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Timor-Leste is in the process of addressing a key issue for the country's health sector' a medical workforce that is too small to provide adequate care. In theory, a bilateral programme of medical cooperation with Cuba created in 2003 could solve this problem. By the end of 2013, nearly 700 new doctors trained in Cuba had been added to Timor- Leste's medical workforce and by 2017 a further 328 doctors should have been trained in the country by Cuban and local health professionals. A few more doctors who have been trained in Indonesia and elsewhere will also soon enter the workforce. It is expected that the number of physicians in Timor-Leste in 2017 will be more than three times the number present in the country in 2003. Most of the new physicians are expected to work in rural communities and support the national government's goal of improving health outcomes for the rural majority. Although the massive growth in the medical workforce could change the way health care is delivered and substantially improve health outcomes throughout the country, there are challenges that must be overcome if Timor-Leste is to derive the maximum benefit from such growth. It appears crucial that most of the new doctors be deployed in rural communities and managed carefully to optimize their rural retention. Le Timor-Leste s'occupe actuellement d'un probleme essentiel du secteur de la sante du pays' l'effectif medical est trop restreint pour pouvoir dispenser des soins adequats. En theorie, un programme bilateral de cooperation medicale avec Cuba cree en 2003 pourrait resoudre ce probleme. A la fin de 2013, pres de 700 nouveaux medecins formes A Cuba ont rejoint l'effectif medical du Timor-Leste et d'ici 2017, 328 medecins supplementaires devraient avoir ete formes dans le pays par des professionnels de la sante locaux et cubains. Quelques autres medecins, formes en Indonesie et ailleurs, integreront bientot cet effectif medical. On s'attend A ce que le nombre de medecins exercant dans le Timor-Leste en 2017 soit trois fois superieur au nombre de medecins presents dans le pays en 2003. La plupart des nouveaux medecins devraient travailler dans les communautes rurales et soutenir l'objectif du gouvernement national d'ameliorer l'etat de sante de la majorite rurale. Bien que l'augmentation importante de l'effectif medical puisse changer la maniere de dispenser les soins de sante et ameliorer considerablement la sante dans l'ensemble du pays, des defis doivent etre surmontes pour que leTimor-Leste puisse tirer le benefice maximal de cette augmentation. Il semble crucial que la majorite des nouveaux medecins soient deployes dans les communautes rurales et geres soigneusement pour qu'ils restent le plus possible dans les zones rurales. Timor-Leste se encuentra en proceso de abordar una cuestion clave para el sector sanitario del pais' un personal medico demasiado escaso para proporcionar una atencion adecuada. En teoria, un programa bilateral de cooperacion medica con Cuba, creado en el ano 2003, podria solucionar este problema. A finales de 2013, casi 700 medicos nuevos formados en Cuba se unieron al personal medico de Timor-Leste, y se espera que profesionales de la salud nacionales y cubanos formen a otros 328 medicos en el pais hasta 2017. En Indonesia y otros lugares han recibido formacion algunos medicos mas, que se sumaran pronto a este personal. Se espera que el numero de medicos en Timor-Leste triplique en el ano 2017 el numero de medicos existentes en el pais en 2003. La mayoria de estos medicos nuevos trabajaran en comunidades rurales y respaldaran el objetivo del gobierno nacional de mejorar los resultados sanitarios de la mayoria rural. Aunque el Incremento masivo del personal medico podria cambiar el modo de proporcionar la atencion sanitaria y mejorar notablemente los resultados sanitarios en todo el pais, hay desafios que es necesario superar si Timor-Leste pretende obtener el maximo beneficio de dicho crecimiento. Parece fundamental que la mayor parte de los nuevos medicos se despliegue en comunidades rurales y se gestione con gran atencion para optimizar su permanencia en dichas zonas., Introduction The retention of health workers in rural areas has been the focus of increasing attention in recent years, particularly since the World Health Organization (WHO) launched its programme for [...]

Abstract Background Cuba has extended its medical cooperation to Pacific Island Countries (PICs) by supplying doctors to boost service delivery and offering scholarships for Pacific Islanders to study medicine in Cuba. Given the small populations of PICs, the Cuban engagement could prove particularly significant for health systems development in the region. This paper reviews the magnitude and form of Cuban medical cooperation in the Pacific and analyses its implications for health policy, human resource capacity and overall development assistance for health in the region. Methods We reviewed both published and grey literature on health workforce in the Pacific including health workforce plans and human resource policy documents. Further information was gathered through discussions with key stakeholders involved in health workforce development in the region. Results Cuba formalised its relationship with PICs in September 2008 following the first Cuba-Pacific Islands ministerial meeting. Some 33 Cuban health personnel work in Pacific Island Countries and 177 Pacific island students are studying medicine in Cuba in 2010 with the most extensive engagement in Kiribati, the Solomon Islands, Tuvalu and Vanuatu. The cost of the Cuban medical cooperation to PICs comes in the form of countries providing benefits and paying allowances to in-country Cuban health workers and return airfares for their students in Cuba. This has been seen by some PICs as a cheaper alternative to training doctors in other countries. Conclusions The Cuban engagement with PICs, while smaller than engagement with other countries, presents several opportunities and challenges for health system strengthening in the region. In particular, it allows PICs to increase their health workforce numbers at relatively low cost and extends delivery of health services to remote areas. A key challenge is that with the potential increase in the number of medical doctors, once the local students return from Cuba, some PICs may face substantial rises in salary expenditure which could significantly strain already stretched government budgets. Finally, the Cuban engagement in the Pacific has implications for the wider geo-political and health sector support environment as the relatively few major bilateral donors, notably Australia (through AusAID) and New Zealand (through NZAID), and multilaterals such as the World Bank will need to accommodate an additional player with whom existing links are limited.

Abstract Background District health systems in Africa depend largely on public funding. In many countries, not only are these funds insufficient, but they are also released in an untimely fashion, thereby creating serious cash flow problems for district health managers. This paper examines how the untimely release of public sector health funds in Ghana affects district health activities and the way district managers cope with the situation. Methods A qualitative approach using semi-structured interviews was adopted. Two regions (Northern and Ashanti) covering the northern and southern sectors of Ghana were strategically selected. Sixteen managers (eight directors of health services and eight district health accountants) were interviewed between 2003/2004. Data generated were analysed for themes and patterns. Results The results showed that untimely release of funds disrupts the implementation of health activities and demoralises district health staff. However, based on their prior knowledge of when funds are likely to be released, district health managers adopt a range of informal mechanisms to cope with the situation. These include obtaining supplies on credit, borrowing cash internally, pre-purchasing materials, and conserving part of the fourth quarter donor-pooled funds for the first quarter of the next year. While these informal mechanisms have kept the district health system in Ghana running in the face of persistent delays in funding, some of them are open to abuse and could be a potential source of corruption in the health system. Conclusion Official recognition of some of these informal managerial strategies will contribute to eliminating potential risks of corruption in the Ghanaian health system and also serve as an acknowledgement of the efforts being made by local managers to keep the district health system functioning in the face of budgetary constraints and funding delays. It may boost the confidence of the managers and even enhance service delivery.

Background: Universal health coverage (UHC) is critical to global poverty alleviation and equity of health systems. Many low-income and middle-income countries, including small island states in the Pacific, have committed to UHC and reforming their health financing systems to better align with UHC goals. This study provides the first comprehensive evidence on equity of the health financing system in Fiji, a small Pacific island state. The health systems of such states are poorly covered in the international literature., Methods: The study employs benefit and financing incidence analyses to evaluate the distribution of health financing benefits and burden across the public and private sectors. Primary data from a cross-sectional survey of 2000 households were used to assess healthcare benefits and secondary data from the 2008-2009 Fiji Household Income and Expenditure Survey to assess health financing contributions. These were analysed by socioeconomic groups to determine the relative benefit and financing incidence across these groups., Findings: The distribution of healthcare benefits in Fiji slightly favours the poor-around 61% of public spending for nursing stations and 26% of spending for government hospital inpatient care were directed to services provided to the poorest 20% of the population. The financing system is significantly progressive with wealthier groups bearing a higher share of the health financing burden., Conclusions: The healthcare system in Fiji achieves a degree of vertical equity in financing, with the poor receiving a higher share of benefits from government health spending and bearing a lower share of the financing burden than wealthier groups., Competing Interests: Competing interests: None declared.