2015年-世界发展银行全球_Health_Worker_Survey_in_Timor-Leste_107页_1mb

报告摘要

Summary of the Health Worker Survey in Timor-Leste (June 2015)

Core Content

The Health Worker Survey in Timor-Leste was conducted by the World Bank and Oxford Policy Management (OPM), in collaboration with the Dili Institute of Technology (DIT) and the Ministry of Health (MoH). The survey aimed to assess the labour market dynamics, preferences and concerns, skills, competence and motivation of health workers, and the working environment of health facilities in Timor-Leste. The findings were used to provide evidence-based policy guidance for the health workforce in the country.

Main Objectives

Understand the labour market dynamics among health workers.
Explore preferences and concerns of health workers.
Assess the skills, competence, and motivation of doctors.
Evaluate the working environment of health facilities.

Key Findings

Labour Market Dynamics

443 health workers were surveyed, including 175 doctors, 150 nurses, and 118 midwives (about 20% of the total health workforce).
56% of health workers were women, with 58% of doctors and 100% of midwives being female.
64% of nurses were male.
53% of doctors worked in rural facilities, while 70% of nurses were in urban areas.
21% of doctors worked in Health Posts (HPs), compared to 8% of nurses and 16% of midwives.
96% of doctors had less than five years of experience in the sector.
97% of respondents were not looking for another job in the short term.
99% of doctors expressed a desire to remain in the public sector long-term.

Motivation and Preferences

Only 4% of respondents were unsatisfied with their work.
80% of medical staff indicated they would stay until the last patient is treated, even without additional financial compensation.
99% of doctors, and a majority of nurses and midwives, intended to continue working in the public sector.
HPs were the least attractive long-term work locations, with 6% of doctors preferring them.
32% of doctors were content to work in Community Health Centres (CHCs).
22% of doctors preferred rural sucos long-term.
88% of respondents felt that MoH would determine their next assignment.

Salary and Financial Benefits

Wage differentials within each cadre were relatively small.
Doctors with more than ten years of experience earned US$50 more on average than newly joined doctors.
52% of respondents believed there was not enough opportunity to learn current medical knowledge.
63% of respondents agreed or strongly agreed that salaries were too low.
Only 2% of health workers experienced delays in salary payments.
Non-financial benefits such as housing and motorbikes were reported by doctors and lower-level facilities.
Only half of health workers received sufficient fuel or funds for motorbikes, and over half experienced delays in these benefits.

Workload

63% of health workers worked five days a week in HPs, CHCs, and district/regional hospitals.
22% to 36% worked six to seven days a week.
The mean number of patients seen per day by sampled doctors was 10.2, with SD of 7.5.
Urban facilities had a higher patient load (11.5, SD 6.9) compared to rural facilities (9.6, SD 7.8).
45% of respondents felt they had too much work.
There was no clear correlation between workload and feelings of overload.

Training

Almost all health workers felt their training was adequate.
Nurses and midwives attended three or more short-term training sessions in the last three years (about 50%).
35% of doctors attended three or more short-term training sessions.
52% of respondents felt there was not enough opportunity to learn current medical knowledge.
75% of doctors required training on community health.
51% of urban doctors attended three or more training sessions in the last year, compared to 26% in rural areas.
Older or more satisfied doctors were less interested in training.
Females were more likely to seek specialist visits.
Workers in HPs and CHCs showed more interest in specialisation.

Supervision

85% of respondents had a supervisor who provided feedback on performance.
Supervisory meetings occurred at least every three months, with urban staff having more frequent meetings.
Supervisors focused on technical development and quality control, such as observing consultations, providing health instructions, and conducting knowledge assessments.
75% of respondents felt the need to discuss difficulties with supervisors.
95% of them actually discussed the issue, and 66% noticed improvements.

Challenges

The most reported challenges included:
- Low salaries (63%)
- Inadequate opportunities to learn (52%)
- Lack of transport (50%)
- Inadequate housing (48%)
- Too much work (47%)
- Security problems (39%)
- Lack of supervision (30%)
- Lack of feedback on performance (23%)
- Lack of motivation (20%)

Absence from Work

8% of respondents were absent due to sickness in the last 30 days.
5% were absent for personal reasons.
In the case of absence, 13% were called by the facility head, 5% had supervisor discussions, and 2% had salary deductions.

Working Environment

69 health facilities were surveyed across 13 districts, including 6 hospitals, 33 CHCs, and 30 HPs.
National and referral hospitals were well-equipped, while HPs were poorly equipped and lacked basic services.
Rural facilities were significantly under-resourced compared to urban ones.
Medicine storage conditions were a concern, especially in rural areas.
Service availability was generally high, except for HIV/AIDS treatment, caesarean sections, and blood transfusions.
HPs provided fewer services than CHCs and hospitals.

Health Worker Preferences

The Discrete Choice Experiment (DCE) revealed that:
- Specialisation was the top-ranked factor for doctors.
- In-service training, transportation, equipment, remote location, and housing were also important.
- Newly graduated doctors were neutral toward wages.
- Nurses and midwives valued training most highly, followed by transportation.
- Female doctors had a negative coefficient on wage, indicating less preference for higher wages.
- Nurses and midwives were more likely to prefer higher wages and better facilities.

Competence of Doctors

635 cases were observed, mostly in outpatient departments, with 40% in urban and 60% in rural areas.
Clinical performance was good in attitudes (91%) but moderate in history taking (57%), health education (50%), and treatment accuracy (69%).
Physical examination performance was low (28%), likely due to lack of examination tools.
Vignettes showed a 'know-do' gap, with higher scores in knowledge than in practice.
Low hand-washing rates (slightly above 20% in observed cases and below 10% in vignettes) were a concern, not explained by lack of facilities.
Clinical performance was lower in HPs and rural areas, possibly due to poor infrastructure and limited resources.
Longer consultation periods were associated with better clinical performance.

Recommendations

Ensure Policy Compliance at All Levels

Match service availability to the Basic Service Package (BSP) to improve rural facility functionality and worker motivation.
Ensure medicine availability aligns with the Essential Drug List (EDL) to reduce stock-outs and misuse.
Enforce clinical guidelines to improve doctor performance, though implementation challenges must be considered.

Strengthen the Health Human Resource Policy

Implement clear salary progression for doctors to retain experienced workers and encourage better performance.
Provide regular in-service training and specialist visits to improve competence and confidence.
Improve supervision effectiveness by focusing on action-oriented and meaningful visits.
Adjust workload expectations to better reflect actual patient load and improve understanding behind reported high workload.

Improve the Functionality of Health Facilities

Strengthen the pharmaceutical chain through demand-driven procurement and distribution.
Improve availability of medical supplies to enhance service delivery and rural retention.
Improve infrastructure, including water, electricity, and communication, and accommodation for health workers through inter-sectoral initiatives.

Conclusion

The survey highlights positive aspects such as high motivation, satisfaction, and preparedness of health workers. However, it also identifies key challenges that require policy intervention and investment. The recommendations focus on policy compliance, training and supervision, and facility functionality to improve the health workforce management and ensure better health services, especially in rural areas. A follow-up survey is recommended to monitor trends over time.