Introduction Small island developing states face some of the most complex health system challenges—small in size, but large in health and development constraints. Dispersed populations, remoteness, small labor markets, and limited economies of scale make it difficult to obtain timely, quality health services, particularly specialized care. Climate vulnerability, reliance on imported processed foods, and small risk pools further strain health systems, increasing costs and reducing resilience. Among Asian Development Bank (ADB) developing member countries, 14 are small island developing states: Fiji, Kiribati, Maldives, Marshall Islands, Federated States of Micronesia, Nauru, Palau, Papua New Guinea, Samoa, Solomon Islands, Timor-Leste, Tonga, Tuvalu, and Vanuatu. Small island states share structural, geographic, and economic constraints that challenge their health systems. They also bear a “triple burden” of disease—communicable diseases, noncommunicable diseases, and injuries—resulting in health outcomes that resemble lower-middle-income countries despite higher income classifications. While many countries are already taking steps to address these challenges, further reforms are needed to ensure health services are available, reachable, and responsive to population needs. Addressing these challenges requires reforms not only in how systems are financed, but in how services are delivered and brought closer to dispersed populations. Expanding Access to Health Services Expanding access to essential health services in small island developing states, including the Pacific, depends on how health systems are financed and organized to reach dispersed populations, particularly through revenue collection, effective risk pooling, and strategic purchasing. These functions are critical to ensuring services are available, affordable, and delivered where people live, in small island contexts where limited scale constrains availability. Health Taxes for Sustainable FinancingAchieving sustainable health financing requires moving away from fragmented, donor-dependent models toward pooled, primarily tax-funded systems. Expanding fiscal space through innovative measures is essential. Sustained domestic financing is critical to expand access, enabling countries to fund primary care, outreach services, and prevention programs that reach dispersed populations. Excise taxes on tobacco, alcohol, and sugar-sweetened beverages are increasingly used as fiscal and public health strategies to address noncommunicable diseases. Health taxes are policy instruments that simultaneously reduce risk factors, mobilize domestic resources, and strengthen prevention and frontline primary health services. In small island developing states, these fiscal measures often form part of national strategies against noncommunicable diseases, given their substantial contribution to mortality and health system demand. While traditional tax incidence analysis may classify such taxes as regressive, broader economic evidence from extended cost-effectiveness analysis shows benefits such as health gains, financial risk protection, lower out-of-pocket spending, and reduced income losses. This can outweigh the initial burden, particularly among lower-income groups who are more responsive to price change. When these wider welfare effects are considered, health excise taxes can be progressive. Allocating revenues to prevention, health promotion, and primary health care enhances the fiscal space for health and reduces socioeconomic inequalities in noncommunicable disease outcomes over time. Risk Pooling for Financial Protection and CoverageBy spreading costs across populations, risk pooling helps sustain the availability of essential services and reduces financial barriers to care, particularly in small island settings where small populations limit service provision. However, a key challenge for small island developing states is small size of national risk pools. Small populations limit the viability of traditional insurance-based approaches, making tax-funded health systems the dominant mechanism fpor ooled financing. World Health Organization data indicates that broad public pooling arrangements are more effective in expanding equitable access to health services than fragmented financing arrangements with multiple small or voluntary pools, including private insurance. Regional pooling offers additional opportunities by allowing countries to share funds and enable cross-border care through strategic purchasing. Larger pooled systems improve equity and efficiency by spreading risk and reducing costs. When combined with strategic purchasing, stronger pooling arrangements improve performance by linking financing to health outcomes, service quality, and population needs. Strategic purchasing—how funds are allocated to providers and services—is critical to ensuring efficiency and quality in resource-constrained settings. Strengthening Health Workforce in Small StatesHuman resource constraints are a major barrier to ensuring people can obtain needed care in remote and outer islands. Small labor markets, migration, and limited training capacity exacerbate shortages across many specialties. Instead of copying large-country models, small states can adopt flexible workforce approaches focused on generalists—such as family physicians, nurse practitioners, and community health workers—supported by task shifting and sharing. Regional cooperation—such as shared centers of excellence and mutual recognition of qualifications—can help address persistent gaps. Digital tools, including telemedicine and AI, can further expand service delivery by supporting care in remote areas and enhancing the capacity of frontline health workers. Reaching Dispersed Populations with Essential CareGeographic fragmentation presents major challenges for equitable access to health services—requiring innovative models to reach dispersed populations. A hub-and-spoke approach, linking central hospitals to decentralized primary care facilities and mobile outreach teams, can improve geographic coverage and continuity of care. Telemedicine and digital health platforms enable remote consultations, diagnostics, and follow-up care, reducing the need to travel. Mobile clinics, periodic specialist visits, and mobile-based support further extend service reach to outer islands, reducing inequities while maintaining cost efficiency. Climate-Resilient Health Systems for Continuity of CareClimate-resilient health infrastructure is essential for small island developing states due to high exposure to extreme weather and sea-level rise. Building and retrofitting facilities to withstand cyclones, floods, and rising sea levels, while ensuring reliable water, sanitation, and access to renewable energy, is critical to maintaining essential health services during crises. Strengthening supply chains, emergency preparedness, and backup services are crucial to maintaining care during disasters. Aligning health infrastructure planning with national climate adaptation strategies and international best practices can address growing climate risks. Conclusion Health systems in small island developing states face growing pressures from rising noncommunicable diseases and climate risks. Strengthening financing, expanding risk pooling, and adopting results-based public financial reforms can improve equity and sustainability. Workforce innovation, digital tools, and climate-resilient facilities can boost access to quality care. With targeted, efficient, and equitable reforms, small island developing states can ensure that essential health services reach even the most remote communities, improving health outcomes across dispersed populations. This Insight captures issues discussed during the ADB UHC PEERS (Universal Health Coverage Practitioners and Experts Knowledge Exchange and Resources) Forum and Fiji Health Transformation Summit hosted by the Ministry of Health and Medical Services, ADB, and Australia-Fiji Health Program. Resources ADB. 2025. Innovative Financing for Noncommunicable Diseases in Asia and the Pacific. ADB. 2023. Kiribati: Climate-Resilient Health Infrastructure and Systems Project. Global Health Observatory. Universal Health Coverage (UHC) Service Coverage Index (SDG 3.8.1). World Health Organization. T. Postolovska et al. 2019. Distributional and Financial Protection Effects of Tobacco Taxation: Extended Cost-Effectiveness Analysis (World Bank Policy Research Working Paper). World Bank. World Health Organization. 2019. Strategic Purchasing for Universal Health Coverage: Unlocking the Potential. Ask the Experts Eduardo P. Banzon Director, Health Practice Team, Human and Social Development Office, Sectors Department 3, Asian Development Bank Dr. Eduardo Banzon champions Universal Health Coverage and has long provided technical support to countries in Asia and the Pacific in their pursuit of this goal. Before joining ADB in 2014, he was President and CEO of the Philippine Health Insurance Corporation, World Health Organization (WHO) regional adviser for health financing for the Eastern Mediterranean region, WHO health economist in Bangladesh, and World Bank senior health specialist for the East Asia and Pacific region. Nishant Jain Senior Health Specialist, Human and Social Development Sector Office, Sectors Department 3, Asian Development Bank Dr. Nishant Jain is a global champion of universal health coverage (UHC), with over two decades of experience in the field. He played a key role in designing and implementing India’s national health insurance schemes, which now cover more than half a billion people. He has also supported countries across Asia, the Middle East, and Africa in developing and implementing their UHC programs. He previously led the health and social security portfolio for German Development Cooperation (GIZ) in India. Ammar Aftab Health Specialist, Human and Social Development Office, Sectors Department 3, Asian Development Bank Ammar Aftab works on health sector engagement and operations across the Pacific. This includes leading the project design and development, implementation support, and coordination with internal and external stakeholders, including government counterparts and development partners. His work in the Pacific focuses on climate- and disaster-resilient health infrastructure, digital health systems to improve access to quality care, and health workforce development and training. Rouselle F. Lavado Principal Social Sector Economist, Human and Social Development Office, Sectors Department 3, Asian Development Bank Rouselle F. Lavado specializes in health financing and human capital development. She previously worked at the World Bank (Europe and Central Asia), the World Health Organization—where she was part of the team that developed the Global Monitoring Report on universal health coverage—and the Institute for Health Metrics and Evaluation. Her work advances global evidence and policy on financial hardship and universal health coverage. Vasoontara S. Yiengprugsawan Senior Universal Health Coverage Specialist (Service Delivery), Human and Social Development Office, Sectors Department 3, Asian Development Bank Dr. Vasoontara Yiengprugsawan oversees ADB's health technical assistance, including noncommunicable diseases and mental health and regional cooperation in the Greater Mekong Subregion and BIMP-EAGA. She has held senior health research positions in Australia, a WHO Fellowship with the Asia Pacific Observatory on Health Systems and Policies, and worked in policy and research with a UN Migration Agency in Geneva. She holds a PhD in Epidemiology from Australian National University and an MA in International Development from Syracuse University. Follow Vasoontara S. Yiengprugsawan on Leave your question or comment in the section below: View the discussion thread.