The frontline effort to improve healthcare

The frontline effort to improve healthcare in remote villages

UNICEF Timor-Leste
UNICEF Timor-Leste/2019/Soares
01 August 2019

The UNICEF-supported Continuous Quality Improvement (CQI) programme is re-energizing the health workforce to help them make positive changes. The Ossu Community Health Centre in Viqueque municipality is leading the drive. 

VIQUEQUE, Timor-Leste – Midway along a bumpy road that connects two of Timor-Leste’s mountainous municipalities sits a health centre. Like most remote centres of its kind across the country, the Ossu Community Health Centre (CHC) is modest in the services it can provide to the surrounding community. But those it does provide are vital to the people who depend on them. 

People such as Domingas da Costa, 29, who is pregnant for her third child have come to the Ossu CHC for an antenatal care (ANC) appointment, just as she did during her first two pregnancies. Domingas is here early in the morning. She is the first to register her name for the day - one of the benefits of living just across the road. Many of the women who visit today will have walked long distances to get here. 

The gradual winds of change

As a young nation with a largely remote population dispersed over challenging, mountainous terrain, Timor-Leste has faced many challenges in building its health system to meet the needs of its people.  “Sometimes there would only be one bench [at the health centre] so we’d have to stand up in the sun to wait,” says Domingas. “And when we came to see the midwives, they'd be attending to women giving birth in the same room that they were providing family planning services.”

When progress is slow, particularly in remote areas, health workers can become disillusioned. The Ministry of Health does what it can to support all health facilities, but resources are limited.  

At the Ossu CHC, however, the UNICEF-supported Continuous Quality Improvement (CQI) programme is re-energising the health workforce to help them make positive changes. This programme enables the health workers to identify the problems encountered in their respective health facilities and propose corrective actions to address them. Since the introductory training that took place in February 2019, a number of improvements have been made in this CHC.  

A wake-up call 

“We felt like our quality of services before the training was normal. But since this programme started, we can feel the benefits it provides us and our patients,” says Leopoldina da Costa Gutteres, Special Coordinator for ANC and the only full-time midwife at the Ossu CHC.

Martinho Guterres da Costa, a nurse at the center, reaffirms what Leopoldina had said. “It’s woken us up,” says Martinho. “Before the training we’d do what we could, but we didn’t really know the right process to create change. From the training we gained a better understanding of the things we can do individually, as a team and the things that need higher level support.” 

Martinho and Leopoldina both sit on the commission set up within the Ossu CHC as part of the CQI programme. Composed of a range of staff members - from managers to security guards - the commission meets once in a month to identify and address issues that need to be rectified and will have a positive impact on the community that the CHC serves. 

Key to the success of the CQI programme is a self-assessment checklist – a simple tool that is helping health workers to improve their services over time. “It provides an opportunity for us to identify our own weaknesses and fix them in order to better serve our patients,” says Martinho. “The checklist really helps us,” agrees Leopoldina. “We can identify the things we have done and the things that may have been overlooked. It is a continuous wake-up call to keep improving our work.”

By having ownership over the process and a clearer pathway for creating change, staff within the health facility have a renewed enthusiasm for improving the quality of the services they provide to their community. 

Rolling up their sleeves 

Through the CQI process, staff identified that the poor condition of the patient waiting facilities and location of the delivery bed as the two most pressing areas in need of attention. And this time, they were able to do something about it. “We asked ourselves, ‘what can we do about this?’” says Martinho. “Some suggested that we send a proposal to the Ministry’s hierarchy, but others thought that would take too long. So, instead, we pooled money, contributed materials and built the waiting space ourselves.”

The local business people also chipped in with building supplies and some young people from the neighbourhood provided un-paid labour. Together they built a patient waiting lounge under a veranda in one weekend. Much like a Timorese family preparing for a big event, everyone contributed where they could. The team also separated the family planning counselling place from the delivery space, so that patients would feel more comfortable, despite the limited space available. 

“It didn’t feel safe for the women giving birth in an unrestricted space; they were embarrassed,” explains Leopoldina. “But now that we’ve moved the delivery bed to a more private space, women can come to the separate family planning room for counselling. The program has changed our thinking,” she says. 

UNICEF Timor-Leste/2019/Soares
Thanks to the staff and community members who built the new waiting room, parents and children no longer need to stand in the hot sun while waiting for services at the CHC.

The changes are strengthening relationships between health workers and their patients, too. “Now when we come, we have somewhere good to sit, and our kids can play undercover as well. We’re happy,” says Domingas. 

Sitting in the new space while they wait for a consultation, Januario da Cruz and his wife feel the same way. They have brought their eight-month-old daughter to the Ossu CHC for her latest check-up. “For us as patients, we feel that the facility is much better now,” says Januario. 

“We used to stand under the sun to wait for registery of our names, but they have moved [the registration area] over here under the new veranda and it’s much better for us and the children.”  

Just what the doctor ordered

“If it’s not us who make the change, then who else are we waiting for? The programme has motivated us,” says Martinho. “Timor-Leste is independent now, so we can’t just wait for others. We have to do something ourselves.” 

The pride among Ossu’s health staff and community leaders is palpable. It is motivating them to seek alternative pathways to achieving outcomes that will improve the lives of the people around them. “I feel happy and proud. Before the training we didn’t think we could do anything and just sat around indifferent, but now we can identify the things we’re able to do ourselves because the process is clear. Taking action has been motivating for us,” says Martinho. 

UNICEF Timor-Leste/2019/Soares
The proud members of the CHC who are leading the change through their own initiatives.

It is a sentiment shared by Celestino Monteiro de Carvalho, the village chief. “As a community leader, I’m proud that they have had the integrity to do this. Despite the government not yet being able to provide support, [the CHC staff] had the initiative to do something.”

Bolstered by their success to date, the team has their sights set on building additional delivery facilities. Doing this would provide much needed privacy and a safer and more comfortable delivery space for the many women who welcome their babies into the world here. “Our next plan, because we’re the only CHC in Viqueque municipality that doesn’t have a labour room, is to build one or two additional rooms,” says Martinho. “The only problem is that while we have enough resources to build the waiting lounge for our patients ourselves, we don’t have enough to build a whole building. So, we’re looking for extra support for that.” 

With renewed confidence in their ability to create positive change for their community, Martinho, Leopoldina and the other members of the Ossu CHC CQI commission are confident they will find creative solutions to future challenges. Their community’s health depends on the good quality of their health services. 

This programme is supported by the Australian Government through the Australian NGO Cooperation Program (ANCP).