Why Burnout Looks Different in Small Systems

In the Caribbean, exhaustion is structural — and personal

Disclaimer
Field Notes reflect the editorial analysis of the Managing Editor, informed by direct professional experience across Caribbean healthcare systems. These observations surface recurring structural patterns and do not represent the official positions of any government, institution, or commercial partner.

Burnout is often described in universal terms: long hours, emotional exhaustion, administrative overload.

But in small health systems, burnout does not simply scale down.

It concentrates.

In large systems, professionals may feel like numbers. In small systems, you feel indispensable — and trapped — at the same time.

And that difference matters.

1. There Is No Bench

In larger countries, if one director leaves, another can be recruited domestically.
If a specialist resigns, there may be a training pipeline behind them.

In small island systems:

• There may be one cardiologist.
• One health economist.
• One biomedical engineer.
• One procurement lead who understands the legacy contracts.

When one person burns out, the system does not flex.

It fractures.

Burnout becomes a systems risk — not just a human resources issue.

2. Professional and Personal Worlds Overlap

In small states, the people you regulate are your cousins.
The minister you brief is someone you see at church.
The journalist calling for comment may be your former classmate.

There is no anonymity buffer.

Conflict is not abstract — it is relational.

This creates a unique emotional tax:

• Decisions are public.
• Accountability is intimate.
• Criticism is personal.

You cannot “leave work at work” when the system is socially intertwined with your daily life.

3. Visibility Is Constant

In larger systems, responsibility diffuses across layers.

In small systems, everyone knows exactly who made the decision.

There are fewer institutional shields.
Fewer communication teams.
Fewer middle layers.

Leadership is exposed.

And exposure, over time, exhausts.

4. Resource Scarcity Amplifies Moral Distress

Burnout literature often focuses on workload.

But in Caribbean health systems, moral distress is a deeper driver.

You know what best practice looks like.
You know what your population deserves.
You also know the fiscal ceiling, the workforce shortage, the procurement delays.

You carry the tension between ideal and feasible every day.

That gap — lived repeatedly — erodes even the most mission-driven professional.

5. You Cannot Simply Exit

In larger markets, burnout sometimes ends with mobility.

In small states:

• There may be no equivalent employer.
• Migration means uprooting family.
• Leaving can feel like abandoning the system.

So many leaders do not leave.

They endure.

And endurance, without systemic redesign, turns into quiet depletion.

6. Burnout Fuels Brain Drain — and Brain Drain Fuels Burnout

In small systems, burnout does not just exhaust individuals.

It accelerates migration.

When high-performing clinicians, analysts, and administrators leave, they are not simply
seeking higher pay. They are often seeking:

• Functional systems
• Adequate staffing
• Professional growth pathways
• Psychological safety
• Predictable governance

When one leader exits, the burden shifts to those who remain.

That increased strain pushes the next person closer to departure.

This is the burnout–brain drain cycle.

And in small states, cycles move quickly.

Brain drain is often framed as a salary problem.

Compensation matters.

But so do career ceilings in small bureaucracies, limited specialist peer networks, political volatility, reform fatigue, and the absence of succession planning.

If professionals cannot see a future version of themselves inside the system, they will build one
elsewhere.

What Small Systems Actually Need

Burnout in small health systems is not a resilience problem.

It is a structural design problem.

Mitigating burnout — and mitigating brain drain — requires:

• Succession planning, even when teams are small
• Cross-island talent collaboration
• Regional technical pools
• Shared services models
• Protected leadership development time
• Redundancy in critical roles
• Diaspora contribution models that allow brain circulation without permanent return

Retention will not improve through patriotic appeals.

It will improve when roles become sustainable.

A Regional Responsibility

At Caribbean Currents, our mission is to empower healthcare leaders and elevate conversations
that strengthen delivery and governance across the region.

Burnout is not simply a wellness topic.

It is a governance issue.
A sustainability issue.
A regional competitiveness issue.

The Caribbean does not suffer from a lack of talent.

It suffers from over-concentrating it.

When we design systems that require heroism to function, we should not be surprised when heroes leave.

Small systems do not need more heroes.

They need structures strong enough that good people can stay — and thrive — without breaking.

About the Author

Mary Miller Sallah, MHA is the Managing Editor of Caribbean Currents and a healthcare operator with lived experience across Caribbean health systems. Her work focuses on health system transformation, leadership under constraint, and the practical realities of implementing change in small-state environments. She writes regularly on healthcare reform, digital health, and regional leadership.