103441 Understanding Bottlenecks and Future HRH Challenges: Will Health Workers Remain Motivated in Timor-Leste? June 2015 This briefing note presents the key findings and policy implications of the health worker survey implemented in all 13 districts of Timor-Leste in 2014. The survey was administered to 443 health workers. The key findings are:  Most of the health workers were intrinsically motivated  The majority of respondents would like to continue working in the government/public sector, however, most of them would eventually prefer to be posted in higher tier facilities  Wage differentials within each cadre were relatively small, and income did not vary much based on years of experience, particularly for doctors  Workload was not too high, especially in rural health facilities  In-service trainings were inadequate especially in rural health facilities  Supervision were frequent The following recommendations are based on the evidence gathered through this survey:  Develop a long term Human Resource for Health plan to manage the career development expectation of health workers, particularly for doctors  Ensure salary progression for doctors to provide an incentive to stay in public service as staff gain experience  Provide necessary training for health workers, especially in rural areas  Ensure more active and effective supervision of health workers Background competence of doctors. This briefing note presents the findings of the health worker At the time of independence in 2002, Timor- survey, which investigated health labour Leste had a seriously weak health system market dynamics. with only a handful of doctors in the country. At that time the governments of Timor-Leste Methods signed an agreement and the Cuban Medical Brigade started to train medical students and Doctors, midwives and nurses were sampled deploy them in the country, particularly in from all 13 districts of Timor-Leste. The rural areas. While the initial massive shortage sampling was conducted using systematic has been minimised, there are concerns over random sampling with probability proportional more complex issues including facility to size. The health worker survey functionality, rural retention and the questionnaire included modules on motivation, preferences and competence of demographic characteristics, job history, health workers. preferences, views on the profession, current job, training, supervision and absenteeism. The objectives of this study, conducted in Three field teams collected the survey data 2014, were to understand (1) facility during July and August 2014. The team also functionality; (2) health labour market reviewed the existing government policies dynamics among health workers, including and guidelines to understand the benchmarks the preferences, concerns and motivation of and compared the findings to them. Results health workers; and (3) the skills and were analysed using STATA, SPSS and SAS. Weights were used to correctly motivation might change if private represent the survey population. opportunities develop and increase in the future. Table 1: Long-term Preference of Sectors Doctors Nurses Mid-wives Public 99% 93% 96% Private 1% 6% 2% NGO 0% 0% 1% Others 0% 1% 0% In the long run, the majority of respondents would prefer to continue working in the government/public sector, including 99% of Key Findings the doctors. This is also the case for the majority of nurses and midwives, although Health worker characteristics 6% of nurses would prefer to move to the private sector. HPs were the least attractive The survey was administered to 443 health stations for medical staff, with only 6% of workers (175 doctors, 150 nurses and 118 doctors choosing HPs as their long-term midwives). Among the sampled health preferred facility type, although 32% were workers, the majority (56%) were women, content to work in community health centres including 58% of the doctors, 36% of the (CHCs). Only 22% see themselves working in nurses and all of the midwives. The rural sucos in the long term. The majority of distribution of the sample broadly coincides respondents (97%) were not looking for with the 2014 health worker census data another job in the short term. obtained by the World Bank from the Civil Service Commission, which indicates that Salary and financial benefits 53% of the health workers were female including 48% of the doctors, 37% of the The average monthly income of health nurses and 97% of the midwives. Since there workers was US$ 505. The average salary were only a few doctors in Timor-Leste at the was higher for rural health workers (US$ 514) time of independence, almost the entire than for urban health workers (US$ 500). The cohort of doctors was newly trained. Most of wage differentials within each cadre were the doctors (96%) interviewed in the survey relatively small, and income did not vary had less than five years of experience in the much by years of experience, particularly for sector. Data also showed that the doctors. On average, a doctor with more than experienced health workers were working in 10 years of experience earned only US$ 50 higher tier health facilities. more per month than a newly joined doctor. Motivation and preference More than half of the health staff interviewed believed their salary to be too low. However, The vast majority of staff selected medicine in they did not see other preferable labour order to help people and health workers market opportunities. All medical staff receive indicated high levels of satisfaction: only 4% their money through a direct deposit to their of respondents indicated they were bank account and only very few (2%) have “unsatisfied” or “very unsatisfied” with their experienced any delays in receiving their work. Intrinsic motivation is also shown by the money. fact that eight in ten medical staff say they would stay in the facility until the last patient Very few reported working in private practice is treated – even if they do not receive (but this may be under-reported). More non- 2 additional money. However, this level of financial benefits (such as housing and motorbikes) are reported by doctors and at respondents agreed that, “there is not lower-level facilities. However, only half of enough opportunity to learn.” respondents reported that they receive either sufficient fuel, or funds to buy fuel for the Although a large number of doctors are motorbike, and more than half of all posted in rural areas, only 19% underwent respondents mentioned that these benefits training on community health. Around 75% of are often delayed. doctors indicated that they require training on IMCI and 64% on EmONC. The doctors Workload located in urban areas were found to benefit more: roughly half (51%) of them attended Although most respondents work five days a three or more training sessions in the year week in HPs, CHCs and district/regional preceding the study, as opposed to 26% in hospitals (63%, 66% and 54%, respectively), rural areas. 22% to 36% work six and sometimes seven days a week. The number of patients seen by Older doctors or highly satisfied doctors tend the sampled doctors who participated in the to be less interested in any kind of training, direct clinical observation was counted; the while females are keener than males to opt mean number of patients per day was 10.2 for visits from specialists. Workers in HPs with the standard deviation (SD) being 7.5. In and CHCs are more interested in urban facilities the mean (SD) patient load specialisation. was 11.5 (6.9) compared to 9.6 (7.8) in rural facilities. Highly satisfied doctors have a lower level of interest in all kinds of training. Older nurses The number of patients also varied by level of and midwives, as well as those with more facility, with higher-tier facilities having more medical experience, tend to be more patients. Despite of relatively low patient interested in any kind of training. Rural facility load, nearly half of the respondents agreed health workers are significantly more willing with the statement that they have “too much to finish their bachelor’s degrees. work to do.” Supervision Table 2: Patient Load per Doctor per Day, by Type of Health Facility Eighty-five percent of respondents indicated that they have a supervisor who is Mean SD Min Max responsible for providing feedback on their Hospital 13.2 9.2 4 26 performance. CHC 10.9 7.2 2 37 The majority of staff has supervisory HP 8.5 7.4 1 28 meetings at least every three months, with urban-based staff having more meetings. Training Supervisors’ activities are heavily biased toward activities that support technical staff Almost all respondents believe that their development and quality control: supervisors training well prepared them to diagnose and observe consultations, provide health treat clinical cases in Timor-Leste. Roughly instructions and ask knowledge assessment half of the nurses and midwives reported attending three or more short-term trainings questions. of less than thirty days duration and one- quarter did not attend any such training in the The administrative task of checking records is timeframe. at the top of the list. Seventy-five percent of all respondents mentioned that they felt the At the same time, roughly one-third (35%) of need to discuss difficulties with their doctors attended three or more training supervisor within the last year. There are no sessions and around the same percentage important differences between rural and (37%) attended none. Despite all the training urban facilities. opportunities, roughly half (52%) of 3 Challenges their work and high intrinsic motivation, the positive intention to stay in the public sector Challenges facing health workers include: low and the relatively frequent and satisfactory salaries (63% agreed or strongly agreed), supervisions that are reported. However, inadequate opportunities to learn (52%), lack some areas require more investigation and of transport to see patients (50%), investment, including: inadequate housing (48%), too much work  Planning for future HRH needs so as to (47%), security problems (39%), lack of ensure continuity of service. It is supervision (30%), lack of feedback on important since most of the health performance (23%), and lack of motivation workers (especially doctors) wish to move (20%). to higher tier facilities. In addition, this Absenteeism large cohort of doctors, who were deployed in a short span of time, will Due to the scope of the study unannounced leave a vacuum when they retire. health facility visits to collect robust data on absenteeism were not conducted, rather the  Ensuring a salary progression for doctors team collected self-reported absenteeism that provides an incentive to stay data, which should be interpreted with motivated and perform. Otherwise caution. The data indicates that 8% of experienced health workers will be respondents reported being absent from work demotivated, may leave the public sector due to sickness in the 30 days prior to the or engage in dual practice. interview. Five percent were absent for  Arranging more frequent in-service personal reasons in the same timeframe. In trainings and visits from specialists for the event of an absence, roughly 13% of doctors who are working in rural health respondents stated that their facility head had facilities. called them. In 2% of cases money was deducted from their salary due to their  Improving the supervision of health absence. workers to be more active and effective. To this end, government needs to have Policy Implications clear guidance and training on the purpose, procedure and reporting of The study highlights some encouraging findings, including the gender balance of supervision. The supervisory visits should health staff (overall, if not within specific focus more on improving performance cadres), the concentration of doctors in rural through clear feedback and motivation. areas, the high level of staff satisfaction with This project was carried out by World Bank and Oxford Policy Management (OPM) with funding from the Australian Department and European Commission. The Ministry of Health of the Government of Timor-Leste provided support at every stage of this project. Dili Institute of Technology (DIT) was the local partner. Detailed results and interpretations are available in the full report, which can be accessed at www.worldbank.org/en/country/timor-leste. If you have any queries please contact Xiaohui Hou, Senior Economist, World Bank (email: xhou@worldbank.org) or Rashid Zaman, Consultant, Health Portfolio, Oxford Policy Management (email: rashid.zaman@opml.co.uk). © World Bank and Oxford Policy Management 4