Shortage of health workers is in short supply globally, but the effect is felt more acutely in small Pacific Island countries (PIC). Small PICs like Nauru, Kiribati, the FSM, Marshal Islands and Palau to name a few have chronically suffered from lack of doctors and nurses. It is something that can not be fixed overnight and is a chronic problem. These small PICs do not have their own training institutions so they have to sent their smartest and brightest students outside of their borders to get training to be a MD or RN. Most of the small PICs sent their students to Fiji. In the past students were trained in PNG but that has stopped now. I once asked a senior health manager in Pohnpei (FSM) why they are unable to send students to UPNG for MD or RN training and he told me that the decision is made by the sponsor (WHO, UN, NZ government or Australian government). They have no say in where their students go to study. Recently the Chinese government has offered many scholarships to students to study in China, including MD scholarships.

Many of the small PICs within the Micronesia region are US Affiliated States so they do get a lot of funding for health and education. One short term solution is to hire doctors and nurses from within the region or globally to work there. Unfortunately the remuneration packages offered by the small PICs do not reflect the regional market for MDs and RNs. As a result very few doctors or nurses end up going and working in the small PICs in Micronesia. Those that do decide to go there (including yours truly) have other reasons – new culture, experience new place, broaden work experience etc. Certainly it was my reason for moving to the FSM in late 2018.

Small PICs also tend to have weak government systems and weak governance systems (including PNG even though it is the biggest country in the Pacific). A recent flaw in doctors and nurses contract uncovered during an audit of government finance in the state of Pohnpei threatens to weaken health services in the state hospital. During the audit it was discovered that all state employees are not allowed to get more than 30% of their base pay in overtime. This law was implemented suddenly without prior notice to doctors and nurses causing some doctors to resign or more elsewhere. Even though a clause in the foreign doctors’ and nurses’ contract say that contract employees are exempted, the blanket decision was made to include all employees (in-state and out-of sate). Legal issues were also raised such as state breaching contracts of doctors and nurses. Unfortunately these legal questions have not been answered. Such unthoughtful measures do not take into consideration the fact that small PICs that rely on foreign doctors and nurses may not recruit any more health workers if the states do as they please without considering the rippling effects of their decision within the Pacific region. The danger is that Pohnpei state or FSM will continue to struggle to recruit doctors and nurses from overseas with government decisions that does not honor contracts. Doctors and nurses will feel reluctant to go to the sate of Pohnpei knowing that the government can change their decision anytime regarding contracts without honoring any prior commitment.

Attracting and retaining health professionals is challenging because they are highly paid and small PICs sometimes can not afford to pay them. But in the long run, health managers can look within the region and see regional pay packages and make an attempt to close the gap so that they continue to recruit foreign health workers to provide service to them. Such hard line decisions as recently observed in Ponpei, may be in fact be a disincentive to health workers and Pohnepi State may find itself struggling to recruit foreign health workers.