Country Profile. Timor-Leste

Transcription

1 Human Resources for Health Country Profile Timor-Leste + WHO TLS logo Ministériu da Saúde, Timor-Leste

2 Acknowledgement The Ministerio da Saude, Timor-Leste would like to thank World Health Organization, Country Office for Timor-Leste for its assistance in compilation of Human Resources for Health Country Profile for Timor Leste.

3 Content 1. Introduction Country context Geography and demography Economic context Political context Health status 7 3. Country health system Governance Organization of health care service delivery Service provision Health care financing Health information system Health Workforce Situation Health workforce stock and trends Distribution of health workforce by category/cadre Gender distribution by health workforce categories/cadre Age distribution by occupation/cadre Region/province/district distribution by occupation/cadre Urban/rural distribution by occupation/cadre Distribution by occupation/cadre 34 5 HRH Production Pre-service education In-service and continuing education Health workforce requirements HRH Utilization Recruitment Deployment and distribution mechanisms Governance for HRH HRH policies and plans Policy development, planning and managing for HRH Professional Regulation HRH information HRH research 45 Annex 1: Classification of health workforce of the WHO South-East Asia Region Annex 2: Health workforce classification mapping of the WHO South-East Asia Region Annex 3: Health workforce classification mapping of Timor Leste Annex 4: Members of the taskforce

4 1. Introduction The purpose of Human Resources for Health (HRH) profile for Timor Leste is to provide a comprehensive picture of the health workforce situation in the country; Systematically present the HRH policies and management situation to help monitoring the HRH stock and trends; Serve as communication with and between policy-makers and stakeholders; and Strengthen the HRH information system by establishing evidence for baselines and trends; Preparation of the HRH profile was posed with a number of challenges. Limited information on health workforce exists, particularly for private sector and policies related to motivation and incentives. Due to absence of single data source, multiple sources have been used to collect information on HRH. Secondary sources of information like key ministry documents were used to compile the information. The HRH profile begins with the country context, followed by description of health system, health workforce situation, Human Resource production, Human Resource utilization and Governance of Human Resources for Health. Data and tables are used in each section to support the findings. 3

5 2. Country context 2.1 Geography and demography Timor-Leste covers the eastern half of the island of Timor and includes Atauro Island located north of Dili, Jaco Island located on the easternmost end of the island and the enclave of Oecussi situated within Indonesia on the northwestern side of the island. It spans approximately 180km east-west and 75km northsouth and has a land mass of approximately 14,610 square kilometers. According to the 2010 Census, the population in 2010 was 1,066, The national capital is Dili. 1 Census

6 Timor-Leste became independent on 28 November 1975 after being under Portuguese rule since the 16 th century. Nine days later, on 7 December 1975, it was invaded by Indonesian forces and incorporated as a province in Indonesia in July It is estimated that nearly one quarter of the population died during the occupation as a consequence of conflict, forced migration, malnutrition and unattended public health needs (MoH 2011). Between 1974 and 1999 there were an estimated 102,800 conflict-related deaths including 18,600 killings and 84,200 hunger and illness related deaths (UNESCO, 2009). On 20 May 2002, Timor-Leste became independent following a referendum in August The transition was marred by violence in 2006, civil unrest during elections in mid-2007 and an attempted assassination of the President in Elections are scheduled for Timor-Leste is divided into 13 administrative districts, 65 sub-districts, 442 sukus (villages) and 2,225 aldeias (hamlets). Suku (village) is the smallest administrative division. 2 Thirty percent of the population lives in urban areas. Seventy percent of the population lives in rural areas in small, dispersed villages isolated by mountainous terrain and poor roads (MOH 2011). Lack of roads and transportation poses challenges for access to health care. The two largest urban centres, Dili and Baucau, are home to 29 percent of the population. In 2004 the population was 923,198 and the annual population growth rate was 5.3% (NSD, 2006). The 2010 Census showed that the population of Timor-Leste to be 1,066,409 and the annual population growth rate of 2.4%. Forty six percent of the population is below the age of 15. Life expectancy at birth improved from 59 in 2004 to 62 in 2010 (DHS 2010). Table 2.1 Percent Population Distribution by Age Group and year Age Group years 43.2% 41.4% years 53.3% 53.9% 65+ years 3.5% 4.7% Total 100% 100% Total population 923,198 1,066,409 Source: Population distribution by Administrative Areas Volume 2, Population and Housing Census 2010, National Statistic directorate Timor Leste,

7 2.2 Economic context Timor-Leste is a lower-middle income country. Gross National Income (GNI) per capita was US$1,980 in 2009 (although non-oil GDP is only US$536 per capita) and growth was estimated at 12.9 percent. The Petroleum Fund savings are estimated to exceed USD7 billion. Human development outcomes remain low. In 2010 Timor-Leste ranked 120 out of 177 countries on the United Nations Development Program (UNDP) Human Development Index (HDI). It had a Human Development Index (HDI) of According to the 2007 Timor-Leste Survey of Living Standards, nearly 50 percent of the population lives below the national poverty line of $0.88 per capita per day. Between and 2011, total government health spending in monetary terms has increased by approximately 109%: from USD 18.3 million in to USD 38.2 million in However since 2007, the share of government health expenditure of the total government expenditure has exhibited a decline: 7% in 2007, 4.8% in 2009, 4.1% in 2010 and 2.9% in 2011 (MoH 2011). According to World Health Organization (WHO) estimates, private expenditure on health as percentage of total expenditure on health was approximately 20% in It includes out-of-pocket expenses. Donor commitment to the sector remains strong. The total support from development partners was USD 27.7 million in 2008, 36.2 million in 2009 and 23.9 million in 2010 (MoH 2010). According to WHO, external financing for the health sector dropped from 52.5 percent of total health expenditures in 2005 to 28 percent in Public spending on health including donor funds in 2008 was USD 51.2 per capita and predicted to be USD 58.9 in 2009 (MoF 2010). Per capita spending on health excluding donor funds increased from USD 18 dollars in 2006 to USD 31 in 2010 (MoF 2010). This increase can be explained by investment in rebuilding of health infrastructure that was destroyed during independence struggle. The Ministry of Health budgets reveal marked increase in spending on salaries and decreases in spending on goods and services at central and district level. At the central level between 2008 and 2011 the share of salaries and wages increased from 20% to 29%. The share of goods and 6

8 services decreased from 59% to 39% in the same period. The same trend is reflected in district health budgets. Salaries received 34% of total district health resources in 2008, 38% in 2009, 58% in 2010 and 60% in This may pose as a major challenge to service delivery. 2.3 Political context The Democratic Republic of Timor-Leste is a Parliamentary republic. A Semi-Presidential system of government is followed. The Executive consists of the president (head of state), prime minister (head of government), and cabinet. The Legislative, the National Parliament or Parlamento Nacional, is a unicameral parliament. The Judiciary consists of courts and supporting hierarchy. The Supreme Court has not yet been formed; the Court of Appeal functions on an interim basis as the Supreme Court. 2.4 Health status Table 2.2 Selected health and demographic indicators 2010 Life expectancy at birth 60.2 (females) 58.6 (males) Total fertility rate 5.7 Maternal mortality ratio 557 per 100,000 live births Infant mortality rate 44 deaths per 1,000 live births Under-five mortality rate 64 deaths per 1,000 live births Children under-five with stunting (%) 53% Underweight children (%) 52% Source: National Health Sector Strategic Plan , Ministry of Health Table 2.3 Main causes of morbidity and mortality Main causes of morbidity Value /1,000 pop Main causes of mortality Value /1,000 pop 1.Acute Respiratory Tract Bronchopneumonia 0.15 Infections 2. Malaria All forms of TB Diarrhoea 60 3.Diarrhoeal diseases Pneumonia 46 4.Malaria All forms TB prevalence 378 /100,000 pop 6. Injury not caused by 29 traffic accident 7. Scabies 19 Others Source and year: 2010 Annual Health Statistic Report, HMIS and Surveillance Cabinet, Ministry of Health Timor Leste, 2010 Notes: Mortality data obtained from hospital and health facility. The mortality data in Timor Leste is under-reported. 3 and 7

9 Table 2.4 Leading causes of mortality by patient age (patient admission in hospitals) in Timor- Leste, January December 2010 Disease < and older Total Hospital Deaths % of Total No. of Hospital deaths Deaths Bronchopneumonia/pneumonia All forms of tuberculosis Malaria Cardiovascular disease Injury Liver disease Cerebrovascular disease Renal disorder Diarrhoeal diseases Asthma bronchiale/copd Meningitis/encephalitis Malnutrition Anemia Source: National Health Strategic Plan , Ministry of Health, Timor-Leste Table 2.5 Health indicators Indicators Both sex Male Female Source and year Life expectancy Crude mortality rate 10.9 na na Under-5 mortality rate Maternal mortality rate na na 557 HIV/AIDS prevalence rate < 0.2% na nc % with access to safe water 63% na na % with access to sanitation 1) 43% na na 8 Population Projection page 28, National Statistic Directorate Timor Leste Population Projection page 28, National Statistic Directorate Timor Leste Timor Leste DHS ; National Statistic Directorate, 2010 Timor Leste DHS ; National Statistic Directorate, 2010 HIV/AIDS unit, Department of CDC, Ministry of Health Timor Leste, 2010 Timor Leste DHS ; National Statistic Directorate, 2010 Timor Leste DHS ; National Statistic Directorate, 2010 According to the Census 2010,approximately r 66% of the population has access to improved drinking water sources (piped water, protected well, hand pump, tanker, bottled water). In 2001, the household survey reported this figure to be 48%. More than a third of Timorese families live ten or more minutes away from a water source..the main source of drinking water in urban areas

10 is household tap (42%) and in rural areas a well or spring (25%). Springs are the main water source for the rural eastern part of the country and the second main source in the rural central and western areas. The two leading causes of infant and child mortality in Timor-Leste lower respiratory infection and diarrhoeal disease are directly related to a lack of water supply, poor sanitation and hygiene. (Timor Leste, Strategic Development Plan ). 3. Country health system 31 Governance Timor Leste is signatory to various human rights conventions/treaties. The conventions/treaties of relevance to the health sector are: International Covenant on Economic, Social and Cultural Rights; International Covenant on Civil and Political Rights; Second Optional Protocol to the International Covenant on Civil and Political Rights, aiming at the abolition of the death penalty; International Convention on the Elimination of All Forms of Racial Discrimination; Convention on the Elimination of All Forms of Discrimination against Women; Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment; Convention on the Rights of the Child; Convention concerning Forced or Compulsory Labour; Equal Remuneration Convention; Abolition of Forced Labour Convention. The Constitution of the Democratic Republic of Timor Leste protects the right to health, medical care and healthy environment. It also protects other human rights that have an impact on health: gender equality; non-discrimination; protection of persons with specific needs (people with disabilities, the elderly, women, children and youth; health protection at workplace like maternity protection, occupational health. Article 57 of the Constitution states, all Timorese citizens are entitled to health care and the State has a duty to promote and protect this right free of charge, in accordance with its capabilities and in conformity with the law. The Constitution also states that health services shall, as far as possible, run under a decentralized participatory management setting. Thus the Constitution provides an opportunity to translate human rights commitments through laws and policies. 9

11 3.2 Organization of health care service delivery The public sector in Timor-Leste plays an important role in providing healthcare at all levels of care. The private sector is expanding and includes international and national non-government organizations, non-profit private organisations (faith based institutions, coffee cooperatives) and for-profit organisations. Public sector health care provision Timor-Leste has a three-tiered referral system. The three tiers include one national tertiary hospital, five district referral hospitals and numerous community health centres and health posts. In 2008, the Ministry of Health introduced Servisu Integrado du Saude Comunidade - Integrated Community Health Services - (SISCa) in its bid to improve access to health services at the village level. Primary level of care At the district level primary health care is provided through a network of community health centres, health posts and SISCas. Currently, there are 66 community health centres, 210 health posts and 473 SISCas operating throughout the country. Services provided at the primary health care facilities vary with catchment areas. The health services provided by primary health care facilities include the basic health service package (BSP) and those under the national programmes including immunization, maternal and child health, malaria, nutrition, tuberculosis and HIV/AIDS. The health post is the first level of contact at the community. It is staffed with a nurse and a midwife and is designed to deliver a minimum package of curative, preventive and promotive care. The community health centre (CHC) provides inpatient and outpatient services. Selected CHCs also offer dental and laboratory services. CHC staff includes a physician (the district medical officer). CHCs organize mobile clinics for remote areas where health posts are not established. 10

12 In 2007/2008, Servisu Integrado du Saude Comunidade (SISCa) was introduced in a bid to improve access to basic health services package and preventive measures at the suco (village) level. A team of health care professionals (midwives, nurses and doctors) from the CHC organize a clinic on a monthly basis. Community involvement is an important feature of SISCa and community members are mobilized with the assistance of community health workers/volunteers who receive basic training on health issues and are paid a stipend. SISCa has six components: family registration; nutrition assistance and child health promotion; maternal health and family spacing; hygiene, sanitation and malaria prevention; ambulatory primary care; and health promotion activities. Tertiary and secondary levels of care A network of one national tertiary hospital and five district referral hospitals has been established. A national laboratory operates in the capital Dili. The district referral hospitals offer emergency, out-patient and in-patient care. The district hospital staff include general practitioners and specialists in four clinical areas: surgery, paediatrics, gyneco-obstetrics and internal medicine. Cases are referred from district health facilities to district hospitals. The national hospital is the top tier referral facility for specialized services. The national hospital has referral linkages for tertiary care with facilities in Australia, Indonesia and Singapore for services not available in the country. Ambulance services are available to transport referral cases. The referral mechanism needs to be strengthened and standard operating guidelines need to be developed. Private sector The private sector in Timor-Leste is expanding and includes non-profit private organisations (faith-based institutions, coffee cooperatives, international and national non-government organizations) and for-profit organisations. The size of the private sector is not known, however, the MoH estimates that the private sector provides approximately 25% of basic medical service delivery. Doctors, nurses, midwives and dentists operate for-profit private clinics mostly in the urban centers of Dili and Baucau. According to MoH records, 26 private clinics exist. Medicine is sold in pharmacies and retail shops however private clinics and pharmacies are yet to be regulated. 11

13 Figure 3.1 : Current National Health Service Configuration CLINICAL REFERRAL SYSTEM CLINICAL SUPPORT & TRANSFER MANAGEMENT SUPPORTSERVICES Dili National Hospital Regional Referral Hospitals Community Health Centres with beds (1 each District) National Diagnostic Services (Radiology, laboratory) Community Health Centres without beds (1 each Sub-district) Health Post village level, first point of contact Integrated Community Health Service (SISCa) (Suco based community participation for primary health care) A M B U L A N C E S E R V I C E S CENTRAL SERVICES DISTRICT HEALTH SERVICES SUB-DISTRICT HEALTH SERVICES COMMUNITY HEALTH SERVICES Clínica Café Timor (CCT), operated by the Café Timor network, runs eight clinics providing services akin to a CHC, and 24 mobile clinics in five districts and Dili. The NGO Caritas operates 27 mobile clinics. There are approximately 32 faith-based clinics. Traditional medicine also plays an important role in rural areas and a large section of people in these areas seek care from traditional healers. 3.3 Service provision The Ministry of Health, with support from its development partners, has embarked in strong infrastructure development consisting of rehabilitation and construction of health facilities, management offices and training centres, while focus was also given to resourcing these facilities with basic equipments, ambulances and vehicles, access to electricity and water supply. Table 3.1 : Summary of Existing Health Facilities in Timor-Leste Type/Level Public Private TOTAL Health Posts Community Health Centres

14 Maternity Clinic Hospitals TOTAL Health care financing Between and 2011, total government health spending in monetary terms has increased by approximately 109%: from USD 18.3 million in to USD 38.2 million in However since 2007, the share of government health expenditure of the total government expenditure has exhibited a decline: 7% in 2007, 4.8% in 2009, 4.1% in 2010 and 2.9% in 2011 (MoH 2011). According to World Health Organization (WHO) estimates, private expenditure on health as percentage of total expenditure on health was approximately 20% in It includes out-of-pocket expenses. Donor commitment to the sector remains strong. The total support from development partners was USD 27.7 million in 2008, 36.2 million in 2009 and 23.9 million in 2010 (MoH 2010). According to WHO, external financing for the health sector dropped from 52.5 percent of total health expenditures in 2005 to 28 percent in Public spending on health including donor funds in 2008 was USD 51.2 per capita and predicted to be USD 58.9 in 2009 (MoF 2010). Per capita spending on health excluding donor funds increased from USD 18 dollars in 2006 to USD 31 in 2010 (MoF 2010). This increase can be explained by investment in rebuilding of health infrastructure that was destroyed during independence struggle. 3.5 Health information system The Cabinet of Health Management Information System and Surveillance (HMIS-SE) holds the overall responsibility of Health Information System. The information on key health indicators is collected routinely by the MoH through the HMIS. At the district level health information is collected by the HMIS officer and District Public Health Officer. The HMIS-SE provides comprehensive data on quarterly and annual basis to the policy makers, programme managers, district level, health facility and other relevant stakeholders will provide feedback to respective programme managers on monthly basis Information is collected from public and private Health Facilities. Health facilities submit the data to 13

15 District Health Service Office (DHS) which in turn compiles and submits to HMIS-SE. Although a Data management and validation system exists, it is not working properly in all districts and health facilities.. At the national and district level the database management includes both paper based filing and electronic systems. Since 2005, at the national level data management is done using Epi Info while the process of importing HMIS data from Excel to Epi info is ongoing. At the CHC level paper based filing system is used. Majority of the CHCs only received computers in April-May 2010 and staff are being trained. At the HMIS-SE data verification is undertaken before data entry. In case of discrepancy, data is verified from the relevant District Health Service Office (DHS). The HMIS-SE staff and HMIS officers do not have formal training in statistics or epidemiology. Some national and district level staff has attended short term courses in epidemiology in Malaysia and Thailand. One HMIS-SE staff, currently undertaking a postgraduate programme at the FETP Gadjahmada University Yogyakarta,is expected to graduated in early2012. Although HMIS-SE has computers, the number is inadequate. A need for high speed internet access has also been identified. All districts and majority of the CHCs are equipped with computers. However, the internet connectivity is poor. The Cabinet of Health Management Information System and Surveillance (HMIS-SE) collects and compiles HRH data from the district health office and National Human Resources Directorate. However there is a lack of standardized data collection procedures. 14

16 4. Health Workforce Situation Timor-Leste faced a health workforce crisis following the 1999 referendum and declaration of independence in The health workforce shrunk from 3540 to 1500 with the withdrawal of Indonesian health workers. To cite an example, only 20 of the 135 doctors remained. The situation is improving and the health workforce is gradually expanding. The gap has been filled by hiring foreign medical personnel and sending nationals abroad for training. Since 1999, approximately 1,000 Timorese medical students have trained under an agreement of medical cooperation between the governments of Cuba and Timor-Leste (MoH 2011). Approximately 700 Timorese students are currently studying medicine in Cuba. Additionally, around 180 students are studying medicine locally under a program conducted by the Cuban Brigade in cooperation with the National University of Timor-Leste and the Ministry of Health (Dewdney et al. 2009). Despite an increase in the human resources for health a shortage remains of nurses, midwives, radiologists, physiotherapists, pharmacists, laboratory technicians and managers. Absorbing the newly trained doctors in the health system is one of the challenges facing Timor-Leste. By 2010, 18 of the 700 students had returned (MoH 2011) and a large influx is expected in the coming three years. This also entails higher costs and there is a skewed distribution of healthcare professionals favouring urban areas. Incentives in form of subsidies have been introduced to address the rural-urban mismatch (MoH 2011). The Faculty of Health Sciences, National University of Timor-Leste, Ministry of Education, the Institute of Health Science, Ministry of Health and a private university provide pre and in-service training for healthcare providers. National and referral hospitals offer training facilities and internships. A school of nursing and midwifery at the National University Timor Lorosa e (UNTL) is proposed. 4.1 Health workforce stock and trends In 2010, 1407 health personnel (physicians, nurses and midwives) were employed in the public health system (Tables 3.1 and 3.2). Health personnel are also employed by non-profit private organisations as well as for-profit private organisations. The numbers however are not available. The Cuban Brigade constitutes a major component of the clinical workforce providing two out of every three doctors in Timor-Leste. This will change in the coming years once Timorese medical students return from their training in Cuba. 15

17 Despite an increase in the human resources for health a shortage remains of nurses, midwives, radiologists, physiotherapists, pharmacists, laboratory technicians and managers. Absorbing the newly trained doctors in the health system is one of the challenges facing Timor-Leste. By 2010, 18 of the 700 students had returned (MoH 2011) and a large influx is expected in the coming three years. This also entails higher costs and there is a skewed distribution of healthcare professionals favouring urban areas. Incentives in form of subsidies have been introduced to address the rural-urban mismatch (MoH 2011). Table Distribution of health personnel by district Districts Physicians Nurses Midwives Total Physicians Nurses Midwives Total Aileu Ainaro Baucau Bobonaro Covalima Dili Ermera Lautem Liquiça Manatuto Manufahi Oecussi Viqueque Total Source: Ministério da Saúde/Ministry of Health Table 7.2 Timor-Leste in Figures, 2010 Table 4.1.2: Physicians, nurses and midwives per 1,000 inhabitants Districts Physicians Nurses Midwives Physicians Nurses Midwives Aileu Ainaro Baucau Bobonaro Covalima Dili Ermera Lautem Liquiça Manatuto Manufahi Oecussi Viqueque Total Source: Ministério da Saúde/Ministry of Health and DNE calculations. Table 7.3 Timor-Leste in Figures,

18 The Faculty of Health Sciences, National University of Timor-Leste, Ministry of Education, the Institute of Health Science, Ministry of Health and a private university provide pre and in-service training for healthcare providers. National and referral hospitals offer training facilities and internships. A school of nursing and midwifery at the National University Timor Lorosa e (UNTL) is proposed. 17

19 4.2 Distribution of health workforce by category/cadre Table 4.1 Distribution of health workers Category Sub-category Cadre* General Practitioner General Specialists Specialists Dental Dentists Dentists SI Dental nurses DIII Dental Nurse SPRG Dental lab technicians DI Pharmacy practitioners Pharmacists Pharmacist DIII Pharmaceutical technicians/ assistants Junior Pharmacy Technician (D1) Pharmacy Technician (SMF) Nursing and Midwifery practitioners Nursing professionals Nurse SPK/DI Nurse D III Nurse SI Midwifery Professionals Midwife DI Midwife D III Midwife D IV Non- Public Health Public Health Generalists Public Health Specialists Public Health Generalists Public Health Specialists Nutrition Professionals Nutritionist D I Nutritionist D III Environmental Health Officer Community Health Volunteers Environment Health Officer DI Environment Health Officer DIII Environment Health Officer SI Promotores Saude Familia (PSF)

20 Category Technologists Sub-category Imaging Technicians Cadre* Radiographer DI Radiographer DIII Radiographer SI Electromedik DIII Laboratory Assistants Laboratory Assistant SMAK/SPK Laboratory Assistant DI Laboratory Assistant DIII Laboratory Assistant SI Traditional Medicine Practitioner Traditional Medicine Practitioner No cadre, not in government service. NOT recognized in indigenous system of medicine Other Health Workers Optometrists Optometrist DI Physiotherapists Physiotherapist DIII Health management and support staff Health Service Manager Records Technicians Health Service Manager Records Technicians Support staff Support staff TOTAL Source: Human Resources Department, Ministry of Health, Timor-Leste Note: * Please provide names of all cadres, additional rows may be added to accommodate all cadres under each sub-category. 19

21 Details of qualification of each Cadre in Timor Leste: I. 1. General Practitioner: Professionals with minimum of 7 years of university education in the field of medicine with minimum of 1 year internship. (Doctors Trained in Indonesia). OR Professionals with minimum of 6 years of university education in the field of medicine. (Doctors trained in Cuba and Timor Leste) 2. Specialists: doctors with minimum of 2 year of postgraduate education/ training. II. Dental 1. Dentists SI: 12 years of education in school + 6 years university education in dental medicine in Indonesia (Bachelor s degree) 2. Dental nurses DIII: 12 year of education in school + 3 years university education in dental nursing in Indonesia 3. Dental nurse SPRG: 9 years of education in school + 3 years of university education in dental nursing in Indonesia 4. Dental laboratory technicians DI: 12 years of education in school + 1 years training in dental laboratory technician in Indonesia III. Pharmacy practitioners 1. Pharmacist DIII: 12 year of education in school + 3 years of university education in Pharmacy in Indonesia 2. Pharmacist SI: 12 years of education in school + 4 years of education in Pharmacy 3. Junior Pharmacy Technician DI: 12 years of education in school + 3 year of education in pharmacy science in Indonesia 4. Pharmacy Technician SMF: 12 years of education in school + 3 year of education in pharmacy science in Indonesia IV. Nursing and Midwifery practitioners Nursing 1. Nurse SPK/DI: 9 years of education in school + 3 years education in nursing in Indonesia 20

22 2. Nurse D III: 12 years of education in school + 3 years education in nursing or 9 years of education in school + 3 years of education in nursing + additional 2 years education in nursing in Indonesia 3. Nurse SI: Nurse SPK/DI + Nurse DIII + 2 and half year training in Nursing OR Nurse DIII + 2 and half year training in Nursing OR 12 years of education in school + 4 and half years training in Nursing Midwifery 1. Midwife DI: Nurse SPK + 1 year training in Midwifery 2. Midwife D III: Nurse SPK + Midwife DI = 2 years additional training in midwifery 3. Midwife D IV: Nurse SPK + Midwife DIII + 1 year additional training in midwifery OR 12 years of education in school + Midwife DIII OR 12 years of education in school + Midwife DIII + 1 year additional training in midwifery V. Non- Public Health 1. Public Health Generalists: 12 years of education in school + 4 years of education in university in public health (Bachelor s of Public Health) 2. Public Health Specialists: Public Health Generalists + 2 years of post graduate education in university in any speciality of public health (epidemiology, public health nutrition etc..) 3. Nutrition Professionals Nutritionist D I: 12 years of education in school + 1 year training in nutrition Nutritionist D III: 12 years of education in school + 3 years training in nutrition 4. Environmental Health Inspectors Environment Health Inspectors DI: 12 years of education in school + 1 year education in environmental science Environment Health Inspectors DIII: 12 years of education in school + 1 year education in environmental science Environment Health Inspectors SI: Environment Health Inspectors DIII + 2 years education in environmental science (Bachelor s degree) 5. Community Health Volunteers Promotores Saude Familia (PSF): People chosen by the community and trained to deal with health problems of individuals and the community 21

23 VI. Technologists Imaging Technicians 1. Radiographer DI: 12 years of education in school + 1 year of training in radiography 2. Radiographer DIII: 12 years of education in school + 3 years of training in radiography 3. Radiographer SI: Radiographer DIII + 1 year additional training in radiography 4. Electromedik DIII: 12 years of education in school + 3 years of training in electro medical science Laboratory Assistants 1. Laboratory Assistant SMAK/SPK : 9 years of education in school + 6 months training in laboratory technology 2. Laboratory Assistant DI: 9 years of education in school + 3years of training in laboratory technology or 12 years of education in school + 3 years of training in laboratory technology 3. Laboratory Assistant DIII: Laboratory Assistant DI + 3 years of education in laboratory technology 4. Laboratory Assistant SI: Laboratory Assistant SMAK/SPK + DIII + 2 and half additional education in laboratory technology or 12 years of education in school + 4 years of education in laboratory technology (Bachelor s degree) VII. Other Health Workers Optometrists 1. Optometrist DI: 12 years of education in school + 1 year of training in optometry at IHS, Timor Leste 2. Optometrist SI (Bachelor s degree): 12 years of education in school + 4 years of education in Optometry Physiotherapists 1. Physiotherapist DIII: 12 years of education in school + 3 years of education in physiotherapy (Indonesia) VIII. Health management and support staff 1. Health Service Manager: 9 years of education in school + 3 years of training in nursing + some training in health service managment 22

24 2. Records Technicians: 12 years of education in school + 2 years of training in any health area + 2 years training in records (Indonesia) 3. Support staff: 9 or 12 years of education in school with some training in support functions 23

25 4.2.1 Gender distribution by health workforce categories/cadre Table 4.2 Gender distribution by health workforce category/cadre Category Sub-category Cadre* Total (2011) Female % Female General Practitioner General Specialists Specialists Dental Dentists Dentists SI Dental nurses DIII Dental Nurse SPRG Dental lab technicians DI Pharmacy practitioners Pharmacists Pharmacist DIII Pharmaceutical technicians/ assistants Junior Pharmacy Technician (D1) Pharmacy Technician (SMF) Nursing and Midwifery practitioners Nursing professionals Nurse SPK/DI Nurse D III Nurse SI Midwifery Professionals Midwife DI Midwife D III Midwife D IV Non- Public Health Public Health Generalists Public Health Specialists Public Health Generalists Public Health Specialists Nutrition Professionals Nutritionist D I Nutritionist D III Environmental Health Officer Environment Health Officer DI Environment Health Officer DIII Environment Health Officer SI

26 Category Sub-category Cadre* Total (2011) Female % Female Community Health Volunteers Promotores Saude Familia (PSF) Technologists Imaging Technicians Radiographer DI Radiographer DIII Radiographer SI Electromedik DIII Laboratory Assistants Laboratory Assistant SMAK/SPK Laboratory Assistant DI Laboratory Assistant DIII Laboratory Assistant SI Traditional Medicine Practitioner Traditional Medicine Practitioner No cadre, not in government service. NOT recognized in indigenous system of medicine Other Health Workers Optometrists Optometrist DI Physiotherapists Physiotherapist DIII Health management and support staff Health Service Manager Records Technicians Health Service Manager Records Technicians Support staff Support staff TOTAL Source: Human Resources Department, Ministry of Health, Timor-Leste Note: * Please provide names of all cadres, additional rows may be added to accommodate all cadres under each sub-category. 25

27 4.2.2 Age distribution by occupation/cadre Table 4.3 Workers by age group and cadre Category Sub-category Cadre* Total (2011) 30 Yrs yrs General Practitioner General Specialists Specialists Dental Dentists Dentists SI Dental nurses DIII 1 1 Dental Nurse SPRG Dental lab technicians DI 1 1 Pharmacy practitioners Pharmacists Pharmacist DIII Pharmaceutical technicians/ assistants Junior Pharmacy Technician (D1) Pharmacy Technician (SMF) Nursing and Midwifery practitioners Nursing professionals Nurse SPK/DI Nurse D III Nurse SI 1 1 Midwifery Professionals Midwife DI Midwife D III Midwife D IV 2 2 Non- Public Health Public Health Generalists Public Health Specialists Public Health Generalists Public Health Specialists Nutrition Professionals Nutritionist D I Nutritionist D III Environmental Health Officer Community Health Volunteers Environment Health Officer DI Environment Health Officer DIII Environment Health Officer SI Promotores Saude Familia (PSF)

28 Category Sub-category Cadre* Total (2011) 30 Yrs yrs Technologists Imaging Technicians Radiographer DI Radiographer DIII Radiographer SI 1 1 Electromedik DIII Laboratory Assistants Laboratory Assistant SMAK/SPK Laboratory Assistant DI Laboratory Assistant DIII Laboratory Assistant SI Traditional Medicine Practitioner Traditional Medicine Practitioner No cadre, not in government service. NOT recognized in indigenous system of medicine Other Health Workers Optometrists Optometrist DI Physiotherapists Physiotherapist DIII 1 1 Health management and support staff Health Service Manager Records Technicians Health Service Manager Records Technicians Support staff Support staff TOTAL Source: Human Resources Department, Ministry of Health, Timor-Leste Note: * Please provide names of all cadres, additional rows may be added to accommodate all cadres under each sub-category. 27

29 4.2.3 Region/province/district distribution by occupation/cadre Please discuss major variations in the distribution of workers by region/sub-national level. Table 4.4 Regional/District/province distribution of workers Category Subcategory Cadre* Total (2011) Aileu Ainaro Baucau Bobonaro Covalima Dili Ermera Lautem Liquisa Manatuto Manufahi Oecusse Viqueque General Practitioner General Specialists Specialists 9 9 Dental Dentists Dentists SI Dental nurses DIII 1 1 Dental Nurse SPRG Dental lab technicians DI Pharmacy practitioners Pharmacists Pharmacist DIII Pharmaceuti cal technicians/ assistants Junior Pharmacy Technician (D1) Pharmacy Technician (SMF) Nursing and Midwifery Nursing professionals Nurse SPK/DI Nurse D III

30 Category Subcategory Cadre* Total (2011) Aileu Ainaro Baucau Bobonaro Covalima Dili Ermera Lautem Liquisa Manatuto Manufahi Oecusse Viqueque practitioners Nurse SI 1 1 Midwifery Professionals Midwife DI Midwife D III Midwife D IV 2 2 Non- Public Public Health Public Health Health Generalists Generalists Public Public Health Health Specialists Specialists Nutrition Professionals Nutritionist D I Nutritionist D III Environment al Health Officer Community Health Volunteers Environment Health Officer DI Environment Health Officer DIII Environment Health Officer SI Promotores Saude Familia (PSF) Technologists Imaging Radiographer DI Radiographer DIII

31 Category Subcategory Cadre* Total (2011) Aileu Ainaro Baucau Bobonaro Covalima Dili Ermera Lautem Liquisa Manatuto Manufahi Oecusse Viqueque Technicians Radiographer SI 1 1 Electromedik DIII Laboratory Assistants Laboratory Assistant SMAK/SPK Laboratory Assistant DI Laboratory Assistant DIII Laboratory Assistant SI Traditional Medicine Practitioner Traditional Medicine Practitioner No cadre, not in government service. NOT recognized in indigenous system of medicine Other Health Workers Optometrists Optometrist DI Physiotherap Physiotherapist 1 1 ists DIII Health Health Health Service management and Service Manager support staff Manager Records 1 1 Records Technicians 30

32 Category Subcategory Cadre* Total (2011) Aileu Ainaro Baucau Bobonaro Covalima Dili Ermera Lautem Liquisa Manatuto Manufahi Oecusse Viqueque Technicians Support staff Support staff Total Source: Human Resources Department, Ministry of Health, Timor-Leste Note: * Please provide names of all cadres, additional rows may be added to accommodate all cadres under each sub-category. 31

33 4.2.4 Urban/rural distribution by occupation/cadre Table 4.5 Urban/Rural distribution of workforce Category Sub-category Cadre* Total (2011) % Urban % Rural General Practitioner General Specialists Specialists Dental Dentists Dentists SI Dental nurses DIII Dental Nurse SPRG Dental lab technicians DI Pharmacy practitioners Pharmacists Pharmacist DIII Pharmaceutical technicians/ assistants Junior Pharmacy Technician (D1) Pharmacy Technician (SMF) Nursing and Midwifery practitioners Nursing professionals Nurse SPK/DI Nurse D III Nurse SI Midwifery Professionals Midwife DI Midwife D III Midwife D IV Non- Public Health Public Health Generalists Public Health Specialists Public Health Generalists Public Health Specialists Nutrition Professionals Nutritionist D I Nutritionist D III Environmental Health Officer Community Health Volunteers Environment Health Officer DI Environment Health Officer DIII Environment Health Officer SI Promotores Saude Familia (PSF)

34 Category Sub-category Cadre* Total (2011) % Urban % Rural Technologists Imaging Technicians Radiographer DI Radiographer DIII Radiographer SI Electromedik DIII Laboratory Assistants Laboratory Assistant SMAK/SPK Laboratory Assistant DI Laboratory Assistant DIII Laboratory Assistant SI Traditional Medicine Practitioner Traditional Medicine Practitioner No cadre, not in government service. NOT recognized in indigenous system of medicine Other Health Workers Optometrists Optometrist DI Physiotherapists Physiotherapist DIII Health management and support staff Health Service Manager Records Technicians Health Service Manager Records Technicians Support staff Support staff TOTAL Urban health workforce = All health workers working in cities, municipalities, and district centres/head offices (including those health workers in other sectors outside health ministries). Rural health workforce = All health workers working outside cities, municipalities, and district centres/head offices (including those health workers in other sectors outside health ministries). Source: Human Resources Department, Ministry of Health, Timor-Leste 33

35 4.2.5 Distribution by occupation/cadre Private sector in Timor-Leste exists. The size of the private sector is not known. It consists of non-profit private clinics (faith based institutions, Coffee Cooperatives, international and national non-government organizations); and for-profit private. Table 4.6 Public/Private for profit/faith based organization/private not for profit distribution of health workers Category Sub-category Cadre* Total (2011) % Public sector % Private sector % Faith based organization % Private not-forprofit General Practitioner General Specialists Specialists 9 9 Dental Dentists Dentists SI 7 7 Dental nurses DIII 1 1 Dental Nurse SPRG Dental lab technicians DI 1 1 Pharmacy practitioners Pharmacists Pharmacist DIII Pharmaceutical technicians/ assistants Junior Pharmacy Technician (D1) Pharmacy Technician (SMF) Nursing and Midwifery practitioners Nursing professionals Nurse SPK/DI Nurse D III Nurse SI 1 1 Midwifery Professionals Midwife DI Midwife D III Midwife D IV 2 2 Non- Public Health Public Health Generalists Public Health Specialists Public Health Generalists Public Health Specialists Nutrition Professionals Nutritionist D I 6 6 Nutritionist D III Environmental Health Officer Environment Health Officer DI

36 Category Sub-category Cadre* Total (2011) % Public sector % Private sector % Faith based organization % Private not-forprofit Environment Health Officer DIII Environment Health Officer SI Technologists Community Health Volunteers Imaging Technicians Promotores Saude Familia (PSF) Radiographer DI Radiographer DIII Radiographer SI 1 1 Electromedik DIII 7 7 Laboratory Assistants Laboratory Assistant SMAK/SPK Laboratory Assistant DI Laboratory Assistant DIII Laboratory Assistant SI Traditional Medicine Practitioner Traditional Medicine Practitioner No cadre, not in government service. NOT recognized in indigenous system of medicine Other Health Workers Optometrists Optometrist DI Physiotherapists Physiotherapist DIII 1 1 Health management and support staff Health Service Manager Records Technicians Health Service Manager Records Technicians Support staff Support staff TOTAL Public sector: Includes all government owned/funded health facilities under health ministry and other related ministries. Source: Human Resources Department, Ministry of Health, Timor-Leste 35

37 5 HRH Production 5.1 Pre-service education The Faculty of Health Sciences, National University of Timor-Leste, Ministry of Education, the Institute of Health Science, Ministry of Health and a private university provide pre and in-service training for healthcare providers. National and referral hospitals offer training facilities and internships. A school of nursing and midwifery at the National University Timor Lorosa e (UNTL) is proposed. Twinning arrangements exist with institutions in Portugal for nursing and midwifery. These arrangement were made to overcome barriers imposed by a lack of qualified teachers. An MOH policy for admissions of students from sub-district to the nursing and midwifery under UNTL could not materialize due to a lack of concurrence from the Ministry of Education. In 2003 a bilateral cooperation agreement between the governments of the Democratic Republic of Timor Leste and the Republic of Cuba was signed. Under this agreement the first group of 20 students went to study medicine in Cuba in A medical school was established in Timor-Leste under the National University of Timor Leste (Univercidade Nacional de Timor Lorosae - UNTL). It is managed by Cuban medical professors and the medium of instruction is Spanish. As part of the collaboration, 162 Cuban medical doctors, 30 nurses and 32 technicians are currently working in Timor-Leste as health-care providers and teachers in the medical school. On completing the 4th year of the medical school, the Timorese medical students return to Timor Leste for clinical training. This forms part of years 5 and 6 of the curriculum. Students have also been sent to other countries like Indonesia, Papua New Guinea, Fiji, Malaysia and Australia. Details of the number of students is given in Table