Country Learning on Maintaining Quality Essential Health Services (EHS) during COVID-19 in Timor-Leste: A mixed methods qualitative analysis
Authors: Kleine-Bingham Melissa , Rangel Gregorio , Sarakbi Diana , Kelleher Treasa , Mensah-Abrampah Nana , Neilson Matthew , Bodson Oriane , White Philippa , Bothra Vinay , de Carvalho Helder M. , Pinto Feliciano da C.A. , Syed Shamsuzzoha Babar 
Published: January 2023

ABSTRACTObjectiveThis research study examines the enabling factors, strengths, and challenges experienced by the Timor-Leste health system as it sought to maintain quality essential health services (EHS) during the COVID-19 pandemic.DesignA mixed methods qualitative analysisSettingNational, municipal, facility levels in Baucau, Dili and Ermera Municipalities in TLSParticipantsKey informant interviews (n=40) and focus group discussions (n=6) working to maintain quality EHS in TLS.ResultsA reduction in people accessing general health services was observed in 2020, reportedly due to fears of contracting COVID-19 in healthcare settings, limited resources (eg. human resources, personal protective equipment, clinical facilities, etc) and closure of health services. However, improvements in maternal child health services simultaneously improved in the areas of skilled birth attendants, prenatal coverage, and vitamin A distribution, for example. Five themes emerged as enabling factors for maintaining quality EHS including 1) high level strategy for maintaining quality EHS, 2) implementation of quality activities across the three levels of the health system, 3) measurement for quality and factors affecting service utilization 4) the positive impact of quality improvement leadership in health facilities during COVID-19, and 5) learning from each other for maintaining quality EHS now and for the future. Other countries may benefit from the challenges, strengths and enablers found on planning for quality.ConclusionThe maintenance of quality essential health services (EHS) is critical to mitigate adverse health effects from the COVID-19 pandemic. When quality health services are delivered prior to and maintained during public health emergencies, they build trust within the health system and promote healthcare seeking behavior. Planning for quality as part of emergency preparedness can facilitate a high standard of care by ensuring health services continue to provide a safe environment, reduce harm, improve clinical care, and engage patients, facilities, and communities.DATA SHARINGAll data is kept with MBK and GR and is available upon request. The dataset analysis is available from the corresponding author upon reasonable request.QUALITATIVE CHECKLISTThe Standards for Reporting Qualitative Research (SRQR) checklist was used for this original research.STRENGTHS AND LIMITATIONS OF THIS STUDYThe qualitative data gave detailed insights to the operationalization of key strategic COVID-19 emergency documents and the national quality implementation strategy.Data collection was performed in three out of thirteen municipalities, including the largest metropolitan city of Dili.The qualitative research was conducted in the participants native language (Tetum).Not all pre-identified national level KII participants were available to provide feedback.