out for all the people he was representing. What should we do about this?

Why Dispensaries?

There is no argument that dispensaries are important throughout Micronesia. Needless to say, it is a good investment in the future in terms of disease prevention and health promotion, a concept accepted by many as the future trend in health care. They provide preventive and basic clinical care to the people living far from the central hospitals, something necessary for good medical practice. For those residing far from the central hospitals, dispensaries are often the only health care facility that they will ever see for health care in their lifetime. In addition, from a pragmatic view, the local people would prefer to visit a health clinic (dispensary) within their community, rather than travel to the main hospital in the commercial center. This is not only because of the cost of traveling to the center, but also because of the logistical inconvenience. Most old people would prefer to have a health assistant visit them at their home rather than be transported to the main hospital.

The simple fact that there are 105 dispensaries operating in the FSM today speaks to the important role the dispensaries play in health services delivery. In an effort to examine how dispensaries can be improved throughout the FSM, Micronesian Seminar recently conducted a survey on a sample of them. The survey focused on how dispensaries were meeting the needs of the local communities. It also identified major issues that prevent some dispensaries from functioning as well as others. These include lack of supplies, lack of supervision of dispensary staff, conflicts over land use, and other clashing issues. Let us look at each one of these issues more closely.

Land Problems

Land in Micronesia has always been considered important. Its importance continues today, but perhaps in a different form than before. Today's economists would say that land is a commodity. Whatever it is, it is becoming a highly contested issue, particularly because of the potential benefit it could provide to people. In the above real-life conflict, we have seen an island turn its capital into what should be a good investment for its people, by purchasing a piece of land outright and building a dispensary and civil affairs office. The intention, of course, was to make health care available and accessible to the entire people of the island, a service that is critically needed throughout Micronesia. However, building dispensaries to ensure that these important services are provided is no guarantee that it will happen.

As we have seen in the story above, the municipal government seems to have surrendered to the demand of the original landowners, forgoing its responsibility to provide a dispensary where people can receive basic health care. The mayor's failure to act in the best interest of the people denies the entire island basic health care. As a result, the people of the island are forced to seek health care elsewhere, or worse, to live without any. Although it may be painful to stand against public pressure, the mayor should have exercised his judicious responsibility by asserting municipal ownership over property.

As far back as the 1950's people were willing to donate private land for the good of the community. Those who donated their land were usually the traditional chiefs, but other landowners with suitable locations would donate as well. All of this was done free of charge. Hence, when a dispensary had to be built for the entire community, it was built on undisputed land. To show their appreciation to the chief or the families who freely donated their lands, the community reciprocated by assuming all responsibilities pertaining to the physical management and upkeep of the facility.

In the early 1960s, the Trust Territory (TT) government centralized health care services and took full control over financial and administrative matters, as well as personnel. These matters included supplies, the type of service typically provided, and land leases. With land leases, the TT government identified certain land parcels as ideal locations for dispensaries and leased them. Some landowners managed to put up their land on the condition that a family member was given the health assistant job. This too was received with enthusiasm by the TT administration because it lowered the financial cost that it would have otherwise paid in land leases.

The lands that were donated were never secured through any written agreement. It was done as a customary understanding between the health services department of the TT government and the landowners. The arrangement seemed to work then. But now, twenty years later, the TT administration has disappeared from the scene and left the dispensaries on unsecured land.

In the 1980s, the FSM inherited the dispensaries, along with the responsibilities and obligations that came with them. Some of those responsibilities included ensuring salaries for the dispensary personnel and providing medical supplies. At this time the emphasis put on money had increased dramatically, and people's attitude and mentality changed as well. The landowners who once donated their land for free now wanted to be compensated and threatened to take over the buildings otherwise. For example, a man who used to be a health assistant donated his land to the government for a dispensary. After he died, his wife took over the position and decided to ask the government for a lease payment. "My husband donated the land to the government for more than 20 years. He died and the value of land has gone up. It is time I lease it to the government to support my family," said the woman. "Nothing is for free anymore. The new concept of getting paid for everything you do is affecting our dispensaries," she pointed out.

When the family made their demands, the FSM state governments yielded in order to maintain a health care facility at the municipal level that could provide care to all the people, a responsibility embedded in their constitutions. Leases between the once altruistic landowners and the respective state governments are now commonly drafted and signed, usually to the advantage of the landowners.

As this practice continued, the state governments realized that it was going to become too costly to uphold the leases. In one of the FSM states alone, the state government pays around $400,000 a year for land leases. Now the state governments want to acquire ownership over certain land parcels but cannot afford to buy at today's market value. As we have seen in the opening story, dispensaries that are built on non-secured (private) land are subject to takeover any time. Even the families who once looked out for the good of the general public are now leasing their lands.

A Possible Solution: Outright Purchase

Perhaps an easy answer to our land lease problem is the notion of secured land. Secured land belongs to the government (state or municipal) who is free from paying any financial compensation for its use. Around 1990, some state and municipal governments took over the land leases and began to purchase land outright for the dispensaries. This should have solved the land problems, but didn't. Even with an outright purchase, as was the case in the opening story, people still find ways to manipulate the system and abusively demand more money for their land. In the same story, people expected the mayor to defend the takeover of the land since it was already purchased by the municipal government. He did not because he was afraid to lose his political allies.

Our example shows the negative impact of the mayor's inaction on the community. But the community themselves also neglected their own responsibility to prevent the takeover of their dispensary. As a group, they could have been more proactive by asking the state government to intervene on their behalf when the mayor failed to take action. As a community, they could have tried to approach the landowners in the traditional way to settle the dispute, but they did not.

While land use right is a complex issue, all the above examples suggest the need to have secured land first before building any dispensary on it. Evidence of ownership of the land by the government must also be secured. If this means that the government needs to purchase outright the property, it must do so. Likewise, if a community donates land, the government should not settle for a "hand-shake" deal. Instead, it should ensure that all legal documents pertaining to the transfer of ownership are filed.

One practical change that could be made before any transaction occurs is to have a public announcement for communities to hear, and to maintain records as public information. This will not only affirm governments claiming ownership, but will also protect against any possible litigation. Of course this will not solve all the problems, but it will minimize the burden on the governments in trying to defend itself.

Inheriting the Health Assistant Job

After Kasmira's father passed away, she decided to take on the job as health assistant, despite opposition from the island council. As a member of the paramount clan on the island, she threatened to evict the municipal government and the dispensary from her property if she was not granted the job.

Kasmira went to the health assistant training program and then came back to her village to run the dispensary. After a few years, she decided to build a small store as a supplemental source of income for her chiefly family. As her business grew, she started spending more time at the store and neglected her responsibility as health assistant. She was adamant about giving up the job because it was passed on to her by her father, and because it was a source of income. Although the people complained about the health assistant and her incompetence, nobody would do anything because she was a high-class member of the community.

Historically, a family who donated land for a dispensary received the job of health assistant. It was then treated as an inheritance from father to son, or in a case when there is no son, it is passed on to a cousin or a brother or sister. So when the assistant retired, he passed the position on to the next heir. For example, in one of the villages, a brother and a sister were working side by side as a health assistant and a midwife. When the brother passed away, the job was passed on to the son of the sister, a nephew who was only an elementary school graduate. This practice may have curtailed costs on land leases during the TT time, but it did not take into account the potential impact of unqualified, hand-picked health assistants. This is also true in the Kasmira story above, in which the job was passed down from her father, regardless of qualification. In another instance, a health assistant was appointed during naval times when a dispensary was first constructed, and since then that position has been passed on from one generation to the other within a family. Culturally, this may have been appropriate. In the past, it was the father's utmost duty to leave his children something. It could be argued that in the beginning the health assistant's job was infused into a cultural practice, but that does not mean it should still apply today.

What's wrong with this practice? The first obvious problem is that it could easily leave out well-trained, qualified candidates for this important position. When an incompetent family member has been passed down the job of the health assistant, it discourages community involvement and creates resentment. Feelings such as "It's that family's problem" or "It's the government's problem, not my problem," become common reasons for not supporting the dispensaries. This practice of predetermined selection of who gets the job is often destructive in a small island society, where public service should help everyone, not just one family.

Another problem with the hereditary position is that it could stifle the community from having an open bidding system, which would otherwise facilitate change toward check and balance. The bidding system is intended to provide equal opportunity, but when it fails to exist, the rest of the community suffers. In the Kasmira story, the community suffered as a result of an unqualified and uninterested health assistant. As time went on, Kasmira paid less attention to the job she inherited.

In addition to the reasons mentioned above, advances in health care today mean that a service provider must meet certain requirements. On a basic level, it means that they must have a rudimentary education with knowledge and skills in science and related fields. If the skills do not exist, one can imagine the likelihood of misdiagnosing and mistreating acute diseases.

Although qualification should be the leading determinant for the health assistant job, on-the-job training should be provided where experience and related skills are limited. If this is the case, on-going supervision of the health assistants' performance should be closely monitored. This means that when a health assistant reports to his dispensary, there should be regular contact and communication between him and the main hospital.

Lack of Training and Supervision

A group of people were discussing a recent election when the topic of the conversation switched to the dispensary on their island. They all complained about the health assistant. According to them, the health assistant was never in the dispensary from 8:00 in the morning to 5:00 in the afternoon, the official working hours for government employees. However, the health assistant claimed to be in the dispensary during working hours and at his house during non-working hours. If he was not in his house, his wife was always available to dispense medicine to them.

According to the discussion, the health assistant could not resist the inviting calm water and school of fish being spotted one afternoon and decided to go after them. While away on his fishing excursion, a patient came to the dispensary for care after having experienced some chest pain. He went to the health assistant's house and after hearing his complaints, the wife gave him some medicine, which her husband advised her to dispense with "chest pain" cases. However, the wife dispensed a medication that caused an adverse reaction in the patient and worsened his condition. The patient later died before he could make it to the main hospital.

The practice of a health assistant not attending work when he is supposed to is typical in an island lifestyle. The state government cannot adequately monitor the performance of the health assistants in the dispensaries at all times. The state and local governments (municipal governments) must work together to ensure that the health assistants are accountable to the local people they are serving, instead of going fishing when they are supposed to be at work. Obviously, the danger of this practice is that it could result in a life or death situation, as it did in the example.

How can this be done? Perhaps the first thing is for the state government to let the municipal government manage the day-to-day responsibilities of the dispensaries. Once the local government has invested in the operation and maintenance of the dispensary, it should then work on trying to maintain regular hours and supplies.

There is no dispute that regular contact between hospital health workers and dispensary staff is critically needed in order to manage an effective primary health care system. What this boils down to is the need to provide on-going training for the health assistants in acute disease diagnosis and treatment, health promotion and disease prevention, and dispensary management. While it was once felt that the dispensaries should be used as outlets of the public health programs administered through the central health department, emphasis should now be on providing training to the health assistants so that they themselves can provide the services. Local community members are concerned that doctors rarely visit the dispensaries to provide on-site training. They believe that if the doctors visit them more often, some of the problems could be improved. This would increase community confidence in the health assistants as medical care providers.

In addition to the need for frequent visits to the dispensaries by doctors and nurses from the hospital, there is also a need for local accountability. This means that there should be a mechanism in place where the community can provide input to the management and operation of the dispensaries regarding their needs and concerns.

Lack of Basic Medical Supplies and Equipment

During the last flu season, parents brought their children to the health assistant at his house at 9:00 o'clock a.m. By this time, the health assistant had already run out of the basic fever control medications he had. He turned to a lady and gave her a few of the antibiotic capsules in a folded piece of paper from the medicine cabinet, and he said, "Give this to your baby, but I am sorry I do not have a stethoscope to listen to her lungs. This will take care of her lungs, too, if they are wet. Come back after 5 days."

The dispensary was full of children with the epidemic flu. Everyone was waiting for the only thermometer that was being passed from one patient to another. There wasn't even any sterilizing equipment to disinfect the thermometer. The ladies were all sitting on the floor, chatting and complaining about the lack of medical supplies and equipment. One lady stood up and opened the small medicine cabinet. She turned to the crowd and said, "Look at these few things here. There are only two jars of antibiotics, a bottle of cough syrup, a bottle of Tylenol, a bottle of aspirin, a few packages of diarrhea solutions, a bottle of vermox, and IV solutions. These are not enough for all of us."

After waiting almost all morning to see the health assistant, a man decided to go back home and give his son, who only had a fever, leftover antibiotic medicine that was prescribed for him when he encountered similar problems.

Another area that seems to have a severe impact on dispensaries is the lack of basic supplies. The above story shows typical problems and frustrations people are facing when they seek care at the dispensaries. We have heard report after report about the lack of basic medicine that one would expect to see on the shelves in the dispensaries throughout the FSM. There were testimonies from local people about how they don't want to go to the dispensaries when they get sick because they never get any medicine. "What's the use of going to the dispensary if they don't have medicine? I would rather look for local medicine. The last time I went there, they gave me Korean medicine, and even the health assistant could not read the instructions," exclaimed one woman. Sometimes, the health assistants have to use a disposable thermometer over and over again. One might say that sterilized equipment should be highly observed, but in most cases, it is not. Others explained that when they have a wound or cut, they would rather apply local medicine first because of fear that the dispensaries might not be able to do anything.

For their part, the health assistants expressed their frustration at the scarcity of medical supplies. With the limited funds they receive from the local governments, they cannot stock their dispensaries on a permanent basis. One day they will be able to get enough supplies from the main hospital, the next day there will be none. Most of the time, they race against each other to get supplies from the supply room at the central hospital. Whoever gets there first gets more.

Record Keeping and Fee Collection

Often, health assistants do not keep records of their daily activities. Some do not have a written summary of patients' medical history, despite the importance of keeping such information. There are usually no filing cabinets; therefore, it is obvious that records are not kept or made available for future use. For a dispensary that has been in existence for more than ten years, one would expect to see full cabinets with bulky files.

Many of the people interviewed in the study conducted by MicSem said that if their dispensaries were improved and supplied with more medicine and medical equipment, they would be willing to pay appropriate fees to subsidize the costs. They feel that some kind of fee structure should be made so that the money can be used to get more medicine and equipment. They also believe that it would be fair to be charged for better health care and well-qualified health care providers. Although some health assistants indicate that they collect about $20 a month, this is hardly enough to ensure consistent flow of essential supplies. Nevertheless, whatever they collect at their dispensary, they are supposed to properly account for and deposit their money at the main hospital before they pick up their supplies for the next month. Unfortunately, this practice is not being enforced because the hospitals themselves usually run out of medicine. When that happens, the health assistants use their collected money to buy supplies from the local stores.

What's Really Wrong?

All of the issues discussed above have, one way or the other, impacted how communities today relate to their community health centers. What was once an effective community ownership system--where the community put up the land, provided the upkeep of the building, and participated in its management and operation--seems to have faded. Perhaps the main reason this is true is because people no longer have a sense of doing something for free for the benefit of everyone. Community members are now unable to find time to help health assistants maintain clean dispensaries. Though some of these people used to be very supportive of dispensaries, now they seem to have lost interest. They identify dispensaries as the property of the "government" that is rich, and needs no help. When people get angry at a public figure, they take it out on the facilities by vandalizing them, as the story in the beginning shows.

But if the dispensaries are truly important to us, shouldn't we take good care of them as we do with things or people important to us? Yes, there are obstacles that need to be confronted, but there will be far greater benefits if we put the needs of our community ahead of our personal needs. These dispensaries are ours, and we, as a community, must reclaim them by taking charge of them. We cannot expect dispensaries to operate efficiently and effectively if we do not take their ownership upon ourselves. Only when these pre-requisites are in place can one be confident that community investment exists. Perhaps then dispensaries will not be looked at as just another "government" thing.

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