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|a Despite more than $1 billion disbursed in health aid regionally over the last decade, the poor health of people in Pacific Island Countries and Territories (PICTs) remains deeply concerning. This has included significant investment in infrastructure supporting quality health services. However, there has been less attention on the context of health aid delivery, such as social, economic and cultural factors or "modern/western" lifestyle transitions that lie outside the health sector but not addressing a variety of behavioural, social, cultural, traditions and more particularly. Given the stark disparity between people's health outcomes and investment levels, there is an urgent need to examine the factors influencing aid delivery processes in small Pacific nation states. These factors are the focus of this study. This research explores how health aid can be more effectively delivered in Samoa utilising the Paris, Busan and Accra aid agreements, and considers the applicability of such international aid models. More particularly, my focus was on principles of participatory decision-making, and how aid donors and recipients perceived their role and rationale in this process. The study focus years were 2002-2012, and fieldwork carried out between December 2012 and January 2013. Fieldwork comprised interviews with aid personnel, practitioners and NGOs, with the aim of gaining three perspectives of health aid decision-making, including participants' views of what constitutes good aid, how this worked, challenges to good aid and ways to improve health delivery. Unfortunately, Samoa was hit by Cyclone Evan as fieldwork began and this naturally impacted data collection, as all national resources were directed to cyclone recovery. At the same time, this situation clearly highlighted the vulnerability all PICTs to natural disasters, and how this directly affects all planning, particularly in the area of health. The major finding of this research was that while agreeing to international mandates such as Paris, Accra and Busan Agreements as well as the Pacific aid principles, Samoa experienced major constraints in implementation. This was largely due to limited human resource capacity and economic constraints, with emigration also playing a role. Limited budgets impacted negatively on training, the establishment and maintaining of robust data collection systems by which to inform planning, and even the release of medical staff to allow the opportunity for participation in decision- making. In a similar vein, NGO participation in health decision-making was minimal. In sum, while participatory planning and donor harmony was espoused by all, this was practised in a limited way. In fact, there are questions as to how a participatory model is fully achieved in small nation states such as Samoa. For Samoa, this research on perceptions of health aid decision-making highlights the need for a rethink of planning and policymaking, including linkages to cross-sector development strategy. It is likely that this will resonate with the experience of other PICTs. Findings will also add to global understanding of factors influencing the application of the Paris principles, and subsequent agreements in small nation states.
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