Annual Report 2023
Table of Contents
From our Boards
2023 was another momentous year for Maluk Timor as it brought the opportunity for us to start work on developing a comprehensive training program for primary health care doctors and nurses in Timor-Leste. With the support of Australia’s Department of Foreign Affairs, and working closely with Timor’s Ministry of Health, we delivered an integrated primary health care training curriculum that has now been accepted by the Ministry of Health for implementation in 2024-2026.
For Maluk Timor, this is a wonderful opportunity to build on our experience over the past seven years working across many different health programs and develop an integrated approach to primary health care training. We are excited that we have been chosen as the organisation within Timor to implement this training over the next two years. This will happen alongside our ongoing work on existing programs, including rheumatic heart disease, tuberculosis, maternal and child health, oral health and HIV.
We can only do what we do because of the extraordinary commitment and professionalism of our Timorese staff. Our vision has always been – and will continue to be – to focus on people: the Timorese people we serve and the staff who work with us. We know that by supporting our staff, we can rely on them to sustain Maluk Timor and the impact we have on the provision of primary health care in Timor-Leste. We thank each and every one of our staff for being part of this mission.
Francisca Baptista
President, Associação Maluk Timor
Julie Hamblin
Chair, Maluk Timor Australia
Finally, we must again thank the many donors who put their trust in Maluk Timor by supporting our work. Now more than ever, we need your help to ensure we can continue our work to strengthen Timor-Leste’s health system. We have achieved a great deal but there is still so much more to be done.
From our Leaders
What an amazing journey we’ve had this year! We’ve taken on major new areas of work. From rehabilitating government healthcare facilities, to supporting a national drug logistics system, to launching a project to prevent tooth cavities in kids – all while keeping our core healthcare system strengthening work running smoothly. We’ve forged stronger partnerships. And we’re relentlessly sharpening our skills for greater impact.
One highlight was the opening of a new Integrated Care Clinic for people with HIV. Under the leadership of Dili Municipality Health and the National AIDS Programme, and in consultation with the PLHIV community, we moved to Formosa Community Health Centre (CHC) in October. This move signalled the culmination of our support for Vera Cruz CHC (2018- 2023), which is now proudly running independently, with two Ministry of Health staff.
In the larger site at Formosa, our team works alongside three Ministry of Health staff, in close collaboration with the Australasian Hepatitis and Sexual Medicine Society (ASHM) and the maternity department. We’ve expanded to provide special care HIV issues in pregnancy and babies.
This year also saw us lay the groundwork for a new nationwide initiative for upskilling clinical and management skills for primary healthcare. The new “Continuing Professional Development in Integrated Primary Healthcare” (CPD-IPHC) project leverages digital methods to make essential clinical knowledge available to front line providers wherever they are, and whenever they need it.
We have been investing heavily in our staff’s growth. A number of our team members attend international conferences: deepening their knowledge, connecting with the global health community, and returning with renewed enthusiasm to transform Timor-Leste’s primary healthcare system.
As the new government takes over the reins in 2023, we look forward to continuing to support the Ministry of Health to achieve its vision of “a Healthy East Timorese people in a healthy East Timor”.
Natarajan (Raj) Rajaraman
Executive Director, Associação Maluk Timor
Michelle Wilson
Managing Director, Maluk Timor Australia
2023 Highlights
Professional Development in Integrated Primary Health Care
Training the primary health care workforce to strengthen basic clinical skills and provide quality services
An essential part of improving quality health services is to ensure that the primary health care workforce is well trained in basic clinical skills.
Maluk Timor developed the Continuing Professional Development Integrated Primary Healthcare (CPD-IPHC) syllabus for training primary health care professionals (doctors, nurses, midwives, nutritionists, pharmacists, allied health, and other healthcare professionals) in an integrated curriculum for basic clinical competencies.
To reach the wider workforce, Maluk Timor trains Formadors (trainers) to then deliver training to the national primary health care workforce.
In 2023 we laid the foundations for strengthening in-service training in 3 municipalities. We combined extensive stakeholder engagement with training needs assessments and a rapid review of existing training programs to formulate a context-appropriate modular curriculum blueprint for
in-service training of Timor-Leste’s frontline primary healthcare workers. Here’s what went into it:
- Stakeholder Engagement: Before formulating the curriculum, we met 53 Timorese healthcare leaders, clinicians and policymakers to gather valuable input on course development, best practices in health professionals’ education, making the curriculum truly unique to the specific challenges and needs of Timor-Leste.
- Review Existing Training Programs: We conducted a comprehensive review of 56 existing primary health care (PHC) training This involved desk reviews, 20 stakeholder interviews, and the analysis of 30 training materials. Our review highlighted gaps, such as the lack of training materials in digital repositories and uneven access to existing materials, particularly in rural areas.
- Training Needs Assessment: We conducted a thorough training needs assessment across 18 health centres in the districts of Dili, Oecusse, and Ermera, engaging over 147 health This assessment identified critical areas for training, including emergency care, non- communicable diseases, and maternal and child health. We also highlighted significant infrastructural challenges, such as inadequate equipment and the need for improved living conditions for health care workers.
We learned 3 key things about primary care health worker training in Timor-Leste:
- Training Needs: There is high demand for training in emergency care and the management of chronic Health professionals in rural areas were particularly eager to learn and update their skills.
- Resource Gaps: Despite huge gains made in the past years, many health facilities still lack basic medical equipment, reliable water supply, and adequate space for training and patient
- Digital learning is coming: Despite poor internet coverage in Timor-Leste’s rural areas, handphone use is high and there is great interest in “e-learning”. Our passionate team of IT- trained educators will be exploring ways to use technology to bridge rural-urban gaps in training and learning opportunities.
In 2024, we will be pressing on to implement this curriculum in 3 districts (Dili, Oecusse and Ermera).
Health Professionals Development
Training the trainers to upskill all healthcare personell
In 2023 Maluk Timor assembled our Health Professionals Development (HPD) team to start designing and delivering the Integrated Primary Health Care Program (IPHC). The team’s goal was to build the capacity of the Timor-Leste National Institute of Health (INS-PTL) to design and deliver training to all healthcare personnel in the Ministry of Health (MoH) facilities.
Key projects included:
- Integrated Primary Health Care (IPHC)
- Guidelines translation project
- Clinical upskilling of HPD team members
- Continuous Professional Development (CPD) system for Maluk Timor staff
Key projects delivered by our Health Professionals Development Team:
1. Integrated Primary Health Care (IPHC) program phase one
- Conducted consultation workshops with partners to gain input and acceptance of the program.
- Conducted a Learning Needs Assessment across 17 health centres.
- Developed a Primary Care Curriculum Blueprint for the training of medical doctors, nurses, midwives, public health professionals, and allied health technicians. This is an eight-module curriculum, including: Emergency Care, Communicable Diseases, Non-Communicable Diseases, Maternal and Child Health, Child and Adolescent Health, Function and Rehabilitation, and Palliative Care.
- Selected Clinical Educators in MoH facilities for training
- Provided digital literacy training for 20 Clinical Educators.
2. Integrated Primary Health Care (IPHC) program phase one
- Translated non-clinical content of the training guidelines from Bahasa to Tetum.
3. Clinical upskilling of HPD team members
- Started clinical upskilling activities for HPD team members according to their clinical experience and skills gaps.
4. Continuous Professional Development (CPD) system for Maluk Timor staff
- Developed and implemented a CPD system to build staff capacity for continued learning, attain mastery of their roles and understand other professional roles within the team.
- 183 CPD sessions were conducted with an average attendance of 10 participants per session.
Health Professionals Development
Impact highlights:
Maternal & Child Health
We increase community involvement and awareness in maternal and newborn health
Our Maternal and Child Health program (MCH) focuses on supporting rural communities where women and girls have limited access to healthcare and health education. Our goal is to increase community involvement and awareness about the importance of taking care of the health of mothers and babies.
We provide important maternal and child health information with an emphasis on antenatal care, nutrition, giving birth at healthcare facilities with skilled staff and accepting obstetric emergency
In 2023 we reached 14 out of 19 communities in Railaco district within Ermera municipality. Activities included:
- Participatory Action Research (PAR),
- Dissemination of key MNH promotion messages
- Mobile antenatal care and malnutrition clinics
- Upskilling of MNH workforce in people-centred care
- Provision of essential MNH physical resources
Maternal and Child Health
Impact highlights:
More babies delivered safely in healthcare facilities.
Timor-Leste has one of the highest maternal mortality rates in Southeast Asia with 195 deaths per 100,000 live births. Only 57% of births are attended by qualified health professionals. A complex range of factors are responsible for the low number of births attended by qualified health professionals including previous negative experience with healthcare services, low health literacy, traditional practices of giving birth at home, lack of an effective and accessible emergency obstetric and newborn care network, few qualified health professionals, and long distances, difficult terrain and costs that prevent pregnant women from travelling to healthcare centres.
Maluk Timor has been partnering with the Ministry of Health to train skilled birth attendants, encourage pregnant women to attend antenatal clinics (including mobile outreach clinics), and promoting the benefits of giving birth in healthcare centres or at home with skilled birth attendants.
In 2023 there were 24 babies delivered in healthcare facilities with skilled birth attendants. This marked an increase of 16 deliveries from the baseline. The skilled birth attendants successfully handled 13 complex cases that could have easily lead to negative outcomes for mother and baby. These included 2 cases of previous caesarean sections, 1 case where the baby was overdue, 1 case where the mother had pre-eclampsia, and 2 cases where the babies were clinically large for their gestational age.
These achievements highlight the clinic’s success in managing a diverse range of maternal and fetal health conditions. Word of mouth travels fast in communities. Our success helps to gain the confidence of communities to use maternal and child health services and encourage women to deliver babies with skilled birth attendants.
Nutrition
Support is urgently needed to reduce soaring malnutrition
Timor-Leste holds a challenging record – it’s the most undernourished country in Asia, with child malnutrition rates among the highest in the world. One in five children presenting at local health centres, battles moderate to severe malnutrition.
Almost half of the children under five years old in Timor-Leste are experiencing stunted growth (low height-for-age), while 8.6% grapple with acute malnutrition (low weight for height). Meanwhile 23% of women in the of reproductive age (15-49) suffer from anaemia.
Malnutrition is worse than just being hungry all the time – it leaves children with weakened immune systems and makes them more susceptible to infections like Tuberculosis. It has long-lasting effects for children and even affects the next generation after them.
The issue of malnutrition in Timor-Leste is complex, but it’s a challenge that many are stepping up to meet. A cluster of organizations, both local and international, are rolling up their sleeves to provide nutrition-specific interventions. They include the World Food Programme, Unicef, and the SUN network, as well as World Vision, Plan International, Nutrition Innovation Lab, TOMAK, and CRS. Together, they’re helping deliver a healthier future for Timor-Leste.
Oral Health
We improve the knowledge, capacity and skills of the oral health workforce
The Timor-Leste National Strategic Development Plan (2011-2030) states that with the treatment of dental problems beyond the capacity of the existing dental health workforce, the Ministry of Health will focus on oral health promotion and the prevention of oral diseases, while making emergency dental care available throughout the country.
Timor-Leste has a high prevalence of untreated caries (35 – 45%, WHO 2019). Maluk Timor has therefore aligned our work with the Ministry of Health’s emphasis on oral health promotion and disease prevention, through training health workers in early disease recognition and translating theory to practical application in the primary care setting.
Our oral health program aims to improve the knowledge, capacity and skills of the oral health workforce, especially dental nurses who are the main providers of dental healthcare in Timor-Leste. We also support the clinical services delivered with our partners at Klibur Domin
Oral Health
Impact highlights:
Key activities in 2023
Deliver oral health clinical services with partner Klibur Domin:
We support the delivery of comprehensive oral clinical services including emergency, restorative and preventative treatments, and dental promotion.
The services address the immediate health needs of the community and plays a vital role in prevention, education, and promoting long-term health benefits.
Upskill national oral health workforce:
Continuing Professional Development for dentists and other healthcare workers:
- We developed content for 2 new training modules: Atraumatic Restorative Treatment, and Fissure Sealant. Next steps include stakeholder engagement, and piloting the training.
- Our team was approached by the Ministry of Health and World Health Organisation to support the development and delivery of other oral health training materials such as “Say no to 5S” and “School Health Package”.
- We are also developing core training modules for primary healthcare
In March, we successfully launched the national module for the prevention of dental caries in Timor Leste, using Silver Diamine Fluoride (SDF).
In September, we collaborated with the National Department of Non-Communicable Disease and the INSP-TL (Instituto Nacional de Saúde Pública de Timor-Leste) to upskill 12 Dentists and Dental nurses from five Community Health Centres (CHCs) in the Dili Municipality. The training focused on how to use Silver Diamine Fluoride effectively to prevent and arrest dental caries.
We’ve read about (SDF) in school but we never been able to actually use it–until now.”