Initial Steps in Rebuilding the Health Sector in East Timor (2003) / Chapter Skim
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The situation was characterized by high child and maternal mortality rates and a high prevalence of communicable diseases, including malaria and tuberculosis. The health infrastructure was in total disarray, with more than a third of health facilities totally destroyed and much of the rest substantially damaged.
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in February 2000. This body brought together remaining senior East Timorese health staff with the UNTAET health staff to coordinate rehabilitation and development of the sector.
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It makes some general recommendations and specific suggestions directed at UN transitional administrations, the World Bank, international NGOs, and those who provide funding. Box 1 is a list of acronyms and abbreviations used in this paper.
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After the Popular Consultation on the future status of East Timor, organized under the auspices of the United Nations in August 1999, in which autonomy within Indonesia was rejected by the East Timorese people in favor of independence, the territory suffered several weeks of terror and
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THE HEALTH SECTOR INEAST TIMOR destruction at the hands of pro-Indonesian militia groups backed by uncontrolled elements of the Indonesian army. An apparent scorched earth policy was implemented with terrible efficiency in the few weeks between the referendum and the arrival of the multinational peacekeeping force known as INTERFET.
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1The authors include the three most senior East Timorese of ficials of the central health authority during 2000 and 2001, the two most senior members of the UNTAET health sector team, one of whom also served as the director of the program management unit of the part of the HSRDP funded through the multidonor TFET administered by the World Bank, and the three World Bank, Washington, staff most directly involved in the HSRDP, including the two task managers who served in succession in that role.
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Reported figures suggest that the maternal mortality rate was in the range of 550-900 deaths per 100,000. Whatever the exact figures, East Timor in 2000 had a health profile similar to some of the poorest developing countries despite the previous relatively large number of health facilities and staff.
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A Joint Health Working Group, consisting of members of the ETHPWG, the UN agencies concerned with health, and the NGOs, did its best to coordinate activities among its members and with UNTAET, but the focus, appropriately, was on emergency relief rather than on planning how to rebuild the system. Establishment of "Government" Coordination On February 16, 2000, UNTAET created the Interim Health Authority, consisting of 16 senior East Timorese health professionals at the central level (plus 1 in each of 13 districts)
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One of the important early activities of the newly formed IHA was team visits to all of the districts to gather information to inform the upcoming first Joint Donor Health Mission. This was intended not only to provide a basis for analysis and planning, but also to demonstrate to the donors that the IHA was the authority with the best information and the institution "in charge" of the situation in the health sector.
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In the implementation of the first component, a critical element of the transitional strategy was reaching agreement with NGOs to work with the IHA to prepare district health plans. Despite initial reluctance by some of the international NGOs to be coordinated by the "government," that is, UNTAET, the legitimate role of the IHA was eventually accepted and a close relationship with the NGOs ensued.
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. 1qul,ca Manatuto Oecussi · OIKOS · World Vision International · Timor Aid · CIC/ASP · ICRC · Medecins Sans Frontieres, Belgium · German Doctors for Development Bobonaro · Medecins Sans Frontieres, Holland · World Vision International · Timor Aid · Jesuit Relief Services · Assistencia Medica International, Portugal · Services for the Health in Asian and African Regions · International Committee of the Red Cross · Medecins du Monde, Portugal · Alliance of Friends for Medical Care in East Timor · Jesuit Relief Services · Medecins Sans Frontieres, Holland · Asistencia Medica International Portugal · Medecins Sans Frontieres, France · International Medical Corps Same S
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The ceilings were, however, sufficiently high to allow basic repairs and initial rehabilitation to all facilities included in the district health plans. Not surprisingly, the planned downsizing of the health system provoked some strong reaction from some NGOs and especially from the health workers, already justifiably insecure about their futures, all of them at that stage receiving stipends from UNTAET (or, in a minority of cases, from the NGOs)
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Long delays in the recruitment process, related in large part to the lack of sufficient professional expertise in the area of civil service development and recruitment in the transitional administration, added to the frustration of health workers, all of whom were anxious to know whether and where they would be employed. The delays affected the credibility of the DHS with some NGOs, which had to bear much of the discontent in the districts.
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By the third quarter of 2001, East Timorese district health management teams had been recruited in each of the districts, and it was not
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IMCI, RH, immunization, communicable diseases, human resource development, other Bilateral Atleast 10 over3 years Mental, dental, HIV/AIDS, tuberculosis control, other considered appropriate to put in place what would effectively have been another, nongovernmental layer in the system. The DHS extended funding to some NGOs that agreed to continue to provide services, at lower levels, to the end of 2001, but a phase-out strategy was announced and vigorously defended by the newly recruited leaders of the DHS, which in September 2001 became the Ministry of Health.
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vehicles had been procured for the health system, including appropriately equipped ambulances, and installation of a high-frequency radio network had been contracted after researching needs and experience elsewhere. Policy and regulation development on pharmaceuticals and medical practice had been started through initial consultancy visits followed by a number of working sessions in which senior East Timorese health staff de2The term central health authority is introduced here for convenience to cover the IHA, the DHS, and the MOH which, in sequence, were the administration/government entities responsible for coordinating the health sector.
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One notable overall achievement was the collaboration among all major actors in the health sector, including multilateral, bilateral, and UN
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The main objective of the sectorwide approach, to achieve one coherent program of development in the health sector, was very largely achieved. Constraints and Failures Despite what we believe to be the considerable achievements in the development of the health sector, there were also a number of areas in which progress was frustratingly slow or inadequate.
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In one instance, there was a significant delay when a request for proposals was reissued because the first was deemed not to have resulted in effective competition. As some of the rehabilitation carried out by NGOs restored health facilities to a level not compatible with the district health plans and because much of it was of a superficial nature, the IHA imposed limitations on rehabilitation activities.
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A considerable achievement, obtained through the skillful negotiation of several senior East Timorese health staff, was the establishment of the National Centre for Health Education and Training. This brought together what had been in Indonesian times a number of independent educational and training centers for health professionals, for example, the nursing school, the nursing academy, and training institutions for sanitarians and nutritionists.
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The interest of the East Timorese unit heads in the financing was largely focused on the budgets for planned activities and on funds within their direct control. Few beyond the most senior staffwere interested in the budgeting of funds over which they considered they had little influence.
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One other group not examined in detail here meriting particular mention is the ETHPWG, formed within days of the conflict by the remaining senior East Timorese. The fact that this group was formed so early was critical.
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One example of the consequences was a distribution of transport and communication facilities that did not reflect the priority of the development activities. While the UNTAET administrative staffwere all equipped with 4WD vehicles, often used only in the capital, the health sector staff, required to assess, organize, and supervise health activities throughout the country were not aupplied with a vehicle for many months, despite frequent requests.
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It took a leading role in the early joint assessment of needs and in the development of the Health Sector Rehabilitation and Development Project (HRSDP) , including the provision of high-quality technical assistance, managed the Trust Fund for East Timor (TFET)
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A more flexible interpretation of the rules or better still, a set of adapted rules for post-conflict situations would appear to be a more efficient way of arriving at the same result. Given the need to work with existing World Bank procurement procedures and taking into account the wide range of goods and services that needed to be procured simultaneously, the specialist procurement capacity within the central health authority/program management unit (CHA/ PMU)
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Without this close collaboration, the task of reestablishing a health system and transferring responsibility for it to East Timorese health professionals would have been very much more jifflCUlt. Among the factors constraining the performance of the NGOs was a relative lack of development experience among their personnel.
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. In the East Timor context, the combined communication and logistics capacity of the NGOs working in the health sector dwarfed the capacity of the CHA.
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While some NGOs do have true professional experience in and resources for the rehabilitation of health facilities, for example, others claimed to have such expertise but, in fact, made shoddy repairs that did not last long after the photographs had been taken for the head office and the donors. It was difficult for the CHA to assess, a priori, the expertise of different NGOs, including some with excellent self-promotional skills.
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A particular consequence of the availability of emergency funding to the health sector was the rehabilitation of some health facilities, including hospitals, by NGOs before any plan for health facility location and size had been completed. Rehabilitation is popular with donors to emergency situations (in part because it is visible and can absorb considerable resources)
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We hope that readers' analysis of the preceding text may also provide lessons that are not specifically mentioned here. Specific suggestions directed at UN transitional administrations, the World Bank, international NGOs, and those who provide funding are made below.
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It should be made clear that decisions concerning rehabilitation, construction, placement, size, and services available at health facilities are to be made by the interim government. Without jeopardizing the above areas, the authors feel that compromises should be made in procedures, in the time frame for producing results, in centralized control, and in application of unrealistically high standards of quality.
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One serious constraint to the health sector in East Timor was the very delayed recruitment of national health staff. In situations in which a health service has to be recreated, senior health staff should be recruited as soon as possible so that, from a secure position, they can participate fully in the development process, including the recruitment of staff at lower levels.
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It is difficult to make a succinct set of recommendations concerning NGOs, in part because of the diversity of their nature and competence. Among the international NGOs that can be considered the leaders in the field, there does seem to be an active process of self-analysis and attempts at reform.
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This should not perpetuate the emergency phase or delay the imperatives of ownership and capacity building. It could be facilitated by allowing funds raised in the first flush of donor support to be put in reserve, for example in sector-specific trust funds, for use when capacity and development needs are increasing.
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