DOOR Newsletter on East Timor home
"The present health system
is in danger of being hindered by methodologies and equipment that are
quite unsuited to the Timorese context, particularly after the foreign
technicians and agencies leave. Development does not necessarily have to
involve implementing sophisticated state of the art systems. The focus
should be on addressing the population’s real needs and building its capacity,
so that the Timorese themselves are able to create their institutions and
set their own priorities. This may mean that it takes longer to achieve
results, and these might be less spectacular in the short-term, but they
would certainly be more solid and long lasting." East
Subject: The health service: sustainable in
1. Health indicators
4. Official Health Services
5. Health providers
6. Health structures
7. Human resources
8. Pharmaceuticals and
9. Reproductive Health,
HIV/AIDS and STD
10. Mental health and
11. Health Sector Rehabilitation
& Development Programme
12. Other funds
The health service in East Timor must evolve
from the emergency phase, characterised by the presence of host of international
relief agencies, into a system that is capable of relying almost entirely
on the resources of a developing country. In this new context, the key
aspects to be considered are those that will help to maintain the structures
that are to serve most of the population. The health system being set up
will not only have to address the needs of the territory, where the prevalence
of diseases such as tuberculosis is indicative of inadequate nutrition,
hygiene and housing conditions, but will also have to be consistent with
the availability of technical resources, especially human resources, and
availability of budget funds to cover its costs.
1. Health indicators
Although they are not entirely reliable, health
indicators published by various international agencies show standards of
health in East Timor to be generally low. Among the most telling figures
are: the (perinatal) infant mortality rate that has risen from 70/90 in
the period prior to the post-referendum crisis to 135 per 1.000 births
(in Indonesia, the rate is 48/1,000, placing the country in the 109th position
out of 174 countries in the UNDP Human Development Programme Report); the
maternal mortality rate, which is estimated (probably underestimated) to
be between 300 and 850 per 100.000 at assisted and non-assisted births
(Indonesia’s rate is 390/100.000), while previously that rate was around
450 to 500/100.000; the % of births assisted by qualified health professionals,
which is now 20% in contrast to 40% previously; and the average life expectancy
rate that is under 50 years old (in Indonesia it is 65 years).
These figures place East Timor among the
most disadvantaged countries in the under-developed world. There are several
possible explanations for the worsening figures, of which the most likely
appears to be the changes to the health service: from the Indonesian model,
with a large poorly qualified health workforce, to the current model with
better qualified but much less numerous professionals.
Malaria, tuberculosis and diarrhoea are still
reported to be the main causes of death and illness. In spite of the implementation
of the Disease Surveillance System in September 1999, the number of confirmed
cases depends largely on the ability of healthcare providers working on
the ground to submit weekly reports to the WHO.
· Malaria is highly endemic in
all districts, with the highest mortality rates reported in children. In
the 1st quarter of 2000, almost 62,000 (approximately 8% of the population)
suspected malaria cases (including 40 deaths) were reported by the WHO.
In collaboration with Merlin and the International Rescue Committee, the
WHO implemented a malaria control campaign (Roll Back Malaria) to address
the need for better preventive action. The initial phase of the campaign
involved education in mosquito net usage, developing studies into malaria
and its treatment, and equipping the districts with laboratory systems
and diagnostic facilities.
· A nationwide programme aimed
to control mosquito-transmitted diseases [malaria and dengue] is being
organised by the WHO, and coordinated with an environmental health initiative.
Development projects, especially those involving “water and sanitation”
and agriculture may be associated with the spread of these diseases. They
should, therefore, be checked for any possible environmental impact before
being implemented, so that any negative effects on health may be avoided
(MERLIN, 20-7-00; WHO, 18-8-00).
· In June 2000, the number of active
TB cases was estimated to be around 8,000 - 1% of the entire population.
Of this number, over 1,300 were undergoing treatment, and 31% were patients
under 15 years of age (WHO, 18-8-00).
· The WHO, Caritas Norway and Caritas
East Timor, and Australia’s Menzies School of Health Research have been
actively supporting the establishment of a national TB control programme
in East Timor. By July, it was in operation in 9 districts (UN, S/2000/738,
26-7-00); 91% of all diagnosed cases (1,300) were being treated in just
TB 3 clinics (Motael, Bairo Pite e Becora), all in Díli, each enrolling
between 25 and 30 new patients a week (WHO, 18-8-00). By November, the
total number under treatment had risen to 2,800 (UNTAET, 2-11-00). Implementation
of the programme in all districts and the training of about 90 people in
TB identification were both factors that had contributed to the increase
(DHS, November 2000).
· In early March, UNICEF, in collaboration
with the WHO and other agencies, launched the 1st vaccination campaign
[Expanded Programme of Immunization] (UNICEF, 5-7-00); as a result, over
45,000 children were immunised against measles, and this significantly
limited the number of cases being reported (WHO, 18-8-00).
· In line with the worldwide campaign
“Race to Reach the Last Child:
Countdown to a Polio-free World”, “National
Immunization Days” were held to vaccinate over 100,000 children under five
against Polio, and distributing Vitamin A. The campaign was organised by
the Health Services Division of the East Timor Transitional Administration
(ETTA) and supported by national leaders, volunteers, international agencies
and NGOs and Peacekeeping Forces (PKF). As a result of the campaign, which
lasted for over a month between November and December 2000 (UNTAET, 13-10
and 3-11-00), an estimated overall coverage rate of 80% of the target group
was achieved (Joint Donor Review Mission, Nov. 2000).
3 to 4% of all children aged 6 months to 5
years are acutely malnourished. The main contributing factors are:
the vicious cycle of poverty, dietary deficiency and lack of knowledge
about appropriate weaning foods for babies and small children (WHO, 18-8-00).
Clusters of malnutrition have been identified, especially in the Ermera
district. This could be due to Ermera being a mainly coffee-growing rather
than subsistence agriculture area. A Timor
Aid report recommends that international agencies and NGOs be made
aware of the relationship between diet and health: “(...) If a large percentage
of a population is suffering from lesser illnesses and those people say
they have limited access to food (don’t get enough to eat), professional
investigation might show that diet of the general population is lacking
in certain nutrients; that is, that lack of sufficient nutrition is having
a detrimental impact on the health of that population” (Timor Aid, 30-11-00).
4. Official Health Services
· In December 1999, an East Timorese
Health Professionals’ Working Group (ETHPWG) was set up to develop guidelines
for the establishment of the territory’s new health system. In view of
the urgent need to coordinate the different strands of healthcare work
being carried out by a wide range of players, UNTAET established an Interim
Health Authority (IHA) in February 2000. This structure, consisting of
16 Timorese health professionals and 7 international staff, was to channel
the different healthcare initiatives into a single health service [see.
· From April to December 2000,
a planning mission run jointly with the IHA developed the Rehabilitation
& Development of the Health Sector Programme, within the scope of the
World Bank administered Trust Fund for East Timor
[TFET]; in August, the IHA was substituted by the Health Services Division
(HSD), to be supervised by ETTA’s Social Services Dept., headed by Father
Filomeno Jacob (HSD, Nov. 2000).
5. Health providers
In November, healthcare services in East Timor
were provided by various agencies: 15 international NGOs, 6 local NGOs,
23 Church organisations, 4 military contingents, and two private health
Non-Governmental Organisations (NGOs)
· NGOs responded with efficiency
to the humanitarian crisis that emerged after the 30 August 1999 referendum.
However, as transition from the emergency phase to development phase progresses,
their role has necessarily been changing.
· In order to extend healthcare
provision to the whole population, the IHA requested proposals from leading
NGOs for the provision and management of health services for each district,
in the form of a District Health Plan (DHP). After DHPs were submitted,
District health committees were set up in each district, and a Memorandum
of Understanding agreed between these committees and the HSD.
· By September, the 12 DHPs were
ready [the health plan for the District of Dili is being drawn up separately],
but only 4 Plans, in Baucau, Bobonaro, Aileu e Liquiça, had actually
been launched (WB-TFET update no.3, 6-10-00). This was still true
in November (Joint Donor Review Mission, Nov. 2000). One explanation for
the delay in implementing the DHPs is the difficulty in recruiting healthcare
staff (WB-TFET update no.6, 9-2-01).
· The announced departure from
Dili’s Central Hospital next June of the ICRC, which alone has been supporting
since October 1999, is going to give rise to serious problems. No NGO has
the capacity to run the hospital (210 beds, 26 international doctors, 311
Timorese professionals), and the official health service is not yet ready
enough to do so. This is just the kind of situation which will be repeated
when the international NGOs can no longer receive financial support from
the TFET and other emergency funding for their work in Timor (ICRC, 28-9-00).
Many of the specialised services, such
as dental care, ophthalmology, and even surgery, have so far been provided
by military contingents stationed in East Timor, such as battalions from
Japan, New Zealand, the US and Korea, as well as by other military teams
visiting the territory.
· Church-run clinics are to be
found throughout the territory, playing a vital role in providing medical
care ever since Indonesia’s occupation. These clinics are not, however,
part of ETTA’s HSD structure, but are supported and financed by the Church
· Timor’s Coffee Cooperative [NCBA]
set up 3 health posts and intends to open 14 more in the coffee-growing
districts (The La’o
Hamutuk Bulletin, 17-11-00). The NCBA (National Cooperative Business
Association) receives funding from USAID (USAID, 3-10-00).
6. Health structures
· In view of expected financial constraints,
the World Bank’s Health Programme quite drastically cut back the number
of existing health structures [see ETO HEA01]. In June 2000, there were
150 functioning health structures, many still in need of repair, and only
23 of which had any beds. Half of the total 592 beds were in Dili
(UNTAET, 29-8-00). By January this year, 3 hospitals (Baucau, Dili e Oecussi),
116 mobile clinics, 85 health posts and 71 community health centres were
functioning (UN S/2001/42, 20-1-01).
· According to the HSD, by November
at least 50 buildings had been rehabilitated and restored, mainly by NGOs,
and the contracts for implementing and supervising the construction of
25 health centres had been awarded. Kits of medical equipment and supplies
had also been distributed and lists of equipment for community health centres
and health posts finalised (HSD).
· The central medical laboratory,
rehabilitated by UNICEF with support from the Australia’s Northern Territory
University, has become operational (UNICEF, 15-1-01).
· One difficulty being encountered
is the supply and availability of medical equipment, which was largely
destroyed. In November, a joint emergency services’ mission from Australia
visited Timor to take stock of ambulances, equipment and staff, and assess
its operational relation to Timor’s health services (UNTAET, 21-11-00).
· A hospital (in Liquiça)
was rebuilt by Portuguese soldiers and the Municipality of Oeiras (Portugal),
and all the equipment sent to Timor. However, the undertaking, which
was carried out before the national health infrastructures plan was finalised,
turned out to be pointless as there is no provision in the plan for any
hospital in Liquiça, near Dili (Público, Portugal, 6-3-01).
7. Human resources
· Of the 135 doctors working in the
territory before the referendum, only 20 stayed on afterwards. However,
80% of the nurses and midwives were Timorese and remained in the country
(UN CCA, Nov.2000). This is leading to the redefinition of the roles and
responsibilities of available health workers:
“health workers of all categories will
have to take on extra roles and responsibilities, in both clinical and
administrative areas. It is crucial that these health workers are given
appropriate training for their new functions.” (WHO, 18-8-00).
· The size of the future health
workforce is giving rise to controversy because it is to be considerably
smaller than the workforce employed by the Indonesian administration (then
3,500 staff): UNTAET proposes 1,480 staff, while the NCC and CNRT,
concerned about sustainability in the future, are proposing 1,087 staff
(WHO, 18-8-00). By December, 1,077 staff had been recruited, including
54 permanent and 1,023 stipend contract staff (UNTAET e BM, 6-12).
· A wide variety of training schemes
have been provided to Timorese health workers: bacteriology-training course
for medical laboratory scientists (UNTAET, 17-7-00); 2nd training course
provided by UNICEF to the Association of Midwives of East Timor (UNTAET,
27-7-00). Less formal practical on-the-job training has also been provided
to health workers. However, very few training courses designed to promote
capacity-building of Timorese human resources have been delivered so far
· A National Centre for Health
Education and Training (NCHET) is now being established, which will integrate
various functions and disciplines. Its main responsibilities will be: to
enable students who are near to the end of their courses to complete them,
and to provide continuing education for health workers to facilitate their
adaptation to current needs (DHS e Joint Donor Review Mission, Nov. 2000).
8. Pharmaceuticals and drug
Reopened in Dili in April 2000, the Central
Pharmaceutical Warehouse (or Central Pharmacy), restored by UNICEF, Goal
and the IHA, is now the main drugs distribution centre in the country.
Since it opened, there have been developments in the pharmaceuticals area:
an Essential Drugs List for East Timor has been drawn up by a WHO technical
consultant, in consultation with Timorese doctors, to ensure rational and
cost effective drug prescription (UNTAET, 21-7-00); some progress has been
made in terms of regulations on pharmaceuticals (UNTAET and WB, 6-12-00);
and a start has been made on a new Central Medical Store (HSD, Nov.2000).
9. Reproductive Health, HIV/AIDS
· In July, UNICEF, supported by UNFMA
and UNAIDS [UN agencies for family planning and HIV/AIDS respectively]
sent a mission to undertake a first assessment of the HIV/AIDS situation.
It reported that, although there is insufficient information to assess
the existence of an HIV epidemic, and assumed that current rates HIV/AIDS
are low, there was a worrying combination of factors that could contribute
to a future increased prevalence, such as, low levels of awareness of HIV/AIDS
and sexually transmitted diseases (STD), lack of awareness-raising activities,
prevention and care; increased activity of male and female prostitution;
cultural and religious constraints in the use of condoms and open discussion
of these issues. The report also identifies vulnerable groups, such as
the large number of young expatriates, young school leavers, mobile populations
(traders, other expatriate workers), soldiers, police and guards (UNTAET,
17-7-00 and UN CCA, Nov. 2000).
· In view of this situation, the
UN is setting up a theme group on HIV/STD issues, which will work in liaison
with the HSD. The group’s tasks will include awareness-raising initiatives
and training of health staff, and it will coordinate the work between the
HSD, NGOs and the various UN departments (UNTAET, 15-12-00).
10. Mental health and psychosocial
· The IRCT
(International Rehabilitation Council for Torture Victims) conducted
a study on the extent of torture and trauma, and the post-conflict health
impact on the population. The study found that 97% of the sample (1,033
households, comprising a total of around 75,000 individuals, were interviewed)
had experienced at least one traumatic event, 57% had been subjected to
some form of torture, about 34% suffered from post-traumatic stress disorder,
12% had children who died as a result of political violence, 14% had lost
their spouse, and 22% witnessed the death of a relative or friend. The
study results have provided the basis for the proposed National Psychosocial
Rehabilitation Programme, and serve as a stark reminder of the urgent need
for attention to this area of health (The Lancet,
vol. 356, 18-11-00); as of October, there was no direct funding for
mental healthcare from the district health service, and the only assistance
was being provided by just two NGOs - PRADET and FOKUPERS
(UNTAET, 5-10-00). In November, with support from the Australian
Government, psychiatrists began to arrive in the territory for periods
of one week per month (The
La’o Hamutuk Bulletin, 17-11-00 and HSD, Nov.2000).
· The appropriateness of western-style
psychiatric/psychosocial support practices to heal the deep psychological
wounds caused by such trauma is questionable. Are they likely to be effective
in the context of health sequelae left on an entire population by decades
of wide-scale repression and violence, especially when the presence of
other elements, such as communication difficulties (linguistic and/or cultural
factors) compound the medical aspects? The East Timorese victims themselves
say they look primarily to family members, the church, and the local community
for assistance (The Lancet, vol. 356, 18-11-00),
but for some, their cultural tradition (e.g. rejection
of women rape victims and of children born as a result of rape) only
actually exacerbates the trauma they suffer.
11. Health Sector Rehabilitation
& Development Programme
· The overall goals of the Health Sector
Rehabilitation & Development Programme, financed by the WB-TFET, are
to restore access to basic health services and develop a health policy
and system. Agreement on the first tranche of grants (for US$12,7 million,
of a total US$38 million over a 3-year period) was signed in June 2000,
for the first 15 months of the project [see ETO HEA01].
· A joint donor mission visited
the territory from 10 to 22 November, to: assess implementation of phase
1 of the programme [from July 2000 to August 2001]; initiate discussion
of preparations for phase 2 that will run from July 2001 to June 2003 and
cover support for the ET Health Programme, and, lastly, to explore ways
to consolidate the option of wide access to health services option (Joint
Donor Review Mission, Nov. 2000).
12. Other funds
In addition to the multilateral WB fund and
ETTA budget, other sources provide funding for health service: humanitarian
aid given by NGOs, provided mainly by ECHO, and bilateral cooperation and
technical cooperation from UN agencies.
The health sector in East Timor is confronting
a vast range of problems and needs. In the territory’s current context
and the time constraints imposed, resolving these healthcare issues is
going to be an uphill struggle. Although any health service has to
consider the patients, availability of material resources, and availability
of qualified human resources to adequately address patients’ needs, in
East Timor there are also other considerations:
1. The most widespread and deadly
diseases are malaria, tuberculosis and diarrhoea. Greater preventive measures
are vital if these are to be controlled, especially in terms of providing
people with better sanitation and food hygiene conditions. As the WHO has
been insisting, the problem of mosquito-transmitted diseases must be tackled
at the source, and more effective and sustainable options must be found.
In the words of Timorese physician Sérgio Lobo, “most diseases in
East Timor do not need to be treated by doctors. Nurses and trained local
health workers are able to treat many of these diseases with existing resources”
2. In the emergency situation they
encountered on arrival in East Timor, the international agencies responded
in the right way to the exceptional circumstances, for which they are usually
highly prepared. However, integrating these agencies in what is to be a
comprehensive healthcare plan for the long-term future is, unquestionably,
foreign to their specificities, expertise and customary line of work, and
even beyond their mandate and/or funding;
3. Establishing an adequate medical
corps has to be a medium to long-term objective, because there are so few
qualified senior healthcare professionals in East Timor. Using the health
professionals that are currently available and that can respond effectively
the population’s most pressing needs should, therefore, be a priority.
While senior professionals are being trained in the various branches of
medicine, the role of other professionals with training and experience,
for example nurses and midwives, should be redefined.
4. There is an apparent incompatibility
between the desire to provide a free and accessible public health service
and the constraints on a new country’s financial resources. Bishop Belo
says that “Health is just as much a question of political will as it is
of basic economic level” (CNS, 5-7-00), but unless resources are limitless,
some choices will have to be made, and priorities set that will benefit
the majority of patients. A compromise solution might be to split healthcare
services, so that the public health service would be responsible for preventive
medicine and combating widespread diseases, while more specialised healthcare
would be provided by private services or NGOs.
5. The present health system is
in danger of being hindered by methodologies and equipment that are quite
unsuited to the Timorese context, particularly after the foreign technicians
and agencies leave. Development does not necessarily have to involve implementing
sophisticated state of the art systems. The focus should be on addressing
the population’s real needs and building its capacity, so that the Timorese
themselves are able to create their institutions and set their own priorities.
This may mean that it takes longer to achieve results, and these might
be less spectacular in the short-term, but they would certainly be more
solid and long lasting.
Documents and information on this issue were compiled by the East Timor
Observatory between 1-7-2000 and 28-2-2001, in a 46-page thematic dossier,
“Health - ref. HEA02” (for further information and to order, please contact
the East Timor Observatory). The La’o Hamutuk Bulletin contains
additional information on health issues in East Timor. See
Observatory for the monitoring of East Timor's
transition process a programme by the 'Comissão para os Direitos
do Povo Maubere'
Coordinator: Cláudia Santos
Rua Pinheiro Chagas, 77 2ºE - 1069-069
Lisboa - Portugal
ph.: 351 1 317 28 60 - fax: 351 1 317 28 70 - e-mail:
Timor Leste Updated Jan 25
Duas Organizações Não
Governamentais portuguesas, a COMISSÃO PARA OS DIREITOS DO POVO
MAUBERE (CDPM) e o grupo ecuménico A PAZ É POSSÍVEL
EM TIMOR LESTE que, desde o início da década de oitenta,
se solidarizam com a causa do Povo de Timor Leste, tomaram a decisão
de criar o OBSERVATÓRIO TIMOR LESTE. A vocação do
Observatório Timor Leste é, no quadro das recentes alterações
do regime de Jacarta face a Timor Leste, o acompanhamento, a nível
internacional, do processo negocial e, no interior do território,
do inevitável período de transição que se anuncia.
correio electrónico: email@example.com
Timor Observatory Updated Jan 25
ETO was set up by two Portuguese NGOs
- the Commission for the Rights of the Maubere People (CDPM) and
the ecumenical group Peace is Possible in East Timor, which
have been involved in East Timor solidarity work since the early eighties.
The aim of the Observatory was to monitor East Timor's transition process,
as well as the negotiating process and its repercussions at international
level, and the developments in the situation inside the territory itself.
Timor-Oriental Updated Jan 25
Deux Organisations Non Gouvernementales
portugaises, la ‘Commission pour les Droits du Peuple Maubere’ et l’association
oecuménique "La Paix est Possible au Timor Oriental", qui se solidarisent
avec la cause du peuple du Timor Oriental depuis le début des années
80, ont pris la décision de créer un OBSERVATOIRE TIMOR ORIENTAL.
La vocation de cet observatoire est d’accompagner le processus de transition
du Timor Oriental, aussi bien le processus de négociation que ses
répercussions au niveau international et l’évolution de la
situation à l’intérieur du territoire.
courrier électronique: firstname.lastname@example.org
Boletim La’o Hamutuk:
[Tetum PDF format]
Vol. 1, No. 3. 17 Novembro
2000 Hari Sistema Saude Nasional iha Timor Lorosa’e: http://www.etan.org/lh/PDFs/LHbul3tm.pdf
La'o Hamutuk Bulletin:
Vol. 1, No. 3: 17 November
2000 Building a National Health System for East Timor: http://www.etan.org/lh/PDFs/lhbul3en.pdf
DOOR Newsletter on East Timor home
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