REPUBLICA DEMOCRATICA DE TIMOR-LESTE
MINISTERIO DA SAUDE
Gabinete do Ministro
Gabinete do Ministro
Presentation Paper: “Leading Priorities for Health Systems Strengthening in East Timor”
By H.E. Dr. Nelson Martins, MD, MHM, PhD
Minister of Health
John Hopkins University, Washington DC
13th June 2011
Ladies and Gentleman,
It is an honor and a great privilege for me to stand here at this prestigious institution, John Hopkins University, to share my thoughts and experience about the Leading Priorities for the National Health System in Timor-Leste.
I would like to begin with a description of the historical context within which the foundations of Timor-Leste national health system were created while presenting, at the same time, effective progress made over the past ten years. To end, leading priorities for health system strengthening are outlined within a progressive form for sustainable development of the Timorese health sector.
East Timor, renamed Timor-Leste after independence in May 2002, is a half island country with a territory of 18 900km2, sharing borders with Indonesia to the west and north and Australia to the south. The state of East Timor also includes an enclave (Oecusse) located within West Timor’s borders, as well as two small islands (Atauro and Jaco). Tetum and Portuguese are the two official languages, while Indonesian and English are also used.
In November 1975, after more than four centuries of Portuguese colonization, a civil war broke out in East Timor, as political parties fought for power in anticipation of independence from Portugal. By October same year Indonesia invaded the country, leading to the death of 200 000 East Timorese (25% of the population), either killed or victims of starvation and disease. After 24 years of Indonesian rule, a referendum on independence was held on 30 August 1999 under the auspices United Mission for East Timor (UNAMET). A turnout of 98% resulted in 78.5% of the registered electorate voting for independence.
In September 1999, the announcement of the results triggered a violent outbreak by militia, supported by the Indonesian army, which resulted in the pull-out of UN Mission in East Timor and the destruction of 70% of infrastructure and displacement of two-thirds of the population. Over 35% of health facilities were completely destroyed and more than 40% seriously damaged. Most physicians and senior management staff from central and district levels left the country and virtually all medical equipment and supplies were looted or destroyed. In the aftermath of the conflict, GDP declined by almost 40% and prices rose by around 200%.
On 15 September 1999, UN Security Council resolution number 1264/99 set the stage for deployment of a multinational force to restore peace and security in East Timor; and a second resolution (1272/99) established the United Nation Transitional Administration for East Timor (UNTAET), which had a mandate to administer the country, exercise legislative and executive power, coordinate humanitarian assistance and support capacity building for self-government.
THE “UNTAET” GOVERNMENT
In March 2000, the international agencies declared the end of the emergency phase and recommended that all efforts be directed towards sustainable development. An Interim Health Authority (IHA) was established, composed of East Timor Health Professionals Working Group and international UNTAET staff, responsible for coordination of all health sector activities. One Timorese member of the IHA was nominated in each district as the focal person for health, to work closely with the social services international officer, with international agencies providing technical assistance for decision-making.
Following the initial emergency phase, some of the NGOs left the country. From those that remained, one was assigned by the IHA to each district as the lead agency for management and provision of health services. The NGOs, with limited participation of local counterparts and following guidelines and standards established by the IHA, designed health plans for each district. The operational priorities were to ensure maximum coverage of basic services and to build the capacity of East Timorese staff.
The new health system rationalized the previous Indonesian network, limiting the number of health facilities and staff to the minimum necessary to ensure provision of basic services to the population; also planning their distribution according to administrative, geographic and accessibility criteria. This system configuration approach was founded on the basis of the reality at the time as little was known about the future oil revenues.
One Community Health Centre with inpatient facilities was rehabilitated in each district capital and one Community Health Centre with an outpatient department in each sub-district. Health posts, each staffed by two health workers, were established to provide basic services in more remote areas. Outreach (mobile) clinics were organized, providing minimum services to the most inaccessible locations twice per week. The initial aim was to provide outreach on a temporary basis as a way of exploring the demand for services that outreach triggered in each location, so as to assist in planning the location of additional fixed health posts. After withdrawal of NGO support, this strategy suffered drawbacks due to limited logistic capacity by local health staff and implemented unevenly.
During the early reconstruction period (2000–01), East Timor’s health system had a staff complement of about 1500 as compared with approximately 3540 during the Indonesian occupation (Joint Assessment Mission, The World Bank 1999). From 135 doctors working before the crisis, only 20 remained after September 1999. International medical staffs were recruited as a temporary measure. Nurses and midwives were allocated to every health facility.
Hospital service configuration was re-assessed in November 2001 and January 2002 through two in-depth rationalization studies, leading to the current composition that was approved by the Parliament in April 2002. The plan comprised four small 20-bed hospital units, one regional hospital with 110 beds and a national referral hospital with 220 beds.
The role of the international community, particularly through the UN Agencies such as World Bank, WHO and UNICEF, the International NGOs such as ICRC and over 15 NGOs, as well as Church Clinics like Caritas and the Canossa Sisters were instrumental in the aftermath of the Referendum.
THE FIRST CONSTUTIONAL GOVERNMENT
An independent Ministry of Health (MoH) was established, to which a physician was appointed as Minister and a nurse as Vice Minister. The new Constitution was signed into force in March 2002.
After gaining independence in May 2002, health policy direction was needed to better create the foundations for a sustainable health care system, yet resources were limited in terms of health financing, human resources, infrastructures, drugs and medical equipment. Recognizing the extremely limited revenues available in the country, Timor-Leste development partners agreed to establish the health sector Trust Fund through the World Bank.
From 2002 to late 2006 major efforts were directed towards policy development and strategic planning at national and sector level, focusing on achieving both national and internationally developed targets established under the Millennium Development Goals (MDGs). Among key policy documents, the following were most significant:
• National Development Plan
• Millennium Development Goals
• Health Policy Framework and associated legislative publications
• Strategic Plan developed for various health programmes
• Establishment of the Autonomous Medical Store
• Implementation of National Health Services Configuration Plan (incl. staffing, Transport, Medical Equipment & Infrastructure)
• Investment on Health Human Resource Development through scholarship offers under the health sector rehabilitation and development project, and through several bilateral agreements
• Development of Basic Services Packages for Primary Health Care and Hospitals
• Development of a medium term health sector strategic plan.
• Establishment of the Faculty of Medicine at UNTL
• Establishments of the National Institution of Health Science
• Development of s Health Sector Strategic Plan 2007-2012
• Establishment of National HIV/AIDS Commission to oversight the HIV/STI strategic plan.
Rehabilitation and construction of health facilities were key priorities throughout this period while recruiting, at the same time, health professionals to fill human resources shortages in the National Health Services, as per the tables presented below.
Whilst the National Health Services lacked the necessary qualified staff and the right number required to provide basic health services to the population, efforts were made to gradually recruit managers and health professionals who had been trained during the Indonesian annexation as well as new graduates committed towards helping build a strong health system.
In order to fill the HR gaps at the primary health care facilities and hospitals, the Government of Timor-Leste signed an agreement with the Cuban Government to deploy over 200 Cuban Doctors, including other allied health professionals such as Lab technicians and biomedical engineers to Timor-Leste, while the Cuban Medical Brigade took the responsibility of training 1000 medical students both in Cuba and in Timor-Leste.
General State Budget for the Ministry of Health has experience a steady increase over the years, while external financial assistance to the health sector begin to decline gradually from 2002 till 2005, picking-up its course from 2006 up until now.
2006 POLICE-MILITARY CRISES - 2nd & 3rd Constitutional Government
The period of 2006-2007 was most turbulent, with humanitarian crisis in the country, political uncertainty and increased violence despite continuing support by United Nations and donor communities. However, the process of development of health sector continued and the Ministry of Health demonstrated dedicated hard work carried out by the staff of MoH, which has been continuously recognized by the National Government, people of Timor-Leste, international institutions, donor and UN Agencies.
THE FOURTH CONSTITUTIONAL GOVERNMENT
From mid 2007, a new Constitutional Government lead by H.E. Kay Rala Xanana Gusmao took office. The focus on health sector was primarily directed towards assessing the strengths and the weaknesses of the National Health System in order to better move ahead.
Priority focus were and on interventions to reducing maternal and child mortality rates, improving the nutritional status of the population, reducing mortality rates caused by infection diseases such as malaria, dengue, TB and HIV-AIDS, while at the institutional level, reforms are being introduced at both organizational structure and support systems: new multifunctional vehicles being purchased, school of nursing and midwifery to counter shortage of these health professionals and the new biomedical equipments procured in 2008 made further impact in overall health status of Timor-Leste.
In 2008, interventions to help solve immediate shortage of health professionals included recruitment of additional staffs and introduction of new incentive measures to complement extra working hours and highly demanding working conditions of health professionals around the country.
The Integrated Community Health Services (SISCa) was launched to improve access and quality of health services to reach community leaving in the most rural and remote areas across the territory.
The introduction of “Past Mutin”(white folder) as means of deconcentrating budget allocation and management to the district health offices and health facilities.
The National Commission for Controlling the Disease Out-Break was established in the earlier 2009 to coordinate the immediate response to various disease outbreaks, including H1N1-2009, Dengue fever in 2010 and Measles outbreak in 2011.
At the same time, Schools of Nursing and Midwifery were opened at the Universidade Nacional de Timor Lorosae (UNTL) in order to anticipate medium and long term needs.
The Construction of Maternity Clinic and procurement of Multifunction Vehicles to improve the access of health assistance to pregnant mother, child, elderly& disable people, were all key policies introduced in a late 2008 and which are now showing great results.
The cooperation with the Indonesian and Singapore Hospitals to provide a tertiary sub-specialist care were major initiatives introduced in early 2008 to assist patients that could receive medical treatment inside the country.
The establishment of Cabinet of health Research & Development late 2009 was guided by the need to help health policy-makers towards working with and develop evidence based policies for strengthening health system development in Timor-Leste.
A new 20 Years National Health Strategic Plan covering the period of 2011-2030 was recently completed and currently in Consultations outlines the Ministry of Health Vision and Strategic directions for the next 20 years.
FUTURE PRIORITIES & DIRECTION
Despite all the efforts made so far in Timor-Leste, the challenges facing current health systems are multifaceted. They range from limited human resources management capacity and limited number of qualified health professionals, to weak support services such as health management information system, basic infrastructure to assist health personnel in their daily delivery of health services to the population, as well as weak financing mechanism required to effectively invest in the national health system.
As a result, leading priorities for health system strengthening includes integrated efforts that were already identified in a twenty year health plan, as per the following:
1. Investment in Human Capital - A comprehensive workforce plan detailing with current staffing gaps, training opportunities and recruitments as per health facility and service levels has been developed, given priorities to the district health services. Dependency to foreign experts in helping shape national policies and development course of the nation is becoming an eye opener for the need to invest in human capital with diversified area of expertise.
2. Infrastructure Investment - Infrastructure development for the national health services will focus on policy decision to improve access to health services in an equitable manner, thus, introducing family health provision at Suco (Village) level, expansion of current community health centers able to accommodate population growth and the challenges of economic development in the next twenty years, as well as provision of secondary health care services at district level.
There is a direct link between national health configuration and the human resources development required for the provision of primary, secondary and tertiary health care. In this regard, strategies for infrastructure development will cater service delivery needs, including staff accommodation, equipping medical and non-medical investment which supports delivery of services.
3. Health Management & Administration - Institutional strengthening of the Ministry of Health will require major organizational reforms in order to improve its management capacity. In this regard, priority focus are to ensure the Ministry plays its stewardship role accordingly to clear policies and regulations, by establishing intersectorial consultative bodies able to oversee system development, and by establishing administrative and management tools required to translate health policies into practice.
As a post-conflict country, Timor-Leste continues to experience the challenges of nation building for a truly independent state. The efforts made in the health sector over the past ten (10) years since independence, have resulted in great improvements in the country’s health profile. 2010 Demographic Health Survey shows progress in infant and child mortality rates, with Timor-Leste now considered an early achiever of MDG 4. Improvements in the control of communicable diseases such as malaria and TB show indication of possible MDG achievement by 2015. However, despite some progress, areas such as malnutrition and maternal deaths continue to pose great challenges to the national health system, as well as an increase in non-communicable diseases.
Priorities for National Health System Strengthening in Timor-Leste cannot be defined in isolation. In turn, there is a combination of factors that makes a healthy nation that goes beyond health.
Indeed, as a young country with just over 1 Million populations at its early stages of development, the answer to strengthening Timor-Leste health systems is in the investment of Human Resources and basic infrastructures at national level and in particular at the national health services level. These two conditions are imperative for the overall development of health system in Timor-Leste, particularly in a sense that without qualified health professional (both at clinical and at management level), without improving access to appropriately build and equipped health facilities, it can be very difficult to achieve the vision set for the health sector in the country.
The sooner investments are made in Human Resources for Health, sooner the health system can be strengthened. From health policy specialists, to health planning, monitoring and evaluation personnel, from health management information specialists to ICT specialists, from human resources specialists to health education and training professionals specialized in curriculum development to teaching and course management, from health financing specialists to accountants, from public health specialists to doctors, nurses, midwives, biomedical engineers and other allied health sciences, to medical specialists and sub-specialists, etc...
Thank you all very much for listening.