Speaking Softly & Carrying a Big Stethoscope: Universal Health Care for Pacific Island Nations Opinion Editorial

Dr Duke Mataka is Tonga’s sole ophthalmologist and provides specialist eye care services, including to local communities in remote parts of his country. The Kingdom of Tonga has a population of over 100,000 across 45 inhabited islands—scattered over 700,000 square kilometres of ocean. With such a small population spread across such a vast area, many rely on visiting health professionals for everything from primary health care to sight-restoring surgeries.

“Because we don’t know when we’ll be back,” Dr Mataka reflects, “we’re always under pressure to get through all the operations. The doctors have to work on rotation, sometimes into the night, to ensure we see all the people who need our help.”

Far away, in the small regional community of Gawler in South Australia, these gaps in healthcare availability have not gone unnoticed. Dr John Willoughby, also an ophthalmologist, was recently awarded an OAM in recognition of his long-term commitment through a charity he formed called Vision of Islands to bring visiting surgical teams to the people of Tonga and Tuvalu. He is just one of many health professionals from numerous nations who have demonstrated a commitment to help, despite the hurdles of transport and logistics. The Royal Australasian College of Surgeons (RACS) – Pacific Island Program (PIP) has supported visiting medical teams across a range of Pacific nations. At a larger scale, the Pacific Partnership, often spearheaded by the large hospital ship USNS Mercy—has also been a welcome presence when it has visited over the years providing healthcare, amongst other support, to remote Pacific communities.

Valued as these annual or bi-annual, short-term outreach activities are, they do not provide a persistent and predictable medical presence to support the breadth of healthcare needs of Pacific nations’ communities. Statements following Pacific Health Ministers Meetings have highlighted that achieving universal health coverage, even for primary care, remains among the region’s key priorities.

To address this health challenge, it is helpful to consider what measures have worked well to date and to understand the potential to build on success rather than re-inventing the wheel.

When the Senate Standing Committee on Foreign Affairs, Defence and Trade reported on the delivery and effectiveness of Australia’s bilateral aid to Papua New Guinea (PNG), one program in particular stood out as a more sustained and collaborative provision of medical services and training.

For over a decade, Australia and PNG have partnered with the Youth With A Mission (YWAM) Medical Ships Australia (MSA) program to provide medical support to remote PNG communities in western regions facing geographic and infrastructure hurdles at least as challenging as those experienced elsewhere in the Pacific Islands.

“It was wonderful for me to see, firsthand, the incredible work that YWAM is doing in our rural areas,” PNG’s then Minister for National Planning, the Honourable Charles Abel noted, “I was amazed to see the mother ship concept in action; one week of this vessel operating can saturate a large area with both basic and specialised health services and training.”

Since 2014, YWAM has operated an AUSTAL designed and built commercial catamaran refitted as a registered health facility complete with dental clinic, day procedure unit and laboratory. It can house four patrol tenders and is manned by as many as 130 volunteers from over 20 nations.

Teams deploy onshore via small boats or inland via a chartered helicopter to provide much-needed specialist medical services to remote communities and to triage those needing surgery on the ship. All health professionals involved submit accreditation details to the PNG Medical Board and the MSA program is coordinated with regional authorities and other health programs or providers where they exist. The PNG Health Department funds MSA along with contributions from regional authorities, the Australian Department of Foreign Affairs and Trade (DFAT) and other donors.

The MSA program has had a significant impact. Between 2010 and 2020, over 570,000 patients received care. Local medical workers received training—enabling them to deliver healthcare to their own communities, and medical, nursing and dental students and graduates from the University of Papua New Guinea gained supervised experience. An independent evaluation commissioned by DFAT found that MSA performance exceeded their service delivery targets, “[The program] is a partnership in the true sense,” said Mr Abel in 2020, “in that it is helping to assist and support and promote what is already contained in our national health plan—and working very much in collaboration with the existing health system.”

PNG’s then Deputy Secretary for Health, Dr Paison Dakulala, commented, “the training element of [MS] is very very important. What that does—especially our health workers, working in remote settings and those difficult settings—it empowers them; it strengthens them…”

During the COVID-19 pandemic, teams of volunteer nurses, midwives, and rural healthcare students were deployed to support local health authorities, with over 62,000 patients given care during the first year of the pandemic.

How can the best of programs such as MSA, Pacific Partnership, Vision of Islands be built on and scaled to work with regional health authorities, local providers such as Dr Mataka and communities across the Pacific Island nations to assess the need, coordinate the response and facilitate the delivery of reliable health care?

Effective collaboration by national and local authorities, existing providers and international partners to assess gaps in services and coordinate additional support could be an outcome of the Pacific Health Ministers Meeting. In practical terms this could be achieved through the Pacific Community (SPC) Public Health Division (PHD) directly, or if necessary, by creating a regional coordination body based on the model of the successful Pacific Islands Forum Fisheries Agency (FFA). Like FFA and Pacific Partnerships, a possible Pacific Islands Forum Health Agency (PIFHA) would work with partner stakeholders who wish to contribute to health outcomes in the Pacific. MSA attracts significant numbers of medical professionals as volunteers—more than can be accommodated each year—suggesting that there is scope to scale such a model beyond PNG. Feedback from other volunteer programs such as Vision of Islands is that keeping surgical equipment safe and effective for intermittent use despite periods of transport or storage is one of their biggest challenges and that they would welcome a coordinated provision of enabling infrastructure. The engagement of commercial providers such as ASPEN Medical highlight an increasing role for the private sector, whether funded by PIF governments or partner nations. Some universities and governments have agreements to support MSA with staff and programs such as Pacific Partnerships see salaried medical staff (military and civilian) involved. Government sponsored volunteer programs are also possible—for example a hybrid of Australian Medical Assistance Teams (AUSMAT) and Australian Volunteers. The PIFHA would not only coordinate the efficient employment of this “whole of nation(s)” health workforce to enable a persistent and predictable presence, but could establish a framework for accreditation of health practitioners providing services under this collaborative model.

Collaborations such as the FFA, the Pacific Partnership, the Pacific Quadrilateral Defence Coordination Group (Australia, the United States, New Zealand, and France), and Australia’s OPERATION SOLANIA highlight the willingness of like-minded nations to contribute military and commercial materiel to support the communities of the Pacific Island nations.

In terms of vessels, the United States Navy (USN) already has plans to retire their two aging hospital ships (Mercy and Comfort) and acquire a larger fleet, commencing with the AUSTAL EPF-14 expeditionary ship with enhanced medical facilities followed by the Bethesda Class Expeditionary Medical Ships — capable of providing a more sustained medical service to far-flung regions like the Pacific. An investment by several like-minded nations of an additional EPF-14 configuration ships (or civilian specification equivalents available from AUSTAL) each would ensure sufficient capacity to rotate an agreed number of vessels though the PIFHA program each year. The EPF medical ships, with a common configuration, would become a key enabler for volunteers, commercial and government personnel to maintain a persistent, planned presence, providing Pacific Island communities with training and scheduled health services.

At a time when much discussion concerning the Pacific revolves around great power rivalry, we should recall the words of two well-known leaders. Former Prime Minister of Fiji, Frank Bainimarama noted in 2022 that Fiji’s greatest concern isn’t geopolitics. Former President of the US, Theodore Roosevelt in articulating his “big stick” approach to foreign policy noted that a nation must not just be capable, it must choose to treat other nations with respect.

With these words in mind, why should democratic nations invest in a collaborative effort to address the health concerns of Pacific Island nations? I would argue not primarily from a desire to influence support for a stable rules-based order in the Indo-Pacific, but because we are capable of listening respectfully and providing a response to a critical need identified by our neighbours.

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