103438 Increasing Functionality and Compliance to Policies at Rural Health Posts: A Way Forward to Achieving Universal Access to Essential Health Care in Timor-Leste June 2015 This briefing note presents the key findings and policy implications of the health facility survey implemented in 2014 in 69 sampled health facilities in Timor-Leste. The key findings are:  Hospitals are generally well equipped and Community Health Centres (CHC) were moderately equipped  General service provision was consistently low in rural Health Posts (HPs) and was yet to comply with the Basic Service Package  Drug supplies were inconsistent with the Essential Drug List The following recommendations are based on the evidence gathered through this survey:  Increase the functionality of rural health facilities in accordance with the Basic Service Package  Improve pharmaceutical procurement (demand driven) and distribution to ensure availability of medicines on the Essential Drug List Background were not functioning (Martins & Trevena, 2014). Timor-Leste had a seriously fragile health system when it became independent in 2002. Lack of access is also a problem. A recent During the war preceding independence study suggested that 25% of households more than 70% of health facilities were were more than two hours away from their destroyed or seriously damaged. While the usual health care provider and 12% of situation has gradually improved over the households in Timor-Leste did not seek years, there are still a lot of obstacles to health care when a household member was reaching international standards in Timor- ill (Deen et al., 2013). The poor functionality Leste’s health facilities. of health facilities could also be a reason for this lack of access to formal health care. Lack and quality of infrastructure and limited resources at health facilities are longstanding In 2014, a study was conducted in Timor- problems. According to a recent report there Leste to better understand facility was no Magnetic Resonance Imaging (MRI) functionality, labour market dynamics, the machine in Timor-Leste and only one quite preferences of health workers and the old Computed Tomography (CT) scan competence of doctors. machine (McCall, 2014). This briefing note presents the findings of the Facility functionality is the worst in rural health facility survey investigating the areas. A recent article reported that half of functionality of health facilities in Timor-Leste the Servisu Integrado du Saude Comunidade in 2014. Methods Service availability The sampling frame covered 277 health The percentage of service availability was facilities, including 6 hospitals (national and consistently low in HPs (which are usually referral), 66 community health centres located in rural areas) compared to CHCs (CHCs) and 205 HPs. Sixty-nine (25%) of the and hospitals. 277 health facilities were sampled. Three field teams collected the survey data during Table 1 presents the service availability of July and August 2014. some selected services, which are supposed to be available in all types of health facilities The survey respondents were the head of the according to the Basic Service Package sampled health facility, the person in-charge 2007, which was in place at the time of the of the facility, or the most senior health survey. worker responsible for client services present at the facility at the time of the survey. The results clearly show that HPs often lack even the basic services that they are supposed to have. Table 1: Service Availability, by Facility Type Hosp. CHC HP Family planning 100% 100% 88% Antenatal care 100% 100% 93% Malaria treatment 100% 100% 86% STI treatment 100% 93% 38% TB treatment 100% 100% 55% HIV testing 100% 91% 63% Minor surgery 100% 85% 65% Normal delivery 100% 100% 83% The team administered a structured questionnaire covering various dimensions of Infrastructure the health workers’ working environment, including inpatient service availability, Access to clean water remains a significant processing of medical equipment, supplies problem, particularly in rural areas. More than and storage of medicines, user fees and half of the CHCs and HPs did not have a sources of finance, sources of water and water source on their premises and had to power supply, staff management and external collect water from elsewhere. One-third of supervision, and disability and gender HPs are also not connected to the electricity perspectives. grid. Uninterrupted electricity was available in 72% of hospitals, 52% of CHCs and 34% of Key Findings HPs. Sample distribution All hospitals were equipped with functioning landlines, cellular coverage and computers, The team visited 69 health facilities in all 13 and 70% had an internet connection. districts of Timor-Leste including 6 hospitals, However, a considerable percentage of 33 CHCs and 30 HPs. Among all health CHCs and HPs did not have any functioning facilities 21 were urban and 48 were rural. means of communication. That said, cellular coverage was quite high: all of the hospitals, 57% of CHCs and 29% of HPs had coverage that allowed mobile phones to function. 2 The privacy of patients in client examination facilities, and in 41% of the facilities the store rooms meets standards in hospitals. In room was not well ventilated (Figure 2). contrast, 58% of HPs do not have any audio or visual privacy in the client examination Similarly, there were shortages of supply rooms (Figure 1). items in HPs. Less than 10% had nebulizer machines, peak-flow meters and pulse Figure 1: Privacy of Client Examinations oximeters. HP Figure 2: Storage Conditions for Drugs CHC 100% 80% Hospital 60% 40% 0% 20% 40% 60% 80% 100% 20% 0% Private Room Audio and Visual Privacy Medicines Sun light Evidence of Not well on floor may fall on rodents or ventilated Visual Privacy No Privacy medicine pets Hospital Community Health Centre Health Post Drugs and supplies The survey data showed that the availability of drugs was generally inconsistent across Equity the facility levels. The survey data indicate that most of the CHCs and HPs are not user-friendly for Table 2: Availability of Drugs people with a disability. The HPs should be equipped with guidelines and treatment for Hosp. CHC HP domestic violence (DV). Should be available at all levels Amoxicillin tab. 100% 72% 54% Table 3: Disability and Gender Readiness Ampicillin inj. 100% 78% 29% Hosp. CHC HP Ciprofloxacin tab. 100% 54% 46% Doxycycline cap. 100% 88% 50% Disability Metronidazole tab. 100% 94% 61% Ramps 100% 44% 3% Handrail 100% 15% 3% Should be available at Hospitals and CHCs Signs 39% 4% 3% Gentamycin inj. 80% 68% N/A Tetracycline cap. 12% 26% N/A Gender Guidelines for 100% 50% 27% Should be available at hospital only Domestic Ceftriaxone inj. 91% N/A N/A Violence(DV) Treatment for DV 100% 80% 46% The survey data was matched with the Maternity leave 100% 98% 98% Essential Drug List 2010, which should be followed for the disbursement of drugs. As shown in Table 2 above, none of the CHCs or Policy Implications HPs should have Ceftriaxone injections, yet 63% and 15% respectively had the drug in Increasing the functionality of rural health stock. facilities The storage conditions of the medicines were The survey highlights some of the challenges not ideal in the majority of facilities. Based on in terms of bringing rural health infrastructure visual observation by the survey teams, there up to standard. The availability of a fixed was evidence of rodents or pests in the water source and power supply is strongly medicine storage room in 50% of the health associated with the tier of health facility: availability is lowest for HPs, followed by 3 CHCs. Hospitals have the most stable water It is therefore important to ensure that health and power supplies. facilities receive drugs based on the existing policy and clear guidelines. These findings highlight the urgency of equipping HPs, in particular, to mandated Using mobile phone technology standards, which will not only improve patient care but also improve health staff retention Effective means of communication is a and performance. challenge in Timor-Leste’s health facilities. This ‘shortage’ in communication has made it Ensuring policy compliance on drugs difficult for staff to report urgent cases, shortages in medical supplies and Many health facilities had drugs they were pharmaceutical needs. However, a large not supposed to stock according to the number of health facilities were found to have Essential Drug List. Similarly, service functioning mobile phone coverage. availability often does not match the Basic Service Package. It is important to ensure Mobile phone technology should be more that policies are implemented consistently widely used for inventory monitoring and across the country. At the same time, issues other communications. relating to the practicability of policies need to be identified and resolved. References The team tried to understand the push–pull Deen, J. et al. (2013) Identifying national mechanism contributing to the inconsistent health research priorities in Timor-Leste distribution of drugs and established that, through a scoping review of existing health although health facilities should receive data. Health Research Policy and Systems , medicines and supplies based on the 11(8). requests they raise, this rarely happens in practice. Often, lower-level health facilities Martins, N. & Trevena, L. (2014) are simply supplied with the drugs that are Implementing what works: a case study of available and unused at the district level. integrated primary health care revitalisation in Timor-Leste. Asia Pacific Family Medicine, There are certain risks in having higher-level 13(5). medicines in lower-level facilities, especially in regard to antibiotics. This may result in McCall, C. (2014) East Timor striving for irrational use of drugs and subsequent universal access to health care. The Lancet, resistance to antibiotics. On the other hand, 384(9953), pp. 1491–1492. these drugs may also be left unused and ultimately destroyed when they expire. 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