We should all understand that Liberation
of the Fatherland is only half the objective of independence.
After independence, Liberation of the People constitutes the other half of the objective of independence.
(Xanana Gusmão, 1999)
East Timor Observatory
Subject: Health - international agencies withdrawing already
Many international organisations and Timorese
NGOs operating in East Timor since October 1999 were involved in the provision
of health services. They came to provide emergency healthcare and/or to
support the creation of a health service that would adequate address the
needs of the East Timorese after the emergency phase. Two years on, some
agencies are leaving and others are preparing to do so. What is the health
status of the Timorese now, and how has international intervention helped
to consolidate the new country’s health service?
1. Health indicators:
Previous indicators reveal extremely poor
health: Under-5 Mortality Rate of 125 per 1.000 live births, and maternal
mortality ratio 890 per 100,000 live births (World Bank Mission Report
1999). Eighteen months after that report, the WHO says it is difficult
to verify current figures, and believes previous figures may have been
underestimated (WHO, 15-6-01).
The most prevalent diseases continue to be those reported in ETO’s previous documents (HEA01 and HEA02), namely: malaria, TB and diarrhoea. However, as health teams’ work progressed, it became clear that these diseases were far more widespread than previously anticipated. The WHO coordinated infectious disease surveillance system recorded, since January 2000, over 162,357 cases of malaria, over 62,500 cases of lower respiratory tract infection and over 50,000 cases of diarrhoea (WHO, 15-6-01).
a) Malaria, dengue, Japanese encephalitis - The WHO reports that these vector-borne diseases are endemic; cases of Japanese encephalitis have been identified for the first time in East Timor, and it is now considered an important public health problem. Malaria is the most common reported cause of death, especially among children. Death rates among those contracting dengue and Japanese encephalitis are 10% and 20-40% respectively. Incidence of malaria is higher in four districts: Lautém (Lospalos), Manatuto, Aileu and Dili. Peak malaria transmission periods are usually July/August and in December/January, although in Lautém transmission periods are longer. P falciparum and P vivax are most common, and chloroquine resistant strains have been reported (WHO, 15-6-01).
b) Tuberculosis - The alarm was raised back in September 1999, when TB was diagnosed in 3% of the 1,500 Timorese who, after taking refuge at the UN headquarters in Dili to escape militias, were evacuated to Australia. In March 2000, 557 TB sufferers were being treated in Dili, while 50 cases had been diagnosed outside the capital. In June, the number of patients receiving treatment was 1,300, while WHO estimates for the total number of active cases was 8,000 (WHO, 18-8-00). One year later, the TB control programme covered 23 of the territory’s 65 sub-districts, and the estimated number of active cases had risen to 20,000 (2,500 per 100.000 inhabitants). Multidrug resistant TB cases have been reported. The WHO says TB is a major health problem. (WHO, 15-6-01).
c) Diarrhoeal diseases - There is a high incidence of watery and bloody diarrhoea - 41,397 and 7,131 registered cases respectively. The WHO estimates that 80% of all children have intestinal parasitic infection (WHO, 15-6-01). In the Oecussi district, diarrhoea led to 50 deaths in April (Timor Post, 25-4-01) and 6 deaths in September (Lusa, 27-9-01).
d) Reproductive health - The WHO reports that sexually transmitted infections (STI) are common, and that about 35 cases per week are treated, mostly in Dili and Baucau (WHO, 15-6-01).
Conditions nowadays for the spread of HIV/AIDS
- rare in East Timor before 1999 (only one reported suspected death due
to AIDS) - are now more favourable (in part, due to the significant influx
of foreigners and young male expatriates). 7 out of 531 potential blood
donors screened by the WHO since February 2000 for HIV infection and Hepatitis-B
were found to be positive for HIV infection.
The WHO has prioritised combating the high maternal mortality rate (referred to above), providing training for 335 midwives and for 1,647 ‘dukun’ - traditional birth attendants who previously had no medical training.
e) Mental health - There is no formalised mental health care to respond to the high incidence of mental disorder, often linked to the military occupation and 1999 violence (see HEA02): not only are there no Timorese mental health professionals, but also the population generally is not familiar with concepts of mental disorders.
f) Other illnesses - A study of pregnant women at the ICRC Hospital and Dili’s Bairro Pite clinics revealed that 6.4% were positive for Hepatitis B. Newborns should, therefore, be vaccinated, but this would only be possible after improving the performance of the routine immunization programme coverage.
g) Malnutrition - In spite
of the heavy presence of agencies specialised in emergency aid, WHO reports
suggest that, in some districts, 3- 4% of children aged 6-months to 5 years
are acutely malnourished and 20% are chronically malnourished (WHO, 15-6-01).
The problem particularly acute in certain areas of coffee monoculture districts,
while food shortage is chronic throughout the territory from November to
February, before the rice harvest (February-April), and affects almost
80% of the population January (National Development Agency, 16-6-01).
3. Human resources
a) Around 2,000 of the 2,632 Timorese who, prior to 1999, were employed by the Indonesian administration’s health service, are currently living in East Timor. However, for reasons of finance and future sustainability, the number of health workers in the new official health service was cut down to 1,087 employees. There are plans to allocate a further 367 posts in the coming fiscal year. The majority of Timorese health workers are nurses and midwives, as most doctors and senior health staff were Indonesian and are now unlikely to return to East Timor. Of the 34 known East Timorese doctors, 25 are in East Timor, 3 are currently studying in Australia, and 6 are living overseas (contacts being underway to bring about their return to the territory) (WHO, 15-6-01). A number of medical students (10 to 14 according to sources) returned to Jakarta to continue their studies. There is only one Timorese X-ray technician, and very few qualified lab technicians.
b) UN agencies and other international organisations attracted a large number of expatriates, many highly qualified, and employed an often high number of Timorese: the Dili Hospital, run by the ICRC until the end of June, employed 45 expatriates and 315 Timorese. As agencies left, however, problems arose when the same Timorese health workers became employees of the national health service. At the Dili Hospital, for example, they protested about pay in the public service (between US$123 and US$154 per month) (Suara Timor Lorosae, 2-7-01).
c) ICRC staff left in late June, before the international medical staff due to substitute them had been recruited. While recruitment of new staff was underway, the Dili Hospital was reduced to providing just “essential” services, and these were only possible thanks to the intervention of the Dutch NGO Cordaid (Trust Fund TFET, 8-01). Some NGOs worked for the Transitional Administration’s Health Directorate on 3-month contracts from July to September (IMC, CAM, MDM-France, MDM e AMI-Portugal), while others prepared to do so for the last quarter (Healthnet, Oikos and IMVF) (TFET, 11-9-01). On 28 September, the Health Minister, Timorese doctor Rui Araújo, thanked the departing NGOs for their help: World Vision, Timor-Aid (Australia), MDM (France), AMI e Oikos (Portugal). Others will be leaving at the end of January 2002. The Minister said that now that the emergency phase was over, it was time for the Timorese health service to take over the responsibilities in the development phase. Control of the service by the Timorese is a priority for the new Government (UNTAET, 27-9-01).
d) “Since a minimums of 6-7 years
is needed to educate and train a doctor, … the roles of trained nurses
and auxiliary staff have to be redefined” (WHO, 16-5-01). Nurses and
midwives will, therefore, need extra training to equip them for their extended
roles and functions. In an attempt to offset shortages, the World Bank-led
Trust Fund is seeking, internationally, 20 to 25 doctors for the districts
and sub-districts, and 15 to 20 specialists for hospitals, as well as some
technicians (TFET 12, 11-9-01).
4. Material resources
a) The National Development Agency reports there are 191 fixed health structures: 9 hospitals, 9 community centres (CC) with beds, 107 CC without beds, and 66 medical posts, in addition to 27 mobile units. The opening hours and staffing of these structures varies, even among the same type of structure: some hospitals are permanently open while others are only open to the public on 16 days per month and for 6 hours per day. Hospital staffing varies from 115 to 7; averages for the 9 hospitals are: 26 days/month, 22 hours/day and 57 health professionals on duty. At the CC with beds, the averages are 23 days, 17 hours/day and 13 professionals. Averages for the CC without beds are 16 days/month and open for 7 hours daily. For the medical posts, the averages fall to 8 days/month and 6 hours/day, and only 3 days/month for mobile units.
Of the 592 available beds, around half
are in Dili, 226 of which are in the Dili Hospital. The 44 beds in Lospalos
were not enough, and some patients were being treated on the hospital floor
(The Lancet, 17-3-01).
50% of the structures belong to the public sector, 39 % belong to NGOs, 8% to Churches, and 3% to the private sector. Services are charged for in 11% of the State structures, 5% of the NGO structures, 65% of the church structures and 57% of private sector structures.
b) From January 2000 to May 2001, 979,912 consultations and curative interventions were provided by NGOs and international military medical teams (WHO 15-6-01). In March, TFET calculated the rate at which individuals were using health services to be 0,2 per quarter (less than one consultation/treatment session per year). The services registered varied considerably according to the time of year, the district and, above all, the regularity of feedback from the bodies involved.
The WHO report (15-6-01) stated that, as of March 2001, 80% of the population had access to a permanent health care facility within two hours, but that utilization was low with below 40% of health facilities being appropriately utilised.
c) From April to June TFET sought tenders for the building of the central medicines warehouse (AMS) and 22 community health centres: Cômoro, Becora and Hera (Dili); Fatumasi and Maubara (Liquiça), Atsabe and Hatolia (Ermera); Acumao and Nameleso (Aileu); Balibo and Bobonaro (Bobonaro); Hatubuilico and Hatu Udo (Ainaro); Clacuc and Mahaquidan (Manufahi); Orlalan and Uma Boco (Manatuto); Laleia and Vemasse (Baucau); Iliomar, Lautém and Luro (Lautém). The districts of Covalima, Viqueque and Oecussi were not included. The World Bank expected 25 centres be ready by December 2001 (WB, TFET Summary July-December 2000), but construction work on the first 21 centres is only likely to commence in October (TFET, update 12, 11-9-01).
The WHO considers the Central Laboratory,
opened in June 2000 and scheduled for renovation work in July 2001, to
have a very limited capacity, and described the network of district laboratories
as “very basic” (only malaria and TB microscopy). They are faced with problems
ranging from unreliable electricity supply and staff shortages to lack
of reagents (WHO, 15-6-01).
a) In May 2000 the IHA (Interim
Health Authority), composed up of 16 Timorese health professionals and
7 expatriates, developed the following strategic aims:
1) delivery of basic services to the maximum possible population,
2) training for Timorese health workers,
3) ensure more efficient use of resources,
4) non-interference (by NGOs) in the development of the future health system,
5) take into account the principles developed by the East Timorese Professional Working Group (ETPWG), including sensitivity to culture, religion and traditions of the East Timorese people.
b) To address the shortcomings in public health services, health service authorities identified one lead NGO in each district to plan, organise and manage the provision of services, and draw up a District Health Plan. The differing characteristics of the NGOs themselves resulted in considerable variations between the various health plans developed and in “difficulties in communications” (WHO, 15-6-01) and in “coordination” (The Lancet, 17-3-01) with the public services.
c) Efforts have been made to identify essential services and priorities, draw up rules, list basic equipment and medicines, define integrated strategies to combat a particular disease or a range of childhood diseases, with emphasis on prevention with the professionals available, and on basic public education in nutrition and food safety. Furthermore, there has been focus on measures to improve physical conditions in an attempt to combat the spread of epidemics. All this work has been started and it is important that it continues:
· The Infectious Disease Surveillance & Epidemic Preparedness (IDSEP) Unit, which publishes a Weekly Epidemiological Bulletin; although feedback from teams on the ground is sometimes irregular, this organisation has managed to provide a more accurate picture of public health and made more comprehensive and concerted action possible.
· The vaccination programmes were successful when they were launched as nationwide campaigns, such as the National Immunisation Days that covered over 84% of the children targeted, but routine childhood immunisation has fallen far short (20%) of the set targets, so, for example, generalised child immunisation against Hepatitis B if failing.
The danger of relapses is real: immunisation programmes for polio and for routine immunisation, which in 2000 reached 92% and 19% respectively in the sucos (administrative division above village level), had, by March 2001, dropped to 4% and 12% respectively (National Development Agency, 16-6-01).
· Integrated strategy to combat malaria: mapping of high risk areas/peak periods; preventative measures: distribution of mosquito bednets, especially for children and pregnant women; reduction of vector breeding sites and promotion of water storage in mosquito proof containers (dengue control), improving drainage systems, environmental health impact assessment of all development projects, especially those involving water resources for agriculture; timely diagnosis and treatment of malaria.
The mosquito net distribution and sanitation programmes that, in 1999-2000, were being implemented in 66% and 24%, respectively, of the sucos, had reduced drastically by March 2001, when they were only active in 1% and 8% of the sucos respectively (National Development Agency, 16-6-01).
Intervention by the Australian NGO Merlin and the district laboratories has been vital to the distinctive treatment now being given for malaria, dengue and Japanese encephalitis. The future establishment of district laboratories with adequate diagnostic facilities is essential.
· Integrated Treatment of Childhood Illnesses (IMCI): 60% of child deaths are the result of respiratory infections, diarrhoea and malaria. Vaccination, vitamin A, childhood nutrition, improved family and community nutrition and food safety, can all be part of the same programme. In July, an 11-day training course was held for IMCI trainers and supervisors.
· Sexually Transmitted Diseases & AIDS Working Group: the fact that this 12-member group now includes representatives of the Catholic Church, Timorese NGOs and medical associations, may help to minimise problems arising from the introduction of means to prevent these diseases.
- National Essential Drugs List: useful in any situation, this list is all the more essential in view of the prevalence of certain diseases. Since most health facilities will have to be staffed by nurses/auxiliary staff, detailed instructions with the List have also been prepared for use by such staff.
· National Centre for Health Education and Training (NCHET): this centre must define and systematise training in areas where, previously, learning was empirical. For the reasons outlined above, nurses and midwives now need to receive a broader type of training. Delays in the training of laboratory technicians are due to delays in staff recruitment (WHO, 15-6-01).
d) On the question of the health
service, Fretilin’s election programme prioritised
the development and provision of broad educational and preventative services,
focusing particularly on endemic and contagious diseases: compulsory vaccination,
medical assistance in schools, healthcare for mothers and children. Fretilin
stated that, while developing conventional medicine, it would not undermine
the country’s traditional medicine, and would develop models for provision
of free medical assistance for the elderly, as far as the country’s finances
1. The health sector is one of the areas that most benefited from international emergency aid: qualified specialist workers and relatively abundant international funding, especially from the Trust Fund. However, all this is beginning to be phased out.
2. Even before the August 1999 referendum, in seminars dealing with development issues, the World Bank and Timorese leadership were underlining the importance of ensuring the sustainability of the future health service. But the contradictions between providing emergency aid and constructing a suitable sustainable health service model do not disappear just because there is awareness of them.
3. Contrasting levels of expertise among the medical professionals (foreign and Timorese) did not help to consolidate genuine teamwork. The technical know how of the foreign professionals naturally led to an emphasis on technical skills. There were times when foreign doctors, in their dealings with patients, used Timorese nurses merely as interpreters, while there were also cases of absenteeism among the Timorese health workers.
4. The most prevalent diseases are usually linked to development-related structural conditions: sanitation in the case of malaria, housing, nutrition and food hygiene in the cases of TB and diarrhoea. Prevention rather than cure is the way to go about combating these diseases. A large body of sanitation professionals concentrating on preventative measures could go some way towards compensating for a less qualified medical professional body. Before a new prevention/cure balance is established, the presence of foreign doctors is vital if a general worsening of the situation is to be avoided.
5. While international NGOs were in charge of the health service during the UN Administration phase, doctors recruited for the next phase must be prepared to fit in to a Timorese-run service, and to give greater importance to collaboration, for which they will need skills that go beyond their medical/technical expertise.
6. The international community must honour its pledges, not only in terms of rehabilitating buildings and healthcare provision, but also its pledges to help set up appropriate sustainable services and to train Timorese health professionals.
Observatório 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 URL: http://homepage.esoterica.pt/~cdpm/framep.htm
East 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.
E-mail: firstname.lastname@example.org Homepage: http://homepage.esoterica.pt/~cdpm/frameI.htm
Observatoire 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: email@example.com URL: http://homepage.esoterica.pt/~cdpm/framef.htm
Out 15 OTL: Saúde - a retirada das organizações internacionais começou Report added Nov 1
"Muitas das organizações internacionais ou ONG nacionais que entraram em Timor Leste em Outubro de 1999 estavam ligadas ao sector dos serviços de saúde. Vinham numa perspectiva de ajuda de urgência ou de apoio à criação dum serviço de saúde que pudesse servir a população timorense depois da fase de urgência. Dois anos depois algumas retiram-se e outras preparam-se para o fazer. Como se encontra a saúde dos timorenses e em que medida esta intervenção internacional terá contribuído para fortalecer o serviço de saúde do novo país?" Observatório Timor Leste
Mar 13 ETO: The
health service: sustainable in the future?
Report added Apr 13
"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 Timor Observatory
BD: Reconstruction and 'Aid & Development' / Rekonstrusaun i 'Ajuda i Dezenvolvimentu' / Reconstrução e 'Ajuda e Desenvolvimento' - A collection of recent press releases, reports, and articles
BD: Capacity Building & 'Timorisation' / à Criação de Capacidades - A collection of recent statements, reports, articles and news
BD: Financing Reconstruction in East Timor / Fundu Ba Rekonstrusaun Timor Loro Sa’e / Bantu uang: Rékonstruksi - A collection of recent reports and articles