Retaining doctors in rural Timor-Leste: a critical appraisal of the opportunities and challenges
Augustine D Asante a, Nelson Martins b, Michael E Otim c & John Dewdney a
a. School of Public Health and Community Medicine (Level 2, Samuels Building), The University of New South Wales, Sydney NSW 2052, Australia.
b. Faculty of Medicine and Health Sciences, Universidade Nacional Timor-Leste, Dili, Timor-Leste.
c. Sydney School of Public Health, The University of Sydney, Sydney, Australia.
Correspondence to Augustine D Asante (e-mail: firstname.lastname@example.org).
(Submitted: 09 April 2013 – Revised version received: 20 September 2013 – Accepted: 28 November 2013 – Published online: 12 February 2014.)
Bulletin of the World Health Organization 2014;92:277-282. doi: http://dx.doi.org/10.2471/BLT.13.123141
The retention of health workers in rural areas has been the focus of increasing attention in recent years, particularly since the World Health Organization (WHO) launched its programme for “increasing access to health workers in remote and rural areas through improved retention”.1 Possible interventions for recruiting and retaining health workers in rural areas include financial incentives, compulsory service in rural communities, professional support schemes and priority access to postgraduate training.2 Thailand insists that all physicians work for three years in rural areas, while both Australia and South Africa provide financial incentives specifically to attract physicians to rural areas and retain them there.3
Timor-Leste is a lower-middle-income country. In 2010 it had a gross national income of 2220 United States dollars (US$) per capita and a population of 1.1 million.4 In the same year, about 41% of the population earned less than US$ 0.55 per day and therefore fell below the national “poverty line”.4 Per capita expenditure on health care has been steadily increasing over recent years: from US$ 18 in 2006 to US$ 31 in 2010.5
In 2010, Timor-Leste had 557 maternal deaths per 100 000 live births, only 22% of births occurred in health facilities.6 The insufficient number of skilled health workers is a major contributor to the country’s generally poor health conditions. Only 1407 doctors, nurses and midwives were employed in the public sector in 2010.5 The corresponding density of health workers – 1.3 per 1000 population – fell well below WHO’s recommended lower threshold of 2.3 per 1000 population.5,7 The shortage of health workers, although a national problem, leaves the largest gaps in health care in rural and remote areas. About two thirds of the country’s doctors are Cuban and members of the “Cuban Medical Brigade”. Several other expatriate doctors provide clinical services, mentoring and clinical staff supervision.8
In this article we aim to contribute to the current health policy debate on the retention of health professionals in rural areas. We analyse the opportunities for – and challenges to – the rural retention of doctors in Timor-Leste, particularly of the many new doctors who have either been trained within Cuba or by members of the Cuban Medical Brigade in Timor-Leste. While we argue that the deployment of new doctors to rural communities is crucial to adequate health-care provision throughout Timor-Leste, the long-term availability of doctors in rural areas will still depend on the taking of concrete steps to improve the retention of rural doctors.
Health policies and human resource development
The government of Timor-Leste recognizes the influence of various social determinants – e.g. education, housing, water and sanitation – on health and therefore seeks to integrate the health sector with several other sectors. The national health sector strategic plan for 2011–2030 embodied the government’s goal of providing comprehensive, free primary care and hospital services to all Timorese until 2030.9 Investment in human capital is one of the four priority areas identified in the plan as critical for the efficient delivery of health services.9
Improvement of Timor-Leste’s human resources for health has been high on the national government’s policy agenda. Soon after the country achieved independence in 2002, the Ministry of Health prepared a Human resources master plan for 2002–2011 to guide future development of the health workforce.10 A year later, a major bilateral agreement between the governments of Timor-Leste and Cuba resulted in the Cuban government offering scholarships to study medicine in Cuba to nearly 700 Timorese students.11 Simultaneously, the Cuban government sent around 230 doctors to work in Timor-Leste. At the time of writing, more than 270 Timorese students are being trained as doctors in Timor-Leste, in a medical education programme being run jointly by Timor-Leste’s National University and the Cuban Medical Brigade (Table 1).9
Table 1. Cuban training of Timorese medical students, by year of enrolment, Cuba and Timor-Leste, 2004–2011
If all of the Timorese currently being trained as doctors are employed by Timor-Leste’s health system, the number of medical doctors will be more than three times as high as in 2003.11 Several hundred Timorese students are also being trained as nurses and midwives at Timor-Leste’s National University or Institute of Health Science. Other Timorese students are being trained as public health officers, either in Timor-Leste – at the Universidade da Paz or the Universidade Dili – or in overseas institutions.
Although Timor-Leste’s Ministry of Health does not currently have a comprehensive development plan for the country’s human resources for health, the National health sector strategic plan for 2011–2030 contains a “road map” for the development of health professionals at each level of the health system.9 Accreditation and registration of medical doctors are the responsibility of the Ministry of Health and are governed by a decree issued in 2004.5
The new Cuban-trained doctors are deployed mostly in rural areas – in line with the ethos of the Cuban training programme – although there is no specific legislation that commits such doctors to rural practice. Each such doctor does sign a contract with the government and agrees to work in Timor-Leste’s public health sector for at least six years.12 Between 2010 and 2013 nearly 500 graduates from the Cuban programme – including 406 who graduated in November 2012 – were deployed across the various districts of Timor-Leste (Table 2).
Table 2. Deployment of 406 new Cuban-trained Timorese doctors, by sex and area of deployment, Timor-Leste, 2010–2013
There is no firm timetable for the withdrawal of the Cuban Medical Brigade from Timor-Leste. At the moment, the memorandum of understanding covering the medical cooperation between Cuba and Timor-Leste is renewed each year by the two governments. Some members of the Brigade are expected to remain in Timor-Leste – perhaps to assist in specialist training – after all of the new Cuban-trained doctors have been deployed.
Opportunities for deployment and rural retention
The Timor-Leste Ministry of Health has estimated the number of health workers that would be required to roll out the Basic services package for primary health care and hospitals, adopted in 2007, in an effective manner.13 The current goal of the government is to employ one generalist doctor, two nurses, two midwives and a laboratory technician in each of the 442 villages in the country, as well as to staff community health centres and referral hospitals “adequately”.9 Several opportunities exist for the Ministry of Health to achieve this goal.
Sufficient number of medical graduates
The large number of new medical graduates joining the workforce offers a great opportunity for the government to deploy doctors to rural areas. With nearly 1000 new graduates coming from the Cuban medical programme – and a few more from training overseas in countries other than Cuba – the Ministry of Health already has a sufficient pool of doctors to meet its immediate human resource targets. The numbers of advertised vacancies for generalist medical officers in urban areas will drop considerably once all the new doctors have been deployed – making it difficult for doctors serving in rural areas to find public sector positions in urban centres. Some opportunities for urban employment will arise as expatriate medical staff exit Timor-Leste’s health system, but the Ministry of Health expects the withdrawal of such staff to be slow and methodical.
Although the Ministry of Health has predicted that 20% of the newly trained doctors will be lost to emigration, the actual level of attrition might be much lower for several reasons. First, there is strong political will to employ the new doctors. A guarantee of employment in the public service could reduce the risk of emigration substantially, especially if coupled with deployment close to the doctors’ families and home towns. Second, the Ministry of Health offers an incentive package for remote area service that is likely to benefit the new doctors and may motivate them to remain in rural practice. Finally, the general ethos of the Cuban training programme – which appeals to the students’ community spirit and emphasizes service to the public14 – may counter any aspirations to emigrate.
Suitability of medical training for rural settings
The Cuban model of medical education integrates the concepts of prevention, social determinants of health and active community partnering into curriculum design. It trains doctors in primary health care and uses a comprehensive clinical, epidemiological and social approach that involves health promotion, disease prevention, diagnosis, treatment and rehabilitation, with much community-based “service learning”.15–17
Students training in Cuba undertake a year-long pre-medicine course that includes lessons in Spanish and basic sciences and is followed by a 5-year integrated medicine course.18 The students from Timor-Leste spend their final two years of training back home, under the supervision of the Cuban Medical Brigade. Some Timorese students are trained as new doctors by Cubans without leaving Timor-Leste.
The overall quality of the Cuban training programme has not been independently assessed, but policy-makers in Timor-Leste believe that it is at least adequate for the needs of the local health system.12
Absence of a medical council
Medical councils ensure that the statutory requirements for the registration and re-registration of doctors are met.19 Although the lack of a medical council in Timor-Leste may be seen as a barrier to the country’s attempts to improve the quality of health care, for the new graduates and the Ministry of Health it may be an advantage, at least in the short-term. The Cuban-trained doctors could easily face opposition from a medical council regarding their competence, as observed in several other countries.20
In the absence of an operational medical council, Timor-Leste has not encountered any public opposition to the Cuban-trained doctors – although there was, initially, some passive opposition to the Cuban Medical Brigade.21 A medical council for Timor-Leste is in the pipeline. However, given the high-level political support for the Cuban training programme, it is unlikely that such a council will pose any serious threat to the government’s plans to improve the rural retention of doctors.14
In recent video documentaries on the Cuban medical cooperation with Timor-Leste, the new Cuban-trained doctors spoke about their wish to serve their communities, help improve health and work for the “public good”.22 Most of the Timorese entrants into the Cuban training programme were selected from underprivileged backgrounds. The medical cooperation with Cuba has therefore provided the new doctors with the chance to make major achievements in their lives, for which the only cost is a moral commitment to work in underserved communities.23 Many of the graduates who featured in the recent documentaries perceived working in underserved communities as a worthy moral commitment. Such altruism is, however, likely to wane over time. An appropriate mix of incentives – such as deployment close to family, remote area subsidies, effective payroll management and opportunities for postgraduate training – may help to sustain or, at least, prolong a doctor’s service in rural areas.
Challenges for deployment and rural retention
Finances pose perhaps the largest single challenge to the retention of doctors and other health workers in rural areas. The Ministry of Health is already experiencing sharp increases in personnel costs. For example, the Ministry’s spending on salary and wages at the district level increased from 34% of the total district health budget in 2008 to 60% in 2011.5 With the deployment of hundreds of new graduates in 2013 and more expected in the near future, the Ministry will continue to experience an upsurge in personnel costs, including salaries, allowances and remote area subsidies.
The Timor-Leste economy is potentially strong and may be able to absorb these increased costs in the short-term. However, as a new nation emerging from conflict, Timor-Leste has many other developmental challenges that require sustainable public financing – in direct competition with any health financing. Public health expenditure declined from 7% of total government expenditure in 2007 to 2.9% in 2011.24,25 The retention of large numbers of doctors in rural areas might require a considerable expansion of the fiscal space for health.
The need and demand for specialist training and continuing professional development are a threat to Timor-Leste’s rural retention goals. Timor-Leste has a critical shortage of medical specialists. Only nine specialists were employed by the Ministry of Health in 2010. In an informal discussion, several junior doctors who were among the first to be trained in the Cuban programme said they were keen to undertake specialist training. While this keenness may be due to the exposure of this particular batch of doctors to clinical practice at the National Hospital – and is perhaps not representative of the attitudes of many new doctors – any aspirations for specialist training and continuing professional development will require careful management.
Timor-Leste’s National University – in collaboration with the Ministry of Health and the Royal Australasian College of Surgeons – already delivers postgraduate training in general surgery, obstetrics, paediatrics, anaesthesia and internal medicine.26 After at least two years of service, doctors can enrol on this 18-month diploma course, which is seen as a pathway to specialization. The Ministry of Health is exploring possibilities for future international collaboration for specialist training with Cuba, Indonesia and several other countries.
Constraints in managing the performance of the health workforce, particularly inadequate supportive supervision and limited access to specialist advice, are a serious problem and a potential threat to the rural retention of the new doctors. Currently, the supervision of doctors and other health workers is the responsibility of district-level health managers and health management teams.27 Most of the district-level managers are nurses and midwives who would struggle to provide adequate clinical supervision to new doctors. All of the senior clinicians who could provide useful supervision and mentoring are Cubans who are currently expected to return home as the new doctors are deployed.
The deployment of a large cohort of young doctors without an established support hierarchy of more senior doctors to provide clinical supervision does not augur well for patient safety, given the potential risk of medical errors. A lack of supervision may also increase the new doctors’ sense of professional isolation,28 which could undermine any retention efforts. The Ministry of Health intends to provide training in management and leadership to some of the new doctors, to enable them to assume managerial roles and provide technical support to fellow doctors. An agreement with Cuba to engage senior medical officers from the Cuban Medical Brigade in the provision of supportive clinical supervision may well be necessary.
Health infrastructure and logistics
The health infrastructure in rural Timor-Leste is very underdeveloped despite considerable government investment. There are five district referral hospitals, 66 government-owned community health centres, 42 maternity clinics and 193 health posts.9 The current number of health posts is far short of the planned 442 and not all of the posts that do exist meet the Ministry of Health’s minimum standards deemed necessary to support a doctor. The Ministry of Health intends to place three doctors in each community health centre and one in each health post meeting the minimum standards. The inadequate standards of many health units may eventually result in underemployment of some of the new doctors and in inefficient use of doctors’ time – to the detriment of motivation and retention.
The health service’s management system for procurement and supply also needs a major overhaul. Drugs, other supplies and equipment are in short supply in most rural facilities12 – in sharp contrast to the situation in Cuba, where most of the new doctors were trained.29 The referral system in Timor-Leste needs to be streamlined to make it easier for the doctors working in health posts to refer patients to community health centres and hospitals.9 It is also crucial that adequate resources for environmental health activities be made available to the new doctors.
The results of the present appraisal raise several policy issues for the government of Timor-Leste – and not only for the health sector. A debate about sustainable health financing is needed in Timor-Leste. The government is committed to providing free health care until 2030, but what happens afterwards? Given the general level of poverty in Timor-Leste, it is important to ensure equitable access to health services. However, such a goal requires substantial public financing that may not be sustainable in the long term because of competing problems. A strategic plan for health financing – including social health insurance – is urgently needed.
Collaboration between Timor-Leste’s Ministry of Health and the nongovernmental health sector needs to be strengthened. About one quarter of the country’s basic health service delivery is currently handled by 26 private clinics, some of which are in rural areas.9 Some of the new medical graduates could be deployed to private facilities, especially if the government agrees to subsidize their salaries.
The large number of new doctors trained in Cuba who have been deployed or await deployment in Timor-Leste has implications for the development of local medical education. The influx of doctors trained overseas may limit opportunities for the local production of new doctors and reduce pre-service enrolment – at least in the short-term. Much will depend on the Ministry of Health’s ability to create new positions for doctors. At the same time, there is an urgent need to scale up the production of specialists – using, perhaps, a “diploma” approach rather than a “fellowship” approach. Although the National University’s postgraduate diploma programme is a step in the right direction, it requires sustained resourcing to be viable. Specialist training overseas is probably necessary but needs to be carefully planned to avoid undermining rural retention goals. The choice between postgraduate training in general public health and postgraduate training in a specialty area also deserves attention, given the important role of the Cuban-trained graduates in health promotion.
The quality of Cuban medical training has not been widely assessed in Timor-Leste. In South Africa, similar training did not initially impart all of the skills needed by generalist medical officers.17 In Timor-Leste, a carefully designed programme of continuing professional development may help the new doctors acquire the knowledge they need.
Finally, the training of allied health personnel – particularly laboratory technicians and analysts – is also urgently needed. District-level pathology services remain poor and require substantial investment. Nursing and midwifery education also needs to keep pace with the rapid expansion of the medical workforce to ensure that an appropriate doctor-to-nurse ratio is maintained.
We thank Graham Roberts, School of Public Health and Community Medicine, University of New South Wales, for his helpful comments on earlier drafts.
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