It is my great pleasure to be involved in another innovative project of the Japan International Cooperation Agency (JICA). My previous involvement was my facilitation, in 1998 and 1999, of the field visits in my region of the first three batches of participants of the JICA Training Course for Prospective Experts of Primary Health Care (PHC). Through that training course, JICA was able to send out trained Japanese recruits to coordinate JICA-supported PHC projects in several Third World countries of Asia and Africa.

This two-week Area Focused Training Course on Community Health and Welfare Policy in Islands Regions, beginning with the countries of Oceania, pursues another complementary approach to attain “bottom-to-top” health development goals of Third World countries. The PHC Expert Training Course pursued a unique Third World-to-Third World transfer of PHC-related knowledge by representatives of a donor nation.

This Oceania project of JICA extends from a more time-tested methodology: Third World participants would still observe successful rural health development activities in a donor nation. But this time in an area that approximates the environmental and geographic circumstances of the participants’ origins (i.e., a region comprising of islands). The project is also not expected to end with the training course. Possibilities for mutual networking and optimal direction of future international cooperation would be explored, with the end-view of contributing to the progress of health care programs in the Oceania countries.

It was early November 2000 when I received from Dr. Yoichi Yamagata, Senior Advisor of JICA, the e-mailed invitation to be involved in this seminar to disseminate Okinawa’s experience in rural health development to the countries of Oceania. Previously unknown to him, Okinawa was part of my itinerary during a study visit to Japan in 1985. The host and travel companion of our group of four Filipino exchange scientists was Dr. Noboru Iwamura, the famous former Japanese missionary doctor to Nepal, who was Professor of the International Center for Medical Research (ICMR) of Kobe University School of Medicine at that time. (The recipient of the first Rotary Award for World Understanding in 1981, Dr. Iwamura also received the 1993 Ramon Magsaysay Award for International Understanding.)

Traveling around with a famous Japanese personality had its own benefits. In four days, we were able to visit more health centers, facilities and schools in Okinawa than the places included in your program. And for two days, we traveled around on two cars provided courtesy of the governor of Okinawa Prefecture.

On a personal note, the visit to Okinawa was a sentimental journey for me. The name of this place is part of my childhood and growing up. It is in the vocabulary of my father, who told tales about his experiences as a young Philippine Scout stationed in Okinawa from 1946 to 1948, a member of the US Army’s Occupation Force.

The e-mailed invitation cited that “Okinawa’s history and geography are comparable to those of the Philippines. The health system in Okinawa from 1945 to 1972 [when the administration of Okinawa was turned over by the US to Japan] was a combination of US institution and Okinawan human resources. Newly trained Public Health Nurses and Clinical Officers filled the shortage of medical doctors. [At present] both malaria and bancroftian filiriasis have been eradicated in Okinawa and its people enjoy the world’s longest average life span.”

I was pleasantly surprised by this information, which showed improvements to the observations I noted in a diary in 1985, some of which I narrate below.

I noted then that Okinawan females already had the longest average life span, at 81.72 years. And the Okinawan males, with 74.518 years for average life span, was eclipsed by the males from Kanagawa Prefecture by a mere .001 year (i.e., 74.519 years).

Malaria had been nearly eradicated in Okinawa since the early 1960s by a combination of vector control through radial spray of all houses and every possible spot of water, home treatment, and strong community participation through the submission of blood specimens from 100% of the population. Filariasis was already 99% controlled, and they had given a timetable of 5 years to eradicate it altogether.

The Department of Community Health of the University of the Ryukyus was 10 years old in 1985, just a year older than my home institution, the School of Health Sciences (SHS) of the University of the Philippines in Leyte (not to be confused with the SHS in Okinawa, which was established in 1969). This innovative department, the second to be established in Japan, is probably the source of the Clinical Officers that would fill the shortage of medical doctors in Okinawa in later years.

The need for health workers with higher-level skills remained critical in 1985. Doctor’s aides, not physicians (!), were attending to the medical care needs of half (50%) of the patients in isolated islands of Okinawa Prefecture. Only over one-third (37.5%) of the patients were referred to local or central hospitals.

An example that might interest the seminar participants (because this is part of their itinerary) was the case of Kume Island, which is 91 kilometers away from mainland Okinawa. In 1985, this island with a population of 10,000 only had 3 physicians, 1 doctor’s aide, and 2 public health nurses to take care of its medical and health care needs.

To cope with its distance and isolation, Kume Island invested in computers and communication technology and linked up with the university hospital to improve the monitoring of their patients. This made possible the conduct of surgical operations by medical staff in the island, which could be monitored by consultants based in the university hospital through video facilities and computerized transmittal and analysis of ECG findings by telephone. This happened at a time when computers were still very expensive and had much slower speed and capabilities than the recent gadgets.

I hope the same system has been sustained, or even improved, in Kume Island. After all, the cost of computers has drastically dropped over the past 15 years, and the speed and capabilities of this technology have geometrically improved since then.

The backbone of the public health system in Okinawa in 1985 consisted of the 69 public health nurses (PHNs) for a population of nearly one million. There was one public health nurse for nearly 15,000 people.

The public health nurses were particularly effective in the tuberculosis (TB) control and surveillance program, for which Okinawa had been awarded by their national government.

We gained many insights about the TB program from Mrs. Setsuko Yonahara, a retired nurse who had authored a book on the development of TB nursing in Okinawa, and a great inspiration to many younger nurses in the island. It was a surprise for us to learn from Mrs. Yonahara that they did not have drugs for Okinawa’s TB control program in the first 10 years. They only had fresh air, good rest, and food for the patients.

Later on, community-based public health nurses would follow up TB patients in their homes and motivate them to submit for treatment with anti-TB drugs, which was centralized in the health centers.

There is no magical formula for the success of the TB program in Okinawa. Just plain and simple persistence and creativity of dedicated and motivated health workers.

Through the course of the seminar, the participants have probably noticed the US-influence in Okinawa’s health care institutions. They might also have been impressed by the high-level performance of the co-medical personnel here, a fact that I had observed before.

According to Dr. Yamagata, many people in Okinawa mentioned that repeated on-the-job training, particularly on community assessment, was the key to the success of their rural health development pursuits.

Incidentally, an approach to community assessment was mandated for adoption by all barangay (village) governments all over the Philippines a few years ago. A nationally published manual for the so-called Minimum Basic Needs (MBN) Program used models developed by SHS students in the laboratory communities as showcase for this effort. SHS students on “service leave” in their home communities also spearheaded the initial implementation of the MBN program in several provinces of our region.

I assume a similar community assessment process is being implemented in the countries of Oceania. But the Okinawa experience already shows an example of how this approach has been translated into responsive human and material support systems for health development, and to actual improvements in health status.

Like Okinawa, Oceania is not a very strange geography for me. Mainly through Health and Development, the newsletter of the Manila-based World Health Organization Regional Office for the Western Pacific (WHO-WPRO), I occasionally came across published reports on health development activities in various Oceania countries since I joined SHS as a research staff some 20 years ago.

My first contact with health officials from Oceania countries was during a field exchange program in Leyte in April 1981. Sponsored by WHO-WPRO, that five-day seminar-workshop was intended to introduce the WHO-supported PHC Research and Development (R&D) Project in Leyte to participants from several Asian and Pacific countries. That R&D project from 1977 to 1982 was a joint activity of the SHS and the regional office of the Department of Health (DOH). Five participants came from the former Trust Territory of the Pacific Islands (TTPI) and another five came from a school in Papua New Guinea that was patterned after SHS.

In later years, I learned about the WHO-supported redirection of the Fiji School of Medicine (FSM) towards the “two-step, community-oriented medical teaching curriculum.” Two SHS founders traveled to Fiji between 1989 and 1991 to help its medical school establish innovations in their curriculum, which adopted the “step-ladder” and “service leave” concepts of our school. One of them is Dr. Alberto Romualdez, at that time the Director for Health Services Development and Planning of WHO-WPRO. Dr. Romualdez is the previous Secretary of Health of the Philippines.

In relation to this development, I understand the Government of Japan also extended support by cooperating in the renovation of the Colonial War Memorial Hospital in Fiji, which serves as FSM’s main teaching hospital for doctors.

I also came across a feature article in 1992 about the first graduates of the community-oriented Pacific Basin Medical Officers’ Training Program in Pohnpei, Federated States of Micronesia. The article mentioned the determination of the graduates to “take up assignments within the Pacific region, which remains largely in need of well-trained and appropriately deployed health personnel.”

I would not be surprised if some of the Okinawa seminar participants are graduates of the two schools in Fiji and Micronesia.

Whether in Okinawa, Oceania countries, or Leyte, we cannot avoid the common observation that, in the pursuit of rural health development goals, there is a crucial need for properly trained and motivated health workers, who are responsive to the people’s felt needs and are able to work simultaneously with poor individuals, families and communities and “bureaucratic” supports systems. The “traditional” hospital-based training of health personnel, which did not factor the added expectations, is simply no longer sufficient to cope with the demands of rural health work.

In this regard, I would like to believe that, over the past decade, innovative health sciences schools in Okinawa and Oceania countries and the SHS in Leyte have produced health workers and professionals with knowledge, skills and attitude that made them socially and culturally fit to work in their home settings.

The challenge for the seminar participants is to formulate policies that would institutionalize better support systems for the work of their essentially community-based health staffs. Of course, the measures to be adopted would also depend upon the economic circumstances of the individual countries.

In preparation for this tele-conference, I read more about the Oceania countries and took notes of their land areas, populations, population density and per capita GNP from various literatures and references. I also researched the same data for Okinawa and my milieu in the Philippines. The summary of my findings is found in Table 1.

The data show that six Oceania countries (Palau, Marshall Islands, Nauru, Tuvalu, American Samoa, and Cook Islands) have smaller land areas and populations than Biliran, my home province north of Leyte.

Unfortunately, Biliran’s advantage ends with the comparison of land areas and populations. It is disadvantaged in almost every other aspect.

For one, Biliran is at the bottom of a multi-tiered (national, regional, provincial, municipal/city, village) government structure with roughly just one-third ($340) of the Philippines’ per capita GNP ($1,050). Its budget for essential drugs is equally low. A batch of participants of a JICA PHC training course visited two towns of Biliran in 1999 and estimated an average allocation of only $0.15 worth of purchased assorted drugs and medical supplies per person per year. What could you make out of this gesture by municipal governments in terms of health impact? Not much I suppose, except as token support.

In a sense, we have village-level Barangay Health Stations (BHSs, or village health centers) each staffed by a Rural Health Midwife, but almost without basic supplies and equipment to make them effective in their work.

I have not yet conducted field research on this issue. But I have hypothesized that a BHS staffed by a midwife responsible for an average population of 4,000 (from an average of three barangays) needs at least $600 worth of essential drugs per year, available when needed, just to appear “credible” to the residents in its area of coverage. The estimated amount is based on the premise that essential drugs in the Philippines cost 5-10 times more than in neighboring countries. Sadly, most of the BHSs in the Leyte-Samar Region do not even have one-third of that supply in their stocks.

The irony here is that the hypothesized amount for essential drugs is within the capacity of village governments to allocate from their shares of government taxes and revenues. But most village funds go to infrastructure projects, allowances of elective village officials and other personnel expenses. A fixed budget for social services or essential drugs from village funds has yet to be legislated by Congress.

Still, based on a USAID-supported survey conducted in 1999, Biliran managed to achieve the best coverage in the nationally coordinated health programs (child immunization, pre-natal and post-natal care of mothers, vitamin A consumption of children, etc.) among the six provinces of the Leyte-Samar region.

The difficult case of Biliran is probably not shared by the six Oceania countries I mentioned earlier. After all, these countries have flatter (and presumably more responsive) national government structures. Also, they have bigger per capita GNP than Biliran, the Leyte-Samar Region, or even the Philippines. Indeed, all the Oceania countries appear to have the basic economic capacities to have well-equipped and well-stocked village health centers, particularly for their populations in remote and isolated islands.

As I had shown in a paper about a European Union-funded project in the Leyte-Samar Region (which I had requested to be distributed at the start of the seminar), well-equipped and well-stocked village health centers influenced the assigned Rural Health Midwives to become effective and efficient in their work, attracted the village mothers to avail of their services and heed health education messages, and motivated the pilot villages to adopt community-wide health promotion activities.

However, translating the lessons and insights from the project into appropriate legislation and institutionalized support systems for rural health development remains problematic. Our politicians welcome the entry of more externally funded health development projects. But they hesitate to address basic disparities in budgetary allocations that are biased against social services.

The comparisons and contrasts I have presented about health development experiences in Okinawa and Leyte could provide the seminar participants with valuable lessons and insights to strengthen or improve health and welfare policies in their respective countries. Let me point out the essentials:

First, there is a need for properly trained and motivated community-based health workers, ones with the added qualifications I had mentioned and preferably natives of the place, to take care of the health programs and activities in their area of coverage. Of course, these workers need to be adequately paid, lest they would leave and find “greener pastures” elsewhere.

Second, there is a need for these health workers to be provided with well-equipped and well-stocked village health centers, for them and their centers to appear “credible” to their service populations. This is particularly important for countries without national health insurance systems.

It is in the aspect of referral systems for patients where the Oceania countries would probably vary, based on the affordability of the options.

The example of Kume Island’s link with the university hospital is one extreme using the high end of technology. But this may not be affordable to some Oceania countries. The more practical option is to invest in speedboats and ambulance cars for emergency transport of patients to referral hospitals or facilities.

All these alternatives require an efficient and effective communication infrastructure. The fax machines and telephones must now be complemented with microcomputers and Internet technology. The use of these technologies would minimize weather-related risks associated with the frequent personal monitoring and supervision of health workers and their activities especially in remote islands.

I am certain you would discuss a wide range of policy options and areas for networking and international cooperation during the last days of this seminar. In this regard, I am satisfied with my role of providing a third perspective that could hopefully help the participants arrive at a better definition of problems to be addressed with relevant policies in the months and years ahead.

Thank you and good day.

Table 1. Land Area, Population and Per Capita GNP of Oceania Countries and Okinawa, Leyte-Samar, Biliran, and the Philippines

Notes:

Six Oceania countries (Palau, Marshall Islands, Nauru, Tuvalu, American Samoa, and Cook Islands) have smaller land areas and populations than Biliran. Only Australia, New Zealand and Papua New Guinea have bigger land areas and populations than the Leyte-Samar Region in the Philippines. All Oceania countries have bigger per capita GNP than the entire Leyte-Samar Region, probably the most depressed region of the Philippines.

References for Table:

Circling the Globe. New York: D.S. MAX International, 1995.
Year 2000 Grolier Multimedia Encyclopedia.

Home