Inadequate Healthcare in Pacific Islands

May 20

Viewpoints published by Ballard Brief are not necessarily endorsed by BYU or The Church of Jesus Christ of Latter-day Saints.

Summary+

Pacific Island Countries and Territories (PICTs) face significant healthcare challenges due to a high burden of noncommunicable and communicable diseases (NCDs and CDs), limited rural healthcare access, and chronic shortages of medical personnel and resources. These issues, compounded by economic constraints, have led to healthcare systems that consistently fall short of World Health Organization (WHO) standards. As a result, Pacific Islanders experience higher rates of preventable deaths, delayed diagnoses, poor disease management, and overall increased morbidity and mortality. Despite recognition of these shortcomings, efforts to improve healthcare systems remain slow and insufficient, leaving treatment gaps unaddressed.

Key Takeaways+

The prevalence of NCDs presents a major burden to PICT healthcare systems, as PICTs hold the top twelve highest national diabetes prevalence rates and nine of the top ten highest national obesity prevalence rates in the world.^1,2
All but three PICTs with available data (Cook Islands, Palau, and Niue) fall below the recommended threshold for doctors.³
More than 60% of the population in PICTs would be without hospital services in the case of an extreme weather event.⁴
The inadequate healthcare systems in PICTs disproportionately affect mothers, children, and individuals living in rural areas.⁵
Researchers estimate that inadequate healthcare contributes to somewhere between 5.74 and 8.47 million deaths annually in low- to middle-income countries (LMICs), which includes most PICTs.⁶

Key Terms+

Communicable disease (CD)—An illness caused by viruses or bacteria that spread between people.⁷ These diseases spread through direct contact, insect bites, or airborne transmission.⁸

Healthcare worker—A person who delivers care and services to the sick or ailing, namely doctors and nurses.⁹

Low- to middle-income countries (LMICs)—Countries with a gross national income per capita of $14,005 or less in 2023.¹⁰

Medical equipment—Supplies and devices used for diagnosis, prevention, monitoring, or treatment of a disease or injury.¹¹

Medical facilities—Places where healthcare is provided and include hospitals, clinics, and care centers.¹²

Medical technology—Systems that allow patients and healthcare workers to access vital information pertaining to a patient’s health, as well as increase healthcare efficiency and outreach.¹³

Morbidity—The amount of disease, both communicable and noncommunicable, within a population.¹⁴

Mortality rate—The number of deaths that occur within a particular group of people during a specific period.¹⁵

Noncommunicable disease (NCD)—A chronic health condition that is not caused by infectious agents and does not spread from person to person.¹⁶

Overseas Medical Referral—Sending a patient to another country or region to receive medical care that is either unavailable or of superior quality compared to what is offered in their home country.¹⁷

Shortage—A situation where the demand for a good exceeds its supply.¹⁸ According to economic theory, shortages of most goods will result in the market quickly adjusting prices to either decrease demand or increase supply to eliminate the shortage.¹⁹

Telemedicine—The provision of healthcare services via real-time audio or video calls.²⁰

Context

Q: What are the Pacific Islands?

A: Pacific Island Countries and Territories (PICTs) are several thousand islands that comprise a portion of Oceania in the Pacific Ocean and encompass three ethnogeographic groupings: Melanesia, Micronesia, and Polynesia. Melanesia includes countries such as the Solomon Islands, Vanuatu, New Caledonia, and Fiji; Micronesia includes Palau, Guam, Nauru, the Marshall Islands, and Kiribati; and Polynesia—the largest geographic area—covers Tuvalu, Tokelau, Samoa, American Samoa, Tonga, Niue, the Cook Islands, and French Polynesia.²¹ Organizations concerned with global epidemiology often group PICTs together because of their geographic proximity (despite being spread across vast ocean distances) and shared characteristics (including similar physical environments and ecosystems).^22,23 These nations and territories also possess deep cultural ties, common roots, and a shared historical heritage.²⁴

Arial view of small Island with palm trees — Credit: Prem Kurumpanai

Q: What burdens are posed to the PICTs’ healthcare systems?

A: With similar environments, experiences, and lifestyles, PICTs also face analogous challenges to their healthcare systems, primarily the burden of noncommunicable diseases (NCDs). These illnesses often progress slowly, have a long duration, and are rarely entirely curable.²⁵ The World Health Organization (WHO) identifies the main types of NCDs as cardiovascular diseases (CVD), cancers, chronic respiratory diseases, diabetes, and obesity.²⁶ National prevalence rates of these NCDs are highest in PICTs.

Map of diabetes prevalence in the Pacific Islands

For instance, as of 2014, PICTs held the top twelve highest national diabetes prevalence rates in the world, with American Samoa leading at 31.9%.²⁷ In 2024, PICTs made up nine of the ten countries with the highest obesity rates worldwide.²⁸ According to the latest WHO STEPS reports, which provide standardized data on key NCD risk factors including obesity, seven PICTs have national overweight rates over 65%, three exceed 80%, and one—American Samoa—surpasses 92%.^29,30,31,32

In Pacific Island Countries and Territories, NCDs—most commonly cardiovascular disease (CVD) and diabetes—were the leading cause of death in 2016, accounting for approximately 60% of deaths in the Solomon Islands and up to 80% in Fiji.^33,34,35 However, the impact of NCDs extends beyond mortality. These diseases also contribute significantly to the nonfatal burden of disease, which includes long-term disability, reduced quality of life, and economic strain due to lost productivity and healthcare costs.³⁶ This burden is especially pronounced in conditions like mental health disorders, musculoskeletal problems, and chronic obstructive pulmonary disease—illnesses that may not be immediately life-threatening but significantly impact quality of life and place strain on both individuals and healthcare systems.³⁷ One study found that while one in ten patients admitted to hospitals in Tonga were treated for a NCD, their care accounted for one in every five dollars spent on treatment—highlighting the disproportionately high cost of managing NCDs.³⁸ Additionally, the World Bank Group in 2012 reported that while NCD-related hospital admissions in Tonga made up 10.4% of all admissions, 19.6% of hospital expenditure went toward treating NCD-related cases.³⁹ As of 2025, the percentage of GDP needed to treat NCDs was higher in Pacific Island areas than in other countries worldwide. NCD mortality is responsible for approximately 3.3% of global GDP; however, it accounts for 5–10% of GDP for PICTs.⁴⁰ In other words, NCDs are already a major economic burden in Pacific Island countries, costing them a much larger share of their economies than the global average—and this financial strain is projected to rise as high as 15% by 2040.⁴¹

Q: What is adequate healthcare, and how well do Pacific Island countries meet these criteria?

A: Although quality is inherently subjective, health authorities agree on key principles that define high-quality healthcare. The WHO and the United States Institute of Medicine have established that quality healthcare, at a minimum, should be effective, equitable, safe, accessible, and efficient.^42,43 Effective healthcare is defined as evidence-based care that yields superior outcomes compared to alternative interventions or lack of treatment.⁴⁴ When healthcare is equitable, the quality of care remains consistent across all demographics, regardless of age, sex, gender, race, ethnicity, geographical location, religion, or socioeconomic status.⁴⁵ Safe healthcare means that patients receiving treatment are free from accidental injury and harm.⁴⁶ Healthcare is considered accessible when members of a population have timely access to health services that help them achieve the best possible health outcomes.⁴⁷ Finally, healthcare is efficient when it limits the waste of equipment, ideas, supplies, and energy.⁴⁸

Graphic depicting the aspects of quality healthcare

Photo of a woman and child sitting — Credit: Elias Alex

Effectiveness is one of the most difficult healthcare standards for PICTs to uphold. The simplest way to determine the effectiveness of a healthcare system is by evaluating its health outcomes, such as mortality rates. For example, deaths of adults living in PICTs are slightly higher than global averages. In 2022, the global mortality rates for adult males and females were 199.7 and 133.5 per 1,000 people, respectively, compared to 214.0 and 153.0 per 1,000 in PICTs.⁴⁹ An examination of mortality rates among infants, children, and mothers highlights a significant disparity between PICTs and the global average.

In 2023, the United Nations (UN) reported that the Pacific region had the second-highest infant mortality rate in the world at a rate of 38 deaths per 1,000 live births.⁵⁰ The same region also had the second-highest child and young adult mortality rate for every age up to 24.⁵¹ The WHO similarly found that the maternal mortality ratio of the Pacific region in 2020 was the second highest in the world, with an estimated 173 maternal deaths per 100,000 live births.⁵² These statistics underscore the significant challenges PICTs face in meeting global healthcare standards, indicating that their healthcare systems fall short of providing adequate care based on fundamental health outcome measures.

Under-five mortality rates in the Pacific compared to Asia and Africa

Maternal mortality rates in the Pacific Islands compared to Asia and Africa

Effective healthcare depends on accessibility, yet in many PICTs, access to essential medical services remains limited or difficult to obtain. For example, despite the high prevalence of diabetes, ischemic heart disease, chronic kidney disease, and chronic obstructive pulmonary disease in most PICTs, treatments for these conditions are largely unavailable, resulting in patients traveling long distances at high costs to medical facilities where treatment is available.^53,54,55 Between 2000 and 2017, the proportion of individuals in the Western Pacific region facing catastrophic health expenses—defined as out-of-pocket health spending exceeding 10% of household budgets—doubled, rising from one in ten to one in five.⁵⁶

Additionally, a 2019 survey reported that Pacific Island nations collectively spent approximately $125 million annually on overseas medical referrals, highlighting the unavailability of effective treatment options locally.⁵⁷ For some patients, such as those living on Lojwa and requiring immediate surgery, evacuation might involve traveling 300 miles to Kwajalein or even to Tripler Army Medical Center in Hawaii, a process that can take up to 60 hours from identification of need to arrival.^58,59 Even when treatment is available nearby, understaffed healthcare systems lead to overcrowded hospitals and long wait times, further restricting access to treatment.⁶⁰ In a hospital in Samoa, researchers surveyed 60 patients and found that 100% of the participants waited more than eight hours to be admitted. This prolonged wait resulted from overcrowding, which significantly strained the hospital's resources and compromised its ability to provide timely care.⁶¹

Patient safety refers to the prevention of harm to patients within healthcare systems, relying on adequate staffing, sufficient resources, reliable technology, and informed health decision-making.^62,63,64 In PICTs, these elements are often lacking, putting patient safety at serious risk. For example, seven PICTs—Kiribati, the Federated States of Micronesia, Papua New Guinea, Samoa, the Solomon Islands, Tuvalu, and Vanuatu—have fewer than 49 health workers per 10,000 people, far below the World Health Organization’s recommended threshold for adequate staffing.⁶⁵ Reliable technology varies widely across PICTs, and in some countries, such as Papua New Guinea, only 32% of the population have access to an internet connection, limiting many people’s ability to receive treatment and guidance via technology.⁶⁶ These two examples of deficiencies illustrate the systemic barriers that compromise patient safety throughout PICTs.

Q: Which populations in PICTs are most impacted by inadequate healthcare?

A: While everyone in PICTs is affected by the quality of healthcare available to them, the shortcomings of the healthcare systems disproportionately impact mothers and children. As mentioned previously, the Pacific region faces some of the highest infant, child, and maternal Mortality rates globally, ranking second worst in the world.^67,68 In addition to high mortality rates, mothers and children also experience other harmful effects from inadequate healthcare. In 2022, one systematic review reported several adverse birth outcomes in PICTs and found the prevalence rates of low birth weight and preterm birth were 12% and 13%, respectively.⁶⁹ Another study found that hospital capacity limitations, poor infection control measures, and infrastructure issues were all common barriers to improving the quality of maternal and infant healthcare in PICTs especially.⁷⁰

Photo three children using a cell phone — Credit: Elias Alex

Another demographic greatly affected is the rural population in PICTs—which makes up 60% of the total—due to decreased access to health facilities and sanitation.⁷¹ Hospitals and specialists in PICTs are typically concentrated in urban areas, where national populations have increasingly migrated and settled on central islands. As a result, rural regions are left with limited infrastructure and healthcare access.⁷² Moreover, migration opportunities are often available only to the most skilled and innovative healthcare professionals, further depleting rural areas of qualified workers and exacerbating healthcare inaccessibility.⁷³ Examples of such medical facilities in urban areas include those in Palau and Tuvalu, where the only healthcare facility on the island is located in the city.⁷⁴ Additionally, a report from 2016 noted that 55% of residents in rural areas of PICTs had access to adequate sanitation, and 43% had access to safe drinking water, compared to 87% and 93% of residents in urban areas, respectively.⁷⁵ Inadequate sanitation and lack of access to clean drinking water contribute to a rise in CDs across PICTs. This surge in disease burden places additional pressure on the already limited healthcare resources in rural areas, further widening the gap in access to essential health services for rural populations.⁷⁶

Q: What progress has been made in PICTs concerning healthcare in the most recent decades?

A: While significant challenges remain for healthcare in PICTs, the healthcare system within these countries has improved over the past 75 years. Considering their shared needs, Pacific Island nations have banded together, combining efforts to improve health and its systems. Sponsored by the U.S. Department of Health, WHO, and non-profit organizations, PICTs formed the Pacific Islands Health Officers’ Association (PIHOA) in 1986. PIHOA is a place for principal health officers in the Pacific region to come together and discuss their common health interests, issues, and history.⁷⁷ While the PIHOA is specifically for the US-affiliated PICTs—namely Guam, the Northern Mariana Islands, American Samoa, Palau, the Marshall Islands, and the Federated States of Micronesia—the Pacific Health Ministers’ Meeting (PHMM) includes all PICTs.⁷⁸ The first PHMM in 1995 initiated biennial meetings among all PICTs, where health ministers discuss regional health priorities and collaborate on health protection and promotion. At the inaugural meeting, the name ‘Healthy Islands’ was adopted, and it continues to remain the overarching vision for the region today.⁷⁹ This collaboration through official bodies reflects a coordinated effort and shared investment between PICTs and external governments and organizations; however, some researchers argue that these initiatives have produced fewer tangible outcomes than expected.⁸⁰

The heightened focus on reducing CDs is another notable achievement in the progress of healthcare in PICTs. In 1980, immunization coverage of several vital vaccines, including the Hepatitis B vaccine, the measles vaccine, and the polio vaccine, was below 5% but improved to over 90% by 2023.⁸¹ Since 2000, all PICTs have been polio-free, and many PICTs have reached less than 1% prevalence of Hepatitis B in children.⁸² Moreover, many PICTs have successfully eliminated lymphatic filariasis, once a common parasitic disease.⁸³

The emergence of telemedicine in some PICTs is another step in the right direction. Telemedicine, while still facing many issues, has improved healthcare accessibility for Pacific Islanders living in rural or isolated areas.⁸⁴ These healthcare advancements have contributed to a steady decline in infant and child mortality rates across all age groups since 1990, as well as a 34% reduction in maternal mortality between 2000 and 2020.^85,86

Contributing Factors

Healthcare Worker Shortage

Inadequate healthcare in the Pacific Islands is largely driven by critical shortages of medical professionals, with most countries falling well below global and WHO-recommended thresholds for doctors and nurses needed to ensure basic health coverage. Based on WHO guidelines and occupational data from PICTs such as Samoa, Micronesia, the Solomon Islands, Vanuatu, and Papua New Guinea, these countries faced shortages of skilled healthcare workers as of 2019.^87,88 The WHO has recommended an average threshold of 4.45 medical professionals (1.5 doctors and three nurses) per 1,000 people and identified meeting this baseline as a key indicator for achieving universal health coverage.⁸⁹ All but three PICTs with available data (Cook Islands, Palau, and Niue) fall below the recommended threshold for doctors, and the average number of doctors is 0.84 per 1,000.⁹⁰ Papua New Guinea has the lowest rate at 0.06 doctors per 1,000.⁹¹ More PICTs meet the WHO threshold for nurses, with an average of 4.16 per 1,000 people, though only four Pacific Island countries surpass the global average.⁹² These numbers indicate that most PICTs are experiencing healthcare worker shortages.

Bar graph depicting the distribution of doctors per 1000 people in the pacific islands

The emigration of health professionals from PICTs to higher-income countries primarily contributes to the healthcare worker shortage. In 2008, research showed that over a third of doctors born in Niue, Fiji, Tonga, Samoa, Cook Islands, and Papua New Guinea practiced medicine in Australia or New Zealand. More doctors from Niue worked in Australia or New Zealand than in Niue itself, and nearly as many Fiji-born doctors practiced in Australia or New Zealand as in Fiji.⁹³ Nurses and midwives born in PICTs emigrate at higher rates than doctors. In 2008, researchers discovered that more nurses and midwives born in Niue, Samoa, Tonga, and Fiji worked in Australia or New Zealand than within their home countries, totaling 3,567 Pacific-born nurses and midwives employed abroad.⁹⁴ Similarly, in 2023, Kiribati, Tonga, and Fiji reported losing approximately 50, 80, and almost 800 nurses, respectively, to overseas opportunities.⁹⁵

Bar graph depicting the distribution of nurses per 1000 people in the Pacific Islands

The shortage of healthcare workers in PICTs, caused by nursing school closures, the requirement for additional training, and the effects of natural disasters, reduces both the accessibility and quality of health services and contributes to the region’s inadequate healthcare system. Strict regulations, lengthy education requirements, and extensive training slow the expected increase in healthcare workers.⁹⁶ For instance, in 2020, the Vanuatu Qualifications Authority (VQA) de-registered a nursing school for failing to meet established standards—creating a significant gap in nursing education and workforce development, as the closure prevents over 80 potential nurses from entering the workforce each year.⁹⁷ For those programs still running, additional training is often required to adequately prepare nurses to practice safely and sustainably in rural areas, which can discourage potential candidates, thus slowing the growth of the nursing workforce.⁹⁸ Limited access to secondary education and the required health professional training exacerbate this issue.⁹⁹ Furthermore, shortages worsen when external shocks, such as the COVID-19 pandemic and natural disasters, sharply increase demand.¹⁰⁰ With a lagging supply and steady or rising demand, healthcare worker shortages persist and remain difficult to resolve.¹⁰¹

Research assessing the impact of healthcare worker shortages on health systems is often qualitative; however, one quantitative study found that patient mortality rates increase by 6% when a unit is understaffed.¹⁰² While this data is not specific to PICTs, it highlights a likely correlation found within PICTs between workforce shortages and inadequate care, underscoring the broader burden on healthcare systems.

Limited Healthcare Resources

The lack of infrastructure and equipment in Pacific Island healthcare systems is another major factor contributing to inadequate healthcare in PICTs. These physical resources, foundational to care delivery, can be broadly sorted into three categories: facilities, equipment, and technology.¹⁰³

Photo of a house with corrugated walls and clothing drying on a clothesline — Credit: Nik Schmidt

Many PICTs either lack the medical facilities needed to sustain an adequate healthcare system or risk losing them in the future. In four PICTs—Palau, Nauru, Tuvalu, and Niue—a single hospital serves the entire country.¹⁰⁴ In most other PICTs, each island or island group typically has only one hospital, limiting access to care across dispersed populations.¹⁰⁵ The absence of medical facilities is not simply due to a lack of infrastructure; a 2024 report on the health systems of the Pacific Islands documented that many medical facilities were no longer deemed fit for purpose due to poor maintenance.¹⁰⁶ In addition, an evaluation of 78 Pacific Island hospitals found that 56% of PICT hospitals were within 300 meters of a hydrologic threat—a potential hazard from water-related events such as tropical cyclones or floods.¹⁰⁷ Moreover, the populations of eight PICTs rely entirely on these at-risk hospitals. In an extreme weather event, such as a cyclone, severe damage caused to one of these hospitals would result in their entire population being without hospital services.¹⁰⁸ The same evaluation estimated that, overall, 63% of the population in PICTs would be without hospital services in the case of an extreme weather event.¹⁰⁹ Limited access to medical facilities and the prospect of losing existing facilities represent a threat to healthcare accessibility.

PICTs also face the problem of limited medical equipment, supplies, and technology. First, PICTs are unable to maintain a consistent level of pharmaceuticals for many common conditions, primarily due to small national budgets.^110,11,112 In 2009, the WHO found the total per capita expenditure on pharmaceuticals in the Cook Islands, Fiji, Papua New Guinea, Samoa, and Tonga ranged from $4–50.¹¹³ In comparison, per capita expenditures of countries such as France and Spain, averaged $401 per person in 2005.¹¹⁴ The limited budgets of PICTs have hindered their ability to provide consistent access to medications needed to treat NCDs such as diabetes and hypertension.¹¹⁵

Second, many healthcare facilities in PICTs do not have the necessary equipment and supplies to provide effective care.¹¹⁶ For instance, a 2011 study found that every hospital in the Solomon Islands was experiencing major deficiencies in the oxygen and anesthesia machines needed for surgeries.¹¹⁷ Furthermore, many of the consumable surgical supplies stocked in those hospitals had already expired.¹¹⁸ Such shortages and outdated resources correlate to lower quality of care, increasing the likelihood of misdiagnoses, prolonged hospital stays, and reduced patient trust. In 2017, a qualitative study in South Africa, a country facing similar equipment shortages to PICTs, found that nurses linked prolonged hospital stays, misdiagnoses, and even death to the lack of medical equipment.¹¹⁹ Additionally, a 2024 review found that medical supply shortages lead to disruptions in the continuity of care, an increased work burden on providers, a loss of patient trust in health professionals, and therefore diminished adherence to medical advice.¹²⁰

Third, the lack of consistent digital infrastructure in PICTs forces much of the work to be done manually, hindering the implementation of health information systems that greatly enhance healthcare delivery.^121,122 Even in PICTs where health information systems exist, fundamental issues remain with data analysis, information utilization, and the timely generation of high-quality data.¹²³ For example, many systems lack the technological capacity to integrate and analyze data effectively, preventing meaningful insights at both the patient and public health levels.¹²⁴ In 2021, the United Nations Global Marketplace A 2009 review of Vanuatu’s health information systems revealed fragmentation that placed an undue burden on clinicians, who were required to collect data using inconsistent methods, making the information difficult to compare.¹²⁵ In contrast, a 2006 U.S. review found that well-integrated health information technology can improve patient adherence, strengthen disease surveillance, reduce medication errors, and enhance overall care efficiency.¹²⁶ Overall, shortages in physical healthcare resources across PICTs directly limit access to care, reduce treatment effectiveness, compromise patient safety, and diminish system efficiency—further contributing to inadequate healthcare.

Economic Constraints

Chart showing a comparison of health expenditure per capita by country

Economic constraints in PICTs, driven by small national budgets and limited financial flexibility, directly inhibit the reliability and effectiveness of their healthcare systems. In most PICTs, governments are the primary financiers of healthcare.¹²⁷ For example, the Marshall Islands provides basic health insurance to all citizens, and Tonga offers healthcare services free of charge.^128,129 Notably, several PICTs allocate a significant portion of their GDP to healthcare, often well above global averages. In 2021, Tuvalu, Palau, Kiribati, Nauru, and Micronesia all exceeded the global average of 10.3% health expenditure as a share of GDP, with Tuvalu reaching nearly 20%.¹³⁰ However, despite the high percentage of GDP spent, most PICTs still fall below the global average in per capita health expenditure. As of 2024, the global average was $1,177 per person; of twelve PICTs observed, only Palau surpassed this benchmark.¹³¹ In contrast, per capita spending in the U.S. and Australia was $12,012 and $7,055. This contrast is evidence that even when a large share of GDP is devoted to health, the small size of those economies leaves PICTs without sufficient means to cover basic healthcare needs.¹³²

The financial restraints regarding PICT healthcare systems are evident in the shortage of supplies, medicines, and trained healthcare workers discussed previously.¹³³ As a result of lack of funding, PICTs are unable to deliver consistent and comprehensive care, leaving the delivery of healthcare services to be unreliable.¹³⁴ Additionally, limited funds inhibit the preventative care efforts of PICT healthcare systems, as most funding must be allocated to curative care.¹³⁵ This lack of preventative care ultimately perpetuates the high incidence rates of NCDs that continually burden the healthcare systems of PICTs.¹³⁶

Consequences

Worse Health Outcomes

Greater Mortality

Many deaths occur in PICTs that could have been prevented by sufficient healthcare services, suggesting that insufficient healthcare systems lead to an increase in mortality. Measuring mortality rates from inadequate healthcare in PICTs is difficult due to limited data; however, global data helps illustrate how insufficient healthcare impacts mortality. To quantify the burden of low-quality healthcare worldwide, researchers studying Asia and the Pacific Islands estimated that inadequate healthcare contributes to somewhere between 5.74 and 8.47 million deaths annually in LMICs, which include most PICTs.¹³⁷ Most of these deaths stem from ineffective or unsafe care, common in PICT healthcare systems.¹³⁸ These inadequacies are particularly evident in NCD treatment, with at least 4.11 million annual deaths in LMICs linked to poor care.¹³⁹ This data shows that limited healthcare leads to a higher mortality rate and also fails to treat NCDs effectively. And as was previously mentioned, NCDs affect PICTs more than any other region in the world, causing 77% of deaths in the region.^140,141,142

The quality and accessibility of healthcare in PICTs significantly impact mortality rates, with many deaths resulting from preventable or inadequately treated conditions. In 2018, another study compared mortality rates in LMICs to those in high-income countries with more robust healthcare systems to assess deaths preventable through healthcare.¹⁴³ The study found that in 2016, the LMICs of Oceania—comprising all PICTs—had 20,721 deaths attributable to healthcare. Of these deaths, 12,742 occurred because of poor quality healthcare services.¹⁴⁴ In other words, 61.5% of these people were treated but died because the care was inadequate.¹⁴⁵ These statistics show how both the inaccessibility and ineffectiveness of healthcare in PICTs lead to many preventable deaths and higher mortality rates.

The Prolonged Burden of NCDs

In addition to raising mortality rates, inadequate healthcare in PICTs increases morbidity by delaying diagnosis, limiting treatment options, and failing to manage conditions effectively. Key political and economic changes, including modernization, migration, importation, and urbanization, have primarily driven the high prevalence of NCDs in PICTs.¹⁴⁶ However, inadequate healthcare has also prolonged the burden of NCDs on populations. A review of 36 studies on LMICs in the Asia-Pacific region highlighted major gaps in healthcare responses to NCDs, including weak infrastructure, ineffective referral systems, limited provider skills, and underdeveloped health information systems.¹⁴⁷ As a result, access to quality care remains restricted, leading to lower diagnosis rates, delayed treatment, and poorer outcomes for NCDs compared to high-income countries, and therefore increasing morbidity rates.¹⁴⁸

Complications from Poor NCD Management

The inadequate healthcare in PICTs also fails to avert the adverse effects of NCDs. A 2014 study focused on the Pacific Islands of Nauru, the Solomon Islands, and Vanuatu estimated that 11% of individuals with diabetes in these countries had a diabetes-related amputation.¹⁴⁹ For reference, a systematic review from 2010–2020 estimated that only 0.14% of diabetics worldwide required minor amputations during that time period.¹⁵⁰ These amputations occur from untreated diabetes-related foot disease but can be prevented with proper care.^1512,152 A multidisciplinary team can reduce diabetes-related complications, including limb amputation, by up to 40–60%.¹⁵³ When asked about diabetic foot care, healthcare workers at a hospital in Fiji stated that the foot care they provided was poor because of a lack of knowledge, resources, and building capacity.¹⁵⁴ Another complication of diabetes is retinopathy, which is when high blood sugar causes damage to the blood vessels of the retina, possibly leading to blindness.¹⁵⁵ In Nauru, the Solomon Islands, and Vanuatu, the prevalence of retinopathy among diabetics in 2014 was 69%, 40%, and 42%, respectively, whereas the global prevalence among diabetics was approximately 35% in 2012.^156,157 Nauru, along with four other PICT countries, reported having no available ophthalmologists (specialists in retina treatment) to treat retinopathy in 2020.¹⁵⁸ The lack of adequate healthcare in PICTs not only prolongs the prevalence of NCDs but also exacerbates the effect that these diseases have on Pacific Islanders.

The Burden of Communicable Diseases (CD)

Inadequate healthcare in PICTs also increases the burden of CDs on the population. In 2024, the Marshall Islands, Kiribati, and Papua New Guinea reported some of the highest tuberculosis incidence rates in the world—692, 533, and 432 cases per 100,000 people, respectively—with the Marshall Islands recording the highest rate globally.¹⁵⁹ In 2023, the tuberculosis treatment success rate in PICTs was 74%, which was significantly lower than the global rate of 88%.^160,161 Researchers attributed this relatively low rate to delays in diagnosis and treatment because of the limited access to health facilities in PICTs.¹⁶²

These systems also face challenges in detecting and responding to outbreaks. A review of literature published between 2010 and 2019 on infectious disease surveillance in PICTs found that limited healthcare resources across Pacific Island nations hindered their ability to promptly detect and respond to epidemics.¹⁶³ The analysis stated that PICTs were more susceptible to infectious disease outbreaks because of their healthcare limitations.¹⁶⁴

Practices

The Regional Quality Improvement Programme

Under the PHMM, an initiative was created to actively support the ongoing development of a subregional quality improvement program, called The Regional Quality Improvement Programme, aimed at enhancing education and regulatory standards for nurses and other essential healthcare professionals.¹⁶⁵ The program aims to strengthen nursing capacity across Pacific regions by supporting the development of consistent regulation and accreditation standards for nursing and midwifery education programs, guided by a committee (called the Steering Committee) responsible for overseeing and implementing these efforts.¹⁶⁶ This effort is carried out in partnership with the Australian Nursing & Midwifery Accreditation Council, the Pacific Community, the World Health Organization, and the University of Technology, Sydney.¹⁶⁷

Tongan children walking down a path — Credit: Autumn Vaitohi

Impact

With the development of the Steering Committee, several PICTs have sought to create new institutions to train healthcare workers. For example, in 2023, the government of Vanuatu dedicated land and 2.2 billion dollars toward building a new nursing school.¹⁶⁸ Additionally, a 2022 report detailed that the Cook Islands had revised their nurse training program, Kiribati developed a new curriculum for a nursing diploma, and Papua New Guinea was reviewing the credentials for nursing diplomas.¹⁶⁹ At the same time, PICTs are securing scholarships for citizens to pursue education abroad. In late 2023, Vanuatu’s Ministry of Health reported that the country had obtained over 80 scholarships for students to study at PICT institutions such as Fiji National University—with 80% of recipients training to become nurses.¹⁷⁰

Quantitative data on the direct impact of the practices outlined in improving PICT healthcare systems is scarce, particularly given that many of these efforts are still relatively recent, having emerged only in 2024. As a result, statistically significant outcomes are not yet available, and progress is primarily tracked through output data. In 2023, the Steering Committee monitored eight PICTs for advancements in addressing the nursing shortage, and five had already implemented policies aimed at attracting, recruiting, and retaining nurses.¹⁷¹ These policies included creating new nursing positions in Fiji and creating incentive packages for nurses in Vanuatu.¹⁷²

Gaps

PICTs have made progress in addressing the healthcare worker shortage; however, critical gaps remain. Current strategies largely focus on increasing the number of healthcare workers, with less emphasis on retaining existing personnel. Resignations and emigration continue to drive the shortage, particularly among lower-paid healthcare workers, who make up the largest share leaving.¹⁷³ While some PICTs, like Fiji, have taken steps to address this issue—such as introducing a retention allowance (a financial incentive to encourage continued service for a specified period)—most have yet to implement any initiative.¹⁷⁴ This lack of action stems largely from the economic constraints PICT governments face, limiting their ability to allocate additional funding to healthcare systems.¹⁷⁵

The second significant gap in PICTs’ strategy to reduce the healthcare worker shortage is the lack of action toward increasing the number of doctors. As stated earlier, the shortage of doctors in the Pacific Island Region is greater than the shortage of nurses; however, the efforts of PICTs seem to focus almost exclusively on nurses. While a few institutions in PICTs offer Doctor of Medicine (MD) degrees or their equivalents, the majority of countries rely on government-funded programs to send students abroad to countries such as Georgia, Morocco, and Cuba for medical education.^176,177 Attrition is relatively high in this scenario, and there are no systems in place to integrate doctors trained overseas into PICT healthcare systems.¹⁷⁸ The actions taken by PICTs to address the challenges affecting the number of doctors are insufficient, particularly in comparison to the more substantial efforts made to address the nursing shortage.

Preferred Citation: Vaitohi, Brook. “Inadequate Healthcare in Pacific Islands.” Ballard Brief. June 2025. www.ballardbrief.byu.edu.

Viewpoints published by Ballard Brief are not necessarily endorsed by BYU or The Church of Jesus Christ of Latter-day Saints

Footnotes

By Brook Vaitohi
Published Winter 2025
*Special thanks to Jackie Durfey for editing and research contributions.*

Pacific Islands

Brook Vaitohi

Brook is studying Strategic Management in the Marriott School of Business at Brigham Young University. Upon graduating, he hopes to attend medical school and become a physician. It was after living in Tonga, a South Pacific country, that his main aspiration became to help improve the accessibility of healthcare for Pacific Islanders in underserved communities.