13 April 2001
Dear Friends of East Timor,
I hope that this e-mail finds you well.
At a time when East Timor is no longer in the news and the future of healthcare in East Timor is changing I would like you to take a view of the present situation on the Island. Medical Aid East Timor a project of the Madison ETAN chapter hopes that you can help in this most pressing hour. Dr Dan Murphy and the Bairro Pite Clinic continue seeing hundreds of outpatients daily and is one of three facilities on the island able to treat TB. Bairro Pite as one of the independent clinics may very possibly loose all funding. The Clinic and its work with the poor in the islands interior will stop. Medical Aid for East Timor continues to do all it can for the East Timorese medical students and staff of the island. Thanks to all those of you who were able to provide textbooks for the medical community there. Please consider a fundraiser for "Dr Dan" and the continued existence of the Bairro Pite Clinic. Medical Aid East Timor has the video "East Timor's Health Undone," a video about Dr Dan and the Motael Clinic in Indonesian occupied East Timor.
Medical Aid East Timor
Subject: The health service: sustainable in the future?
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.
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).
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. ETO HEA01].
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).
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 providers.
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 itself.
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).
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).
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). Health education/training
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 (WHO, 18-8).
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).
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).
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).
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.
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).
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:
Note: 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, and may be accessed on: http://www.etan.org/lh.