2016年-世界发展银行全球_Turning_Challenges_into_Opportunities___The_Medium_Term_Health_Expenditure_Pressure_Study_in_Timor-Leste_75页_1mb

Summary of "Turning Challenges into Opportunities: the Medium Term Health Expenditure Pressure Study in Timor-Leste"

Core Content

This report provides an in-depth analysis of the medium-term health expenditure pressures in Timor-Leste, focusing on the fiscal implications of staffing, pharmaceutical spending, and donor funding. It aims to support strategic planning and budgeting for the Ministry of Health (MOH) by identifying key challenges and opportunities for improving health resource distribution and service delivery efficiency.

Main Objectives

• To understand the critical strategic issues requiring fiscal space in the health sector.
• To analyze trends in health sector public expenditures (budgets and realized expenditures).
• To document trends in staffing and training, including their costs.
• To forecast the likely resource envelope available to the health sector over the next five years.
• To provide options for adjusting expenditures to support key priorities and improve efficiency.

Key Findings

• Health Sector Wage Bill: The health sector wage bill has increased significantly, rising by 344% from 2008 to 2014, far outpacing the overall government wage bill growth of 233%. This is primarily due to the expansion of the health workforce, especially doctors. The report suggests that maximizing the value of the current workforce can help sustain the wage bill.
• Pharmaceutical Expenditure: Government pharmaceutical spending is high but not excessive compared to other low- and middle-income countries (LMICs). However, inefficiencies and possible wastages have been identified, particularly in the area of pharmaceutical expenditures.
• Overseas Medical Transfers (OMTs): OMTs account for a significant portion of non-salary recurrent spending. There are indications that OMTs expenditure is beginning to decline, but the government must continue monitoring these costs.
• Health Resource Envelope: The overall health resource envelope is tightening, with both government and donor funding expected to decline in the medium term. This will place pressure on the MOH to fund previously donor-supported projects.

Economic Context

• Timor-Leste is a lower-middle-income economy with significant economic growth from 2002 to 2014, driven largely by oil revenues.
• Per capita non-oil GDP grew continuously, outpacing the East Asia and Pacific region, but from a very low base.
• The oil sector is crucial to the economy, but oil reserves are being depleted, and oil revenues are expected to peak in 2011.
• The non-oil GDP growth rate has moderated to 4.3% in 2015, and is projected to rise slightly in 2016 and 2017.
• Economic growth is expected to be subdued in the short to medium term due to declining oil prices and limited diversification.

Demographics and Population Health Outcomes

• Timor-Leste has one of the youngest populations in the world, with 60% under the age of 25.
• The fertility rate in 2013 was still among the highest globally, with women averaging 5.2 children.
• Maternal mortality rate (MMR) remains high, at 215 per 100,000 live births in 2015, compared to other countries in the region.
• Under-five mortality rate (U5MR) has declined from 175.7 in 1990 to 52.6 in 2015, but remains high compared to regional peers.
• Life expectancy has improved from 48.5 years in 1990 to 67.5 in 2013, but is still lower than most neighboring countries.
• The country is undergoing an epidemiology transition, with a growing burden of noncommunicable diseases (NCDs) alongside high infectious disease prevalence.

Health System Overview and Utilization

• The health system has made progress since independence, with re-established infrastructure and services.
• The system includes a national referral hospital in Dili, five district referral hospitals, 66 community health centers, and 42 maternity centers.
• Despite improvements, access to quality health services remains limited, especially in rural areas.
• Health services utilization is uneven, with significant disparities in service availability and quality across regions.

Health Financing

• The health budget has increased significantly over the past decade, with actual government health spending more than doubling between 2008 and 2014.
• The growth of the health budget has been constrained by the subdued economic outlook and reduced donor funding.
• The MOH faces the challenge of maintaining quality health services while managing rising costs and limited fiscal space.

Policy Recommendations

1. Maximize the Value of the Current Health Workforce:

   • Develop a strategy to optimize the current workforce rather than expanding it.
   • Establish a specialty training program for a percentage of primary doctors.
   • Improve the functionality of rural health facilities in accordance with the Basic Service Package.
   • Increase the number of midwives and nurses while maintaining the current number of doctors.
   • Evaluate opportunities to retrain and convert some health workers to address shortages.

2. Improve the Efficiency of Health Spending:

   • Strengthen public financial management (PFM) across the health system.
   • Improve the disbursement of funds to districts, with a focus on efficient pharmaceutical spending.
   • Enhance planning and budget management at the district level to reduce centralization of spending.

3. Develop a Long-Term Financing Sustainability Plan:

   • Support the MOH in developing a sustainability plan for donor projects.
   • Use the "phasing out" period of donor support to prepare for the integration of projects into national programs.
   • Fully cost all possible options to evaluate their impact on health outcomes and the budget.

4. Systematically Document Health Information:

   • Document budget, expenditure, personnel, and health utilization information.
   • Break down data by occupation, district, and facility type.
   • Monitor staff deployment and workload to improve service delivery and planning.

Key Stakeholders and Support

• The report was produced by Xiaohui Hou and Augustine Asante, with contributions from Ian Morris and technical and administrative support from various government agencies and international organizations, including the World Bank, UNDP, USAID, and others.
• The Ministry of Health, Ministry of Finance, and Public Service Commission were key partners in the study.

Conclusion

The report highlights the critical need for strategic planning and efficient use of health resources in Timor-Leste. It outlines the challenges posed by rising wage bills, pharmaceutical costs, and declining donor support, and provides actionable policy recommendations to address these issues. The ultimate goal is to ensure the sustainability of the health sector and the continued improvement of health outcomes in the country.