Prioritizing Health System Development in the Pacific: A Layered Approach

The Issue

This brief gives an overview of health challenges across the Pacific Islands region and identifies the need for development partners such as the United States to reframe their approach to health system development. The document provides several recommendations for policymakers and development organizations as they work with the Pacific to effectively meet the health needs of the region.

Increasingly alarmed by aggressive Chinese efforts to broaden a security foothold in the Pacific, the United States, along with partners such as Australia and New Zealand, has stepped up efforts in recent years to be present and responsive to the needs of the Pacific Islands—with varied levels of success. One critical area, health development, has continued to fall short—and yet, working with the Pacific to prioritize health system development could have significant and long-lasting positive effects on U.S. presence and influence in this critical region.

After decades of relative neglect, the United States faces an uphill battle to prove it is a reliable partner in the Pacific Islands region—defined for this paper as inclusive of countries and territories stretching across the Pacific Ocean from Palau to French Polynesia, exclusive of Australia and New Zealand. To combat this perception, the United States has focused on a series of high-level engagements and initiatives, as well as publishing the first-ever U.S. strategy for the Pacific: the Pacific Partnership Strategy. Top initiatives have focused on climate, maritime security, and successfully concluding negotiations on the regional Tuna Treaty and three Compact of Free Association (COFA) agreements. In 2023, the U.S. Agency for International Development (USAID) established an office in Suva, Fiji, overseeing programming across the region, and the Peace Corps returned to multiple Pacific locations. These are all essential pieces of U.S. engagement, but so too is health system strengthening, which focuses on supporting education, training and staffing up local medical personnel, establishing services that are needed in order to strengthen approaches toward all health challenges, and improving the physical infrastructure of crumbling and vulnerable hospitals and clinics. The World Health Organization states: “A well-functioning health system working in harmony is built on having trained and motivated health workers, a well-maintained infrastructure, and a reliable supply of medicines and technologies, backed by adequate funding, strong health plans and evidence-based policies.”

The Pacific Islands region consists of over 14 million people living on thousands of islands spread out over 30 percent of the Earth’s surface. Despite spanning thousands of miles and hundreds of ethnicities, there is a homogeneity to the significant health challenges facing all Pacific Islands. The Pacific Partnership for Health System Sustainability and Resilience summarizes ongoing issues including difficulty with reliable transport, costly overseas medical referrals, modest and fragile economies, workforce and supply chain shortages, and extreme vulnerability to natural disasters. These factors have hampered the establishment of sustainable health systems in addition to limiting economic development.

Health programming is not always considered a top foreign policy priority, but both the immensity of health challenges in the Pacific and the cross-cutting nature of the health sector across economic, political, and security dimensions demand a more concerted effort by the United States and other development partners to effectively deliver on health.

The United States has several existing health programs in the Pacific, and numerous other partners, such as Australia, are heavily involved in health capacity building as well. And yet, many programs are siloed to address specific diseases or aimed at meeting short-term needs, instead of laying the groundwork to strengthen the very foundation of a host nation’s health system. Coordination is not enough. There also needs to be a shift in mindset—from expatriate provision of services to local partnership collaboration—in order to enhance services. A shift toward multinational collaboration in the Pacific requires moving from temporary, news-making projects to a layered, committed approach that allows donor, host nation, and regional organizational efforts to build on one another. This report will first present an overview of the current state of health systems in the Pacific and ongoing development activities. It will then present recommendations for shifting to a more coordinated, layered approach to most effectively strengthen Pacific health systems.

Pacific Health Systems—Underfunded and Under-Resourced

Having access to sufficient healthcare is top of mind across the Pacific; health shortfalls affect every Pacific Islander, regardless of social or economic status. Despite international focus on the recent Solomon Islands election as a metric of U.S.-China competition, Solomon Islanders voted on issues much closer to home—namely lack of healthcare and a dwindling economy. What Solomon Islands voters voiced this April is not unique. Limited access to essential healthcare is a region-wide problem that adversely impacts economic development and stability. The disparate, far-flung tropical geography of the Pacific region, combined with modest populations, small economies, and limited inter-island connectivity, has resulted in a unique set of health challenges that were only further exacerbated during the Covid-19 pandemic.

Programs that address infectious diseases, such as malaria, dengue, and TB, are already common in the Pacific Islands, but they do not address the leading causes of premature mortality: noncommunicable diseases (NCDs), such as cancer and diabetes. Along with obesity and mental health, these chronic diseases are responsible for upwards of 80 percent of deaths in the region. The increasing incidence of injuries and trauma occurring following natural disasters, road traffic accidents, and personal injury further stresses already under-resourced regional health systems.

Health systems in the Pacific Islands are under-resourced, as evidenced by health spending per capita per year. The Institute for Health Metrics and Evaluation’s (IHME) 2021–2022 data shows that average annual health expenditure (in USD) per person in the Pacific region, excluding Australia and New Zealand, was $583. In U.S.-affiliated territories and Freely Associated States, it was $922; in non-affiliated Pacific Island countries, it was $388. When contrasted with health expenditure in the United States and Australia—at $12,012 and $7,055 respectively—these low health expenditure rates per person are striking and reflect a reality of limited budgets, services, and access (Figure 1).

The shortage of doctors and nurses remains a critical issue in the Pacific Islands, despite a number of medical and nursing universities and schools in the region (Figures 2–3). The number of nurses in all Pacific Island countries falls below WHO recommendations. The number of doctors in 67 percent of PICs is below WHO recommendations. A limited healthcare workforce makes it difficult to achieve universal health coverage. This is partly due to training volume, but it is also due to external migration of both doctors and nurses looking for better pay and the opportunity to work in better quality health systems.

In 2015, the United Nations introduced the Sustainable Development Goals. Included in this ambitious agenda is universal health coverage (UHC); the goal does not refer to health insurance, but calls for all people to have “access to the full range of quality health services they need, when and where they need them, without financial hardship.” The data on progress toward UHC in the Pacific Islands region shows the region is underperforming in achieving many of the basic services needed in order to deliver UHC. This is largely due to limited essential services addressing non-communicable diseases, represented on the right side of Figure 4 below.

Adding further complexity is the region’s exceptional vulnerability to natural disasters such as cyclones, earthquakes, drought, and flooding, which not only threaten people and their food sources but also the very health system that serves them. Fifty-six percent of Pacific Island hospitals are especially vulnerable to extreme weather damage due to low-lying coastal locations, resulting in grave risk to health access for over half the Pacific population. When health clinics and dispensaries are included, 62 percent of all Pacific Island health infrastructure exists in vulnerable locations. Under-resourced health systems are further hampered by natural disasters inducing the loss of services and subsequent costly repairs that consume 1–9 percent of their annual GDP. In 2021, the World Risk Report, an annual assessment of disaster risk from extreme natural events and negative climate change impacts for 193 countries, had 5 Pacific Island countries in its 10 most vulnerable countries worldwide.

Current State of Health Development in the Pacific

Within the Pacific, the Secretariat of the Pacific Community (SPC) is the primary regional scientific and technical organization. The SPC, through its public health division, holds two health ministerial meetings per year that are attended by health ministers as well as development partners working within the region, including representatives from the U.S. Department of Health and Human Services (HHS), USAID, and the Centers for Disease Control and Prevention (CDC). During these meetings, health issues facing the Pacific Islands are discussed and prioritized.

Among development partners, Australia is by far the largest grantor in the region; this extends to Pacific health programing, including assisting with management of health systems and supply chains, training, infrastructure, and advancing UHC. Australia’s Department of Foreign Affairs and Trade (DFAT) funding also supports several educational and training programs, including the Australia Award Fellowships, which allow for training at Australian medical center sites. The Pacific Islands Program (PIP), through the Royal Australasian College of Surgeons and the Royal Australasian College of Physicians, sends visiting surgical and oncological partnership teams to Pacific Island hospitals. Australian Aid also supports the Australian Volunteers Program.

New Zealand’s Ministry of Foreign Affairs and Trade (MFAT) also supports a number of health-related programs, including the newly introduced New Zealand Medical Treatment Scheme (NZMTS) overseen by the Pasifika Medical Association Group. This scheme provides overseas referrals for people requiring specialized medical care living in Fiji, Kiribati, Samoa, Tonga, Tuvalu, and Vanuatu, and it includes medical team visits and capacity building.

Japan has become more active as a geostrategic player in the Indo-Pacific, especially on infrastructure. Since 2008, Japan has committed $3.8 billion to the Pacific, largely directed toward big infrastructure projects such as building or remodeling hospitals, medical university buildings, roads, and bridges. Japan has also experimented with creative initiatives such as donating the ship Liwãtoon-Mour to the Ministry of Health and Human Services of the Marshall Islands to act as a floating clinic. With its low draft, the ship can extend basic healthcare to otherwise hard-to-reach outer islands.

Taiwan, despite limited diplomatic presence in the Pacific Islands, continues to provide health assistance through education, research, medical supplies, and visiting medical teams to Palau, the Marshall Islands, and Tuvalu.

Since 2019, China has been a rising health donor in the Pacific. In Kiribati, Papua New Guinea (PNG), Solomon Islands, and Nauru, Chinese medical teams (CMTs) work alongside local doctors; China has also established bidirectional exchanges, including participation in medical education observerships, at Chinese medical centers and provided medical scholarships to Pacific Island residents of Fiji, PNG, Samoa, Tonga, Solomon Islands, Vanuatu, and Kiribati. China’s navy hospital ship, the Peace Ark, has conducted medical missions in 43 countries worldwide since 2008.

According to the Lowy Institute Pacific Aid Map, since 2008 the United States has committed $386 million toward health in the Pacific. Outside of U.S. territories and Freely Associated States, however, U.S. health engagement has primarily been focused on vaccine programs and infectious disease prevention. During the pandemic, the United States donated Covid-19 vaccines to many countries in the region. USAID and the CDC have programs that focus on providing vaccines and addressing specific diseases through the Global Fund’s TB, malaria, and HIV programs. The recently released U.S. Government Global Health Security Strategy (GHSS) addresses disaster and infectious disease responses—but not actual health system development. Additionally, the United States provides short-duration care to some Pacific Islands via an annual U.S. Navy hospital ship deployment as part of the Pacific Partnership (PP) program. The overarching mission of this program is to focus on “strengthening capacity of host nations to respond to crisis and fostering enduring bonds of friendship and multinational cooperation.”

NGOs and Public-Private Partnerships in the Pacific Islands

The Pacific Islands are also the recipients of significant assistance from a multitude of private and nongovernmental organizations (NGOs). Some are quite large, work worldwide, and focus on specific healthcare issues. In addition to these larger NGOs, many smaller organizations visit the region to provide short-term care and deliver donated medical supplies. There are also numerous ad hoc visiting service arrangements between providers or institutions and Pacific hospitals or clinics that have the potential to create sustainable benefits if coordinated.

However, to date there is no comprehensive coordination between donors and development partners. This is particularly true with NGOs. Furthermore hampering efforts, donors sometimes fail to coordinate with the host country, and may even come and go with little to no collaboration with local providers, despite the fact that local providers often have the best awareness of current health needs.

The establishment of private clinics and hospitals in several PICs has introduced the potential benefits of public-private partnerships in contributing to improved healthcare in the region. For example, in Fiji, Aspen Medical established hospitals in Lautoka and Ba through a partnership with Fiji’s National Provident Fund health insurance scheme and the Fiji government. As part of the agreement, Aspen hospitals provide some pro bono cardiac surgical care to Fijians without insurance. Additional private hospital partnerships are present in Guam and in Pohnpei.

Despite the large number of development and donor parties working in the region, healthcare in the Pacific Islands remains woefully inadequate. While most country and private or nonprofit sector efforts are well intentioned, very few are coordinated or delivered in a way that maximizes their potential to do good. For example, in Solomon Islands, when the USNS Mercy visited the capital city of Honiara in 2022 and 2023, the U.S. Navy donated Storz laparoscopic surgery towers and equipment to the National Referral Hospital—but unfortunately, training in the use of that equipment was not included. As of February 2024, this equipment had yet to be used. Generous donations like this one could have a much greater impact if accompanied by follow-on training, either by the U.S. Navy or another partner.

A sample list of governments, NGOs, and public-private partnerships operating in the Pacific region is included in Appendix 1.

Health Development: Recommendations for a Regional, Layered Approach

By its very nature, health is a broad and complex development sector. While there are many players providing some form of health service in the Pacific, the reality is needs are not being met—in fact, health indicators in the Pacific have stagnated and in some cases declined on the heels of the pandemic. The answer is not to simply throw more money and resources at the problem, although more of both are needed. To sufficiently raise the level and quality of healthcare in the Pacific, efforts must be better coordinated as part of a total, layered approach. Current initiatives, while usually imperfect in a vacuum, could be mutually reinforcing and, ultimately, round out a strong Pacific system of health. A coordinated multinational and multiorganizational approach can reduce cost as well as redundancy—while collectively addressing the real health challenges of the region. This following section presents several considerations and steps the United States, as a multinational partner, can take in order to strengthen health systems in the region and see tangible results in the near future.

Place Pacific Health Leaders at the Center

As a guiding principle, any development program must be Pacific-led, as host nation and local input and direction is critical to the success of any project or initiative. This is not simply a platitude of foreign relations with the Pacific Islands; the nations of the Pacific already have established organizations and health officials with the most accurate assessments of regional and island-specific needs. Programs that do not work through Pacific health officials and institutions risk having limited effectiveness and threaten the longevity of programming.

The SPC health division, as mentioned above, serves as the main health advisory body for the Pacific region. SPC plays a central role in collecting Pacific health data and coordinating regional health meetings. The Pacific Island Health Officers Association (PIHOA) represents the collective interests of the ministers, secretaries, and directors of health for the Freely Associated States and U.S. territories. Country heads of health play a critical role in crafting national and regional health plans and initiatives, such as the location and prioritization of health facilities. Including the SPC and PIHOA can help to efficiently coordinate health system strengthening efforts, but it cannot replace working directly with national health authorities on country-specific initiatives.

Meetings of all participating parties should be held regularly in order to foster Pacific ownership, define priorities, ensure programs are synchronized with identified needs, and ensure resources are appropriately allocated. Whenever possible, input should be sought from doctors and nurses who can speak to the interface point of care. It is the doctors and nurses who are the local champions that the health system services are built on. This approach emphasizes the need to establish permanent high-quality health capacity that is Pacific driven, versus simply bringing in (sometimes temporary) outside resources and personnel.

Reduce the Burden on Pacific Governments

With a Pacific-led approach to health development, there must be an understanding of the limited capacity of many smaller-staffed ministries and organizations in the Pacific. While Pacific institutions and national health officials should set priorities through consultations, donor countries and institutions should shoulder the majority burden of cost, coordination, and deconfliction. One solution might be to establish a quarterly meeting of outside donors to coordinate programming in accordance with Pacific-set objectives, followed by a report to the SPC (for regional programs) and national leaders (for country-specific initiatives).

From an administrative standpoint, partners should avoid overburdening Pacific governments with the redundant administrative paperwork associated with many programs. Development partners should consider simplifying and consolidating reporting requirements or recognizing already-submitted paperwork in applicable cases. Additionally, grouping existing programs together into larger initiatives avoids a multitude of siloed programs—such as disease-specific projects—and could further help alleviate some of this administrative burden.

Strengthen Health System Human Capacity

Health system human capacity in the Pacific is lacking, both in sheer numbers—as depicted by Figures 2 and 3—and in opportunities for specialized training and continuing education. Development partners can play a significant role in providing opportunities for clinical training and education through university partnerships, medical education support, clinical fellowships, and specialized training. In a recent article on tackling diabetes in Solomon Islands, a diabetes nurse highlighted the need for continuing medical education in what is a major health problem for the country: “One big problem is the lack of education. There are no postgraduate studies in diabetes care for our nurses.”

Two models that successfully address workforce strengthening and education and could be replicated in the Pacific Islands are the Medical Education Partnership Initiative (MEPI) and Nursing Education Partnership Initiative (NEPI). These initiatives were established as part of the President’s Emergency Plan for AIDS Relief in 2010.

The goals of MEPI and NEPI were to significantly increase the number of new healthcare workers, strengthen in-country medical education systems, and build clinical and research capacity in Africa by pairing African and U.S. medical universities. The results from the five-year program were significant: MEPI increased the number of medical and nursing student enrollees and graduates by over 100 percent and enhanced the retention of healthcare workers while increasing community care sites by 42 percent. Data from the WHO National Health Workforce Accounts Data Portal shows that 90 percent of the 12 Africa-based programs participating in MEPI and NEPI had an increase in the number of physicians and nurses from 2010 to 2015. An additional sustainable benefit from MEPI was that it created “communities of practice” whereby medical schools in the United States and Africa shared data and collaborated together, strengthening regional cooperation. At a cost of $130 million over five years, MEPI and NEPI are excellent examples of high-yield, low-cost initiatives that have a direct positive impact on medical human resource development. Exporting a MEPI/NEPI model to the Pacific, albeit on a smaller scale and focused on clinical development, could have significant and rapid positive results across the region.

Address Health System Infrastructure

With 62 percent of all health infrastructure vulnerable to extreme weather or tropical environment degradation, an “island hopping” campaign to rebuild and relocate medical infrastructure is needed. To achieve the basic healthcare services that UHC calls for, Pacific health infrastructure will need to be expanded and upgraded. Hospitals, clinics, and dispensaries must be seen as critical infrastructure, just like the roads and bridges used to access them. Some of this work is already happening. For example, Japan is currently renovating the National University of Samoa Faculty of Health Science, and Australia just committed to renovating the Colonial War Memorial Hospital in Suva, Fiji. New Zealand has done excellent work refitting existing community clinics across Fiji, demonstrating the impact that smaller, fit-for-purpose projects can have on basic health services. 

Addressing health infrastructure must include bolstering telecommunications networks to facilitate telehealth consultations between nurses, doctors, and specialists across the region. Where far-flung smaller populations do not have quick, physical access to major hospitals, it is essential to include communications network linkages between hospitals and smaller (rural) medical clinics. Telehealth connectivity allows not only for patients to be seen for virtual consultations and check-ups, but also for local health professionals to benefit from the expertise of specialists located elsewhere. A successful example is the use of telemedicine in the Alaska Native health system, which decreased unnecessary travel and improved access to care in rural areas by facilitating real-time consultations with specialists. Partners conducting efforts to bolster Pacific telecommunications should ensure that health connectivity is prioritized.

Establish Medical Specialty Care Centers in the Pacific

While basic health infrastructure on a country-by-country level must be a priority, the availability of specialty care should also be addressed through the establishment of regional medical specialty centers. Currently, when specialty care is not available on island, it is provided through overseas medical referrals (OMR). A 2019 survey of costs of OMRs incurred by Pacific Islands reported a regional annual cost of US$125 million. Developing Pacific region medical specialty care centers increases timely access to care and can reduce costs. There are already some sites where regional specialty care is provided, and these hospitals can be strengthened, or new ones developed. Fiji, for example, has two sites where cardiac care is available. But the region also needs comprehensive and cost-effective cancer and neurological care. Establishing regional specialty care centers must consider accessibility, ease of travel, ability to expand services to fit patient referral workload, and the potential to become a regional medical training center. These medical specialty care centers must also be seen as a collective extension of every Pacific Island health system.

Filling the Gaps: Implement Creative Solutions over Land and Sea

Even if the above workforce and infrastructure objectives are met, gaps in health coverage will remain due to the remoteness of some Pacific populations. It is here that the creativity of NGOs and health organizations can provide an essential bridge between existing health capacity and patient needs.

Initiatives that capitalize on mobility and flexibility can be especially effective. For example, Youth With a Mission (YWAM) Medical Ships Australia, an NGO that has delivered health services and training to remote provinces in Papua New Guinea for over 10 years, has had some success filling critical healthcare delivery gaps in these communities. Expanding this concept across the Pacific would provide mobile clinics that stop at outlying islands and remote communities on a regular basis, providing screenings and limited specialty appointments such as dental services.

To ensure that programs such as YWAM are additive (versus disjointed or detrimental to other development efforts), they must be integrated into the overall layered approach toward health development in the region. It is also essential that these types of programs do not siphon off national resources that would otherwise be directed at building essential infrastructure or providing adequate salaries to host-nation medical professionals.

In the same vein, the periodic visits by military hospital ships such as the USNS Mercy could be exponentially more effective if integrated with other partner efforts—for example, by building upon training that is ongoing through a university partnership with a local hospital, or by delivering new medical equipment in conjunction with training on its use and maintenance. This type of coordination requires a broader understanding of the strategic health objectives and regular touch points between partners, but it would also vastly increase both the effectiveness of hospital ship visits and the goodwill that they engender. Additionally, hospital ships should visit more remote locations, instead of larger cities where medical infrastructure is readily available.

Expanding ship-based medical and dental clinics can also be accomplished by increasing the fleet of smaller, more agile fitted ships in the Pacific. Partners should look for opportunities to transfer smaller-draft Coast Guard or naval vessels to Pacific countries, fitted with a basic medical and dental clinic, in the same vein as the Japanese ship Liwãtoon-Mour in the Marshall Islands.

Filling the Gaps: Expand Private Involvement in Health

Lastly, private companies and corporations have the potential to play a critical role in building infrastructure, establishing regional medical specialty centers, addressing supply chain issues, and enhancing human resource capacity. Using public-private partnerships to reduce the investment risk for private entities that have both the expertise and the capacity to bolster health systems in the Pacific could contribute substantial value—while offering private industry a new market. In addition to hospitals, public-private partnerships can play a critical role in the establishment of affordable, regularly available, and high-quality pharmaceutical and medical supply chains through initiatives such as creating regional purchasing centers to negotiate costs that are scaled to local economies. These private efforts should be done in concert with training and education programs to avoid the risk of drawing healthcare workers away from understaffed public systems. This same internal brain drain can occur when well-funded disease-specific programs are introduced. 

Conclusion

In 1961, when President John F. Kennedy established the U.S. Agency for International Development, the goal was to prevent developing countries from becoming failed states that “would be disastrous to our national security, harmful to our comparative prosperity and offensive to our conscience.” These matters of conscience apply very much to health. A child should not die from diarrhea due to a lack of clean water nor a young adult prematurely die due to a normally treatable heart condition. Recognizing the value of sustainably addressing long-overdue human development policy through health system strengthening can have a big impact in the Pacific Islands. As stated in the 2007 CSIS Commission on Smart Power report, “Smart power is neither hard nor soft—it is the skillful combination of both.” It is the very embodiment of enduring friendships, respect, and value.

In the same vein, the United States must recognize that health diplomacy, currently underutilized, should be an essential component of its strategy in the Pacific. Access to quality healthcare is a universal human concern, and it is directly linked to economic development. The McKinsey Global Institute’s 2022 report Prioritizing Health: A Prescription for Prosperity “found an economic return of between $2 to $4 across developing countries for every $1 invested in health.” In the Pacific Islands alone, the report found that addressing health through services and prevention would result in 32 percent fewer early deaths, 42 percent fewer illnesses, and a 25 percent increase in labor productivity. Bolstering Pacific Island nations’ health capacity would directly and positively impact Pacific stability, prosperity, and resilience in a proactive way—objectives stated in the U.S. Pacific Partnership Strategy.

To shift from a reactive to a proactive approach in the Pacific, the United States and development partners must reframe how health development is conducted, moving from a myriad of well-meaning but disparate and siloed programs to a comprehensive, coordinated, and layered approach. Each program should relate to the next. The Pacific Healthcare Initiative, currently supported by a number of bipartisan members of Congress, can begin to take the United States into this type of coordinated approach. Other similar efforts will be needed.

Working more effectively with Pacific Island countries and other development partners toward strengthening Pacific healthcare not only benefits the people of the Pacific. It is one of the best ways to demonstrate that the United States is a committed and reliable partner for the region—and one that is in the Pacific to stay.

Kathryn Paik is a senior fellow with the Australia Chair at the Center for Strategic and International Studies in Washington, D.C. Eileen Natuzzi is a physician affiliated with the Georgetown University Walsh School of Foreign Service, Center for Australian, New Zealand and Pacific Studies.

This brief is made possible by general support to CSIS. No direct sponsorship contributed to this brief.

Appendix: Health Development Programs in Pacific Island Countries

The following is a list of donors and organizations working on health in the PICs. This list is meant to be representative and not comprehensive.

Primary Government Development Partners

• Australia
• New Zealand
• Japan
• United States
• China
• Taiwan

Financial Institutions

• World Bank
• Asian Development Bank
• International Monetary Fund

Nongovernmental Organizations

• Open Heart International
• Youth With a Mission (YWAM) Medical Ships Australia
• Sai Prema Foundation Fiji
• Fred Hollows Foundation
• Pasifika Medical Association Group
• Australia New Zealand Gastrointestinal International Training Association (ANZGITA)
• Loloma Foundation
• Doctors Assisting in South Pacific Islands (DAISI)

Private Healthcare Institutions

• Lautoka and Ba Hospitals, Fiji: Aspen Medical
• Oceania Hospital, Fiji: Bank of the South Pacific
• Pacific Specialist Healthcare, Fiji: Private owners and investments
• Guam Regional Medical Center, Guam: Philippines The Medical City/ CVC Capital Partners Asia V
• Genesis Hospital, Pohnpei: Privately owned