Currently, the Timorese Ministry of Health (MOH) have registered seven dentists and forty-six dental nurses in Timor Leste, with an average of one dental nurse per 59,478 people. Dental nurses are the main providers of primary oral health care in Timor Leste and they are charged with managing oral disease in the population.
With comprehensive treatment of dental problems beyond the capacity of the existing dental health workforce, the MOH focuses on oral health promotion and the prevention of oral diseases, while making emergency dental care available throughout the country.
However, a major problem is that the dental nurses have received limited professional development and little ongoing support to enable them to carry the burden of providing sustained care for the population. While other parts of the health sector have received much more attention, the oral health workforce remains underserved.
As part of Maluk Timor’s five-year plan for oral health, the MT Oral Health Team has developed ‘Projeto Nehan Saudavel’ (Healthy Teeth project) and will be working collaboratively with the MOH and partners to design and implement upskilling modules that can be delivered and continued by the current MOH systems via Institute Nasional Saude (INS). INS was established in 2005 (previously known as the National Centre for Health Education, established in 2001) as an autonomous body under MOH. INS delivers post-graduate training and upskilling to all health professionals.
Through upskilling, MT will trial and assess a competency-based system that could then be replicated for continued professional development (CPD) on various topics over five years. Dental nurses upskilled in Dili Community Health Centres (CHC’s) funded through the ICD grant would be characterised as ‘model’ dental professionals and each year the Maluk Timor training program will increase their scope of practise on a different procedure/ treatment modality, for example, year 1 silver diamine fluoride (SDF), year 2 ART/Sealants and so on. The target is to upskill dental nurses, assess their competencies and expand their scope of practice in CHC’s across Dili municipality to reduce the suffering created from dental caries.
Our view regarding the sustainability of CPD is that INS has a health ‘Training of Trainer’ (TOT) module, whereby health professionals within their respective fields, are trained to be certified trainers and facilitators of specific INS accredited upskilling modules. In partnership with INS, we will establish learning material (facilitator guides and participant handbooks) towards the theoretical component of this project. MT trusts that by developing CPD modules to be delivered through the INS and MOH system, they will receive INS accreditation which will ensure sustainability and efficiency to be carried by the national bodies into the future.
To ensure implementation, MT will work with experienced national dentists within MOH and National Dental Association Timor Leste. These dentists are well respected within Timor Leste and are viewed as senior professionals by their peers (dental nurses). Through our consultations with the MOH, INS, National Dental Association Timor Leste, and Municipal Health Services Dili (SSM Dili), we understand that involving the senior dentists within Timor Leste in the upskilling project design, module development and upskilling delivery is crucial to ensure sustainability of the project.
Given that this project has a practical aspect we will collaborate with SSM Dili, i.e., the district health authority for Dili, to deliver the practical component of upskilling at schools across Dili Municipality as part of the INS course completion accreditation. We will have access to their oral health workforce that services a population of 37,632 middle school children. Hence, through this partnership we would be able to offer professional support in their clinical practice across six CHC’s in Dili. Our focus is not to achieve successful SDF applications for all school children in Dili but to sustainably upskill the workforce to be competent in their health service delivery.
MT has an excellent record of collaborative work with national partners. We have a Memorandum of Understanding (MOU) with the MOH, and a Technical Agreement with the INS. Under our MOU with MOH, MT is permitted to implement activities under the following scope – “Establishment of dental health facilities suited to providing clinical supervision and post-graduate education to dental nurses, promoting oral heath in schools, and collaborating with other dental partners to develop a coordinated approach to oral health in Timor-Leste”.
The Maluk Timor Oral Health Team along with MOH (figure 1) have strived over the past 6 months to get to the point where Healthy Teeth Project, (i.e., upskilling of government staff) will be ready to commence in early 2022. The initial consultations on the ground were led by Dr. Sanjay Mathew (figure 2) with assistance from the Maluk Timor Oral Health Sub-Committee to gain stakeholder buy-in from all oral health stakeholders in Timor-Leste. The training syllabus and trainer manuals have been prepared by Prof Bethy Turton with help from Dr Sanjay Mathew, Dr. Jenifer Ximenes and Mana Efigenia dos Santos, (the Maluk Timor Oral Health team) and advice from Dr. Blanche Tsetong.
Figure 1: Maluk Timor Team collaborating with Oral Health unit, Ministry of Health
Figure 2: Dr. Sanjay Mathew presenting ‘The Healthy Teeth Project’ (Projeto Nehan Saudavel) to Ministry of Health, National Dental Association & SSM-Dili at Lahane, Dili
The module development has been in consultation with the Ministry of Health, the National Dental Association Timor-Leste, and the Institute Nasional Saude (INS). Given the scope of the work Maluk Timor is undertaking this has been an intense and challenging process which has obviously taken time, but we believe we are on track to have all approvals and logistics in place to start on time in mid-2022. Maluk Timor recently hosted the first Technical Working Group meeting (figure 3) to review the first draft of the SDF CPD module between all national stakeholders, such as MOH – Dept of Non-Communicable Disease, INS, National Dental Association Timor-Leste, World Health Organisation, SSM Dili and specialist dentist from the National Hospital (HNGV).
Figure 3: Projeto Nehan Saudavel (Healthy Teeth Project) First Technical Group Discussion with all National Stakeholders
This first module on SDF is the first small step in what is a large and long-term project, so we are endeavouring to do it well, and to facilitate good long-term relationships with all stakeholders. We are at the beginning of discovering a holistic and comprehensive approach to mentor, upskill and guide Timorese government staff- breaking the norm that used to shame continuous learning/ continuous professional development and the language barriers previously faced.
We hope to eventually strengthen the capacity of the Oral Health workforce in Timor-Leste so that the vast majority of the people of Timor Leste have access to at least good preventive measures and basic dental treatment.