Human Resources Development Project

Human Resources Development Project

“Support to Human Resources Development for Health in

East Timor”

15 March – 15 June 2000

Joyce H. Smith

HRD Specialist

HealthNet International

15 June 2000

List of Contents

Page

List of Abbreviations3

1. Background……………………………4

2. Terms of Reference……………………4

3. Activities and Findings……………4

3.1. Central Health Administration4

3.2. Human Resources Development5

3.2.1. Health Workforce6

3.2.2. Human Resources Database6

3.2.3. Workforce Planning7

3.2.4. HR Policy Development7

3.2.5. Definition of roles and functions7

3.2.6. Continuing Education7

3.2.7. Basic Training8

3.3. Support to MPH Research9

3.4. WHO Collaboration9

3.5. Collaboration with World Bank9

4. Conclusions and Recommendations……9

4.1. HRD Policy Development9

4.2. HRD Plannning10

4.3. HRD Management10

4.4. Health Personnel Education10

4.5. Early Mobilization of Technical Advisers11

1. Acknowledgements11

Annex1. Interim Health Authority Task groups

Annex 2.Proposed New structure of IHA June 2000

Annex 3.World Bank Project Appraisal Document

Annex 4. East Timor Health Professional Group workforce numbers.

List of Abbreviations

CNRTNational Resistance Council

EPIExpanded Programme of Immunization

ETHPWGEast Timorese Health Professionals Working Group

HNIHealthNet International

HRDHuman Resources Development

IHAInterim Health Authority

MPHMasters in Public Health

NCCnational Consultative Council

NGONon Governmental Organization

TFETTrust Fund for East Timor

UNUnited Nations

UNICEFUnited Nations Childrens Fund

UNTAETUnited Nations Transitional Authority in East Timor

WBWorld Bank

WHOWorld Health Organization

1. Background

The violence which followed the referendum in East Timor in September 1999 resulted in severe damage to the health care infrastructure and a loss of a large number of health workers of Indonesian origin who occupied the majority of senior professional and managerial posts in the health services. These health workers left the country and are unlikely to return. There however remains a large number of mid and lower level health workers who were trained under the Indonesian Health System.

The World Bank Joint Assessment Mission in November 1999, identified the priority of establishing a central health authority and specifically establishing expertise on human resources development for health., as did UNICEF’s discussion paper and WHO’s Appeal. In response HealthNet made available a senior health planner with extensive experience in human resources development for health in South East Asia and also with experience in complex emergencies and post conflict human resource development for health issues. This expert was to be attached to the UNTAET transitional authorities and the newly formed Interim Health Authority which was expected to form the nucleus of the future central health authority working under direct responsibility of the WHO Coordinator for Health in East Timor. The assignment was originally projected to be for 6 months, however funding was only available for 3 months.

1. Terms of Reference

To develop the institutional capacity for human resource development within the central health authorities, which is able to:

• Assess the need for the various categories and numbers of health personnel in the country;
• Assess the training needs for health personnel;
• Take responsibility for training to be carried out; and
• Recruit personnel

It was agreed that the consultant should review the TOR on arrival in Dili in view of the shortened length of the project. Shortly after arrival of the consultant WHO agreed to fund the project for a further 3 months. It was therefore agreed that the TOR should remain unchanged.

1. Activities and Findings

3.1.Central Health Administration

The central health administration lies within United Nations Transitional Authority in East Timor (UNTAET). A group of East Timorese health professionals formed the East Timorese Health Professionals Working Group (ETHPWG) who worked with UNTAET and undertook activities to register the remaining health workers in the country. During a workshop in February 2000 the ETHPWG under the direction of leading members of the National Resistance Council (CNRT ) was declared to become the Interim Health Authority. This gave impetus for the Interim Health Authority composed of East Timorese and UNTAET health professionals to begin the process of planning the future national health services.

The IHA, which is located within the Social Services Sector of UNTAET, was divided into a number of task groups (Annex 1). During the 3 months of the project there has been a reduction in the number of UNTAET expatriate staff.

The Interim Health Authority is jointly headed by Dr Sergio Lobo, (a former specialist surgeon), and Dr Jim Tulloch (seconded by WHO). The structure of the IHA is currently being revised based on (a) the World Bank proposed organizational structure, and (b) the current strategy to involve more East Timorese at senior level who will be supported by UNTAET staff as technical advisors. (Annex 2)

The IHA is funded by two sources the UNTAET administered Trust Fund and the World Bank administered Trust Fund (TFET). The World Bank has recently completed negotiations with UNTAET and the IHA for implementation of the trust fund. (Annex 3).

The IHA functioning has been constrained by the involvement of all the East Timorese members in an Australian funded intensive 6 week English Language Course. Other major constraints are politically based. Whilst UNTAET is the legal transitional authority, there is mounting pressure for the East Timorese to take over. CNRT has taken the lead and has confirmed bodies such as the IHA, however the right of CNRT to take these decisions is being questioned by other political parties and issues of coalition are beginning to be explored. The current political environment is a major constraint to policy development which is the foundation of health service development. It is hoped that issues will be resolved during the CNRT conference in July 2000.

In the mean time District Health Officers have been appointed to all districts except Dili, and the IHA is partnering with NGO’s to develop district health plans.

The writer has worked closely with the IHA, particularly the members of the HRD task group.

3.2.Human Resources Development

The issue of human resources for health are complex ones. There has been a common supposition amongst a number the donors that destruction of buildings and infrastructure equates with loss of human capacity. In many post conflict situations there is a huge loss of health workers (Rwanda 80% and Cambodia 75%). In

East Timor however there was a largely inflated civil sevice and the loss to the health workforce has been of medical practitioners and specialists as well as senior health administrators, and other specific technical staff such as X-ray technicians. These posts were mainly taken by Indonesians who have left the country. There is a no shortage of mid and lower level workers particularly nurses and midwives.

The current uncertainties related to future reduced possibilities for government employment being faced by a traumatized population are manifesting in labour unrest, demonstrations and disputes over pay with NGO’s and other agencies. Possibilities of private practice are being discouraged by CNRT and there is a real possibility of an unregulated private sector developing.

3.2.1. Health Workforce

The information on the numbers and categories of health workers remaining in the country were unclear with contradictory numbers from different sources. The most realistic figures were those which were produced by the East Timorese Health Professional Working Group. Which although incomplete indicated an existing health workforce, including general staff, of approximately 2000 (Annex 4)

It was discovered that the personnel records of all the staff in the Ministry of Health had been saved when the building was destroyed. The records were stored by UNICEF for safe keeping in a container. These records, which contain detailed information on the education, training and work history of health workers, are a valuable took to support future workforce planning, recruitment and training.

The size and structure of the future workforce will bear little resemblance to that of the preceding Indonesian period when the workforce was estimated to number around 3500. The workforce was largely inflated due to single skilling e.g. nurses employed solely as vaccinators for EPI programmes. Within the financial constraints of the UNTAET and World Bank Trust Funds workforce projections were low, the UNTAET/IHA proposal being a workforce of 1480, based on the UNTAET four level pay structure.

Recent meetings in CNRT and the National Consultative Council (NCC) to discuss the future civil service has resulted in a decision by the NCC to begin with a small civil service which they hope will be sustainable and affordable once UNTAET leaves. The number of health workers proposed by NCC is 1087 based on a seven level pay scale. This number is extremely low to provide essential basic health services throughout the country. In the interim extra posts may be provided by NGO and IO employed medical and health staff.

Immediate health workforce issues include:

• The absence of senior health administrators;
• The limited number of senior health administrators;
• The shortage of doctors and skilled health technicians;
• The excess number of nurses in the system, against projected future workforce requirements;
• Uneven geographic distribution of health workers;
• Different levels of training within the same occupational category;
• The number of tertiary students with incomplete degrees;
• The number of nursing students in the system with expectations of completing their studies and finding employment in the sector; and
• Managing the processes of structural adjustment and downsizing.

3.2.2. Human Resources Database

Priority has been given to the establishment of a computerized database. The writer has worked in collaboration with IHA, UNTAET and WHO to develop this database.

HealthNet has contracted an East Timorese database expert to design the HRD database in consultation with the UNTAET Civil Service database expert. This collaboration will ensure the compatibility of the HRD database to the National Civil Service Database. Filing cabinets and cupboards were supplied for storage of the personnel records at the UNTAET/IHA premises. Two former clerks from the former personnel office are currently working under short term “Agreement for Performance of Work” contracts with HealthNet to abstract data from the records for computer entry.

Two data entry clerks have been employed by UNTAET under civil service contracts to enter the data.

WHO has provided computer facilities and a venue for training the data entry clerks. With the arrival of a dedicated computer the data entry will be relocated to the IHA for data entry to commence. It is anticipated that the data entry should be completed by mid July 2000, prior to the civil service recruitment process. Once data entry is complete a process of verification and registration of health workers will be required.

3.2.3.Workforce Planning

The immediate determining of the health services establishment is currently linked to the available budget and the numbers decided by the NCC. Other factors such as policies and workload indicators have not been fully considered, however once the establishment is in place and the HRD database is completed and operational it will be possible to adopt a policy approach to future long term workforce planning. It is recommended that use of workload indicators of staffing need be employed. Within the constraints of the reduced numbers of the workforce the writer has commenced working with IHA and district health authorities on district level staffing as part of overall district health planning.

3.2.4.Human Resources Policy Development

The already mentioned constraints, which have affected overall health policy development, also affect development of human resources policies. Areas requiring policy decisions related to human resources have been introduced to members of the IHA HRD Task group.

3.2.5.Definition of Roles and Functions

With the greatly reduced workforce it is evident that the roles and functions of most health workers will change. Nurses and Midwives will have to take on a wider mid level practitioner role, the limited number of doctors will have to deal with serious cases and referrals. Health workers will have to change from a single skill role to multi skills. All categories of staff will have to assume supervisory and managerial roles. Whilst discussions have been held with IHA members, a huge amount of work will have to be undertaken in the next two months to develop national job descriptions prior to the civil service recruitment process. These job descriptions will also be used in conjunction with the HRD database to identify training requirements to prepare the newly appointed staff for their new roles and functions.

3.2.6.Continuing Education

A large number of NGO’s are conducting health worker training in an ad hoc fashion, some on-the –job to meet immediate needs. An analysis of training courses by NGO’s revealed that very few are being developed in a competency based format. Some technical training courses(e.g. Malaria) have been developed and trainers trained however there has been no supportive supervision provided to these trainers or follow up to assess level of training being conducted , and its impact. Details of staff training is not being provided to IHA centrally and therefore cannot be included in the HRD database. It has become evident that guidelines need to be drawn up related to development, implementation and evaluation of training. This work will commence shortly.

All training courses will have to be reviewed once the job descriptions are finalized and the standardized training packaged clearly delineated together with a reporting system on training courses and their results. In the interim NGO’s will continue on the job training.

There is a need for specialist medical training in many areas, however the lack of doctors is a major constraint and the highest immediate priority is for the East Timorese doctors to re-establish the health services. Short term specialist input can be provided by visiting specialist medical teams.

Future planning for specialist training for East Timorese doctors will be addressed within the long term workforce planning process.

3.2.7.Basic Training

The current situation of increasing the medical workforce is an urgent one. Efforts are being made to ensure that medical and specialist health workers who are undertaking basic training in Indonesia are supported to continue their studies. WHO is taking a lead in this area.

The establishment of a medical school is not an option in a country with a population of less that one million particularly when there is a severe lack of medical staff who could undertake teaching responsibilities, medical students have to continue to go overseas for training. Donor agencies are looking at sponsoring medical students to study in schools such as the Fiji Medical Shool where they can be trained for type of health system which is being redeveloped in East Timor. Although there are many offers to sponsor medical training, realistically there will be a limited number of school leavers in the population with the required educational qualifications for entry for medicine. Also future medical students will require training in the appropriate second language such as English or Portuguese before commencing studies abroad

As there is a current oversupply of nurses and midwives it is not recommended that basic training in these fields recommence in the near future. Future basic health worker training requirements will be identified as part of national health workforce planning, however the training content will have to change considerably to reflect the new roles and functions of nurses.

Training of other categories of workers such as radiographers, physiotherapists and other professions which are understaffed is being discussed and donor support will be sought for scholarships.

Nutritionists were trained locally in the past, however there are currently limited possibilities for employment within the health services. It is unlikely that this training will recommence in its previous form.

Basic Laboratory Technicians were also trained locally, as with the other professions the future training needs will be reviewed within the context of national long term workforce planning.

3.3.Support to MPH Research

HealthNet has, under this project, provided financial support to Dr Rui Maria Ararujo, who is currently undertaking studies for a Masters in Public Health at the University of Duneidin, New Zealand. Dr Ararujo is conducting his research into the policy and planning process for development of the health system in East Timor from the East Timorese perspective. He is currently conducting interviews of East Timorese political, church and community leaders about health planning issues. Funding is to support this field research which he will complete at the end of August 2000. It is expected that his research will make a valuable contribution to the health services development process. He will return to New Zealand in September and is scheduled to have completed his studies in November 2000 a which time he will return to East Timor.