68719
                TIMOR-LESTE HEALTH SECTOR REVIEW (HSR):
                    Meeting Challenges and Improving Health
                                Short Summary

1.       Timor-Leste has accomplished a great deal in the health sector since separation
from Indonesia. A major accomplishment has been rebuilding the country’s health care
facility infrastructure following its devastation. In addition, there have been important
accomplishments in formulating policies, developing the health workforce, and building
up the Ministry of Health’s organization, planning and implementation capacities. A
great deal more money is being spent by the Government on the provision of health
services at present than at the beginning of the decade.

2.     Despite the progress that has been made, some of the key indicators of the
population’s health –such as the rates of infant and child mortality, maternal mortality,
and the prevalence of malnutrition in young children— show that there is still much room
for improvement.

3.      One important reason for the still relatively poor health indicators is the fact that
households are not utilizing certain essential health services which are available from
government and NGO health care facilities, such as antenatal and postnatal care and child
immunization, to the extent that would be desirable. Another important reason is that the
quality of these available health services is sometimes deficient, so that patients’ health
needs are not met even though they do utilize the available services. Yet other important
reasons for the relatively poor health indicators are unrelated to the use of health services;
such as deficiencies in the availability of safe water and sanitation facilities.

4.      Why many households fail to make use of available health services from
government and NGO facilities is a complex issue, but in recent years some light has
been shone on the problem by several household surveys and studies. These surveys and
studies show that low utilization of essential health services relates both to the
characteristics of available services and to certain limitations on the part of the
households themselves.

5.      On the services side, many households report access problems, such as too-distant
health facilities and/or no transportation, as a barrier to utilization of services. Other
households point to problems related to the behavior of health care workers --health
workers are sometimes unfriendly or absent from their posts, or appear incompetent to
the patients.

6.      But there are also some barriers to utilization within the households themselves.
One is financial, with some households reporting that the cost of availing themselves of
health services is a problem. Also, there is evidence that many households tend to under-
estimate the risks of certain health conditions such as malaria, and those risks associated
with pregnancy and delivery. Under-estimation of health risks reduces these households’
demand for health services. Furthermore, households (especially in rural areas) are
making extensive use of traditional health care practitioners, which detracts from their
use of the services available from government and NGO facilities staffed by qualified
health care providers (doctors, nurses, etc.).

7.      Improving the health status of the population will continue to be a high priority
for the Government in the years ahead. The above discussion suggests that in pursuing
this goal the Government, through the Ministry of Health, will need to put in place
interventions that (a) raise the levels of utilization of essential health services, and (b)
improve the quality/effectiveness of those services.

8.       Improving the quality/effectiveness of health services is difficult. However,
now that most of the basic health care infrastructure is in place, the time seems right for
MOH to start a concerted effort to develop a system to monitor and upgrade the quality of
health care services, starting with services in the public sector. Spelling out the details of
a suitable quality assurance program exceeds the scope of this report, but the key
components of such a program would include: (a) gathering information on the quality of
essential services systematically and continuously; (b) by analyzing the information,
identify the major problem areas; (c) translate [b] into an action plan to make changes in
staff training and supervision and to provide any other missing inputs (drugs, equipment,
etc.) that might be needed to raise the quality of services to internationally accepted
standards.

9.      With regard to raising the utilization of essential health services, there a
number of interventions available to the Government, and several are discussed in the
report (Health Sector Review).

10.     One is to make households more active and better-informed participants in
health matters through health education. Health education delivered through various
channels –mass media, community-level health workers, NGOs and other civil society
groups, schools—would make households better aware of the risks associated with
certain health conditions/symptoms and the importance of using the available health
services from government and NGO facilities.

11.     In addition to leading households towards a greater utilization of essential health
services provided by government and NGO facilities, health education could have an
important additional impact on the health of the population by teaching households what
they themselves can do to protect the health of their members. There is much the
households themselves could accomplish through the adoption of good practices
concerning basic hygiene within the house, good child feeding and care practices, and the
preparation of more nutritious foods, among other.

12.     A second type of intervention the Government could explore is the introduction of
subsidy schemes tied to the utilization of essential health services. A number of countries
have been experimenting with conditional cash transfers, whereby the Government
pays a subsidy to households (usually poor ones) in exchange for certain behaviors
beneficial to society, such as having their children immunized. The experiences of other
low- and middle-income countries which have started these types of schemes should be
studied prior to launching a similar scheme in Timor-Leste.

13.     Third, while currently about 80 percent of the population lives within two hours
of a health facility, which is a major achievement, many households still face access
problems and more work needs to be done to improve access to health services. How
best to improve access to health services further is a problem that needs to be analyzed
locally. Additional health care facilities are one of the options, but beyond a point it
would be difficult to justify adding more facilities because there would be too few people
utilizing them. Hence the option of establishing new facilities needs to be considered
together with three other options to improve access: (i) increased outreach activities from
existing facilities; (ii) a community health worker program; and (iii) taking measures to
improve transportation and/or reduce transportation costs for those seeking care. In some
places the Government may also be able to facilitate access to health services for the
local population by entering agreements with NGOs already providing such services.

14.     Fourth, in some cases difficulty of access to health services arises not because of
households’ difficulty in reaching existing facilities, but rather because there are gaps in
the staffing of those facilities. The MOH is facing difficulties in filling positions in
remote health care facilities. Deployment is currently application-based, and mandatory
deployment to specific posts is not used. Changing to a system of mandatory
deployment, however, may lead to greater absenteeism. A better strategy may be to
recruit staff originally from the local communities where there are vacant posts. The
MOH has already started using this approach for recruitment to midwifery training.
Other strategies could include special incentives such as establishing fixed three-year
assignments in areas with staff shortages and offering accelerated access to promotions,
cash bonuses and/or access to training for those who take up these assignments.

15.     Carrying out the various interventions described above would require that the
Government increased its spending on health services further. Because the amount
of money the Government will be able to spend for this purpose is limited, it will be
important to set priorities among the various possible interventions. The
Government/MOH, with the assistance of the World Bank and other donor partners, are
in the process of doing this.


Note: The Health Sector Review (HSR) was undertaken jointly by the World Bank and the
Ministry of Health. The analysis is based primary on the 2003 Demographic and Health Study
(DHS), as well as the 2002 Multi-Indicator Cluster Survey (MICS) and other data sources. The
lead authors for the World Bank were: Ian Morris (Team Leader), Magnus Lindelow, and Hugo
Diaz-Etchevery. The findings and conclusions of the study are entirely those of the authors, and
do not necessary represent the views of the World Bank. Copies of the full study are available
upon request from the World Bank.