We identified 19 documents, including nine regional meeting reports, five Pacific Heads of Health meeting reports [16–20], three Pacific Health Ministers meeting reports [5, 8, 21], six WHO Western Pacific Regional Committee meetings reports [22–27], and three peer-reviewed papers [1, 10, 28].
Across these documents, five main themes emerged. These are presented below.
The Healthy Islands vision has (and continues) to have a unifying influence on action for UHC
Evidence across the literature indicates that the Healthy Islands vision has provided a powerful call to action that has rallied decisionmakers' attention in favor of health [1, 3, 29]. The vision’s resonance with Pacific decisionmakers is said to be because it frames health within an ecological worldview, an attitude that aligns with Pacific Islanders’ perception that health, environment, and culture are intimately linked . Matheson et al. (2017) comment that the Healthy Islands vision encapsulates a sentiment of harmonization and unification that - in practical terms - aligns with a preference for collaborative action and settings approaches to address challenges, including those that impede health development .
The Healthy Island vision is closely aligned with the Sustainable Development Goals and UHC. As explained during the 7th Pacific Heads of Health Meeting in 2019, the Healthy Islands vision “embodies a holistic approach that is still relevant and mirrors the Sustainable Development Goals”  and UHC is regarded as a strategy to focus efforts and resources on “gaps for health development, which are identified as major impediments to progress of Healthy Islands in the Pacific” [3, 20].
While sentiment for the vision is strong, and initiatives are often framed as contributing to its overall goals, there is broad consensus that more could have been achieved over the last 20-years had greater attention been paid to implementation barriers, including the fragmentation of efforts driven by vertical programming and a focus on the development of central agencies’ capacity over that of provincial and local authorities who, in many PICTs, carry the responsibility for delivery of primary health care services [1, 10].
Adoption of appropriate service delivery models that support integrated primary health care at the community level is needed
The delineation of packages of services, both preventive and curative, required to meet health care needs at the various levels of the health system, as well as having health care workers with the right skills mix in the right locations to deliver those services, are key strategies for UHC-aligned health sector reform across the PICTs . First mentioned at the 2018 Pacific Heads of Health meeting, these themes appear linked to the release of the report Universal health coverage on the journey towards Healthy Islands in the Pacific  the previous year. The report (and subsequent dialogue) encourages PICT decisionmakers to consider models by which health services are delivered that integrate community and primary health care (PHC); increasing the share of resources allocated to lower level health facilities and community-based services for delivery of PHC; and improving the managerial, administration, or supervisory capacity of the health system to ensure that resources reach the periphery of the health system and are well used [9, 10].
Strong and accessible primary health care (i.e., the first contact a person has with the health system (typically a general practitioner or community health worker)  is deemed essential for the achievement of UHC and is directly supportive of the Healthy Islands vision [18, 20, 25] In 2017, a report from the 5th Pacific Heads of Health Meeting noted that PHC “has been neglected for years in the region and yet increasingly is considered an important starting point for UHC” . Calls for the ‘revitalization’ of PHC were repeated in 2019 at the 7th Pacific Heads of Health Meeting, where participants “acknowledged the importance of strengthening their PHC systems and the need for political will for health sector reform.” Pacific Health Ministers reiterated this in the same year through their commitment to “strengthening PHC as the key delivery strategy for UHC in the Pacific” . This is in line with the international commitment made at the Global Conference on PHC in 2018 and captured in conference’s declaration, the Declaration of Astana (2018) .
Human resources for health are critical if efforts to achieve UHC are to be successful
(In)adequate human resources for health have been a constant theme of senior Pacific health leader meetings, with opinions raised at these meetings reflected in the literature. There is recognition given to the importance of increasing the number of skilled health workers to achieve UHC, with some progress noted in the number of doctors, but less in scaling up additional frontline workers. The health workforce profile in PICTs shows that while many have reached the critical threshold required to meet the SDGs, some PICTs with bigger populations (i.e., PNG, Vanuatu, Solomon Islands, and Samoa) have not. In PNG, for instance, it is estimated that 3.5 million people do not have access to a doctor within their district and that the country will need 17,600 additional skilled health workers to meet the SDG goal .
Delegates at the 66th Regional Committee Meeting for the Western Pacific  noted that the dominant SDG indicator by which workforce sufficiency is measured (i.e., the number of skilled health workers per 10,000 population) does not take into account the challenges in delivering care to highly decentralized populations dispersed over thousands of islands and atolls. While Pacific-specific thresholds to guide workforce adequacy have not been developed, individual PICTs have devised human resource for health indicators and targets that take into consideration local conditions [33, 34].
Heads of Health and Ministers’ meetings note that domestic capacity to train adequate numbers of health workers is lacking in many of the smaller PICTs and that there is significant variation in education and training available to health practitioners. Pacific Health Ministers noted in 2017 that more than 250 health-focused courses are on offer across the region with “varying levels of curriculum standards, academic support, [and] education and teaching materials” . This has raised concerns about both the quality of education and training offerings and their relevance to the needs of Pacific populations [8, 19].
Lack of domestic training capacity has required either the ‘importation’ of staff from overseas or the sending of nationals for training at education institutions overseas. Both options are expensive and logistically challenging. Initiatives to train Pacific Islander doctors abroad, notably in Cuba [28, 35, 36], have helped address human resources for health gaps and provide much-needed capacity in health. For example, the number of doctors in Kiribati increased from 18 to 51, with 23 of the new doctors Cuban trained. In Solomon Islands, the number of doctors in the same period grew from 79 to 170, with the return of 74 medical graduates from Cuba between 2014–2018, and another 34 expected to graduate by 2025. Cuban trained doctors also contributed to significant increases in the number of doctors in Tonga, Tuvalu, Vanuatu, and Nauru [28, 37]. However, these initiatives are not without problems with delegates to the 2016 Heads of Health meeting raising concerns for the ‘job readiness’ of returning overseas educated doctors and the resource-intensive need to provide additional primary care-focused training and mentorship [10, 17].
Ministers note that a response to the health workforce deficit will require a nuanced approach considering the different islands’ contexts. The challenge will be to train and/or recruit adequately skilled staff, fund and support their deployment to rural areas where there is typically the greatest need and support them once there. At the 13th Pacific Health Ministers Meeting in 2019, this was acknowledged in the commitment to “develop training programs targeted at isolated medical practitioners and [implement] effective health workforce retention strategies” .
Ministers highlight that global disparities and shortages in the supply of healthcare workers exist, with high to severe shortages reported in many PICTs, where the need for health workers is most significant. Central to their concerns is the emigration of health workers to other PICTs and Pacific-rim countries and the deficits in capacity left. Research shows that this “continuing exodus of skilled health care professionals”  is high, and Australia and New Zealand’s contribution to this ‘brain drain’ has increased from 455 Pacific-born doctors and 1,158 Pacific-born nurses and midwives reported as working in Australia in 2006, to 607 doctors and 2,954 nurses in 2016 . The result is increased deficits in human resources for health in these contexts, weaker health systems and the undermining of regional capacity development efforts .
Access to reliable health information is central to health sector improvement
A reliance on antiquated paper-based health information reporting and the lack of data quality standards/checks are noted challenges to the reliable monitoring and reporting of PICT populations’ health status and the availability of evidence to base system development decisions to support UHC .
The limitations of PICTs’ health information systems are eloquently articulated in the foreword to the second Healthy Islands Monitoring Framework [HIMF] progress report when the author writes, “Many datasets [on which accurate monitoring relies] are works in progress that require improvement, including capacity-building and overall strengthening of health information systems” and, “[the] primary challenge is to ensure that monitoring systems are strengthened or introduced to ensure data are collected regularly and with a high degree of accuracy.” Underpinning these efforts is the recognition that investment is required to strengthen national health information systems” . Delegates have noted that these efforts should include improved data sources; increased capacity to manage and analyze data and ensure information is translated into action; and work to “reinforce equity-oriented health information systems with more disaggregated data across age, sex, geography, household income levels and other characteristics appropriate to the country context” .
Pacific health leaders recognize the limitations and highlight the transformative opportunities prudent digitization of health information offers health systems – both in terms of the opportunity to enhance the continuum of care provided and for macroscopic health system performance oversight and reporting [19, 20, 26].
While not a panacea for all challenges, digital health offers many opportunities
Adoption of digital health interventions, through a range of applications such as eLearning, telemedicine, and digital health information systems, has been raised by delegates to senior health fora as an opportunity to support efforts to address UHC. For example, attendees at 2019 Heads of Health meeting highlight telemedicine as a tool that may help overcome challenges in the delivery of health services in rural and remote areas .
Delegates to the 2020 WHO Regional Committee Meeting noted that there has been a rapid acceleration in the use of digital health in some countries while others remain in the early stages of adoption; and that this has resulted in a ‘digital divide’ between countries. They highlighted the UHC principles of equity and stress the need to explore ways and means by which well-advanced countries can support those with fewer resources to capitalise on the opportunities digital health may offer .
Discussion at the 2018 Regional Committee Meeting noted the “roll-out of information and communications technology for health service delivery was uneven across the Region” but that the recently developed Regional Action Agenda on Harnessing E-Health for Improved Service Delivery in the Western Pacific  (in draft at the time of writing) was a tool to guide countries’ adoption of e-health. This document sought to guide the rational use of e-health through cost-effective means with an emphasis on the “development of appropriate infrastructure, information-sharing, and privacy and security mechanisms.” Strategies to ensure the development of effective digital health interventions featured again at the 2019 7th Pacific Heads of Health Meeting, where delegates from Vanuatu stressed the need for investment in infrastructure to support digital health roll-out in the Pacific together with legislation to guide information-sharing and data privacy. Further, delegates stressed the need to include end-users (i.e., health staff) in developing digital health strategies to garner buy-in and support for e-health initiatives and ultimately increase the likelihood of sustained utilization of digital tools . The importance of ongoing external technical assistance to support PICTs’ transition to digital platforms while the human resource capacity for domestically managed e-health is developed, Pacific regional cooperation for the sharing of insights and development costs, and the need for visionary leadership to drive the adoption of digital health were highlighted .