ObjectiveThis case study examines the enabling factors, strengths, challenges and lessons learnt from Timor-Leste (TLS) as it sought to maintain quality essential health services (EHS) during the COVID-19 pandemic.DesignA qualitative case study triangulated information from 22 documents, 44 key informant interviews and 6 focus group discussions. The framework method was used to thematically examine the factors impacting quality EHS in TLS.SettingNational, municipal, facility levels in Baucau, Dili and Ermera municipalities in TLS.ResultsBased on the TLS National Health Statistics Reports, a reduction in outpatient, emergency department and primary care service delivery visits was observed in 2020 when compared with 2019. However, in contrast, maternal child health services simultaneously improved in the areas of skilled birth attendants, prenatal coverage and vitamin A distribution, for example. From the thematic analysis, five themes emerged as contributing to or impeding the maintenance of quality EHS including (1) high-level strategy for maintaining quality EHS, (2) measurement for quality and factors affecting service utilisation, (3) challenges in implementation of quality activities across the three levels of the health system, (4) the impact of quality improvement leadership in health facilities during COVID-19 and (5) learning systems for maintaining quality EHS now and for the future.ConclusionThe maintenance of quality EHS is critical to mitigate adverse health effects from the COVID-19 pandemic. When quality health services are delivered prior to and maintained during public health emergencies, they build trust within the health system and promote healthcare-seeking behaviour. Planning for quality as part of emergency preparedness can facilitate a high standard of care by ensuring health services continue to provide a safe environment, reduce harm, improve clinical care and engage patients, facilities and communities.

Objective: This research study examines the enabling factors, strengths, and challenges experienced by the Timor-Leste health system as it sought to maintain quality essential health services (EHS) during the COVID-19 pandemic. Design: A mixed methods qualitative analysis Setting: National, municipal, facility levels in Baucau, Dili and Ermera Municipalities in TLS Participants Key informant interviews (n=40) and focus group discussions (n=6) working to maintain quality EHS in TLS. Results: A reduction in people accessing general health services was observed in 2020, reportedly due to fears of contracting COVID-19 in healthcare settings, limited resources (eg. human resources, personal protective equipment, clinical facilities, etc) and closure of health services. However, improvements in maternal child health services simultaneously improved in the areas of skilled birth attendants, prenatal coverage, and vitamin A distribution, for example. Five themes emerged as enabling factors for maintaining quality EHS including 1) high level strategy for maintaining quality EHS, 2) implementation of quality activities across the three levels of the health system, 3) measurement for quality and factors affecting service utilization 4) the positive impact of quality improvement leadership in health facilities during COVID-19, and 5) learning from each other for maintaining quality EHS now and for the future. Other countries may benefit from the challenges, strengths and enablers found on planning for quality. Conclusion: The maintenance of quality essential health services (EHS) is critical to mitigate adverse health effects from the COVID-19 pandemic. When quality health services are delivered prior to and maintained during public health emergencies, they build trust within the health system and promote healthcare seeking behavior. Planning for quality as part of emergency preparedness can facilitate a high standard of care by ensuring health services continue to provide a safe environment, reduce harm, improve clinical care, and engage patients, facilities, and communities.