WORLD HEALTH ORGANIZATION
East Timor
East Timor Health Sector
Situation report
January – December 2000
OVERVIEW
Beginning at the time of the referendum on independence for East Timor on August 30, 1999, civil unrest during the early month of September lead to the displacement up to 75% of the 850 000 residents of East Timor. Many hundreds of people were killed and a large proportion of private and public buildings heavily destroyed. During this time, 77% of health facilities were damaged. In addition to the physical destruction of health facilities, the emigration from East Timor of doctors and core health professionals (many of them Indonesian nationals) caused the total collapse of the health systems in the territory.
East Timor needed urgent assistance from the international community. Within a few days of the deployment of INTERFET (the International Force for East Timor), OCHA, UNHCR, ICRC and WHO’s Department of Emergency and Humanitarian Action (EHA) had established a presence in East Timor. WHO/EHA role was to immediately coordinate the public health interventions and ensure timely and appropriate information sharing among all partners involved. WHO deployed staff members from HQ, Regional Office for South-East Asia and WHO Country Office in Indonesia as well as employed professionals on short-term assignments. ICRC and fifteen international NGOs, together with military medical teams from INTERFET, began to provide curative services to the general population. During the year 2000, a total of 694,745 consultations and curative interventions were undertaken almost half a million consultations have been provided – more than 80% of the current population of East Timor.
At the early stage in September 1999 to January 2000, WHO together with UNICEF acted as a "Temporary Ministry of Health" coordinating health sector activities in the Territory. ICRC and fifteen International NGOs, together with military medical teams from INTERFET provided curative services to the general population.
On 25 October 1999, by resolution 1272/1999, the Security Council established the United Nations Transitional Administration in East Timor (UNTAET) with overall responsibility for the administration of East Timor through exercise of all legislative and executive authority, including the administration of justice. UNTAET was mandated to consult and cooperate with the East Timorese people to develop national democratic institutions, and to transfer to these institutions its administrative and public service functions.
WHO, with technical back-up from the EHA Department, actively participated in and technically supported the review of health services of East Timor (conducted in December 1999 and January 2000) and the subsequent establishment in February 2000 of the Interim Health Authority - a precursor of the present Division of Health Services.
On 15 July 2000, a transitional Government of East Timor was established, headed by the Transitional Administrator, a Cabinet consisting of 8 Members - four East Timorese and four international staff from ETTA - and a National Council with 33 members. WHO will work in partnership with the Divisions of Health Services and Water & Sanitation under the charge of Cabinet Members for Social Affairs and Infrastructure.
Consistent with the latest developments when East Timor is now ready to move from a state of emergency to development stages, the direction of WHO collaborative activities will be aligned accordingly. In the current situation in East Timor, more than 80% of the population have inadequate income, poor health status, lack of access to adequate health care, safe water & sanitation, insufficient food and nutrition and are faced with poor housing, especially due to wide scale destruction of buildings. Consequently, health would be a major priority for the development of East Timor.
The visit of the WHO Director-General, Dr Gro Harlem Bruntland in October 2000 was instrumental in creating realization in East Timor Transitional Administration on the importance of the health sector, as a major part of social and economical development of East Timor. Consequent upon her visit, health was given priority in administrative as well as at all political levels. This report is intended to give an account of WHO activities during the year 2000.
DEMOGRAPHICS AND HEALTH STATUS
Demographics
· Provisional estimates by the UNTAET Bureau of Statistics, Research and Census (May 2000) put the population of East Timor at 841 000.
· Over 280 000 individuals were displaced during the East Timor crisis of 1999; of those, 165 000 have now returned to their usual place of abode. Within East Timor, more than 80% of the remaining population was internally displaced due to destruction of their homes and ongoing violence. UNHCR estimates that about 105 000 East Timorese remain in West Timor, but most of these are eventually expected to return to East Timor. In addition, 6,000 to 10,000 East Timorese are currently residing in Australia; there is no indication of when they may return to East Timor.
· Just over 50% of the population is under 20 years of age; children under 5 years of age make up 13.5% of the population.
· The birth rate is high (almost 60% in 1998), but an accurate post-crisis estimation is difficult to make.
· The true crude mortality rate during and after the crisis is difficult to estimate; few deaths have been reported through the WHO communicable diseases surveillance system or other avenues.
· It is thought that over 95% of the population is ethically East Timorese. Ethnic minority groups include a small Chinese community; there is also a small population of Indonesian Muslims who chose to remain in the country after the crisis.
· Approximately 9,000 foreign nationals are presently in East Timor, working on reconstruction, aid and development and security related activities.
· Unemployment among East Timorese nationals is estimated at 70%. Per capita income is now estimated around US$210 per year, approximately 50% below its 1996 level (Source: (a) Project Appraisal Document on a Proposed Grant in the amount of US$12,7 Million Equivalent to East Timor for a Health Sector Rehabilitation and Development Project, May 24 2000; World Bank Document. Source: (b) Building Blocks for a Nation, November 2000 – The Common Country Assessment (CCA) for East Timor prepared by the UN country team).
Health status
· Pre-crisis estimates suggest an infant mortality rate (IMR) of between 70 and 90 per 1 000 live births; the most common causes were infections, prematurity and birth trauma.
· Only one in five births is attended by appropriately skilled personnel; prior to the crisis, this figure was approximately 40%.
· The maternal mortality ratio has been estimated to be as high as 890 per 100 000 live births. This is unacceptably high; for example, in Indonesia, the mortality ratio is estimated to be half as high (390 per 100 000 life births). The most common cause of maternal death is severe bleeding, generally occurring in postpartum period.
· The under 5 mortality rate (U5MR) was reportedly 125 per 1 000 live births (World Bank Joint Assessment Mission, 1999), but this may be an underestimate.
· The most common childhood illnesses are acute respiratory and diarrhoeal diseases, followed by malaria and dengue infection. An estimated 80% of children have intestinal parasitic infection.
· Cross sectional nutritional surveys have been conducted in selected districts, and suggest that 3-4% of children aged 6 months to five years are acutely malnourished, while one in five are chronically malnourished. WHO, WFP and the IHA propose to conduct a national nutritional survey for the identification of nutritional problems for targeted intervention.
· Malaria is highly endemic in all districts, with the highest morbidity and mortality rates reported in children. The peak transmission periods are July/August and December/January, although a longer transmission season exists in the east of the country (Lautem district), owing to the prolonged wet season. Based on historical and recent data, P falciparum and P vivax malaria are equally represented. Four districts, including the capital, are high transmission areas and chloroquine resistant strains have been reported. Since 1 January 2000, over 128 000 suspected malaria cases (with 140 deaths) have been reported to the national communicable diseases surveillance system. (WHO Weekly Epidemiological Bulletin, East Timor.
· East Timor is endemic for leprosy; the registered leprosy case prevalence rate is 1.8 per 10 000.
· East Timor is highly endemic for lymphatic filariasis; three species are present (Brugia timori, Bruga malayi and Wuchereria bancrofti), and patients with clinical manifestations of chronic lymphatic obstruction have been well documented.
· Tuberculosis is a major public health problem, with an estimated 20 000 active TB cases nationally (over 2.5% of the total population, and representing a prevalence of approximately 2 500 per 100 000. During the year 2000, 4,054 patients were diagnosed and treatment for TB commenced.
· Sexually transmitted infections (STI) are common in sexually active age groups. The existing curative institutions reported a total of about 35 STI cases per week, mostly in Dili and Baukau districts. However, the actual situation is still to be ascertained.
· Routine childhood immunization recommenced in early March. To prevent an expected outbreak of measles, more then 45 000 children were immunized during a special campaign; this immunization programme has limited the number of cases of measles reported in East Timor (1,343 reported cases between 1 January and 31 December 2000, representing a crude attack rate of 14.5 cases per 100 000 per month). National Immunization Days (NID) for polio eradication campaign in the entire territory was observed in November and December 2000. Total coverage was over 84%. At the same time, the routine EPI coverage was noticed to be very low, for e.g., DTP-3 coverage was less than 20%.
· The level of knowledge on health matters in the general population is poor, and health promotion has been identified as a key component of the basic package of health services to be introduced.
· Between 1 January and 31 December 2000,the curative institutions (international NGOs and the military medical team from INTERFET) provided 694,745 consultations and curative interventions to the population.
· Communicable diseases account for the majority of deaths, approximately 60%, particularly in children associated with respiratory infection, diarrhoea and malaria, followed by the non-communicable diseases, chronic diseases, road traffic accidents and other conditions.
Health System
- WHO played a catalytic role in East Timor in the formation of future direction of health development, the formation of its health authority and in formulating health policy, planning and health regulations.
Starting from the emergency phase, many NGOs, national and international institutions, UN agencies and donors wished to be involved in the process of restoration of health services in East Timor. To harmonize and coordinate these efforts, WHO had the responsibility for the overall coordination. Later Interim Health Authority successfully took over this function.
A group composing of representatives from WHO, UNICEF, UNFPA, International NGOs and East Timorese Health Professionals' working group undertook in January 2000 a review of health service provision throughout the territory and drafted a document defining minimum standards for health care service provision. At the second workshop, which took place in mid February 2000, a consensus was reached on the minimum standards document and the formation of the Interim Health Authority was formally announced. The Interim Health Authority was composed of 16 senior East Timorese health professionals supported by seven international UNTAET staff.
Later on 15 July 2000 as a result of reorganization and establishment of an East Timor Transitional Authority (ETTA) the Interim Health Authority had been renamed as Division of Health Services (DHS). Dr Sergio Lobo has been appointed as the Head of Division of Health Services.
The Division of Health Services, with support of WHO is in the process of formulating health policy guidelines for East Timor, and draft for the reform of health services in the country is being prepared. The reform is based on an integrated approach to health care delivery. Health services are proposed to be free at the point of delivery, but now and future, mean that the main policy makers are considering options for contributory financing, including health insurance schemes and patient co-payments.
Health services in East Timor are currently provided by a large number of different entities. Coverage of the population is uneven both in terms of physical access and in terms of the services provided. This situation has arisen from the necessary involvement of NGOs in health service provision during the emergency and early development phases. A strategy is being developed and implemented to guide the transition from the current situation to the future health system. This strategy must:
¨ Be rapidly implementable
¨ Ensure delivery of basic services to the maximum possible population
¨ Build capacity among East Timorese health staff
¨ Ensure more efficient use of resources
¨ Not interfere with the development of the future health system
¨ Take into account the principles developed by the East Timorese Professional Working Group (technically supported by WHO) including sensitivity to culture, religion and traditions of the East Timorese people.
To ensure more equitable coverage, more efficient use of resources, and clear division of responsibilities along with greater accountability, DHS has proposed that one key entity be identified in each district to plan, organize and manage the provision of services. Other health agencies working in the district will need to collaborate and coordinate their activities with the lead agency. DHS has requested proposals from lead NG0s for the provision and management of health services for each district, in the form of a District Health Plan.
To facilitate a development of a District Health Plan, WHO had organized a workshop, on10 June 2000. This was a good opportunity for WHO and DHS to provide detailed information and recommendations to the NGOs regarding important components of district health and specificity of the task during the transitional period (12-18 month). In addition, during the preparation of a District Health Plan all NGOs involved in health sector had received technical support and help from WHO.
Health service providers (NGOs, church health services and others) have collaborated with the Division of Health Services and the District Administration to prepare District Health Plans (DHP) drawing on their knowledge of the districts. This was the most rapid way to plan and start to implement activities to improve the quality of care provided and to ensure more effective and equitable use of available resources.
In August 2000, the draft plans (for all districts except Dili District which is being handled differently) were reviewed by the DHS and modifications negotiated with the NGO health service providers.