Annually health systems across Pacific Island Countries and Territories (PICTs) demonstrate their resilience to acute external shocks. Generally presenting as natural disasters including cyclones, tsunamis and earthquakes, the region’s disaster-prone locale means that PICTs’ health systems unfortunately have an extensive history of responding in the wake of crises. Yet, while tried and tested in response to natural disasters, alongside the rest of the world’s health systems, it remains too early to fully conceptualise how these systems may respond to the global pandemic COVID-19. However, as Pacific-based cases escalate, it is important to mitigate panic (and its causal relationship with mistakes) by alleviating blind spots and taking stock of the current strengths and weaknesses of PICTs’ health systems.

While often discussed collectively, it is important to acknowledge that ‘the Pacific’ is a diverse region. Although home to nations which share similar geographic, cultural and historic communalities, there are also distinct differences between countries and territories in the region.

Such differences are evident when analysing World Bank data to assess regional health and economic standings. With gross domestic product (GDP) per capita varying from 1,625USD in Kiribati to 35,712USD in Guam, the economic position of nations dictate the available funds to spend on health. Analysing health-specific expenditure, regional variance is again apparent. Many PICTs spend less than 6% of GDP on health, whereas data from the Federated States of Micronesia and Marshall Islands indicates expenditure as great as 12.6% and 23.3% respectively. While not linear, there is a relationship between health expenditure, system responsiveness and metrics such as life expectancy. This is apparent than when making regional comparisons, where projections currently exhibit a 15-year life expectancy gap between the region’s highest and lowest performing states. This stark diversity is apparent before we have even begun to consider how health systems across the region are structured, function or are financed.

So, given such diversity, is it helpful or even feasible to consider how the region may be affected by or respond to COVID-19? In my opinion, yes. Despite their diversity, there are also a number of regionally unique factors which both exacerbate risk and afford protection to PICTs in response to COVID-19. Highlighting these factors may support regional and state policy makers in ensuring responses are contextually tailored and evidence informed.

Regional geography offers PICTs both protection and risk in responding to COVID-19. The island nature of states means few land borders for transmission of disease. With the majority of PICTs restricting marine and air arrivals, nations yet to receive the virus or that have tightly controlled cases may be able to prevent transmission long enough to learn valuable lessons from the global community, flatten the curve or even wait out a vaccine. However, difficult terrain and population dispersal are ongoing challenges to health care provision. Severely limiting economies of scale, in responding to COVID-19, this dispersal may exacerbate the deficiencies in such a thin spread of health resources. Further, while oceanic borders may limit the spread between islands, it is also important to note that rapid and unplanned urbanisation may place urban centres and, in particular, those in cramped or informal settlements at greater risk.

As highlighted above, when nations have more money, typically, more is spent on health. Unfortunately, many low- and middle-income PICTs experience constrained access to global markets and are particularly reliant on tourism; an industry currently scrambling to remain afloat. With potentially less money in national economies, this raises concerns that fewer funds may be available to forge sufficient responses to the pandemic. Further, with several nations and their health systems reliant on foreign aid, the current downward trajectory of Western economies could constrain donor partners’ generosity into the future.

The socio-political structures and cultures of PICTs look to provide some protection in response to COVID-19. The complex political histories of many PICTs has typically meant there is lower reliance on centralised government mechanisms. Coupled with greater power afforded to local decision makers and those in the chiefly system, distribution of authority is likely to support proactivity and community ownership in prevention and response.  

Finally, the intersection of epidemiology and demography also presents risk and protection in the face of COVID-19. Populations of PICTs are typically young by comparison to global average. With evidence indicating older persons to be at greater risk, the relatively young makeup of PICTs may afford some protection from COVID-19. By contrast however, evidence also indicates COVID-19 adversely impacts those with underlying health conditions. In this respect, unfortunately, the non communicable disease crisis faced by the region may undo some age-afforded concessions. Further, with the double burden of communicable and non-communicable diseases experienced by many PICTs placing a significant strain on health systems, this may weaken responses to COVID-19. With greater exposure to communicable diseases however, it may be argued that PICTs’ communities are more aware of and conscious of implementing hygiene and infection control practices; behaviours that appear poorly instigated in nations experiencing escalating disease transmission.

COVID-19 presents an opportunity to reflect on the importance of health, health systems and health workers in this increasingly interconnected world. While we face this week more uncertain than before, in considering how PICTs may respond to this challenge, one may draw comfort in reflecting on the resilience these systems have shown in the past. Whether we consider Samoa’s response to measles, responses to landslides in PNG, cyclones in Fiji, Vanuatu and Tuvalu or the region-wide response to climate change, PICTs health systems and populations have proven themselves incredibly resilient. I’m not saying our current situation isn’t incredibly challenging but, in being pragmatic, I don’t believe that panic is helpful. PICTs’ health systems and their regional agencies have grown immensely and are led nationally and driven locally by dedicated health workers and public servants. Drawing on these personnel in forming and executing evidence-informed responses will give PICTs the best chance to proactively prepare for, recognise and respond to the diverse impacts COVID-19 may have on populations and their health now and into the future.


Lana Elliott is a lecturer in health policy at Queensland University of Technology (QUT) and doctoral student at James Cook University. Her work focus on health policy and systems research in the Pacific.