AbstractTimor-Leste’s independence in 1999 provided an opportunity for Timorese health leaders, in conjunction with donors and technical advisors, to direct the nation’s health policy agenda. Reducing the high rate of maternal mortality was a national priority. In 2005 a maternity waiting home policy was developed to improve access to care for women in rural and remote areas, and to facilitate a transition from birthing at home to birthing in hospital. By 2007 the concept had been incorporated into the Basic Services Package and was planned for every health post, health centre and hospital in the country.
Drawing on the anthropology of policy and mixed methods research, this project uses maternity waiting homes as a case study to examine the factors that influence the development of maternal health policy and use of maternity services in Timor-Leste. An analysis of the policy process revealed complex power relationships which favoured the role of national elites when setting the policy agenda. Solutions tended to be based on dominant ideology rather than evidence. Despite strong national leadership, maternity waiting homes were transformed during implementation indicating ‘street level bureaucrats’ such as health managers and midwives had more control over implementation than expected. The maternity waiting homes in Timor-Leste were used as postpartum care facilities, mostly by women who lived within 5km of the health centre. They were not used by women to ‘wait’ prior to labour and did not improve access to hospital birth for women in remote areas. A range of qualitative and quantitative data is used to illustrate the importance of other issues affecting access to care, including individual, sociocultural, societal and health system factors.
The failure of maternity waiting homes to meet national objectives highlights the need to invest in transport, decentralised birthing services and improved quality of care in hospitals. An alternative model of policy is presented, one which frames implementation as a process of adaptation. This model emphasises the need to re-evaluate the dominant approach to policy-making so that women’s needs and the health system context inform the development and implementation of policies. It advocates for the participation of street level bureaucrats and rural women in setting a rural health policy agenda.
|Date of Award||2009|
|Supervisor||Lesley Barclay (Supervisor) & Nelson Martins (Supervisor)|