Content uploaded by Paulo Ferrinho
Author content
All content in this area was uploaded by Paulo Ferrinho on Oct 17, 2017
Content may be subject to copyright.
Scaling-up the medical workforce in Timor-Leste: Challenges of a great
leap forward
Jorge Cabral
a
,
b
,
*
,
1
, Gilles Dussault
a
,
b
, James Buchan
a
,
b
,
c
, Paulo Ferrinho
a
,
b
a
International Public Health and Biostatistics Unit, Institute of Hygiene and Tropical Medicine, Rua da Junqueira 100, 1349-008 Lisbon, Portugal
b
World Health Organization Collaborating Centre on Health Workforce Policy and Planning, Portugal
c
School of Health Science, Queen Margaret University, Edinburgh EH21 6UU, UK
article info
Article history:
Available online xxx
Keywords:
Scaling-up
Health workforce
East Timor
Cuban international health program
Health systems
Low-income countries
abstract
The health services system of Timor-Leste (T-L) will, by 2015, add 800 physicians, most of them trained in
Cuba, to the 233 employed by the national health system in 2010e2011. The need for more physicians is
not in discussion: poor health indicators, low coverage and utilization of services, and poor quality of
services are well documented in T-L. However, the choice of this scaling-up, with a relatively narrow
focus on the medical workforce, needs to be assessed for its relevance to the health profile of the country,
for its comprehensiveness in terms of other complementary measures needed to make it effective. This
article discusses the potential effects of the rapid scaling-up of the medical workforce, and the organi-
zational capacity needed to monitor the process and eventually mitigate any deleterious consequences.
The analysis is based on a review of documentation collected on site (T-L) and on interviews with key-
informants conducted in 2011. We stress that any workforce scaling-up is not simply a matter of
increasing numbers of professionals, but should combine improved training, distribution, working
conditions, management and motivation, as a means towards better performing health services’systems.
This is a major challenge in a context of limited organizational and managerial capacity, underdeveloped
information systems, limited training and research capacity, and dependency on foreign aid and tech-
nical assistance. Potential risks are associated with funding the additional costs of recruiting more
personnel, associated expenditures on infrastructure, equipment and consumables, the impact on cur-
rent staff mix, and the expected increased demand for services. We conclude that failing to manage
effectively the forthcoming “great leap forward”will have long term effects: formal policies and plans for
the balanced development of the health workforce, as well as strengthened institutions are urgently
needed.
Ó2013 Elsevier Ltd. All rights reserved.
Introduction
This paper addresses the rapid deployment (“scaling-up”)ofa
large number of Cuban trained physicians in Timor-Leste (T-L)
which began in 2010 and is planned to be concluded by 2015.
T-L is a small and fragile country which has embarked on a rapid
process of developing its medical workforce in order to rebuild a
health service weakened by a devastating war. From a base of 233
physicians in 2010 (including 169 expatriates) (MoH T-L, 2010) for a
population of 1.07 million (2010 Census), it is envisaged to have 790
newly graduated physicians available for recruitment over a period
of five years, with support from the Government of Cuba: 600
Timorese students trained in Cuba, and 190 trained by a “Cuban
medical brigade”(CMB) at the Universidade Nacional de Timor-
Leste (UNTL). The aim is to deploy these physicians mainly in rural
areas (Supplementary data).
This fast-track program, in addition to rapidly increasing the
number of physicians, will change significantly the skill-mix of the
health workforce. It will have a major impact on health care ser-
vices: on training and employment costs, as well as on the overall
size, composition and distribution of the health workforce, and
consequently on access to services.
Health care systems with limited resources, such as T-L’s, are
particularly sensitive to the systemic effects of interventions in any
of their “building blocks”(De Savigny-WHO, 2009; GHWA, 2008;
WHO, 2007). As regards the scaling-up of numbers of physicians, if
the new personnel are concentrated in hospitals, or if retention
*Corresponding author. Instituto de Higiene e Medicina Tropical, Rua da Jun-
queira 100, 1349-008 Lisbon, Portugal.
E-mail addresses: jcabral@ihmt.unl.pt,ajcabral2001@yahoo.com (J. Cabral).
1
Working temporarily as a Technical Assistant to the Faculty of Medicine and
Health Sciences of the National University of Timor-Leste, from August, 2012eJuly,
2013. Under contract with the Calouste Gulbenkian Foundation (Lisbon).
Contents lists available at ScienceDirect
Social Science & Medicine
journal homepage: www.elsevier.com/locate/socscimed
0277-9536/$ esee front matter Ó2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.socscimed.2013.07.008
Social Science & Medicine xxx (2013) 1e5
Please cite this article in press as: Cabral, J., et al., Scaling-up the medical workforce in Timor-Leste: Challenges of a great leap forward, Social
Science & Medicine (2013), http://dx.doi.org/10.1016/j.socscimed.2013.07.008
policies are ineffective and physicians migrate, equity of access will
not improve as expected. Increases in staffing payroll costs and in
the utilization of services may strain the financial sustainability of
the system (Van Olmen, 2010).
In addition to increasing the number of workers available in the
health labor market, “scaling-up”of the workforce can be achieved
through a mix of other strategies (Dussault et al., 2009, 48 pp.;
GHWA, 2008) which will be considered in the paper.
Assessment strategy
We organize our paper around three research questions. First,
we discuss the relevance of this policy choice to “train a large
number of physicians”: was it adapted to the health problems and
corresponding human resources for health (HRH) needs in T-L, and
to the capacity of absorption of the health system?
The second question concerns the comprehensiveness and insti-
tutional capacity needed to make the policy effective, in particular
the incentives systems and management mechanisms which will
keep the new physicians motivated and retain them in the public
system and in the country. The discussion of this second question is
time-bound to May, 2011, when the data were collected and the
first large batches of physicians were about to arrive from Cuba.
A third set of questions deals with the possible effects of the scaling-
up strategy on equity of access, efficiency and quality of services, and
eventually on health needs. These questions address four of the
building blocks of health systems as defined by WHO (2000):human
resources (HR), governance, financing and service provision.
The main focus of this paper is the first research question, for
which a more reliable set of evidence was available. The responses
to the other two research questions are inevitably more speculative
at this stage, as additional time for implementation will provide the
evidence for testing of assumptions and assessment of impact.
The focus of this paper is on scale-up the production of physi-
cians and its consequences, rather than the details of their training
(while recognizing that this is also important, particularly due to
the “community medicine”orientation of the Cuban-based training
curriculum).
Data sources
The assessment is based on secondary data, supplemented by
information from primary research. Secondary data on population,
health status, determinants of health, resources and outputs of the
public health services system, health spending, and on health
policies come from national and international publically available
sources.
Data to respond to the second and third research questions
consist in the views and information about institutional capacity
obtained from key informants in Timor-Leste, in May, 2011, during
an Aid inter-agency mission econducted primarily for operational,
not for research, purposes. A policy impact analysis approach
(ECHP, 1999) was used for that purpose.
Data collection from three groups of front-line managers and
mid-level professional staff, and one group of eight young physi-
cians recently returned from Cuba, was through focus groups on the
following topics: i) district team composition, working conditions,
management capacity and information systems; ii) experience with
settling-in preparations for returning physicians and working
conditions in peripheral facilities.
Additionally, individual interviews, and one group interview,
were held with:
Key informants in various National Directorates of the Ministry
of Health (MoH) (Human Resources, Planning and Finances,
Administration): planning and management capacity, de-
pendency on foreign technical expertise, plans for the inte-
gration of the new physicians trained in Cuba and budgetary
consequences;
Boards of training institutions (Faculty of Medicine and Health
Sciences eFMHS, National Institute of Health eNIH): teaching
and infrastructure capacity, role of the CMB, enrolled and
graduate numbers, dependency on foreign technical expertise;
Representatives of the CMB, and Timorese coordinators of the
Cuba-based training program: numbers and roles of Cuban
experts; numbers of students enrolled in Cuba and at UNTL;
origins and logistics of the program;
The selection of informants was based on their involvement
with the planning, production and management of HRH, or by self-
selection of the district managers and mid-level professionals
(MLP) attending the discussion on health workforce issues at the
three workshops.
Results
The policy context: poverty, post-conflict and scarcity
Approximately 40% of the population lives below the poverty
line (World Bank, 2010). As a post-conflict country which became
fully independent in 2002, T-L found itself with weak technical and
managerial capacity in most sectors, including health (Dewdney,
Martins, Asante, & Zwi, 2009;World Bank, 2010). More than 70%
of T-L’s health facilities were destroyed or badly damaged and
around 80% of the country’s health managers left the country, as did
all but approximately 20 doctors (RDT-L, 2002; World Bank, 2005).
The first formal and stable training institutions, the NIH and the
FMHS with its Medical, Nursing and Midwifery Schools at the UNTL
started functioning in 2005e2006. The provision of medical ser-
vices, including at the Central Hospital in Dili, was maintained by a
mix of physicians from emergency relief and international organi-
zations until the arrival of the first CMB in 2004 (Asante et al.,
2012). Similarly, various MoH’s functions were dependent on
foreign technical advisors (Rosi, 2010).
Health transition
The health profile of the Timorese population reflects the initial
phase of the health transition: communicable diseases and prob-
lems linked to reproductive health still account for 70% of the
burden of disease; maternal mortality rate is within the 560e660/
100.000 range (WHO, 2010a). Life expectancy at birth, in 2010, was
estimated at 62 years (up from 54, in 2000) and infant mortality
rate at approximately 45/1000 (down from 85, in 2000) (WHO,
2010a). Despite the declining fertility rate (TFR has declined from
7.8 in 2003, to 5.7 in 2010, according to T-L DHS, 2010), the popu-
lation will increase by approximately 80% by 2025 (Bulatao, 2008).
The national health services system (NHS) and the current mix of
health professionals
The Timorese NHS is dominated by the public sector, with 5
hospitals, 65 community health centers (CHC) and 211 health posts
(HP) (MoH T-L, 2010). The primary level delivers approximately 90%
of the outpatient visits, employs 45% of doctors and 52% of other
technical personnel (MoH T-L, 2011)(Supplementary data).
This network suffers from various constraints, from the lack of
laboratory technology in most CHC’s, to very limited imaging and
oncology equipment in the central hospital in Dili (MoH, 2007b);
J. Cabral et al. / Social Science & Medicine xxx (2013) 1e52
Please cite this article in press as: Cabral, J., et al., Scaling-up the medical workforce in Timor-Leste: Challenges of a great leap forward, Social
Science & Medicine (2013), http://dx.doi.org/10.1016/j.socscimed.2013.07.008
64% of hospital admissions do not have a diagnosis on discharge
(MoH T-L, 2010).
The overall utilization of curative services has been growing but
obstacles remain in rural areas, because of the mountainous
topography and poor roads; other obstacles are the unavailability of
drugs and communication between users and health professionals
(Zwi et al., 2009).
In nominal terms, the budget of the MoH has doubled between
2005e2006 and 2009e2010 (MoFin T-L, 2010). In real terms the per
capita spending on health has decreased since 2007, and the
reduction of external aid to the sector is a cause forconcern (Asante
et al., 2012;MoFin T-L, 2010)(Table 1).
Salaries represent a growing percentage of the recurrent budget
(MoFin T-L, 2010). Clinical consumables are mostly financed by a
multi-donor trust fund (Table 2).
In 2010, the NHS staff establishment included 64 Timorese
physicians (out of a total of 233) and 1300 nurses and midwives
(MoH T-L, 2010; and Staff Count MoH T-L/HR Dept., April, 2011), of
which 80%e85% had been trained at the Indonesian Diploma I level,
e.g.3 years of training, for candidates coming out of junior high
school. After 2007, new nursing and midwifery diploma courses for
candidates from senior high school replaced previous programs
assessed as producing poorly skilled staff (MoH, 2007a).
The 2nd National Health Sector Strategic Plan (NHSSP-II) (MoH,
2011a) aims to bring the health workforce closer to South-East
Asia’s regional averages. The Plan also intends to deploy 24%
(200) of the new physicians at HP level (Table 3).
There are two phases to the Cuban supported strengthening of
the medical capacity of the NHS: i) from 2004 until 2011, the CBM
provided services at all levels of the NHS and trained medical
students; ii) from 2011 onwards the growing contingent of Tim-
orese physicians will provide the candidates for medical speciali-
zation and enable the phasing-out of the CBM (Supplementary
data).
The scaling-up strategy
The focus of scaling-up is the approximately 800 Timorese
students being trained by the Cuban health project, in Cuba and T-L,
which will become available to the NHS up to 2015. The first group
of 8 medical graduates returned from Cuba in 2010.
The decision to train large numbers of doctors exploited a
window of opportunity for a “fast-track”program of substituting
the expatriate medical workforce in the country (Dewdney et al.,
2009; MoH T-L, 2010). The decision and subsequent accord be-
tween the governments of T-L and Cuba were made at a time when
HRH concerns were many, varied and not systematically assessed,
but included: skills level, productivity, training capacity,
geographical distribution, poor management, and financial capac-
ity (Health Policy Framework Paper 2002, in MoH, 2007a,2010).
In support of the scale-up, a Timorese diplomatic representation
was established in Cuba in 2004, including a senior medical officer.
In T-L, efforts were made to recruit candidates from remote
locations.
The graduates from this program (both the initial group which
underwent the full training in Cuba, the group with training
divided between Cuba and T-L, and those trained entirely in T-L)
receive, on completion of their studies and evaluations: i) a diploma
from the UNT-L; ii) a certificate of studies (full description of syllabi
and marks) from the Latin American School for Medical Sciences
(ELAM), in Havana (personal communication CMB).
Managing the scaling-up strategy: limitations and constraints
Though a comprehensive HRH development plan was not
available in 2011, the draft of the NHSSP-II included figures on the
distribution of the various categories of professionals (including the
new Timorese physicians) across the levels of the public health
system (MoH, 2010). Interviews in 2011 could not obtain forecasts
of personnel expenditure to accommodate the increased numbers
of physicians, though MoH officials stated its inclusion in the pro-
posed budget for 2012; no installation subsidies were foreseen for
the new physicians, and no plans reported on the creation of
minimum working and living conditions for remote assignments.
Planning the distribution of staff was impaired by conflicting data
and weak analytical capacity.
Graduate training for health professionals has been legally
restricted to the UNTL. Teaching tools are scarce and basic medical
equipment insufficient for practical facility-based training. Returning
graduates from Cuba have been briefed upon arrival on locally
prevalent diseases and treatment protocols, though the quality of
such briefing was questioned, in May 2011, during a focus group with
early arrivals, who confirmed the absence of tutoring visits, and the
scarcity of technological diagnostic support outside hospitals.
The medical training is potentially adequate to the service needs
in T-L: students who returned from Cuba at the end of the
4th academic year spend their last years of training in health fa-
cilities in the 13 Districts of T-L, under supervision from Cuban
tutors, and are expected to respond to local health needs (curricular
plan, courtesy of the CBM).
The new graduates sign a contract on receiving their diploma
and certificate: in accordance with a Government Decree (Decree
N.
38/2012) approved in July, 2012, they must serve in the public
health system for a minimum of six years, and may be prosecuted
(and forced to reimburse the State for the cost of their training) if
fail to do so (personal communication Directorship of the FMHS
and the HR Directorate of the MoH).
The risk of emigration to neighboring countries is unknown:
this depends basically on the recognition of their (dual) graduation
certificates. The first test may occur when the first professionals on
post-graduate training start traveling abroad for specialized rota-
tions (a local program for this purpose has already started, with
Table 1
Financing indicators, Health Sector, Timor-Leste.
2007 2008 2010
Health Expenditure
(total)/Capita (US$)
58 51.21 52.16
IDEM, without Foreign Aid -NA- 25.54 31.06
Health Expenditure (total),
as % of GDP
13.60% 10.50% 9%
IDEM, without Foreign Aid 5.04% 5.53% 4.98%
Health Spending (public),
as % of Government Expenditure
15% -NA- 6%
IDEM, without Foreign Aid 5e6% 5e6% -NA-
Financial Support from Foreign
Aid, as % of Health Expenditure
-NA- 28% -NA-
Note: a) Aid support to the Health Sector, in Timor-Leste represented 52% of the
health budget in 2005.
Sources: T-L, Ministry of Finance, Health Sector Expenditure Review, 2010; WHO
Country Data, Timor-Leste (Figures for Financial Support from Foreign Aid, 2005,
2008)
Table 2
Components of the health sector’s recurrent budget, 2008.2010, Timor-Leste.
2008 2009 2010
Capital development 9% 22% 30%
Salaries and wages 20% 25% 29%
Goods and services 57% 49% 36%
Note: The percent distribution is similar in both Central and District Budgets.
Source: T-L, Ministry of Finance, Health Sector Expenditure Review, 2010;
J. Cabral et al. / Social Science & Medicine xxx (2013) 1e53
Please cite this article in press as: Cabral, J., et al., Scaling-up the medical workforce in Timor-Leste: Challenges of a great leap forward, Social
Science & Medicine (2013), http://dx.doi.org/10.1016/j.socscimed.2013.07.008
support from Australian Aid and the Royal Australasian College of
Surgeons eR.A.C.S.).
At the focus groups workshops, MLP’s reported that they
resented the absence of career paths and the possibility that phy-
sicians might benefit from rural installation subsidies that the other
professionals have long been waiting for.
Discussion
The decision to invest significantly in the training of physicians
has been justified by the T-L authorities as needed to reduce de-
pendency on foreign expertise and to approach T-L to the regional
average physician: population ratios. The development of a “com-
munity-oriented”medical workforce, with periods of training at
primary care level in rural areas is consistent with identified needs
and draws on past experiences in countries as diverse as Cuba, Israel,
Australia, Ethiopia and South Africa (Habbick, 1996; Mullan, 2002).
This relatively narrow scaling-up focus on physicians can be
contrasted with recent scaling-up programs in other low-income
countries with critical HRH shortages such as Ethiopia and
Tanzania, where the scale-up strategies have focused on a broader
and combined expansion of physicians, MLP’s and community
health workers (Balabanova, 2011; GWHA, 2008; Kinfu, 2009).
In the case of T-L, the literature provides some arguments in
favor of expanding the number of physicians, such as a more cost-
effective introduction of clinical protocols for non-communicable
diseases (DCPP, 2006, pp. 35-86), and capacity to attend to the
expected increasing demand for hospital-based referral services, as
the utilization of PHC grows (GWHA, 2008). However it could be
counter-argued that the present health profile of the Timorese
population would benefit more from a combination of accessible,
technologically simple health interventions, manageable by MLP’s,
together with improved living conditions for the population
(Bulatao, 2008).
MLPs work in a range of different semi-autonomous roles
within different country health systems. A recent review (WHO,
2010b) concluded that “.longstanding and mostly positive ex-
periences with MLPs, particularly in Africa, and more recently
some rigorous studies of their performance, have led to a recog-
nition that MLPs can indeed play a crucial role within health
teams”(p9).
In examining options on scaling-up the health workforce, policy
makers need to weigh up a range of policy considerations related to
the cost, service/quality improvement and timeline for the policy to
have impact.
The shortfalls identified in the capacity of the HR Department of
the MoH (Dewdney et al., 2009) and in the management capacity
and logistics at District and hospital level (Asante et al., 2012) raise
questions about the ability to achieve the objectives of absorbing
effectively the significant additional numbers of physicians, and
deploying and retaining them in peripheral regions.
There are significant cost implications of the scaling-up program,
which must be factored into any assessment of options. At present
the (starting) salary for a physician is approximately 2.25 times the
average salary for other health professionals (Dewdney et al., 2009);
physicians formed 15% of the professional workforce in 2011, but
will become 38% by 2018 (NHSSP-II). In 2010, physicians were paid
the equivalent of 300 USD on average and it is unlikely that they will
remain satisfied with this level of income. There are issues of in-
ternal pay relativities as well: if the physicians receive pay increases
or rural retention subsidies, other health workers will also expect
the same benefits (Focus groups May, 2011).
Additional costs may also result from greater utilization of ser-
vices and more intensive use of medical technologies (Asante,
Negin, Hall, Dewdney, & Zwi, 2012). Data from various sources
shows a time-trend of increasing utilization of PHC (MoH Annual
Reports 2006, 2010;Povey & Mercer, 2002), which might place
additional demands on other health goods and hospital resources
(Funk, 2010). Another unintended consequence of the program
may be a “reverse”task-shifting (or “task aquisition”) with hyper-
medicalization of health care, lesser emphasis on prevention and
promotion (WHOePEPFAReUNAIDS, 2008).
A sustainable financial framework (with potential for donor
participation) is needed to ensure the performance (or even pres-
ence) of the new graduates as they are posted in rural areas. This
has been done in other countries, such as Mozambique and Guiné-
Bissau (Tyrell, Russo, Dussault, & Ferrinho, 2010).
The evaluation of the relevance and adequacy of the Cuban
“community medicine”approach to T-L will benefit from
comparing its application in contexts with different levels of
resource availability, system structuring, and levels of inequality of
access (De Vos, De Ceukelaire, Bonet, & Van der Stuyft, 2007; PAHO,
2006; Zwi et al., 2007).
Conclusion
In the absence of a HR strategy T-L is following a bold approach
focused on a relatively narrow “scale up”of physicians, in contrast
to other countries which have more broadly focused on MLP and
other cadres. Like other issues of allocative efficiency, the relevance
of this decision is more easily discussed in the abstract than in real
conditions of policy-making, in which other factors inform and
influence choices.
The gaps in information for planning (e.g. productivity, incentive
needs for rural retention), management and monitoring capacity
(e.g. poorly integrated information systems, weak district manage-
ment teams) identified above highlight the need to build national
capacity to plan, manage, monitor and develop the health workforce,
supported by reliable information systems. Scaling-up of physicians
or any other part of the workforce should be assessed and planned as
part of an overall costed workforce strategy and plan.
This in turn requires research-driven institutions with the
knowledge, memory, and analytical capacity to transform data into
information and monitor the evolution of local scenarios. What is
now required is sufficient technically qualified staff to provide this
capacity at the level of the MoH.
Table 3
Projected Human Resources for Health, Timor-Leste, 2010e2018.
Timor-Leste Regional average Southeast Asia Regional average Western Pacific
2010 2015 2018
Ratio “Nurses þMidwifes”/Physician 5.52 2.47 2.63 2.5 1.4
Physician/1.000 Inhabitants 0.20 0.68 0.68 0.5 -NA-
“Nurses þMidwifes”/1.000 Inhabitants 1.08 1.67 1.79 1.2 -NA-
Total “Nurses þMidwifes þPhysicians”/1.000 Inhabitants 1.28 2.35 2.47 2.3 8.5
Sources: T-L, Ministry of Health. 2nd National Health Strategic Plan, 2011e2030; Vujicic, M. 2005 (Regional Average figures for “HRH/Inhabitants”); Global Health Observatory
Data Repository (Regional Average figures for Ratio “Nurses þMidwifes”Physician).
J. Cabral et al. / Social Science & Medicine xxx (2013) 1e54
Please cite this article in press as: Cabral, J., et al., Scaling-up the medical workforce in Timor-Leste: Challenges of a great leap forward, Social
Science & Medicine (2013), http://dx.doi.org/10.1016/j.socscimed.2013.07.008
Acknowledgment
Primary data has been collected during an AID-coordination
(World Bank, European Commission, Australian Aid) mission to T-
L (May, 2011). The collaboration of officers from the Dili offices of
these three agencies is acknowledged, as well as the frankness in
the views expressed by officers and staff in the Ministry of Health
and the National Health System.
The views expressed in this text are the full responsibility of the
authors, and do not intend in any way to represent the views of the
Aid agencies involved in the mission to Timor-Leste, in May 2011,
nor the views of the Calouste Gulbenkian Foundation.
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2013.07.008.
References
Asante, A. D., Negin, J., Hall, J., Dewdney, J., & Zwi, A. B. (6 May 2012). Analysis of
policy implications and challenges of the Cuban health assistance program
related to human resources for health in the Pacific. Human Resources for Health,
10,10.http://dx.doi.org/10.1186/1478-4491-10-10.
Balabanova, D., McKee, M., & Mills, A. (Eds.). (2011). Good Health at Low Cost 25 years
on what makes a successful health system. London: London School of Hygiene &
Tropical Medicine.
Bulatao, R. A. (Lead author). (2008). Population growth and its implications in Timor-
Leste. Policy Note. October 9. Washington, D.C.: The World Bank.
De Savigny, D., & Adam, T. (Eds.). (2009). Systems thinking for health systems
strengthening. Alliance for Health Policy and Systems Research.WHO.
De Vos, P., De Ceukelaire, W., Bonet, M., & Van der Stuyft, P. (2007). Cuba’s inter-
national cooperation in health: an overview. International Journal of Health
Services, 37(4), 761e776.
Dewdney, J., Martins, J., Asante, A., & Zwi, A. (2009). Strengthening human resources
for health in Timor-Leste: Progress, challenges and ways forward. Mission Report,
draft, July. University of New South Wales.
Disease Control PrioritiesProject. (2006). Disease control customized book.InChapter 2
eIntervention cost-effectiveness: Overview of main messages. The World Bank.
Dussault, G., et al. (2009). Scaling up the stock of health workers: A review. Geneva:
International Council of Nurses, ISBN 978-92-95065-64-2. http://www.ichrn.
com/publications/policyresearch/Scaling_up-EN.pdf.
European Centre for Health Policy. (December 1999). Health impact assessment:
Main concepts and suggested approach. Gothenburg consensus paper. WHO
Regional Office for Europe.
Funk, L. M., et al. (2010). Global operating theatre distribution and pulse oximetry
supply: an estimation from reported data. Lancet, 376, 1055e1061.
Global Health Workforce Alliance. (2008). Scaling up, saving lives. Task force for
scaling up. Geneva: GHWA.
Habbick, B. F., & Leeder, S. R. (1996). Orienting medical education to community
need: a review. Medical Education, 30(3), 163e171.
Kinfu, Y., Dal Poz, M. R., Mercer, H., & Evans, D. B. (2009). The health worker
shortage in Africa: are enough physicians and nurses being trained? Bulletin of
the World Health Organization, 87, 225e230.
Ministry of Finance, Timor-Leste. (2010). Health sector expenditure review. Dili.
Ministry of Health, Timor-Leste. (2006). Relatóriu Estatístika Saúde, 2007. Tinan.
Ministry of Health, Timor-Leste. (2007a). Revised health workforce plan 2007e2015.
Draft. Dili.
Ministry of Health, Timor-Leste. (2007b). Basic services package for primary health
care and hospitals.May.
Ministry of Health, Timor-Leste. (2010). Relatóriu Estatístika Saúde, 2011. Tinan.
Ministry of Health, Timor-Leste. (2011a). 2nd National health sector strategic plan,
2011a, Draft, April.
Mullan, F., & Epstein, L. (November 2002). Community-oriented primary care: new
relevance in a changing World. American Journal of Public Health, 92(11), 1748e
1755. http://dx.doi.org/10.2105/AJPH.92.11.1748.
Pan American Health Organization. (2006). Mission Barrio Adentro: The right to
health and social inclusion in Venezuela. Caracas/Venezuela: PAHO.
Povey, G., & Mercer, M. A. (2002). East Timor in transition: health and health care.
International Journal of Health Services, 32(3), 607e623.
República Democrática de Timor-Leste, Gabinete do Ministro da Saúde. (2002).
Health profile. Dili.
Rosi, L. (June, 2010). Timor-Leste health sector: Human resources and broader insti-
tutional capacity building assessment mission report. Dili: World Bank/Ausaid/EC
HSSPSP.
Tyrell, A., Russo, G., Dussault, G., & Ferrinho, P. (25 June 2010). Costing the scaling-
up of human resources for health: lessons from Guinea Bissau and
Mozambique. Human Resources for Health, 8,14.http://www.human-resources-
health.com/content/8/1/14.
Van Olmen, J., et al. (2010). Analysing health systems to make them stronger.InStudies
in Health Services Organisation & Policy (Vol. 27). Antwerp: ITG Press.
Vujicic, M. (2005). Macroeconomic and fiscal issues in scaling up human resources for
health in low-income countries. Background Paper Prepared for the World
Health Report 2006. October. Washington DC: Human Development Network.
The World Bank.
World Bank. (2005). Implementation completion report on a grant from the trust fund
for Timor-Leste, for a health sector rehabilitation and development project (Tf-
23768). Report No: 32519-TP.
World Bank, Timor-Leste. Country Brief. (2010). http://go.worldbank.org/
C85WTQRE40, Assessed May, 2011.
World Health Organization. (2000). World health report 2000: Health systems:
Improving performance. Geneva: WHO.
World Health Organization. (2007). Everybody business: Strengthening health sys-
tems to improve health outcomes: WHO’s framework for action. Geneva: WHO.
World Health Organization. (2010a). Country profile, Timor-Leste. Updated, March.
World Health Organisation. (2010b). Mid-level health providers: A promising resource
to achieve the health millennium development goals. Geneva: WHO. http://www.
who.int/workforcealliance/knowledge/resources/Final_MLP_web_2.pdf.
World Health Organization, PEPFAR and UNAIDS. (2008). Task shifting: Rational
redistribution of tasks among health workforce teams. Global recommendations
and guidelines. Geneva http://data.unaids.org/pub/Manual/2007/ttr_taskshi
fting_en.pdf. Assessed 15.01.13.
Zwi, A. B., et al. (2009). Timor-Leste health care seeking behaviour study. Sydney: The
University of New South Wales.
Zwi, A. B., Martins, J., Grove, N. J., Wayte, K., Martins, N., Kelly, P., et al. (2007). Timor-
Leste health sector resilience and performance in a time of instability. Sydney: The
University of New South Wales. www.sphcm.med.unsw.edu.au/SPHCMWeb.
nsf/page/Timor-Leste.
J. Cabral et al. / Social Science & Medicine xxx (2013) 1e55
Please cite this article in press as: Cabral, J., et al., Scaling-up the medical workforce in Timor-Leste: Challenges of a great leap forward, Social
Science & Medicine (2013), http://dx.doi.org/10.1016/j.socscimed.2013.07.008
