Table 2 Timor-Leste case report

Background

Timor-Leste achieved its independence in 2002 after 450 years of Portuguese colonization and 24 of Indonesian occupation. Following the vote for Independence in August 1999, an Australian-led multinational force was deployed to stop the violence and destruction triggered by the results [80]. A UN Transitional Administration (UNTAET) was established in October 1999. The country’s health system faced serious problems due to destruction of infrastructure and severe health workforce deficiencies as skilled health workers and managers fled the country [48,53]. NGOs were the main health service providers during the emergency period from 1999 to 2001. A Trust Fund for East Timor (TFET) administered by the World Bank was created in early 2000 [53]. Timor-Leste faced a relapse of violence in 2006, and a UN mission (UNMIT) was deployed. In preparation for its withdrawal in 2012, the country developed a transition plan in 2011 to move from peacekeeping “…to the new phase of state building” [81].

Institutional capacity

Weak institutional capacity was part of the legacy left by Indonesia after withdrawal in 1999. During the Indonesian occupation, most middle and top managerial positions in the government, including the health sector, were held by non-Timorese Indonesians [82]. Around 7 000 civil servants fled the country after Indonesia’s withdrawal [83]. In the health sector, destruction of health facilities and institutions, including destruction of records, left severely weakened institutions. UNTAET and the first National Government had as a priority to develop individual and institutional capacity. In the health sector, training of district managers and senior officers working at MoH level was prioritized and undertaken as early as 2001 and 2002 [51]. This allowed, for instance, for the assumption of responsibility over district health management by the government. However, there was a sense of scepticism about this decision among NGOs and development partners who thought there was not enough capacity built yet to ensure an efficient health service provision [48] which speaks about the limited international legitimacy of the emerging government. Soon after the initial emergency phase, strengthening educational institutions for health professions was prioritized. Establishment of a Faculty of Medicine in 2005 and schools of Nursing and Midwifery in 2008 allowed for local production of these key cadres. This contributed to a relatively more sustainable workforce than in other small countries in the region which still depend on international recruitment and on sending students abroad.

Intersectoral coordination

The Timor-Leste Ministry of Health’s vision implies a broad definition of health which involves social determinants of health [84]. This approach requires intersectoral collaboration. The Strategic Development Plan 2011–2030 recognizes that in order to address health problems an intersectoral approach is required and that coordination with other sectors such as agriculture, environment or infrastructures is paramount [85]. However, the implementation remains a challenge due to HR and institutional capacity limitations [86].

Adequacy and coverage of HRH

Deployment of skilled health professionals to remote areas as part of the government’s policy to staff each facility with one doctor, two nurses and two midwives in every village is currently ongoing. However, while deployment of physicians is already achieving 76% of the target (335 of 442 TL’s villages), appointment of nurses and midwives is proving more difficult mainly due to the more limited production of these professionals^a.

MNCH indicators in Timor-Leste are still poor. Access to MNCH service in remote areas is limited mainly due to shortage of adequate HRH. In order to address this issue, Timor-Leste is currently supporting nurses with rural backgrounds to undertake training in midwifery to ensure their deployment and retention in these remote locations [87]. During the pre-Independence period, assistance during delivery in Timor-Leste was usually provided by traditional birth attendants (TBAs), partially due to the mistrust of the population on the Indonesian health services. Ribeiro Sarmento [88] found that the integration of TBAs in the public health workforce as family health promoters contributes to increase access to these essential services to population living in remote areas hence contributing to increase equity in health service delivery.

Only 31 doctors remained in Timor-Leste after the withdrawal of Indonesia [58]. The government of Timor-Leste signed a bilateral agreement with Cuba in April 2004 to deploy between 150 and 200 doctors to provide clinical services and to train 1 000 Timorese doctors [89]. As a result, 838 medical doctors graduated between 2010 and 2014 and are now being deployed across the country including remote areas [90].

Presence of funded, effective and responsive public servants and CHWs following public goals

Weak institutional capacity within the transitional administration was reflected in the slow pace of the process of recruitment of civil servants in 2001, which is reported to have undermined the credibility of the newly established Civil Service [53]. However, initiatives like the reorientation and integration of TBAs within the national workforce and the scaling up of the midwifery workforce mentioned above are contributing to improve the availability of services provided by these key professionals.

Integration of HRH: the role of HRH in the 2006 political instability

After some years of peace, political instability caused widespread communal violence in 2006, leading to the displacement of approximately 150 000 people. The conflict deepened the division in the Timorese community between “East—Lorosa’e” and “West—Loromonu”. Timorese health workers belonging to both sides of this divide played a commendable role avoiding being dragged into this division and continuing to work maintaining their neutrality and impartiality and providing health care to people from East and West without discrimination. Cuban doctors and NGO staff played also an important role. Strong leadership by the Minister of Health, communication and effective coordination are among the factors identified that kept staff morale to continue working in such an unstable environment [90]. This contributed to promote a sense of resilience among the people living in IDP camps and the general population who was able to access health services during the crisis without disruption. This is likely to have contributed to increase the government’s legitimacy. Dr. Araujo, former Minister of Health and regarded as the leader of the health system rehabilitation, has been recently sworn in as the 5th Prime Minister. This shows the key role that health professionals, thanks to their social legitimacy, can play not only in reconstructing health systems after conflict but also in assuming leadership roles and contributing to national reconstruction and state-building.