Challenges

This section should provide an overview of the challenge(s) the project is seeking to overcome in the country or region in which the initiative is being implemented in (or has been implemented), as well as what is required to address them for the achievement of one or more of the SDGs.

Timor-Leste faces the highest maternal mortality ratio (MMR) in Southeast Asia at 195 deaths per 100,000 live births according to the 2019 Demographic Health Survey while Thailand’s MMR in 2022 is 27 per 100,000 live births (SDG target is less than 70 death per 100,000 live births). This critical health challenge in Timor-Leste is linked to limited access to quality maternal care, particularly due to gaps in midwifery education and practice. Timor-Leste requested support from Thailand through UNFPA country offices in Timor-Leste and Thailand who reached out to the Ministry of Foreign Affairs’ Thailand International Cooperation Agency (TICA) to enhance midwifery capacity in Timor-Leste to reduce maternal death and increase safe birth for all.

Toward a Solution

This Thailand-Timor Leste SSTC initiative contributes directly to SDG 3: Good Health and Well-being, Target 3.1 – Reduce the global maternal mortality ratio to less than 70 per 100,000 live births) and and SDG 5 Gender Equality, Target 5.6: Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences.

To address the challenges of Timor-Leste’s high maternal mortality ratio UNFPA Thailand and Timor-Leste Country Offices facilitated rounds of online discussion between the Thai and Timor-Leste Governments and came to an agreement to pursue a systematic three-phase approach which exemplifies effective SSTC. First, a deployment of a mission to conduct a comprehensive assessment in Timor-Leste by TICA, Thai NEDA, Thai midwife nurse instructor experts along with UNFPA Thailand officials in August 2023 to conduct a comprehensive needs assessment in August 2023. Using the WHO-ICM midwifery educator competencies framework, the assessment results identified three key challenges which are 1) lack of standardized national midwifery program management aligned with WHO-ICM requirements, 2) insufficient management capacity of midwifery colleges and training hospitals, and 3) inconsistencies across midwifery curricula between institutions. These are in addition to the lack of appropriate and adequate maternal clinic infrastructure. These gaps contribute to varying levels of midwifery graduate competencies, limited employment of qualified midwives in rural communities, insufficient equipments and facility for materal care and ultimately to preventable maternal and newborn deaths.

Second, a knowledge exchange study visit by Timor-Leste delegates to Thailand in November 2023 which brought 11 high-level Timorese delegates from the Ministries of Health and Education and UNFPA Timor-Leste official to learn about Thailand’s successful midwifery governance system and education. Participants visited key institutions including the Thai Ministry of Public Health, Nursing and Midwifery Council, and educational institutions to gain practical insights into regulatory frameworks and quality assurance mechanisms. The final phase focused on implementing lessons learned through co-creation of curriculum harmonization and institutional capacity building. The process demonstrates genuine triangular partnership among Thailand, Timor-Leste, and UNFPA.

Thailand provided technical expertise in midwifery education standards based on its successful experience developing regulatory frameworks and quality assurance systems. Timor-Leste led the identification of priority areas based on their contextual needs and committed to implementing necessary reforms. UNFPA played the critical third-party facilitation role by coordinating between partners, providing technical guidance, and ensuring alignment with international standards.

Thailand’s successful model in establishing nursing and midwifery councils, developing standardized curricula, and implementing quality assurance mechanisms was transferred through both formal presentations and practical observations during the study visit. Timorese participants gained insights into regulatory frameworks that they could adapt to their context. UNFPA’s facilitation enhanced the effectiveness of this exchange by bridging language and cultural barriers and providing additional technical resources.

Several outcomes are already emerging that directly contribute to SDG targets. The National Agency for Academic Accreditation (ANAAA) has proposed formal cooperation with Thailand’s Ministry of Higher Education, Science, Research and Innovation to strengthen accreditation processes for midwifery programs. Participants have initiated plans to establish a Timor-Leste Midwifery Council as a regulatory body. Additionally, curriculum harmonization efforts have begun across the three midwifery schools. These structural changes will ultimately contribute to reduced maternal mortality by ensuring competent midwives throughout the healthcare system.

The initiative’s innovation lies in its comprehensive approach that addresses both immediate capacity needs and underlying systemic issues. Rather than focusing solely on infrastructure or training, it tackles the root causes of quality variation in midwifery education through policy and regulatory frameworks. The triangular arrangement adds value by combining Thailand’s context-relevant experience with UNFPA’s technical expertise and global standards.

Sustainability is ensured through institutional capacity development rather than individual training. The planned Midwifery Council will provide ongoing quality oversight beyond the project timeframe. Formal cooperation agreements between Thai and Timorese institutions will facilitate continuous knowledge exchange. In addition to technical and capacity development support by UNFPA and TICA, Thai NEDA’s financial commitment of USD 500,000 also supports infrastructure improvements and capacity development, as demonstrated by the development of Basic Emergency Obstetric and Newborn Care Centers in Baucau Municipality.

The model is highly replicable in various contexts with similar challenges in maternal health and midwifery education systems. Key conditions for replication include: government commitment to regulatory reform, engagement of professional associations, availability of a mentor country with relevant experience, and facilitation support from an international organization. The systematic methodology – needs assessment, knowledge exchange, institution strengthening – provides a flexible framework that can be adapted to different contexts while maintaining the core principles of effective South-South and Triangular Cooperation.

Key lessons learned include the importance of mutual understanding and clear expectation of the SSTC from all parties. For this case, it was strategic and practical to have a comprehensive needs assessment before designing interventions, the value of exposing policymakers to functioning regulatory systems in similar contexts, and the effectiveness of addressing both individual capacity and systemic frameworks simultaneously. Feedback from Timorese participants confirms that this South-South and Triangular Cooperation approach provided contextually relevant solutions that would have been difficult to achieve through traditional North-South assistance.