By Jenny Lei Ravelo 

After 72 years, the World Health Organisation’s regional office in the Western Pacific will for the first time be led by a Pacific islander, Dr Saia Ma’u Piukala, Tonga’s health minister.

Piukala emerged as the top candidate in all voting rounds during last week’s 74th session of the WHO Regional Committee for the Western Pacific but was up against fellow Pacific Island candidate Dr Jimmie Rodgers of Solomon Islands in the final round where he won narrowly by three votes at 16-13, with one abstention.

“To be honest, for me, at the time it doesn’t matter to me anymore. Because I know that either one of us it will be a Pacific Island regional director. … But I was happy that we ended up having the two Pacific Island countries in the final round,” he told Devex.

The result and the process itself were historic. Five out of the seven past regional directors were from high-income countries — either Japan or South Korea. Countries also agreed to a public forum that allowed the public to hear the candidates’ plans and priorities ahead of the election last week.

The work ahead is now cut out for Piukala. The regional office caters to the most diverse region in all of WHO and serves more than one-quarter of the world’s population. It faces a host of challenges, such as a rise in noncommunicable diseases, health impacts of climate change, and shortages in health workers. The regional office is also undergoing significant changes after its former regional director was fired from the job over misconduct.

“I am under no illusions as to the magnitude of the role and what is required. But I am confident that I have the skills and experience to work together with a very professional and qualified staff within the organisation,” he said.

From a small village to health minister

Piukala’s election is historic not just for the region, but for the man himself, who grew up in a small village in Vava’u, a group of islands in Tonga. His parents were farmers who, with no stable income, struggled to raise 10 children.

After school, Piukala and his siblings would go straight home to help on the farm.

“My father made sure that we all go to school, despite the financial challenges. He always tells us if you want a better life, you must study hard so you can be able to get a better job, so we do not have to struggle and work hard like him,” he said.

Studying itself was a challenge. There was no transport in the village, so they had to walk six kilometers to reach school. At night, there was no electricity, so they had to use a candle or kerosene lamp to study.

Seeing his parents’ hard work Piukala persevered and became a doctor, which was considered the “better job” in his village. Piukala said looking after his paralysed brother in the hospital when he was young also contributed to his aspirations of becoming a doctor.

Piukala practiced as a surgeon in Tonga. In 2014, he served as the medical superintendent at the country’s main hospital, Vaiola Hospital. As superintendent, he struggled with bureaucracy and faced challenges in working with a limited budget and resources. This led him to consider politics, “to make a difference,” he said.

He said he never dreamt of becoming a politician but found wisdom in the words of one of his mentors, who told him that “the only way to make a difference is to be in the decision-making level.”

He became a member of parliament and was appointed minister of health in the same year, a position he would hold under two prime ministers. The same reason motivated him to run for the WHO regional director position.

In his speech to member states of the WHO Western Pacific region after his election as the new regional director, he said: “That boy I talked about in my presentation, if you had told him or his parents or the villages in Vava’u that one day he would be the RD nominee, they will tell you you must be on some kind of medication, probably the illicit kind.”

“But God works in mysterious ways. And here we are today,” he said.

An open leader

Piukala has said under his leadership, “there will be zero tolerance to any misbehaviour.”

But he also places importance on Talanoa, a Pacific concept that he described as bringing people together to share stories and listen to feedback.

“I am very approachable [and] easygoing. And I do not refuse anyone who’d come to me seeking my advice or help, regardless of their status,” Piukala said of his leadership style.

Dr Colin Tukuitonga, associate dean for the Pacific at the University of Auckland who was in the meeting on behalf of the health minister of Niue, described Piukala as modest and respectful, and his leadership style as very much open and consultative. But he is someone who can also make hard decisions, which would be critical for a regional director.

“There will always be demands that cannot be met. So you’ll have to have a regional director, a leader, who has to accept that responsibility and make some hard decisions about some services that can’t [be funded], for example,” Tukuitonga said, adding he’s seen Piukala operate this way as current chair of the Pacific Health Ministers Meeting, which this year was hosted by the government of Tonga.

Palau Minister of Health Gaafar Uherbelau meanwhile described him as a leader that promotes inclusivity, including in the way he speaks, using terminology such as “we.”

“I think, although minute, [it] actually [has] a very big impact to those audiences who hear that type of terminology, and it gives you a sort of subconscious confidence that a person who is now in a leadership position has that mindset of one for all,” he said.

But they all agree it’s a tough job. Samoa Minister of Health Valasi To’ogamaga Tafito Selesele warned Piukala not to be “careless” in his position. If he makes a wrong move, he will be criticized, he said.

“It’s a very difficult task, and you’re going to face a lot of problems,” he said.

But he just needs to be “who he is,” Tuikuitonga said. “Lots of people including me will try to tell him stuff. Just be yourself [and] lead in an authentic way.”

Looking ahead

Piukala understands his new role is tough and his boss, WHO Director-General Tedros Adhanom Ghebreyesus, reminded him of it.

“This role will demand all of the technical, managerial and diplomatic skill and experience you have, and more,” Tedros told him after the election.

The region is home to several countries with an increasingly aging population that could further increase the noncommunicable disease burden in the region. NCDs are the leading cause of mortality in the Western Pacific, accounting for 87 percent of deaths. Many islands are also under stress from the effects of climate change, and the region, like others, is vulnerable to health emergencies.

Office culture is another challenge. Several employees at the Western Pacific regional office complained of racism and abusive conduct by the former regional director, leading to a change in leadership and the introduction of processes and policies to strengthen systems to report abuses and build a more positive workplace culture.

While acting regional director Dr Zsuzsanna Jakab has done work to restore a positive working culture at the office, much remains to be done, an organisational culture survey conducted in late 2022 still showed a high prevalence of harassment or abusive conduct reported, and low levels of confidence in senior management’s handling of reported cases of bullying, abuse, and harassment, according to a recent report on the regional office’s transformation.

Tukuitonga said Piukala needs to “restore the spirit of the place,” but also ensure he develops relationships with other countries in the region, not just the Pacific, and has the right people to run WHO’s technical programmes.

Piukala said the region’s health security is one of his top priorities, ensuring countries and areas in the region have stronger and more resilient health systems, and that communities and villages are protected and not left behind.

While he faced many challenges as Tonga’s health minister, the COVID-19 global emergency topped that list. The Pacific was mostly spared from the devastating impact of the pandemic in the first two years, but it came at the expense of prolonged isolation and closed borders. When the first COVID-19 outbreak happened in early 2022 in Tonga, it came just two weeks after a volcanic eruption and tsunami, making the response even more challenging.

Despite that, Tonga was successful in containing the outbreak and having few COVID-19 deaths. Piukala attributed this to their early preparedness and response. Upon learning of COVID-19 cases, the government immediately imposed lockdowns, carried out tests, and boosted vaccination rates.

But for his first year, he’ll also prioritise staff well-being, ensuring staff at the regional office “feel motivated, supported and empowered.” This will be key in the efficient functioning of the office, and in delivering on their mandate in the region, he said.

It might be a long journey, but Piukala believes that “if we all at least do what we can, no matter how small it is … it’s a small step in the right direction.