Many countries in the South Pacific face critical problems with regard to waste management. Common problems include: insufficient government priority and political support for action; lack of finance; no long-term planning or business planning; poor landfill siting, design, planning and management; lack of skilled personnel; lack of awareness of the problems caused by poor waste management; physical limitations to the establishment of landfill sites; poor handling of clinical waste; insufficient recycling and reuse, including limited reuse of organic wastes, septic sludge, sewage sludge and effluent. Failure to adequately address these problems is leading to escalating environmental and health problems for Pacific Islanders, and serious consequences for economic development based on tourism, export agriculture and small ‘clean’ industries. This article reviews the causes and consequences of many of these problems and provides recommendations for action to improve the situation. Improvements will result from a combination of technical, economic and social changes. The main change required is waste management being given a higher priority in government planning so that sustainable funding mechanisms can be developed for these activities. Governments also need to develop integrated waste management policies, strategies and plans, and provide support through appropriate legislative and institutional frameworks.