The Tyranny of Size: challenges of health administration in Pacific Island States

Abstract

There is great diversity among Pacific Island states (n=22) in geography, history, population size, political status, endemic disease, resources, economic and social development and positions in the demographic and health transitions and their variants. Excluding Papua New Guinea, all Pacific states are less than one million, and half of them (11) are less than 100,000. Smallness also means fewer resources available for health, even if percentage allocations are similar to larger countries, and a disproportionate amount may derive from international aid. Specialisation is not cost-effective or even possible in clinical, administrative or public health domains in small populations, even if resources or personnel were available, since such staff would lose their skills. In instances where only one to two staff are required, retirement or migration means decimation of the workforce. Training doctors within the Pacific Island region provides appropriately trained personnel who are more likely to remain, including those trained in the major specialities. Nursing training should be in-country, although in very small entities, training in neighbouring states is necessary. Outmigration is a significant issue, however, opportunities in Pacific Rim countries for medical doctors are contracting, and there is now a more fluid workforce among Pacific health personnel, including those resident in Pacific Rim countries. International and regional agencies have a disproportionate influence in small states which can mean that global policies intended for larger polities are often promulgated inappropriately in small Pacific states.Smallness also leads to strong personal relationships between health staff, and contributes to teamwork, but can also create issues in supervision. Small health services are not just scaled-down versions of large health services; they are qualitatively different. Smallness is usually intractable, and its effects require creative and particularistic solutions involving other more endowed Pacific states and Pacific Rim countries. Abbreviations: NCD – Non-Communicable Disease; NGOs – Non Government Organisations; ODA – Overseas Development Assistance; TFR – Total Fertility Rate.