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"the lack of significant inclusion of local businesses and organizations in the construction of health centers is a manifestation of a larger problem: the marginalization of local interests in the development of the national health sector." LHB
From:

The La'o Hamutuk Bulletin Volume 1, no. 3.
17 November 2000
Issue focus:
Building a National Health System for East Timor
Tetum edition as downloadable PDF files is available.
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Building a National Health System for East Timor

Contents:
Introduction
From the Interim Health Authority to the Division of Health Services
The Role of International NGOs
Concerns and Criticisms
  • Marginalization of the local population
  • Insufficient Involvement of International NGOs in the Design of the National Health Sector
  • Sustainability and the Maintenance of a Strong, Public Health Sector
  • Insufficient Emphasis on Environmental Health

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    Introduction

    The health of the East Timorese people depends to a significant degree on the implementation of an effective and reliable national health care service accessible to the entire population. Given the massive destruction of September 1999, the poor health system inherited from Indonesia, and the long-term effects of Indonesia’s war and occupation on the physical and psychological state of the East Timorese, the health needs in East Timor are great.

    The Indonesian military and its militia forces damaged 77 percent of the health posts following the 30 August 1999 vote for independence, totally destroying or severely damaging about 35 percent. In addition, they looted or destroyed 67 percent of East Timor’s medical equipment. At the same time, Indonesian doctors and nurses fled the territory. While many East Timorese nurses were trained under the Portuguese and the Indonesians, the number of doctors was small. Today, the doctor-patient ratio (not including internationals) in East Timor is about 3 doctors to 100,000 people, while in Indonesia it is 12 per 100,000, and in Australia it is about 240 per 100,000.

    In the aftermath of the Indonesian military’s post-referendum campaign of terror, international and local NGOs filled the vacuum created by the destruction of the previous health infrastructure. Currently, there are 23 East Timorese medical doctors and one surgeon in the entire territory. As such, the existing system is heavily reliant on international assistance. Non-governmental organizations, funded by a number of donors and coordinated by the Division of Health Services (DHS), are the main providers of health services. Specialist services are sometimes available, but only in Baucau and Dili.

    The emergency phase of health provision is now considered over. East Timor’s health sector is now in a transitional phase, one of long-term development. The establishment of the Interim Health Authority (IHA) in late February was an important step in this development process. In early August, the IHA changed its name to the Division of Health Services.

    From the Interim Health Authority to the Division of Health Services

    The IHA grew out of the efforts of the East Timorese Health Professionals Working Group, which held its first workshop in December and decided to undertake a review of the territory’s health infrastructure. They initiated a Joint Working Group on Health Services, including representatives from UNTAET, international NGOs, the World Health Organization, UNICEF and the United Nations Population Fund. The Working Group identified the most pressing needs in healthcare service provision, the measures that would rapidly address them, and the minimum short-term requirements for the fulfillment of these needs. A second workshop in February discussed the findings and agreed on a minimum set of standards for establishing an organization to coordinate East Timor’s health system. After this meeting, UNTAET established the IHA as a joint international-East Timorese body, and as the embryonic "Ministry of Health" for East Timor.

    The DHS consists of 16 East Timorese health professionals, along with seven international staff from the UNTAET Office of Health. Dr. Sergio Lobo and Dr. Jim Tulloch head the organization. The main short-term goals of the Division, in collaboration with various UN agencies, health NGOs, and the World Bank are:

    1) To provide basic health services; and
    2) To design the health system most suitable to East Timor’s needs.
    Activities toward the first goal include: the re-building and rehabilitation of healthcare facilities; the re-establishment of basic health services; ensuring the supply of essential drugs and immunization services; the training and support of local health workers; and the maintenance of the communicable disease surveillance system instituted by the World Health Organization in Sept. 1999, along with the improvement of disease prevention and control.

    The DHS is also responsible for helping to develop national health policies, systems, legislation, and regulations, and to determine mechanisms to ensure adequate funding mechanisms for the health system. At this point, the health sector receives most of its funding from international donors—a significant portion of which the World Bank administers.

    In addition to a few local health NGOs and associations, there are many other health-related activities taking place outside of the DHS. Most important are the health posts of the Catholic and Protestant churches. The Catholic Church alone has 23 clinics and health centers throughout the territory. As well, the Timor Coffee Cooperative (CCT) presently has three clinics, and aims to establish 14, which will be located throughout the four coffee-growing districts. The CCT eventually expects to employ 100 health workers, all East Timorese, with two doctors in each of the four districts. The CCT clinics will service the 17,000 members of the cooperative and their families (bringing the total number of people covered to more than 70,000). Finally, different contingents of the United Nations-led peacekeeping force also provide medical care.

    The IHA/DHS will spend approximately US$70 million over the next three years in carrying out its various functions, and will employ 1,087 health sector workers in 2001 (the vast majority of whom will be nurses—a category that includes midwives). (During Indonesia’s occupation, there were 1,887 registered East Timorese nurses.) The reduction in the number of health sector employees was a deliberate decision by the United Nations, the World Bank, and the CNRT. They feared that a larger number of employees would prove unsustainable once East Timor becomes independent, given the assumption that the country will have very limited financial resources. Some are concerned that there will not be enough employees to meet the East Timorese population’s health needs—despite the presence of health providers outside the DHS structure.

    Dr. Sergio Lobo acknowledges the shortage of medical personnel, especially doctors, in East Timor, but he is confident that the DHS will have the capacity to serve the population adequately when UNTAET leaves . Dr. Lobo contends that most diseases in East Timor do not need the care of a doctor, that trained nurses and local health workers can treat many of these illnesses by drawing on already existing resources. In this regard, he foresees increased opportunities for community participation, with a local health committee in every sub-district, and a much greater role for women in health care provision and education. At the same time, Lobo states that—in order to minimize conflicts—such a social transformation must arise from prevailing, indigenous social values, rather than from good, but "imported", ideas.

    In terms of actual health facilities in the territory, the current plan foresees the following:

    1) 5 hospitals (the main one will be in Dili; the others will be in Ainaro, Baucau, Maliana, and Oe-cusse;

    2) a small number of "level three" clinics in some of the remaining districts, with each clinic having 6 to 10 beds;

    3) 63 health posts (both with and without beds), with one in each sub-district; and

    4) 85 health posts and 116 mobile clinics based in each sub-district to cover outlying villages.

    The DHS intends to construct 25 new clinics in the most needy sub-districts by the end of 2001. After their completion, the DHS and the World Bank will assess the situation and decide how many other health posts to build in 2002 and 2003, and will determine where to locate them. During this time, they will also build or rehabilitate of the four hospitals outside of Dili.

    The Role of International NGOs

    The major responsibility of the DHS is to support the health policy development process and the design of a health system suited to the needs of East Timor, and to design and oversee the implementation of a national health strategy. It is beyond the DHS’ current capacity to provide health services. For this reason, the DHS has to rely—at least temporarily—on the work of various international NGOs (INGOs) to fulfill district-level health needs.

    The DHS thus designated responsibility for implementing district health systems to different INGOs on the basis of district-level processes involving NGOs working within the district, local health authorities, and the Catholic Church. These lead INGOs are charged with planning, organizing, and managing the provision of health services in each district. All other health organizations working in the districts will have to work with and coordinate their activities with the lead INGOs. The DHS has also appointed temporary (East Timorese) district-level health officers who will work closely with the District Administrators, serve as the link between the DHS and the lead health agency in each district, and oversee local health education. In addition, the DHS will assign an assistant to each district officer to focus on preventative public health issues. The DHS may also encourage the use of volunteer community workers at the sub-district level.

    There is a good deal of diversity among the various district-level plans. This diversity is important because it demonstrates a recognition on the part of the DHS that needs vary between districts. It will also allow the DHS to evaluate the strengths and weaknesses of the various plans over a one-year period, and to come up with a strong, standard model for the future for all districts. At the same time, East Timorese health professionals will use the time to research models of health systems from other parts of the world (although it is not clear how the DHS will facilitate this research process). Future district-level health systems will possibly be a mixture of services from the government, NGOs, churches, and local cooperatives.

    Concerns and Criticisms

    Various "stakeholders" in the evolving health system have voiced criticisms regarding its development. The most common one relates to a perceived insufficient amount of consultation with the local population, and with international NGOs and local partners involved in the health sector. At the same time, many worry that funding is inadequate to ensure minimum health standards and long-term sustainability in terms of health service provision. Along the same lines, there are concerns that not enough technical, on-the-job training is taking place.

    Marginalization of the local population

    The construction of health facilities is an area in which local companies could potentially participate. But because the World Bank and the DHS are requiring very high standards of all contractors and may only accept contract bids for clusters of 5 clinics, it is doubtful that East Timorese businesses (or local or international NGOs) will receive any contracts. (To undertake such a project requires high amounts of capital and capacity.) As a result, millions of dollars will probably go to foreign businesses, rather than stay within East Timor and help to strengthen the local economy. It is possible, however, for foreign businesses that win the contracts to sub-contract all or part of the work to East Timorese businesses. This will inevitably happen to a certain degree, thus ensuring some economic benefit to the local economy.

    Critics of the DHS argue that this is not enough. Furthermore, they fear that having foreign companies responsible for the construction of the health centers will undermine the long-term maintenance of these facilities as local people will be less familiar with their construction. In addition, they contend that foreign businesses are unfamiliar with the difficult conditions—especially in the sub-districts—present in East Timor. Local businesses, and even INGOs somewhat, on the other hand, are already accustomed to the conditions, and are, thus, better-equipped to carry out the construction.

    Some argue that the lack of significant inclusion of local businesses and organizations in the construction of health centers is a manifestation of a larger problem: the marginalization of local interests in the development of the national health sector. Many local health NGOs and associations, for example, do not participate in the DHS structure. This is a result of a deliberate decision by the DHS due to the concern of many East Timorese health professionals that the excluded local entities have insufficient skill levels and capacity. As such, these local NGOs and associations do not receive direct funding through the DHS structure (see page 2). At the same time, local health associations have not played a significant role in the design of the current health system. It is for this reason, some contend, that local people have a very low-level of understanding of what is actually taking place in the health sector.

    Insufficient Involvement of International NGOs in the Design of the National Health Sector

    While lead INGOs in the districts will have considerable space to operate as they think best, the autonomy is not as great as it might seem. INGOs have to work under DHS and UNTAET restrictions regarding the number of local employees and the salaries received by local staff.

    Many INGOs working in the health sector have called attention to what they see as an inadequate level of consultation with both the World Bank and the East Timor Transitional Administration (ETTA)—the two principal architects of the new health system. According to a number of INGO personnel, the World Bank and UNTAET are very eager to receive information from them, but do not consider their views about the shape of the new health system. In part, this may be because the INGOs are only here on a temporary basis. These same INGOs, however, are directly providing health care and also have to address the local consequences of the policies developed by the DHS and the World Bank.

    INGOs, for example, carried out district-level assessments under the misapprehension that there were adequate funds in the trust funds for all district-level health needs. The INGOs had this false idea because of insufficient communication between the DHS and the World Bank (and, subsequently, the INGOs). Only later, when the World Bank presented its budget for the health rehabilitation project, did the INGOs learn that funding would not cover all needs, and that many local health workers would lose their jobs. The INGOs were left to deal with the consequences from the unfulfilled expectations among local people and many of their staff, thus damaging their relationships with the local population.

    INGOs continue to be critical because the World Bank/DHS Health Sector Rehabilitation and Development Program did not provide any direct funding for INGO activities, yet assumed INGOs would continue to provide hospital, community and outreach services. From the World Bank’s perspective, such funding makes no sense given the limited funds available to build the health sector and given the fact that INGOs are only in East Timor for the short-term. INGOs respond, however, that one of their principal responsibilities is to build capacity among East Timor’s health workers and that their work and indeed very presence have very important long-term implications. That said, without adequate funding, INGOs cannot fulfill their mission.

    Ideally, all health projects involving internationals should have a strong training component. For example, consultations should be the primary responsibility of East Timorese nurses, with expatriates on hand to act as observers and/or consultants when necessary. The need for such a heavy emphasis on skills transfer is all-the-more important given the small number of local health workers that exist. For such reasons, INGOs must put a heavy emphasis on the skills of expatriates as teachers, not simply as health providers.

    Sustainability and the Maintenance of a Strong, Public Health Sector

    Because of an assumption that the government of an independent East Timor will have very limited resources, UNTAET, the World Bank, and the CNRT have all agreed to limit the size of the country’s civil service. The goal of this policy is to ensure that an independent East Timorese government will be able to afford to pay the salaries of its civil servants. While fiscally sound, the wisdom of the policy is questionable if the goal is to ensure the servicing of the health needs of the East Timorese population—especially those that live in rural areas and sub-district towns. In addition, given the small size of the civil service and what is perceived to be the insufficient funds for training, there are serious questions about the ability of the future Ministry of Health that will evolve out of the DHS to maintain the organizational and physical infrastructure that UNTAET is constructing.

    Given the poverty of financial resources, there are fears of the privatization of health care, in the form of for-profit services. According to a World Bank representative in Dili, there is strong agreement between all the "stakeholders" that basic necessities—such as immunization of children, maternal and infant care, and anti-malaria and anti-tuberculosis treatment—should be free. Given the limited resources of East Timor, however, privatized, or profit-driven health care is a definite possibility for particular services.

    Insufficient Emphasis on Environmental Health

    Many INGOs would like to see the DHS place a much greater emphasis on environmental health, hygiene promotion initiatives, and sanitation. As of yet, there has been hardly any coordination between the DHS and relevant ETTA departments such as the Environmental Protection Unit, Water and Sanitation, and Agriculture.


    La'o Hamutuk, The East Timor Institute for Reconstruction Monitoring and Analysis
    P.O. Box 340, Dili, East Timor (via Darwin, Australia)
    Local Contact: Mobile: +61(408)811373  Land phone: +670(390)325-013  Email: lhproject@one.net.au
    La'o Hamutuk: East Timor Institute for Reconstruction Monitoring and Analysis

    La'o Hamutuk (Tetum for Walking Together) is a joint East Timorese-international organization that seeks to monitor, to analyze, and to report on the reconstruction activities of the principal international institutions. It believes that the people of East Timor must be the ultimate decisionmakers in the reconstruction process and that the process should be as democratic and transparent as possible ...
    East Timorese staff: Inès Martins, Benjamin Sanchez Afonso; International staff: Pamela Sexton, Mark Salzer; Executive board: Sr. Maria Dias, Joseph Nevins, Fr. Jovito Rego de Jesus Araùjo, Aderito Soares
    International contact: +1-510-643-4507  Email: lh@etan.org  Homepage: http://www.etan.org/lh
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