The loss of skilled labour has been a serious issue for several island states, but perhaps especially for some of the smallest, which need, but have few, skilled workers. In larger states such as Fiji, the loss is significant and problematic. Of the 8,669 professionals who left Fiji between 1987 and 2001, 2,728 were teachers, 1,774 architects and engineers, 1,410 accountants, 1,137 medical professionals and 1,620 were other professionals (Voigt-Graf 2003). Even these figures might well underestimate the true numbers due to the unreliability of data sources, overstaying, and so on, and Fiji has also lost airline pilots, army personnel and sportsmen. A survey in 2000 of the Fiji Nurses’ Association found that 88 per cent of nurses migrated for higher wages; and across the region at least two-thirds of migrant workers sought higher wages (Connell 2004a). Between May 2001 and 2002, 32 doctors emigrated and the Ministry of Health has had to recruit 56 doctors from the Philippines and the Indian subcontinent to fill the gaps (Chandra 2003: 194–5). This has raised concerns about the costs and the cultural differences between patients and health workers. In some smaller states the brain drain has been equally excessive; the Cook Islands, for example, lost more than half its vocationally qualified population in the single decade from 1966 to 1976 (Connell 2005a) and much the same happened again in the mid-1990s when the national economy collapsed.

Return migration has not solved labour shortage problems and, as in Fiji and other states, the Cook Islands has turned towards Asian labour markets for replacements (Connell 2005a). In the case of the migration of Tongans and Samoans to the USA alone, ‘Emigration results in the permanent loss of young educated skilled labour from the Pacific Island nations. Skilled labour is in short supply and emigration probably hinders development’ (Ahlburg and Levin 1990: 84). This is certainly true more generally in the health sector, where more costly (and sometimes less skilled) replacements have sometimes been required, and in the movement of sportsmen. The combination of changing aspirations and the migration of the more educated young contributes to the brain and skill drain from national peripheries and from small states, perhaps ultimately worsening the welfare and bargaining position of those places (Connell 2004a). In small island states, it is unusually difficult to replace skilled migrants, because of the duration of training that is required and the very small demand for particular skills.

The outcome in the health sector is that basic needs are less well satisfied, especially in more remote areas, and there is a loss of morale among those who have remained, as working conditions deteriorate. Wards are closed, waiting lists and times lengthen, examinations are more cursory, or complicated by cultural differences (Connell 2004a). Large proportions of budgets are directed to referrals to distant places, and the Millennium Development Goals recede into the distance. It is equally evident that, because of the necessity for appropriate skills training, it is more difficult to substitute for (or transfer from elsewhere in the public service) absent skills in the health workforce.

Given the global demand for skilled health workers, and active recruiting by New Zealand and other states in the region (especially Fiji) there is no easy solution (Connell 2004a, 2004b). Recent work, however, has shown that nurses at least send very high levels of remittances, sustained over long periods, to the extent that their remittances are almost certainly substantially above the training costs (Brown and Connell 2004). At the same time, more nurses are joining the profession because it provides migration opportunities, hence some of the Pacific states are moving towards the situation in the Philippines, where nurses are effectively trained to be migrants. This does suggest that the economic costs of skilled migration are not as great as has been feared and might not even be negative, even if training is in the public sector and remittances are private, and it is impossible to accurately cost the health disadvantages of high levels of emigration.

Helen Ware has argued that the problems of ‘brain-drain’ are overstated and having an excess of professionals is not a bad thing if they have the chance to work overseas, while emigration frees up the job market at home (Sharp 2005). These are, however, two quite different contexts and job markets that have become conflated. There is a surplus of teachers in Fiji, at the same time as there is a deficit of doctors, measured by unfilled vacancies and declining service provision. While other skilled migration losses, outside the health sector, might not now be either generally significant or have negative implications, such demand-driven migration is likely to have negative consequences in the future. There are hints that this might already be so in the context of the migration of sportsmen and military personnel.