Understanding HRH recruitment in post-conflict settings: an analysis of central-level policies and processes in Timor-Leste (1999–2018)

Abstract

BackgroundAlthough human resources for health (HRH) represent a critical element for health systems, many countries still face acute HRH challenges. These challenges are compounded in conflict-affected settings where health needs are exacerbated and the health workforce is often decimated. A body of research has explored the issues of recruitment of health workers, but the literature is still scarce, in particular with reference to conflict-affected states. This study adds to that literature by exploring, from a central-level perspective, how the HRH recruitment policies changed in Timor-Leste (1999–2018), the drivers of change and their contribution to rebuilding an appropriate health workforce after conflict.MethodsThis research adopts a retrospective, qualitative case study design based on 76 documents and 20 key informant interviews, covering a period of almost 20 years. Policy analysis, with elements of political economy analysis was conducted to explore the influence of actors and structural elements.ResultsOur findings describe the main phases of HRH policy-making during the post-conflict period and explore how the main drivers of this trajectory shaped policy-making processes and outcomes. While initially the influence of international actors was prominent, the number and relevance of national actors, and resulting influence, later increased as aid dependency diminished. However, this created a fragmented institutional landscape with diverging agendas and lack of inter-sectoral coordination, to the detriment of the long-term strategic development of the health workforce and the health sector.ConclusionsThe study provides critical insights to improve understanding of HRH policy development and effective practices in a post-conflict setting but also looking at the longer term evolution. An issue that emerges across the HRH policy-making phases is the difficulty of reconciling the technocratic with the social, cultural and political concerns. Additionally, while this study illuminates processes and dynamics at central level, further research is needed from the decentralised perspective on aspects, such as deployment, motivation and career paths, which are under-regulated at central level.Electronic supplementary materialThe online version of this article (10.1186/s12960-018-0325-5) contains supplementary material, which is available to authorized users.

Flexibility of deployment: challenges and policy options for retaining health workers during crisis in Zimbabwe

“…There is little evidence of flexibility of these policies and practices in time of conflict or crisis [23] with the exception of post-conflict Timor Leste [24, 25]. This study sought to contribute to this evidence.…”

Policies on return and reintegration of displaced healthcare workers towards rebuilding conflict-affected health systems: a review for The Lancet-AUB Commission on Syria

“…Tables 2 and 3 present an overview of the peer-reviewed articles and grey literature reports, respectively. These covered numerous conflict and post-conflict contexts, including Timor-Leste ( n = 1) [ 39 ], Afghanistan ( n = 1) [ 40 ], Zimbabwe ( n = 1) [ 41 ], South Sudan ( n = 3) [ 42 , 44 , 48 ], Lebanon ( n = 1) [ 43 ], Namibia ( n = 1) [ 45 ], Kosovo ( n = 1) [ 46 ], Iraq ( n = 1) [ 47 ] and northern Uganda ( n = 1) [ 15 ]. Two records examined multiple contexts [ 49 , 51 ].…”

“…In a case study from Afghanistan, the Minister of Public Health appealed to expatriate Afghan physicians in the U.S. to return to Afghanistan in order to train local physicians as well as provide essential services to their fellow citizens [ 39 ]. .This is supported through the distribution of public surveys by the Ministry of Public Health (MoPH) in Afghanistan in order to map the existing Afghan medical diaspora and gauge their interest in supporting the Afghan health system [ 52 ].…”

“…One example from Timor-Leste demonstrated the importance of salvaging records of health personnel in order to track those who have left as well as verify certification for future recruitment [ 39 ]. Drawing on lessons learned from a variety of contexts, a WHO report suggested an expansion of HCW registration on a global level (via the International Organization for Migration-IOM), including a database with the Ministry of Health regarding work experience and qualifications of HCWs, including diaspora HCWs to identify skilled potential returnees [ 51 ].…”

“…Articles documented feelings of resentment towards returning HCWs felt by colleagues who did not leave during the conflict. For example, in Afghanistan, administrators noted emotional resentment from HCWs who did not leave during the conflict towards “Westernized” professionals who returned, noting that “working through those relationships is tricky.” [ 39 ] An example from Namibia claimed that fear of “well-educated returnees,” including health professionals, was “unfounded as formal qualifications are not matched with work experience.” [ 45 ] Nonetheless, those who return to Namibia are noted to be likely more educated, and therefore, will have higher chances of finding employment.…”