2005年-世界发展银行全球_Health_Service_Delivery_and_Utilization_in_Timor-Leste___A_Qualitative_Study_36页_690kb

Summary of Health Service Delivery and Utilization in Timor-Leste: A Qualitative Study

I. Introduction

This qualitative study explores the challenges in health service delivery and utilization in Timor-Leste, focusing on health seeking behaviour and human resource issues. Despite progress since independence, the country continues to face a high burden of disease due to factors like environmental sanitation, poverty, and a shortage of doctors. The health sector also grapples with low utilization of services, which is influenced by cultural beliefs and practices, including "medical pluralism" where traditional and biomedical systems coexist. The study was conducted as part of a broader Health Sector Review by the World Bank and involved group discussions with health care workers and clients.

II. Core Findings

Part 1: Health Seeking Behaviour and Barriers to Health Service Utilization

• Medical Pluralism: Clients in Timor-Leste often use a combination of traditional and biomedical treatments. They believe in both systems, with some preferring traditional methods for "non-physical" illnesses.
• Perceptions of Disease Aetiologies: Illness is often attributed to both physical and spiritual causes. Physical causes include mosquitoes, dirt, and the rainy season, while spiritual causes involve violations of sacred rituals, black magic, and malevolent spirits.
• Traditional Healers (Matan Dook): These practitioners, often referred to as duku in Indonesian, are respected and widely used. They use methods such as betel-nut chewing, candle light, and animal sacrifice. Some have national reputations and charge high fees.
• Ritual Practices: Clients may perform rituals before seeking biomedical care, believing it is necessary for successful treatment. This can delay or prevent timely care, especially for severe conditions.
• Attitudes Toward Biomedicine: While there is general acceptance of biomedical treatment, some clients distrust it due to past negative experiences or beliefs that it is too "strong." This can lead to avoidance of hospitals, especially for children with high fever.
• Pharmaceutical Perceptions: Clients rate medicines by their "strength" and form. Injections (sona) are often seen as more powerful than oral medications, leading to pressure on health workers to administer them. Conversely, some believe injections can be fatal, especially for children.
• Community Reliance on Traditional Healers: Despite some negative experiences, traditional healers and birth attendants remain popular, especially among those who cannot afford biomedical care. There is a perception that traditional medicine is more effective for certain conditions, such as mental illness.
• Health Worker Perceptions: Health workers are generally seen as skilled and trustworthy, but some clients report rudeness, lack of explanation, and preferential treatment for those with connections. This can affect patient satisfaction and trust in the health system.

Part 2: Problems in Service Delivery and Human Resource Issues

• Service Quality Concerns: Some clients feel that health workers are not adequately explaining treatment regimens and are dismissive of patient questions. This can lead to non-compliance and mistrust.
• Staff-Client Relationships: There are reports of poor communication and interactions between health workers and clients, sometimes due to overcrowding and lack of training.
• Community Perceptions of Health Facilities: Some communities, particularly in rural areas, have negative views of hospitals, perceiving them as places "for dying" rather than for recovery. This perception is linked to cultural beliefs about the afterlife and the need for proper funerary rituals.
• Access Challenges: Distance and transportation difficulties are major barriers to accessing health services, especially for pregnant women and those living in remote areas. Poor transportation infrastructure and lack of affordable options further limit access.
• Economic and Social Factors: Poor families may avoid health care due to cost and lack of resources, while some urban residents are willing to pay for traditional services. There is also a perception that government health facilities are less reliable than private or NGO providers.

III. Policy Implications

• Need for Health Promotion: Education and health promotion efforts should address misconceptions about disease aetiologies and the role of traditional medicine.
• Improving Communication: Health workers need better training in patient communication and explanation of treatment protocols.
• Strengthening Community Engagement: Policies should consider the cultural context of health seeking and integrate traditional practices where appropriate.
• Enhancing Access to Services: Improving transportation and reducing costs can help increase utilization of health facilities, especially in rural areas.
• Addressing Mistrust: Efforts should be made to build trust in biomedical services, particularly in communities with historical resistance to government health facilities.

IV. Key Issues and Recommendations

• Medical Pluralism: Must be acknowledged and integrated into health policy to improve service utilization.
• Traditional Healers: Should be engaged in public health initiatives to ensure their role is understood and managed effectively.
• Client Education: Needs to focus on understanding disease aetiologies and the importance of timely biomedical care.
• Service Quality: Requires investment in training and resources to improve the delivery of care and patient satisfaction.
• Transportation and Accessibility: Infrastructure improvements and community-based health services can help overcome geographical barriers.

V. Conclusion

The study highlights the complex interplay between traditional and biomedical health systems in Timor-Leste. While biomedical services are generally viewed positively, cultural beliefs and practices significantly influence health seeking behaviour. Addressing these cultural dimensions is essential for improving health outcomes and service delivery. The findings suggest that a more holistic and culturally sensitive approach to health policy and service delivery is needed.