Retaining doctors in rural Timor-Leste: a critical appraisal of the opportunities and challenges

Asante, Augustine; Martins, Nelson; Otim, Michael; Dewdney, John C.

doi:10.2471/blt.13.123141

Cited by 28 publications

(33 citation statements)

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“…In 2010, the health worker density in Timor-Leste was 1.3 per 1,000 population [9], which was below the WHO minimum recommended threshold of 2.3 [10]. In the neighbouring country Indonesia, the density in 2010 was 2.11 per thousand people [11].…”

Section: Introductionmentioning

confidence: 99%

“…The selection of the students started with an application to enter the programme: any young high school graduate in the country was eligible. 677 doctors were enrolled between 2004 and 2007 for training in Cuba and 328 for Cuban training in Timor-Leste between 2005 and 2011 [9], Admission to the program was not based on an exam, but the place of origin, as per the letter of recommendation of village authorities. It is recognised that rural origin is a strong determinant of work place selection for medical staff [14].…”

Section: Introductionmentioning

confidence: 99%

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Understanding Health Workers’ Job Preferences to Improve Rural Retention in Timor-Leste: Findings from a Discrete Choice Experiment

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BackgroundTimor-Leste built its health workforce up from extremely low levels after its war of independence, with the assistance of Cuban training, but faces challenges as the first cohorts of doctors will shortly be freed from their contracts with government. Retaining doctors, nurses and midwives in remote areas requires a good understanding of health worker preferences.MethodsThe article reports on a discrete choice experiment (DCE) carried out amongst 441 health workers, including 173 doctors, 150 nurses and 118 midwives. Qualitative methods were conducted during the design phase. The attributes which emerged were wages, skills upgrading/specialisation, location, working conditions, transportation and housing.FindingsOne of the main findings of the study is the relative lack of importance of wages for doctors, which could be linked to high intrinsic motivation, perceptions of having an already highly paid job (relative to local conditions), and/or being in a relatively early stage of their career for most respondents. Professional development provides the highest satisfaction with jobs, followed by the working conditions. Doctors with less experience, males and the unmarried are more flexible about location. For nurses and midwives, skill upgrading emerged as the most cost effective method.ConclusionsThe study is the first of its kind conducted in Timor-Leste. It provides policy-relevant information to balance financial and non-financial incentives for different cadres and profiles of staff. It also augments a thin literature on the preferences of working doctors (as opposed to medical students) in low and middle income countries and provides insights into the ability to instil motivation to work in rural areas, which may be influenced by rural recruitment and Cuban-style training, with its emphasis on community service.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Understanding Health Workers’ Job Preferences to Improve Rural Retention in Timor-Leste: Findings from a Discrete Choice Experiment

et al. 2016

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“…From 2010, many Timorese doctors, trained in Cuba's Latin American Medical School (Escuela Latinoamericana de Medicina), started entering the health system with 819 new doctors graduated to date, and there will be just over 1000 by the end of 2017 . With this rapid increase in doctor numbers there was a need for ATLASS to develop in‐country training pathways and more broadly address the postgraduate medical training requirements of Timor‐Leste.…”

Section: Resultsmentioning

confidence: 99%

Surgical capacity building in Timor‐Leste: a review of the first 15 years of the Royal Australasian College of Surgeons‐led Australian Aid programme

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et al. 2016

ANZ Journal of Surgery

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Background Timor‐Leste suffered a destructive withdrawal by the Indonesian military in 1999, leaving only 20 Timorese‐based doctors and no practising specialists for a population of 700 000 that has now grown to 1.2 million. Methods This article assesses the outcomes and impact of Royal Australasian College of Surgeons (RACS) specialist medical support from 2001 to 2015. Three programmes were designed collaboratively with the Timor‐Leste Ministry of Health and Australian Aid. The RACS team began to provide 24/7 resident surgical and anaesthesia services in the capital, Dili, from July 2001. The arrival of the Chinese and Cuban Medical Teams provided a medical workforce, and the Cubans initiated undergraduate medical training for about 1000 nationals both in Cuba and in Timor‐Leste, whilst RACS focused on specialist medical training. Results Australian Aid provided AUD$20 million through three continuous programmes over 15 years. In the first 10 years over 10 000 operations were performed. Initially only 10% of operations were done by trainees but this reached 77% by 2010. Twenty‐one nurse anaesthetists were trained in‐country, sufficient to cover the needs of each hospital. Seven Timorese doctors gained specialist qualifications (five surgery, one ophthalmology and one anaesthesia) from regional medical schools in Papua New Guinea, Fiji, Indonesia and Malaysia. They introduced local specialist and family medicine diploma programmes for the Cuban graduates. Conclusions Timor‐Leste has developed increasing levels of surgical and anaesthetic self‐sufficiency through multi‐level collaboration between the Ministry of Health, Universidade Nacional de Timor Lorosa'e, and sustained, consistent support from external donors including Australian Aid, Cuba and RACS.

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“…The high levels of reported supervision, its substantial content and satisfaction with supervision are also encouraging. The findings suggest that policies have been successful in creating a motivated workforce in general, perhaps as a result of the training programme ethos [8] or that they are motivated by being back in their rural communities. However, the age of the cohort and the short time in service may also be important explanatory factors, along with the newly independent status of the country, which encourages a public service ethic, and the relative absence of other employment options in the health labour market.…”

Section: Discussionmentioning

confidence: 99%

“…However, because of the poor functionality of the rural health facilities, doctors may be unwilling to work in those facilities. There are also concerns regarding a lack of supervision and unclear career development paths for those working in rural areas [8]. …”

Section: Introductionmentioning

confidence: 99%

What do health workers in Timor-Leste want, know and do? Findings from a national health labour market survey

et al. 2016

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BackgroundThe objectives of this study were to understand the labour market dynamics among health workers, including their preferences and concerns, and to assess the skills, competence and performance (i.e. the ‘know–do gap’) of doctors working in Timor-Leste.MethodsThis cross-sectional survey was implemented in all 13 districts of Timor-Leste in 2014. We surveyed 443 health workers, including 175 doctors, 150 nurses and 118 midwives (about 20% of the health workers in the country). We also observed 632 clinical consultations with doctors, including 442 direct clinical observations, and tested 190 vignettes.ResultsThe study highlights some positive findings, including the gender balance of health workers overall, the concentration of doctors in rural areas, the high overall reported satisfaction of staff with their work and high motivation, the positive intention to stay in the public sector, the feeling of being well prepared by training for work, the relatively frequent and satisfactory supervisions, and the good attitudes towards patients as identified in observations and vignettes. However, some areas require more investigations and investments. The overall clinical performance of the doctors was very good in terms of attitude and moderate in regard to history taking, health education and treatment. However, the average physical examination performance score was low. Doctors performed better with simulated cases than the real cases in general, which means they have better knowledge and skills than they actually demonstrated. The factors that were significantly associated with the clinical performance of doctors were location of the health facility (urban doctors were better) and consultation time (cases with more consultation time were better). Regression analysis suggests that lack of knowledge was significantly associated with lack of performance, while lack of motivation and equipment were not significant.ConclusionsThe survey provides essential information for workforce planning and for developing training policies and terms and conditions that will attract and retain health workers in rural service. Improving the work environment and performance of doctors working in rural health facilities and ensuring compliance with clinical protocols are two priority areas needed to improve the performance of doctors in Timor-Leste.

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Retaining doctors in rural Timor-Leste: a critical appraisal of the opportunities and challenges

Cited by 28 publications

References 8 publications

Understanding Health Workers’ Job Preferences to Improve Rural Retention in Timor-Leste: Findings from a Discrete Choice Experiment

Understanding Health Workers’ Job Preferences to Improve Rural Retention in Timor-Leste: Findings from a Discrete Choice Experiment

Surgical capacity building in Timor‐Leste: a review of the first 15 years of the Royal Australasian College of Surgeons‐led Australian Aid programme

What do health workers in Timor-Leste want, know and do? Findings from a national health labour market survey

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