The collapsing borders of the more-than-national health system of Timor-Leste

Karel Caals1

1Department of Geography, Faculty of Arts and Social Sciences, National University of Singapore, Singapore, Singapore

Globalisation debates in health often pit global health against national health systems. Some argue that (ill) health does not stop at borders: “viruses don’t have passports”; that the nation-state is passé, and that in the 21st century, issues in health can only be addressed globally. Others resist this discourse and put forward the notion that only strong national health systems can guarantee health in an equitable way. In contrast to these positions, I argue that this dichotomy is ultimately false. Additionally, such classic (anti-)globalisation debates lose sight of the local. In this paper, I propose an alternative conceptual framework named the more-than-national health system in which issues in health are considered concurrently on global, national and local levels.

This paper illustrates the application of the more-than-national health system approach by explaining how Timor-Leste has addressed its health workforce needs in a manner that challenges conventional understanding in health systems development. Since its independence, Timor-Leste has drawn on an assemblage of health workforce resources from seemingly opposing sources to meet its health workforce needs. The Cuban Medical Brigade has trained almost 1,000 doctors, while The Royal Australasian College of Surgeons is preparing some doctors for specialist training in Papua-New-Guinee and Fiji. Additionally, some East Timorese were invited to study medicine in China. Similarly, nurses and midwives are trained in Timor-Leste and Indonesia, while the Australian NGO St John of God assists the national hospital with additional on-the-job training. The more-than-national health system approach draws on qualitative research carried out in Timor-Leste to show how its health system has been re-assembled with resources that cut across the global, national and local, to meet its health workforce needs. It is further argued that this approach gives greater attention to health workforce deficiencies and could thereby better support ethical decision-making on public health policies.


Karel CAALS worked as a research assistant at the NUS Centre for Biomedical Ethics, where he was involved in projects ranging from end-of-life care to access to medicines, and clinical trials in low-and-middle-income countries. This is where he developed an interest in the fields of Health Systems, Global Health and Medical Travel, and what inspired him to pursue his PhD in Human Geography at NUS. As a Health Geographer, he explores different forms of association between health systems, studying Timor-Leste and its relations with various health systems of countries such as Cuba, Australia and Indonesia, as these countries collaborate with the East Timorese health system on medical care and training.

About the Association

The Australasian Association of Bioethics and Health Law (AABHL) was formed in 2009.

It encourages open discussion and debate on a range of bioethical issues, providing a place where people can ask difficult questions about ideas and practices associated with health and illness, biomedical research and human values.

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