This project has provided important insights into challenges and opportunities within the health system in Timor-Leste.
Katie McIntosh, Rashid Zaman, Sophie Witter, Sourovi De, Tomas Lievens
At the time of independence in 2002, the country had an extremely weak health system with seriously damaged infrastructure and only a handful of doctors in the country. Despite recent revitalisation in the sector,a number of more complex issues have emerged – including those around service delivery, rural retention, motivation, preferences and the competence of health workers. Our team was contracted by the World Bank to undertake a comprehensive, nationally representative study of health facilities and health workers across the country. Our survey included four components: a health facility survey, a health worker survey, a discrete choice experiment (DCE) and direct clinical observations (DCO). The survey provided important information and evidence to support improved policy understanding of health labour market dynamics within the country.
During the war preceding Timor-Leste’s independence in 2002, more than 70% of the country’s health facilities were destroyed or seriously damaged and only approximately 20 doctors remained in the country. While this radical shortage of health workers began to improve as doctors trained by the Cuban Medical Brigade started to return in 2004, Timor-Leste still faces deep-rooted health sector challenges There remains a severe shortage of all categories of health workers, including general doctors, specialists, nurses and midwives. Furthermore, lack of quality infrastructure and limited resources at health facilities are longstanding problems across the country, particularly in rural areas. Since the literature suggests that the country’s rural facilities lack facilities and supplies, management function, supervision and opportunities to learn, there is a possibility that the health workers deployed in these facilities are not motivated.
Retention of health workers in rural areas is another major challenge. The literature suggests that a lack of facilities, supplies, effective management functions and career development severely reduces the motivation of health workers.
This project was established to help address these issues by taking stock of the current situation in order to build a robust base of evidence to inform effective policy making around health sector reform in the country.
The OPM team conducted a comprehensive survey of health facilities and health workers across Timor-Leste. We visited a representative sample of 69 health facilities across the country’s 13 districts and interviewed 443 health workers (20% of the entire workforce). Specific activities carried out by the team included:
- Designing a sampling strategy based on the Ministry of Health’s updated list of health facilities and health workers Sampling health facilities and health workers using a probability proportionate to size (PPS) methodology
- Conducting quantitative surveys of health facilities and health workers Completing statistical analysis to test associations between various predictor and outcome variables.
We adopted a collaborative approach, publishing a range of briefing notes and disseminating survey findings to key stakeholders including policymakers and development partners within Timor-Leste.
This project has helped provide important insights into the state of health facilities and health workers in Timor-Leste. These nationally-representative findings include information on facility functionality as well as the preferences and concerns of health workers. They also act as a way of assessing the skills, competence and motivation of doctors, supporting crucial analysis of the factors that affect the retention of health sector staff.
In turn, these insights will help feed into evidence-based policymaking that will support effective health sector reform in Timor-Leste. By identifying the barriers to efficient service delivery, the Ministry of Health can tailor policymaking around removing these obstacles and creating opportunities for health workers that helps ensure expected levels of competency and their continued motivation.